Preoperative carotid duplex scanning in patients undergoing coronary artery bypass grafting

Abstract Objective: The aim of this study was to determine the prevalence and risk factors of carotid artery stenosis (CAS) using carotid duplex ultrasound in patients undergoing coronary artery bypass grafting (CABG). Methods: This retrospective study was conducted between January 2017 and January 2018 and included 166 consecutive patients [130 males (78.31%), 36 females (21.69%); mean age: 64.25±9.78 years] who underwent elective and isolated CABG. Patients who had significant CAS (≥50% stenosis) were compared with patients who had non-significant CAS (<50% stenosis). Logistic regression analysis was applied across the selected parameters to identify risk factors for significant CAS. Results: Of all patients, 36 (21.68%) had CAS ≥50% and 8 (4.81%) had unilateral carotid stenosis ≥70%. Carotid endarterectomy/CABG was performed simultaneously in five (3.01%) patients. None of these patients had cardiac and neurological problems during the postoperative period. The overall incidence of cerebrovascular accident (CVA) after CABG was 1.20% (n=2). Age (P=0.011) and history of CVA (P=0.035) were significantly higher in the CAS ≥50 group than in the CAS <50 group. Significant CAS was identified as a risk factor for postoperative CVA (P=0.013). Conclusion: Age and history of CVA were identified as risk factors for significant CAS. Furthermore, significant CAS was identified as a risk factor for postoperative CVA. For this reason, carotid screening is recommended for patients undergoing CABG even in the absence of associated risk factors.

Enfermedad carotídea aterosclerosa y enfermedad de sustancia blanca en sujetos sin historia de infarto cerebral o isquemia cerebral transitoria / Atherosclerotic Carotid Disease and White Matter Disease in Subjects Without a History of Cerebral Infarction or Transient Cerebral Ischemia

Resumen Introducción: La enfermedad carotídea aterosclerosa (ECA) es un factor de riesgo importante para enfermedad vascular cerebral. Objetivo: Analizar la asociación entre factores de riesgo vascular mayores con ECA y leucopatía cerebral en pacientes sin historia de ictus isquémico. Método: Se evaluaron factores de riesgo en sujetos con exploración de carótidas mediante ultrasonografía Doppler dúplex. No se incluyeron casos con historia de infarto cerebral o ataque isquémico transitorio. Los sujetos contaron con resonancia magnética cerebral y se excluyeron aquellos con lesiones isquémicas de grandes vasos. Se construyeron modelos multivariable para la predicción de ECA, estenosis carotídea significativa, carga de ateromas y leucopatía cerebral. Resultados: Se estudiaron 145 sujetos (60.7 % mujeres, edad de 73 años). Se documentó ECA en 54.5 %, estenosis carotídea ≥ 50 % en 9 %, carga de placas de ateroma > 6 en 7.6 % y leucopatía periventricular o subcortical en 28.3 % (20.6 % tenían concurrentemente ECA y leucopatía). Los factores asociados independientemente con ECA fueron edad e hipertensión; con estenosis ≥ 50 %, hipertensión; con cargas de ateromas > 6 placas, edad; con leucopatía, edad, diabetes e hipertensión. La obesidad no se asoció con las variables independientes analizadas. Conclusiones: En los sujetos asintomáticos sin historia de ictus isquémico, la edad y la hipertensión fueron los factores de riesgo más importantes para enfermedad macrovascular. La diabetes mellitus se asoció con enfermedad microvascular. La obesidad por sí sola no fue un determinante mayor de ECA o leucopatía cerebral.

Abstract Introduction: Atherosclerotic carotid artery disease (CAD) is a major risk factor for cerebrovascular disease. Objective: To analyze the association of major vascular risk factors with atherosclerotic CAD and white matter disease (WMD) in patients without a history of ischemic stroke. Method: Risk factors were assessed with carotid examination using Doppler duplex ultrasound. Cases with a history cerebral infarction or transient ischemic attack were not included. Subjects had brain magnetic resonance imaging scans available and those with large-artery ischemic lesions were excluded. Multivariate models were constructed for the prediction of atherosclerotic CAD, significant carotid stenosis, atheroma burden and WMD. Results: One-hundred and forty-five subjects were assessed (60.7% were females, mean age was 73 years). Atherosclerotic CAD was documented in 54.5%, carotid stenosis ≥ 50% in 9.0%, > 6 atheroma plaques in 7.6%, and periventricular or subcortical WMD in 28.3% (20.6% had atherosclerotic CAD and WMD concurrently). Risk factors independently associated with atherosclerotic CAD were age and hypertension; hypertension was associated with ≥ 50% carotid stenosis; age was associated with > 6 atheroma plaques; and age, diabetes and hypertension were associated with WMD. Obesity was not associated with any of the analyzed independent variables. Conclusions: In asymptomatic subjects without a history of ischemic stroke, age and hypertension were the most important risk factors for macrovascular disease. Diabetes mellitus was associated with microvascular disease. Obesity alone was not a major determinant of CAD or WMD.

El priapismo en la Leucemia Mieloide Crónica Hallazgos radiológicos en casos de Leucemia Mieloide Crónica que se presentaron con priapismo / 7 PRIAPISM IN CHRONIC MYELOID LEUKEMIA : IMAGING FINDINGS IN CASES OF CHRONIC MYELOID LEUKEMIA WHO PRESENTED WITH PRIAPISM

El priapismo es una emergencia urológica que debe ser diagnosticada y tratada apropiadamente. Específicamente en casos conocidos de leucemia el pene turgente doloroso debe hacer surgir la sospecha de priapismo de primera movida y el Doppler peneano debe ser la mera línea de modalidad de imágenes. Esta información debe ser transmitida al paciente y al departamento clínico emergentológico

Priapism is an urological emergency and must be diagnosed and treated appropriately. Specifically in known cases of leukemia painful turgid penis should raise suspicion of priapism in first hand and penile Doppler should be the first line of imaging modality. This information should be forwarded to patient and emergency department clinician

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.

Morphological and hemodynamic patterns of carotid stenosis treated by endarterectomy with patch closure versus stenting: a duplex ultrasound study

OBJECTIVES: A duplex ultrasound study was performed to investigate morphological and hemodynamic patterns of carotid stenoses treated by endarterectomy with patch closure versus stenting. MATERIALS AND METHOD: Twenty-nine carotid stenoses were treated with stenting and 65 with patch closure. Duplex ultrasound parameters (luminal diameter, mm; peak systolic velocity and end-diastolic velocity, cm/s) were measured 24 hours after the procedures and also at 12 months post-procedure. Residual stenoses (immediately postprocedure) and restenoses (within 12 months of procedure) were defined as narrowings of >50 percent on duplex ultrasound examination. RESULTS: In stented patients, the luminal diameter of the proximal internal carotid artery increased in the interval between the 24-hour and 12-month post-procedure studies, while in the patch closure patients, the diameter decreased. Carotid hemodynamics normalized immediately after both patching and stenting and remained relatively stable thereafter up to 12 months. No statistically elevated flow velocities (in the absence of residual stenosis or restenosis) were observed in the patched or stented carotid arteries. No significant differences in residual stenosis rates were observed between the stenting group (3 cases, 10.34 percent) and the patch closure group (1 case, 1.53 percent, P = 0.08). At 12 months, 2 stenting patients (6.88 percent) and 2 patch closure patients (3.07 percent) had $50 percent restenosis (P = 0.58). One case of late stroke due to restenosis was observed in the stenting group; the patient died 12 months postoperatively, before receiving new intervention. CONCLUSION: Measurements over time in luminal diameter signalized differences in arterial remodeling mechanisms between patched and stented carotids. Both stenting and patch closure were associated with carotid patency and flow restoration. This study does not support a general approach to new velocity criteria indiscriminately applied to stented or patched carotids.

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.