Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 6 uppsatser.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Anaesthesia Johannesburg, April 2013 / BACKGROUND: Once lauded as one of the most valuable interventions across all fields of contemporary medicine, perioperative beta blockade (PBB) is a practice that has come under intense scrutiny. Publication of the PeriOperative ISchemic Evaluation (POISE) study forced a modification of recommendations for PBB in consensus guidelines. Practice in South Africa has not been previously reported. OBJECTIVES: The primary objective of this study was to describe current intended practice, with respect to PBB, in patients undergoing major vascular surgery at South African specialist training facilities. Secondary objectives were describing participant satisfaction with current strategy, reporting suggested modifications to clinician responsibilities in the future, and identifying potential barriers to the intervention. METHOD: One anaesthesiologist and one vascular surgeon from each of the seven recognised training facilities for vascular surgery in South Africa were included in a partially selective observational survey. Data was generated by the use of a semi-structured questionnaire specifically developed to address the objectives of the study. RESULTS: The POISE study results and updated international consensus guidelines had not prompted a change in approach at most facilities. There was inconsistency in methods of risk stratification, treatment implementation, titration practices, and the timing of withdrawal of medication. Anaesthesiologist and vascular surgeon opinion on current intended practice correlated poorly. Opinions correlated least well at facilities where both clinicians claimed responsibility for PBB, implying that communication may be a problem. Similarities, where they did occur, were in keeping with recommendations that are widely supported in the literature. Less than half of the participants were satisfied with current practice. The involvement of the anaesthesiologists in the perioperative management of vascular surgery patients was less than reported in other countries. The participants supported a major role for anaesthesiologists in the future, and a move towards multidisciplinary involvement in policy development and patient management. The need for appropriate monitoring was identified as one of many important barriers. CONCLUSIONS: This study describes current intended practice at South African training facilities for vascular surgery. The variable practice across the country; the poor correlation of participant responses; widespread dissatisfaction with current strategy; suggested changes to clinician responsibilities; and the identification of multiple barriers to the implementation of strategy, highlight the need for review at all facilities. Further research is needed, since the optimal strategy for reducing risk in patients undergoing vascular surgery remains elusive.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. / Objective The objective of this study was to investigate the effect of preoperative diastolic dysfunction on postoperative mortality and morbidity after cardiovascular surgery. Methods We systematically searched for articles that assessed the prognostic role of diastolic dysfunction on cardiovascular surgery in PubMed, Cochrane Library, Web of Science, Embase and Scopus until February 2016. Twelve studies (n=8224) met our inclusion criteria. Due to scarcity of outcome events, fixed-effects meta-analysis was performed using the Mantel-Haenszel method. Results Preoperative diagnosis of diastolic dysfunction was associated with higher postoperative mortality (OR 2.41, 95% CI 1.54-3.71; p<0.0001), major adverse cardiac events (MACE) (OR 2.07, 95% CI 1.55-2.78; p <=0.0001) and prolonged mechanical ventilation (OR 2.08, 95% CI 1.04-4.16; p=0.04) in comparison to patients without diastolic dysfunction among patients who underwent cardiovascular surgery. The odds of postoperative myocardial infarction (OR: 1.29, 95% CI 0.82, 2.05; p=0.28) and atrial fibrillation (OR: 2.67; 95% CI 0.49-14.43; p=0.25) did not significantly differ between the two groups. Severity of preoperative diastolic dysfunction was associated with increased postoperative mortality (OR 21.22, 95% CI 3.74 -120.33; p=0.0006) for Grade 3 diastolic dysfunction compared with patients with normal diastolic function. Inclusion of left ventricular ejection fraction (LVEF) <40% accompanying diastolic dysfunction, did not further impact postoperative mortality (p=0.27; I2 =18%) when compared with patients with normal LVEF and diastolic dysfunction. Conclusions Presence of preoperative diastolic dysfunction was associated with higher postoperative mortality and MACE, regardless of LVEF. Mortality was significantly higher in grade III diastolic dysfunction. Keywords Diastolic dysfunction; cardiovascular surgical procedures; mortality; meta-analysis / Revisión por pares

O objetivo deste estudo foi avaliar o prognostico de portadores de insuficiência cardíacadoe diferentes etiologias, incluindo a Doença de Chagas, na década de noventa ern uma unica intituição. Foram avaliados 1 220 pacientes portadores de insuficiência cardíaca encaminhados para avaliação de tratamento cirúrgico, acompanhados por período de 25,6+- 26 meses. As idades variavarn entre 13 e 72 anos (45,5 +- 11 anos); 952 (78%) pacientes eram do sexo masculino e 268 (22%) do feminino.A insuficiência cardíaca foi considerada idiopática em 454 (37,2%) doentes. A etiologia da insuficiência cardiaca foi a Doença de Chagas em 242 (19,8%) pacientes, a isquemia em 121 (17,4%) a hipertensiva em 170 (13,9%) e outras etiologias em 142 (11,7%). O tratamento medicamentoso padrão incluiu os inibidordes da enzimaa conversora da anqiotensma. Depois da análise exploratória Inicial, foi realizada análise de sobrevivência, pelo método de Kaplan Meier para cada variável clínica observada. Em seguida, realizaram-se análises dos riscos proporcionais pelo método de Regressão de Cox univariada e multivariada para avaliar o proqnostico por meio de variáveis clínicas não invasivas por meio de variáveis clínicas não invasivas (modelo não invasivo) e variáveis obtidas do cateterismo cardíaco direito (modelo invasivo). Quatrocentos e vinte e cinco (34,8%) pacientes morreram na evolução 74 (6,1 %) foram submetidos a transplante cardíaco e 28 (2,3%) foram submetidos a outras intervenções cirúrgicas. Com o emprego do modelo não invasivo, foram identificados a etiologia da Doença de Chagas (risco relativo 2,72), o diâmetro diastólico do ventrículo esquerdo (risco relativo 1,13) e a fração de ejeção do ventrículo esquerdo (risco relativo 0,96), como as variáveis mais importantes relacionadas com o prognóstico. Com o emprego do modelo invasivo foram identificados o índice cardíaco (risco relativo 0,40) e a etiologia da Doença de Chagas (risco relativo 9,13) como as variáveis mais importantes relacionadas com o prognóstico. A Doença de Chagas foi identificada nesta casuística como o principal fator prognóstico em pacientes portadores de insuficiência cardíaca sintomática grave encaminhados para avaliação de tratamento cirúrgico / To evaluate clinical determinants of prognosis in a hospital based series of outpatients with severe failure of differente etiologies, including Chagas\' heart disease, we followed up a large series of patients in the nineties in a Instituition. 1220 outpatients referred for treatment of heart failure in a tertiary care university hospital dedicated to cardiology were followed-up for 25.6 +- months. The ages of the patients ranged between 13 and 72 (45.5 +- 11) years, 952 (78%) patients were men and and 268 patients (22%) women. Heart failure was attrubuted to indiopathic dilated cardiomyopathy in 454 (37.2%) patients. Etiologies were Chagas\' heart disease in 242 (19.8%) patients, ischemic heart disease in 212 (17.4%) in hypertensive heart disease in 170 (13.9%) and others in 142 (11.7% ). Therapy included anqiotensin converting enzimy inhibitors titrated to the patients\' needs and standard therapy to heart failure. The probability of survival of the patients was assessed through Kaplan Meier method for each clinical variable. Subsequently, an univariate Cox proportional hazard was fitted and multivariate analysis was performed for evaluating prognosis, through pooled non-invasive clinical variables (invasive model). 425 (34.8%) patients died in the follow-up, 74 (6.1%) patients underwent heart transplantation and 28 (2.3%) underwent other surgical interventions. Through the non-invasive model Chagas\' heart disease etiology (relative risk 2.72), left ventricular injection fraction (relative risk 0.96) were identified as the leading determinants of prognosis. Through the invasive model Chagas heart etiology (relative risk of 9.13) and the cardiac index (relative risk 0.40) identified as the most important determinants of prognosis. Chagas disease etiology of heart failure referred to surgical treatment.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 5 uppsatser.

Submitted by Fabio Sobreira Campos da Costa (fabio.sobreira@ufpe.br) on 2016-07-26T12:53:09Z No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) TESE ISAAC NEWTON GUIMARAES ANDRADE DIGITAL.pdf: 5924981 bytes, checksum: 481aa6cbdb8b4916d3675f5338bd96d0 (MD5) / Made available in DSpace on 2016-07-26T12:53:09Z (GMT). No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) TESE ISAAC NEWTON GUIMARAES ANDRADE DIGITAL.pdf: 5924981 bytes, checksum: 481aa6cbdb8b4916d3675f5338bd96d0 (MD5) Previous issue date: 2016-02-19 / Objetivo: Avaliar a aplicabilidade do European System for Cardiac Operative Risk Evaluation (EuroSCORE) na predição de risco de desenvolvimento das principais complicações pós-operatórias em cirurgia cardíaca: infecção do trato respiratório (ITR), acidente vascular Cerebral (AVC) e insuficiência renal dialítica (IRD).Métodos: Foram analisados, retrospectivamente, os prontuários de 900 pacientes operados no Real Hospital Português do Recife e admitidos na unidade de terapia intensiva pós-operatória. Foram incluídos todos os pacientes com prontuários completos, sendo excluídos aqueles que foram a óbito no transoperatório, submetidos a transplante ou a correção de cardiopatia congênita. Foi avaliado o desenvolvimento de ITR, AVC e IRD, sendo o EuroSCORE comparado em relação às três complicações, usando-se o teste de Mann-Whitney. A calibração do modelo para predição das morbidades estudadas foi avaliada com o teste de ajuste de bondade de Homer-Lemeshow. A acurácia do modelo foi avaliada utilizando-se a área sob a curva ROC (ASROC). Resultados: O modelo apresentou boa calibração na predição de infecção respiratória, insuficiência renal dialítica (P=0,285; P=0,789; P=0,45, respectivamente) e mostrou-se não calibrado para predição de AVC. Obteve-se boa acurácia para infecção respiratória (ASROC =0,710 e P<0,001) e insuficiência renal dialítica (ASROC=0,834 e P<0,001) e sem acurácia para acidente vascular cerebral (ASROC=0,519). Os pacientes de alto risco apresentaram maior chance de desenvolver infecção respiratória (OR=9,05; P<0,001) e insuficiência renal dialítica (OR=39,6; P<0,001). A probabilidade de desenvolver infecção respiratória e insuficiência renal dialítica foi de menos de 10% com EuroSCORE até 7 e de mais de 70% com EuroSCORE maior que 15. Conclusão: O EuroSCORE mostrou-se aplicável na predição das principais morbidades pós-operatórias em cirurgia cardíaca: infecção respiratória e insuficiência renal dialítica, apresentando adequada calibração e bom poder de discriminação. / Objective: Evaluate the applicability of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) in the of risk prediction of major postoperative complications in cardiac surgery: respiratory tract infection (RTI), cerebrovascular accident (CVA) and renal failure dialytic (IRD). Methods: We retrospectively analyzed the charts of 900 patients operated on and admitted to the intensive care unit postoperatively at the Real Hospital Português of Recife. We included all patients with complete medical records, excluding those who died during surgery, underwent transplantation or correction of congenital heart disease. We evaluated the development of respiratory infection, cerebrovascular accident, and dialysis-dependent renal failure, and the EuroSCORE was compared in terms of the three complications using the Mann-Whitney test. The calibration model for predicting the morbidities being studied was evaluated using the test set of Homer-Lemeshow goodness. The accuracy of the model was assessed using the area under the ROC curve (AUROC). Results: The model showed good calibration in predicting respiratory infection, renal dialysis (P = 0.285; P = 0.789; P = 0.45, respectively) and proved not calibrated for stroke prediction. It obtained good accuracy for respiratory infection (AUROC = 0.710 and P <0.001) and renal dialysis (AUROC = 0.834 and P <0.001) and no accuracy for stroke (AUROC = 0.519). The high-risk patients were more likely to develop respiratory infection (OR=9.05, P<0.001) and dialysis-dependent renal failure (OR=39.6, P<0.001). The probability of developing respirato-ry infection and dialysis-dependent renal failure was less than 10% with EuroSCORE up to 7 and more than 70% with EuroSCORE greater than 15. Conclusion: The EuroSCORE proved to be applicable in the prediction of major postoperative morbidities in cardiac surgery: respiratory tract infection and renal failure dialitic, with proper calibration and good discrimination.

O objetivo deste estudo foi avaliar o prognostico de portadores de insuficiência cardíacadoe diferentes etiologias, incluindo a Doença de Chagas, na década de noventa ern uma unica intituição. Foram avaliados 1 220 pacientes portadores de insuficiência cardíaca encaminhados para avaliação de tratamento cirúrgico, acompanhados por período de 25,6+- 26 meses. As idades variavarn entre 13 e 72 anos (45,5 +- 11 anos); 952 (78%) pacientes eram do sexo masculino e 268 (22%) do feminino.A insuficiência cardíaca foi considerada idiopática em 454 (37,2%) doentes. A etiologia da insuficiência cardiaca foi a Doença de Chagas em 242 (19,8%) pacientes, a isquemia em 121 (17,4%) a hipertensiva em 170 (13,9%) e outras etiologias em 142 (11,7%). O tratamento medicamentoso padrão incluiu os inibidordes da enzimaa conversora da anqiotensma. Depois da análise exploratória Inicial, foi realizada análise de sobrevivência, pelo método de Kaplan Meier para cada variável clínica observada. Em seguida, realizaram-se análises dos riscos proporcionais pelo método de Regressão de Cox univariada e multivariada para avaliar o proqnostico por meio de variáveis clínicas não invasivas por meio de variáveis clínicas não invasivas (modelo não invasivo) e variáveis obtidas do cateterismo cardíaco direito (modelo invasivo). Quatrocentos e vinte e cinco (34,8%) pacientes morreram na evolução 74 (6,1 %) foram submetidos a transplante cardíaco e 28 (2,3%) foram submetidos a outras intervenções cirúrgicas. Com o emprego do modelo não invasivo, foram identificados a etiologia da Doença de Chagas (risco relativo 2,72), o diâmetro diastólico do ventrículo esquerdo (risco relativo 1,13) e a fração de ejeção do ventrículo esquerdo (risco relativo 0,96), como as variáveis mais importantes relacionadas com o prognóstico. Com o emprego do modelo invasivo foram identificados o índice cardíaco (risco relativo 0,40) e a etiologia da Doença de Chagas (risco relativo 9,13) como as variáveis mais importantes relacionadas com o prognóstico. A Doença de Chagas foi identificada nesta casuística como o principal fator prognóstico em pacientes portadores de insuficiência cardíaca sintomática grave encaminhados para avaliação de tratamento cirúrgico / To evaluate clinical determinants of prognosis in a hospital based series of outpatients with severe failure of differente etiologies, including Chagas\' heart disease, we followed up a large series of patients in the nineties in a Instituition. 1220 outpatients referred for treatment of heart failure in a tertiary care university hospital dedicated to cardiology were followed-up for 25.6 +- months. The ages of the patients ranged between 13 and 72 (45.5 +- 11) years, 952 (78%) patients were men and and 268 patients (22%) women. Heart failure was attrubuted to indiopathic dilated cardiomyopathy in 454 (37.2%) patients. Etiologies were Chagas\' heart disease in 242 (19.8%) patients, ischemic heart disease in 212 (17.4%) in hypertensive heart disease in 170 (13.9%) and others in 142 (11.7% ). Therapy included anqiotensin converting enzimy inhibitors titrated to the patients\' needs and standard therapy to heart failure. The probability of survival of the patients was assessed through Kaplan Meier method for each clinical variable. Subsequently, an univariate Cox proportional hazard was fitted and multivariate analysis was performed for evaluating prognosis, through pooled non-invasive clinical variables (invasive model). 425 (34.8%) patients died in the follow-up, 74 (6.1%) patients underwent heart transplantation and 28 (2.3%) underwent other surgical interventions. Through the non-invasive model Chagas\' heart disease etiology (relative risk 2.72), left ventricular injection fraction (relative risk 0.96) were identified as the leading determinants of prognosis. Through the invasive model Chagas heart etiology (relative risk of 9.13) and the cardiac index (relative risk 0.40) identified as the most important determinants of prognosis. Chagas disease etiology of heart failure referred to surgical treatment.

Introdução. O estudo procurou investigar a evolução pós-operatória (PO) mediata e tardia de pacientes que participaram de um estudo anterior, sendo submetidos à primeira cirurgia de revascularização do miocárdio (CRM), correção de valvopatias e cirurgias combinadas, entre agosto/2013 e fevereiro/2015. Objetivo. Identificar as principais complicações e a ocorrência de óbito no PO mediato e investigar a evolução tardia desses pacientes, dentro de dois anos, quanto aos locais de retorno, necessidade de novas internações e de procedimentos relacionados ao aparelho circulatório, presença de infecção de sítio cirúrgico (ISC) e desfecho ao término deste período. Método. Estudo observacional, tipo coorte retrospectiva. Coletouse os dados mediante consulta aos prontuários dos pacientes e ao sistema de intranet do hospital, de março/2016 a outubro/2017. No PO mediato investigou-se a presença de complicações por sistema e o desfecho da internação; no PO tardio investigou-se o local dos retornos ambulatoriais; reinternações e suas causas; novos procedimentos/condutas relacionados ao aparelho circulatório; presença de ISC e desfecho clínico após dois anos. Realizamos uma análise descritiva das variáveis do estudo. Resultados. A amostra foi composta por 118 pacientes, 59 (50%) submetidos à CRM, 48 (40,6%) às cirurgias para correção de valvopatias e 11 (9,4%) às cirurgias combinadas. A hiperglicemia foi a complicação mais frequente entre pacientes que realizaram a CRM (64,4%) e entre aqueles submetidos às cirurgias combinadas (45,5%). No grupo de pacientes que realizaram cirurgias para correção de valvopatias, a complicação mais frequente foi o distúrbio de coagulação (20,8%). Todos os pacientes da amostra tiveram alta hospitalar. Quanto ao seguimento PO inicial, todos os pacientes, independentemente da cirurgia realizada, tiveram pelo menos um retorno no hospital do estudo. Ao longo de dois anos após a alta, 25,4% dos pacientes submetidos à CRM foram reinternados, assim como 33,3% dos submetidos às cirurgias para correção de valvopatias e 18,2% dos submetidos às cirurgias combinadas. Dois pacientes do grupo de CRM foram submetidos à intervenção coronária percutânea (ICP) e apenas um do grupo de válvula foi submetido a uma nova cirurgia cardíaca no período do estudo. Quanto à ISC, no grupo de CRM, cinco pacientes apresentaram infecção na safenectomia, um evoluiu com endocardite e um com mediastinite; no grupo de valva, apenas um evoluiu com endocardite, daqueles submetidos às cirurgias combinadas, um apresentou infecção da ferida esternal e um mediastinite. A maioria dos pacientes encontrava-se vivo após dois anos da alta hospitalar (CRM = 96,6%; cirurgia de valva = 83,3% e cirurgia combinada = 90,9%). Conclusão. A frequência de complicações dos pacientes no PO mediato foi baixa, e todos tiveram alta hospitalar. Quanto à evolução PO tardia, a maioria dos pacientes permanecia em acompanhamento ambulatorial no hospital do estudo após dois anos da alta hospitalar. Entre os pacientes estudados, apenas um do grupo de cirurgias corretivas de valvopatias foi submetido a nova cirurgia cardíaca, e dois do grupo de CRM à ICP. Quanto à ISC, poucos a desenvolveram, a maioria dos quais pertencia ao grupo de CRM. A maioria deles, independentemente da cirurgia realizada, encontrava-se vivo após dois anos da alta hospitalar. / Introduction. This study aimed at investigating the medium and long-term postoperative (PO) evolution of patients who participated in a previous study, who were submitted to the first myocardium revascularization surgery (MRS), valvopathy correction and to combined surgeries, from August/2013 to February/2015. Objective. Identifying the main complications and cases of death among patients in the medium-term PO and investigate the late evolution of these patients, within two years, their return to the hospital, the need for other hospitalizations, the need for new procedures regarding their circulatory system, the presence of surgical site infections (SSI) and their outcome in this period. Method. Observational and retrospective cohort study. Data was collected from the records of patients and the intranet system of the hospital, from March/2016 to October/2017. In the medium-term PO, the complications in each system were investigated as was the outcome of the hospitalization; in the long-term PO, the site of outpatient returns; rehospitalizations and their motives; new procedures/conducts related to the circulatory system; the presence of SSI and the clinical outcome after two years. A descriptive analysis of the study variables was made. Results. The sample of the study included 118 patients, 59 (50%) had undergone MRS, 48 (40.6%) valvopathy correction surgeries and 11 (9.4%) combined surgeries. Hyperglycemia was the most common medium-term PO complication among patients who underwent the combined surgery (45.5%), while those who underwent valvopathy correction surgeries most commonly presented coagulation disorder (20.8%). All patients in the sample were discharged. Regarding the initial PO monitoring, all patients came back to the hospital at least once. Regarding the rehospitalizations in the first two years after the discharge from the first heart surgery, 25.4% of patients who underwent MRS were re-hospitalized, as were 33.3% of those who underwent valvopathy correction surgeries and 18.2% of those who underwent combined surgeries. Two patients from the MRS group were submitted to percutaneous coronary interventions (PCI) and only one in the group of corrective valvopathy was submitted to another surgery in the period of the study. Regarding the presence of SSI, in the SMR group, five patients had infections after saphenectomies, one had endocarditis and one, mediastinitis; considering valvopathy correction patients, one presented with endocarditis, while one of those who underwent combined surgeries had sternum injuries and another, mediastinitis. Most patients were alive two years after discharge (SMR=96.6%; valvopathy correction=83.3% and combined surgery=90.9%). Conclusion. The frequency of complications among patients in the medium-term PO was low, and all of them were discharged from the hospital. Regarding long-term PO evolution, most patients were undergoing outpatient monitoring in the hospital were the study was conducted two years after hospital discharge. Among all patients in the study, only one, in the group of valvopathy correction, underwent new cardiac surgeries, and two of the SMR group underwent PCI. Few patients presented SSI, and most were in the MRS group. Most patients were alive after two years.

INTRODUÇÃO: A trombose venosa profunda é uma doença de alta incidência, e uma das principais causas de insuficiência venosa profunda. O tratamento clássico, com heparina e anticoagulante oral, não tem ação direta sobre o tempo de remoção do trombo. O tratamento trombolítico seletivo por cateter permite rápida remoção do coágulo com complicações inferiores a administração sistêmica do fibrinolítico. OBJETIVO: Comprovar a eficácia da infusão seletiva de rt-PA em baixas doses no tratamento da trombose venosa profunda iliacofemoral aguda e na prevenção do desenvolvimento dos sinais, sintomas e alterações hemodinâmicas tardios relacionados à síndrome pós-trombótica.METODO: Em pacientes portadores de trombose venosa profunda iliacofemoral aguda, implantou-se um cateter reto multiperfurado no segmento venoso acometido, e infundiuse dose contínua de 1,0 mg/hora de rtPA diluído. O controle do procedimento foi feito por flebografia transcateter a cada 12-18h. RESULTADOS: Quinze pacientes foram selecionados. Houve fibrinólise efetiva em 12 dos 15 casos (80%), com restabelecimento da perviedade iliacofemoral. O tempo médio de infusão do rt-PA foi de 41 horas. Houve correlação entre o grau de fibrinólise e a magnitude da melhora clínica (p < 0,05). Não ocorreram complicações maiores, tais como embolia pulmonar ou hemorragias graves. Quatro pacientes apresentaram episódios de retrombose. O grupo foi seguido por um período de 45 a 131 semanas (mediana de 99). Nos oito pacientes em que a fibrinólise foi efetiva e não houve retrombose, a incidência de seqüelas clínicas e de refluxo valvular venoso ao duplex-scan foi inferior a observada nos sete pacientes com falha terapêutica ou retrombose (p < 0,01 nas duas amostras). A diferença na incidência de recanalização venosa completa também foi estatisticamente significativa (p < 0,05) em favor do grupo com fibrinólise efetiva. CONCLUSÕES: A terapêutica trombolítica seletiva com rt-PA em baixas doses é eficaz e segura no tratamento agudo da trombose venosa iliacofemoral. A evolução clínica e ultrassonográfica tardia foram significativamente superiores nos pacientes em que a terapêutica foi efetiva / INTRODUCTION: Deep venous thrombosis keeps being a high incidence disease and one of the leading causes of chronic venous insufficiency. The classic therapy with heparin and oral anticoagulation doesn\'t have direct action over thrombus removal time. Seletive catheter-directed thrombolysis allows an early thrombus removal with a lower rate of complications than systemic thrombolysis. OBJECTIVES: To prove the efficacy of catheterdirected low-dose rt-PA infusion in the treatment of acute iliofemoral deep vein thrombosis and in the prevention of late clinical and haemodinamic sequelae of post-thrombotic syndrome. METHODS: In selected patients with acute iliofemoral deep venous thrombosis, a straight multiside-hole catheter was introduced through the thrombotic venous segments. A low-dose (1mg/h) rt-PA continuous infusion was initiated and control transcatheter phlebography was taken every 12-18 hours. RESULTS: Fifteen patients were selected. Effective fibrinolysis was achieved in 12 of 15 cases (80%), with iliofemoral patency obtained. The medium time of rt-PA infusion was 41 hours. Statistic correlation between lysis grade and clinical improvement was observed (p < 0,05). There were no episodes of major complications such as transfusion-needed hemorrhage or pulmonary embolism. Four patients presented with rethrombosis. The group was followed by a period of 45 to 131 weeks (median 99). In the eight patients in witch lytic therapy was well succeeded and venous patency was kept, the incidence of clinical signs and symptoms of venous insufficiency and duplex-scan findings of valvular reflux was statistically lower than in the seven patients with acute therapeutic failure or rethrombosis (p < 0,01 for both). There was also difference in findings of complete venous recanalization between the two groups (p < 0,05), showing benefit to the group with effective therapy. CONCLUSIONS: Low-dose rt-PA fibrinolytic therapy is safe and effective in the treatment of iliofemoral acute venous thrombosis. The clinical and ultrasound late evolution was superior in patients in witch lytic therapy was effective