Amniotic Membrane in the Treatment of Varicose Ulcers: a Center Experience.

INTRODUCTION: Amniotic membrane (AM) is an option as a cover in varicose leg ulcers, promoting epithelization. Anti-inflammatory and analgesic proprieties are described, as well as high levels of growth factors and angiogenesis. The costs are inferior to surgical plasty. The aim of this work is to describe the results of AM in the treatment of varicous leg ulcers in a group of patients refractory to the best medical treatment. METHODS: A pilot prospective trial was conducted. Thirteen patients were selected for the treatment with AM from an outpatient clinic. The inclusion criteria included: ulcer area inferior to 100 cm2, ulcer size variation inferior to 30% in the last month, duration superior to 2 years and refractory to best medical treatment including compressive therapy. The exclusion criteria were ABI>0,8m active infection, bone exposure, severe myopathy of the low limb and acute decompensation of systemic chronic disease. The first five cases were applied on the enfermary (mean stay 3 days), the last 8 patients were applied in the outpatient clinic. After the treatment behavioral reinforcement was made. RESULTS: The mean sample age was 56 YO (50-71), 70% were female, 30% were diabetic, and post-thrombotic syndrome was present in 54% (7), only one patient was an active smoker. After 2 years a recurrence was observed in 23% (3) cases. CONCLUSION: AM is effective in the treatment of varicose ulcers unresponsive to best medical treatment.

[Endovascular management of iatrogenic renal arteriovenous fistulas]. / TRATAMENTO ENDOVASCULAR DE FÍSTULAS ARTERIOVENOSAS RENAIS IATROGÉNICAS.

Renal arteriovenous fistulas are uncommon in clinical practice, however the higher frequency of percutaneous renal procedures led to an increase of iatrogenic renal vascular lesions and associated fistulas. Many of these lesions are asymptomatic, however in case of symptoms they can be indicated for treatment. With the emergence of new techniques and materials for embolization, this therapeutic option has been increasingly used to treat this type of injury. The authors present two clinical cases of iatrogenic renal arteriovenous fistulas successfully treated using percutaneous embolization. The percutaneous management of iatrogenic renal vascular lesions is a safe and effective procedure and should be considered as the first-line treatment.

[Surgical management of an innominate artery aneurysm]. / Tratamento cirúrgico de um aneurisma do tronco arterial BR aquiocefálico.

Aneurysms of the innominate artery are rare, representing only 3% of all aneurysms of the supra-aortic trunks. Early treatment of these aneurysms is recommended in order to prevent the occurrence of rupture and/or embolization to the brain or peripheral circulation. The authors report the case of an asymptomatic patient, with an aneurysm of the brachiocephalic trunk with 3.2 cm of greatest diameter, associated to ectasia of the right subclavian artery and common carotid double kinking. A bypass was performed from the ascending aorta to the carotid and subclavian arteries using a Dacron bifurcated prosthesis, through median sternotomy and right supraclavicular approach, to exclude the aneurysm. A review of the literature is made and the clinical features and surgical treatment of such aneurysms are described and discussed.

[Renal cell carcinoma extending into the right atrium. Case report]. / Carcinoma de células renais com extensão até à aurícula direita caso clínico.

We report the clinical case of a 48-year-old woman with advanced renal cell carcinoma, and an inferior vena cava thrombus extending into the right atrium. The patient underwent complete tumor excision with radical nephrectomy and inferior vena cava trombectomy using adjunctive cardiopulmonary bypass and deep hypothermic circulatory arrest. Pathological studies revealed no capsular invasion by the renal cell carcinoma. Eighteen months postoperatively the patient is asymptomatic and on immunosuppressive therapy for suspected metastatic disease. We discuss the morbilidity, mortality and long term survival of patients with similar presentation of renal cell carcinoma based in a review of the published literature. Long term survival after surgical treatment is possible in a patient with localized renal cell carcinoma extending into the right atrium. In patient with localized renal cell carcinoma and inferior vena cava tumor thrombus the cephalad extent of inferior vena caval involvement does not appear to influence the prognosis.

[Femoro-distal revascularization surgery: 5-years retrospective analysis of results]. / Resultados da cirurgia de revascularização femoro-distal: Análise retrospectiva de 5 anos.

PURPOSE: We describe the outcomes of femoro-distal bypass procedures used to treat peripheral arterial occlusive disease (PAOD). The aim of this retrospective analysis was to evaluate primary patency and limb salvage at 5 years. METHODS AND PATIENTS: We retrospectively studied 122 consecutive patients who underwent femoro-distal bypass surgery from 1999 to 2002. Information was collected from clinical charts at S. João Hospital, Porto, Portugal. Kaplan-Meier curves were used to calculate primary patency and limb salvage rates; groups were compared using Cox proportional hazards models. RESULTS: Five-year cumulative primary patency was 67,1% and limb-salvage rate was 71,1%. Major amputation risk for diabetics was significantly higher - 49% - compared with 18% in non-diabetics patients (p=0,0001). There were trends associating major amputation with women and smokers; there were also trends associating hypertension and in situ saphenous vein bypass with lower risk of major amputation . CONCLUSION: Our preliminary results support the view that infrainguinal revascularization can be safely performed, with acceptable five-year cumulative primary patency and major amputation rates. The risk of major amputation, however, is significantly increased in diabetic patients.

Stress cardiomyopathy in thromboembolic arterial disease.

Apical ballooning is a novel clinical entity reported in different contexts of physical and psychological stress, which is more common in middle-aged women. Of unknown etiology, the syndrome is characterized by a sudden and transient dilatation of the left ventricular apex in the absence of obstructive atherosclerotic coronary disease or evidence of myocardial necrosis, with total late recovery of ventricular function. The authors report the case of a 53-year-old woman who was admitted to the emergency room with left arm ischemia and low cardiac output, requiring ventilatory support. Left catheterization showed typical medial and apical myocardial dysfunction, with normal coronary arteries. Transesophageal echocardiography revealed a thrombus attached to the lower face of the aortic arch, which probably explained the thromboembolism of the arm but was unlikely to be the cause of the left ventricular dysfunction since there were no enzymatic or electrocardiographic signs of myocardial necrosis and normal wall motion was fully recovered.

[Rupture of venous bypass graft associated to infection of multiresistant bacteria]. / Rotura de bypass venoso associada a infecção por bactérias multirresistentes.

We report two cases of severe trauma of the upper limb requiring arterial revascularization. A brachio-brachial inverted saphenous bypass graft was done in both cases. Graft rupture attributed to local infection occurred at fourth post-operative week. Pseudomonas aeruginosa was isolated from the surgical wound in the first case and Acinetobacter baumanni in the second. The first case ended up with arm amputation mostly owing to extensive destruction of soft tissue, the patient being discharged home without any other sequel. In the second case the patient was successfully resuscitated after cardiopulmonary arrest, secondary to hemorrhagic shock. He underwent new brachio-brachial venous bypass graft avoiding the contaminated area. Irreversible ischemic signs plus growing overt infection led to arm amputation later on. This patient developed multi-organ failure and died by the fifth post-operative week. Acinetobacter baumannii and Pseudomonas aeruginosa are gram-negative bacilli widely present in hospital environment. Most of them are resistant to commonly used antibiotics. Their association with vascular conduit infections might have dreadful consequences as it happened in these cases.

[Supra-genicular femoro-popliteal bypass: 5 years retrospectively analysis]. / Bypass femoro-poplíteo supra-genicular: análise retrospectiva de 5 anos.

We report a retrospective study of patients submitted to supragenicular femoro-popliteal bypass surgery in our department between 1998 and 2002. A SPSS package was used for statistical analysis. Eighty bypasses were performed in 74 patients with a median follow up of 19,6 months [1-71 (+/- 22,5 months)]. Leriche-Fontaine stage IV chronic ischemia was the main indication for surgery accounting for 68,8% of cases, followed by stage III (25%) and stage IIb (6,2%). The most prevalent vascular conduit was PTFE (87,5%), with great saphenous vein and Dacron being used on 7,5 % and 5% of cases. Ten patients (12,5 %) later required major amputation and limb salvage at 12, 24 and 36 months was 91,6 %, 87,7 % and 82,8 %. The primary patency rates were 81,7 %, 78,9 % and 71 % at the end of the first, second and third year of follow up. Patient survival was 92,8 %, 92,8 % e 88,6 % at 12, 24 e 36 months of follow up. A large proportion of patients (61,7 %) required an accessory procedure. Our results might be considered acceptable in face of other published results, though care must be taken given the intrinsic limitations of this retrospective study.

[Carotid eversion endarterectomy: retrospective analysis]. / Endarteriectomia carotídea por eversão "versus" não-eversão: análise retropectiva.

The aim of this study was to report the initial experience with eversion carotid endarterectomy technique at our department. We undertook a retrospective analysis of prospectively collected data on all carotid endarterectomies performed since January 2004 to March 2006. A comparison between both groups - eversion endarterectomy (EE) and conventional endarterectomy (CE) - was done using a statistical software package. A total of 150 consecutive carotid endarterectomies were performed, 26 (17 %) of them being done using EE. Median age for all patients was 69 [52 - 89] years old with a clear male predominance (n=119; 79,3%). Cardiovascular risk factors were distributed as follows: hypertension, 126 (84%); diabetes, 40 (26,7%); dyslipidaemia, 105 (70%); tobacco smoking, 44 (29,3%). There were proportionately more patients on the EE group submitted to simultaneous CABG (30,8 % vs. 8,8 %; p=0,043) and asymptomatic for previous neurological events (53,9 %vs. 27,3%; p=0,05). There was one case of cervical haematoma reported for the EE technique. Neither neurological morbidity nor deaths were reported within this group. In the CE group the mortality was 0,8 % (1 patient) and the neurological morbidity (either stroke or TIA) was 2,4 % (3 patients). The overall stroke and death rate combining both groups was 2,7 %. Outcome differences between EE and CE patients were nonsignificant, even on multivariate analysis. Eversion carotid endarterectomy is a safe procedure that might be considered as a valid option to conventional endarterectomy.