Produção Nacional
Revisado por pares
Vascular Surgery in Brazil
2021; Elsevier BV; Volume: 62; Issue: 4 Linguagem: Inglês
10.1016/j.ejvs.2021.06.023
ISSN1532-2165
AutoresBruno de Lima Naves, Paulo Eduardo Ocke Reis, Maurício Serra Ribeiro, Leonardo Reis de Souza, Gustavo S. Oderich,
Tópico(s)Cardiac, Anesthesia and Surgical Outcomes
ResumoBrazil is a vast and diverse country with 200 million inhabitants distributed through 8.5 million km2 with denser population on the coastal regions. It is the world’s ninth largest economy, with significant cultural, educational, and financial inequities.1The World Bank. GDP. Available at: https://data.worldbank.org/indicator/NY.GDP.MKTP.CD. [Accessed 10 April 2020].Google Scholar An estimated 8% of the population is over 65 years of age. The median life expectancy is 75 years. The fertility rate is lower than 2%. The entire population is covered by the public healthcare system (Sistema Único de Saúde or SUS). A fourth of the population has private health insurance. Since its implementation in 1990, SUS has provided wider access to healthcare, but resources are still concentrated in urban and higher income areas. SUS has been underfunded since its inception.2Castro M.C. Massuda A. Almeida G. Menezes-Filho N.A. Andrade M.V. Noronha K.V.M.S. et al.Brazil’s unified health system: the first 30 years and prospects for the future.Lancet. 2019; 394: 345-356Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar Tertiary care accounts for 50% of SUS costs. Most of the high complexity procedures within SUS are performed in private institutions through public money transfers.3Oliveira P.R. Guerra M. Gomes A.O. Martins A.L. Relação público-privada na política brasileira de atenção cardiovascular de alta complexidade.Rev Adm Pública. 2019; 53: 753-768Google Scholar There are 4 474 certified vascular surgeons in Brazil.4Scheffer M. Demografia médica no Brasil 2020. FMUSP, CFM, 2020Google Scholar Training includes at least four years of residency, with the first two in general surgery followed by two years in vascular surgery. Although a fifth year of vascular residency is not mandatory, several programmes offer additional experience dedicated to endovascular procedures or non-invasive vascular laboratory and ultrasound. The Brazilian Society for Vascular Surgery (Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV) was founded in 1952 and has 3 923 members. Every two years, the SBACV organises a national congress, in addition to numerous smaller regional or national events. Since 2002, the society has sponsored and published a scientific journal, the Jornal Vascular Brasileiro, with original articles in Portuguese and English.5Presti C.O. início da adolescência.J Vasc Br. 2012; 11: 91-92Crossref Scopus (1) Google Scholar The SBACV has initiated the implementation of a national registry of vascular diseases (Registro Vascular Brasileiro – RVB), aiming to provide quality benchmarks and to analyse trends in vascular care and outcomes in Brazil. Cardiovascular disease is a leading cause of death, similar to other western countries. The prevalence of obesity and overweight has increased, affecting more than half of the population. Diabetes is also on the rise affecting as much as 20% of the adult population. Hypertension prevalence is estimated at around 30%. Dyslipidaemia is frequent. More than 40% of the population is sedentary or underperform to the recommended level of physical activity.6Ribeiro A.L.P. Duncan B.B. Brant L.C.C. Lotufo P.A. Mill J.G. Barreto S.M. Cardiovascular health in Brazil.Circulation. 2016; 133: 422-433Crossref PubMed Scopus (160) Google Scholar The national programme for preventing smoking has been very successful with a decline in tobacco use from 35% to 15% between 1989 and 2013.6Ribeiro A.L.P. Duncan B.B. Brant L.C.C. Lotufo P.A. Mill J.G. Barreto S.M. Cardiovascular health in Brazil.Circulation. 2016; 133: 422-433Crossref PubMed Scopus (160) Google Scholar,7Portes L.H. Machado C.V. Turci S.R.B. Figueiredo V.C. Cavalcante T.M. Costa et al.A política de controle do tabaco no Brasil: um balanço de 30 anos.Ciênc Saúde Colet. 2018; 23: 1837-1848Crossref PubMed Scopus (23) Google Scholar In 2008, a study identified the prevalence of peripheral arterial disease (PAD) to be 11%, with only 9% of these individuals being symptomatic.8Makdisse M. Pereira A.C. Brasil D.P. Borges J.L. Machado-Coelho G.L.L. Krieger J.E. et al.Prevalência e fatores de risco associados à doença arterial periférica no projeto corações do Brasil.Arq Bras Cardiol. 2008; 91: 402-414Crossref Scopus (66) Google Scholar More than 20 000 lower limb amputations are performed annually, most because of the advanced stages of diabetes and vascular disease.9Datasus. SIH. Available at: http://tabnet.datasus.gov.br. [Accessed April 10, 2020].Google Scholar,10Jesus-Silva S.G. de Oliveira J.P. Brianezi M.H.C. Silva M.A.M. Krupa A.E. Cardoso R.S. Análise dos fatores de risco relacionados às amputações maiores e menores de membros inferiores em hospital terciário.J Vasc Bras. 2017; 16: 16-22Crossref PubMed Scopus (7) Google Scholar Few and small screening studies in elderly populations described a prevalence of abdominal aortic aneurysm (AAA) at around 2%.11Barros F.S. Pontes S.M. Taylor M.A.S.A. Roelke L.H. Sandri J.L. Jacques C.M. et al.Rastreamento do aneurisma da aorta abdominal na população da cidade de Vitória (ES).J Vasc Br. 2005; 4: 59-65Google Scholar Since 2008, the incidence of ruptured AAA as a cause of death has decreased.12Santo A.H. Puech-Leão P. Krutman M. Trends in abdominal aortic aneurysm-related mortality in Brazil, 2000-2016: a multiple-cause-of-death study.Clinics. 2021; 76: e2388Crossref PubMed Scopus (3) Google Scholar Stroke is one of the leading causes of death and disability. SUS performs around 3 500 carotid interventions each year.9Datasus. SIH. Available at: http://tabnet.datasus.gov.br. [Accessed April 10, 2020].Google Scholar There are an estimated 130 000 patients on dialysis.13Neves P.D.M.M. Sesso R.C.C. Thomé F.S. Lugon J.R. Nascimento M.M. Censo brasileiro de diálise: análise de dados da década 2009-2018.J Bras Nefrol. 2020; 42: 191-200Crossref PubMed Google Scholar Haemodialysis access procedures are an important part of vascular surgery practice. Chronic venous insufficiency (CVI) occurs in as much as 50% of the population.14Virgini-Magalhães C.E. Salvadori R.A.M. Fagundes F.B. Gomes C.F.A. Grupilo C.E.R. de Albuquerque R.M. et al.Cirurgia de varizes em regime de mutirão.J Vasc Bras. 2007; 6: 231-237Crossref Google Scholar In 2019, almost 75 000 procedures were performed for CVI in the SUS.9Datasus. SIH. Available at: http://tabnet.datasus.gov.br. [Accessed April 10, 2020].Google Scholar Also significant are traumatic injuries from motor vehicle accidents or gun violence. Venous disease constitutes most of the daily practice of vascular surgeons in private clinics, including treatment of varicose veins for aesthetic reasons. Vascular ultrasound is also an area of increasing interest among vascular surgeons. Unlike many countries, in Brazil vascular ultrasound examinations are performed by physicians and not by technicians. The demand for specialised non-invasive vascular imaging has led to increasing development of duplex ultrasonography, computed tomography, and magnetic resonance imaging. Like other countries, treatment of vascular diseases has evolved in Brazil. There has been a transition from the traditional open surgical approaches to endovascular techniques for almost every type of pathology. National data from the SUS database showed that, since 2007, over 65% of infrarenal AAAs have been treated by EVAR. The same trends have been shown for revascularisation procedures indicated to treat PAD and carotid disease.9Datasus. SIH. Available at: http://tabnet.datasus.gov.br. [Accessed April 10, 2020].Google Scholar Recently, endovenous treatment of superficial venous incompetence with laser, radiofrequency ablation, and foam therapy has increased, but traditional methods of high ligation, vein stripping, and phlebectomy remain widely accepted as a reasonable alternative and are associated with lower cost. Although widespread access to latest cutting edge technology remains limited, such as some endovascular devices for complex aortic diseases, several centres have increasing clinical experience with fenestrated, branched, and parallel graft techniques for complex aneurysms. SBACV created the national registry (RVB) as a pilot project in August 2020. It aims to register quality improvement in Brazil. The main objective is to catalogue the procedures of the specialty of vascular surgery performed by vascular surgeons associated with SBACV in participating centres and to establish the performance objectives by SBACV that can serve as goals indicators in institutions. It is challenging to start a national registry, but lessons from the VASCUNET countries suggested that a start could be made with limited data collection for two to five types of treatment and gradually expand this across the country.15Behrendt C.A. Venermo M. Cronenwett J.L. Sedrakyan A. Beck A.W. Eldrup-Jorgensen J. Mani K. VASCUNET, the Vascular Quality Initiative and the International Consortium of Vascular Registries. VASCUNET, VQI, and the International Consortium of Vascular Registries - Unique Collaborations for Quality Improvement in Vascular Surgery.Eur J Vasc Endovasc Surg. 2019; 58: 792-793Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar It will help to disseminate and update knowledge in the specialty so that all vascular surgeons can have their best and most up to date practice for effective patient care.16Veith F.J. Ocke Reis P.E. Energy level: an important determinant of success in vascular surgery.J Vasc Bras. 2019; 18e20190029Crossref PubMed Scopus (1) Google Scholar The effects of the COVID-19 pandemic have been devastating in Brazil as in other parts of the world. The high infection and mortality rate has strained the already overwhelmed healthcare system. Initially and during the second wave, most hospitals suspended elective procedures for extended periods. As an example, in 2020 SUS performed less than half of the number of operations for CVI than in the year before.9Datasus. SIH. Available at: http://tabnet.datasus.gov.br. [Accessed April 10, 2020].Google Scholar Delays in diagnosis and treatment of vascular diseases are expected and its consequences are difficult to account for. Additionally, training of new vascular surgeons has been compromised because of decreased surgical volume, especially for elective conditions. Conversely, vascular surgeons continue to be busy as responders on the frontlines, especially assisting with management of vascular access and thromboembolic complications of this new disease. Although exact statistics are not available, the general perception is that COVID-19 has resulted in significant increase in cardiovascular deaths.17Brant L.C.C. Nascimento B.R. Teixeira R.A. Lopes M.A.C.Q. Malta D.C. Oliveira G.M.M. et al.Excess of cardiovascular deaths during the COVID-19 pandemic in Brazilian capital cities.Heart. 2020; 106: 1898-1905Crossref PubMed Scopus (27) Google Scholar
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