Igor Rafael Sincos

Hemoperitoneum in a Cirrhotic Patient Due to Rupture of Retroperitoneal Varix

The rupture of retroperitoneal varices is a rare and catastrophic complication of portal hypertension. We describe a case of this nature, the first in Brazilian medical literature, and also reviewing all previous 34 cases. We systematically analyzed all therapeutic approach and propose a management algorithm for diagnosis and treatment of this lethal condition. The majority of the patients presented with abdominal pain, distention and hypotension, and developed hemorrhagic shock. Rupture of retroperitoneal varices can be properly managed if an early diagnosis is made and surgery is performed promptly, which is the only effective treatment. Arteriography should be used when the suspicion is of rupture of hepatocellular carcinoma.

Impact of stent-graft oversizing on the thoracic aorta: experimental study in a porcine model.

Purpose To analyze in an experimental animal model the effect of 4 different levels of stents-graft oversizing on non-atherosclerotic aortas such as those found in young individuals who undergo stent-graft repair for traumatic aortic injuries. Methods The diameter of the porcine thoracic aorta is similar to the aorta of young adults (18–20 mm), so 25 pigs were randomized into 5 groups: 1 control (without stent-graft) and 4 oversizing groups (A: 10%–19%, B: 20%–29%, C: 30%–39%, and D: >40%). Two types of biomechanical tests were performed on all aortas 4 weeks after endoprosthesis deployment. Results The results of the detachment test, which analyzed the strength necessary to remove the stent-graft from the aorta, were similar in the 4 groups (A: 42 N, B: 41 N, C: 46 N, and D: 46 N). However, 2 aortas ruptured during the tests (groups C and D). The second test was performed in 3 aortic segments. Maximum shear strength, maximum stress, and maximum tension supported by the aortic wall had a negative and linear correlation with oversizing. There were significant differences in all 4 groups when compared with the control group. Strain, which reflects the elastic properties of the aortic wall, was very similar in all 4 groups, but a great difference was found when compared with the control group (p<0.0001). Conclusion The study showed an important subacute change in the biomechanical properties of the aortic wall after implantation of an oversized endoprosthesis. This weakness of the aortic wall was confirmed by 2 ruptures during the detachment test. These results partially explain the interaction of stent-grafts with non-atherosclerotic thoracic aortas and may serve as a basis for further studies and the development of specific material to be used in vascular trauma and young patients.

Endovascular treatment of peripheral arterial injury with covered stents: an experimental study in pigs

OBJECTIVE: To evaluate the feasibility of using endovascular repair to treat penetrating arterial injuries with covered stents. Feasibility was examined according to the circumferential extent of the injury. INTRODUCTION: Surgical trauma often increases the risk of major morbidity and mortality associated with vascular injury, and endovascular repair has many advantages in such situations. METHODS: Twenty white male domestic pigs weighing 28-38 kg with controlled vascular injuries were divided into four equal groups according to the circumferential extent of their vascular lesion (i.e., no lesion, lesion <50%, lesion >50%, and complete lesion). The left common carotid artery was dissected with proximal and distal control, and this procedure was followed by controlled sectioning of the arterial wall. Local manual compression was applied for 10 min and was followed by endovascular repair with the placement of a 5×50 mm VIABHANTM covered stent using the femoral approach. We also monitored additional variables, such as the duration of the procedures (the mean was 56.3±19.1 min), ultrasound parameters (e.g., maximum arterial diameter, peak systolic and diastolic velocity, and resistance index), arteriography findings, and fluctuations in vital signs (e.g., cardiac output, arterial pressure, and central venous pressure). RESULTS: The experimental procedure was found to be feasible and reproducible. Repairs were successful in all animals in the control (no lesion) and <50% lesion groups. Success was also achieved in four out of five pigs in the >50% group and in one pig in the complete lesion group. DISCUSSION: The endovascular repair of an arterial injury is possible, but success depends on the circumferential extent of the arterial lesion. The present experimental model, which involved endovascular techniques, highlighted important factors that must be considered in future studies involving similar animals and materials.

Endovascular and open repair for blunt aortic injury, treated in one clinical institution in Brazil: a case series

OBJECTIVE The objective of this retrospective study is to analyze and compare the results of conventional surgical repair and endovascular treatment of blunt aortic injury over the past 8 years. METHODS Twenty-eight patients (25 male; mean age, 35 years) were treated for blunt aortic injury between April 2001 and March 2009 in a university hospital in Brazil. Twenty-six patients were included in the study: five were treated with operative repair (OR) and 21 with endovascular treatment (TEVAR). Two patients were excluded from analysis: one was managed conservatively, and one was treated with endovascular treatment for chronic dissection related to aortic trauma. RESULTS Mean age was lower in the OR group than in the endovascular treatment group (17.8 vs. 38 years, P = .003). There was one death in the OR group and four deaths in the endovascular treatment group. Mean follow-up for the overall group was 33.6 months, with 48.7 months (range 8-83 months) for the OR group, and 29.8 months (range 2-91 months) for the TEVAR group. Mean time elapsed from injury to repair was 23.4 hours (range 8-48 h, median 20 h) for the OR group and 30.3 hours (range 2-240 h, median 18 h) for the TEVAR group (P = .374). The duration of surgery was shorter in the endovascular treatment group (142 versus 237 minutes; P = .005). There were no significant differences with respect to the number of postoperative days requiring mechanical ventilation, duration of ICU stay or duration of hospital stay. CONCLUSION In this retrospective analysis, endovascular treatment was a safe method for repair of blunt aortic trauma, with immediate and midterm results that were comparable to those results obtained with operative repair. No complications from the stent graft were identified during follow-up. Nevertheless, long-term follow-up is necessary to confirm the effectiveness of this treatment.

Veno-active drugs for chronic venous disease: A randomized, double-blind, placebo-controlled parallel-design trial

Introduction: Our current understanding of the pathophysiology of chronic venous disease (CVD) suggests that veno-active drugs (VAD) can provide effective symptom relief. Few studies have conducted head-to-head comparisons of VAD and placebo while also assessing objective measures (such as water plethysmography findings and tibiotarsal joint range of motion) and patient-reported quality of life outcomes. Objectives: To compare the effects of different VAD on limb volume reduction, tibiotarsal range of motion, and quality of life. Methods: 136 patients with CVD (CEAP grades 2–5) were randomly allocated into four groups to receive micronized diosmin + hesperidin, aminaphthone, coumarin + troxerutin, or placebo (starch). Patients were administered a questionnaire consisting of a quality of life (QoL) measure designed specifically for persons with CVD, and underwent tibiotarsal joint angle measurement and water plethysmography of the lower extremity before and 30 days after pharmacological intervention. Assessors were blind to the treatment groups. Results: Nine patients dropped out of the trial. Data collected from the 127 remaining patients was considered for statistical analysis. There were no differences in tibiotarsal joint range of motion. Volume reductions ≥100 mL were more frequent in the diosmin + hesperidin group than in any other group. QoL scores were best in the aminaphthone group, and between-group differences were found on individual analysis of questionnaire items. Conclusions: Use of VAD was associated with significant improvements in QoL as compared with placebo. VAD may be effective for providing symptom relief in patients with CVD.

Chronic thrombosed abdominal aortic aneurysms: a report on three consecutive cases and literature review

Case 1: A 71-year-old man entered our emergency department presenting with abdominal pain that had lasted for six months and had worsened in the last week. His past medical history revealed hypertension, tabagism, dyslipidemia and epilepsy. His left lower leg was amputated 11 years earlier, after an accident with chemicals; the right lower leg of the patient was also amputated after an episode of acute ischemia six years before that date. His physical examination revealed a painful, palpable pulsatile mass extending from the mesogastrium to the infraumbilical area. There was no femoral pulse, but the stumps and buttocks had a normal temperature. An abdominal computed tomography (CT) scan revealed a thrombosed infra-renal aneurysm with a maximum transverse diameter of 10.5 cm (Pictures 1 and 2).After cardiac evaluation, an elective laparotomy was performed. The surgery revealed an inflammatory aortic aneurysm with clearly visible local wall necrosis (Picture 3). After clamping the aorta, the aneurysm sac was incised, releasing a great volume of thrombosed and liquefied clots under significant pressure. The aorta and both iliac common arteries were sutured, and no bypass was performed. The postoperative course was unremarkable, and the patient was sent home on the sixth postoperative day. He continued with ambulatory consultations. On the 40th postoperative day, the patient returned to the emergency room in a septic state with abdominal pain, ascites and circulatory shock. The patient expired in the emergency room before surgery could be performed, despite aggressive attempts to resuscitate him. The post mortem examination revealed diffused peritonitis as a consequence of mesenteric ischemia and perforation of the small intestine, associated with pancreatitis. There was neither an aortic stump blow-out nor a colon ischemia.

Tratamento endovascular de aneurismas da aorta em pacientes com doença de Behçet: relato de dois casos

Behcets disease, a systemic vasculitis of unknown etiology, may be the cause of aortic aneurysmal diseases in some patients. We report our experience with two Behcets disease patients who presented with aortic aneurysms and were submitted to endovascular therapy, and describe their respective follow-ups. Current pathophysiology, diagnosis, and treatment approaches were reviewed. Our experience suggests that the endovascular approach, combined with adequate immunosuppressive treatment, is an excellent therapeutic option for some patients with Behcets disease suffering from aneurysms.

Tratamento da úlcera varicosa dos membros inferiores mediante cirurgia e bota de Unna: uma economia para o sistema de saúde brasileiro

Objective: To perform an analysis of the costs of treatment of varicose ulcers by radical surgery of varices and the use of Unna boot. Methods: Fifteen outpatients were selected to receive treatment of varicose ulcers with radical surgery and Unna boot. The total cost of treatment was calculated (hospitalization, surgery, dressings, and outpatient?s follow-up visits) and compared to the cost of clinical follow-up with daily simple dressing changes. Results: The proposed treatment was on average 55.71% more economical than the management with daily dressings (approximately US

Coral reef aorta, emergency surgical: case report and literature review

452.32 versus US

Angioplasty of a persistent sciatic artery: case report

1,021.39). Conclusion: Radical varicose vein surgery associated with the useof the Unna boot proved meaningly less expensive for the public health system than clinical follow-up with daily dressings. Objetivo: Realizar uma analise de custo do tratamento da ulcera varicosa mediante cirurgia radical de varizes e uso de bota de Unna. Metodos: quinze pacientes foram selecionados ambulatorialmente para receber o tratamento da ulcera varicosa com cirurgia radical de varizes e bota de Unna, sendo o custo total do tratamento contabilizado (internacao, cirurgia, curativos e retornos ambulatoriais) e comparado ao custo do acompanhamento clinico com curativos simples trocados diariamente. Resultados: O tratamento proposto foi em media 55,71% mais economico que o manejo com curativos diarios (R