Best practices in diagnosis and treatment of chronic iliac vein obstruction.

Iliac vein obstruction occurs in 20-30% of the general population. In patients with severe chronic venous insufficiency, this prevalence can be even higher, reaching 50-90% when the obstruction is investigated using intravascular ultrasound. Less invasive methods, such as venous Duplex Scanning, and even invasive ones such as venography may fail to diagnose the condition. Endovascular treatment of these obstructions is effective, safe, and associated with excellent clinical outcomes and stent patency rates, provided that fundamental anatomical and technical principles are considered and applied.

A system to help physicians with fracture detection in stents.

Fractures in stents are usually detected by visual analysis, which may be affected by the presence of noise and image deformations. The lack of research into automating stent fracture detection has motivated this work, in which techniques are developed to facilitate diagnosis by observation (Image Delineation Algorithm) and, when possible, to point out areas of possible fractures (Fracture Detection Algorithm). The use of classical elements and the development of additional computational techniques contributed to the process of image analysis, providing a possible way to aid medical diagnosis. The developed algorithms are applied to image samples from femoropopliteal arteries, and the results are compared to those of medical diagnosis. As a result, aside from the improvement of image display, a kappa concordance index of 0.878 for the detection of fractures confirms the method as satisfactory, with very good agreement with medical diagnosis.

Association between the degree of iliac venous outflow obstruction by intravascular ultrasound and lower limb venous reflux.

OBJECTIVE: The present study aims to evaluate the association between the degree of iliac venous outflow obstruction (IVOO) identified by intravascular ultrasound (IVUS) and venous reflux presentation in the lower limbs on duplex ultrasound (DU). METHODS: Patients with bilateral chronic venous insufficiency, CEAP (clinical-etiology-anatomy-pathophysiology) C3 to C6, and a visual analog scale score for pain >5 underwent DU for reflux evaluation of the deep venous system (reflux ≥1 second); superficial system, great saphenous vein, and small saphenous vein (reflux ≥0.5 second); and perforator system (reflux ≥0.35 second). All patients underwent IVUS in the iliac venous territory. The area of the impaired venous segments was categorized as obstruction <50% (category 1), 50% to 79% (category 2), and ≥80% (category 3). The venous clinical severity score and reflux multisegment score (RMS) were assessed. RESULTS: A total of 51 patients (n = 102 limbs; age, 50.53 ± 14.5 years; 6 men) were included. The predominant clinical severity CEAP class was C3 in 54 of 102 limbs (52.9%). The mean VCSS was 14.3 ± 6.7. A severe RMS (≥3) was registered in 63.4% of the limbs. Of the 102 limbs, 51 (50%) presented with category 1, 27 (26.5%) with category 2, and 24 (23.5%) with category 3. Previous deep vein thrombosis (DVT) was associated with critical obstruction (odds ratio [OR], 3.65; 95% confidence interval [CI], 1.29-10.38; P = .015). The superficial and perforator venous systems had no association with the degree of IVOO. Deep venous reflux (DVR) had a significant association with significant IVOO (obstruction ≥50%; OR, 6.44; 95% CI, 2.19-18.93; P = .001) and critical IVOO (obstruction ≥80%; OR, 4.57; 95% CI, 1.70-12.27; P = .003) and a significant linear association with the IVOO degree and reflux in the femoral veins (P < .001) and popliteal vein (P = .008). Significant lesions were significantly more likely to develop in the left limb (OR, 5.76; 95% CI, 2.46-13.50; P < .001). After multivariate analysis, DVR remained a predictor for significant and critical obstruction (P < .003 and P < .012, respectively). Left limb and previous DVT remained as predictors for IVOO of ≥50% and ≥80% (P < .001 and P = .043, respectively). CONCLUSIONS: We found a significant linear association between the degree of IVOO and reflux in the deep venous system on DU. Limbs with DVR, a severe RMS, loss of respiratory variation on DU, and previous DVT were more likely to be affected by IVOO of ≥50%, especially with left leg involvement.

Uterine artery embolization with highly compressible calibrated microspheres for the treatment of uterine fibroids.

Objective: To evaluate the safety and efficacy of using highly compressible calibrated microspheres in uterine artery embolization (UAE) for the treatment of uterine fibroids. Materials and Methods: This was a prospective multicenter study. Thirty-two women with symptomatic uterine fibroids were selected for UAE between January 2019 and March 2020. The participants completed the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire, underwent contrast-enhanced pelvic magnetic resonance imaging (MRI), and were submitted to anti-Müllerian hormone measurement, subsequently undergoing UAE with Embosoft microspheres. After six months, the patients again completed the UFS-QOL questionnaire and underwent pelvic MRI. Results: The most common symptoms were abnormal uterine bleeding (in 81.3% of the cases), pelvic pain (in 81.3%), and compression (in 46.9%). Of the 32 patients evaluated, 12 (37.5%) had anemia due to abnormal uterine bleeding. Thirty patients completed the study. Among those patients, we observed median reductions of 21.4% in uterine volume and 15.9% in dominant fibroid volume. We identified no adverse events that could be attributed to the material itself, although there were events attributed to the UAE procedure in general. Conclusion: For the treatment of uterine fibroids, UAE using Embosoft microspheres shows satisfactory results, providing reductions in uterine and dominant fibroid volumes, with a low rate of adverse events, and improving patient quality of life, as well as demonstrating safety and efficacy.

Objetivo: Avaliar a eficácia e segurança da embolização da artéria uterina (EAU) com microesferas calibradas de alta compressibilidade no tratamento de miomas uterinos. Materiais e Métodos: Este foi um estudo prospectivo e multicêntrico. Foram selecionadas 32 mulheres com miomas uterinos sintomáticos para EAU de janeiro de 2019 a março de 2020. As participantes preencheram o questionário Uterine Fibroid Symptom and Quality of Life (UFS-QOL), realizaram ressonância magnética (RM) pélvica com contraste e teste para medição dos hormônios antimüllerianos, seguido de embolização de miomas com microesferas Embosoft. Após seis meses, as pacientes novamente preencheram o UFS-QOL e realizaram RM pélvica. Resultados: Os sintomas mais relatados foram sangramento uterino anormal (81,3%), dor pélvica (81,3%) e compressão (46,9%). Doze pacientes (37,5%) apresentaram anemia consequente a sangramento uterino anormal. Nas 30 pacientes que completaram o estudo, observou-se redução mediana de 21,4% no volume uterino e 15,9% no volume do mioma dominante. Não foram identificados eventos adversos possivelmente relacionados ao material utilizado, apenas em relação ao procedimento de EAU. Conclusão: EAU com microesferas Embrosoft mostrou resultados satisfatórios no tratamento de miomas uterinos, com redução dos volumes uterino e do mioma dominante, baixa taxa de eventos adversos e melhora na qualidade de vida, demonstrando segurança e eficácia.

Correlation between venous pressure gradients and intravascular ultrasound in the diagnosis of iliac vein compression syndrome.

OBJECTIVE: The objective of this study was to evaluate the correlation between venous pressure gradients (VPGs) and intravascular ultrasound (IVUS) for the diagnosis of caval-iliac venous obstructions in patients with advanced chronic venous insufficiency. METHODS: Fifty patients with advanced chronic venous insufficiency symptoms (Clinical, Etiology, Anatomy, and Pathophysiology class 3 to 6) were prospectively submitted to multiplanar venography (MV) with intravenous pressure measurements and IVUS. The patients' lower limbs were divided accordingly: group I, limbs with <50% obstruction on IVUS (n = 49); and group II, limbs with ≥50% obstruction on IVUS (n = 51). Receiver operating characteristic curves compared the diagnostic performance of the VPGs. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy assessed the performance of VPGs in categories to determine the presence of significant obstruction. Logistic regression assessed the capacity of the VPGs to identify significant obstruction. RESULTS: The most frequent point of venous compression according to IVUS was the proximal left common iliac vein (70%; P < .05). Group II showed a greater prevalence of transpelvic (group I, 8.2%; group II, 74.5%; P < .001) and paravertebral collaterals (group I, 4.1%; group II, 45.1%; P < .001) on MV. The femoral vein pressures at rest and after reactive hyperemia as well as the femorocaval gradient after reactive hyperemia (FCG-rh) and the femoral gradient after reactive hyperemia were significantly higher in group II (P = .001, P < .001, P = .002, and P = .006). The FCG-rh and the femoral gradient after reactive hyperemia presented the best diagnostic performance among the VPGs (P = .004 and P = .007) in the receiver operating characteristic curve analysis, although no significant differences between them were found. All the gradients presented low values of sensitivity (<40%), negative predictive value (<60%), and accuracy (<30%). Logistic regression showed that FCG-rh was significantly independent of MV (OR, 8.1; P = .011) in identifying significant obstructions. CONCLUSIONS: There is correlation between the VPGs and significant obstructions with IVUS. However, this correlation does not translate to a good diagnostic performance of these VPGs. Only the FCG-rh added significant information to MV in identifying significant caval-iliac vein obstructions.

Prospective, double-blind, randomized controlled trial comparing electrocoagulation and radiofrequency in the treatment of patients with great saphenous vein insufficiency and lower limb varicose veins.

OBJECTIVE: Thermoablation has been replacing conventional surgery in the surgical treatment of great saphenous vein (GSV) reflux in patients with lower limb varicose veins; however, thermoablation is expensive. Intravenous electrocoagulation (EC) may, selectively and safely, cause necrosis of the GSV wall, but the clinical results have never been studied. The objective of this study was to compare EC and radiofrequency ablation (RFA) in the treatment of GSV insufficiency, considering efficacy, complications, and effect on quality of life. METHODS: This was a prospective, double-blind, randomized clinical trial. Patients with lower limb varicose veins and GSV reflux confirmed by duplex ultrasound were randomized into two treatment groups: EC and RFA. Patients were followed up at 1 week, 3 months, and 6 months after the procedure. Occlusion of the GSV confirmed by duplex ultrasound was considered the primary outcome, and the rate of complications and improvement in quality of life, using the Aberdeen Varicose Vein Questionnaire score, were the secondary outcomes. RESULTS: Fifty-seven patients were included, with a total of 85 treated GSVs; 43 were treated with RFA and 42 with EC. There was no statistically significant difference between the groups regarding age (P = .264), sex (P = .612), Aberdeen Varicose Vein Questionnaire score (P = .054), and diameter (P = .880) and depth (P = .763) of the treated GSV. In the intraoperative period, immediately after thermoablation, all GSVs treated with EC presented no flow and incompressibility in the treated segment, whereas 12 limbs still had flow in the treated GSV (P < .001) and 9 veins showed compressibility (P < .001) when treated with RFA. The main postoperative complication was paresthesia; however, there was no statistical significance between the groups (P = .320) regarding its presence. Time to return to routine activities was lower in the EC group than in the RFA group (P = .026). There was no difference between the groups at the 3-month (P = .157) and 6-month (P = .157) follow-up in occlusion of the GSV and improvement of the quality of life score (P = .786 and P = .401, respectively). CONCLUSIONS: EC has been shown to be an effective method for ablation of the GSV, with venous occlusion rate, occurrence of complications, and effect on quality of life similar to those with RFA.

Uterine artery embolization with highly compressible calibrated microspheres for the treatment of uterine fibroids / Embolização de miomas uterinos com microesferas calibradas de alta compressibilidade

Abstract Objective: To evaluate the safety and efficacy of using highly compressible calibrated microspheres in uterine artery embolization (UAE) for the treatment of uterine fibroids. Materials and Methods: This was a prospective multicenter study. Thirty-two women with symptomatic uterine fibroids were selected for UAE between January 2019 and March 2020. The participants completed the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire, underwent contrast-enhanced pelvic magnetic resonance imaging (MRI), and were submitted to anti-Müllerian hormone measurement, subsequently undergoing UAE with Embosoft microspheres. After six months, the patients again completed the UFS-QOL questionnaire and underwent pelvic MRI. Results: The most common symptoms were abnormal uterine bleeding (in 81.3% of the cases), pelvic pain (in 81.3%), and compression (in 46.9%). Of the 32 patients evaluated, 12 (37.5%) had anemia due to abnormal uterine bleeding. Thirty patients completed the study. Among those patients, we observed median reductions of 21.4% in uterine volume and 15.9% in dominant fibroid volume. We identified no adverse events that could be attributed to the material itself, although there were events attributed to the UAE procedure in general. Conclusion: For the treatment of uterine fibroids, UAE using Embosoft microspheres shows satisfactory results, providing reductions in uterine and dominant fibroid volumes, with a low rate of adverse events, and improving patient quality of life, as well as demonstrating safety and efficacy.

Resumo Objetivo: Avaliar a eficácia e segurança da embolização da artéria uterina (EAU) com microesferas calibradas de alta compressibilidade no tratamento de miomas uterinos. Materiais e Métodos: Este foi um estudo prospectivo e multicêntrico. Foram selecionadas 32 mulheres com miomas uterinos sintomáticos para EAU de janeiro de 2019 a março de 2020. As participantes preencheram o questionário Uterine Fibroid Symptom and Quality of Life (UFS-QOL), realizaram ressonância magnética (RM) pélvica com contraste e teste para medição dos hormônios antimüllerianos, seguido de embolização de miomas com microesferas Embosoft. Após seis meses, as pacientes novamente preencheram o UFS-QOL e realizaram RM pélvica. Resultados: Os sintomas mais relatados foram sangramento uterino anormal (81,3%), dor pélvica (81,3%) e compressão (46,9%). Doze pacientes (37,5%) apresentaram anemia consequente a sangramento uterino anormal. Nas 30 pacientes que completaram o estudo, observou-se redução mediana de 21,4% no volume uterino e 15,9% no volume do mioma dominante. Não foram identificados eventos adversos possivelmente relacionados ao material utilizado, apenas em relação ao procedimento de EAU. Conclusão: EAU com microesferas Embrosoft mostrou resultados satisfatórios no tratamento de miomas uterinos, com redução dos volumes uterino e do mioma dominante, baixa taxa de eventos adversos e melhora na qualidade de vida, demonstrando segurança e eficácia.

Criteria for detecting significant chronic iliac venous obstructions with duplex ultrasound.

OBJECTIVE: The purpose of this study was to determine the sonographic criteria for diagnosis of iliac venous outflow obstruction by assessing the correlation of this method with intravascular ultrasound (IVUS) in patients with advanced chronic venous insufficiency (CVI). METHODS: The evaluation included 15 patients (30 limbs; age, 49.4 ± 10.7 years; 1 man) with initial CVI symptoms (Clinical class, Etiology, Anatomy, and Pathophysiology [CEAP] classification, CEAP1-2) in group I (GI) and 51 patients (102 limbs; age, 50.53 ± 14.5 years; 6 men) with advanced CVI symptoms (CEAP3-6) in group II (GII). Patients from both groups were matched by gender, age, and race. The Venous Clinical Severity Score was considered. All patients underwent structured interviews and duplex ultrasound (DU) examination, measuring the flow phasicity, the femoral volume flows and velocities, and the velocity and obstruction ratios in the iliac vein. The reflux multisegment score was analyzed in both groups. Three independent observers evaluated individuals in GI. GII patients were submitted to IVUS, in which the area of the impaired venous segments was obtained and compared with the DU results and then grouped into three categories: obstructions <50%, obstructions between 50% and 79%, and obstructions ≥80%. RESULTS: The predominant clinical severity CEAP class was C1 in 24 of 30 limbs (80%) in GI and C3 in 54 of 102 limbs (52.9%) in GII. Reflux was severe (reflux multisegment score ≥3) in 3 of 30 limbs (10%) in GI and in 45 of 102 limbs (44.1%) in GII (P < .001). There was a moderately high agreement between DU and IVUS findings when they were grouped into three categories (κ = 0.598; P < .001) and high agreement when they were grouped into two categories (obstructions <50% and ≥50%; κ = 0.784; P < .001). The best cutoff points and their correlation with IVUS were 0.9 for the velocity index (r = -0.634; P < .001), 0.7 for the flow index (r = -0.623; P < .001), 0.5 for the obstruction ratio (r = 0.750; P < .001), and 2.5 for the velocity ratio (r = 0.790; P < .001). Absence of flow phasicity was observed in 62.5% of patients with obstructions ≥80%. An ultrasound algorithm was created using the measures and the described cutoff points with accuracy of 86.7% for detecting significant obstructions (≥50%) with high agreement (κ = 0.73; P < .001). CONCLUSIONS: DU presented high agreement with IVUS for detection of obstructions ≥50%. The velocity ratio in obstructions ≥2.5 is the best criterion for detection of significant venous outflow obstructions in iliac veins.

O caminho das pedras no diagnóstico e tratamento da síndrome obstrutiva ilíaca venosa crônica / Best practices in diagnosis and treatment of chronic iliac vein obstruction

Resumo A obstrução venosa ilíaca ocorre em 20% a 30% da população. Nos portadores de insuficiência venosa crônica grave, essa prevalência é ainda maior, podendo chegar a 50% a 90% dos pacientes, situação em que essa obstrução é investigada pelo ultrassom intravascular. Métodos diagnósticos menos invasivos, como o Doppler vascular, ou mesmo invasivos, como a flebografia, podem falhar em seu diagnóstico. O tratamento endovascular dessas obstruções tem se demonstrado eficaz, seguro e associado a excelente resultado clínico e de perviedade, desde que princípios anatômicos e técnicos fundamentais sejam considerados e aplicados.

Abstract Iliac vein obstruction occurs in 20-30% of the general population. In patients with severe chronic venous insufficiency, this prevalence can be even higher, reaching 50-90% when the obstruction is investigated using intravascular ultrasound. Less invasive methods, such as venous Duplex Scanning, and even invasive ones such as venography may fail to diagnose the condition. Endovascular treatment of these obstructions is effective, safe, and associated with excellent clinical outcomes and stent patency rates, provided that fundamental anatomical and technical principles are considered and applied.

Hybrid treatment of aortic arch disease.

INTRODUCTION: The management of thoracic aortic disease involving the ascending aorta, aortic arch and descending thoracic aorta are technically challenging and is an area in constant development and innovation. OBJECTIVE: To analyze early and midterm results of hybrid treatment of arch aortic disease. METHODS: Retrospective study of procedures performed from January 2010 to December 2012. The end points were the technical success, therapeutic success, morbidity and mortality, neurologic outcomes, the rate of endoleaks and reinterventions. RESULTS: A total of 95 patients treated for thoracic aortic diseases in this period, 18 underwent hybrid treatment and entered in this study. The average ages were 62.3 years. The male was present in 66.7%. The technical and therapeutic success was 94.5% e 83.3%. The perioperative mortality rate of 11.1%. There is any death during one-year follow- up. The reoperation rates were 16.6% due 2 cases of endoleak Ia and one case of endoleak II. There is any occlusion of anatomic or extra anatomic bypass during follow up. CONCLUSION: In our study, the hybrid treatment of aortic arch disease proved to be a feasible alternative of conventional surgery. The therapeutic success rates and re- interventions obtained demonstrate the necessity of thorough clinical follow-up of these patients in a long time.

Left subclavian artery stenting: an option for the treatment of the coronary-subclavian steal syndrome.

INTRODUCTION: The subclavian steal syndrome is characterized by the vertebral artery flow inversion, due to a stenotic lesion in the origin of the subclavian artery. The Coronary-subclavian Steal Syndrome is a variation of the Subclavian Steal Syndrome and is characterized by inversion of flow in the Internal Thracic artery that has been used as conduct in a myocardial revascularization. Its diagnosis must be suspected in patients with difference in pulse and arterial pressure in the upper limbs, that present with angina pectoris and that have done a myocardial revascularization. Its treatment must be a surgical bypass or a transluminal angioplasty. OBJECTIVE: The objective is to show the left subclavian artery stenting as a safe and effective method to treat the coronary-subclavian steal syndrome. METHODS: Historical prospective, non-randomized trial, through revision of the hospital records of the patients treated with the stenting of the left subclavian artery, from January 2006 to September 2012. RESULTS: In the mentioned period, 4.291 miocardial revascularizations were performed with the use of the left mammary artery, and 16 patients were identified to have the Coronary-subclavian steal syndrome. All of them were submitted to endovascular treatment. The success rate was 100%; two patients experienced minor complications; none of them presented with major complications. Eleven of the 16 patients had ultrassonographic documentation of patent stent for at least one year; two patients lost follow up and other two died. CONCLUSION: The stenting of the left subclavian artery is a good option for the treatment of the Coronary-subclavian Steal Syndrome, with high level of technical and clinical success.

Open vs. endovascular repair of abdominal aortic aneurysm: a comparative analysis / Análise comparativa entre tratamentos convencional e endovascular de aneurisma de aorta abdominal

Context: Abdominal aortic aneurysm (AAA) is a condition that is usually asymptomatic, but potentially fatal, and has a prevalence in men over 60 years old ranging from 4.3% to 8%. There are two treatment options available: open surgery (OS) and endovascular treatment (ET). Objective: To compare the results of repairs conducted using these two treatment methods from 2008 to 2013 in a tertiary hospital. Methods: A retrospective analysis comparing 119 patients treated with OS and 219 patients who underwent ET for AAA repair. Results: The ET group was older (71.3 vs. 68.2 years; p<0.001) and had a higher rate of coronary disease (44.7% vs. 27.7%; p=0.002) and a lower ejection fraction (57.6% vs. 64.3%; p<0.001); in turn, the OS group had more chronic obstructive pulmonary disease (16.0% vs. 5.9%; p=0.004) and a smaller proximal infrarenal neck (15.5 mm vs. 23.0 mm; p<0.001). However, there was no difference in ASA classification (American Society of Anesthesiology) (p=0.36). The ET group had less intraoperative bleeding (171 mL vs. 729 mL; p<0.001) and required fewer blood transfusions (11.9% vs. 73.1% p<0.001), and spent shorter stays in both ICU (2.4 vs. 3.5 days; p=0.002) and hospital (5.8 vs. 10.3 days; p<0.001). Thirty-day mortality was similar (OS 5.0% vs. ET 4.1%; p=0.78) and there was also no difference in postoperative complications. The average cost of ET was higher (R$34,277.76 vs. R$4,778.60; p<0.001). Conclusions: Rates of morbidity and mortality were similar, although ET was associated with less bleeding, fewer transfusions and shorter hospital stays, but was more expensive. .

Contexto: O aneurisma de aorta abdominal (AAA) é uma condição frequentemente assintomática, porém potencialmente fatal, cuja prevalência em homens com 60 anos ou mais está entre 4,3% e 8%. Existem duas modalidades de tratamento disponíveis: cirurgia aberta (TA) e endovascular (TE). Objetivo: Comparar os resultados dessas duas modalidades de tratamento, entre 2008 e 2013, em um hospital terciário. Métodos: Análise retrospectiva comparando 119 pacientes submetidos ao TA e 219 pacientes submetidos ao TE, para correção de AAA. Resultados: O grupo submetido ao TE apresentou maior idade (71,3 vs. 68,2 anos; p<0,001) e doença coronariana (44,7% vs. 27,7%; p=0,002), além de menor fração de ejeção (57,6% vs. 64,3%; p<0,001); por sua vez, o grupo submetido ao TA exibiu mais doença pulmonar obstrutiva crônica (16,0% vs. 5,9%; p=0,004) e menor colo proximal infrarrenal (15,5 mm vs. 23,0 mm; p<0,001). Entretanto, não houve diferença na classificação ASA (American Society of Anesthesiology) (p=0,36). O grupo de TE apresentou menor sangramento intraoperatório (171 mL vs. 729 mL; p<0,001), com menor necessidade de hemotransfusão (11,9% vs. 73,1% p<0,001), menor permanência em UTI (2,4 vs. 3,5 dias; p=0,002) e menor tempo de internação hospitalar (5,8 vs. 10,3 dias; p<0,001). A mortalidade em 30 dias foi semelhante (TA 5,0% vs. TE 4,1%; p=0,78), também não havendo diferença nas complicações pós-operatórias. O custo médio do TE foi maior (R$34.277,76 vs. R$4.778,60; p<0,001). Conclusão: As taxas de morbimortalidade foram semelhantes, sendo no TE o sangramento, a necessidade transfusional e a duração da internação hospitalar menores, porém com custo mais elevado. .

Embolization by micro navigation for treatment of persistent type 2 Endoleaks after endovascular abdominal aortic aneurysm repair / Embolização por micronavegação para tratamento de Endoleak tipo 2 persistente após reparo endovascular do aneurisma de aorta abdominal

Background: Endovascular repair has become established as a safe and effective method for treatment of abdominal aortic aneurysms. One major complication of this treatment is leakage, or endoleaks, of which type 2 leaks are the most common. Objective: To conduct a brief review of the literature and evaluate the safety and effectiveness of embolization by micronavigation for treatment of type 2 endoleaks. Method: A review of medical records from patients who underwent endovascular repair of abdominal aortic aneurysms identified 5 patients with persistent type 2 endoleaks. These patients were submitted to embolization by micronavigation. Results: In all cases, angiographic success was achieved and control CT scans showed absence of type 2 leaks and aneurysm sacs that had reduced in size after the procedure. Conclusion: Treatment of type 2 endoleaks using embolization by micronavigation is an effective and safe method and should be considered as a treatment option for this complication after endovascular repair of abdominal aortic aneurysms. .

Contexto: O reparo endovascular se estabeleceu como uma modalidade segura e efetiva no tratamento do Aneurisma de Aorta Abdominal. Uma das principais complicações deste tipo de tratamento é o Vazamento ou Endoleak, sendo o do tipo 2 o mais frequente deles. Objetivo: Fazer uma breve revisão de literatura e avaliar a segurança e a efetividade da embolização por micronavegação para o tratamento do Vazamento tipo 2. Método: A revisão dos prontuários dos pacientes submetidos ao Reparo Endovascular do Aneurisma de Aorta abdominal identificou cinco pacientes que apresentavam Endoleak tipo 2 persistente. Esses pacientes foram submetidos à embolização por micronavegação. Resultado: Em todos os casos, houve sucesso angiográfico e as tomografias de controle evidenciavam ausência de Vazamento tipo 2 e diminuição do saco aneurismático, após o procedimento. Conclusão: O tratamento do Endoleak tipo II por embolização por micronavegação é um método efetivo e seguro, sendo considerado uma opção para esta complicação após o Reparo Endovascular do Aneurisma de Aorta Abdominal. .

Evaluation of preoperative computed tomography angiography in association with conventional angiography versus computed tomography angiography only, in the endovascular treatment of aortic diseases / Avaliação da realização pré-operatória da angiotomografia associada a angiografia convencional versus angiotomografia apenas no tratamento endovascular das doenças da aorta

Objective To evaluate the association of conventional angiography (AG) with computed tomography angiography (CTA) as compared with CTA only, preoperatively, in the treatment of aortic diseases. Materials and Methods Retrospective study involving patients submitted to endovascular treatment of aortic diseases, in the period from January 2009 to July 2010, with use of preoperative CTA + conventional AG or CTA only. The patients were divided into two groups, namely: G1 – thoracic aortic diseases; and G2 – abdominal aortic diseases. G1 was subdivided into 1A (preoperative AG + CTA) and 1B (preoperative CTA). G2 was subdivided into 2C (CTA + AG) and 2D (CTA only). Results The authors evaluated 156 patients. In subgroups 1A and 1B, the rate of technical success was, respectively, 100% and 94.7% (p = 1.0); and the rate of therapeutic success was, respectively, 81% and 58% (p = 0.13). A higher number of complications were observed in subgroup 1B (p = 0.057). The accuracy in the calculation of the prosthesis was higher in subgroup 1A (p = 0.065). In their turn, the rate of technical success in subgroups 2C and 2D was, respectively, 92.3% and 98.6% (p = 0.17). The rate of therapeutic success was 73% and 98.6% (p = 0.79). Conclusion Preoperative conventional AG should be reserved for cases where CTA cannot provide all the information in the planning of a therapeutic intervention. .

Objetivo Avaliar a associação entre angiografia (AG) e angiotomografia (ATG) pré-intervenção, comparada apenas à ATG, no tratamento de doenças aórticas. Materiais e Métodos Estudo retrospectivo, envolvendo pacientes submetidos a tratamento endovascular de doenças aórticas, no período de janeiro de 2009 a julho de 2010, com o uso de AG + ATG pré-operatória ou apenas ATG. Os pacientes foram divididos em: G1 – doenças da aorta torácica; G2 – doenças da aorta abdominal. O G1 foi subdividido em 1A (submetidos a AG + ATG pré-operatória) e 1B (ATG pré-operatória). O G2 foi subdividido em 2C (ATG + AG) e 2D (ATG). Resultados Foram analisados 156 pacientes. Nos subgrupos 1A e 1B, o sucesso técnico foi 100% e 94,7% (p = 1,0) e o sucesso terapêutico de 81% e 58%(p = 0,13). Foram observadas mais complicações no subgrupo 1B (p = 0,057). A precisão do cálculo da prótese foi maior no subgrupo 1A (p = 0,065). Por sua vez, nos subgrupos 2C e 2D, o sucesso técnico foi 92,3% e 98,6% (p = 0,17) e o sucesso terapêutico foi 73% e 98,6% (p = 0,79). Conclusão A AG diagnóstica deve ser reservada aos casos em que a ATG não é capaz de fornecer todas as informações necessárias no planejamento de uma intervenção terapêutica. .

Tratamento endovascular das doenças da aorta torácica: análise dos resultados de um centro / Endovascular treatment of thoracic aortic diseases: a single center result analysis

OBJETIVO: Analisar os resultados do tratamento de uma série consecutiva de pacientes submetidos a tratamento endovascular de doenças da aorta torácica. Foram observados o sucesso técnico, o sucesso terapêutico, a morbimortalidade e a taxa de complicações perioperatórias e de reintervenções. MATERIAIS E MÉTODOS: Estudo retrospectivo, realizado em um centro de referência, no período de janeiro de 2010 a julho de 2011, em que foram analisados pacientes submetidos a correção endovascular de doenças da aorta torácica. A população foi dividida em dois grupos: grupo 1 (G1) - aneurismas de aorta torácica verdadeiros, úlcera aórtica e pseudoaneurisma; grupo 2 (G2) - dissecção aórtica tipo B crônica. RESULTADOS: Em um total de 55 pacientes tratados, 29 pertenciam ao G1 e 26, ao G2. As idades médias foram 66,8 ± 10 e 56,4 ± 7 anos, respectivamente. Os sucessos técnico e terapêutico foram, respectivamente, 86,3% e 68,6% no G1 e 100% e 74% no G2. A mortalidade perioperatória foi 10,3% no G1 e 7,6% no G2, com taxa de mortalidade anual de 10,3% no G1 e de 19,3% no G2. As taxas de reintervenções foram 10,3% e 15,3%, respectivamente. CONCLUSÃO: Em nosso estudo, o tratamento endovascular das doenças da aorta torácica demonstrou ser um método viável e associado a aceitáveis taxas de complicações.

OBJECTIVE: To analyze treatment outcomes in a consecutive series of patients submitted to endovascular treatment of thoracic aortic disease. Technical success, therapeutic success, morbimortality, rate of perioperative complications and reinterventions were taken into consideration. MATERIALS AND METHODS: The present retrospective study was developed in a reference center in the period from January 2010 to July 2011, involving patients submitted to endovascular treatment of thoracic aortic disease. The study population was divided into two groups: group 1 (G1) - true thoracic aortic aneurysms, aortic ulcer and pseudoaneurysm; group 2 (G2) - chronic type B aortic dissection. RESULTS: Out of a total of 55 patients, 29 belonged to the G1 and 26 to the G2 group. Mean ages were 66.8 ± 10 and 56.4 ± 7 years, respectively. The technical and therapeutic success reached respectively 86.3% and 68.6% in G1 and 100% and 74% in G2. The perioperative mortality rate was 10.3% in G1 and 19.3% in G2. The reintervention rate was 10.3% in G1 and 15.3% in G2. CONCLUSION: In the present study, the endovascular treatment of thoracic aortic disease proved to be a feasible method associated with acceptable rate of complications.

Quantificação volumétrica da hiperplasia neointimal em artérias ilíacas após implante de suporte intravascular metálico / Volumetric assessment of neointimal hyperplasia in iliac arteries after metal stent implantation

OBJETIVO: Quantificar a hiperplasia neointimal em artérias ilíacas após stent, correlacionando fatores clínicos, arteriais e materiais dos stents. MATERIAIS E MÉTODOS: De junho de 2003 a agosto de 2005, 60 pacientes realizaram angioplastia transluminal percutânea e stent. Desses, 30 foram reestudados com ultrassonografia intravascular. Os dados foram analisados no laboratório de análise quantitativa. RESULTA-DOS: Dezesseis pacientes eram do sexo masculino (53,3 por cento) e 14 (46,7 por cento), do sexo feminino. A média de idade foi de 60,3 anos. Apresentaram hipertensão arterial 22 pacientes (73,3 por cento), tabagismo, 18 (62,1 por cento), hiperlipidemia, 20 (66,7 por cento), e diabetes, 9 (30 por cento). Foram implantados 20 stents de nitinol (66,7 por cento) e 10 de aço inoxidável (33,3 por cento). Quatro pacientes eram TASC A (13,3 por cento), 15 eram TASC B (50 por cento) e 11, TASC C (36,7 por cento). O volume da hiperplasia variou de 49,02 mm³ a 112,87 mm³ (média de 80,33 mm³). O percentual de obstrução intra-stent variou de 18 por cento a 47 por cento (média de 27,4 por cento). Os resultados clínicos obtidos com stent se mantiveram até o reestudo. CONCLUSÃO: A hiperplasia neointimal sempre ocorre após a angioplastia transluminal percutânea e stent, porém os percentuais de obstrução não foram superiores a 50 por cento em nenhum caso. Não houve diferença estatisticamente significante dos percentuais de obstrução intra-stent quanto aos materiais dos stents, aos fatores clínicos e aos fatores arteriais.

OBJECTIVE: To quantify neointimal hyperplasia in iliac arteries after stent implantation, correlating clinical, arterial factors and stent material. MATERIALS AND METHODS: In the period from June/2003 to August/ 2005, 60 patients were submitted to percutaneous transluminal angioplasty and stenting. Among these patients, 30 were followed-up with intravascular ultrasonography. Data were analyzed in a laboratory of quantitative analysis by means of a specific software. RESULTS: Sixteen (53.3 percent) patients were men, and 14 (46.7 percent), women, and the mean age was 60.3 years. Arterial hypertension was observed in 22 patients (73.3 percent), smoking in 18 (62.1 percent), hyperlipidemia in 20 (66.7 percent), and diabetes in 9 (30 percent). A total of 20 nitinol stents (66.7 percent) and 10 stainless steel stents (33.3 percent) were implanted. Four patients were classified as TASC A (13.3 percent), 15 TASC B (50 percent) and 11 TASC C (36.7 percent). The neointimal hyperplasia volume ranged from 49.02 mm³ to 112.87 mm³ (mean, 80.33 mm³). The rate of intrastent obstruction ranged from 18 percent to 47 percent (mean, 27.4 percent). The clinical outcomes achieved with stenting were sustained through the follow-up. CONCLUSION: Neointimal hyperplasia is a common finding after percutaneous transluminal angioplasty and stenting, but in the present study the stenosis rate was never higher than 50 percent. There was no statistically significant difference in intrastent stenosis rates in relation to stents materials, clinical and arterial risk factors.

Radiodiagnóstico das malposiçöes cardíacas e cardioviscerais: apresentaçäo de 100 casos / Radiological diagnosis of cardiac and cardiovisceral malpositions: report of 100 cases

O "situs" ou posiçäo do coraçäo e de órgäos e vísceras tóraco-abdominais foi determinado com radiografias frontais e oblíquas do tórax e parte superior do abdome em 100 casos, tendo ou näo cardiopatias congênitas ou adquiridas ou pneumopatias. Em alguns casos praticou-se também a tomografia ou a broncografia visando o estudo da morfologia dos brônquios para determinaçäo do "situs" pulmonar e conseqüentemente, atrial. Foi analisada a relaçäo entre os achados radiológicos e o eletrocardiograma em todos os casos. As malposiçöes e anomalias cardiovasculares foram confirmadas por meio do cateterismo cardíaco, cineangiocardiografia e, em alguns casos, durante a cirurgia ou também a necropsia. Pesquisa de corpúsculos de Howell-Jolly foi efetivada em 3 casos com asplenia. Finalmente, consultou-se a literatura sobre outros métodos de diagnóstico com raios x ou ultra-som na detecçäo das malposiçöes do coraçäo e de orgäos e vísceras torácicos e abdominais

Estenose pulmonar congênita e tuberculose: apresentaçäo de 3 casos / Congenital pulmonary stenosis and tuberculosis: report of 3 cases

Säo apresentados 3 casos com estenose pulmonar congênita, defeitos septais intracardíacos e tuberculose. Em um caso, com estenose pulmonar valvar e defeito do septo atrial, "shunt" direito-esquerdo e severa cianose, a tuberculose manifestou-se muito discreta, afetando ambas as pleuras e o ápice do pulmäo direito, antes da valvotomia e fechamento da comunicaçäo interatrial. O exame radiológico praticado 1 ano e 5 meses após demonstrou lobite superior direita com escavaçöes e a baciloscopia foi positiva. Em outro caso, praticou-se anastomose Blalock-Taussig numa criança de 5 anos com estenose pulmonar infundibular associada à comunicaçäo interventricular e a infecçäo tuberculosa manifestou-se no exame radiológico praticado quando o paciente atingiu 18 anos de idade, observando-se na radiografia lesäo cavitária no ápice esquerdo. No terceiro caso, com estenose pulmonar valvar e defeito do septo ventricular, "shunt" bidirecional entre os ventrículos e ausência de cianose, a tuberculose instalou-se como processo primária agudo (quadro pneumônico) no final do primeiro mês de vida. Em seguida, tornou-se crônico e causou fibrotórax esquerdo, com forte retraçäo costofrênica mediastinal, conforme radiografias obtidas aos 7 anos de idade. Consideraçöes quanto a freqüência, hipótese sobre a predisposiçäo para a tuberculose nos caso com estenose pulmonar congênita, isolada ou associada com outras malformaçöes, sua importância na indicaçäo da cirurgia e na evoluçäo pós-operatória, säo feitas de acordo com a literatura ao alcance