Totally Percutaneous Repair of an Aortic Arch Dissection: A Case Report

ABSTRACT Although the endovascular repair of descending thoracic aorta diseases is an already consolidated procedure, this approach is not well-established for ascending aorta and arch pathologies. A 71-year-old male patient who had undergone an open ascending aorta replacement ten years ago presented with a huge dissected aortic arch aneurysm. Vascular accesses were obtained with ultrasound-guided punctures, followed by aortic arch exclusion using aortic endoprostheses and the chimney-graft technique for preserving supra-aortic branches flow. This case demonstrates the feasibility of a totally percutaneous aortic arch repair provided that careful preprocedural planning and a dedicated team are available for such a challenging intervention.

Ecocardiografia Tridimensional na avaliação de endocardite de válvula nativa: um relato de caso e semelhança entre achados ecocardiográficos e cirúrgicos / Three-Dimensional transesophageal echocardiography in native valve endocarditis: a case report and similarities between echocardiography and surgical findings

A endocardite de valva nativa é uma doença incomum, complexa, e de alta morbimortalidade. Requer tratamento clínico prolongado, com várias complicações possíveis, e o seu tratamento cirúrgico é complexo e tecnicamente difícil. O ecocardiograma transtorácico e transesofágico são fundamentais na avaliação da doença, inclusive seus achados são parte dos critérios diagnósticos de endocardite. Adicionalmente, o ecocardiograma tridimensional (3D) contribui com detalhamento anatômico na avaliação das estruturas cardíacas acometidas pela doença. Mostramos um caso em que é ilustrado o papel da ecocardiografia no diagnóstico e avaliação de complicações da endocardite, comparando as imagens do ecocardiograma 3D pré-operatórias, com os achados durante o ato cirúrgico. (AU)

Native valve bacterial endocarditis is an uncommon, complex, and highly morbid disease that requires prolonged clinical treatment and challenging surgical interventions. Transthoracic and transesophageal echocardiography are paramount assessment tools whose findings are included in the diagnostic criteria. Three-dimensional echocardiography shows further realistic imaging details. Here we present a case demonstrating the role of echocardiography in the diagnosis of endocarditis and the identification of its complications to show how advanced imaging techniques may have a remarkable resemblance with in vivo surgical findings. (AU)

Endovascular treatment of coarctation of the aorta with a self-expanding endoprosthesis: how i do it using the braile dominus ® coarctation aorta device

Abstract The coarctation of the aorta is a relatively highly prevalent congenital heart disease and may be diagnosed as an underline cause of hypertension in adolescents and adults. The gold standard treatment for coarctation of the aorta in these patients is being replaced - from open surgery to endovascular therapy. Some prostheses have been developed to treat the coarctation with less acute and chronic complications. The Dominus® Coarctation Aorta (Braile Biomédica) is the first self-expandable prosthesis created specifically to treat coarctation of the aorta, reducing possible acute complications, like aortic rupture or aortic dissection. Here, we discuss the step-by-step method for using this prosthesis.

The role of the axillary artery as a second access choice in TAVI procedures

Abstract With transcatheter aortic valve implantation (TAVI) technology expanding its indications for low-risk patients, the number of TAVI-eligible patients will globally grow, requiring a better understanding about the second-best access choice. Regarding the potential access sites, the transfemoral retrograde route is recognized as the standard approach and first choice according to current guidelines. However, this approach is not suitable in up to 10-15% of patients, for whom an alternative non-femoral access is required. Among the alternative non-femoral routes, the transaxillary approach has received increasing recognition due to its proximity and relatively straight course from the axillary artery to the aortic annulus, which provides a more accurate device deployment. Here we discuss some particular aspects of the transaxillary access, either percutaneously performed or by cutdown dissection.

Urinary incontinence and quality of life in female patients with obesity / Incontinência urinária e qualidade de vida em pacientes femininas com obesidade

Abstract Objective To analyze the prevalence of urinary incontinence (UI) in female patients with an indication for bariatric surgery, to investigate the potential risk factors and the impact on quality of life. Methods A cross-sectional study with female patients with obesity. The evaluation consisted of a structured interview, a specific study form and quality of life questionnaires. The Poisson regression was performed to identify independent risk factors related to UI. Results A total of 221 patients were enrolled; 118 of the study participants (53.4%) reported UI episodes. Mixed UI (MUI), stress UI (SUI) only, and urgency UI (UUI) only were reported by 52.5% (62), 33.9% (40) , and 13.5% (16) of these patients respectively. The prevalence of UI was increased by 47% among the women who had given birth vaginally and by 34% of the women who had entered menopause. Vaginal delivery and menopause were identified as independent risk factors related to UI. The mean International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) score was 9.36 ± 4.9. The severity of symptoms was considered moderate in 53.3% (63) of the patients with UI. Conclusion Urinary incontinence impacts quality of life negatively, and the prevalence of UI is high among obese patients. In the present study, vaginal delivery and menopause were independently associated with UI.

Resumo Objetivo Analisar a prevalência de incontinência urinária (IU), os fatores de risco e o impacto na qualidade de vida em pacientes femininas comindicação para realização de cirurgia bariátrica. Métodos Estudo transversal com pacientes femininas obesas. A avaliação consistiu em entrevista estruturada, com questionários de estudo específico e de qualidade de vida. A regressão de Poisson foi utilizada para identificar os fatores de risco independentes para IU. Resultados Um total de 221 pacientes foram incluídos; 118 participantes (53.4%) relataram episódios de IU. Incontinência urinária mista, IU de esforço e IU de urgência foram relatadas por 52.5% (62), 33.9% (40) e 13.5%(16) das pacientes, respectivamente. A prevalência de IU foi 47%maior emmulheres que tiveramparto vaginal, e 34% maior em mulheres que já entraram no período da menopausa. Parto vaginal e menopausa foram identificados como fatores de risco independentes para IU. A média da pontuação do International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) foi de 9.36 ± 4.9. A severidade dos sintomas foi considerada moderada em 53.3% (63) das pacientes com IU. Conclusão A IU impacta negativamente a qualidade de vida, e a prevalência de IU é maior empacientes obesas. Neste estudo, parto vaginal e menopausa foram fatores de risco independentes para a ocorrência de IU.

Imunização nos pacientes em tratamento oncológico / Immunization in patients under oncological treatment

Introdução: A vacinação representa importante impacto na saúde populacional. No paciente oncológico, a importância de um calendário vacinal completo faz-se ainda maior, visto que muitos pacientes tornam-se mais suscetíveis a infecções devido ao estado de imunossupressão facilitado pela neoplasia e pelos tratamentos impostos. Métodos: Revisão de literatura visando elucidar questionamentos relacionados à vacinação em pacientes oncológicos. Resultados: Em geral, as vacinas inativadas são seguras e incapazes de causar infecção, mesmo nos pacientes em vigência de tratamento oncológico. Já as vacinas de vírus vivos atenuados, em imunodeprimidos, são capazes de desencadear um processo infeccioso exacerbado e devem ser aplicadas seguindo algumas regras. Conclusão: Devido às peculiaridades relacionadas à vacinação de pacientes em tratamento oncológico, as orientações para sua implantação devem ser seguidas com atenção visando o benefício do paciente e a prevenção de danos.

Introduction: Vaccination represents an important impact on social health. In oncologic patients, the importance of a complete immunization schedule is even greater, since many patients become more susceptible to infections due to the immunosuppressed state facilitated by neoplasia and by the imposed treatments. Methods: Literature review in order to elucidate questions related to vaccination in cancer patients. Results: In general, inactivated vaccines are safe and unable to cause infection even in patients under oncological treatment. In contrast, live attenuated vaccines in immunosuppressed patient are likely to trigger an exacerbated infectious process and must be applied following a few rules. Conclusion: Due to the peculiarities related to vaccination in patients under oncological treatment, the guidelines for its application must be carefully followed aiming benefit and prevention of harm.

Síndrome da veia cava superior / Superior vena cava syndrome

Introdução: A síndrome da veia cava superior (SVCS) é uma condição potencialmente grave, principalmente em pacientes acometidas por neoplasias malignas (2 a 4% dos pacientes com neoplasias pulmonares malignas desenvolverão SVCS em algum momento da doença). A obstrução normalmente é gradual, permitindo formação de circulação venosa colateral como fluxo alternativo do sangue ao encontro do átrio direito. Métodos: Revisão narrativa da literatura, a fim de elucidar os aspectos mais importantes sobre a síndrome da veia cava superior. Resultados: O diagnóstico é feito basicamente por sinais e sintomas da obstrução venosa central, tanto clínicos quanto radiológicos, sendo a dispneia o sintoma mais comum. A tomografia computadorizada é o exame de imagem geralmente utilizado para o diagnóstico. O tratamento é voltado para a causa base e alívio dos sintomas. O alívio sintomático pode ser conseguido tanto por terapia clínica quanto intervencionista. O tratamento definitivo é realizado pela terapia oncológica. Conclusão: Em paciente com SVCS por compressão extrínseca por câncer de pulmão não pequenas células, que é a causa mais comum, a SVCS é um forte preditor de mal prognóstico, com sobrevida mediana de cinco meses. Esse artigo visa fazer uma revisão sobre os aspectos clínicos e de diagnóstico e tratamento da SVCS.

Introduction: Superior vena cava syndrome (SVCS) is a potentially serious condition, especially in patients with malignancy, (2 to 4% of patients with malignant lung tumors will develop SVCS at some point in the disease). The obstruction is usually gradual, allowing formation of collateral venous circulation as an alternative blood flow to the right atrium. Methods: Narrative review of the literature in order to elucidate the most important aspects about superior vena cava syndrome. Results: The diagnosis is basically made by signs and symptoms of central venous obstruction, both clinical and radiological, with dyspnea being the most common symptom. Computed tomography is the imaging test usually used for diagnosis. The treatment is geared towards the underlying cause and symptoms relief. Symptomatic relief can be achieved by both clinical and interventional therapy. Definitive treatment is provided by oncologic therapy. Conclusion: In a patient with SVCS by extrinsic compression from non-small cell lung cancer, which is the most common cause, SVCS is a strong predictor of poor prognosis, with a median survival of five months. This article aims to review the clinical presentation, diagnosis and treatment of SVCS.

Totally percutaneous access using perclose proglide for endovascular treatment of aortic diseases

Abstract Objective: To evaluate our experience following the introduction of a percutaneous program for endovascular treatment of aortic diseases using Perclose Proglide® assessing efficacy, complications and identification of potential risk factors that could predict failure or major access site complications. Methods: A retrospective cohort study during a two-year period was performed. All the patients submitted to totally percutaneous endovascular repair (PEVAR) of aortic diseases and transcatheter aortic valve implantation since we started the total percutaneous approach with the preclosure technique from November 2013 to December 2015 were included in the study. The primary endpoint was major ipsilateral access complication, defined according to PEVAR trial. Results: In a cohort of 123 patients, immediate technical success was obtained in 121 (98.37%) patients, with only two (0.82%) cases in 242 vascular access sites that required intervention immediately after the procedure. Pairwise comparisons revealed increased major access complication among patients with >50% common femoral artery (CFA) calcification vs. none (P=0.004) and > 50% CFA calcification vs. < 50% CFA calcification (P=0.002). Small artery diameter (<6.5 mm) also increased major access complication compared to bigger diameters (> 6.5 mm) (P=0.027). Conclusion: The preclosure technique with two Perclose Proglide® for PEVAR is safe and effective. Complications occur more often in patients with unfavorable access site anatomy and the success rate can be improved with proper patient selection.