Um cirurgião sob o olhar de Deus

Objetivo A síndrome de Terson (ST), também conhecida como hemorragia vítrea, é relatada em pacientes com hemorragia subaracnóide causada por um aneurisma rompido. Este estudo tem como objetivo avaliar a presença de hemorragia ocular nesses pacientes, buscando identificar aqueles que poderiam se beneficiar do tratamento específico para a recuperação do déficit visual. Métodos Estudo prospectivo de 53 pacientes com hemorragia subaracnóide espontânea (SSAH) por aneurisma rompido. Os pacientes foram avaliados quanto à hemorragia vítrea por fundoscopia indireta com 6 a 12 meses de seguimento. Resultados A idade dos pacientes variou de 17 a 79 anos (média de 45,9 ± 11,7); 39 pacientes eram do sexo feminino (73%) e 14 do sexo masculino (27%). Seis pacientes (11%) apresentaram ST e 83,3% apresentaram perda transitória de consciência durante a ictus. Conclusões Uma avaliação oftalmológica deve ser realizada rotineiramente em pacientes com hemorragia subaracnóide, especialmente naqueles com pior grau neurológico. Além disso, o prognóstico foi ruim em pacientes com ST.

Terson Syndrome: Assessment of 53 Patients with Subarachnoid Hemorrhage by a Ruptured Aneurysm

Objective Terson syndrome (TS), also known as vitreous hemorrhage, is reported in patients with subarachnoid hemorrhage caused by a ruptured aneurysm. This study aims to evaluate the presence of ocular hemorrhage in such patients, trying to identify those who could benefit from the specific treatment for visual deficit recovery. Methods Prospective study of 53 patients with spontaneous subarachnoid hemorrhage (SSAH) due to ruptured aneurysm. The patients were evaluated for vitreous hemorrhage through indirect fundoscopy with 6 to 12 months of follow-up. Results The ages of the patients ranged from 17 to 79 years-old (mean age, 45.9 11.7); 39 patients were female (73%) and 14 were male (27%). Six patients (11%) presented TS, and 83.3% had a transient loss of consciousness during ictus. Conclusions An ophthalmologic evaluation must be routinely performed in subarachnoid hemorrhage patients, especially in those with worse neurological grade. Moreover, prognosis was bad in TS patients.

"Overtime Hours Effect" on emergency surgery of acute type A aortic dissection

Abstract Objective: Treatment of acute diseases of the aorta is still associated with high mortality and morbidity. It is believed that interventions for these diseases on overtime hours (night shifts or weekend shifts) may increase mortality. In this study, we investigated the effect of performing acute type A aortic dissection surgery on overtime hours in terms of postoperative outcomes. Methods: 206 patients who underwent emergency surgery for acute type A aortic dissection were retrospectively evaluated. Two groups were constituted: patients operated on daytime working hours (n=61), and patients operated on overtime hours (n=145), respectively. Results: Chronic obstructive pulmonary disease and repeat surgery were higher in group 1. There was no statistically significant difference between the two groups in terms of operative and postoperative results. Mortality rates and postoperative neurological complications in group 1 were 9.8% and 13.1%, respectively. In group 2, these rates were 13.8% and 12.4%, respectively (P=0.485 - P=0.890). Multivariate analysis identified that cross-clamp time, amount of postoperative drainage, preoperative loss of consciousness and postoperative neurological complications are the independent predictors of mortality. Conclusions: As the surgical experience of the clinics improves, treatment of acute type A aortic dissections can be successfully performed both overtime and daytime working hours.

Risk factors for survival following open surgical repair of ruptured abdominal aortic aneurysms: a 13-year experience

Surgical treatment of a ruptured abdominal aorta aneurysm [RAAA] continues to present a significant challenge to surgeons. There are some patient factors such as age and gender that cannot be changed, and comorbid conditions can be optimized but not eliminated. The purpose of this study was to identify the risk factors affecting high mortality after the surgical repair of an RAAA. Data on 121 patients who underwent surgical repair for RAAAs between January 1997 and June 2011 in our institution were collected retrospectively. All the patients had been diagnosed by computed tomography [CT] scans, and intraoperative extra-luminal blood was visualized intraoperatively. Variables studied comprised demographic data; preoperative, operative, and postoperative data; and the causes of mortality. Multivariate regression analysis was used to determine the predictors of mortality. One hundred eight [89.2%] patients were male and 13 [10.7%] were female at an average age of 68.9 +/- 10.5 years. Totally, 121 patients underwent surgery for RAAAs. Fifty-four patients had aortic tube grafts, 32 aortobiiliac grafts, 20 aortobifemoral grafts, 1 aortoiliac graft, and 1 aortofemoral graft for the replacement of the RAAAs. Seven patients had only surgical exploration. Operative mortality was 41.3% [50 patients]. The factors associated with mortality were preoperative shock, free blood, positive inotropic agent, hematocrit value, and need for blood and plasma. In the multivariate analysis, preoperative shock and positive inotropic agents were found to be significant as the predictors of death [OR: 19.8, 95%CI: 3.2-122.8 and OR: 8.6, 95% CI: 2.9-26.3, respectively]. This study revealed that the preoperative clinical findings affected the mortality associated with RAAAs

Endovascular Repair versus Open Repair for Isolated Descending Thoracic Aortic Aneurysm

PURPOSE: To compare the outcomes of thoracic endovascular aortic repair (TEVAR) with those of open repair for descending thoracic aortic aneurysms (DTAA). MATERIALS AND METHODS: We compared the outcomes of 114 patients with DTAA and proximal landing zones 3 or 4 after TEVAR to those of 53 patients after conventional open repairs. Thirty-day and late mortality were the primary endpoints, and early morbidities, aneurysm-related death, and re-intervention were the secondary endpoints. RESULTS: The TEVAR group was older and had more incidences of dissecting aneurysm. The mean follow-up was 36+/-26 months (follow-up rate, 97.8%). The 30-day mortality in the TEVAR and open repair groups were 3.5% and 9.4% (p=0.11). Perioperative stroke and paraplegia incidences were similar between the groups [5.3% vs. 7.5% (p=0.56) and 7.5% vs. 3.5% (p=0.26), respectively]. Respiratory failure occurred more in the open repair group (1.8% vs. 26.4%, p<0.01). The incidence of acute kidney injury requiring dialysis was higher in the open repair group (1.8% vs. 9.4%, p<0.01). The cumulative survival rate was higher in the TEVAR group at 2 to 5 years (79.6% vs. 58.3%, p=0.03). The free from re-intervention was lower in the TEVAR group (65.3% vs. 100%, p=0.02), and the free from aneurysm-related death in the TEVAR and open repair groups were 88.5% and 86.1% (p=0.45). CONCLUSION: TEVAR is safe and effective for treating DTAAs with improved perioperative and long-term outcomes compared with open repair.

Predictors of Postoperative Mortality of Ruptured Abdominal Aortic Aneurysm: A Retrospective Clinical Study

PURPOSE: Despite significant improvements in surgery, anesthesia, and postoperative critical care, the postoperative mortality rate of ruptured abdominal aortic aneurysm (RAAA) has remained at 40% to 50% for several decades. Therefore, we evaluated factors associated with the postoperative mortality of RAAA. MATERIALS AND METHODS: From January 1999 to December 2008, a retrospective study was performed with 34 patients who underwent open repair of RAAA. The preoperative factors included age, sex, smoking, comorbidities, serum creatinine, hemoglobin, shock, pulse rate, and time from emergency room to operation room. The intraoperative factors included blood loss, transfusion, aortic clamping site and time, aneurysmal characteristics, rupture type, graft type, hourly urine output (HUO), and operative time. The postoperative factors included inotropic support, renal replacement therapy (RRT), reoperation, bowel ischemia, multiple organ failure (MOF), and intensive care unit stay. The 2-day and the 30-day mortality rates were analyzed separately. RESULTS: The 2-day and the 30-day mortality rates were 14.7% and 41.2%, respectively. On univariate analysis, shock, transfusion, HUO, inotropic support and MOF for the 2-day mortality and serum creatinine, transfusion, aortic clamping site, HUO, inotropic support, RRT and MOF for the 30-day mortality were statistically significant. On multivariate analysis, shock, inotropic support and MOF for the 2-day mortality and aortic clamping site, RRT and MOF for the 30-day mortality were statistically significant. CONCLUSION: To decrease the postoperative mortality rate of RAAA, prevention of massive hemorrhage and acute renal failure with infrarenal aortic clamping, as well as prompt operative control of bleeding and maintenance of systemic perfusion are important.

Mejores resultados en ruptura de aneurismas de aorta abdominal manejados con reparación endovascular: Algoritmo sugerido / Improved outcome of ruptured abdominal aortic aneurysms managed with endovascular repair: A suggested algorithm

Antecedentes: El propósito de este estudio es comparar la morbilidad y la mortalidad tanto de la reparación abierta (RA) como endovascular de la ruptura del aneurisma aórtico abdominal(rAAAs); y de presentar un algoritmo para el tratamiento y evaluaciones de la tomografía computarizada (CT) para determinar el uso de un balón oclusivo supra-celíaco. Métodos: Una revisión gráfica retrospectiva se realizó de los rAAAs tratados ya sea con reaparicióna cielo abierto (RA), ya sea con reparación aórtica endovascular (EVAR) entre junio de 1998 y junio de 2009. Se informaron las co-morbilidades, los datos peri-procedimientos y tanto la morbosidad como la mortalidad. Las TC se revisaron desde el uso inicial del balón oclusivo (Marzo de 2001) a fin de evaluar el hematoma retroperitoneal. Se desarrolló un algoritmo para determinarcuándo el balón oclusivo se debería implementar. El test exacto de Fisher, el t-test, y el test log rank fueron los que se utilizaron para el análisis estadístico.Resultados: Entre junio de 1998 y junio de 2009, 105 pacientes, 75 (71.4%) hombres, edad promedio de 74 años (rango 47-93) presentaron un rAAA y a 69 (65.2%) se les realizó la reparación a cielo abierto. 87 pacientes (82.9%) fueron sintomáticos y 25 (23.8%) tenían un AAA conocido. El tiempo medio transcurrido entre el diagnóstico y el tratamiento fue de 5 a 6 horas, 4.5 horas para la RA y de 8 horas para EVAR. El test rank log mostró una mejoría en la supervivencia con EVARa pesar del tiempo promedio más prolongado desde el diagnóstico al tratamiento. (p=0.02). Se administraron casi tres veces más concentrados de hematíes en el cohorte de reparación a cielo abierto (RA), 6.3 unidades y en EVAR 2.2 unidades. Se utilizaron vasopresores perioperatorios en el 57.1% de los casos, dos veces más en la RA, 69.6%, que con EVAR 33.3%. Se utilizó el balón oclusivo aórtico en el 27,6% de los casos, dos veces más frecuente en RA que en EVAR (41,7% verus 20,3%)...

Antecedentes: O propósito deste estudo é comparar a morbilidade e a mortalidade tanto da reparação aberta (RA) quanto endovascular, utilizadas no tratamento da ruptura do aneurisma aórtico abdominal (rAAAs); e de apresentar um algorítmo para o tratamento e avaliações da tomografiacomputarizada (CT) para assim determinar o uso de um balão para oclusão supra-celíaca. Métodos: Realizou-se uma revisão gráfica retrospectiva das rAAAs tratadas, seja com reparação a céu aberto (RA), ou com reparação aórtica endovascualar (EVAR) entre os meses de junho de1998 e junho de 2009. Informaram-se as comorbilidades, os dados periprocedimentos , além da morbidade e mortalidade. As TC foram revisadas desde o uso inicial do balão oclusivo (março de 2001) com o objetivo de avaliar o hematoma retroperitoneal. Desenvolveu-se um algorítmo para determinar quando o balão oclusivo deveria ser implementado. Para esta análise estatística, utilizaram-se o teste exato de Fisher, o t-test, e o test log Rank. Resultados: Entre junho de 1998 ejunho de 2009, 105 pacientes, 75 (71.4%) homens, com média de idade de 74 anos (média 47-93) apresentaram uma rAAA e em 69 (65.2%) realizou-se uma reparação a céu aberto. 87 pacientes (82.9%) foram sintomáticos e 25 (23.8%) tinham um AAA conhecido. O tempo médio transcorrido entre o diagnóstico e o tratamento foi de 5 a 6 horas, 4.5 horas para a RA e de 8 horas para aEVAR. O test rank log mostrou uma melhoria na sobrevivência com a EVAR, apesar do tempo médio mais prolongado do diagnóstico ao tratamento. (p=0.02). Administraram-se quase três vezes mais concentrados de hematies no grupo de reparação a céu aberto (RA), 6.3 unidades e no grupo EVAR, 2.2 unidades. Utilizaram-se vasopressores perioperatórios em 57.1% dos casos: 33.3% com EVAR e 69.6% com a RA, ou seja, duas vezes a mais. Utilizou-se o balão oclusivo aórtico em 27.6 % dos casos, duas vezes mais frequente nos casos da RA do que nos de EVAR (41.7 % versus 20.3%)...

Background: The purpose of this study is to compare morbidity and mortality of open and endovascular repair of ruptured abdominal aortic aneurysms (rAAAs); and present a treatment algorithm and assessment of computer tomography (CT) to determine usage of a supra-celiac occlusive balloon.Methods: Restrospective chart review was done of rAAAs treated with open (OR) or endovascular aortic repair (EVAR) between June 1998 and June 2009. Comorbidities, periprocedural data, and postoperative morbidity and mortality were recorded. CTs were reviewed from the initial use of the occlusive balloon (March 2001) to assess the retroperitoneal hematoma. An algorithm was developed determining when the occlusive balloon should be implemented. Fisher’s exact test, and log rank test were used for statistical analysis. Results: Between June 1998 and June 2009, 105 patients, 75 (71.4%) males, mean age of 74.0 years (range 47-93), presented with a rAAA and 69 (65.2%) received open repair. Eighty-seven patients(82.9%) were symptomatic and 25 (23.8%) had a known AAA. Mean time elapsed between diagnosis to treatment was 5.6 hours, 4.5 hours for OR and 8.0 hours for EVAR. Log rank test showsimproved survivability with the EVAR despite higher mean time from diagnosis to intervention (p=0.02). Nearly three times as much packed red blood cells were given in open repair cohort, O,6.3 units and EVAR, 2.2 units. Perioperative vasopressors were used in 57.1% of total cases, more than 2 times as often for O, 69.6%, and EVAR, 33.3%. Aortic occlusive balloon was used in 27.6% of cases, twice as often in EVAR (41.7% versus 20.3%)...

Aneurismas de aorta torácica e dissecção aórtica / Thoracic aortic aneurysms and aortic dissection

Doença da aorta é uma patologia significante e representa a 12ª maior causa de morte. Apesar de os aneurismas da aorta abdominal e aorta ascendente serem mais comum, aneurismas de aorta ascedentes (AATs) são uma significante contribuição para a patologia. AATs aumentam o risco de dissecção da aorta ou ruptura e representam uma importante fonte de morbidade e mortalidade. Podem ser classificadas como sindrômicas, familiares ou esporádicas. As formas sindrômicas incluem a Síndrome de Marfan, Síndrome de Loeyes-Dietz, Homocistinúria, Sindrome de Ehlers-Danlos, Síndrome B A V e Síndrome de Turner. Em vários casos, já existem testes genéticos específicos que permitem um diagnóstico precoce da patologia em familiares de indivíduos afetados que permitem o acompanhamento precoce com melhora da qualidade de vida e sobrevida desses indivíduos.

Aortic disease is a significant pathology and represents the 12th leading cause of death. Although aneurysms of the ascending aorta and abdominal aorta are more common, descendents aortic aneurysms (TAAs) are a significant contribution to the pathology. TAAs increase the risk of aortic dissection or rupture and represent an important source of morbidity and mortality. They can be classified as syndromic, familial or sporadic. The syndromic forms include Marfan syndrome, Dietz-Loeyes Syndrome, homocystinuria, Ehlers-Danlos syndrome, Turner syndrome and BAV syndrome. In several cases, specific genetic tests are already available and allow an early diagnosis of pathology in relatives of affected individuals that can lead to an early monitoring and improve the quality of life and survival of these individuals.

Enfoque interdisciplinario en el tratamiento del Síndrome de Marfan: resultados a 17 años / Interdisciplinary approach of Marfan Syndrome: a 17-year experience

Introducción: el Síndrome de Marfan (SM) es una enfermedad genética de baja prevalencia (1/5.000) individuos). Esta entidad posee características cardiovasculares, esqueléticas y oculares bien definidas. El pronóstico depende fundamentalmente de la dilatación de la raíz aórtica que provoca disección y/o ruptura de la misma. Hay gran desconocimiento sobre este síndrome por parte de los médicos de todas las especialidades. Con la formación de un equipo interdisciplinario diseñamos un registro sobre esta patología, relevando el comportamiento clínico y quirúrgico. Objetivo: registrar la información clínica y evolutiva de los pacientes con SM derivados de diversos lugares de nuestro país a nuestro centro con el fin de lograr una mejor atención de esta patología y detectar la presencia de dilatación de la raíz aórtica. Material y métodos: entre 1992 y 2009 se incluyeron pacientes con diagnóstico de SM de acuerdo a los criterios internacionales establecidos en Ghent. Fueron evaluados por traumatólogos, cardiólogos, cirujanos cardiovasculares, oftalmólogos, nutricionistas, neumonólogos y psicólogos y controlados periódicamente con un programa preestablecido recibiendo tratamiento preventivo médico y/o quirúrgico. Resultados: se evaluaron 273 pacientes, 145 de sexo masculino (53,5%). La edad promedio fue de 25,7 años (2 a 70 años). Las manifestaciones diagnósticas cardiovasculares correspondieron en orden decreciente a: aneurisma de aorta torácica 84 p (30,7%), insuficiencia valvular aórtica 47 p (17,2%), prolapso de válvula mitral 30 sujetos (10,9%) e insuficiencia mitral en 28 (10,2%). 63 % (90 pacientes) requirió cirugía de reemplazo de aorta ascendente. 76 pacientes en nuestro Hospital, el 84 % de las cirugías fueron programadas. Conclusión: la constitución de un equipo interdisciplinario permitió controlar un importante número de pacientes con SM con la detección de un número significativo de casos pasibles de tratamiento preventivo del aneurisma de aorta torácica.

Introduction: Marfan syndrome is a genetic disorder of low prevalence (1/5,000 subjects). This disorder has well defined cardiovascular, skeletal and ocular features. Its prognosis depends mainly on the aortic root dilation leading to its disection and/or rupture. This Syndrome is not well known among physicians of all specialties. In order to study the clinical and surgical characteristics of this disorder, we form an interdisciplinary team and design a registry. Objective: To register the clinical information and evolution of patients with Marfan Syndrome referred from different areas of our country to our Hospital in order to get a better attention of this disorder and to detect the presence of thoracic aorta dilation. Methods: Between 1992 and 2009, patients with Marfan Syndrome were included according to the international criteria established in Ghent. An interdisciplinary team formed by: traumatologists, cardiologists, cardiovascular surgeons, oftalmologists, specialists in nutrition, neumonologists and psychologists, evaluated and controlled the patients periodically with a pre set program receiving medical and/or surgical treatment. Results: it were evaluated 273 patients, 146 male (53,5%). Average age was 25.7 years (2-70 years old). Cardiovascular manifestations were in decreasing order: thoracic aorta aneurysms 84 p (30.7%), aortic valve regurgitation 47p (17.2%), mitral valve prolapse 30p (10.9%) and mitral regurgitation 28 p (10.2%), 90 patients (63%) required replacement of the ascending aorta, 76 were performed in our Hospital, and 84% of the procedures were scheduled. Conclusions: the formation of an interdisciplinary team allowed to control an important number of patients with Marfan Syndrome detecting a significant amount of cases which could be treated with preventive surgery of the thoracic aorta aneurysms, main cause of early mortality.

Sudden death due to aortic rupture while swimming: A case report.

An eleven year old, healthy boy with no past history of illness suddenly felt acute excruciating chest pain which was radiating to back, while he was swimming in a private swimming pool. He was immediately transferred to a hospital where he was declared dead on arrival. Autopsy and histopathological findings were suggestive of death was due to extensive advential haemorrhge due to inherent weakness in aortic wall.

Outcome after surgical repair of sealed rupture abdominal aortic aneurysms: a case-control study

OBJETIVO: Estabelecer, através de um estudo caso-controle, a mortalidade precoce e sobrevida a longo prazo após o tratamento cirúrgico do aneurisma da aorta abdominal roto contido crônico comparada aos respectivos controles, submetidos ao reparo do aneurisma da aorta abdominal não roto, operado eletivamente. PACIENTES E MÉTODO: De Janeiro de 1992 a Dezembro de 2002, 465 pacientes foram submetidos ao reparo de aneurismas da aorta abdominal. Destes, 13 eram aneurisma da aorta abdominal roto contido crônico (2,8%), que foram comparados a 26 controles nos quais a correção eletiva do aneurisma ocorreu imediatamente antes e após a correção do aneurisma da aorta abdominal roto contido crônico.RESULTADO: Não houve diferença entre os grupos com relação a idade, sexo, fatores de risco para aterosclerose, doenças associadas e cardiopatia isquêmica. Pacientes com aneurisma da aorta abdominal roto contido crônico apresentaram maior incidência de dor lombar (92,3% versus 3,9%; p<0,001); febre e perda ponderal foram detectados em cinco (38,5%) dos pacientes com aneurisma da aorta abdominal roto contido crônico e em nenhum dos controles (p=0,0022). A média de transfusão de hemácias também maior no aneurisma da aorta abdominal roto contido crônico (1516±697 vs. 773±463 ml (p=0,0003). As complicações pós-operatórias foram semelhantes entre os grupos. A mortalidade precoce foi de 7,7% nos pacientes com aneurisma da aorta abdominal roto contido crônico e 0% nos controles. A sobrevida em cinco anos foi significativamente menor nos portadores de aneurisma da aorta abdominal roto contido crônico (68.4%) do que no grupo controle (84,4%, p=0,04). CONCLUSÃO: Concluímos que o aneurisma da aorta abdominal roto contido crônico representa um desafio diagnóstico e terapêutico, que pode ser adequadamente conduzido com mortalidade precoce e taxas de complicações semelhantes ao aneurisma da aorta abdominal eletivo; entretanto, a mortalidade tardia do aneurisma da aorta abdominal roto contido crônico é maior.

Aneurismas de aorta abdominal no complicados / No complicated aneurysms of abdominal aortic

Se presenta una serie de 237 pacientes operados por aneurismas de aorta abdominal no complicados. Fallecieron 10 pacientes (4,22%) La edad del paciente, las hemorragias a raiz de la intervención quirúrgica y la falla múltiple de órganos, con compromisos renal y pulmonar, los más frecuentes, tuvieron significación estadística en los casos fallecidos. En 39 pacientes (17%) hubo complicaciones no fatales, de los cuales las más frecuentes fueron las cardiovasculares. Este y otros factores analizados no tuvieron incidencia en la morbimortalidad. Según el bajo índice de mortalidad, la poca frecuencia de complicaciones y el aceptable por ciento de supervivencia tardía permite insistir en que estos pacientes deben ser operados electivamente antes de que sucedan las complicaciones, por la elevada mortalidad de estas últimas aún tratadas quirúrgicamente

Aneurismas de aorta abdominal rotos / Rupture abdominal aortic aneurysms

Se presenta una serie de 63 pacientes operados durante los últimos 10 años por aneurismas de aorta abdominal rotos. Fallecieron 28 pacientes (44%) y la falla múltiple de órganos fue la causa más importante de mortalidad (46%), siendo el compromiso renal, pulmonar y cardiovascular los más frecuentes. Los factores de riesgo como hipertensión arterial y cardiopatías, así como la hipotensión arterial en el preoperatorio y la calidad de sangre transfundida incidieron significativamente en la mortalidad. No tuvieron significación estadística la presencia de diabetes, la edad de los pacientes, el tipo de reconstrucción utilizada ni el tiempo de evolución de la complicación o el número de complicaciones, sin embargo, en los pacientes operados luego de 6 horas del comienzo de los síntomas y en los sin complicaciones o con menor número, las posibilidades de sobrevivir fueron mayores. La elevada mortalidad comparada con la de los operados electivamente por aneurismas no complicados, nos permite insistir en que los aneurismas de aorta abdominal deben ser tratados adecuadamente antes de la complicación.

Aneurismas de aorta abdominal rotos: análisis de una serie de 18 casos / Abdominal aorta ruptured aneurysms: analysis of 18 cases

Se analiza una pequeña serie de 18 casos de aneurismas rotos de abdomen asistidos en un centro de terapia intensiva. La edad promedio fue de 69 años, y todos presentaban como antecedente importantes enfermedades cardiorespiratorias. Hubieron 10 muertes perioperatorias, debidas a fallas multisistémicas