Resultados en el corto y mediano plazo del tratamiento endovascular en la enfermedad arterial obstructiva infrapoplítea en pacientes con isquemia crítica de una extremidad / Short to midterm results after endovascular approach in critical limb isquemia in patients with below-the-knee arterial disease

Resumen Objetivo: Mostrar los resultados en el corto y mediano plazo del tratamiento endovascular de angioplastia transluminal percutánea (ATP) con balón en pacientes en estado de isquemia crítica por enfermedad arterial obstructiva infrapoplítea. Materiales y Método: Estudio descriptivo, observacional, retrospectivo. Se incluyeron los pacientes hospitalizados entre 2009 y 2018 por isquemia crítica Fontaine III o IV sometidos a una ATP del territorio infrapoplíteo. Se observó como objetivos primarios la preservación de la extremidad afectada y la mortalidad posoperatoria a un año plazo, y como objetivos secundarios los procedimientos adicionales en pacientes con lesiones o necrosis distales, estadía hospitalaria, complicaciones posoperatorias y necesidad de reintervención. Resultados: Se incluyeron 42 pacientes con un promedio de edad de 66 años (46-82), con importantes comorbilidades. Un 83,3% ingresó en etapa Fontaine IV. En 16 casos se realizó una angioplastia percutánea en más de una arteria. No se colocó stents. Se presentaron complicaciones en 3 pacientes, 2 requirieron una amputación mayor y en otro se debió efectuar un nuevo procedimiento endovascular de rescate. La estadía hospitalaria promedio fue 22 días. No hubo mortalidad precoz posprocedimiento. La mortalidad global a un año fue 9,5%. A todos los pacientes en etapa Fontaine IV se les efectuó algún procedimiento adicional, a 31 una amputación menor, 3 cerraron sus lesiones por segunda intención y en otro se realizó un injerto dermo-epidérmico. De los 35 pacientes con seguimiento, 77% preservó su extremidad a un año. Conclusión: La reparación endovascular mediante una angioplastia percutánea en estos casos es un procedimiento seguro y tiene una alta tasa de preservación de la extremidad inicial a un año de seguimiento.

Aim: Show initial and midterms results of endovascular Percutaneous Transluminal Angioplasty (PTA) in critical limb isquemia (CLI) patients caused by below-the-knee arterial disease. Materials and Method: Observational, descriptive and retrospective study. 42 CLI patients admitted in our hospital from 2009 until 2018 with Fontaine III or IV treated by PTA in infrapopliteal arteries were analyzed, collecting demographic, clinical and surgical characteristics, additional procedures in Fontaine IV, hospital stay, postoperative complications, need of reintervention, limb preservation and mortality with one year follow-up after procedure. Results: 42 patients, average age 66 year-old (46-82), with significant comorbidities. Fontaine IV stage patients were 83.3%. In 16 cases more than one artery was intervened. No stent revascularization was performed. Complications occurred in 3 patients, 2 required major amputation and an urgent endovascular reintervention was required in another. Average hospital stay was 22 days with no post-operative mortality. One-year global mortality was 9.5 One-year follow-up in 35 patients shows that 77% preserved their limb. Conclusión: Percutaneous transluminal angioplasty procedure in this patients has a high rate of limb preservation in a one-year follow-up. There was no post-operative mortality.

Comparison of standard balloon and drug-coated balloon angioplasty in patients with the below-the-knee peripheral artery disease

SUMMARY OBJECTIVE: The objective of this study was to compare the interventions of percutaneous transluminal drug-coated balloon angioplasty (DCB PTA) and standard PTA in the treatment of patients with the below-the-knee peripheral artery disease (BTK PAD). METHODS: Overall, 196 patients (113 males and 83 females; mean age: 63.56±11.94 years; 45-83 years) were treated with PTA for BTK PAD between June 2014 and March 2019. RESULT: Standard PTA (group 1; 96 patients) and DCB PTA (group 2; 100 patients) results were analyzed and compared retrospectively. No statistically significant difference was found between the mean ages of group 1 and 2 patients (p=0.371, p>0.05). Demographic and clinical data were compared and no any statistically significant differences was found between the two groups. Comparing in terms of the iliac lesion, there was no statistically significant difference between the two groups. However, a statistically significant difference was found between the two groups in terms of frequency of popliteal lesions (p=0.001; p<0.05). There was not a statistically significant difference between the two groups in terms of other lesions. In addition, limb salvage rates were 82.0% (18 amputations) and 65.6% (33 amputations) in the drug-release balloon group and the naked balloon group, at the end of 1 year, respectively. No distal embolism, limb-threatening ischemia, and mortality were observed in any patients. CONCLUSIONS: Based on this study, patients in the DCB group had significantly higher rates of primary patency as compared with the other patients.

Endovascular revascularization of chronic total arterial occlusion of the lower limb using the SAFARI technique / Revascularização endovascular utilizando a técnica SAFARI em casos de oclusão arterial total do membro inferior

Abstract The SAFARI technique or Subintimal Arterial Flossing with Antegrade-Retrograde Intervention is an endovascular procedure that allows recanalization of Chronic Total Occlusive (CTO) lesions when conventional subintimal angioplasty is unsuccessful. Retrograde access is usually obtained through the popliteal, anterior tibial, dorsalis pedis artery, or posterior tibial arteries and may potentially provide more options for endovascular interventions in limb salvage. The case of an 81-year-old man with a history of uncontrolled hypertension, diabetes mellitus, and dyslipidemia is presented. He presented with a cutaneous ulcer on the right lower limb with torpid evolution and poor healing. The Doppler ultrasound and arteriographic study revealed a CTO lesion of the popliteal artery that was not a candidate for antegrade endovascular revascularization, but was successfully treated using the SAFARI technique. The patient had no perioperative complications, the wound showed better healing, and he was discharged with an indication of daily dressings and control by an external outpatient clinic.

Resumo A técnica SAFARI, ou Subintimal Arterial Flossing with Antegrade-Retrograde Intervention, é um procedimento endovascular que permite a recanalização de lesões por oclusão total crônica (OTC) em caso de fracasso da angioplastia subintimal convencional. O acesso retrógrado é geralmente obtido através da artéria poplítea, tibial anterior, pediosa ou tibial posterior e pode fornecer mais alternativas de intervenções endovasculares para o salvamento do membro. É apresentado o caso de um homem de 81 anos com histórico de hipertenção não controlada, diabetes melito e dislipidemia. Ele apresentava uma lesão ulcerativa cutânea no membro inferior direito com evolução tórpida e má cicatrização. O ultrassom Doppler e o estudo arteriográfico revelaram uma lesão por OTC na artéria poplítea. O paciente não era candidato a revascularização endovascular anterógrada; sendo assim, esta foi realizada com successo utilizando a técnica SAFARI. O paciente não apresentou complicações perioperatórias e recebeu alta com indicação de cuidados diários com a ferida e controle em um ambulatório externo. Além disso, a ferida apresentou melhor cicatrização.

Síndrome de Budd-Chiari por obstrução da via de saída da veia hepática por membrana: tratamento percutâneo por angioplastia com balão / Budd-Chiari syndrome due to hepatic venous web outflow obstruction: percutaneous treatment with balloon angioplasty

Resumo A síndrome de Budd-Chiari é uma doença venosa hepática rara, mais incidente em adultos jovens, podendo se apresentar na forma aguda, subaguda ou crônica, o que resulta em hipertensão portal. O tratamento tradicional consiste em técnicas de trombólise e de shunts portossistêmicos intra-hepáticos, como pontes para o transplante hepático. Recentemente, técnicas de angioplastia com balão ou stents têm sido relatadas para o tratamento dessa afecção. Neste artigo, é relatado e discutido um caso de síndrome de Budd-Chiari por obstrução membranosa da via de saída da veia supra-hepática com trombose da veia hepática média em uma paciente de 24 anos. O tratamento estabelecido foi a angioplastia transjugular com balão, que obteve resultados satisfatórios e boa evolução clínica.

Abstract The Budd-Chiari syndrome is a rare hepatic venous disease. It is more prevalent in young adults and may present in acute, subacute, or chronic forms, causing portal hypertension. Traditional treatment consists of thrombolysis techniques and transjugular intrahepatic portosystemic shunt, as a bridge to liver transplantation. Recently, use of balloon or stent angioplasty techniques has been reported for treatment of this condition. In this article, we report and discuss a case of BCS by membranous obstruction in the hepatic vein outflow tract, with middle hepatic vein thrombosis, in a 24-year-old patient. The treatment chosen and employed was transjugular balloon angioplasty, which achieved satisfactory results and good clinical evolution.

Angioplastía con balón para el tratamiento de la hipertensión arterial pulmonar por enfermedad tromboembólica crónica. Resultados hemodinámicos y clínicos inmediatos / Balloon pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension

Background: Balloon pulmonary angioplasty (BPA) is a therapeutic alternative for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Aim: To report the initial experience with the "refined BPA technique" with the use of intravascular images. Patients and Methods: Between June 2015 and June 2016 we selected fourteen patients with CTEPH who were considered candidates for BPA. Lesions targeted for treatment were further analyzed using intravascular imaging with optical frequency domain imaging (OFDI). We report the immediate hemodynamic results and four weeks of follow-up of the first eight patients of this series. Results: We performed 16 BPA in eight patients aged 61 ± 14 years (88% women). Mean pulmonary artery pressure (PAPm) was 48.6 ± 5.8 mmHg. Success was achieved in seven patients (88%). A mean of 2.3 segments per patient were intervened in 11 sessions (1.6 sessions/ patient). Only one patient developed lung reperfusion injury. No mortality was associated with the procedure. After the last BPA session, PAPm decreased to 37.4 ± 8.6 mmHg (p=0.02). Pulmonary vascular resistance (RVP) decreased from 858,6 ± 377,0 at baseline to 516,6 ± 323,3 Dynes/sec/cm−5 (p<0.01) and the cardiac index increased from 2.4±0.6 at baseline to 2.8±0.3 L/min/m2 (p=0.01). At 4 weeks after the last BPA, WHO functional class improved from 3.3±0.5 to 2.5±0.5 (p<0,01) and six minutes walking distance from 331±92 to 451±149 m (p=0.01). Conclusions: BPA guided by OFDI for the treatment of inoperable CTEPH patients is a safe alternative with excellent immediate hemodynamic and clinical results.

Angioplastia percutánea con balón en hipertensión pulmonar tromboembólica crónica / Percutaneous balloon angioplasty for treatment of chronic thromboembolic pulmonary hypertension

La hipertensión pulmonar tromboembólica crónica se caracteriza por la presencia de material trombótico organizado dentro de las arterias pulmonares que genera elevación de la resistencia vascular pulmonar, insuficiencia cardíaca derecha y, eventualmente, la muerte. El tratamiento de elección es la tromboendarterectomía pulmonar, que suele ser curativa si la obstrucción es proximal. En algunos casos este tratamiento no es posible y surge como alternativa la angioplastia pulmonar con balón (APB), que está generando creciente interés. Se presentan tres casos de pacientes con hipertensión pulmonar tromboembólica a los que por diferentes circunstancias no pudo tratarse con tromboendarterectomía y se realizó APB comprobándose, en los tres casos, mejoría de la clase funcional, prueba de la caminata de seis minutos, además de parámetros hemodinámicos y angiográficos.

Chronic thromboembolic pulmonary hypertension is characterized by the presence of organized thrombotic material in the pulmonary arteries which causes elevation of the pulmonary vascular resistance, right heart failure, and death if not treated. Pulmonary thromboendarterectomy is the treatment of choice and can be curative when the obstruction is proximal. There are cases in which this therapy is not possible, and pulmonary angioplasty is a therapeutic alternative of growing interest. We present our experience with three patients diagnosed with chronic thromboembolic pulmonary hypertension in whom pulmonary endarterectomy was not possible and pulmonary angioplasty was performed. All patients showed improvement of functional class, six-minute walk distance, and hemodynamic as well as angiographic parameters.

O uso do balão com paclitaxel no tratamento da reestenose intra-stent no segmento fêmoro-poplíteo / Use of paclitaxel-coated balloon to treat in-stent restenosis in femoropopliteal segments

Resumo Contexto A reestenose intra-stent por hiperplasia miointimal pós-angioplastia é uma intercorrência frequente e que limita a perviedade do procedimento a longo prazo. A terapia com balões revestidos de droga com ação antiproliferativa pode ser uma alternativa no tratamento dessa complicação. Objetivos Demonstrar eficácia e as complicações (óbito, grandes amputações, etc.) do balão farmacológico no tratamento da reestenose intra-stent de segmento femoropoplíteo. Métodos Estudo de coorte retrospectivo de 32 pacientes consecutivos tratados entre os anos de 2012 e 2016, submetidos a terapia de reestenose intra-stent de segmento femoropoplíteo com angioplastia com balão farmacológico revestido com paclitaxel. A taxa de sucesso foi mensurada pela ocorrência de sucesso do procedimento e reestenose inferior a 50% em avaliação por eco-Doppler colorido 30, 90 e 180 dias após o procedimento. Resultados Quatro pacientes (12,5%) apresentaram reestenose superior a 50%, sendo um (3,1%) após 90 dias e três (9,4%) após 180 dias, conferindo uma taxa de sucesso de 87,5% ao procedimento. Após 180 dias, todos os pacientes referiam melhora ou cessação dos sinais e/ou sintomas apresentados antes do procedimento. Não houve óbitos, e complicações ocorreram apenas em dois casos, no pós-operatório imediato. Conclusões Os resultados a curto prazo da terapia com balão farmacológico são promissores, com redução na taxa de reestenose e baixo índice de complicações. Ainda precisam ser apresentados estudos demonstrando os efeitos a longo prazo dessa terapia, assim como seu impacto econômico quando comparada a outros procedimentos.

Abstract Background In-stent restenosis due to myointimal hyperplasia after angioplasty is common and limits long-term patency. Treatments using balloons coated with antiproliferative drugs may offer an alternative option for this pathology. Objectives To demonstrate the efficacy and complications (death, major amputations, etc.) of drug-coated balloons for treatment of in-stent restenosis in femoropopliteal segments. Methods This was a retrospective cohort study of 32 consecutive patients treated between 2012 and 2016 who underwent treatment to correct in-stent restenosis in the femoropopliteal segment using paclitaxel-coated balloons. The success rate was measured in terms of technical success and restenosis of less than 50% on Doppler ultrasonography at 30, 90, and 180 days after the procedure. Results Four patients (12.5%) exhibited restenosis greater than 50%, one (3.1%) after 90 days and three (9.4%) after 180 days, equating to a success rate of 87.5% of procedures, and by 180 days all patients experienced improvement or cessation of the signs and/or symptoms they had presented prior to the procedure. There were no deaths and complications occurred in just 2 cases in the immediate postoperative period. Conclusions Short-term results are promising, with reductions in the magnitude of restenosis and a low rate of complications. Further studies are needed that can demonstrate the long-term effects and the economic impacts in comparison to other procedures.

Carotid artery stenting in the context of endovascular treatment of acute ischemic stroke / Angioplastia com stent de carótida no contexto do tratamento endovascular do acidente vascular cerebral isquêmico agudo

ABSTRACT Mechanical thrombectomy as an adjunctive to intravenous thrombolysis is now the standard treatment for acute ischemic stroke (AIS) due to large vessel occlusions. However, the best management of acute carotid tandem occlusions (CTO) remains controversial. Method Twenty patients underwent endovascular treatment of acute CTO. The primary endpoint was the composite rate of complete or partial recanalization without a symptomatic intracranial hemorrhage (sICH). Secondary endpoints were recanalization times, procedure times, and clinical outcomes at three months. Results The primary endpoint was reached in 17 (85%) patients. Recanalization rate was reached in 90% of patients (19/20) and sICH rate was 5% (1/20). At the 3-month follow-up we obtained a mRS ≤ 2 rate of 35% (7/20) and a mortality rate of 20% (4/20). Conclusion Carotid angioplasty stenting and endovascular treatment of AIS due to CTO appears effective with an acceptable rate of sICH.

RESUMO Trombectomia mecânica com stentrievers associada a trombólise endovenosa com rTPA é o tratamento padrão-ouro do acidente vascular cerebral isquêmico agudo (AVCi) devido à oclusões de grandes vasos. No entanto, a melhor estratégia terapêutica para oclusões carotídeas combinadas ainda permanece controversa. Método Vinte paciente receberam tratamento endovascular. O desfecho primário foi a taxa de recanalização completa sem sangramento intracraniano sintomático. Os desfechos secundários foram os tempos de recanalização, duração dos procedimentos e desfechos clínicos em 3 meses. Resultados O desfecho primário foi alcançado em 17 (85%) pacientes. A taxa de recanalização foi de 90% (19/20) e a taxa de HIS foi de 5% (1/20). Em três meses, foi obtido bom desfecho neurológico em 35% (7/20) dos pacientes e a mortalidade foi de 20% (4/20). Conclusão A angioplastia com stent de carotída associada ao tratamento endovascular para oclusões combinadas agudas de carótida parece ser efetiva sem um aumento de HIS.

Aterectomia rotacional em artérias com calcificação extrema ou falha em dilatação prévia: aspectos técnicos e evolução tardia após intervenção coronária percutânea / Rotational atherectomy in arteries with extreme calcification or previous failed dilation: technical aspects and late outcomes after percutaneous coronary intervention

A aterectomia rotacional com incorporação de novas estratégias ablativas tem sido proposta para o preparo de lesões extremamente calcificadas. Entretanto, pouco se conhece a respeito da adoçãodessas novas estratégias na prática contemporânea e sobre a evolução tardia dos pacientes submetidos aesse tratamento. Objetivamos avaliar os aspectos técnicos da aterectomia e a evolução tardia dos pacientesquanto à ocorrência de eventos cardiovasculares adversos maiores (ECAM). Métodos: Estudo retrospectivo e unicêntrico, incluindo todos os pacientes submetidos à aterectomiarotacional como parte do tratamento de lesões coronárias com calcificação extrema ou falha de dilataçãoem procedimento prévio, no período de julho de 2012 a novembro de 2014. Foram definidos como ECAM: óbito, infarto agudo do miocárdio com onda Q ou nova revascularização do vaso-alvo.Resultados: Foram submetidos à aterectomia 29 pacientes com idade média de 69,5 ± 7,6 anos. A médiada relação oliva/vaso foi de 0,54 ± 0,07; a velocidade de rotação inicial adotada foi de 161.000 ± 13.928 e a taxa de utilização de cutting balloon pós-aterectomia foi de 45,1%. Sucesso angiográfico foi obtido em todos os procedimentos. Na evolução tardia, a mediana de tempo de seguimento foi de 13,2 meses (intervalo interquartil: 4,0 a 17,4 meses). Foram registrados um óbito por causa não cardíaca e duas novas revascularizações do vaso-alvo. A média do tempo de sobrevivência livre de ECAM foi de 29,7 ± 2,1 meses.Conclusões: A aterectomia rotacional contemporânea incorporou estratégias menos agressivas de ablação,com elevada taxa de sucesso imediato e baixa ocorrência de ECAM na evolução tardia...

Rotational atherectomy with new ablative strategies have been proposed for the treatment of extremely calcified lesions prior to stent implantation. Nevertheless, few data are available about the adoption of these new strategies in contemporary practice and about late outcomes of patients undergoing this therapy. Methods: From July 2012 to November 2014, a retrospective single center registry was conducted, including all patients undergoing rotational atherectomy as part of the treatment of coronary arteries with heavy calcification or previous failed dilation. We evaluated technical aspects of atherectomy and late outcomes of patients for the occurrence of major adverse cardiovascular events (MACE), defined as death, Q-wave myocardial infarction or repeat target vessel revascularization.Results: Twenty-nine patients with a mean age of 69.5 ± 7.6 years, underwent atherectomy. The averageburr-to-artery ratio was 0.54 ± 0.07, the initial rotational speed was 161.000 ± 13.928 and the rate of cuttingballoon utilization after atherectomy was 45.1%. Angiographic success was achieved in all procedures. The median follow-up time was 13.2 months (IQ: 4.0-17.4) and there were three events: 1 death of non cardiac cause and 2 new target vessel revascularizations. The mean MACE-free survival time was 29.7 ± 2.1 months. Conclusions: Contemporary rotational atherectomy incorporates less aggressive strategies of ablation with high rates of acute success and low occurrence of major adverse cardiovascular events during late follow-up...

Procedimientos endovasculares como tratamiento de la esclerosis múltiple?: la hipótesis de la insuficiencia venosa crónica cerebro medular: [revisión] / Endovascular procedures as multiple sclerosis treatment?: the hipothesis of the chronic cerebrospinal venous insufficiency: [review]

In this "point of view" or special article, it has been reviewed the main bibliographic antecedents related to the entity denominated as chronic cerebrospinal venous insufficiency (CCSVI), which formulation has been stated by Zamboni et col, from the Vascular Diseases Center of the University of Ferrara-Italy, who have assigned it a pathogenic role or of aggravation one in Multiple Sclerosis (MS), what has led them to propose and carry out endovascular balloon angioplasty or venous stent in MS patients as a treatment. The bibliographic review at this stage of the knowledge of CCSVI does not let us to conclude whether this hypothetical entity has any role in the development or aggravation of MS. On the other hand, we agree with most of the clinicians and neuroimaging MS researchers because of the absence of arguments to indicate, support or propose envovascular "therapeutic" procedures for MS. To advance in the knowledge of CCSVI and the eventual relation with MS it is required some multicentric controlled studies carefully led and clinical and methodological rigorous procedures approved by committee of ethic in very well informed patients invited to participate in protocols of formal investigation who should be protected by complementary pertinent insurances and responsibilities connected to the investigation expenses.

En este artículo especial de la modalidad "puntos de vista", se revisan los antecedentes bibliográficos principales relacionados a la entidad denominada "Insuficiencia venosa crónica cerebro medular (IVCCM)" cuya formulación ha sido planteada por Zamboni y col, del Centro de Enfermedades Vasculares de la Universidad de Ferrara-Italia quienes le han adjudicado un rol patogénico o de agravación en la Esclerosis Múltiple (EM), que les ha llevado a proponer y realizar procedimientos de angioplastía mediante balón endovascular o stent venoso en pacientes con EM. La revisión de la bibliografía, en esta etapa del conocimiento de la IVCCM, no permite concluir si esta hipotética entidad tiene algún rol en el desarrollo o agravación de la EM. Por otro lado, concordamos con la mayoría de los clínicos e imagenólogos dedicados al estudio y tratamiento de la EM, en la ausencia de argumentos para indicar, alentar o propiciar procedimientos "terapéuticos" endovasculares para la EM. Para avanzar, en el conocimiento de la IVCCM y de eventual relación con la EM, se requieren estudios multicéntricos cuidadosamente conducidos, clínica y metodológicamente rigurosos, aprobados por comités de ética, en pacientes que sean invitados informadamente a participar en protocolos de investigación formales, que cuenten con las protecciones de seguros complementarios pertinentes y responsabilidades del gasto a costas de los investigadores.

Índice de resistividade renal como preditor da revascularização renal para hipertensão renovascular / Renal resistance index predicting outcome of renal revascularization for renovascular hypertension

FUNDAMENTO: A estenose arterial renal (EAR) é uma causa potencialmente reversível de hipertensão arterial sistêmica (HAS) e nefropatia isquêmica. Apesar da revascularização bem sucedida, nem todos os pacientes (pt) apresentam melhora clínica e alguns podem piorar. OBJETIVO: O presente estudo se destina a avaliar o valor do índice de resistividade renal (IR) como preditor dos efeitos da revascularização renal. MÉTODOS: Entre janeiro de 1998 e fevereiro de 2001, 2.933 pacientes foram submetidos ao duplex ultrassom renal. 106 desses pacientes apresentaram EAR significativa e foram submetidos a angiografia e revascularização renal. A pressão arterial (PA) foi medida antes e depois da intervenção, em intervalos de até 2 anos e as medicações prescritas foram registradas. Antes da revascularização, o IR foi medido em 3 locais do rim, sendo obtida uma média dessas medições. RESULTADOS: Dos 106 pacientes, 81 tiveram IR<80 e 25 RI>80. A EAR foi corrigida somente por angioplastia (PTA) em 25 pts, PTA + stent em 56 pts e cirurgicamente em 25 pts. Dos pacientes que se beneficiaram da revascularização renal; 57 dos 81 pacientes com IR <80 apresentaram melhora em comparação a 5 de 25 com IR > 80. Usando um modelo de regressão logística múltipla, o IR esteve significativamente associado à evolução da PA (p = 0,001), ajustado de acordo com os efeitos da idade, sexo, PAS, PAD, duração da hipertensão, o tipo de revascularização, número de fármacos em uso, nível de creatinina, presença de diabete melito, hipercolesterolemia, volume sistólico, doença arterial periférica e coronariana e tamanho renal (OR 99,6-95 por centoCI para OR 6,1-1.621,2). CONCLUSÃO: A resistividade intrarrenal arterial, medida por duplex ultrassom, desempenha um papel importante na predição dos efeitos pós revascularização renal para EAR.

BACKGROUND: Renal artery stenosis (RAS) is a potentially correctable cause of hypertension and ischemic nephropathy. Despite successful renal revascularization, not all patients (pt) overcome it and some get worse. OBJECTIVE: This study was designed to assess the value of renal resistance index (RI) in predicting the outcome of renal revascularization. METHODS: Between Jan 1998 and Feb 2001, 2,933 pts were referred to renal duplex ultrasound. 106 out of these had significant RAS and underwent angiography and renal revascularization. Arterial blood pressure (BP) was measured before and after the intervention, at intervals of up to 2 years and medications recorded. Prior to revascularization, RI was measured at 3 sites of each kidney and averaged. RESULTS: Out of the 106 patients, 81 had RI<80 and 25 RI>80. RAS was corrected with angioplasty (PTA) alone in 25 pts, PTA + stent in 56 pts and corrected by surgery in 25 pts. Of patients who benefited from renal revascularization; 57 of the 81 patients with RI <80 improved as compared to 5 of 25 with RI>80. Using a multiple logistic regression model, RI was significantly associated with BP outcome (p=0.001), adjusted for the effects of age, sex, SBP, DBP, duration of hypertension, type of revascularization, number of medication in use, creatinine level, presence of diabetes mellitus, hypercholesterolemia, stroke, peripheral and coronary artery disease and kidney size (OR 99.6 - 95 percentCI for OR 6.1 to 1,621.2). CONCLUSION: Intrarenal arterial resistance measured by duplex ultrasound plays an important role in predicting BP outcome after renal revascularization for RAS.

Utilización del stent pospérdida tardía en la angioplastia con balón en pacientes con cardiolatía isquemica crónica spostar / Stent utilization for late loss following balloon angioplasty in patients with chronic ischemic heart disease

La cardiopatía isquémica de origen ateroesclerótico tiene indicación de tratamiento farmacológico, de angioplastia con balón y colocación de stent coronario o la cirugía de revascularización. Evaluar la necesidad de stent coronario pospérdida tardía en la angioplastia con balón en pacientes con cardiopatía isquémica crónica. Se determinó la pérdida tardía posangioplastia con balón, en diferentes tiempos, con el ultrasonido coronario (IVUS) y angiográfico. Se estudiaron prospectivamente 21 pacientes con cardiopatía isquémica crónica ateroesclerótica (B2, C), en ASCARDIO, de febrero 2002 a julio 2008. Se realizó angiografía coronaria y IVUS. Se utilizó programa SPSS versión 15.0; para el análisis de datos: frecuencias, porcentajes, promedios, desviación estándar; t de Student, prueba de Wilcoxon (z), con 0,05 de significación estadística. Hubo predominio de género masculino, con 49 a 58 años. Como factores de riesgo: hipertensión arterial sistémica (85,7%), dislipidemia (80,9%), consumo de tabaco (47,6%), diabetes mellitus tipo 2 (38,1%). La arteria descendente anterior fue la más tratada. Se encontró lesión arterial coronaria B2 (47,6%), C (52,4%) con alta producción de disecciones posangioplastia con balón clase A (19,0%),B (33,3%), C (19,0%). Con incidencia de retroceso elástico de 29,5%. Todos requirieron Stent. El severo grado ateroesclerótico de las lesiones coronarias de 21 pacientes explicaría el alto grado de complicaciones posterior a la angioplastia con balón y el alto porcentaje de retroceso elástico hallado. Se evidencia la utilidad del uso del IVUS para la obtención de un mejor diagnóstico y cuantificación de la lesión, escogencia del tamaño del stent e impactación adecuada en el vaso coronario.

Ischemic heart disease of atherosclerotic origin is an indication for drug treatment, balloon angioplasty and coronary stenting or bypass surgery. To evaluate the need forcoronary stent use for late loss following balloon angioplasty in patients with chronic ischemic heart disease. Llate loss was determined post-balloon angioplasty, at different times, with coronary ultrasound(IVUS) and angiography. We prospectively studied 21 patients with chronic atherosclerotic coronary artery disease (B2,C), ASCARDIO, from February 2002 to July 2008. We performed coronary angiography and IVUS. We used SPSS version 15.0, fordata analysis: frequencies, percentages, averages, standard deviation,Student t test, Wilcoxon test (z), with 0.05 statistical significance.There was a male predominance, from 49 to 58 years ofage. Risk factors: systemic hypertension (85.7%), dyslipidaemia(80.9%), tobacco use (47.6%), and Type 2 diabetes (38.1 %). The anterior descending artery was treated the most. The following coronary arterial lesions were found: B2 (47.6%), C (52.4%) witha high occurrence of dissections post-balloon angioplasty class A(19,0%), B (33.3%), C (19.0%). The incidence of elastic recoilwas 29.5%. All required stents. The degree of severe atherosclerotic coronary lesions in 21 patients explains the high rate of complications after balloon angioplasty and the high percentage of elastic recoil found. This study demonstrates the utility of using IVUS to obtain a better diagnosis, quantification of the injury, choice of stent size and proper implantation in the coronary vessel.

Coração de atleta e cardiomiopatia hipertrófica: é possível diferenciar? / Athlete's heart and hypertrophic cardiomyopathy: is it possible to differentiate?

A doença arterial coronariana é uma das principais causas de morbidades no mundo. O tratamento clínico, associado à mudança de estilo de vida, é sua base terapêutica. Somando-se a isso, para evitar a progressão da doença arterial coronariana, melhorar a qualidade de vida e reduzir a intensidade da angina, deve-se considerar a revascularização miocárdica. As indicações da cirurgia de revascularização miocárdica tem passado por mudanças, desde que a primeira intervenção cirúrgica foi realizada em 1967. Nesse texto é feita a revisão da literatura com base nos estudos que avaliaram as indicações cirúrgicasde revascularização miocárdica na doença arterial crônica, enfocando, principalmente, aqueles que compararam a abordagem cirúrgica com o tratamento clínico...

Revascularização endovascular infrainguinal: fatores determinantes para a perviedade / Endovascular infrainguinal revascularization: predictive factors for patency

Contexto: A terapia endovascular tem avançado muito como tratamento para a doença arterial oclusiva infrainguinal, principalmente com o desenvolvimento dos materiais e dos stents autoexpansíveis de nitinol. Objetivo: Avaliar os resultados e os fatores determinantes da angioplastia fêmoro-poplítea em pacientes portadores de isquemia de membros inferiores. Métodos: Foram tratados, através de angioplastia com ou sem stent, 114 pacientes, e acompanhados por um período médio de 12 meses. A média de idade foi de 66 anos; 53 por cento eram do sexo feminino; 23,7 por cento eram portadores de claudicação incapacitante; 8,8 por cento, de dor isquêmica de repouso; e 67,5 por cento, de lesão trófica. As lesões foram classificadas segundo o TransAtlantic Inter-Society Consensus II em A (53 por cento), B (34 por cento), C (5 por cento) e D (9 por cento). Resultados: A análise angiográfica do leito distal mostrou uma média de 1,4±1,0 artérias infrapoplíteas pérvias. O sucesso inicial foi de 97 por cento. No seguimento de 1, 6, 12 e 24 meses, a perviedade primária foi de 94, 78, 48 e 31 por cento, e a primária assistida, de 94, 84, 73 e 61 por cento, respectivamente (p = 0,005). O leito distal pobre e a presença de diabetes melito foram associados a uma menor perviedade primária (p = 0,01), enquanto a extensão da lesão não influenciou os resultados. As taxas de salvamento de membro em 6, 12 e 24 meses foram de 95, 90 e 90 por cento, respectivamente. Conclusões: A extensão das lesões tratadas não foi um fator determinante em nossa casuística para o menor sucesso da angioplastia, o que pode sugerir que as indicações para o tratamento endovascular possam ser ampliadas para pacientes com lesões TransAtlantic Inter-Society Consensus II C/D.

Background: Endovascular techniques have undergone major advances with regard to the treatment of infrainguinal arterial occlusive disease, mainly as a result of development of new devices and self-expanding nitinol stents. Objective: To evaluate the results and determinant factors of femoropopliteal angioplasty in patients with critical lower limb ischemia. Methods: During the study, 114 patients were submitted to angioplasty or stenting and followed during an average of 12 months. Mean age was 66 years, and 53 percent were female; 23.7 percent presented disabling claudication, 8.8 percent ischemic rest pain and 67.5 percent tissue loss. Lesions were classified as A (53 percent), B (34 percent), C (5 percent) and D (9 percent) according to the TransAtlantic Inter-Society Consensus II. Results: Angiographic run-off analysis showed an average of 1.4±1.0 patent infrapopliteal artery. Initial success rate was 97 percent. At 1, 6, 12 and 24 months of the follow-up period, primary patencies of 94, 78, 48 and 31 percent, and assisted primary patencies of 94, 84, 73 and 61 percent were achieved (p = 0.005). Poor run-off and diabetes mellitus were directly associated with lower primary patency rates (p = 0.01), while angiographic severity of the lesions did not influence results. Limb salvage rates calculated at 6, 12 and 24 months were 95, 90 and 90 percent, respectively. Conclusions: Lesion length was not a determinant factor of lower success rates for angioplasty or stenting, which may suggest that indications for endovascular treatment can be extended to patients with TransAtlantic Inter-Society Consensus II C/D lesions.

Alternativas terapéuticas en el tratamiento de la hipertensión pulmonar tromboembólica crónica / Therapeutic alternatives for the treatment of chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertensión (CTPH) usually develops as a consequence of an unresolved pulmonary thromboembolism (PTE). Clinically it can evolucionate from different forms, being in many times similar in its presentation to the idiopathic pulmonary hypertension (IPH), motive by which is frequently misdiagnosed. The treatment of choice is the pulmonary thromboendarterectomy (PT)... An unfrequent case of a patient with a diagnosis of CTPH submitted to non-conventional treatment with pulmonary angioplasty is reported, and later on a revision of diagnosis and treatment is presented.

Angioplastía renal con stent utilizandode contraste. Caso clínico CO2 como medio de contraste: Caso Clínico / Renal angioplasty with stent using CO2 as contrast medium: Report of one case

Revascularization procedures for atherosclerotic renovascular hypertension are aimed to improve or cure hypertension and to reduce the progression to ischemic nephropathy and renal failure. Renal angioplasty is the preferred method, but a common complication is contrast-induced nephropathy. To avoid or lessen this complication, CO2 can be used as a contrast medium. We report a 68 year-old woman with renovascular hypertension and mild deterioration of renal function in whom we implanted an stent using digital substraction angiography and CO2 as contrast medium, which was injected manually. We obtained satisfactory images and we ended the procedure without complications. Blood pressure fell and creatinine levels did not change.

Tratamiento quirúrgico de la isquemia mesentérica crónica: Caso clínico / Surgical treatment of chronic mesenteric ischemia: Report of one case

Although the classic therapy for chronic mesenteric ischemia is surgical revascularization, endovascular therapy is a new therapeutic option. We report a 55 year-old female, with a 2 years history of post prandial abdominal pain, diarrhoea, and weight loss, with occlusion of both mesenteric arteries and critical stenosis of the celiac artery. The initial treatment consisted in angioplasty and celiac artery stent placement in two occasions, with a brief symptomatic relief. Finally, a visceral artery bypass was performed, with good post operative outcome and complete symptomatic resolution at one year follow up. In our opinion endovascular therapy is a good therapeutic option for chronic mesenteric ischemia in high surgical risk patients, specially when dealing with stenotic injuries. It may also be a complement for patients who need to recover their nutritional status prior to revascularization surgery. On the other hand, due to the long term patency and symptomatic relief, surgical treatment is a good option in low risk patients.

Eficácia clínica da revascularização renal percutânea com implante de stent em pacientes com doença renovascular aterosclerótica / Clinical efficacy of percutaneous renal revascularization with stent placement in atherosclerotic renovascular disease

OBJETIVO: Avaliar a eficácia da revascularização renal percutânea com implante de stent no controle da hipertensão e na preservação/restauração da função renal, em pacientes com doença renovascular aterosclerótica. MÉTODOS: De maio/1999 a outubro/2003, foram revascularizados 46 pacientes com estenose da artéria renal aterosclerótica (EAR-A), os quais foram submetidos ao implante de stent. A indicação para o procedimento foi controle da hipertensão e/ou preservação/restauração da função renal. Características gerais - Idade: 33-84 anos (mediana: 58,5±10,7), homens: 26 (56,5 por cento), diabéticos: 4 (10 por cento), DAC: 21 (46 por cento), creatinina < 2,0 mg/dl: 39 (64 por cento), ICC: 6 (14 por cento), estenoses ostiais 20 (43 por cento), estenose bilateral 15 (33 por cento). O controle da hipertensão foi averiguado pelo número de agentes utilizado antes do procedimento e durante o seguimento, e pela aferição da pressão arterial (PA). RESULTADOS: O seguimento mínimo foi de sete meses e variou de 7-52 (mediana: 23, média: 24,2±15,2). Houve apenas um óbito não-cardíaco (2 por cento) e uma falha técnica de tratamento (2 por cento). Não houve complicação grave do procedimento. Nenhum paciente apresentou evento cardiovascular. A função renal melhorou ou permaneceu inalterada em 32 (82 por cento) pacientes, e piorou em 4 (10 por cento). O controle da pressão arterial melhorou em 19/44 (43,8 por cento) dos pacientes e continuou descontrolada ou piorou em 6 (14 por cento). CONCLUSÃO: A angioplastia renal com implante de stent em pacientes com EAR demonstrou ser uma estratégia eficaz na recuperação e preservação da função renal e no controle da pressão arterial.

OBJECTIVE: To evaluate the clinical efficacy of percutaneous renal revascularization with stenting to control hypertension and preserve/restore renal function in patients with atherosclerotic renovascular disease. METHODS: From May/1999 to October/2003, 46 patients with atherosclerotic renal artery stenosis (ARAS) underwent revascularization with stenting. The indication for the procedure was hypertension control and/or renal function preservation/restoration. Clinical characteristics: age range: 33-84 years (median = 58.5 ±10.7), males: 26 (56.5 percent), 4 (10 percent) patients with dia betes mellitus, 21 (46 percent) patients with coronary artery disease, creatinine <2.0mg/dl: 39 (64 percent), 6 patients (14 percent) with congestive heart failure, 20 (43 percent) patients with ostial stenosis and 15 (33 percent) patients with bilateral stenosis. Hypertension control was evaluated by the number of drugs used before the procedure and at follow-up (FU) and by blood pressure (BP) measurement. RESULTS: The minimum follow-up was 7 months (range of 7-52, median: 23, mean: 24.2 ± 15.2). There were no major complications. No patient experience any cardiovascular event. There was only one non-cadiac death (2 percent) and one technical failure in the treatment(2 percent). There was no serious complication in the procedure. None of the patients presented cardiovascular events. The renal function improved or stabilized in 32 patients (82 percent) and worsened in 4 (10 percent). The BP control improved in 19/44 (43,8 percent) patients and worsened / stabilized in 6 patients (14 percent). CONCLUSION: Angioplasty with renal artery stenting for ARAS showed to be an effective treatment strategy to restore and preserve renal function and to control blood pressure.