Endovascular treatment of a patient with nutcracker syndrome and pelvic varices involving anterior and posterior renal veins.

We have reported a case of a 36-year-old woman with flank and pelvic pain and hematuria. She had posterior nutcracker syndrome and pelvic varices involving one anterior and three posterior renal veins (including one major vein). We used a complete endovascular approach, which included stent implantation in the major posterior renal vein and left gonadal vein embolization. During a 12-month follow-up period, the patient had had no symptoms and good computed tomography results. Endovascular treatment represents a safe and successful option for patients with nutcracker syndrome and pelvic varices involving the anterior and posterior renal veins.

Superior vena cava syndrome: endovascular management.

BACKGROUND: The objective of management of superior vena cava syndrome (SVCS) is to promptly alleviate the uncomfortable symptoms. Conventional approaches do not always achieve results as rapidly as endovascular management with stent placement. OBJECTIVES: To report the experience with endovascular management of SVCS of a Vascular and Endovascular Surgery Service at a Brazilian university hospital. METHODS: Symptomatic type III SVCS cases were managed with angioplasty and stent placement in 28 patients aged from 37 to 68 years, between 2002 and 2012. The etiology of SVCS was lung or thoracic cancer in 18 patients, while occlusion of the vein for prolonged use of catheters was the cause in the other 10 cases. RESULTS: Superior vena cava occlusion repair was not possible in one oligosymptomatic patient with a very severe lesion. Technical success was achieved in 96.4%. There were two deaths, one due to pulmonary embolism, 24 hours after a successful procedure, and the other due to compression of the airways by tumor mass some hours after the procedure. Clinical success was achieved in all cases of technical success, including one patient who died suddenly, after total regression of SVCS symptoms. Symptoms disappeared 24 hours and 48 hours after management in16 and 8 patients respectively; improvement was slower but progressive after 48 hours in the remaining patients. CONCLUSIONS: Endovascular stent placement was effective for management of SVCS, with good technical and clinical success rates and provided prompt relief from symptoms.

CONTEXTO: O tratamento da síndrome da veia cava superior (SVCS) visa aliviar, rapidamente, os sintomas desconfortáveis. Os resultados das abordagens convencionais nem sempre são tão rápidos quanto os do tratamento endovascular com colocação de stent. OBJETIVOS: Relatar a experiência de um Serviço de Cirurgia Vascular e Endovascular de hospital universitário brasileiro com o tratamento endovascular da SVCS. MÉTODOS: Vinte e oito pacientes com SVCS sintomática tipo III foram tratados com angioplastia e colocação de stent, entre 2002 e 2012. A idade variou entre 37 e 68 anos. A SVCS resultou de doença neoplásica pulmonar ou torácica em 18 pacientes e de oclusão da veia por uso prolongado de cateteres em 10 pacientes. RESULTADOS: Não foi possível reparo da oclusão da veia em um paciente oligossintomático com lesão bastante grave. O sucesso técnico foi de 96,4%. Houve duas mortes, sendo uma por embolia pulmonar 24 horas após procedimento bem-sucedido e outra por compressão das vias aéreas por massa tumoral algumas horas após o procedimento. Houve sucesso clínico em todos os casos de sucesso técnico, incluindo o paciente que faleceu de repente após ter apresentado regressão total dos sintomas. Os sintomas desapareceram em 24 e 48 horas após o tratamento em, respectivamente, 16 e oito pacientes. A melhora foi mais lenta, embora progressiva, após 48 horas nos demais pacientes. CONCLUSÕES: A colocação de stent endovascular no tratamento da SVCS foi eficaz, com boas taxas de sucesso técnico e clínico e alívio mais rápido dos sintomas.

Superior vena cava syndrome: endovascular management / Tratamento endovascular da síndrome da veia cava superior

The objective of management of superior vena cava syndrome (SVCS) is to promptly alleviate the uncomfortable symptoms. Conventional approaches do not always achieve results as rapidly as endovascular management with stent placement. Objectives To report the experience with endovascular management of SVCS of a Vascular and Endovascular Surgery Service at a Brazilian university hospital. Methods Symptomatic type III SVCS cases were managed with angioplasty and stent placement in 28 patients aged from 37 to 68 years, between 2002 and 2012. The etiology of SVCS was lung or thoracic cancer in 18 patients, while occlusion of the vein for prolonged use of catheters was the cause in the other 10 cases. Results Superior vena cava occlusion repair was not possible in one oligosymptomatic patient with a very severe lesion. Technical success was achieved in 96.4%. There were two deaths, one due to pulmonary embolism, 24 hours after a successful procedure, and the other due to compression of the airways by tumor mass some hours after the procedure. Clinical success was achieved in all cases of technical success, including one patient who died suddenly, after total regression of SVCS symptoms. Symptoms disappeared 24 hours and 48 hours after management in16 and 8 patients respectively; improvement was slower but progressive after 48 hours in the remaining patients. Conclusions Endovascular stent placement was effective for management of SVCS, with good technical and clinical success rates and provided prompt relief from symptoms

O tratamento da síndrome da veia cava superior (SVCS) visa aliviar, rapidamente, os sintomas desconfortáveis. Os resultados das abordagens convencionais nem sempre são tão rápidos quanto os do tratamento endovascular com colocação de stent. Objetivos Relatar a experiência de um Serviço de Cirurgia Vascular e Endovascular de hospital universitário brasileiro com o tratamento endovascular da SVCS. Métodos Vinte e oito pacientes com SVCS sintomática tipo III foram tratados com angioplastia e colocação de stent, entre 2002 e 2012. A idade variou entre 37 e 68 anos. A SVCS resultou de doença neoplásica pulmonar ou torácica em 18 pacientes e de oclusão da veia por uso prolongado de cateteres em 10 pacientes. Resultados Não foi possível reparo da oclusão da veia em um paciente oligossintomático com lesão bastante grave. O sucesso técnico foi de 96,4%. Houve duas mortes, sendo uma por embolia pulmonar 24 horas após procedimento bem-sucedido e outra por compressão das vias aéreas por massa tumoral algumas horas após o procedimento. Houve sucesso clínico em todos os casos de sucesso técnico, incluindo o paciente que faleceu de repente após ter apresentado regressão total dos sintomas. Os sintomas desapareceram em 24 e 48 horas após o tratamento em, respectivamente, 16 e oito pacientes. A melhora foi mais lenta, embora progressiva, após 48 horas nos demais pacientes. Conclusões A colocação de stent endovascular no tratamento da SVCS foi eficaz, com boas taxas de sucesso técnico e clínico e alívio mais rápido dos sintomas

Indication of endovascular treatment of type B aortic dissection--literature review.

Aortic dissection is a cardiovascular event of high mortality if not early diagnosed and properly treated. In Stanford type A aortic dissection, there is the involvement of the ascending aorta, whereas in type B the ascending aorta is not affected. The treatment of type A aortic dissection is mainly surgical. The hospital mortality of type B aortic dissection surgical treatment is approximately 20%, while medical therapy is 10%. However, half the patients who are discharged from hospital after medical treatment, progress to aortic complications in the following years, and the mortality in three to five years may reach 25-50%. In addition, the surgical treatment of aortic complications after medical treatment, has also a significant mortality. This way, the endovascular treatment comes up as an interesting alternative of a less invasive treatment for this disease. They presented a mortality rate lower than 10% with more than 80% success rate of occlusion and thrombosis of the false lumen. The INSTEAD TRIAL, which randomized patients with uncomplicated type B aortic dissection for optimal medical therapy and endovascular treatment in addition to optimal medical therapy, showed that after three years of follow up, patients who underwent endovascular treatment had lower mortality and aorta-related complications. Therefore, there is a current tendency to recommend the endovascular treatment as a standard for the treatment of type B aortic dissection.

Indication of endovascular treatment of type B aortic dissection - Literature review / Indicação do tratamento endovascular na dissecção de aorta do tipo B - Revisão da literatura

Aortic dissection is a cardiovascular event of high mortality if not early diagnosed and properly treated. In Stanford type A aortic dissection, there is the involvement of the ascending aorta, whereas in type B the ascending aorta is not affected. The treatment of type A aortic dissection is mainly surgical. The hospital mortality of type B aortic dissection surgical treatment is approximately 20%, while medical therapy is 10%. However, half the patients who are discharged from hospital after medical treatment, progress to aortic complications in the following years, and the mortality in three to five years may reach 25-50%. In addition, the surgical treatment of aortic complications after medical treatment, has also a significant mortality. This way, the endovascular treatment comes up as an interesting alternative of a less invasive treatment for this disease. They presented a mortality rate lower than 10% with more than 80% success rate of occlusion and thrombosis of the false lumen. The INSTEAD TRIAL, which randomized patients with uncomplicated type B aortic dissection for optimal medical therapy and endovascular treatment in addition to optimal medical therapy, showed that after three years of follow up, patients who underwent endovascular treatment had lower mortality and aorta-related complications. Therefore, there is a current tendency to recommend the endovascular treatment as a standard for the treatment of type B aortic dissection.

A dissecção da aorta é um evento cardiovascular de alta mortalidade quando não diagnosticado precocemente e tratado adequadamente. Na dissecção de aorta do tipo A de Stanford há o envolvimento da aorta ascendente enquanto na do tipo B este a aorta ascendente não está acometida. O tratamento da dissecção de aorta do tipo A é predominantemente cirúrgico. A mortalidade hospitalar do tratamento cirúrgico da dissecção da aorta do tipo B é de aproximadamente 20%, enquanto a do tratamento clínico é de 10%. Entretanto, metade dos pacientes que recebem alta hospitalar após o tratamento clínico, evoluem com complicações aórticas nos anos subsequentes, sendo que a mortalidade em três a cinco anos pode atingir 25 a 50%. Além disto, o tratamento cirúrgico das complicações aórticas, após o tratamento clínico, também apresenta alta mortalidade. Desta forma, o tratamento endovascular surge como interessante alternativa para o tratamento menos invasivo desta doença. Inicialmente indicado apenas para os casos complicados, apresentavam mortalidade hospitalar menor que 10% com mais de 80% de sucesso de oclusão e trombose da falsa luz. O INSTEAD TRIAL, que randomizou pacientes com dissecção de aorta do tipo B não complicada para o tratamento médico otimizado e para o tratamento endovascular em adição ao tratamento médico otimizado, demonstrou que após três anos de acompanhamento, aqueles pacientes submetidos ao tratamento endovascular apresentaram menor mortalidade e complicações relacionados a aorta. Portanto, atualmente há uma tendência em se indicar o tratamento endovascular como padrão para o tratamento da dissecção de aorta do tipo B.

[Hepatogastric fistula after chemoembolization of liver metastasis: a case report]. / Fistula hepatogástrica após quimioembolização de metástase hepática.

Liver metastases of colorectal cancer are a challenge in current oncology. Less than 5% of untreated patients are alive after 5 years of diagnosis. The only curative treatment is surgical resection, but there are other options for palliative or neoadjuvant treatment such as transarterial chemoembolization. Serious complications after liver chemoembolization are very rare, and one of the possible complications is a liver abscess. We report a case of hepatogastric fistula caused by a liver abscess ten days after the chemoembolization of a liver metastasis. It was treated surgically with left hepatectomy and parcial gastrectomy, with good outcome. There are only a few reported cases of hepatogastric fistula after liver transarterial chemoembolization.