New wavelength for the endovascular treatment of lower limb venous insufficiency.

AIM: The aim of this research was to show the efficacy of the 1 470-nm wavelength diode laser for endovenous laser treatments and the clinical results obtained. METHODS: Patients with varicose veins stratified by CEAP classification (clinical) in C2-6 and low-flow venous malformations were treated with and without crossectomy. Endolaser venous system with Ceralas E 1 470 nm diode laser (ELVeS PainLess, Biolitec AG, Jena, Germany) was used. The average power applied was in the range of 2-6 W, continuous mode and pull-back of 10 mm/5 s. Two optical fibres were used; frontal emission bare fibre of 400 micro (ELVeS) and radial emission fibre of 600 micro (ELVeS). All patients were evaluated with Duplex ultrasonography (US) before, intraproceeding, immediately after, at 48 hours, 7 and 30 days after the initial procedure. An average follow-up of twelve months was attained. In 15% of the cases, the endovenous laser proceeding was also evaluated during the treatment with thermographic images, direct thermography and direct venous angioscopy to assess the local temperature increase. After the treatment histopathological studies were also performed. RESULTS: Between 30% and 50% of the vein's initial diameter was immediately reduced in 100% of patients and fibrosis was observed by histopathological analysis. Thirty days post-treatment all cases presented venous obliteration observed by Duplex US. Clinical symptoms were resolved. Side-effects were: minimal discomfort, local pain, postpuncture ecchymosis and minimal fibrosis of the treated veins. Nevertheless, there was absence of hyperpigmentation in all patients and absence of neuritis in 98.6% of patients. Popliteal thrombosis was presented 24 hours after the procedure in 2.9% of the patients (these patients did not receive heparin). CONCLUSIONS: With this laser wavelength, which is new in phlebology applications, remarkable effective results were achieved with lower power comparing to the results currently obtained by using higher power and shorter laser wavelengths. This development provides the benefit of potentially better therapeutic results with less collateral damage.

Multidetector CT angiography and virtual angioscopy of the abdomen.

Computed tomographic angiography (CTA) has gained wide clinical acceptance as a powerful diagnostic tool in the non-invasive evaluation of vascular disorders and has became the method of choice for the assessment of aortic pathology. In addition, recent advances in computed tomography (CT) technology improve the image quality and diagnostic performance of the procedure in the abdominal vascular system. In this paper, we briefly review the CTA technique and describe the main applications of abdominal CTA.

Endovascular treatment of chronic type A dissection.

Type A aortic dissection is usually treated with standard surgery, requiring cardiopulmonary bypass and sometimes deep hypothermia. Besides the well-established procedure, mortality and complications are considerable. Using the knowledge and lessons learned from the endovascular treatment of descending aortic diseases, emerging reports describe new approaches to the condition, using endovascular stent-grafts. This report describes an endovascular treatment of a chronic type A aortic dissection without cardiopulmonary bypass and avoiding thoracotomy.

Incidence and natural history of proliferative sickle cell retinopathy: observations from a cohort study.

OBJECTIVE: To describe the incidence, prevalence, and natural history of proliferative sickle cell retinopathy (PSR). DESIGN: Prospective longitudinal study over 20 years. PARTICIPANTS: Newborn screening of 100000 consecutive deliveries from 1973 to 1981 identified 315 children with homozygous sickle cell (SS) disease and 201 with SS-hemoglobin C (SC) disease. By the age of 5 years, 307 SS patients and 166 SC patients were alive and living in Jamaica and were recruited for this ophthalmic study. METHODS: Description of retinal vascular changes on annual angiography and angioscopy. MAIN OUTCOME MEASURES: Incidence and prevalence of PSR and its behavior on follow-up. Progression of PSR was investigated using the number of eyes affected (none, one, both) and the interval until PSR onset. RESULTS: At last review in January 2000, PSR had developed in 59 patients (14 SS, 45 SC), unilaterally in 36 patients and bilaterally in 23. Incidence increased with age in both genotypes, with crude annual incidence rates of 0.5 cases (95% confidence interval [CI], 0.3-0.8) per 100 SS subjects and 2.5 cases (95% CI, 1.9-3.3) per 100 SC subjects. Prevalence was greater in SC disease, and by the ages of 24 to 26 years, PSR had occurred in 43% subjects with SC disease and in 14% subjects with SS disease. Patients with unilateral PSR had a 16% (11% SS, 17% SC) probability of regressing to no PSR and a 14% (16% SS, 13% SC) probability of progressing to bilateral PSR. Those with bilateral PSR had an 8% (8% SS, 8% SC) probability of regressing to unilateral PSR and a 1% (0 SS, 2% SC) probability of regressing to a PSR-free state. Irretrievable visual loss occurred in only 1 of 82 PSR-affected eyes, and 1 required detachment surgery and recovered normal visual acuity. CONCLUSIONS: Longitudinal observations over 20 years in a cohort of patients followed from birth confirms a greater incidence and severity of PSR in SC disease, and shows that spontaneous regression occurred in 32% of PSR-affected eyes. Permanent visual loss was uncommon in subjects observed up to the age of 26 years.

Multislice CT virtual angioscopy of the abdomen.

BACKGROUND: Computed tomographic (CT) angiography represents an important clinical tool in the evaluation of vascular disorders. Virtual angioscopy can be reconstructed with volumetric CT data sets. We evaluated the feasibility and clinical value of this application in the assessment of abdominal vessels. METHODS: Data sets of CT angiographic studies obtained with helical (n = 120) and multislice (n = 180) CT scanners were analyzed on a workstation for postprocessing. Vascular evaluation was done on conventional enhanced axial images, three-dimensional reconstructions, and virtual angioscopic images. RESULTS: We made 123 studies in patients without aortic disease. Of the patients evaluated for stent-graft treatment, 63 showed normal patency, seven had partial thrombosis of the stent-graft, five showed total occlusion of the stent-graft, and 10 had leaks. From the 92 remaining CT studies, 63 vascular aneurysms and nine dissections were diagnosed. CONCLUSION: The current technology produces high-quality virtual angioscopic images. Although axial and multiplanar views are usually adequate for detecting a vascular disorder, virtual angioscopic views better define anatomic details.

[Endovascular treatment: peripheral vascular disease]. / Tratamiento endovascular: enfermedad vascular periférica.

Peripheral arterial disease comprises those entities that result in obstruction to blood flow in the supra-aortic, mesenteric, renal and infrainguinal vessels. This review focuses on the endovascular treatment of extracranial internal carotid obstructive lesions, descending thoracic aorta aneurysms, and reconstruction of the aortoiliac bifurcation. The utilization of carotid artery stenting as a less invasive alternative to the surgical treatment for the extracranial internal carotid artery stenosis has progressively increased. Preliminary reports of carotid stenting with distal protection have shown a favorable reduction in the adverse event rates; but, the advantage of the endovascular approach has to be established in comparative and randomized trials. Transluminal endovascular stent grafting is rapidly emerging as a modality to repair descending thoracic aorta aneurysms. Preliminary experience has demonstrated the feasibility and safety of endovascular stent-graft treatment. However, further long-term follow-up is mandatory. Reconstruction of the aortoiliac bifurcation is not usually considered an indication for percutaneous treatment. Although there is limited experience, the results are encouraging with > 90% technical success and high primary patency at 3 years. Endovascular intervention has the potential benefit to reduce the cardiopulmonary and neurological complications and to be applicable to most traditional vascular operations.

Aspectos hemodinâmicos da ruptura da placa e implicações para o tratamento percutâneo / Hemodynamic aspects of the atherosclerotic plaque ruptureand implications for percutaneous intervention

São abordados os mecanismos que contribuem para a instabilização da placa aterosclerótica, assim como são conceituadas as lesões angiograficamente complexas, as placas particularmente vulneráveis à ruptura e as placas estáveis. As limitações da coronariografia na definição prognóstica dos ateromas são justificadas e, dentre as novas modalidades diagnósticas intravasculares, discutiu- se a importância da angioscopia coronária. Finalmente, do ponto de vista terapêutico, são enfatizadas a aplicabilidade e a eficácia da intervenção coronária percutânea nos quadros relacionados a síndromes isquêmicas miocárdicas instáveis...

Derivación aorta torácica descendente bifemoral para salvamento de extremidades inferiores / Descending thoracic aortabifemoral bypass to save lower extremities

Cuando la aorta abdominal no es un sitio con flujo adecuado o es técnicamente inaccesible para derivar el flujo a las extremidades inferiores por representar un alto riesgo secundario a múltiples situaciones complejas, se justifica el recurso de las derivaciones extraanatómicas en pacientes apropiadamente seleccionados con resultados de baja morbilidad y mortalidad, mejor calidad de vida y menores costos en comparación con la amputación de extremidades inferiores.Presentamos el caso de un paciente sometido a derivación aorta torácica descendente bifemoral (DATDB) como una alternativa satisfactoria de manejo diferente a las derivaciones extraanatómicas convencionales utilizadas en nuestro medio, con mayor permeabilidad reportada por tener flujo directo de la aorta y sin incremento de la morbilidad y de la mortalidad.

[Endovascular treatment of arterial occlusive disease of the iliac arteries]. / Tratamiento endovascular de la enfermedad aterooclusiva de las arterias iliacas.

Atherosclerotic disease is one of the most important health problems in the United States and in the entire world. The endovascular techniques for the treatment of peripheral vascular disease have been investigated in recent years. This is a review of the literature of the endovascular techniques used in the treatment of occlusive iliac disease. Angioplasty has showed excellent results in concentric lesions, of less 5 cm of length with a technical success of 96%, primary patency of 90%, 81% and 72% at one, two and three years. The complication rate is 0.5% to 0.8% and the mortality rate is 0.2%. The use of stents has improved the success of arterial recanalization, with a technical success of 97%, and a primary patency of 90%, 84% and 71% at one, two and three years. Major complications appear in less than 1% of the cases. In conclusion the endovascular techniques have been proved to be the treatment of choice for certain selected forms of presentation of atherosclerotic disease in the iliac arteries, specifically short, focal lesions. The results have been excellent with less mortality and morbidity than surgery.

Video-endoscopic dissection of multiple pedicled arterial grafts for use in minimally invasive coronary artery bypass surgery.

BACKGROUND: We evaluated the possibility of video-endoscopic dissection of both internal thoracic arteries (rTAs) through the left thoracic approach and right gastroepiploic artery (GEA) via a small laparoscopic access, for use in minimally invasive coronary artery bypass surgery. METHODS: The procedure was performed on twenty-two mongrel dogs. Three 10 mm ports were inserted in the left hemithorax to enable the introduction of a rigid 0-degree videoscope and forceps which allowed access to the left and right ITAs. For dissection of the GEA, one 10 mm and two 5 mm ports were inserted in the para-umbilical region. RESULTS: The left and right ITAs and the GEA were easily visualized and dissection and complete mobilization was achieved without injury, which was checked by the presence of good blood flow. The ITAs and GEA were divided distally, exteriorized through a small left anterior thoracotomy and the length of these three grafts were able to reach all of the left coronary artery branches. CONCLUSIONS: We have demonstrated, in dogs, the feasibility of video-assisted dissection of both the left and right ITAs through the left thoracic approach, without sternotomy, avoiding the risks of sternal complications and expanding its use for all patients. Furthermore, a third arterial conduit (the RGA) can be used without requiring laparotomy.

Safenoextracción o esclerosis in situ en la cirugía ambulatoria de las várices / Safenoextraction or sclerosis in situ in ambulatory surgery of varicose veins

Se realizó un estudio comparativo entre dos grupos de pacientes operados ambulatoriamente de várices. Setenta y cuatro de ellos mediante Safenoesclerosis in situ con ligadura escalonada de la gran safena y a noventa pacientes se les realizó fleboextracción de forma convencional. Encontramos un 5,4 por ciento de complicaciones en el. grupo de la safenoesclerosis y 9,9 por ciento en el grupo de fleboextracción destacándose en el primer grupo la ausencia de hematomas y de secuelas neurológicas(AU)

Nail fold capillaroscopy: normal findings in children and adolescents.

OBJECTIVES: Capillaroscopy is a simple diagnostic method that permits noninvasive in vivo study of the capillary network. Studies designed to standardize capillary normality in children are limited. This article presents the capillaroscopic findings in healthy children and adolescents, thus making the application of this methodology viable for patients in this age range. MATERIAL AND METHODS: Healthy children were recruited from a private elementary school and junior high school. Nail fold capillaroscopy was performed using a stereomicroscope at 16 times magnification, addressing the following parameters: capillary morphology, capillary enlargement, devascularization, microhemorrhage, and subpapillary venous plexus visibility (PVS). These parameters were related to age, sex, ethnicity, and local periungal conditions. RESULTS: The sample comprised 329 individuals with mean age of 8.2 years. We observed atypical capillary morphology in 118 of the studied cases (36%), mainly bizarre capillaries in 90 (27%), meandering capillaries in 32 (10%), and bushy capillaries in 20 (6%). The enlarged capillary phenomenon was uncommon, being observed in 30 cases (9%). The number of capillaries per millimeter varied from five to nine. Deletion areas were detected in only seven individuals (2%). The subpapillary venous plexus was not visualized in 13 (4%) cases. Younger children presented higher PVS scores and fewer capillaries/mm as compared with older children. PVS scores were lower in males and in nonwhite children. Other variables were not associated with sex or ethnicity. CONCLUSIONS: The normal nail fold capillary network in children resembles that observed in adults with some differences, such as a lower number of loops per millimeter, a higher PVS score, and a higher frequency of atypical loops. This information is important for the diagnostic evaluation of children in the context of autoimmune rheumatic diseases.

Endoscopic placement of stents in aneurysms of the descending thoracic aorta.

This is a case of a patient with two saccular aneurysms in the descending aorta. Two self-expanding stents were inserted through an opening in the aortic arch, guided by the use of an Olympus endoscope, under profound hypothermia and total circulatory arrest. The bloodless field made possible the identification of the main thoracic branches, facilitating the positioning and deployment of both stents. Immediate postoperative recovery was excellent.

Agregación globular: consistecia y validéz de la "Oftalmoangioscopia conjuntival" / Globular aggregation: congesteme and validity of the \"Oftalmoangyoscopy conjunctival\"

Evaluar la consistencia y validez de la "Oftalmoangioscopia conjuntival" en el diagnóstico de agregación globular en vasos conjuntivales, como evidencia clínica de Velocidad de Sedimentación Globular (VSG) aumentada. Estudio de Corte Transversal. Se evaluaron dos muestras de 32 pacientes de ambos sexos, hospitalizados en los Servicios de Medicina Interna del Hospital Universitario de Caracas. La primera muestra está compuesta de 20 pacientes femeninos y 12 masculinos, la segunda 17 y respectivamente. Los treinta y dos pacientes de cada muestra fueron seleccionados por azar simple por un clínico independiente quien registró: identificación, datos demográficos y último valor de VSG. los pacientes fueron evaluados individualmente por seis observadores: Dos médicos Especialistas en Medicina Interna, dos médicos Generales Residentes del primer año del Postgrado de Medicina, dos estudiantes de Pregrado del quinto año del régimen anual. La"oftalmoangioscopia conjuntival" fue demostrada y estandarizada previamente entre los seis observadores (Siguiendo la descripción de Muci-Mendoza), las dos muestras fueron evaluadas con un lapso entre ellas de quince días, utilizando para el entrenamiento individual en la técnica. La consistencia se estudió como variabilidad interobservador, calculada a través del estadístico Kappa pesado, la validez de la técnica fue explorada con el cálculo de las probabilidades intermedias (sensibilidad, especificidad) y probabilidades posteriores (valores predictivos positivos y negativos). El acuerdo de los seis observadores estimado a través del Kappa pesado entre mínimo y regular, independientemente del nivel de experiencia de los observadores; con amplias variaciones en los valores de sensibilidad, especificidad y valores predictivos positivos y negativos. la "oftalmoangioscopia conjuntival" como técnica semiológica para el diagnóstico de agregación globular en los vasos conjuntivales y marcador clínico de VSG elevada resultó inconsistente y poco válida independientemente del nivel de experiencia del observador

Angioscopía coronaria percutánea: su contribución a la interpretación fisiopatológica de los síndromes isquémicos agudos: estudio prospectivo / Percutaneous coronary angioscopy: its contribution to the physiopathological interpretation of the acute ischemic syndromes: prospective study

Con objeto de determinar mediante angioscopía coronaria la prevalencia de ruptura de placa y trombo en angina inestable e infarto agudo del miocardio transmural, y de correlacionar los hallazgos angioscópicos con las modalidades de presentación clínica de la angina inestable, estudiamos, prospectivamente, 23 pacientes, 18 hombres y 5 mujeres, de 58 ñ 9,5 años, 19 de ellos con angina inestable y 4 con infarto agudo de miocardio transmural

Cateter óptico para aplicaçöes espectroscópicas / Optic catheter for spectroscopic applications

Neste trabalho é apresentada a caracterização de cateteres utilizando fibras ópticas para aplicações de espectroscopia in vivo. Estes cateteres apresentam a configuração de seis fibras em torno de uma fibra central de mesmo diâmetro, sendo estas fibras do tipo multimodo com diâmetro de núcleo de 100 mum. A eficiência de coleta de radiação para este tipo de cateter é da ordem de 0,05 por cento, variando em função da distância ao tecido e da distribuição de intensidade de sinal retroespalhado na superfície do mesmo.

ln this work we describe the characterization of fiber optic catheters for in vivo spectroscopy applications. This type of catheters have the geometry of one central fiber sun-ounded by six 100 µm diameter multimode fibers. The collection efficiency of these type of catheter is about 0.05% and it changes with the distance to the tissue surface and the signal intensity distribution on it.

Time course and mechanism of early luminal diameter loss after percutaneous transluminal coronary angioplasty.

To assess the time course and mechanism of early minimal luminal diameter (MLD) loss, serial angiographic observations were performed. Seventy-four patients (with 74 severe narrowings [ > or = 70%]) with acute ischemic syndromes who had an early loss in MLD of > 0.3 mm at 24 hours after percutaneous transluminal coronary angioplasty (PTCA) also underwent 1 hour post-PTCA angiography. In 12 consecutive patients with early loss 1 hour after PTCA, angioscopy was also performed to assess the mechanism of early loss. The percent diameter stenosis for the 74 lesions was 16.8 +/- 8.4% immediately after PTCA, 35.1 +/- 14.2% 1 hour after PTCA (p < 0.002 vs immediately after), and 41.4 +/- 13.2% at 24 hours (p < 0.10 vs 1 hour after). The MLD also showed similar differences: 2.6 +/- 0.3 mm immediately after to 2.0 +/- 0.4 mm 1 hour after(p < 0.002) to 1.8 +/- 0.4 mm 24 hours after PTCA (p < 0.10 vs 1 hour). In 60 patients (81%), the > 0.3 mm loss was detected 1 hour after PTCA. These 60 patients had no further decreases in MLD at 24 hours (1.9 +/- 0.4 vs 1.8 +/- 0.4 mm at 1 and 24 hours, respectively, p = NS). Adequate angioscopic images available in 11 patients showed that red thrombus was present in 1, minor or multiple dissection in 5, and neither thrombus nor dissection in 5 other patients (consistent with early wall recoil). Thus, in narrowings demonstrating early loss in MLD at 24 hours, 81% showed that the early loss occurred within 1 hour after PTCA. Early loss is not related to thrombus but usually to dissection or recoil.

[Percutaneous coronary angioscopy: 200 observations in 100 candidates for angioplasty]. / Angioscopía coronaría percutánea: 200 observaciones en 100 pacientes candidatos a angioplastía.

Due to the recent technological advances, it is possible to perform percutaneous coronary angioscopy in a straightforward fashion in most patients. To know the safety and usefulness of this technique we present 200 observations in 100 patients candidates for coronary intervention. We used a coronary angioscope (Baxter, Edwards LIS Division), that can be placed using the conventional technique for percutaneous coronary angioplasty. The system incorporates a proximal occluding balloon, and distally a movable optical fiber. Case selection considered non-ostial coronary segments relatively straight. It was possible to obtain adequate images in 86 percent of cases. The technique is safe in experienced hands: there were two cases of ventricular fibrillation, and two cases of local dissection occurred, none of these associated with clinical consequences. No myocardial infarction, surgery or death, related to this procedure occurred. Valuable diagnostic information is derived from angioscopy as the method provides some histopathological correlation. Stable plaques are usually uniformly white or yellow. Unstable plaques are yellow and ulcerated. Thrombus can be easily recognized in acute coronary syndromes. Also in percutaneously treated segments, the final result and the presence of dissection or hemorrhage can be visualized. Coronary percutaneous angioscopy is safe and brings useful clinical information. Its applications in the clinical practice are still to be determined.

Peripheral retinal vasculature in normal Jamaican children.

A prospective study of the peripheral retinal vasculature in a Jamaican cohort of subjects with sickle cell disease has been in progress over a period of 12 years using fluorescein angiography. Various vascular patterns were identified but their significance was unclear since no comparable records were available in subjects of a similar age with normal (AA) haemoglobin genotype. Fluorescein retinal angioscopy and angiography have been performed in 76 haemoglobin AA controls participating in the cohort study. The peripheral retinal capillary bed could be seen and photographed in a limited portion of the temporal peripheral fundus in a majority of this group, and there was considerable variation in the vascular pattern which could be characterised. These observations allow deviations from normal to be identified in the retinal vasculature in subjects with sickle cell disease.