El reto del aneurisma de la aorta abdominal para especialistas en medicina general integral e internistas / The challenge of abdominal aortic aneurysm for general practitioners and internists

El aneurisma de la aorta abdominal es una enfermedad asintomática, frecuente en los adultos mayores del sexo masculino. Su aparición está asociada a enfermedades crónicas no transmisibles como la hipertensión arterial, la enfermedad arterial periférica, la diabetes mellitus, entre otras. A nivel comunitario constituye un problema de salud el diagnóstico tardío de la entidad en pacientes con factores de riesgo, por lo que se decide realizar el artículo de revisión con el objetivo de actualizar los aspectos de diagnóstico clínico, imagenológico, terapéutico y la conducta a seguir ante un paciente con sospecha de aneurisma de la aorta. Se realizó una revisión exhaustiva del tema en bases de datos como SciELO, MEDISAN, Revistas de Angiología y Cirugía Cardiovascular. Para lograr mejores resultados en el diagnóstico precoz y la atención a los pacientes con aneurisma de la aorta abdominal, es necesario mantener la actualización del tema, el uso del método clínico y el trabajo en conjunto de la atención primaria con el nivel secundario(AU)

Abdominal aortic aneurysm is an asymptomatic disease, common in older males. Its appearance is associated with chronic non-communicable diseases such as arterial hypertension, peripheral arterial disease, diabetes mellitus, among others. At the community level, the late diagnosis of the entity in patients with risk factors constitutes a health problem, so it was decided to carry out the review article with the aim of updating the clinical, imaging and therapeutic aspects of diagnosis and the behavior to be followed in a patient with suspected aortic aneurysm. We conducted an exhaustive review of the subject in databases such as SciELO, Medisan, Magazines of Angiology and Cardiovascular Surgery. To achieve better results in the early diagnosis and care of patients with abdominal aortic aneurysm, it is necessary to keep up-to-date on the subject, the use of the clinical method, and the joint work of primary care with the secondary level(AU)

Signs of impending rupture in abdominal aortic and iliac artery aneurysms by computed tomography: Outcomes in 41 patients

OBJECTIVES: This study aimed to determine the prevalence of signs of impending rupture (SIR) in asymptomatic patients with abdominal aortic and iliac artery aneurysms, and to evaluate whether these signs were associated with rupture in asymptomatic patients. METHODS: This was a retrospective study of patients with abdominal aortic and iliac artery aneurysms identified on computed tomography (CT) over a 10-year period in a single center. The CT scans were reviewed by two reviewers, and patients with SIR were assigned to one of three groups: (1) early symptomatic (ES), (2) late symptomatic (LS), and (3) always asymptomatic (AA). The four main SIR described in the literature were investigated: 1) crescent sign, 2) focal wall discontinuity of circumferential calcifications, 3) aortic bulges or blebs, and 4) aortic draping. RESULTS: From a total of 759 aortic and iliac aneurysm reports on 2226 CT scans, we identified 41 patients with at least one SIR, and a prevalence of 4.14% in asymptomatic patients. Focal wall discontinuity of circumferential calcifications was the most common sign, and it was present in 46.3% of these patients (19/41); among these, 26 were repaired (ES: 9, LS: 2, AA: 15). Eleven asymptomatic patients underwent follow-up CT. The aneurysm increased in size in 6 of the 11 (54.5%) patients, and three ruptured (all with discontinuity of calcifications), one of which had no increase in diameter. CONCLUSIONS: The presence of focal wall discontinuity of circumferential calcifications was the most common SIR. There was a prevalence of all signs in less than 5% of asymptomatic patients. In unrepaired patients, the signs could be observed on follow-up CT scans with an increase in aneurysm size, indicating that the presence of SIR alone in the absence of other clinical factors or aneurysm characteristics is an insufficient indication for surgery.

A workshop on asthma management programs and centers in Brazil: reviewing and explaining concepts / Programas e centros de atenção a asmáticos no Brasil; uma oficina de trabalho: revisitando e explicitando conceitos

Objective: To report the results of a workshop regarding asthma management programs and centers (AMPCs) in Brazil, so that they can be used as a tool for the improvement and advancement of current and future AMPCs. Methods: The workshop consisted of five presentations and the corresponding group discussions. The working groups discussed the following themes: implementation of asthma management strategies; human resources needed for AMPCs; financial resources needed for AMPCs; and operational maintenance of AMPCs. Results: The workshop involved 39 participants, from all regions of the country, representing associations of asthma patients (n = 3), universities (n = 7), and AMPCs (n = 29). We found a direct relationship between a lack of planning and the failure of AMPCs. Based on the experiences reported during the workshop, the common assumptions about AMPCs in Brazil were the importance of raising awareness of managers; greater community participation; interdependence between primary care and specialized care; awareness of regionalization; and use of medications available in the public health system. Conclusions: Brazil already has a core of experience in the area of asthma management programs. The implementation of strategies for the management of chronic respiratory disease and their incorporation into health care system protocols would seem to be a natural progression. However, there is minimal experience in this area. Joint efforts by individuals with expertise in AMPCs could promote the implementation of asthma management strategies, thus speeding the creation of treatment networks, which might have a multiplier effect, precluding the need for isolated centers to start from zero. .

Objetivo: Relatar os resultados de uma oficina de trabalho sobre programas e centros de atenção a asmáticos (PCAAs) no Brasil para que possam servir como instrumento para melhoria e avanço dos PCAAs existentes e criação de novos. Métodos: A oficina de trabalho constituiu-se de cinco apresentações e discussões em grupos. Os grupos de trabalho discutiram os seguintes temas: implementação de uma linha de cuidado em asma; recursos humanos necessários para os PCAA; recursos necessários para financiar os PCAA; e manutenção do funcionamento dos PCAAs. Resultados: A oficina envolveu 39 participantes de todas as regiões do país, representando associações de asmáticos (n = 3), centros universitários (n = 7) e PCAAs (n = 29). Evidenciou-se uma relação direta entre a ausência de planejamento e o insucesso dos PCAAs. Com base nas experiências brasileiras elencadas durante a oficina, as premissas comuns foram a importância da sensibilização do gestor, maior participação da comunidade, interdependência entre a atenção primária e a especializada, observação da regionalização e utilização dos medicamentos disponíveis no sistema público de saúde. Conclusões: O Brasil já tem um núcleo de experiências na área programática da asma. A implementação de uma linha de cuidado em doenças respiratórias crônicas e sua inclusão nas redes de saúde parecem ser o caminho natural. Porém, a experiência nessa área ainda é pequena. Agregar pessoas com experiência nos PCAAs na elaboração da linha de cuidado em asma encurtaria tempo na criação de redes de atenção com possível efeito multiplicador, evitando que se partisse do zero em cada local isolado. .

Utilidad del eco-Doppler en el screening de la aorta abdominal / Usefulness of Doppler ultrasound for the screeining of the abdominal aorta

An aneurysm is a permanent dilatation of an artery due to a weakness in the arterial wall. The aortic aneurysm is defined as the enlargement of the diameter greater than 50% in his original size compared with a previous segment, or greater than 3 cm. If an abdominal aortic aneurysm is suspected on the basis of either the patient history or a prominent aortic pulse, an abdominal ultrasound examination should be done. The presence of an aneurysm is an indication for complete evaluation for strong consideration of surgical treatment. Rupture of an abdominal aneurysm is associated with sudden, massive blood loss. Many of these patients die before reaching a hospital. The striking difference in mortality rates between patients with ruptured aneurysms and those undergoing elective treatment makes a strong case for advising surgery to prevent deaths due to rupture. For these motives it is imperious to indicate ultrasound studies to provide concrete images of this disease. These considerations are expressed in this paper

Prevalência dos métodos de diagnóstico nos aneurismas de aorta abdominal / Prevalence between methods of diagnosis in abdominal aortic aneuryms

Objetivo: identificar com qual frequência diferentes métodos são responsáveis pelo diagnóstico inicial dos aneurismas de aorta abdominal (AAA) operados em nossa instituição no período de 2000 a 2002. Materias e métodos: foram estudados retrospectivamente, através da análise de prontuários, 200 pacientes consecutivamente submetidos à correção de AAA no períodode de dois anos. Resultados: oitenta e seis (43 por cento) pacientes tiveram o AAA clinicamente detectados, 113 (56,5 por cento) através de exames de imagem e um (0,5 por cento) durante laparotomia / Objectives: to identify the initial diagnostic method of abdominal aortic aneurysms (AAA)in patients submitted to surgeries from 2000 to 2002. Material and methods: there were analyzed 200 consective patients with an AAA submitted to resection and revascularization. Results: eight-six (43 per cent) were diagnosed clinically, 113 (56,5 per cent) during an imaging investigation...

Aneurismas de aorta abdominal: ¿está justificado su rastreo sistemático? / Aneurisms of abdominal aorta: is just its systematic tracking?

El presente estudio revisa la evidencia para el rastreo de aneurismas de aorta abdominal y está basado principalmente en la revisión sistemática de la Fuerza de Tareas Preventivas Estadounidense (US Preventive Service Task Force; Ann Intern Med 2005;142:203-211). Se analiza la definición, la epidemiología, la evidencia proveniente de distintos ensayos clínicos y se detallan las recomendaciones actuales para el rastreo en población y se analiza algunas consideraciones especiales (influencia del género; del tabaquismo; posibilidad de nueva ecografía luego de un estudio inicial normal; los posibles daños generados por el rastreo y por la reparación de AAA) . A su vez, los autores realizan un comentario acerca de la aplicabilidad de dichas recomendaciones, un posible algoritmo de rastreo y sus posibles dificultades al aplicarse a un contexto local.

Prevalence of abdominal aortic aneurysms: a screening program in São Paulo, Brazil

CONTEXTO: O aneurisma da aorta abdominal é uma doença assintomática, mas potencialmente fatal. Correção cirúrgica eletiva pode prevenir a rotura, e está indicada para aneurismas maiores do que 49 mm. Uma vez que os aneurismas tendem a crescer ao longo do tempo, a detecção daqueles pequenos implica em um acompanhamento cuidadoso destes pacientes. OBJETIVO: Conhecer a prevalência do aneurisma da aorta abdominal na população de São Paulo, Brasil. DESENHO: Estudo prospectivo, descritivo. LOCAL: Hospital Universitário da Universidade de São Paulo. PARTICIPANTES: Foi oferecida, por meio da imprensa, a indivíduos com 50 anos ou mais, a oportunidade de serem examinados para detecção de aneurisma da aorta abdominal. O número total de pessoas examinadas foi 2.756. PROCEDIMENTO: Todos foram submetidos a palpação abdominal e a ultra-sonografia. VARIAVEIS ESTUDADAS: Um diâmetro máximo de 30 mm ou mais foi considerado aneurisma. RESULTADOS: 64 aneurismas foram detectados, 9 dos quais medindo mais de 49 mm. A palpação detectou 60 aneurismas, mas apenas 20 destes foram confirmados pela ultra-sonografia; por outro lado, 41 dos aneurismas detectados pela ultra-sonografia não eram palpáveis. A percentagem de aneurismas da aorta abdominal encontrados na ultra-sonografia nos subgrupos e o intervalo de confiança de 95% foram os seguintes: total, 2,3 (1,8-3); homens, 4,6 (3,5-5,9); mulheres, 0,6 (0,3-1,1); homens com 60 anos ou mais, 6 (4,3-8); mulheres com 60 anos ou mais, 0,9 (0,4-1,8). CONCLUSAO: Em São Paulo, Brasil, estima-se que 1,8 a 3% das pessoas com 50 anos ou mais tenham aneurisma da aorta abdominal. No subgrupo de homens com 60 anos ou mais, a prevalência está entre 4,3 e 8%.

Frecuencia de aneurisma aórtico abdominal en población adulta con factores de riesgo conocidos / Frequency of abdominal aortic aneurysms in adult population with known risk factors

BACKGROUND: The incidence of abdominal aortic aneurysms has increased. Its predisposing factors are smoking, high blood pressure and dislipidemia. Progressive aneurysmal enlargement may lead to its rupture, which is associated to a mortality rate above 80 per cent. AIM: To assess the prevalence of abdominal aortic aneurysms in Chilean subjects with cardiovascular risk factors. SUBJECTS AND METHODS: Through announcements in open media we invited individuals aged over 60 years, who smoked, had hypertension and/or had occlusive arterial disease, to participate in a study that included medical history and physical examination. An aortic ultrasound was performed in all subjects in whom the aorta was not palpable or there was a suspicion of dilatation. Aortic diameter over 3 cm was considered aneurysmal. RESULTS: Three hundred fifty six subjects aged 67.1 +/- 6.7 years, (73.9 per cent males), were evaluated. The study group included 62 per cent hypertensives, 39 per cent with abnormal lipids and 46 per cent smokers. Known coronary heart disease or peripheral arterial diseases were present in 14 per cent and 10 per cent, respectively. Ultrasound was required in 159 subjects. Aneurysms were detected in 21 persons (5.9 per cent), 7.6 per cent in males and 1.1 per cent in females. The mean transverse diameter of the aneurysm was 4.1 cm (3-7.5). Aneurysm was found in 2.3 per cent of subjects younger than 65 years and 8.3 per cent of subjects aged over 65 years. CONCLUSIONS: In this sample the prevalence of abdominal aortic aneurysms was 5.9 per cent, affecting predominantly males, with a notorious increase with advanced age.

Screening for abdominal aortic aneurysms

OBJECTIVE AND METHODS: Screening for abdominal aortic aneurysms may be useful to decrease mortality related to rupture. We conducted a study to assess the prevalence of abdominal aortic aneurysms in southern Brazil and to define risk factors associated with high prevalence of this disorder. The screening was conducted using abdominal ultrasound. Three groups were studied: Group 1 - cardiology clinic patients; Group 2 - individuals with severe ischemic disease and previous coronary surgery, or important lesions on cardiac catheterism; Group 3 - individuals without cardiac disease selected from the general population. All individuals were male and older than 54 years of age. The ultrasonographic diagnosis of aneurysm was based on an anteroposterior abdominal aorta diameter of 3 cm, or on an abdominal aorta diameter 0.5 cm greater than that of the supra-renal aorta. RESULTS: A total of 2.281 people were screened for abdominal aortic aneurysms in all groups: Group 1 - 768 individuals, Group 2 - 501 individuals, and Group 3 - 1012 individuals. The prevalence of aneurysms was 4.3 percent, 6.8 percent and 1.7 percent, respectively. Age and cigarette smoking were significantly associated with increased prevalence of aneurysms, as was the diagnosis of peripheral artery disease. DISCUSSION: We concluded that screening may be an important tool to prevent the mortality associated with abdominal aortic aneurysms surgery. Additionally, the cost of screening can be decreased if only individuals presenting significant risk factors, such as coronary and peripheral artery disease, smokers and relatives of aneurysm patients, are examined

Aneurismas aórticos yuxta y pararrenales / Juxtarenal and pararenal aortic aneurysms

Los aneurismas aórticos yuxta y pararrenales siguen siendo un reto para el angiólogo y cirujano vascular que se enfrenta a ellos, no sólo por sus complejas soluciones quirúrgicas, sino también por sus limitaciones diagnósticas dada su topografía y al momento en que se desencadenan sus síntomas clínicos, que por lo general constituyen urgencias medicoquirúrgicas. En busca de un mejor manejo clínico, diagnóstico y terapéutico se realiza esta amplia y actualizada revisión de la enfermedad ectasiante de la aorta abdominal en su segmento yuxta y pararrenal, que permita a todos los angiólogos, cirujanos vasculares, generales, urólogos, en fin, a todos los relacionados con afecciones de esta topografía, reflexionar en algunos artificios técnicos, en nuevos diseños diagnósticos y manejo anestésico, que permitan lograr soluciones reales y de supervivencia a los pacientes que sufran de esta entidad(AU)

Juxtarenal and pararenal aneurysms are still a challenge to the angiologist and vascular surgeon not only because of their complex surgical solutions, but also because of their diagnostic limitations resulting from their topography and from the time their clinical symptoms, which are generally medicosurgical emergencies, appear. In order to have a better clinical, diagnostic and therapeutic management, this wide and updated review of the ectatic disease in its juxtarrenal and pararenal segment of the aorta was made, allowing angiologists, vascular and general surgeons, urologists, and all those related to affections of this topography to reflect on some technical artifices, new diagnostic designs and anesthetic management that make possible to find real and survival solutions for those patients suffering from this disease(AU)

Obstrucción duodenal por aneurisma de aorta abdominal / Duodenal obstruction due to aortic aneurism

La obstrucción duodenal por un aneurisma de aorta abdominal es un hallazgo infrecuente. Se reporta un caso de obstrucción de la tercera porción duodenal producida por un gran aneurisma de la aorta abdominal. A diferencia de otros casos reportados, donde el aneurisma produce disminución del ángulo de salida de la arteria mesentérica superior, produciendo obstrucción de la tercera porción del duodeno, en el caso presentado se muestra claramente que la obstrucción es provocada por el aneurisma aórtico y no por la arteria mesentérica superior

Revisión de 57 casos de aneurismas de la aorta abdominal en el Hospital Dr. Salvador B. Gautier / Review of 57 cases of abdominal aorta aneurysm in Dr. Salvador B. Gautier Hospital

Revisamos 57 casos admitidos en el Hospital Dr. Salvador B. Gautier, con el diagnóstico de Aneurisma de la Aorta Abdominal. El 82//fueron masculinos y localizados debajo de las arterias renales en el 91//de los casos. Los síntomas y hallazgos fueron los mismos reportados en la mayoría de la literatura. La sonografía y tomografía demostraron ser de mucha importancia para localizar anatómicamente el aneurisma, asi como medir su diámetro transversal. En nuestros casos usamos mayormente injertos bifurcados tipo DeBakey de dacron tejido. El 21//de los casos fueron operados de emergencia por rotura, con una mortalidad aceptable de 42//. La mortalidad operatoria en los casos electivos fue ligeramente elevada (8.8//), pero mucho más baja que en los casos rotos, por lo que recomendamos intervenir electivamente estos pacientes, que presenten aneurismas de 5 cm o más de diámetro o que presenten dolor