The fate of spinal arteries after the stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair technique: a case series.

Objective: We evaluated the patency of the spinal arteries (intercostal and lumbar) after the STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique. Methods: A retrospective analysis of all patients with aortic dissection treated with the STABILISE technique between April 2018 and July 2021 was performed. Imaging analysis of the spinal cord vascular supply was accomplished using multiplanar and maximum intensity projection reconstructed images of pre- and postoperative computed tomography angiograms at 1 month, 12 months, and annually thereafter. Results: Twelve patients were treated for complicated aortic dissection. Primary technical success was 100% and mid-term clinical success, at a mean follow-up of 27 ± 12 months, was 90%. No cases of spinal cord ischemia were identified. One patient died after 1 year (non-aortic related), and one patient was lost to follow-up. A significant decrease was found in the mean number of patent spinal arteries in the stent graft area at 1 month (P < .001), 1 year (P < .001), and 2 years (P = .004). However, no significant reduction was found in the number of spinal arteries in either the bare metal stented or nonstented aorta (P > .05). Conclusions: Use of the STABILISE technique decreased intercostal artery patency in the thoracic stent graft area, but spinal artery patency was not significantly affected by the bare metal stent nor its aggressive ballooning. These findings constitute a step toward a better understanding of the safety of this technique.

The evolution of management of type B aortic dissection in a series of 100 consecutive cases in a tertiary center.

INTRODUCTION AND OBJECTIVES: Management of aortic dissection is rapidly evolving. The present study aims to assess paradigm shifts in type B aortic dissection (TBAD) treatment modalities and their outcomes according to clinical presentation and type of treatment. We also aim to assess the impact of endovascular technology in TBAD management in order to define organizational strategies to provide an integrated cardiovascular approach. METHODS: We performed a retrospective review with descriptive analysis of the last 100 consecutive patients with TBAD admitted to the Vascular Surgery Department of Centro Hospitalar Universitário Lisboa Norte over a 16-year period. Results were stratified according to treatment modality and stage of the disease. The study was further divided into two time periods, 2003-2010 and 2011-2019, respectively before and after the introduction of a dedicated endovascular program for aortic dissections. RESULTS: A total of 100 patients (83% male; mean age 60 years) were included, of whom 59 were admitted in the acute stage (50.8% with complicated dissections). The other 41 patients were admitted for chronic dissections, most of them for surgical treatment of aneurysmal degeneration. Temporal analysis demonstrated an increase in the number of patients operated for aortic dissection, mainly due to an increase in chronic patients (33.3% in 2003-2010 vs. 64.4% in 2011-2019) and a clear shift toward endovascular treatment from 2015 onward. Overall in-hospital mortality was 14% and was significantly higher in the chronic phase (acute 5.1% vs. chronic 26.8%; OR 5.30, 95% CI 1.71-16.39; p=0.003) and in patients with aneurysmal degeneration, regardless of the temporal phase. Only one death was recorded in the endovascular group. CONCLUSION: Management of TABD carried an overall mortality of 14% during a 16-year period, but the appropriate use of endovascular technology has substantially reduced in-hospital mortality.

Herbicides employed in sugarcane plantations have lethal and sublethal effects to larval Boana pardalis (Amphibia, Hylidae).

The increasing demand for biofuels favored the expansion of sugarcane and, as a consequence, in the consumption of pesticides in Brazil. Amphibians are subject to pesticide exposure for occurring in or around sugarcane fields, and for breeding at the onset of the rainy season when pesticide consumption is common. We tested the hypothesis that herbicides used in sugarcane crops, although employed for weed control and manipulated at doses recommended by the manufacturers, can cause lethal and sublethal effects on amphibian larvae. Boana pardalis was exposed to glyphosate, ametryn, 2,4-D, metribuzin and acetochlor which account to up to 2/3 of the volume of herbicides employed in sugarcane production. High mortality was observed following prolonged exposure to ametryn (76%), acetochlor (68%) and glyphosate (15%); ametryn in addition significantly reduced activity rates and slowed developmental and growth rates. AChE activity was surprisingly stimulated by glyphosate, ametryn and 2,4-D, and GST activity by ametryn and acetochlor. Some of these sublethal effects, including the decrease in activity, growth and developmental rates, may have important consequences for individual performance for extending the larval period, and hence the risk of dessication, in the temporary and semi-permanent ponds where the species develops. Future studies should seek additional realism towards a risk analysis of the environmental contamination by herbicides through experiments manipulating not only active ingredients but also commercial formulations, as well as interactions among contaminants and other environmental stressors across the entire life cycle of native amphibian species.

Complete Disruption of The Iliac Vessels During Spinal Surgery With Delayed Presentation.

INTRODUCTION: The posterior approach to the lumbar spine is most commonly used to treat lumbar spine pathology. Vascular complications, although rare, have a high mortality rate. This is the report of an arterial lesion complicating a L5 hemilaminectomy and its surgical resolution. The need to remain vigilant for this condition, which requires prompt diagnosis and treatment, is emphasised. REPORT: A 31 year old woman was admitted to the neurosurgery department with L5 right-sided sciatica and an associated radiculopathy, and paraesthesia of the first toe of the right foot. She had previously undergone surgical correction of a L4 - L5 lumbar disc herniation, as well as a left oophorectomy and chemotherapy for ovarian neoplasia. A right L5 hemilaminectomy associated with right L5 - S1 foraminotomy and L5 - S1 discectomy was performed with the patient in the ventral position. The procedure was carried out without any apparent complications. In the first three post-operative days the patient complained persistently of orthostatic hypotension and a drop in haemoglobin was observed. Computed tomography angiography revealed what appeared to be a complete transection of the right common iliac artery and vein, with active haemorrhage, and a large pseudoaneurysm. Immediate surgery was carried out with reconstruction consisting of a 9 mm Dacron graft interposed in the right common iliac artery, as well as ligation of the right common iliac vein, which was not amenable to repair. The post-operative period was uneventful. The patient was discharged on day 13 with normal lower limb pulses and mild oedema of the right lower limb, controlled with elastic compression stockings. DISCUSSION: Iatrogenic injuries of the large abdominal vessels during spinal surgery is rare but serious. Close patient surveillance and remaining vigilant for these life threatening vascular lesions are crucial in the peri-operative period of spinal surgery.

Lethal toxicity of the herbicides acetochlor, ametryn, glyphosate and metribuzin to tropical frog larvae.

Despite the high amphibian biodiversity and increasing pesticide use in tropical countries, knowledge on the sensitivity of tropical amphibians to pesticides remains limited. The aim of this study was to evaluate the acute toxicity of the active ingredients of four of the main herbicides used in Brazilian sugarcane production to tadpoles of two tropical frog species: Physalaemus cuvieri and Hypsiboas pardalis. The calculated 96 h-LC50 (median lethal concentration; in mg a.s./L) values for P. cuvieri and H. pardalis were 4.4 and 7.8 (acetochlor); 15 and <10 (ametryn); 115 and 106 (glyphosate); and 85 and 68 (metribuzin), respectively. These toxicity values demonstrated little interspecies variation and the toxicity of the herbicides appeared to be at least partly related with the respective octanol-water coefficient. Published acute toxicity data of fish and amphibians for herbicides were also compiled from the US-EPA ECOTOX database. These data indicated little difference in herbicide sensitivity between tropical amphibians and both non-tropical amphibians and fish. These findings indicate that temperate (fish and amphibian) herbicide toxicity data are also protective for tropical amphibians. Constraints in such extrapolations and indications for future research are discussed.

Global Impact of Peripheral Obstructive Arterial Disease in Portugal: An Eight Year Study.

INTRODUCTION: Peripheral arterial disease has an important impact on morbidity/mortality. The objective of this study was to quantify the impact of this disease in Portugal during the last eight years, expressed by the volume of admissions, treatment strategies and associated morbidity and mortality. MATERIAL AND METHODS: We collected data from the Diagnosis Related Group national database on primary diagnosis, procedures codes, demographic variables, a number of risk factors, and mortality of all cases admitted from 2009 to 2016 with a primary diagnosis of peripheral arterial disease coded according to the 9th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-9). RESULTS: In this study, peripheral arterial disease led to 27 684 hospitalisations, which corresponded to 26.7% of all admissions for vascular disease in this period. Approximately 49.9% of patients were admitted to the emergency department. The volume of procedures in patients with claudication decreased over the eight years, unlike patients with critical ischaemia, in which the number of procedures increased. DISCUSSION: Age and the presence of cardiovascular risk factors have been associated with the severity of disease, as observed in our series. Overall hospital mortality varied, being significantly higher in patients with more advanced severity of the disease. CONCLUSION: Peripheral arterial disease represents an important burden in the overall volume of admissions in Portuguese public hospitals. A large number of patients was admitted in the context of emergency.

Introdução: A doença arterial obstrutiva periférica tem um importante impacto a nível de morbi/mortalidade. O objetivo deste trabalho é quantificar o impacto desta doença em Portugal, ao longo dos últimos oito anos, expresso pelo volume de internamento, tratamento e pela morbi-mortalidade respetiva. Material e Métodos: Foram analisados os registos de internamento no Serviço Nacional de Saúde entre 2009 e 2016 da base de dados dos grupos de diagnósticos homogéneos utilizando os códigos 9th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-9) de diagnóstico e procedimentos. Verificámos o número de casos em cada ano por estadio de doença, dados demográficos, fatores de risco, tratamento e morbi-mortalidade. Resultados: No período de estudo a doença arterial periférica conduziu a 27 684 internamentos o que correspondeu a cerca de 26,7 % do total de internamentos por patologia vascular neste período. Cerca de 49,9 % dos doentes foram admitidos em contexto de urgência. Os procedimentos em doentes claudicantes diminuíram ao longo dos oito anos ao contrário dos doentes com isquémia crítica em que os procedimentos aumentaram. Discussão: A idade e a presença de fatores de risco cardiovasculares têm sido associadas à gravidade da doença, tal como na nossa série. A mortalidade hospitalar global varia, sendo mais significativa nos doentes com doença mais avançada. Conclusão: A doença arterial periférica é uma patologia com importante representação no internamento dos hospitais do Serviço Nacional de Saúde. Há ainda um importante volume de doentes admitidos no contexto de urgência o que sugere eventual falta de reconhecimento/referenciação atempada por parte dos cuidados saúde primários, devendo mais esforços ser realizados no sentido de aumentar a interação entre os cuidados de saúde primários e os hospitais terciários.

Is stenting for atherosclerotic renal stenosis an effective technique?

INTRODUCTION: One of the treatments for renal artery stenosis is endovascular intervention, but its effectiveness is controversial. The present study aims to analyze the experience of a working group in the endovascular treatment of selected patients with severe obstructive atherosclerotic lesions of the renal arteries, and to characterize early and late results. METHODS: This is a retrospective study of symptomatic patients with atherosclerotic renal artery stenosis who underwent endoluminal therapy between May 12, 1999 and March 12, 2015 at two institutions. Statistical analysis was performed using the PASW Statistics program. RESULTS: A total of 99 patients were treated, mean age 66 years and 76.8% male. The mean degree of stenosis measured by renal Doppler echocardiography was 83% and 64.6% were ostial lesions. Mean preoperative creatinine level was higher than the postoperative mean: 1.3 vs. 1.2 mg/dl (p=0.014). The number of antihypertensive drugs in the preoperative period was higher than in the postoperative period: 2.0 vs. 1.3 (p=0.001). The mean follow-up was 40 months (0-164). The mean peak systolic velocity over time in the postoperative period was 77 cm/s (40-250). The restenosis rate was 8%, and 30-day mortality was 0%. CONCLUSIONS: The results demonstrated that the endovascular technique has a beneficial effect on blood pressure and renal function in selected patients, and is a safe technique associated with a high rate of technical success and few complications.

[A community-based study of stroke code users in northern Portugal]. / Avaliação da Via Verde do Acidente Vascular Cerebral no Norte de Portugal: Caracterização e Prognóstico dos Utilizadores.

INTRODUCTION: By 2002 Portugal had one of the highest mortality rates due to cerebrovascular diseases among the European Countries. Meanwhile, several strategies have been adopted to improve prevention and treatment in the acute phase, amongst which the Stroke Code. The purpose of this study is to describe how this measure has been used and its outcome as part of a prospective community based study of stroke/TIA incidence in Northern Portugal. MATERIALS AND METHODS: Between 1st October 2009 and 30th September 2010 all strokes occurred in patients registered at Western Porto, Mirandela and Vila Pouca de Aguiar health centres have been recorded. For cases ascertainment multiple sources of information were used, including the WEB, letter, e-mail and Alert P1, as well as systematic searches on databases provided by the entities involved in this study: hospital emergency, discharge records, diagnosis procedures, death certificates, Stroke Code admissions and health centre emergency records. RESULTS: Six hundred strokes were recorded in a population of 241 000 (incidence rate of 250 / 100 000 person-years) and 434 were first-ever-in-the-lifetime (180 / 100 000). There were 72 Stroke Code calls and in 66.7% of them a stroke was confirmed. Considering the criteria for Stroke Code call (age = 80 years, functional independency, the stroke signs/symptoms, and time after episode = 3 hours), only 15.9% patients "could" have access to it. Of those who used the Stroke Code, only 56.3% fulfilled the criteria. Considering all patients fulfilling Stroke Code criteria, 96.3% that used prehospital Stroke Code were inpatients, as well as 83.3% that used intra/interhospital Stroke Code and 64.0% of the remainder; this trend is also present in patients with ischaemic stroke submitted to fibrinolysis, 77.3%, 36.4% and 17.4%, respectively. A high post-stroke Rankin was more frequent among Stroke Code users (70.3% vs. 35.3%), but they exhibit more often the three stroke signs/symptoms (44.0% vs. 16.2%). After adjusting for age, sex and number of signs, the risk of a more severe post-stroke Rankin is not significantly different among patients using the prehospital Stroke Code (OR = 2.9, 95% CI: 0.8 - 10.2). CONCLUSIONS: The criteria for accessing the Stroke Code are currently restrictive. Though the Stroke Code is accessed in case of more severe patient's conditions, the proportion of patients treated with fibrinolysis is relatively high in comparison with other studies.

Introdução: Em 2002 Portugal detinha uma das mais altas taxas de mortalidade por doenças cerebrovasculares entre os países europeus. Várias estratégias foram adoptadas para melhorar a prevenção da doença e o seu tratamento na fase aguda, entre as quais a criação da Via Verde do Acidente Vascular Cerebral. O objectivo deste trabalho é descrever a utilização e resultados desta estratégia no contexto de um registo prospectivo comunitário na Região Norte de Portugal. Material e Métodos: Foram registados todos os AVCs ocorridos entre 1 de Outubro de 2009 e 30 de Setembro de 2010 nos utentes inscritos no agrupamento de centros de saúde do Porto Ocidental e nos de Mirandela e Vila Pouca de Aguiar. Para a detecção de casos utilizaram-se múltiplas fontes de informação: notificação via WEB, e-mail, Alerta P1 e pesquisas sistemáticas em registos disponibilizados pelas entidades envolvidas - urgências hospitalares, listas de altas, procedimentos de diagnóstico, óbitos, Via Verde do Acidente Vascular Cerebral e serviço de atendimento de situações urgentes. Resultados: Ocorreram 600 AVCs em 241 000 habitantes (taxa de incidência de 250 / 100 000), dos quais 434 foram primeiros na vida (180 / 100 000). Foram registados 72 acessos à Via Verde do Acidente Vascular Cerebral, dos quais 66,7% foram diagnosticados como AVC. Considerando os quatro critérios de activação (idade ≤ 80 anos, independência funcional, sinais/sintomas do AVC e tempo após episódio ≤ 3 horas), só 15,9% dos doentes a poderiam utilizar e, dos utilizadores, apenas 56,3% satisfaziam esses critérios. Dos doentes com critérios de activação, foram internados 96,3% pela VV pré-hospitalar, 83,3% pela VV intra/inter-hospitalar e 64,0% dos restantes; a fibrinólise foi realizada em 77,3%, 36,4% e 17,4% dos doentes com enfarte cerebral, respectivamente. O Rankin pós- AVC é mais grave nos utilizadores da VV pré-hospitalar (70,3% vs. 35,3%), mas estes apresentam mais assiduamente os três sinais/ sintomas de AVC (44,4% vs. 16,2%). Ajustando para a idade, sexo e número de sinais, o risco de incapacidade grave pós-AVC não é significativamente diferente no acesso pela VV pré-hospitalar (RP = 2,9; IC 95%: 0,8 - 10,2), bem como a taxa de letalidade. Conclusões: Os critérios para activação da Via Verde do Acidente Vascular Cerebral são muito restritivos. Embora esta seja mais vezes accionada em situações clínicas graves, a proporção de doentes que realizou fibrinólise é relativamente alta em comparação com outros estudos.