Limb ischemia in patients with COVID-19 / Isquemia de membros em pacientes com COVID-19

Abstract This narrative review covers the life-threatening thromboembolic events associated with SARS-CoV-2 infection/COVID-19. It addresses the physical changes that cause vascular and arterial damage to limbs, laboratory management of coagulation, and management of anticoagulation. COVID-19's relationship with deep venous thrombosis and arterial thrombosis is also emphasized. The main thromboembolic events described in the literature are illustrated with examples from our experience with COVID-19 patients.

Resumo Esta revisão narrativa abrange os eventos tromboembólicos com risco de vida associados a infecção por SARS-CoV-2/COVID-19. Aborda as mudanças físicas que causam danos vasculares e arteriais aos membros, o manejo laboratorial da coagulação e o manejo da anticoagulação. A relação de COVID-19 com trombose venosa profunda e trombose arterial também é enfatizada. Os principais eventos tromboembólicos descritos na literatura são ilustrados a partir de nossa experiência com pacientes COVID-19.

Cerebrovascular ischemia following ultrasound-guided foam sclerotherapy / Isquemia cerebral após escleroterapia com espuma guiada por ultrassom

Cerebral ischemia is a very rare and harmful complication of ultrasound-guided foam sclerotherapy for treatment of varicose veins. This case describes a documented cerebrovascular ischemia in Broca's area following ultrasound-guided foam sclerotherapy. Less than one hour after intravenous injection of 10 ml of sclerosing foam, an otherwise healthy woman experienced aphasia without any other signs of neurological changes. When she arrived home, a complete inability to talk was observed. The event was misdiagnosed by another doctor as an allergic reaction. Next morning she came to the office to report the allergic reaction, where an appropriate diagnosis was made. She recovered just two days after the injection, but signs of recent cerebral ischemia were seen in Broca's area on magnetic resonance and transesophageal bubble study echocardiogram revealed a patent foramen ovale. Although rare, we must make great effort to prevent these events instead of treating them

A isquemia cerebral é uma complicação muito rara e perigosa da escleroterapia com espuma guiada por ultrassom no tratamento de varizes. Este caso descreve uma isquemia cerebral da área de Broca após escleroterapia com espuma guiada por ultrassom. Menos de uma hora após injeção de 10 mL de espuma, uma até então saudável mulher apresentou afasia, sem quaisquer outros sinais neurológicos. No caminho para casa, uma completa incapacidade de fala foi observada. Levada ao hospital mais próximo, foi diagnosticada com reação alérgica. Na manhã seguinte, compareceu ao consultório para relatar a reação alérgica, quando um correto diagnóstico foi feito. Ela ficou recuperada dois dias depois do procedimento, mas uma ressonância magnética mostrou sinais de isquemia recente da área de Broca e um ecocardiograma transesofágico mostrou um forame oval patente. Embora raros, devemos concentrar nossos esforços em prevenir tais eventos para que não precisem de tratamento

Fibrilación auricular en pacientes con ictus isquémico en Hospital Universitario Comandante Faustino Pérez. 2017 / Atrial fibrillation in patients with ischemic stroke in the University Hospital Comandante Faustino Pérez. 2017

Introducción: se realizó un estudio observacional transversal en pacientes con fibrilación auricular ingresados con ictus isquémico en la sala de neurología en el Hospital Universitario Comandante Faustino Pérez el año 2017. Objetivo: caracterizar la fibrilación auricular en estos pacientes en relación con edad y sexo, factores de riesgo, tipo de fibrilación y factores de riesgo de embolismo. Materiales y métodos: el universo del estudio fue de 40 pacientes con fibrilación auricular e ictus isquémico. Durante el ingreso a los pacientes y/o sus familiares se les aplicó una encuesta para la obtención de la información. Resultados: predominó el grupo de edades de 75-84 años y el sexo masculino con el 50 % y 70 % respectivamente. Los factores de riesgo más frecuentes en los pacientes con fibrilación auricular e ictus isquémico fueron la hipertensión arterial y edad mayor de 75 años con 85 % y la insuficiencia cardiaca con 70 %. La fibrilación auricular más frecuente fue la diagnosticada por primera vez con 55 %. Según la respuesta ventricular predominó la fibrilación auricular con respuesta ventricular rápida con 75 %. Los factores de riesgo de embolismo predominantes fueron la hipertensión arterial y la edad ≥ 75 años con 85 % seguida de la insuficiencia cardiaca con 70 %. Conclusiones: la fibrilación auricular en los pacientes con ictus isquémico predominó en hombres mayores de 75 años, hipertensos con insuficiencia cardiaca y en la mayoría de los pacientes se realizó el diagnóstico de la fibrilación auricular durante el ingreso con ictus isquémico (AU).

Introduction: it was carried out a transversal observational study in the in-patients with atrial fibrillation and ischemic stroke in the neurology ward of the Faustino Pérez Hospital in 2017. Objective: to characterize the atrial fibrillation in these patients taking into account age, sex, risk factors, fibrillation type and embolic risk. Materials and methods: the universe of the study was 40 patients with atrial fibrillation and ischemic stroke. During the hospitalization, a survey was applied to patients and/or their relatives for collecting the information. Results: The 75-84 age group predominated and male patients predominated. With 50 % and 70 % respectively. The most frequent risk factors in patients with atrial fibrillation and ischemic stroke were arterial hypertension and being more than 75 years old with 85 % and heart failure with 70 %. The most frequent atrial fibrillation was the one diagnosed for the first time with 55 %. According to the ventricular answer, atrial fibrillation with fast ventricular answer predominated, with 75 %. The predominant embolic risk factors were arterial hypertension and patients aged ≥ 75 years with 85 %, followed by heart failure with 70 %. Conclusions: atrial fibrillation in in-patients with ischemic stroke was predominant in male hypertensive patients aged 75 years and more with cardiac failure; in most of the patients the atrial fibrillation was made during the hospitalization with ischemic stroke (AU).

Bilateral Macula-involving Metastatic Infection Resulting from Septic Embolization

No abstract available.

Effect of Arterial Deprivation on Growing Femoral Epiphysis: Quantitative Magnetic Resonance Imaging Using a Piglet Model

OBJECTIVE: To investigate the usefulness of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and diffusion MRI for the evaluation of femoral head ischemia. MATERIALS AND METHODS: Unilateral femoral head ischemia was induced by selective embolization of the medial circumflex femoral artery in 10 piglets. All MRIs were performed immediately (1 hour) and after embolization (1, 2, and 4 weeks). Apparent diffusion coefficients (ADCs) were calculated for the femoral head. The estimated pharmacokinetic parameters (Kep and Ve from two-compartment model) and semi-quantitative parameters including peak enhancement, time-to-peak (TTP), and contrast washout were evaluated. RESULTS: The epiphyseal ADC values of the ischemic hip decreased immediately (1 hour) after embolization. However, they increased rapidly at 1 week after embolization and remained elevated until 4 weeks after embolization. Perfusion MRI of ischemic hips showed decreased epiphyseal perfusion with decreased Kep immediately after embolization. Signal intensity-time curves showed delayed TTP with limited contrast washout immediately post-embolization. At 1-2 weeks after embolization, spontaneous reperfusion was observed in ischemic epiphyses. The change of ADC (p = 0.043) and Kep (p = 0.043) were significantly different between immediate (1 hour) after embolization and 1 week post-embolization. CONCLUSION: Diffusion MRI and pharmacokinetic model obtained from the DCE-MRI are useful in depicting early changes of perfusion and tissue damage using the model of femoral head ischemia in skeletally immature piglets.

Percutaneous Aspiration Embolectomy Using Guiding Catheter for the Superior Mesenteric Artery Embolism

OBJECTIVE: To evaluate the technical feasibility and clinical outcome of percutaneous aspiration embolectomy for embolic occlusion of the superior mesenteric artery (SMA). MATERIALS AND METHODS: Between January 2010 and December 2013, 9 patients with embolic occlusion of the SMA were treated by percutaneous aspiration embolectomy in 2 academic teaching hospitals. The aspiration embolectomy procedure was performed with the 6-Fr and 7-Fr guiding catheter. Thrombolysis was performed with urokinase using a multiple-sidehole infusion catheter. The clinical outcome was investigated retrospectively. RESULTS: Superior mesenteric artery occlusion was initially diagnosed by computed tomography (CT) in all patients, and all patients had no obvious evidence of bowel infarction on CT scan. Percutaneous aspiration embolectomy was primarily performed in 6 patients, and thrombolysis was initially performed in 3 patients. In 3 patients who received primary thrombolysis, percutaneous aspiration was undertaken because the emboli were resistant to urokinase. Complete angiographic success was achieved in 6 patients and partial angiographic success was accomplished in 3 patients. One patient underwent bowel resection. One patient died of whole bowel necrosis and sepsis, and 8 patients survived without complications. CONCLUSION: Percutaneous aspiration embolectomy is a useful tool in recanalization of embolic occlusion of the SMA in select patients.

Mortality and Embolic Potential of Cardiac Tumors / Mortalidade e Potencial Embólico dos Tumores Cardíacos

Background: Cardiac tumors are rare, mostly benign with high embolic potential. Objectives: To correlate the histological type of cardiac masses with their embolic potential, implantation site and long term follow up in patients undergoing surgery. Methods: Between January 1986 and December 2011, we retrospectively analyzed 185 consecutive patients who underwent excision of intracardiac mass (119 females, mean age 48±20 years). In 145 patients, the left atrium was the origin site. 72% were asymptomatic and prior embolization was often observed (19.8%). The diagnosis was established by echocardiography, magnetic resonance and histological examination. Results: Most tumors were located in the left side of the heart. Myxoma was the most common (72.6%), followed by fibromas (6.9%), thrombi (6.4%) and sarcomas (6.4%). Ranging from 0.6cm to 15cm (mean 4.6 ± 2.5cm) 37 (19.8%) patients had prior embolization, stroke 10.2%, coronary 4.8%, peripheral 4.3% 5.4% of hospital death, with a predominance of malignant tumors (40% p < 0.0001). The histological type was a predictor of mortality (rhabdomyomas and sarcomas p = 0.002) and embolic event (sarcoma, lipoma and fibroelastoma p = 0.006), but not recurrence. Tumor size, atrial fibrillation, cavity and valve impairment were not associated with the embolic event. During follow-up (mean 80±63 months), there were 2 deaths (1.1%) and two recurrences 1 and 11 years after the operation, to the same cavity. Conclusion: Most tumors were located in the left side of the heart. The histological type was predictor of death and preoperative embolic event, while the implantation site carries no relation with mortality or to embolic event. .

Fundamento: Os tumores do coração são infrequentes, em sua maioria benignos e com alto potencial embólico. Objetivo: Correlacionar o tipo histológico do tumor cardíaco com seu potencial embólico, com o sítio de implantação e analisar a evolução tardia destes pacientes submetidos à cirurgia. Métodos: No período de dezembro de 1986 a setembro de 2011 foram retrospectivamente analisados 186 pacientes operados (119 do sexo feminino e idade média de 48 ± 20 anos). Foram 145 tumores de átrio esquerdo (77%), 72% dos pacientes assintomáticos e 19,8% com embolização prévia. O diagnóstico foi confirmado por ecocardiograma, ressonância magnética e exame histológico. Resultados: A maioria dos tumores situava-se nas câmaras esquerdas. O mixoma foi o mais frequente (72,6%), seguido dos fibromas (6,9%), trombos (6,4%) e sarcomas (6,4%). Seus tamanhos variaram de 0,6cm a 15 cm (média de 4,6 ± 2,5cm). Houve 37 embolizações prévias à operação (10,2% AVC, 4,8% IAM e 4,3% periférica). Foram 5,4% de óbito hospitalar, com predomínio nos tumores malignos (40% p < 0,0001). O tipo histológico foi preditor de mortalidade (rabdomioma e sarcomas p = 0,002) e de evento embólico (sarcomas, fibroelastoma e lipoma p = 0,006), porém não de recidiva. O tamanho tumoral, a fibrilação atrial, a cavidade e valva acometida não apresentaram relação com o evento embólico. Durante o seguimento (média de 80 ± 63 meses), houve 2 óbitos (1,1%) e duas recidivas tumorais 1 e 11 anos após a operação, ambas para a mesma cavidade. Conclusão: O tipo histológico foi preditor de óbito e de evento embólico pré-operatório, enquanto o sítio de implantação não. .

Hybrid treatment of bullet embolism at the abdominal aortic bifurcation, complicated with thoracoabdominal aorta pseudoaneurysm and common iliac artery occlusion: case report / Tratamento híbrido de embolia por projétil de arma de fogo em bifurcação aórtica abdominal complicada com pseudoaneurisma de aorta tóraco-abdominal e oclusão de artéria ilíaca comum: relato de caso

Embolization due to a firearm projectile entering the bloodstream is a rare event that is unlikely to be suspected during initial treatment of trauma patients. We describe and discuss a case of bullet embolism of the abdominal aortic bifurcation, complicated by a pseudoaneurysm of the thoracoabdominal aorta and occlusion of the right common iliac artery, but successfully treated using a combination of endovascular methods and conventional surgery.

A embolização por projétil de arma de fogo na circulação sanguínea é rara e de difícil suspeição no atendimento inicial ao trauma. Relatamos e discutimos um caso de embolia em bifurcação aórtica abdominal complicada com pesudoaneurisma de aorta tóraco-abdominal e oclusão de artéria ilíaca comum direita, tratada de forma efetiva pelos métodos endovascular e cirúrgico convencional.

Embolização da prótese de amplatzer após fechamento percutâneo de comunicação interatrial / Embolization of Amplatzer™ Occluder after Transcatheter Closure of Atrial Septal Defect

Relata-se o caso de paciente jovem, do sexo masculino,sem nenhum antecedente de doença cardíaca. Durante admissão em clube de futebol, detectou-se através de exame clínico e análise ecocardiográfica a presença de comunicação interatrial (CIA) tipo ostium secundum. Foi realizado o fechamento por via percutânea, sendo colocada prótese de Amplatzer®, sem intercorrências. No terceiro dia após o procedimento, o paciente referiu palpitações e procurou o Instituto de Cardiologia do estado. Detectou-se a embolização da prótese para ventrículo direito. Feito tratamento com cirurgia para retirada da prótese e colocação de pericárdio bovino para fechamento da CIA.

This is a case report on a young male patient with no history of heart disease. During his admission to a soccer club, a clinical examination and echocardiographic analysis detected the presence of an atrial septal defect, ostium secundum type. This was closed percutaneously, placing an Amplatzer™ prosthesis with no adverse occurrences. On the third day after the procedure, the patient complained of palpitations, and contacted the State Cardiology Institute. The embolization of the prosthesis into the right ventricle was detected. This was treated through surgery to remove the prosthesis, using a bovine pericardium to close the atrial septal defect.

Embolia coronariana associada a prolapso de valva mitral / Coronary embolism associated with mitral valve prolapse

Embolia coronariana é um evento raro. Neste trabalho, relatamos caso de pacientes, sexo masculino, de 64 anos, com um evento embólico coronariano associado a prolapso e rotura de valva mitral mixomatosa, situação essa extremamente incomum.

Mixoma atrial: multiples formas de presentacion: reporte de casos y discusion del tema

Los tumores primarios del corazón son raros con una incidencia en autopsia que varia entre 0.0017 y 0.19%. Estos pueden ser clasificados en benignos y malignos. El 75% de estos tumores son benignos y cerca de la mitad de los tumores benignon son mixomas los cuales se encuentran en la mayoria de los casos en las cavidades izquierdas principalmente la aurícula izquierda. Las manifestaciones clínicas de los mixomas son variables y dependen del sitio de localización del tumor. Se presentan 3 casos de mixomas atriales com multiples formas de presentación.

Spectral domain optical coherence tomography findings of acute branch retinal artery occlusion from calcific embolus.

An 82-year-old female presented with sudden painless decrease in vision in the right eye after awakening. She could see the “superior half” of her vision from the right eye only. On examination, best-corrected vision was 20/300 in the right eye and 20/30 in the left eye. The fundus in the right eye revealed recent superotemporal branch retinal artery occlusion (BRAO) with calcified plaque at the disc. Spectral domain optical coherence tomography (OCT) (OTI Ophthalmic Technologies, Inc.), revealed hyperreflectivity and increased thickness of the inner retinal layers of the superior compared to the inferior retina. Imaging at the optic disc revealed the blocked artery containing a highly reflective material. The high reflectivity of the material and underlying optical shadowing could be characterized as calcific emboli.

Análisis de variables clínicas en pacientes con obstrucción arterial aguda en Hospital Gustavo Fricke / Clinical variables analysis in patients with acute arterial obstruction in Gustavo Fricke’s Hospital

INTRODUCCIÓN: La obstrucción arterial aguda (OAA) de extremidades es un cuadro grave, con una mortalidad cercana al 20 por ciento, por lo que requiere un diagnostico etiológico y manejo oportuno. El objetivo del presente estudio fue analizar sobrevida y variables clínicas según etiología. MATERIAL Y MÉTODO: Estudio observacional analítico de casos de OAA no traumáticos atendidos entre años 2003 y 2007 en el Hospital Dr. Gustavo Fricke, con seguimiento vía registro civil y telefónico para obtener datos actualizados. RESULTADOS: Hubo 65 episodios de OAA en 60 pacientes durante el período. Se registraron 42 embolías (64,6 por ciento), 17 trombosis (26,1 por ciento), y 6 trombosis de by pass (9,2 por ciento). Se apreciaron diferencias significativas en edad (p=0,031) y género (p=0,033). El tabaquismo presentó un LR(+) de 2,61 y claudicación intermitente LR(+) 6,67para predecir etiología trombótica. El antecedente de accidente cerebrovascular presentó un LR(+) 4,65, el de arritmia LR(+) 12,05 y el de insuficiencia cardíaca LR(+) 8,76 para predecir etiología embólica. La sobrevida libre de amputación a 6 meses fue 90 por ciento. La sobrevida a 5 años fue 54,2 por ciento, siendo 37,8 por ciento en el grupo con embolía y 81,8 por ciento en el con trombosis (p<0,001). Pacientes con OAAde etiología embólica tenían un OR de 5,42 (IC95 por ciento 1,53-19,12) de fallecer comparados con pacientes con etiología trombótica. DISCUSIÓN: Las variables clínicas analizadas se comportarían como factores predictores de la etiologia de OAA, y por tanto del pronóstico y sobrevida de los pacientes. La mayor mortalidad del grupo de embolías se puede explicar por mayor edad, comorbilidades cardiovasculares, y embolías fatales a otros territorios.

INTRODUCTION: The acute arterial obstruction (AAO) of a limb is a severe condition, with almost 20 percent mortality, and therefore requires an appropriate diagnosis and treatment. The objective of this study was to analyze survival rates according to etiology and clinical variables. MATERIAL AND METHODS: Analytic observational study of non-traumatic AAO cases treated between 2003 and 2007 at Hospital Dr. Gustavo Fricke, confirming survival through the Office of Civil Registration and telephonic follow up. RESULTS: There were 65 episodes of AAO in 60 patients during this period; 42 of these were embolism episodes (64.6 percent), 17 thrombosis episodes (26.1 percent) and 6 by-pass thrombosis (9.2 percent). There was significant difference in age (p=0.031) and gender (p=0.033). Smoking had a LR (+) of 2.61 for predicting thrombotic etiology whereas intermitent claudication had a LR (+) of 6.67. History of stroke, arrhythmia, and heart failure showed LR (+) for predicting embolic etiology of 4.65, 12.05, and 8.76 respectively. The amputation-free survival at 6 months was 90 percent. The 5 years survival was 54.2 percent 37.8 percent in the group with embolic etiology and 81.8 percent for thrombosis etiology (p <0.001). Patients with AAO with embolic etiology had an OR of 5.42 (IC95 percent 1,53-19,12) for decease compared with patients with thrombotic etiology. DISCUSSION: The clinical variables analyzed were proven to be good predictors for AAO etiology, hence for patients´ prognosis and survival. Higher mortality in the embolic etiology group could be explained by older age, cardiovascular comorbidities, and fatal stroke in other territories.