Ricardo Aun

Diagnosis of limbs and neck arterial trauma using duplex ultrasonography

OBJECTIVE To evaluate duplex ultrasonography for diagnosis of arterial trauma in limbs and neck. METHOD Fifty-one wounds in 47 patients, with indication for arteriography, were prospectively studied and grouped according to the presence (PCS group: 21 wounds, 41.2%) or absence (ACS group: 30 wounds, 58.8%) of clinical signs of arterial injury. All underwent duplex ultrasonography and arteriography. RESULTS Arteriography disclosed arterial injury in 21 wounds, of which 19 were visualized by duplex ultrasonography. In the other 30 wounds neither methods disclosed any arterial injury. The sensitivity of duplex ultrasonography was 90.5%, the specificity was 100% and the accuracy was 96.1%. In PCS group duplex ultrasonography showed 14 injuries (93.3%) and one false-negative result, and in ACS group, five injuries (83.3%) and one false-negative result in the ACS group. CONCLUSIONS Duplex ultrasonography reproduces the results of arteriography as a non-invasive diagnostic method in trauma of the limbs and neck.

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.

Ruptura traumática da aorta por traumatismo torácico fechado

Eprovavel que nenhuma area da cirurgia vascular ou da cirurgia do trauma tenha sido tao beneficiada nos ultimos anos quanto o diagnostico e tratamento das lesoes traumaticas da aorta toracica por trauma toracico fechado. Se, de um lado, foram implantadas leis que tornaram obrigatorios metodos de protecao nas colisoes automobilisticas frontais – como o uso do cinto de seguranca, o uso de dispositivos inflaveis, conhecidos como air bags, e as carrocerias deformaveis que absorvem o impacto –, de outro lado, surgiram nas grandes cidades novos costumes, como a adocao demotocicletas para entregas rapidas e esportes de alto impacto e energia, conhecidos como esportes radicais, que envolvem aceleracao e desaceleracao subitas e quedas sob velocidades elevadas, que mantem a prevalencia dessas lesoes alta.

Tratamento endoluminal de aneurismas anastomóticos na aorta abdominal: relato de dois casos

Proximal anastomosis aneurysm is a rare and severe complication in aortofemoral bypass surgery. Surgical treatment is complex and has a high morbidity and mortality rate. We report two cases of proximal anastomosis aneurysm in late follow up of aortobifemoral bypass surgery, which occurred 15 and 18 years, respectively, after the bypasses and were repaired by the endovascular technique. Both patients progressed well and were submitted to 6- and 12-month follow-up CT scans showing aneurysm exclusion.

Tratamento das lesões de aorta nos traumatismos torácicos fechados

OBJETIVO: Rever a casuistica, etiologia, lesoes associadas, tipos de tratamento e evolucao das lesoes da aorta por trauma toracico fechado. METODOS: Estudo retrospectivo em prontuario dos pacientes atendidos no Pronto-Socorro do Hospital das Clinicas da Universidade de Sao Paulo e tratados pelo Grupo de Cirurgia Vascular de janeiro de 2001 a junho de 2004. Foram analisados 10 pacientes, todos do sexo masculino, sendo sete com tecnica endovascular e tres com tecnica operatoria aberta. RESULTADOS: Quanto a localizacao, foram observadas oito lesoes da aorta descendente junto ao istmo, uma lesao da aorta descendente na transicao toraco-abdominal e uma disseccao traumatica da aorta. O intervalo de tempo para o tratamento cirurgico foi, em media, de 10,62 ± 3,45 horas para os que receberam tratamento endoluminal e 28 ± 32,39 para os operados de forma convencional. Ja o periodo de internacao total variou de 9 a 180 dias (media de 23,33 ± 6,66 dias para os tratados com endoprotese e 42,55 ± 52,7 para os operados de forma convencional). Foram utilizadas uma endoprotese Excluder®, uma Apolo® e cinco Talent®. Dos pacientes operados, dois utilizaram bomba atrio femoral. Ocorreram dois obitos, um entre os operados de forma convencional e um entre os operados com endoproteses. CONCLUSOES: As lesoes da aorta em casos de trauma toracico fechado sao pouco frequentes e geralmente associadas a um grande numero de lesoes associadas. O diagnostico precoce e preciso e fundamental para a evolucao do paciente. A correcao com endoproteses nos pacientes estaveis do ponto de vista hemodinâmico apresenta-se como solucao eficaz.

Abdominal aortic pseudoaneurysm diagnosed 42 years after abdominal gunshot wound

Traumatic pseudoaneurysm of the abdominal aorta is a life threatening and a rare condition in aortic injuries. Most lesions are caused by a penetrating injury and may not be detected during the first evaluation. The time interval from initial trauma to appearance of clinical signs and symptoms may range from a few days to many years, and there are only a few reports of delayed presentation. We describe the case of a 59-year-old man who presented with abdominal pain 42 years after an abdominal gunshot injury. A traumatic pseudoaneurysm of the infrarenal abdominal aorta was diagnosed. Resection of the pseudoaneurysm and a Dacron graft interposition were the treatment, and there were no postoperative complications. The time interval from injury to diagnosis of the traumatic abdominal aorta pseudoaneurysm is the longest found in the literature.

Follow-up of the aneurysmal sac after exclusion and bypass of popliteal artery aneurysms

UNLABELLED Popliteal artery aneurysms are frequent and may lead to thromboembolic events and limb loss. PURPOSE To evaluate clinical and ultrasonographic follow-up of patients who underwent exclusion of a popliteal artery aneurysm using the technique proposed by Edwards. METHODS Data of all patients who underwent surgery to repair a popliteal artery aneurysm at Hospital das Clinicas, the São Paulo University Medical School between 1996 and 2004 were reviewed. Inclusion criteria were repair with aneurysm exclusion and bypass using the technique proposed by Edwards, as well as the existence of preoperative and postoperative measurements of the aneurysmal sac. RESULTS Data of 16 patients who underwent 20 procedures for popliteal artery aneurysm exclusion and bypass were available to analysis. The preoperative diameter of the popliteal artery aneurysms ranged from 1.3 cm to 6.1 cm (mean = 3.1 cm). Patients underwent duplex ultrasound scanning 1 month to 7 years after surgical repair. Follow-up of the 20 cases revealed that 10 aneurysms exhibited decreased mean transverse diameters, ranging from 0.2 to 2.3 cm, while 7 had increased in diameter, ranging 0.3 to 3.3 cm, and 3 remained unchanged. Flow was observed only in 5 out of the 20 procedures, 3 of which (60%) had increased diameters. CONCLUSION Although exclusion is a widely accepted procedure for the repair of popliteal artery aneurysms, data in the literature and the results of this study, which did not include cases of rupture or compression, suggest that strict follow-up of patients who undergo aneurysm exclusion is necessary.