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Abstract Background Aortic aneurysm and dissection are important causes of death in older people. Ruptured aneurysms show catastrophic fatality rates reaching near 80%. Few population-based mortality studies have been published in the world and none in Brazil. The objective of the present study was to use multiple-cause-of-death methodology in the analysis of mortality trends related to aortic aneurysm and dissection in the state of Sao Paulo, between 1985 and 2009. Methods We analyzed mortality data from the Sao Paulo State Data Analysis System, selecting all death certificates on which aortic aneurysm and dissection were listed as a cause-of-death. The variables sex, age, season of the year, and underlying, associated or total mentions of causes of death were studied using standardized mortality rates, proportions and historical trends. Statistical analyses were performed by chi-square goodness-of-fit and H Kruskal-Wallis tests, and variance analysis. The joinpoint regression model was used to evaluate changes in age-standardized rates trends. A p value less than 0.05 was regarded as significant. Results Over a 25-year period, there were 42,615 deaths related to aortic aneurysm and dissection, of which 36,088 (84.7%) were identified as underlying cause and 6,527 (15.3%) as an associated cause-of-death. Dissection and ruptured aneurysms were considered as an underlying cause of death in 93% of the deaths. For the entire period, a significant increased trend of age-standardized death rates was observed in men and women, while certain non-significant decreases occurred from 1996/2004 until 2009. Abdominal aortic aneurysms and aortic dissections prevailed among men and aortic dissections and aortic aneurysms of unspecified site among women. In 1985 and 2009 death rates ratios of men to women were respectively 2.86 and 2.19, corresponding to a difference decrease between rates of 23.4%. For aortic dissection, ruptured and non-ruptured aneurysms, the overall mean ages at death were, respectively, 63.2, 68.4 and 71.6 years; while, as the underlying cause, the main associated causes of death were as follows: hemorrhages (in 43.8%/40.5%/13.9%); hypertensive diseases (in 49.2%/22.43%/24.5%) and atherosclerosis (in 14.8%/25.5%/15.3%); and, as associated causes, their principal overall underlying causes of death were diseases of the circulatory (55.7%), and respiratory (13.8%) systems and neoplasms (7.8%). A significant seasonal variation, with highest frequency in winter, occurred in deaths identified as underlying cause for aortic dissection, ruptured and non-ruptured aneurysms. Conclusions This study introduces the methodology of multiple-causes-of-death to enhance epidemiologic knowledge of aortic aneurysm and dissection in São Paulo, Brazil. The results presented confer light to the importance of mortality statistics and the need for epidemiologic studies to understand unique trends in our own population.

Purpose: The purpose of this study is to evaluate the safety and efficacy of the mechanical thrombectomy with the Indigo System in the treatment of thrombosed arteriovenous fistulas and grafts., Methods: A retrospective search of endovascular procedures performed from November 2018 to June 2020 was conducted. Inclusion criteria were: acute arteriovenous fistula or graft thrombosis that underwent endovascular mechanical thrombectomy with Indigo System. The following information was collected from each case: sex, age, fistula modality, fistula location, treatment modality, and outcomes. Endpoints evaluated were: technical and clinical success rates; primary, assisted primary, and secondary patency rates; complication rates., Results: Twenty-six mechanical thrombectomy procedures for declotting of arteriovenous fistula thrombosis, using the Indigo System, were performed in 22 patients. Technical and clinical success was achieved in 23/26 cases (88%). Mean follow-up was 9 months (range 11-539 days). The 6-month primary, primary assisted, and secondary patency rates were 71%, 86%, 93% and the 12-month primary, primary assisted, and secondary patency rates were 71%, 72%, 80%, respectively. No technical or device-related complications were observed during thrombectomy, however two venous ruptures occurred on the angioplasty of the underlying stenosis., Conclusion: In conclusion, vacuum-assisted thrombectomy of acutely thrombosed arteriovenous fistulas and grafts with Indigo System is safe and effective, providing good short term patency rates., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The invasion of truncal arteries and veins by malignant neoplasms is rare and the surgical treatment remains a challenge. Several techniques can be used to re-establish blood flow in a resected vessel and choice of the ideal vascular substitute frequently arises a debate. Comparative studies between prosthetic and autologous grafts disclose conflicting patency results. The aim of this study is to compare patency outcomes of vascular reconstructions performed using autologous or prosthetic replacement grafts in surgical oncology, in light of a standardized antithrombotic protocol used in our institution since 1997., Methods: This retrospective study compared patency of prosthetic versus autologous interposition grafts following the resection of malignancies in 117 patients between September 1997 and February 2020. The 181 reconstruction procedures performed were analyzed according to the body segment involved, and divided into: head and neck, thorax, abdomen, and extremities., Results: Overall survival estimates after 24 and 60 months were 53.2% (standard error 4.8%) and 38.1% (standard error 4.9%), respectively. No significant difference was observed between overall arterial patency, using autologous or synthetic grafts (P = 0.41). Overall venous patency showed a tendency to be lower in synthetic grafts, although no significant difference was observed (P = 0.062). For both arterial and venous reconstructions in the extremities (upper and lower limbs), significantly higher patency was observed using autologous grafts., Conclusions: Autologous long-term graft patency may be superior to prosthetic in vascular reconstructions associated with malignancies of the extremities. This outcome was obtained using a standardized post-operative anticoagulation protocol., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The incidence of asymptomatic pulmonary embolism (PE) exceeds 70% in patients with deep venous thrombosis (DVT), even in cases of distal deep vein thrombosis. We report the case of a patient with a diagnosis of DVT in the lower left limb associated with asymptomatic PE who presented late symptoms due to this same PE. The absence of acute symptoms and the late onset of symptoms could have provoked doubts about the most appropriate treatment, resulting in unnecessary interventions, if pulmonary embolism had not already been diagnosed with tomography. In the present case, we demonstrate that computed tomography angiography conducted at the time of DVT diagnosis accurately diagnosed PE and prevented any misinterpretation of recurrent DVT in a patient already being medicated, which could have been mistakenly interpreted as demonstrating failure of anticoagulant therapy. Such a situation could lead to unnecessary intervention to fit an inferior vena cava filter. We cannot suggest that a classic medical conduct should be reformulated simply on the basis of a case report. However, we would be remiss not to suggest that well-designed studies should be carried out in the future to assess the need for this examination in the acute phase., Competing Interests: Conflicts of interest: No conflicts of interest declared concerning the publication of this article., (Copyright© 2021 The authors.)

Background: Association of abdominal aortic aneurysm with congenital pelvic kidney is rare and association with isolated iliac artery aneurysm is not yet described in the literature., Case Presentation: We present a case of successful repair of an isolated common iliac artery aneurysm associated with a congenital pelvic kidney treated by an endovascular technique. A 75-year-old man was referred for the treatment of an asymptomatic left common iliac artery aneurysm. A computed tomography angiography revealed an isolated left common iliac artery aneurysm and a left pelvic kidney. The maximum diameter of the aneurysm was 32 mm. The congenital pelvic kidney was supplied by three small superior polar arteries that emerged from the proximal non-aneurysmal portion of the common iliac artery and the main artery that arose from the left internal iliac artery. The aneurysm exclusion was accomplished by using an iliac branch device (Gore Excluder Iliac Branch, Flagstaff, AZ). The 1 and 6 months computed tomography angiography after the procedure demonstrated complete exclusion of the aneurysm and preservation of all renal arteries., Conclusion: Treating patients with an association of iliac artery aneurysms and pelvic kidneys can be a challenge due the variable arterial anatomy. The use of iliac branch device is a safe and effective alternative in selected cases.

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/m 2 , 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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Remarkable changes in the epidemiology of abdominal aortic aneurysm (AAA) have occurred in many countries during last few decades, which have also affected Brazilian mortality concurrently. This study aimed to investigate mortality trends related to AAA mortality in Brazil from 2000 to 2016., Methods: Annual AAA mortality data was extracted from the public databases of the Mortality Information System, and processed by the Multiple Cause Tabulator., Results: In Brazil, 2000 through 2016, AAA occurred in 69,513 overall deaths; in 79.6% as underlying and in 20.4% as an associated cause of death, corresponding to rates respectively of 2.45, 1.95 and 0.50 deaths per 100,000 population; 65.4% male and 34.6% female; 60.6% in the Southeast region. The mean ages at death were 71.141 years overall, and 70.385 years and 72.573 years for men and women, respectively. Ruptured AAA occurred in 64.3% of the deaths where AAA was an underlying cause, and in 18.0% of the deaths where AAA was an associated cause. The standardized rates increased during 2000-2008, followed by a decrease during 2008-2016, resulting in an average annual percent change decline of -0.2 (confidence interval [CI], -0.5 to 0.2) for the entire 2000-2016 period. As associated causes, shock (39.2%), hemorrhages (33.0%), and hypertensive diseases (26.7%) prevailed with ruptured aneurysms, while hypertensive diseases (29.4%) were associated with unruptured aneurysms. A significant seasonal variation, highest during autumn and followed by in winter, was observed in the overall ruptured and unruptured AAA deaths., Conclusions: This study highlights the need to accurately document epidemiologic trends related to AAA in Brazil. We demonstrate the burden of AAA on mortality in older individuals, and our results may assist with effective planning of mortality prevention and control in patients with AAA.

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., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

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.

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., (© The Author(s) 2016.)

Objective: To prospectively evaluate the perioperative safety, early complications and satisfaction of patients who underwent the implantation of central catheters peripherally inserted via basilic vein., Methods: Thirty-five consecutive patients with active oncologic disease requiring chemotherapy were prospectively followed up after undergoing peripheral implantation of indwelling venous catheters, between November 2013 and June 2014. The procedures were performed in the operating room by the same team of three vascular surgeons. The primary endpoints assessed were early postoperative complications, occurring within 30 days after implantation. The evaluation of patient satisfaction was based on a specific questionnaire used in previous studies., Results: In all cases, ultrasound-guided puncture of the basilic vein was feasible and the procedure successfully completed. Early complications included one case of basilic vein thrombophlebitis and one case of pocket infection that did not require device removal. Out of 35 patients interviewed, 33 (94.3%) would recommend the device to other patients., Conclusion: Implanting brachial ports is a feasible option, with low intraoperative risk and similar rates of early postoperative complications when compared to the existing data of the conventional technique. The patients studied were satisfied with the device and would recommend the procedure to others., Objetivo: Avaliar prospectivamente segurança perioperatória, complicações precoces e grau de satisfação de pacientes submetidos ao implante de cateteres centrais de inserção periférica pela veia basílica., Métodos: Foram acompanhados prospectivamente e submetidos ao implante de cateteres de longa permanência de inserção periférica, entre novembro de 2013 e junho de 2014, 35 pacientes consecutivos com doença oncológica ativa necessitando de quimioterapia. Os procedimentos foram realizados em centro cirúrgico por uma mesma equipe composta por três cirurgiões vasculares. Os desfechos primários avaliados foram as complicações pós-operatórias precoces, ocorridas em até 30 dias após o implante. A avaliação do grau de satisfação foi realizada com base na aplicação de um questionário específico já utilizado em estudos prévios., Resultados: Em todos os casos, a punção ecoguiada da veia basílica foi possível, e o procedimento foi concluído com sucesso. As complicações precoces observadas incluíram um caso de tromboflebite de basílica e um de infecção de bolsa, ambos tratados clinicamente sem necessidade de retirada do dispositivo. Dos 35 pacientes interrogados, 33 (94,3%) recomendariam o dispositivo para outras pessoas., Conclusão: A implantação do port braquial é uma opção factível, com baixo risco intraoperatório e taxas semelhantes de complicações pós-operatórias imediatas quando comparada a dados já existentes da técnica convencional. Os pacientes estudados apresentaram-se satisfeitos com o dispositivo e recomendariam o procedimento para outras pessoas., Competing Interests: none.

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., (© The Author(s) 2016.)

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., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The treatment of thoracoabdominal aortic aneurysms, both surgical and endovascular, has always been challenging. In the last years, the multilayer stent has emerged as an alternative device for the treatment of this condition. In this paper, we describe a catastrophic complication of the multilayer stent in a patient with thoracoabdominal aortic aneurysm, a case of massive visceral ischemia and death 3 months after stent deployment., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Oxybutynin for treating hyperhidrosis in children has been evaluated only in short-term studies. We aimed to investigate the long-term effects of oxybutynin in treating children with palmar and plantar hyperhidrosis who had not undergone surgery and who were monitored for at least 6 months (median 19.6 mos). A cohort of 97 patients was evaluated retrospectively, with particular attention to 59 children (ages 4-14 yrs) who were treated for longer than 6 months. Their quality of life (QOL) was evaluated using a validated clinical questionnaire before and after 6 weeks of pharmacologic therapy. A self-assessment of hyperhidrosis was performed after 6 weeks and after the last consultation. By their final office visit, more than 91% of the children with hyperhidrosis treated with oxybutynin experienced moderate or great improvement in their level of sweating and 94.9% experienced improvement in QOL. More than 90% of children reported improvement of hyperhidrosis at other sites. Dry mouth was the most common side effect. Oxybutynin appears to be an effective treatment option for children with hyperhidrosis, and positive results are maintained over the long term (median 19.6 mos)., (© 2014 Wiley Periodicals, Inc.)

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., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

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., (© 2015 The International Society of Dermatology.)

Purpose: 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., Methods: 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., Results: 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., Conclusion: 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 <25 kg/m(2), and in those who noted an improved QOL after 6 weeks.

Background: In head and neck squamous cell carcinoma, invasion of the carotid artery is a severe mortality predictor. We report an updated experience of 19 patients who underwent head and neck resection for squamous cell carcinoma with concomitant carotid reconstruction. This study aims to analyze overall survival rates, primary patency of the reconstructions, vascular and nonvascular complications, radiotherapy dosing as well as late follow-up and outcomes., Methods: From September 1997 to 2011, 19 patients with advanced squamous cell carcinoma with carotid artery invasion were submitted to resection and concomitant vascular reconstruction in a single referred oncological institution. Patient follow-up was done by means of periodic outpatient returns, where clinical and duplex scan evaluations were performed to study graft patency., Results: The average length of follow-up was 23.3 (± 34.4) months. Nonvascular complications occurred in 6 patients (31.6%). Only 1 (5.3%) vascular complication was observed, resulting from the immediate occlusion of the carotid graft. All patients were submitted to preoperative, adjuvant, or curative intent radiotherapy during the course of the oncologic treatment, with varying doses. Overall disease-free survival, primary patency, and survival with patent graft rates in 5 years are respectively 12.9%, 93.1%, and 13.0%. Three patients (15.9%) are still alive, all without tumor recurrence, and present a disease-free long-term follow-up with patent grafts 21 months, 68 months, and 151 months after surgery., Conclusions: Aggressive surgical approach for patients with advanced squamous cell head and neck carcinoma with carotid invasion can lead to cure in a select group of patients. Saphenous vein grafts demonstrated favorable outcomes with low infection and high patency rates, suggesting a valid alternative for arterial reconstruction in these cases., (Copyright © 2014 Elsevier Inc. All rights reserved.)

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.

Background: Hyperhidrosis may affect nearly 3% of the population, and thoracic/lumbar sympathectomy has been highly effective. Compensatory hyperhidrosis is a risk associated with surgical procedures, and its treatment is both complex and not well defined. Treatment of primary hyperhidrosis with oxybutynin has yielded positive results; however, its use in compensatory hyperhidrosis (CH) has not been described., Methods: Twenty-one patients (11 female patients) received oxybutynin for severe CH at a median of 5 years after sympathectomy. Patients were evaluated to determine quality of life before starting oxybutynin and 6 weeks afterward; they assigned grades to determine improvement after 6 weeks and at their last consult visit for each site at which they complained of symptoms., Results: Six and 15 patients underwent operation for axillary hyperhidrosis and palmar hyperhidrosis, respectively. Median follow-up time with oxybutynin was 377 days (49-1,831 days). Most common CH sites were the back (n=8) and abdomen (n=5). After 6 weeks, the quality of life improved in 71.4% of patients. Five patients stopped treatment: 2 because of unbearable dry mouth, 1 because of absence of pharmacologic response, 1 because of excessive somnolence, and 1 because of probable tachyphylaxis. At the last visit, 71.4% of patients presented with moderate to major improvement at the main sites at which sweating was noted., Conclusions: More than 70% of patients presented with improved overall quality of life and improvement at the most prominent site of compensatory sweating. Long-term treatment was ineffective in less than 25% of patients, primarily because of the side effects of dry mouth and somnolence. Oxybutynin appears to be effective in treating bothersome CH., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The advances in endovascular surgery for treatment of aortic aneurysms have allowed a greater number of patients, who were previously considered unsuitable for the approach, to benefit from this therapeutic modality. Despite the current availability of highly comfortable endografts, cases with unfavorable anatomy remain a challenge for surgeons. We report a case with difficult anatomy that was successfully managed using an unconventional endovascular technique.

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 (CO2) 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 CO2 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: CO2 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 CO2, 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 CO2). There were no CO2-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 CO2 group and a decrease in ICM group, however, with no statistically significant difference between the delta clearance in each group. All CO2 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 CO2 group (P < 0.001)., Conclusions: The use of CO2 in patients with no restriction for ICM is an alternative that does not limit the feasibility of the procedures. Similar outcomes were observed with CO2 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., (Copyright © 2014 Elsevier Inc. All rights reserved.)

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., (Copyright © 2014 Elsevier Inc. All rights reserved.)

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., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: This retrospective study evaluated the results of sclerotherapy with low doses of ethanol for treatment of head and neck venous malformations., Methods: We treated 51 patients, 37 females. Median age was 23 years. Patients were treated with percutaneous intralesional injection of alcohol every two weeks and followed up prospectively for a median period of 18 months. Most lesions affected the face and cosmetic disfigurement was the most frequent complaint., Results: We performed a median of 7 sessions of sclerotherapy. Complete resolution or improvement was observed in 48 patients presented. Five cases of small skin ulceration, two cases of hyperpigmentation and two of paresthesia were documented; all of them were treated conservatively., Conclusion: Percutaneous sclerotherapy with low doses of ethanol is a safe and effective treatment modality for venous malformations affecting the head and neck.

The effects of oxybutynin for treating hyperhidrosis in children are still unknown. Therefore the aim of this study was to investigate the effects of oxybutynin on improving symptoms of hyperhidrosis and quality of life (QOL) in children with palmar hyperhidrosis (PH). Forty-five children ages 7-14 years with PH were evaluated 6 weeks after protocol treatment with oxybutynin. QOL was evaluated before and after treatment using a validated clinical questionnaire. More than 85% of the children with PH treated with oxybutynin experienced moderate or greater improvement in the level of sweating and 80% experienced improvement in QOL. Children who initially presented with very poor QOL were those who benefited most from oxybutynin therapy. Side effects occurred in 25 children (55.5%) and were mainly dry mouth. Only one patient had neurologic symptoms, which was reported as drowsiness. Oxybutynin is an effective treatment option for children with PH because it improves clinical symptoms and QOL. Further studies are required to determine the long-term outcomes of treatment with oxybutynin., (© 2013 Wiley Periodicals, Inc.)

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.

Objective: The aim of our study is to evaluate the incidence of asymptomatic pulmonary embolism (PE) in patients with deep venous thrombosis (DVT), submitted to routine angiography of pulmonary vessels, and analyze the relationship between the site of DVT and extent of PE., Methods: Between January 2006 and April 2012, 52 consecutive patients with acute inferior limb DVT were divided into two study groups composed of individuals with proximal and distal thrombotic involvement. All patients had no respiratory symptoms and were submitted to routine pulmonary computed tomography angiography for active investigation of PE. We assessed the incidence and extent of PE in both study groups., Results: Thirty-eight patients (72%) had PE, detected by computed tomography angiography. The incidence of PE in patients with proximal and distal thrombosis, respectively, was 72.7% and 73.7%. Occurrence of segmental embolism was equally high in both groups, affecting 71.4% of the patients with distal thrombosis and 66.6% of the individuals with proximal DVT (P > .99)., Conclusions: The incidence of asymptomatic PE observed in patients with DVT is higher than what is reported in the current literature. This supports the importance of screening and the need for high levels of suspicion regarding this complication., (Copyright © 2013 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Until the present moment, the lack of efficient therapeutic options available for hyperhidrosis treatment in obese patients has left this population without prospect of clinical or quality of life (QOL) improvements. Outcomes of oxybutynin treatment for overweight and obese patients with hyperhidrosis are unknown. This study aims to investigate the results related to clinical and QOL improvements in this specific population, submitted to a 12-week protocol treatment with oxybutynin., Methods: 559 patients with palmar and axillary hyperhidrosis, routinely followed in this service, were divided into the groups, according to their body mass index (BMI) (<25kg/m(2); 25 < BMI < 30kg/m(2), > 30kg/m(2)). Improvements in QOL and in the level of hyperhidrosis were analyzed after 12 weeks of protocol treatment with oxybutynin. These parameters were investigated using a scoring system based on a scientifically validated clinical questionnaire, applied before and after treatment., Results: 67.8% of the overweight sample group and 63% of the obese patients presented "partial" or "great" improvement in the level of hyperhidrosis. Over 65% of patients demonstrated improvement in QOL ("much better" or "slightly better") for all three groups, with no statistical difference between them. The only adverse event associated with oxybutynin was dry mouth, observed in 63.0% of the patients., Conclusion: Overweight and obese patients with palmar or axillary hyperhidrosis present significant improvement in QOL after treatment with oxybutynin, and the results are comparable to those of normal weight individuals., (Copyright © 2013 Elsevier Editora Ltda. All rights reserved.)

Objective: To assess the results of palmar and axillary hyperhidrosis treatment in males and females using low doses of oxybutynin., Methods: A retrospective analysis was conducted in 395 women and 170 men followed up in our service with complaint of palmar and axillary hyperhidrosis., Results: A total of 70% of patients in both groups presented partial or great improvement in the level of hyperhidrosis after treatment. The best results were obtained in the female group, in which 40% classified their improvement as "great". Approximately 70% of the patients in both groups improved their quality of life after medical therapy and 30% presented no change in condition., Conclusion: Gender is not a factor that significantly interferes in oxybutynin treatment results. Quality of life indices and clinical improvement level were similar in men and women.

Objective: To study the occurrence of adverse events after administration of a capsular polysaccharide vaccine against 23 pneumococcal serotypes in individuals for whom such vaccination is indicated., Methods: This was a prospective study, conducted in a general hospital in the city of Sumaré, in which 152 individuals were evaluated after intramuscular vaccination with 0.5 mL of the Pneumo 23 vaccine. The study variable was subject complaint of at least one symptom forming a temporal nexus with the vaccine (appearing within 48 h after its administration). The subjects were evaluated at five to seven days after vaccination. The covariables age, gender and clinical profile were tested using the chi-square test and multiple logistic regression, with the level of significance set at 5%., Results: The age of the population ranged from 5 to 86 years (mean, 61.8 years). For nearly all (99%) of the subjects, the vaccination evaluated was their first dose of the vaccine. Events occurring at the injection site were reported in 36 subjects (23.7%). Of those 36 events, 24 (68%) were mild and had no repercussions for the daily activities of the subjects. Pain at the site of the injection was the most common symptom, being reported by 97.2% of the subjects. Erythema and localized edema were found in 6.3% and 5.1% of the subjects, respectively. Of the subjects evaluated, 12.8% reported general symptoms (malaise, fever, sleepiness and generalized pain). In the bivariate analysis, none of the covariables were found to present a statistically significant correlation with adverse events (p > 0.20). The same held true in the multivariate analysis., Conclusion: Although, the 23-valent pneumococcal vaccine provokes few reactions in the first dose, it is still rarely recommended in the region, even for patients at risk.