Marcelo Calil Burihan

Trauma vascular na população pediátrica

BACKGROUND: Vascular trauma in the pediatric population is a unique challenge, mainly due to its relatively low incidence, even in high complexity medical centers. Due to the fragility of the tissues, the small size of vessels and low incidence, it manifests with significant rates of morbidity and mortality. OBJECTIVE: To describe and analyze the cases of vascular trauma in pediatric patients admitted to a tertiary hospital. METHODS: Through retrospective study we analyzed the cases of vascular trauma in patients younger than 18 years, admitted from January 2000 to July 2010, taking into account demographic data, mechanisms of injury, associated injuries, treatment techniques and complications. RESULTS: During the studied period, 242 patients were admitted with vascular trauma, 37 (15.2%) belonging to the pediatric population. The average age was 12.5 years, and 81% of the research participants were male. Related to the mechanisms of injury, penetrating trauma was the most common (57%), followed by blunt (38%) and iatrogenic (5%). Among the surgical techniques employed, arterial bypass with autologous vein was the most common (13 cases). There was a case of primary major amputation (below the knee) and four amputations in the early postoperative period (three transfemoral and one transtarsic). For the 11 patients admitted with popliteal artery injury, the rate of postoperative transfemoral amputation was 27.3%. There was only one death due to an iatrogenic trauma in a hemophilic lactant. CONCLUSIONS: Vascular trauma in pediatric patients involves several technical challenges, such as vasospasm and vessel diameter. The high rates of amputation in patients with popliteal artery injuries, despite attempts of revascularization, reinforce the seriousness of this type of trauma.

Relato de caso: implante transparietohepático de cateter de longa permanência para diálise

Transhepatic insertion of long-term dialysis catheter is an exception procedure used to obtain access in patients with central vein occlusion of lower and upper limbs. We report on a case of a young patient with history of dialysis for 15 years, who was submitted to an unsuccessful renal transplantation. This patient was in dialytic emergency and had confirmed occlusion of upper limb central veins and iliac veins. Transhepatic insertion of a long-term catheter was performed under general anesthesia. The catheter tip was placed at the level of the right atrium. Dialysis was satisfactorily performed on the same day.

Resultados do tratamento da Insuficiência Venosa Crônica grave com espuma de polidocanol guiada por ultrassom

CONTEXTO: A insuficiencia venosa cronica (IVC) em suas formas mais graves, com ulceracao e lesoes inflamatorias, associa-se a um tratamento cirurgico convencional de dificil execucao. A escleroterapia de veias tronculares com espuma de polidocanol e considerada uma alternativa terapeutica com resultados satisfatorios. OBJETIVO: Relatar os resultados da escleroterapia com espuma de polidocanol no tratamento de pacientes com IVC de membros inferiores com ulcera ativa. METODOS: Em um periodo de 48 meses, 71 pacientes (76 membros) foram submetidos a escleroterapia de veias tronculares com espuma de polidocanol a 3% guiada por ultrassom. O seguimento pos-procedimento foi feito por meio de questionario clinico, exame fisico e ultrassom Doppler, realizados em sete dias, um e seis meses e, a partir de entao, semestralmente. Analisou-se tempo de cicatrizacao da ulcera, melhora de sintomas clinicos, recanalizacao, recidiva dos sintomas e complicacoes. RESULTADOS: O sexo feminino correspondeu a 61% dos casos, e a idade variou de 25 a 85 anos (media de 59 anos). O tempo medio de acompanhamento foi de 460 dias. O refluxo do sistema venoso profundo foi observado em 53,4% dos membros. A cicatrizacao das ulceras ocorreu em 84,2% dos casos, com um tempo medio de cicatrizacao de 37 dias. A recanalizacao ocorreu em 31,5%, porem a recidiva de sintomas, com ressurgimento de ulcera, foi de 11,8%. CONCLUSAO: A esclerose com espuma e efetiva e apresenta altas taxas de cicatrizacao de ulceras, com baixos indices de complicacoes, em pacientes com IVC grave.

Tratamento endovascular de pseudo-aneurisma da artéria subclávia em criança hemofílica

O uso de cateteres venosos centrais em pacientes hemofilicos e muito frequente, devido as proprias caracteristicas terapeuticas da doenca. As complicacoes desses procedimentos, tais como pseudo-aneurisma, geralmente sao mais graves nesses pacientes. A correcao cirurgica do pseudo-aneurisma que acomete a arteria subclavia constitui um dos maiores desafios da cirurgia vascular. Em pacientes hemofilicos, a dificuldade habitual de exposicao cirurgica somam-se os problemas de alteracao no processo normal de coagulacao. Como alternativa ao tratamento cirurgico convencional, a utilizacao de tecnicas endovasculares constitui uma solucao segura e com bons resultados.

Implante de endoprótese aórtica através de acesso totalmente percutâneo

O acesso totalmente percutâneo para o implante de endoproteses aorticas, atraves da preclose technique, e possivel mesmo quando utilizadas bainhas introdutoras de elevado perfil. Relatamos sete casos de tratamento endovascular de doencas da aorta, todos realizados de modo percutâneo, e discutimos os principais aspectos desta tecnica.

High-flow priapism and urinary retention

Priapism, considered a medical emergency, is a relatively uncommon condition.1 Patients presenting with priapism require immediate intervention in an attempt to relieve those with ischemic priapism as promptly as possible. High flow priapism, the outcome of an exaggerated arterial flow into the cavernous artery, is not always an emergency and it can be at first treated only by observation.1,2 Both types of priapism can be distinguished by gas determination of the blood drawn from the cavernous bodies.3 We report on the case of a child with arterial priapism presenting with urinary retention, which led us to intervene by applying superselective arterial embolization.

Femoral vessel injury by a nonlethal weapon projectile

Rubber projectiles are used as an alternative to metal bullets owing to their lower morbidity and mortality rate. There are few reports of vascular lesions of extremities caused by rubber projectiles in the literature. The authors report the case of a 37-year-old man who was the victim of a penetrating injury to the left thigh with a rubber projectile. He reported only pain at the site of the injury; pulses were decreased in the affected limb. After arteriography confirmed an injury to the superficial femoral artery, he underwent an arterial and venous femorofemoral bypass using a reversed contralateral saphenous vein.

Endovascular treatment of penetrating arterial trauma with stent grafts

BACKGROUND The endovascular management of arterial injuries has resulted in reduced operating time, blood loss, hospital mortality, lower incidence of sepsis, and decrease in mortality rates. For penetrating trauma, however, the benefits of endovascular therapy are questionable. PATIENTS AND METHODS Data were obtained by retrospective analysis of electronic medical records. All patients with vascular trauma seeking care at our institution from January 2010 to December 2015 were reviewed. A total of 223 vascular trauma patients were enrolled. Of these, 18 patients (8 %) were treated with endovascular techniques. The data related to clinical presentation, patient characteristics, technical aspects of the treatment, and follow-up were analysed. RESULTS The mean patient age was 35.4 ± 17.8 years, 94 % were male. The mean injury severity score was 10.4 ± 2.5. The most commonly observed trauma mechanism was a gunshot in 10 cases (55 %), followed by lesions provoked by arterial catheter misplacement in five cases (27 %), and stab wounds in three cases (16.6 %). The main injury site was the subclavian artery, accounting for eight cases (44 %), followed by the superficial femoral artery and the tibiofibular trunk in two cases, respectively (18 %). The anterior tibial, fibular artery, axillary, common carotid, superior mesenteric, and profunda femoris were each affected once. Arteriovenous fistula was detected in nine cases (50 %), pseudoaneurysms in nine cases (50 %), and short occlusion in two cases (11 %). The mean follow-up duration was 753 days. The primary patency rate was 92.3 and 61.5 % after one and two years, respectively. The survival rate was 94.4 % after one and two years. Infection of the stents or limb amputations were not identified at follow-up. CONCLUSIONS The endovascular treatment of penetrating arterial injuries with covered stents is feasible. However, the criteria used to choose the best method must be individualized.

Revascularização endovascular infrainguinal: fatores determinantes para a perviedade

Contexto: A terapia endovascular tem avancado muito como tratamento para a doenca arterial oclusiva infrainguinal, principalmente com o desenvolvimento dos materiais e dos stents autoexpansiveis de nitinol. Objetivo: Avaliar os resultados e os fatores determinantes da angioplastia femoro-poplitea em pacientes portadores de isquemia de membros inferiores. Metodos: Foram tratados, atraves de angioplastia com ou sem stent, 114 pacientes, e acompanhados por um periodo medio de 12 meses. A media de idade foi de 66 anos; 53% eram do sexo feminino; 23,7% eram portadores de claudicacao incapacitante; 8,8%, de dor isquemica de repouso; e 67,5%, de lesao trofica. As lesoes foram classificadas segundo o TransAtlantic Inter-Society Consensus II em A (53%), B (34%), C (5%) e D (9%). Resultados: A analise angiografica do leito distal mostrou uma media de 1,4±1,0 arterias infrapopliteas pervias. O sucesso inicial foi de 97%. No seguimento de 1, 6, 12 e 24 meses, a perviedade primaria foi de 94, 78, 48 e 31%, e a primaria assistida, de 94, 84, 73 e 61%, respectivamente (p = 0,005). O leito distal pobre e a presenca de diabetes melito foram associados a uma menor perviedade primaria (p = 0,01), enquanto a extensao da lesao nao influenciou os resultados. As taxas de salvamento de membro em 6, 12 e 24 meses foram de 95, 90 e 90%, respectivamente. Conclusoes: A extensao das lesoes tratadas nao foi um fator determinante em nossa casuistica para o menor sucesso da angioplastia, o que pode sugerir que as indicacoes para o tratamento endovascular possam ser ampliadas para pacientes com lesoes TransAtlantic Inter-Society Consensus II C/D.

Endovascular treatment of complex traumatic lesions of the infrapopliteal segment

A ocorrencia de trauma vascular decorrente de diversas causas aumentou consideravelmente. Nesse contexto, o tratamento endovascular surge como um metodo novo e menos invasivo. Relatamos o caso de tres pacientes com lesoes abaixo do joelho que foram tratadas por procedimentos endovasculares.