Analysis of the effects of the interruption of the flow in the normal arterial endothelium morphology and the correlation with the ischemia duration in rabbits

The study of acute arterial insufficiency of the extremities is an area of continuing interest and investigation, in light of the possible effects stemming from the evolution of the disease and the necessity for urgent treatment.

PURPOSE

To analyze the effects of the interruption of the flow in the normal arterial endothelium morphology and correlate them with the ischemia duration.

METHODS

We submitted 30 rabbits to the ligature of the right external iliac artery for 6 hours or 72 hours and observed specific morphological variables in the endothelial layer under optical and electronic microscopy.

RESULTS

In the optical microscopic study, no statistically significant results were observed in the comparison of the groups (control, 6- and 72-hour occlusions). With electronic microscopy, we observed alterations in the endothelial cell characterized by hyperpigmentation with detachment of the same from its bed; and rupture of the internal elastic membrane, with the exposure of the subendothelial material to the vascular lumen.

CONCLUSIONS

The optical microscopy was not an effective method for the determination of endothelial morphological alterations; the electronic microscopy allowed us to observe initial signals of the endothelial cell and layer injury 72 hours after the interruption of the normal arterial flow.

Aspectos cirúrgicos dos aneurismas isolados das artérias ilíacas

OBJETIVO: Discorrer sobre os aspectos clínicos e o tratamento cirúrgico de uma série de casos de aneurismas isolados das artérias ilíacas. MÉTODOS: Foram analisados retrospectivamente os dados protocolados e os prontuários de 12 pacientes com diagnóstico de aneurisma isolado das artérias ilíacas, operados no Departamento de Cirurgia da Santa Casa de São Paulo, no período de novembro de 1999 a fevereiro de 2003. RESULTADOS: A freqüência do aneurisma isolado das artérias ilíacas foi de 1,5% dos aneurismas abdominais operados no período do estudo. A faixa etária variou entre 56 e 80 anos, 33% dos doentes apresentavam aneurisma bilateral, e os diâmetros dos aneurismas variaram entre 2,0 e 8,5 cm. Em 83% dos casos, os pacientes encontravam-se sintomáticos no momento do tratamento. Em nenhum dos casos o aneurisma se encontrava roto. A via de acesso utilizada nos aneurismas unilaterais foi a extraperitoneal homolateral à dilatação e, nos aneurismas bilaterais, a transperitoneal, longitudinal ou transversa. Não dissecamos o segmento posterior das artérias ilíacas para clampeamento, para evitar a ocorrência de lesão venosa intra-operatória. Não observamos mortalidade no período peroperatório. Em todos os casos, preservamos pelo menos uma artéria ilíaca interna. CONCLUSÃO: A via de acesso para os aneurismas isolados das artérias ilíacas deve ser individualizada. A preservação de pelo menos uma artéria ilíaca interna constitui uma regra a ser observada, bem como deve-se evitar a dissecção circunferencial das artérias ilíacas no intra-operatório.

Risk factors for primary major amputation in diabetic patients

CONTEXT AND OBJECTIVE

Diabetic patients present high risk of having to undergo minor or major amputation during their lifetimes, because of ischemia or infection. The aim of this study was to identify and quantify risk factors for major amputation in diabetic patients with foot infections.

DESIGN AND SETTING

Retrospective clinical-surgical trial at the Vascular Surgery Service of Santa Casa de São Paulo.

METHODS

Ninety-nine patients with diabetic foot infections who underwent 129 hospitalizations in the Vascular Surgery Unit were analyzed in accordance with a pre-established protocol to compare two groups of diabetic patients: one that underwent major amputations and the other that underwent minor amputations or debridements. The patients were predominantly male, in their sixth decade of life, and had type 2 diabetes mellitus. Chronic arterial insufficiency, age, diabetes mellitus duration, ascending lymphangitis, calcaneal lesions, Wagner's classification, laboratory tests and different microorganisms in deep tissue cultures were the risk factors evaluated in all patients.

RESULTS

The statistically significant risk factors for major amputation included age, ascending lymphangitis (odds ratio, OR: 2.5), calcaneal lesions (OR: 10.5), Wagner grade 5 lesions (OR: 3.4), chronic arterial insufficiency without possibility of revascularization (OR: 5.4) and diabetes duration. Presence of Gram-positive microorganisms was associated with the need of major amputation. The serum urea, creatinine, glucose and white blood cell levels were not significant risk factors for major amputation.

CONCLUSIONS

The risk factors for major amputation were: age, ascending lymphangitis, calcaneal lesions, Wagner grade 5 lesions, arterial insufficiency, diabetes duration and Gram-positive microorganisms in cultures.

Estenose carotídea acima de 70% em pacientes no pré-operatório de cirurgia da aorta abdominal: freqüência e fatores de risco

OBJETIVO: Analisar a freqüência e os fatores de risco associados à estenose carotídea acima de 70% em pacientes que serão submetidos a cirurgias de aorta abdominal. MATERIAL E MÉTODO: Foram analisados 94 pacientes que realizaram ultra-som Doppler de carótidas no pré-operatório de cirurgias de aorta abdominal entre janeiro de 2000 e janeiro de 2003, pela disciplina de Cirurgia Vascular da Santa Casa de São Paulo. RESULTADOS: Sessenta e sete pacientes (71%) eram homens. Dentre os 94 pacientes, 42 (44,6%) tinham doença oclusiva aorto-ilíaca, e 52 (53,4%), aneurismas da aorta abdominal (AAA). A análise dos dados mostrou uma prevalência de estenose de carótidas acima de 70% em 8,33% dos pacientes com AAA e em 13,51% dos pacientes com doença oclusiva aorto-ilíaca, diferença esta sem significância estatística (P = 0,5). Nos pacientes que apresentavam antecedente de isquemia cerebral - acidente vascular cerebral (AVC) ou ataque isquêmico transitório (AIT) -, houve uma prevalência estatisticamente maior de estenose carotídea entre 70 e 99%. Outros fatores de risco para aterosclerose, como sexo masculino, diabetes, hipertensão arterial e tabagismo, não foram preditivos da presença de estenose carotídea acima de 70%. CONCLUSÃO: A freqüência de estenose da carótida acima de 70% em pacientes no pré-operatório de cirurgia de aorta foi de 9,57%, e a presença de antecedente de AVC ou AIT na história foi preditiva de estenose acima de 70% neste grupo de pacientes.

V, Caffaro RA. Ruptured abdominal aortic aneurysm: prognostic factors

OBJECTIVE: To analyze the prognostic factors related to the mortality of ruptured abdominal aortic aneurysm. METHOD: Seventy-two patients who suffered ruptured abdominal aortic aneurysm and were operated in the period between 1976 and 2000 by the Vascular Surgery Unit of the Santa Casa de São Paulo - School of Medical Sciences were retrospectively analyzed. RESULTS: The descriptive analysis of the data shows a mean age of 67.93 years, with a standard deviation of 11.58, 32% female and 68% male. Of the total number, 28% had a previous history of aneurysm and 72% were not aware of the disease. Mean systolic blood pressure during hospital admission was 96.53 mmHg. Pain was present in 100% of the patients, as well as throbbing abdominal mass. In 93% of the cases the location of the aneurysm rupture was the retroperitoneum, 4% in the duodenum, and 2% in the free peritoneum. CONCLUSION: The prognostic factors related to mortality and morbidity that demonstrated statistical significance were: age, initial blood pressure at hospital admission, diuresis during surgery, volume infused, and creatinine levels.

Vascular trauma in Latin America: a regional survey

As has been demonstrated, significant differences exist in demographics and the likelihood of accidents among Latin American countries; however, when figures were standardized, they showed a clear similarity in all the reviewed features of vascular trauma. A total of 66.4% of cases were managed solely on a clinical basis, with 78.9% of surgical procedures being performed within 6 hours of injury. Vascular repair was attempted in 84% of arterial injuries and 43% of venous injuries. Results are extremely good, with an 89% rate of success, especially considering that 63% of injuries were gunshot wounds and that the largest series, from Brazil, had a 21.3% rate of abdominopelvic injuries. The mortality rate amounted to 12.7%, but associated injuries, and particularly multiple trauma, account for 50.0% of the deaths.

Via de acesso para exposição ampla da coluna toracolombar anterior (T10 -L5)

Os autores descrevem técnica de via de acesso para exposição ampla da coluna toracolombar anterior (T10 -L5) a que foi submetida uma série de cem pacientes com indicação cirúrgica para correção de diversas doenças da coluna. A partir das estruturas envolvidas, são analisados e comentados os tempos operatórios pertinentes bem como as complicações transoperatórias e pós-operatórias decorrentes da técnica. Sugere-se que a técnica de acesso proposta seja utilizada quando adequada à doença a cuja correção se destina, independente da área de comprometimento clinicamente objetivada.

Factors related to mortality in inferior vena cava injuries. A 5 year experience

Forty-nine patients sustaining Inferior Vena Cava (IVC) injuries, during a 5 year period were retrospectively analyzed in order to assess those factors related to early deaths. Mean age was 32 and 45 were male. GSW was the most frequent mechanism of injury (59.2%), followed by SW (28.6%) and blunt trauma (12.2%). There were 4 injuries in the supra diaphragmatic IVC, 14 retrohepatic, 16 suprarenal and the remaining 15 were in the infrarenal portion of the IVC. Twenty patients were in shock and 8 were unstable on admission. The liver was the most frequently injured organ in association with IVC and there were also 7 concomitant abdominal vascular injuries. Venorrhaphy was performed in 28 patients, IVC ligature in 5, intracaval shunt in 3 and in the remaining 13, only temporary hemostasis was attempted. Mortality rate was 100% in supra diaphragmatic injuries, 71.4% in retrohepatic, 68.8% in suprarenal and 33% in infrarenal injuries. There was a significant difference when comparing mortality rate in stable against shock or unstable patients on admission (p < 0.001), as well as in those with diaphragmatic IVC injuries compared with all other injury sites together (p < 0.05). Hemodynamic instability on admission was the most important cause of early deaths, and all patients with concomitant abdominal vascular injuries also died.

[Inferior vena cava trauma: analysis of 36 cases]

The authors analysed 36 trauma patients with inferior vena cava injuries to evaluate different surgical approaches, as well as, important aspects related to morbidity and mortality. Gunshot wounds were the most frequent cause of inferior vena cava injuries and 55% of the patients had circulatory instability on admission. Retrohepatic inferior vena cava was frequently injured in association with liver injury. From those 20 unstable patients on admission, there were 17 deaths, and injury was in the retrohepatic portion of the inferior vena cava in 9, and in the supradiaphragmatic portion in 3. These data support the concept that site of injury and hemodynamic status on admission are the principal factors related to morbidity and mortality in inferior vena cava injuries.