Jorge Eduardo de Amorim

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.

Eficácia clínica da revascularização renal percutânea com implante de stent em pacientes com doença renovascular aterosclerótica

OBJECTIVE To evaluate the clinical efficacy of percutaneous renal revascularization with stenting to control hypertension and preserve/restore renal function in patients with atherosclerotic renovascular disease. METHODS From May/1999 to October/2003, 46 patients with atherosclerotic renal artery stenosis (ARAS) underwent revascularization with stenting. The indication for the procedure was hypertension control and/or renal function preservation/restoration. Clinical characteristics: age range: 33-84 years (median = 58.5 +/-10.7), males: 26 (56.5%), 4 (10%) patients with diabetes mellitus, 21 (46%) patients with coronary artery disease, creatinine <2.0mg/dl: 39 (64%), 6 patients (14%) with congestive heart failure, 20 (43%) patients with ostial stenosis and 15 (33%) patients with bilateral stenosis. Hypertension control was evaluated by the number of drugs used before the procedure and at follow-up (FU) and by blood pressure (BP) measurement. RESULTS The minimum follow-up was 7 months (range of 7-52, median: 23, mean: 24.2 +/- 15.2). There were no major complications. No patient experience any cardiovascular event. There was only one non-cadiac death (2%) and one technical failure in the treatment(2%). There was no serious complication in the procedure. None of the patients presented cardiovascular events. The renal function improved or stabilized in 32 patients (82%) and worsened in 4 (10%). The BP control improved in 19/44 (43,8%) patients and worsened / stabilized in 6 patients (14%). CONCLUSION Angioplasty with renal artery stenting for ARAS showed to be an effective treatment strategy to restore and preserve renal function and to control blood pressure.

Gestação e varizes de membros inferiores: prevalência e fatores de risco

Background: During and after pregnancy, lower limb varicose disease presents specific features that have influenced the conduction of studies designed to provide a better understanding of the condition. Such features include the appearance of lower limb varicose veins, their early development and intensity, and their rapid regression after delivery. Objective: To assess the prevalence of lower limb varicose disease during pregnancy and to identify the main associated risk factors. Prevalence of varicose disease during pregnancy is high, affecting almost 70% of pregnant women considering all types of varicose disease. This high prevalence is mainly caused by the increase in the estrogen and progesterone levels during pregnancy. Material and method: We analyzed 352 pregnant women during prenatal follow-up. The subjects were randomly selected during a 14-month period. Varicose disease was clinically identified and classified according to Widmers criteria: trunk varicose veins, reticular varicose veins, and telangiectasias; being reclassified according to the criteria of the CEAP clinical classification. The results of prevalence and risk factors were statistically analyzed using univariate and multivariate analyses. Results: Considering all types of varicose veins, prevalence of varicose disease was 72.7% (256 pregnant women). Only 27.3% (96) of pregnant women did not have varicose disease (C0), and this group was considered the control group. After multivariate analysis, the main risk factors were: family history and pregnant womens age. Conclusion: The high prevalence of varicose disease and the associated risk factors suggest the need of providing the health professionals involved in womens health care, especially during the fertile period, with information on this disease.

Endovascular Stenting of Brachial Artery Occlusion in Critical Hand Ischemia

Critical upper limb ischemia caused by atherosclerosis is uncommon. Endovascular treatment, with angioplasty or stenting, has been successfully performed for subclavian and below the elbow diseases; however, theres a lack of report regarding the treatment of brachial artery disease causing critical hand ischemia. In this article, we describe the treatment of a brachial artery occlusion with endovascular stenting in a patient with chronic upper limb ischemia.

Dissecção espontânea do tronco celíaco: qual a melhor abordagem terapêutica?

A disseccao espontânea das arterias viscerais e um evento relativamente raro. Dor abdominal subita no epigastrio e o sintoma mais frequentemente manifestado pelos pacientes. O avanco das tecnicas de exames de imagem possibilitou o diagnostico deste evento com maior facilidade, aumentando a incidencia das disseccoes das arterias viscerais. O tratamento clinico conservador, a revascularizacao cirurgica, e a terapia endovascular sao as tres possiveis opcoes terapeuticas. Neste artigo, relatamos os casos de dois pacientes com disseccao espontânea do tronco celiaco conduzidos de formas diversas, de acordo com a apresentacao clinica e exames de imagem, alem de realizar uma revisao bibliografica sobre esta doenca.

Avaliação da ocorrência do refluxo venoso da safena magna pela ultrassonografia com doppler colorido após tratamento cirúrgico da insuficiência da junção safeno-femoral

OBJECTIVE To evaluate the occurrence of reflux from the great saphenous vein by color Doppler ultrasonography in subjects undergoing treatment of insufficiency of the saphenofemoral junction by simple ligation or ligation with section of the saphenous arch. METHODS We performed 60 operations (in 45 subjects) of varicose insufficiency of the saphenofemoral junction (SFJ), belonging to the CEAP clinical classification of 2-5, who were randomly divided into two groups. A group called C, with ligature and section of the saphenous arch, and a group called L, with simple ligation of the saphenous vein and no sectioning of its arch. We then investigated the occurrence of reflux from the great saphenous vein in groups C and L through postoperative color Doppler ultrasonography at intervals of six months to one year. RESULTS Of the 60 members submitted to the approach of the saphenous arch, 57 were evaluated by postoperative doppler ultrasound, since two subjects (three limbs) did not return and were excluded from the study. The mean age was 54 years, with 93% females and predominance of CEAP classification 2 in 60.5%. Of the 57 operations for the treatment of reflux of the saphenous arch, 43.9% had reflux postoperatively,14.1% in group C and 29.8% in group L (p < 0,05). The relative risk of reflux of the saphenous arch in group L was 2.03 times higher compared with group C. CONCLUSION the section of the arch of the great saphenous vein causes less postoperative reflux than simple ligation in treatment of insufficiency of the great saphenous vein.

Contribuicao da quimioembolizacao de hepatocarcinomas em pacientes cirroticos na espera pelo transplante hepatico

OBJECTIVE: To evaluate the results of hepatocellular carcinoma arterial chemoembolization in cirrhotic patients awaiting liver transplantation. MATERIALS AND METHODS: Twenty-three cirrhotic patients with hepatocellular carcinoma awaiting liver transplantation were submitted to multiple sessions of chemoembolization using mitomycin C and lipiodol. A prospective evaluation of the following factors was performed: a) serum levels of alpha-fetoprotein; b) tumor size; c) maintenance of the viability criteria for hepatic transplantation; d) degree of liver dysfunction. RESULTS: The mean serum levels of alpha-fetoprotein were reduced by 43% during the first 13 months. The mean tumor size, as measured by the long axis, after a mean follow-up period of 13.5 months was 3.2 cm, which is considered stable for the period according to the World Health Organization criteria. The mean survival rate was 14 months. CONCLUSION: In this trial, pre-transplantation use of chemoembolization in combination with an adequately chosen therapy showed few complications and contra-indications as well as a considerable anti-tumor efficacy. Despite the fact that the adopted therapy increased survival rates in comparison to historical evolution data in hepatocellular carcinoma, this increase had not the same dimension if the median waiting time for transplantation is taken into consideration. Therefore, other strategies need to be associated to either make survival rate longer or to reduce transplantation waiting time.

Popliteal Artery Entrapment Syndrome: A Case Report and Review of the Literature

Patient: Female, 47 Final Diagnosis: Popliteal artery entrapment syndrome Symptoms: Thermal gradient • limb pain Medication: — Clinical Procedure: Supra-genicular popliteal derivation – infragenicular popliteal with inverted parenial saphenous vein graft Specialty: Surgery Objective: Rare disease Background: Popliteal artery entrapment syndrome (PAES) results from an anomalous relationship between the popliteal artery and the myofascial structures of the popliteal fossa. The most common presenting symptoms include intermittent pain in the feet and calves on exercise, resulting in lameness. PAES can lead to popliteal artery thrombosis, stenosis, distal arterial thromboembolism, or arterial aneurysm. The treatment of PAES includes surgical exploration with fasciotomy, myotomy, or sectioning of fibrous band formation, to release the popliteal artery. However, in cases with thrombotic occlusion, thromboendarterectomy with venous patch arterioplasty, or venous graft arterial bypass surgery may be required. This report describes the presentation and surgical management of a case of PAES presenting with limb pain and includes a review of the literature on this condition. Case Report: A previously healthy 47-year-old woman presented with a 20-day history of sudden pain in the left lower limb, associated with pallor and a loss of arterial pulses below the knee. Angiography of the affected limb showed occlusion of the left supragenicular popliteal artery, with arterial occlusion, suggestive of arterial thrombus. Imaging of the right popliteal artery, which was not occluded, showed that it was medially deviated. An ipsilateral saphenous vein graft was used to bypass the left supragenicular popliteal artery to the infragenicular popliteal artery, resulting in resolution of the patient’s symptoms. Conclusions: PAES is rare and can be under-diagnosed, possibly due to lack of knowledge of this condition. However, if the diagnosis is made early, the prognosis is usually favorable, following appropriate surgical treatment.

Spontaneous carotid dissection

Carotid dissection is a rare occurrence but it is the main cause of stroke in individuals aged less than 45 years, and can be the etiology in up to 25% of strokes in young adults. We report a case with classic image of ying yang on vascular ultrasound, which was treated according to the best available medical evidence, yielding a favorable outcome.

Response to correspondence regarding ‘Evaluation and management of symptomatic isolated spontaneous celiac trunk dissection’ by Galastri et al.

We appreciate the letter to the editor regarding our study. Isolated spontaneous celiac trunk dissection (ISCTD) is an uncommon disease. Owing to the wider use of computed tomography for evaluation of abdominal pain, diagnosis is increasing in recent years.1,2 The rarity and unpredictable occurrence of ISCTD makes prospective studies unfeasible. The current available literature of symptomatic patients consists mainly of case reports and case series with fewer than 10 patients.2 For this reason, there is a lack of high quality evidence and management decisions are complex. In our study, we have proposed an objective and straightforward management algorithm for ISCTD.1 Recently, our group has also published a systematic literature review on ISCTD which reinforces the idea that conservative treatment should be preferred and that intervention (endovascular or open surgery) should be performed only in four situations: failure of conventional medical therapy, hemodynamic instability, visceral ischemia, or aneurysmal degeneration during the follow-up period.1,2 We believe that compression of the true lumen, associated with visceral ischemia, should be an indication for intervention; however, there is no consensus for the management of cases of severe stenosis without ischemia. Also, since two out of 10 patients in our series presented with aneurysmal dilatation after 6 and 44 months of conservative treatment, it is important to maintain close follow-up of these cases, as further intervention may be required. Declaration of conflicting interests