Ana Terezinha Guillaumon

Tratamento endovascular do trauma arterial dos membros

Treatment of arterial traumatic injuries is usually performed with conventional revascularization techniques. However, vascular injuries can increasingly be repaired efficiently through minimally invasive procedures. We report four cases of extremity arterial trauma treated by endovascular techniques in a reference center. All patients showed satisfactory development over a 15-month follow-up. We suggest that endovascular therapy is a promising alternative to surgery for selected patients with extremity arterial trauma.

Aneurisma de artéria esplênica associado a uma variação anatômica na origem

O aneurisma de arteria esplenica foi descrito pela primeira vez por Beaussier em 1770, e o primeiro tratamento bem-sucedido foi apresentado por McLeod em 1940. O aneurisma da arteria esplenica e considerado o mais comum do territorio esplâncnico, afetando 46 a 60% dos doentes com aneurismas viscerais. A maioria dos doentes e assintomatica, e o achado do aneurisma de arteria esplenica costuma ser casual, durante a investigacao de outra doenca abdominal por imagem. Descrevemos o caso incomum de uma doente do sexo feminino, com 31 anos de idade, com um grande aneurisma de arteria esplenica que se originava da arteria mesenterica superior.

Dual gene transfer of fibroblast growth factor-2 and platelet derived growth factor-BB using plasmid deoxyribonucleic acid promotes effective angiogenesis and arteriogenesis in a rodent model of hindlimb ischemia

The protein infusion of basic fibroblast growth factor-2 (FGF-2) and platelet derived growth factor-BB (PDGF-BB) have been shown to promote the formation of a stable and functional vascular network in small and large animal models of ischemia. Here, we sought to determine whether a similar effect could be obtained using a gene-therapy-based strategy with nonviral vectors. Rats underwent a surgical procedure to create hindlimb ischemia and were injected with a combination of plasmids that expressed FGF-2 and PDGF-BB. Anatomical and functional parameters of the angiogenesis and arteriogenesis response were evaluated after 4 weeks. The results were compared with rats injected with plasmids that expressed a reporter gene or the extensively studied vascular endothelial growth factor (VEGF165) alone. Treatment with the FGF-2/PDGF-BB combination increased the angiogenesis and arteriogenesis response compared with the empty plasmid, and it was as effective as VEGF165. In terms of safety, the combination allowed the use of a 50% lower individual dose of each plasmid and in addition promoted the formation of more stable vessels than VEGF165. In conclusion, the dual gene transfer of FGF-2 and PDGF-BB using nonviral vectors is safe and effective in promoting the formation of a functional vascular network in a rodent model of hindlimb ischemia.

Carotid Stenting versus Endarterectomy Cognitive Outcomes

BACKGROUNDnThe objectives are to analyze the impact of carotid revascularization on cognitive performance after a 3-month period in patients, who have undergone carotid artery stenting (CAS) or carotid endarterectomy (CEA), and to compare the cognitive outcomes between these 2 groups of patients. This a nonrandomized and prospective single-center experience.nnnMETHODSnThis study was performed in the University of Campinas Hospital from January 2010 to January 2012 and included 30 patients with carotid stenosis who received carotid interventions. Nineteen patients received CEA and 11 patients received CAS. Neuropsychologic evaluation included general cognitive, language, visuospatial, attentional, executive function, and memory tests.nnnRESULTSnAfter the follow-up period, there was improvement in episodic memory, encoding subitem (P = 0.02), and delayed recall (P = 0.02) for the CEA group. The CAS group improved in episodic memory, encoding subitem (P = 0.009), working memory (P = 0.04), and executive functions (P = 0.02). Comparing the techniques, the CAS group showed higher scores only in executive functions (P = 0.02).nnnCONCLUSIONSnBoth groups had a similar performance in cognitive tests, comparing preoperative and postoperative results. However, patients who underwent CAS tended to achieve higher scores in executive function and operational memory/attention tests.

Plasmatic vasopressin in patients undergoing conventional infra-renal abdominal aorta aneurysm repair.

OBJECTIVESnTo evaluate plasmatic arginine vasopressin (AVP) levels in patients undergoing scheduled conventional abdominal aortic aneurysm (AAA) repair.nnnMETHODSnPlasmatic AVP concentrations were measured by radioimmunoassay in 22 non-consecutive adult patients undergoing infra-renal AAA repair. They were under combined general and epidural anesthesia at the following time frames: 1--pre-operative (T0); 2--2h (T1) and 6h (T2) after the surgical procedure; 3--in the morning at the first (T3), second (T4) and third (T5) post-operative days. Some clinical and laboratory variables were also recorded.nnnRESULTSnThe mean age of patients was 68 ± 10 years; 17 were males. Plasmatic AVP (mean ± SD; pg/mL) was within the normal range at T0 (1.4 ± 0.7; baseline), increasing significantly at T1 (62.6 ± 62.9; P<0.001) and at T2 (31.5 ± 49.7; P<0.001), with a progressive fall, returning to basal levels at T5 (2.1 ± 3.8; P = NS). Positive and statistically significant correlations were found between AVP and glycemia, serum lactate and white blood cells counts, but not with systemic arterial pressure or plasma osmolarity during the postoperative period.nnnCONCLUSIONSnConsidering that no correlations were found between AVP levels and hemodynamic or plasmatic osmolarity variations in AAA repair, it seems that stress response is mainly secondary to noxious stimulation mediated by the autonomic nervous system that is not completely blocked by anesthetics.Objectives: To evaluate plasmatic arginine vasopressin (AVP) levels in patients undergoing scheduled conventional abdominal aortic aneurysm (AAA) repair. Methods: Plasmatic AVP concentrations were measured by radioimmunoassay in 22 non-consecutive adult patients undergoing infra-renal AAA repair. They were under combined general and epidural anesthesia at the following time frames: 1 - pre-operative (T0); 2 - 2h (T1) and 6h (T2) after the surgical procedure; 3 - in the morning at the first (T3), second (T4) and third (T5) post-operative days. Some clinical and laboratory variables were also recorded. Results: The mean age of patients was 68±10 years; 17 were males. Plasmatic AVP (mean±SD; pg/mL) was within the normal range at T0 (1.4±0.7; baseline), increasing significantly at T1 (62.6±62.9; P<0.001) and at T2 (31.5±49.7; P<0.001), with a progressive fall, returning to basal levels at T5 (2.1±3.8; P=NS). Positive and statistically significant correlations were found between AVP and glycemia, serum lactate and white blood cells counts, but not with systemic arterial pressure or plasma osmolarity during the postoperative period. Conclusions: Considering that no correlations were found between AVP levels and hemodynamic or plasmatic osmolarity variations in AAA repair, it seems that stress

Early in vivo anticoagulation inhibits the angiogenic response following hindlimb ischemia in a rodent model

Emerging findings have demonstrated the critical role of blood clotting factors in the formation and stabilization of embryonic blood vessels. Whether a similar role is true during post-natal angiogenesis remains to be determined. Here we sought to determine whether the suppression of thrombin generation with anticoagulant drugs at doses routinely used for therapeutic purposes would affect the angiogenesis pattern following hindlimb ischemia in rats. Animals were treated with r-hirudin or enoxaparin within six hours post induction of hindlimb ischemia, whereas two other groups received oral anticoagulation warfarin beginning at day 3 post-ischemia or saline (as control). The revascularization anatomical and functional responses were evaluated 30 days following tissue ischemia. Chronic administration of the drugs resulted in stable anticoagulation in all animals throughout the experiment. Animals that received drugs with fast anticoagulation effects (i.e. r-hirudin and enoxaparin) presented a significant decrease in capillary density and capillary-to-myocyte ratio compared to control animals. These effects were not associated with changes in relative perfusion of the hindlimb at steady state. These anti-angiogenic effects occur in a time-dependent manner, since delayed inhibition of coagulation (>72 hours) presents no adverse effect on the angiogenic response. We conclude that the use of anticoagulant drugs immediately after tissue ischemia induction hampers in vivo angiogenic response in a rodent hindlimb ischemia model.

Avaliação carotídea em doentes submetidos a revascularização miocárdica

OBJETIVO: Como a doenca carotidea e a principal causa isolada de acidente vascular cerebral de origem tromboembolica, acredita-se ser imprescindivel o seu diagnostico precoce. O presente estudo tem por objetivo realiza-lo, mantendo os conceitos de praticidade e viabilidade economica, adequando-se as condicoes socioeconomicas desfavoraveis locais. METODO: No periodo de 18 meses foram avaliados 50 doentes, sendo 35 homens e 15 mulheres, com media de idade de 67,2 anos. Todos apresentavam indicacao de revascularizacao miocardica, considerados coronariopatas graves. Avaliou-se a incidencia e o grau de estenose carotidea com base no mapeamento duplex. Da mesma forma, foi avaliada a relacao com possiveis fatores de risco: diabetes melito, hipertensao arterial sistemica, tabagismo, sintomatologia neurologica focal previa, doenca arterial troncular dos membros inferiores e presenca de sopro carotideo. RESULTADOS: A incidencia de estenose carotidea hemodinamicamente significativa (>50%) foi de 48%, e critica (>70%) de 32%. Mostraram-se fatores de risco estatisticamente significativos, antecedentes de diabetes melito, sintomatologia neurologica focal previa, presenca de sopro carotideo e presenca de alteracoes arteriais tronculares dos membros inferiores. CONCLUSAO: Concluiu-se que no grupo estudado houve aumento significativo de risco para estenose carotidea hemodinamicamente significativa e critica, em relacao a populacao geral. Desta forma, justifica-se o rastreamento ultra-sonografico para doenca carotidea em doentes coronariopatas, principalmente quando os fatores de risco significativos se fizerem presentes.

Thoracoabdominal aneurysm rupture: a modification of the visceral perfusion circuit

A patient with ruptured type IV thoracoabdominal aortic aneurysm (TAAA), underwent surgical treatment utilizing visceral perfusion assisted by a centrifugal pump and neonatal membrane oxygenator. This circuit allows visceral perfusion with oxygenated blood during the ischemic period and the fast infusion of intravenous volume after clamp removal.

Efficacy Analysis of a Script-based Guide for EVAR Execution: is it Possible to Reduce Patient Exposure to Contrast, Operative Time and Blood Loss even when Advanced Technologies are not Available?

INTRODUCTION Despite the patient and medical staff exposure to radiation in endovascular aneurysm repair, the benefits of this abdominal aortic aneurysm type of surgical management are justfied by minor recovery time and hospitalization, as well as an option for patients not elected to conventional open repair. In this minimally invasive surgical aproach, time of procedure and radiation doses can be substantial - and the increasing frequency of these procedures and its complexity have impelled vascular surgeons to face additional and successive risk to occupational radiation exposure. Meticulous study of the computed tomography angiography during the endovascular aneurysm repair preparation allows reduction of unnecessary radiation exposure, as also reduces consecutive image acquisition and contrast use (that may be related to renal overload in susceptible patients). Some studies have proposed strategies to optimize endovascular intervention to reduce contrast use and X-ray exposure. Although they might prove to be effective, they rely on use of additional specific and advanced equipment, available only in major centers. As an alternative to this expensive and restrict technology, it is presented a simpler technique through image manipulation on software OsiriX, aiming to reduce both exposures. OBJECTIVE To analyze the efficacy of the adoption of a study protocol and a script-based guide in preparation for endovascular aneurysm repair through verifying its impact over the surgical procedure - as referred to intravascular contrast infuse, effects over renal function, blood loss and operatory time. METHODS A longitudinal prospective study from March 2014 through March 2015, where 30 performed endovascular aneurysm repair were compared to a historic control group. The planning for endovascular aneurysm repair through the patients tomographic image manipulation in the prospective group was performed with OsiriX MD software. A script-based guide upon gathering detailed computed tomography angiography images was elaborated by the author and distributed to the performing surgical team for appreciation, instruction and pre operatory judgment. Based upon the script, the C-arm gantry angle was specifically corrected in each case of endovascular aneurysm repair, for image optimization and aneurysms neck visualization. Arteriography was performed under digital subtraction angiography after catheters were positioned according to predicted level description in the referred guide. Statistical analysis were performed with a significance level of 5% (P value<0.05). RESULTS There was a statistically significant relationship between the two studied periods and the variables: contrast volume (284.5 vs. 31.8 mL), operative time (207.5 vs. 140.4 min.) and blood loss (798.1 vs. 204.4 mL), revealing that they are considerably larger in the historical control group than in the script guided current group. There was no difference related to the volume of contrast used in the two groups and the occurrence of renal impairment. CONCLUSION In the present paper it was possible to demonstrate the impact of the ability to manipulate digital formats of medical images without the need of sophisticated equipment, in adoption of a guide based on the compilation of informations collected with assistance of an accessible software performed on a personal computer. Although we could not prove relation to occurrence of renal impairment, there were direct results on reduction of intravascular contrast use, even as surgical time and blood loss, compared to a previous historical period.

Proposta de correção virtual geométrica da projeção ostial da artéria renal no estudo operatório de aneurismas infrarrenais: resultados iniciais de um estudo piloto

Introduction Endovascular aneurysm repair requires the precise deployment of the graft. In order to achieve accurate positioning, the anatomical and morphological characteristics of the aorta and its branches is mandatory. Software that perform three dimensional reformatting of multislice tomographic images, allow for the study of the whole aorto-iliac axis and the perpendicular visualization of the origin of the renal arteries. The correct length of the proximal neck can be evaluated and adequate graft fixation and sealing may be foreseen. A technique is presented, using an software, for the orthogonal correction of the position of the renal arteries in relation to the proximal neck, which may guide the radioscopic orientation intraoperatively. Methods Within a multiplanar tomographic image reconstruction, virtual triangulation allows for the three dimensional orthogonal correction of the renal arteries ostia position. The predetermined best angulations for visualization are annotated and used for the positioning of the surgical C-arm. Results/Discussion Some authors discuss that the anatomic position of the renal vessels seen on the tomographic scan can change during the surgical procedure. It is known that the renal arterys angular positioning does not alter, even after insertion of stiff guidewires, introducers, and the endograft itself. Therefore, it is possible, using concepts of spacial geometry and orthogonal correction, to predict the ideal bidimensional intraoperative positioning of the radioscopy device in order to reproduce the optimized renal artery ostial projection, ensuring the best accuracy during endograft deployment. Conclusion As closer to the tomographic reproduction was the radioscopic correction, more careful is the visualization of the ostium of the renal artery, better is the exploitation of the lap for fixing and sealing and the endoprosthesis deployment is more accurate.