Gaudencio Espinosa

A 10-Year Single-Center Prospective Study of Endovascular Abdominal Aortic Aneurysm Repair with the Talent Stent-Graft

Purpose: To report a 10-year prospective study of patients submitted to endovascular treatment for infrarenal abdominal aortic aneurysms (AAA). Methods: Between June 1997 and June 2007, 337 patients (284 men; mean age 72.5±7.4 years, range 52–89) with AAA underwent endovascular aneurysm treatment (EVAR) with implantation of Talent stent-grafts. The mean AAA diameter was 59.0±14.4 mm. All patients were clinically followed using computed tomography in the immediate post surgery period (15–30 days), after 6 months, and yearly thereafter. Plain abdominal radiography was performed yearly to assess the metallic components of the stent-grafts. Data concerning endoleaks, secondary procedures, and aneurysm diameter behavior were evaluated. Survival was evaluated using Kaplan-Meier estimates. Results: Endoprosthesis implantations were successful in 99.1% (334/337). There were 2 surgical conversions, and the delivery system could not be inserted in 1 female patient. The perioperative mortality was 3.9% (n=13). Nineteen (5.7%) aneurysms showed endoleaks during the first 30 days (6 type I and 13 type II); 5 type I and 3 type II endoleaks were repaired (secondary clinical success of 92.6%). Another 15 late endoleaks were detected (4 type I, 5 type II, 3 type III, 1 type IV, 2 endotension), for a total of 34 (10.2%) endoleaks. Follow-up (mean 58.7 months, range 12–120) was available in 273 (81.0%) patients. During this time, there were 2 (0.7%) aneurysm ruptures, 1 due to type III endoleak and the other to endotension. Over the course of the study, 75 patients died; the estimated survival rates by the Kaplan-Meyer analysis were 67.3% after 5 years and 54.2% after 7 years. The mean AAA diameter decreased to 45.7±18.4 mm (p<0.001 versus mean postoperative diameter) at 60 months and to 37.8±15.0 mm at 120 months (p<0.019). Conclusion: Endovascular aneurysm treatment with the Talent stent-graft has proven to be effective in the prevention of AAA rupture into the long term.

Cavernous carotid artery pseudo-aneurysm treated by stenting in acromegalic patient

We report on a case of endovascular management of pseudoaneurysm of the cavernous segment of the internal carotid artery with covered stent reconstruction. A 36 years-old woman with a history of previous transsphenoidal approach for pituitary macroadenoma and false aneurysma formation was studied in a protocol that included balloon test occlusion and cerebral blood flow evaluation. An endovascular covered stent deployment in the area of the carotid laceration was performed with isolation of the aneurysm from the circulation and maintenance of the carotid flow. Helical angio-CT and cerebral digital subtraction angiography showed the carotid preservation without stenosis in the stented area. In conclusion, endovascular stent reconstruction for post-transsphenoidal carotid artery laceration and false aneurysm is demonstrated as useful technical adjunct in the management strategy and with the potential for carotid sacrifice morbidity avoidance.

Estudo comparativo da reação inflamatória renal entre álcool de polivinil - flocular e álcool de polivinil + acetato de polivinil - esférico: estudo experimental

BACKGROUND: To evaluate the characteristics and the effects of an embolic agent, available commercially, consisting of irregular - Polyvinyl Alcohol (PVA), and to compare with a spherical agent, of brazilian technology, consisting of Polyvinyl Alcohol and Polyvinyl Acetate (PVA + PVAc). METHODS: Renal arterial embolization was performed in females of New Zealand White rabbits. Irregular - PVA was used in 24 animals. Spherical - PVA+PVAc was used in 24 animals. Six animals were used as control. All animals were maintained in captivity until the euthanasia, after 48 hours, 5 days, 10 days and 30 days. RESULTS: Both agents resulted in vessel occlusion and organ infarction. The initial macroscopic study of the arteries embolized with irregular-PVA, the occluding plug consisted of thrombus and PVA. In vessels embolized with spherical-PVA+PVAc, the occluding plug consisted mostly of the embolic agent. After 30 days, there is absorption of the thrombus and retraction of the agents of PVA-irregular, creating spaces. With spherical-PVA+PVAc, it can be observed the agents surrounded by intense fibrosis. CONCLUSION: Both particles were effective to cause tissue ischemia. The inflammatory reaction was more intense with spherical-PVA+PVAc, besides presenting larger degree of penetration in the vascular system.

Endovascular treatment of carotid stenosis associated with incidental intracranial aneurysm.

The coexistence of internal carotid artery (ICA) stenosis and intracranial aneurysm, although uncommon, can be a therapeutic dilemma. We present a case of a 73-year-old woman with a history of arterial hypertension and diabetes who had a severe symptomatic ICA stenosis (>90%) and an incidental ipsilateral cerebral aneurysm. The carotid stenosis was treated with angioplasty and stenting using a distal cerebral protection system. The patient was anticoagulated and maintained on antiplatelet therapy according to a standard protocol. Microcoil embolization of the aneurysm was performed 5 months after an intracranial stent was implanted. No growth has been observed in the aneurysm of the arterial lumen since the carotid intervention. There were no complications after the procedures during the postoperative period. This case shows that the incidental presence of an ipsilateral intracranial aneurysm does not appear to be a contraindication for the endovascular treatment of a carotid artery stenosis.

Evaluation of ultrasound-guided femoral nerve block in endoluminal laser ablation of the greater saphenous vein.

BACKGROUND Endoluminal laser ablation has emerged as a new method for treating greater saphenous vein insufficiency. However, the procedure is not completely painless and requires applying tumescent anesthesia. The aim of this study was to evaluate the safety and efficacy of ultrasound-guided femoral nerve block in patients subjected to endoluminal laser ablation of the greater saphenous vein. METHODS Two consecutive groups of 25 patients subjected to ambulatory endoluminal laser ablation of the greater saphenous vein were analyzed in this study. Tumescent anesthesia only was applied in the first group. In the second group, before applying tumescent anesthesia, ultrasound-guided femoral nerve block was performed with 20 mL of 1% lidocaine. The pain during the application of tumescent anesthesia and vein ablation was evaluated by the patients using a 5-point scale. The heart rate and blood pressure was monitored during the procedures. The duration of the postprocedure stay in the recovery area was also recorded. The results were analyzed using statistical methods. RESULTS No complications associated with performing the femoral nerve block were observed. The pain associated with applying the tumescent anesthesia and that of performing the ablation was more intense in group 1 (p > 0.001). The volume of tumescent anesthesia solution was lower in group 2, 240 (±73) mL, compared to 399 (±137) mL in group 1, (p < 0.001). The group 2 patients had less hemodynamic changes during the procedure (p = 0.01). CONCLUSIONS In conclusion, ultrasound-guided femoral nerve block was shown to be a safe and effective option to decrease intraoperative discomforts associated with tumescent anesthesia and endoluminal laser ablation of the greater saphenous vein.

Renal Function in Patients Treated With Abdominal Aortic Stentgraft Implantation With an Intentional Occlusion of Accessory Renal Artery

BACKGROUND The purpose of this study was to analyze renal function in patients who underwent endovascular aneurysm repair with intentional occlusion of accessory renal artery (ARA). MATERIAL AND METHODS A prospective study of six patients with abdominal aortic aneurysm who underwent an abdominal stentgraft implantation with intentional occlusion of at least one ARA was performed. The mean age of the patients was 71 (53-84) years. None of the patients had an estimated glomerular filtration rate (according to Modification of Diet in Renal Disease equation 4) lower than 60 mL/min/m(2). Before the intervention, a possible influence of the occlusion of ARA was assessed with a renal scintigraphy and percentage value of a renal mass at risk. After the intervention, a control renal scintigraphy was performed, and percentage value of lost renal mass was determined. Data on the renal function before the intervention and 1, 3, 10, 30, and 90 days after the intervention were collected. RESULTS There were no deaths, and none of the patients required hemodialysis in the follow-up period. In an early postoperative period, five patients had pain in the lumbar region that ceased with analgesics. An increase of the serum creatinine concentration occurred between 24 and 72 hours after the procedure and, except for 1 patient, started to decrease thereafter. After 30 and 90 days, all the patients presented serum creatinine concentrations similar to the basal values. The mean value of renal mass at risk was 18.5% (13.5-26%), and the mean value of lost renal mass was 18.4% (9.6-22.5%). CONCLUSION The endovascular aneurysm repair with an intentional occlusion of ARA is a safe therapeutic option of treatment of abdominal aortic aneurysm in the patients without preexisting renal disease. The renal scintigraphy seems to be useful in determining loss of functional renal mass.

Complex paraclinoidal and giant cavernous aneurysms: importance of preoperative evaluation with temporary balloon occlusion test and SPECT

In the treatment of complex paraclinoidal and giant cavernous aneurysms, preservation of the patency of the internal carotid artery (ICA) is not always possible, and therapeutic occlusion of the carotid is still an important option for their management. A complete preoperative evaluation of the carotid reserve circulation, including the use of temporary balloon occlusion test and single photon emission computerized tomography (SPECT) should be included in the current paradigms of paraclinoidal and intracavernous aneurysms management. We present a series of fifteen patients with sixteen giant or complex carotid cavernous or ophthalmic aneurysms that were treated following a protocol for our preoperative decision-making analysis. Extracranial to intracranial saphenous vein bypass was reserved to the cases where carotid occlusion would be associated with high risk of ischemic complications and was performed in three patients. Besides the difficulties in dealing with those complex aneurysms, good clinical outcome was possible in our experience with the designed paradigm.

Increased Levels of Metalloproteinase 10 and Hemostatic Markers in Patients With Noncomplicated Primary Varicose Veins

The purpose of the study was to analyze a systemic activation of hemostasis and concentration of matrix metalloproteinase 10 (MMP-10) in patients with primary varicose veins (PVVs). A study group consisted of 41 patients with noncomplicated PVVs. A control group consisted of 30 age- and sex-matched healthy individuals without varicose veins. The concentration of d-dimers (DD), prothrombin fragments 1 and 2 (F1+2), antigen of von Willebrand factor (vWF), and activity of plasminogen activator inhibitor (PAI-1) in plasma and concentration of MMP-10 in serum were analyzed. In patients with PVVs, higher concentrations of DD (P < .001), F1+2 (P < .001), vWF (P = .027), MMP-10 (P = .006), and higher activity of PAI-1 (P < .001) were observed. However, no correlation between the concentrations of MMP-10 and prothrombotic markers was found. Noncomplicated PVVs are associated with systemic, prothrombotic activation of hemostasis and increased concentration of MMP-10, suggesting a prothrombotic and proinflammatory state.

Embolização intra-arterial pré-operatória de tumor do corpo carotídeo

Os autores relatam um caso de tumor de corpo carotideo (paraganglioma) em um paciente de 74 anos de idade, submetido a embolizacao intra-arterial com microparticulas esfericas, de polivinil acetato, com casca de polivinil alcool (PVAc + PVA), previamente a resseccao do tumor. O estudo angiografico demonstrou massa altamente vascularizada na bifurcacao carotidea esquerda, sendo a embolizacao pre-operatoria utilizada no intuito de diminuir a vascularizacao e reduzir a perda sanguinea, aumentando a seguranca do tratamento cirurgico. O estudo histopatologico confirmou a presenca de trombose e isquemia tecidual.

Embolização pré operatória de tumores renais com microparticulas esféricas de tecnologia nacional. (Spherus®-First line Brasil)

The authors report a brand new component for embolization composed by a polivinil acetate core and a polivinil-alcohol coat in a microspherical form ( Spherus®-First Line Brasil) used as preoperative management in three patients with renal tumors in an attempt to reduce the size of the tumors and to avoid hemorrhagic complications during the operations. This new component was developed in COPPE/UFRJ laboratories. The preoperative arterial embolization with this new component caused strong ischemia in the tumor tissue , facilitating the operative procedure.