Tratamiento endovascular de la enfermedad obstructiva aortoilíaca / Endovascular management of aortoiliac occlusive disease

Resumen Introducción: La angioplastia transluminal percutánea (ATP), se ha convertido en una técnica aceptada, en el tratamiento de la enfermedad obstrutiva aortoilíaca, con tasas de éxito del 90-92% y permeabilidad primaria del 55-72% a 5 años. Objetivo: Evaluar los resultados del tratamiento endovascular del sector aortoilíaco. Material y Método: Estudio descriptivo, retrospectivo (revisión de serie de casos unicéntrica), de pacientes, sometidos consecutivamente al tratamiento endovascular (ATP simple y ATP con stent) de la patología obstructiva del sector aortoilíaco, durante un período de 7 años (2002-2019), en el Hospital Dr. Eduardo Pereira de Valparaíso, Chile. Resultados: Se realizaron 103 procedimientos en 94 pacientes, sexo masculino: 63,83%, femenino: 36,17%, edad promedio: 67,4 años (rango 47-96), distribución de las lesiones según la clasificación TASC II: A (46,24%), B (39,78%), C (8,60%), D (5,38%), remodelando la biburfaccción aórtica (kissing stent) en un 6,80%, procedimientos híbridos (12,62%), seguimiento promedio (47,13 meses), éxito clínico (90,29%), exito técnico (94,17%), permeabilidad primaria, primaria asistida y secundaria a 5 años del 68,09%, 75,53% y 81,91% respectivamente, tasa de salvación de la extremidad a 5 años del 84,04%, mortalidad < 30 días del 1,94%, supervivencia a 5 años del 90,42%. Discusión: Las técnicas endovasculares del sector aortoilíaco son fiables, sus resultados ténicos y permeabilidad, están influenciados por el estadio clínico del paciente y severidad de las lesiones tratadas. Conclusión: En pacientes adecuadamente seleccionados, el tratamiento endovascular del sector aortoilíaco presenta excelentes resultados, permitiendo aumentar la indicación de tratamiento en pacientes considerados de alto riesgo.

Introduction: Percutaneous transluminal angioplasty (PTA) has become an accepted technique in the treatment of aortoiliac occlusive disease, with success rates of 90-92%, and primary patency of 55-72% at 5 years. Aim: To evaluate the results of endovascular treatment (PTA or PTA with stents) of the aortoiliac sector. Material and Method: Descriptive, retrospective study (single-center case series) of patients, consecutively subjected to endovascular treatment (PTA or PTA with stents) of aortoiliac occlusive disease, during a period of 7 years (2002 - 2019), at the Dr. Eduardo Pereira Hospital in Valparaíso, Chile. Results: 103 procedures were performed in 94 patients, male: 63.83%, female: 36.17%, mean age: 67.4 years (range 47-96), distribution of the lesions according to the TASC II classification: A (46.24%), B (39.78%), C (8.60%), D (5.38%), remodeling the aortic bifaction (kissing stent) in 6.80%, hybrid procedures (12.62%), average follow-up (47.13 months), clinical success (90.29%), technical success (94.17%), primary patency, assisted primary and secondary at 5 years of 68.09%, 75, 53% and 81.91% respectively, 5-year limb salvage rate of 84.04%, mortality < 30 days of 1.94%, 5-year survival of 90.42%. Discussion: Endovascular techniques in the aortoiliac sector are reliable, their technical results and patency are influenced by the clinical stage of the patient and the severity of the lesions treated. Conclusion: In appropriately selected patients, endovascular treatment of the aortoiliac sector, presents excellent results, allowing an increase in the indication for treatment in patients considered to be at high risk.

Ulcera aórtica penetrante como causa de dolor torácica en urgencias: presentación de caso y revisión de la literatura / Penetrating aortic ulcers as a cause of chest pain in emergency room: presentation of case and review of the literature

La úlcera penetrante de aorta describe una condición en la que una placa ateroesclerótica se ulcera y penetra con las laminas elástica interna y media de la aorta. Esta lesión puede asociarse o complicarse con la formación de un hematoma intramural, disección, dilatación aneurismática, pseudoaneurisma o ruptura de la aorta. Se presenta el caso de un paciente masculino de 58 años quien consultó a urgencias con disnea, síncope y dolor torácico agudo con diagnosticó final de úlcera aórtica penetrante.

Penetrating aortic ulcer describes the condition in which an ulceration of an atherosclerotic plaque penetrates the internal and medial elastic laminas of the aorta. This lesion can be associated or complicated with the formation of an intramural hematoma, dissection,aneurysmatic dilatation, pseudo aneurysm or aortic rupture. We report the case of a 58 year old male who entered the emergency department with dispnoea, syncope and acute chest pain, with final diagnosis of penetrating aortic ulcer.

[Isolation of periodontal bacteria from blood samples and atheromas in patients with atherosclerosis and periodontitis]. / Aislamiento de bacterias periodontopáticas desde hemocultivos y ateromas obtenidos de pacientes con aterosclerosis y periodontitis.

BACKGROUND: Periodontitis is a common oral disease produced by bacterial species that reside in the subgingival plaque. These microorganisms have been associated to atherosclerosis and it is suggested that periodontitis is a cardiovascular risk factor. AIM: To isolate periodontal bacteria from blood and atheroma samples, from patients with atherosclerosis and periodontitis. MATERIAL AND METHODS: Twelve patients with periodontitis and a clinical diagnosis of atherosclerosis and 12 patients with periodontitis but without atherosclerosis were studied. Blood samples were obtained immediately before and after scaling and root planing. The samples were incubated in aerobic and anaerobic conditions. One week after scaling, atheromatous plaques were obtained during endarterectomy in the 12 patients with atherosclerosis. These were homogenized and cultured for aerobic and anaerobic bacteria. Microorganisms were identified by means ofPCR. RESULTS: Five patients with and two without atherosclerosis, had bacteremia after scaling and root planing. Bacterial species isolated from blood samples were the same found in periodontic pockets. Four atheromatous plaques of patients with bacteremia yielded positive cultures. The isolated bacteria were the same found in blood samples and periodontal pockets. CONCLUSIONS: Bacteremia occurred in seven of 24 patients after scaling and root planing. In four patients, the same species found in periodontic pockets and blood cultures were detected in atherosclerotic plaques obtained one week after the dental procedure.

Aislamiento de bacterias periodontop ticas desde hemocultivos y ateromas obtenidos de pacientes con aterosclerosis y periodontitis / Isolation of periodontal bacteria from blood samples and atheromas in patients with atherosclerosis and periodontitis

Background: Periodontitis is a common oral disease produced by bacterial species that reside in the subgingival plaque. These microorganisms have been associated to atherosclerosis and it is suggested that periodontitis is a cardiovascular risk factor. Aim: To isolate periodontal bacteria from blood and atheroma samples, from patients with atherosclerosis and periodontitis. Material and methods: Twelve patients with periodontitis and a clinical diagnosis of atherosclerosis and 12 patients with periodontitis but without atherosclerosis were studied. Blood samples were obtained immediately before and after scaling and root planing. The samples were incubated in aerobic and anaerobic conditions. One week after scaling, atheromatous plaques were obtained during endarterectomy in the 12 patients with atherosclerosis. These were homogenized and cultured for aerobic and anaerobic bacteria. Microorganisms were identified by means ofPCR. Results: Five patients with and two without atherosclerosis, had bacteremia after scaling and root planing. Bacterial species isolated from blood samples were the same found in periodontic pockets. Four atheromatous plaques of patients with bacteremia yielded positive cultures. The isolated bacteria were the same found in blood samples and periodontal pockets. Conclusions: Bacteremia occurred in seven of 24 patients after scaling and root planing. In four patients, the same species found in periodontic pockets and blood cultures were detected in atherosclerotic plaques obtained one week after the dental procedure.

Use of endovascular stents in atherosclerotic renovascular stenosis: blood pressure and renal function changes in hypertensive patients.

Atherosclerotic renal artery stenosis may result in hypertension and ischemic nephropathy. Renal artery endovascular stenting has emerged as current therapy; however, the percentage of patients who benefit from this procedure is still not well established. The authors studied 116 hypertensive patients with atherosclerotic renovascular stenosis who underwent successful renal artery stenting for the first time. At 1 year, there was a significant overall decrease in blood pressure in the group after stenting; however, there was no change in renal function. Also, no significant change in the number of antihypertensive drugs was noted. Blood pressure improved in 55% of the patients, worsened in 14%, and remained unchanged in 31%. Renal function improved in 16% of the patients, worsened in 30%, and remained stable in 54%. In relation to blood pressure control, patients with resistant or difficult-to-control hypertension showed the most improvement in blood pressure control after stenting.

Uma nova técnica para avaliar a lesão endotelial na arteriosclerose / A new technique to evaluate the endotelium lesion in atheroesclerosis

Os autores propõem uma nova técnica para avaliar a relação entre infecção e aterosclerose pela coleta de sangue da artéria coronária depois da lesão ou do seio coronariano em casos de insuficiência coronariana aguda durante a angioplastia, buscando bactérias, vírus e fragmentos de DNA virais

Aortofemoral thromboendarterectomy.

PURPOSE: To study whether endarterectomy is feasible in all patients with aortofemoral atherosclerotic obstruction, considering early and late results. METHODS: A clinical, prospective, and descriptive study carried out in a university hospital. Inclusion criteria were atherosclerotic aortofemoral obstructive disease, clinical status compatible with major surgery, and absence of prior restorative procedure. Exclusion criteria were aneurysm, inflammatory arterial disease, and prior restorative procedure found during surgery. Eighty patients entered the protocol, but 9 were excluded (11.2%). Seventy-one patients, mean age of 57.3 years, underwent endarterectomy. Operative indications were intermittent claudication and critical ischemia. A ring-stripper endarterectomy technique was employed in all patients. Results were related to age, gender, symptoms, presence of diabetes mellitus, extension of endarterectomy, and extent of obstructive disease. Chi square or Fisher exact tests were used when appropriate, and the Wilkoxon (Gehan) test was used to compare survival curves. RESULTS: Sixty-eight (100%) endarterectomies were patent at discharge. The mortality rate was 4.2%. The amputation rate (4.3%) was higher in diabetic patients and when there was associated femoropopliteal obstruction. The 5-year survival rate was 83.3%, and late deaths were mostly cardiovascular. Diabetes mellitus, age above 65 years, and associated femoropopliteal obstruction lowered the survival rate. The 5-year patency rate was 87.0%. Critical ischemia and less extensive endarterectomies were associated with a lower patency rate. There were no anastomotic aneurysms or deep infections. CONCLUSIONS: Aortofemoral thromboendarterectomy is feasible in 90% of patients, early mortality rate is low, diabetic patients and those with associated femoropopliteal obstructive disease have a higher mortality rate, amputation rate is low, late deaths are mostly cardiovascular, and late patency rate is high, and even higher in the intermittent claudication group.

Hipertensión renovascular: caso clínico / Renal vascular hypertension: clinical case

Se presenta un caso de hipertensión secundaria de causa renovascular, detectado en una mujer diabética de 74 años con historia de hipertensión severa de 28 años de evolución conocida, acentuada en los últimos 3 meses. En el caso analizado, la arteriografía renal fue normal pero el cintigrama demostró la existencia de isquemia renal bilateral frente al uso de captopril. Debe recordarse que a pesar de que la arteriografía es el "gold standar"para el diagnóstico de la hipertensión renovascular, su sensibilidad no es 100 por ciento, especialmente en los casos en que existe enfermedad de pequeños vasos. Dentro del estudio de esta paciente hubiese sido ideal realizar un exámen con ecografía Doppler, el que, asociado al cintigrama, aumenta el rendimiento diagnóstico en los casos de hipertensión por estenosis de los vasos intrarrenales. Se aprovecha el caso para analizar brevemente el diagnóstico de la hipertensión renovascular: sospecha clínica; exámenes de laboratorio; imágenes y estudio funcionales. Desde el punto de vista terapéutico, el tratamiento quirúrgico es el más indicado en las estenosis ateroescleróticas de la arteria renal y la angioplastía en las de naturaleza fibromuscular

Arteria vertebral extracraneal-porción distal. Aspectos anatómicos de su abordaje quirúrgico / Extracranial vertebral artery-distal portion. Anatomical aspects of its surgical approach

La demostración reciente de la eficacia en el manejo quirúrgico de la porción distal de la arteria vertebral extracreneal provee una alternativa para muchas patologías que afectan esta porción. El tratamiento quirúrgico es el manejo de elección en enfermedad arteriosclerótica, así como en algunas otras condiciones estructurales. Presentamos una técnica quirúrgica, la cual es segura y eficaz en el alivio de la sintomatología, haciéndose énfasis en los aspectos anatómicos.

[Phenotype and reactivity of T-lymphocytes isolated from atheromatous plaque. Knowledge obtained from a transplant case]. / Fenotipo y reactividad de linfocitos T aislados de la placa ateromatosa. Enseñanzas de un transplante.

The primary immunologic hypothesis assumes that the initial damage in atherosclerotic lesions is mediated by T lymphocytes reactive to heat shock proteins, lipoproteins, bacteria, virus or even donor MHC antigens. A frequent cause of heart transplant failure is the de novo formation of atheromatous lesions in the vessels of the transplanted organ despite their absence in the donor, thus suggesting that new lesions are secondary to a cellular immune response by the receptor. In this study we determined the phenotype and the reactivity of T cells from peripheral blood and from endomyocardial and atherectomy biopsies obtained from the same immunosuppressed patient who underwent a heart transplant in 1989. A panel of homozygous HLA-typed, Epstein-Barr virus transformed B lymphocytes were used as stimulators in functional assays. Our results showed an important increase in the percentage of CD4+ cells in the atheromatous plaque as well as in the endomyocardium, and a considerable amount of TCR sigma+ lymphocytes in the atheromatous plaque. A considerable loss of alloreactivity to HLA antigens was also observed. These results suggest that although there are adequate conditions to mount a cellular immune response a state of cellular anergy exists towards HLA antigens probably as result of prolonged immunosuppressive therapy. The presence of obstructive lesions in this particular patient don't seem to be secondary to HLA alloreactivity but could be secondary to a switch in the cellular immune response as a consequence of chronic exposure to some donor antigen, thus explaining the increased proportion of TCR sigma+T lymphocytes.

Carotid atherosclerosis. Immunocytochemical analysis of the vascular and cellular composition in endarterectomies.

Papers dealing with rupture of carotid plaque surface are few in spite of the growing importance of the subject. The aim of this study was to analyze the cellular and vascular components of surgically excised carotid endarterectomies in order to obtain information about their role in the pathogenesis of the plaque rupture and intraplaque hemorrhage. Seventy-six surgical specimens of carotid endarterectomies were used for this study. The findings of immunophenotyping of the cellular constituents of the plaques were: 1) endothelial lining: the fibrous cap at the site of the rupture showed an eroded surface with loss of the endothelial lining. Conversely, in the remaining surface a continuous, not damaged row of endothelial cells stained with anti-CD31 and anti-CD34 was observed; 2) fibrous cap: the collagenous fibrous cap at the site of erosion was attenuated and the phenotypic characterization of the cells showed inflammatory components consisting mainly of macrophages (CD68 positive), 2/3 of the total infiltration. The remaining 1/3 was composed of T-lymphocytes and scarce B-lymphocytes. A close interaction between macrophages and capillaries and macrophages and T-lymphocytes was observed; 3) lipid cores: two different types of lipid cores could be depicted. Avascular or mildly vascularized lipid cores and highly vascularized, with neoformed vessels stained with CD34 and CD31. CD34 stained endothelia of all kind of vessels; conversely, neoformed vessels showed a weak stain with CD31. T-lymphocytes were found to be in close contact with neoformed vessels, and in some cases, migrating through the endothelial cells; 4) deeper layers of the plaque: the base and the shoulder of the plaques showed in 28/76 cases neoformed vessels, thin or thick walled, CD34 positive, generally surrounded by mild to extensive mononuclear infiltrates. Atherosclerotic plaques were found to belong to six different lesions: plaque rupture plus thrombosis (18/76, 23.6%), plaque rupture plus intraplaque hemorrhage plus thrombosis (18/76, 23.6%), intraplaque hemorrhage without plaque rupture (16/76, 21.0%), plaque rupture plus intraplaque hemorrhage (5/76, 6.5%), stable calcified non complicated plaque (14/76, 18.4%) and unstable, soft, non complicated plaque (5/76, 6.5%). The first four lesions were considered as "complicated lesions". Complicated plaques presented neoformed vessels in the periphery, shoulder and base of the plaque in 22/57 (38.5%) cases. Conversely only 1/14 (7.1%) of non complicated, stable calcified plaques presented neoformed vessels, (p < 0.05). Of note, the 5 causes of unstable, soft non complicated plaque presented neoformed vessels surrounding the plaque. In 10/57 (17.5%) complicated plaques unequivocal histological signs of old hemorrhages were found surrounding those vessels. Irrespective of presenting no rupture, 11/35 plaques showed a mononuclear infiltrate in the fibrous cap. In conclusion, rupture of carotid plaques (50% of the cases), is characterized by the presence of a macrophagic infiltration of the caps and by the direct apposition of T-lymphocytes to macrophages and a close relation of these cells to endothelial cells. This highly suggests a cell-to-cell interaction, which results in an inflammatory process. Intraplaque hemorrhage without rupture represented 21% of the endarterectomies. These lesions are not related to cap erosion, but to plaque vascularization. Most lipid cores were highly vascularized with neoformed vessels with macrophages and T-cells in close contact and in some cases disrupting the endothelium. The abrupt growing of the lipid core and/or an overproduction of oxygen free radicals could lead to the breakdown of core vessels and intraplaque hemorrhage.

Estudo do tempo de internaçäo adicional causado por infecçäo de ferida cirúrgica em amputados com arteriosclerose periférica / Study on additional time of hospitalization caused by surgical wound infection in patients with amputations for peripheral arteriosclerosis

O presente estudo ao abordar a infecçäo em ferida cirúrgica baseou-se na análise do tempo adicional de hospitalizaçäo. Foram observados 111 pacientes amputados primariamente por arteriosclerose periférica sendoque 40 desenvolveram infecçäo no coto de amputaçäo e 71 näo apresentaram infecçäo. Foram selecionados 40 casos e 40 controles, agrupados em pares pela idade, sexo, operaçäo, disgóstico, antecedentes e classificaçäo do risco operatório. O tempo médio de internaçäo foi de 44,9 dias para os casos e de 20.8 dias para os controles. O tempo adicional de internaçäo foi de 24,1 dias. Concluimos portanto que a infecçäo de ferida cirúrgica em amputados por arteriosclerose periférica pode ser responsável por um tempo de internaçäo maior

Estudo da letalidade causada por infecçäo de ferida cirúrgica em amputados com arteriosclerose periférica / Study of lethality by surgical wound infection in amputees with peripheric arteriosclerosis

O presente estudo ao abordar a infecçao em ferida cirúrgica baseou-se na análise da taxa de mortalidade atribuída à infecçao. Foram observados 111 pacientes amputados primariamente por arteriosclerose periférica sendo que 40 desenvolveram infecçao no coto de amputaçao e 71 nao apresentaram infecçao. Foram selecionados 40 casos e 40 controles, agrupados em pares pela idade, sexo, operaçao, diagnóstico, antecedentes e classificaçao do risco operatório. A letalidade geral dos pacientes agrupados por pares foi de 30 por cento nos casos e de 15 por cento nos controles. A letalidade atribuída à infecçao foi de 15 por cento. Concluímos portanto que a infecçao de ferida cirúrgica em amputados por arteriosclerose periférica pode ser responsável por uma letalidade maior.

[Survival after aorto-femoral shunt with Dacron prosthesis]. / Sobrevivência após derivação aorto-femoral com próteses de Dacron.

The purpose of this paper is to establish the survival rate of patients submitted to aorto-femoral bypass grafting and compare it with the general mortality rate of the population in the State of São Paulo. The records of 210 patients with aorto-femoral bypass grafts and mean age of 54 years were analysed according the Kaplan and Meyer method. The survival curves of the normal population with the age of 55 and 70 years were used for comparison. Our results are comparable with those reported in the international literature. The aorto-femoral atherosclerotic disease Hás the same features wherever lives the patient. The death is caused mainly by cardiac disease. In our patients, however, the infection of the prosthesis was also an important factor in the fatal outcome of the disease. After ten years about half of the patients submitted to an aorto-femoral bypass grafting are still alive.

Atuaçäo da fisioterapia em pacientes submetidos à cirurgia de By Pass fêmoro-poplítea na faixa etária de 40 a 70 anos por obstruçäo / Actuation of physioterapy in patients to urdergo of phemoral-poplital By Pass surgery in 40 to 70 years old by obstruction

Nos meados de 1.950, começaram a ser realizadas cirurgias de revascularizaçäo por Gross. Com o passar dos anos a cirurgia vascular vem sendo aprimorada, através de novas pesquisas em relaçäo a novos materiais que foram utilizados como enxerto, onde podemos citar as próteses sintéticas de PTEE e dacron. Aos poucos a fisioterapia vem ocupando um espaço dentro da cirurgia de BY PASS, mas de acordo com a pesquisa observou-se que näo däo ênfase à fisioterapia no pré-operatório, näo por falta de interesse, e sim pela falta de indicaçäo médica. Desta maneira o processo de recuperaçäo pós-cirúrgica torna-se mais lento, levando a acamamento prolongado, aumentando o índice de complicaçöes

Variaçöes do pH e da PaCO2 na veia jugular interna durante: circulaçäo extracorpórea, hipotermia profunda (18-20oC) e clampeamento dos vasos arteriais braquiocefálicos: estudo experimental em cäes / Alterations in the pH and PaCO2 of internal jugular vein during cardiopulmonary bypass, deep hypothermia (18-20oC) and arterial brachial-encephalic clamping

Este trabalho visa avaliar as alteraçöes do pH e da PaCO2 do retorno venoso cerebral durante circulaçäo extracorpórea (CEC) e hipotermia profunda (20oC) em cäes, a fim de avaliar indiretamente o grau de risco de dano cerebral metabólico que pode ocorrer em procedimentos cirúrgicos do arco aórtico. Nessas cirurgias a circulaçäo cerebral encontra-se excluída da CEC através do clampeamento arterial necessário para efetuar o procedimento, enquanto o restante do organismo permanece perfundido (60 kg/min), visando conferir proteçäo aos tecidos miocárdico e renal, medula espinhal e outros. Um grupo de 15 cäes mestiços foi submetido a clampeamento dos vasos supra-aórticos (tronco arterial braquiocefálico, carótida e subclávia esquerdas) durante CEC e hipotermia profunda (18-20oC), sendo colhidas amostras sanguíneas de 15 em 15 min, a partir da veia jugular interna canalizada em direçäo cefálica. Os dados obtidos mostraram uma queda acentuada de pH e uma aumento da PaCO2 a partir de 45 min de clampeamento, levando à conclusäo de que, quando o período de clampeamento arterial dos vasos supra-aórticos excede 45 min, ocorrem alteraçöes metabólicas importantes no retorno venoso cerebral, que podem causar algum dano neurológico