Brazilian Society of Angiology and Vascular Surgery guidelines on peripheral artery disease.

Patients with peripheral artery disease and generalized atherosclerosis are at high risk of cardiovascular and limb complications, affecting both quality of life and longevity. Lower limb atherosclerotic disease is associated with high cardiovascular morbidity and mortality and adequate management is founded on treatments involving patient-dependent factors, such as lifestyle changes, and physician-dependent factors, such as clinical treatment, endovascular treatment, or conventional surgery. Medical management of peripheral artery disease is multifaceted, and its most important elements are reduction of cholesterol level, antithrombotic therapy, control of arterial blood pressure, control of diabetes, and smoking cessation. Adhesion to this regime can reduce complications related to the limbs, such as chronic limb-threatening ischemia, that can result in amputation, and the systemic complications of atherosclerosis, such as stroke and myocardial infarction.

Olfactory cleft evaluation: a predictor for olfactory function in smell-impaired patients?

OBJECTIVE: In this study, we introduce an extension of previous work by Soler et al. (Int Forum Allergy Rhinol 6(3):293-298, 2016) on a modified endoscopic scoring system of the Lund-Kennedy Score (focusing on the olfactory cleft) to evaluate its correlation with the olfactory function in patients with various smell disorders. STUDY DESIGN: A prospective cohort study. METHODS: Two-hundred and eighty-eight participants were included and categorized in five groups according to the cause of their olfactory disorder: (0) control, (1) idiopathic, (2) sino-nasal, (3) postinfectious and (4) post traumatic olfactory loss. Olfaction was evaluated using the "Sniffin' Sticks" test. The classical Lund-Kennedy scoring and a new olfactory cleft specific Lund-Kennedy scoring (OC-LK) were performed to evaluate mucosal changes. RESULTS: Significantly higher OC-LK scores on both sides were found in smell-impaired patients as compared to normosmic controls. When comparing the 4 groups, a significant difference of the OC-LK score were present between the sino-nasal and all other groups. Most importantly, significant negative correlations with strong effects were shown in the sino-nasal group between the OC-LK score and odor discrimination and odor identification. However, no such correlation emerged between the classical LK score and smell function. CONCLUSION: Olfactory cleft evaluation using the OC-LK score correlates with the olfactory function in patients with sino-nasal smell disorder. This diagnostic tool may reflect the underlying pathophysiological mechanism of sino-nasal smell loss, and therefore, should complement olfactory diagnostics in patients with sino-nasal smell disorder.

Dissecção espontânea da aorta abdominal infrarrenal / Spontaneous dissection of the infrarenal aorta

A rotura da camada íntima que marca o início da dissecção aórtica se origina na maioria dos casos na aorta torácica, sendo rara a dissecção espontânea da aorta abdominal infra-renal. As três principais causas são: iatrogênica, traumática ou espontânea. A dor abdominal e a isquemia de membros são os sintomas mais comuns e um número significativo de pacientes e´ assintomatico. O diagnóstico tem sido feito através de métodos de imagem como ultrassonografia, tomografia computadorizada, ressonância nuclear magnética e angiografia aliados ao alto índice de suspeição. Relatamos os casos de duas pacientes que apresentaram dissecção de aorta abdominal infrarrenal com quadro de dor abdominal súbita, sem sinais de irritação peritoneal com pulsos presentes e simétricos ao exame físico que deram entrada no pronto socorro do Hospital e Maternidade Celso Pierro da PUC Campinas e que foram tratadas pela equipe de Cirurgia Vascular. As duas pacientes no momento do exame apresentavam-se hipertensas e ao ultrassom apresentavam alteração da conformidade da aorta abdominal que foram tratada s cirurgicamente. Uma paciente foi tratada cirurgicamente submetida a endarterectomia da placa dissecada da aorta abdominal infrarrenal de 2,2 cm de diâmetro e 2,0 cm de extensão. A outra paciente foi submetida a revascularização da aorta abdominal bi-iliaca com prótese de Dacron 16 × 8 mm por apresentar disseccao da aorta abdominal distal. As duas pacientes apresentaram boa evolução pos-operatoria tendo alta hospitalar em bom estado geral.

The rupture of the intimal layer marks the beginning of the aortic dissection, which usually happens in the thoracic aorta. The spontaneous dissection of the infrarenal aorta is rare. The main causes are: iatrogenic, traumatic and spontaneous. Abdominal pain and limb ischemia are the commonest symptoms, and some patients are asymptomatics. The diagnosis is made by ultrasound, computed tomography, nuclear magnetic resonance and angiography, with a high suspicious index. We describe two cases of spontaneous rupture of the infrarenal aorta that were treated surgically. We report two cases of patients who were admitted to the emergency room of Celso Pierro Hospital with infrarenal abdominal aortic dissection and were treated by the vascular surgery group. They have presented sudden abdominal pain, no signs of peritoneal irritation and pulses were presents and simmetrics in physical examination The two patients during the examination were hypertensive and the ultrasound showed abnormal compliance of the abdominal aorta who were treated surgically. One patient was treated surgically with dissected plaque endarterectomy of infrarenal abdominal aorta of 2.2 cm in diameter and 2.0 cm in length. The other patient underwent revascularization of the abdominal aorta with bi-iliac Dacron graft 16 × 8 mm due to distal abdominal aortic dissection. Both patients had good postoperative evolution and they were discharged in good general condition.

Dificuldade no diagnostico da hiperelevação hipotônica do diafragma / Difficulty to diagnose hypotonic diaphragmatic hyperelevation

É relatado o caso de paciente de 45 anos que apresentou obstrução intestinal mecânica secundária a hérnia interna na fosseta duodenojejunal superior. No pré-operatório, verificou-se pela radiografia simples de tórax imagem sugestiva de hérnia diafragmática à esquerda. No transoperatório, foi encontrado desarranjo das estruturas anatômicas e consequente encarceramento de segmento ileal na fosseta duodenojejunal superior. Em consequência da dificuldade de abordagem do diafragma esquerdo pela ocupação anatômica das vísceras, fez-se toracotomia anterolateral esquerda e foi evidenciada a hiperelevação hipotônica do diafragma. Com base na revisão da literatura, é sugerida uma sequência propedêutica para auxiliar no diagnóstico pré-operatório dessa afecção: radiografia simples do tórax, radiografia contrastada do esôfago, estômago e duodeno com fluoroscopia, tomografia computadorizada, ultra-sonografia e enema opaco.

A 45-years-old woman was admitted with signs of a mechanical intestinal obstruction. The preoperative X-ray suggested a left diaphragmatic hernia. During the surgery, the anatomical structures were dislocated and revealed the incarceration of the ileal segment at the superior duodenojejunal fossete. Due to the disposition of the viscera, it was difficult to reach the left diaphragm. Therefore, a left antero-lateral thoracotomy was performed, revealing a left hypotonic diaphragmatic hyperelevation. Upon review of the literature, a propedeutic sequence to help the diagnosis of this abnormal condition was recommended: chest X-ray, esophagus, stomach and duodenum contrastaded radiography with fluoroscopy, computed tomography, ultrasonography and an pague enema.