Fibroelastoma, uma Doença Incidentaloma? - Imagem de Casos de Fibroelastomas como Achados Incidentais em Quatro Pacientes, Quatro Valvas Diferentes / Fibroelastoma, an Incidentaloma Disease? - Image Cases of Fibroelastomas as Incidental Findings in Four Patients, Four Different Valves

Resumo Os fibroelastomas são o segundo tumor cardíaco benigno mais comum. São estruturas pequenas, avasculares, com uma dimensão média de 9mm, podendo atingir até 70mm, habitualmente aderentes à superfície das válvulas cardíacas (válvulas aórtica e mitral são as mais comumente afetadas, seguidas das válvulas tricúspide e pulmonar). A etiologia não é clara, sendo a hipótese de formação de microtrombos nas margens de coaptação das válvulas a mais aceite. Na ecocardiografia apresentam aspeto pediculado, móvel, com superfície filamentosa, tipicamente com uma aparência pontilhada nas margens e ecolucente. Do ponto de vista clínico, podem estar associados a fenómenos embólicos, no entanto, na maioria dos casos o diagnóstico é incidental. Apresentamos de seguida quatro casos de diagnóstico incidental de fibroelastomas nas quatro válvulas cardíacas, diagnosticados por ecocardiograma transtorácico (ETT) (Vídeo 1; Figura 1). Vídeo 1 Da esquerda para a direita, de cima para baixo: fibroelastomas no folheto anterior da válvula tricúspide, folheto anterior da válvula mitral, cúspide esquerda da válvula pulmonar e cúspide esquerda da válvula aórtica, cada um correspondendo a um doente diferente. Em: http://abccardiol.org/supplementary-material/2024/12102/2023-0222_IM_video01.mp4 Figura 1 Da esquerda para a direita, de cima para baixo: fibroelastomas no folheto anterior da válvula tricúspide, folheto anterior da válvula mitral, cúspide esquerda da válvula pulmonar e cúspide esquerda da válvula aórtica, cada um correspondendo a um doente diferente.

Abstract Fibroelastomas are the second most common benign cardiac tumor1. They are small avascular structures with a mean size of 9mm, ranging up to 70mm, usually attached to the heart valves' surface (aortic and mitral are the most affected, followed by tricuspid and pulmonary valves). Their etiology is unclear, but the hypothesis of coalescence of microthrombus at the coaptation margins of valves is the most widely accepted theory. On echocardiography, they are pedicled, mobile, with a filamentous surface, and usually have a speckled appearance with echolucencies and a stippled pattern near the edges. Clinically, they may be associated with embolic phenomena; however, in most cases, the diagnosis is incidental. We present a series of four clinical cases with an incidental diagnosis of fibroelastomas across the four cardiac valves as assessed by transthoracic echocardiography (Video 1; Figure 1). Video 1 From left to right and top to bottom: fibroelastomas of the anterior leaflet of the tricuspid valve, anterior leaflet of the mitral valve, left cusp of the pulmonary valve and left cuspid of the aortic valve, each corresponding to a different patient. Link: http://abccardiol.org/supplementary-material/2024/12102/2023-0222_IM_video01.mp4 Figure 1 From left to right and top to bottom: fibroelastomas of the anterior leaflet of the tricuspid valve, anterior leaflet of the mitral valve, left cusp of the pulmonary valve and left cuspid of the aortic valve, each corresponding to a different patient.

Safety of preoperative branch embolization in patients undergoing evar / Segurança da embolização pré-operatória do ramo em pacientes submetidos a evar

Abstract The purpose of this systematic review is to evaluate the safety of pre-endovascular abdominal aortic aneurysm repair (EVAR) embolization of aortic side branches - the inferior mesenteric artery and lumbar arteries. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. A search of MEDLINE and DIMENSION databases identified 9 studies published from 2011 to 2021 that satisfied the inclusion and exclusion criteria. These studies were analyzed to detect the incidence of embolization-related complications. A total of 482 patients underwent preoperative aortic side branch embolization, 30 (6.2%) of whom suffered some kind of minor complication. The only major complication observed was ischemic colitis in 4 (0.82%) patients, two (0.41%) of whom died after bowel resection surgery. Regarding these findings, aortic side branch embolization seems to be a safe procedure, with very low percentages of both minor and major complications.

Resumo O objetivo desta revisão sistemática foi avaliar a segurança da embolização de artéria mesentérica inferior (AMI) e artérias lombares (ALs) pré-correção endovascular de aneurisma da aorta abdominal. Foram realizadas pesquisas nas bases de dados MEDLINE e Dimensions. Foram encontrados 9 estudos publicados de 2011 a 2021 que atendiam aos critérios de inclusão e exclusão. Os estudos foram analisados ​​para definir a incidência de complicações relacionadas à embolização. No total, 482 pacientes foram submetidos a embolização de AMI e/ou ALs, dos quais 30 (6,2%) sofreram algum tipo de complicação menor. A única complicação importante observada foi colite isquêmica em 4 (0,82%) pacientes. Dois (0,41%) desses pacientes morreram após cirurgia de ressecção intestinal. Em relação a esses achados, a embolização de AMI e ALs parece ser um procedimento seguro, com um percentual muito baixo de complicações menores e importantes.

Clinical management strategies for recipients with renal graft loss / 器官移植

With the maturity of kidney transplantation, introduction of new immunosuppressive drugs and improvement of immunosuppressive regimen, the short-term survival rate of kidney transplant recipients has been significantly improved, whereas the long-term survival rate has not been significantly elevated. Kidney transplant recipients may have the risk of renal graft loss. Clinical management after renal graft loss is complicated, including the adjustment of immunosuppressive drugs, management of renal graft and selection of subsequent renal replacement therapy. These management procedures directly affect clinical prognosis of patients with renal graft loss. Nevertheless, relevant guidelines or consensuses are still lacking. Clinical management of patients after renal graft loss highly depend upon clinicians’ experience. In this article, the adjustment of immunosuppressive drugs, management of renal graft and selection of subsequent renal replacement therapy were reviewed, aiming to provide reference for prolonging the survival and improving the quality of life of these patients.

Malformação arteriovenosa uterina: um relato de caso / Uterine arteriovenous malformation: a case report

O presente estudo tem como objetivo relatar o caso de uma paciente com malformação arteriovenosa uterina, efetivamente tratada com embolização seletiva e com fertilidade preservada. A malformação arteriovenosa uterina é uma alteração vascular rara até então pouco descrita na literatura. A paciente do sexo feminino apresentou quadro de sangramento uterino anormal, com início 30 dias após um abortamento, sem realização de curetagem, de uma gestação resultante de fertilização in vitro. Foram, então, realizados exames de imagem, que levaram ao diagnóstico de malformação arteriovenosa uterina. O tratamento de escolha foi a embolização arterial seletiva, com resolução do caso. Após sete meses, nova fertilização in vitro foi realizada, encontrando-se na 36a semana de gestação. São necessários mais estudos sobre essa malformação a fim de que sejam estabelecidos os métodos mais eficazes para o manejo de casos futuros, especialmente quando há desejo de gestar.

The present study aims to report the case of a patient with uterine arteriovenous malformation, effectively treated with selective embolization and with preserved fertility. Uterine arteriovenous malformation is a rare vascular disorder that has so far been rarely described in the literature. Female patient presented with abnormal uterine bleeding, starting 30 days after an abortion without subsequent curettage, of a pregnancy resulting from in vitro fertilization. Imaging tests were then performed that led to the diagnosis of uterine arteriovenous malformation. The treatment of choice was selective arterial embolization, with successful results. After seven months, a new in vitro fertilization was performed, being in the 36th week of pregnancy. Further studies on this pathology are needed in order to establish the most effective methods for the management of future cases, especially when there is a desire to become pregnant.

Efficacy of Embolization in Acquired Uterine Vascular Malformations: An Experience in Tertiary Care Centre in India / Eficácia da embolização em malformações vasculares uterinas adquiridas: uma experiência em centro de atendimento terciário na Índia

Abstract Objective: To determine the efficacy of Uterine Artery Embolization in patients with bleeding acquired uterine arteriovenous malformations (AVMs). Methods: A prospective review of all patients who underwent Uterine Artery Embolization at our institution between July 2015 and April 2022 was performed. 225 patients were diagnosed with a uterine vascular malformation on doppler and corresponding MRI imaging. All patients underwent transcatheter embolization of the uterine arteries. Embolic agents in the 375 procedures included Histoacryl glue only (n = 326), polyvinyl alcohol (PVA) particles and Histoacryl glue (n = 29), PVA particles (n = 5), Gelfoam (n = 5), coils (n = 4), PVA particles and coils (n = 3), Histoacryl glue and Gelfoam (n = 2), and Histoacryl glue and coils (n = 1). Results: A total of 375 embolization procedures were performed in 225 patients. 90 patients required repeat embolization for recurrence of bleeding. The technical success rate of embolization was 100%. The clinical success rate was 92%: bleeding was controlled in 222 of 225 patients and three patients underwent a hysterectomy. 60 of the 225 patients had uneventful intrauterine pregnancies carried to term. The 210 patients who underwent successful embolization had no recurrence of bleeding at a median follow-up of 53 months (range, 5-122 months) after treatment. 15 patients were eventually lost to follow-up. One minor complication (0.4%) of non-flow-limiting dissection of the internal iliac artery occurred. Conclusion: Uterine Artery Embolization is a safe, effective, minimally invasive method to treat uterine AVMs with long-term efficacy, which can provide the preservation of fertility.

A Rare Complication of Gastrointestinal Bleeding: Jejunal Diverticulosis. A Case Report

Introduction: Small intestine diverticula are a rare condition with an incidence of 0.6% to 2%. Their location at the level of the jejunum is a rare alteration, and their diagnosis is often delayed due to low clinical suspicion. The clinical manifestation of this pathology is related to the development of complications -15% to 30% of patients, with approximately 10% requiring surgical intervention. Clinical case: We present a case of a middle-aged adult patient who experienced a complication due to a bleeding jejunal diverticulum. The patient underwent surgical management, which resulted in a satisfactory outcome. Objective: This article aims to describe jejunal diverticulosis, a rare condition that can have a significant impact on affected individuals. Emphasizing its clinical suspicion as a differential diagnosis for gastrointestinal bleeding is crucial. Additionally, we discuss diagnostic methods and highlight various therapeutic options, including surgical management.

Introducción: los divertículos del intestino delgado presentan una incidencia del 0,6% al 2%, su localización a nivel del yeyuno es una alteración poco frecuente y, dada su baja sospecha clínica, se retrasa el diagnóstico oportuno. La manifestación clínica de esta patología se encuentra relacionada con el desarrollo de complicaciones, las cuales ocurren entre el 15% y el 30% de los pacientes, y el 10% de estos pacientes requiere manejo quirúrgico. Caso clínico: un paciente adulto medio cursó con una complicación secundaria a la presencia de un divertículo del yeyuno sangrante, al cual se le dio un manejo quirúrgico con un resultado satisfactorio. Objetivo: este artículo tiene como objetivo describir la diverticulosis yeyunal que, aunque poco frecuente, puede generar un compromiso importante en quien la padece, lo que prioriza su sospecha clínica como diagnóstico diferencial causante de hemorragia gastrointestinal, así como dilucidar métodos diagnósticos y estar al tanto de las diferentes opciones terapéuticas que existen, incluido el manejo quirúrgico.

Atrial Septal Defect Occluder Device Embolization: Experience of a Tertiary Care Cardiac Center

Background: Percutaneous device closure of atrial septal defect (ASD) has become an increasingly popular procedure as it offers several advantages. However, it is associated with infrequent, but life?threatening complications such as device embolization. Objective: To analyze the risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed. Settings and Design: A retrospective study was performed at a tertiary referral center for cardiac services. Material and Methods: Pre?procedure, intra?procedure, and post?procedure data of patients whose ASD device embolized was collected retrospectively and analyzed for risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed. Results: Thirty devices were embolized, out of which 13 were retrieved percutaneously in the Catheter laboratory, whereas 17 patients underwent surgery. Fourteen patients had an unfavorable septal morphology for device closure. Ten devices were embolized in the catheter laboratory, five in the intensive care unit, and two in the ward. The devices were embolized to almost all chambers of the heart and great vessels. One patient had an inferior vena cava rim tear while attempting percutaneous retrieval. One patient required a short period of total circulatory arrest (TCA) for retrieval of the device from ascending aorta, while another required a lateral position for retrieval from descending aorta. One patient required re?exploration for bleeding, while another had an air embolism and succumbed. Conclusions: Once embolization occurs, the risks associated increase manifold. Most of the surgical extractions are uneventful; however, there could be certain complications that may need repair of valvular apparatus, the institution of TCA, or the need for the lateral position. Air embolization though very rare can occur which could be fatal.

Embolización de aneurismas intracraneales múltiples en sesión única

Objetivo: Determinar los resultados clínicos y angiográficos en pacientes con aneurismas intracraneales múltiples tratados endovascularmente en una única sesión. Materiales y Métodos: Se incluyó a todos los pacientes mayores de 18 años con aneurismas múltiples (≥2), rotos o no rotos, tratados con terapia endovascular en una única sesión entre 2019 y 2021. Se recolectaron los datos clínicos y angiográficos. Se determinó la tasa de oclusión inmediata y del seguimiento. La escala de Rankin modificado se usó para valorar el resultado clínico. Resultados: Se trataron 25 pacientes, de los cuales 14 se presentaron con hemorragia subaracnoidea. Se diagnosticaron un total de 78 aneurismas, de los cuales 59 aneurismas fueron tratados. La localización más frecuente fue el segmento oftálmico. La altura máxima promedio fue de 5.2mm, lo cual tuvo diferencia estadística significativa con el estado de ruptura (p ≤ 0.02). El principal tipo de tratamiento endovascular fue la técnica de remodeling en el 39 % de casos. El Raymond Roy inmediato fue I en el 60 % y IIIa en el 35 % de casos. La tasa de complicaciones fue del 24 % y de mortalidad fue del 8 %. Conclusiones: El tratamiento endovascular en una única sesión es una opción efectiva y segura en casos de aneurismas intracraneales múltiples en nuestra institución con tasa de oclusión y complicaciones aceptable.

Objective: To determine clinical and angiographical outcomes in patients with multiple intracranial aneurysms who underwent endovascular therapy in a single session. Materials and Methods: Patients older than 18 years with multiple (≥2) ruptured or non-ruptured aneurysms were included, and all of them underwent endovascular therapy in a single session between 2019 and 2021. Clinical and angiographic data was collected. Immediate occlusion and follow-up data were collected. Rankin modified scale was used for assessing clinical outcomes. Results: Twenty-five patients were treated, and fourteen had subarachnoid hemorrhage. Seventy-eight aneurysms were diagnosed, and 59 of them were treated. The most frequent location was at the ophthalmic segment. Maximum average height was 5.2- mm, which showed significant statistical difference with a ruptured condition (p≤0.02). The main modality for endovascular therapy was the remodeling technique, which was used in 39% of all cases. Immediate Raymond Roy staging was I in 60% of all cases, and IIIa in 35% of all cases. Complication rate was 24%, and mortality rate was 8%. Conclusions: Single session endovascular therapy is an effective and safe option for cases of multiple intracranial aneurysms in our institution. Occlusion and complication rates were acceptable.

Acute and chronic changes in porcine rete mirabile after embolization with the Menox system: angiographic and histopathological analyses / Alterações angiográficas e histopatológicas agudas e crônicas da rete mirabile no modelo suíno com sistema embólico líquido Menox

Abstract Objective: To evaluate acute and chronic changes seen on angiographic and histopathological studies of porcine rete mirabile, comparing those treated with the Menox liquid embolic system (LES) and those treated with the Onyx LES. Materials and Methods: Five pigs, each weighing approximately 35 kg, were submitted to rete mirabile embolization under general anesthesia and fluoroscopic guidance, with the Menox LES or Onyx LES. Four animals were treated with the Menox LES and underwent cerebral angiography, followed by euthanasia, at 1, 30, 60, and 90 days after embolization. One animal was treated with the Onyx LES underwent the same procedures at 30 days after embolization. In a subsequent histopathological analysis, we compared the Menox LES and Onyx LES in terms of the acute and chronic changes observed. Results: We observed no significant changes in blood pressure, heart rate, or electrocardiographic parameters that could be attributed to the super-selective infusion of dimethyl sulfoxide or the Menox embolic agent. Fluoroscopy showed adequate material opacity, appropriate progression to the center of the rete mirabile and complete unilateral embolization. Microcatheters were uneventfully detached from the embolized nidus. We observed mild to moderate intravascular and extravascular inflammatory responses, without histological evidence of necrotizing arteritis. There were no adverse neurovascular events. Conclusion: The Menox LES appears to be safe and effective, as well as being apparently equivalent to the Onyx LES in terms of the postprocedure angiographic and histopathological findings.

Resumo Objetivo: Avaliar as alterações angiográficas e histopatológicas agudas e crônicas em rete mirabile suína tratadas com o Menox liquid embolic system (LES) e comparar essas alterações com a embolização com Onyx LES. Materiais e Métodos: A embolização da rete mirabile com Menox LES e Onyx LES foi realizada em cinco suínos pesando cerca de 35 kg sob anestesia geral e orientação fluoroscópica. Quatro animais tratados com Menox LES foram submetidos a angiografia cerebral seguida de eutanásia após 1, 30, 60 e 90 dias e um animal tratado com Onix LES foi submetido ao mesmo procedimento após 30 dias. A análise histopatológica subsequente para alterações agudas e crônicas avaliou o desempenho do Menox LES comparado ao Onyx LES. Resultados: Não foram observadas alterações significativas atribuíveis à infusão superseletiva de dimetilsulfóxido ou Menox nos parâmetros de pressão arterial, frequência cardíaca ou eletrocardiograma. A fluoroscopia mostrou opacidade adequada do material, progressão adequada para o centro da rete mirabile e embolização unilateral completa. Os microcateteres foram retirados do nidus embolizado sem complicações. Observou-se resposta inflamatória intravascular e extravascular leve a moderada, sem indício histológico de arterite necrosante. Nenhum dos casos apresentou eventos neurovasculares adversos. Conclusão: A injeção de Menox LES mostrou-se segura e eficaz, além de ser equivalente ao Onyx LES em relação aos achados angiográficos e histopatológicos pós-procedimento.

It's not always postdural puncture headache: a case report and note to the astute anesthesiologist

Abstract Dural puncture is either diagnosed by unexpectedly profound response to medication test dose or development of a postpartum postural headache. Epidural blood patch is the gold standard for treatment of PDPH when conservative management fails. However, postpartum headaches can be resistant to multiple epidural blood patches. In such cases, preexisting intracranial processes should be considered and ruled out. We report here the unique case of a pregnant patient who developed a resistant headache in the postpartum period related to an incidental intracranial aneurysm. Subsequent treatment with endovascular embolization adequately relieved her symptoms. Early surgical consultation and a multidisciplinary team approach involving neurology and neuroimaging is required for successful management of patients such as the one described here.

Embolização percutânea de fístulas arteriovenosas pulmonares / Percutaneous embolization of pulmonary arteriovenous fistulas

Malformações arteriovenosas pulmonares são uma comunicação anormal entre uma artéria e uma veia, causando manifestações clínicas, como hipoxemia crônica e eventos embólicos. As malformações arteriovenosas eram tratadas cirurgicamente, com taxa expressiva de complicações. Na década de 1970, a primeira embolização percutânea por cateter foi realizada com molas. Descrevemos três casos nos quais técnicas de embolização percutânea foram efetivas em prevenir eventos embólicos, hemorrágicos e hipoxêmicos no seguimento dos pacientes.

Pulmonary arteriovenous malformation is an abnormal communication between an artery and a vein, causing clinical manifestations, such as chronic hypoxemia and embolic events. Arteriovenous malformations were treated surgically, with a significant rate of complications. In the 1970 ́s, the first percutaneous catheter embolization was performed with coils. We describe three cases in which percutaneous embolization techniques were effective to prevent embolic, hemorrhagic, and hypoxemic events in the follow-up of patients.

Um Stent Mal Colocado na Artéria Septal Perfurante: Fístula Ventricular Direita, Hematoma do Septo Interventricular e Obstrução da Via de Saída do Ventrículo Direito / A Stent Misplaced in the Septal Perforating Artery: Right Ventricular Fistula, Interventricular Septal Hematoma, and Right Ventricular Outflow Tract Obstruction

Resumo As fístulas coronário-camerais, embora consideradas em sua maioria como entidades congênitas, também têm sido encontradas como complicações de grandes traumas e intervenções coronárias percutâneas (ICPs).1 Por outro lado, o hematoma do septo interventricular (SIV) pode potencialmente surgir principalmente durante intervenções de oclusão total crônica retrógrada (OTC) e tem um curso benigno nesse contexto.2 Aqui, descrevemos uma complicação desafiadora da ICP (e sua estratégia de manejo) apresentando hematoma do SIV, fístula ventricular direita e obstrução da via de saída do ventrículo direito (VSVD) devido a um stent coronário mal implantado na artéria septal perfurante (ASP).

Abstract Coronary-cameral fistulas, though mostly regarded as congenital entities, have also been encountered as complications of major traumas and percutaneous coronary interventions (PCIs).1 On the other hand, interventricular septal (IVS) hematoma might potentially arise mostly during retrograde chronic total occlusion (CTO) interventions and has a benign course in this context.2 Herein, we describe a challenging PCI complication (and its management strategy) presenting with IVS hematoma, right ventricular fistula, and right ventricular outflow tract (RVOT) obstruction due to a misimplanted coronary stent in the septal perforating artery (SPA).

Braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in patients with unruptured complex intracranial aneurysms

Abstract Purposes: Braided and laser-cut stents both are efficacious and safe for coiling intracranial aneurysms. The study aimed to compare outcomes following braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in 266 patients who were diagnosed with unruptured intracranial aneurysms of different types and locations. Methods: Patients with unruptured complex intracranial aneurysms underwent braided (BSE cohort, n = 125) or laser engraved (LSE cohort, n = 141) stent-assisted embolization. Results: The deployment success rate was higher for patients of the LSE cohort than those of the BSE cohort (140 [99%] vs. 117 [94%], p = 0.0142). Seventy-one (fifty-seven percentages) and 73 (52%) were coil embolization procedure success rates of the BSE and the LSE cohorts. Periprocedural intracranial hemorrhage was higher in patients of the BSE cohort than those of the LSE cohort (8 [6%] vs. 1 [1%], p = 0.0142). Four (three percentages) patients from the LSE cohort and 3 (2%) patients from the BSE cohort had in-stent thrombosis during embolization. Permanent morbidities were higher in patients of the LSE cohort than those of the BSE cohort (8 [6%] vs. 1 [1%], p = 0.0389). Higher successful procedures (76% vs. 68%) and fewer postprocedural intracranial hemorrhage (0% vs. 5%) and mortality (0% vs. 5%) were reported for patients of the BSE cohort in posterior circulation aneurysmal location than those of the LSE cohort. Laser engraved stent has fewer problems with deployment and may have better periprocedural and follow-up outcomes after embolization. Conclusions: Braided stent-assisted embolization should be preferred when the aneurysm is present in the posterior circulation.

Malformación arteriovenosa uterina como causa de hemorragia puerperal tardía / Uterine arteriovenous malformation as a cause of late puerperal hemorrhage

Resumen ANTECEDENTES: Las malformaciones arteriovenosas uterinas constituyen una causa infrecuente de hemorragia puerperal, en la bibliografía solo se encontraron 150 casos. Su conocimiento es importante porque son potencialmente mortales y porque se ha registrado un aumento en los últimos años. Suelen estar relacionadas con intervenciones en el útero: legrados, cesáreas o miomectomías o asociadas con neoplasias (enfermedad trofoblástica gestacional o adenocarcinoma endometrial), aunque otras son congénitas. CASO CLÍNICO: Paciente de 32 años, con una conización cervical y ablación de un mioma uterino mediante radiofrecuencia como únicos antecedentes de interés. A los 15 días posteriores a un parto eutócico, que fue el primero en su historial, tuvo un episodio de abundante metrorragia. En el puerperio inmediato tuvo una hemorragia abundante que requirió la transfusión de dos concentrados de hematíes. En la ecografía transvaginal el útero se observó de 22 x 44 mm, que podría corresponder a un cotiledón retenido. Ante la persistencia del sangrado se colocó un taponamiento intracavitario con una sonda de Foley con lo que se consiguió el cese del sangrado. Luego de descartar la embolización de las arterias uterinas debido al gran tamaño de la malformación arteriovenosa, se procedió a la histerectomía total simple por vía laparotómica. CONCLUSIÓN: Las malformaciones arteriovenosas uterinas, aunque son una causa infrecuente de hemorragia puerperal, deben ser sospechadas en virtud de ser potencialmente mortales.

Abstract BACKGROUND: Uterine arteriovenous malformations are a rare cause of puerperal hemorrhage, with only 150 cases reported in the literature. Their knowledge is important because they are life-threatening and because there has been an increase in recent years. They are usually related to interventions in the uterus: curettage, caesarean section or myomectomy or associated with neoplasms (gestational trophoblastic disease or endometrial adenocarcinoma), although others are congenital. CLINICAL CASE: A 32-year-old patient with a cervical conization and ablation of a uterine myoma by radiofrequency as the only history of interest. Fifteen days after a euthecological delivery, which was the first in her history, she had an episode of abundant metrorrhagia. In the immediate postpartum period, she had a heavy hemorrhage that required the transfusion of two red blood cell concentrates. Transvaginal ultrasound showed a uterus measuring 22 x 44 mm, which could correspond to a retained cotyledon. In view of the persistent bleeding, intracavitary tamponade was placed with a Foley catheter, which led to cessation of bleeding. After ruling out embolization of the uterine arteries due to the large size of the arteriovenous malformation, a simple total hysterectomy by laparotomy was performed. CONCLUSION: Uterine arteriovenous malformations, although an infrequent cause of puerperal hemorrhage, should be suspected because they are potentially fatal.

The essential role of thoracic duct embolization in management of traumatic iatrogenic chylothorax / O papel fundamental da embolização do ducto torácico no manejo de quilotórax traumático iatrogênico

Abstract This study aims to describe a case series of patients who underwent thoracic duct embolization (TDE) to treat traumatic iatrogenic chylothorax (TIC). Three patients were included: Case #1, a 49-year-old woman with follicular lymphoma developed a TIC following video-assisted thoracoscopic surgery to resect a solid right paravertebral mass and was treated with TDE using microcoils and N-butyl cyanoacrylate (NBCA) glue. Case #2, a 68-year-old man with cardiac amyloidosis developed a TIC following heart transplantation and was treated with TDE using microcoils and ethylene vinyl alcohol copolymer. Case#3: A 6-year-old patient with congenital heart disease developed a TIC following a Fontan procedure and was treated with TDE using NBCA glue. All lesions were identified during lymphangiography and TDE was successfully performed in all cases. TDE is a safe and valuable technique that provides minimally invasive treatment for TCI.

Resumo Este estudo objetiva descrever uma série de casos de pacientes submetidos a embolização do ducto torácico (EDT) para tratamento de quilotórax iatrogênico (QI). Três pacientes foram incluídos. Caso 1: um homem de 49 anos com linfoma folicular apresentou QI após ressecção de uma massa paravertebral por toracoscopia vídeo-assistida e foi submetido a EDT com micromolas e n-butil-cianoacrilato (NBCA). Caso 2: um homem de 68 anos com amiloidose cardíaca apresentou QI após ser submetido a transplante cardíaco e foi submetido a EDT com micromolas e copolímero de etileno e álcool vinílico. Caso 3: um paciente de 6 anos com malformação cardíaca congênita apresentou QI após cirurgia de Fontan e foi submetido a EDT com NBCA. Todas as lesões foram identificadas durante a linfangiografia, e a EDT foi realizada com sucesso. A EDT é uma técnica segura e valiosa, que pode oferecer um tratamento minimamente invasivo em casos de QI.

Hemodynamic course during ablation and selective hepatic artery embolization for metastatic liver carcinoid: a retrospective observational study

Abstract Background: Manipulation of carcinoid tumors during ablation or selective hepatic artery embolization (transarterial embolization, TAE) can release vasoactive mediators inducing hemodynamic instability. The main aim of our study was to review hemodynamics and complications related to minimally invasive treatments of liver carcinoids with TAE or ablation. Methods: Electronic medical records of all patients with metastatic liver carcinoid undergoing ablation or TAE from 2003 to 2019 were abstracted. Noted were severe hypotension (mean arterial pressure [MAP] ≤ 55 mmHg), severe hypertension (systolic blood pressure ≥ 180 mmHg), and perioperative complications. Associations of procedure type and pre-procedure octreotide use with intraprocedural hemodynamics were assessed using linear regression. A robust covariance approach using generalized estimating equation method was used to account for multiple observations. Results: A total of 161 patients underwent 98 ablations and 207 TAEs. Severe hypertension was observed in 24 (24.5%) vs. 15 (7.3%), severe hypotension in 56 (57.1%) vs. 6 (2.9%), and cutaneous flushing observed in 2 (2.0%) vs. 48 (23.2%) ablations and TAEs, respectively. After adjusting for preprocedural MAP, ablation was associated with lower intraprocedural MAP compared to TAE (estimate −27 mmHg, 95%CI −30 to −24 mmHg, p < 0.001). Intraprocedural declines in MAP were not affected by preprocedural use of octreotide (p = 0.7 for TAE and p = 0.4 for ablation). Conclusions: Ablation of liver carcinoids was associated with substantial hemodynamic instability, especially hypotension. In contrast, a higher number of TAE patients had cutaneous flushing. Preprocedural use of octreotide was not associated with attenuation of intraprocedural hypotension.

Transjugular intrahepatic portosystemic shunt combined with collateral vessel embolization in treatment of gastroesophageal variceal bleeding in liver cirrhosis： Research advances and controversies / 临床肝胆病杂志

Transjugular intrahepatic portosystemic shunt （TIPS） has been recommended as a treatment method for cirrhotic portal hypertension in domestic and foreign guidelines， but there is still uncertainty in its therapeutic efficacy. More and more studies have shown that TIPS combined with collateral vessel embolization （TIPS+E） has certain advantages in the treatment of gastroesophageal variceal bleeding in liver cirrhosis. This article reviews the major studies on TIPS+E in China and globally， summarizes related recommendations in guidelines and the current status of clinical application， and proposes the issues that need to be solved， such as indication， hemodynamic criteria， and selection of materials for embolization， and large－sample multicenter randomized controlled trials are needed for further clarification.

Safety and effectiveness of Neuroform Atlas stent-assisted coiling in the endovascular treatment of intracranial aneurysms: a single-center observational study / 中华内科杂志

Objective:To investigate the safety and effectiveness of Neuroform Atlas stent-assisted coiling in the endovascular treatment of intracranial aneurysms.Methods:This was a retrospective, single-center observational study of 77 patients who underwent endovascular treatment of intracranial aneurysms using the Neuroform Atlas device at the Department of Neurology, People′s Liberation Army General Hospital from July 2020 to May 2022. There were 34 males and 43 females, with a median (range) age of 59 (23-81) years. The degree and effect of aneurysm embolization were evaluated by modified Raymond grading post procedure and after 6 months. Complications occurring during the perioperative period were recorded. Vaso computed tomography was performed immediately after the operation to assess stent opening and adherence. Digital subtraction angiography was performed 6 months after discharge and the aneurysm was classified as cured, stable, or recurrent.Results:A total of 87 Atlases were successfully released in 77 cases. Angiography performed immediately after the embolization revealed 19 (24.7%) modified Raymond grade Ⅰ, 10 (13.0%) grade Ⅱ, and 48 (62.3%) grade Ⅲa cases. Three perioperative complications were observed including thrombotic events in 2 cases and stent migration in 1 case. A follow-up angiogram was available for 47 aneurysms, and showed that modified Raymond grade Ⅰ occlusion was achieved in 38 (80.9%) cases, grade Ⅱ in 2 (4.3%) cases, and grade Ⅲa in 7 (14.9%) cases. At the 6-month follow-up, 38 patients were cured and 7 were stable, whereas 2 patients experienced a recurrence of aneurysm. Stenosis of the parent artery occurred in 3 (6.4%) cases, including 2 at the head and 1 inside the stent.Conclusions:The results of this preliminary study suggest that Neuroform Atlas stent-assisted coiling has a high occlusion rate and low incidence of complications in the endovascular treatment of aneurysms. However, the effectiveness of this procedure for large aneurysms and long-term outcomes require further investigation.

A case report of severe hematuria after transrectal prostate biopsy treated by repeat interventional embolization / 中华泌尿外科杂志

Hemorrhage after prostate biopsy is common, but hemorrhagic shock is rare. We reported a case of sudden severe hematuria on the third day after prostate biopsy, which was considered to be bleeding at the puncture site. Conservative treatment was ineffective, and interventional embolization was performed. Bilateral bulbar urethral arteries were embolized, and the bleeding was stopped successfully. On the 4th day after embolization, the patient developed hypovolemic shock. Angiography showed bilateral prostatic artery bleeding, and the bleeding site and its superior branch arteries were embolized immediately. At 4 months after embolization, no bleeding related events occurred.

Clinical efficacy of TACE combined with PVE versus percutaneous microwave ablation liver partition with PVE for planned hepatectomy for hepatocellular carcinoma with insufficient remnant liver volume / 中华肝胆外科杂志

Objective:To evaluate the safety and clinical efficacy of transcatheter arterial chemoembolization (TACE) combined with portal vein embolization (PVE) and percutaneous microwave ablation liver partition with PVE for planned hepatectomy in patients with hepatocellular carcinoma (HCC) with insu-fficient remnant liver volume.Methods:The clinical data of 51 patients with initially unresectable HCC due to insufficient remnant liver volume admitted to Zhejiang Provincial Tongde Hospital and Zhejiang Provincial People’s Hospital from January 2014 to December 2021 were retrospectively analyzed, including 37 males and 14 females, aged (56.7±11.2) years old. Patients were divided into two groups according to the treatment prior to hepatectomy: percutaneous microwave ablation liver partition combined with PVE (AP group, n=12) and TACE with PVE (TP group, n=39). Patients who successfully underwent planned hepatectomy in the above two groups were marked as resectable AP group ( n=10) and the resectable TP group ( n=29), respectively. Clinical data including the waiting time for surgery and the incidence of complications were analyzed. Patients were followed up by telephone or outpatient review. Kaplan-Meier and log-rank analysis were used for survival comparison. Results:The FLR growth rate was higher in AP group [76.5% (65.3%, 81.6%)] than that in TP group [31.4% (28.2%, 41.9%), P<0.01]. The waiting time for planned hepatectomy in the resectable AP group was 12.0 (11.3, 14.5) d, shorter than that in the resec-table TP group [21.0 (15.0, 29.0) d, P<0.05]. The incidence of postoperative complications was higher in the resectable AP group than that in the resectable TP group [80.0% (8/10) vs. 27.6% (8/29), P<0.05]. There was one perioperative death in the resectable AP group. The survival rate after PVE was lower in AP group than that in TP group, and the survival rate after hepatectomy was also lower in the resectable AP group than that in the resectable TP group (all P<0.05). Conclusion:For HCC patients with insufficient FLR, TACE combined with PVE is a safe and effective method for enlargement of liver remnant, whereas percutaneous microwave ablation liver partition with PVE showed a poor prognosis, despite the higher rate of FLR enlargement and shortened the waiting time for planned hepatectomy.