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1.
Rev. colomb. cardiol ; 27(4): 314-318, jul.-ago. 2020. graf
Artigo em Espanhol | LILACS, COLNAL | ID: biblio-1289231

RESUMO

Resumen La sífilis es una infección bacteriana producida por el Treponema pallidum (espiroqueta). Consta de varias etapas: primaria, secundaria y terciaria, según el tiempo de evolución desde el momento en que se adquiere la infección. Cada etapa comprende diferentes manifestaciones clínicas; los síntomas cardiovasculares forman parte de la sífilis terciaria, en cuyo caso la aortitis sifilítica es la principal forma de presentación. Se expone el caso de un paciente que consultó por déficit neurológico focal, en quien por medio de estudios de extensión se documentó neurosífilis e insuficiencia valvular aórtica severa secundaria a perforación de la válvula coronaria derecha, que requirió recambio valvular aórtico por bioprótesis. Adicionalmente, se hace una revisión de las principales manifestaciones cardiovasculares de esta enfermedad. Aunque en la era postantibiótica este tipo de manifestaciones tardías son cada vez menos frecuentes, es imperativo conocerlas.


Abstract Syphilis is a bacterial infection caused by Treponema pallidum (spirochete). It has various stages: primary, secondary and tertiary; depending on the time to progression from the moment the infection is acquired. Each stage involves various clinical manifestations; cardiovascular symptoms are part of tertiary syphilis, and syphilitic aortitis is the main form of presentation. We present the case of a patient who consulted with a focal neurological deficit, in whom extension studies reported neurosyphilis and severe aortic failure secondary to perforation of the right coronary valve, which required aortic valve replacement by bioprosthesis. We also undertake a review of the main cardiovascular manifestations of this disease. Although in the post-antibiotic era this type of late manifestation is increasingly less frequent, it is imperative that we are aware of it.


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Aórtica , Sífilis Cardiovascular , Sífilis , Aortite/complicações
2.
Rev. argent. radiol ; 84(2): 61-67, abr. 2020. tab, graf, il.
Artigo em Espanhol | LILACS | ID: biblio-1125857

RESUMO

Resumen La inflamación de la aorta (aortitis) es una patología poco frecuente, con etiología infecciosa (pseudoaneurisma micótico, sífilis) y no infecciosa (arteritis, aortitis idiopática, espondilitis anquilosante, entre otras) de difícil diagnóstico clínico y variable pronóstico. Por esa razón, la utilización de diversos métodos por imágenes, tales como la tomografía computada multidetector (TCMD), la tomografía computada por emisión de positrones (PET-TC), la resonancia magnética (RM) y ultrasonido (US) facilitan la identificación, seguimiento y tratamiento de esa entidad. El siguiente trabajo tiene como objetivo realizar una revisión y actualización bibliográfica acerca de la aortitis y sus diversas etiologías, ejemplificando con casos de nuestra institución.


Abstract Aortic inflammation (aortitis) is a rare pathology, with infectious (fungal pseudoaneurysm, syphilis) and noninfectious etiology (arteritis, idiopathic aortitis, ankylosing spondylitis, among others), it has a difficult clinical diagnosis and a variable prognosis. The use of various imaging methods such as multidetector computed tomography (MDCT), magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT) and ultrasound (US) facilitate the identification, monitoring and treatment of this entity. The following paper aims to perform a literature review and update about aortitis and its various etiologies, exemplifying cases of our institution.


Assuntos
Aortite/etiologia , Aortite/diagnóstico por imagem , Espondilite Anquilosante/diagnóstico por imagem , Arterite de Células Gigantes/diagnóstico por imagem , Angiografia/métodos , Arterite de Takayasu/etiologia , Arterite de Takayasu/diagnóstico por imagem , Tomografia Computadorizada Multidetectores/métodos
3.
Rev. cientif. cienc. med ; 23(1): 87-91, 2020. ilus
Artigo em Espanhol | LILACS | ID: biblio-1126283

RESUMO

Presentamos el caso de una mujer de 55 años sin antecedentes, que acude por dolor abdominal, se realiza una tomografía abdominopélvica evidenciando un tumor retroperitoneal de aspecto quístico en la periferia de la aorta abdominal, que afecta el riñón izquierdo. Se le realizó una laparotomía exploratoria, nefrectomía izquierda, tumorectomía retroperitoneal y una resección de un fragmento de la aorta abdominal con reporte histopatológico, corroborado por una prueba inmunohistoquímica de fibrosis retroperitoneal y aortitis por IgG4. El espectro de enfermedades relacionadas con IgG4 es de origen inmunológico con la capacidad de involucrar casi cualquier órgano. La epidemiología no es precisa, aunque se observa mayor predilección por la raza asiática, siendo más común durante la séptima década de vida. El diagnóstico radica en la coexistencia de varios parámetros clínicos, laboratoriales e histopatológicos, sin ser ninguno de estos patognomónicos. El objetivo del presente artículo es exponer el reporte de un caso con manifestación inusual de fibrosis retroperitoneal y dar a conocer que la importancia del diagnóstico radica en la decisión terapéutica, ya que cursa con buena respuesta al tratamiento inmunosupresor.


We present the case of a 55-year-old woman, with noclinical pathological history, who presented with abdominal pain, abdominopelvic tomography showing retroperitoneal tumoral in the periphery of the abdominal aorta, which affects the left kidney producing hydronephrosis. Exploratory laparotomy, left radical nephrectomy, retroperitoneal tumorectomy and resection of a fragment of abdominal aorta were performed, with histopathological report, corroborated by immunohistochemistry of retroperitoneal fibrosis and IgG4 aortitis. The spectrum of diseases related to IgG4, are of immunological origin that can involve almost any organ. The epidemiology is not precise, although a greater predilection for the Asian race is observed, being more common in the seventh decade of life, it should be suspected in patients with unexplained pain in one or more organs.The diagnosis lies in the coexistence of several clinical, laboratorial and histopathological parameters, without being any of these pathognomonic. We present a case with unusual presentation of retroperitoneal fibrosis and the importance of the diagnosis lies in the therapeutic decision, since it responds well to immunosuppressive treatment, without requiring surgical management.


Assuntos
Aorta Abdominal , Fibrose Retroperitoneal , Diagnóstico , Doença Relacionada a Imunoglobulina G4 , Laparotomia , Aortite , Tomografia
4.
Rev. colomb. cardiol ; 25(3): 236-236, mayo-jun. 2018. graf
Artigo em Espanhol | LILACS, COLNAL | ID: biblio-978230

RESUMO

Resumen Se expone el caso de un paciente de sexo masculino, de 69 años, con antecedentes de hipertensión arterial, tabaquismo, ataque cerebrovascular, fibrilación auricular, insuficiencia aórtica y cardiopatía isquémica, quien ingresa a un hospital de alta complejidad por deterioro de la clase funcional, edema de miembros inferiores y episodios de palpitaciones. En la ecocardiografía se halló fracción de eyección normal, insuficiencia aórtica grave y dilatación de aorta ascendente con criterios quirúrgicos. Dentro de los estudios prequirúrgicos, se documentó VDRL reactivo en títulos altos y confirmación del diagnóstico de sífilis con TP-PA. Se realizó reemplazo valvular aórtico con prótesis biológica e injerto de dacrón en aorta ascendente, y el estudio patológico del material quirúrgico confirmó aortitis sifilítica. Se presenta una revisión respecto a esta patología poco frecuente en la actualidad.


Abstract The case is presented of a 69-year-old male patient with a history of arterial hypertension, smoking, stroke, atrial fibrillation, aortic regurgitation, and ischaemic heart disease, who was admitted to a tertiary hospital due to functional class deterioration, lower limb oedema, and episodes of palpitations. A normal ejection fraction, with severe aortic regurgitation and ascending aortic dilation with surgical criteria, was found on echocardiography. Within pre-surgical studies, the VDRL had high titres and confirmation of the diagnosis of syphilis with TP-PA. Aortic valve replacement was performed using a biological prosthesis and Dacron graft in the ascending aorta. The histopathology study of the surgical material confirmed syphilitic aortitis. A review is presented on the current status of this rare pathology.


Assuntos
Humanos , Masculino , Idoso , Aortite , Sífilis Cardiovascular , Aneurisma Aórtico , Ecocardiografia
5.
Rev. chil. reumatol ; 34(2): 78-84, 2018. ilus
Artigo em Espanhol | LILACS | ID: biblio-1254220

RESUMO

La arteritis de células gigantes corresponde a una vasculitis granulomatosa que afecta arterias de mediano y gran tamaño. El fenotipo clínico más conocido es la arteritis de la temporal, caracterizado por síntomas craneales clásicos como cefalea temporal, claudicación mandibular y síntomas visuales. Sin embargo, esta enfermedad puede comprometer otras grandes arterias como la aorta y sus ramas principales, denomi-nándose así, como arteritis de células gigantes de grandes vasos, la cual puede o no estar asociada a síntomas craneales. Presentamos el caso de una mujer de 74 años, con un cuadro de un mes de evolución, caracterizado por claudicación intermitente de extremidades inferiores, asociado a baja de peso de 3 kilos, sudoración nocturna. Al examen físico, fiebre y pulsos dismi-nuidos en extremidades inferiores.


Giant cell arteritis is a granulomatous vasculitis that affects arteries of medi-um and large size. The most well-known clinical phenotype is temporal arteri-tis, characterized by classic cranial symptoms such as temporal headache, man-dibular claudication and visual symptoms. However, this disease can involve other large arteries such as the aorta and its main branches, known as large ves-sel giant cell arteritis, which may or may not be associated with cranial symptoms.A 74-year-old woman is presented with claudication of lower extremities, associated with weight loss of 3 kilos, night sweats and fever over the past month. Physical ex-amination reveals decreased pulses in the lower extremities.


Assuntos
Humanos , Feminino , Idoso , Artérias/patologia , Arterite de Células Gigantes/diagnóstico , Aortite , Arterite de Células Gigantes/tratamento farmacológico , Biópsia , Prednisona/uso terapêutico , Glucocorticoides/uso terapêutico
6.
Rev. Assoc. Med. Bras. (1992) ; 63(12): 1028-1031, Dec. 2017. tab, graf
Artigo em Inglês | LILACS | ID: biblio-896332

RESUMO

Summary The inflammation of aortic wall, named aortitis, is a rare condition that can be caused by a number of pathologies, mainly inflammatory or infectious in nature. In this context, the occurrence of combined audiovestibular and/or ocular manifestations eventually led to the diagnosis of Cogan's syndrome, making it the rare case, but susceptible to adequate immunosuppressive treatment and satisfactory disease control.


Resumo A inflamação da parede da aorta, denominada aortite, é uma condição clínica rara, que pode ser causada por diversas patologias, principalmente as de fundo inflamatório e/ou infeccioso. Nesse contexto, a ocorrência de sintomas vestibulares e oftalmológicos associados ao quadro remete ao diagnóstico de síndrome de Cogan, tornando o caso raro, mas passível de tratamento imunossupressor adequado e controle satisfatório da doença.


Assuntos
Humanos , Masculino , Idoso , Aortite/diagnóstico por imagem , Síndrome de Cogan/diagnóstico por imagem , Aorta Torácica/diagnóstico por imagem , Aortite/patologia , Angiocardiografia , Diagnóstico Diferencial , Síndrome de Cogan/tratamento farmacológico , Imunossupressores/uso terapêutico
8.
Acta méd. colomb ; 41(4): 259-265, oct.-dic. 2016. tab, graf
Artigo em Espanhol | LILACS, COLNAL | ID: biblio-949524

RESUMO

Resumen Se presenta el caso de un hombre de 65 años con cuadro clínico de cefalea y velocidad de sedimentación globular elevada en quien se sospechó arteritis de células gigantes (ACG), pero durante el proceso diagnóstico se le documentó paquimeningitis, hiperproteinorraquia y biopsia de arteria temporal reportada como normal. La búsqueda de otras enfermedades sistémicas que explicaran el cuadro clínico evidenció además la presencia de aortitis, glomerulonefritis y anticuerpos anticitoplasma de neutrófilos (ANCA) positivos, lo cual permitió hacer el diagnóstico de granulomatosis con poliangeítis (GP). Se presenta el análisis y enfoque diagnóstico de esta inusual asociación de paquimeningitis, aortitis y glomerulonefritis. (Acta Med Colomb 2016; 40: 259-265).


Abstract The case of a 65-year-old man with a clinical picture of headache and elevated erythrocyte sedimentation rate in whom giant cell arteritis (GCA) was suspected, but that during the diagnostic process was documented as pachymeningitis, hyperproteinorrachia and temporal artery biopsy reported as normal, is presented. The search for other systemic diseases that could explain the clinical picture also revealed the presence of aortitis, glomerulonephritis and anti-neutrophil cytoplasmic antibodies (ANCA), and allowed to make the diagnosis of granulomatosis with poliangeítis (GPA). The analysis and diagnostic approach of this unusual association of pachymeningitis, aortitis and glomerulonephritis is reported. (Acta Med Colomb 2016; 40:259-265).


Assuntos
Humanos , Masculino , Idoso , Aortite , Meningite , Relatos de Casos , Granulomatose com Poliangiite , Nefrite
9.
Rev. méd. Chile ; 144(11): 1486-1490, nov. 2016. ilus
Artigo em Espanhol | LILACS | ID: biblio-845472

RESUMO

Large vessel vasculitis and particularly Temporal Arteritis are systemic diseases that may affect the aorta and its major branches, mainly involving extra cranial branches of the carotid artery. We report a 72-year-old man presenting with weight loss, fever and malaise. Positron emission computed tomography (PET CT) showed an extensive inflammation of the aorta and its major branches. Temporal artery biopsy confirmed the presence of vasculitis with granulomas. Treatment with a high dose of steroids had an excellent clinical response. This case underscores the utility of PET CT in the assessment of this disease.


Assuntos
Humanos , Masculino , Idoso , Aortite/patologia , Aortite/diagnóstico por imagem , Arterite de Células Gigantes/patologia , Arterite de Células Gigantes/diagnóstico por imagem , Aortite/tratamento farmacológico , Artérias Temporais/patologia , Arterite de Células Gigantes/tratamento farmacológico , Biópsia , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada
11.
Rev. méd. Chile ; 143(9): 1206-1209, set. 2015. ilus
Artigo em Espanhol | LILACS | ID: lil-762690

RESUMO

Pauci-immune glomerulonephritis in systemic vasculitides usually have anti-neuthrophil cytoplasmic antibodies (ANCA). However, vasculitides of large vessels such as Takayasu’s and giant cell (temporal) arteritis do not. Exceptionally ANCA(+) small vessel vasculitides are associated with large vessel vasculitis. It may be a coincidence or both vasculitides have a common pathogenesis. We report a 30 years old woman on hemodialysis due to a chronic glomerulonephritis ANCA(+) diagnosed nine years ago. Eight years later, she presented with an aortitis with severe stenosis of distal aorta and vasculitis of left subclavian artery. She was treated with adrenal steroids and cyclophosphamide. During the ensuing five years she has been stable and without signs of reactivation of the disease.


Assuntos
Adulto , Feminino , Humanos , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/tratamento farmacológico , Estenose da Valva Aórtica/tratamento farmacológico , Aortite/tratamento farmacológico , Ciclofosfamida/uso terapêutico , Esteroides/uso terapêutico , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/complicações , Estenose da Valva Aórtica/diagnóstico , Aortite/diagnóstico , Insuficiência Renal/complicações , Arterite de Takayasu/tratamento farmacológico
12.
J. vasc. bras ; 14(2): 193-196, Apr.-June 2015. ilus
Artigo em Inglês | LILACS | ID: lil-756475

RESUMO

Behcet's disease is form of systemic vasculitis of unknown etiology. One surprising feature is that arterial involvement is less common in this disease than venous forms, accounting for 1 to 7% of patients. In 7 to 30% of cases the vascular symptoms precede the clinical diagnosis of Behcet. We describe the case of a patient with Thromboangiitis Obliterans who was treated with lumbar sympathectomy and an aortobiiliac bypass. Around 1 year later he was diagnosed with Behcet's disease after presenting with oral ulcers, genital ulcers and scaling lesions on the hands.


A Doença de Behçet é uma vasculite sistêmica de etiologia desconhecida. O inusitado é que o acometimento arterial nesta doença é menos comum que o venoso, correspondendo a 1 a 7% dos pacientes. Já os sintomas vasculares precedem o diagnóstico clínico de Behçet em 7 a 30%. Relatamos o caso de um paciente portador de Tromboangeíte Obliterante que foi submetido a simpatectomia lombar e derivação aorto-bi-ilíaca. Após cerca de um ano, diagnosticou-se Doença de Behçet, devido a quadro clínico de úlceras orais, genitais e lesões descamativas nas mãos.


Assuntos
Humanos , Masculino , Adulto , Síndrome de Behçet , Diagnóstico Tardio , Doença Arterial Periférica , Trombose/complicações , Trombose/terapia , Aortite/complicações , Doença Crônica , Artérias da Tíbia
14.
Rev. méd. Chile ; 142(7): 924-929, jul. 2014. ilus
Artigo em Espanhol | LILACS | ID: lil-726182

RESUMO

Aortitis is a nonspecific term that describes an inflammation of the aortic wall caused by inflammatory, infectious, paraneoplastic and idiopathic diseases. The symptoms are variable and nonspecific; therefore a high level of clinical suspicion is required to diagnose it. It is often an incidental finding while looking for other diagnoses and it is confirmed mainly through imaging studies. We report three cases of aortitis: A 29-year-old woman presenting with alopecia, oral and nasal ulcers and positive antinuclear antibodies. A CAT scan showed a segmental thickening of thoracic aorta, with dilated and stenotic areas. She was successfully treated with steroids, hydroxychloroquine, cyclophosphamide and azathioprine. A 41-year-old male presenting with dorsal pain and cough. The CAT scan showed an extra-intimal thickening of the descending aorta and stenosis of the celiac artery. The final diagnosis was a polyangiitis and was treated with steroids, cyclophosphamide and azathioprine. A 28-year-old woman presenting with pain in the left upper abdomen. Imaging studies showed a thickening of the aortic arch and subclavian artery. The final diagnosis was sarcoidosis and the patient was treated with prednisone.


Assuntos
Adulto , Feminino , Humanos , Masculino , Aortite , Aortite/etiologia , Tomografia Computadorizada por Raios X
15.
Rev. méd. Chile ; 142(5): 646-650, mayo 2014. ilus
Artigo em Espanhol | LILACS | ID: lil-720673

RESUMO

Due to its multisystem involvement, IgG4 -related disease should be considered in the differential diagnosis of medical conditions such as lymphadenopathies, aortitis, serositis and retroperitoneal fibrosis. It shares features with other entities historically described as "great mimickers" such as syphilis, tuberculosis, sarcoidosis, and systemic lupus erythematosus. We report a 40 year-old male with recurrent effusive - constrictive pericarditis, lymphadenopathy and aortitis. The study revealed an inactive tuberculosis with negative cultures for acid fast bacilli. The patient had high serum levels of IgG4 and a mediastinal lymph node biopsy was consistent with IgG4 -related disease. The patient was treated with prednisone 40 mg/day with an excellent response.


Assuntos
Adulto , Humanos , Masculino , Aortite/diagnóstico , Imunoglobulina G/sangue , Doenças Linfáticas/diagnóstico , Aortite/sangue , Biópsia , Diagnóstico Diferencial , Doenças Linfáticas/sangue , Tomografia Computadorizada por Raios X
16.
Acta méd. colomb ; 34(2): 85-87, abril.-junio. 2009. ilus
Artigo em Espanhol | LILACS | ID: lil-523808

RESUMO

La infección por Streptococcus equi zooepidemicus es propia de animales y en el hombre es generalmente accidental con reporte de pocos casos. Presentamos el caso de un hombre de 56 años, matarife, con cuadro de dolor abdominal, documentándose por TAC y en cirugía dilatación aneurismática de la aorta por debajo de las renales, con colección purulenta y ulceración del vaso de donde se aisló Streptococcus equi zooepidemicus, aislándose también la bacteria de los hemocultivos.


Assuntos
Humanos , Aneurisma da Aorta Abdominal , Aortite , Bacteriemia , Streptococcus equi , Zoonoses
17.
São Paulo med. j ; 119(4): 150-153, July 2001. ilus, tab
Artigo em Inglês | LILACS | ID: lil-302322

RESUMO

CONTEXT: Primary aortoenteric fistulas usually result from erosion of the bowel wall due to an associated abdominal aortic aneurysm. A few patients have been described with other etiologies such as pseudoaneurysm originating from septic aortitis caused by Salmonella. OBJECTIVE: To present a rare clinical case of pseudoaneurysm caused by septic aortitis that evolved into an aortoenteric fistula. CASE REPORT: A 65-year-old woman was admitted with Salmonella bacteremia that evolved to septic aortitis. An aortic pseudoaneurysm secondary to the aortitis had eroded the transition between duodenum and jejunum, and an aortoenteric fistula was formed. In the operating room, the affected aorta and intestinal area were excised and an intestine-to-intestine anastomosis was performed. The aorta was sutured and an axillofemoral bypass was carried out. In the intensive care unit, the patient had a cardiac arrest that evolved to death


Assuntos
Humanos , Feminino , Idoso , Doenças da Aorta , Aortite , Fístula Intestinal , Falso Aneurisma , Sepse , Fístula , Aorta , Doenças da Aorta , Aortite , Fístula Intestinal , Falso Aneurisma , Fístula
18.
Medicina (B.Aires) ; 55(4): 341-4, 1995.
Artigo em Espanhol | LILACS | ID: lil-161638

RESUMO

Endovascular infection of atherosclerotic aorta is a rare event in the setting of aged patients gram negative bacteremia of the salmonella group. Until the beginning of the 60s this meant an ominous diagnosis with an almost unavoidable fatal prognosis. Presently, this trend has been reverted, mostly due to an earlier diagnosis, the development of more sophisticated imaging techniques, the correct use of broad spectrum bactericidal antibiotics and prompt surgical management. Paradoxically, the incidence of arterial infections has increased in recent years, specially in old people with atherosclerotic abdominal aortic aneurysms, in whom infective endocarditis could not be demonstrated. We describe the case of a 65 year old man, with a history of long-standing non-insulin-dependent diabetes, presenting with protracted fever, weight loss and thigh pain. Blood cultures and serologic studies as well as several echocardiograms yielded negative results. An abdominal CT scan showed an infrarenal aortic aneurysm raising the clinical suspicion of arterial infection of abdominal aorta. The patient underwent surgery because of highly presumptive diagnosis of complicated aortic aneurysm. The resection was followed by an in situ graft. There was no evidence of disruption or gross collection. Samples of the aortic wall and perianeurysmatic fluid grew Salmonella enteritides. We describe the main etiopathogenic and clinic features of the entity highlighting the high sensitivity and specificity of the CT scan in the identification and characterization of infected aortic aneurysm. Certain features may firmly suggest this diagnosis without using preoperative aortography.


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Aortite/etiologia , Febre de Causa Desconhecida/etiologia , Infecções por Salmonella/complicações , Aneurisma da Aorta Abdominal/complicações , Aortite/terapia , Infecções por Salmonella/diagnóstico , Salmonella enteritidis/isolamento & purificação , Tomografia Computadorizada por Raios X
19.
An. oftalmol ; 10(1): 74-6, 1991.
Artigo em Português | LILACS | ID: lil-152294

RESUMO

Um caso de Doença de Takayasu com comprometimento retiniano é descrito bem como o tratamento realizado através de foto-coagulaçäo


Assuntos
Humanos , Feminino , Adulto , Arterite de Takayasu/diagnóstico , Arterite de Takayasu/tratamento farmacológico , Arterite de Takayasu/cirurgia , Arterite de Takayasu/terapia , Angiografia , Síndromes do Arco Aórtico , Aortite
20.
Arq. bras. cardiol ; 37(3): 195-8, 1981. ilus
Artigo em Português | LILACS | ID: lil-5185

RESUMO

E relatado o caso de uma paciente de 10 anos de idade com dados clinicos tipicos de coartacao da aorta toracica. O estudo angiografico demonstrou estreitamento severo da parte media da aorta toracica descendente.A paciente foi submetida a tratamento cirurgico, verificou-se trata-se de uma aortite e foi realizada ampliacao da zona estreitada com placa de teflon. A paciente teve excelente resultado clinico e angiografico. Sao feitos comentarios relativos a natureza da aorto-arterite e a tecnica operatoria empregada


Assuntos
Aortite , Retalhos Cirúrgicos
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