Factores asociados al éxito de la cirugía revascularizadora en diabéticos con isquemia crítica crónica de las extremidades / Factors associated with the success of revascularization surgery in diabetic patients with chronic critical limb ischemia

Introducción: La cirugía revascularizadora es una de las estrategias fundamentales para el tratamiento de la isquemia crítica crónica de los miembros inferiores. Objetivo: Identificar los factores asociados al éxito de la cirugía revascularizadora de los miembros inferiores en diabéticos con isquemia crítica crónica. Métodos: Se realizó un estudio descriptivo, prospectivo y de tipo cohorte en pacientes diabéticos sometidos a una cirugía revascularizadora, por presentar isquemia crítica crónica de la extremidad. Estos fueron seguidos durante seis meses en el Instituto Nacional de Angiología y Cirugía Vascular entre septiembre de 2019 y enero de 2021. La variable principal de salida resultó los factores pronosticadores del éxito de la cirugía, la cual se consideró exitosa cuando el paciente permaneció vivo y sin una amputación mayor. Resultados: Se incluyeron 50 pacientes con una edad promedio de 64 ± 10,21 años y un 24 por ciento de mujeres. El 88 por ciento fueron fumadores; y el 78 por ciento, hipertensos. La efectividad global de la cirugía resultó del 64 por ciento (IC al 95 por ciento 50 por ciento-78 por ciento). Solamente el sexo femenino, con una probabilidad de 0,053 y un Odds Ratio de 4,23; el antecedente de enfermedad cerebrovascular (p: 0,13 y OR: 6,98); y la infección (p: 0,18 y OR: 2,7) mostraron una tendencia a asociarse de forma estadísticamente significativa con el éxito de la cirugía. Conclusiones: El sexo femenino, el antecedente de enfermedad cerebrovascular y la presencia de infección fueron los principales candidatos para estudiarse como variables pronosticadoras del éxito de la cirugía revascularizadora(AU)

Introduction: Revascularizing surgery is one of the fundamental strategies for the treatment of chronic critical ischemia of the lower limbs. Objective: To identify the factors associated with the success of lower limb revascularization surgery in diabetics with chronic critical ischemia. Methods: A descriptive, prospective, cohort-type study was conducted in diabetic patients undergoing revascularization surgery due to chronic critical limb ischemia. The patients were followed for six months at the National Institute of Angiology and Vascular Surgery from September 2019 to January 2021. The primary endpoint variable was the predictor of the success of surgery, which was considered successful when the patient remained alive and without major amputations. Results: 50 patients with an average age of 64 ± 10.21 years and 24 percent women were included. 88 percent of the patients were smokers; and 78 percent hypertensive ones. The overall effectiveness of surgery was 64 percent (95 percent CI 50 percent-78 percent). Only the female sex, with a probability of 0.053 and an Odds Ratio of 4.23, history of cerebrovascular disease (p: 0.13 and OR: 6.98); and infection (p: 0.18 and OR: 2.7) showed a tendency to be statistically, significantly associated with the success of surgery. Conclusions: Female sex, history of cerebrovascular disease and presence of infection were the main candidates as prognostic variables of the success of revascularizing surgery(AU)

Ventilatory Muscle Strength Six Months After Coronary Artery Bypass Grafting in Patients Submitted to Inspiratory Muscular Training Based on Anaerobioc Threshold: A Clinical Trial

Abstract Introduction Coronary artery bypass grafting (CABG) surgery is associated with a decline in ventilatory muscle strength and lung function. Inspiratory muscle training (IMT) based on anaerobic threshold (AT) has been used to minimize the impact of CABG on these parameters, but the long-term impact is unknown. Objective To test the hypothesis that AT-based IMT improves inspiratory muscle strength and lung function even six months after CABG. Methods This is a randomized controlled clinical trial. In the preoperative period, maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), vital capacity (VC) and peak expiratory flow (PEF) rate were assessed. On the first postoperative day, patients were randomized into two groups: AT-based IMT (IMT-AT) (n=21) where the load was prescribed based on glycemic threshold and conventional IMT (IMT-C) (n=21), with load of 40% of MIP. Patients were trained during hospitalization until the day of discharge and were assessed at discharge and six months later. For within-group comparison, paired Student's t-test or Wilcoxon test was used, and independent Student's t-test or the Mann-Whitney test was used to analyze the different time points. A p<0.05 was considered significant. Results At six months after CABG surgery, statistical difference was found between the IMT-AT and the IMT-C groups in MIP (difference between the means of -5cmH2; 95% CI=- 8.21to-1.79) and VC (difference between the means of -2ml/kg;95%CI=-3.87to-0.13). No difference was found between groups in the other variables analyzed. Conclusion IMT-AT promoted greater recovery of inspiratory muscle strength and VC after six months of CABG when compared to conventional training.

Fatores que Impactam a Decisão de Realizar Ventriculografia Esquerda em Doença Arterial Coronariana / Factors That Impact the Decision to Perform Left Ventriculography in Coronary Artery Disease

Resumo Fundamento A ventriculografia esquerda é um método invasivo para avaliar a função sistólica do ventrículo esquerdo. Depois do advento de métodos não invasivos, o seu uso tem sido questionado por resultar em algum risco para o paciente. Objetivos Avaliar quais fatores associam-se independentemente com a decisão de realizar ventriculografia em pacientes com doença arterial coronariana. Métodos Tratou-se de um estudo analítico, retrospectivo, avaliando prontuários eletrônicos e banco de dados e comparando 21 variáveis de interesse pré-definidas entre pacientes submetidos a cineangiocoronariografia. Foi considerado significante p < 0,05. Resultados Avaliamos 600 pacientes consecutivos, e a ventriculografia esquerda foi realizada na maioria dos pacientes submetidos a uma cineangiocoronariografia (54%). Depois da análise multivariada, os pacientes com síndromes coronarianas crônicas ( odds ratio [OR] 1,72; intervalo de confiança de 95% [IC 95%]: 1,20-2,46; p < 0,01) tiveram maior chance de serem submetidos ao procedimento. Os pacientes com função ventricular conhecida (OR = 0,58; IC 95%: 0,40-0,85; p < 0,01), os revascularizados (OR 0,31; IC 95% 0,14-0,69; p < 0,01), os hipertensos (OR 0,58; IC 95%: 0,36-0,94; p = 0,02) e aqueles com maiores valores de creatinina (OR 0,42; IC 95% 0,26-0,69; p < 0,01) tiveram maior chance de não realizar ventriculografia. Conclusões Nos pacientes submetidos a cineangiocoronariografia, o diagnóstico de síndrome coronariana crônica associou-se de modo independente com uma maior realização da técnica, enquanto ter a função ventricular previamente conhecida, ser hipertenso, ter sido submetido a revascularização cirúrgica prévia e ter valores de creatinina mais elevados associaram-se a uma maior chance de não realizar o método.

Abstract Background Left ventriculography is an invasive method for assessment of left ventricular systolic function. Since the advent of noninvasive methods, its use has been questioned, as it carries some risk to the patient. Objective To assess which factors are independently associated with the decision to perform ventriculography in patients with coronary artery disease. Methods Analytical, retrospective, database review study of electronic medical records comparing 21 predefined variables of interest among patients undergoing coronary angiography. P-values <0.05 were considered significant. Results We evaluated 600 consecutive patients undergoing coronary angiography. Left ventriculography was performed in the majority of cases (54%). After multivariate analysis, patients with chronic coronary syndrome (OR 1.72; 95% CI: 1.20-2.46; p < 0.01) were more likely to undergo the procedure. Patients with known ventricular function (OR 0.58; 95% CI: 0.40-0.85; p < 0.01); those with a history of CABG (OR 0.31; 95% CI: 0.14-0.69; p < 0.01) or hypertension (OR 0.58; 95% CI: 0.36-0.94; p = 0.02); and those with higher creatinine levels (OR 0.42; 95% CI: 0.26-0.69; p < 0.01) had greater odds of not undergoing ventriculography. Conclusions In patients undergoing coronary angiography, a diagnosis of chronic coronary syndrome was independently associated with greater likelihood of left ventriculography, while having previously determined ventricular function, a history of hypertension or CABG, and higher creatinine levels were associated with a decreased likelihood of undergoing this procedure.

Fragilidade entre Pacientes não Idosos Submetidos à Cirurgia Cardíaca / Frailty Among Non-Elderly Patients Undergoing Cardiac Surgery

Resumo Fundamento: Geralmente vista como uma característica da velhice, a fragilidade também pode ocorrer em pessoas não idosas, principalmente naquelas que sofrem de doenças crônicas. A fragilidade pode aumentar o risco operatório. Objetivos: Determinar a prevalência de fragilidade em pacientes submetidos à cirurgia de revascularização do miocárdio (CRM) e/ou troca ou reconstrução valvar e/ou cirurgia valvar, bem como a influência da fragilidade nos desfechos pós-operatórios. Métodos: Nosso estudo incluiu 100 adultos que foram submetidos a operações cardíacas eletivas consecutivas. A fragilidade foi avaliada por meio da escala de Fried. Os pacientes também realizaram um teste de caminhada de 6 minutos, e medimos as pressões inspiratória e expiratória máximas. Um valor de p < 0,05 foi considerado significativo. Resultados: De uma coorte de 100 pacientes, com base nos critérios de fragilidade de Fried, 17 pacientes (17%) foram considerados frágeis, 70 (70%) pré-frágeis e apenas 13 (13%) não frágeis. Entre os portadores de valvopatia, 11 (18,6%) foram considerados frágeis e 43 (73%) pré-frágeis. Cinquenta e três por cento dos pacientes considerados frágeis tinham menos de 60 anos (mediana=48 anos). As diferenças no fenótipo de fragilidade entre os pacientes com valvopatia e doença arterial coronariana não foram estatisticamente significativas (p=0,305). A comparação entre pacientes não frágeis, pré-frágeis e frágeis não mostrou diferença significativa na distribuição das comorbidades e do estado funcional cardíaco, independentemente da doença cardíaca. No entanto, a mortalidade hospitalar mostrou-se significativamente maior em pacientes frágeis (29,4%, p=0,026) que em pacientes pré-frágeis (8,6%) e não frágeis (0%). Conclusões: A fragilidade é prevalente mesmo entre pacientes não idosos submetidos a CRM ou cirurgia cardíaca valvar e está associada a maior mortalidade hospitalar pós-operatória.

Abstract Background: Usually viewed as a characteristic of old age, frailty may also occur in non-elderly people, primarily in those suffering from chronic disease. Frailty may increase operative risk. Objectives: To determine the prevalence of frailty patients undergoing coronary artery bypass (CABG) and/or heart valve replacement or reconstruction and/or heart valve surgery, as well as the influence of frailty on postoperative outcomes. Methods: Our study comprised 100 adults who underwent consecutive elective cardiac operations. Frailty was assessed using the Fried scale. Patients also performed a 6-minute walk test, and we measured maximal inspiratory and expiratory pressures. A p value <0.05 was considered significant. Results: Of a cohort of 100 patients, based on the Fried frailty criteria, 17 patients (17%) were considered frail, 70 (70%) pre-frail and only 13 (13%) were non-frail. Among patients with valvular heart disease, 11 (18.6%) were considered frail and 43 (73%) pre-frail. Fifty three percent of the patients considered frail were less than 60 years old (median=48 years old). The differences in frailty phenotype between patients with valvular heart disease and coronary artery disease were not statistically significant (p=0.305). A comparison between non-frail, pre-frail, and frail patients showed no significant difference in the distribution of comorbidities and cardiac functional status, regardless of their cardiac disease. However, hospital mortality was significantly higher in frail patients (29.4%, p=0.026) than in pre-frail patients (8.6%) and non-frail patients (0%). Conclusions: Frailty is prevalent even among non-elderly patients undergoing CABG or valvular heart surgery and is associated with higher postoperative hospital mortality.

Efectividad de la cirugía arterial en pacientes diabéticos en un período de cinco años / Effectiveness of arterial surgery in diabetic patients over a period of five years

Introducción: La macroangiopatía diabética constituye un serio problema para los pacientes que la portan y la cirugía revascularizadora constituye una alternativa de tratamiento. Objetivo: Demostrar la efectividad de las cirugías arteriales realizadas en pacientes diabéticos en un período de cinco años. Métodos: Estudio descriptivo, retrospectivo, en 71 historias clínicas de pacientes portadores de macroangiopatía diabética que recibieron cirugía arterial en el Instituto Nacional de Angiología y Cirugía Vascular (enero/2011- diciembre/2015). Se analizaron las variables: edad, género, color de la piel, supervivencia de la extremidad, estado de permeabilidad de los injertos y frecuencia de fallecimientos, que en su conjunto medirán la efectividad de la cirugía. Resultados: Hubo un incremento lineal de las cirugías revascularizadoras. La edad media fue de 64,5 ± 9,7 años, con un 67,6 por ciento de mayores de 60 años y más del 60 por ciento eran hombres. El 52,9 por ciento tenía piel blanca, el 80,3 por ciento tuvo grado 4 según Fontaine y el 66,2 por ciento tenía oclusión arterial severa. En más del 90 por ciento se realizó cirugía derivativa o endarterectomía, el 87,3 por ciento tuvo afectado el sector infrainguinal y en el 64,8 por ciento sobrevivió la extremidad. No se registraron muertes perioperatorias ni fallecidos a los seis meses. El 63 por ciento de las cirugías fueron permeables a los seis meses. Conclusiones: Las cirugías arteriales son efectivas pues la mayoría de los pacientes mantienen la extremidad afectada y no se registran fallecimientos perioperatorios ni a los seis meses de evaluación, además, la mayor cantidad de injertos resultaron ser permeables en ese tiempo(AU)

Introduction: Diabetic macroangiopathy is a serious problem for patients who suffer it; and revascularization surgery is an alternative to its treatment. Objective: To show the effectiveness of arterial surgeries performed in diabetic patients over a period of five years. Methods: Descriptive, retrospective study in 71 clinical records of patients with diabetic macroangiopathy who received arterial surgery at the National Institute of Angiology and Vascular Surgery (January / 2011- December / 2015). The variables analyzed were: age, gender, skin color, survival of the limb, state of permeability of the grafts and frequency of deaths, which as a whole will measure the effectiveness of the surgery. Results: There was a linear increase in revascularization surgeries. The mean age was 64.5 ± 9.7 years, with 67. 6 percent of people over 60 years old, and more than 60 percent were men. 52.9 percent had white skin, 80.3 percent had grade 4 according to Fontaine and 66.2 percent had severe arterial occlusion. In more than 90 percent, derivative surgery or endarterectomy was performed; 87.3 percent had affectations in the infrainguinal sector and in 64.8 percent the limb survived. There were no perioperative deaths or deaths at six months. 63 percent of the surgeries were permeable at six months. Conclusions: Arterial surgeries were effective because the majority of patients maintained the affected limb and there were no perioperative deaths neither at the six months evaluation; in addition, most of the grafts were permeable in that time(AU)

Rapamycin Combined with α-Cyanoacrylate Contributes to Inhibiting Intimal Hyperplasia in Rat Models / Rapamicina em Combinação com α-Cianoacrilato Contribui à Inibição de Hiperplasia Intimal em Modelos em Ratos

Abstract Background: Vein graft restenosis has an adverse impact on bridge vessel circulation and patient prognosis after coronary artery bypass grafting. Objectives: We used the extravascular supporter α-cyanoacrylate (α-CA), the local application rapamycin/sirolimus (RPM), and a combination of the two (α-CA-RPM) in rat models of autogenous vein graft to stimulate vein graft change. The aim of our study was to observe the effect of α-CA, RPM, and α-CA-RPM on vein hyperplasia. Methods: Fifty healthy Sprague Dawley (SD) rats were randomized into the following 5 groups: sham, control, α-CA, RPM, and α-CA-RPM. Operating procedure as subsequently described was used to build models of grafted rat jugular vein on carotid artery on one side. The level of endothelin-1 (ET-1) was determined by enzyme-linked immunosorbent assay (ELISA). Grafted veins were observed via naked eye 4 weeks later; fresh veins were observed via microscope and image-processing software in hematoxylin-eosin (HE) staining and immunohistochemistry after having been fixed and stored" (i.e. First they were fixed and stored, and second they were observed); α-Smooth Muscle Actin (αSMA) and von Willebrand factor (vWF) were measured with reverse transcription-polymerase chain reaction (RT-PCR). Comparisons were made with single-factor analysis of variance and Fisher's least significant difference test, with p < 0.05 considered significant. Results: We found that intimal thickness of the α-CA, RPM, and α-CA-RPM groups was lower than that of the control group (p < 0.01), and the thickness of the α-CA-RPM group was notably lower than that of the α-CA and RPM groups (p < 0.05). Conclusion: RPM combined with α-CA contributes to inhibiting intimal hyperplasia in rat models and is more effective for vascular patency than individual use of either α-CA or RPM.

Resumo Fundamento: Reestenose de enxertos venosos tem um impacto adverso na circulação de pontagens e no prognóstico de pacientes após a cirurgia de revascularização miocárdica. Objetivos: Nós utilizamos α-cianoacrilato (α-CA) como suporte extravascular, rapamicina/sirolimus (RPM) como aplicação local e a combinação dos dois (α-CA-RPM) em modelos de enxerto venoso autógeno em ratos para estimular mudança no enxerto venoso. O objetivo do nosso estudo foi observar o efeito de α-CA, RPM e α-CA-RPM na hiperplasia venosa. Métodos: Cinquenta ratos Sprague Dawley (SD) saudáveis foram randomizados nos 5 grupos seguintes: sham, controle, α-CA, RPM e α-CA-RPM. O procedimento operacional descrito subsequentemente foi utilizado para construir modelos de enxertos da veia jugular na artéria carótida em ratos, em um lado. O nível de endotelina-1 (ET-1) foi determinado por ensaio de imunoabsorção enzimática (ELISA). As veias enxertadas foram observadas a olho nu 4 semanas após; as veias frescas foram observadas via microscópio e software de processamento de imagem com coloração hematoxilina-eosina (HE) e imuno-histoquímica depois de serem fixadas e armazenadas; α-actina do músculo liso (αSMA) e o fator de von Willebrand (vWF) foram medidos com reação em cadeia da polimerase-transcriptase reversa (RT-PCR). Realizaram-se as comparações com análise de variância de fator único (ANOVA) e o teste de diferença mínima significativa (LSD) de Fisher, com p < 0,05 sendo considerado estatisticamente significante. Resultados: Nós achamos que a espessura intimal nos grupos α-CA, RPM e α-CA-RPM era menor que no grupo controle (p < 0,01) e a espessura no grupo α-CA-RPM era notavelmente menor que nos grupos α-CA e RPM (p < 0,05). Conclusão: A combinação de RPM e α-CA contribui à inibição de hiperplasia em modelos em ratos e é mais efetivo para patência vascular que uso individual de α-CA ou RPM.

Hemorrhagic Moyamoya Disease : A Recent Update

Moyamoya disease (MMD) is a progressive cerebrovascular disease with unknown etiology, characterized by bilateral stenoocclusive changes at the terminal portion of the internal carotid artery and an abnormal vascular network formation at the base of the brain. MMD has an intrinsic nature to convert the vascular supply for the brain from internal carotid (IC) system to the external carotid (EC) system, as indicated by Suzuki’s angiographic staging. Insufficiency of this ‘IC-EC conversion system’ could result not only in cerebral ischemia, but also in intracranial hemorrhage from inadequate collateral anastomosis, both of which represent the clinical manifestation of MMD. Surgical revascularization prevents cerebral ischemic attack by improving cerebral blood flow, and recent evidence further suggests that extracranial-intracranial bypass could powerfully reduce the risk of re-bleeding in MMD patients with posterior hemorrhage, who were known to have extremely high re-bleeding risk. Although the exact mechanism underlying the hemorrhagic presentation in MMD is undetermined, most recent angiographic analysis revealed the characteristic angio-architecture related to high re-bleeding risk, such as the extension and dilatation of choroidal collaterals and posterior cerebral artery involvement. We sought to update the current management strategy for hemorrhagic MMD, including the outcome of surgical revascularization for hemorrhagic MMD in our institute. Further investigations will clarify the optimal surgical strategy to prevent hemorrhagic manifestation in patients with MMD.

Hemorrhagic Moyamoya Disease : A Recent Update

Moyamoya disease (MMD) is a progressive cerebrovascular disease with unknown etiology, characterized by bilateral stenoocclusive changes at the terminal portion of the internal carotid artery and an abnormal vascular network formation at the base of the brain. MMD has an intrinsic nature to convert the vascular supply for the brain from internal carotid (IC) system to the external carotid (EC) system, as indicated by Suzuki’s angiographic staging. Insufficiency of this ‘IC-EC conversion system’ could result not only in cerebral ischemia, but also in intracranial hemorrhage from inadequate collateral anastomosis, both of which represent the clinical manifestation of MMD. Surgical revascularization prevents cerebral ischemic attack by improving cerebral blood flow, and recent evidence further suggests that extracranial-intracranial bypass could powerfully reduce the risk of re-bleeding in MMD patients with posterior hemorrhage, who were known to have extremely high re-bleeding risk. Although the exact mechanism underlying the hemorrhagic presentation in MMD is undetermined, most recent angiographic analysis revealed the characteristic angio-architecture related to high re-bleeding risk, such as the extension and dilatation of choroidal collaterals and posterior cerebral artery involvement. We sought to update the current management strategy for hemorrhagic MMD, including the outcome of surgical revascularization for hemorrhagic MMD in our institute. Further investigations will clarify the optimal surgical strategy to prevent hemorrhagic manifestation in patients with MMD.

Influencia del síndrome metabólico en los resultados de la cirugía del sector aorto-iliaco / Influence of the metabolic syndrome on the results of the surgery of the aortic-iliac sector

Introducción: El síndrome metabólico está relacionado con el incremento de la morbilidad y mortalidad de las enfermedades. Objetivo: Determinar la influencia del síndrome metabólico sobre los resultados de la cirugía revascularizadora del sector aorto-ilíaco. Métodos: Se realizó un estudio descriptivo en dos etapas, en 114 pacientes atendidos en un período de cuatro años (2010-2014) en el Hospital Hermanos Ameijeiras con el diagnóstico de aneurisma de la aorta infrarrenal o enfermedad esteno-oclusiva aorto-ilíaca. Las variables fueron: presencia del síndrome metabólico y tipo de sus criterios positivos, enfermedad al ingreso, complicaciones posoperatoria, condición al alta (vivo /fallecido) y estancia hospitalaria. Se realizó el análisis estadístico correspondiente. Resultados: El 64 por ciento presentó el síndrome metabólico (p= 0,004), que predominó en la enfermedad esteno-oclusiva (48,2 por ciento) y en el aneurisma de la aorta abdominal infrarrenal (15,8 por ciento) sin diferencias significativas entre ambas entidades (p= 0,466). El 43,8 por ciento presentó cuatro criterios positivos, donde la hipertensión arterial fue la más frecuente (94,5 por ciento). Las complicaciones posquirúrgicas (relacionadas con la cirugía y respiratorias) se produjeron en el 64,4 por ciento. Hubo cinco fallecidos (5,3 por ciento) por enfermedades cardiovasculares y vasculares periféricas. El 50,7 por ciento de los enfermos con síndrome metabólico complicado acumuló más de 10 días de estadía posoperatoria. Conclusiones: El síndrome metabólico influye de forma negativa en los resultados de la cirugía revascularizadora del sector aorto-ilíaco en los pacientes con aneurisma de la aorta abdominal infrarrenal o con enfermedad esteno-oclusiva aorto-ilio-femoral, por el incremento de la frecuencia de complicaciones posoperatorias(AU)

Introduction: The metabolic syndrome is related to the increase of the morbidity and the mortality of diseases. Objective: To determine the influence of the metabolic syndrome on the results of the revascularization surgery performed in the aortic-iliac sector. Methods: A two-phase descriptive study was conducted in 114 patients, who were diagnosed with infrarenal aortic aneurysm or steno-occlusive aortic-iliac disease and treated in Hermanos Ameijeiras hospital from 2010-2014. The study variables were presence of metabolic syndrome and type of positive criteria of the same, disease on admission, postoperative complications, patient´s condition on discharge (alive/dead) and hospital length of stay at hospital. The corresponding statistical analysis was made. Results: Sixty four percent presented with the metabolic syndrome (p= 0.004), predominating in steno-occlusive disease (48.2 percent) and the infrarenal abdominal aorta aneurysm (15.8 percent) without significant differences between the two conditions (P= 0.466). In the group, 43.8 percent showed four positive criteria, being hypertension the most common (94.5 percent). Post-surgical complications (related to surgery and respiratory problems) occurred in 64.4 percent. There were five deaths (5.3 percent) due to cardiovascular disease and peripheral vascular diseases. The 50.7 percent of patients with complicated metabolic syndrome had stayed more than 10 days at hospital after surgery. Conclusions: The metabolic syndrome has negative impact on the results of the revascularization surgery of the aortic-iliac sector in patients with infrarenal abdominal aorta aneurysm or with aortic-iliac-femoral steno-occlusive disease, due to increased frequency of postoperative complications(AU)

Reestenosis de la arteria coronaria descendente anterior en mujeres diabéticas / Left anterior descending coronary artery restenosis in diabetic women

Resumen Las mujeres diabéticas con la enfermedad arterial coronaria sometidas a revascularización tienen mayor riesgo de reestenosis debido a las alteraciones fisiopatológicas a nivel vascular propias de la diabetes, a la disminución del efecto protector de los estrógenos después de la menopausia y porque el calibre de sus arterias es menor que el de las no diabéticas y menor que el de los hombres. El objetivo de este artículo es comparar la tasa de reestenosis en la arteria coronaria descendente anterior en las mujeres diabéticas que se sometieron a intervención coronaria percutánea más el stent, frente a la cirugía de revascularización. Para ello se realizó una revisión de la literatura utilizando artículos publicados en bases de datos científicas, que compararan las dos técnicas, haciendo énfasis en la población diabética femenina. Encontrando que hubo una ventaja de la cirugía de revascularización sobre la intervención coronaria percutánea en los eventos de revascularización de la lesión diana (OR 0,253, IC 95% 0,092-0,703, p = 0,008) y revascularización del vaso diana (OR 0,185, 95% CI 0,079 a 0,432, p < 0,001), correspondiente a una ventaja en la presentación de evento cardiovascular y cerebrovascular (OR 0,429, CI 95% 0,254-0,723, p = 0,001). Finalmente, se hizo un análisis crítico, concluyendo que la cirugía de revascularización es la técnica de elección en las pacientes diabéticas puesto que tiene una tasa de reestenosis menor y con ello menos eventos adversos que de esta se derivan.

Abstract Women with diabetes and coronary artery disease who undergo revascularization have a higher risk of restenosis due to the pathophysiological alterations at vascular level inherent to diabetes, to the decrease of the protective effect of estrogens after menopause and to the caliber of their arteries being smaller than women without diabetes or men. The goal of this study is to compare the rate of restenosis in anterior descending coronary artery in women with diabetes who underwent percutaneous coronary intervention and the stent, compared to revascularization surgery. For that a literature review was carried out using medical articles published in scientific databases where both techniques were compared, and focusing on female population with diabetes. Results showed there was an advantage for the revascularization surgery versus percutaneous coronary intervention in the revascularization events of the target lesion (OR 0.253, IC 95% 0.092-0.703, p = 0.008) and revascularization of the target vessel (OR 0.185, 95% CI 0.079 a 0.432, p <0.001), corresponding to an advantage in the presentation of the cardiovascular and cerebrovascular event (OR 0.429, CI 95% 0.254-0.723, p = 0.001). Finally, a critical analysis was conducted, thus concluding that revascularization is the chosen technique for female patients with diabetes because of the lower restenosis rate, avoiding its adverse events.

Morphological Analysis of Major Segments of Coronary Artery Occlusion: Importance in Myocardial Revascularization Surgery / Análisis Morfológico de los Principales Segmentos de Oclusión de las Arterias Coronarias: Importancia en la Cirugía de Revascularización Miocárdiaca

Revascularization surgery should ensure morphological similarity between the coronary artery and the graft. This is an important factor for its duration and permeability. The aim of this study was to analyze the morphological characteristics and morphometrics of the coronary artery segments with greater occlusion. This was an observational, cross-sectional descriptive study that consisted of two phases. A macroscopic phase in which 11 cadaveric hearts were extracted and coronary dominance and length of the anterior interventricular artery (AIA), the right coronary artery (RCA) and the circumflex artery (CXA) were determined. In the microscopic phase a total of 77 segments of these arteries were obtained and the luminal diameter, wall thickness, and amount of elastic fibers and the presence and size of the atheroma were determined. Right coronary dominance was the most frequent. Total vessel length was 15.65±1.17 cm for the AIA, 12.67±2.02 cm for the RCA and 8.79±2.5 cm for the CXA. Diameters ranged from 2.3 mm in the proximal segments and between 1.1 mm to 1.8 mm in the distal segments. Wall thickness in the proximal segments was between 354 µm and 396 µm and in the distal segments it ranged from 120 µm to 305 µm. The amount of elastic fibers showed that they were muscular arteries. Atheromas were present in 35% in the CXA, and in 32.5% in the AIA and the RCA. The largest ones were found in the proximal segments. This study examined the morphology and morphometry of the segments of the coronary arteries that are more frequently occluded. It provides information on the most significant parameters to be considered for election of the vascular graft in myocardial revascularization surgery.

En la cirugía de revascularización miocárdica se debe asegurar la similitud morfológica entre la arteria coronaria y el injerto. Esto es un factor importante en su duración y permeabilidad. El objetivo fue analizar las características morfológicas y morfométricas de los segmentos de mayor oclusión de las arterias coronarias. Estudio observacional, transversal y descriptivo que constó de dos fases. Una macroscópica en la que se extrajeron 11 corazones de cadáveres y se determinó la dominancia coronaria y longitud de la arteria interventricular anterior (AIA), la arteria coronaria derecha (ACD) y la arteria circunfleja (ACX). En la fase microscópica se obtuvo un total de 77 segmentos de estas arterias y se determinó el diámetro luminal, grosor de pared, cantidad de fibras elásticas y presencia y tamaño de ateroma. La dominancia coronaria derecha fue la más frecuente. La longitud total de los vasos fue de 15,65±1,17 cm para la AIA, de 12,67±2,02 cm para la ACD y 8,79±2,5 cm para la ACX. Los diámetros oscilaron entre los 2,3 mm en los segmentos proximales y entre 1,1 mm a 1,8 mm en los segmentos distales. Los grosores de pared en los segmentos proximales se presentaron entre 354 µm y 396 µm y en los segmentos distales oscilaron entre 120 µm a 305 µm. La cantidad de fibras elásticas demostró que son arterias musculares. El 35% de los ateromas se presentó en la ACX y el 32,5% en la AIA al igual que en la ACD. Los de mayor tamaño se encontraron en los segmentos proximales. Este estudio analizó la morfología y la morfometría de los segmentos de las arterias coronarias que se ocluyen con mayor frecuencia. Los resultados encontrados aporta información sobre los parámetros más significativos que se deben considerar para la elección del injerto vascular en la cirugía de revascularización miocárdica.

Clinical features and surgical efficacy analysis of subarachnoid hemorrhagic moyamoya disease / 中国脑血管病杂志

Objective To investigate the clinical features of subarachnoid hemorrhagic moyamoya disease and the therapeutic effect of encephalo-duro-arterio-synangiosis (EDAS). Methods The clinical and imaging data of 38 patients with subarachnoid hemorrhagic moyamoya disease admitted to the Department of Neurosurgery,the 307th Hospital of PLA from January 2002 to April 2013 were analyzed retrospectively. Thirty-five patients underwent unilateral or bilateral EDAS (64-sides underwent EDAS,4 patients with aneurysms underwent endovascular embolization first),and 3 patients did not undergo any surgery. Results (1)Subarachnoid hemorrhagic moyamoya disease accounted for 10. 8%(38/353)of all the hemorrhagic moyamoya disease admitted in hospital over the same period,including 37 adults and 1 child. The male to female ratio was 1∶3. 22 (9/29),and the age of onset was 12 to 59 years. The mean age of patients was 39 ± 11 years. Four patients were combined with aneurysms. There were no significant differences in the distribution of Suzuki stage,anterior choroidal artery dilatation and posterior communicating artery dilatation in the remaining 34 patients without aneurysms between the bleeding sides and non-bleeding sides (P>0.05). (2 ) The patients were followed up for 13 -125 months (mean 51 ± 27 months ),two patients had rebleeding,one of them was intraventricular hemorrhage,the other was parenchymal hemorrhage. The postoperative modified Rankin score (mRS)was significantly lower in 35 patients whom were treated with EDAS. Compared with before surgery,there was significant difference (P<0. 05). The re-examination of positron emission tomography (PET)for 16 patients at 3 to 19 months after surgery showed that among the 23 surgically treated hemispheres,the cerebral metabolisms of 17 hemispheres were improved after surgery, and 6 did not have any change after surgery. The re-examination of whole brain digital subtraction angiography (DSA)at 5 to 30 months after surgery in 13 patients showed that revascularizations in 19 of 23 surgical hemispheres were effective. Conclusion Subarachnoid hemorrhagic moyamoya disease often occurs in adults,and women are more common. EDAS can achieve good revascularization effect and improve brain metabolism of patients,and thus relieve the symptoms of cerebral ischemia.

Thirteen-year Experience of 44 Patients with Adult Hemorrhagic Moyamoya Disease from a Single Institution: Clinical Analysis by Management Modality

Our objective was a retrospective assessment of the management modalities that provided the most beneficial treatment in hemorrhagic moyamoya disease during the last 13 years at our institution. The clinical results of 44 patients with hemorrhagic moyamoya disease were investigated, comparing revascularization surgery (direct, indirect, and combined bypass) or conservative treatment. Angiographic features, rebleeding, and clinical outcome were investigated. Six of the 35 patients (17.1%) with revascularization surgery experienced rebleeding, as did 4 of 9 patients (44.4%) with conservative treatment. However, patients who underwent bypass surgery had a lower chance of rebleeding. No significant difference in chance of rebleeding was observed between bypass surgery and non surgery groups (p > 0.05). Cerebral angiography performed after bypass surgery showed that for achieving good postoperative revascularization, direct and combined bypass methods were much more effective (p < 0.05). While the risk of rebleeding in the revascularization group was generally lower than in the conservative treatment group, there was no statistically significant difference between treatment modalities and conservative treatment. Although statistical significance was not attained, direct and combined bypass may reduce the risk of hemorrhage more effectively than indirect bypass.

Thirteen-year Experience of 44 Patients with Adult Hemorrhagic Moyamoya Disease from a Single Institution: Clinical Analysis by Management Modality

Our objective was a retrospective assessment of the management modalities that provided the most beneficial treatment in hemorrhagic moyamoya disease during the last 13 years at our institution. The clinical results of 44 patients with hemorrhagic moyamoya disease were investigated, comparing revascularization surgery (direct, indirect, and combined bypass) or conservative treatment. Angiographic features, rebleeding, and clinical outcome were investigated. Six of the 35 patients (17.1%) with revascularization surgery experienced rebleeding, as did 4 of 9 patients (44.4%) with conservative treatment. However, patients who underwent bypass surgery had a lower chance of rebleeding. No significant difference in chance of rebleeding was observed between bypass surgery and non surgery groups (p > 0.05). Cerebral angiography performed after bypass surgery showed that for achieving good postoperative revascularization, direct and combined bypass methods were much more effective (p < 0.05). While the risk of rebleeding in the revascularization group was generally lower than in the conservative treatment group, there was no statistically significant difference between treatment modalities and conservative treatment. Although statistical significance was not attained, direct and combined bypass may reduce the risk of hemorrhage more effectively than indirect bypass.

Primeros resultados comparativos de dos vías de abordajes de cirugía de revascularización coronaria mínimamente invasiva / First comparative results from two-ways surgical approaches of minimally-invasive coronary revascularization

INTRODUCCIÓN. El objetivo de esta investigación fue exponer y comparar los resultados de 2 vías de abordaje diferentes (toracotomía anterior izquierda y esternotomía media longitudinal) para revascularización miocárdica con corazón latiendo, practicadas en el Hospital Hermanos Ameijeiras entre septiembre de 2007 (cuando se introdujo en el centro la técnica mediante toracotomía) y enero del 2008. MÉTODOS. Se realizó un estudio prospectivo y descriptivo longitudinal para comparar resultados según la vía de abordaje quirúrgico para revascularización miocárdica mínimamente invasiva: vía habitual, por esternotomía media longitudinal (29 operados; 65,9 por ciento) y vía nueva y no habitual por toracotomía anterior izquierda (15 operados; 34,1 por ciento). RESULTADOS. El promedio de derivaciones realizadas fue de 3,31 mediante esternotomía y de 3 por toracotomía. Requirió transfusiones el 96,6 por ciento y el 26,7 por ciento de los pacientes operados por esternotomía y toracotomía, respectivamente, lo cual fue estadísticamente significativo. El uso de fármacos inotrópicos y de balón de contrapulsación intraórtico no fue estadísticamente significativo. El tiempo quirúrgico usual en ambas técnicas fue de 5 a 7 h, mientras que el tiempo de intubación fue significativamente mayor en los pacientes operados por esternotomía (11-14 h frente a 3-6 h en la toracotomía). Igual fue significativa la estadía, mayor en la esternotomía (3-4 días frente a 1-2 días en la toracotomía). La hemorragia posoperatoria fue significativamente mayor en la esternotomía. No hubo diferencia estadística cuando se compararon las complicaciones y la mortalidad. CONCLUSIONES. La vía de abordaje por toracotomía para la revascularización miocárdica es una técnica alternativa, efectiva y segura. Observamos que es posible realizar una revascularización miocárdica completa sin comprometer la seguridad del procedimiento y la calidad de las anastomosis. Los costos son algo menores por esta vía que por la habitual, e igualmente son significativos los resultados en cuanto a estadía hospitalaria y uso de hemoderivados, por lo cual proponemos continuar trabajando en la estabilización de esta nueva vía de cirugía coronaria en nuestro servicio(AU)

INTRODUCTION.The objective of present paper was to expose and to compare the results from two-ways different approaches (left anterior thoracotomy and longitudinal medium sternotomy) for myocardial revascularization with the heart beating carried out in the Hermanos Ameijeiras Clinical Surgical Hospital between September, 2007 (when this technique was introduced by thoracotomy ) and January, 2008. METHODS. A longitudinal, descriptive and prospective study was conducted to compare the results depending on the surgical approach for minimally invasive myocardial revascularization: usual route, by longitudinal medium sternotomy (29 operated on, 65,9 percent) and the new rout and unusual by left anterior thoracotomy (15 operated on, 34,1 percent). RESULTS. The average of shunts carried out was of 3,31 by sternotomy and of 3 by thoracotomy. The 96,6 and the 26,7 percent of operated on sternotomy and thoracotomy, respectively need blood transfusions which was statistically significant. The use of inotropic drugs and of intra-aortic balloon counterpulsation hasn't statistical significance.The usual surgical time in both techniques was of 5 to 7 h, whereas the intubation was greater in patients operated on using sternotomy (11-14 h versus 3-6 h in the thoracotomy). The hospital stay was greater in the cases of sternotomy ( 3-4 days versus 1-2 days in those of sternotomy. There weren't statistical difference when complications and mortality were compared. CONCLUSIONS. The approach route using thoratocomy for myocardial revascularization is a alternative, effective and safe technique. It is possible to carry out a complete myocardial revascularization without compromising the procedure safe and he anastomoses quality. The costs are less using this route than with the usual one and the results are similarly significant as regards hospital stay and the use of hemoderivatives, thus, authors propose to continue working in the stabilization of this new route or coronary surgery in our service(AU)

Miniesternotomia na cirurgia de revascularização miocárdica preserva função pulmonar pós-operatória / Ministernotomy in myocardial revascularization preserves postoperative pulmonary function

FUNDAMENTO: Na cirurgia de revascularização miocárdica (RM), a necessidade da esternotomia mediana tem sido considerada um fator para a redução de função pulmonar pós-operatória. OBJETIVO: Avaliar prospectivamente a função pulmonar no pós-operatório (PO) precoce de pacientes submetidos à RM sem circulação extracorpórea (CEC), comparando a esternotomia mediana convencional com a miniesternotomia. MÉTODOS: Foram estudados 18 pacientes e alocados em dois grupos: Grupo esternotomia mediana convencional (EMC, n=10) e Grupo miniesternotomia (ME, n=8). Registros espirométricos da capacidade vital forçada (CVF) e do volume expiratório forçado no primeiro segundo (VEF1) foram obtidos antes e no 1º, 3º e 5º dias de PO, e a gasometria arterial, antes e no 1º dia de PO. Também foram avaliados o percentual do shunt pulmonar e o escore de dor. RESULTADOS: Quando comparados em percentual do valor do pré-operatório, a CVF foi maior no grupo ME do que no grupo EMC no 1º, 3º e 5º dias de PO (p<0,001). Resultados similares foram encontrados para o VEF1. A recuperação da CVF entre o 1º e o 5º dia de PO foi maior no grupo EM do que no grupo EMC (p=0,043). A PaO2 diminuiu no 1º dia de PO em ambos os grupos (p<0,05), com maior queda no grupo EMC (p=0,002). O shunt aumentou nos dois grupos no 1º dia de PO (p<0,05), porém foi menor no grupo ME (p=0,02). A dor referida e a permanência hospitalar foram menores no grupo ME. CONCLUSÃO: Pacientes submetidos à cirurgia de RM por miniesternotomia apresentaram melhor preservação e recuperação da função pulmonar que os submetidos à esternotomia mediana.

BACKGROUND: In coronary artery bypass graft (CABG) surgery, the need to perform a midsternotomy has been considered a factor for the decrease in postoperative pulmonary function. OBJECTIVE: To prospectively evaluate early postoperative (PO) pulmonary function in patients submitted to off-pump CABG, comparing the conventional midsternotomy with the ministernotomy approach. METHODS: A total of 18 patients were evaluated and assigned to the two groups: Group Conventional Midsternotomy (CMS, n=10) and Group Ministernotomy (MS, n=8). Spirometric results of the forced vital capacity (FVC) and the Forced Expiratory Volume in one second (FEV1) were obtained on the 1st, 3rd and 5th PO days and the arterial gasometry was obtained before and on the 1st PO day. The pulmonary shunt percentage and the pain score were also assessed. RESULTS: When compared in terms of percentage of the preoperative value, the FVC was higher in the MS group than in the CMS group on the 1st, 3rd and 5th PO days (p<0.001). Similar results were obtained for FEV1. The recovery of the FVC between the 1st and the 5th PO days was higher in the MS than in the CMS group (p=0,043). The PaO2 decreased on the 1st PO day in both groups (p<0.05), with a higher decrease in the CMS group (p=0.002). The shunt increased in the two groups on the 1st PO day (p<0.05); however, it was lower in the MS group (p=0.02). The reported pain score was lower and the duration of the hospital stay was shorter in the MS group. CONCLUSION: Patients submitted to CABG by MS present better preservation and recovery of pulmonary function than those submitted to CMS.