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1.
Angiol Sosud Khir ; 27(3): 54-65, 2021.
Artigo em Inglês, Russo | MEDLINE | ID: mdl-34528589

RESUMO

Described in the article is a clinical case report regarding complete endovascular arterialization of deep crural and pedal veins in a male patient with accompanying pathology and impossibility of intraluminal restoration of the arterial bed. Peculiarities of the presented case report consisted in creation of an arteriovenous anastomosis in the upper third of the crus using an endovascular technique. During treatment, a repeat intervention was required, i. e., balloon angioplasty of veins and implantation of an additional stent graft due to reocclusion of veins because of long-term local treatment of wounds and cytostatic therapy for background diseases (chronic myeloleukaemia and rheumatoid arthritis). The performed treatment resulted in a clear trend towards healing of the wounds on the foot and limb salvage.


Assuntos
Procedimentos Endovasculares , Isquemia , Amputação , , Humanos , Isquemia/diagnóstico , Isquemia/etiologia , Isquemia/cirurgia , Perna (Membro) , Salvamento de Membro , Masculino , Resultado do Tratamento , Veias/cirurgia
2.
Angiol Sosud Khir ; 27(3): 173-179, 2021.
Artigo em Russo | MEDLINE | ID: mdl-34528603

RESUMO

The article is a review of literature dedicated to simultaneous open and endovascular (hybrid) operations in treatment of patients with chronic ischaemia of lower limbs. Despite good results of endovascular interventions, in many situations involvement of arteries below the inguinal fold and multilevel lesions are arguments in favour of performing an open operation. On the other hand, open multilevel interventions are accompanied by an increased risk of complications and mortality. Hybrid interventions appear to be a safe and efficient alternative combining advantages of two methods of treatment and making it possible to achieve an optimal outcome with a minimal surgical wound. Also discussed herein are the problems of terminology, indications for, techniques and results of treatment, providing a historical background, followed by analysing problem spots of using this technique and trends of development.


Assuntos
Isquemia , Extremidade Inferior , Artérias , Humanos , Isquemia/diagnóstico , Isquemia/etiologia , Isquemia/cirurgia , Salvamento de Membro , Extremidade Inferior/cirurgia , Resultado do Tratamento
3.
BMJ Case Rep ; 14(8)2021 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-34389593

RESUMO

Gastric ulcers secondary to gastric ischaemia is rare because of the rich blood supply of the stomach. We present a case where a patient with history of atherosclerotic vascular disease (ASCVD) presented with unintentional weight loss and failure to thrive for several months. Initial imaging studies ruled out any active malignancy. Oesophagogastroduodenoscopy revealed multiple shallow gastric ulcers. CT angiography was performed in later course of the hospital stay, which demonstrated a high-grade stenosis at the origin of both the superior mesenteric artery and the coeliac trunk. This combination stenosis is a rare finding, which can lead to ischaemia of the stomach by blocking the stomach's dual blood supply. Although the patient underwent revascularisation attempt with stent placement, she expired due to critical postoperative condition. This case signifies the importance of keeping a low threshold for suspicion for gastric ischaemia in patients with ASCVD risk factors and unexplained weight loss.


Assuntos
Úlcera Gástrica , Artéria Celíaca , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/etiologia , Artéria Mesentérica Superior , Úlcera Gástrica/complicações
4.
BMJ Case Rep ; 14(8)2021 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-34389601

RESUMO

COVID-19 is caused by the SARS-CoV-2, and its presentation ranges from mild upper respiratory illness to critical disease including acute respiratory distress syndrome and multiorgan dysfunction. While it was initially believed to primarily target the respiratory system, numerous studies have demonstrated it to cause a hypercoagulable state that predisposes to arterial and venous thrombosis. We present a case where a patient with COVID-19 developed acute lower limb ischaemia due to arterial thrombosis in the setting of full-dose enoxaparin, followed by heparin infusion protocol. The patient developed recurrent ischaemia despite thrombolysis in addition to anticoagulation, and eventually required open thrombectomy before making a full recovery.


Assuntos
COVID-19 , Anticoagulantes/uso terapêutico , Humanos , Isquemia/tratamento farmacológico , Isquemia/etiologia , SARS-CoV-2 , Terapia Trombolítica
5.
World J Gastroenterol ; 27(29): 4746-4762, 2021 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-34447224

RESUMO

Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.


Assuntos
Colite Isquêmica , Procedimentos Endovasculares , Isquemia Mesentérica , Oclusão Vascular Mesentérica , Doença Aguda , Doença Crônica , Humanos , Isquemia/etiologia , Isquemia/terapia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/epidemiologia , Isquemia Mesentérica/etiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
7.
Int J Mol Sci ; 22(13)2021 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-34210091

RESUMO

(1) Background: We established a new bladder ischemia rat model through bilateral partial iliac arterial occlusion (BPAO) and investigated the therapeutic effect of adipose-derived stem cells (ADSCs) and ADSC-derived microvesicles (MVs); (2) Methods: The study included four groups: (1) sham, (2) BPAO, (3) BPAO + ADSCs, and (4) BPAO + ADSC-derived MVs. Female Wistar rats with BPAO were injected with ADSCs or ADSC-derived MVs through the femoral artery. Doppler flowmetry and real-time laser speckle contrast imaging were performed to quantify blood flow in the common iliac arteries and bladder microcirculation. A 24-h behavior study and transcystometrogram were conducted after 2 weeks. Bladder histology, immunostaining, and lipid peroxidation assay were performed. The expressions of P2X2, P2X3, M2, and M3 receptors and nerve growth factor (NGF) were evaluated; (3) Results: BPAO significantly reduced bladder microcirculation, intercontraction interval (ICI), and bladder volume and increased the amplitude of nonvoiding contraction, neutrophil infiltration, and malondialdehyde and NGF levels. ADSCs and ADSC-derived MVs significantly ameliorated these effects. The results of Western blot showed that the BPAO group exhibited the highest expression of M3 and P2X2 receptors. ADSCs significantly attenuated the expressions of M2 and P2X2 receptors. ADSC-derived MVs significantly attenuated the expressions of M3 and P2X2 receptors; (4) Conclusions: ADSCs and ADSC-derived MVs ameliorated the adverse effects of BPAO including bladder overactivity, bladder ischemia, and oxidative stress. Inflammation, muscarinic signaling, purinergic signaling, and NGF might be involved in the therapeutic mechanism.


Assuntos
Tecido Adiposo/citologia , Células-Tronco Adultas/transplante , Micropartículas Derivadas de Células/transplante , Bexiga Urinária Hiperativa/terapia , Células-Tronco Adultas/citologia , Animais , Arteriopatias Oclusivas/complicações , Arteriopatias Oclusivas/terapia , Micropartículas Derivadas de Células/fisiologia , Modelos Animais de Doenças , Feminino , Artéria Ilíaca/patologia , Isquemia/etiologia , Isquemia/terapia , Ratos , Ratos Wistar , Bexiga Urinária/patologia , Bexiga Urinária Hiperativa/etiologia
8.
Br J Nurs ; 30(14): 846-851, 2021 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-34288743

RESUMO

This article will discuss chronic limb ischaemia as the result of peripheral artery disease (PAD) using a case study. The patient's concurrent diagnosis of metastases meant clinical decision making was complex and treatment options were limited. PAD is the third most common clinical presentation of atherosclerosis after coronary artery disease and stroke. Although advances in radiological technology and biochemical screening offer the potential for earlier intervention and improved survival rates for patients with PAD, a review of the evidence suggests that commitment to more conservative approaches, such as exercise therapy and health promotion, could have more sustainable, longer-term benefits for patients with chronic limb ischaemia. The therapeutic nature of the nurse-patient relationship makes nurses ideally placed for encouraging lifestyle changes and signposting to support services. Active participation from the patient is imperative for any potential modifications, which should be individualised as part of a holistic care plan, to ensure patient engagement and compliance. Therefore emphasis should remain on the management and prevention of modifiable risk factors, for which the nurse's role is an integral part to ensure success.


Assuntos
Isquemia , Doença Arterial Periférica , Doença Crônica , Humanos , Isquemia/etiologia , Isquemia/enfermagem , Doença Arterial Periférica/complicações , Doença Arterial Periférica/enfermagem
9.
Int J Mol Sci ; 22(13)2021 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-34281273

RESUMO

Muscular dystrophies (MDs) are a group of inherited degenerative muscle disorders characterized by a progressive skeletal muscle wasting. Respiratory impairments and subsequent hypoxemia are encountered in a significant subgroup of patients in almost all MD forms. In response to hypoxic stress, compensatory mechanisms are activated especially through Hypoxia-Inducible Factor 1 α (HIF-1α). In healthy muscle, hypoxia and HIF-1α activation are known to affect oxidative stress balance and metabolism. Recent evidence has also highlighted HIF-1α as a regulator of myogenesis and satellite cell function. However, the impact of HIF-1α pathway modifications in MDs remains to be investigated. Multifactorial pathological mechanisms could lead to HIF-1α activation in patient skeletal muscles. In addition to the genetic defect per se, respiratory failure or blood vessel alterations could modify hypoxia response pathways. Here, we will discuss the current knowledge about the hypoxia response pathway alterations in MDs and address whether such changes could influence MD pathophysiology.


Assuntos
Subunidade alfa do Fator 1 Induzível por Hipóxia/metabolismo , Hipóxia/etiologia , Hipóxia/metabolismo , Distrofias Musculares/complicações , Distrofias Musculares/metabolismo , Animais , Humanos , Subunidade alfa do Fator 1 Induzível por Hipóxia/efeitos dos fármacos , Isquemia/etiologia , Modelos Biológicos , Desenvolvimento Muscular , Músculo Esquelético/irrigação sanguínea , Músculo Esquelético/metabolismo , Distrofias Musculares/genética , Estresse Oxidativo , Regeneração , Transdução de Sinais
10.
Int J Mol Sci ; 22(13)2021 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-34202056

RESUMO

Mesenchymal stem cells (MSC) are known for their vascular regeneration capacity by neoangiogenesis. Even though, several delivery approaches exist, particularly in the case of intravascular delivery, only limited number of cells reach the targeted tissue and are not able to remain on site. Applicated cells exhibit poor survival accompanied with a loss of functionality. Moreover, cell application techniques lead to cell death and impede the overall MSC function and survival. 3D cell spheroids mimic the physiological microenvironment, thus, overcoming these limitations. Therefore, in this study we aimed to evaluate and assess the feasibility of 3D MSCs spheroids for endovascular application, for treatment of ischemic peripheral vascular pathologies. Multicellular 3D MSC spheroids were generated at different cell seeding densities, labelled with ultra-small particles of iron oxide (USPIO) and investigated in vitro in terms of morphology, size distribution, mechanical stability as well as ex vivo with magnetic resonance imaging (MRI) to assess their trackability and distribution. Generated 3D spheroids were stable, viable, maintained stem cell phenotype and were easily trackable and visualized via MRI. MSC 3D spheroids are suitable candidates for endovascular delivery approaches in the context of ischemic peripheral vascular pathologies.


Assuntos
Transplante de Células-Tronco Mesenquimais , Células-Tronco Mesenquimais/citologia , Esferoides Celulares , Animais , Técnicas de Cultura de Células , Diferenciação Celular , Humanos , Isquemia/diagnóstico , Isquemia/etiologia , Isquemia/metabolismo , Isquemia/terapia , Imageamento por Ressonância Magnética , Transplante de Células-Tronco Mesenquimais/métodos , Células-Tronco Mesenquimais/metabolismo , Células-Tronco Mesenquimais/ultraestrutura , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/etiologia , Doença Arterial Periférica/metabolismo , Doença Arterial Periférica/terapia , Esferoides Celulares/citologia , Esferoides Celulares/ultraestrutura , Coloração e Rotulagem
11.
Khirurgiia (Mosk) ; (7): 57-64, 2021.
Artigo em Russo | MEDLINE | ID: mdl-34270195

RESUMO

OBJECTIVE: To study the incidence of peptic ulcers accompanied by gastrointestinal bleeding after surgery for critical lower limb ischemia and their relationship with the factors predisposing to mucous membrane damage. MATERIAL AND METHODS: The study involved 94 patients with critical lower limb ischemia who were eligible for open bypass surgery. All patients underwent preoperative gastro- and duodenoscopy. The patients were followed up for 1 year, while the relationship between the nature of the lesion of the proximal gastrointestinal tract mucosa and the duration of pain syndrome against the background of ischemia, painkiller consumption and redo surgery. RESULTS: All study participants had lesions of the mucous membrane of the stomach and duodenum: inflammatory changes were identified in 92.6% of patients, ulcerative defects in 7.4%. When conducting a correlation analysis, we obtained a weak and moderate strength of the relationship between the duration of rest pain and severity of mucous membrane lesion and strong correlation between painkiller consumption and endoscopic data. Postoperative gastrointestinal bleeding was more common after redo reconstructive surgery or amputation compared to one intervention (7.7% and 1.8%, respectively). CONCLUSION: Various lesions of gastrointestinal mucous membrane are diagnosed in all patients with critical lower limb ischemia. It is associated with the underlying disease and painkiller consumption. Risk of bleeding is higher after redo surgery and amputations. Prevention of lesions requires comprehensive examination of patients and individual approach.


Assuntos
Isquemia , Úlcera Péptica , Amputação , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/etiologia , Humanos , Incidência , Isquemia/diagnóstico , Isquemia/epidemiologia , Isquemia/etiologia , Salvamento de Membro , Extremidade Inferior/cirurgia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
12.
BMC Musculoskelet Disord ; 22(1): 631, 2021 Jul 20.
Artigo em Inglês | MEDLINE | ID: mdl-34284739

RESUMO

BACKGROUND: This study was to evaluate the effects of repetitive brief ischemia (RBI) on bone healing in patients with tibial shaft fractures. METHODS: In this prospective clinical trial, patients with tibia shaft fractures were enrolled between January 2016 and January 2021. The intermittent pneumatic compression (IPC) device was used to make RBI on the affected limb after surgical operation 24 h. The inflation pressure was the systolic pressure of patients + 50 mmHg. Patients were received 30 s inflation/30 s deflation 30 times twice a day for 4 weeks. The primary outcome was bone healing time and the secondary outcomes were the rates of delayed union and nonunion, the rates of venous thrombosis of lower limbs, Johner-Wruhs scores, Lysholm knee score, VAS scores, postoperative complications, serum BMP-2, osteocalcin (OC) and bone specific alkaline phosphatase (BS-ALP). RESULTS: A total of 32 patients were enrolled finally and all were completed with a 12 months follow-up. All the fractures were healed and the bone healing time was 3(1) months in RBI group. However, the bone healing time of control group was 4(1) and there was statistical difference between the two groups (p < 0.01). No patient with fracture delayed union, nonunion and venous thrombosis of lower limbs in RBI group. 2 patients were delayed union in the control group. In RBI group, the Lysholm knee score was 83(6) at 6 months and 100(8) at 12 months. In the control group, the score was 78(4) and 90.5(17), there was statistical difference between the two groups (p < 0.01, p = 0.014, respectively). VAS scores were postoperative 2 weeks 6(1) in RBI group and 7(0.5) in the control group, there was statistical difference between the two groups (p = 0.016). There were 2 patients with intramuscular venous thrombosis of lower extremity in control group. Besides, RBI treatment increased the serum BMP-2, OC and BS-ALP at postoperative 2 weeks and 1 month. CONCLUSIONS: RBI is a new method to accelerate bone healing in tibia shaft fracture patients and is a simple and noninvasive method. TRIAL REGISTRATION: Chinese clinical trial registry, ChiCTR-INR-17014208 . Registered 28 December 2017-Retrospectively registered.


Assuntos
Fixação Intramedular de Fraturas , Fraturas da Tíbia , Consolidação da Fratura , Humanos , Isquemia/etiologia , Estudos Prospectivos , Tíbia/diagnóstico por imagem , Tíbia/cirurgia , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Resultado do Tratamento
13.
Eur J Vasc Endovasc Surg ; 62(2): 225-232, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34090781

RESUMO

OBJECTIVE: The aim of this study was to provide long term survival and limb salvage rates for patients with non-revascularisable (NR) chronic limb threatening ischaemia (CLTI). METHODS: This was a retrospective review of prospectively collected data, derived from a randomised controlled trial (JUVENTAS) investigating the use of a regenerative cell therapy. Survival and limb salvage of the index limb in CLTI patients without viable options for revascularisation at inclusion were analysed retrospectively. The primary outcome was amputation free survival, a composite of survival and limb salvage, at five years after inclusion in the original trial. RESULTS: In 150 patients with NR-CLTI, amputation free survival was 43% five years after inclusion. This outcome was driven by an equal rate of all cause mortality (35%) and amputation (33%). Amputation occurred predominantly in the first year. Furthermore, 33% of those with amputation subsequently died within the investigated period, with a median interval of 291 days. CONCLUSION: Five years after the initial need for revascularisation, about half of the CLTI patients who were deemed non-revascularisable survived with salvage of the index limb. Although the prospects for these high risk patients are still poor, under optimal medical care, amputation free survival seems comparable with that of revascularisable CLTI patients, while the major amputation rate within one year, especially among NR-CLTI patients with ischaemic tissue loss, is very high.


Assuntos
Amputação/estatística & dados numéricos , Isquemia/terapia , Salvamento de Membro/estatística & dados numéricos , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/terapia , Fatores Etários , Idoso , HDL-Colesterol/sangue , Doença Crônica , Feminino , Humanos , Claudicação Intermitente/etiologia , Isquemia/etiologia , Isquemia/cirurgia , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/complicações , Modelos de Riscos Proporcionais , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Gestão de Riscos , Índice de Gravidade de Doença , Taxa de Sobrevida , Fatores de Tempo
14.
Urol Int ; 105(9-10): 916-919, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34107472

RESUMO

Infection by COVID-19, being a respiratory disease caused by SARS-CoV-2, can predispose to arterial and venous thrombotic disease, in response to excessive inflammation, platelet activation, endothelial dysfunction, and venous stasis. During the COVID-19 pandemic period, the technological and resource availability for the care of these patients with thrombotic disease is critical, marking a factor of morbidity and poor prognosis in these cases. We describe a case of priapism in a patient with COVID-19, during the course of systemic inflammatory response syndrome and respiratory distress syndrome with a procoagulant state, seeking to relate the pathophysiological factors of ischemic priapism in patients with infection with SARS-Cov-2.


Assuntos
COVID-19/complicações , Isquemia/etiologia , Ereção Peniana , Pênis/irrigação sanguínea , Priapismo/etiologia , Adulto , COVID-19/diagnóstico , COVID-19/virologia , Evolução Fatal , Humanos , Isquemia/diagnóstico , Isquemia/fisiopatologia , Masculino , Priapismo/diagnóstico , Priapismo/fisiopatologia , Fluxo Sanguíneo Regional
17.
BMJ Case Rep ; 14(6)2021 Jun 22.
Artigo em Inglês | MEDLINE | ID: mdl-34158327

RESUMO

We present a case of mesenteric ischaemia caused by hypermagnesaemia after ingestion of a large oral dose of magnesium citrate, which resulted in smooth muscle relaxation, hypotension and bowel infarction. The patient had a history of chronic bowel dysmotility and renal impairment. On operative exploration, the bowel was noted to have a distinct pattern of ischaemia along its antimesenteric border. Small bowel resection was performed, and the patient was left in discontinuity, with definitive repair and anastomosis performed 24 hours later. The patient's magnesium level was 8.39 mg/dL, which was treated with intermittent haemodialysis and eventually normalised over several sessions. Our patient recovered and was discharged after a month-long hospitalisation. She returned shortly after with respiratory failure and died. On review of the literature, we identified similar cases and present a pathophysiological mechanism of hypermagnesaemia causing mesenteric ischaemia, consistent between our cases and those already reported.


Assuntos
Isquemia Mesentérica , Feminino , Humanos , Infarto/etiologia , Intestino Delgado/cirurgia , Isquemia/etiologia , Magnésio , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/etiologia
18.
BMJ Case Rep ; 14(6)2021 Jun 23.
Artigo em Inglês | MEDLINE | ID: mdl-34162612

RESUMO

Internal hernias due to mesenteric defects are a rare cause of bowel obstruction, but once present their complications are associated with a high morbidity and mortality. We present the case of a 24-year-old patient who presented to the emergency department with a 6-hour history of abdominal pain. Initial surgical review, taking into consideration the patient's clinical, biochemical and radiological findings, led to the patient being taken for immediate surgical exploration. Operative findings included a very mobile caecum and proximal ascending colon which had herniated through a defect in the small bowel mesentery, the sigmoid colon had subsequently become incarcerated by the caecum and small bowel too. Both the ascending and sigmoid colon had become ischaemic. Due to the early decision for surgical intervention, we were able to consider a number of surgical strategies, and the surgery led to a positive outcome for our patient.


Assuntos
Hérnia Abdominal , Obstrução Intestinal , Adulto , Colo Sigmoide/diagnóstico por imagem , Colo Sigmoide/cirurgia , Hérnia Abdominal/diagnóstico por imagem , Hérnia Abdominal/cirurgia , Humanos , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/etiologia , Obstrução Intestinal/cirurgia , Isquemia/diagnóstico por imagem , Isquemia/etiologia , Isquemia/cirurgia , Mesentério/diagnóstico por imagem , Mesentério/cirurgia , Adulto Jovem
19.
Ann Vasc Surg ; 75: 140-143, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34044096

RESUMO

The incidence of venous and arterial thromboembolic complications in COVID-19 patients is significant. The vast majority of COVID-19 patients spend their quarantine at home in a self-isolation condition. The occurrence of Acute limb ischemia (ALI) is a dangerous event that needs prompt diagnosis and management with time-dependent recanalization outcomes. We present a case series of three COVID-19 patients who suffered from ALI that occurred during home self-isolation, and that were diagnosed and treated with a significant time-delay due to COVID-19 social implications.


Assuntos
COVID-19/complicações , Diagnóstico Tardio , Erros de Diagnóstico , Isquemia/diagnóstico por imagem , Doença Arterial Periférica/diagnóstico por imagem , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Amputação , Anticoagulantes/uso terapêutico , Implante de Prótese Vascular , COVID-19/diagnóstico , COVID-19/terapia , Embolectomia , Humanos , Isquemia/etiologia , Isquemia/cirurgia , Masculino , Doença Arterial Periférica/etiologia , Doença Arterial Periférica/cirurgia , Valor Preditivo dos Testes , Trombectomia , Terapia Trombolítica , Tempo para o Tratamento , Resultado do Tratamento
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