New-Onset Atrial Fibrillation in St-Segment Elevation Myocardial Infarction: Predictors and Impact on Therapy And Mortality / Fibrilação Auricular de Novo no Infarto Agudo do Miocárdio com Supradesnível do Segmento ST: Preditores e Impacto na Terapêutica e Mortalidade

Abstract Backgrund: New-onset atrial fibrillation complicating acute myocardial infarction represents an important challenge, with prognostic significance. Objective: To study the incidence, impact on therapy and mortality, and to identify predictors of development of new-onset atrial fibrillation during hospital stay for ST-segment elevation myocardial infarction. Methods: We studied all patients with ST-elevation myocardial infarction included consecutively, between 2010 and 2017, in a Portuguese national registry and compared two groups: 1 - no atrial fibrillation and 2 - new-onset atrial fibrillation. We adjusted a logistic regression model data analysis to assess the impact of new-onset atrial fibrillation on in-hospital mortality and to identify independent predictors of its development. A p value < 0.05 was considered significant. Results: We studied 6325 patients, and new-onset atrial fibrillation was found in 365 (5.8%). Reperfusion was successfully accomplished in both groups with no difference regarding type of reperfusion. In group 2, therapy with beta-blockers and angiotensin-conversion enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) was less frequent, 20.6% received anticoagulation at discharge and 16.1% were on triple therapy. New-onset atrial fibrillation was associated with more in-hospital complications and mortality. However, it was not found as an independent predictor of in-hospital mortality. We identified age, prior stroke, inferior myocardial infarction and complete atrioventricular block as independent predictors of new-onset atrial fibrillation. Conclusion: New-onset atrial fibrillation remains a frequent complication of myocardial infarction and is associated with higher rate of complications and in-hospital mortality. Age, prior stroke, inferior myocardial infarction and complete atrioventricular block were independent predictors of new onset atrial fibrillation. Only 36.7% of the patients received anticoagulation at discharge.

Resumo Fundamento: A fibrilação auricular de novo no contexto de infarto agudo do miocárdio representa um importante desafio com potencial impacto prognóstico. Objetivo: Determinar a incidência, impacto na terapêutica e mortalidade, e identificar possíveis preditores do aparecimento de fibrilação auricular de novo durante o internamento por infarto agudo do miocárdio com supradesnivelamento do segmento ST. Métodos: Estudamos todos os pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST inseridos consecutivamente de 2010 a 2017 num registro nacional português e comparamos dois grupos: 1 - sem fibrilação auricular; 2- com fibrilação auricular de novo. Efetuamos análise com modelo de regressão logística para avaliar o impacto de fibrilação auricular de novo na mortalidade intra-hospitalar e identificar preditores independentes para o seu aparecimento. Para teste de hipóteses, considerou-se significativo p < 0,05. Resultados: Estudamos 6325 pacientes, dos quais 365 (5.8%) apresentaram fibrilação auricular de novo. Não houve diferença no número de pacientes reperfundidos nem na estratégia de reperfusão. No grupo 2, terapêutica com betabloqueadores e IECA/ARA foi menos frequente, 20.6% tiveram alta sob anticoagulação oral e 16.1% sob terapêutica tripla. A fibrilação auricular de novo associou-se a maior incidência de complicações e mortalidade intra-hospitalar, mas não foi preditor independente de mortalidade intra-hospitalar. Identificamos idade, acidente vascular cerebral prévio, infarto inferior e bloqueio auriculoventricular completo como preditores independentes de fibrilação auricular de novo. Conclusões: A fibrilação auricular de novo continua sendo uma complicação frequente do infarto agudo do miocárdio, estando associada a aumento das complicações e mortalidade intra-hospitalar. Apenas 36.7% desses pacientes teve alta sob anticoagulação.

Up to 15-Year Survival of Men and Women after Percutaneous Coronary Intervention Paid by the Brazilian Public Healthcare System in the State of Rio de Janeiro, 1999-2010 / Sobrevida em até 15 Anos de Homens e Mulheres após Intervenção Coronariana Percutânea Paga pelo Sistema Único de Saúde no Estado do Rio de Janeiro, 1999-2010

Abstract Background: Percutaneous coronary intervention (PCI) is the most frequently used invasive therapy for ischemic heart disease (IHD). Studies able to provide information about PCI's effectiveness should be conducted in a population of real-world patients. Objectives: To assess the survival rate of IHD patients treated with PCI in the state of Rio de Janeiro (RJ). Methods: Administrative (1999-2010) and death (1999-2014) databases of dwellers aged ≥ 20 years old in the state of RJ submitted to one single PCI paid by the Brazilian public healthcare system (SUS) between 1999 and 2010 were linked. Patients were grouped as follows: 20-49 years old, 50-69 years old and ≥ 70 years old, and PCI in primary PCI, with stent and without stent placement (bare metal stent). Survival probabilities in 30 days, one year and 15 years were estimated by using the Kaplan-Meier method. Cox hazards regression models were used to compare risks among sex, age groups and types of PCI. Test results with a p-value < 0.05 were deemed statistically significant. Results: Data of 19,263 patients (61 ± 11 years old, 63.6% men) were analyzed. Survival rates of men vs. women in 30 days, one year and 15 years were: 97.3% (97.0-97.6%) vs. 97.1% (96.6-97.4%), 93.6% (93.2-94.1%) vs. 93.4% (92.8-94.0%), and 55.7% (54.0-57.4%) vs. 58.1% (55.8-60.3%), respectively. The oldest age group was associated with lower survival rates in all periods. PCI with stent placement had higher survival rates than those without stent placement during a two-year follow-up. After that, both procedures had similar survival rates (HR 0.91, 95% CI 0.82-1.00). Conclusions: In a population of real-world patients, women had a higher survival rate than men within 15 years after PCI. Moreover, using a bare-metal stent failed to improve survival rates after a two-year follow-up compared to simple balloon angioplasty.

Resumo Fundamento: A intervenção coronariana percutânea (ICP) é o tratamento invasivo mais frequentemente realizado na doença isquêmica do coração (DIC). Estudos capazes de prover informação sobre a sua efetividade são importantes. Objetivo: Avaliar a sobrevida em até 15 anos de pacientes submetidos a ICP no estado do Rio de Janeiro (ERJ). Métodos: Bases de dados administrativas (1999-2010) e de óbitos (1999-2014) dos residentes com idade ≥ 20 anos do ERJ submetidos a uma única ICP paga pelo Sistema Único de Saúde (SUS) entre 1999-2010 foram relacionadas. Os pacientes foram agrupados em 20-49, 50-69 ou ≥ 70 anos, e as ICP em primária (ICP-P), sem stent (ICP-SS) e com stent convencional (ICP-CS). As probabilidades de sobrevida em 30 dias, um ano e 15 anos foram estimadas pelo método de Kaplan-Meier. Modelos de regressão de risco de Cox foram utilizados para comparar riscos entre sexo, faixas etárias e tipos de ICP. Resultados dos testes com um valor de p < 0,05 foram considerados estatisticamente significativos. Resultados: Foram analisados os dados de 19.263 pacientes (61±11 anos, 63,6% homens). A sobrevida de homens vs. mulheres em 30 dias, um ano e 15 anos foram: 97,3% (97,0-97,6%) vs. 97,1% (96,6-97,4%), 93,6% (93,2-94,1%) vs. 93,4% (92,8-94,0%), e 55,7% (54,0-57,4%) vs. 58,1% (55,8-60,3%), respectivamente. Idade ≥ 70 anos foi associada à menor taxa de sobrevida em todos os períodos. A ICP-CS foi associada a uma sobrevida maior do que a ICP-SS até dois anos de acompanhamento, e após este período ambos os procedimentos apresentaram taxas de sobrevida semelhantes (HR 0,91, IC 95% 0,82-1,00). Conclusões: Mulheres apresentaram maiores taxas de sobrevida em 15 anos após ICP, e o uso de stent convencional não esteve associado a um aumento de sobrevida em longo prazo.

Complicaciones vasculares durante la trombectomía mecánica en el ictus agudo, una experiencia multicéntrica en España / Vascular Complications during Mechanical Thrombectomy in Acute Stroke, a Multicentric Experience in Spain

Objetivo Determinar la frecuencia de las complicaciones observadas durante la trombectomía en el ictus isquémico agudo. Materiales y Métodos Se revisó de forma retrospectiva las trombectomías realizadas en nuestra institución cuando los ictus isquémicos tuvieron una indicación de tratamiento endovascular. Se registraron los diferentes dispositivos utilizados en ese periodo de tiempo y si presentaron relación con el desarrollo de las complicaciones inmediatas mediante arteriografía. Resultados De un total de 228 casos, se registraron complicaciones en el 16,6% de los casos. Se identificaron embolias (n » 31), hemorragias subaracnoideas (n » 2), hemorragia gangliobasal (n » 1), vasoespasmo (n » 1), disección (n » 1) y peusoaneurismas (n » 2). La embolia a nuevos territorios se presentó solo en 5 casos. Discusión El tratamiento endovascular ha demostrado ser efectivo para la recanalización en oclusión de gran vaso. El uso de dispositivos presume un riesgo por la manipulación de los vasos. Conclusión La embolia fue la complicación más frecuente. El tratamiento endovascular en el ictus genera un desenlace clínico favorable de los pacientes, al mismo tiempo, el bajo porcentaje de complicaciones que encontramos no suponen una afectación negativa en el desenlace final.

Purpose To determine the complications we observed during thrombectomy in acute ischemic stroke. Materials and Methods We reviewed retrospectively thrombectomies performed in our institution when endovascular treatment for stroke was done. The different devices used in this period of time were recorded and we determined if these were related to the development of immediate complications duringthe procedure visualized in arteriography. Results We had 228 cases, complications were found in 16.6% of the cases. Embolisms (n » 31), subarachnoid hemorrhages (n » 2), gangliobasal hemorrhage (n » 1), vasospasm (n » 1), dissection (n » 1) and peusoaneurysms (n » 2) were identified. 5 embolisms happened to new territories during thrombectomy. Discussion Endovascular treatment has been shown to be effective for recanalization in large vessel occlusion. The use of devices presumes a risk for the manipulation of the vessels. Conclusion Embolism was the most frequent complication. The endovascular treatment in the acute stroke produces a favorable clinical outcome of the patients and we found a low percentage of complications that would not suppose a negative affectation in the final outcome.

Práticas de cuidado e desafios do autocateterismo intermitente limpo: as vozes dos escolares / Healthcare practices and challenges of the clean intermittent catheterization: the voices of the children

As crianças portadoras de disfunções miccionais, sendo de ordem neurológica (bexiga neurogênica) ou funcionais, necessitam de cuidados especiais para evitar a deterioração do sistema urinário inferior e insuficiência renal. Na maioria dos casos de bexiga neurogênica, indica-se, o cateterismo intermitente limpo. Também indicado para as disfunções não neurogênicas quando não se consegue bons resultados com outros tratamentos. São crianças com necessidades especiais de saúde (CRIANES), com mudanças na sua vida cotidiana e necessidade de cuidados especiais. O enfermeiro necessita interagir com as mesmas, de forma que, na fase escolar, possam juntos, planejar e administrar o autocuidado, necessários para facilitar o processo de viver saudável. Objeto de estudo: o autocateterismo intermitente limpo realizado pelo escolar portador de disfunção miccional. Objetivos: descrever as práticas de cuidados concernentes ao autocateterismo intermitente limpo realizado pelo escolar portador de disfunção miccional e analisar os desafios para a realização dessa prática de cuidado por esse escolar nos diversos espaços de socialização. Metodologia: estudo de natureza qualitativa, desenvolvido sob o método criativo sensível, através das dinâmicas de criatividade e sensibilidade Corpo Saber e Mapa Falante. Os participantes da pesquisa foram sete crianças portadoras de disfunção miccional, com idade entre 9-11 anos. O cenário de estudo foi um ambulatório de pediatria, situado em um hospital de ensino e pesquisa no estado do Rio de Janeiro. Os dados foram coletados no período entre fevereiro e março de 2015, e foram analisados a partir da análise de discurso em sua corrente francesa, sendo interpretados à luz do autocuidado de acordo com o conceito de Orem, a Teoria do Desenvolvimento Psicossocial de Erik Erikson e da educação em saúde com as concepções freirianas para a educação. Resultados:através da análise da prática de cuidados desses escolares, evidenciamos a preocupação com a higienização das mãos, da região íntima e do óstio de Mitrofanoff e, cuidados com o esvaziamento completo da bexiga. Quanto aos desafios, foram evidenciados a necessidade do uso de dispositivos para a visualização do meato urinário, dificuldades para a visualização do meato uretral feminino no período matutino, no posicionamento para a realização do autocateterismo, a presença de desconfortos com a sondagem uretral, a irregularidade na frequência do autocateterismo, as dificuldades para brincar em função da realização do autocateterismo, a (in) dependência no autocateterismo e o (des)velamento do autocateterismo nos diversos espaços de socialização. Conclusão: Revelou-se uma consciência ingênua na prática de cuidados, assim como fatores ambientais interferindo no autocuidado e riscos de infecção do trato urinário. Os diversos desafios enfrentados pelos escolares, na realização do autocateterismo, apontam para a necessidade de aproximação com estes de forma dinâmica e criativa, facilitando a exposição de suas dúvidas, medos e anseios, e para a promoção da conscientização crítica e a socialização dos saberes, capacitando-os para o autocuidado. Também na divulgação junto aos órgãos competentes, para a adequação social, com vistas à inclusão destas CRIANES nos diversos espaços de socialização.

Children suffering from voiding dysfunction, which stems from a neurological (neurogenic bladder) or a functional disorder, need special care to prevent deterioration of the lower urinary tract and kidney failure. In most cases of neurogenic bladder it is indicated clean intermittent catheterization. Also suitable for non-neurogenic dysfunction when you don`t get good results with other treatments. These are children with special health care needs(CSHCN), with changes in their daily lives. The nurse needs to interact with them, so that, at school age, they can together plan and manage the self-care necessary to facilitate the process of healthy living. Subject: clean intermittent catheterization performed by the children that suffers from voiding dysfunction. Objectives: To describe the practices from care concerning the clean intermittent catheterization performed by the children that suffers from voiding dysfunction and analyze the challenges for the realization of this practice by that children in the various spaces of socialization. Methodology: qualitative study developed under the sensitive creative method, through the dynamics of creativity and sensitivity "Corpo Saber e Mapa Falante". The survey participants were seven children with voiding dysfunction, aged 9-11 years.The study setting was an outpatient pediatric clinic located in a teaching hospital in the state of Rio de Janeiro. Data were collected between February and March 2015 and were analyzed from the speech analysis in its French stream being interpreted in the lightof the self-care according to the Orem concept, the Psychosocial Development Theory of Erik Erikson and of health education with Freirian concepts for education. Results: by analyzing the practice of these children we noted the concern on hands, genitals and the Mitrofanoff ostium hygienization, and, the complete evacuation of the bladder.Regarding the challenges, were highlighted the necessity of devices for visualizing the urinary meatus, difficulties in the visualization of the feminine urethral meatus in the morning, the position to perform the catheterization, the discomfort with the urethral probe, the irregularity in the frequency of catheterization, the difficulties to play due the realization of catheterization, the (in)dependence on autocatheterism and the (un)veiling of autocatheterism in various spaces of socialization. Conclusion: It was revealed an ingenuous consciousness in the practice of cares, as well as environmental factors interfering in the self-care and risk of urinary tract infection.The various challenges faced by the children in performing the catheterization point to the necessity of closer ties in a dynamic and creative way, facilitating the exposure of their doubts, fears and desires, to promote critical awareness and the socialization of knowledge, enabling them for self-care. Also, in the disclosure with the competent organs, to social adaptation, aiming to incorporate such CSHCN in various spaces of socialization.

Role of ureteric stents in relieving obstruction in patients with obstructive uropathy

The aim of this study is to evaluate the role of ureteric stents in relieving obstruction and improvement of kidney function in patients with obstructive uropathy. This study involved 138 patients with obstructive uropathy with age ranged from 2 months to 73 years. Patients classified into two groups: Group [I]: Includes 57 patients [41.3%], ureteric stents fixed to them; and Group [II]: Includes 81 patients [58.6%] managed by other treatment modalities. All patients underwent clinical assessment, Laboratory and radiologic investigations: At presentation and postoperative. These included: Complete urine analysis, urine culture and sensitivity, serum creatinine, serum urea nitrogen, serum uric acid, serum sodium [Na], serum potassium [K], Fasting blood glucose level and blood picture and plain X-ray [KUB], abdominal ultrasonography [US], diuretic renography and retrograde pyelography. Renal glomerular filtration rate [GFR] was used as an indicator for improvement of renal function after fixation of ureteric stent. In group I: 56 [71.8%] kidneys showed significant recovery compared to 61 kidneys [66.3%]. In group II, there is statistically significant relation between renal perfusion and renal recovery [P < 0.004], statistically significant relation between parenchymal thickness and recovery in both groups [P < 0.0002], statistically significant relation between degree of corticomedullary differentiation and recovery [P < 0.0003] and statistically significant relationship between hemoglobin levels at presentation and the recoverability [P < 0.002]. The predictors of renal recoverability revealed that ureteral stents alone can help in regaining renal function and significant improvement of clinical condition in patients with obstructive uropathy.

Number of coils necessary to treat cerebral aneurysms according to each size group: a study based on a series of 952 embolized aneurysms / Quantidade de molas necessárias para o tratamento endovascular dos aneurismas cerebrais de acordo com seu tamanho: estudo baseado em uma série de 952 aneurismas embolizados

OBJECTIVE: The Brazilian public health system determines a quantity of coils allowed to treat a cerebral aneurysm. The goal of this paper was to determine the number of coils necessary to treat an aneurysm based on size. METHODS: All patients harboring an aneurysm treated by endovascular approach between 1999 and 2003 were reviewed. RESULTS: There were 952 aneurysms included. Mean diameter sac was 8.2 mm with 7.9 coils per aneurysm. Out of 462 small aneurysms, mean size was 4.8 mm, with 4.6 coils/aneurysm used. A total of 315 medium aneurysms were treated, mean size was 8.6 mm, with 8.2 coils. Out of 135 large, mean size was 17 mm, with 16.1 coils. Forty giant aneurysms were treated with a mean size of 32 mm and 28.7 coils. CONCLUSIONS: We propose size as a reference to predict the number of coils necessary to treat each aneurysm: one coil for each millimeter of diameter.

OBJETIVO: O sistema público brasileiro determina uma quantidade limitada de molas permitida para o tratamento endovascular dos aneurismas cerebrais. O objetivo deste trabalho foi determinar a quantidade de molas necessária para tratar um aneurisma usando tamanho como referência. MÉTODO: Foram revisados todos os pacientes com aneurismas embolizados entre 1999 e 2003. RESULTADOS: No total, 952 aneurismas foram analisados. O diâmetro médio foi de 8,2 mm, com 7,9 molas usadas por aneurisma. Do total, 462 aneurismas eram pequenos, com tamanho médio de 4,8 mm e 4,6 molas/aneurisma. Foram tratados 315 aneurismas médios, com tamanho médio de 8,6 mm e 8,2 molas/aneurisma. Dentre os 135 aneurismas grandes, o tamanho foi de 17 mm, com 16,1 molas/aneurisma. Foram tratados 40 aneurismas gigantes, com média de 32 mm e 28,7 molas/aneurisma. CONCLUSÃO: Propomos que se utilize o tamanho do aneurisma como referência para prever o número de molas necessário para embolização: uma mola para cada milímetro de tamanho do saco aneurismático.

Short term outcome of carotid artery angioplasty and stenting with cerebral protection devices

Management of carotid bifurcation stenosis is a cornerstone of stroke prevention. Carotid artery stenting [CAS] is now used as an alternative to surgical endarterectomy. To evaluate short term outcome of CAS with the use of cerebral protection devices as well as assess the impact of various adverse anatomical features of the aortic arch and culprit carotid lesion oil difficulty and rate of complication during CAS procedures. The study included consecutive eligible patients with internal carotid artery [ICA] stenosis with >/= 50% in symptomatic stenosis and >/= 70% in asymptomatic stenosis presented to the catheterization labs of Catania and Ragusa hospitals during the period from October 2009 till May 2011. According to the anatomical adverse characteristics, the patients were classified into 4 groups: group I represented the least anatomical complexity while group IV represented the most complex anatomical features. Data of the CAS procedures and intra-procedural complications as well as during the 1st month after the procedures were collected and studied. The study included 104 ICA lesions in 100 consecutive eligible patients. Seventy-one males and twenty-nine females, mean age 71.9 +/- 7.85 years and 21 patients were >/= 80 years old [octogenarians]. Most of the patients had asymptomatic ICA stenosis [76%] while 24% of patients had symptomatic ICA stenosis. Technical success was obtained in 103 procedures [99%], failed one procedure due to complex anatomical features. Combined cerebrovascular events had occurred in 5 patients [1 major stroke, 1 minor stroke and 3 transient ischemic attacks] with estimated rate 4.8%. No cases of amaurosis fugax, myocardial infarction or death had occurred. Symptomatic patients had stroke rate of 4.1% while stroke rate in asymptomatic patients was 1.3%. Adverse events showed significant statistical difference with increased anatomical complexity [P < 0.001]. Cerebrovascular events in symptomatic patients did not show significant statistical difference in comparison to asymptomatic patients [P = 0.064]. CAS procedures in octogenarians [>/=80 years] showed no significant statistical difference with the number of cerebrovascular adverse events [P = 0.285]. CAS is a relatively safe procedure could be done with low incidence of complications when performed by trained operators. Evaluation of the anatomical characteristics has an important impact oil procedural difficulty and complications

Role of multidetector computerized tomography in coronary in-stent restenosis

We described the role of multi detector computerized tomography in the detection and exclusion of coronary in-stent re-stenosis compared with the conventional coronary angiography. 30 patients pretreated with coronary stenting and complaining of angina like symptoms underwent dual source coronary angiography one day before performing conventional coronary angiography. 47 stents were examined 43 of them were assessable by DSCT-CA and the calculated sensitivity, specificity, negative predictive value, positive predictive value and overall accuracy of all assessable stents were 100%, 90%, 100%, 81% and 93%, respectively. When analyzing the results for stents

Análise dos valores SUS para a revascularização miocárdica percutânea completa em multiarteriais / Analysis of Brazilian Public Health System values for complete percutaneous myocardial revascularization in multi-arterial patients

FUNDAMENTO: O Sistema Único de Saúde (SUS) estabelece que a angioplastia coronariana com o implante de duplo stent não deve exceder 20 por cento das angioplastias, resultando na necessidade de escalonar a maioria dos procedimentos nos pacientes com doença multiarterial. OBJETIVO: O objetivo do presente estudo foi avaliar os valores remunerados pelo SUS para a obtenção da revascularização miocárdica percutânea completa em pacientes do SUS com doença multiarterial relacionados ao número de procedimentos necessários e de stents implantados. MÉTODOS: Foram incluídos 141 pacientes com doença coronariana multiarterial, submetidos à revascularização completa com sucesso pelo implante de stent, com coronariografia aos 6 meses pós-implante. A revascularização completa foi definida como o tratamento percutâneo de todas as lesões com percentual de estenose > 70 por cento, em vasos com diâmetro > 2 mm. Para análise dos custos, foram considerados os valores da Tabela SIH/SUS de R$ 2.263,77 para o procedimento e R$ 2.034,23 por stent implantado. RESULTADOS: No período de 07/2006 a 12/2007 foram implantados 416 stents em 141 pacientes. A idade média foi de 59,7 ± 9,9 anos, com predomínio do sexo masculino (68,1 por cento). O número de vasos foi 356 e o número de lesões 416. Para a obtenção da revascularização completa pelo implante de stent coronáriano foi necessário o escalonamento em até 4 procedimentos. O tempo médio entre a 1ª e 2ª, 2ª e 3ª e 3ª e 4ª angioplastias foi de 45,8 ± 37,7, 55,4 ± 55,3 e 33,5 ± 19,1 dias, respectivamente. CONCLUSÃO: A revascularização percutânea completa em pacientes do SUS com doença coronariana multiarterial, realizada em sua grande maioria de forma escalonada, ocasiona considerável elevação de gastos públicos devido ao aumento do número de procedimentos.

BACKGROUND: The Brazilian Public Health System (SUS, acronym in Portuguese) establishes that coronary angioplasty with the double implant stent must not exceed 20 percent of the angioplasties, resulting in the need of assigning most of the procedures in patients with multiarterial disease. OBJECTIVE: The objective of the present study was to assess the paid values by the SUS in order to obtain the complete percutaneous myocardial revascularization in the SUS patients with the multiarterial disease, related to the number of necessary procedures and of implanted stents. METHODS: A total of 141 patients with multiarterial coronary disease, submitted to a successful complete revascularization, were included by the stent implant with coronariography in a 6-month period of post-implant. The complete revascularization was defined as the percutaneous treatment of all stenosis > 70 percent in vessels with diameter > 2 mm. For the costs analysis, the values from the Sistema de Informações Hospitalares (SIH) of the SUS table were considered as R$ 2,263.77, for the procedure; and R$ 2,034.23, per implanted stent. RESULTS: In the period from 7/2006 to 12/2007, 416 stents were implanted in 141 patients. The mean age was of 59.7 ± 9.9 years old, prevailing the male sex (68.1 percent). The number of vessels was 356 and the lesions number corresponded to 416. In order to obtain the complete revascularization by the coronary stent implant, it was necessary to stagger in up to four procedures. The mean time between the 1st and 2nd, 2nd and 3rd and 3rd and 4th angioplasties was of 45.8 ± 37.7; 55.4 ± 55.3 and 33.5 ± 19.1 days, respectively. CONCLUSION: The complete percutaneous revascularization in patients from the SUS with the multiarterial coronary disease, carried out in most of them staggered, causes considerable elevation of public expenses due to the increase of procedures' number.

The initiation of coronary angioplasty and stenting in a single outpatient centre in Barbados / La iniciación de la angioplastia y el estent de la arteria coronaria en un centro ambulatorio en Barbados

Percutaneous transluminal coronary angioplasty (PTCA) is a novel procedure to Barbadian healthcare. Only one centre in Barbados provides PTCA and stenting. This is a retrospective study aimed at describing the initial results of coronary angioplasty and stenting in the first 48 patients at the Carib-American Heart Centre and exploring the feasibility and safety of coronary angioplasty and stenting in Barbados. Forty-eight patients underwent PTCA during the period March 2002 to June 2004 inclusive, with or without intracoronary stenting. Most (64.6%) of the patients were male and 43.7% were diabetic. The most common vessels involved were the left anterior descending coronary artery (LAD) and the right coronary artery (RCA). In one patient, attempted stenting was unsuccessful but PTCA reduced stenosis. One patient had previous PTCA and stenting of the LAD and two patients had coronary artery bypass grafting (CABG) prior to the procedure. Twenty-one per cent of the patients treated had severe triple vessel disease. There were no cases of restenosis or acute vessel closure, during or immediately following the procedure that required emergency PTCA or CABG. All patients were discharged within 24 hours of the procedure. Procedural success was 100%. In conclusion, outpatient PTCA and stenting is safe and feasible in the Barbadian population. Coronary artery bypass grafting is still the procedure of choice for treating coronary artery disease (CAD) involving the left main coronary artery but PTCA is indicated in some cases of severe triple vessel disease.

La angioplastia coronaria transluminal percútanla (ACTP) es un procedimiento nuevo en la atención a la salud en Barbados. Sólo un centro en Barbados ofrece ACTP y estent (o cánula intraluminal de arteria coronaria). El presente trabajo es un estudio retrospectivo destinado a describir los resultados iniciales de la angioplastia y el estent coronarios en los primeros 48 pacientes en el Centro Caribe-americano de Cardiología, y explorar la factibilidad y seguridad de la angioplastia y el estent en Barbados. Cuarenta y ocho pacientes fueron sometidos a ACTP durante el periodo de marzo 2002 a junio 2004 inclusive, con o sin estent intracoronario. La mayor parte (64.6%) de los pacientes eran varones y un 43.7% eran diabéticos. Los vasos más comúnmente involucrados fueron la arteria coronaria descendente anterior izquierda (DAI) y la arteria coronaria derecha (ACD). En un paciente, el intento de estent no tuvo éxito, pero la ACTP redujo la estenosis. A un paciente le fue practicada previamente la ACTP y el estent de la DAI, y a dos pacientes se les realizó injerto de bypass de la arteria coronaria (IBAC) antes del procedimiento. El veintiún por ciento de los pacientes tratados tuvo enfermedad vascular triple. No hubo ningún caso de reestenosis o cierre vascular agudo, durante o inmediatamente después del procedimiento, que requiriera ACTP o IBAC de emergencia. Todos los pacientes fueron dados de alta dentro de las 24 horas tras el procedimiento. El éxito de los procedimientos fue del 100%. En conclusión, el estent y el ACTP ambulatorios son seguros y factibles para la población barbadense. El injerto de bypass de la arteria coronaria sigue siendo el procedimiento de elección para tratar casos de la enfermedad de la arteria coronaria (EAC) que involucren la arteria coronaria izquierda principal, pero la ACTP se indica en algunos casos de enfermedad vascular triple.

[Stent-ghaft new technique for treatment of aneurysms]

Endovascular aneurysm repair involves the transluminal placement of a graft within the aneurysm that completely excludes the sac from the general circulation, the graft is anchored in place by a balloon-expandable or self-expanding metal frame that supports all or part of the graft and provides a watertight seal proximal and distal to the dilated segment of the artery. Because it avoids the need for laparotomy, cross-clamping of the aorta, and the obligatory blood loss associated with the opening of the aneurysm sac, this technique has much to be recommended. It has the potential to reduce the morbidity and mortality associated with conventional open abdominal aortic aneurysms [AAA] repair and extend the scope of repair to those patients with severe medical co-morbidities who were previously denied treatment

use of nasal stent for choanal atresia

To assess the role of the use of nasal stent NS on the outcome of choanal atresia CA surgeries, as well as the effect on the age at the time of surgery. The study involved a retrospective review of the files of the case with the diagnosis of congenital CA that were surgically managed at King Abdul-Aziz University Hospital between January 1999 and June 2005. The review included: the age, gender, associated congenital anomalies, surgical intervention, and use of nasal stent NS. A comparative study was carried out between the outcome of the cases who received NS, and those who did not. A total of 31 cases with the diagnosis of CA comprised our study group. Thirteen of the cases received NS and 18 did not. Generally, the use of NS for CA surgery resulted in poor outcome. Seventy-five percent of the unilateral cases with no-NS had successful outcome compared to 13% of those who received NS p=0.00988. On the other hand, only 33% of the bilateral cases with no-NS had a successful outcome compared to 60% of those who received NS p=0.3917. NS mandates an increased medical care. Its use in unilateral CA was associated with poor outcome. Based on our findings, it is recommended not to use NS in unilateral CA, as well as to postpone the surgical intervention, if possible, until the child is one year old or more

Routine use of cerebral protection [filter wire] during carotid artery stenting: results of a single center registry of 37 patients

To evaluate the short-term outcome of patients who underwent carotid stenting with the routine use of cerebral protection devices. In our center, 36 successful carotid stenting procedures [of 38 at tempted] were performed in 37 patients [23 men; aged 66 +/- 7 years]. Cerebral protection involved distal filter devices [n = 36] of which 12 were Accunet and 24 were EZ filter wires. The protection devices were positioned successfully in 36 of the 38 attempted vessels. The 30-day incidence of stroke and neurological death was three. Neurological complications included one major stroke, and one minor stroke. There was also one [sudden cardiac death on the first day]. The proportion of stroke or death was two for symptomatic lesions and one for asymptomatic lesions, and two in patients aged < 80 years and one in those aged >/= 80 years. Protection device-related vascular complications included mild spasm, which occurred after three procedures [8%], none of which led to neurological symptoms. There were another four cardiogenic deaths in 30-day follow-up. In this uncontrolled study, routine cerebral protection during carotid artery stenting was technically feasible and clinically safe. The incidence of major neurological complications in this study was lower than in previous reports of carotid artery stenting without cerebral protection

Covered self-expanding metal stent in palliative treatment of dysphagic patient with end-stage malignancy of cardia: the first experience in stent placement and literature review

More than 50% of patients with carcinoma of the esophagus or gastric cardia have incurable disease at presentation and require palliative treatment for dysphagia. Insertion of a self-expanding metal stent has become the treatment of choice for these patients. We report successful placement of a covered self-expanding metal stent in a patient with malignant squamous cell carcinoma [SCC] of esophagogastric junction. A 62-year-old man referred to the gastrointestinal division of the 501 medical center, Tehran, Iran due to dysphagia. During upper gastrointestinal endoscopy, a seven cm tumor was seen 35 cm distal to dental line. Histologic examination of the biopsy samples confirmed malignant SCC. The tumor was in stage Ill/IV and therefore it was inoperable. Palliative therapy with 11-cm covered Choo stent [Mi-Tech Ltd., Seoul, South Korea] was considered for this patient. On March 12, 2006 after sedation with midazolam, the stent was placed under the fluoroscopic and endoscopic guide. The patient underwent radiotherapy, thereafter. During the two-month follow-up, the patient's general condition recovered and he gained weight. Fluoroscopically guided insertion of covered self-expanding metal stents is a safe and comfortable method of palliation for patients suffering with malignant dysphagia. For prevention of restenosis, covered types should be given priority

Comparison of stenting with minimally invasive bypass surgery for high grade stenosis of the proximal left anterior descending coronary artery: six months follow up of randomized study

High grade stenosis of the proximal left anterior descending coronary artery [LAD] in patients with single-vessel disease is associated with a significantly worse prognosis than lesions at any other location. To compare the merits of stenting with minimally invasive coronary artery bypass [MICAB] surgery for high grade stenosis of isolated proximal LAD. One hundred patients with isolated high grade lesion [stenosis] >75% of laminal diameter in the proximal LAD were included. The patients were classified into two groups: Group A included 50 patients in whom successful stenting was performed. Group B included 50 patients in whom successful MICAB was performed. In group A the mean percentage of stenosis was significantly reduced to 10.48 +/- 4.112. After stenting, non of the patients died, 2Q wave infarction, 2 non Q wave infarction and 1 required coronary bypass surgery, 1 stroke, 3 LAD dissection, 5 angina pectoris, 3 needed revascu-larization, 4 vascular complications and 4 needed blood transfusion. In group B, after surgery 1 patient had Q wave infarction, 1 non Q wave infarction, 2 patients needed necessary sternotomy because of an intramyocardial segment of the LAD, 3 angina pectoris, 2 needed revascularization, 2 vascular complications, 2 needed blood transfusion, 2 developed AF and 2 chest wall hernias. The mean duration of lCU stay after surgery was 2.62 +/- 1.086 days as compared to 1.8 +/- 1.591 days after stenting [p < 0.05], the mean duration of hospitalization after surgery was 8.64 +/- 3.186 days as compared to 2.34 +/- 2.471 days after stenting [p < 0.01], Follow-up was complete for all patients except two patients in each group [2 patients died in group B while in group A one patients traveled and other was excluded, eleven asymptomatic patients refused repeated cardiac catheterization after stenting, as did 13 patients after surgery. No statistically significant difference was found between both groups as regard to positive exercise stress test [p > 0.05]. After stenting, the angina class improved 79.2% were free of angina. After surgery, the mean angina class improved, 91.6% of patients were free of angina. After six months of follow up, in-stent restenosis was detected in 11 patients [29.7%] and subgroup analysis showed a restenosis rate 15.4 for type B lesion and 46.2% for type C lesion. The recurrence of stenosis was more in type C and B than type A in stenting group. In surgical group, 3 patients [8.6%] had stenosis > 50% of the luminal diameter at the anatomic region, and subgroup analysis showed a restenosis rate of 3.6% for type B lesions and 21.4% for type C lesions. The recurrence of stenosis was more in type C and B than type A in surgical group. Secondary end points were 56% in group A vs 26% in group B. Stenting and minimally invasive bypass surgery are safe and effective treatment options for high grade lesions in the proximal LAD; MICAB requires longer hospitalization, more cost but has better an-giographic outcome while stenting has higher target vessel revascularization and secondary adverse cardiac event than MICAB

Value of serum nitric oxide in patients with coronary artery disease before and after percutaneous transluminal coronary angioplasty with or without stent

Our study was planned to assess the value of plasma NO as an early marker for endothelial injury and to detect its relation to the severity of coronary artery disease and its relation to restenosis after PCI. This study included [51] patients; [14] were normal control group [Group I]; and [37] patients were diseased [Group II], whom classified into three subgroups; subgroup [A] patients with single vessel disease [15 patients], subgroup [B] patients with two vessels disease [15 patients], subgroup [C] multi-vessels disease included [7 patients]. All patients subjected to coronary angiography with or without intervention [PTCA only, PTCA + stent or without stent]. [21] Patients accepted and respected follow-up by coronary angiography after 4 months. NO serum level was done before PCI and after 4 months in those accepted follow-up. Mean NO serum level on control group was 83 micro mol/L, while mean plasma NO serum level in subgroup [A] [34.8 +/- 10.3 micro mol/L], [17.5 +/- 3.5 micro mol/L] in subgroup [B]; and [8.9 +/- 2.2 micro mol/L in subgroup [C]. This revealed a highly significant decrease than control group, with P-value <0.05, <0.0005 and <0.0005 respectively when compared mean NO serum level in control group with each subgroup. On comparing the mean values of plasma NO level of subgroups [A, B, C]; to each other there was more or less gradual mathematical decrease in NO serum level between the subgroups, with highly significant P-values. Comparing the mean level of plasma NO of restenosis cases before and after PCI in each subgroup [A, B and C], we found a significant decrease in plasma NO level after PCI than before PCI. Endothelial dysfunction is an important contributing factor in CAD and it is associated with NO deficiency which can be considered as one of the endothelial markers for CAD. The more the degree of endothelial dysfunction, the more the deficiency of NO, the more the severity of CAD. Restenosis is a multi-factorial subject requiring a lot of work and lack of NO is related at least in part to the development of restenosis after angioplasty. We can suggest that if plasma NO level after PCI is reduced at least 30% of its initial level before PCI, most probably restenosis has occurred

significance of stenting after ureteroscopic removal of distal ureteral calculi

We determine the morbidity associated with no stent placement following uncomplicated ureteroscopy for removal of distal ureteral calculi. A total of 93 patients undergoing uncomplicated, complete removal of distal ureteral calculi were contacted 1 to 3 days and 7 to 10 days postoperatively to determine analgesic requirements and time of return to normal activity. Radiological follow-up consisted of an excretory urogram or renal ultrasound 8 weeks postoperatively. Of 93 patients 40 [43%] had no discomfort postoperatively. Of the 53 patients who had discomfort 45 [85%] had mild discomfort only, controlled with oral analgesics. When discomfort occurred it resolved in 41 patients [77%] in 2 days or less. Of 12 patients who required intravenous narcotics postoperatively 5 required preoperative hospitalization for the narcotics and were still hospitalized at the time of stone removal. None of the 59 patients who had follow-up excretory urogram or renal ultrasound has had a newly identified ureteral stricture to date. In the majority of patients undergoing uncomplicated ureteroscopy for removal of distal ureteral calculi postoperative discomfort is modest, lasts less than 2 days and is easily controlled with oral analgesics. Stricture formation has not been identified. We do not believe that routine placement of a ureteral stent following uncomplicated ureteroscopy for distal ureteral calculi is necessary