A 53 year-old male presented with a one-day history of a swollen arm and dull, aching pain in the right upper extremity. The patient reported commencing exercising daily over the prior week with a modified, oscillating dumbbell; commonly referred to as a Shake Weight. Imaging revealed an occlusive thrombus in the right axillary, proximal brachial and basilic veins. The patient was treated with a 24-hour tPA infusion followed by mechanical thrombectomy, balloon angioplasty, and stent placement for a residual thrombus and stenosis. The patient was discharged the following day on warfarin and aspirin. This is the first report of effort-induced thrombosis of the upper extremity following the use of a modified, oscillating dumbbell. Due to the growing popularity of modified dumbbells and the possible risk for axillary vein thrombosis, consideration should be made to caution consumers of this potential complication.

Venous disease is a common vascular condition affecting the lower limbs and causes considerable morbidity in affected patients. National Health Service (NHS) treatment costs are substantial and there is a large demand for treatment much of which cannot be met. Roughly half a million people in the United Kingdom contact their general practitioner each year about varicose veins and associated clinical symptoms. In order to assign priorities and target interventions properly, authorities need to know which patients with venous disease will progress. Although many epidemiological studies have investigated the prevalence of venous disease, information on deterioration is scarce. The overall aim of this study is to determine the natural history of venous disease in the population and to identify lifestyle and clinical factors related to deterioration which might aid clinical decision making and health services policy. The specific objectives were to determine which risk factors were associated with deterioration of venous disease and venous reflux, and to ascertain the natural history of asymptomatic venous incompetence in terms of deteriorating to overt trunk varicose veins and chronic venous insufficiency. The study design was a population based cohort in the Edinburgh Vein Study which the survivors of the 1566 individuals aged 18 to 64 randomly sampled years from the general population at baseline underwent a 13-year follow-up examination. Details of the 1566 participants in the baseline study were sent to the Practitioner Services Division (PSD) of the NHS in Scotland who provided updated addresses and general practitioner registration details. Information collected on each subject at a follow-up clinic included lifestyle factors and medical history, height and weight measurement (by means of a questionnaire), clinical examination for classification of venous disease according to the Basle and CEAP systems, and duplex scanning to assess incompetence of venous valves in the deep and superficial systems of ten vein segments in each leg. Of the subjects from the baseline, 880 participated in the follow-up study, and 576 did not participate, providing a response rate of 60.4% of which 490 were female (55.7%) and 390 were male (44.3%). The study subjects were generally older and slightly more affluent than residents of the City of Edinburgh. For trunk varicose veins, the baseline prevalence was higher in males compared to females (p<0.01), but there was no difference in prevalence among subjects at the follow-up stage of the study (p=0.56). The overall rate of deterioration in trunk varicose veins was 3.55% per annum. More females than males deteriorated (p=0.04). Among subjects who showed deterioration in their trunk varicose veins, the commonest deterioration was from Basle Grade I (mild) at baseline to Grade II (moderate) at follow-up in both the right and left leg (28.1% and 32.9% respectively). Subjects older than 55 years of age (OR=1.59, 95% CI 1.01-2.51), who had a positive family history of varicose veins or venous ulcer (OR=1.92, 95% CI 1.20-3.07), and sat down at work for more than half the working day (OR=1.69, 95% CI 1.04-2.73) had increased risk of deteriorating trunk varicose veins. There was no significant difference between males and females in the prevalence of chronic venous insufficiency (CVI) among subjects at both the baseline and follow-up stage of the study (p=0.15 and 0.16 respectively). The rate of deterioration in CVI was 1.76% per annum. Similarly, among subjects who deteriorated, the commonest deterioration was from Grade I (mild) to Grade II (moderate) CEAP classification in both the right and left leg (42.4% and 45.5% respectively). The risk of worsening of CVI among those older than 55 was nearly three times more than those aged less than 55 (OR=2.85, 95% CI 1.18-6.87), and was still significant when adjusted for gender. The prevalence of telangiectasia was higher in females than in males in both the baseline and follow-up stages of the study (both p<0.01). The rate of deterioration in telangiectasia was 1.6% per annum. The commonest deterioration was from grade I (mild) at baseline to grade II (moderate) follow-up in the left and right leg (using the Basle Classification). Females subjects (OR=1.87, 95% CI 1.35-2.64), those older than 55 (OR=1.68, 95% CI 1.19-2.36), with a positive family history of venous disease (OR=1.60 95% CI 1.14-2.24) were associated with an increased risk of deterioration from telangiectasia compared to male subjects under 55 years of age and with no family history of the disease. The risk of telangiectasia deterioration was more than twice as high in subjects with venous reflux in the greater saphenous vein (origin) (OR=2.34, 95% CI 1.53-3.57), the greater saphenous vein (lower third of the thigh) (OR=2.28, 95% CI 1.59-3.27) and in the small saphenous vein (1.89, 95% CI 1.06-3.36) compared to those with no segments affected. The age and gender adjusted risk was also more than twice as high in subjects with venous reflux in two segments of the superficial system compared to subjects with no venous reflux in any segment (OR=2.06, 95% CI 1.23-3.44), and almost four times as high in subjects with reflux in more than three segments of the superficial system (OR=3.97, 95% CI 2.16-7.31) compared to subjects with no segments affected. On duplex scanning, the prevalence of reflux was higher in females than in males in the superficial system at baseline and follow-up stages of the study (p<0.01 respectively). In the deep system, the prevalence was higher in males than females at the baseline stage (p<0.01) with no significant difference at the follow-up stage (p=0.85). The rate of deterioration in venous reflux was 1.28% per annum. Most subjects deteriorated from one to two vein segments affected in the leg, the majority of which had reflux in the greater saphenous vein (thigh) at baseline and developed reflux in the greater saphenous vein (origin) at follow-up. Subjects more than 55 years of age had significantly more deterioration than those aged less than 55 (p<0.01). Obese or overweight subjects (OR=1.59, 95% CI 1.32-3.67), those aged more than 55 (OR=2.20, 95% CI 1.32-3.67), with a family history of varicose veins (among female subjects only, OR=2.55, 95% CI 1.16-5.56), and who sat down at work more than half the working time (among male subjects only) (OR=2.26, 95%CI 0.97-5.23) had increased risk of showing deterioration in reflux in any leg and in any vein segment from baseline to follow-up. Subjects with venous reflux at baseline were over two and half times more likely to show deterioration in trunk varicose veins compared to those with no reflux (OR=2.69, 95%CI 1.44-5.01), and four times more likely to deteriorate in either trunk varicose veins or chronic venous insufficiency (OR=4.20, 95% CI 2.42-7.29). Subjects with venous reflux at baseline were twice as likely to develop new trunk varicose veins (OR=2.08, 95%CI 1.25-3.46), and 1.78 times more likely to develop either trunk varicose veins or chronic venous insufficiency (OR=1.78, 95%CI 1.12-2.80). Age and gender adjusted risk of trunk varicose veins increased more than fourfold among subjects with venous reflux in the greater saphenous veins (OR=4.04, 95% CI 2.36-6.92), and more than threefold in the greater saphenous vein (lower third of the thigh) (OR=3.13, 95% CI 1.85-5.27) and the small saphenous vein (OR=3.17, 95% CI 1.55-6.48). Subjects with venous reflux in two or more than three vein segments in the superficial system were more than five times more likely to deteriorate from trunk varicose veins (OR=5.39, 95% CI 2.64-10.99 and OR=5.96, 95% CI 2.71-13.10 respectively). The Edinburgh Vein Study follow-up identified factors linked to deterioration of trunk varicose veins and CVI. The findings of this follow-up study have important implications in decision making in NHS and a prognostic tool could be produced to assist clinicians in deciding who should receive treatment or maintained under surveillance. Increasing age, and family history will likely lead to worsening of trunk varicose veins and CVI. The findings also confirm the association between asymptomatic and symptomatic venous valvular incompetence with worsening and developing new cases of venous disease. Such information will be essential for policy makers facing difficult decisions over prioritisation of services in the future. Further research might include trials of surgical and non-surgical interventions designed to limit deterioration in high risk individuals and enable surgeons to target interventions appropriately. Larger prognostic studies of many factors, including genotype, might be conducted to link progression of venous disease, and to provide further information on high risk individuals who might benefit from treatment.

Knowledge about biomechanical properties of veins is of importance for understanding the physiologyof the venous system. Specifically for this thesis there is a motivation based on an idea of how to usebiomechanics of the vein in the development of new non-invasive measurement techniques for assessingthe pressure in the brain. The cross sectional area of veins is known to depend on pressure changes insidethe vessel. There are many ways of provoking these pressure changes, like changing posture or creating apositive airway pressure. The hypothesis is that the positive airway pressure will increase the intrathoracic pressure and in turnincrease the pressure in the internal jugular veins by the same magnitude. The cross sectional area will from a pressure change subsequently change with respect to the biomechanical properties of the vessel walls. A first aim in this study was to determine how the cross sectional area of the internal jugular veins is altered due to changes in airway pressure. A second aim was to develop and evaluate a model where the biomechanical properties of the internal jugular veins is described, based on the relationship between pressure and area of the vein. Ultrasound measurements were performed on one healthy adult man to study the effect on the cross sectional area at different pressure provocations. Measurements on the subject was performed at four different head up tilt angles, causing a pressure decrease in the internal jugular vein. A controlled Valsalva method was performed to give the positive airway pressure giving corresponding pressure increases. With an increased airway pressure the effect on cross sectional area changes was about 23% of the effect dueto hydrostatic pressure changes, at a tilt angle from 0° to 8°. At a tilt angle from 8° to 16° the effect was about 35%. Thus the venous pressure seems to be increased due to an increased airway pressure, but not tothe same magnitude. The theoretical model was developed and subsequently evaluated using existing head down tilt magneticresonance imaging data on nine healthy volunteers. An expression for how radius of the vessel depends on pressure changes was derived and evaluated. This expression included individual biomechanical properties that were estimated on group level for the nine subjects. The resulting equation could beused to give an approximate prediction of the increase in radius to a change in venous pressure. In conclusion, the hypothesis suggesting that a positive airway pressure would give an equally increased venous pressure could not be confirmed, and this knowledge should be considered when trying to assess thepressure in the brain with this technique. The derived biomechanical model was promising for predictionof cross sectional area with respect to a change in venous pressure. / Att ha kännedom om biomekaniska egenskaper hos vener är viktigt för att kunna förstå fysiologin hos vensystemet. I den här rapporten finns det i synnerhet ett intresse av detta baserat på en idé för hur veners biomekanik kan användas för att utveckla en ny icke-invasiv mätteknik för att uppskatta trycket i hjärnan. Det är känt att tvärsnittsnittarean av vener beror på tryckförändringar inne i kärlet. Att provocera fram dessatryckförändringar går att göra på många sätt, till exempel genom en förändrad kroppsposition eller genomatt sätta ett positivt tryck på luftvägarna. Hypotesen är att ett positivt luftvägstryck kommer att höja det intratorakala trycket, vilket i sin turkommer att höja trycket inne i de interna jugularvenerna lika mycket. Tvärsnittsarean kommer därmed att ändras enligt biomekaniska egenkaper hos kärlväggen. Ett första syftet i det här arbetet var att bestämma hur tvärsnittsarean av de internal jugularvenerna varierar enligt förändringar i luftvägstryck. Det andra syftet var att utveckla en modell som beskriver de biomekaniska egenskaperna hos de interna jugularvenerna. Detta baserat på relationen mellan tryck och area hos venen. För att studera effekten på tvärsnittsarea för olika tryckprovokationer, genomfördes ultraljudsmätningar på en frisk och vuxen man. Mätningarna på subjektet genomfördes med överkroppen positionerad i fyra olika positiva vinklar relativt horisontalplanet, vilket leder till ett minskat tryck i jugularvenerna. En kontrollerad Valsalvametod användes för att skapa det positiva luftvägstrycket som då ska ge en motsvarande tryckökning. Vid en tiltvinkel på 8° var effekten på areaförändringarna som en följd av ökat luftvägstryck ca 23% av effekten som en följd av de hydrostatiska tryckförändringarna. Vid en tiltvinkel på 16° var effekten ca 35%. Det verkar som att ventrycket ökar med ökat luftvägstryck, men inte med samma storleksordning som det pålagda trycket. Den teoretiska modellen utvecklades och utvärderades sedemera med hjälp av befintligt MRI-data för nio friska och frivilliga subjekt, där överkropparna var positionerade i nedåt tilt. Modellen bestod av ettuttryck för hur radien av ett kärl beror på tryckförändringar inne i det. Modellen innehåller individspecifika egenskaper men utvärderingen gjordes på gruppnivå för de nio subjekten. Det resulterande uttrycket kunde användas för att ge en approximativ förutsägelse om hur radie förändras till följd av en variation i ventryck. Som slutsats så kunde hypotesen som föreslog att ett positivt luftvägstryck skulle ge en lika stor ökning av ventryck inte bekräftas. Om denna teknik ska användas för att försöka bestämma trycket i hjärna så måste hänsyn tas till dessa resultat. Den utvecklade biomekaniska modellen verkar lovande för att kunna förutsäga tvärsnittsarea utifrån ventrycksförändringar.

A novel technique for saphenous vein (SV) graft harvesting, the No-touch technique (NT), has been developed at the Dept. of Cardiovascular surgery, Örebro University hospital. With NT the SV is harvested with a pedicle of surrounding tissue. This avoids graft spasm and eliminates the need for distension. The surrounding tissue acts as a structural support and is a rich source of vaso-dilating agents. A randomized controlled trial (RCT) has shown a significantly higher patency rate for NT SV grafts compared to SV grafts harvested with conventional technique (CT). This thesis evaluates some of the properties of the surrounding tissue and compares patency rates between NT SV and radial artery (RA) grafts and patency rates for internal thoracic artery (ITA) grafts harvested with and without surrounding tissue. Paper I investigated vasa vasorum (VV) in SV grafts and showed that the NT preserves an intact VV whereas CT does not. This could be one of the mechanisms underlying the improved patency for NT SV grafts. Paper II evaluated VV and associated nitric oxide (NO) in SV and arterial grafts. SV grafts showed a higher number and larger VV, which correlated with NO production, compared to arterial grafts. NT SV grafts showed higher activity for e-NOS compared to CT SV grafts. Paper III is a RCT comparing patency rates between NT SV and RA grafts, three years after surgery, showing a significantly higher patency rate for NT SV grafts. Paper IV is a RCT comparing patency rates for ITA graft harvested with and without surrounding tissue and did not show any difference between graft preparations. In conclusion, the NT for SV graft harvesting preserves an intact vasa vasorum and associated NO production. NT SV grafts show a higher patency rate than RA grafts. Harvesting of ITA with or without surrounding tissue does not affect patency rate.

As afecções dos componentes umbilicais merecem destaque no período neonatal, pois são comumente encontradas nos bezerros, podendo levar a graves complicações. O diagnóstico das doenças umbilicais muitas vezes não é totalmente esclarecido pela palpação abdominal bimanual, uma vez que, em parcela dos casos, esse método semiológico não é sensível para determinar o grau de acometimento das estruturas umbilicais intra-abdominais. Assim, a ultrassonografia apresenta-se como um valioso exame complementar para o estabelecimento de um diagnóstico preciso sobre a localização e extensão das onfalopatias intra-abdominais. Diante dessas limitações e da raridade de pesquisas com estabelecimento de padrões da ultrassonografia do umbigo, a proposta desse estudo foi avaliar o processo de involução fisiológica dos componentes umbilicais de bezerros sadios, considerando o uso de antisséptico clássico, a tintura de iodo, em concentrações de 2% e 5%, usado na cura do umbigo nos primeiros dias após o nascimento. A avaliação foi realizada por meio do exame ultrassonográfico dos componentes umbilicais, em diferentes posições, caracterizando as modificações ocorridas durante o processo de involução, em relação ao aspecto das imagens, com medidas de diâmetro e espessura dos componentes vasculares e úraco, assim como às peculiaridades decorrentes dos dois tipos de desinfecção da região. Foram avaliados 23 bezerros da raça Holandesa, machos, oriundos de propriedade leiteira localizada no Estado de São Paulo, desde o nascimento até os 30 dias de vida. Os resultados obtidos, evidenciaram que a veia e as artérias umbilicais perdem as suas características de vasos, assumindo aspecto de ligamento devido à proliferação de tecido fibroso. Esse processo caracterizou-se e seguiu um padrão, no qual o tecido fibroso inicialmente estava presente na região interna da parede do vaso, seguindo, com a involução, em direção ao centro da luz vascular. Esse processo de involução é mais precoce em porções dos vasos mais distantes do umbigo externo, não havendo distinção de comportamento determinada por uso das diferentes concentrações do antisséptico. Além das imagens, foram também padronizadas as medidas do diâmetro dos componentes umbilicais e da espessura de suas paredes, ao longo do processo de involução fisiológica, durante os primeiros 30 dias de vida dos bezerros, comprovando-se a precisão do exame ultrassonográfico para essa avaliação e estabelecendo-se referências ultrassonográficas para fundamentar o diagnóstico e escolha do tratamento das onfalopatias / Diseases of the umbilical components are very important in the neonatal period. Commonly found in calves, they can lead to serious complications. Diagnosis of umbilical diseases is often not fully enlightened by bimanual abdominal palpation, since this semiotic method is not sensitive enough to determine the extent of involvement of the umbilical intra-abdominal structures in part of the cases. Thus, ultrasonography is a valuable complementary test for establishing an accurate diagnosis on the location and extent of intra-abdominal omphalitis. Because of these limitations and the scarce research on the establishment of the standards of navel ultrasound, the purpose of this study was to evaluate the physiological involution process of umbilical components of healthy calves, considering the use of classic antiseptic, iodine tincture in concentrations 2% and 5%, used in navel treatment during the first days after birth. Evaluation was performed by ultrasonography of umbilical components in different positions and the changes were characterized during the process of involution regarding the appearance of the images, the measures of the diameter and thickness of vascular and urachus components, as well as the peculiarities from the two types of disinfecting. Twenty-three Holstein male calves, reared in dairy property located in the State of São Paulo, were evaluated from birth to 30 days old. Results obtained showed that the vein and umbilical arteries lose their blood vessels characteristics, assuming a ligament aspect due to fibrous tissue proliferation. This process was characteristic and followed a pattern, in which the fibrous tissue was initially present in the inner part of the vessel wall, following with involution, toward the center of the vessel lumen. This process of involution was earlier in the parts of the blood vessels that were farthest from the external navel, with no particular behavior distinct by the use of different antiseptic concentrations. Besides the images, the measurements of the diameter of the umbilical components and the thickness of their walls were also standardized along the physiological involution process during the first 30 days of life the calf, confirming the accuracy of ultrasonography for such assessment and establishing references to improve the diagnosis and the choice of treatment of umbilical diseases

O Nitroxil (HNO), forma reduzida em um elétron e protonada do óxido nítrico (NO), apresenta características químicas diferentes do seu congênere redox, com ações farmacológicas distintas e vantagens terapêuticas. Em conjunto, NO e HNO parecem ter um papel fundamental no controle do tônus vascular. A produção e/ou biodisponibilidade do HNO deve estar preservada durante o estresse oxidativo, ao contrário do que acontece com o NO. O HNO também apresenta potencial atividade antioxidante, atuando assim como citoprotetor e exibindo características desejáveis no tratamento de doenças cardiovasculares. O presente trabalho teve como objetivo estudar o efeito relaxante do nitroxil liberado do composto sal de Angeli (SA) e investigar os mecanismos celulares envolvidos nesse efeito em veia cava de ratos. Verificamos que o SA aumentou a concentração citosólica de HNO, medida pela sonda fluorescente DAF-2DA, por citometria de fluxo em células de veia umbilical humana (HUVECs). O aumento na intensidade de fluorescência foi abolido pelo sequestrador de HNO (L-cisteína), mas não foi alterado pelas espécies reativas de oxigênio (EROs). O SA promoveu relaxamento dependente da concentração em aorta e veia cava de ratos, com endotélio. Entretanto, o relaxamento induzido em veia cava foi menor que o relaxamento máximo (Emáx) em aorta. Analisando o tempo necessário para o composto induzir o Emáx, observamos que na aorta de ratos, o tempo máximo foi de 50 seg e na veia cava foi de 20 min. A conversão de HNO a NO pela superóxido dismutase (SOD) não foi necessária para a ativação da via de sinalização, uma vez que o relaxamento foi reduzido na presença de L-cisteína, mas não foi alterado em presença do inibidor da SOD (DDC) e do sequestrador de NO (Hidroxicobalamina). O relaxamento estimulado com o SA também foi inibido pelo L-NAME e ODQ, indicando a participação das enzimas NO-sintase e guanilil-ciclase solúvel (GCs), respectivamente. O bloqueador não seletivo de canais para K+ (TEA) e o sequestrador de ânion superóxido (O2¯) (Tiron) não modificaram o relaxamento para o SA quando realizada a curva concentração-efeito. Porém, ambos inibiram o relaxamento quando estudamos o efeito temporal do composto. Na presença do inibidor da NADPH oxidase (Apocinina), o relaxamento também foi reduzido. Deste modo, canais para K+, O2¯ e a NADPH oxidase parecem contribuir para o relaxamento induzido pelo SA. Aparentemente, não há participação da enzima proteína quinase G (GK), Ca2+-ATPase reticular (SERCA) ou de canais para Ca2+ dependentes de voltagem na via de sinalização. Com relação ao potencial antioxidante, em menor concentração (0,1 mmol/L) o SA apresentou efeito antioxidante, enquanto que em altas concentrações (1 mmol/L) ele atuou como um pró-oxidante. A principal espécie envolvida no efeito pró-oxidante do SA é o O2¯. Este é produzido, pelo menos em parte, pela ação da NADPH oxidase, uma vez que o aumento da produção de EROs estimulado pelo SA foi inibido em pelo Tiron e reduzido em presença de Apocinina. Esses dados foram obtidos por fluorescência da sonda DHE por citometria de fluxo em HUVECs. Apesar da produção de EROs em altas concentrações, o composto não apresentou toxicidade. / Nitroxyl (HNO), the one electron reduced and protonated form of nitric oxide (NO), displays different chemical characteristics compared to its redox sibling, with different pharmacological actions and therapeutic benefits. Together, NO and HNO seem to have an integral role in the control of vascular tone. The production and/or bioavailability of HNO must be preserved during oxidative stress, different from what happens to NO. In addition, HNO also has a potential antioxidant activity, thus acting as a cytoprotector and displaying desirable characteristics in the treatment of cardiovascular diseases. The present study aimed to study the relaxing effect of HNO released from Angeli\'s salt (AS) and to investigate the cellular mechanisms involved in this effect in rat vena cava. We found that AS increased cytosolic concentration of HNO, measured by fluorescent probe DAF-2DA by flow cytometry in human umbilical vein cells (HUVECs). HNO increase was abolished by HNO scavenger (L-cysteine), but it did not change in presence of the reactive oxygen species (ROS). AS promoted concentration-dependent relaxation in aorta and vena cava of rats with endothelium. However, the relaxation induced in vena cava was lower than the maximum relaxation (ME) induced in aorta. Analyzing the time necessary for the compound to induce ME, we observed that the effect in function of time was also significantly different between the vessels. In rat aorta, the maximum time was 50 seconds and in vena cava was 20 minutes. HNO conversion to NO by superoxide dismutase (SOD) was not required for signaling pathway activation, since AS relaxation was reduced in presence of L-cysteine, but it was not modified in presence of SOD inhibitor (DDC) or NO scavenger (Hydroxocobalamin). SA-induced relaxation was reduced by L-NAME and ODQ, indicating the involvement of NO synthase and soluble guanylyl cyclase (sGC), in the relaxation. Non-selective blocker of K+ channels (TEA) and superoxide anion (O2¯) scavenger (Tiron) did not modify the relaxation induced by AS when concentration-effect curve was performed. However, both inhibited relaxation when we performed the temporal effect compound study. Moreover, in the presence of NADPH oxidase inhibitor (Apocynin) relaxation was also reduced. Thus, K+ channels, O2¯ and NADPH oxidase seem to contribute to AS relaxation. Apparently there is no participation of protein kinase G (GK), sarcoplasmic reticulum Ca2+ ATPase (SERCA) or voltage-dependent Ca2+ channels in relaxation signaling pathway. Also, low concentrations (0.1 mmol/L) of AS presented antioxidant effect, whereas in high concentrations (1 mmol/L) it acted as a prooxidant. The main ROS involved in AS prooxidant effect was O2¯, which was produced, at least in part, by the action of NADPH oxidase, since the increase of ROS production by AS was inhibited by Tiron and reduced in the presence of Apocynin. These data were obtained by fluorescence DHE probe by flow cytometry in HUVECs. Despite the production of ROS in high concentrations, the compound did not show toxicity.

Complicações vasculares do transplante hepático podem causar alterações de perfusão e drenagem do enxerto com prejuízo à sua função, comprometendo a qualidade de vida e a sobrevida do receptor. A angioplastia transluminal percutânea é uma opção de tratamento para estas complicações. No entanto, pela falta de trabalhos dedicados para população pediátrica, não há consenso sobre sua segurança em longo prazo e qual técnica seria a mais adequada. Este estudo teve como objetivo avaliar a resposta terapêutica do tratamento endovascular percutâneo da estenose de veia porta em crianças submetidas ao transplante de fígado. Entre agosto de 2000 e agosto de 2009, foram realizados 254 transplantes hepáticos no Instituto da Criança Professor Pedro de Alcântara do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Quinze delas (5,9%; 15/254) desenvolveram estenose de veia porta com indicação de tratamento. O diagnóstico da lesão foi confirmado pela ultrassonografia em todos os casos. O tratamento da estenose consistiu inicialmente na angioplastia com balão por acesso transparietohepático ao sistema porta, sendo o implante de stent indicado nos casos de estenose residual maior que 30%, ou na recidiva da estenose. A idade média do grupo tratado foi de 4,5 anos ± 2,9 anos (mediana de 3,6 anos) e o peso médio, de 15,3 kg ± 5,7 kg (mediana de 14,6 kg). Dez pacientes (66,7%; 10/15) foram tratados com sucesso por uma única sessão de angioplastia com balão. Outra criança (1/15; 6,7%) foi tratada com sucesso por implante de stent indicado pela estenose residual > 30% após a tentativa de tratamento com balão numa mesma sessão. Outras quatro, inicialmente tratadas por angioplastia com balão (26,7%; 4/15), evoluíram com recidiva da estenose após 19 dias, 2 meses, 8 meses e 2 anos do tratamento e foram submetidas a nova angioplastia, desta vez com implante de stent. O tempo médio de seguimento foi de 7,4 anos ± 2,6 anos (mediana de 7,9 anos) com taxa de perviedade primária foi de 73,3% (11/15) e taxa de perviedade primária assistida, obtida pela reintervenção precoce da re-estenose da veia porta antes de sua obstrução, de 100%. A angioplastia com balão da estenose de veia porta após transplante hepático em crianças demonstrou ser um método seguro e efetivo neste grupo de pacientes no seguimento avaliado. Os casos tratados com stent apresentaram índices semelhantes de segurança e sucesso terapêutico / Vascular complications of liver transplantation can compromise grafts perfusion and drainage affecting its function and recipients quality of life. Percutaneous transluminal angioplasty is an option for these complications. However, especially in children, there is no consensus about its long-term safety and which technique would be most appropriate. This study has the objective to evaluate the therapeutic response of percutaneous endovascular treatment of portal vein stenosis in children submitted to liver transplantation. Between August 2000 and August 2009, 254 liver transplants were performed at the Instituto da Criança - Professor Pedro de Alcântara do Hospital da Clínicas da Faculdade de Medicina da Universidade de São Paulo. Fifteen of them (5.9%, 15/254) developed portal vein stenosis confirmed by ultrasound in all cases. The treatment of the portal vein stenosis consisted initially in balloon angioplasty. The stent was indicated in residual (greater than 30%) or recurrent stenosis. The mean age of the treated group was 4.5 years ± 2.9 years (median 3.6 years) and the mean weight was 15.3 kg ± 5.7 kg (median 14.6 kg). Ten patients (66.7%, 10/15) were successfully treated by a single session of balloon angioplasty. Another child (1/15, 6.7%) was successfully treated by stent due to residual stenosis after balloon angioplasty. Four other children (26.7%, 4/15) developed recurrent stenosis after 19 days, 2 months, 8 months and 2 years of initial treatment with balloon and underwent to a new angioplasty this time, with stent. The primary patency rate was 73.3% (11/15) and the assisted primary patency rate, determined by early intervention before portal vein occlusion, was 100%. Follow-up time was 7.4 years ± 2.6 years (median 7.9 years). Balloon angioplasty of portal vein stenosis after liver transplantation in children demonstrated to be a safe and effective method in this group of patients during the follow-up period of this research. Cases treated with stent had similar rates of safety and therapeutic successes

Introdução: A termoablação vem substituindo a cirurgia convencional no tratamento cirúrgico do refluxo da veia safena magna em pacientes portadores de varizes dos membros inferiores. Contudo, a termoablação apresenta elevados custos. A Eletrocoagulação endovenosa pode, seletivamente e de forma segura, causar necrose da parede da veia safena magna, mas seus resultados clínicos nunca foram estudados previamente. O objetivo deste estudo é comparar a Eletrocoagulação e a Radiofrequência no tratamento da insuficiência da veia safena magna, considerando eficácia, complicações e impacto na qualidade de vida. Métodos: Trata-se de um ensaio clinico prospectivo, randomizado e duplo-cego. Os pacientes portadores de varizes de membros inferiores e refluxo de veia safena magna ao Eco Doppler colorido foram randomizados em dois grupos de tratamento: Eletrocoagulação ou Radiofrequência. O seguimento dos pacientes ocorreu após uma semana, três meses e seis meses do procedimento. O desfecho primário foi considerado como oclusão da veia safena magna ao Eco Doppler colorido e o desfecho secundário, como a taxa de complicações e a melhora na qualidade de vida, mediante pontuação do Escore de Gravidade Clínica Venosa e Questionário Aberdeen para Veias Varicosas. Resultados: Foram incluídos no estudo 57 pacientes, totalizando 85 veias safenas magnas tratadas, sendo que 43 foram submetidas à Radiofrequência e 42, à Eletrocoagulação. Não houve diferença estatisticamente significante entre os grupos, no pré-operatório, em relação à idade (P = 0,264), gênero (P = 0,612), Escore de Gravidade Clínica Venosa (P = 0,125), Questionário Aberdeen para Veias Varicosas (P = 0,054), diâmetro (P = 0,880) e profundidade (P = 0,763) da veia safena magna tratada. No intraoperatório, imediatamente após a realização da termoablação, todas as veias safenas magnas submetidas à eletrocoagulação apresentaram ausência de fluxo no segmento tratado e incompressibilidade, enquanto 12 membros ainda exibiam fluxo em sua veia safena magna tratada (P < 0,001) e 9 veias apresentavam-se compressíveis (P < 0,001), quando submetidas à Radiofrequência. A principal complicação pós-operatória encontrada foi a parestesia, não havendo significância estatística quanto à sua presença entre os grupos (P = 0,320). O tempo de retorno às atividades rotineiras foi menor no grupo da Eletrocoagulação em relação ao grupo da Radiofrequência (P = 0,026). Não houve diferença entre os grupos em relação à taxa de oclusão da veia safena magna no seguimento de 3 meses (P = 0,157) e 6 meses (P = 0,157), bem como na melhora da pontuação do Questionário Aberdeen para veias varicosas após 3 meses (P = 0,786) e 6 meses (P = 0,401) e na melhora da pontuação do Escore de Gravidade Clínica Venosa após 3 meses (P = 0,324) e 6 meses (P = 0,367). Conclusões: A Eletrocoagulação revelou-se um método eficaz para ablação da veia safena magna, com taxa de oclusão venosa, ocorrência de complicações e impacto na qualidade de vida semelhantes àqueles encontrados na Radiofrequência. / Background: Thermoablation has been replacing conventional surgery in the surgical treatment of great saphenous vein reflux in patients with lower limb varicose veins; however, thermoablation is expensive. Intravenous Electrocoagulation may, selectively and safely, cause necrosis of the great saphenous vein wall, but the clinical results have never been studied. The objective of this study was to compare Electrocoagulation and Radiofrequency in the treatment of great saphenous vein insufficiency, considering efficacy, complications and effect on quality of life. Methods: This is a prospective, double-blind, randomized clinical trial. Patients with lower limb varicose veins and great saphenous vein reflux confirmed by duplex ultrasonography were randomized into two treatment groups: Electrocoagulation or Radiofrequency. Patients were followed-up 1 week, 3 months and 6 months after the procedure. Occlusion of the great saphenous vein confirmed by duplex ultrasonography was considered the primary outcome and the rate of complications and improvement in quality of life, using the Aberdeen Varicose Veins Questionnaire and Venous Clinical Severity Score, were the secondary outcome. Results: Fifty-seven patients were included, with a total of 85 treated great saphenous veins; 43 were treated with Radiofrequency and 42 with Electrocoagulation. There was no statistically significant difference between the groups regarding age (P = 0,264), sex (P = 0,612), Venous Clinical Severity Score (P = 0,125), Aberdeen Varicose Veins Questionnaire score (P = 0,054), diameter (P = 0,880) and depth (P = 0,763) of the treated great saphenous vein. In the intraoperative period, immediately after thermoablation, all great saphenous veins treated with Electrocoagulation presented no flow in the treated segment and incompressibility, while 12 limbs still had flow in treated great saphenous vein (P < 0,001), and 9 veins showed compressibility (P < 0,001) when treated with Radiofrequency. The main postoperative complication was paresthesia; however there was no statistical significance between the groups (P = 0,320) regarding its presence. Time to return to routine activities was lower in the Electrocoagulation group than in the Radiofrequency group (P = 0,026). There was no difference between the groups at the 3-month (P = 0,157) and 6-month (P = 0,157) follow-ups regarding occlusion of the great saphenous vein and in improvement of Aberdeen Varicose Veins Questionnaire score after 3 months (P = 0,786) and 6 months (P = 0,401) and Venous Clinical Severity Score after 3 months (P = 0,324) and 6 months (P = 0,367). Conclusions: Electrocoagulation has been shown to be an effective method for ablation of the great saphenous vein, with venous occlusion rate, occurrence of complications, and effect on the quality of life similar to that with Radiofrequency.

Complicações vasculares do transplante hepático podem causar alterações de perfusão e drenagem do enxerto com prejuízo à sua função, comprometendo a qualidade de vida e a sobrevida do receptor. A angioplastia transluminal percutânea é uma opção de tratamento para estas complicações. No entanto, pela falta de trabalhos dedicados para população pediátrica, não há consenso sobre sua segurança em longo prazo e qual técnica seria a mais adequada. Este estudo teve como objetivo avaliar a resposta terapêutica do tratamento endovascular percutâneo da estenose de veia porta em crianças submetidas ao transplante de fígado. Entre agosto de 2000 e agosto de 2009, foram realizados 254 transplantes hepáticos no Instituto da Criança Professor Pedro de Alcântara do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Quinze delas (5,9%; 15/254) desenvolveram estenose de veia porta com indicação de tratamento. O diagnóstico da lesão foi confirmado pela ultrassonografia em todos os casos. O tratamento da estenose consistiu inicialmente na angioplastia com balão por acesso transparietohepático ao sistema porta, sendo o implante de stent indicado nos casos de estenose residual maior que 30%, ou na recidiva da estenose. A idade média do grupo tratado foi de 4,5 anos ± 2,9 anos (mediana de 3,6 anos) e o peso médio, de 15,3 kg ± 5,7 kg (mediana de 14,6 kg). Dez pacientes (66,7%; 10/15) foram tratados com sucesso por uma única sessão de angioplastia com balão. Outra criança (1/15; 6,7%) foi tratada com sucesso por implante de stent indicado pela estenose residual > 30% após a tentativa de tratamento com balão numa mesma sessão. Outras quatro, inicialmente tratadas por angioplastia com balão (26,7%; 4/15), evoluíram com recidiva da estenose após 19 dias, 2 meses, 8 meses e 2 anos do tratamento e foram submetidas a nova angioplastia, desta vez com implante de stent. O tempo médio de seguimento foi de 7,4 anos ± 2,6 anos (mediana de 7,9 anos) com taxa de perviedade primária foi de 73,3% (11/15) e taxa de perviedade primária assistida, obtida pela reintervenção precoce da re-estenose da veia porta antes de sua obstrução, de 100%. A angioplastia com balão da estenose de veia porta após transplante hepático em crianças demonstrou ser um método seguro e efetivo neste grupo de pacientes no seguimento avaliado. Os casos tratados com stent apresentaram índices semelhantes de segurança e sucesso terapêutico / Vascular complications of liver transplantation can compromise grafts perfusion and drainage affecting its function and recipients quality of life. Percutaneous transluminal angioplasty is an option for these complications. However, especially in children, there is no consensus about its long-term safety and which technique would be most appropriate. This study has the objective to evaluate the therapeutic response of percutaneous endovascular treatment of portal vein stenosis in children submitted to liver transplantation. Between August 2000 and August 2009, 254 liver transplants were performed at the Instituto da Criança - Professor Pedro de Alcântara do Hospital da Clínicas da Faculdade de Medicina da Universidade de São Paulo. Fifteen of them (5.9%, 15/254) developed portal vein stenosis confirmed by ultrasound in all cases. The treatment of the portal vein stenosis consisted initially in balloon angioplasty. The stent was indicated in residual (greater than 30%) or recurrent stenosis. The mean age of the treated group was 4.5 years ± 2.9 years (median 3.6 years) and the mean weight was 15.3 kg ± 5.7 kg (median 14.6 kg). Ten patients (66.7%, 10/15) were successfully treated by a single session of balloon angioplasty. Another child (1/15, 6.7%) was successfully treated by stent due to residual stenosis after balloon angioplasty. Four other children (26.7%, 4/15) developed recurrent stenosis after 19 days, 2 months, 8 months and 2 years of initial treatment with balloon and underwent to a new angioplasty this time, with stent. The primary patency rate was 73.3% (11/15) and the assisted primary patency rate, determined by early intervention before portal vein occlusion, was 100%. Follow-up time was 7.4 years ± 2.6 years (median 7.9 years). Balloon angioplasty of portal vein stenosis after liver transplantation in children demonstrated to be a safe and effective method in this group of patients during the follow-up period of this research. Cases treated with stent had similar rates of safety and therapeutic successes

The site of confluence of the artery and the portal vein in the liver still appears to be controversial. Anatomical studies suggested a presinusoidal or an intrasinusoidal confluence in the first, second or even final third of the sinusoids. The objective of this investigation was to study the problem with functional biochemical techniques. Rat livers were perfused through the hepatic artery and simultaneously either in the orthograde direction from the portal vein to the hepatic vein or in the retrograde direction from the hepatic vein to the portal vein. Arterial how was linearly dependent on arterial pressure between 70 cm H2O and 120 cm H2O at a constant portal or hepatovenous pressure of 18 cm H2O. An arterial pressure of 100 cm H2O was required for the maintenance of a homogeneous orthograde perfusion of the whole parenchyma and of a physiologic ratio of arterial to portal how of about 1:3. Glucagon was infused either through the artery or the portal vein and hepatic vein, respectively, to a submaximally effective ''calculated'' sinusoidal concentration after mixing of 0.1 nmol/L. During orthograde perfusions, arterial and portal glucagon caused the same increases in glucose output. Yet during retrograde perfusions, hepatovenous glucagon elicited metabolic alterations equal to those in orthograde perfusions, whereas arterial glucagon effected changes strongly reduced to between 10% and 50%. Arterially infused trypan blue was distributed homogeneously in the parenchyma during orthograde perfusions, whereas it reached clearly smaller areas of parenchyma during retrograde perfusions. Finally, arterially applied acridine orange was taken up by all periportal hepatocytes in the proximal half of the acinus during orthograde perfusions but only by a much smaller portion of periportal cells in the proximal third of the acinus during retrograde perfusions. These findings suggest that in rat liver, the hepatic artery and the portal vein mix before and within the first third of the sinusoids, rather than in the middle or even last third.