Aneurisma da artéria dorsal do pé: relato de caso / Aneurysm of the dorsal artery of the foot: case report modality

RESUMO: Paciente do sexo feminino, 59 anos, comerciante. Assintomática até há 1 ano, quando observou surgimento de massa pulsátil em dorso do pé direito, eventualmente dolorosa. Refere trauma, 5 anos antes, por queda de uma barra de ferro sobre os pés. ANTECEDENTES: hipertensão arterial, diabetes mellitus e dislipidemia. No atendimento, estava em uso contínuo de Sinvastatina, Metformina e Losartana. Exame físico normal, exceto pela presença de massa pulsátil em dorso do pé direito, varizes e dermatite ocre em ambos os membros inferiores. PA: 120 X 85mmHg; FC=76bpm. Foram realizados exames laboratoriais, eletrocardiograma, RX de tórax e ecocardiograma transtorácico, que estavam dentro da normalidade. A Ultrassonografia Vascular (USV) das artérias do membro inferior direito demostrou imagem sugestiva de aneurisma fusiforme da artéria dorsal do pé (ADP) direita, com presença de trombos, medindo cerca de 1,9cm X 0,7cm, o fluxo estava presente, de padrão trifásico (multifásico). Demais artérias do membro inferior direito com fluxo presente e trifásico. Realizada arteriografia do membro inferior direito que demonstrou dilatação sacular da ADP, próximo aos ramos metatarsianos com diâmetro máximo de 1,0mm, sugestiva de pseudoaneurisma. A paciente foi submetida à procedimento cirúrgico cujo achado intraoperatório, na abertura do saco aneurismático, não demostrou evidência de orifício de pseudoaneurisma e havia configuração de aneurisma verdadeiro. Realizado enxerto término-terminal com veia safena magna invertida com preservação do fluxo arterial. A paciente teve alta hospitalar no dia seguinte, sem intercorrências. O aneurisma verdadeiro da ADP, ou artéria pediosa, é raro e suas manifestações clínicas são pouco conhecidas, em geral, apresenta-se como uma massa pulsátil, podendo cursar com microembolização, rotura e compressão nervosa. Foi descrito pela primeira vez em 1907 e, desde então, outros autores relataram esse tipo de aneurisma. No entanto, de acordo com a literatura, muitos aneurismas da ADP são pseudoaneurismas e ocorrem após um trauma. O tratamento de escolha, geralmente é cirúrgico. Aneurismas verdadeiros apresentam todas as três camadas da parede arterial, enquanto os pseudoaneurismas se referem aos hematomas com fluxo, resultantes de uma rotura da parede arterial. Há casos, em que somente o exame histopatológico é capaz de diferenciar entre pseudoaneurismas e aneurismas verdadeiros da ADP.

Artéria torácica interna como fonte de circulação colateral em paciente com obstrução aorto-ilíaca e indicação de cirurgia de revascularização miocárdica ­ relato de caso / Internal thoracic artery as a source of collateral circulation in a patient with aortoiliac obstruction and indication for myocardial revascularization surgery ­ case report

RESUMO: Paciente do sexo feminino, 51 anos, com doença arterial coronariana (DAC), angina e dispnéia (classe III NYHA). Antecedentes: hipertensão arterial, dislipidemia, ex-tabagista e claudicação intermitente, estável para 200 metros. A cineangiocoronariografia realizada pela artéria radial (AR) esquerda revelou doença triarterial, com função ventricular preservada, sendo indicada a cirurgia de revascularização miocárdica (CRM). Pulsos femorais não eram palpáveis, havia pulso filiforme na AR direita e houve oclusão da AR esquerda após o procedimento. Solicitada ultrassonografia vascular (USV) das artérias dos membros inferiores que mostrou perviedade de todos os segmentos arteriais, com fluxo monofásico, de velocidade reduzida, desde as artérias femorais comuns, compatível com obstrução em território aorto-ilíaco. A USV das artérias torácicas internas (ATI) demonstrou calibre acima de 3,0 mm das mesmas (ATI direita: 3,6 mm e ATI esquerda: 3,3 mm), possivelmente relacionado à participação na colateralização para manutenção do fluxo para os membros inferiores. Realizada angiotomografia computadorizada (ATC) de aorta e ATIs, confirmando oclusão da aorta após a emergência das artérias renais e as ATIs, bilateralmente, como fonte da circulação colateral para o território distal à oclusão. Diante da impossibilidade de utilização das ATIs para a CRM, optou-se por tratamento percutâneo, realizado com sucesso, tendo a paciente, alta no dia seguinte. A artéria torácica interna (ATI) tem indicação Classe I como enxerto para a artéria descendente anterior esquerda (DA) na CRM. Em casos com oclusão aortoilíaca (síndrome de Leriche), a ATI pode ser fonte de circulação colateral para artérias abaixo do nível da oclusão. Seu uso inadvertido pode levar a graves complicações isquêmicas nos territórios dependentes. Em pacientes com indicação de CRM e doença arterial obstrutiva periférica, a USV no pré operatório pode diagnosticar as obstruções arteriais, incluindo o acometimento do território aorto-ilíaco. Nesses casos é fundamental a investigação também das ATIs e avaliar a origem da circulação colateral para os membros inferiores.

Posicionamento de ultrassonografia vascular do departamento de imagem cardiovascular da Sociedade Brasileira de Cardiologia ­ 2019 / Vascular Ultrasound Positioning of the Department of Cardiovascular Imaging of the Society Brazilian Cardiology - 2019

Posicionamento de Ultrassonografia Vascular do Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia ­ 2019. (AU)

Unsaturated Fatty Acids Improve Atherosclerosis Markers in Obese and Overweight Non-diabetic Elderly Patients.

BACKGROUND: Several studies have demonstrated the benefits of replacing trans and saturated fats with unsaturated fatty acids on cardiovascular diseases. We aimed to demonstrate the effect of polyunsaturated and monounsaturated fat supplementation on the biochemical and endothelial markers of atherosclerotic disease in obese or overweight non-diabetic elderly patients. METHOD: Seventy-nine patients were randomly divided into three groups: flaxseed oil, olive oil, and sunflower oil; patients in each group received 30 mL of oil for 90 days. Patients were subjected to anthropometric and bioimpedance assessments; biochemical and endothelial evaluations were performed through ultrasonography of the brachial artery and carotid artery for endothelium-dependent dilation and intima-media thickness assessment, respectively, before and after the intervention. The participants' usual diet remained unchanged. RESULTS: The flaxseed oil group had improved ultra-sensitive C-reactive protein levels (p = 0.074) and reduced carotid intima-media thickness (CIMT) (p = 0.028); the olive oil group exhibited an improved apolipoprotein (Apo)B/ApoA ratio (p = 0.021), reduced CIMT (p = 0.028), and improved flow-mediated vasodilation (FMV) (p = 0.054); and similarly, the sunflower oil group showed an improved ApoB/ApoA ratio (p = 0.024), reduced CIMT (p = 0.048), and improved FMV (p = 0.001). CONCLUSION: Unsaturated fatty acid supplementation using the three vegetable oils attenuated pro-inflammatory properties and improved prothrombotic conditions. Therefore, introducing or replacing saturated and trans fat with unsaturated fatty acids is beneficial for cardiovascular risk reduction in obese or overweight non-diabetic elderly people. Further studies are needed to determine which unsaturated fat best prevents cardiovascular disease in elderly patients.

High prevalence of subclinical atherosclerosis in Brazilian postmenopausal women with low and intermediate risk by Framingham score.

Cardiovascular diseases are the leading cause of mortality among women in several countries. Early detection of subclinical atherosclerosis (SA) could enable the adoption of preventive measures to avoid cardiovascular events. This study aimed to determine the prevalence of SA in Brazilian asymptomatic postmenopausal women in Framingham Risk Score (FRS) low and intermediate groups. Computed tomography (CT) and ultrasound (US) scans were performed in 138 asymptomatic postmenopausal women (56.1 ± 4.9 years of age) to survey for coronary artery and aortic calcification (CT scan) and assess carotid intima-media thickness (CIMT) and identify carotid plaques (US). The mean FRS was 2.64 ± 2.13 %. The prevalence of increased CIMT, carotid plaques, increased CIMT and/or plaques, coronary artery calcification (CAC) >0 and aortic calcification (AC) were, respectively, 45.7, 37.7, 62.3, 23.9 and 45.7 %. Normal imaging tests were found in 22.4 %. SA, defined as at least one abnormal imaging test, was associated with age, FRS, waist-to-rip ratio, systolic and diastolic blood pressure, HDL-c and ApoA1 levels, and ApoA1/ApoB ratio. In logistic regression, SA was associated with higher age (OR 1.108, 95 % CI 1.010-1.215, p = 0.029) and lower ApoA1 levels (OR 0.979, 95 % CI 0.960-0.998, p = 0.029). SA was prevalent in Brazilian postmenopausal women with low and intermediate risk groups (FRS) and was associated with higher age and lower levels of ApoA1. Carotid atherosclerosis was the most common presentation of SA in this group.

High prevalence of subclinical atherosclerosis in Brazilian postmenopausal women with low and intermediate risk by Framingham score

Cardiovascular diseases are the leading causeof mortality among women in several countries. Early detection of subclinical atherosclerosis (SA) could enable the adoption of preventive measures to avoid cardiovascular events. This study aimed to determine the prevalence of SA in Brazilian asymptomatic postmenopausal womenin Framingham Risk Score (FRS) low and intermediategroups. Computed tomography (CT) and ultrasound (US)scans were performed in 138 asymptomatic postmenopausal women (56.1±4.9 years of age) to survey for coronary artery and aortic calcification (CT scan) and assesscarotid intima-media thickness (CIMT) and identify carotidplaques (US). The mean FRS was 2.64±2.13%. The prevalence of increased CIMT, carotid plaques, increased CIMT and/or plaques, coronary artery calcification (CAC)>0 and aortic calcification (AC) were, respectively, 45.7,37.7, 62.3, 23.9 and 45.7%. Normal imaging tests werefound in 22.4%. SA, defined as at least one abnormalimaging test, was associated with age, FRS, waist-to-ripratio, systolic and diastolic blood pressure, HDL-c andApoA1 levels, and ApoA1/ApoB ratio...

Unsaturated fatty acids improve atherosclerosis markers in obese and overweight non-diabetic elderly patients

BACKGROUND: Several studies have demonstrated the benefits of replacing trans and saturated fats with unsaturated fatty acids on cardiovascular diseases. We aimed to demonstrate the effect of polyunsaturated and monounsaturated fat supplementation on the biochemical and endothelial markers of atherosclerotic disease in obese or overweight non-diabetic elderly patients. METHOD: Seventy-nine patients were randomly divided into three groups: flaxseed oil, olive oil, and sunflower oil; patients in each group received 30 mL of oil for 90 days. Patients were subjected to anthropometric and bioimpedance assessments; biochemical and endothelial evaluations were performed through ultrasonography of the brachial artery and carotid artery for endothelium-dependent dilation and intima-media thickness assessment, respectively, before and after the intervention. The participants' usual diet remained unchanged...

Criteria for detecting significant chronic iliac venous obstructions with duplex ultrasound.

OBJECTIVE: The purpose of this study was to determine the sonographic criteria for diagnosis of iliac venous outflow obstruction by assessing the correlation of this method with intravascular ultrasound (IVUS) in patients with advanced chronic venous insufficiency (CVI). METHODS: The evaluation included 15 patients (30 limbs; age, 49.4 ± 10.7 years; 1 man) with initial CVI symptoms (Clinical class, Etiology, Anatomy, and Pathophysiology [CEAP] classification, CEAP1-2) in group I (GI) and 51 patients (102 limbs; age, 50.53 ± 14.5 years; 6 men) with advanced CVI symptoms (CEAP3-6) in group II (GII). Patients from both groups were matched by gender, age, and race. The Venous Clinical Severity Score was considered. All patients underwent structured interviews and duplex ultrasound (DU) examination, measuring the flow phasicity, the femoral volume flows and velocities, and the velocity and obstruction ratios in the iliac vein. The reflux multisegment score was analyzed in both groups. Three independent observers evaluated individuals in GI. GII patients were submitted to IVUS, in which the area of the impaired venous segments was obtained and compared with the DU results and then grouped into three categories: obstructions <50%, obstructions between 50% and 79%, and obstructions ≥80%. RESULTS: The predominant clinical severity CEAP class was C1 in 24 of 30 limbs (80%) in GI and C3 in 54 of 102 limbs (52.9%) in GII. Reflux was severe (reflux multisegment score ≥3) in 3 of 30 limbs (10%) in GI and in 45 of 102 limbs (44.1%) in GII (P < .001). There was a moderately high agreement between DU and IVUS findings when they were grouped into three categories (κ = 0.598; P < .001) and high agreement when they were grouped into two categories (obstructions <50% and ≥50%; κ = 0.784; P < .001). The best cutoff points and their correlation with IVUS were 0.9 for the velocity index (r = -0.634; P < .001), 0.7 for the flow index (r = -0.623; P < .001), 0.5 for the obstruction ratio (r = 0.750; P < .001), and 2.5 for the velocity ratio (r = 0.790; P < .001). Absence of flow phasicity was observed in 62.5% of patients with obstructions ≥80%. An ultrasound algorithm was created using the measures and the described cutoff points with accuracy of 86.7% for detecting significant obstructions (≥50%) with high agreement (κ = 0.73; P < .001). CONCLUSIONS: DU presented high agreement with IVUS for detection of obstructions ≥50%. The velocity ratio in obstructions ≥2.5 is the best criterion for detection of significant venous outflow obstructions in iliac veins.

Criteria for detecting significant chronic iliacvenous obstructions with duplex ultrasound

The purpose of this study was to determine thesonographic criteria for diagnosis of iliac venous out flow obstruction by assessing the correlation of this method with intravascular ultrasound (IVUS) in patients with advanced chronic venous insufficiency (CVI). The evaluation included 15 patients (30 limbs; age,49.4 % 10.7 years; 1 man) with initial CVI symptoms (Clinicalclass, Etiology, Anatomy, and Pathophysiology [CEAP]classification, CEAP1-2) in group I (GI) and 51 patients (102limbs; age, 50.53 % 14.5 years; 6 men) with advanced CVI symptoms (CEAP3-6) in group II (GII). Patients from bothgroups were matched by gender, age, and race. The Venous Clinical Severity Score was considered. All patients underwent structured interviews and duplex ultrasound (DU) examination, measuring the flow phasicity, the femoral volume flowsand velocities, and the velocity and obstruction ratios in the iliac vein. The reflux multisegment score was analyzed in bothgroups. Three independent observers evaluated individuals inGI. GII patients were submitted to IVUS, in which the area ofthe impaired venous segments was obtained and comparedwith the DU results and then grouped into three categories: obstructions <50%, obstructions between 50% and 79%, andobstructions...