Critical issues in vascular surgery: Education in Brazil.

BACKGROUND: Vascular surgery practice and education vary widely across the globe. In Brazil, the largest and most populated country of South America, vascular surgery is an independent specialty, with >3000 practicing specialists. Vascular surgery education in Brazil consists of 6 years of medical school, followed by a 4-year residency in vascular surgery. Endovascular surgery training is provided by part-time mini-fellowships after a residency program has been completed. The author of this report, who represents the Sociedade Brasileira de Angiologia e de Cirurgia Vascular (SBACV) or Brazilian Society of Angiology and Vascular Surgery, presents the critical issues in vascular surgery education in Brazil. METHODS: An informal survey was conducted among residency program directors and members of the SBACV National Board to identify the critical issues in vascular surgical education in Brazil. RESULTS: The 25 responders pointed to two issues as the most critical. The first is funding for vascular surgical education. Currently, 73 vascular residency programs are accredited, with 142 first-year positions and 288 residents in training. Vascular surgery residents are paid a meager stipend, but instructors receive no pay. Endovascular fellows have to pay for their training. This has led to endovascular training being financed by the industry, despite the potential conflicts of interest created by this situation. The second critical issue is endovascular surgery training. The vascular surgical community in Brazil faces the huge task of how to offer training in endovascular techniques to the 140 or so young vascular surgeons coming out of residency programs every year, as well as how to teach endovascular techniques to several hundred certified vascular surgeons already in practice. CONCLUSIONS: Funding vascular surgery educational programs and training surgeons in the new endovascular techniques are the critical issues faced by vascular surgical educators in Brazil.

Comparação entre os tratamentos aberto e endovascular dos aneurismas da aorta abdominal em pacientes de alto risco cirúrgico / Comparison between open and endovascular treatment of abdominal aortic aneurysms in high surgical risk patients

OBJETIVO: Comparar os resultados dos tratamentos aberto e endovascular de aneurismas da aorta abdominal em pacientes de alto risco cirúrgico. MÉTODOS: O tratamento aberto foi realizado em 31 pacientes, e o endovascular, em 18. Sucesso no tratamento endovascular foi definido como perviedade da endoprótese sem endoleaks ou conversão para tratamento aberto. RESULTADOS: Não houve diferença na mortalidade perioperatória entre o tratamento aberto (dois óbitos [6,45 por cento] em 31) e o endovascular (um óbito [5,55 por cento] em 18) (P = 0,899); também não houve diferença entre a mortalidade tardia no tratamento aberto (dois óbitos [6,9 por cento] em 29) e no endovascular (dois óbitos [11,7 por cento] em 17) (P = 0,572). A taxa de sucesso imediato foi de 100 por cento (31/31) no tratamento aberto e de 66,7 por cento (12/18) no endovascular (P = 0,0006); a taxa de sucesso tardio foi de 100 por cento (27/27) no tratamento aberto e de 73,3 por cento (11/15) no endovascular (P = 0,0047). Os valores médios do tempo de internação na UTI, tempo de internação hospitalar e da perda de sangue para os grupos dos tratamentos aberto e endovascular foram: 65,6 versus 34,1 horas*, 9 versus 5,6 dias* e 932 versus 225 ml*, respectivamente (*P < 0,05). O tratamento endovascular foi 436 por cento mais caro que o tratamento aberto. CONCLUSÕES: Na presente série, o tratamento aberto foi o método mais confiável para o reparo dos aneurismas da aorta abdominal, apresentando a mesma mortalidade perioperatória e tardia que o endovascular.

OBJECTIVE: To compare the results of open repair and endoluminal repair of abdominal aortic aneurysms in high surgical risk patients. METHODS: Open repair was performed in 31 patients, and endoluminal repair was performed in 18. Success in the endoluminal repair group was defined as continuing graft function without endoleak or conversion to open repair. RESULTS: No significant difference was found between the perioperative mortality rate for open repair (two deaths [6.45 percent] in 31 patients) and endoluminal repair (one death [5.55 percent] in 18 patients) (P = 0.899); similarly, no significant difference was seen in late mortality between open repair (two deaths [6.9 percent] in 29 patients) and endoluminal repair (two deaths [11.7 percent] in 17 patients) (P = 0.572); The rate of immediate success was 100 percent (31/31) for open repair and 66.7 percent (12/18) for endoluminal repair (P = 0.0006); the rate of late success was 100 percent (27/27) for open repair and 73.3 percent (11/15) for endoluminal repair (P = 0.0047). The mean values for intensive care stay, hospital stay and blood loss for open repair and endoluminal repair groups were: 65.6 vs. 34.1 hours*, 9 vs. 5.6 days* and 932 vs. 225 ml*, respectively (P < 0.05). Endoluminal repair was 436 percent more expensive than open repair. CONCLUSIONS: In this series, conventional open repair was the most reliable method of successfully managing abdominal aortic aneurysms, sharing the same perioperative and late mortality rates as endoluminal repair.

Riscos do uso de anticoagulante oral após embolectomia arterial / The risks of the use of oral anticoagulant after arterial embolectomy

Os autores comparam as complicaçöes de uma série de 32 pacientes com embolia arterial de origem cardíaca, dos quais 15 receberam anticoagulante oral (ACO) a longo prazo e 17 näo receberam anticoagulante. O tempo médio de seguimento foi de 24,7 meses (7 a 51 meses). No grupo que usou ACO ocorreu uma embolia recidivante e cinco episódios de sangramento, dos quais dois fatais. No grupo que näo recebeu ACO ocorreram dois episódios de embolia, ambas tratadas com sucesso. Os autores concluem que o risco de complicaçöes graves e óbitos foi muito mais alto nos pacientes anticoagulados. No nosso meio, näo usar ACO pode ser mais prudente que usá-lo em condiçöes precárias