Comparison of Vertebral Artery Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography in the Diagnosis of Vertebral Artery Stenosis in Patients with Posterior Circulation Ischemia

SUMMARY: The aim of this study was to compare the clinical value of vertebral artery ultrasound (VAU), Magnetic Resonance Angiography (MRA) and Digital Subtraction Angiography (DSA) on vertebral artery stenosis in patients with posterior circulation ischemia. Seventy-three patients with posterior circulation ischemia underwent vertebral artery ultrasound and magnetic resonance angiography as well as digital subtraction angiography, and the diagnosis of vertebral artery stenosis (VAS) and the degree of stenosis (normal, mild stenosis, moderate stenosis, severe stenosis, and occlusion) were recorded and compared between digital subtraction angiogram and vertebral artery ultrasound and magnetic resonance angiography. The vertebral artery stenosis rates on digital subtraction angiography and vertebral artery ultrasound were 87.30 % (55/63) and 49.20 % (31/63), respectively, and the difference was statistically significant. The rates of vertebral artery stenosis on digital subtraction angiography and, magnetic resonance angiography was 90.38 % (47/52) and 88.46 % (46/ 52), respectively, and the differences was not statistically significant. The sensitivity, accuracy, negative predictive value, and positive predictive value of vertebral artery ultrasound in diagnosing vertebral artery stenosis were 51.35 %, 54.76 %, 18.18 %, and 95.00 %, respectively, lower than those of magnetic resonance angiography, which were 91.89 %, 90.48 %, 57.14 %, and 97.14 %, respectively. Of the noninvasive imaging techniques, vertebral artery ultrasound does not accurately characterize vertebral artery stenosis and its degree of stenosis. Magnetic resonance angiography effectively screens for vertebral artery stenosis and its degree of stenosis, and can be used as a reliable tool for vertebral artery stenosis in posterior circulation cerebral infarction, and can be used in conjunction with digital subtraction angiogram in order to improve diagnostic convenience and accuracy.

El objetivo de este estudio fue comparar el valor clínico de la ecografía de la arteria vertebral (VAU), la angiografía por resonancia magnética (ARM) y la angiografía por sustracción digital (DSA) en la estenosis de la arteria vertebral en pacientes con isquemia de la circulación posterior. A 73 pacientes con isquemia de la circulación posterior se les realizó una ecografía de la arteria vertebral y una angiografía por resonancia magnética, así como una angiografía por sustracción digital, y se les diagnosticó estenosis de la arteria vertebral (EVA) y el grado de estenosis (normal, estenosis leve, estenosis moderada, estenosis grave, y oclusión) se registraron y compararon la angiografía por sustracción digital y la ecografía de la arteria vertebral y la angiografía por resonancia magnética. Las tasas de estenosis de la arteria vertebral en la angiografía por sustracción digital y la ecografía de la arteria vertebral fueron del 87,30 % (55/63) y del 49,20 % (31/63), respectivamente, y la diferencia fue estadísticamente significativa. Las tasas de estenosis de la arteria vertebral en la angiografía por sustracción digital y la angiografía por resonancia magnética fueron del 90,38 % (47/52) y del 88,46 % (46/52), respectivamente, y las diferencias no fueron estadísticamente significativas. La sensibilidad, precisión, valor predictivo negativo y valor predictivo positivo de la ecografía de la arteria vertebral en el diagnóstico de estenosis de la arteria vertebral fueron 51,35 %, 54,76 %, 18,18 % y 95,00 %, respectivamente, inferiores a los de la angiografía por resonancia magnética, que fueron 91,89 %, 90,48 %, 57,14 % y 97,14 %, respectivamente. De las técnicas de imagen no invasivas, la ecografía de la arteria vertebral no caracteriza con precisión la estenosis de la arteria vertebral y su grado de estenosis. La angiografía por resonancia magnética detecta eficazmente la estenosis de la arteria vertebral y su grado de estenosis, y puede usarse como una herramienta confiable para la estenosis de la arteria vertebral en el infarto cerebral de circulación posterior, y puede ser utilizada junto con la angiografía por sustracción digital para mejorar el diagnóstico y la exactitud.

Manejo del tracto de salida del ventrículo derecho con implante percutáneo de válvula Melody en pacientes pediátricos: experiencia en un centro de alta complejidad en Colombia / Management of right ventricular outflow tract with percutaneous Melody valve implantation in pediatric patients: experience in a high complexity center in Colombia

Resumen Antecedentes: Las cardiopatías congénitas plantean un desafío terapéutico, específicamente la estenosis de la válvula pulmonar. Esta ha sido tratada durante muchos años con procedimientos invasivos e inserción de bioprótesis, que con el tiempo se vuelven disfuncionales y pueden reestenosarse por acumulación de tejido fibroso y calcificación. Debido a las complicaciones generadas por la injuria quirúrgica, se han descrito medidas menos invasivas para el manejo de la estenosis residual e inicial por medios endovasculares en adultos y más recientemente en población pediátrica. Objetivo: El objetivo de este reporte es describir la misma en el manejo endovascular del tracto de salida del ventrículo derecho, como el inicio de un trabajo continuo para la mejoría de los resultados pediátricos en países en vía de desarrollo. Métodos: Se presentan siete casos pediátricos de manejo endovascular del tracto de salida derecho; tres de ellos sometidos a valvuloplastia quirúrgica con persistencia de la estenosis pulmonar, por lo cual se decidió inserción percutánea de una válvula pulmonar (IVPP) transcatéter con válvula Melody utilizando la técnica valve-in-valve, con lo que se consiguió una resolución del 100% de la estenosis y no se presentó ningún tipo de complicación asociada al procedimiento. Resultados: En cuatro pacientes se logró una implantación exitosa de la válvula por vía percutánea en diferentes cardiopatías congénitas, siendo uno de ellos en tracto nativo; además, destaca el caso de un paciente en quien se realizó fractura intencional de la válvula pulmonar, procedimiento innovador en el manejo endovascular pediátrico en Colombia. Conclusiones: En estos pacientes el procedimiento resultó ser poco invasivo, seguro y efectivo. La técnica IVPP podría ser considerada una opción viable en Colombia (y en otros países en desarrollo) para el manejo de implantes valvulares primarios fallidos o incluso en tractos nativos.

Abstract Background: Congenital heart disease poses a therapeutic challenge, specifically pulmonary valve stenosis. This has been treated for many years with invasive procedures and bioprostheses, which over time, become dysfunctional due to the accumulation of fibrous tissue and calcification. Objective: The aim of this study is to describe the use of endovascular management in the right ventricular outflow tract, as the beginning of an ongoing effot to improve pediatric outcomes in developing countries. Methods: Seven pediatric patients with endovascular management of the right outflow tract are presented. Three of them underwent surgical valvuloplasty with persistent pulmonary stenosis. They decided to insert a percutaneous transcatheter pulmonary valve (PPVI) with a Melody valve using the valve-in-valve technique, with 100% stenosis and no complications associated with the procedure. Results: Four patients with successful percutaneous valve implantation had different congenital heart diseases. In addition, the case of a patient in whom an intentional pulmonary valve fracture was performed, an innovative procedure in pediatric endovascular management in the country, is highlighted. Conclusions: The procedure was minimally invasive, safe, and effective. The IVPP technique could be a viable option in our country for managing failed primary valve implantations or even in native tracts.

Prevalencia de estenosis aórtica moderada-grave en pacientes con amiloidosis cardiaca en un centro de referencia / Prevalence of moderate-severe aortic stenosis in patients with cardiac amyloidosis in a referral center

Resumen Antecedentes: La estenosis aórtica (EA) es actualmente la enfermedad valvular más frecuente, con una prevalencia estimada de más del 4 % en octogenarios. Objetivo: Describir la prevalencia de estenosis aórtica (EA) moderada-grave en pacientes con amiloidosis por transtiretina wild type (ATTRwt). Además, describir las características clínicas, ecocardiográficas y la evolución en este grupo de pacientes. Método: Estudio de cohorte retrospectiva de pacientes con diagnóstico de ATTRwt, pertenecientes al Registro Institucional de Amiloidosis del Hospital Italiano de Buenos Aires, en el periodo del 30/11/2007 al 31/05/2021. El seguimiento de los pacientes se realizó a través de la historia clínica electrónica de la institución. Se estimó la prevalencia de EA moderada-grave, que se presenta como porcentaje con su intervalo de confianza del 95% (IC 95%). Se compararon las características por grupos según tuvieran o no EA moderada-grave. Resultados: Se incluyeron 104 pacientes con diagnóstico de ATTRwt. La mediana de seguimiento fue de 476 días [rango intercuartílico: 192-749]. La prevalencia de EA moderada-grave al momento del diagnóstico de ATTRwt fue del 10.5% (n = 11; IC95%: 5-18%). La mediana de edad de los pacientes con EA fue de 86 años [78-91] y predominó el sexo masculino (81.8%). La mayoría de los pacientes tenían el antecedente de insuficiencia cardiaca (n = 8) y fibrilación auricular (n = 8). Predominaron los pacientes con EA grave de bajo flujo y bajo gradiente (n = 7). Cuatro pacientes fueron sometidos a alguna intervención en la válvula aórtica. Durante el seguimiento, 5 pacientes (46%) tuvieron internaciones por insuficiencia cardiaca descompensada y 4 (36%) fallecieron. Conclusiones: En nuestra cohorte, la coexistencia de ambas patologías tuvo una prevalencia similar a la reportada en la literatura internacional. Se trató de una población añosa con alto porcentaje de fibrilación auricular y antecedente de insuficiencia cardiaca. La mayoría presentaron EA grave de bajo flujo y bajo gradiente.

Abstract Background: Aortic stenosis (AS) is currently the most common valvular disease, with an estimated prevalence of over 4% in octogenarians. Objective: To describe the prevalence of moderate-severe aortic stenosis (AS) in patients with wild type transthyretin amyloidosis (ATTRwt). Also, describe the clinical features, echocardiographic characteristics and clinical evolution. Method: Retrospective cohort of patients with diagnosis of ATTRwt, belonging to Hospital Italiano de Buenos Aires Institutional Amyloidosis Registry, from 30/11/2007 to 31/05/2021. Patients follow up was carried out through the institution clinical history. The prevalence of moderate-severe AE was estimated and presented as a percentage with its 95% confidence interval (95% CI). The characteristics were compared by groups according to whether or not they had moderate-severe AS. Results: 104 patients with ATTRwt were included. Median follow up was 476 days [interquartile range: 192-749]. Moderate-severe AS prevalence at the ATTRwt time of diagnosis was 10.5% (n = 11; 95% CI: 5-18%). The median age of patients with AS moderate-severe at the time of diagnosis of ATTRwt was 86 years [78-91] and the male sex predominated (82%). Most of the patients had a history of heart failure (n = 8) and atrial fibrillation (n = 8) prior to the diagnosis of ATTRwt. Most of the patients were subclassified as low flow low gradient severe AS group (n = 7). Four patients underwent some intervention on the aortic valve. During follow-up, 5 patients (46%) were hospitalized for decompensated heart failure and 4 (36%) died. Conclusions: In our cohort, the coexistence of both pathologies had a similar prevalence as reported in the international literature. It was an elderly population with a high percentage of atrial fibrillation and history of heart failure. Most of the patients presented with severe AS with low flow low gradient.

Slide tracheoplasty for congenital tracheal stenosis with involvement of the carina and bronchi: a case report

ABSTRACT A female newborn presented with respiratory distress at birth and was diagnosed with congenital tracheal stenosis. The stenosis was positioned at the distal trachea and compromised the carina and the right and left bronchi. She underwent surgical treatment using circulatory life support with veno-arterial peripheral extracorporeal membrane oxygenation, and the airway was reconstructed using the slide tracheoplasty technique to build a neocarina. The patient had an excellent postoperative course, was successfully weaned from extracorporeal membrane oxygenation and invasive ventilation, and was discharged.

Diretrizes da Sociedade Brasileira de Angiologia e Cirurgia Vascular para o tratamento da doença cerebrovascular extracraniana / Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease

Resumo A doença cerebrovascular extracraniana tem sido intensamente investigada em todo o mundo, sendo tema de suma importância para os cirurgiões vasculares. A presente Diretriz foi elaborada pela Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV) em sucessão à Diretriz de 2015. As doenças de etiologia não ateroscleróticas não foram incluídas nesse documento. O objetivo desta Diretriz é congregar as evidências mais robustas nessa área para auxiliar os especialistas no processo decisório do tratamento. Foi utilizada a metodologia AGREE II e o sistema da Sociedade Europeia de Cardiologia para as recomendações e níveis de evidências. As recomendações foram graduadas de I a III, e os níveis de evidência classificados em A, B e C. A presente Diretriz foi dividida em 11 capítulos, que tratam dos vários aspectos da doença cerebrovascular extracraniana: diagnóstico, tratamentos e complicações, de forma atualizada e com as recomendações propostas pela SBACV.

Abstract Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

Accuracy of duplex ultrasonography versus angiotomography for the diagnosis of extracranial internal carotid stenosis / Acurácia da ultrassonografia duplex comparada à angiotomografia para o diagnóstico de estenose de carótida interna extracraniana

ABSTRACT Introduction: Internal carotid artery (ICA) stenosis causes about 15% of ischemic strokes. Duplex ultrasonography (DUS) is the first line of investigation of ICA stenosis, but its accuracy varies in the literature and it is usual to complement the study with another more accurate exam when faced with significant stenosis. There is a lack of studies that compare DUS with angiotomography (CTA) in the present literature. Methods: we performed an accuracy study, which compared DUS to CTA of patients in a tertiary hospital with a maximum interval of three months between tests. Patients were selected retrospectively, and two independent and certified vascular surgeons evaluated each image in a masked manner. When there was discordance, a third evaluator was summoned. We evaluated the diagnostic accuracy of ICA stenosis of 50-94% and 70-94%. Results: we included 45 patients and 84 arteries after inclusion and exclusion criteria applied. For the 50-94% stenosis range, DUS accuracy was 69%, sensitivity 89%, and specificity 63%. For the 70-94% stenosis range, DUS accuracy was 84%, sensitivity 61%, and specificity 93%. There was discordance between CTA evaluators with a change from clinical to surgical management in at least 37.5% of the conflicting reports. Conclusion: DUS had an accuracy of 69% for stenoses of 50-94% and 84% for stenoses of 70-94% of the ICA. The CTA analysis depended directly on the evaluator with a change in clinical conduct in more than 37% of cases.

RESUMO Introdução: a estenose da artéria carótida interna (ACI) causa cerca de 15% dos acidentes vasculares cerebrais isquêmicos. A ultrassonografia duplex (USD) é a primeira linha de investigação da estenose de ACI, mas sua acurácia varia na literatura e é comum complementar o estudo com outro exame de maior acurácia diante de estenose significativa. Há uma escassez de estudos que comparem a USD com a angiotomografia computadorizada (ATC) na literatura atual. Métodos: realizamos um estudo de acurácia, que comparou a USD à ATC de pacientes de um hospital terciário com um intervalo máximo de três meses entre os exames. Os pacientes foram selecionados retrospectivamente e dois cirurgiões vasculares independentes e certificados avaliaram cada imagem de maneira mascarada. Quando houve discordância, um terceiro avaliador foi convocado. Avaliou-se a precisão diagnóstica da estenose da ACI de 50-94% e 70-94%. Resultados: foram incluídos 45 pacientes e 84 artérias após a aplicação dos critérios de inclusão e exclusão. Para a faixa de estenose de 50-94%, a acurácia da USD foi 69%, sensibilidade 89% e especificidade 63%. Para a faixa de estenose de 70-94%, a acurácia da USD foi 84%, sensibilidade 61% e especificidade 93%. Ocorreu discordância entre avaliadores da ATC com mudança de conduta clínica para cirúrgica em pelo menos 37,5% dos laudos conflitantes. Conclusão: a USD teve uma acurácia de 69% para estenoses de 50-94% e de 84% para estenoses de 70-94% da ACI. A análise das ATC dependeu diretamente do avaliador com mudança de conduta clínica em mais de 37% dos casos.

Desfechos de curto prazo da cirurgia de carótida: experiência no "mundo real" em um centro único de formação profissional / Short term outcomes of carotid surgery: the real-world experience of a single teaching center

Resumo Contexto A abordagem cirúrgica para estenose carotídea sintomática está consolidada na literatura para a prevenção de eventos neurológicos, devendo seguir padrões ótimos de qualidade. Entretanto, há uma crescente preocupação relacionada à possibilidade ou não de replicar os dados dos trabalhos controlados no mundo real. Objetivos Avaliar a população com estenose carotídea sintomática submetida a cirurgia e seus desfechos de curto prazo em um contexto de mundo real em um centro de formação profissional. Métodos Tratou-se de um estudo observacional realizado por meio de coleta de dados em prontuário de janeiro de 2012 a janeiro de 2023. Foram excluídos pacientes operados por outras etiologias e com cirurgia cardíaca concomitante. Resultados Foram incluídos 70 pacientes submetidos a angioplastia ou endarterectomia carotídea. Os subgrupos populacionais submetidos a angioplastia ou endarterectomia foram semelhantes. Houve diferença estatisticamente relevante quanto à modalidade anestésica e ao tempo cirúrgico maior para o subgrupo de endarterectomia carotídea. Houve quatro casos de acidente vascular encefálico isquêmico, e três deles estavam relacionados à lesão, sendo dois menores e um maior. Dessa forma, a taxa de acidente vascular encefálico maior relacionado à lesão foi de 1,43% e de qualquer acidente vascular encefálico relacionado à lesão, de 4,29%. A taxa total de eventos adversos cardiovasculares maiores foi de 5,71%. Houve um caso de infarto agudo do miocárdio no grupo angioplastia e nenhum óbito. Não houve diferença estatística entre os grupos de endarterectomia e angioplastia quanto aos desfechos principais. Conclusões Os desfechos acidente vascular encefálico isquêmico, infarto agudo do miocárdio, óbito e eventos adversos cardiovasculares maiores neste centro são semelhantes aos encontrados em estudos clínicos randomizados, demonstrando viabilidade da manutenção deste tratamento em centros com programas de ensino.

Abstract Background Surgical treatment of symptomatic extracranial carotid stenosis is well established for preventing neurological events and should adhere to optimal quality standards. However, there is growing concern as to whether results of controlled trials are replicable in real-world settings. Objectives To assess a symptomatic carotid stenosis population that underwent surgery and its short-term outcomes in a real-world context at a professional training center. Methods Observational study using data collected from medical records from January 2012 to January 2023. Patients undergoing operations for other carotid diseases and with concomitant heart surgery were excluded. Results A total of 70 patients undergoing angioplasty or carotid endarterectomy were included. Population subsets undergoing angioplasty or endarterectomy were similar. Differences in anesthetic modality and a longer operative time in the carotid endarterectomy subgroup were statistically significant. There were 4 cases of stroke, only 3 of which (2 minor and 1 major) were related to the index lesion. Thus, the rate of major operation-related stroke was 1.43% and the rate of any lesion-related stroke was 4.29%. There was 1 case of AMI in the angioplasty group and there were no deaths in the sample. The overall rate of major adverse cardiovascular events was 5.71%. There were no statistical differences between the endarterectomy and angioplasty groups regarding the main outcomes. Conclusions The rates of outcomes of ischemic stroke, acute myocardial infarction, death, and major adverse cardiovascular events at this center are in line with the rates reported by randomized controlled trials, demonstrating the feasibility of carotid surgery in centers with teaching programs.

The Effect of Aortic Angulation on Clinical Outcomes of Patients Undergoing Transcatheter Aortic Valve Replacement

ABSTRACT Introduction: The aim of this study was to assess the impact of aortic angulation (AA) on periprocedural and in-hospital complications as well as mortality of patients undergoing Evolut™ R valve implantation. Methods: A retrospective study was conducted on 264 patients who underwent transfemoral-approach transcatheter aortic valve replacement with self-expandable valve at our hospital between August 2015 and August 2022. These patients underwent multislice computer tomography scans to evaluate AA. Transcatheter aortic valve replacement endpoints, device success, and clinical events were assessed according to the definitions provided by the Valve Academic Research Consortium-3. Cumulative events included paravalvular leak, permanent pacemaker implantation, new-onset stroke, and in-hospital mortality. Patients were divided into two groups, AA ≤ 48° and AA > 48°, based on the mean AA measurement (48.3±8.8) on multislice computer tomography. Results: Multivariable logistic regression analysis was performed to identify predictors of cumulative events, utilizing variables with a P-value < 0.2 obtained from univariable logistic regression analysis, including AA, age, hypertension, chronic renal failure, and heart failure. AA (odds ratio [OR]: 1.73, 95% confidence interval [CI]: 0.89-3.38, P=0.104), age (OR: 1.04, 95% CI: 0.99-1.10, P=0.099), hypertension (OR: 1.66, 95% CI: 0.82-3.33, P=0.155), chronic renal failure (OR: 1.82, 95% CI: 0.92-3.61, P=0.084), and heart failure (OR: 0.57, 95% CI: 0.27-1.21, P=0.145) were not found to be significantly associated with cumulative events in the multivariable logistic regression analysis. Conclusion: This study demonstrated that increased AA does not have a significant impact on intraprocedural and periprocedural complications of patients with new generation self-expandable valves implanted.

Endothelial Microparticles: Markers of Inflammatory Response After Sutureless Valve Implantation

ABSTRACT Introduction: Systemic inflammatory response syndrome (SIRS) is related to increased circulating endothelial microparticles (EMP). Objective: The aim of this study was to compare the plasma concentration of EMP between patients undergoing aortic valve replacement with conventional bioprosthesis implantation and Perceval™ S (LivaNova) and to evaluate its impact on the inflammatory response in the short-term follow-up. Methods: This is a randomized clinical trial with 24 patients submitted to isolated aortic valve replacement divided into two groups: Perceval™ S (Group P) and conventional bioprostheses (Group C). Incidence of severe SIRS (three or more criteria) in the first 48 hours postoperatively, EMP release profile, interleukins (IL) 6 and 8, C-reactive protein, and procalcitonin were analyzed preand postoperatively at 24 hours and three months. Results: There were 24 patients (12 in each group), mean age was 69.92±5.17 years, 83.33% were female, the incidence of severe SIRS was 66.7% and 50% in groups C and P, respectively (P=0.68), and EMP showed a significant increase in the 24-hour postoperative period (P≤0.001) and subsequent decrease in the three-month postoperative period (P≤0.001), returning to baseline levels. For IL-6 and IL-8, there was a greater increase in group C at 24 hours postoperatively (P=.0.02 and P<0.001). Conclusion: The incidence of severe SIRS was similar in both groups, with significantly higher levels of IL-6 and IL-8, at the 24-hour postoperative period, in group C, however with higher levels of EMP in group P, and subsequent return to baseline levels at the three-month postoperative period in both groups.

Five-Year Follow-Up After Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis and Concomitant Coronary Artery Disease: A Single-Center Experience

ABSTRACT Introduction: There is no consensus on the impact of coronary artery disease in patients undergoing transcatheter aortic valve implantation. Therefore, the objective of this study was, in a single-center setting, to evaluate the five-year outcome of transcatheter aortic valve implantation patients with or without coronary artery disease. Methods: All transcatheter aortic valve implantation patients between 2009 and 2019 were included and grouped according to the presence or absence of coronary artery disease. The primary endpoint, five-year all-cause mortality, was evaluated using Cox regression adjusted for age, sex, procedure years, and comorbidities. Comorbidities interacting with coronary artery disease were evaluated with interaction tests. In-hospital complications was the secondary endpoint. Results: In total, 176 patients had aortic stenosis and concomitant coronary artery disease, while 170 patients had aortic stenosis only. Mean follow-up was 2.2±1.6 years. There was no difference in the adjusted five-year all-cause mortality between transcatheter aortic valve implantation patients with and without coronary artery disease (hazard ratio 1.00, 95% confidence interval 0.59-1.70, P=0.99). In coronary artery disease patients, impaired renal function, peripheral arterial disease, or ejection fraction < 50% showed a significant interaction effect with higher five-year all-cause mortality. No significant differences in complications between the groups were found. Conclusion: Five-year mortality did not differ between transcatheter aortic valve implantation patients with or without coronary artery disease. However, in patients with coronary artery disease and impaired renal function, peripheral arterial disease, or ejection fraction < 50%, we found significantly higher five-year all-cause mortality.

Association of Estimated Glucose Disposal Rate With the Stenosis Severity of Coronary Artery Disease： A Cross-sectional Study / 中山大学学报(医学科学版)

ObjectiveTo investigate the association between estimated glucose disposal rate （eGDR） and the severity of coronary heart disease. MethodsWe conducted a hospital-based cross-sectional study that included 1258 patients （mean age： 62（53-68） years） who underwent coronary angiography for suspected coronary artery disease （53.9% were male）. Insulin resistance level （IR） was calculated according to eGDR formula： eGDR = 21.158 - （0.09 × WC） - （3.407 × hypertension） - （0.551 × HbA1c） ［hypertension （yes = 1 / no = 0）， HbA1c = HbA1c （%）］. Subjects were grouped according to the eGDR quantile. CAD severity was determined by the number of narrowed vessels： no-obstructive CAD group （all coronary stenosis were<50%， n=704）， Single-vessel CAD group （only one involved major coronary artery stenosis≥50%， n=205）， Multi-vessel CAD group （two or more involved major coronary arteries stenosis≥50%， n=349）； Multivariate logistic regression model was used to analyze the association between eGDR and CAD severity. The linear relationship between eGDR and CAD in the whole range of eGDR was analyzed using restricted cubic spline. Subgroup analyses were used to assess the association between eGDR and CAD severity in different diabetic states. Receiver operating characteristic （ROC） curve analysis were used to evaluate the value of eGDR in improving CAD recognition. ResultsA decrease in the eGDR index was significantly associated with an increased risk of CAD severity （OR： 2.79； 95%CI： 1.72~4.55； P<0.001）. In multivariate logistic regression models， individuals with the lowest quantile of eGDR （T1） were 2.79 times more likely to develop multi-vessel CAD than those with the highest quantile of eGDR （T3） （OR： 2.79； 95%CI： 1.72~4.55； P<0.001）. Multivariate restricted cubic spline analysis showed that eGDR was negatively associated with CAD and multi-vessel CAD （P-nonlinear>0.05）. In non-diabetic patients， compared with the reference group （T3）， the T1 group had a significantly increased risk of CAD （OR： 1.42； 95% CI： 1.00~2.01； P<0.05） and multi-vessel CAD （OR： 1.86； 95%CI： 1.21~2.86； P<0.05）. No statistical association was found between eGDR and CAD in diabetic patients. In ROC curve analysis， when eGDR was added to traditional model for CAD， significant improvements were observed in the model's recognition of CAD and multi-vessel CAD. ConclusionOur study shows eGDR levels are inversely associated with CAD and CAD severity. eGDR， as a non-insulin measure to assess IR， could be a valuable indicator of CAD severity for population.

Lung transplantation after paraquat poisoning in an adolescent: one case report and literature review / 器官移植

Objective To summarize the effect of the timing of lung transplantation and related treatment measures on clinical prognosis of patients with paraquat poisoning. Methods Clinical data of a patient with paraquat poisoning undergoing bilateral lung transplantation were retrospectively analyzed. Clinical manifestations, auxiliary examination, diagnosis and treatment of this patient were summarized and analyzed. Results A 17-year-old adolescent was admitted to hospital due to nausea, vomiting, cough and systemic fatigue after oral intake of 20-30 mL of 25% paraquat. After symptomatic support treatment, the oxygen saturation was not improved, and pulmonary fibrosis continued to progress. Therefore, sequential bilateral lung transplantation was performed under extracorporeal membrane oxygenation (ECMO). After postoperative rehabilitation and active prevention and treatment for postoperative complications, the patient was discharged at postoperative 50 d. Conclusions The timing of lung transplantation after paraquat poisoning may be selected when the liver and kidney function start to recover. Active and targeted prevention of potential pathogen infection in perioperative period and early rehabilitation training contribute to improving clinical prognosis of lung transplant recipients.

Analysis of three-dimensional visualization imaging of severe portal vein stenosis after liver transplantation and clinical efficacy of portal vein stent implantation / 器官移植

Objective To analyze three-dimensional imaging characteristics and advantages for severe portal vein stenosis after liver transplantation, and to evaluate clinical efficacy of portal vein stent implantation. Methods Clinical data of 10 patients who received portal vein stent implantation for severe portal vein stenosis after liver transplantation were retrospectively analyzed. Imaging characteristics of severe portal vein stenosis, and advantages of three-dimensional reconstruction imaging and interventional treatment efficacy for severe portal vein stenosis were analyzed. Results Among 10 patients, 3 cases were diagnosed with centripetal stenosis, tortuosity angulation-induced stenosis in 2 cases, compression-induced stenosis in 2 cases, long-segment stenosis and/or vascular occlusion in 3 cases. Three-dimensional reconstruction images possessed advantages in accurate identification of stenosis, identification of stenosis types and measurement of stenosis length. All patients were successfully implanted with portal vein stents. After stent implantation, the diameter of the minimum diameter of portal vein was increased [(6.2±0.9) mm vs. (2.6±1.7) mm, P<0.05], the flow velocity at anastomotic site was decreased [(57±19) cm/s vs. (128±27) cm/s, P<0.05], and the flow velocity at the portal vein adjacent to the liver was increased [(41±6) cm/s vs. (18±6) cm/s, P<0.05]. One patient suffered from intrahepatic hematoma caused by interventional puncture, which was mitigated after conservative observation and treatment. The remaining patients did not experience relevant complications. Conclusions Three-dimensional visualization technique may visually display the location, characteristics and severity of stenosis, which is beneficial for clinicians to make treatment decisions and assist interventional procedures. Timely implantation of portal vein stent may effectively reverse pathological process and improve portal vein blood flow.

Diagnosis and treatment of the portal vein complications for children undergoing spilt liver transplantation / 器官移植

Objective To investigate the diagnosis and treatment strategy of the portal vein complications in children undergoing split liver transplantation. Methods The clinical data of 88 pediatric recipients who underwent split liver transplantation were retrospectively analyzed. Intraoperative anastomosis at the bifurcating site of the portal vein or donor iliac vein bypass anastomosis was performed depending on the internal diameter and development of the recipient's portal vein. A normalized portal venous blood stream monitoring was performed during the perioperative stage. After operation, heparin sodium was used to bridge warfarin for anticoagulation therapy. After portal vein stenosis or thrombosis was identified with enhanced CT or portography, managements including embolectomy, systemic anticoagulation, interventional thrombus removal, balloon dilatation and/or stenting were performed. Results Among the 88 recipients, a total of 10 children were diagnosed with portal vein complications, of which 4 cases were diagnosed with portal vein stenosis at 1 d, 2 months, 8 months, and 11 months after surgery, and 6 cases were diagnosed with portal vein thrombosis at intraoperative, 2 d, 3 d (n=2), 6 d, and 11 months after surgery, respectively. One patient with portal vein stenosis and one patient with portal vein thrombosis died perioperatively. The fatality related to portal vein complications was 2% (2/88). Of the remaining 8 patients, 1 underwent systemic anticoagulation, 2 underwent portal venous embolectomy, 1 underwent interventional balloon dilatation, and 4 underwent interventional balloon dilatation plus stenting. No portal venous related symptoms were detected during postoperative long term follow up, and the retested portal venous blood stream parameters were normal. Conclusions The normalized intra- and post-operative portal venous blood stream monitoring is a useful tool for the early detection of portal vein complications, the early utilization of useful managements such as intraoperative portal venous embolectomy, interventional balloon dilatation and stenting may effectively treat the portal vein complications, thus minimizing the portal vein complication related graft loss and recipient death.

Diagnosis and treatment strategies for vascular complications after kidney transplantation / 器官移植

With persistent progress in donor-recipient evaluation criteria, organ procurement and preservation regimens and surgical techniques, the incidence of vascular complication after kidney transplantation has been declined, whereas it is still one of the most severe surgical complications of kidney transplantation, which may lead to graft loss and recipient death, and seriously affect the efficacy of kidney transplantation. Therefore, the occurrence, clinical manifestations, diagnosis and treatment strategies of common vascular complications after kidney transplantation, including vascular stenosis, arterial dissection, pseudoaneurysm, vascular rupture and thrombosis were reviewed in this article. In combination with the incidence, diagnosis and treatment of vascular complications after kidney transplantation in the First Affiliated Hospital of Xi'an Jiaotong University, diagnosis and treatment strategies for common vascular complications after kidney transplantation were summarized, aiming to provide reference for clinical diagnosis and treatment of vascular complications after kidney transplantation, lower the incidence of vascular complications, and improve clinical efficacy of kidney transplantation and survival rate of recipients.

Influencing factors of survival of patients with airway stenosis requiring clinical interventions after lung transplantation / 器官移植

Objective To analyze the influencing factors of survival of patients with airway stenosis requiring clinical interventions after lung transplantation. Methods Clinical data of 66 patients with airway stenosis requiring clinical interventions after lung transplantation were retrospectively analyzed. Univariate and multivariate Cox’s regression models were adopted to analyze the influencing factors of survival of all patients with airway stenosis and those with early airway stenosis. Kaplan-Meier method was used to calculate the overall survival and delineate the survival curve. Results For 66 patients with airway stenosis, the median airway stenosis-free time was 72 (52,102) d, 27% (18/66) for central airway stenosis and 73% (48/66) for distal airway stenosis. Postoperative mechanical ventilation time [hazard ratio (HR) 1.037, 95% confidence interval (CI) 1.005-1.070, P=0.024] and type of surgery (HR 0.400, 95%CI 0.177-0.903, P=0.027) were correlated with the survival of patients with airway stenosis after lung transplantation. The longer the postoperative mechanical ventilation time, the higher the risk of mortality of the recipients. The overall survival of airway stenosis recipients undergoing bilateral lung transplantation was better than that of their counterparts after single lung transplantation. Subgroup analysis showed that grade 3 primary graft dysfunction (PGD) (HR 4.577, 95%CI 1.439-14.555, P=0.010) and immunosuppressive drugs (HR 0.079, 95%CI 0.022-0.287, P<0.001) were associated with the survival of patients with early airway stenosis after lung transplantation. The overall survival of patients with early airway stenosis after lung transplantation without grade 3 PGD was better compared with that of those with grade 3 PGD. The overall survival of patients with early airway stenosis after lung transplantation treated with tacrolimus was superior to that of their counterparts treated with cyclosporine. Conclusions Long postoperative mechanical ventilation time, single lung transplantation, grade 3 PGD and use of cyclosporine may affect the survival of patients with airway stenosis after lung transplantation.

Estenosis Tricuspídea Severa secundaria a enfermedad carcinoide cardiaca: presentación de caso clínico y revisión de la literatura / Severe Tricuspid Stenosis Secondary to Cardiac Carcinoid Disease: Case Report and Literature Review

RESUMEN: La estenosis tricuspídea (ET) es una valvulopatía infrecuente cuyas principales etiologías son la enfermedad reumática y la endocarditis infecciosa. En raras ocasiones puede deberse a un fenómeno carcinoide subyacente, en lo que se conoce como la enfermedad carcinoide cardiaca (ECC). Esta condición lleva a la fibrosis del endocardio del ventriculo derecho, principalmente de sus válvulas, lo cual puede provocar falla cardiaca derecha, complicando el pronóstico. En este artículo se presenta un caso de una ET severa por una posible ECC, en conjunto con las imagenes ecocardiográficas obtenidas durante el abordaje diagnóstico (imágenes bidimensionales, imagen multiplanar y ecocardiografía en 3D). Se discuten las implicaciones clínicas, los retos diagnósticos, las opciones terapeuticas y el pronóstico de esta rara entidad.

ABSTRACT Severe Tricuspid Stenosis Secondary to Cardiac Carcinoid Disease: Case Report and Literature Review Tricuspid stenosis is an unfrequent valvulopathy that can be caused by multiple etiologies, including rheumatic disease and infectious endocarditis. In rare occasions, it occurs in the context of a carcinoid syndrome, in what is known as carcinoid heart disease. This condition causes fibrosis of the valves and the endocardium of the right ventricule, which can progress into right ventricular failure, worsening the patient's prognosis. In this article, we present a case of a severe tricuspid stenosis in which this ethiology is suspected. We show the echocardiographic images obtained for the diagnosis (two-dimensional imaging, multimodal imaging and 3D echocardiography), and we discuss the clinical and diagnostic implications, therapeutic options and prognosis of this rare condition.

¿Cuánto tiempo debe permanecer un stent traqueal implantado? Curación de la estenosis luego de 10,16 y 22 años de implante / How Long Should a Tracheal Stent Remain Implanted? Healing of Stenosis 10, 16, and 22 Years After Implantation

RESUMEN Tres stents traqueales fueron removidos luego de 10, 16 y 22 años, a lo que le siguió la correspondiente curación de la estenosis traqueal. Se reportan dos nuevos casos de estenosis traqueal benigna, tratados con prótesis de silicona, que se presentaron a control luego de muy largas ausencias: 16 años en uno y 22 en otro. Se suman a un caso anteriormente publicado y curado luego de 10 años de permanencia del stent, que también presentó una amplia y estable luz traqueal luego la remoción. Se describen los hallazgos endoscópicos, y se incluyen reflexiones sobre la curación de la estenosis observada en todos ellos y su probable relación con el largo tiempo de permanencia de las prótesis. Se investigan las propiedades físicas de los stents, luego de tan prolongado lapso de implante y se las compara con un dispositivo nuevo. Se emite una propuesta que podría conducir a la curación de las estenosis traqueales con tratamiento endoscópico y stent por tiempo prolongado.

ABSTRACT Three tracheal stents were removed after 10, 16, and 22 years, followed by healing of tracheal stenosis. Two new cases of benign tracheal stenosis are reported, treated with silicone pros theses, which presented for follow-up after very long absences: 16 years in one case and 22 years in the other. They add to a previously published case that was healed 10 years after the stent was implanted, which also had a wide and stable tracheal lumen after removal. The endoscopic findings are described, and reflections are included on the healing of the observed stenosis in all cases and its probable relationship with the prolonged indwelling of the prostheses. The physical properties of the stents are inves tigated after such a long period since implantation, and they are compared with a new device. A proposal is put forward that could lead to the healing of tracheal stenosis with endoscopic treatment and prolonged indwelling of the stent.

Estenosis hipertrófica del píloro en la Orinoquía colombiana (2010-2020)

Introducción: La hipertrofia del esfínter pilórico (EHP) es una condición que se caracteriza por la obstrucción del vaciamiento gástrico fisiológico y se considera una patología de resolución quirúrgica. Objetivo: Realizar la caracterización de los pacientes con hipertrofia congenita del píloro atendidos en el Hospital Regional de la Orinoquía entre 2010 y 2020. Metodología: Estudio observacional, descriptivo y retrospectivo en el cual se incluyeron los pacientes que consultaron al Hospital Regional de la Orinoquía entre el 01 de enero del 2010 y el 31 de diciembre del 2020 y que presentaron diagnóstico de hipertrofia congenita del píloro, identificados mediante los códigos CIE 10. Resultados: En total, se incluyeron 18 pacientes que cumplían con los criterios de selección. El promedio de edad de los participantes fue de 24,3 días de edad. La mayoría eran varones, asimismo, dos pacientes presentaban sobrepeso al nacer. El síntoma predominante fue la emesis posprandial en un 100 %. El diagnóstico se realizó mediante las medidas del píloro con ecografía abdominal y a la totalidad de los pacientes se les realizó piloromiotomía, de los cuales uno solo requirió una reintervención, sin embargo, ningún paciente falleció. Conclusiones: La hipertrofia congenita del píloro es una entidad patológica poco común, su síntoma clínico cardinal es la emesis postprandial. El método diagnóstico por excelencia es el estudio ecográfico. A pesar de su complejidad, esta entidad patológica tiene un buen pronóstico a corto y largo plazo.

Introduction: Hypertrophic pyloric stenosis (HPS) is a condition that is characterized by the obstruction of physiological gastric emptying and is considered a surgically-resolved pathology. Objective: To characterize patients with congenital hypertrophy of the pylorus treated at the Regional Hospital of Orinoquía between 2010 and 2020. Methods: Observational, descriptive and retrospective study of patients who were admitted at the Orinoquía Regional Hospital between January of 2010 and December of 2020. The patients that were included had a diagnosis of hypertrophic pyloric stenosis identified by the ICD-10 codes. Results: A total of patients were included by selection criteria. The average age of participants was 24.3 days old. Most of them were males and 2 patients were overweight at birth. The most common symptom was postprandial emesis in 100%. The diagnosis was made through measurements of pylorus measured with abdominal ultrasound. All the patients performed pyloromyotomy, and only one required a surgical reintervention, however, the mortality was 0. Conclusions: Congenital hypertrophy of pylorus is an uncommon pathology, whose cardinal symptom is postprandial emesis. The ideal diagnostic method is an ultrasound study. Despite its complexity, this pathology has a good short and long-term prognosis.

Criterios broncoscópicos, laboratoriales y anatomopatológicos de enfermedad de la vía aérea en pacientes diagnosticados con granulomatosis con poliangitis / Bronchoscopic, laboratory and anatomopathological criteria for airway disease in patients diagnosed with granulomatosis with polyangiitis

Introducción: los pacientes con granulomatosis con poliangitis (GPA) pueden presentar compromiso de la vía aérea superior (VAS) o inferior (VAI). Objetivos: describimos las manifestaciones endoscópicas de las vías respiratorias, los hallazgos histológicos y los anticuerpos anticitoplasma de neutrófilos (ANCA) en un grupo de pacientes con GPA. Métodos: estudio retrospectivo de historias clínicas de pacientes con GPA sometidos a broncoscopia entre 2012 y 2019. Se analizaron hallazgos de la vía aérea, biopsias y ANCA. Resultados: se incluyeron 40 pacientes, con una edad media de 46,92±17,61 años, predominantemente del sexo femenino (67,5%). Se observó afectación de la vía aérea en el 90% (n=36). El C-ANCA fue reactivo en el 63,9%, P-ANCA en el 25%, ANCA doblemente reactivo en el 8,33% y no reactivo en el 20%. Los hallazgos comunes en la vía aérea superior (VS) fueron sinusitis crónica (41,7%), destrucción del tabique nasal (16,7%); y en la vía aérea inferior (AI): estenosis traqueobronquial (38,9%), traqueobronquitis (25%). Los hallazgos más frecuentes de las biopsias broncoscópicas fueron proceso inflamatorio polimorfonuclear (61,9%) y necrosis geográfica (47,6%). Conclusión: la vía aérea está comprometida hasta en un 90% de los pacientes con GPA. ANCA no reactivos no descartan esta posibilidad. La sinusitis crónica y los procesos fibroestenóticos traqueobronquiales fueron los hallazgos endoscópicos más comunes. La vasculitis en biopsias se encontró en una minoría de casos.

Introduction: patients with granulomatosis with polyangiitis (GPA) may present upper airway (UA) and lower airway (LA) involvement. Objectives: we describe the endoscopic manifestations of the airways, histological findings from biopsied tissue and antineutrophilic cytoplasm antibody (ANCA) in a group of patients with GPA. Methods: retrospective study of medical records of patients with GPA undergoing bronchoscopy between 2012 and 2019. Airway findings, results of biopsies performed and ANCA results were analyzed. Results: 40 patients were included, with a mean age of 46.92±17.61 years and predominantly female (67.5%). Airway involvement was observed in 90% (n=36). The C-ANCA was reactive in 63.9%, P-ANCA in 25%, doubly reactive ANCA in 8.33% and non-reactive in 20%. The findings in upper airway (UA) were: chronic sinusitis (41.7%), destruction of the nasal septum (16.7%); and in lower airway (LA) were: tracheobronchial stenosis (38.9%) and tracheobronchitis (25%). The pathological findings most common of bronchoscopic biopsies were: polymorphonuclear inflammatory process (61.9%) and geographic necrosis (47.6%). Conclusion: the airway is involved in up to 90% of patients with GPA. Non-reactive ANCA does not rule out this possibility. Chronic sinusitis and tracheobronchial fibrostenotic processes were the most common endoscopic findings. Vasculitis in biopsies was found in a minority of cases.