Deep venous thrombosis of the contralateral iliac vein after stenting of the iliocaval confluence: a therapeutic challenge.

The treatment of choice for patients with symptomatic venous compression syndrome is venous stenting. However, this treatment has well-documented complications and, although rare, contralateral deep venous thrombosis is one of these complications. Our objective is to present a case of deep venous thrombosis of the contralateral iliac vein resulting from placement of the stent beyond the recommended position and the therapeutic challenge is to recanalize the vein with reconstruction of the iliocaval confluence.

Duplex scan and histologic assessment of acute renal injury in a kidney-kidney crosstalk swine experimental model.

OBJECTIVE: The objective of this study was to identify the effect of two left renal vasculature occlusion strategies on the duplex ultrasound-assessed rheology and histology of the contralateral kidney. METHODS: Pigs were randomly assigned to one of two groups: left renal artery-only clamping (A group, n = 8) or left renal artery and vein clamping (AV group, n = 9). Bilateral renal parenchymal biopsy specimens were taken every 10 minutes for 90 minutes. Duplex ultrasound resistive index (RI) and pulsatility index (PI) were measured. Mixed models with normal distribution and first-order autoregressive correlation structure and generalized estimating equation models were used. Results are presented as adjusted means with standard errors, estimated proportions with standard errors, and line plots with 95% confidence intervals. RESULTS: RI and PI increased in the nonischemic kidney. In A group animals, RI values increased significantly (P < .01) after 30 minutes of ischemia and PI increased significantly (P < .04) from 30 to 60 minutes of ischemia. The number of histologic abnormalities was higher in A group than in AV group biopsy specimens. The percentage of lesions increased significantly after 10 minutes in A group nonischemic kidneys (P < .02) and between 50 and 80 minutes in AV group nonischemic kidneys (P < .01). CONCLUSIONS: Nonischemic kidneys were acutely affected by contralateral ischemia. Their function was more adversely affected by unilateral renal artery occlusion with preserved renal vein patency (A group).

Flow-diverting Stent in the Treatment of Cervical Carotid Dissection and Pseudoaneurysm: Review of Literature and Case Report.

BACKGROUND: The endovascular technique has been recommended over the past few years to extracranial carotid dissection and pseudoaneurysm with promising results, especially after medical therapy failure. Flow-diverting stents are an alternative for complex cases. These stents have proven to be effective treatment devices for intracranial aneurysms. METHODS: The reference list of Pham's systematic review, published in 2011, and Seward's literature review, published in 2015, was considered, as well as all new articles with eligible features. Search was conducted on specific databases: MEDLINE and Literatura Latino-Americana e do Caribe em Ciências da Saúde. RESULTS: For carotid dissection and pseudoaneurysm, our review yielded 3 published articles including 12 patients. The technical success rate of flow-diverting stent was 100% with no procedural complication described. Mean clinical follow-up was 27.2 months (range 5-48), and in 5 months' angiographic follow-up, all lesions had healed. No new neurological events were reported during the clinical follow-up. CONCLUSIONS: Flow diverter stent use on intracranial and peripheral vascular surgery demonstrates satisfactory initial results, but it is still under investigation. There are very few cases treated till now and the initial results with flow-diverting stents to cervical carotid dissection are promising. In well-selected cases, where simple embolization or conventional stent is not appropriate, this technic may be considered.

Histologic analysis of stent graft oversizing in the thoracic aorta.

OBJECTIVE: To elucidate the histologic changes after stent graft oversizing in nonatherosclerotic aortas using an experimental porcine model. We previously reported that the diameter and angulation of the aorta in this model are similar to those in young individuals who undergo stent graft repair for blunt aortic injuries. The lack of commercially available stent grafts specific for repairing blunt aortic injuries, particularly for small and angulated aortas, may be related to the high rate of endograft complications in this population. METHODS: Twenty-five pigs were randomized into one control group (without stent graft implantation) and four oversized groups (A: 10%-19%, B: 20%-29%, C: 30%-39%, and D: >40%). Three circumferential fragments were collected from the aorta for histologic and immunohistochemical studies. Morphometric analyzes were performed using an inflow system and image analysis software (Quantimet 500; Leica Cambridge Ltd, Cambridge, UK). RESULTS: Collagen expression in the aortic wall was not significantly different among the five groups (P = .5604). There were significantly fewer muscle fibers in the aortic wall in the oversized groups compared with the control group (P = .000198). The proportion of elastic fibers in the aortic wall was significantly smaller in the oversized groups compared with the control group (P = .0000001). Immunohistochemical analysis showed that α-actin expression in the aortic wall was significantly decreased in the oversized groups compared with the control group (P = .002031). There were no significant differences in either the number of muscle fibers or α-actin expression among the four oversized groups. CONCLUSIONS: Histologic and immunohistochemical studies confirmed the structural disarrangement of the aortic wall after insertion of an endoprosthesis, including reduced number of muscle and elastic fibers.

Impact of stent-graft oversizing on the thoracic aorta: experimental study in a porcine model.

PURPOSE: To analyze in an experimental animal model the effect of 4 different levels of stents-graft oversizing on non-atherosclerotic aortas such as those found in young individuals who undergo stent-graft repair for traumatic aortic injuries. METHODS: The diameter of the porcine thoracic aorta is similar to the aorta of young adults (18-20 mm), so 25 pigs were randomized into 5 groups: 1 control (without stent-graft) and 4 oversizing groups (A: 10%-19%, B: 20%-29%, C: 30%-39%, and D: >40%). Two types of biomechanical tests were performed on all aortas 4 weeks after endoprosthesis deployment. RESULTS: The results of the detachment test, which analyzed the strength necessary to remove the stent-graft from the aorta, were similar in the 4 groups (A: 42 N, B: 41 N, C: 46 N, and D: 46 N). However, 2 aortas ruptured during the tests (groups C and D). The second test was performed in 3 aortic segments. Maximum shear strength, maximum stress, and maximum tension supported by the aortic wall had a negative and linear correlation with oversizing. There were significant differences in all 4 groups when compared with the control group. Strain, which reflects the elastic properties of the aortic wall, was very similar in all 4 groups, but a great difference was found when compared with the control group (p<0.0001). CONCLUSION: The study showed an important subacute change in the biomechanical properties of the aortic wall after implantation of an oversized endoprosthesis. This weakness of the aortic wall was confirmed by 2 ruptures during the detachment test. These results partially explain the interaction of stent-grafts with non-atherosclerotic thoracic aortas and may serve as a basis for further studies and the development of specific material to be used in vascular trauma and young patients.

A randomized clinical trial of the effects of saphenous and perforating veins radiofrequency ablation on venous ulcer healing (VUERT trial).

OBJECTIVES: To investigate whether radiofrequency endovenous ablation (RFA) of saphenous and perforating veins increases venous leg ulcer (VLU) healing rates and prevents ulcer recurrence. METHOD: This prospective, open-label, randomized, controlled, single-center trial recruited 56 patients with VLU divided into: compression alone (CR, N = 29) and RFA plus compression (RF, N = 27). Primary endpoints were ulcer recurrence rate at 12 months; and ulcer healing rates at 6, 12, and 24 weeks. Secondary endpoints were ulcer healing velocity; and Venous Clinical Severity Score (VCSS). RESULTS: Recurrence was lower in the RF group (p < .001), as well as mean VCSS after treatment (p = .001). There were no significant between-group differences in healing rates. Healing velocity was faster in the RF group (p = 0.049). In the RF group, 2 participants had type 1 endovenous heat-induced thrombosis (EHIT). CONCLUSIONS: RFA plus compression is an excellent treatment for VLU because of its safety, effectiveness, and impact on ulcer recurrence reduction and clinical outcome.Registration: Clinicaltrials.gov, NCT03293836, clinicaltrials.gov.

Multilayer stents affect the final diameter of aortic aneurysms and maintain renal artery patency for a short time in a swine experimental model.

OBJECTIVES: We sought to analyze the hemodynamic effects of the multilayer flow-modulated stent (MFMS) in Thoracoabdominal aortic aneurysms (TAAAs). METHODS: The hemodynamic effects of MFMS were analyzed in aortic thoracoabdominal aneurysms in experimental swine models. We randomly assigned 18 pigs to the stent or control groups and underwent the creation of an artificial bovine pericardium transrenal aneurysm. In the stent group, an MFMS (Cardiatis, Isnes, Belgium) was immediately implanted. After 4 weeks, we evaluated aneurysm sac thrombosis and renal branch patency by angiography, duplex scan, and morphological analysis. RESULTS: All the renal arteries remained patent after re-evaluation in both groups. Aneurysmal sac thrombosis was absent in the control group, whereas in the stent group it was present in 66.7% of aneurysmal sacs (p=0.061).The mean final aneurysm sac diameter was significantly lower in the stent group (mean estimated reduction, 6.90 mm; p=0.021). The proximal neck diameter decreased significantly in the stent group (mean difference, 2.51 mm; p=0.022) and grew significantly in the control group (mean difference, 3.02 mm; p=0.007). The distal neck diameter increased significantly in the control group (mean difference, 3.24 mm; p=0.017). There were no significant findings regarding distal neck measurements in the stent group. CONCLUSION: The MFMSs remained patent and did not obstruct the renal arteries within 4 weeks. In the stent group, the device was also associated with a significant decrease in aneurysmal sac diameter and a large proportion (albeit non-significant) of aneurysmal sac thrombosis.

Prospective randomized trial comparing radiofrequency ablation and complete saphenous vein stripping in patients with mild to moderate chronic venous disease with a 3-year follow-up.

OBJECTIVE: To compare the use of the radiofrequency thermoablation of the saphenous vein with the ligation technique, and complete removal of the saphenous vein, from the saphenofemoral junction to the ankle. METHODS: A total of 49 patients with chronic venous disease in the Comprehensive Classification System for Chronic Venous Disorders (CEAP) classes 2 to 4 for clinical signs, etiology, anatomic distribution and pathophysiology, were assessed at baseline, after 4 weeks, and after 1 year. The parameters assessed were complications, period of absence from activities, Venous Clinical Severity Score (VCSS) and quality of life scores according to Aberdeen Varicose Veins Questionnaire (AVVQ). They were re-examined 1 and 3 years after treatment to evaluate recurrence rates. RESULTS: The success rate per limb (p=0.540), VCSS (p=0.636), AVVQ (p=0.163), and clinical complications were similar in the two treatment groups. Nevertheless, the radiofrequency thermoablation group had significant shorter length of hospital stay (0.69±0.47) and absence from activities (8.62±4.53), p<000.1. CONCLUSION: Patients submitted to radiofrequency thermoablation had an occlusion rate, clinical recurrence and improvement in quality of life comparable to removal of the saphenous vein. However, these patients spent less time hospitalized and away from their daily activities during recovering.

Trombose venosa profunda de veia ilíaca contralateral após stent venoso posicionado na confluência ilíaco-cava: um desafio terapêutico / Deep venous thrombosis of the contralateral iliac vein after stenting of the iliocaval confluence: a therapeutic challenge

Resumo O tratamento de escolha para pacientes com síndrome de compressão venosa sintomática é o implante de stent venoso. Entretanto, esse tratamento possui complicações bem documentadas e, embora rara, trombose venosa profunda contralateral é uma dessas complicações. Nosso objetivo é apresentar um caso de trombose venosa profunda da veia ilíaca contralateral como resultado do posicionamento do stent além do preconizado e o desafio terapêutico que é a recanalização da veia com reconstrução da confluência ilíaco-cava.

Abstract The treatment of choice for patients with symptomatic venous compression syndrome is venous stenting. However, this treatment has well-documented complications and, although rare, contralateral deep venous thrombosis is one of these complications. Our objective is to present a case of deep venous thrombosis of the contralateral iliac vein resulting from placement of the stent beyond the recommended position and the therapeutic challenge is to recanalize the vein with reconstruction of the iliocaval confluence.

Multilayer stents affect the final diameter of aortic aneurysms and maintain renal artery patency for a short time in a swine experimental model

OBJECTIVES: We sought to analyze the hemodynamic effects of the multilayer flow-modulated stent (MFMS) in Thoracoabdominal aortic aneurysms (TAAAs). METHODS: The hemodynamic effects of MFMS were analyzed in aortic thoracoabdominal aneurysms in experimental swine models. We randomly assigned 18 pigs to the stent or control groups and underwent the creation of an artificial bovine pericardium transrenal aneurysm. In the stent group, an MFMS (Cardiatis, Isnes, Belgium) was immediately implanted. After 4 weeks, we evaluated aneurysm sac thrombosis and renal branch patency by angiography, duplex scan, and morphological analysis. RESULTS: All the renal arteries remained patent after re-evaluation in both groups. Aneurysmal sac thrombosis was absent in the control group, whereas in the stent group it was present in 66.7% of aneurysmal sacs (p=0.061). The mean final aneurysm sac diameter was significantly lower in the stent group (mean estimated reduction, 6.90 mm; p=0.021). The proximal neck diameter decreased significantly in the stent group (mean difference, 2.51 mm; p=0.022) and grew significantly in the control group (mean difference, 3.02 mm; p=0.007). The distal neck diameter increased significantly in the control group (mean difference, 3.24 mm; p=0.017). There were no significant findings regarding distal neck measurements in the stent group. CONCLUSION: The MFMSs remained patent and did not obstruct the renal arteries within 4 weeks. In the stent group, the device was also associated with a significant decrease in aneurysmal sac diameter and a large proportion (albeit non-significant) of aneurysmal sac thrombosis.

Coral reef aorta, emergency surgical: case report and literature review.

Coral reef aorta is described as an uncommon entity characterized by the presence of coarse calcifications, which are developed in the visceral aorta. These calcifications grow toward the lumen of the artery and can result in significant stenosis, so that causing malperfusion of the lower limbs, visceral ischemia or hypertension secondary to renal involvement. We report here a case of a 54-year-old patient with coral reef aorta and symptomatic. The clinical presentation of the patient required the surgical approach. A review of literature in major databases was conducted to compare health-related aspects of the disease presentation and management. Coral reef aorta should be considered as the diagnosis for patients with visceral and limbs ischemia. The approach in our case was consistent with other studies previously published in the literature.

Prospective randomized trial comparing radiofrequency ablation and complete saphenous vein stripping in patients with mild to moderate chronic venous disease with a 3-year follow-up / Ensaio clínico randomizado prospectivo comparando a ablação por radiofrequência e a retirada completa de veia safena em pacientes com doença venosa crônica leve à moderada com seguimento de 3 anos

ABSTRACT Objective: To compare the use of the radiofrequency thermoablation of the saphenous vein with the ligation technique, and complete removal of the saphenous vein, from the saphenofemoral junction to the ankle. Methods: A total of 49 patients with chronic venous disease in the Comprehensive Classification System for Chronic Venous Disorders (CEAP) classes 2 to 4 for clinical signs, etiology, anatomic distribution and pathophysiology, were assessed at baseline, after 4 weeks, and after 1 year. The parameters assessed were complications, period of absence from activities, Venous Clinical Severity Score (VCSS) and quality of life scores according to Aberdeen Varicose Veins Questionnaire (AVVQ). They were re-examined 1 and 3 years after treatment to evaluate recurrence rates. Results: The success rate per limb (p=0.540), VCSS (p=0.636), AVVQ (p=0.163), and clinical complications were similar in the two treatment groups. Nevertheless, the radiofrequency thermoablation group had significant shorter length of hospital stay (0.69±0.47) and absence from activities (8.62±4.53), p<000.1. Conclusion: Patients submitted to radiofrequency thermoablation had an occlusion rate, clinical recurrence and improvement in quality of life comparable to removal of the saphenous vein. However, these patients spent less time hospitalized and away from their daily activities during recovering.

RESUMO Objetivo: Comparar o uso da termoablação por radiofrequência da veia safena com a técnica de ligação e retirada completa da veia safena da junção safeno-femoral ao tornozelo. Métodos: Foram avaliados 49 pacientes com doença venosa crônica nas categorias 2 a 4 (Comprehensive Classification System for Chronic Venous Disorders − CEAP) para classificação clínica, etiológica, anatômica e fisiopatológica, no início do estudo, 4 semanas e 1 ano após o procedimento. Os parâmetros analisados foram complicações, período de ausência de atividades,(Venous Clinical Severity) Score revisado (R-VCSS) e escore de qualidade de vida de acordo com o Aberdeen Varicose Veins Questionnaire(AVVQ). Os pacientes foram reexaminados 1 e 3 anos após o tratamento, para avaliar as taxas de recorrência. Resultados: As taxas de sucesso por membro (p=0,540), VCSS (p=0,636), AVVQ (p=0,163) e complicações clínicas foram semelhantes nos dois grupos. No entanto, o grupo termoablação por radiofrequência teve períodos de internação significativamente mais curtos (0,69±0,47) e ausência de atividades (8,62±4,53), com p<000,1. Conclusão: Pacientes submetidos à termoablação por radiofrequência apresentaram taxa de oclusão, recidiva clínica e melhora da qualidade de vida comparáveis à retirada completa da veia safena. No entanto, esses pacientes passaram menos tempo internados e ausentes de suas atividades diárias durante a recuperação.

Mycotic aneurysm of the tibioperoneal trunk: a first manifestation of an infected endocarditis.

Infrapopliteal mycotic aneurysm resulting from endocarditis is rare, with only a few reported cases. We describe the case of a 28-year-old male patient who was suffering with pain and edema in the right leg. The ultrasound revealed an aneurysm of the right tibioperoneal trunk and a deep vein thrombosis (DVT). The patient was admitted and developed acute congestive heart failure, being diagnosed with possible endocarditis. A pseudo-aneurysm was revealed by arteriography. Aggressive antibiotic treatment was initiated, and open surgery confirmed a mycotic pseudo-aneurysm of the tibioperoneal trunk. To our knowledge, this is the 8th case reported of an infected aneurysm in this particular location.

Treatment of varicose ulcer of the lower limbs by surgery and Unna boot: savings for the Brazilian healthcare system.

OBJECTIVE: To perform an analysis of the costs of treatment of varicose ulcers by radical surgery of varices and the use of Unna boot. METHODS: Fifteen outpatients were selected to receive treatment of varicose ulcers with radical surgery and Unna boot. The total cost of treatment was calculated (hospitalization, surgery, dressings, and outpatient's follow-up visits) and compared to the cost of clinical follow-up with daily simple dressing changes. RESULTS: The proposed treatment was on average 55.71% more economical than the management with daily dressings (approximately US$452.32 versus US$1,021.39). CONCLUSION: Radical varicose vein surgery associated with the use of the Unna boot proved meaningly less expensive for the public health system than clinical follow-up with daily dressings.

Endovascular treatment of peripheral arterial injury with covered stents: an experimental study in pigs.

OBJECTIVE: To evaluate the feasibility of using endovascular repair to treat penetrating arterial injuries with covered stents. Feasibility was examined according to the circumferential extent of the injury. INTRODUCTION: Surgical trauma often increases the risk of major morbidity and mortality associated with vascular injury, and endovascular repair has many advantages in such situations. METHODS: Twenty white male domestic pigs weighing 28-38 kg with controlled vascular injuries were divided into four equal groups according to the circumferential extent of their vascular lesion (i.e., no lesion, lesion <50%, lesion >50%, and complete lesion). The left common carotid artery was dissected with proximal and distal control, and this procedure was followed by controlled sectioning of the arterial wall. Local manual compression was applied for 10 min and was followed by endovascular repair with the placement of a 5x50 mm VIABHAN TM covered stent using the femoral approach. We also monitored additional variables, such as the duration of the procedures (the mean was 56.3 ± 19.1 min), ultrasound parameters (e.g., maximum arterial diameter, peak systolic and diastolic velocity, and resistance index), arteriography findings, and fluctuations in vital signs (e.g., cardiac output, arterial pressure, and central venous pressure). RESULTS: The experimental procedure was found to be feasible and reproducible. Repairs were successful in all animals in the control (no lesion) and <50% lesion groups. Success was also achieved in four out of five pigs in the >50% group and in one pig in the complete lesion group. DISCUSSION: The endovascular repair of an arterial injury is possible, but success depends on the circumferential extent of the arterial lesion. The present experimental model, which involved endovascular techniques, highlighted important factors that must be considered in future studies involving similar animals and materials.

Endovascular and open repair for blunt aortic injury, treated in one clinical institution in Brazil: a case series.

OBJECTIVE: The objective of this retrospective study is to analyze and compare the results of conventional surgical repair and endovascular treatment of blunt aortic injury over the past 8 years. METHODS: Twenty-eight patients (25 male; mean age, 35 years) were treated for blunt aortic injury between April 2001 and March 2009 in a university hospital in Brazil. Twenty-six patients were included in the study: five were treated with operative repair (OR) and 21 with endovascular treatment (TEVAR). Two patients were excluded from analysis: one was managed conservatively, and one was treated with endovascular treatment for chronic dissection related to aortic trauma. RESULTS: Mean age was lower in the OR group than in the endovascular treatment group (17.8 vs. 38 years, P = .003). There was one death in the OR group and four deaths in the endovascular treatment group. Mean follow-up for the overall group was 33.6 months, with 48.7 months (range 8-83 months) for the OR group, and 29.8 months (range 2-91 months) for the TEVAR group. Mean time elapsed from injury to repair was 23.4 hours (range 8-48 h, median 20 h) for the OR group and 30.3 hours (range 2-240 h, median 18 h) for the TEVAR group (P = .374). The duration of surgery was shorter in the endovascular treatment group (142 versus 237 minutes; P = .005). There were no significant differences with respect to the number of postoperative days requiring mechanical ventilation, duration of ICU stay or duration of hospital stay. CONCLUSION: In this retrospective analysis, endovascular treatment was a safe method for repair of blunt aortic trauma, with immediate and midterm results that were comparable to those results obtained with operative repair. No complications from the stent graft were identified during follow-up. Nevertheless, long-term follow-up is necessary to confirm the effectiveness of this treatment.

Alternative grafts for brachioaxillary hemodialysis access: 1-year comparative results

BACKGROUND: Many chronic renal patients lack autologous veins in the upper limbs suitable for construction of arteriovenous fistulas for hemodialysis. Alternative fistula options for these patients should be evaluated and compared.OBJECTIVE: To compare different types of grafts used for brachioaxillary access in hemodialysis patients in terms of their patency and complication rates.METHOD: Forty-nine patients free from arterial system abnormalities and with no venous options for creation of arteriovenous fistulae in the arm and/or forearm underwent brachioaxillary bypass with implantation of autologous saphenous vein, polytetrafluoroethylene (PTFE), or PROPATEN(r) grafts. Patients were assessed by Doppler ultrasonography at 3, 6, and 12 months after surgery. RESULTS: The four first saphenous vein grafts had failed by 3 or 6 months after surgery. The autologous saphenous vein group was discontinued at the beginning of the study because of extreme difficulty in achieving puncture and hematoma formation. Failure rates of PTFE and PROPATEN(r) grafts did not differ after 3 (p = 0.559), 6 (p = 0.920), or 12 months (p = 0.514). A log-rank test applied to cumulative survival of grafts at 1 year (0.69 for PTFE, 0.79 for PROPATEN(r)) detected no significant differences (p = 0.938). There were no differences in complications resulting in graft failure between the two types of prosthetic graft.CONCLUSION: Autologous saphenous vein grafts do not appear to be a good option for brachioaxillary hemodialysis access because of difficulties with achieving puncture. Brachioaxillary fistulae constructed using PTFE or PROPATEN(r) grafts exhibited similar patency and complication rates. Further studies with large samples size are warranted to confirm our findings.

CONTEXTO: Há inúmeros pacientes renais crônicos sem veias autólogas nos membros superiores para confecção de fístulas arteriovenosas para realização de hemodiálise. As opções de fístula nestes pacientes devem ser avaliadas e comparadas.OBJETIVO: Comparar diferentes enxertos para acesso braquioaxilar em pacientes hemodialíticos, em relação a permeabilidade e taxas de complicação. MÉTODO: Um grupo de 49 pacientes, sem alterações no sistema arterial e sem opções venosas para criação de fístula arteriovenosa no braço e/ou antebraço, foi submetido a procedimentos cirúrgicos para implante de diferentes enxertos: veia safena autóloga, enxertos de PTFE e PROPATEN(r).RESULTADOS: Os quatro primeiros implantes de veia safena falharam no terceiro e no sexto mês após a cirurgia. Interrompeu-se o uso de veia safena autóloga no início do estudo pela extrema dificuldade de punção e pela formação de hematoma. Não houve diferenças nas taxas de falha dos enxertos de PTFE e PROPATEN(r) após três (p = 0,559), seis (p = 0,920) e 12 meses (p = 0,514) de seguimento. O teste de Logrank aplicado à sobrevida cumulativa dos enxertos por um ano (0,68 para PTFE; 0,79 para PROPATEN(r)) não relevou diferenças (p = 0,938). Não foram encontradas diferenças entre os enxertos prostéticos em relação ao tipo de complicação que determinou as falhas.CONCLUSÃO: O enxerto de veia safena autóloga parece não ser é uma boa opção para acesso braquioaxilar em hemodialíticos, já que implica em dificuldade na punção. Os enxertos de PTFE e PROPATEN(r) em fistula braquioaxilar resultaram em permeabilidade e taxas de complicações similares. Estudos com amostras maiores são necessários para confirmar nossos achados.

Hemoperitoneum in a cirrhotic patient due to rupture of retroperitoneal varix.

The rupture of retroperitoneal varices is a rare and catastrophic complication of portal hypertension. We describe a case of this nature, the first in Brazilian medical literature, and also reviewing all previous 34 cases. We systematically analyzed all therapeutic approach and propose a management algorithm for diagnosis and treatment of this lethal condition. The majority of the patients presented with abdominal pain, distention and hypotension, and developed hemorrhagic shock. Rupture of retroperitoneal varices can be properly managed if an early diagnosis is made and surgery is performed promptly, which is the only effective treatment. Arteriography should be used when the suspicion is of rupture of hepatocellular carcinoma.

Coral reef aorta, emergency surgical: case report and literature review / Aorta em recife de coral, emergência cirúrgica: relato de caso e revisão da literatura

Coral reef aorta is described as an uncommon entity characterized by the presence of coarse calcifications, which are developed in the visceral aorta. These calcifications grow toward the lumen of the artery and can result in significant stenosis, so that causing malperfusion of the lower limbs, visceral ischemia or hypertension secondary to renal involvement. We report here a case of a 54-year-old patient with coral reef aorta and symptomatic. The clinical presentation of the patient required the surgical approach. A review of literature in major databases was conducted to compare health-related aspects of the disease presentation and management. Coral reef aorta should be considered as the diagnosis for patients with visceral and limbs ischemia. The approach in our case was consistent with other studies previously published in the literature.

A aorta em recife de corais é descrita como uma entidade incomum caracterizada pela presença de calcificações grosseiras, que se desenvolvem na aorta visceral. Essas calcificações crescem em direção ao lúmen da artéria e podem resultar em estenose significativa, gerando má perfusão dos membros inferiores, isquemia visceral ou hipertensão secundária ao acometimento renal. Relata-se aqui o caso de um paciente de 54 anos portador de aorta em recife e sintomático. O quadro clínico do paciente exigiu abordagem cirúrgica. Foi realizada revisão de literatura nas principais bases de dados para comparar os aspectos relacionados à apresentação e à conduta da doença. Em pacientes com sinais de isquemia visceral ou em membros inferiores, deve-se considerar o diagnóstico de aorta em recife de coral. A abordagem, no caso relatado, foi consistente com estudos publicados anteriormente na literatura.

Endovascular management of massive pulmonary embolism with clot fragmentation and suction / Tratamento endovascular de embolia pulmonar maciça com fragmentação e aspiração de trombos

Massive pulmonary embolism with right ventricular dysfunction may be treated with thrombolysis, embolectomy, or percutaneous mechanical thrombectomy. This study describes our experience with two patients that had massive pulmonary embolism and were treated with percutaneous mechanical thrombectomy and reports on the mid-term results of this procedure. A 28-year-old man and a 70-year-old woman were diagnosed with deep venous thrombosis and massive pulmonary embolism. They first had lower limb edema followed by sudden onset of dyspnea. Their physical examination revealed edema, tachypnea, chest discomfort and jugular turgescence. Both needed to receive oxygen using a nasal cannula. Doppler ultrasound, echocardiography, and computed tomography angiography were used to establish the diagnoses. Patients underwent percutaneous mechanical thrombectomy using the Aspirex® system (Straub Medical), and their clinical condition and imaging study findings improved substantially. At mid-term follow-up, patient conditions were improving satisfactorily.

A embolia pulmonar maciça com disfunção do ventrículo direito pode ser tratada com trombólise, embolectomia ou trombectomia mecânica percutânea. Este estudo descreve nossa experiência com dois pacientes com embolia pulmonar maciça tratados com trombectomia mecânica percutânea e relata os resultados a médio prazo desse procedimento. Um homem de 28 anos e uma mulher de 70 anos foram diagnosticados com trombose venosa profunda e embolia pulmonar maciça. Inicialmente, eles tiveram edema de membros inferiores seguido por início súbito de dispneia. O exame físico revelou edema, taquipneia, desconforto torácico, turgência jugular. Em ambos havia sinais de hipóxia e precisaram receber oxigênio usando uma cânula nasal. A ultrassonografia Doppler ecocardiograma e angiotomografia foram utilizadas para estabelecer os diagnósticos. Os pacientes foram submetidos à trombectomia mecânica percutânea utilizando o sistema Aspirex® (Straub Medical). Sua condição clínica e os achados dos estudos de imagem melhoraram substancialmente. No acompanhamento a médio prazo, os pacientes apresentaram melhora significativa do quadro.