Joaquim Maurício da Motta-Leal-Filho

Quality of Life and Clinical Symptom Improvement Support Prostatic Artery Embolization for Patients with Acute Urinary Retention Caused by Benign Prostatic Hyperplasia

PURPOSE To show that prostatic artery embolization (PAE) improves quality of life (QoL) and lower urinary tract symptoms in patients with acute urinary retention caused by benign prostatic hyperplasia (BPH). MATERIALS AND METHODS This was a single-center prospective study of PAE in 11 patients with BPH managed with indwelling urinary catheters. International Prostate Symptom Score (IPSS), ultrasound, magnetic resonance (MR) imaging, QoL, and urodynamic tests were used to assess outcomes. Prostate size ranged from 30 to 90 g, and embolizations were performed with 300-500-μm Embosphere microspheres. RESULTS The rate of technical success (ie, bilateral PAE) was 75%, and the rate of clinical success (ie, catheter removal and symptom improvement) was 91% (10 of 11 patients). Postembolization syndrome manifested as mild pain in the perineum, retropubic area, and/or urethra. Ten of 11 patients urinated spontaneously after Foley catheter removal 4-25 days after PAE (mean, 12.1 d). No major complications were observed. Follow-up ranged from 19 to 48 months. In an asymptomatic patient, a discrete area of hypoperfusion suggesting small ischemia of the bladder was observed on 30-day MR imaging follow-up, but the bladder was normal on 90-day MR imaging. After 1 year, mean prostate volume reduction was greater than 30%, symptoms were mild (mean IPSS, 2.8 ± 2.1; P = .04), no erectile dysfunction was observed, and QoL improved significantly (mean, 0.4 ± 0.5; P = .001) using the paired t test. CONCLUSIONS Patients with severe symptoms and acute urinary retention caused by BPH can be treated safely by PAE, which improves clinical symptoms and QoL.

Midterm Follow-Up After Prostate Embolization in Two Patients with Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is the most common benign neoplasm in men [1, 2]. Transurethral resection of the prostate (TURP) is still the ‘‘gold standard’’ surgical treatment for prostates. Due to the relative morbidity of TURP, minimally invasive techniques have been developed as alternatives for treatment for BPH, such as transurethral microwave thermotherapy and other laser ablations, but surgery (accomplished by transurethral or open means) constitutes the traditional treatment for BPH. Taking into account the patients’ comorbidities, surgical intervention in this age group may be considered high risk [3]. We report the radiological and clinical midterm follow-up of PAE in two patients with acute urinary retention due to BPH. Two patients with acute urinary retention due to BPH were selected for the study. Both patients were been previously described in this same journal in 2010 [4]. Prostatic artery embolization was performed under local anesthesia in both patients. One underwent bilateral embolization and the other had a unilateral embolization procedure. After PAE procedure, ultrasonography (US) and magnetic resonance imaging (MRI) were used for evaluation of effectiveness at 1, 3, 6, and 18 months. International prostate symptom score (IPSS), quality of life score (QUOL), and international index of erectile function score (IIEF) were evaluated until the last 24 month follow-up.

Variation of mechanical properties and quantitative proteomics of VSMC along the arterial tree

Vascular smooth muscle cells (VSMCs) are thought to assume a quiescent and homogeneous mechanical behavior after arterial tree development phase. However, VSMCs are known to be molecularly heterogeneous in other aspects and their mechanics may play a role in pathological situations. Our aim was to evaluate VSMCs from different arterial beds in terms of mechanics and proteomics, as well as investigate factors that may influence this phenotype. VSMCs obtained from seven arteries were studied using optical magnetic twisting cytometry (both in static state and after stretching) and shotgun proteomics. VSMC mechanical data were correlated with anatomical parameters and ultrastructural images of their vessels of origin. Femoral, renal, abdominal aorta, carotid, mammary, and thoracic aorta exhibited descending order of stiffness (G, P < 0.001). VSMC mechanical data correlated with the vessel percentage of elastin and amount of surrounding extracellular matrix (ECM), which decreased with the distance from the heart. After 48 h of stretching simulating regional blood flow of elastic arteries, VSMCs exhibited a reduction in basal rigidity. VSMCs from the thoracic aorta expressed a significantly higher amount of proteins related to cytoskeleton structure and organization vs. VSMCs from the femoral artery. VSMCs are heterogeneous in terms of mechanical properties and expression/organization of cytoskeleton proteins along the arterial tree. The mechanical phenotype correlates with the composition of ECM and can be modulated by cyclic stretching imposed on VSMCs by blood flow circumferential stress.

Long-term results of the percutaneous transhepatic venoplasty of portal vein stenoses after pediatric liver transplantation

Carnevale FC, de Tarso Machado A, Moreira AM, dos Santos ACB, da Motta‐Leal‐Filho JM, Suzuki L, Cerri GG, Tannuri U. Long‐term results of the percutaneous transhepatic venoplasty of portal vein stenoses after pediatric liver transplantation. 
Pediatr Transplantation 2011: 15: 476–481.

Evaluation and management of symptomatic isolated spontaneous celiac trunk dissection

The purpose of this study is to describe 10 cases of symptomatic isolated spontaneous celiac trunk dissection (ISCTD) in order to evaluate the initial clinical presentation, diagnosis, treatment modalities and outcomes. A retrospective search was performed from 2009 to 2014 and 10 patients with ISCTD were included in the study. Patients with associated aortic and/or other visceral artery dissection were excluded. The following information was collected from each case: sex, age, associated risk factors, symptoms, diagnostic method, anatomic dissection pattern, treatment modality and outcome. Most patients were male (90%), with an average age of 44.8 years, and the most common symptom was abdominal pain (100%). Hypertension and vasculitis (polyarteritis nodosa) were the most frequent risk factors (40% and 30%, respectively). Diagnosis was made in all patients with computed tomography. Dissection was limited to the celiac trunk in three patients and extended to celiac branches in the other seven. Initial conservative treatment was attempted in every case and was successful in nine patients. In one case, initial conservative treatment was unsuccessful and arterial stenting with coil embolization of the false lumen was performed. After successful initial treatment, late progression of the dissection to aneurysmal dilatation was observed in two patients and it was decided to perform endovascular treatment. Mean follow-up was 19 months, ranging from 2 to 59 months. In conclusion, initial conservative treatment seems adequate for most patients with ISCTD. Long-term follow-up is mandatory, owing to the risk of later progression to aneurysm.

Infection Related to Implantable Central Venous Access Devices in Cancer Patients: Epidemiology and Risk Factors

OBJECTIVE To describe the epidemiology of infections related to the use of implantable central venous access devices (CVADs) in cancer patients and to evaluate measures aimed at reducing the rates of such infections. DESIGN Prospective cohort study. SETTING Referral hospital for cancer in São Paulo, Brazil. PATIENTS We prospectively evaluated all implantable CVADs employed between January 2009 and December 2011. Inpatients and outpatients were followed until catheter removal, transfer to another facility, or death. METHODS Outcome measures were bloodstream infection and pocket infection. We also evaluated the effects that the creation of a multidisciplinary team for CVAD care, avoiding in-hospital implantation of CVADs, and limiting CVAD insertion in neutropenic patients have on the rates of such infections. RESULTS During the study period, 966 CVADs (mostly venous ports) were implanted in 933 patients, for a combined total of 243,792 catheter-days. We identified 184 episodes of infection: 154 (84%) were bloodstream infections, 21 (11%) were pocket infections, and 9 (5%) were surgical site infections. During the study period, the rate of CVAD-related infection dropped from 2.2 to 0.24 per 1,000 catheter-days ([Formula: see text]). Multivariate analysis revealed that relevant risk factors for such infection include surgical reintervention, implantation in a neutropenic patient, in-hospital implantation, use of a cuffed catheter, and nonchemotherapy indication for catheter use. CONCLUSIONS Establishing a multidisciplinary team specifically focused on CVAD care, together with systematic reporting of infections, appears to reduce the rates of infection related to the use of these devices.

Totally Implantable Venous Catheters: Insertion via Internal Jugular Vein with Pocket Implantation in the Arm is an Alternative for Diseased Thoracic Walls:

Purpose Insertion of totally implantable catheters via deep vessels that drain into the superior vena cava results in a lower incidence of venous thrombosis and infection as compared to catheters inserted into femoral and arm veins. Superior vena cava obstruction and inadequacy of the thoracic wall are conditions that prevent reservoir implantation in the chest wall. In this article, we describe a technical innovation that enables the pocket to be fixed in the arm while still allowing access to be achieved via the internal jugular vein. Method The procedure reported maintains the use of the internal jugular vein for access even when the patients chest is not suited for reservoir implantation, which is localized in the arm. Results The procedure was successful and no complications occurred. The position of the catheter tip did not alter with arm movement. Conclusion The implantation of a port reservoir in the arm following venous access via the internal jugular vein is both safe and convenient.

Vascular smooth muscle cells exhibit a progressive loss of rigidity with serial culture passaging

One drawback of in vitro cell culturing is the dedifferentiation process that cells experience. Smooth muscle cells (SMC) also change molecularly and morphologically with long term culture. The main objective of this study was to evaluate if culture passages interfere in vascular SMC mechanical behavior. SMC were obtained from five different porcine arterial beds. Optical magnetic twisting cytometry (OMTC) was used to characterize mechanically vascular SMC from different cultures in distinct passages and confocal microscopy/western blotting, to evaluate cytoskeleton and extracellular matrix proteins. We found that vascular SMC rigidity or viscoelastic complex modulus (G) decreases with progression of passages. A statistically significant negative correlation between G and passage was found in four of our five cultures studied. Phalloidin-stained SMC from higher passages exhibited lower mean signal intensity per cell (confocal microscopy) and quantitative western blotting analysis showed a decrease in collagen I content throughout passages. We concluded that vascular SMC progressively lose their stiffness with serial culture passaging. Thus, limiting the number of passages is essential for any experiment measuring viscoelastic properties of SMC in culture.

Acesso venoso trans-hepático percutâneo para hemodiálise: uma alternativa para pacientes portadores de insuficiência renal crônica

BACKGROUND: Percutaneous transhepatic venous access is an option for hemodialysis patients who have exhausted all traditional sites of venous access. OBJECTIVES: To present a small sample regarding the possibility and the functionality of transhepatic implantation of long-term catheters for hemodialysis in patients with no other possible access routes. METHODS: Retrospective observational analysis was made of the charts of six patients in which nine tunneled dialysis catheters were implanted by the percutaneous transhepatic route. Transhepatic catheters were placed in the absence of an available peripheral venous site. Patients were monitored to evaluate technical success, the complication rate, the infection rate and the duration of catheter patency. RESULTS: Four men and two women aged 31 to 85 years (mean age: 55 years). Technical success was 100%. The mean duration of catheter function was 300.5 days (range: 2 to 814 days). Means of primary and secondary patency were 179.60 and 328.33 days, respectively. The catheter thrombosis rate was 0.05 per 100 catheter-days as the infection rate. There were three early complications (within the first 30 days of catheter implantation): two catheter displacement and one infection. Two late complications were observed: one thrombosis and one migration. Three patients (50%) needed to have their catheters changed. The 30-day mortality rate was 33% but with no relation to the procedure. CONCLUSION: It may be suggested that this technique is safe, however transhepatic hemodialysis catheters may be used in patients with no other options for deep venous access for hemodialysis, albeit as a last resort access route.

Catheter‐based induction of renal ischemia/reperfusion in swine: description of an experimental model

Several techniques to induce renal ischemia have been proposed: clamp, PVA particles, and catheter‐balloon. We report the development of a controlled, single‐insult model of unilateral renal ischemia/reperfusion (I/R) without contralateral nephrectomy, using a suitable model, the pig. This is a balloon‐catheter‐based model using a percutaneous, interventional radiology procedure. One angioplasty balloon‐catheter was placed into the right renal artery and inflated for 120 min and reperfusion over 24 h. Serial serums were sampled from the inferior vena cava and urine was directly sampled from the bladder throughout the experiment, and both kidneys were excised after 24 h of reperfusion. Analyses of renal structure and function were performed by hematoxylin–eosin/periodic Acid‐Schiff, serum creatinine (SCr), blood urea nitrogen (BUN), fractional excretion of ions, and glucose, SDS‐PAGE analysis of urinary proteins, and serum neutrophil gelatinase‐associated lipocalin (NGAL). Total nitrated protein was quantified to characterize oxidative stress. Acute tubular necrosis (ATN) was identified in every animal, but only two animals showed levels of SCr above 150% of baseline values. As expected, I/R increased SCr and BUN. Fractional sodium, potassium, chloride, and bicarbonate excretion were modulated during ischemia. Serum‐nitrated proteins and NGAL had two profiles: decreased with ischemia and increased after reperfusion. This decline was associated with increased protein excretion during ischemia and early reperfusion. Altogether, these data show that the renal I/R model can be performed by percutaneous approach in the swine model. This is a suitable translational model to study new early renal ischemic biomarkers and pathophysiological mechanisms in renal ischemia.