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Lower limb amputations represent a high social, economic and health burden. Most of them are preventable and reflect areas for improvement in health care, making it essential to know their epidemiology.This is a retrospective population-based cross-sectional analysis on all lower limb amputations performed in public hospitals in Sao Paulo between 2009 and 2020, the most populous Brazilian state, with 46 million inhabitants. Using a public database, we evaluated types, rates and trends of the amputations performed, main etiologies leading to the indication for amputation, hospital length of stay and in-hospital mortality rates, demographics of the amputees and procedure costs.In total, 180,595 lower limb amputations and surgical revision of amputations were performed, with toe amputations (45%) and major amputations (33%) being the most frequent types of surgeries, with a recent significant increase in the rates for both these procedures. Peripheral artery disease was the most frequent etiology, followed by diabetes mellitus, with both showing an upward trend over the years. Most patients were male (69.3%), Caucasians (55.6%) and elderly. August was the month with the highest number of amputations in all years. Overall in-hospital mortality after lower limb amputations was 6.6%. Total reimbursed by the government was US$ 67,675,875.55.Peripheral artery disease is the most frequent underlying diagnosis for lower limb amputations, followed by diabetes mellitus, with both showing an upward trend over the years. We observed seasonality in procedure rates, with peaks in August in all years.

2.Structured AbstractObjectivesto assess the total numbers of surgical procedures performed between 2008 and 2019 for the treatment of varicose veins in the Public Health System, which exclusively insures more than 160 million Brazilians, the distribution of surgeries over time, as well as its costs and mortality rates.Study designretrospective cross-sectional population-based studyMaterials and Methodspublic and open data referring to all surgeries to treat chronic venous disease between 2008 and 2019 were extracted from the database of the Brazilian Public Health System.ResultsIn total, 869,220 surgeries were performed to treat chronic venous disease in public hospitals and outpatient clinics in Brazil, with an average rate of 4.5 surgeries per 10,000 inhabitants per year. From 2015 on, we observed a slight downward trend in the total number of procedures. The total amount reimbursed by the government was US$ 232,775,518.11. A total of 49 deaths were registered following varicose vein surgery, corresponding to a mortality rate of 0.0056%.Conclusionsa total of 869,220 surgeries performed to treat chronic venous disease over twelve years, with an overall rate of 4.52 procedures per 10,000 inhabitants per year. The mortality rate was very low, 0.0056%.

Purpose: The calcium score is a measure of vessel wall calcification and has clinical applications when studied in different vascular beds. The presence of vascular calcification in the arteries of the lower limbs is very common in patients with peripheral arterial disease; however, its relationship with the postoperative outcomes in patients undergoing lower limb revascularization is still poorly studied. The aim of this study is to evaluate association between the calcium score of lower limbs and the postoperative outcomes in patients with peripheral arterial disease undergoing revascularization procedures. Methodology: We retrospectively analyzed 88 lower limb revascularization procedures in 72 patients with critical limb ischemia who had enhanced computed tomography for preoperative evaluation. The calcium score was calculated, from the angiographic phase of preoperative computed tomography, in the segments of the aorta, iliac, femoropopliteal, and infrapopliteal. It was also calculated the calcium score of the operated limb, and the total calcium score using a standardized method. The outcomes evaluated were the occurrence of acute myocardial infarction, amputation, patency, technical success, and death from any cause. Patients were followed up through a 12 month period. Results: Among the 88 procedures performed, 31 (43.1%) lesions were classified as Trans-Atlantic Inter-Society Consensus Document II D. There were 66 (75%) endovascular procedures, 16 (18.2%) open surgery, and 6 (6.8%) hybrid interventions. No statistically significant relationship was found between the calcium score of the segments (aorta, iliac, femoropopliteal, infrapopliteal, the operated limb, and total calcium score) and the outcomes of acute myocardial infarction, amputation, patency, and technical success in any of the periods analyzed. The calcium score of the operated limb was higher in patients who died within 30 days and 6 months (6571 vs 2590.6; p=0.026) and (5227.8 vs 2335.3; p=0.036). Conclusion: A standardized calcium score calculation method with the angiographic phase of the computed tomography is feasible and reproducible. Higher values of the calcifications of the operated limb are related to a greater chance of death in the postoperative period. The calcium score of the operated limb can be considered as a marker of clinical severity and prognosis in this group of patients

The aim of this study was to evaluate the influence of the institutional volume of abdominoperineal resections (APR) on the short-term outcomes and costs in the Brazilian Public Health system.This population-based study evaluated the number of APRs by institutions performed in the Brazilian Public Health system from January/2010 to July/2022. Data were extracted from a public domain from the Brazilian Public Health system.Four hundred and twelve hospitals performed APRs and were included. Only 23 performed at least 5 APRs per year on average and were considered high-volume institutions. The linear regression model showed that the number of hospital admissions for APRs was negatively associated with in-hospital mortality (Coef. = - 0.001; p = 0.013) and length of stay in the intensive care unit (Coef. = - 0.006; p = 0.01). The number of hospital admissions was not significantly associated with personnel, hospital, and total costs. The in-hospital mortality in high-volume institutions was significantly lower than in low-volume institutions (2.5 vs. 5.9%; p: 0.001). The mean length of stay in the intensive care unit was shorter in high-volume institutions (1.23 vs. 1.79 days; p = 0.021). In high-volume institutions, the personnel (R$ 952.23 [US$ 186.64] vs. R$ 11,129.04 [US$ 221.29]; p = 0.305), hospital (R$ 4078.39 [US$ 799.36] vs. R$ 4987.39 [US$ 977.53]; p = 0.111), and total costs (R$ 5030.63 [US$ 986.00] vs. R$ 6116.71 [US$ 1198.88]; p = 0.226) were lower.Higher institutional APR volume is associated with lower in-hospital mortality and less demand for intensive care. The findings of this nationwide study may affect how Public Health manages APR care.

Purposeto study the totality of inferior vena cava filters placed in the Brazilian Public Health System, which insures more than 160 million Brazilians, trends by geographic region and in-hospital deaths after filter placements and also due to pulmonary embolism between 2008 and 2019.Patients and methodspublic and open data regarding in-hospital mortality due to pulmonary embolism and all inferior vena cava filters placed in Brazilian public hospitals between January 2008 and December 2019 were extracted from the Brazilian Public Health System’s databases.Results9108 inferior vena cava filters were placed, 98.18% of which was therapeutic. There was an overall increasing use of these devices, statistically significant for all Brazilian regions, except the North. In-hospital mortality rate in patients who received inferior vena cava filters was 6.21%, stable over time. We observed an upward trend in in-hospital mortality rate due to pulmonary embolism, statistically significant for all Brazilian regions, except the North.ConclusionWe observed a low standardized rate of inferior vena cava filter placements in Brazil between 2008 and 2019, but with a trend towards an increasing trend use. Almost all indications for filter placement were therapeutic. In hospital mortality in patients receiving inferior vena cava filters was high, 6.21%, and stable over time, whereas the trend of in-hospital mortality rate due to pulmonary embolism is increasing. Our findings were heterogeneous across Brazilian regions and contrasted to those observed in the USA, which is likely due to cultural and socioeconomic factors.

Studying epidemiology of abdominal aortic aneurysms repairs is essential to prevent related deaths. Although outcomes are influenced by socioeconomic factors, there are no nationwide studies on these statistics in low-and-middle income countries. Therefore, we designed this study to evaluate abdominal aortic aneurysms repair rates, trends, costs, and in-hospital mortality in the Brazilian Public Health System, which exclusively insures over 160 million Brazilians.Retrospective cross-sectional population-based analysis of publicly available data referring to all abdominal aortic aneurysm repairs performed between 2008 and 2019 in Brazilian public hospitals.We observed a total of 13,506 abdominal aortic aneurysm repairs, of which 32% were emergency endovascular repairs, 20% emergency open repairs, 32% elective endovascular repairs and 16% elective open repairs. There has been a downward trend in total abdominal aortic aneurysms repairs and an increasing predominance of endovascular repair. Elective and endovascular repairs were significantly associated with lower in-hospital mortality. For ruptured abdominal aortic aneurysms, we observed mortality rates of 13.8% after endovascular repair and 52.1% after open repair. For intact abdominal aortic aneurysms, we observed mortalities of 3.8% after endovascular repair and 18.6% after open repair. Procedure and mortality rates varied significantly among the Brazilian regions.We observed a low and decreasing rate of abdominal aortic aneurysm repair. Most repairs were emergency and endovascular and there was an increasing predominance of endovascular repair. Endovascular and elective repairs were associated with lower mortality.

Although peripheral aneurysms can be limb- or life-threatening, the literature is scarce and there are only two large population-based epidemiological studies on peripheral aneurysm repair, comprising data from high-income countries only.This is a retrospective cross-sectional analysis on open and endovascular peripheral aneurysm repairs performed between 2008 and 2019 in the Brazilian Public Health System, which exclusively insures more than 160 million Brazilians.A total of 3,306 peripheral aneurysm repairs were observed. Most patients were elderly (57.74%) and male (72.66%), and patients treated with endovascular repair were older (P = 0.008). Most repairs were emergency (59.56%) and open (93.8%), and there was an overall downward trend in procedure rates. We observed a decreasing predominance of emergency open repair over elective open repair (P0.001), but open repairs prevailed over endovascular procedures, with no tendency to change this predominance. Mortality rates were 3.12% and 3.67% after elective and emergency open repair, respectively, with no difference, and 0 and 4.24% for elective and emergency endovascular repair, respectively. The government reimbursed an average of $1170.05 for open PA repair and $1802.01 for endovascular repair.We presented the largest series of the literature analyzing all 3,306 lower limb peripheral aneurysm repairs performed in public hospitals in a middle-income country. Procedure rates tended to decrease. Open repair predominated. Mortality rates ranged from 0 to 4%. Most procedures were emergency, but there was a relative increase of elective treatments over the years.

OBJECTIVES: In Brazil, descending thoracic aorta disease (TAD), including aneurysms and dissection, are preferentially managed by endovascular treatment (TEVAR) due to the feasibility and good results of this technique. In this study, we analyzed endovascular treatment of isolated TAD (ITAD) in the public health system over a 10-year period in São Paulo, a municipality in Brazil in which more than 5 million inhabitants depend on the governmental health system. METHODS: Public data from procedures performed between 2008 and 2019 were extracted using web scraping techniques. The following types of data were analyzed: demographic data, operative technique, elective or urgent status, number of surgeries, in-hospital mortality, length of hospital stay, mean length of stay in the intensive care unit, and reimbursement values paid by the government. Trauma cases and congenital diseases were excluded. RESULTS: A total of 1,344 procedures were analyzed; most patients were male and aged ≥65 years. Most individuals had a residential address registered in the city. Approximately one-third of all surgeries were urgent cases. There were 128 in-hospital deaths (9.52%), and in-hospital mortality was lower for elective than for urgent surgeries (7.29% vs. 14.31%, p=0.031). A total of R$ 24.766.008,61 was paid; an average of R$ 17.222,98 per elective procedure and R$ 18.558,68 per urgent procedure. Urgent procedures were significantly more expensive than elective surgeries (p=0.029). CONCLUSION: Over a 10-year period, the total cost of ITAD interventions was R$ 24.766.008,61, which was paid from the governmental system. Elective procedures were associated with lower mortality and lower investment from the health system when compared to those performed in an urgent scenario.

Resumo Contexto O ultrassom contrastado por microbolhas (CMUS) é uma modalidade diagnóstica de acurácia bem demonstrada por estudos internacionais para seguimento de reparo endovascular do aneurisma de aorta abdominal (EVAR). Não existem, no entanto, estudos nacionais focados nesse método de seguimento. Objetivos O objetivo deste estudo foi relatar a experiência inicial com CMUS em um hospital terciário, traçando uma comparação dos achados do CMUS com o ultrassom Doppler convencional (USGD), com o intuito de verificar se a adição de contraste ao protocolo padrão de controle ultrassonográfico incorreu alteração nos achados. Métodos Entre 2015 e 2017, 21 pacientes em seguimento de EVAR foram submetidos ao USGD seguido de CMUS. Foram avaliados os achados de exame referentes à identificação de complicações, bem como à capacidade de identificação da origem da endofuga. Resultados Entre os 21 casos avaliados, 10 complicações foram evidenciadas no total: sete pacientes apresentaram endofuga (33,3%); dois pacientes apresentaram estenose em ramo de endoprótese (9,52%); e um paciente apresentou dissecção em artéria ilíaca externa (4,76%). Em 21 pacientes avaliados, o uso combinado dos métodos identificou 10 casos de complicações pós-EVAR. Em seis dos sete casos de endofugas (85,71%), o uso dos métodos combinados foi capaz de identificar a origem. O USGD isolado falhou na identificação da endofuga em dois casos (28,5%), identificando achados duvidosos em outros dois casos (28,5%), que obtiveram definição diagnóstica após associação do CMUS. Conclusões O CMUS é uma técnica de fácil execução, a qual adiciona subsídios ao seguimento de EVAR infrarrenal. Abstract Background Microbubble contrast enhanced ultrasound (CEUS) is an accurate diagnostic method for follow-up after endovascular abdominal aortic aneurysm repair (EVAR) that has been well-established in international studies. However, there are no Brazilian studies that focus on this follow-up method. Objectives The objective of this study was to report initial experience with CEUS at a tertiary hospital, comparing the findings of CEUS with those of conventional Doppler ultrasound (DUS), with the aim of determining whether addition of contrast to the standard ultrasonographic control protocol resulted in different findings. Methods From 2015 to 2017, 21 patients in follow-up after EVAR underwent DUS followed by CEUS. The findings of these examinations were analyzed in terms of identification of complications and their capacity to identify the origin of endoleaks. Results There was evidence of complications in 10 of the 21 cases examined: seven patients exhibited endoleaks (33.3%); two patients exhibited stenosis of a branch of the endograft (9.52%); and one patient exhibited a dissection involving the external iliac artery (4.76%). In the 21 patients assessed, combined use of both methods identified 10 cases of post-EVAR complications. In six of the seven cases of endoleaks (85.71%), use of the methods in combination was capable of identifying the origin of endoleakage. DUS alone failed to identify endoleaks in two cases (28.5%) and identified doubtful findings in another two cases (28.5%), in which diagnostic definition was achieved after employing CEUS. Conclusions CEUS is a technique that is easy to perform and provides additional support for follow-up of infrarenal EVAR.

OBJECTIVE to analyze the number of endoscopic thoracic sympathectomies performed to treat hyperhidrosis in the Universal Public Health System of Brazil, the government reimbursements and the in-hospital mortality rates. BACKGROUND Even though endoscopic thoracic sympathectomy has been widely performed for the definitive treatment of hyperhidrosis, no series reported mortality and there are no population-based studies evaluating its costs or its mortality rate. MATERIALS AND METHODS Data referring to endoscopic thoracic sympathectomy to treat hyperhidrosis between 2008 and 2019 were extracted from the database of the Brazilian Public Health System, which insures more than 160 millions inhabitants. RESULTS 13,201 endoscopic thoracic sympathectomies to treat hyperhidrosis were performed from 2008 to 2019, with a rate of 68.44 procedures per 10 million inhabitants per year. There were 6 in-hospital deaths during the whole period, representing a mortality rate of 0.045%. The total expended throughout the years was U$ 6,767,825.14, with and average of U$ 512.68 per patient. CONCLUSIONS We observed a rate of 68.44 thoracoscopic sympathectomies for hyperhidrosis' treatment per 10 million inhabitants per year. The in-hospital mortality rate was very low, 0.045%, though not nil. To our knowledge, no published series is larger than ours and we are the first authors to formally report deaths following endoscopic thoracic sympathectomies to treat hyperhidrosis. Moreover, there is no other population-based study addressing costs and mortality rates of every endoscopic thoracic sympathectomy for the treatment of any site of hyperhidrosis in a given period.

Objective The main objectives of the present study were to analyze the right internal jugular vein tunneled dialysis catheter (TDC) tip displacements, functional changes, pathway deformities, and angulations associated with different arm positions. Methods We prospectively studied 21 patients who had undergone TDC implantation for hemodialysis via the right internal jugular vein at a single center from February to September 2020. After implantation, a baseline resting fluoroscopy image was taken, and three movement-mimicking images of the ipsilateral arm were obtained for comparison, with the arm in maximum abduction, maximum flexion, and maximum adduction. Device function was analyzed for each movement-mimicking position and correlated with catheter tip displacement, catheter deformity, and catheter pathway angulation. Results TDC pathway deformity occurred in 16 patients (69.5%). Deformities were more frequent in the movement-mimicking positions than in to the control resting baseline images (P = .004). The different arm positions did not lead to significant tip displacement (either horizontal or vertical; P > .05), nor did they result in significant pathway angulation between the subcutaneous and intravenous regions (P = .114). However, in the maximum abduction position, a positive relationship was present between the catheter pathway angle and impairment of catheter function (P = .028). Conclusions Catheter deformity was more frequent and more severe with maximum adduction and flexion of the arm. Although no significant changes were observed in the tip of the catheter with the movements, a positive relationship was found between the catheter pathway angle and impairment of catheter function with the arm in the maximum abduction position.

Background Stroke is a leading cause of death worldwide, with carotid atherosclerosis accounting for 10–20% of cases. In Brazil, the Public Health System provides care for roughly two-thirds of the population. No studies, however, have analysed large–scale results of carotid bifurcation surgery in Brazil. Methods This study aimed to describe rates of carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed between 2008 and 2019 in the country through web scraping of publicly available databases. Results Between 2008 and 2019, 37,424 carotid bifurcation revascularization procedures were performed, of which 22,578 were CAS (60.34%) and 14,846 (39.66%) were CEA. There were 620 in-hospital deaths (1.66%), 336 after CAS (1.48%) and 284 after CEA (1.92%) (P = 0.032). Governmental reimbursement was US$ 77,216,298.85 (79.31% of all reimbursement) for CAS procedures and US$ 20,143,009.63 (20.69%) for CEA procedures. The average cost per procedure for CAS (US$ 3,062.98) was higher than that for CEA (US$ 1,430.33) (P = 0.008). Conclusions In Brazil, the frequency of CAS largely surpassed that of CEA. In-hospital mortality rates of CAS were significantly lower than those of CEA, although both had mortality rates within the acceptable rates as dictated by literature. The cost of CAS, however, was significantly higher. This is a pioneering analysis of carotid artery disease management in Brazil that provides, for the first time, preliminary insight into the fact that the low adoption of CEA in the country is in opposition to countries where utilization rates are higher for CEA than for CAS.

This study aims to examine the changes in anxiety and depression scores in 138 patients with critical limb ischemia (rest pain or gangrene) who had no previous psychiatric history, at 30 days and 6 months after surgical revascularization.Patients were submitted to a questionnaire-based evaluation using the Beck Anxiety and Depression Inventories before surgery (no more than three days before surgery) ("Pre-Op"), 30 days after surgical revascularization ("Early PO") and at least 6 months after surgical revascularization ("Late PO"). The cut-off scores for depression were (1)10, no depression or minimal depression; (2) 10‒18, mild to moderate depression; (3) 19‒29, moderate to severe depression; and (4) 30‒63, severe depression. The cut-off scores for anxiety were (1)8, no anxiety or minimal anxiety; (2) 8‒15, mild anxiety; (3) 16‒25, moderate anxiety; and (4) 26‒63, severe anxiety.No perioperative mortality was observed 30 days after surgical revascularization. Thirty-nine (28.2%) patients underwent major (above-ankle) amputation within 30 days. Mean anxiety and depression scores, respectively, declined from 12.48 ± 9.74 (mean ± SD) and 16.92 ± 12.48 preoperatively to 4.89 ± 7.04 and 6.52 ± 9.36 postoperatively (P0.001, both). Anxiety and depression scores were not significantly affected by preoperative comorbidities (systemic arterial hypertension, diabetes mellitus, previous stroke, and smoking), affected arterial territory (aortoiliac, femoropopliteal, or infrapopliteal), or surgical technique (open surgery vs endovascular therapy). Only patients undergoing amputation within 30 days showed no improvement in depressive symptoms.Patients with critical limb ischemia have a high incidence of anxiety and depressive symptoms, which improve considerably after successful surgical revascularization. Major amputation was associated with a lack of improvement in depression scores. A formal psychiatric evaluation may be beneficial in patients who show no improvement in depressive symptoms.

Background The incidence of totally implantable catheter fracture ranges from 0.48% to 5.00%, and these fractures represent a potentially fatal complication. The fracture mechanism of catheters implanted via the jugular vein is unclear, and whether extreme arm movements represent an additional risk factor for repetitive stress of the material remains unknown. The aim of this study was to demonstrate and classify catheter deformations caused by extreme arm mobilization and associations with changes in catheter function and displacement. Methods We analyzed the fluoroscopy images of 60 consecutive patients undergoing long-term indwelling port implantation via the jugular vein. Three images were taken: arm in maximal abduction, maximal frontal elevation, and maximal adduction. The images were compared with an image of the remainder of the arm. We analyzed three catheter regions to classify the deformity: A, connection between catheter and reservoir; B, the catheter's subcutaneous tunnel; and C, the catheter's entrance in the jugular vein. The deformations were classified in comparative manner as follows: 0 (no changes), 1 (minor changes, new slightly curvatures with an angle of >90°), and 2 (major changes, new severe curvatures with angles of ≤90°). In each position, catheter function (injection and aspiration) and displacement of the reservoir and tip were analyzed. Results Only 15% of patients did not show a deformity; 33.3% had a deformity in only one position, 47.7% in two positions, and 10% in three positions. Minor deformities were observed in 70% of patients and major deformities in 40%. Moreover, 25% of patients presented both major and minor deformities. Major deformities were observed in 25.0% of patients on maximal frontal elevation, in 23.3% on maximal adduction and in none on maximal abduction. Region B was the most affected, with 57.8% of all minor deformities and 78.1% of all major deformities. No change in function was noted in 91.7% of the catheters. Maximal arm adduction resulted in greater vertical and horizontal displacement of the catheter tip and horizontal displacement of the reservoir. Higher body mass index values were associated with major deformities. Conclusions Maximal frontal elevation and maximal adduction were associated with major catheter deformities, and the subcutaneous tunnel region was the most deformed catheter region. An association between major catheter deformity and high body mass index was noted; in contrast, no association between the severity of catheter deformity, tip or reservoir displacement, or worsened functioning was observed.

Background Worldwide, peripheral arterial disease (PAD) is a disease with high morbidity, affecting more than 200 million people. Our objective was to analyze the surgical treatment for PAD performed in the Unified Health System of the city of Sao Paulo during the last 11 years based on publicly available data. Methods The study was conducted with data analysis available on the TabNet platform, belonging to the DATASUS. Public data (government health system) from procedures performed in Sao Paulo between 2008 and 2018 were extracted. Sex, age, municipality of residence, operative technique, number of surgeries (total and per hospital), mortality during hospitalization, mean length of stay in the intensive care unit and amount paid by the government system were analyzed. Results A total of 10,951 procedures were analyzed (either for claudicants or critical ischemia—proportion unknown); 55.4% of the procedures were performed on males, and in 50.60%, the patient was older than 65 years. Approximately two-thirds of the patients undergoing these procedures had residential addresses in Sao Paulo. There were 363 in-hospital deaths (mortality of 3.31%). The hospital with the highest number of surgeries (n = 2,777) had lower in-hospital mortality (1.51%) than the other hospitals. A total of $20,655,272.70 was paid for all revascularizations. Conclusions Revascularization for PAD treatment has cost the government system more than $20 million over 11 years. Endovascular surgeries were performed more often than open surgeries and resulted in shorter hospital stays and lower perioperative mortality rates.

Background Standard treatment for venous thromboembolism is anticoagulation; vena cava filter placement is an alternative in special situations. We aimed to evaluate the outcomes in patients with cancer undergoing filter placement in a cancer center during a 10-year period and assess which preoperatory variables were associated with poorer survival. Methods Retrospective unicenter analysis during a 10-year period was carried out in patients with cancer who had undergone placement of vena cava filter. Early deaths were those that occurred less than 30 days after the filter placement or that occurred during the same hospital stay of the placement. Results About 250 patients were analyzed. About 51.6% were females; 77.2% had proximal lower limb deep vein thrombosis; 34.8% had contraindications to anticoagulation; 32.8% presented bleeding after the onset of anticoagulation; and 18.4% had the filter implanted because they were going to undergo surgery and could not be anticoagulated immediately after. About 51.2% of the filters were removable. However, only 2 had the filter removed. About 59.2% had metastatic disease at the time of filter placement. About 31.2% fulfilled criteria for early death. Of those, 34 patients were put in palliative care after filter insertion (median, 13.5 days). Body mass index >18 kg/m2, the absence of metastatic disease, and filter placement during the same anesthesia of another surgery (especially if elective and curative) were associated with a higher chance of survival. Conclusions Multidisciplinary evaluation (and possibly consideration for palliation) should take place before the decision to insert a vena cava filter in severe oncologic cases depending on overall status. Patients with a greater chance of survival at a 3 or 5 years interval seem to be those whose filters were placed in the perioperative context of other surgeries (specially elective and curative), who were not undernourished, and whose disease was not metastatic at that time. For patients who survived, an active investigation protocol for filter removal should be implemented.

Background There are only 3 studies comparing the efficacy of 2 different types of lock used in totally implantable catheters regarding occlusion or reflux dysfunction. The present study contains the largest published casuistry (862 patients) and is the only one that analyzes 3 parameters: occlusion, reflux dysfunction, and flow dysfunction. Methods This was a retrospective study of patients operated at a large oncology center and followed up in the outpatient clinic between 2007 and 2015. The patients were divided into 2 groups according to the type of lock: the Hep group (heparine), whose lock was composed of saline solution 0.9% with heparin (100 IU/mL) and the SS group (saline solution), whose lock was composed of saline solution 0.9%. Results The Hep group was composed of 270 patients (31%) and the SS group of 592 patients (69%). Regarding occlusion, there were 8 cases in the Hep group (2.96%) and 8 in the SS group (1.35%; P = 0.11); in relation to reflux dysfunction, there were 8 cases in the Hep group (2.96%) and 8 in the SS group (1.35%; P = 0.11); in relation to flow dysfunction, there was 1 case in the Hep group (0.37%) and 4 cases in the SS group (0.68%; P = 1). Conclusions There was no statistically significant difference between the groups regarding occlusion, reflux dysfunction, and flow dysfunction.

Introduction Facial hyperhidrosis (FH) may lead patients to a significantly impaired quality of life (QOL). Video-assisted thoracoscopic sympathectomy (VATS) is reserved for more severe cases refractory to common first-line agents. The aim of this study was to evaluate the efficacy of VATS for FH and to compare the results between patients with facial hyperhidrosis as main complaint (FHMC) and patients with facial hyperhidrosis as nonmain complaint (FHNMC). Methods This was a retrospective study based on medical chart analysis from March 2000 to January 2014: 40 patients with FHMC and 136 patients with FHNMC. Patients underwent VATS at the T2, T3, or T4 level, according to the main site of complaint. We assessed improvement in QOL, improvement in hyperhidrosis, and presence of complications and side effects, notably compensatory hyperhidrosis (CH). Results Patients with FHMC reported greater improvement in FH (97.1% versus 93.6%; P = 0.006) but had lower improvement in QOL (78.2% versus 92.7%; P = 0.024) compared to patients with FHNMC. For patients with FHNMC, any degree of improvement in FH was reported by 100%, almost 95%, and nearly 80% of the patients who underwent VATS at the T2, T3, and T4 level, respectively ( P = 0.039). Pain and CH were reported by more than 61% and 92% of the patients, respectively, with no statistical difference between both groups. Conclusions Patients with FHMC, despite the greater improvement in FH, experienced lower improvement in QOL compared to patients with FHNMC. CH was the most frequent side effect in both groups, affecting more than 92% of the patients.

OBJECTIVES Video thoracoscopic sympathectomy is the recommended surgical treatment for primary hyperhidrosis and has a high success rate. Despite this high success rate, some patients are unresponsive and eventually need a resympathectomy. Few studies have previously analysed exclusively the results of these resympathectomies in patients with primary hyperhidrosis. None of the studies have objectively evaluated the degree of response to surgery or the improvement in quality of life after resympathectomies. METHODS This is a retrospective study, evaluating 15 patients from an initial group of 2300 patients who underwent resympathectomy after failure of the primary surgical treatment. We evaluated sympathectomy levels of resection, technical difficulties, surgical complications preoperative quality of life, response to treatment and quality-of-life improvement 30 days after each surgery. RESULTS Regarding gender, 11 (73.3%) patients were women. The average age was 23.2 with SD of 5.17 years, and the mean body mass index was 20.9 (SD 2.12). Ten patients had major complaints about their hands (66%) and 5 (33%) patients about their forearms. A high degree of response to sympathectomy occurred in 73% of patients. In 11 of these patients, the improvement in quality of life was considered high, 3 showed a mild improvement and 1 did not improve. No major complications occurred; the presence of adhesions was reported in 11 patients and pleural drainage was necessary in 4 patients. CONCLUSIONS Resympathectomy is an effective procedure, and it improves the quality of life in patients with primary hyperhidrosis who failed after the first surgery.

Purpose: To study the safety and efficacy of rivaroxaban—a direct oral anticoagulant—use in patients with active cancer and venous thromboembolism (VTE). Patients and Methods: Retrospective cohort study of 400 patients with active cancer and associated VTE, defined as deep venous thrombosis and/or pulmonary embolism. This single-center study was carried out from January 2012 to June 2015. The aim of this study was to determine the efficacy and safety, using the incidence of recurrent symptomatic VTE and major bleeding, respectively, throughout the treatment with rivaroxaban. Results: Of the 400 patients enrolled, 223 (55.8%) were female. A total of 362 (90.5%) patients had solid tumors and 244 (61%) had metastatic disease. A total of 302 (75.5%) received initial parenteral therapy with enoxaparin (median: 3, mean: 5.6, standard deviation [SD]: 6.4 days) followed by rivaroxaban. Ninety-eight patients (24.5%) were treated with on label rivaroxaban treatment. Recurrence rates were 3.25% with major bleeding occurring in 5.5% during the anticoagulant therapy (median: 118, mean: 163.9, SD: 159.9 days). Conclusion: Rivaroxaban can be an attractive alternative for the treatment of cancer-associated thrombosis.

Introduction: Insertion of central catheters in peripheral vessels is a common procedure performed for a variety of indications, including parenteral nutrition. Hyperemesis gravidarum may require parenteral nutrition in exceptional situations. Although globally safe, insertion of peripherally inserted central catheters (PICCs) can lead to complications. Case Report: We describe a case of a pregnant woman who required parenteral nutrition and underwent an unsuccessful PICC insertion attempt resulting in arterial puncture, and who 34 days later presented with right upper limb paresthesia. A pseudoaneurysm with nerve compression was diagnosed and treated by open surgery, without maternal or fetal complications. Conclusion: We recommend active surveillance ultrasound (e.g. in the first 24–48 h) of unsuccessful PICC insertion attempts, because late complications may occur and require invasive procedures for treatment.

Background Stroke is the second leading cause of death worldwide with approximately 5.7 million cases/year, and carotid atherosclerosis accounts for 10 to 20% of cases. Methods In Brazil, the Unified Health System (Sistema Unico de Saude [SUS]) is a tax-funded public health care system that provides care for roughly half the population. Sao Paulo is the eighth largest city in the world with an estimated population of over 12 million people, of whom more than 5 million rely solely on SUS. This study aimed to describe rates of carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed between 2008 and 2017 in the city of Sao Paulo through web scraping of publicly available databases. Results Three thousand seven hundred and four carotid revascularization procedures were performed between 2008 and 2017, of which 2,432 were CAS (65.7%). Rates of CAS ranged from 59.9% in 2016 to 86% in 2011. There were 57 in-hospital deaths (1.54%), 34 after CAS (1.4%; 34/2,432) and 23 after CEA (1.81%; 23/1,272) (P = 0.562). SUS reimbursements were US $7,862,017.09 (81.44% of all reimbursements) for 2,432 CAS procedures and US $1,792,324.06 (18.56%) for 1,272 CEA procedures. Average SUS reimbursement for CAS (US $3,232.73) was more than double than that for CEA (US $1,409.05). Conclusions In a city whose population exceeds that of some European countries, costs of CAS and CEA to the public health care system totaled more than US$ 9 million over 10 years. Epidemiologically, CAS was performed more commonly than CEA with no difference in in-hospital mortality between CAS and CEA, but reimbursements were 2.29 times higher for CAS. The low adoption of CEA in Sao Paulo is in contrast to countries where utilization rates are higher for CEA than for CAS.

Endovascular aneurysm repair (EVAR) has become the preferred approach for the treatment of infrarenal abdominal aortic aneurysm (IRAAA) in detriment of open surgical repair (OSR). EVAR results in lower mortality rates within 30 days, but rates tend to be the same after longer periods. Moreover, reduced use of hospital resources with EVAR does not necessarily offset the costs of the endoprosthesis. We aimed, in this study, to estimate hospital expenses after OSR or EVAR, including early and late readmissions.Retrospective analysis of hospital expenses (2005-2012) with elective IRAAA surgeries performed in a tertiary hospital, including 127 patients divided into 2 groups, EVAR (n = 102) and OSR (n = 25).One perioperative death occurred in each group. EVAR interventions lasted 145 vs. 210 min of OSR (P 0.001). Among OSR patients, 68% required packed red blood cells. Among EVAR patients, this proportion was 7.8% (P 0.001). Median hospitalization time differed significantly for EVAR (4 days) and OSR (8 days; P 0.001, intervals EVAR: 1-17 days, OSR: 2-442 days). The median and mean expenses with EVAR were US $53,080.95 and US $56,289.49, respectively. The median and mean expenses with OSR were US $37,116.04 and US $68,788.54, respectively. Early readmissions reached 11.2%. None of the OSR patients required late reinterventions, but 10 (9.9%) EVAR patients did, one of whom died.EVAR resulted in higher expenses with the exclusion of one outlier. Late reinterventions, with elevated costs, were only required by EVAR patients. Thus, when patients are eligible to undergo either intervention, OSR seems to have lower costs and better long-term results.

Objective Vascular invasion is no longer considered to be an absolute contraindication to tumor removal, and complex reconstructions are part of the daily activity of vascular surgeons in specialized cancer centers. Our aim was to report a single-center experience of complex vascular reconstructions involving en bloc resection of tumors and patients' long-term survival and graft patency outcomes. To the best of our knowledge, this is the largest report of vascular reconstructions published to date, with the longest follow-up. Methods Between September 1997 and January 2016, there were 91 patients who underwent 92 arterial and 47 venous reconstruction procedures in this retrospective cohort study. Long-term survival and patency outcomes were analyzed for all study patients and individually assessed in different body segments (head and neck, thorax, upper limbs, abdomen, and lower limbs). Results The estimated mean and median follow-up times were 112.66 and 100 months, respectively. The 24- and 60-month survival estimates for the patients overall were 55.3% and 31.1%, respectively. Survival estimates were significantly lower in the head and neck cases compared with the other body segments. The primary arterial patency rates at 24 and 60 months were 96.7% and 84.9%, respectively, and they were similar in all body segments. The venous patency rates were 71.4% and 64.2% at 24 and 60 months, respectively. Seven cases (7.6%) of arterial vascular complications were observed. Conclusions Vascular reconstruction performed in conjunction with oncologic resection is a feasible treatment option for tumors with vessel involvement. When surgery is performed in specialized centers, low perioperative morbidity and long-term patency rates are expected irrespective of the vascular territory undergoing intervention.

Objective Several factors may potentially influence the efficacy and patient satisfaction after bilateral thoracic sympathectomy as the treatment for hyperhidrosis, but few studies have specifically analyzed the impact of age on the efficacy of this treatment, the occurrence of compensatory hyperhidrosis (CH), and variations in the quality of life. Methods We retrospectively analyzed the effect of age, body mass index, surgical techniques, quality of life before surgery, betterment in the quality of life after surgery, clinical improvement in sweating at the main site, and the occurrence and intensity of CH in patients with hyperhidrosis (n = 1633) who underwent bilateral sympathectomy. Results Quality of life improved in more than 90% of patients, and severe CH occurred in 5.4%. Age did not affect these outcomes. The older, the greater reduction in sweating, and CH was linked to other variables (body mass index, craniofacial hyperhidrosis, and level of resection). Conclusions We observed that patients with old age reported an improvement in sweating in the main site of hyperhidrosis. Sympathectomy outcomes in older patients are similar to those observed in younger patients in terms of quality of life improvement and occurrence of CH.

OBJECTIVES: Primary hyperhidrosis usually affects the hands, armpits, feet and cranio-facial region. Sweating in other areas is common in secondary hyperhidrosis (after surgery or in specific clinical conditions). Oxybutynin has provided good results and is an alternative for treating hyperhidrosis at common sites. Our aim was to evaluate the efficacy of oxybutynin as a treatment for primary sweating at uncommon sites (e.g., the back and groin). METHODS: This retrospective study analyzed 20 patients (10 females) who received oxybutynin for primary focal hyperhidrosis at uncommon sites. The subjects were evaluated to determine quality of life before beginning oxybutynin and six weeks afterward and they were assigned grades (on a scale from 0 to 10) to measure their improvement at each site of excessive sweating after six weeks and at the last consult. RESULTS: The median follow-up time with oxybutynin was 385 days (133-1526 days). The most common sites were the back (n = 7) and groin (n = 5). After six weeks, the quality of life improved in 85% of the subjects. Dry mouth was very common and was reported by 16 patients, 12 of whom reported moderate/severe dry mouth. Five patients stopped treatment (two: unbearable dry mouth, two: excessive somnolence and one: palpitations). At the last visit, 80% of patients presented with moderate/great improvement at the main sites of sweating. CONCLUSION: After six weeks, more than 80% of the patients presented with improvements in their overall quality of life and at the most important site of sweating. Side effects were common (80% reported at least one side effect) and caused 25% of the patients to discontinue treatment. Oxybutynin is effective for treating bothersome hyperhidrosis, even at atypical locations and most patients cope well with the side effects.

Background Iodine contrast medium (ICM) is considered gold standard in endovascular revascularization procedures. However, nephrotoxicity and hypersensitivity to ICM are causes that limit its indiscriminate use. Carbon dioxide (CO 2 ) contrast angiography has been used as an alternative in patients with formal contraindication to ICM. However, no studies to the present date have compared in a randomized and prospective way, outcomes of revascularization procedures performed with either ICM or CO 2 in patients eligible for use of both contrasts. Methods Between April 2012 and April 2013, 35 patients with peripheral arterial disease with arterial lesions classified as Trans-Atlantic Inter-Society Consensus A or B (identified on preoperative angio computed tomography scan) and adequate runoff underwent femoropopliteal revascularization by endovascular technique in a prospective, randomized, and controlled study. Patients were randomized into 2 groups: CO 2 group and ICM group, according to the contrast media selected of the procedure. We evaluated the following outcomes in both groups: feasibility of the procedures, complications, surgical outcomes (ankle-brachial index [ABI]), glomerular filtration rate using the Cockcroft–Gault formula, relationship between the volume of injected iodine and postoperative creatinine clearance, quality of the angiographic images obtained with CO 2 , costs of the endovascular materials, and finally, cost of contrast agents. Results We were able to perform the proposed procedures in all patients treated in this series (ICM group and CO 2 ). There were no CO 2 -related complications. No procedures required conversion to open surgery. Clinical results were satisfactory, with regression of ischemia and increased levels of ABI in both groups. Variations in creatinine clearance levels showed a numerical increase in the CO 2 group and a decrease in ICM group, however, with no statistically significant difference between the delta clearance in each group. All CO 2 arteriograms of the supragenicular arteries were graded as good or fair by both observers with high interobserver image quality concordance. There was no statistical difference between endovascular material costs between the groups, but the contrast cost was significantly lower in CO 2 group ( P Conclusions The use of CO 2 in patients with no restriction for ICM is an alternative that does not limit the feasibility of the procedures. Similar outcomes were observed with CO 2 when compared with the gold standard contrast (ICM) regarding quality of images produced, with no associated changes in creatinine clearance or hypersensitivity reactions and also allows a reduction in contrast-related costs in angioplasty procedures.

Background Axillary hyperhidrosis (AH) is a common disease, with a significant impact on quality of life (QOL). Good short-term results are reported with oxybutynin, but longer follow-up data are lacking. We evaluated its effectiveness in a large series of patients who were not surgically treated and who had at least 6 months of follow-up. Methods From September 2007 to September 2013, 431 consecutive patients were enrolled in “pharmacological first” protocol for treatment of AH with oxybutynin. Thirty-four patients were lost to follow-up, and data are available for 397 patients treated for at least 6 weeks. Data at the start of the protocol, 6 weeks after beginning treatment, and at final visit were analyzed. Results One hundred fourteen patients (28.7%) did not improve and were referred for surgery (sympathectomy). Eight patients (2.01%) presented significant side effects (e.g. dry mouth) and discontinued therapy. Twenty-six patients (9.4%) preferred surgery over pharmacologic treatment. Sixty-two patients have not yet been under treatment for 6 months. The 181 patients with more than 6 months of follow-up (median: 17 months, range: 6–72) were analyzed as follows: 82.9% of patients presented moderate or great improvement in AH and 89% of patients presented improvement in other sites of hyperhidrosis after a median of 17 months. Conclusions In patients with good initial response to oxybutynin, >80% presented moderate or great improvement in axillary and in other sites of excessive sweating. Results were particularly better in women and those who presented better QOL after 6 weeks.

Background Studies have suggested that quality of life (QOL) evaluation before video-assisted thoracoscopic sympathectomy for patients with hyperhidrosis may serve as a predictive factor for positive postoperative outcomes. Our study aims to analyze if this tendency is also observed in patients treated with oxybutynin for palmar and axillary hyperhidrosis. Methods Five hundred sixty-five patients who submitted to a protocol treatment with oxybutynin were retrospectively analyzed between January 2007 and January 2012 and were divided into 2 groups according to QOL assessment before treatment. The groups consisted of 176 patients with “poor” and 389 patients with “very poor” QOL evaluation before oxybutynin treatment. Outcomes involving improvements in QOL and clinical progression of hyperhidrosis were evaluated using a validated clinical questionnaire that was specifically designed to assess satisfaction in patients with excessive sweating. Results Improvements in hyperhidrosis after oxybutynin were observed in 65.5% of patients with very poor pretreatment QOL scores and in 75% of patients with poor pretreatment QOL scores, and the only adverse event associated with oxybutynin treatment was dry mouth, which was observed with greater intensity in patients with very poor initial QOL evaluation. Conclusion Improvements in hyperhidrosis after oxybutynin treatment were similar in both groups, suggesting that QOL before treatment is not a predictive factor for clinical outcomes, contrasting with surgical results that disclose significantly better results in patients with initially poorer QOL analysis.

Objective : Our aim was to analyze the effectiveness of oxybutynin for hyperhidrosis treatment in patients over 40 years. Methods : Eighty-seven patients aged over 40 years were divided into two groups. One group consisted of 48 (55.2%) patients aged between 40 and 49 years, and another was composed of 39 (44.8%) patients aged over 50 years (50 to 74 years). A comparative analysis of Quality of Life and level of hyperhidrosis between the groups was carried out 6 weeks after a protocol treatment with oxybutynin. A validated clinical questionnaire was used for evaluation. Results : In the younger age group, 75% of patients referred a “partial” or “great” improvement in level of hyperhidrosis after treatment. This number was particularly impressive in patients over 50 years, in which 87.2% of the cases demonstrated similar levels of improvement. Over 77% of patients in both groups demonstrated improvement in Quality of Life. Excellent outcomes were observed in older patients, in which 87.1% of patients presented “slightly better” (41%) or “much better” (46.1%) improvement. Conclusion : Patients aged over 40 years with hyperhidrosis presented excellent results after oxybutynin treatment. These outcomes were particularly impressive in the age group over 50 years, in which most patients had significant improvement in Quality of Life and in level of hyperhidrosis. Objetivo : Analisar a efetividade da oxibutinina para tratamento da hiperidrose em pacientes com mais de 40 anos. Métodos : Oitenta e sete pacientes com idade superior a 40 anos foram divididos em dois grupos: o primeiro com 48 pacientes (55,2%), com idades entre 40 e 49 anos. O segundo com 39 pacientes (44,8%), com mais de 50 anos (intervalo: 50 a 74 anos). Uma análise comparativa da Qualidade de Vida e do nível de hiperidrose entre os grupos foi realizada 6 semanas após o início do tratamento com oxibutinina. Para isso, foi utilizado um questionário validado para Qualidade de Vida. Resultados : No grupo mais jovem, 75% dos pacientes referiram melhora “parcial” ou “ótima” no nível de hiperidrose após o tratamento. Esse número foi particularmente impressionante em pacientes acima de 50 anos, sendo que 87,2% apresentaram níveis similares de melhora. Mais de 77% dos pacientes, em ambos os grupos, demonstraram melhora na Qualidade de Vida. Desfechos excelentes foram observados em pacientes mais idosos, dentre os quais 87,1% dos pacientes apresentaram melhora “pouco melhor” (41%) ou “muito melhor” (46,1%). Conclusão : Os pacientes acima de 40 anos com hiperidrose tiveram excelentes resultados com o tratamento com oxibutinina. Esses desfechos foram particularmente importantes nos pacientes com mais de 50 anos, nos quais a maioria apresentou melhora da Qualidade de Vida e da hiperidrose.

Background Videothoracoscopy sympathectomy (VATS) is the only definitive treatment for primary hyperhidrosis (HH). Since 2007, in our institution, patients with HH were initially treated with oxybutynin chloride to avoid VATS and reduce compensatory hyperhidrosis incidence with good results. The aim of this study was to analyze the surgical response of patients suffering from essential hyperhidrosis after failure of oxybutynin chloride treatment. Methods This was an observational retrospective study that included 737 patients who were diagnosed with palmar or axillary hyperhidrosis and received VATS from January 2007 to January 2014. Patients were selected for 2 different groups: The post-oxybutynin surgery group consisted of 167 patients that were initially treated with oxybutynin chloride for 6 weeks and then received VATS after drug treatment failure. The primary surgery group consisted of a historic control group of 570 patients who were referred directly to surgical treatment. We evaluated the degree of improvement in symptoms 30 days after surgery and quality of life before and after the surgical treatment. Results All patients showed poor or very poor quality of life before surgery. Most patients showed a response between moderate and high after surgical treatment. However, those in primary surgery group responded better (95.1% vs. 98.2%). In the quality of life after surgery, most of the patients reported improvement, and the primary surgery group had better improvement (92.2% vs. 95.1%). Conclusions VATS showed good results in patients with palmar or axillary hyperhidrosis regarding surgical response and improvement on quality of life even when the previous oxybutynin chloride treatment failed.

Background Iodine contrast medium (ICM) is considered to be gold standard in endovascular procedures, but its nephrotoxicity and hypersensitivity limit the widespread use. Carbon dioxide (CO 2 ) is considered as an alternative for endovascular procedures in patients with contraindication to ICM. However, no studies have compared the outcomes of endovascular aneurysm repair (EVAR) performed with ICM or CO 2 among patients with no contraindication to ICM. Methods From May 2012 to April 2014, 36 patients with abdominal aortic aneurysms underwent EVAR in a prospective, randomized, and controlled study. Patients were randomized into 2 groups, CO 2 or ICM group. Results We were able to perform the proposed procedures in all patients in this study. There were no conversions to open surgery and no CO 2 -related complications. Endovascular material costs, duration of surgery, and time of fluoroscopy were similar between groups, and the cost of the contrast media was smaller in the CO 2 group than in the ICM group. Among CO 2 group procedures, 62.5% of the patients needed ICM complementary use. Conclusions The use of CO 2 as a contrast medium for EVAR is an alternative in patients with no restriction for ICM, with similar outcomes when compared to ICM, regarding duration of surgery, duration of fluoroscopy, and endovascular material costs. Using CO 2 , there were no changes in creatinine clearance and no risk of hypersensitivity reactions; moreover, there was a reduction in contrast-related costs for EVAR procedures. However, in our study, additional use of ICM to visualize the internal iliac artery was needed in most procedures.

Background: Distal deep venous thrombosis (DVT) accounts for approximately half of all the cases of lower limb thrombosis. The impact and management of this condition is still controversial. This study aims to evaluate the incidence of pulmonary embolism (PE) in patients with distal DVT in comparison to proximal DVT and evaluate the correlation between DVT and PE extension. Methods: 100 patients with acute lower limb DVT diagnosed with whole leg Doppler ultrasound from January 2006 to December 2014 were retrospectively analyzed. Active investigation for PE was carried out in all patients using multislice computed tomography angiography. Classification of DVT and PE was based on the proximal extension of the thrombus. Results: The overall incidence of PE in our sample patients was 72%. In the subgroup analysis, incidence of PE was equal in both the proximal and distal DVT groups (77%, p > 0.99). PE was detected in 43% of the patients with isolated calf vein thrombosis (ICVT). No statistical difference was observed between the distribution of lobar, segmental and subsegmental PE in the 3 DVT subgroups (p = 0.665); however, truncular PE was only observed in the proximal DVT group. Conclusion: Distal DVT is associated with a high incidence of PE compared to proximal DVT. Distal DVT and ICVT can provoke PE with involvement of proximal vessels in the pulmonary arterial tree, even in asymptomatic patients. Our study arises discussion in the controversial debate regarding the need for routine anticoagulation in distal DVT.

Rivaroxaban is a target-specific oral anticoagulant approved for the treatment of venous thromboembolism (VTE). On its major clinical trials, treatment was initiated directly with a 3-week dose of oral 15 mg twice daily followed by 20 mg every day for at least 3 months. We retrospectively evaluated an initial therapy for confirmed VTE with 1 to 18 days of enoxaparin (1 mg/kg twice daily parenteral) followed by oral rivaroxaban 20 mg every day. Of 49 patients, we found no symptomatic recurrence, no major bleeding, and only 1 clinically relevant nonmajor bleeding. We concluded in this pilot study that it is safe and effective to treat patients with enoxaparin course followed directly by a dose of 20 mg of rivaroxaban.

Infrapopliteal mycotic aneurysm resulting from endocarditis is rare, with only a few reported cases. We describe the case of a 28-year-old male patient who was suffering with pain and edema in the right leg. The ultrasound revealed an aneurysm of the right tibioperoneal trunk and a deep vein thrombosis (DVT). The patient was admitted and developed acute congestive heart failure, being diagnosed with possible endocarditis. A pseudo-aneurysm was revealed by arteriography. Aggressive antibiotic treatment was initiated, and open surgery confirmed a mycotic pseudo-aneurysm of the tibioperoneal trunk. To our knowledge, this is the 8th case reported of an infected aneurysm in this particular location. Aneurisma micótico infra-poplíteo resultante de endocardite infecciosa é raro, com apenas alguns casos relatados. Descrevemos o caso de um paciente de 28 anos do sexo masculino que apresentou dor e edema na perna direita. A ultrassonografia demonstrou um aneurisma do tronco tíbio-fibular e trombose venosa profunda do membro inferior direito. O paciente foi internado e desenvolveu falência cardíaca aguda, sendo diagnosticado de endocardite bacteriana. Um pseudo-aneurisma foi evidenciado na arteriografia. Antibioticoterapia agressiva foi iniciada e cirurgia aberta confirmou um pseudo-aneurisma micótico do tronco tibio-fibular. Para o nosso conhecimento, este é o oitavo caso relatado de aneurisma infectado localizado especificamente nesta região.

OBJECTIVES: Compare the use of carbon dioxide contrast medium with iodine contrast medium for the endovascular treatment of ilio-femoral occlusive disease in patients without contraindications to iodine. MATERIALS AND METHODS: From August 2012 to August 2014, 21 consecutive patients with ilio-femoral occlusive disease who were eligible for endovascular treatment and lacked contraindications to either iodine contrast or carbon dioxide were randomized into the carbon dioxide or iodine groups and subjected to ilio-femoral angioplasty. We analyzed the feasibility of the procedures, the surgical and clinical outcomes, the procedure lengths, the endovascular material costs, the contrast costs and the quality of the angiographic images in each group. RESULTS: No conversions to open surgery and no contrast media related complications were noted in either group. A post-operative femoral pulse was present in 88.9% of the iodine group and 80% of the carbon dioxide group. No differences in procedure length, endovascular material cost or renal function variation were noted between the groups. Four patients in the carbon dioxide group required iodine supplementation to complete the procedure. Contrast media expenses were reduced in the carbon dioxide group. Regarding angiographic image quality, 82% of the carbon dioxide images were graded as either good or fair by observers. CONCLUSIONS: The use of carbon dioxide contrast medium is a good option for ilio-femoral angioplasty in patients without contraindications to iodine and is not characterized by differences in endovascular material costs, procedure duration and surgical outcomes. In addition, carbon dioxide has lower contrast expenses compared with iodine.

Background The aim of this study was to analyze the outcomes of oncologic patients with associated aneurysm of the abdominal aorta (AAA), treated at a specialized cancer (Ca) hospital more than a 10-year period. Methods This was a retrospective study, and the data were obtained from our institution's prospective database. Between September 2003 and 2013, a total of 36 consecutive patients with AAA in association with Ca underwent surgical repair. Of these, 9 patients were excluded because the Ca treatment was performed at another service. Most of the patients were male (22) and the most frequent form of neoplasia was prostate Ca. Surgery for AAA repair was performed after the Ca treatment in 19 cases, before Ca treatment in 7 cases and concomitantly in 1 case. The intraoperative characteristics, treatment technique used, complications, patients' clinical evolution, and survival outcomes were analyzed. Results Endovascular aneurysm repair (EVAR) was used in 19 cases (70.4%) and conventional open repair (OR) in 8 cases (29.6%). Surgical treatment was uneventful in 19 cases, however, when present, postoperative complications occurred more frequently with EVAR (36.84% vs. 12.5%). There were no cases of death related to the aneurysm surgery. Most of the patients in both groups were alive at the end of the study. The probability of survival in our study was 65.8% at 3 years and 53% at 5 years, with no statistically significant difference between the EVAR and OR groups. The main cause of death was progression of the neoplastic disease. Conclusions Patients who present Ca in association with AAA benefit from surgical treatment of both conditions, simultaneously or not. In these cases, it is important for the treatment to be individualized, and the disease of greater severity should be treated first. The endovascular and conventional open techniques were shown to be equivalent.

Background Plantar hyperhidrosis is a common illness with significant impact on quality of life. Oxybutynin presents good short-term results, but longer follow-up results are lacking. We evaluated oxybutynin effectiveness in patients who were not surgically treated and who had at least six months of follow-up. Methods From September 2007 to September 2013, 85 consecutive patients were enrolled in our institutional protocol for the “pharmacological-first” treatment of primary plantar hyperhidrosis with oxybutynin. Eight patients were lost to follow-up, 15 patients have not yet been under treatment for six months, and data were available for 39 patients (all female) treated for at least six months. Data at the start of the protocol, six weeks after beginning treatment, and at their final visit were analyzed. Results Twenty-three of the 77 patients (29.87%) did not improve after pharmacological therapy. From the 39 patients with more than six months of follow-up (median 16.9 months, range 9–71), 79.5% reported moderate/great improvement in excessive plantar sweating after six weeks of treatment, and this rate increased to 84.7% in the last follow-up visit; 82.85% showed improvement in other sites presenting hyperhidrosis. Dry mouth was the most common side effect; 51.6% of patients reported it to be moderate/severe at the last visit. Conclusion In patients with good initial response to oxybutynin, more than 82% presented moderate or great improvement in plantar and other sites' excessive sweating; dry mouth was the most common side effect but was tolerable and did not lead any patient to interrupt treatment.

Background Limb-sparing procedures are currently considered the standard treatment for lower limb soft tissue sarcoma (STS). Surgical excision combined with vascular resection may be necessary to provide an adequate safety margin and to improve the oncologic outcomes. In this scenario, vascular reconstruction is required to preserve limb function. We evaluated the long-term patency and survival outcomes of arterial and venous reconstruction after resecting lower limb STS in the largest single-center case series to date. Methods Between November 1995 and July 2014, 25 patients with lower limb STS and vascular invasion underwent surgical resection followed by arterial or venous reconstruction. Patients were followed up at regular outpatient visits, at which clinical examinations and duplex ultrasound mapping were performed to assess graft patency. Results A total of 44 revascularization procedures were performed. The median follow-up time for the arterial and venous groups combined was 25.2 months (range, 0.26-225.6 months). The 5-year survival probability was 42.1%. The graft occlusion rate was significantly higher after reconstruction with synthetic grafts than after reconstruction with saphenous vein substitutes ( P = .02). The occlusion rate was not significantly different between arterial reconstruction and venous reconstruction ( P > .05). Conclusions Arterial and venous reconstruction is feasible after surgical resection of lower limb STS. Vascular reconstruction provides favorable long-term patency outcomes and low complication rates, allowing limb preservation and disease control in a select group of patients. Vascular reconstruction using venous grafts had a significantly higher patency rate than reconstruction with artificial venous substitutes.

BACKGROUND: Facial hyperhidrosis can lead to serious emotional distress. Video-assisted thoracic sympathectomy resolves symptoms effectively, though it may be associated with compensatory hyperhidrosis, which may be more common in patients undergoing resection of the second thoracic ganglion. Oxybutynin has been used as a pharmacological approach to facial hyperhidrosis but the long-term results of this treatment are unclear. OBJECTIVE: To evaluate the use of low oxybutynin doses in facial hyperhidrosis patients for at least six months. METHODS: 61 patients were monitored for over six months and assessed according to the following variables: impact of hyperhidrosis on quality of life (QOL) before treatment and after six weeks, evolution of facial hyperhidrosis after six weeks and at the last consultation, complaints of dry mouth after six weeks and on last return visit, and improvement at other hyperhidrosis sites. RESULTS: Patients were monitored for 6 to 61 months (median=17 months). Thirty-six (59%) were female. Age ranged from 17-74 (median:45). Pre-treatment QOL was poor/very poor in 96.72%. After six weeks, 100% of patients improved QOL. Comparing results after six weeks and on the last visit, 91.8% of patients maintained the same category of improvement in facial hyperhidrosis, 3.3% worsened and 4.9% improved. Dry mouth complaints were common but not consistent throughout treatment. More than 90% of patients presented moderate/great improvement at other hyperhidrosis sites. CONCLUSION: Patients who had a good initial response to treatment maintained a good response long-term, did not display tachiphylaxis and experienced improvement on other hyperhidrosis sites.

Objective To describe and analyze the results of a public-private partnership between the Ministry of Health and a private hospital in a project of assistance and scientific research in the field of endovascular surgery. Methods: The flows, costs and clinical outcomes of patients treated in a the public-private partnership between April 2012 and July 2013 were analyzed. All patients underwent surgery and stayed at least one day at the intensive care unit of the private hospital. They also participated in a research protocol to compare two intravenous contrast media used in endovascular surgery (iodinated contrast and carbon dioxide). Results A total of 62 endovascular procedures were performed in 57 patients from the public healthcare system. Hospital and endovascular supplies expenses were significantly higher as compared to the amount paid by the Unified Health System (SUS - Sistema Único de Saúde) in two out of three disease groups studied. Among outpatients, the average interval between appointment and surgery was 15 days and, in hospitalized patients 7 days. All procedures were successful with no conversion to open surgery. The new contrast medium studied - carbon dioxide – was effective and cheaper. Conclusion The waiting time for patients between indication and accomplishment of surgery was significantly reduced. Public-private partnerships can speed up care of patients from public health services, and generate and improve scientific knowledge.

Palmar hyperhidrosis (PH) is a common illness that significantly impacts Quality of Life (QOL). Oxybutynin offers excellent short-term results, but long-term follow-up results are limited. We evaluated its effectiveness in a large group of patients who did not have surgery and who had at least 6 months of follow-up. Between September 2007 and September 2013, 570 consecutive patients were enrolled in our institutional protocol regarding the “pharmacological-first” treatment of primary PH with oxybutynin. Fifty-nine were lost to follow-up, and the data were available for 511 patients treated for at least 6 weeks. Data recorded at the start of the protocol, 6 weeks after beginning treatment, and during patients’ final visits were analyzed. 112 patients (21.9 %) did not improve and were referred for surgery (sympathectomy). Eight (1.56 %) developed significant side effects (e.g., dry mouth) and discontinued therapy. Thirty (5.9 %) preferred surgery over pharmacological treatment. 111 have not yet received treatment for 6 months. The 246 patients with more than 6 months of follow-up (median 16 months, range 6–72) were analyzed, as follows: 90.2 % experienced moderate or great improvement in their PH; 90.34 % experienced improvement at other sites of hyperhidrosis following a median of 16 months. Among patients with good initial responses to oxybutynin, more than 90 % experienced moderate or great improvement in their palmar sweating, as well as in their hyperhidrosis in other sites, after 6 months. The results were particularly favorable in those patients with BMI