RESUMO
BACKGROUND: In this article, we report the ultrasound aspects and recanalization rates of patients with deep venous thrombosis (DVT) in the lower limbs treated with the rivaroxaban, focusing on the recanalization rate and the ultrasonographic aspects. METHODS: This was a prospective and consecutive cohort study of patients admitted with DVT who were submitted to treatment with rivaroxaban for 6 months at the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil, between March 2016 and July 2018. RESULTS: Fifty-one patients with DVT were admitted to the Vascular Surgery Department and received rivaroxaban for 6 months. The follow-up time was 360 days. Analyses were performed at 180 and 360 days. The rate of total venous recanalization at 360 days was 76.4% (39 patients). The incidence of partial venous recanalization was 23.5% (12 patients). At the first month, 11 patients (21.7%) continued with total occlusion of the vein, with 4 patients (6.5%) with no residual thrombi. However, at 6 months, only 2 patients (2.2%) continued with total occlusion of the vein, with 26 patients (47.8%) with no residual thrombi. At 12 months, there were 39 patients (76.4%) with no residual thrombi. Univariate and multivariate logistic regression identified the following factors related to total venous recanalization: the absence of popliteal vein reflux (odds ratio [OR], 0.386; P = 0.007), no residual thrombi (OR, 3.213; P = 0.008), femoropopliteal clot length at 1 month (OR, 3.021; P = 0.016), femoropopliteal clot length at 6 months (OR, 2.234; P = 0.008). The incidence of post-thrombotic syndrome (PTS) at 12 months was 8.3%. CONCLUSIONS: In this study, patients who received oral rivaroxaban displayed satisfactory total vein recanalization rate after 6 months and 12 months. The factors associated with better total recanalization rates were the absence of popliteal vein reflux, the absence of residual thrombi in the veins, femoropopliteal clot length at 1 month (OR, 3.021; P = 0.016), and femoropopliteal clot length at 6 months (OR, 2.234; P = 0.008). Moreover, the incidence of PTS at 12 months was 8.3%.
Assuntos
Inibidores do Fator Xa/administração & dosagem , Extremidade Inferior/irrigação sanguínea , Rivaroxabana/administração & dosagem , Ultrassonografia de Intervenção , Grau de Desobstrução Vascular/efeitos dos fármacos , Veias/efeitos dos fármacos , Trombose Venosa/tratamento farmacológico , Administração Oral , Brasil/epidemiologia , Inibidores do Fator Xa/efeitos adversos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Síndrome Pós-Trombótica/diagnóstico por imagem , Síndrome Pós-Trombótica/epidemiologia , Síndrome Pós-Trombótica/fisiopatologia , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Rivaroxabana/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Veias/diagnóstico por imagem , Veias/fisiopatologia , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/epidemiologia , Trombose Venosa/fisiopatologiaRESUMO
BACKGROUND: Incomplete venous thrombolysis and residual nonstented iliac vein disease are known predictors of recurrent deep venous thrombosis (DVT). Controversy exists as to whether the number of thrombolysis sessions affects total stent treatment length or stent patency. The goal of this study was to evaluate the outcomes of patients who underwent single vs multiple catheter-directed lysis sessions with regard to stent extent and patency. METHODS: Consecutive patients who underwent thrombolysis and stenting for acute iliofemoral DVT between 2007 and 2018 were identified and divided into two groups on the basis of the number of treatments performed (one vs multiple sessions). Operative notes and venograms were reviewed to determine the number of lytic sessions performed and stent information, including size, location, total number, and length treated. End points included total stent length, 30-day and long-term patency, and post-thrombotic syndrome (Villalta score ≥5). The χ2 comparisons, logistic regression, and survival analysis were used to determine outcomes. RESULTS: There were 79 patients who underwent lysis and stenting (6 bilateral interventions; mean age, 45.9 ± 17 years; 48 female). Ten patients (12 limbs) underwent single-stage treatment with pharmacomechanical thrombolysis, and the remaining 69 (73 limbs) had two to four operating room sessions combining pharmacomechanical and catheter-directed thrombolysis. Patients who underwent a single-stage procedure were older and more likely to have a malignant disease. These patients received less tissue plasminogen activator compared with the multiple-stage group (17.2 ± 2.2 mg vs 27.6 ± 11.6 mg; P = .008). Average stent length was 8.8 ± 5.2 cm for the single-stage group vs 9.2 ± 4.6 cm for the multiple-stage group (P = .764). Patients who underwent a single-stage procedure had no difference in average length of stay from that of patients who underwent multiple sessions (8.5 days vs 5.9 days; P = .269). The overall 30-day rethrombosis rate was 7.3%. Two-year patency was 72.2% and 74.7% for the single and multiple stages, respectively (P = .909). The major predictors for loss of primary patency were previous DVT (hazard ratio [HR], 5.99; P = .020) and incomplete lysis (HR, 5.39; P = .014) but not number of procedures (HR, 0.957; P = .966). The overall post-thrombotic syndrome rate was 28.4% at 5 years and was also not associated with the number of treatment sessions. CONCLUSIONS: Single- vs multiple-stage thrombolysis for DVT is not associated with a difference in extent of stent coverage. Patency rates remain high for iliac stenting irrespective of the number of lytic sessions, provided lysis is complete and the diseased segments are appropriately stented.
Assuntos
Angioplastia com Balão/instrumentação , Cateterismo Periférico , Veia Femoral/efeitos dos fármacos , Fibrinolíticos/administração & dosagem , Veia Ilíaca/efeitos dos fármacos , Stents , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Grau de Desobstrução Vascular/efeitos dos fármacos , Trombose Venosa/tratamento farmacológico , Adulto , Angioplastia com Balão/efeitos adversos , Cateterismo Periférico/efeitos adversos , Feminino , Veia Femoral/diagnóstico por imagem , Veia Femoral/fisiopatologia , Fibrinolíticos/efeitos adversos , Fibrinolíticos/economia , Humanos , Veia Ilíaca/diagnóstico por imagem , Veia Ilíaca/fisiopatologia , Masculino , Pessoa de Meia-Idade , Síndrome Pós-Trombótica/etiologia , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/fisiopatologia , Adulto JovemRESUMO
BACKGROUND: In this article, we report the outcomes of patients with deep venous thrombosis in the lower limbs treated with the oral anticoagulant rivaroxaban or warfarin, focusing on the recanalization rate (measured with duplex ultrasound) and the incidence of postthrombotic syndrome. METHODS: This was a prospective, consecutive, randomized, blind cohort study of patients admitted with deep venous thrombosis to the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil, between March 2016 and July 2018. The patients were randomized into 2 groups and treated with oral anticoagulation for 6 months: either rivaroxaban (group 1) or warfarin (group 2). The study was registered at clinicaltrials.gov under NCT 02704598. RESULTS: Eighty-eight patients with deep venous thrombosis were admitted to the Vascular Surgery Department and randomized into the 2 groups. The follow-up time was 360 days. Analyses were performed at 180 and 360 days. Four patients were excluded from the study during follow-up because of a diagnosis of ovarian cancer (1 patient), head and neck cancer (1 patient), lung cancer (1 patient), and stomach cancer (1 patient). Therefore, 84 patients were evaluated: 46 patients in group 1 and 38 in group 2. The incidence of postthrombotic syndrome was 17.9% (15 cases) in the total cohort, but was significantly higher in group 2 (11 cases, 28.9%) than in group 1 (4 cases, 8.7%; P < .001; odds ratio, 4.278). The rate of total venous recanalization at 360 days was 40.5% (34 patients) in the total cohort, but was significantly higher in group 1 (35 patients, 76.1%) than in group 2 (5 patients, 13.2%; P < .001). The incidence of partial venous recanalization was 46.4% and was significantly higher in group 2 (28 patients, 73.7%) than in group 1 (11 patients, 23.9%; P = .016). Five patients in the total cohort (6%) showed no venous recanalization, all of them in group 2 (P = .016). CONCLUSION: In this study, patients who received oral rivaroxaban displayed a lower incidence of postthrombotic syndrome and a better total vein recanalization rate after 6 and 12 months than patients who received warfarin.
Assuntos
Anticoagulantes/administração & dosagem , Síndrome Pós-Trombótica/epidemiologia , Rivaroxabana/administração & dosagem , Grau de Desobstrução Vascular/efeitos dos fármacos , Trombose Venosa/tratamento farmacológico , Varfarina/administração & dosagem , Administração Oral , Brasil/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Extremidade Inferior , Masculino , Pessoa de Meia-Idade , Síndrome Pós-Trombótica/diagnóstico por imagem , Síndrome Pós-Trombótica/etiologia , Estudos Prospectivos , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Trombose Venosa/complicações , Trombose Venosa/diagnóstico por imagemRESUMO
Coronary artery bypass graft (CABG) is a consolidated treatment in patients with coronary artery disease (CAD) for both symptom control and improvement of prognosis. The patency of venous grafts is still the most vulnerable point of the surgical treatment since it presents a high prevalence of occlusion both in the immediate postoperative period and in the long-term follow-up. Aspirin plays a well-established role in this setting, and for a long time, clopidogrel use has been restricted to patients allergic to aspirin. Recently, subgroup analyses of studies with different anti-platelet therapies have shown reduced mortality and cardiovascular events in patients on dual anti-platelet antiplatelet therapy (DAPT) undergoing CABG, although such studies have not been designed to evaluate this patient profile. However, there is still an insufficient number of randomized studies using DAPT in this context, resulting in a disagreement between the European and American cardiology societies guidelines regarding their indication and generating doubts in clinical practice.
Assuntos
Ponte de Artéria Coronária/métodos , Oclusão de Enxerto Vascular/prevenção & controle , Inibidores da Agregação Plaquetária/uso terapêutico , Grau de Desobstrução Vascular/efeitos dos fármacos , Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/cirurgia , Humanos , Ticagrelor/uso terapêutico , Resultado do TratamentoRESUMO
SUMMARY Coronary artery bypass graft (CABG) is a consolidated treatment in patients with coronary artery disease (CAD) for both symptom control and improvement of prognosis. The patency of venous grafts is still the most vulnerable point of the surgical treatment since it presents a high prevalence of occlusion both in the immediate postoperative period and in the long-term follow-up. Aspirin plays a well-established role in this setting, and for a long time, clopidogrel use has been restricted to patients allergic to aspirin. Recently, subgroup analyses of studies with different anti-platelet therapies have shown reduced mortality and cardiovascular events in patients on dual anti-platelet antiplatelet therapy (DAPT) undergoing CABG, although such studies have not been designed to evaluate this patient profile. However, there is still an insufficient number of randomized studies using DAPT in this context, resulting in a disagreement between the European and American cardiology societies guidelines regarding their indication and generating doubts in clinical practice.
RESUMO A cirurgia de revascularização miocárdica (CRM) é tratamento fundamental em pacientes com doença arterial coronariana (DAC) tanto para controle de sintomas quanto para melhora do prognóstico. A patência dos enxertos venosos ainda hoje é o ponto mais vulnerável do tratamento cirúrgico, por apresentar alta prevalência de oclusão tanto no pós-operatório imediato como no seguimento em longo prazo. A aspirina tem papel bem estabelecido neste cenário e, por muito tempo, o uso do clopidogrel ficou restrito a pacientes alérgicos a aspirina. Recentemente, análises de subgrupos de estudos com diferentes terapias antiplaquetárias demonstraram redução de mortalidade e eventos cardiovasculares em pacientes em uso de dupla antiagregação plaquetária (Dapt) submetidos à CRM, ainda que tais estudos não tenham sido desenhados para avaliar este perfil de pacientes. Contudo, há ainda uma quantidade insuficiente de estudos randomizados com uso de Dapt nesse contexto, resultando em uma discordância entre as diretrizes europeia e americana de cardiologia quanto à sua indicação e gerando dúvidas na prática clínica.
Assuntos
Humanos , Grau de Desobstrução Vascular/efeitos dos fármacos , Inibidores da Agregação Plaquetária/uso terapêutico , Ponte de Artéria Coronária/métodos , Oclusão de Enxerto Vascular/prevenção & controle , Doença da Artéria Coronariana/cirurgia , Aspirina/uso terapêutico , Ponte de Artéria Coronária/efeitos adversos , Resultado do Tratamento , Clopidogrel/uso terapêutico , Ticagrelor/uso terapêuticoRESUMO
OBJECTIVES: To determine the indications for the use, potential benefits, and adverse reactions of alprostadil in a group of Colombian patients. METHODS: A retrospective cross-sectional study was conducted in patients diagnosed with critical limb ischemia who received alprostadil in five hospitals in Colombia between September 2011 and July 2017. We reviewed the clinical records of each patient to obtain the sociodemographic and pharmacological variables, clinical stages, complications, comorbidities, reported effectiveness and adverse reactions. RESULTS: Sixty-one patients treated with alprostadil were evaluated; 50.8% of patients were men, and the average age of 72.5 ± 10.7 years. A total of 86.9% of patients were hypertensive, and 65.6% were diabetic. A total of 77.0% presented ulceration, and this condition was considered as a diabetic foot in 57.4% of patients. A total of 81.9% of patients were classified as Fontaine stage 4; 60.7% received therapy as initially indicated, with an average of 19 days of alprostadil use. Regarding the therapy results, 58.0% of the patients with ulcers or trophic lesions showed improvement, 86.2% showed improvement of pain, and the limb was saved in 72.1% of patients. CONCLUSIONS: Critical limb ischemia was presented by patients with advanced age and high cardiovascular risk who were treated during severe and advanced stages where therapeutic options are limited. Treatment with alprostadil achieved satisfactory results with improvement in ulcers, pain, and limb salvage rates in this series of patients.
Assuntos
Alprostadil/administração & dosagem , Isquemia/tratamento farmacológico , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/tratamento farmacológico , Vasodilatadores/administração & dosagem , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Alprostadil/efeitos adversos , Colômbia , Estado Terminal , Estudos Transversais , Bases de Dados Factuais , Feminino , Humanos , Isquemia/diagnóstico , Isquemia/fisiopatologia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular/efeitos dos fármacos , Vasodilatadores/efeitos adversosRESUMO
Thrombosis of tunneled central venous catheters (CVC) in hemodialysis (HD) patients is common and it can lead to the elimination of vascular sites. This study aimed to evaluate the incidence of thrombotic obstruction of tunneled CVC in HD patients and the efficacy of occlusion treatment with alteplase use, and identify factors associated with thrombotic occlusion. It was a prospective cohort study performed in two centers which evaluated the diagnosis and treatment of thrombotic occlusion of CVC in HD patients for 24 consecutive months. The catheter occlusion was defined as the difficulty infusing or withdrawing fluid from their paths. Alteplase dose was infused to fill the lumen of the occluded catheter and remained for 50 min. As there was no obstruction of the catheter, the procedure was repeated. Three hundred and thirty-nine CVC in 247 patients were evaluated and followed, totalling 67,244 CVC-days. One hundred fifty-seven patients had only one CVC, 88 patients had two CVC during the study, and two patients had three CVC. The median age was 58 (47-66) years, patients were predominantly men (54%), with diabetic nephropathy as the main cause of chronic kidney disease (44%), the internal jugular vein as the main site of implantation (82%), and duration of dialysis before CVC implantation of 119 (41.5 to 585.5) days. Eight hundred and fifteen occlusion episodes were diagnosed (12 episodes/1000 CVC-days), with primary success with alteplase in 596 episodes (77%) and secondary in 81 cases (10%). In 99 episodes (13%), success was not achieved after the second dose of alteplase. Two hundred and thirty CVC were removed during the study and the removal causes were arteriovenous fistula use in 88 patients (38.3%), infectious and mechanical complications in 89 (38.7%) and 21 (9.1%), respectively, and others (transplantation, transfer, or death) in 32 patients (13.9%). Adverse effects were also not observed. In the multivariate analysis, we identified the greatest number of days with CVC (OR = 1.02, CI = 1.01-1.04, P = 0.004), the presence of diabetes (OR = 1.560, CI = 1.351-1.894, P = 0.015), and exit site infection (ESI) (OR = 1.567 CI = 1347-1926, P = 0.023) as factors associated with obstruction. Thrombotic occlusion showed frequent mechanical complication in CVC of HD patients. We observed 12 episodes of obstruction per 1000 CVC-days, with a high success rate after alteplase use (87%). In the multivariate analysis, the time with CVC, the presence of diabetes, and ESI were identified as variables associated with thrombotic obstruction.
Assuntos
Cateteres Venosos Centrais/efeitos adversos , Fibrinolíticos/uso terapêutico , Oclusão de Enxerto Vascular/tratamento farmacológico , Oclusão de Enxerto Vascular/etiologia , Diálise Renal/efeitos adversos , Trombose/tratamento farmacológico , Trombose/etiologia , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Grau de Desobstrução Vascular/efeitos dos fármacosRESUMO
Despite their propensity for significant infectious and mechanical complications, tunneled central venous catheters (CVCs) have become a common means of vascular access in the world for patients requiring chronic hemodialysis for end-stage renal disease. The objective of this study was to explore if cryopreserved solutions of the thrombolytic agent alteplase could be used as an effective, safe, and economically reasonable alternative in hemodialysis patients with occluded tunneled CVC. Patients requiring chronic hemodialysis and presenting with occluded tunneled CVC received a sufficient volume of the alteplase solution to fill the occluded catheter. To make alteplase economically feasible, it was diluted to 1-mg/mL aliquots and they were stored at -20°C until use. Eighty-one patients accounting for 179 attempted clearances were assessable for efficacy. One hundred forty-seven (82.1%) of the 179 catheter clearance attempts resulted in successful catheter clearance after one dose. Twenty-seven (15.1%) of all occluded CVCs were successful after two doses whereas five (2.8%) were not. No adverse events were reported. Cryopreserved 1-mg/mL aliquots of alteplase are safe and effective in the clearance of occluded CVC for hemodialysis patients.
Assuntos
Cateteres Venosos Centrais/efeitos adversos , Fibrinolíticos/uso terapêutico , Diálise Renal/instrumentação , Trombose/prevenção & controle , Ativador de Plasminogênio Tecidual/uso terapêutico , Grau de Desobstrução Vascular/efeitos dos fármacos , Idoso , Cateterismo Venoso Central/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
Mutalysin II (mut-II) is an alpha-fibrinogenase isolated from Lachesis muta muta (bushmaster) snake venom. The enzyme lyses fibrin clots in vitro, and this activity does not depend on plasminogen activation. The aim of this study was to assess by intravital microscopy the effect of Mutalysin II on the recanalization of microvessels after thrombus induction in the ears of hairless mice. Photochemical thrombus formation was induced after i.v. injection of 5% fluorescein isothiocyanate labelled dextran (FITC-dextran) followed by mercury light exposure of individual microvessels of the ear of five anesthetized animals. Video playback analysis of intravital microscopy images of the ear microcirculation permitted us to measure blood flow velocity (microm/s) under control conditions (before thrombus formation) in the ear microvessels. Thirty minutes after thrombus formation (blood flow velocity stopped completely), each animal (n=5) was infused with Mutalysin II (2.0 mg/kg, i.v.). All animals treated with Mutalysin II showed evident thrombolysis after approximately 12 min, followed by recanalization. A separate group of mice (n=5) which received urokinase type-plasminogen activator (u-PA, 250 U/mouse, i.v.) showed blood flow restoration within the same interval (12 min). These in vivo data suggest that Mutalysin II has the potential to be an effective thrombolytic agent.
Assuntos
Orelha Externa/irrigação sanguínea , Fibrinolíticos/farmacologia , Metaloendopeptidases/farmacologia , Microcirculação/efeitos dos fármacos , Trombose/tratamento farmacológico , Grau de Desobstrução Vascular/efeitos dos fármacos , Venenos de Víboras/farmacologia , Animais , Velocidade do Fluxo Sanguíneo/efeitos dos fármacos , Modelos Animais de Doenças , Feminino , Camundongos , Camundongos Pelados , Microcirculação/patologia , Microcirculação/fisiopatologia , Trombose/patologia , Trombose/fisiopatologia , ViperidaeRESUMO
Breast reconstruction after cancer treatment is based on the circulation of pedicle and microvascular flaps. This article aimed to verify the effect of tamoxifen (TMX) pretreatment in arterial anastomosis in rats. Twenty female Wistar rats were equally divided into two groups. TMX (0.3 mg/kg) was administered to the experimental group for 2 weeks orally. After this period, the right femoral artery was sectioned and a terminoterminal anastomosis performed. The same procedure was done in the control group, except that the animals received the vehicle without TMX. One week later, the femoral arteries were inspected for flow through the anastomosis, and the vessel near it was sent to light microscopic examination. It was observed mild vasculite in both groups. The intimal thickness and total vessel wall in the TMX-treated group was significantly higher. A real thrombotic effect upon the arterial vascular anastomosis was not observed, eventhough, TMX induced intimal hyperplasia.