Uso de balões intrauterinos em pacientes com hemorragia pós-parto / Use of intrauterine balloons in patients with postpartum haemorrhage

A hemorragia pós-parto é uma complicação presente em mais de 18% dos nascimentos e responsável por cerca de 25 a 30% das mortes maternas no mundo. No Brasil, apesar da ampliação do acesso aos serviços de saúde e da melhoria em praticamente todos os indicadores de saúde materna, esta etiologia continua se apresentando entre os três principais grupos de causas de morte no ciclo grávido-puerperal. Nas últimas décadas, várias técnicas conservadoras visando o controle hemorrágico no período pós-parto têm sido relatadas, com destaque para as técnicas de desvascularização uterina, suturas compressivas, embolização arterial, balões intrauterinos e a interrupção do ato operatório com laparostomia, empacotamento pélvico e posterior reabordagem cirúrgica. O presente artigo apresenta uma revisão do uso de balões intrauterinos no controle hemorrágico com destaque para os tipos, aplicabilidades e cronologia de invenção e publicações. Foram avaliados os balões de Sengstaken-Blakemore, os artesanais, as sondas de Foley, balão de Rusch, de Bakri e o BT-cath. Detalhou-se também o teste do tamponamento e a técnica do "sanduíche uterino".(AU)

Postpartum hemorrhage is present in over 18% of births and accounts for 25-30% of maternal deaths worldwide. In Brazil, despite the expansion of access to health care and the improvement of virtually all maternal health indicators, such etiology is still present among the three main causes of death during pregnancy and childbirth. In the last decades, several conservative techniques direct at controlling hemorrhage in the postpartum period have been reported, principally techniques of uterine devascularization, compression sutures, arterial embolization, intrauterine balloons and surgery interruption with laparostomy, pelvic packing and subsequent surgical intervention. This article presents a review of the use of intrauterine balloons in controlling hemorrhage especially types, applicability and chronology of invention and publications. Sengstaken-Blakemore balloons, the artisanal, Foley probes, Rusch balloon, Bakri and BT-cath were reviewed. The tamponade test and the "uterine sandwich" technique were also detailed.(AU)

Initial Experience with the New Double-lumen Scepter Balloon Catheter for Treatment of Wide-necked Aneurysms

OBJECTIVE: A new double-lumen balloon catheter was being developed for the treatment of cerebral aneurysms. The purpose of this study is to report our initial experience of a double-lumen balloon catheter for the treatment of wide-necked aneurysms. MATERIALS AND METHODS: Seventeen patients (mean age, 63 years; range, 45-80 years) with wide-necked, with or without a branch-incorporated aneurysms, (10 ruptured and 9 unruptured) were treated with balloon-assisted coil embolization using a double-lumen balloon catheter (Scepter C(TM) or Scepter XC(TM)) for 7 months after being introduced to our country. Locations of the aneurysms were posterior communicating artery (n = 7), anterior communicating artery or A2 (n = 7), middle cerebral artery (MCA) bifurcation (n = 3), basilar artery tip (n = 1) and anterior choroidal artery (n = 1). The initial clinical and angiographic outcomes were retrospectively evaluated. RESULTS: Coil embolization was successfully completed in all 19 aneurysms, resulting in complete occlusions (n = 18) or residual neck (n = 1). In one procedure, a thrombus formation was detected at the neck portion of the ruptured MCA bifurcation aneurysm near to the end of the procedure. It was completely resolved with an intra-arterial infusion of Glycoprotein IIb/IIIa inhibitor (Tirofiban, 1.0 mg) without any clinical sequela. There were no treatment-related events in the remaining 18 aneurysms. At discharge, functional neurological state improved in 11 patients (10 patients with ruptured aneurysm and 1 with unruptured aneurysm presenting with mass symptoms) and 6 patients with unruptured aneurysms had no newly developed symptoms. CONCLUSION: In this preliminary case series, the newly developed double-lumen Scepter balloon appears to be a safe and convenient device for coil embolization of wide-necked aneurysms.

Transcatheter closure of perimembranous ventricular septal defect with amplatzer membranous occluder.

BACKGROUND: Use of trancatheter device closure for membranous ventricular septal defect is still in evolving phase. We report the early and mid-term results of our experience with the new asymmetric Amplatzer membranous ventricular septal defect occluder. METHODS AND RESULTS: We attempted, transcatheter closure of perimembranous ventricular septal defect using asymmetric Amplatzer occluder in 26 patients. The patients were selected on the basis of transthoracic and transesophageal echocardiographic assessment of the ventricular septal defect. The procedure was successful in 21 (81%) patients. The age ranged from 3 to 23 years, weight from 10 to 59 kg and defect size ranged from 3 to 9 mm (mean: 5 +/- 1.8 mm). One patient had situs inversus with dextrocardia: 11 had aneurysmal tissue partly occluding the defect and the device was deployed either across (n=6) or within the aneurysmal sac (n=5). Three patients developed high degree atrioventricular block on attempts to cross the defect with the sheath and the procedure was discontinued. In two patients it was not possible to place the sheath in left ventricle despite repeated attempts. There was a residual flow in 4 (19%) patients at 24 hours. Two patients developed bundle branch block and none had complete heart block. At follow-up (1-9 months, n=20), residual flow was seen in two patients. None developed late conduction defect, aortic regurgitation, infective endocarditis or hemolysis. CONCLUSIONS: Transcatheter closure of perimembranous ventricular septal defect can be performed safely and effectively with the new asymmetric Amplatzer occluder device in selected patients with good short- and midterm results. These devices can be deployed safely in and across and the aneurysmal sacs. In selected cases, this procedure is a satisfactory alternative to surgery.

Use of Amplatzer duct occluder to close severely hypertensive ducts: utility of transient balloon occlusion.

BACKGROUND: The dividing line between a patent ductus arteriosus with severe but reversible pulmonary artery hypertension and an Eisenmenger duct remains elusive. Increasing experience with the Amplatzer duct occluder has made non-surgical closure of even large patent ductus arteriosus simple and safe. However, data on the use of this device in severly hypertensive ducti is sparse. METHODS AND RESULTS: There were six patients (2 males, 4 females), wherein transient ductal occlusion was done with an embolectomy balloon catheter. The post-occlusion hemodynamics along with overall clinical and hemodynamic assessment was used to decide the likelihood of benefit of closure and the choice of the device. In four of six patients of patent ductus arteriosus with severe pulmonary artery hypertension (pulmonary vascular resistance index> 8.0 U/m2) the duct was successfully closed using the Amplatzer duct occluder, while in two an Amplatzer ventricular septal defect occluder was used. CONCLUSIONS: Transient balloon occlusion is quite helpful for assessing patients with patent ductus arteriosus with severe pulmonary hypertension, and short-term non-invasive follow-up has shown this strategy to be safe and useful.

Closure of two atrial septal defects using two separate Amplatzer ASD devices.

The majority of patients with atrial septal defect require a single device for closure but a small proportion have more than one defect in the atrial septum. We report a patient who had two moderate-sized atrial septal defects in whom transcatheter closure of both the defects using two Amplatzer septal occluders was performed successfully.

Stenting of a large thrombus-containing subclavian artery stenosis using a distal protection device.

Atheromatous obstructive lesions of the arch vessels that contain thrombi are at high risk for distal embolization during angioplasty. This can lead to catastrophic neurological complications. We report a case of acute-on-chronic ischemia of the left upper limb due to thrombus-containing subclavian artery stenosis. After placement of an intravascular filter device, angioplasty and stent implantation successfully relieved the stenosis without any complications.

Successful transcatheter closure of ruptured sinus of Valsalva aneurysm.

We report a case in which a ruptured aneurysm of the sinus of Valsalva opening into the right atrium was successfully closed transcutaneously by an Amplatzer duct occluder.

Transcatheter coil occlusion of small patent ductus arteriosus: experience at Siriraj Hospital.

Transcatheter coil occlusion of small-to-moderate-size patent ductus arteriosus (PDA, < 3.5 mm) is well established as a procedure of first choice in many institutions. Its much lower cost compared with surgical ligation or other devices makes it an attractive option, especially in Thailand. PATIENTS AND METHOD: Between September 1995 and June 2000, all patients diagnosed with PDA with audible murmur and echo-Doppler confirmation of diameter less than 3.5 mm were scheduled for transcatheter coil occlusion at the Department of Pediatrics, Faculty of Medicine Siriraj Hospital. The hemodynamic studies were obtained both pre and post occlusion. The immediate and late outcome, including complication were assessed. RESULTS: A total of 77 cases, 78 procedures of transcatheter PDA coil occlusion were performed. Seventy cases (90.9%), comprised of 19 males (27.1%) and 51 females (72.9%) were successfully deployed with coils. The remainder were unsuccessfully deployed and later referred to surgery. The median age of the successful group was 6 years and 6 months and median weight was 16.5 kg. Twenty cases (28.6%) had other associated intra and extracardiac anomalies. All patients were asymptomatic, except one case having bronchopulmonary dysplasia (BPD) from prolonged ventilation. Single-coil occlusions were performed in 74.3 per cent and double-coil occlusions in 25.7 per cent. Conventional 0.038-inch Gianturco coils were deployed in 86.5 per cent. The mean procedure time was 78.1 +/- 35.1 minutes. The mean fluoroscopic time was 20.2 +/- 15.6 minutes. The total complete occlusion rate was 87.7 per cent. Tiny residual flow of PDA was demonstrated by follow-up echocardiogram in 12.3 per cent. Seven per cent of the patients were lost to follow-up. There was no significant difference in PDA size and hemodynamics between the groups of patients with complete occlusion and having residual shunt. Minor complications occurred in 12.9 per cent, including mild left pulmonary artery stenosis (10%), coil embolization to distal pulmonary artery (8.6%), slippage of catheter with coil (2.9%) and decreased dorsalis pedis pulse (1.4%). One late death was found in a BPD patient from pneumonia 2 months after the procedure. CONCLUSION: Transcatheter coil occlusion of PDA is as effective, feasible, safe and less costly than surgical ligation. With improvement in technique and device selection and appropriate case selection, there should be an increase rate of complete occlusion and a decrease in complications.

Transcatheter closure of patent ductus arteriosus in adults using the Amplatzer duct occluder: initial results and follow-up.

BACKGROUND: Surgical closure of patent ductus arteriosus in adult patients may be problematic. Transcatheter closure of patent ductus arteriosus is an established procedure. Recently, transcatheter closure of patent ductus arteriosus using the Amplatzer duct occluder has been shown to be safe and efficacious. We present our experience with this device in adults. METHODS AND RESULTS: Between January 2000 and January 2002,41 adult patients (31 females and 10 males) with a patent ductus arteriosus were referred for closure with the Amplatzer duct occluder. The median age was 35.6 years (range 18-70.7 years) and the median weight was 65.8 kg (range 32.7-164.5 kg). Of these 41 patients, 37 underwent attempted closure of the patent ductus arteriosus using the Amplatzer duct occluder. The device was successfully deployed in all patients except 1. Complete angiographic closure was seen Immediately after device deployment in 29 out of 36 patients (81%). Complete echocardiographic closure was demonstrated within 24 hours post-procedure in 34 out of 36 patients (94%), and at 6-month follow-up in 35 out of 36 patients (97%). No complications related to device implantation occurred in any patient. CONCLUSIONS: Closure of patent ductus arteriosus using the Amplatzer duct occluder is safe and effective in adults.