Wunderlich syndrome as a rare complication of polyarteritis nodosa: a case report.

Spontaneous subcapsular and perirenal hemorrhage, known as Wunderlich syndrome (WS), is a rare clinical manifestation of polyarteritis nodosa (PAN). We report a case of a 48-year-old male with a history of recurrent episodes of leg muscle tenderness and dysesthesia, bilateral flank pain, painful nodular skin lesions in the lower limbs, weight loss, and difficult-to-control arterial hypertension. The abdominopelvic computed tomography angiography showed a large left perirenal hematoma, leading to the patient's admission to the intensive care unit. After the exclusion of infectious or neoplastic foci, the patient was diagnosed with PAN and started intravenous methylprednisolone pulses with a good response. Since WS is a rare initial clinical manifestation of PAN, an early diagnosis and aggressive treatment will significantly improve clinical outcomes.

Retinal structural and microvascular deterioration independent of optic neuritis in aquaporin-4 antibody-positive neuromyelitis optica spectrum disorders: An optical coherence tomography angiography study.

PURPOSE: To assess the retinal structural and microvascular change in aquaporin-4 antibody (AQP4) positive neuromyelitis optica spectrum disorder (NMOSD) patients and the correlation with clinical features. METHODS: A cross-sectional study was performed with optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) to measure retinal structure and microvascular parameters in AQP4 positive NMOSD patients. RESULTS: Sixty-two NMOSD patients (44 eyes with ON, NMOSD+ON; 77 eyes without ON, NMOSD-ON) and 62 healthy controls (HC, 124 eyes) were included. BCVA was worse in NMOSD patients compared to HC (p<0.001). Peripapillary retinal nerve fiber layer (pRNFL, p<0.001) and ganglion cell complex (GCC, p<0.001) was thinner in NMOSD+ON eyes compared to NMOSD-ON eyes and HC. Compared to HC, pRNFL (p = 0.002) and GCC (p = 0.001) was thinner in NMOSD-ON eyes. The vessel density (VD) in superficial capillary plexus (SCP, NMOSD+ON vs HC p<0.001, NMOSD-ON vs HC p = 0.002) and radial peripapillary capillary (RPC, NMOSD+ON vs HC p<0.001, NMOSD-ON vs HC p = 0.001) were also lower in NMOSD patients than HC independent of the history of ON. ON frequency and BCVA were correlated with the thickness of pRNFL and GCC, and VD in SCP and RPC (all p<0.001). EDSS was correlated with thickness of GCC (p = 0.008), and VD in SCP (p = 0.013), DCP (p<0.001) and RPC (p = 0.009). CONCLUSIONS: Subclinical degradation of retinal structure and microvasculature was found in NMOSD patients before the occurrence of ON, and was correlated with clinical disability. Retinal parameter might be a tool to estimate the disease progression and investigate the pathogenesis of NMOSD.

Clinical-radiological-pathological correlation in chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and potentially life-threatening complication of acute pulmonary embolism. It is characterised by persistent fibro-thrombotic pulmonary vascular obstructions and elevated pulmonary artery pressure leading to right heart failure. The diagnosis is based on two steps, as follows: 1) suspicion based on symptoms, echocardiography and ventilation/perfusion scan and 2) confirmation with right heart catheterisation, computed tomography pulmonary angiography and, in most cases, digital subtraction angiography. The management of CTEPH requires a multimodal approach, involving medical therapy, interventional procedures and surgical intervention. This clinical-radiological-pathological correlation paper illustrates the diagnostic and therapeutic management of two patients. The first had chronic thromboembolic pulmonary disease without pulmonary hypertension at rest but with significant physical limitation and was successfully treated with pulmonary endarterectomy. The second patient had CTEPH associated with splenectomy and was considered unsuitable for surgery because of exclusive subsegmental lesions combined with severe pulmonary hypertension. The patient benefited from multimodal treatment involving medical therapy followed by multiple sessions of balloon pulmonary angioplasty. Both patients had normalised functional capacity and pulmonary haemodynamics 3-6 months after the interventional treatment. These two examples show that chronic thromboembolic pulmonary diseases are curable if diagnosed promptly and referred to CTEPH centres for specialist treatment.

Perfusión 2D por angiografía en oclusión arterial periférica. Método de evaluación inmediato posproceder / 2D perfusion by angiography in peripheral arterial occlusion. Post-procedural immediate evaluation method

La enfermedad arterial periférica se considera la mayor causa de hospitalización, con riesgo de amputación de la extremidad afectada y muerte debido a la enfermedad per se o sus complicaciones. Se reporta la experiencia del tratamiento a un paciente con macroangiopatía diabética, estenosis del 64 por ciento de la arteria ilíaca izquierda y afectación de los segmentos fémoro-poplíteos bilaterales, al cual, a través de un acceso percutáneo vía arteria braquial izquierda, se le realizó revascularización mediante la implantación de stent de cromo-cobalto liberado por balón catéter. El objetivo de este estudio fue describir la utilidad del 2D-ASD y su valor como herramienta para determinar el transproceder y la repercusión en el flujo sanguíneo de la revascularización realizada, y establecer un pronóstico funcional para el paciente. Se utilizó la angiografía por perfusión bidimensional como herramienta para evaluar el éxito técnico del proceder y la repercusión inmediata en la perfusión distal de la extremidad afecta, y describir la utilidad de la escala paramétrica de colores y las curvas de densidad en función del tiempo obtenidos en el estudio(AU)

Peripheral artery disease is considered the leading cause of hospitalization, with risk of amputation of the affected limb and death due to the disease per se or its complications. It is reported the experience of treatment in a patient with diabetic macroangiopathy, stenosis of 64 precent of the left iliac artery and involvement of the bilateral femoro-popliteal segments, to which, through a percutaneous access via the left brachial artery, revascularization was performed through the implantation of cobalt-chromium stent released by balloon catheter. The objective of this study was to describe the usefulness of 2D-ASD and its value as a tool to determine the trans-procedure and the impact on blood flow of the revascularization performed, and to establish a functional prognosis for the patient. Two-dimensional perfusion angiography was used as a tool to evaluate the technical success of the procedure and the immediate impact on distal perfusion of the affected limb, and to describe the usefulness of the parametric color scale and density curves as a function of the time obtained in the study(AU)

Prevalência de nefropatia induzida por contraste em pacientes cardíacos de um setor de hemodinâmica / Prevalence of contrast-induced nephropathy in cardiac patients in a hemodynamic sector / Prevalencia de nefropatía inducida por contraste en pacientes cardíacos de un sector de hemodinámica

Objetivo: Determinar a prevalência da nefropatia induzida por contraste em pacientes cardiopatas submetidos a procedimentos angiográficos de diagnóstico e/ou tratamento. Método: Estudo prospectivo, quantitativo, realizado no setor de hemodinâmica de um hospital de grande porte, situado na região norte do Rio Grande do Sul, Brasil. A amostra foi constituída por 79 participantes através do cálculo de tamanho amostral. Resultados: A amostra foi formada por 52 (65,8%) homens e 27 (34,2%) mulheres. A idade média foi de 65,9 ± 9,52 anos. A incidência de nefropatia induzida por contraste foi de 30,38%, totalizando 24 pacientes. Conclusão: Foi evidenciada uma alta prevalência de nefropatia por contraste, apesar dos pacientes apresentarem poucos fatores de risco, o que ressalta a necessidade de medidas preventivas e redução do volume de contraste

Objective: To determine the prevalence of contrast-induced nephropathy in cardiac patients undergoing diagnostic and / or treatment angiographic procedures. Method: A prospective, quantitative study in the hemodynamics sector of a large hospital, located in the northern region of Rio Grande do Sul, Brazil. The sample consisted of 79 participants through the calculation of sample size. Results: The sample consisted of 52 (65.8%) men and 27 (34.2%) women. The mean age was 65.9 ± 9.52 years. The incidence of contrast-induced nephropathy was 30,38%, totaling 24 patients. Conclusion: A high prevalence of contrast nephropathy was evidenced, despite the fact that patients presented few risk factors, which highlights the need for preventive measures and reduction of contrast volume

Objetivo: Determinar la prevalencia de la nefropatía inducida por contraste en pacientes cardiopatas sometidos a procedimientos angiográficos de diagnóstico y / o tratamiento. Método: Estudio prospectivo, cuantitativo, realizado en el sector de hemodinámica de un hospital de gran porte, situado en la región norte de Rio Grande do Sul, Brasil. La muestra fue constituida por 79 participantes a través del cálculo de tamaño muestral. Resultados: La muestra fue formada por 52 (65,8%) hombres y 27 (34,2%) mujeres. La edad media fue de 65,9 ± 9,52 años. La incidencia de nefropatía inducida por contraste fue del 30,38%, totalizando 24 pacientes. Conclusión: Se evidenció una alta prevalencia de nefropatía por contraste, a pesar de que los pacientes presentaban pocos factores de riesgo, lo que resalta la necesidad de medidas preventivas y reducción del volumen de contraste

Utilidad de la ecografía Doppler en el diagnóstico de la trombosis carotidea traumática / Usefulness of Doppler echography for the diagnosis of traumatic carotid thrombosis

Los traumatismos del sistema arterial carotideo son raros y tienen alta mortalidad. Se presenta un caso de trombosis de la arteria carótida interna derecha por una herida por arma de fuego a nivel del cuello con el objetivo de evidenciar en la práctica médica la utilidad de la ecografía Doppler para el diagnóstico temprano de estas lesiones, a pesar de reportarse en la literatura la angiografía, la resonancia magnética nuclear y la angiorresonancia como estudios de elección. Con este caso se pudo afirmar que la trombosis carotidea traumática tiene una incidencia baja, pero no descartable en los traumas de la región cervical. Por esta causa, son frecuentes las complicaciones neurológicas dadas por la oclusión arterial y la ecografía Doppler resultó muy útil en el diagnóstico temprano del paciente.

Carotid artery system traumas are rare and show high mortality rates. The case of right internal carotid artery thrombosis caused by a gunshot injury in the neck was presented in this report to show evidence of the usefulness of Doppler echography in the medical practice for the early diagnosis of these lesions in spite of the fact that literature highlights angiography, nuclear magnetic resonance and angioresonance as the imaging studies of choice. This case confirmed that carotid thrombosis due to trauma has low incidence but it can not be ignored in the cervical región traumas. For these reasons, the neurological complications stemming from artery occlusion are frequent and Doppler echography turned to be very useful for the early diagnosis of this illness in a patient.

Endovascular correction of a traumatic internal iliac arteriovenous fistula with a covered stent / Correção endovascular de fístula arteriovenosa traumática em ilíaca interna com stent revestido

Arteriovenous fistulae (AVFs) are anomalous communications between an artery and a vein, bypassing the capillary network. They can be subdivided on the basis of etiology into congenital and acquired fistulae. The latter may be caused by closed or penetrating traumas, or may be iatrogenic injuries. We report on a case of a young adult female gunshot wound victim treated with emergency laparotomy who developed asymmetrical edema of the lower limbs during the late postoperative period. Imaging exams showed the presence of a left internal iliac AVF, treated using endovascular surgery with placement of a covered stent, resulting in total occlusion of arteriovenous communication.

As fístulas arteriovenosas (FAVs) são comunicações anômalas entre uma artéria e uma veia, sem envolvimento capilar. Segundo sua etiologia, podem ser divididas em congênitas e adquiridas, resultantes de traumas fechados ou penetrantes, e de lesões iatrogênicas. Relatamos o caso de mulher jovem, vítima de ferimento por arma de fogo, submetida à laparotomia de urgência, que evoluiu no pós-operatório tardio com edema assimétrico de membros inferiores. Os exames de imagem demonstraram a presença de fístula arteriovenosa ilíaca interna esquerda, tratada através de cirurgia endovascular com stent revestido, determinando a total oclusão da comunicação arterial e venosa.

Análise das complicações hospitalares relacionadas ao cateterismo cardíaco / Analysis of in-hospital complications related to cardiac catheterization / Analysis of in-hospital complications related to cardiac catheterization

Introdução: As complicações relacionadas ao cateterismo cardíaco são os principais limitantes desta técnica, e podem variar desde eventos adversos leves e transitórios até eventos graves, como infarto do miocárdio ou morte. Objetivo: Avaliar a incidência de complicações imediatas do cateterismo cardíaco diagnóstico em adultos, conforme um modelo de categorização das complicações em tipo e gravidade. Método: Estudo de coorte prospectivo em um centro de referência. As características dos pacientes foram registradas, e estes foram acompanhados até a alta hospitalar. As complicações foram categorizadas em nove modalidades: alérgica, isquêmica, vascular, arrítmica, vaso-vagal, pirogênica, neurológica, embólica e congestivas, e estratificadas em leves (intercorrências), moderadas (resolvidas em até 24 horas) ou graves (necessitou internação ou intervenção). Os fatores preditivos de complicações foram identificados por análise multivariada. Resultados: Foram incluídos 1916 indivíduos, sendo 59,4% do sexo masculino e com média de idade de 58,3±11,1 anos. Complicações ocorreram em 175 pacientes (190 eventos), sendo que 62,5% foram intercorrências leves, 24% moderadas e 13,5% graves. Foi registrado apenas um óbito (0,05% dos indivíduos). As complicações vasculares foram as mais incidentes (35,6%), seguidas das vagais (18,3%), isquêmicas (15,4%) e alérgicas (14,4%). Os fatores de risco para complicações pela análise multivariada foram uso de anticoagulante (3,59; 1,67-7,74; p=0,006) e duração prolongada do exame (1,03; 1,02-1,04; p<0,001). Conclusão: As complicações relacionadas ao cateterismo cardíaco são geralmente intercorrências sem gravidade, sendo que as complicações vasculares, reações vagais e isquêmicas foram as mais freqüentes. O uso de anticoagulantes e o tempo de exame prolongado foram os principais fatores preditivos de complicações.

Background: The major limitations of cardiac catheterization are the occurrence of complications related to its invasive nature. Complications can vary from mild and transitory reactions to severe adverse events like myocardial infarction or death. Objective: To assess the incidence, type and severity of complications related to cardiac catheterization in adults using a comprehensive system previously described. Methods: We conducted a prospective cohort study in a tertiary reference center, and patient characteristics and in-hospital outcomes were registered in a dedicated database. Complications were categorized in nine types: allergic, ischemic, vascular, arrythmic, vagal, pyrogenic, neurological, embolic and congestive, and stratified in mild, moderate (resolved in 24 hours) or severe (needed hospitalization or another intervention). The predictive factors of complications were assessed by multivariate analysis. Results: We included 1916 individuals, 59% male and with a mean age of 58±11 years. Complications occurred in 175 patients (190 events), and 63% were mild, 24% moderate e 13% severe. There was one (0.05%) death in the entire cohort. Vascular complications were the most common type (36%), followed by vagal (18%), ischemic (15%) and allergic (14%). Risk factors for complications by multivariate analysis were anticoagulant use (OR=3.59; CI=1.67-7.74; p=0.006) and prolonged examination time (OR=1.03; CI=1.02-1.04; p<0.001). Conclusions: In-hospital complications after cardiac catheterization are generally mild, and the events more commonly presented were vascular, vagal or ischemic. Anticoagulant use and prolonged examination time were independent predictors of complications.

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.

Pé diabético: aspectos clínicos / Diabetic foot: clinical aspects

Objetivo: Estudar os aspectos clínicos do pé diabético, uma vez que o mesmo constitui uma complicação crônica, de etiologia frequentemente multifatorial, com comprometimento vascular, neural articular e infeccioso. Método: Análise retrospectiva de 56 casos de pé diabético avaliados pelo serviço de Angiologia e Cirurgia Vascular do Hospital Universitário de Mato Grosso do Sul (NHU/UFMS) no período de 1998 a 2002. Resultados: A patologia prevaleceu em indivíduos do sexo masculino, entre 51 a 70 anos, portadores de diabetes tipo 2 em uso de hipoglicemiantes orais e com duração inferior a 10 anos. As manifestações clínicas mais comumente encontradas foram aumento de volume dos membros, dor e hiperemia. Foram realizadas amputações em 71,4 por cento dos casos, sendo que, destes 55 por cento foram do tipo menor (distal ao tornozelo) e 45 por cento foram do tipo maior (proximal ao tornozelo). A causa mais comum do pé diabético foi a neuropatia (48,2 por cento), e a doença arterial periférica foi a principal causa de amputação. A prevalência de amputações em pacientes portadores de pé diabético foi de 73,2 por cento...

Acceso venoso percutáneo braquial: Su utilidad en el cateterismo diagnóstico e intervencionista en cardiopatías complejas / Brachial percutaneous venous access: Its usefulness in the diagnostic and interventionist catheterism of complex cardiopathies

Introducción: El acceso venoso a la vena cava superior es obligatorio en pacientes portadores de anastomosis tipo Glenn. En cardiopatías complejas, es habitual la repetición de cateterismos, encontrando frecuentemente dificultades de acceso femoral. Para evitar la punción venosa yugular interna, potencialmente peligrosa, hemos utilizado la vena mediana basílica como acceso inicial. Objetivo: Valorar la efectividad y seguridad de la vía venosa braquial en pacientes, que precisan cateterismo cardíaco. Material y métodos: Se intentó la punción en 37 pacientes. Edad media 10 años (3.1-33.5). Todos ellos postoperados de cardiopatías complejas y con un promedio de 2.45 cirugías y 3.6 cateterismos por paciente. 40% de los pacientes: trombosis femoroilíaca bilateral. Técnica: Compresión venosa axilar, punción venosa basílica y canalización con introductor 4 a 6F. Resultados: Acceso efectivo: en 34 de los 37 pacientes (91.8%). En todos se realizó cateterismo diagnóstico, en 3, prueba pronóstica de oclusión y en 6 -angioplastía de rama pulmonar. Complicaciones: 2 obstrucciones tardías de la vena mediana basílica derecha (6%). Conclusiones: La punción venosa braquial es una técnica alternativa útil que permite acceso a cava superior y cavidades derechas a partir de los 3 años de edad, asociándose a un bajo porcentaje de complicaciones. Ciertas dilataciones vasculares pueden realizarse por esta vía.

Venous access through the superior caval vein is mandatory to study the pulmonary arteries in patients with a Glenn anastomosis. In complex congenital heart disease, repeat catheterizations may lead to iliac vein thrombosis and superior access is needed. In order to avoid the internal jugular venous puncture, we have used puncture of the antecubital vein as an elective access. Material: Brachial puncture was attempted in 37 patients. Mean age: 10 years (3.1-33.5). 2.45 heart surgeries and 3.6 cardiac catheterizations per patient had been previously performed in this group. 40% of patients had bilateral iliac vein thrombosis. Technique: Axillary vein external compression, venous puncture and introduction of 4-6 F sheath. Results: Venous access through brachial vein was achieved in 34 of 37 pts (91.8%). Diagnostic catheterization was done in all, balloon test occlusion of the pulmonary valve in 3 and pulmonary artery branch dilation in 6 pts. Complications: 2 late thrombosis of the right brachial vein (6%). Conclusions: Antecubital venous puncture is an alternative and useful technique that allows easy catheterization of superior caval vein, pulmonary artery and right heart chambers. It is associated with minor complication rate, avoiding internal jugular vein puncture. Certain therapeutic procedures can be performed through such route.

Extracción percutánea de catéteres rotos y migrados en el sistema circulatoria / Removal of the catheter fragment by percutaneous endovascular approach

La rotura y migración de un fragmento de catéter venoso central o angiográfico es una situación poco frecuente pero grave. Suele asociarse con una alta morbimortalidad como consecuencia de taquiarritmias cardíacas, sepsis o complicaciones tromboembólicas. La extracción del catéter por vía percutánea endovascular previene o resuelve estas complicaciones. Esta técnica es altamente efectiva y segura realizada por un equipo experimentado en terapéutica endovascular. Ha reemplazado la extracción por toracotomía a cielo abierto, que a priori, carece de indicaciones

Complicaçöes do cateterismo arterial retrógrado percutâneo / Complications of percutaneous retrograde arterial catheterism

A introduçäo do cateterismo vascular pela técnica de Seldinger veio trazer um enorme avanço ao universo de exames complementares utilizados para diagnóstico na medicina. Entretanto, sendo uma técnica invasiva, esse procedimento poderia causar complicaçöes. Com o objetivo de analisar as complicaçöes envolvidas com a utilizaçäo dessa técnica, estudamos 707 pacientes submetidos a 772 cateterismos arteriais retrógrados percutâneos para diagnóstico. Verificamos a ocorrência de 74 complicaçöes (9,6) sendo 16 consideradas graves (2,1) e 58 leves(7,5). O tratamento operatório foi instituido em 15 complicaçöes vasculares graves (1,9) e medicamentoso e/ou observaçäo clínica nas complicaçöes restantes. Näo ocorreram óbitos nessa amostra