Reparo de lesão vascular não letal causada por tamanduá-bandeira (Myrmecophaga tridactyla) no Brasil / Repair of non-lethal vascular injury caused by giant anteater (Myrmecophaga tridactyla) in Brazil

Resumo O tamanduá-bandeira é um mamífero encontrado na América Central e na América do Sul. Esse animal possui garras que podem chegar a 6,5 cm de comprimento, utilizadas para escavar formigueiros e obter alimento, além de servir para sua defesa. Relatamos o caso de paciente masculino de 52 anos, com histórico de epilepsia, que foi levado desacordado ao pronto-socorro, devido a lesões no seu braço direito causadas por um tamanduá. Frente à suspeita de trauma vascular, o paciente foi submetido a exploração cirúrgica, que evidenciou uma lesão combinada de vasos braquiais, submetida a reparo. Apresentou boa evolução do quadro, recebendo alta hospitalar no segundo dia de pós-operatório e, no seguimento ambulatorial, evoluiu sem sequelas neurológicas ou vasculares.

Abstract The giant anteater is a mammal found in Central and South America. These animals have claws that can reach 6.5 centimeters in length, which they use to dig anthills to obtain food and for defense. We report the case of a 52-year-old male patient with a history of epilepsy who was taken unconscious to the emergency room due to injuries to his right arm caused by an anteater. He underwent surgical exploration to investigate suspected vascular trauma, revealing a combined (arterial and venous) injury of the brachial vessels, which were repaired. He recovered well and was discharged on the second postoperative day. During outpatient follow-up he continued to improve, with no neurological or vascular sequelae.

Aneurismas da artéria e da veia braquial induzidos por uso contínuo de muleta: relato de caso / Aneurysms of brachial artery and vein induced by continuos use of crutch: case report

O aneurisma arterial induzido por uso de muleta é um evento raro, e a associação com aneurismas venosos não está descrita na literatura. Relatamos o caso de uma paciente que, após o uso prolongado dessa órtese, apresentou quadro de isquemia aguda de membro superior secundária à trombose de um aneurisma da artéria braquial, associado ao achado incidental de aneurismas da veia braquial. Embora a principal causa de oclusão arterial aguda de membro superior seja a embolização de fonte cardíaca, deve-se considerar a possibilidade de embolização arterioarterial por aneurismas provocados pelo uso prolongado de muletas. Os aneurismas venosos também devem ser suspeitados, uma vez que podem ser sede de trombos e fonte de êmbolos pulmonares

Crutch-induced arterial aneurysm is a rare event and there are no descriptions in the literature of cases with concomitant venous aneurysms. We report the case of a patient who, after prolonged crutch use, presented with acute ischemia of the upper limb secondary to brachial artery aneurysm thrombosis, associated with the incidental finding of brachial vein aneurysms. Although the main cause of acute upper limb occlusion is embolization of cardiac origin, consideration should be given to the possibility of arterio-arterial embolization due to an aneurysm induced by prolonged use of crutches. Venous aneurysms should also be suspected since they can be sites of thrombosis, and a source of pulmonary embolism

Pulse Oximetry for the Diagnosis and Prediction for Surgical Exploration in the Pulseless Perfused Hand as a Result of Supracondylar Fractures of the Distal Humerus

BACKGROUND: The management of the pulseless perfused hand in association with a supracondylar humerus fracture following operative stabilisation remains controversial. Previous authors have suggested the use of color-flow duplex monitoring, magnetic resonance angiography and segmental pressure monitoring as objective steps to ascertain blood flow following adequate internal fixation. We examine the use of the waveform of the pulse oximeter in objectively determining a perfused limb and in predicting the need for surgical exploration in patients who present with a pulseless perfused hand after operative stabilisation for supracondylar fracture of the humerus. METHODS: A retrospective review of all supracondylar fractures over a 60 month duration (2005-2009) in our instituition was performed. Each electronic record was reviewed and limbs which had absent radial pulse following admission were identified. X-ray films of each of the patients were reviewed. A search using the Pubmed database was performed with the following keywords, supracondylar humerus fracture, pediatric, pulseless, vascular injury, arterial repair. RESULTS: In this series of pulseless perfused hands following operative fixation of supracondylar fracture, a total of 26 patients were reviewed. All were Gartland grade III extension type fractures. Postoperative pulse oximeter waveforms were present in all but 4 patients. These patients subsequently had exploration of the brachial artery with significant findings. In the remaining 22 patients, waveforms were present and the child had return of the radial pulse soon after operative fixation without any further need for surgical exploration. At 24 months follow-up, all children were well with no neurovascular compromise. CONCLUSIONS: The presence of a waveform on a pulse oximeter is a sensitive and easily available modality in determining vascular perfusion as compared to other more complex investigations. The high sensitivity of this test will allow surgeons to objectively determine the requirement for surgical exploration of the brachial artery.

Isquemia arterial aguda del miembro superior por uso de muletas / Isquemia arterial aguda do membro superior por uso de muletas / Crutches induced acute arterial ischemia of the upeer limb

La compresión axilar por el uso de muletas es una causa infrecuente y subdiagnosticada de isquemia arterial aguda del miembro superior. Se presenta el caso de un paciente con isquemia aguda debido a trauma en la confluencia de las arterias axilar y humeral inducido por el uso de muletas. Dicha lesión fue el foco de microembolias que ocluyeron el arco palmar y la arteria humeral. Se diagnosticó con una arteriografía selectiva de la arteria axilar, y se tratómediante un bypass axilo-humeral con prótesis de PTFE anillado de 6 mm, con resultado satisfactorio en el seguimiento clínico a cinco años del postoperatorio.

A compressão axilar devido ao uso de muletas é uma causa pouco frequente e subdiagnosticada de isquemia arterial aguda do membro superior. Apresenta-se o caso de um paciente com isquemia aguda por trauma da confluência das artérias axilar e femoral induzido pormuletas. Esta lesão foi o foco de microembolias que provocaram a oclusão do arco palmar e da artéria femoral. Foi diagnosticado com uma arteriografia seletiva da artéria axilar, e tratado com um bypass axilo-femoral com prótese de capas de PTFE de 6 mm, com resultado satisfatório no seguimento clínico, cinco anos depois do pós operatório.

Crutch induced axillary trauma represents an infrequent but underdiagnosed cause of acuteischemia to the upper limb. We present a case of acute arterial ischemia caused by trauma of the confluence of the axillary and brachial arteries induced by the use of crutches. This lesion was the origin of microembolisms that occluded both the palmar arch and the brachialartery. The diagnosis was made by a selective arteriography of the axillary artery. An axillobrachial bypass with a 6 mm ringed PTFE prosthesis was performed showing satisfactory resultson his 5 year postoperative clinical follow up.

Dilatação Fluxo-Mediada da artéria braquial como método de avaliação da função endotelial na pré-eclâmpsia e em gestantes normotensas / Flow-mediated dilation of the brachial artery as a method of evaluating endothelial function in preeclampsia and in normotensive pregnant women

Introdução: durante as últimas duas décadas, a ativação de células endoteliais tornou-se o evento mais estudado na compreensão da fisiopatologia da pré-eclâmpsia (PE).Acredita-se que fatores desconhecidos, provavelmente de origem placentária, são secretados na circulação materna, provocando ativação e lesão endotelial. A dilatação fluxo mediada (DILA) da artéria braquial é técnica não invasiva, capaz de avaliar a integridade endotelial. Objetivos: este estudo avalia o índice de dilatação da artéria braquial medido pelo DILA em portadoras de PE, comparativamente a gestantes normotensas.Materiais e métodos: foram estudadas 78 gestantes atendidas na Maternidade do Hospital das Clínicas da UFMG, sendo 51 delas com diagnóstico de PE e 27 normotensas. Adilatação fluxo-mediada da artéria braquial foi obtida de acordo com a técnica descrita por Anderson e Mark, em 1989, modificada. Resultados: a dilatação fluxo-mediada da artéria braquial mostrou-se significativamente reduzida nas gestantes portadoras de pré-eclâmpsia em relação às normotensas (6,098±5,633; 15,48±8,56; p menor que 0,01). Conclusões: pacientes em pré-eclâmpsia possuem DILA significativamente alterado quando comparadas às gestantes normais, sugerindo que tenham lesão endotelial.

Introduction: activation of endothelial cells became the most studied event in understanding the pathophysiology of preeclampsia (PE) during the past two decades. Unknown factors, probably of placental origin, are secreted into the maternal blood flow, causing activation and endothelial damage. Flow-mediated dilation (FMD) of the brachial artery is a noninvasive technique able to evaluate endothelial integrity. Objectives: this study evaluates the rate of the brachial artery dilatation measured by FMD in women with PE compared to normotensive pregnant women. Materials and methods: a total of 78pregnant women seen at the University Hospital from Minas Gerais were studied. From the total, 51 were diagnosed with PE diagnostic and 27 were normotensive. The flow-mediated dilation of the brachial artery was obtained according to the technique described by Anderson and Mark in 1989, adapted. Results: Flow-mediated dilation of the brachial artery was significantly reduced in pregnant women with preeclampsia when compared to the normotensive patients (6.098 ± 5.633, 15.48 ± 8.56, p less than 0.01). Conclusion: patients in preeclampsia have significantly altered FMD when compared to the normal pregnancies, suggesting endothelial lesion.

Non-surgical management of iatrogenic arterial pseudoaneurysms-ultrasound-guided manual compression, an Indian experience.

OBJECTIVE: To evaluate the efficacy of ultrasound-guided manual compression of arterial pseudoaneurysms formed as a result of various procedures. METHODS: Ultrasound-guided manual compression was performed in 444 patients with ultrasound-diagnosed pseudoaneurysm. These patients were evaluated for number of locules in pseudoaneurysm, size of pseudoaneurysm, total time of compression, number of sittings, success/failure of the procedure, and possible complications. RESULTS: Out of 444 patients, 231 (52%) were on post-coronary angiography (3 via brachial route and rest via femoral route), 212 (47.7%) had post-coronary angioplasty and 1 (0.22%) was post-nailing of fracture of right tibia (pseudoaneurysm of right anterior tibial artery). Out of 444 patients, 132 (29.7%) had hypertension, 45 (10.1%) had diabetes mellitus, 117 (26.3%) had both hypertension and diabetes, and 90 (20.2%) were obese. 384 (86.5%) had unilocular, 51 (11.5%) had bilocular, 6 (1.3%) had trilocular and 3 (0.67%) had tetralocular pseudoaneurysm. Size of pseudoaneurysm varied between 0.8 cm and 8.1 cm (mean 3.3 cm). 342 (77%), 48 (10.8%), 54 (12.1%) required 1, 2 and 3 sittings, respectively for complete closure. The compression time was between 15 and 120 minutes (mean 40 minutes). Successful compression was achieved in 423 (95.3%). There were 21 (4.7%) failures, 12 out of which required surgical repair, 6 had spontaneous closure between 12 and 24 weeks and 3 were lost to follow up at 1 year. Out of 212 post-coronary intervention patients, 9 were on low molecular weight heparin (LMWH). In 7 of these 9 patients, LMWH was stopped 48 hours before compression and in remaining 2, compression was done during the course of LMWH therapy. The compression was successful in all 9 patients. Only 2 patients had a transient vasovagal attack. CONCLUSIONS: USG manual compression is safe, inexpensive, reliable and effective outpatient procedure for non-surgical management of arterial pseudoaneurysm.

Neurovascular injuries following displaced proximal humerus fractures: case reports and review of literature

Displaced fractures of the proximal part of the humerus with injury of the brachial plexus are not very common. We present two cases of displaced proximal fracture of humerus with median nerve damage. Both the cases were having vascular injuries as welt. One case had injury to profunda brachii artery which was ligated while the other presented with absent radial pulse. Neural injuries were treated conservatively with good functional results

Angiografia coronária: técnica transbraquial revisitada / Coronary angiography: transbrachial technique revisited

Objetivo: Demosntrar a experiência na execução da técnica de punção braquial para a realização de coronariopatia. Método: Foram avaliados 106 pacientes ambulatóriais com suspeita de doença coronária submetidos a coronariografia pela técnica transbraquial. Foi pré-selecionado cateter MP2 introduzido através de bainha 5F, e o cateterismo esquerdo e angiográfico realizado da maneira usual. Ao término do exame foi retirada a bainha e a hemostasia realizada por compressão manual. Resultado: A maioria dos exames (76,4 por cento) foi completada com a utilização de um único cateter (MP2). A mediana do tempo de fluoroscopia foi 4,5 min. Em apenas 4 casos a técnica teve que ser substituída, todas ocorreram com um mesmo operador durante a curva de aprendizagem. Observamos a presença de hematoma de pequeno volume em 3 pacientes, logo após o procedimento, áreas discretas de esquimose em 4 e equimoses mais extensas em 6 doentes, não tendo ocorrido complicações graves. Conclusões: A técnica transbraquial mosntrou-se efetiva e segura , facilitando a realização de cateterismo ambulatorial com baixa frequência de complicações.

Objectives: To report the experience using the transbrachial approach for coronary angiography. Methods: 106 patients were studied with possible diagnosis of coronary artery disease using transbrachial catheterization. A preselected catheter (MP2) was introduced through a 5 F sheath and left heart catheterization and angiography performed in the usual manner. At the end of the procedure, the sheath was removed and hemostasis accomplished by manual compression. Results: Most procedures (76.4%) were performed with a single catheter (MP2). The median fluoroscopy time was 4.5 min. In only 4 cases, during the learning curve of one operator, a different technique had to be performed. Three patients suffered small hematomas, 4 patients presented with small and 6 with moderate ecchymosis; there were no severe complications. Conclusions: The transbrachial technique is effective and safe; it has facilitated outpatient catheterization with a low rate of complications.

Lesiones traumáticas de arteria humeral proximal: 4 casos / Traumatic injuries of proximal humeral artery: 4 cases

Se presenta una serie clíniva de 4 lesiones traumáticas altas consecutivas de arteria humeral. Cada lesión fue diferente en su presentación y manejo. Un caso se resolvió con trombólisis luego de 24 h de isquemia y los otros 3 con cirugía. Dos casos terminaron en amputación, ambos infectados: uno con bypass permeable y el otro con trombosis tardía de un reimplante de extremidad. El último caso resolvió exitosamente con cirugía

Vascular injury associated with fractures and dislocations

We retrospectively reviewed the results of the fractures with concomitant vascular injury in 17 patients seen in the last 36 months at King Fahd Hospital of the University, Dammam, Kingdom of Saudi Arabia. During this period 225 patients were admitted to the hospital due to fractures and dislocations. The minimum age was 3 years and maximum 50 years [mean 25.6 years]. Fourteen cases were males and 3 were females. The majority, 11 [64.7%], sustained the injury as a result of road traffic accident. Popliteal artery was injured in 8 [47%], brachial artery in 4 and femoral artery in 3, subclavian artery in 2. The mean repair time was 12.37 hrs [4-24 hrs.]. Two patients underwent above knee amputation and one patient developed gangrene of big toe and second toe. It is concluded that the incidence of fractures with concomitant vascular injury was notably high in our services [7.5%]. There was quite a delay in the diagnosis and ultimately repair of the vessels. The complications seen were due to delay in repair of the injured vessel

Tratamento cirúrgico da trombose da artéria braquial pós cateterismo cardíaco

Em um período de 5 anos säo estudados 70 procedimentos para a revascularizaçäo dos membros superiores, em casos de trombose da artéria braquial pós cateterismo cardíaco. Säo apresentadas 5 modalidades de restauraçäo: as dos grupos A e B, que näo incluem a ressecçäo de segmento arterial (38,5% dos casos), e as dos grupos C, D e E que säo representados por operaçöes onde praticava-se a arterectomia com ou sem a interposiçäo de substituto arterial (61,5%). A análise dos resultados mostra que nas cirurgias dos grupos C, D e E, o percentual de obstruçöes foi melhor que nos grupos A e B, sendo que, no grupo onde foi realizada a arterectomia com anastomose término-terminal (E) näo houve oclusöes no pós-operatório. O estudo sugere a necessidade de ressecar-se todo o segmento arterial considerado como potencialmente lesado, mesmo na ausência de sinais macroscópicos