Perfusión 2D por angiografía en oclusión arterial periférica. Método de evaluación inmediato posproceder / 2D perfusion by angiography in peripheral arterial occlusion. Post-procedural immediate evaluation method

La enfermedad arterial periférica se considera la mayor causa de hospitalización, con riesgo de amputación de la extremidad afectada y muerte debido a la enfermedad per se o sus complicaciones. Se reporta la experiencia del tratamiento a un paciente con macroangiopatía diabética, estenosis del 64 por ciento de la arteria ilíaca izquierda y afectación de los segmentos fémoro-poplíteos bilaterales, al cual, a través de un acceso percutáneo vía arteria braquial izquierda, se le realizó revascularización mediante la implantación de stent de cromo-cobalto liberado por balón catéter. El objetivo de este estudio fue describir la utilidad del 2D-ASD y su valor como herramienta para determinar el transproceder y la repercusión en el flujo sanguíneo de la revascularización realizada, y establecer un pronóstico funcional para el paciente. Se utilizó la angiografía por perfusión bidimensional como herramienta para evaluar el éxito técnico del proceder y la repercusión inmediata en la perfusión distal de la extremidad afecta, y describir la utilidad de la escala paramétrica de colores y las curvas de densidad en función del tiempo obtenidos en el estudio(AU)

Peripheral artery disease is considered the leading cause of hospitalization, with risk of amputation of the affected limb and death due to the disease per se or its complications. It is reported the experience of treatment in a patient with diabetic macroangiopathy, stenosis of 64 precent of the left iliac artery and involvement of the bilateral femoro-popliteal segments, to which, through a percutaneous access via the left brachial artery, revascularization was performed through the implantation of cobalt-chromium stent released by balloon catheter. The objective of this study was to describe the usefulness of 2D-ASD and its value as a tool to determine the trans-procedure and the impact on blood flow of the revascularization performed, and to establish a functional prognosis for the patient. Two-dimensional perfusion angiography was used as a tool to evaluate the technical success of the procedure and the immediate impact on distal perfusion of the affected limb, and to describe the usefulness of the parametric color scale and density curves as a function of the time obtained in the study(AU)

Prevalência de nefropatia induzida por contraste em pacientes cardíacos de um setor de hemodinâmica / Prevalence of contrast-induced nephropathy in cardiac patients in a hemodynamic sector / Prevalencia de nefropatía inducida por contraste en pacientes cardíacos de un sector de hemodinámica

Objetivo: Determinar a prevalência da nefropatia induzida por contraste em pacientes cardiopatas submetidos a procedimentos angiográficos de diagnóstico e/ou tratamento. Método: Estudo prospectivo, quantitativo, realizado no setor de hemodinâmica de um hospital de grande porte, situado na região norte do Rio Grande do Sul, Brasil. A amostra foi constituída por 79 participantes através do cálculo de tamanho amostral. Resultados: A amostra foi formada por 52 (65,8%) homens e 27 (34,2%) mulheres. A idade média foi de 65,9 ± 9,52 anos. A incidência de nefropatia induzida por contraste foi de 30,38%, totalizando 24 pacientes. Conclusão: Foi evidenciada uma alta prevalência de nefropatia por contraste, apesar dos pacientes apresentarem poucos fatores de risco, o que ressalta a necessidade de medidas preventivas e redução do volume de contraste

Objective: To determine the prevalence of contrast-induced nephropathy in cardiac patients undergoing diagnostic and / or treatment angiographic procedures. Method: A prospective, quantitative study in the hemodynamics sector of a large hospital, located in the northern region of Rio Grande do Sul, Brazil. The sample consisted of 79 participants through the calculation of sample size. Results: The sample consisted of 52 (65.8%) men and 27 (34.2%) women. The mean age was 65.9 ± 9.52 years. The incidence of contrast-induced nephropathy was 30,38%, totaling 24 patients. Conclusion: A high prevalence of contrast nephropathy was evidenced, despite the fact that patients presented few risk factors, which highlights the need for preventive measures and reduction of contrast volume

Objetivo: Determinar la prevalencia de la nefropatía inducida por contraste en pacientes cardiopatas sometidos a procedimientos angiográficos de diagnóstico y / o tratamiento. Método: Estudio prospectivo, cuantitativo, realizado en el sector de hemodinámica de un hospital de gran porte, situado en la región norte de Rio Grande do Sul, Brasil. La muestra fue constituida por 79 participantes a través del cálculo de tamaño muestral. Resultados: La muestra fue formada por 52 (65,8%) hombres y 27 (34,2%) mujeres. La edad media fue de 65,9 ± 9,52 años. La incidencia de nefropatía inducida por contraste fue del 30,38%, totalizando 24 pacientes. Conclusión: Se evidenció una alta prevalencia de nefropatía por contraste, a pesar de que los pacientes presentaban pocos factores de riesgo, lo que resalta la necesidad de medidas preventivas y reducción del volumen de contraste

Utilidad de la ecografía Doppler en el diagnóstico de la trombosis carotidea traumática / Usefulness of Doppler echography for the diagnosis of traumatic carotid thrombosis

Los traumatismos del sistema arterial carotideo son raros y tienen alta mortalidad. Se presenta un caso de trombosis de la arteria carótida interna derecha por una herida por arma de fuego a nivel del cuello con el objetivo de evidenciar en la práctica médica la utilidad de la ecografía Doppler para el diagnóstico temprano de estas lesiones, a pesar de reportarse en la literatura la angiografía, la resonancia magnética nuclear y la angiorresonancia como estudios de elección. Con este caso se pudo afirmar que la trombosis carotidea traumática tiene una incidencia baja, pero no descartable en los traumas de la región cervical. Por esta causa, son frecuentes las complicaciones neurológicas dadas por la oclusión arterial y la ecografía Doppler resultó muy útil en el diagnóstico temprano del paciente.

Carotid artery system traumas are rare and show high mortality rates. The case of right internal carotid artery thrombosis caused by a gunshot injury in the neck was presented in this report to show evidence of the usefulness of Doppler echography in the medical practice for the early diagnosis of these lesions in spite of the fact that literature highlights angiography, nuclear magnetic resonance and angioresonance as the imaging studies of choice. This case confirmed that carotid thrombosis due to trauma has low incidence but it can not be ignored in the cervical región traumas. For these reasons, the neurological complications stemming from artery occlusion are frequent and Doppler echography turned to be very useful for the early diagnosis of this illness in a patient.

Endovascular correction of a traumatic internal iliac arteriovenous fistula with a covered stent / Correção endovascular de fístula arteriovenosa traumática em ilíaca interna com stent revestido

Arteriovenous fistulae (AVFs) are anomalous communications between an artery and a vein, bypassing the capillary network. They can be subdivided on the basis of etiology into congenital and acquired fistulae. The latter may be caused by closed or penetrating traumas, or may be iatrogenic injuries. We report on a case of a young adult female gunshot wound victim treated with emergency laparotomy who developed asymmetrical edema of the lower limbs during the late postoperative period. Imaging exams showed the presence of a left internal iliac AVF, treated using endovascular surgery with placement of a covered stent, resulting in total occlusion of arteriovenous communication.

As fístulas arteriovenosas (FAVs) são comunicações anômalas entre uma artéria e uma veia, sem envolvimento capilar. Segundo sua etiologia, podem ser divididas em congênitas e adquiridas, resultantes de traumas fechados ou penetrantes, e de lesões iatrogênicas. Relatamos o caso de mulher jovem, vítima de ferimento por arma de fogo, submetida à laparotomia de urgência, que evoluiu no pós-operatório tardio com edema assimétrico de membros inferiores. Os exames de imagem demonstraram a presença de fístula arteriovenosa ilíaca interna esquerda, tratada através de cirurgia endovascular com stent revestido, determinando a total oclusão da comunicação arterial e venosa.

Rapidly Aggravated Dissecting Flap by Angiography during Percutaneous Stent Placement for Acute Isolated Superior Mesenteric Artery Dissection

Acutely aggravated dissecting flap and consequent occlusion of the superior mesenteric artery (SMA) by simple contrast passage during initial angiography for percutaneous stent placement is a uncommon event, which usually is not reported. After analysis of many factors that underlie development of such complications, we present herein one case of successful treatment of isolated SMA dissection and its complications with favorable outcomes during 25 months follow-up after percutaneous stent placement.

[ effect of trinitroglycerine injection on angiographic complications]

Currently the ischemic heart disease [IHD] is common worldwide. Coronary angiography is gold standard for detecting coronary artery disease. Death, myocardial infarction, nausea, coronary vessels spasm, chest pain, bradyarrhythmia, hypotension, and hypertension are among the common complications occurring following angiography. The aim of this study was to investigate the effect of simultaneous administration of trinitroglycerine [TNG] and the contrast agent on early complications of angiography. This was a clinical trial carried out in Isfahan Shahid Chamran Hospital in 2005. Patients were randomly allocated to two intervention [n=111] and placebo [n=112] groups. Nausea, coronary vessels spasm, chest pain, bradyarhythmia, and systolic and diastolic blood pressure in both intervention [TNG plus contrast agent] and placebo [distilled water plus contrast agent] groups were investigated during and after angiography. The mean age in intervention and placebo groups were 59.93 +/- 9.14 and 59.37 +/- 10.12 years, respectively. Also, sex distribution showed no significant difference. Between TNG group and placebo group we had considering the nausea [4.5% vs 6.2%], coronary vessels spasm [0.9% vs 5.4%], chest pain [1.8% vs 6.3%], and bradyarrythmia [7.1% vs 7.1%] respectively, that had not any significant lower in TNG group compared to placebo group [p=0.001]. Based on data obtained in the present study, except for blood pressure no benefit in simultaneous administration of TNG and the contrast agent on early complication of angiography was demonstrated. Further investigations using different dose, time tables and also selection of high risk patients are recommended. Furthermore, the late complications and mortality as well as the cost-effectiveness are the subjects deserving more attention

The role of computerized tomography in the evaluation of gastrointestinal bleeding following negative or failed endoscopy: a review of current status.

Gastrointestinal bleeding remains an important cause for emergency hospital admission with a significant related morbidity and mortality. Bleeding may relate to the upper or lower gastrointestinal tracts and clinical history and examination may guide investigations to the more likely source of bleeding. The now widespread availability of endoscopic equipment has made a huge impact on the rapid identification of the bleeding source. However, there remains a large group of patients with negative or failed endoscopy, in whom additional techniques are required to identify the source of bleeding. In the past, catheter angiography and radionuclide red cell labeling techniques were the preferred 'next step' modalities used to aid in identifying a bleeding source within the gastrointestinal tract. However, these techniques are time-consuming and of limited sensitivity and specificity. In addition, catheter angiography is a relatively invasive procedure. In recent years, computerized tomography (CT) has undergone major technological advances in its speed, resolution, multiplanar techniques and angiographic abilities. It has allowed excellent visualization of the both the small and large bowel allowing precise anatomical visualization of many causes of gastrointestinal tract (GIT) bleeding. In addition, recent advances in multiphasic imaging now allow direct visualization of bleeding into the bowel. In many centers CT has therefore become the 'next step' technique in identifying a bleeding source within the GIT following negative or failed endoscopy in the acute setting. In this review article, we review the current literature and discuss the current status of CT as a modality in investigating the patient with GIT bleeding.

Análise das complicações hospitalares relacionadas ao cateterismo cardíaco / Analysis of in-hospital complications related to cardiac catheterization / Analysis of in-hospital complications related to cardiac catheterization

Introdução: As complicações relacionadas ao cateterismo cardíaco são os principais limitantes desta técnica, e podem variar desde eventos adversos leves e transitórios até eventos graves, como infarto do miocárdio ou morte. Objetivo: Avaliar a incidência de complicações imediatas do cateterismo cardíaco diagnóstico em adultos, conforme um modelo de categorização das complicações em tipo e gravidade. Método: Estudo de coorte prospectivo em um centro de referência. As características dos pacientes foram registradas, e estes foram acompanhados até a alta hospitalar. As complicações foram categorizadas em nove modalidades: alérgica, isquêmica, vascular, arrítmica, vaso-vagal, pirogênica, neurológica, embólica e congestivas, e estratificadas em leves (intercorrências), moderadas (resolvidas em até 24 horas) ou graves (necessitou internação ou intervenção). Os fatores preditivos de complicações foram identificados por análise multivariada. Resultados: Foram incluídos 1916 indivíduos, sendo 59,4% do sexo masculino e com média de idade de 58,3±11,1 anos. Complicações ocorreram em 175 pacientes (190 eventos), sendo que 62,5% foram intercorrências leves, 24% moderadas e 13,5% graves. Foi registrado apenas um óbito (0,05% dos indivíduos). As complicações vasculares foram as mais incidentes (35,6%), seguidas das vagais (18,3%), isquêmicas (15,4%) e alérgicas (14,4%). Os fatores de risco para complicações pela análise multivariada foram uso de anticoagulante (3,59; 1,67-7,74; p=0,006) e duração prolongada do exame (1,03; 1,02-1,04; p<0,001). Conclusão: As complicações relacionadas ao cateterismo cardíaco são geralmente intercorrências sem gravidade, sendo que as complicações vasculares, reações vagais e isquêmicas foram as mais freqüentes. O uso de anticoagulantes e o tempo de exame prolongado foram os principais fatores preditivos de complicações.

Background: The major limitations of cardiac catheterization are the occurrence of complications related to its invasive nature. Complications can vary from mild and transitory reactions to severe adverse events like myocardial infarction or death. Objective: To assess the incidence, type and severity of complications related to cardiac catheterization in adults using a comprehensive system previously described. Methods: We conducted a prospective cohort study in a tertiary reference center, and patient characteristics and in-hospital outcomes were registered in a dedicated database. Complications were categorized in nine types: allergic, ischemic, vascular, arrythmic, vagal, pyrogenic, neurological, embolic and congestive, and stratified in mild, moderate (resolved in 24 hours) or severe (needed hospitalization or another intervention). The predictive factors of complications were assessed by multivariate analysis. Results: We included 1916 individuals, 59% male and with a mean age of 58±11 years. Complications occurred in 175 patients (190 events), and 63% were mild, 24% moderate e 13% severe. There was one (0.05%) death in the entire cohort. Vascular complications were the most common type (36%), followed by vagal (18%), ischemic (15%) and allergic (14%). Risk factors for complications by multivariate analysis were anticoagulant use (OR=3.59; CI=1.67-7.74; p=0.006) and prolonged examination time (OR=1.03; CI=1.02-1.04; p<0.001). Conclusions: In-hospital complications after cardiac catheterization are generally mild, and the events more commonly presented were vascular, vagal or ischemic. Anticoagulant use and prolonged examination time were independent predictors of complications.

Tratamento endovascular de pseudo-anuerisma da artéria subclávia em criança hemofílica / Endovascular treatment of subclavian artery pseudoanurysm in a hemophiliac child

O uso de cateteres venosos centrais em pacientes hemofílicos é muito frequente, devido às próprias características terapêuticas da doença. As complicações desses procedimentos, tais como pseudo-aneurisma, geralmente são mais graves nesses pacientes. A correção cirúrgica do pseudo-aneurisma que acomete a artéria subclávia constitui um dos maiores desafios da cirurgia vascular. Em pacientes hemofílicos, à dificuldade habitual da exposição cirúrgica somam-se os problemas de alteração no processo normal de coagulação. Como alternativa ao tratamento cirúrgico convencional, a utilização de técnicas endovasculares constitui uma solução segura e com bons resultados.

Pé diabético: aspectos clínicos / Diabetic foot: clinical aspects

Objetivo: Estudar os aspectos clínicos do pé diabético, uma vez que o mesmo constitui uma complicação crônica, de etiologia frequentemente multifatorial, com comprometimento vascular, neural articular e infeccioso. Método: Análise retrospectiva de 56 casos de pé diabético avaliados pelo serviço de Angiologia e Cirurgia Vascular do Hospital Universitário de Mato Grosso do Sul (NHU/UFMS) no período de 1998 a 2002. Resultados: A patologia prevaleceu em indivíduos do sexo masculino, entre 51 a 70 anos, portadores de diabetes tipo 2 em uso de hipoglicemiantes orais e com duração inferior a 10 anos. As manifestações clínicas mais comumente encontradas foram aumento de volume dos membros, dor e hiperemia. Foram realizadas amputações em 71,4 por cento dos casos, sendo que, destes 55 por cento foram do tipo menor (distal ao tornozelo) e 45 por cento foram do tipo maior (proximal ao tornozelo). A causa mais comum do pé diabético foi a neuropatia (48,2 por cento), e a doença arterial periférica foi a principal causa de amputação. A prevalência de amputações em pacientes portadores de pé diabético foi de 73,2 por cento...

Acceso venoso percutáneo braquial: Su utilidad en el cateterismo diagnóstico e intervencionista en cardiopatías complejas / Brachial percutaneous venous access: Its usefulness in the diagnostic and interventionist catheterism of complex cardiopathies

Introducción: El acceso venoso a la vena cava superior es obligatorio en pacientes portadores de anastomosis tipo Glenn. En cardiopatías complejas, es habitual la repetición de cateterismos, encontrando frecuentemente dificultades de acceso femoral. Para evitar la punción venosa yugular interna, potencialmente peligrosa, hemos utilizado la vena mediana basílica como acceso inicial. Objetivo: Valorar la efectividad y seguridad de la vía venosa braquial en pacientes, que precisan cateterismo cardíaco. Material y métodos: Se intentó la punción en 37 pacientes. Edad media 10 años (3.1-33.5). Todos ellos postoperados de cardiopatías complejas y con un promedio de 2.45 cirugías y 3.6 cateterismos por paciente. 40% de los pacientes: trombosis femoroilíaca bilateral. Técnica: Compresión venosa axilar, punción venosa basílica y canalización con introductor 4 a 6F. Resultados: Acceso efectivo: en 34 de los 37 pacientes (91.8%). En todos se realizó cateterismo diagnóstico, en 3, prueba pronóstica de oclusión y en 6 -angioplastía de rama pulmonar. Complicaciones: 2 obstrucciones tardías de la vena mediana basílica derecha (6%). Conclusiones: La punción venosa braquial es una técnica alternativa útil que permite acceso a cava superior y cavidades derechas a partir de los 3 años de edad, asociándose a un bajo porcentaje de complicaciones. Ciertas dilataciones vasculares pueden realizarse por esta vía.

Venous access through the superior caval vein is mandatory to study the pulmonary arteries in patients with a Glenn anastomosis. In complex congenital heart disease, repeat catheterizations may lead to iliac vein thrombosis and superior access is needed. In order to avoid the internal jugular venous puncture, we have used puncture of the antecubital vein as an elective access. Material: Brachial puncture was attempted in 37 patients. Mean age: 10 years (3.1-33.5). 2.45 heart surgeries and 3.6 cardiac catheterizations per patient had been previously performed in this group. 40% of patients had bilateral iliac vein thrombosis. Technique: Axillary vein external compression, venous puncture and introduction of 4-6 F sheath. Results: Venous access through brachial vein was achieved in 34 of 37 pts (91.8%). Diagnostic catheterization was done in all, balloon test occlusion of the pulmonary valve in 3 and pulmonary artery branch dilation in 6 pts. Complications: 2 late thrombosis of the right brachial vein (6%). Conclusions: Antecubital venous puncture is an alternative and useful technique that allows easy catheterization of superior caval vein, pulmonary artery and right heart chambers. It is associated with minor complication rate, avoiding internal jugular vein puncture. Certain therapeutic procedures can be performed through such route.

Quantitative enzymuria following aorto-renal angiography.

Quantitative estimation of urinary enzymes has been advocated as a more sensitive marker than conventional renal function tests to assess radio-contrast media induced nephrotoxicity. We studied 27 subjects with normal renal functions who underwent abdominal aortography for varied indications. Among these, 8 also required selective renal arteriography and 3 underwent arch aortography in addition. Sodium iothalamate was used as a radio-contrast medium and the average amount injected was 73 ml (45 to 120 ml) per subject. Standard renal function assessment including urinalysis, 24 hour urinary protein excretion, creatinine clearance done both before and after aortography did not show any significant alteration. Urinary excretion of tubular enzymes including leucine aminopeptidase (LAP), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and maltase (MAL) was estimated before and 2, 24 and 48 hours after aortography. All enzymes showed a significant rise at 2 hours. Urinary excretion of LAP, ALP and GGT peaked at 24 hours after aortography without a further change in MAL levels. Enzymuria returned to baseline values 48 hours following the procedure. It is concluded that an increase in the urinary excretion of the brush-border enzymes within 24 hours of contrast media administration may suggest an early nephrotoxicity.

Management plan of post-angiography false aneurysms of the groin

False aneurysm [FA] of the groin is a potentially serious complication of angiographic procedures. We developed a management plan at St. George's Hospital, and prospectively applied it to 14 consecutive cases over a period of one year. Patients and This report is a prospective cohort study of post-angiography false aneurysms. Fourteen patients with groin FA presented to the vascular team between October 1995 and September 1996 [0.2% of 6926 angiographic procedures]. Nine of the 14 patients were fully anticoagulated at the time of treatment. Ultrasound-guided compression [USGC] was tried in 11 patients and was considered inappropriate in three. Embolization was attempted in four patients and surgery was needed in seven patients. The initial angiographic procedure was therapeutic in nine and diagnostic in five patients. The median maximal dimension of the FA was 3 cm [range 2-5]. USGC was successful in three patients and failed in eight, seven of them fully anticoagulated at the time of compression. Embolization of the FA was tried in four patients; all were anticoagulated, and embolization was successful. Surgery was required in seven patients, one with infected groin and bleeding, another with FA at the site of a groin graft anastomosis, three with concomitant evacuation of large groin hematomas, one who refused further angiographic procedures, and one who needed prolonged full anticoagulation before the availability of the embolization. The operation was successful in all the patients except one, who died of myocardial infarction 24 hours after successful surgical closure of a FA. FA can be managed in a step-wise manner, starting with the noninvasive USGC, embolization and surgery. Surgery is indicated if evacuation of a large hematoma is required, or the presence of infection is suspected. Emergency surgery is indicated for bleeding or imminent rupture

Role of pulmonary arteriography in pulmonary embolism

The majority of episodes of deep venous thrombosis are silent, and the manifestations of pulmonary embolism are often non specific, so that the clinical suspicion and accurate diagnosis are mandatory. Ventillation/Perfusion [V/Q] scintigraphy is a non invasive test of reasonably high diagnostic accuracy [Secker-Walker, 1983]. Isotopic scan results should be correlated with a recent chest x-ray, as this increase the efficacy of the test [Secker-Walker, 1983]. On a plain chest film several signs are helpful but there is no pathognomonic radiologic sign that can be relied upon with complete confidence. In developing counteries, there is the problem of regular supply of good ventillation agents. Furthurmore, the [V/Q] scans are sometimes equivocal. Pulmonary arteriography may offer the only possibility of making an absolute diagnosis of pulmonary embolism. In this study pulmonary arteriography was performed for 29 patients, 21 males and 8 females their ages ranging between 30 - 70 years. The technique being relatively invasive, in this article we state our own experience regarding the necessity, diagnostic yield, hazards and safety of the procedure

Extracción percutánea de catéteres rotos y migrados en el sistema circulatoria / Removal of the catheter fragment by percutaneous endovascular approach

La rotura y migración de un fragmento de catéter venoso central o angiográfico es una situación poco frecuente pero grave. Suele asociarse con una alta morbimortalidad como consecuencia de taquiarritmias cardíacas, sepsis o complicaciones tromboembólicas. La extracción del catéter por vía percutánea endovascular previene o resuelve estas complicaciones. Esta técnica es altamente efectiva y segura realizada por un equipo experimentado en terapéutica endovascular. Ha reemplazado la extracción por toracotomía a cielo abierto, que a priori, carece de indicaciones

Complicaçöes do cateterismo arterial retrógrado percutâneo / Complications of percutaneous retrograde arterial catheterism

A introduçäo do cateterismo vascular pela técnica de Seldinger veio trazer um enorme avanço ao universo de exames complementares utilizados para diagnóstico na medicina. Entretanto, sendo uma técnica invasiva, esse procedimento poderia causar complicaçöes. Com o objetivo de analisar as complicaçöes envolvidas com a utilizaçäo dessa técnica, estudamos 707 pacientes submetidos a 772 cateterismos arteriais retrógrados percutâneos para diagnóstico. Verificamos a ocorrência de 74 complicaçöes (9,6) sendo 16 consideradas graves (2,1) e 58 leves(7,5). O tratamento operatório foi instituido em 15 complicaçöes vasculares graves (1,9) e medicamentoso e/ou observaçäo clínica nas complicaçöes restantes. Näo ocorreram óbitos nessa amostra