Filtros de veia cava inferior em pacientes com câncer: experiência em 50 casos

OBJECTIVE: To study the immediate and late results obtained from the implantation of vena cava filters in cancer patients with deep vein thrombosis concomitant with neoplasia. METHODS: This was a retrospective evaluation of 50 patients with an association of cancer and deep venous thrombosis who underwent interruption of the inferior vena cava and the insertion of permanent vena cava filters. The indications for the procedure, filter implantation technique, early and late complications related to the operation, and the clinical evolution were evaluated. RESULTS: The most frequent indication for filter implantation was the contraindication for full anticoagulant treatment (80%). The femoral vein was the preferred access route (86% of the patients). There were no complications related to the surgical procedure. During the follow-up, the following complications were observed: 1 episode of nonfatal pulmonary thromboembolism, 2 cases of occlusion of the inferior vena cava, and 1 case of thrombus retained in the device. Twenty patients (40%) died due to progression of the neoplasm. CONCLUSIONS: Interruption of the inferior cava vein using an endoluminal filter is a procedure with a low rate of complications. It is a safe and efficient measure for preventing pulmonary embolism in cancer patients who have deep vein thrombosis of the lower limbs.OBJETIVO: Estudar os resultados imediatos e tardios obtidos com a implantação de filtros de veia cava inferior em pacientes com trombose venosa profunda concomitante a neoplasia. MÉTODOS: Avaliamos retrospectivamente 50 pacientes com câncer e trombose venosa profunda associada submetidos a interrupção de veia cava inferior com filtros intraluminais definitivos. Foram estudados aspectos referentes à indicação do procedimento, à técnica de implante dos dispositivos, complicações precoces e tardias relacionadas à operação e à evolução dos pacientes. RESULTADOS: A indicação mais freqüente para o procedimento foi a impossibilidade de anticoagulação plena (80% ) e a via de acesso preferencial foi a punção da veia femoral, realizada em 86% dos pacientes. Não houve complicações relativas ao implante dos filtros. Durante a evolução ocorreram: um episódio de tromboembolia pulmonar não fatal e dois casos de oclusão da veia cava inferior; em um paciente foi demonstrada a presença de coágulo retido no dispositivo. Vinte pacientes (40%) faleceram devido à neoplasia. CONCLUSÃO: A interrupção da veia cava inferior com filtro endoluminal é um procedimento com baixo índice de complicações e eficaz na prevenção da embolia pulmonar nos pacientes com tromobose venosa profunda de membros inferiores portadores de câncer

Uso de "stents" no tratamento de lesões arteriais intimas de origem traumática: relato de caso

O tratamento de lesões arteriais íntimais de origem traumática é controversa pela sua evolução natural ser desconhecida. As opções terapêuticas atuais incluem reconstrução arterial e observação clínica. A idéia da utilização de "stents" para a correção de descolamentos intimais é baseada no seu uso em dissecções, "flaps" e irregularidades da artéria após angioplastia com balão. Descrevemos o tratamento bem sucedido de um descolamento de íntima da artéria femoral superficial causado por ferimento de arma de fogo com a utilização de um "stent" de Palmaz na fase aguda. Um ano após a implantação do "stent", o duplex scan mostrou fluxo normal pela artéria com a exclusão completa do descolamento de íntima, com pulsos distais palpáveis e com o paciente completamente assintomático.Treatment of arterial traumatic intimal lesions is controversial due to its unknown natural history. Current therapeutical options include arterial reconstruction and clinical observation. The idea of using stents to correct intimal flaps is based on their use to correct dissections, flaps, and arterial irregularities after angioplasty. We report the successful treatment of a traumatic intimal flap of the superficial femoral artery, caused by gunshot trauma, with a Palmaz stent in the acute period. One year after the operation, a duplex scan revealed normal flow in the artery and complete exclusion of the intimal flap; distal pulses were palpable, and the patient was completely asymptomatic

Reconstruções arteriais associadas à ressecção de tumores malignos

OBJECTIVE: When trunk arteries are affected by malignant neoplasia, and surgical treatment involving tumor and arterial resection is used, the vascular reconstruction must be performed immediately to avoid ischemia in the brain and large tissue masses. The objective of this study was to analyze the results obtained with the treatment of patients with malignant neoplasia who underwent tumor and vascular resection associated with arterial reconstruction. The primary patency of reconstructions, the occurrence arterial complications, and patient survival were assessed. METHODS: Thirty-six patients with cervical, abdominal, or lower limb neoplasias were followed up. These patients underwent elective operations at Hospital do Câncer A.C. Camargo, São Paulo, between September 1997 and September 2004. They were divided into 3 groups according to tumor location: Cervical (14), lower limbs (13), and Abdomen (9). Thirty-eight arterial reconstructions were performed in these 36 patients. RESULTS: There were 5 arterial complications: 2 early- and 3 late-stage. The early complications consisted of 1 symptomatic carotid occlusion with sequelae and 1 femoral graft rupture without sequelae. The late-stage complications consisted of 1 symptomatic carotid occlusion, 1 occlusion of an axillary-carotid graft, and 1 occlusion of a branch of the aortobifemoral graft, all without sequelae. There was no difference between the primary arterial patency rates. All the deaths (22) resulted from progression of neoplasic disease. CONCLUSIONS: Arterial reconstructions associated with resection of malignant neoplasia in cervical, abdominal, or lower limbs can be carried out with low rates of morbidity and mortality. There was no difference in the primary arterial patency rates among the groups studied.OBJETIVO: Quando há acometimento de artérias tronculares por neoplasias malignas e o tratamento cirúrgico é empregado para realização de ressecções tumoral e arterial, a reconstrução vascular deve ser imediata, para evitar a isquemia de tecidos nobres. O objetivo desse trabalho é analisar os resultados do tratamento de pacientes portadores de neoplasias malignas submetidos a ressecções tumoral e vascular associada à reconstrução arterial, avaliando a perviedade primária das reconstruções, as complicações arteriais e a sobrevida dos pacientes. MÉTODOS: Foram acompanhados 36 pacientes com neoplasias em regiões cervical, abdominal ou extremidades inferiores, operados eletivamente no período de setembro de 1997 a setembro de 2004 no Hospital do Câncer A.C.Camargo em São Paulo. Os pacientes foram divididos em três grupos de acordo com a localização das neoplasias: Cervical (14), Extremidade (13) e Abdome (9). Foram realizadas 38 reconstruções arteriais nos 36 pacientes. RESULTADOS: Houve cinco complicações arteriais, sendo duas precoces e três tardias. Entre as precoces, houve uma oclusão carotídea sintomática com seqüelas e uma rotura de enxerto femoral sem seqüelas. Entre as tardias, houve uma oclusão carotídea sintomática, uma oclusão de enxerto carotídeo-axilar e uma oclusão de ramo de enxerto aorto-bifemoral, todas sem sequelas. Não houve diferença entre os índices de perviedade arterial primária . Todos os óbitos (22) ocorreram devido à evolução da doença neoplásica. CONCLUSÕES: As reconstruções arteriais associadas à ressecção de neoplasias malignas em segmentos cervical, abdominal ou extremidades inferiores podem ser realizadas com baixos índices de morbi-mortalidade. Não houve diferença entre os índices de perviedade primária das reconstruções

Outpatient percutaneous treatment of deep venous malformations using pure ethanol at low doses under local anesthesia

INTRODUCTION: Venous malformations are the most frequent vascular malformation. Deep venous malformations are located in subcutaneous tissue or in the muscles. Percutaneous sclerotherapy is the treatment of choice, and the use of ethanol at low doses has not yet been described. OBJECTIVE: To analyze the results of treating Deep venous malformations patients with low doses of ethanol. METHODS: Thirty-nine patients treated between July 1995 and June 2007 were followed up prospectively over a median period of 18 months. Twenty-nine were female (74.4%) and 10 were male (25.6%), with ages ranging from 11 to 59 years (median of 24 years). All of the lesions affected limbs, and the main symptom reported was pain (97.4%). Each patient underwent fortnightly alcohol application sessions under local anesthesia on an outpatient basis. The lesions were classified into three groups according to size using nuclear magnetic resonance imaging: small, up to 3 cm (4 patients); medium, between 3 and 15 cm (27 patients); and large, greater than 15 cm (8 patients). RESULTS: The symptoms completely disappeared in 14 patients (35.9%) and improved in 24 (61.5%). The lesion size reduced to zero in 6 patients (15.4%) and decreased in 32 (82%). The median number of sessions was 7. There were no complications in 32 patients (82%), while 3 presented local paresthesia (7.7%), 2 superficial trombophlebites (5.1%), 1 skin ulcer (2.6%), and 1 case of hyperpigmentation (2.6%). CONCLUSION: Outpatient treatment for Deep venous malformations patients using ethanol at low doses was effective, with a low complication rate

Isolated limb perfusion with hyperthermia and chemotherapy: predictive factors for regional toxicity

OBJECTIVE: Isolated limb perfusion combined with melphalan is an accepted treatment for obtaining locoregional control in advanced melanoma of the extremities and other malignant neoplasias restricted to the limb. This study aims to examine the factors associated with toxicity caused by the regional method. We considered the technical aspects of severe complications associated with the procedure in an attempt to diminish the patient morbidity that occurs during the learning curve. METHODS: We conducted a retrospective analysis of the records of patients who underwent perfusion at the AC Camargo Hospital in São Paulo, Brazil between January 2000 and January 2009. The Wieberdink scale was applied to classify local toxicity and its relation to clinical and laboratory variables. RESULTS: Fifty-eight perfusions were performed in 55 patients. Most patients (86.2%) presented a toxicity level between I and III. Grade V toxicity was seen in five cases (8.6%), four of which occurred in the first 2 years. Creatine phosphokinase, an important predictive factor for toxicity, had an average value of 231.8 for toxicity grades I-III and 1286.2 for toxicity grades IV-V (p = 0.001). There was a relationship between the melphalan dose and toxicity, which was 77 mg (25 to 130 mg) for toxicity grades I-II and 93.5 mg (45 to 120 mg) for toxicity grades IV-V (p = 0.0204). CONCLUSION: It is possible to prevent the toxicity associated with melphalan by adjusting the dose according to the patient's body weight (especially for women and obese patients) and the creatine phosphokinase values in the postoperative period

Arterial reconstructions in patients undergoing resection of neoplasia with vascular involvement

INTRODUÇÃO: O acometimento de artérias ou veias tronculares periféricas por neoplasias malignas é raro. Quando o tratamento cirúrgico é realizado sendo constatado o acometimento arterial pela neoplasia, a melhor conduta é a ressecção conjunta seguida de reconstrução arterial imediata, restabelecendo o eixo vascular e evitando a isquemia de tecidos nobres com suas possíveis conseqüências. OBJETIVOS: O objetivo desse trabalho é analisar os resultados do tratamento cirúrgico de pacientes portadores de neoplasias malignas, submetidos a ressecções tumoral e vascular associadas à reconstrução vascular, avaliando principalmente a morbidade, a mortalidade e a perviedade primária relacionadas às reconstruções arteriais. MÉTODOS: Foram acompanhados os pacientes portadores de neoplasias malignas em regiões cervical, abdominal ou extremidades inferiores, operados eletivamente no período de setembro de 1997 a setembro de 2004 no Hospital do Câncer A.C.Camargo em São Paulo, submetidos à ressecções tumoral e vascular associadas à reconstrução arterial (associada ou não à reconstrução venosa de segmento venoso ressecado no mesmo feixe). O seguimento vascular foi em ambiente ambulatorial, realizando-se exame clínico vascular e exames de imagem para o acompanhamento das reconstruções. Foram analisadas: as características clínicas dos pacientes, as reconstruções vasculares, as complicações vasculares e não vasculares precoces (até 30 dias); as complicações vasculares e não vasculares tardias (após 30 dias), a perviedade primária das reconstruções arteriais e a sobrevida dos pacientes. RESULTADOS: foram operados 36 pacientes, sendo divididos em grupos de acordo com a localização das neoplasias: Cervical (14), Extremidade (13) e Abdome (9). No grupo Cervical, foram realizadas 17 reconstruções (16 arteriais e 1 venosa) nos 14 pacientes, predominantemente com a veia safena. Houve uma oclusão sintomática precoce do enxerto carotídeo com seqüelas importantes e uma oclusão sintomática tardia de enxerto carotídeo sem seqüelas (esse paciente também apresentou oclusão de enxerto arterial para o membro superior sem isquemia grave). No grupo Extremidade, foram realizadas 23 reconstruções (13 arteriais e 10 venosas) nos 13 pacientes, predominantemente com a safena. Houve uma rotura precoce de enxerto arterial femoral, tratada por meio de ligadura e evoluindo sem seqüelas. No grupo Abdome, foram realizadas 13 reconstruções (9 arteriais e 4 venosas) nos 9 pacientes, predominantemente com prótese. Uma paciente apresentou oclusão tardia sintomática de ramo do enxerto aorto-bifemoral, sendo realizado enxerto femoral cruzado, evoluindo sem seqüelas. Não houve diferença estatística entre os índices de perviedade arterial primária entre os grupos (p=0,593). Em relação às reconstruções venosas, houve cinco oclusões sintomáticas. O tempo de seguimento mediano nos grupos Cervical, Extremidade e Abdome foi respectivamente de 11,5, 25 e 18 meses, sendo significantemente menor no grupo Cervical (p=0,034). Houve duas amputações de membro não relacionados às complicações dos enxertos. Não houve óbitos no período intra-hospitalar, sendo todos decorrentes da evolução da doença neoplásica (11 do grupo Cervical, 8 do Extremidade e 3 do Abdome). CONCLUSÕES: 1. as reconstruções arteriais associadas à ressecção de tumores malignos com acometimento arterial em segmentos cervical, abdominal ou extremidades inferiores podem ser realizadas com baixos índices de morbi-mortalidade; 2. não houve diferença entre os índices de perviedade primária das reconstruções arteriais realizadas nos grupos estudadosINTRODUCTION: Arteries or peripheral truncular veins are rarely affected by malignant neoplasias. When arteries affected by neoplasia are observed during surgical treatment, the best approach is in bloc resection followed immediately by arterial reconstruction to reestablish the vascular axis and avoid ischemia of important tissues with the possible consequences. OBJECTIVES: The objectives of this study were to analyze the surgical treatment results from patients with malignant neoplasias who underwent tumor and vascular resection associated with vascular reconstruction and, in particular, to evaluate morbidity, mortality and primary patency relating to arterial reconstruction. METHODS: Patients with malignant neoplasias in the cervical, abdominal or lower extremity regions who underwent elective surgery between September 1997 and September 2004 at Hospital do Câncer A.C. Camargo, São Paulo, were followed up. These patients underwent tumor and vascular resections associated with arterial reconstruction (with or without reconstruction of the venous segment resected in the same bundle). The vascular follow-up was in an outpatient environment, through clinical vascular examination and imaging examinations to monitor the reconstructions. The patients\' clinical characteristics, vascular reconstructions, early vascular and non-vascular complications (within 30 days), late vascular and non-vascular complications (beyond 30 days), primary patency of arterial reconstructions and survival were analyzed. RESULTS: Thirty-six patients underwent surgery and were grouped according to neoplasia location: Cervical (14), Extremity (13) and Abdomen (9). In the Cervical group, 17 reconstructions were performed (16 arterial and 1 venous) in 14 patients, predominantly using the saphenous vein. There were one early symptomatic occlusion of the carotid graft with significant sequelae and one late symptomatic occlusion of the carotid graft without sequelae (this patient also presented arterial graft occlusion to the upper limb, without severe ischemia). In the Extremity group, 23 reconstructions were performed (13 arterial and 10 venous) in 13 patients, predominantly using the saphenous vein. There was one early rupture of a femoral arterial graft, with treatment by means of ligature and evolution without sequelae. In the Abdomen group, 13 reconstructions were performed (9 arterial and 4 venous) in 9 patients, predominantly using a prosthesis. One patient presented a late symptomatic occlusion in a branch of the aortobifemoral graft, for which a femoral crossover graft was performed, which evolved without sequelae. There was no statistical difference in primary arterial patency rates between the groups (p=0,593). Five symptomatic occlusions relating to venous reconstructions occurred. The median follow-up for the Cervical, Extremity and Abdomen groups were 11,5, 25 and 18 months, respectively: significantly shorter in the Cervical group (p=0,034). There were two limb amputations, unrelated to graft complications. There were no deaths while in hospital. Deaths occurred only as a result of neoplastic disease evolution (11 Cervical, 8 Extremity and 3 Abdomen patients). CONCLUSIONS: 1. arterial reconstructions associated with resection of malignant tumors affecting arteries in the cervical, abdominal or lower extremity segments can be performed with low morbidity-mortality rates; 2. there is no difference between primary patency rates of the arterial reconstructions performed, regarding the groups studie

Use of arteriography for the initial evaluation of patients with intermittent lower limb claudication

CONTEXT: Many patients with intermittent claudication continue to be forwarded to the vascular surgeon for initial evaluation after arteriography has already been accomplished. OBJECTIVE: The main objective of this work was to analyze the usefulness and the need for this procedure. TYPE OF STUDY: Retrospective study. SETTING: The patients were divided into two groups: Group 1, with the arteriography already performed and Group 2 without the initial arteriography. PARTICIPANTS: One hundred patients with intermittent claudication were retrospectively studied. Other specialists had forwarded them for the first evaluation of intermittent claudication, without any previous treatment. MAIN MEASUREMENTS: All patients were treated clinically for at least a 6-month period. The total number of arteriographies performed in the two groups was compared and the need and usefulness of the initial arteriography (of Group 1) was also analyzed. RESULTS: The evolution was similar for both groups. The total number of arteriographies was significantly higher in Group 1 (Group 1 with 53 arteriographies vs. Group 2 with 7 arteriographies). For this group, it was found that arteriography was only useful in five cases (10%), because the surgeries were based on their findings. However, even in those cases, no need for arteriography was observed, as the procedure could have been performed at the time of surgical indication. CONCLUSION: There are no indications for arteriography in the early evaluation of patients with intermittent claudication, because it does not modify the initial therapy, independent of its result. In cases where surgical treatment is indicated, this procedure should only be performed prior to surgery

Use of arteriography for the initial evaluation of patients with intermittent lower limb claudication

CONTEXT: Many patients with intermittent claudication continue to be forwarded to the vascular surgeon for initial evaluation after arteriography has already been accomplished. OBJECTIVE: The main objective of this work was to analyze the usefulness and the need for this procedure. TYPE OF STUDY: Retrospective study. SETTING: The patients were divided into two groups: Group 1, with the arteriography already performed and Group 2 without the initial arteriography. PARTICIPANTS: One hundred patients with intermittent claudication were retrospectively studied. Other specialists had forwarded them for the first evaluation of intermittent claudication, without any previous treatment. MAIN MEASUREMENTS: All patients were treated clinically for at least a 6-month period. The total number of arteriographies performed in the two groups was compared and the need and usefulness of the initial arteriography (of Group 1) was also analyzed. RESULTS: The evolution was similar for both groups. The total number of arteriographies was significantly higher in Group 1 (Group 1 with 53 arteriographies vs. Group 2 with 7 arteriographies). For this group, it was found that arteriography was only useful in five cases (10%), because the surgeries were based on their findings. However, even in those cases, no need for arteriography was observed, as the procedure could have been performed at the time of surgical indication. CONCLUSION: There are no indications for arteriography in the early evaluation of patients with intermittent claudication, because it does not modify the initial therapy, independent of its result. In cases where surgical treatment is indicated, this procedure should only be performed prior to surgery

Vena cava filters in cancer patients: experience with 50 patients

OBJECTIVE: To study the immediate and late results obtained from the implantation of vena cava filters in cancer patients with deep vein thrombosis concomitant with neoplasia. METHODS: This was a retrospective evaluation of 50 patients with an association of cancer and deep venous thrombosis who underwent interruption of the inferior vena cava and the insertion of permanent vena cava filters. The indications for the procedure, filter implantation technique, early and late complications related to the operation, and the clinical evolution were evaluated. RESULTS: The most frequent indication for filter implantation was the contraindication for full anticoagulant treatment (80%). The femoral vein was the preferred access route (86% of the patients). There were no complications related to the surgical procedure. During the follow-up, the following complications were observed: 1 episode of nonfatal pulmonary thromboembolism, 2 cases of occlusion of the inferior vena cava, and 1 case of thrombus retained in the device. Twenty patients (40%) died due to progression of the neoplasm. CONCLUSIONS: Interruption of the inferior cava vein using an endoluminal filter is a procedure with a low rate of complications. It is a safe and efficient measure for preventing pulmonary embolism in cancer patients who have deep vein thrombosis of the lower limbs

Idiopathic aneurysm of inferior vena cava associated with retroperitoneal ganglioneuroma: Case report

AbstractIdiopathic aneurysm of the inferior vena cava is rare. Many aneurysms are asymptomatic; others are diagnosed after complications develop. Ganglioneuroma is an infrequently occurring benign tumor preferentially located in the mediastinum and retroperitoneum. Generally the clinical manifestations are symptoms of compression related to growth of the mass. We present a case report of idiopathic aneurysm of the inferior vena cava associated with retroperitoneal ganglioneuroma. The tumor was resected in combination with a procedure to correct the aneurysm that has not previously been described, ie, tangential resection and primary lateral venorrhaphy. The technique provided excellent short-term results. (J Vasc Surg 2003;37:895-8.