Role of Computed Tomography Angiography in the Short-Term Follow-up of Aortic Coarctation Repair

ABSTRACT Introduction: Coarctation of the aorta (CoA) is a narrowing of the thoracic aorta that often manifests as discrete stenosis but may be tortuous or in long segment. The study aimed to evaluate pre and post-surgical aspects of pediatric patients submitted to CoA surgical correction and to identify possible predisposing factors for aortic recoarctation. Methods: Twenty-five patients were divided into groups according to presence (N=8) or absence (N=17) of recoarctation after surgical correction of CoA and evaluated according to clinical-demographic profile, vascular characteristics via computed angiotomography (CAT), and other pathological conditions. Results: Majority of males (64%), ≥ 15 days old (76%), ≥ 2.5 kg (80%). There was similarity between groups with and without recoarctation regarding sex (male: 87% vs. 53%; P=0.277), age (≥ 15 days: 62.5 vs. 82%; P=0.505), and weight (≥ 2.5 kg: 87.5 vs. 76.5; P=0,492). Altered values of aortic root/Valsalva diameter, proximal transverse arch, and distal isthmus, and normal values for aorta prevailed in preoperative CAT. Normal values for the aortic root/Valsalva sinus diameter were observed with and without recoarctation, the same for both groups regarding ascending and descending aorta in postoperative CAT. No significant difference for altered values of proximal transverse arch and alteration in distal isthmus was observed. Conclusion: No predictive risk for recoarctation was observed. CTA proved to be important in CoA diagnosis and management, since CoA is mainly related with altered diameter of aortic root/sinus of Valsalva and proximal and distal aortic arch/isthmus, however, it failed to show predictive risk for recoarctation.

Desempenho Diagnóstico da Angiotomografia Computadorizada e da Avaliação Seriada de Troponina Cardíaca Sensível em Pacientes com Dor Torácica e Risco Intermediário para Eventos Cardiovasculares / Diagnostic Performance of Coronary Tomography Angiography and Serial Measurements of Sensitive Cardiac Troponin in Patients With Chest Pain and Intermediate Risk for Cardiovascular Events

Resumo Fundamento A angiotomografia coronária (ATC) tem sido usada para avaliação de dor torácica principalmente em pacientes de baixo risco, e poucos dados existem com pacientes em risco intermediário. Objetivo Avaliar o desempenho de medidas seriadas de troponinas sensíveis e de ATC em pacientes de risco intermediário. Métodos Um total de 100 pacientes com dor torácica, TIMI score 3 ou 4 e troponina negativa foram prospectivamente incluídos. Todos os pacientes foram submetidos à ATC, e aqueles com obstruções ≥ 50% foram encaminhados à cineangiocoronariografia. Pacientes com lesões < 50% recebiam alta hospitalar, receberam alta e foram contatados 30 dias depois por telefonema para avaliação dos desfechos clínicos. Os desfechos foram hospitalização, morte, e infarto agudo do miocárdio em 30 dias. A comparação entre os métodos foi realizada pelo teste de concordância kappa. O desempenho das medidas de troponina e da ATC na detecção de lesões coronárias significativas e desfechos clínicos foi calculado. Os resultados foram considerados estatisticamente significativos quando p <0,05. Resultados Estenose coronária ≥ 50% na ATC foi encontrada em 38% dos pacientes e lesões coronárias significativas na angiografia coronária foram encontradas em 31 pacientes. Dois eventos clínicos foram observados. A análise de concordância Kappa mostrou baixa concordância entre as medidas de troponina e ATC na detecção de lesões coronárias significativas (kappa = 0,022, p = 0,78). O desempenho da ATC para detectar lesões coronárias significativas na angiografia coronária ou para prever eventos clínicos em 30 dias foi melhor que as medidas de troponina sensível (acurácia de 91% versus 60%). Conclusão ATC teve melhor desempenho que as medidas seriadas de troponina na detecção de doença coronariana significativa em pacientes com dor torácica e risco intermediário para eventos cardiovasculares.

Abstract Background Coronary tomography angiography (CTA) has been mainly used for chest pain evaluation in low-risk patients, and few data exist regarding patients at intermediate risk. Objective To evaluate the performance of serial measures of sensitive troponin and CTA in intermediate-risk patients. Methods A total of 100 patients with chest pain, TIMI risk scores of 3 or 4, and negative troponin were prospectively included. All patients underwent CTA and those with coronary stenosis ≥ 50% were referred to invasive coronary angiography. Patients with coronary lesions <50% were discharged and contacted 30 days later by a telephone call to assess clinical outcomes. Outcomes were hospitalization, death, and myocardial infarction at 30 days. The comparison between methods was performed by Kappa agreement test. The performance of troponin measures and CTA for detecting significant coronary lesions and clinical outcomes was calculated. Results were considered statistically significant when p < 0.05. Results Coronary stenosis ≥ 50% on CTA was found in 38% of patients and significant coronary lesions on coronary angiography were found in 31 patients. Two clinical events were observed. Kappa agreement analysis showed low agreement between troponin measures and CTA in the detection of significant coronary lesions (kappa = 0.022, p = 0.78). The performance of CTA for detecting significant coronary lesions on coronary angiography or for predicting clinical events at 30 days was better than sensitive troponin measures (accuracy of 91% versus 60%). Conclusion CTA performed better than sensitive troponin measures in the detection of significant coronary disease in patients with chest pain and intermediate risk for cardiovascular events.

Enfermedad de Kawasaki: ¿una entidad exclusiva de niños? / Kawasaki disease, is it exclusive of children?

Resumen La enfermedad de Kawasaki es un síndrome febril agudo y autolimitado, de presunta etiología autoinmune, que característicamente afecta a niños menores de 5 años. Esta enfermedad consiste en una vasculitis aguda de pequeños y medianos vasos que favorece la formación de aneurismas en las arterias coronarias. El diagnóstico en la fase aguda es esencialmente clínico, mientras que en la fase crónica suele hacerse al documentar las secuelas vasculares. La importancia de la identificación apropiada de esta enfermedad radica en que muchos de los infartos fatales y no fatales en personas menores de 40 años tienen hallazgos compatibles con este diagnóstico. Se presenta el caso de un adulto joven con dolor torácico y angiotomografía coronaria con hallazgos compatibles con secuelas de enfermedad de Kawasaki del adulto.

Abstract Kawasaki disease is an acute and self-limited febrile syndrome with a presumed autoimmune etiology that characteristically affects children under 5 years of age. Kawasaki disease is an acute vasculitis of small and medium vessels that facilitates the formation of coronary aneurysms. The diagnosis of the disease during the acute phase is essentially clinical, while the diagnosis of Kawasaki disease during the chronic phase is performed when the vascular complications are detected. The importance of proper identification of Kawasaki disease lies in the fact that many of the fatal and non-fatal infarcts in young adults (<40 years) have findings compatible with this diagnosis. This article describes the case of a young patient with chest pain and coronary angiotomography showing sequelae of Kawasaki disease in the adult.

Angiotomografía de la arteria cística en preoperatorio y comorbilidad en colecistectomía laparoscópica por colelitiasis / Angiotomography of the cystic artery in preoperative and comorbidity in laparoscopic cholecystectomy for cholelithiasis

La colecistectomía laparoscópica es el tratamiento de elección de la colelitiasis; sin embargo, se acompaña de comorbilidades y no está exenta de complicaciones mayores que pueden ser letales; la identificación del trígono cistohepático con disección y ligadura de la arteria cística son pasos obligatorios de la cirugía; la identificación de las variaciones de la arteria cística y los conductos biliares pueden minimizar las eventuales complicaciones. Al protocolo preoperatorio se implementó una angiotomografía con Tomógrafo Siemens Somatón Sensation ® de 64 cortes para identificar la arteria cística en pacientes con colelitiasis de la Unidad de Cirugía General del Hospital de Especialidades Teodoro Maldonado Carbo IESS de Guayaquil. Se escogieron 60 pacientes femeninos en forma aleatoria (edades 19-70 años, promedio 44,25 años) y la muestra se dividió en dos grupos de 30; al grupo estudio se aplicó angiotomografía hasta un mes antes de la cirugía y al grupo control se le aplicó el protocolo convencional. Se evaluó morbilidades relacionadas con: hemorragia operatoria por lesión de la arteria cística y en el posoperatorio: infección de herida operatoria, íleo y drenaje. La angiotomografía permitió identificar la arteria cística en el preoperatorio y contribuyó a disminuir comorbilidades que acompañan a la colecistectomía laparoscópica.

Laparoscopic cholecystectomy is the treatment of cholelithiasis of choice; however, it is accompanied by comorbidities and is not exempt from major complications that can be lethal; the identification of the cystohepatic trigone with dissection and ligation of the cystic artery are mandatory steps of surgery; the identification of the variations of the cystic artery and the bile ducts can minimize the possible complications. The preoperative protocol was implemented with an angiotomography with Siemens Somatón Sensation ® 64-slice Tomograph to identify the cystic artery in patients with cholelithiasis of the General Surgery Unit of the Teodoro Maldonado Carbo IESS Specialty Hospital of Guayaquil. 60 female patients were chosen at random (ages 19 -70 years, average 44.25 years) and the sample was divided into two groups of 30; Angiotomography was applied to the study group up to one month before surgery and the conventional protocol was applied to the control group. Morbidities related to: operative haemorrhage due to cystic artery and postoperative injury: operative wound infection, ileus and drainage were evaluated. Angiotomography allowed to identify the cystic artery in the preoperative period and contributed to decrease comorbidities that accompany laparoscopic cholecystectomy.

Secuestro pulmonar intralobar: hallazgo clínico-radiológico. presentación de un caso / Intralobar pulmonary sequestration. presentation of the case

Se presentó una mujer de 40 años con antecedentes de asma bronquial atendida en el Hospital Clínico Quirúrgico "Hermanos Ameijeiras" de La Habana. Refirió historia de un mes de evolución de tos seca, dolor torácico en hemitórax izquierdo, falta de aire y en dos ocasiones fiebre de 38 °C. Cumplió tratamiento para el proceso infeccioso respiratorio sin resolución. En la radiografía de tórax se evidenció una lesión radiopaca en el lóbulo inferior izquierdo y se confirmó el secuestro pulmonar intralobar con la angiotomografía pulmonar. En el secuestro pulmonar se requiere del uso adecuado de método clínico para su diagnóstico y la toma de decisiones terapéuticas definitivas(AU)

Forty years old woman with a history of severe asthma assisted to the Hospital Clínico Quirúrgico "Hermanos Ameijeiras" in Havana, presenting the following symptoms: dry cough, chest pain in left hemithorax, shortness of breath and fever with a temperature of 38°C (100.4°F) twice in the month. The patient was under treatment to control a respiratory infection, with no resolution reported. Radiography of the thorax revealed a radiopaque lesion in the left lower lobe, and lung sequestration was confirmed by pulmonary angiography. An appropiate use of clinical methods is required to diagnose and undertake the right therapy decisions about the intralobar lung sequestration(AU)

Secuestro pulmonar intralobar: hallazgo clínico-radiológico. Presentación de un caso / Intralobar pulmonary sequestration. Presentation of the case

RESUMEN Se presentó una mujer de 40 años con antecedentes de asma bronquial atendida en el Hospital Clínico Quirúrgico Hermanos Ameijeiras de La Habana. Refirió historia de un mes de evolución de tos seca, dolor torácico en hemitórax izquierdo, falta de aire y en dos ocasiones fiebre de 38 °C. Cumplió tratamiento para el proceso infeccioso respiratorio sin resolución. En la radiografía de tórax se evidenció una lesión radiopaca en el lóbulo inferior izquierdo y se confirmó el secuestro pulmonar intralobar con la angiotomografía pulmonar. En el secuestro pulmonar se requiere del uso adecuado de método clínico para su diagnóstico y la toma de decisiones terapéuticas definitivas.

ABSTRACT Forty years old woman with a history of severe asthma assisted to the Hospital Clínico Quirúrgico Hermanos Ameijeiras in Havana, presenting the following symptoms: dry cough, chest pain in left hemithorax, shortness of breath and fever with a temperature of 38°C twice in the month. The patient was under treatment to control a respiratory infection, with no resolution reported. Radiography of the thorax revealed a radiopaque lesion in the left lower lobe, and lung sequestration was confirmed by pulmonary angiography. An appropiate use of clinical methods is required to diagnose and undertake the right therapy decisions about the intralobar lung sequestration.

Angiotomografía de las variantes anatómicas de la arteria cística: estudio en el preoperatorio de colelitiasis / Angiotomography of the anatomical variants of the cystic artery: pre-operative study of cholelithiasis

La colecistectomía laparoscópica es el tratamiento indicado en la colelitiasis, sin embargo el procedimiento no está exento de complicaciones o morbilidad concomitante. Es posible que, debido a lesiones ductales colaterales, ocurra sangrado con posibilidad de conversión de la cirugía e indeseables resultados. Para un correcto abordaje de la región se hace fundamental la identificación del trígono cistohepático (TCH) y sus componentes, a su vez de la ligadura y sección de la arteria cística (AC). Conociendo la elevada variabilidad de la AC, el objetivo de este trabajo consistió en identificar el número, origen, trayecto y relación de la AC con el TCH y sus variaciones, utilizando angiotomografía por medio de un tomógrafo detector de 64 cortes, en el preoperatorio de 30 pacientes de sexo femenino, entre 24 y 54 años de edad, con colelitiasis diagnosticadas clínicamente y por ecosonografía. La AC en el 76,67 % era única y se encontraba dentro del TCH, en el 16,67 % era única y se observó fuera del TCH. En el 6,67 % se observaron dos AC, una dentro y otra fuera del TCH. En el 66,67 % de los casos la AC se originaba de manera normal de la arteria hepática derecha. La trazabilidad de la AC fue en el 53,3 % medianamente visible y en el 46,7 % de trazabilidad excelente. En conclusión, la identificación de la AC y sus variaciones anatómicas se puede determinar en el preoperatorio y puede ser útil para mejorar el plan quirúrgico en pacientes con colelitiasis, brindando información al procedimiento, optimizarlo y disminuir los riesgos de eventuales complicaciones relacionados con sangrado.

Laparoscopic cholecystectomy is the treatment indicated for cholelithiasis, however the procedure is not free of complications or concomitant morbidity. It is possible that, due to collateral ductal lesions, bleeding occurs with the possibility of surgery conversion and undesirable results. For a correct approach to the region it is essential to identify the cystohepatic trigone (CHT) and its components, as well as the ligation and section of the cystic artery (AC). Knowing the high variability of CA, the aim of this work was to identify the number, origin, path and relationship of CA with the CHT and its variations using angiotomography by means of a 64-slice detector tomograph in the preoperative period of 30 female patients, between 24 and 54 years old, with clinically diagnosed cholelithiasis and by echo sonography. The AC in 76.67 % was unique and was within the CHT, in 16.67 % it was unique and was observed outside the CHT. In 6.67 %, two ACs were observed, one inside and one outside the TCH. In 66.67 % of cases, CA originated normally from the right hepatic artery. The traceability of AC was 53.3 % moderately visible and 46.7 % excellent traceability. In conclusion, the identification of AC and its anatomical variations can be determined in the preoperative period and can be useful to improve the surgical plan in patients with cholelithiasis, providing information on the procedure, optimizing it and reducing the risks of possible bleeding related complications.

Atherosclerotic Plaque in Patients with Zero Calcium Score at Coronary Computed Tomography Angiography / Placa Aterosclerótica à Angiotomografia de Coronárias em Pacientes com Escore de Cálcio Zero

Abstract Background: In view of the high mortality for cardiovascular diseases, it has become necessary to stratify the main risk factors and to choose the correct diagnostic modality. Studies have demonstrated that a zero calcium score (CS) is characteristic of a low risk for cardiovascular events. However, the prevalence of individuals with coronary atherosclerotic plaques and zero CS is conflicting in the specialized literature. Objective: To evaluate the frequency of patients with coronary atherosclerotic plaques, their degree of obstruction and associated factors in patients with zero CS and indication for coronary computed tomography angiography (CCTA). Methods: This is a cross-sectional, prospective study with 367 volunteers with zero CS at CCTA in four diagnostic imaging centers in the period from 2011 to 2016. A significance level of 5% and 95% confidence interval were adopted. Results: The frequency of atherosclerotic plaque in the coronary arteries in 367 patients with zero CS was 9.3% (34 individuals). In this subgroup, mean age was 52 ± 10 years, 18 (52.9%) were women and 16 (47%) had significant coronary obstructions (> 50%), with involvement of two or more segments in 4 (25%) patients. The frequency of non-obese individuals (90.6% vs 73.9%, p = 0.037) and alcohol drinkers (55.9% vs 34.8%, p = 0.015) was significantly higher in patients with atherosclerotic plaques, with an odds ratio of 3.4 for each of this variable. Conclusions: The frequency of atherosclerotic plaque with zero CS was relatively high, indicating that the absence of calcification does not exclude the presence of plaques, many of which obstructive, especially in non-obese subjects and alcohol drinkers.

Resumo Fundamento: Diante da alta mortalidade por doenças cardiovasculares, faz-se necessária a estratificação dos principais fatores de riscos e escolha correta da modalidade diagnóstica. Estudos demonstraram que escore de cálcio (EC) zero caracteriza baixo risco de eventos cardiovasculares. No entanto, a frequência de portadores de placa aterosclerótica coronária com EC zero é conflitante na literatura especializada. Objetivo: Avaliar a frequência de pacientes com placa aterosclerótica coronária, seu grau de obstrução e fatores associados em pacientes com EC zero e indicação para angiotomografia computadorizada de coronárias (ATCC). Métodos: Trata-se de estudo transversal, prospectivo, com 367 voluntários portadores de EC zero, mediante a ATCC, no período de 2011-16, em quatro centros de diagnóstico por imagem. Foi assumido nível de significância 5% e intervalo de confiança de 95%. Resultados: A frequência de placa aterosclerótica nas artérias coronárias dos 367 pacientes com EC zero foi de 9,3% (34 indivíduos); neste subgrupo, a média de idade foi 52 ± 10 anos, 18 (52,9%) eram mulheres e 16 (47%) exibiam obstruções coronarianas significativas (> 50%), dos quais 4 (25%) apresentaram placas em pelo menos dois segmentos. A frequência de não obesos (90,6% vs. 73,9%; p = 0,037) e de etilistas (55,9% vs. 34,8%; p = 0,015) foi significativamente maior nos portadores de placa, apresentando, cada variável, odds ratio de 3,4 para o desenvolvimento das referidas placas. Conclusões: A frequência de placa aterosclerótica com EC zero foi considerável, evidenciando, portanto, que a ausência de calcificação não exclui placa, muitas das quais obstrutivas, principalmente nos não obesos e etilistas.

Longa sobrevivência em paciente com síndrome de ALCAPA não corrigida: Relato de caso e revisão da literatura

A origem anômala da artéria coronária esquerda da artéria pulmonar (síndrome de Bland-White-Garland ou ALCAPA: anomalous left coronary artery from the pulmonary artery) é uma cardiopatia congênita rara. Apresenta predominantemente na infância e suas principais formas de apresentação são como isquemia miocárdica ou insuficiência cardíaca. A sobrevivência à idade adulta é bastante incomum. Se não tratada, a mortalidade por ALCAPA se aproxima ao 90% na infância, portanto o reconhecimento precoce e a correção cirúrgica são essenciais. Apresentamos um caso de uma mulher de 56 anos, que acompanha em nosso ambulatório com o diagnóstico de síndrome de ALCAPA, e com piora recente da classe funcional de dispnéia.

The anomalous origin of the coronary artery from the pulmonary artery (ALCAPA or White-Bland-Garland syndrome) is a rare congenital cardiopathy. It presents predominantly in childhood and its main presentation forms are myocardial ischemia and heart failure. The survival to adulthood is unusual. If not treated, mortality by ALCAPA syndrome is close to 90% in childhood, therefore, the early recognition and surgical repair are essential. We present the case of a 56 years old woman, followed by our ambulatory with the ALCAPA Syndrome diagnosis, and recent functional class and dyspnea worsening

Mixoma atrial: más que una neoplasia benigna / Atrial myxoma: more than a beningn neoplasm

RESUMEN Los tumores cardíacos son parte del diagnóstico diferencial en el estudio de las masas intracardíacas, junto con vegetaciones, trombos, calcificaciones valvulares, entre otros. Su localización, tamaño y movilidad pueden dar lugar a importantes implicaciones funcionales y anatómicas que determinan la presentación clínica. Describimos el caso de una mujer de 51 años de edad, quien se presentó con cuadro sugestivo de un síndrome coronario agudo, pero gracias a los hallazgos ecocardiográficos se le diagnosticó un tromboembolismo pulmonar originado por un mixoma en la aurícula derecha con posterior verificación histopatológica..

Cardiac tumors are part of the differential diagnosis in the study of intra-cardiac masses along with vegetations, thrombi, valvular calcifications among others. Their localization, size and mobility can lead to major anatomical and functional implications determining the clinical presentation. We describe the case of a 51 year-old female, who presented with complains suggestive of an acute coronary syndrome, in which an echocardiographic showed it a pulmonary embolism caused by a right atrial myxoma with histopathological verification was made.

Correlación de los hallazgos de la angiotomografia tridimensional con el diagnóstico post operatorio en pacientes con aneurisma cerebral / Correlation of the findings of the three-dimensional angiotomography with postoperative diagnosis in patients with cerebral aneurysm

Objetivo: determinar la correlación de los hallazgos de la Angiotomografía Tridimensional con el diagnostico post operatorio en pacientes con aneurisma cerebral que acuden a urgencias del Hospital Obrero #2 en el periodo comprendido entre enero del 2010 a diciembre del 2013. Métodos: se realiza un estudio de tipo retrospectivo, transversal, descriptivo con un enfoque cuantitativo, de un universo de 100, se seleccionó a 30 pacientes que cumplieron con los criterios de inclusión y exclusión. Resultados: el grado más representativo del estudio fue el Grado II con un porcentaje de 40 % (n=12). La escala de Fisher por tomografías encontrada en mayor proporción fue el Grado II con un 40 % (n=12). Las características angiotomografías de los aneurismas encontrados con más frecuencia son el tamaño del saco aneurismático entre 10 -25 mm( n=23), tamaño de cuello del aneurisma que es mayor a 4 mm en 77 % (n=23), relación cuello y saco entre 1/3 a 1 (n=22); morfología del tipo sacular es de 97 % (n=29); la localización del aneurisma es en el segmento carotideo supraclinoideo 33% (n=10); se encontró una correlación en 29 pacientes del total de 30, entre el diagnostico tomográfico y los hallazgos posoperatorios (en cuanto a tamaño, forma y localización), sin embargo solo se encontró una variante en cuanto a la localización, esto fue descrito en la tomografía que estaba localizado en el segmento clinoideo C5 y el postoperatorio en el segmento comunicante C7. Resultado: en el presente estudio se encontró una buena correlación entre el diagnóstico de la angiotomografia y el postoperatorio ya que hizo el diagnóstico correcto a 88% de nuestros pacientes, con solo una variación respecto a la localización. Creemos que permitió realizar el tratamiento quirúrgico oportuno en pacientes con HSA que ingresaron a nuestro hospital.

Objective. To determine the correlation of the findings of the three-dimensional angiography with post operative diagnosis in patients with cerebral aneurysm attending emergency of the Hospital Obrero #2 in the period from January 2 010 to December 2 013. Metodos: do a study retrospective, tranverse, descriptive type with a quantitative approach, counting with a universe of 100 patients of whom 30 patients who met the inclusion and exclusion criteria were chosen with a intentional non-probability sampling. Results: in those 30 cases the age group that showed higher frequency of aneurysmal rupture was 50-59 years old representing 33%, with 58years old as high peak. The most affected was the female gender with 73% (n = 22). According to clinical evaluation with scale Hund and Hess the most representative of the study was the Grade II level with a percentage of 40% (n = 12) .The Scale of Fisher found in greater proportion was Grade II with 40 % (n = 12) .The Angiotomograffas characteristics of aneurysms most frequently found are: aneurysm sac size 10 -25 mm (n = 23) of the aneurysm neck size: more than 4 mm: 77% (n = 23 ) Relationship neck / sac 1/3 -1 (n = 22); Saccular sac morphology: 97% (n = 29); Aneurysm location: supraclinoid carotid segment 33% (n = 10); A good correlation of 30 patients between the tomographic diagnosis in size, shape and post operative findings was found, however only one variant was found in terms of location: it was described on CT which was located in Segment clinoid C5 and postoperative communicating segment C in July. Conclusions: In this study, a good correlation between the diagnosis and postoperative angiotomography. was found to be diagnosed 100% of our patients, with only one variation, regarding the location. We believe that allowed carrying out timely surgical treatment in patients with SAH admitted to our hospital.

Diagnóstico por tomografía del Síndrome de Leriche: reporte de un caso clínico / Tomography diagnostic of Leriche Syndrome: report of a clinical case

La Angiotomografía se ha convertido en una herramienta diagnóstica fundamental en la evaluación del sistema vascular, aumentando el uso en la valoración preoperatoria y diagnóstica de la patología vascular tanto de arterias cerebrales, aorta, renales y femoral entre otros, permitiendo un análisis de la pared del vaso, de tejidos y órganos adyacentes. Presentamos el caso clínico de una paciente de 59 años de edad, fumadora de 144 cigarrillos al año durante diez años, antecedentes de hipertensión arterial, hipercolesterinemia sisté-mica, que acude por presenta, claudicación intermitente, pie pálido en ambos miembros inferiores, ausencia de pulsos poplíteos, tibial posterior y pedios y en miembro inferior derecho presento un área de necrosis micotica en primer ortejo de pie, se realizó la Angiotomografía concluyendo que se trata de un Síndrome de Leriche o enfermedad oclusiva aortoilíaca.

The Angiotomography has become a major diagnostic tool in the evaluation of the vascular system, increasing use in preoperative assessment and diagnostic vascular pathology both cerebral arteries, aorta, kidney and femoral among others, permitting an analysis of the wall vessel, adjacent tissues and organs. We report the case of a 59 year old smoking 144 cigarettes a year for ten years, history of hypertension, systemic hypercholesterolemia, which goes by shows, intermittent claudication, pale foot in both lower limbs, absent po-pliteal pulse , posterior tibial and dorsalis pedis and right leg present an area of necrosis in the first fungal toe standing, the Angiography was performed and concluded that it is a Leriche syndrome or aortoiliac occlusive disease.

Inteligencia emocional y lesión aterosclerótica coronaria: estudio exploratorio en base a la aplicación del test Trait Meta-Mood Scale / Emotional intelligence and coronary atherosclerosis: exploratory study using the Trait Meta-Mood Scale

Introducción No existen estudios previos que evalúen la inteligencia emocional en adultos asintomáticos con lesiones ateroscleróticas coronarias. ObjetivoEn este trabajo nos proponemos estudiar la inteligencia emocional como rasgo en adultos asintomáticos con y sin lesiones ateroscleróticas coronarias, junto con comparar los datos estadísticos de los mismos. Diseño y método Estudio de corte transversal. Participaron 100 adultos asintomáticos, entre 30 y 80 años, que cumplieron con los criterios de inclusión y exclusión, y que se realizaron una angiotomografía coronaria derivados por su médico tratante. La presencia o ausencia de lesión se determinó utilizando un tomógrafo computarizado multicorte de 64 canales. La inteligencia emocional se evaluó mediante la aplicación del test Trait Meta-Mood Scale. Resultados: La muestra fue constituida por 73 por ciento hombres y 27 por ciento mujeres. 51 por ciento tenía lesión aterosclerótica coronaria, 78 por ciento presentó puntajes inferiores a los valores de referencia tanto para el factor claridad como para el factor reparación emocional. 79 por ciento presentó puntajes superiores a los valores de referencia para el factor atención emocional. Se hallaron asociaciones estadísticamente significativas entre la presencia de lesión aterosclerótica coronaria y cada uno de los tres factores evaluados: atención emocional, Chi-cuadrado: 0,302, p=0,043; claridad emocional, Chi-cuadrado: -0,312, p=0,040; y regulación emocional, Chi-cuadrado: -0,313, p=0,040. Conclusiones: Las personas con lesiones ateroscleróticas coronarias presentaron una tendencia excesiva a centrarse en la experiencia emocional, observando y pensando sobre las propias emociones, así como una baja habilidad para identificar, distinguir y describir las emociones que experimentan. También evidenciaron habilidad disminuida para reducir o eliminar las emociones negativas e incrementar o mantener la intensidad de las emociones positivas.

Introduction There are no prior studies that assess emotional intelligence in asymptomatic adults with coronary atherosclerosis. Aim The purpose of this study is to explore associations between emotional intelligence in asymptomatic adults with and without coronary atherosclerotic lesions. Design and methodCross-sectional design. The sample consisted of 100 asymptomatic 30 to 80 year-old adults that met the inclusion and exclusion criteria and who underwent coronary multislice computed tomography. Coronary atherosclerosis was shown by 64-channel multislice computed tomography. Emotional intelligence was assessed by applying the Trait Meta-Mood Scale. Results The sample was composed of 73 percent men and 27 percent women. Fifty-one percent had coronary atherosclerotic lesions, 78 percent had scores below the reference values for both Clarity and Repair. Seventy-nine percent had scores above the reference values for Attention. Statistically significant associations were found between the presence of coronary atherosclerotic lesion and: a) emotional attention, chi-square: 0.302, p=0.043, b) emotional clarity, chi-square: -0.312, p=0.040, b) emotional regulation, chi-square: -0.313, p=0.040. Conclusions: People with coronary atherosclerotic lesions showed an excessive tendency to focus on their own feelings and higher levels of rumination, together with lower ability to identify, distinguish and describe their emotions. Likewise, they have lower ability to reduce or eliminate negative emotions and to increase or maintain the intensity of positive emotions.

Tromboembolismo pulmonar sin infarto diagnosticado en una radiografía de tórax / Pulmonary thromboembolism without infarction diagnosed by chest roentgenography

Se presenta un paciente del sexo masculino de 23 años de edad, asintomático, con antecedentes patológicos personales de tromboflebitis migratriz en estudio. Se le realizó radiografía de tórax, en la cual se observó imagen hipertransparente basal derecha (signo de Westermark) con vasos escasos a ese nivel e hilio ipsilateral de mayor tamaño, lo que hizo sospechar tromboembolismo pulmonar sin infarto. Se realizó angiotomografía pulmonar, comprobándose dicho diagnóstico al encontrar amputada la arteria segmentaria basal lateral derecha. La radiografía de tórax tiene baja sensibilidad y especificidad para la confirmación de tromboembolismo pulmonar; no obstante, no se debe olvidar que sigue siendo el examen por el que se inicia el estudio, porque resulta el método menos costoso, disponible en todas las instituciones de salud, que permite descartar otras afecciones capaces de simularlo, y en algunos casos, como este, permite incluso, hacer el diagnóstico.

A male 23-year-old asymptomatic patient presents with a personal history of migratory thrombophlebitis under study. Chest roentgenography showed a right basal hypertransparent image (Westermark sign) with scarce vessels at that level and a larger ipsilateral hilum, which raised the suspicion of pulmonary thromboembolism without infarction. The diagnosis was confirmed when pulmonary angiotomography showed that the right lateral basal segmental artery was amputated. Chest roentgenography has low sensitivity and specificity for the confirmation of pulmonary thromboembolism. However, it should be remembered that it continues to be the first test performed in the examination, due to its low cost and its availability in all health care centers, allowing to rule out other conditions which could simulate pulmonary thromboembolism, and in some cases, such as this one, even making it possible to reach a diagnosis.

Angiotomografia coronariana multislice na avaliação da origem anômala das artérias coronarianas / Multislice coronary angiotomography in the assessment of coronary artery anomalous origin / Angiotomografía coronaria multislice en la evaluación del origen anómalo de las arterias coronarias

Fundamento: A origem anômala das artérias coronarianas é uma entidade relativamente rara, podendo se apresentar de várias formas clínicas e evoluir de forma adversa. A angiotomografia multislice das artérias coronarianas vem ganhando espaço na prática clínica diária, representando importante método propedêutico, com grande potencial na avaliação anatômica dessas artérias. Objetivo: O objetivo deste estudo é descrever os achados angiotomográficos e a evolução de pacientes com origem anômala das artérias coronarianas. Métodos: Durante o período de janeiro de 2008 a março de 2011, foram avaliados consecutivamente 404 pacientes encaminhados para realização de angiotomografia das coronárias por diversos motivos, com tempo médio de seguimento de 21 meses. Resultados: Nove pacientes (2,2%) apresentaram origem anômala das artérias coronárias, sendo quatro com origem anômala da artéria circunflexa (Cx) em Coronária Direita (CD), dois com origem anômala da CD (um com origem de CD em Cx, e um com origem de CD em seio coronariano esquerdo), um paciente com tronco coronariano único (descendente anterior e Cx saindo do seio coronariano esquerdo), um com trajeto anômalo do tronco da coronária esquerda entre aorta e artéria pulmonar e um paciente apresentando tronco coronariano esquerdo originando-se do seio coronariano direito. Dos pacientes avaliados, um paciente recebeu um cardiodesfibrilador implantável; um paciente evoluiu com morte súbita durante internação hospitalar; e os outros não tiveram intercorrências. Conclusão: A angiotomografia multislice das coronárias representa método propedêutico minimamente invasivo que possibilita detectar a origem, o curso e terminação das anomalias de origem das artérias coronarianas com excelente acurácia, possibilitando o correto diagnóstico e auxiliando no planejamento terapêutico.

Background: Anomalous origin of coronary arteries is a relatively rare entity, which may show different clinical forms and develop an adverse outcome. Multislice coronary angiotomography has gained importance in daily clinical practice, representing an important patient assessment method with great potential in the anatomical evaluation of these arteries. Objective: This study aimed to describe angiotomographic findings and evolution of patients with anomalous origin of coronary arteries. Methods: From January 2008 to March 2011 404 patients were evaluated consecutively, who had been referred for coronary angiotomography for several reasons, with a mean follow-up of 21 months. Results: Nine patients (2.2%) had anomalous origin of coronary arteries, of which four had an anomalous origin of the Circumflex (Cx) artery in the Right Coronary Artery (RCA), two had anomalous origin of the RCA (one originating from the Cx and one in the left coronary sinus), a patient with single coronary trunk (anterior descending and Cx out of the left coronary sinus), one had anomalous left main coronary artery trajectory between the aorta and pulmonary artery and one patient with left coronary trunk originating from the right coronary sinus. Of the evaluated patients, one received an implantable cardiodefibrillator; one died due to sudden death during hospitalization; and the others showed no complications. Conclusion: The multislice coronary angiotomography represents minimally invasive assessment method that allows detecting the origin, course and termination of anomalous coronary arteries with excellent accuracy, allowing the correct diagnosis and aiding therapeutic planning.

RESUMEN FUNDAMENTO: El origen anómalo de las arterias coronarias es una entidad relativamente rara, pudiendo presentarse de varias formas clínicas y evolucionar de forma adversa. La angiotomografía multislice de las arterias coronarias viene ganando espacio en la práctica clínica diaria, representando importante método propedéutico, con gran potencial en la evaluación anatómica de esas arterias. OBJETIVO: El objetivo de este estudio es describir los hallazgos angiotomográficos y la evolución de pacientes con origen anómalo de las arterias coronarias. MÉTODOS: Durante el período de enero de 2008 a marzo de 2011, fueron evaluados consecutivamente 404 pacientes encaminados para realización de angiotomografía de las coronarias por diversos motivos, con tiempo medio de seguimiento de 21 meses. RESULTADOS: Nueve pacientes (2,2%) presentaron origen anómalo de las arterias coronarias, siendo cuatro con origen anómalo de la arteria circunfleja (Cj) en Coronaria Derecha (CD), dos con origen anómalo de la CD (uno con origen de CD en Cj, y uno con origen de CD en seno coronario izquierdo), un paciente con tronco coronario único (descendente anterior y Cj saliendo del seno coronario izquierdo), uno con trayecto anómalo del tronco de la coronaria izquierda entre aorta y arteria pulmonar y un paciente presentando tronco coronario izquierdo originándose del seno coronario derecho. De los pacientes evaluados, un paciente recibió un cardiodesfibrilador implantable; un paciente evolucionó con muerte súbita durante internación hospitalaria; y los otros no tuvieron intercurrencias. CONCLUSÃO: La angiotomografía multislice de las coronarias representa método propedéutico mínimamente invasivo que posibilita detectar el origen, el curso y terminación de las anomalías de origen de las arterias coronarias con excelente precisión, posibilitando el correcto diagnóstico y auxiliando al planeamiento terapéutico.

Avaliação da aterosclerose subclínica coronariana e carotídea em portadores de hipercolesterolemia familiar: análise pela angiotomografia coronária, rigidez arterial e espessura íntima-média carotídea / Assessment of coronary and carotid subclinical atherosclerosis in patients with familial hypercholesterolemia: analysis by computed tomography coronary angiography, arterial stiffness and carotid intima-media thickness

A hipercolesterolemia familiar (HF) é uma doença autossômica dominante caracterizada por níveis elevados de LDL-c e doença arterial coronária (DAC) precoce. Existem evidências de maior prevalência de aterosclerose subclínica nesta população avaliada pelo escore de cálcio (CAC) e pela espessura íntima-média carotídea (EIMC). O objetivo do nosso estudo foi avaliar aterosclerose subclínica por meio da angiotomografia de coronárias em portadores de HF sem aterosclerose manifesta, correlacionando os achados com parâmetros clínicos, laboratoriais, rigidez aórtica e carotídea e com a EIMC. Incluímos 102 HFs, (45±13 anos, 36% homens, LDL-c 280±54mg/dL) e 35 controles (46±12 anos, 40% homens, LDL-c 103±18mg/dL). O grupo HF apresentava maior carga de placa aterosclerótica representado por: maior número de pacientes com placa (48% versus 14%, p=0,0005), maior número de pacientes com estenose luminal acima de 50% (19% versus 3%, p=0,015), maior número total de segmentos com placas (2,0±2,8 versus 0,4±1,3, p=0,0016), maior número de segmentos com placas calcificadas (0,8±1,54 versus 0,11±0,67, p= 0,0044) e maior escore de cálcio pelo método de Agatston (55±129, mediana:0 versus 38±140, mediana:0; p=0,0028). Houve correlação positiva no grupo HF do número total de segmentos com placa com: idade (r=0,41, p<0,0001), escore de risco de Framingham (r=0,25, p=0,012), colesterol total (r=0,36, p<0,0002), LDL-c (r=0,27, p=0,005), HDL-c (r=0,24, p=0,017), apolipoproteína B (r=0,3, p=0,0032) e escore de cálcio (r=0,93, p<0,0001). Além disso, houve correlação negativa com: variação sísto-diastólica carotídea (r=-0,23, p=0,028) e percentual de distensão carotídeo (r=-0,24, p=0,014). A análise multivariada de determinantes da presença de placa aterosclerótica, revelou que idade (OR=1,105, IC95%: 1,049-1,164, p<0,001) e colesterol total (OR=1,013, IC95%:1,001-1,025) foram as variáveis associadas com a presença da mesma. A única variável...

Familial hypercholesterolemia (FH) is an autosomal dominant disease characterized by high LDL-c levels and premature coronary artery disease (CAD) onset. There is evidence of greater prevalence of subclinical atherosclerosis in this population evaluated by coronary calcium score (CCS) and carotid intima-media thickness (IMT). The aim of our study was to assess subclinical atherosclerosis by computed tomography coronary angiography (CTCA) in patients with FH without manifest atherosclerosis and correlate the findings with clinical and laboratory parameters, aortic and carotid stiffness and IMT. We included 102 FHs (45 ± 13 years, 36% men, LDL-c 280 ± 54mg/dL) and 35 controls (46 ± 12 years, 40% men, LDL-c 103 ± 18mg/dL). The FH group had a greater atherosclerosis plaque burden represented by: higher number of patients with coronary plaque (48% versus 14%, p = 0.0005) and with luminal stenosis greater than 50% (19% versus 3% p = 0.015), higher total number of segments with plaques (2.0 ± 2.8 versus 0.4 ± 1.3, p = 0.0016), higher number of segments with calcified plaques (0.8 ± 1.54 versus 0.11 ± 0.67, p = 0.0044) and higher CCS by the Agatston method (55 ± 129, median: 0 vs. 38 ± 140, median = 0, p = 0.0028). There were positive correlations of total number of segments with plaque in FH group with the following variables: age (r=0.41, p<0.0001), Framingham risk score (r =0.25, p=0.012), total cholesterol (r=0.36, p<0.0002), LDL-c (r=0.27, p=0.005), HDL-c (r=0.24, p=0.017), apolipoprotein B (r=0,3, p=0.0032) and CCS (r=0.93, p<0.0001). In addition there was a negative correlation with: carotid systo-diastolic variation (r=- 0.23, p=0.028) and percentage of carotid distension (r=- 0.24, p=0.014). After multivariate analysis, the determinants of plaque presence were age (OR=1.105, 95% CI=1.049-1.164, p<0.001) and total cholesterol (OR=1.013, 95% CI:1.001-1.025). The only variable associated with presence of luminal stenosis greater than 50% was CCS...

Anomalías congénitas de la arteria aorta: Evaluación mediante tomografía computada multicorte en neonatos y niños / Congenital abnormalities of aortic artery: Assessment in neonates and early childhodd with multislice tomography

Para la evaluación de los defectos congénitos de la arteria aorta, los métodos de imágenes utilizados tradicionalmente son la ecocardiografia y la radiología simple. La angiotomografía computada multicorte aparece como un método de relevancia en el diagnóstico de estas entidades, permitiendo evaluar en forma no invasiva, rápida y precisa las distintas anormalidades, otorgando de esta manera información sumamente útil a los cirujanos cardiovasculares para definir la estrategia quirúrgica. En el presente artículo revisamos las aplicaciones de la angiotomografia computada multicorte en la evaluación de las malformaciones congénitas de la arteria aorta más frecuentes en el periodo neonatal y en la primera infancia.

In the evaluation of aortic artery congenital abnormalities, the echocardiography and the plain X ray are the traditionally used imaging methods. Multislice angiotomography appears as an important method in diagnosis of these different diseases allowing evaluate these entities in a non invasive, fast and accurate form, giving to cardiovascular surgeons very important information to delineate the surgical strategy. In this article, we review the applications of multislice angiotomography in the evaluation of most frequent congenital anomalies of aorta artery, performed in neonates and early childhood.

Evaluación hepática con TC multidetector. Angiotomografía, determinación volumétrica y hepatectomía virtual / Liver evaluation with multidetector CT. Angiotomography, volume determination and virtual hepatectomy

Objetivo: mostrar una nueva técnica de evaluación prequirúrgica del hígado utilizando tomografía computada multidetector (TCMD), determinando la utilidad de las reconstrucciones angiográficas, la volumetría hepática y la hepatectomía virtual, en correlación con los hallazgos quirúrgicos. Métodos: veinte pacientes con tumores hepáticos primarios o secundarios fueron evaluados con TCMD y luego operados. Las TC se efectuaron con técnica de doble fase (arterial y venosa) con un tomógrafo de 4 filas de detectores (Mx8000; Philips Medical Systems) luego de la inyección de 120ml de contraste endovenoso con una bomba inyectora. La adquisición se realizó con una colimación de 4x2.5mm. Las imágenes se evaluaron en conjunto con los cirujanos. Se calcularon los volúmenes hepáticos, se realizaron reconstrucciones vasculares y se efectuó la hepatectomía virtual. Se determinó la correlación del volumen de hígado a resecar establecido por la hepatectomía virtual y el de la pieza quirúrgica mediante el método de Bland y Altman. Resultados: la hepatectomía virtual permitió planificar y realizar en todos los pacientes la cirugía en un solo tiempo quirúrgico. No se produjeron complicaciones. El coeficiente de correlación fue 0.83 (IC 95%: -132.08- 159.78). Conclusiones: la hepatectomía virtual prequirúrgica es una nueva herramienta diagnóstica de la TCMD que, junto con las reconstrucciones vasculares, es útil para determinar la técnica quirúrgica a realizar en cada paciente y para estimar si el volumen hepático remanente será suficiente para evitar el desarrollo de una insuficiencia hepática post-quirúrgica.

Aim: to show a new technique of presurgical liver tumor evaluation using multidetector computed tomography (MDCT), determining the usefulness of angiographic reconstructions, presurgical virtual hepatectomy and 3D liver volume determination, in correlation with surgery findings. Methods: twenty patients with primary or secondary liver tumors were evaluated with MDCT and then operated on. Dualphase CT was performed in all patients on a 4-row multidetector CT scanner (Mx8000; Philips Medical Systems) after mechanical injection of 120ml of iodinated contrast medium. Scanning was performed using a detector configuration of 4x2.5mm. Images were sent to a workstation and they were analysed with the surgeons. The 3D volumes of each lesion, of the total liver and of the segments to be resected were calculated. Vascular reconstructions and virtual hepatectomy were also performed. Correlation of the liver volume between MDCT and surgery was calculated using the Bland and Altman method. Results: virtual liver segmentation allowed to perform the surgery in 100 % of the patients in one time and there were no complications. The correlation coefficient was 0.83 (CI 95%: -132.08, 159.78). Conclusions: presurgical liver hepatectomy is a new application tool of MDCT. The angiographic findings and the volume determination are useful to determine the surgical technique for each patient and this information allows the surgeons to know if the remnant liver will be enough for the patients to avoid a post-surgical liver insufficiency.

Correlación de los hallazgos panangiográficos, angiotomográficos y transoperatorios de los aneurismas intracraneales / Correlation of angiography and angiotomography results and transoperatory surgical finding in intracranial aneurysms

Objetivo: Determinar la correlación de la angiografía de sustracción digital y la angiotomografía con los hallazgos transoperatorios en el diagnóstico de los aneurismas intracraneales. Material y métodos: Este estudio se realizó en el Hospital de Especialidades Centro Médico Nacional La Raza del IMSS, del 1 de diciembre del 2003 al 31 de mayo del 2004, estudiándose un total de 20 pacientes con diagnóstico de aneurisma intracraneal roto o no roto que contara con ambos estudios de imagen: angiotomografía tridimensional y panangiografía cerebral y que recibiera tratamiento quirúrgico. Posteriormente los estudios de imagen se correlacionaron con los hallazgos transoperatorios. Resultados: La localización del aneurisma concordó con los hallazgos quirúrgicos en 100% de los casos por angiografía y 96% por angiotomografía, el tamaño del aneurisma fue 92% por angiografía y 84% por angiotomografía, características del cuello 92% por angiografía y 84% por angiotomografía, relación con arterias adyacentes 96% por angiografía y 88% por angiotomografía, la orientación del domo del aneurisma fue correcta en 100% con los dos estudios. Conclusiones: Los resultados obtenidos en base a la angiotomografía son alentadores, sin embargo sigue existiendo poca disponibilidad en nuestro Hospital para la realización de este estudio con miras a ser el estudio de elección. Deberán mejorarse las técnicas para el procesamiento de las imágenes para realizar a futuro la planeación quirúrgica de los aneurismas en base a la angiotomografía 3D .

Objective: Determine the correlation of angiography and angiotomography imaging results with transoperative findings in the diagnosis of intracranial aneurysms. Material and methods: The study took place at the <> from December 2003 through May 31 2004. We studied 20 patients who underwent surgical treatment due to ruptured or non ruptured intracranial aneurysm and had angiotomography and cerebral angiography. Imaging studies were later correlated with surgical findings. Results: Aneurysm location matched surgical findings in 100% of cases with angiography and 96% with angiotomography. Aneurysm size matched surgical findings in 92% of cases with angiography and 84% with angiotomography. The neck's characteristics matched 92% with angiography and 84% with angiotomography. The relationship of the aneurysm with adjacent arteries correlated in 96% of cases with angiography and 88% with angiotomography. The aneurysm s dome direction had a 100% match in both studies. Conclusions: 3D angiotomography results in our study showed an important correlation with surgical findings. While our results are encouraging, this procedure is not readily available at our facility and therefore cannot be considered the optimum imaging study. We must improve image processing, and train staff to include angiotomography in future surgical management of aneurysms.