[Treatment of atherosclerotic lesion of the first segment of subclavian artery]. / Lechenie ateroskleroticheskogo porazheniya pervogo segmenta podklyuchichnoi arterii.

Severe subclavian artery lesion is an important medical and social problem worsening the quality of life and leading to dire consequences. Vertebrobasilar insufficiency is the main syndrome of lesion of the first segment of subclavian artery. About 20% of all ischemic strokes occur in vertebrobasilar basin. At present, surgical treatment of asymptomatic patients with severe lesion of the 1st segment of subclavian artery is still debatable. Open surgery is optimal for occlusion of this vascular segment. Carotid-subclavian transposition is a preferable option with favorable in-hospital and long-term results. However, carotid-subclavian bypass is an equivalent alternative in case of difficult transposition following anatomical and topographic features of vascular architectonics. Endovascular treatment is preferable for isolated subclavian artery stenosis and should certainly include stenting.

O significado de uma diferença elevada na pressão arterial entre os dois braços e antes dos implantes dentários: um alerta preocupante, reflexões e tratamento / The significance of intearm arterial blood pressure high difference before dental implant placement: shocking alert, lessons, and case management

Este relato de caso mostra os perigos que uma diferença significativa assintomática na pressão arterial pode trazer à Implantodontia. Paciente do sexo feminino com 75 anos de idade, com perdas de elementos dentais na região posterior de maxila, recebeu como plano de tratamento cirurgias de enxertia e posterior instalação de implantes. Exames pré-operatórios e avaliação cardiológica foram requisitados, sendo autorizadas as cirurgias. Dois atos cirúrgicos foram realizados sem intercorrências. Na terceira cirurgia, no pré-operatório, constatou-se uma diferença de pressão arterial entre os braços direito e esquerdo quando optou-se pelo cancelamento da cirurgia e novo encaminhamento com urgência ao cardiologista em posse do relatório clínico. A pressão arterial mais baixa no braço esquerdo era causada por uma estenose na artéria subclávia com risco aumentado para acidentes vasculares e morbidade cardíaca. Uma angioplastia foi realizada com a instalação de stent, medicações anti-hipertensivas foram mantidas e um antiagregante plaquetário foi introduzido. A paciente foi liberada para continuidade de seu tratamento, com orientações do cardiologista e cirurgião vascular a serem seguidas. Diante do ocorrido e das observações apontadas na literatura pesquisada, pôde-se concluir que o cirurgião terá um melhor panorama das condições físicas dos pacientes se na anamnese ele tomar como rotina a correta aferição da pressão arterial nos dois braços e, diante de qualquer anormalidade, fazer os encaminhamentos necessários para sua segurança e de seus pacientes.

This case report demonstrates how a significant difference at the interarm blood pressure can bring risks to implant dentistry. A 75 years-old female patient with loss of posterior maxillary teeth received a treatment planning grafting surgeries and further implant placement. The pre-operative exams and a cardiologic evaluation were requested, and dental surgeries authorized. The first two separate operations were made without complications. However, in the third surgical appointment, a high difference in blood pressure was detected between the left and right arms. In this way, the surgery was cancelled and the patient urgently referred to the physician. The medical report demonstrated low blood pressure at the left arm caused by the subclavian steal syndrome with risk of vascular accident and cardiac morbidity. An angioplasty was made and a stent was placed, in addition to antihypertensive medications. A platelet anticoagulant was introduced. The patient was released for dental procedures under guidance of the cardiologist and the vascular surgeon. It can be concluded that routine check of blood pressure in both arms can better screen the patient's physical condition and to improve necessary referrals for the patient's safety.

Impaired vascular endothelial function in patients with restless legs syndrome: a new aspect of the vascular pathophysiology.

BACKGROUND: Restless legs syndrome (RLS) is a common sleep disorder in which patients feel unpleasant leg sensations and the urge to move their legs during rest, particularly at night. Leg movement improves these symptoms. Although several studies have demonstrated an association between cardiovascular disease and RLS, the mechanisms underlying this relationship remain unclear. Recent studies have shown changes in the peripheral microvasculature, including altered blood flow and capillary tortuosity, and peripheral hypoxia. Vascular endothelial dysfunction can be assessed noninvasively with ultrasound measurements of brachial artery flow-mediated dilatation (FMD). Therefore, this study investigated FMD in RLS patients to determine the involvement of microvascular alterations in this disorder. METHODS: The study enrolled 25 drug-naïve RLS patients and 25 sex- and age-matched controls and compared the FMD values of the two groups. RLS was diagnosed according to the criteria of the International Restless Legs Syndrome Study Group. RESULTS: FMD was significantly lower in the RLS patients (6.6 ± 1.2%) compared to the controls (8.4 ± 1.8%; p<0.05) and the RLS patients showed a weak, negative correlation between RLS severity and FMD (r=-0.419, p=0.04). Multivariate linear regression analysis revealed that RLS (B=-1.87, 95% confidence interval [CI] -2.72 to -1.02; p<0.001) and age (B=-0.06; 95% CI -0.12 to -0.02; p<0.001) were significantly and inversely correlated with FMD. CONCLUSIONS: This study demonstrated that RLS patients have poorer vascular endothelial function than normal healthy subjects and provides further evidence supporting the involvement of peripheral systems in the generation of RLS.

Tumescent local anesthesia for a revascularization of a coronary subclavian steal syndrome.

Tumescent local anesthesia (TLA), originally developed for liposuction, has found widespread application. We report a case of peripheral arterial bypass grafting under TLA. The patient was an 84-year-old female diagnosed as having coronary subclavian steal syndrome caused by proximal left subclavian artery stenosis. Because she had several risk factors for general anesthesia, we performed axilloaxillary artery bypass grafting under TLA and mild sedation. There was no morbidity related to the surgery. The TLA technique may be ideal for performing peripheral arterial bypass grafting if general anesthesia is inappropriate because of cardiac complications.

[Clinical and pathogenetical peculiarities and treatment policy in ischemic stroke of elderly and old age]. / Kliniko-patogeneticheskie osobennosti i voprosy lechebnoi taktiki pri ishemiskom insul'te v pozhilom i starcheskom vozraste.

The data on randomized study of 2 groups of patients with ischemic brain hemisphere stroke of elderly and old (over 70 years) as well as middle (under 60 years) age are presented. In elderly and old age, stroke develops on the basis of common affection of major vessels, with a great role of the "steal syndrome" in its pathogenesis. In authors' opinion, in treatment of ischemic stroke of elderly and old age attention should be paid to metabolic therapy, in particular to using high dosages of Cerebrolysin. Basing on clinical and paraclinical study, efficacy of this medication is revealed.

[Carotid-subclavian bypass. Our experience with locoregional anesthesia]. / Bypass carotido-succlavio. Esperienza in anestesia loco-regionale.

Carotid-subclavian bypass has been adopted since 1956. The commonest indication is to abolish arterial occlusion or stenosis in patients with subclavian steal syndrome. Ten patients were submitted to carotid-subclavian bypass under regional anaesthesia: block of anterior rami of spinal nerves C3-C4 and block of cervico-brachial plexus by injection into the continuous perineural connective tissue space at the level of C6. The surgical procedure required carotid occlusion and cerebral function monitoring. The advantages of regional anaesthesia are the ability to monitor the patient's cerebral perfusion and function, to detect intraoperative ischaemia and embolisation and minimal interference with the cardiovascular and respiratory function.

Postprandial transient painful amaurosis fugax.

A case of recurrent postprandial amaurosis fugax (AF) associated with periorbital pain is described. Clinical and angiographic examination revealed moderate atherosclerosis of the cerebral vessels and narrow-angle glaucoma. Cerebral postprandial hypoperfusion combined with increased intraocular pressure probably precipitated the painful monocular blindness. The attacks of AF subsided partially after treatment of the glaucoma.

[Transoral Doppler ultrasound echography under local anaesthesia for the assessment of vertebral artery blood flow (author's transl)]. / Transorale Doppler-Sonographie unter Schleimhautanästhesie zur Beurteilung der Strömungsverhältnisse in den Aa. vertebrales (Vertebralis-Doppler)

Uncalibrated flow in the vertebral arteries was registered with a bidirectional CW Doppler ultrsound apparatus. It was applied to 20 patients, results being compared with aortic arch angiograms in which the extracranial part of all four cerebral vessels was seen. In 14 the vertebral arteries had a symmetrical flow and lumen, a similar symmetrical result being obtained with the Doppler. Hypoplasia of one vertebral artery was present in two patients the distinct asymmetry being recorded by the ultrasound. Three patients with central stenosis in one subclavian artery and subclavian "steal" were found to have reverse flow by the Doppler method in the vertebral artery on the side of the stenosis. Endarterectomy was performed on the affected subclavian artery in two of these patients: post-operative vertebral ultrasound recordings demonstrated a return to physiological flow direction in both vertebral arteries.