Coagulação e fibrinólise: idéias atuais e suas aplicações clínicas

Nota: Trabalho da Disciplina de Cirurgia Vascular do Departamento de Clínica Cirúrgica da FMUSP. Neste número especial com artigos publicados na Revista de Medicina em 1969, traz um comentário dos Drs. Fernando Luiz Torres Gomes, José Humberto Pucci de Mesquita Filho, Carlos Serrano Jr.  (Departamento de Cardiologia da FMUSP)

Ferimentos arteriais associados a fraturas e luxações

Fifty one patients with arterial injuries associated with fractures and dislocations operated from 1984 January to 1986 June are review. It is emphasized the aspects of the precocius diagnosis of the arterial injuries, use of arteriography and realization of fasciotomy in the same operation, in order to obtain better results. It is showed too, the preference by the bypase of saphenous vein as the best arterial reconstruction, and the alternatives for the bone fixation. It hasbeen obtained in this series a preservation of extremity reate of 84,3%, and an amputation rate of 15,6%. The mortalitywas not implicated with the vascular procedures.Cinqüenta e um pacientes com ferimentos arteriais associados a fraturas e luxações, operados de janeiro de 1984 a junho de 1986 são revistos. São realçados os aspectos relativos ao diagnóstico precoce das lesões arteriais, uso de arteriografia e realização de fasciotomia no próprio ato cirúrgico, com o que se obtém uma melhora nos resultados. É evidenciada também a preferência pelo enxerto de veia safena como melhor (recor—- -~ jxaçãoóssea. Obtev (oxoxoxoxo)15,6%. A mortalidade não esteve relacionada com os procedimentos vasculares

Maintenance treatment of diabetic patients, associating arterial obstructive tibio-peroneal disease

When a melito-diabetic patient presents trophic infected injury on the limb, it is essential an evaluation of the circulatory conditions for therapeutic procedures orientation. In some circumstances, although arterial pulsation is absent, there is no ischemia of tissues. In these cases, the maintenance treatment, with eventual resection of the necrosed and infected tissues may be adopted. Evolution of 70 diabetic patients with trophic injuries on extremities were submitted to a maintenance treatment. Age of patients varied from 28 to 88 years, with an average of 56.8. The most occurrence was verified in women, with 42 cases. Diabetes non-dependant on insuline (type II) was observed in 64 patients (91.5%), being the remaining 6 patients of type I. Diabetic retinopathy was observed in 14 (20%) of the patients, neuropathy in 22 (31%) and nephropathy in 8 patients (11.4%). All the patients presented arterial pulsation until the popliteal region. They were divided in 2 groups, considering trunk arteries of legs: Group I, pervial legs arteries, composed by 48 patients; Group II, occluded legs arteries, with 22 patients. In what refers to the anatomic local of the injuries, patients were classified in three groups: Group A, formed by 32 patients (45.7%), presenting injuries in one or two toes only, without affecting the metatarsic region; Group B, formed by 16 patients (22.9%), trophic injuries affecting the metatarsic region and Group C, formed by 22 patients (31.4%), injuries affecting the calcaneous region. Injuries in both of the groups were caused by mechanical traumatism. Duration of the injury in the inferior member varied from 7 to 48 days, resulting in a 12 days average. Analyzing pervicacity in trunk arterias and evolution of patients, it may be observed that there has been a significantly better result in those with all the pulses present (81.3% x 45.5%)(p0,05)(Table IV)

Trauma to arteries of the forearm

Trauma to arteries of the forearm corresponds to 20% of total arterial trauma. The authors analyzed 24 patients with non iatrogenic trauma of the forearm arteries, cared for from January 1987 to December 1990. All patients were male, trauma by penetrating instrument was the most frequent, with 21 cases (87.5%), absence of pulses was the most frequent clinical manifestation (62.5%), fifteen patients did not present ischemic manifestations (54.2%) and half of the patients did not exhibit neurological symptoms. Injury to only one artery was found in 11 cases, five of them in the radial artery (20.8%), five in the ulnar artery (20.8%) and one in the interosseous artery (4.2%). Concurrent injury to the radial and ulnar arteries was found in 13 cases (54.1%). Regarding nervous impairment, injury to the radial nerve was found in four cases (16.6%) and of the median and ulnar nerves, one case in each (4.1%). All patients with concurrent injury to the ulnar and radial arteries (13) were submitted to arterial restoration. The 11 patients with injury to a sole artery of the forearm were managed as follows: ligature of the interosseous artery in one case, ligature of the radial artery in four cases, raphe of the radial artery in one case, ligature of the ulnar artery in three cases, restoration of the ulnar artery using a segment of the v. saphena in the two cases in which the Allen test had been positive. One patient died in the immediate postoperative period as a result of multiple organ failure due to polytraumatism. Preservation of the member was attained in 23 patients (95.8%) and the sole amputation, was due to extensive traumatism of the soft tissues with severe infection and systemic impairment

Surgical treatment of noniatrogenic trauma of the femoral arteries

Trauma to the femoral arteries corresponds to 30 percent of all arterial traumas. The authors reviewed 74 patients with noniatrogenic trauma of the femoral arteries treated from January 1991 to December 1993. Ages ranged from 11 to 50 years, with a mean of 24. Seventy-one patients were male and three female. Fifty-two patients (70.2 percent) were white, 20 (27 percent) were black and two (2.8 percent) were Asian. Trauma due to firearms had the highest incidence, with 61 cases (82.4 percent). Absence of pulse was the most frequent clinical symptom (62.5 percent). Severe ischemia, with risk of loss of limb, was found in 66.2 percent of the cases. The superficial femoral artery was impaired in 77 percent of the cases. A preoperative arteriography was performed on only five patients, victims of multiple penetrating trauma or an asymptomatic penetrating wound along a vessel passage. In six cases, arterial and venous ligature was the chosen procedure. In three cases, a primary arterial anantomosis was performed. Simple arterriorraphy was feasible in one patient. In 64 of the patients, a venous graft was undertaken using a segment of the inverted great saphenous vein withdrawn from the other lower limb. Fasciotomoy was used in 32 patients (43.2 percent), all of whom exhibited pasting of the lower limb muscles at admission. One patient died during the immediate postoperative period as the result of multiple organ failure caused by polytraumatism. Preservation of the limb was attained in 72 patients (97.3 percent) Severe, previously-incurred ischemia was responsible for the only two amputations, aggravated by an exceedingly long delay between the time of injury and surgery. One of these patients, in addition to severe ischemia, had extensive injuries to the soft tissues. We conclude that trauma of the femoral arteries, attended while the limb still maintains its vitality, has a positive clinical outcome with a high rate of limb preservation. Mortality usually results from injury to other organs

Arterite subcutânea por micobactéria

The authors report three patients with subcutaneous erythematous nodules in different phases of development, inespecific systemic symptoms, positive PPD test, and normal chest X-rays. The histopathological study of the older nodules showed a granulomatous arteritis with a few acid-fast bacilli in the vascular wall. The nodules at an early phase showed an inespecific panniculitis with some acid-fast bacilli in apparently normal cutaneous vessels. These findings suggest that the mycobacterium has a vascular tropism and may cause a primary granulomatous arteritis.Os autores descrevem três casos de pacientes com nódulos subcutâneos em diferentes fases de evolução, com sintomas sistêmicos inespe-cíficos, PPD positivo e raio-X de tórax normal. O estudo anátomo-patológico dos nódulos antigos mostrou arterite granulomatosa e com raros bacilos álcool-ácido resistentes na parede vascular; os nódulos recentes mostraram paniculite inespecífica com alguns bacilos álcool-ácido resistentes na parede de vasos cutâneos aparentemente normais. Esses achados sugerem que a micobactéria tem um tropismo vascular e pode causar arterite granulomatosa