Recanalization of portal vein thrombosis after pediatric liver transplantation: Efficacy and safety of the transsplenic access.

BACKGROUND: Endovascular management of portal vein thrombosis (PVT) is challenging. Transsplenic access (TSA) is growing as an access option to the portal system but with higher rates of bleeding complications. The aim of this article is to evaluate the efficacy and safety of transsplenic portal vein recanalization (PVR) using a metallic stent after pediatric liver transplantation. MATERIALS AND METHODS: This is a retrospective review of 15 patients with chronic PVT who underwent PVR via TSA between February 2016 and December 2020. Two children who had undergone catheterization of a mesenteric vein tributary by minilaparotomy were excluded from the patency analysis but included in the splenic access analysis. The technical and clinical success of PVR and complications related to the procedure via TSA were evaluated. RESULTS: Thirteen children with PVT were treated primarily using the TSA. The mean age was 4.1 years (range, 1.5-13.7 years), and the most common clinical presentation was hypersplenism (60%). Technically successful PVR was performed in 11/13 (84.6%) children, and clinical success was achieved in 9/11 (81.8%) children. No major complications were observed, and one child presented moderate pain in the TSA (from a total of 17 TSA). The median follow-up was 48.2 months. The median primary patency was 9.9 months. Primary patency in the first 4 years was 75%, and primary assisted patency was 100% in the follow-up period. CONCLUSIONS: Transsplenic PVR is a safe and effective method for the treatment of PVT after pediatric liver transplantation.

Safety and efficacy of HepaSphere 50-100 µm in the treatment of hepatocellular carcinoma.

AIM: To evaluate the effects of HepaSphere 50-100 µm (Merit Medical) as a doxorubicin carrier and embolization agent for the treatment of hepatocellular carcinoma (HCC). MATERIAL AND METHODS: A prospective analysis of 18 patients recruited from a national cancer center was conducted. This analysis evaluated the efficacy and safety of HepaSphere, as expressed by the treatment response rate (measured by the modified Response Evaluation Criteria in Solid Tumors, mRECIST) and by the prevalence of treatment-related adverse events, respectively. RESULTS: The cohort was predominantly male, with a mean age of 69 years. The objective response rate (complete + partial response) was 53.3%. The variable most likely to be associated with objective response was Barcelona Clinic Liver Cancer (BCLC) staging. The most prevalent adverse events were nausea, vomiting and abdominal pain. CONCLUSION: HepaSphere chemoembolization yielded a substantial objective response rate with an acceptable toxicity profile and should be considered an option for HCC treatment.

Percutaneous use of ePTFE/FEP-covered metallic stent for palliation of malignant biliary obstruction.

INTRODUCTION: Placement of self-expanding metallic stents has been a standard palliative treatment for patients with inoperable biliary malignancy, aiming at improving quality of life via a minimally invasive procedure. This study aimed to evaluate the efficacy of percutaneous placement of expanded polytetrafluoroethylene/fluorinated ethylene propylene-covered metallic stents for palliation of inoperable biliary malignancy. MATERIAL AND METHODS: Between February 2012 and April 2013, 11 patients with inoperable malignant biliary obstruction were treated with stent implantation. Serum bilirubin and liver enzyme levels were measured before/immediately after stent placement and at one, three, and six months. Patient survival and stent patency were calculated using Kaplan-Meier analysis. RESULTS: No migration occurred. Patients showed clinical improvement immediately and one month after stent placement, with a significant reduction in mean serum bilirubin level (p < 0.05). At six months, bilirubin levels were <1.5 mg/dL in all cases. One patient developed acute liver failure four days after stent implantation, leading to death. Survival rates were 90% at three months and 70% at six months. Primary patency rates were 100%, 100%, and 90% at one, three, and six months, respectively. CONCLUSION: Percutaneous placement of expanded polytetrafluoroethylene/fluorinated ethylene propylene-covered metallic stents offered an effective palliative therapy for patients with inoperable biliary malignancy.

Percutaneous stent placement for the treatment of malignant biliary obstruction: nitinol versus elgiloy stents.

OBJECTIVE: This study aimed to compare two self-expanding stents, a nitinol stent and an elgiloy stent, both placed percutaneously, in terms of their efficacy in palliating inoperable malignant biliary obstruction. MATERIALS AND METHODS: We retrospectively investigated 99 patients with unresectable malignant biliary obstruction treated with percutaneous placement of a self-expanding metallic stent at our institution between May 2007 and January 2010. Serum bilirubin and liver enzyme levels were measured before and 30 days after stenting. For all procedures using elgiloy or nitinol stents, stent occlusion and patient survival rates were calculated using Kaplan-Meyer analysis. RESULTS: All of the patients showed clinical improvement after stent placement, with no difference between the two groups. In both groups, the occlusion-free survival rate was 67% at 30 days, 37% at 90 days, 25% at 180 days, and 10% at 360 days, with no significant difference in relation to the type of stent. CONCLUSION: The two stents evaluated showed comparable efficacy for the percutaneous treatment of unresectable biliary malignancy, with good clinical results.

OBJETIVO: Este estudo procurou comparar a eficácia do implante percutâneo do stent autoexpansível de nitinol versus o stent de elgiloy para paliação da obstrução biliar maligna irressecável. MATERIAIS E MÉTODOS: Nós investigamos, retrospectivamente, 99 pacientes com obstrução maligna irressecável tratada com implante percutâneo de stent metálico autoexpansível em nossa instituição, de março de 2007 até janeiro de 2010. Os níveis séricos de bilirrubina e enzimas hepáticas foram medidos antes e 30 dias após o implante do stent. Para os procedimentos em que foi utilizado o stent de elgiloy ou o stent de nitinol, as taxas de oclusão dos stents e as taxas de sobrevida dos pacientes foram calculadas pela análise de Kaplan-Meyer. RESULTADOS: Os pacientes mostraram melhora clínica após o implante dos stents, sem diferença entre os dois grupos. As taxas de sobrevida livre de oclusão foram 67% aos 30 dias, 37% aos 90 dias, 25% aos 180 dias e 10% aos 360 dias para ambos os grupos, sem diferença significativa em relação ao tipo de stent. CONCLUSÃO: Os dois stents mostraram eficácias comparáveis no tratamento da doença biliar maligna irressecável, com bons resultados clínicos.

BRAZILIAN CONSENSUS FOR MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 3: CONTROVERSIES AND UNRESECTABLE METASTASES.

In the last module of this consensus, controversial topics were discussed. Management of the disease after progression during first line chemotherapy was the first discussion. Next, the benefits of liver resection in the presence of extra-hepatic disease were debated, as soon as, the best sequence of treatment. Conversion chemotherapy in the presence of unresectable liver disease was also discussed in this module. Lastly, the approach to the unresectable disease was also discussed, focusing in the best chemotherapy regimens and hole of chemo-embolization.

Neste último módulo do consenso, abordou-se alguns temas controversos. O primeiro tópico discutido foi o manejo da doença após progressão na primeira linha de quimioterapia, com foco em se ainda haveria indicação cirúrgica neste cenário. A seguir, o painel debruçou-se sobre as situações de ressecção da doença hepática na presença de doença extra-hepática, assim como, qual a melhor sequência de tratamento. O tratamento de conversão para doença inicialmente irressecável também foi abordado neste módulo, incluindo as importantes definições de quando se pode esperar que a doença se torne ressecável e quais esquemas terapêuticos seriam mais efetivos à luz dos conhecimentos atuais sobre a biologia tumoral e taxas de resposta objetiva. Por último, o tratamento da doença não passível de ressecção foi discutida, focando-se nos melhores esquemas a serem empregados e seu sequenciamento, bem como o papel da quimioembolização no manejo destes pacientes.

Improving CT-guided transthoracic biopsy of mediastinal lesions by diffusion-weighted magnetic resonance imaging.

OBJECTIVES: To evaluate the preliminary results obtained using diffusion-weighted magnetic resonance imaging and the apparent diffusion coefficient for planning computed tomography-guided biopsies of selected mediastinal lesions. METHODS: Eight patients with mediastinal lesions suspicious for malignancy were referred for computed tomography-guided biopsy. Diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient measurement were performed to assist in biopsy planning with diffusion/computed tomography fused images. We selected mediastinal lesions that could provide discordant diagnoses depending on the biopsy site, including large heterogeneous masses, lesions associated with lung atelectasis or consolidation, lesions involving large mediastinal vessels and lesions for which the results of biopsy using other methods and histopathological examination were divergent from the clinical and radiological suspicion. RESULTS: In all cases, the biopsy needle was successfully directed to areas of higher signal intensity on diffusion-weighted sequences and the lowest apparent diffusion coefficient within the lesion (mean, 0.8 [range, 0.6-1.1]×10-3 mm2/s), suggesting high cellularity. All biopsies provided adequate material for specific histopathological diagnoses of four lymphomas, two sarcomas and two thymomas. CONCLUSION: Functional imaging tools, such as diffusion-weighted imaging and the apparent diffusion coefficient, are promising for implementation in noninvasive and imaging-guided procedures. However, additional studies are needed to confirm that mediastinal biopsy can be improved with these techniques.

Computed tomography-guided percutaneous biopsy of bone lesions: rate of diagnostic success and complications.

OBJECTIVE: To determine the rates of diagnostic success and complications of computed tomography (CT)-guided percutaneous biopsy of bone lesions suspected for malignancy. MATERIALS AND METHODS: Retrospective study including 186 cases of CT-guided percutaneous biopsies of bone lesions in the period from January, 2010 to December, 2012. All the specimens were obtained with 8-10 gauge needles. The following data were collected: demographics, previous history of malignancy, data related to the lesion, to the procedure, and to histological results. RESULTS: Most patients were women (57%), and the mean age was 53.0 ± 16.4 years. In 139 cases (74.6%), there was diagnostic suspicion of metastasis and the most common primary tumors were breast (32.1%) and prostate (11.8%). The bones most commonly involved were spine (36.0%), hip (32.8%) and long bones (18.3%). Complications occurred in only three cases (1.6%) including bone fracture, paresthesia with functional impairment, and needle breakage requiring surgical removal. The specimens collected from 183 lesions (98.4%) were considered appropriate for diagnosis. Malignant results were more frequently found in patients who had a suspected secondary lesion and history of known malignancy (p < 0.001), and in patients who underwent PET/CT-guided procedures (p = 0.011). CONCLUSION: CT-guided percutaneous biopsy is a safe and effective procedure for the diagnosis of suspicious bone lesions.

OBJETIVO: Determinar taxas de definição diagnóstica e complicações da biópsia percutânea guiada por tomografia computadorizada (TC) de lesões ósseas suspeitas de malignidade. MATERIAIS E MÉTODOS: Estudo retrospectivo que incluiu 186 casos de biópsia percutânea guiada por TC de lesões ósseas no período de janeiro de 2010 a dezembro de 2012. Todas as amostras foram obtidas usando agulhas de 8 a 10 gauge. Foram coletados dados demográficos, história de neoplasia maligna prévia, dados relacionados à lesão, ao procedimento e ao resultado histológico. RESULTADOS: A maioria dos pacientes era do sexo feminino (57%) e a idade média foi 53,0 ± 16,4 anos. Em 139 casos (74,6%) a suspeita diagnóstica era metástase e os tumores primários mais comuns foram de mama (32,1%) e próstata (11,8%). Os ossos mais envolvidos foram coluna vertebral (36,0%), bacia (32,8%) e ossos longos (18,3%). Houve complicações em apenas três pacientes (1,6%), incluindo uma fratura, um caso de parestesia com comprometimento funcional e uma quebra da agulha necessitando remoção cirúrgica. Amostras de 183 lesões (98,4%) foram consideradas adequadas para diagnóstico. Resultados malignos foram mais frequentes nos pacientes com suspeita de lesão secundária e história de neoplasia maligna conhecida (p < 0,001) e nos procedimentos orientados pela PET/CT (p = 0,011). CONCLUSÃO: A biópsia percutânea guiada por TC é segura e eficaz no diagnóstico de lesões ósseas suspeitas.

Percutaneous stent placement for the treatment of malignant biliary obstruction: nitinol versus elgiloy stents / Tratamento percutâneo de obstrução biliar maligna: comparação entre os stents nitinol e elgiloy

Abstract Objective: This study aimed to compare two self-expanding stents, a nitinol stent and an elgiloy stent, both placed percutaneously, in terms of their efficacy in palliating inoperable malignant biliary obstruction. Materials and Methods: We retrospectively investigated 99 patients with unresectable malignant biliary obstruction treated with percutaneous placement of a self-expanding metallic stent at our institution between May 2007 and January 2010. Serum bilirubin and liver enzyme levels were measured before and 30 days after stenting. For all procedures using elgiloy or nitinol stents, stent occlusion and patient survival rates were calculated using Kaplan-Meyer analysis. Results: All of the patients showed clinical improvement after stent placement, with no difference between the two groups. In both groups, the occlusion-free survival rate was 67% at 30 days, 37% at 90 days, 25% at 180 days, and 10% at 360 days, with no significant difference in relation to the type of stent. Conclusion: The two stents evaluated showed comparable efficacy for the percutaneous treatment of unresectable biliary malignancy, with good clinical results.

Resumo Objetivo: Este estudo procurou comparar a eficácia do implante percutâneo do stent autoexpansível de nitinol versus o stent de elgiloy para paliação da obstrução biliar maligna irressecável. Materiais e Métodos: Nós investigamos, retrospectivamente, 99 pacientes com obstrução maligna irressecável tratada com implante percutâneo de stent metálico autoexpansível em nossa instituição, de março de 2007 até janeiro de 2010. Os níveis séricos de bilirrubina e enzimas hepáticas foram medidos antes e 30 dias após o implante do stent. Para os procedimentos em que foi utilizado o stent de elgiloy ou o stent de nitinol, as taxas de oclusão dos stents e as taxas de sobrevida dos pacientes foram calculadas pela análise de Kaplan-Meyer. Resultados: Os pacientes mostraram melhora clínica após o implante dos stents, sem diferença entre os dois grupos. As taxas de sobrevida livre de oclusão foram 67% aos 30 dias, 37% aos 90 dias, 25% aos 180 dias e 10% aos 360 dias para ambos os grupos, sem diferença significativa em relação ao tipo de stent. Conclusão: Os dois stents mostraram eficácias comparáveis no tratamento da doença biliar maligna irressecável, com bons resultados clínicos.

Brazilian consensus for multimodal treatment of colorectal liver metastases. module 3: controversies and unresectable metastases / Consenso brasileiro de tratamento multidisciplinar de metástase hepática de origem colorretal módulo 3: controvérsias e metástases irressecáveis

ABSTRACT In the last module of this consensus, controversial topics were discussed. Management of the disease after progression during first line chemotherapy was the first discussion. Next, the benefits of liver resection in the presence of extra-hepatic disease were debated, as soon as, the best sequence of treatment. Conversion chemotherapy in the presence of unresectable liver disease was also discussed in this module. Lastly, the approach to the unresectable disease was also discussed, focusing in the best chemotherapy regimens and hole of chemo-embolization.

RESUMO Neste último módulo do consenso, abordou-se alguns temas controversos. O primeiro tópico discutido foi o manejo da doença após progressão na primeira linha de quimioterapia, com foco em se ainda haveria indicação cirúrgica neste cenário. A seguir, o painel debruçou-se sobre as situações de ressecção da doença hepática na presença de doença extra-hepática, assim como, qual a melhor sequência de tratamento. O tratamento de conversão para doença inicialmente irressecável também foi abordado neste módulo, incluindo as importantes definições de quando se pode esperar que a doença se torne ressecável e quais esquemas terapêuticos seriam mais efetivos à luz dos conhecimentos atuais sobre a biologia tumoral e taxas de resposta objetiva. Por último, o tratamento da doença não passível de ressecção foi discutida, focando-se nos melhores esquemas a serem empregados e seu sequenciamento, bem como o papel da quimioembolização no manejo destes pacientes.

Endovascular techniques and procedures, methods for removal of intravascular foreign bodies.

INTRODUCTION: The incidence of intravascular embolization of venous catheters reported in the world medical literature corresponds to 1% of all the described complications. However, its mortality rate may vary between 24 to 60%. Catheter malfunction is the most likely signal of embolization, since patients are usually asymptomatic. OBJECTIVE: To report the method of removing intravascular foreign bodies, catheters with the use of various endovascular techniques and procedures. METHODS: This is a two-year retrospective study of 12 patients: seven women and five men. The average age was 29 years (ranging from two months to 65 years). RESULTS: Technical performance was 100% successful. Ten port-a-caths, one intra-cath and one PICC were extracted. The most common sites for the lodging of one of the ends of the intravascular foreign bodies were the right atrium (41.6%) and the right ventricle (33.3%). In 100% of the cases, only one venous access was used for extraction of foreign bodies, and in 91.6% of the cases (11 catheters) the femoral access was used. The loop-snare was used in 10 cases (83.3%). The most common cause of intravascular foreign body insertion was a catheter fracture, which occurred in 66.6% of the cases (eight cases). One major complication, the atrial fibrillation, occurred (8.3%), which was related to the intravascular foreign body extraction. The mortality rate in 30 days was zero. CONCLUSION: Percutaneous retrieval of intravascular foreign bodies is considered gold standard treatment because it is a minimally invasive, relatively simple, safe procedure, with low complication rates compared to conventional surgical treatment.

Chronic portal vein thrombosis after liver transplantation in a child treated by a combined minimally invasive approach.

Portal vein thrombosis (PVT) after orthotopic liver transplantation is an infrequent complication, and when it is present surgical treatment is considered for traditional management. Percutaneous transhepatic portal vein angioplasty has been described as an option to treat PVT with a lower morbidity than conventional surgical treatments. This article describes a case of chronic PVT in a child after a living donor liver transplantation managed by percutaneous transhepatic and surgical approaches.

Biópsia percutânea de lesões ósseas guiada por tomografia computadorizada: taxas de definição diagnóstica e complicações / Computed tomography-guided percutaneous biopsy of bone lesions: rate of diagnostic success and complications

Objetivo: Determinar taxas de definição diagnóstica e complicações da biópsia percutânea guiada por tomografia computadorizada (TC) de lesões ósseas suspeitas de malignidade. Materiais e Métodos: Estudo retrospectivo que incluiu 186 casos de biópsia percutânea guiada por TC de lesões ósseas no período de janeiro de 2010 a dezembro de 2012. Todas as amostras foram obtidas usando agulhas de 8 a 10 gauge. Foram coletados dados demográficos, história de neoplasia maligna prévia, dados relacionados à lesão, ao procedimento e ao resultado histológico. Resultados: A maioria dos pacientes era do sexo feminino (57%) e a idade média foi 53,0 ± 16,4 anos. Em 139 casos (74,6%) a suspeita diagnóstica era metástase e os tumores primários mais comuns foram de mama (32,1%) e próstata (11,8%). Os ossos mais envolvidos foram coluna vertebral (36,0%), bacia (32,8%) e ossos longos (18,3%). Houve complicações em apenas três pacientes (1,6%), incluindo uma fratura, um caso de parestesia com comprometimento funcional e uma quebra da agulha necessitando remoção cirúrgica. Amostras de 183 lesões (98,4%) foram consideradas adequadas para diagnóstico. Resultados malignos foram mais frequentes nos pacientes com suspeita de lesão secundária e história de neoplasia maligna conhecida (p < 0,001) e nos procedimentos orientados pela PET/CT (p = 0,011). Conclusão: A biópsia percutânea guiada por TC é segura e eficaz no diagnóstico de lesões ósseas suspeitas. .

Objective: To determine the rates of diagnostic success and complications of computed tomography (CT)-guided percutaneous biopsy of bone lesions suspected for malignancy. Materials and Methods: Retrospective study including 186 cases of CT-guided percutaneous biopsies of bone lesions in the period from January, 2010 to December, 2012. All the specimens were obtained with 8-10 gauge needles. The following data were collected: demographics, previous history of malignancy, data related to the lesion, to the procedure, and to histological results. Results: Most patients were women (57%), and the mean age was 53.0 ± 16.4 years. In 139 cases (74.6%), there was diagnostic suspicion of metastasis and the most common primary tumors were breast (32.1%) and prostate (11.8%). The bones most commonly involved were spine (36.0%), hip (32.8%) and long bones (18.3%). Complications occurred in only three cases (1.6%) including bone fracture, paresthesia with functional impairment, and needle breakage requiring surgical removal. The specimens collected from 183 lesions (98.4%) were considered appropriate for diagnosis. Malignant results were more frequently found in patients who had a suspected secondary lesion and history of known malignancy (p < 0.001), and in patients who underwent PET/CT-guided procedures (p = 0.011). Conclusion: CT-guided percutaneous biopsy is a safe and effective procedure for the diagnosis of suspicious bone lesions. .

Improving CT-guided transthoracic biopsy of mediastinal lesions by diffusion-weighted magnetic resonance imaging

OBJECTIVES: To evaluate the preliminary results obtained using diffusion-weighted magnetic resonance imaging and the apparent diffusion coefficient for planning computed tomography-guided biopsies of selected mediastinal lesions. METHODS: Eight patients with mediastinal lesions suspicious for malignancy were referred for computed tomography-guided biopsy. Diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient measurement were performed to assist in biopsy planning with diffusion/computed tomography fused images. We selected mediastinal lesions that could provide discordant diagnoses depending on the biopsy site, including large heterogeneous masses, lesions associated with lung atelectasis or consolidation, lesions involving large mediastinal vessels and lesions for which the results of biopsy using other methods and histopathological examination were divergent from the clinical and radiological suspicion. RESULTS: In all cases, the biopsy needle was successfully directed to areas of higher signal intensity on diffusion-weighted sequences and the lowest apparent diffusion coefficient within the lesion (mean, 0.8 [range, 0.6-1.1]×10-3 mm2/s), suggesting high cellularity. All biopsies provided adequate material for specific histopathological diagnoses of four lymphomas, two sarcomas and two thymomas. CONCLUSION: Functional imaging tools, such as diffusion-weighted imaging and the apparent diffusion coefficient, are promising for implementation in noninvasive and imaging-guided procedures. However, additional studies are needed to confirm that mediastinal biopsy can be improved with these techniques. .

Avaliação da imagem funcional através do PET/CT e DW-MRI nas biópsias transtorácicas guiadas por tomografia computadorizada / Functional imaging evaluation through PET / CT and DWMRI in transthoracic biopsies guided by computed tomography

Introdução: A biópsia transtorácica percutânea guiada por tomografia computadorizada apesar de segura e eficaz, não fornece um detalhamento muitas vezes necessário para acesso a uma lesão pulmonar indeterminada suspeita de neoplasia primária na intenção de confirmação histopatológica. Métodos funcionais e metabólicos como a difusão por Ressonância Magnética (DW-RM) e Tomografia por Emissão de Pósitrons (PET-CT) após administração do F18-Fluorodesoxiglicose podem auxiliar na melhora dos resultados, permitindo direcionar a coleta da amostra para uma área de maior representatividade biológica. Objetivo: Verificar de forma prospectiva, a importância da imagem funcional e metabólica, através da utilização da DW-RM e do PET-CT, no resultado histopatológico obtido pela biópsia percutânea guiada por TC de lesões pulmonares indeterminadas suspeitas de neoplasia primária. Metodologia: Foram estudados, de forma prospectiva, 27 pacientes com lesões pulmonares indeterminadas, suspeitas para câncer de pulmão, sendo realizado de forma complementar a DW-RM ou o PET-CT. Foram coletadas amostras de duas áreas distintas de uma mesma lesão guiadas pelos valores locais de SUV e mapas de ADC formando-se duas áreas arbitrariamente definidas como de suspeição menor e maior para câncer. Resultados: Os pacientes que fizeram a DW-RM apresentaram lesões de tamanho mediano de 65,0 mm (37,0 - 75,0 mm). A área de maior suspeição obteve uma mediana de ADC de 1,17 x 10-3mm2/s (0,31 - 2,82 x 10-3mm2/s), enquanto a de menor suspeição uma mediana de 1,87 x 10-3mm2/s (1,00 - 3,44 x 10-3mm2/s; P=0,0001). Foram positivas para câncer 100% das amostras da área de maior suspeição e 71,43% das amostras da área de menor suspeição (P= 0,0184). Os pacientes que realizaram o PET-CT apresentaram lesões de tamanho mediano de 61,0 mm (42,0 - 87,0). A área de maior suspeição obteve uma mediana do SUV de 7,1 (2,3 - 10,9) e a área de menor suspeição de 3,9 (0,9 - 3,9; P= 0,0002). Foram positivos para câncer 76,9 % das amostras em ambas as áreas (P=0,0522). Conclusão: Os métodos diagnósticos utilizados neste estudo, PET-CT e DW-RM, mostraram que os tumores são funcional e metabolicamente heterogêneos, e que esta heterogeneidade tem implicações no diagnóstico histopatológico

Introduction: Computed tomography guided transcutaneous transthoracic biopsy, although safe and effective, does not provide enough detailing that is often necessary to access an indeterminate lung lesion suspected of lung cancer for the purpose of histopathological confirmation. Functional and metabolic methods such as Magnetic Resonance Diffusion (DW-RM) and Positron Emission Tomography (PET-CT) after administration of F18-Fluorodeoxyglucose may help improve the results, in addition to directing sample collection to a lesion area of greater biological representativeness. Objective: To prospectively verify the importance of functional and metabolic imaging, through the use of DW-MRI and PET-CT, in the histopathological results obtained by CT-guided percutaneous biopsy of indeterminate pulmonary lesions suspected of primary cancer. Methodology: Twenty-seven patients with indeterminate pulmonary lesions, suspected of lung cancer, were prospectively evaluated after have been performed in a complementary way the DW-MRI or PET-CT. Samples were collected from two different lesion areas guided by local SUV values and ADC maps forming two arbitrarily defined areas of lower and higher suspicion for cancer. Results: Patients who underwent DW-MRI had median lesion size of 65.0 mm (37.0 - 75.0 mm). The higher suspicion area had a median of ADC of 1.17 x 10-3 mm2 / s (0.31 - 2.82 x 10-3mm2 / s), while the lower suspicion area had a median of 1.87 x 10 -3mm2 / s (1.00 - 3.44x10-3mm2 / s; P = 0.0001). 100% of the samples from the higher suspicion area and 71.43% of the samples from the lower suspicion area (P = 0.0184) were positive for cancer. Patients who performed PET-CT had median lesion size of 61.0 mm (42.0 - 87.0). The higher suspicion area obtained a median SUV of 7.1 (2.3 - 10.9) and the lower suspicion area of 3.9 (0.9 - 3.9; P = 0.0002). 76.9% of the samples were positive for cancer in both areas (P = 0.0522). Conclusion: The diagnostic methods used in this study, PET-CT and DW-MRI, showed that tumors are functional and metabolically heterogeneous and that this heterogeneity has implications for histopathological diagnosis

Acesso venoso trans-hepático percutâneo para hemodiálise: uma alternativa para pacientes portadores de insuficiência renal crônica / Percutaneous transhepatic venous access for hemodialysis: an alternative route for patients with end-stage renal failure

CONTEXTO: Acesso venoso trans-hepático percutâneo para hemodiálise é uma opção para pacientes que já exauriram acessos venosos tradicionais. OBJETIVO: Apresentar uma série de casos que demonstram a factibilidade e a funcionalidade da implantação dos cateteres semi-implantáveis por meio de acesso venoso trans-hepático percutâneo em pacientes sem possibilidades de outros acessos. MÉTODOS: Análise observacional retrospectiva dos prontuários de seis pacientes que foram submetidos à implantação de nove cateteres trans-hepáticos percutâneos para hemodiálise. Os cateteres foram implantados na ausência de acessos venosos periféricos disponíveis. No seguimento dos pacientes, procurou-se avaliar: sucesso técnico do procedimento, taxa de complicação, taxa de infecção e patência do acesso. RESULTADOS: Quatro homens e duas mulheres com idades entre 31 e 85 anos (média: 55 anos). Sucesso técnico obtido em 100 por cento. A média de duração dos cateteres foi de 300,5 dias (2 a 814 dias). Médias de patência primária e secundária foram de 179,60 e 328,33 dias, respectivamente. Taxa de trombose dos cateteres foi de 0,05 por 100 cateteres-dias, assim como a taxa de infecção. Houve três complicações precoces (30 primeiros dias de implantação dos cateteres): dois deslocamentos dos cateteres e uma infecção. Duas complicações tardias foram observadas: uma trombose e uma migração. Três pacientes (50 por cento) tiveram que trocar seus cateteres. Taxa de mortalidade em 30 dias foi de 33 por cento, porém não relacionada ao procedimento. CONCLUSÃO: Implantação do cateter para hemodiálise por meio do acesso venoso trans-hepático percutâneo parece ser uma técnica segura, porém a utilização desse acesso deve ser aplicada somente em casos de esgotamento de outros acessos vasculares profundos.

BACKGROUND: Percutaneous transhepatic venous access is an option for hemodialysis patients who have exhausted all traditional sites of venous access. OBJECTIVES: To present a small sample regarding the possibility and the functionality of transhepatic implantation of long-term catheters for hemodialysis in patients with no other possible access routes. METHODS: Retrospective observational analysis was made of the charts of six patients in which nine tunneled dialysis catheters were implanted by the percutaneous transhepatic route. Transhepatic catheters were placed in the absence of an available peripheral venous site. Patients were monitored to evaluate technical success, the complication rate, the infection rate and the duration of catheter patency. RESULTS: Four men and two women aged 31 to 85 years (mean age: 55 years). Technical success was 100 percent. The mean duration of catheter function was 300.5 days (range: 2 to 814 days). Means of primary and secondary patency were 179.60 and 328.33 days, respectively. The catheter thrombosis rate was 0.05 per 100 catheter-days as the infection rate. There were three early complications (within the first 30 days of catheter implantation): two catheter displacement and one infection. Two late complications were observed: one thrombosis and one migration. Three patients (50 percent) needed to have their catheters changed. The 30-day mortality rate was 33 percent but with no relation to the procedure. CONCLUSION: It may be suggested that this technique is safe, however transhepatic hemodialysis catheters may be used in patients with no other options for deep venous access for hemodialysis, albeit as a last resort access route.

Táticas e técnicas endovasculares para retirada de corpos estranhos intravenosos / Endovascular techniques and procedures, methods for removal of intravascular foreign bodies

INTRODUÇÃO: A incidência da embolização de cateteres intravenosos, na literatura mundial, é de 1 por cento dentre todas as complicações descritas. Porém, possui taxa de mortalidade podendo variar de 24 a 60 por cento. O não funcionamento do cateter é a suspeita diagnóstica principal da embolização, visto que, habitualmente, os pacientes são assintomáticos. OBJETIVO: Relatar o manejo na extração de corpos estranhos intravenosos, com o uso de táticas e técnicas endovasculares diversas. MÉTODOS: Estudo retrospectivo com 12 pacientes, no período de dois anos. Sete pacientes eram do sexo feminino e cinco do sexo masculino, com média de idade de 29 anos (dois meses a 65 anos). RESULTADOS: Sucesso técnico foi obtido em 100 por cento dos casos. Foram extraídos 10 port-a-caths, um intra-cath e um PICC. Os locais mais frequentes de alojamento de uma das extremidades dos corpos estranhos intravenosos foram o átrio direito (41,6 por cento) e o ventrículo direito (33,3 por cento). Em 100 por cento dos casos se utilizou um único acesso venoso. O acesso femoral foi o mais utilizado, em 91,6 por cento dos casos (11 cateteres). Utilizou-se o laço (loop-snare) em 10 (83,3 por cento) casos. O motivo mais frequente da presença do corpo estranho intravascular foi a fratura do cateter, que ocorreu em 66,6 por cento dos casos (oito pacientes). Houve uma complicação, fibrilação atrial (8,3 por cento), relacionada à extração de corpo estranho intravenoso. A taxa de mortalidade em 30 dias foi igual a zero. CONCLUSÃO: A retirada de corpos estranhos intravenosos por via percutânea é considerada tratamento padrão ouro, por se tratar de procedimento minimamente invasivo, relativamente simples, seguro e com baixas taxas de complicações quando comparada ao tratamento cirúrgico convencional.

INTRODUCTION: The incidence of intravascular embolization of venous catheters reported in the world medical literature corresponds to 1 percent of all the described complications. However, its mortality rate may vary between 24 to 60 percent. Catheter malfunction is the most likely signal of embolization, since patients are usually asymptomatic. OBJECTIVE: To report the method of removing intravascular foreign bodies, catheters with the use of various endovascular techniques and procedures. METHODS: This is a two-year retrospective study of 12 patients: seven women and five men. The average age was 29 years (ranging from two months to 65 years). RESULTS: Technical performance was 100 percent successful. Ten port-a-caths, one intra-cath and one PICC were extracted. The most common sites for the lodging of one of the ends of the intravascular foreign bodies were the right atrium (41.6 percent) and the right ventricle (33.3 percent). In 100 percent of the cases, only one venous access was used for extraction of foreign bodies, and in 91.6 percent of the cases (11 catheters) the femoral access was used. The loop-snare was used in 10 cases (83.3 percent). The most common cause of intravascular foreign body insertion was a catheter fracture, which occurred in 66.6 percent of the cases (eight cases). One major complication, the atrial fibrillation, occurred (8.3 percent), which was related to the intravascular foreign body extraction. The mortality rate in 30 days was zero. CONCLUSION: Percutaneous retrieval of intravascular foreign bodies is considered gold standard treatment because it is a minimally invasive, relatively simple, safe procedure, with low complication rates compared to conventional surgical treatment.

Sangramento espontâneo de artéria lombar em paciente com doença de Von Recklinghausen: tratamento endovascular / Spontaneous lumbar artery bleeding in patient with Von Recklinghausen’s disease: endovascular treatment

Os sangramentos no retroperitônio são, em sua grande maioria, secundários a eventos traumáticos envolvendo grande energia cinética, com poucos relatos na literatura caracterizados como espontâneos. No presente relato, descrevemos paciente gestante, portadora de doença de Von Recklinghausen e com volumoso hematoma retroperitoneal diagnosticado durante o parto cesariano, secundário a ruptura espontânea de artéria lombar. A doença de Von Recklinghausen apresenta manifestações vasculares bem descritas, caracterizando-se principalmente por estenoses que são secundárias a tumores intramurais (proliferação das células de Schwann) e raramente dilatações aneurismáticas, assintomáticas em sua maioria. No presente caso, foi realizada a aortografia com cateterização seletiva e embolização da artéria sangrante com sucesso.

Retroperitoneal bleeding is mainly due to traumatic events with a high amount of kinetic energy, with few reported cases of spontaneous events in the literature. We report on a case of a pregnant woman with Von Recklinghausen"s disease and bulky retroperitoneal hematoma diagnosed during cesarean delivery secondary to spontaneous lumbar artery rupture. Von Recklinghausen"s disease has well-described vascular manifestations, mainly characterized by stenoses related to intramural tumors (Schwann cell proliferation) and rarely asymptomatic aneurysmal dilatations. In this case, aortography was performed with successful selective catheterization and embolization of the bleeding artery.

Fístula aorto-esofágica secundária a fratura de endoprótese torácica: relato de caso / Aortoesophageal fistula secondary to thoracic stent-graft fracture: a case report

O tratamento endovascular dos aneurismas aórticos torácicos tem se desenvolvido consideravelmente nos últimos anos. No entanto, complicações tardias desta nova modalidade terapêutica apenas agora estão sendo observadas e analisadas. Fístulas aorto-esofágicas são complicações raras do tratamento endovascular dos aneurismas aórticos, sendo encontrados poucos relatos na literatura. O presente caso reporta um paciente com aneurisma aórtico torácico tratado há 4 anos e complicado com fratura da endoprótese. Após nova intervenção endovascular, foi observada extrusão da antiga endoprótese através do esôfago com formação de fístula. Apesar do tratamento realizado, o paciente evoluiu a óbito 9 dias após por hemorragia digestiva maciça. Aspectos técnicos e revisão de literatura são discutidos.

The endovascular treatment of thoracic aortic aneurysms has undergone considerable development over the past years. However, late complications of this new therapeutic modality have only recently been observed and analyzed. Aortoesophageal fistulas are rare complications of the endovascular treatment of aortic aneurysms, and there are few reports in the literature. We report a case of a patient with thoracic aortic aneurysm treated 4 years ago and with complications due to stent-graft fracture. After a new endovascular intervention, there was extrusion of the old graft through the esophagus with fistula formation. Despite the treatment, the patient died 9 days later due to massive digestive hemorrhage. Technical aspects and review of the literature are discussed.

Tratamento endovascular de pseudo-anuerisma da artéria subclávia em criança hemofílica / Endovascular treatment of subclavian artery pseudoanurysm in a hemophiliac child

O uso de cateteres venosos centrais em pacientes hemofílicos é muito frequente, devido às próprias características terapêuticas da doença. As complicações desses procedimentos, tais como pseudo-aneurisma, geralmente são mais graves nesses pacientes. A correção cirúrgica do pseudo-aneurisma que acomete a artéria subclávia constitui um dos maiores desafios da cirurgia vascular. Em pacientes hemofílicos, à dificuldade habitual da exposição cirúrgica somam-se os problemas de alteração no processo normal de coagulação. Como alternativa ao tratamento cirúrgico convencional, a utilização de técnicas endovasculares constitui uma solução segura e com bons resultados.