RESUMO
The ideal management of concomitant carotid and coronary artery occlusive disease remains elusive. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines among national or international clinical societies. Clinical studies show that coronary artery bypass grafting (CABG) with either staged or synchronous carotid endarterectomy (CEA) is associated with a high procedural stroke or death rate. Recent clinical studies have found carotid artery stenting (CAS) prior to CABG can lead to superior treatment outcomes in asymptomatic patients who are deemed high risk of CEA. With emerging data suggesting favorable outcome of CAS compared to CEA in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options when treating patients with concurrent carotid and coronary disease. This review examines the available clinical data on therapeutic strategies in patients with concomitant carotid and coronary artery disease. A treatment paradigm for considering CAS or CEA as well as CABG and percutaneous coronary intervention is discussed.
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Estenose das Carótidas/complicações , Estenose das Carótidas/cirurgia , Ponte de Artéria Coronária , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/cirurgia , Endarterectomia das Carótidas , Ponte de Artéria Coronária/efeitos adversos , Endarterectomia das Carótidas/efeitos adversos , Humanos , Complicações Pós-Operatórias , Stents , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
INTRODUCTION: Although biological grafts have been utilized as a vascular conduit in leg bypass for many years, reports of a bovine carotid artery graft (BCAG) in lower extremity revascularization have been scarce. This study analyzed the outcome of lower leg bypass using BCAG. METHODS: A retrospective review of a prospectively collected database of all patients undergoing lower extremity bypass using BCAG from 2002 to 2017 was performed. Clinical outcomes including graft patency and limb salvage were evaluated. RESULTS: A total of 124 BCAG (Artegraft, North Brunswick, NJ) were implanted in 120 patients for lower extremity revascularization. Surgical indications included disabling claudication in 12%, rest pain in 36%, tissue loss in 48%, and infected prosthetic graft replacement in 3%. Autologous saphenous vein was either inadequate or absent in 72% of patients. BCAG was used in 46 patients (37%) who had a prior failed ipsilateral leg bypass. Distal anastomosis was performed in the above-knee popliteal artery, below-knee popliteal artery, and tibial artery in 30 cases (25%), 32 cases (26%), and 48 cases (39%), respectively. Distal anastomotic patch was created in all tibial artery to allow BCAG-tibial reconstruction. The yearly primary patency rates in 5 years were 86.5, 76.4, 72.2, 68.3, and 67.5%, respectively. The corresponding yearly secondary patency rates were 88.5, 84.7, 82.4, 78.5, and 75.6%, respectively. The limb salvage rate at one year was 83.6% and at five years was 86.2% for patients with critical limb ischemia. Multivariate analysis showed poor runoff score (P = 0.03, 95% CI, 1.3-5.3; OR, 1.6) was independently associated with graft occlusion. CONCLUSION: BCAG is an excellent vascular conduit and provides good long-term results in lower extremity bypass.
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Artérias Carótidas/transplante , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Idoso , Idoso de 80 Anos ou mais , Animais , Bovinos , Feminino , Humanos , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Grau de Desobstrução Vascular , Procedimentos Cirúrgicos VascularesRESUMO
BACKGROUND: This study evaluated the risk of thromboembolism during endovascular interventions in patients with symptomatic lower extremity deep vein thrombosis (DVT) METHODS: Clinical records of all patients who underwent endovascular interventions for symptomatic lower extremity DVT from 2001 to 2017 were retrospectively analyzed using a prospectively maintained database. Only patients who received an inferior vena cava (IVC) filter were included in the analysis. Trapped intrafilter thrombus was assessed for procedure-related thromboembolism. Clinical outcomes of thrombus management and thromboembolism risk were analyzed. RESULTS: A total 172 patients (mean age 57.4 years, 98 females) who underwent 174 endovascular DVT interventions were included in the analysis. Treatment strategies included thrombolytic therapy (64%), mechanical thrombectomy (n = 86%), pharmacomechanical thrombolysis (51%), balloon angioplasty (98%), and stent placement (28%). Thrombectomy device used included AngioJet (56%), Trellis (19%), and Aspire (11%). Trapped IVC filter thrombus was identified in 58 patients (38%) based on the IVC venogram. No patient developed clinically evident pulmonary embolism (PE). IVC filter retrieval was performed in 98 patients (56%, mean 11.8 months after implantation). Multivariate analysis showed that iliac vein occlusion (P = 0.04) was predictive for procedure-related thromboembolism. CONCLUSIONS: Iliac vein thrombotic occlusion is associated with an increased thromboembolic risk in DVT intervention. Retrievable IVC filter should be considered when performing percutaneous thrombectomy in patients with iliac venous occlusion to prevent PE.
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Procedimentos Endovasculares/efeitos adversos , Veia Ilíaca , Extremidade Inferior/irrigação sanguínea , Embolia Pulmonar/etiologia , Trombose Venosa/terapia , Adulto , Idoso , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Intervalo Livre de Doença , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Feminino , Humanos , Veia Ilíaca/diagnóstico por imagem , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Flebografia , Embolia Pulmonar/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Filtros de Veia Cava , Trombose Venosa/diagnóstico por imagem , Adulto JovemRESUMO
Objectives Thoracic outlet syndrome, a condition commonly reported in adults, occurs infrequently in the pediatric population. The objective of this study was to assess the outcome of surgical interventions of thoracic outlet syndrome in pediatric patients. Methods Clinical records of all pediatric patients with thoracic outlet syndrome who underwent operative repair from 2002 to 2015 in a tertiary pediatric hospital were reviewed. Pertinent clinical variables and treatment outcomes were analyzed. Results Sixty-eight patients underwent a total of 72 thoracic outlet syndrome operations (mean age 15.7 years). Venous, neurogenic, and arterial thoracic outlet syndromes occurred in 39 (57%), 21 (31%), and 8 (12%) patients, respectively. Common risk factors for children with venous thoracic outlet syndrome included sports-related injuries (40%) and hypercoagulable disorders (33%). Thirty-five patients (90%) with venous thoracic outlet syndrome underwent catheter-based interventions followed by surgical decompression. All patients underwent first rib resection with scalenectomy via either a supraclavicular approach (n = 60, 88%) or combined supraclavicular and infraclavicular incisions (n = 8, 12%). Concomitant temporary arteriovenous fistula creation was performed in 14 patients (36%). Three patients with arterial thoracic outlet syndrome underwent first rib resection with concomitant subclavian artery aneurysm repair. The mean follow-up duration was 38.4 ± 11.6 months. Long-term symptomatic relief was achieved in 94% of patients. Conclusions Venous thoracic outlet syndrome is the most common form of thoracic outlet syndrome in children, followed by neurogenic and arterial thoracic outlet syndromes. Competitive sports-related injuries remain the most common risk factor for venous and neurogenic thoracic outlet syndromes. Temporary arteriovenous fistula creation was useful in venous thoracic outlet syndrome patients in selective children. Surgical decompression provides durable treatment success in children with all subtypes of thoracic outlet syndrome.
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Derivação Arteriovenosa Cirúrgica , Descompressão Cirúrgica/métodos , Procedimentos Endovasculares , Osteotomia/métodos , Costelas/cirurgia , Síndrome do Desfiladeiro Torácico/terapia , Adolescente , Fatores Etários , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Criança , Bases de Dados Factuais , Descompressão Cirúrgica/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Hospitais Pediátricos , Humanos , Masculino , Osteotomia/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Centros de Atenção Terciária , Síndrome do Desfiladeiro Torácico/diagnóstico , Síndrome do Desfiladeiro Torácico/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
Spinal cord ischemia (SCI) has been one of the most concerning complications after surgical and endovascular thoracoabdominal aortic aneurysm repair "Open Branch" is an innovative technique to reduce the incidence of SCI Further studies in a larger number of patients with varying pathologies are needed to confirm the advantages of this technique.
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Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Aneurisma , Procedimentos Endovasculares , Humanos , Paraplegia , Resultado do TratamentoRESUMO
Vascular closure devices allow for early sheath removal, allowing for earlier patient mobilization The Boomerang vascular access management system does not alter arterial integrity for future interventions Access site complications provide significant morbidity in diagnostic and therapeutic interventions.
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Procedimentos Cirúrgicos Cardiovasculares/efeitos adversos , Técnicas Hemostáticas/instrumentação , Hemorragia Pós-Operatória/terapia , Punções/efeitos adversos , Dispositivos de Oclusão Vascular , Desenho de Equipamento , Artéria Femoral , Humanos , PressãoRESUMO
Anticoagulant and antiplatelet medications are necessary in peripheral endovascular intervention, but a standardized approach has not yet been established. Glycoprotein IIb/IIIa inhibitor use in endovascular lower extremity interventions decreased overall amputation rates. Glycoprotein IIb/IIIa inhibitor use in endovascular lower extremity interventions increased postprocedural bleeding and complications requiring intervention.
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Pacientes Internados , Resultado do Tratamento , Humanos , Extremidade Inferior/irrigação sanguínea , Inibidores da Agregação Plaquetária/uso terapêutico , Complexo Glicoproteico GPIIb-IIIa de PlaquetasRESUMO
INTRODUCTION: Alcohol is widely used among young families, and leisure time is frequently family time. Heavy alcohol consumption can adversely affect children. The objective of this work is to measure the harm to others in Chile. SUBJECTS AND METHOD: This descriptive and probabilistic study forms part of a collaborative research funded by Thai Health and WHO. The survey was adapted by co-researchers and applied to a nationally representative sample of 1500 Chileans over 18years of age. RESULTS: A total of 408 respondents (27.2%) lived with children at home. Of this total, 10.5% felt that the use of alcohol by any member of the family had adversely affected a child. The most common adverse effects were verbal violence (29.7%), domestic violence (23.1%), unsupervised homes (18.7%), lack of money to provide basic needs of the child (14.3%), and physical violence (7.7%). Furthermore, in 6.6% of the cases child or family services agencies became involved. In almost half of the cases (46.3%), the drinker was the father, mother or step-parents. This was followed by other relatives (24.4%) and brothers (4.9%), or guardian of the child (2.4%). CONCLUSION: These data support the clinical observation that alcohol is common in Chilean homes. Its consumption not only damages the physical and mental health of the drinker but also those around him. Verbal violence and witnessing serious physical violence are frequent issues, as well as economic problems that end up with the inability to provide the child with its basic needs.
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Consumo de Bebidas Alcoólicas/efeitos adversos , Transtornos Relacionados ao Uso de Álcool/epidemiologia , Relações Familiares , Violência/estatística & dados numéricos , Adolescente , Adulto , Idoso , Consumo de Bebidas Alcoólicas/epidemiologia , Criança , Chile/epidemiologia , Estudos Transversais , Saúde da Família , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND: Alcohol can harm both drinkers and their human environment. Most of research in Chile has focused on the drinker. This work focuses on the damage to others. Governmental expenditures due to drinking are estimated to quadruple the income earned through taxation. AIM: To report the results of a population survey conducted in Chile in 2013 to assess the harm done to others from drinking by a known or unknown drinker. MATERIAL AND METHODS: A household survey of a sample of 1500 subjects living in urban areas, predominantly over 50.000 inhabitants, was conducted by trained interviewers. RESULTS: A significant number of respondents reported that the effect of alcohol consumption by third parties was somewhat (18.7%) or very negative (14.8%). The most frequent negative effects were verbal abuse (37.4%), being bullied (17.4%), feeling fearful at home or in a private meeting (19.6%) and family problems (16.9%). CONCLUSIONS: About one third of Chileans surveyed have suffered negative effects due to alcohol consumption of a known or unknown drinker. This finding signals the need of designing public policies addressed to minimize or prevent collateral effects of drinking.
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Consumo de Bebidas Alcoólicas/epidemiologia , Relações Familiares , Relações Interpessoais , Transtornos do Comportamento Social/epidemiologia , Problemas Sociais , Adolescente , Adulto , Idoso , Consumo de Bebidas Alcoólicas/efeitos adversos , Chile/epidemiologia , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos do Comportamento Social/etiologia , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND: Splenic artery aneurysms (SAA) are a rare entity most commonly diagnosed incidentally. Their association with pregnancy increases the risk of rupture resulting in a disproportionately high maternal and fetal mortality. Accordingly, elective surgical treatment is recommended in asymptomatic patients with aneurysms less than 2 cm. In this case, we present a patient during her third trimester of pregnancy with a SAA who was treated by laparoscopic aneurysm resection and splenectomy. METHODS: The patient is a 38-year-old multiparous woman, with an incidental diagnosis of a SAA in 2010. Subsequently, the patient became pregnant and at 27 weeks started to develop abdominal pain. Failed embolization was attempted with worsening of the patient's symptoms. A CT angiogram revealed a 1.6 cm distal third SAA without any evidence of rupture. Due to the localization of the lesion, the patient was offered a laparoscopic aneurysm resection and splenectomy. RESULTS: Operating time was 90 min and estimated blood loss was 5 cc. Postoperative fetal monitoring was normal. No perioperative complications were observed. The patient was discharged on postoperative day 3. Two months after laparoscopic splenectomy, the patient delivered a male infant in perfect health. CONCLUSIONS: Although this is a rare disease, the risk of aneurysmal rupture is increased during pregnancy. As a result of high maternal and fetal mortality, elective surgery should be performed. Laparoscopic surgery is the technique of choice.
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Aneurisma/cirurgia , Laparoscopia/métodos , Complicações Cardiovasculares na Gravidez/cirurgia , Esplenectomia/métodos , Artéria Esplênica/cirurgia , Procedimentos Cirúrgicos Vasculares/métodos , Adulto , Aneurisma/diagnóstico por imagem , Angiografia , Feminino , Humanos , Gravidez , Complicações Cardiovasculares na Gravidez/diagnóstico por imagem , Terceiro Trimestre da Gravidez , Artéria Esplênica/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
The introduction of laparoscopic surgery, and more recently of robotics, has increased the number of living donor kidney transplants. This approach has already improved living donor acceptance rates. Even newer developments in the field have now been introduced with the purpose of further reducing postoperative pain and length of hospital stay, while offering better cosmetic results. In particular, single-incision surgery has gained popularity by improving the well-known benefits of minimally invasive surgery. In this case report, we present the first single-incision robotic-assisted living donor nephrectomy.
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Doadores Vivos , Nefrectomia/métodos , Robótica/métodos , Feminino , Humanos , Transplante de Rim/métodos , Laparoscopia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Coleta de Tecidos e Órgãos , Adulto JovemRESUMO
INTRODUCTION:: In patients who receive chronic hemodialysis but do not have autogenous venous conduit for a native dialysis access, nonautologous grafts serve as an alternative conduit of choice. This study compared the clinical outcome of hemodialysis access using bovine carotid artery graft (BCAG) and prosthetic polytetrafluoroethylene (PTFE) graft in patients who receive chronic hemodialysis. METHODS:: An analysis of all patients undergoing hemodialysis using either BCAG or PTFE grafts from 2010 to 2017 was performed. Clinical outcomes were analyzed including graft patency as well as associated complications related to dialysis grafts and tunneled dialysis catheter (TDC). RESULTS:: During the study period, 142 patients received BCAG and 128 patients received PTFE graft implantation for dialysis access. The mean duration from graft implantation to graft cannulation in the BCAG and PTFE group was 12.3 ± 8.5 days versus 43.5 ± 16.4, respectively ( P = .01). Bovine carotid artery graft group had a higher 2-year primary patency rate (33% vs 14%, P = .03) and assisted primary rate (57% vs 23%, P = .02) compared to the PTFE group. The 2-year secondary patency rates were similar between the 2 groups (56% vs 53%, P = .69). Complication rates in the BCAG and PTFE group was 1.69 ± 0.24 per patient-year versus 2.54 ± 0.48 per patient-year, respectively ( P = .01). Tunneled dialysis catheter-related infection was greater in the PTFE group compared to the BCAG group (10.87 ± 2.61 vs 5.69 ± 0.98 per 1000 TDC days; P = .02). Bovine carotid artery graft cohorts group required a mean of 1.69 interventions per patient-year, compared to 2.76 per patient-year for the PTFE group ( P = .03). CONCLUSIONS:: Bovine carotid artery graft permits earlier cannulation for hemodialysis access with superior primary and assisted primary patency rates compared to PTFE grafts. Patients with BCAG experienced shorter indwelling TDC duration and less TDC-related complications compared to PTFE cohorts.
Assuntos
Derivação Arteriovenosa Cirúrgica/instrumentação , Bioprótese , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Artérias Carótidas/transplante , Cateterismo , Politetrafluoretileno , Diálise Renal , Extremidade Superior/irrigação sanguínea , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Cateterismo/efeitos adversos , Cateteres de Demora , Bovinos , Bases de Dados Factuais , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Xenoenxertos , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Diálise Renal/efeitos adversos , Diálise Renal/instrumentação , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Adulto JovemRESUMO
The etiology of up to 95% of cerebral aneurysms may be accounted for by hemodynamically-induced factors that create vascular injury. The purpose of this review is to describe key physical properties that stents have and how they affect cerebral aneurysms. We performed a two-step screening process. First, a structured search was performed using the PubMed database. The following search terms and keywords were used: "Hemodynamics," "wall shear stress (WSS)," "velocity," "viscosity," "cerebral aneurysm," "intracranial aneurysm," "stent," "flow diverter," "stent porosity," "stent geometry," "stent configuration," and "stent design." Reports were considered if they included original data, discussed hemodynamic changes after stent-based treatment of cerebral aneurysms, examined the hemodynamic effects of stent deployment, and/or described the geometric characteristics of both stents and the aneurysms they were used to treat. The search strategy yielded a total of 122 articles, 61 were excluded after screening the titles and abstracts. Additional articles were then identified by cross-checking reference lists. The final collection of 97 articles demonstrates that the geometric characteristics and configurations of deployed stents influenced hemodynamic parameters such as aneurysmal WSS, inflow, and pressure. The geometric characteristics of the aneurysm and its position also had significant influences on intra-aneurysmal hemodynamics after treatment. In conclusion, changes in specific aneurysmal hemodynamic parameters that result from stenting relate to a number of factors including the geometric properties and configurations of deployed stents, the geometric properties of the aneurysm, and the pretreatment hemodynamics.
RESUMO
Vasculitis is a clinical condition with associated diagnostic challenges due to nonspecific symptoms and lack of a confirmatory imaging modality. We report a case of a 39-year-old female patient who developed generalized malaise, lethargy, and headache. Laboratory evaluation showed elevated inflammatory markers. Conventional imaging studies including computed tomography and carotid duplex ultrasound were unremarkable. Infrared thermography revealed enhanced thermographic signals in the left carotid artery and aortic arch. Corticosteroid therapy was commenced, and the patient responded well. Follow-up infrared thermography at 6 months showed complete resolution of the thermographic pattern, and the patient remained symptom free.
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INTRODUCTION: Laparoscopic insertion of peritoneal dialysis (PD) catheter has become a preferred method compared to the traditional open technique for PD catheter insertion. We retrospectively report the outcome of 1-port laparoscopic placement PD catheters in our institution. METHODS: A total of 263 patients with end-stage renal disease who underwent single-trocar laparoscopic PD catheter insertion during a recent 6-year period were reviewed. Laparoscopic technique involves introducing a PD catheter over a stiff guidewire into the abdominal cavity through a 10-mm laparoscopic port. Pertinent clinical variables, procedural complications, and follow-up outcome were analyzed. RESULTS: There were 182 men and 81 women. The mean age was 56 years. Technical success was 95.8%. Catheter occlusion was the most common early complications (<6 months) that occurred in 4 (1.5%) patients. Late complications (> 6 months) including catheter occlusion, cuff extrusion, catheter leakage, catheter migration, infection, and hernia occurred in 5 patients (1.9%), 2 patients (0.8%), 3 patients (1.1%), 3 patients (1.1%), 6 patients (2.3%), and 4 patients (1.5), respectively. Mean follow-up time was 39 ± 18 months. Catheter survival rate at 1, 2, 3, 4, and 5 years was 96%, 94%, 90%, 85%, and 82%, respectively. CONCLUSION: Laparoscopic PD catheter implantation via a single-trocar utilizing a stiff guidewire technique is feasible and safe. This method can result in low complication and high catheter survival rate.
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Cateteres de Demora , Falência Renal Crônica/terapia , Laparoscopia , Diálise Peritoneal/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Obstrução do Cateter/etiologia , Infecções Relacionadas a Cateter/microbiologia , Infecções Relacionadas a Cateter/terapia , Remoção de Dispositivo , Falha de Equipamento , Feminino , Migração de Corpo Estranho/etiologia , Migração de Corpo Estranho/terapia , Hérnia Ventral/etiologia , Hérnia Ventral/cirurgia , Herniorrafia , Humanos , Falência Renal Crônica/diagnóstico , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Diálise Peritoneal/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Right ventricular failure is a serious complication after left ventricular assist device placement. CASE PRESENTATION: A 70-year-old male in decompensated heart failure with right ventricular failure after the placement of a left ventricular assist device. A single dual-lumen PROTEKDuo cannula was inserted percutaneously via the internal jugular vein to draw blood from the right atrium and return into the pulmonary artery using the CentriMag system, by passing the failing ventricle. The patient was successfully weaned from right ventricular assist device. CONCLUSIONS: In comparison to two-cannula conventional procedures, this right ventrivular assist device system improves patient rehabilitation and minimizes blood loss and risk of infection, while shortening procedure time and improving clinical outcomes in right ventricular failure.
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Insuficiência Cardíaca/cirurgia , Coração Auxiliar , Implantação de Prótese/instrumentação , Disfunção Ventricular Direita/cirurgia , Idoso , Cânula , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos , Estudos RetrospectivosRESUMO
Cytomegalovirus (CMV) is an important pathogen often encountered after solid organ transplantation and is associated with increased morbidity and mortality. Resistance of CMV to antiviral agents is becoming more common but with few treatment strategies. Two specific mutations in the CMV genome--the UL97 and UL54 genes--correlate with antiviral drug resistance. We describe a 49-year-old, CMV-seronegative woman who received a CMV-seropositive donor kidney transplant and appropriate CMV prophylaxis. Approximately 1 month after transplantation, the patient developed CMV viremia that responded to valganciclovir. She was later diagnosed with recurrent CMV infection, CMV resistance, and both the UL97 and UL54 gene mutations. The patient responded to foscarnet and significant reduction of immunosuppression; she was negative for CMV viremia for the next 12 months. This case illustrates the importance of having heightened awareness for the possibility of panresistant CMV early and decreasing immunosuppression as the cornerstone of treatment.
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Infecções por Citomegalovirus/diagnóstico , Infecções por Citomegalovirus/tratamento farmacológico , Citomegalovirus/efeitos dos fármacos , Farmacorresistência Viral/efeitos dos fármacos , Transplante de Rim/efeitos adversos , Citomegalovirus/isolamento & purificação , Infecções por Citomegalovirus/etiologia , Farmacorresistência Viral/fisiologia , Feminino , Ganciclovir/farmacologia , Ganciclovir/uso terapêutico , Humanos , Pessoa de Meia-Idade , Carga Viral/métodosRESUMO
Single-incision laparoscopic surgery (SIS) is less invasive than standard laparoscopic surgery; however, it is more difficult due to restriction of motion and the impossibility to use assistants. To overcome these obstacles, we developed a self-sustaining multipurpose internal retractor by attaching a Lone Star retractor hook to a laparoscopic bulldog clamp. Herein, we report our SIS experience using our novel retractor. Between October 2008 and April 2011, 104 patients underwent SIS using the internal retractor: 67 bandings (43% simultaneous hiatal hernia repair), 8 sleeve gastrectomies, 27 cholecystectomies, and 2 Nissen fundoplication. Mean age was 40 (range, 21 to 85) and mean body mass index was 40 kg/m (range, 20 to 64 kg/m). No intraoperative complications were observed from the use of the retractor but 2 cases required additional retraction due to liver size. This retractor has been successfully used for different SIS procedures showing to be safe, adaptable, and easy to use, lessening some challenges of SIS.