Life-threatening variceal bleeding after liver transplantation and extensive portal vein thrombosis: Desperate times call for desperate measures.

BACKGROUND: The management of complex, intra- and extrahepatic portal vein thrombosis (PVT) after liver transplantation (LT) is challenging. Although most of the patients remain asymptomatic or oligosymptomatic in the chronic setting, some of them may develop severe portal hypertension and related complications, notably gastrointestinal (GI) bleeding. In the emergency scenario, clinical and endoscopic treatments as well as intensive support constitute the bases of conservative management, while more definitive treatment options such as surgical shunting and retransplantation are related to high morbidity rates. Transjugular intrahepatic portosystemic shunt (TIPS) was largely considered of limited role due to technical difficulties arising from extensive PVT. Recently, however, new minimally invasive image-guided techniques emerged, allowing portal vein recanalization and TIPS creation simultaneously (TIPS-PVR), even in complex PVT pretransplant patients. METHODS: Herein, we describe a novel indication for TIPS-PVR in a post-LT adolescent presenting with life-threatening, refractory GI bleeding. RESULTS: The patient presented with complete resolution of the hemorrhagic condition after the procedure, with no deterioration of hepatic function or hepatic encephalopathy. Follow-up Doppler ultrasound after TIPS-PVR showed normal hepatopetal venous flow within the stents, and no evidence of complications, including intraperitoneal or peri splenic bleeding. CONCLUSIONS: This report describes the feasibility of TIPS-PVR in the post-LT scenario complicated by extensive PVT. In this case, a complete resolution of the life-threatening GI bleeding was achieved, with no major complications. Other patients with complex chronic PVT might benefit from the use of the described technique, but further studies are required to determine the correct timing and indications of the procedure, eventually before the occurrence of life-threatening complications.

Direct portal vein recanalization with stenting associated with embolization of esophagogastric varices in a patient with portal vein thrombosis.

Introduction: Chronic extrahepatic non-tumoral thrombotic portal vein occlusion in non-cirrhotic patients is a rare condition, affecting 5-10% of patients with portal hypertension. Presentation of case: The present study reports the case of a young patient without previous comorbidities who presented with portal hypertension secondary to chronic extrahepatic non-tumoral thrombotic occlusion of the portal vein. He underwent portal recanalization with a 12 × 80 mm nitinol self-expandable stent and embolization of esophagogastric varices with fibrous springs and cyanoacrylate via transparieto-hepatic access. Immediate resolution of the trans-lesion pressure gradient was obtained transoperatively, while complete remission of esophagogastric varices was verified by endoscopic control during outpatient follow-up. Discussion: Chronic portal vein occlusion is associated or not with liver cirrhosis. The chronic phase is characterized by cavernomatous transformation of the portal vein, which consists of the formation of multiple collaterals that bypass the lesion. This phase usually courses with portal hypertension and consequent variceal gastrointestinal bleeding. Decompression of the portal system through direct recanalization (angioplasty with stenting) is one therapeutic options. Conclusion: We conclude that, in the present case, resolving portal hypertension by direct portal recanalization was a good therapeutic option, as it decompressed the portal system while maintaining the hepatopetal flow.

Tips and Tricks in Microsurgical Treatment for Previously Embolized Aneurysms-Three-Dimensional Video.

One of the most popular treatment strategies for complex cerebral aneurysms with wide necks is stent-assisted coiling.1 Although it is a minimally invasive technique, it is associated with higher recurrence rates (approximately 20%) compared with surgical clipping.2 Recanalization is more common principally in ruptured aneurysms as well as in giant aneurysms, aneurysms located in the posterior circulation, aneurysms with a relatively wide neck morphology, and aneurysms followed for >1 year.2-6 Tirakotai et al. classified the indications for surgical treatment after coiling into 3 groups: 1) surgery of incompletely coiled aneurysms; 2) surgery for mass effects on neural structures; 3) surgery for vascular complications.7 Recanalization, if significant, often requires retreatment. Retreating with additional coils fails in perhaps 50% of cases.3 On the other hand, surgical clipping is complicated and difficult to perform. Recanalized aneurysms are categorized into 3 types: type I, coils are compressed; type II, coils are migrated; type III, coils are migrated, and multiple coils fill its neck or the parent artery. Direct clipping can be applied to types I and II, whereas trapping, wrapping, or auxiliary revascularization is required in type III.2 Coil extraction should not be attempted regularly because it is associated with high morbidity.8 In this three-dimensional video, we present the microsurgical treatment of a type I recanalized anterior communicating artery aneurysm, which in serial digital subtraction angiography control scans showed residual patency, progressive growth, and changes in its hemodynamic behavior (Video).

Liver Growth and Portal Hypertension Improvement After Percutaneous Recanalization of Chronic Portal Vein Thrombosis in Non-Cirrhotic Participants.

PURPOSE: To evaluate liver function improvement and volume gain after percutaneous recanalization of chronic portal vein thrombosis (PVT) in non-cirrhotic patients. MATERIALS AND METHODS: In this retrospective study, five non-cirrhotic participants between 21 and 67 years old with secondary chronic PVT (4-21 years from diagnose) were submitted to percutaneous portal vein recanalization, followed by varices and shunts embolization. RESULTS: After a mean of 12.6 months, all portal veins remained patent and there was complete resolution of portal hypertension (PH) symptoms in all participants. There was a significant increase in liver volume of 39.8 ± 19.0% (p = 0.042), platelets count of 53120 ± 20188/µl (p = 0.042), and a significant decrease in total bilirubin levels from 1.04 ± 0.23 mg/dL to 0.51 ± 0.09 mg/dL (p = 0.043). We also found a non-significant increase in albumin levels from 3.88 ± 0.39 g/dL to 4.38 ± 0.27 g/dL (p = 0.078) and decrease in spleen diameter from 16.88 ± 4.03 cm to 14.15 ± 2.72 cm (p = 0.068). DISCUSSION: In this retrospective study, even with a small number of participants, we were capable of showing a median of 39.8% increase in liver volume, laboratorial liver function improvement, platelets count and resolution of PH symptoms, including gastroesophageal varices disappearance after portal vein recanalization followed by shunt embolization. CONCLUSION: In this small series of cases, recanalization of chronic PVT in non-cirrhotic participants was feasible, successful and safe despite the prolonged time of occlusion. This is a new and promising approaching to an old and still challenging disease.

Fluoroscopy and endoscopy-guided transanastomotic rendezvous: a novel technique for recanalization of a completely obstructed colorectal anastomosis.

BACKGROUND: Colorectal anastomotic stricture is a frequent complication that may affect up to 30% of patients. However, a complete obstruction is rare. Endoscopic balloon dilation is the first-line therapy, but it invariably requires being able to cross the stricture with the dilation device. When this is not possible, surgical revision is the alternative, but it is associated with higher morbidity. CASE PRESENTATION: A 76-year-old male patient underwent an urgent high anterior resection with transverse loop colostomy for an occlusive high rectal tumor. On postoperative day 8, he presented with anastomotic leakage and abscess formation, requiring percutaneous drainage. Ten months after surgery, a colonoscopy revealed a complete stricture of the anastomosis, refractory to negotiation of a guide wire, thus precluding balloon dilation. Hence, a modified rendezvous technique was planned. Simultaneously, a flexible endoscope and a rigid rectoscope were progressed through the distal loop colostomy, and the anus, respectively. A needle device was introduced through the rectoscope and used to pierce the colonic stump. A guide wire was progressed, and the stricture was dilated with a controlled radial expansion balloon catheter. Finally, a 12-Fr Foley catheter was left through the anastomosis. A total of three endoscopic balloon dilation sessions were completed, and successful colostomy reversal was carried out 10 days after the last session. CONCLUSION: Fluoroscopy-endoscopy-guided recanalization is an effective and safe treatment option for complete colorectal anastomotic stricture.

Performance evolution over 645 acute stroke thrombectomies in a public Brazilian healthcare institution.

BACKGROUND: Assessment of the impact of the thrombectomy learning curve on clinical outcomes is essential for developing healthcare system protocols. AIMS: The aim of this study was to assess the effect of thrombectomy case volume on procedural and clinical outcomes in a Brazilian registry. METHODS: A total of 645 patients with acute ischemic stroke treated by thrombectomy were included in the analysis. Patients were divided into two groups regarding the period of treatment: the early period group and the late period group. RESULTS: In the adjusted analysis, treatment in the late period was an independent predictor of recanalization (odds ratio 1.91, 95% CI 1.28-2.86) and excellent neurologic outcomes at three months (odds ratio 1.77, 95% CI 1.04-3.01). Treatment in the late period had no significant association with mortality (odds ratio 0.88, 95% CI 0.55-1.41). CONCLUSIONS: An increase in thrombectomy case volume for the treatment of AIS over time was an independent predictor of recanalization and excellent neurologic outcome.

Recuperación de la fertilidad en una paciente estéril,mediante microcirugía de trompa uterina, y la aproximación al ovario contralateral / Fertility recovery in a sterile patient, by means of uterine tube microsurgery, and the approach to the contralateral ovary

Para que ocurra un embarazo exitoso, se requiere la integridad del tracto genital femenino, destacando como elementos importantes las trompas uterinas (TU) que transportan gametos y al óvulo fecundado a la cavidad uterina. La enfermedad de las TU por varias causas, como el embarazo ectópico, constituyen un 20% de causas de infertilidad. Gracias al desarrollo de técnicas de reproducción asistida (TRA) como la fecundación in vitro (FIV), en un alto porcentaje de pacientes que tienen un daño permanente y severo en estas estructuras, la cirugía para reparar o recanalizar las trompas uterinas ha sido desplazada por esta técnica de reproducción asistida. La reanastomosis tubárica tiene una tasa de éxito y de embarazos naturales después de la cirugía del 9% en mujeres con enfermedad tubárica severa al 69% en casos de enfermedad tubárica leve. Se presenta el caso de una paciente joven diagnosticada de infertilidad postquirúrgica por antecedentes de dos embarazos ectópicos accidentados previos que afectaron ambas trompas uterinas y ooforectomía izquierda; luego de realizado el procedimiento microquirúrgico, recuperó la posibilidad de ser madre.

For a successful pregnancy to occur, the integrity of the female genital tract is required, highlighting as important elements the uterine tubes (TU) that transport gametes and the fertilized egg into the uterine cavity. The disease of TU due to several causes, such as ectopic preg- nancy, constitute 20% of infertility causes. Thanks to the development of assisted reproduction techniques (ART) such as in vitro fertilization (IVF), in a high percentage of patients who have permanent and severe damage to these structures, surgery to repair or recanalize the uterine tubes has been displaced by This assisted reproduction technique. Tubal reanastomosis has a success rate and natural pregnancies after surgery of 9% in women with severe tubal disease at 69% in cases of mild tubal disease. We present the case of a young patient diagnosed with post-surgical infertility due to a history of two previous injured ectopic pregnancies that affec- ted both uterine tubes and left oophorectomy; After performing the micro-surgical procedure, he recovered the possibility of being a mother.

Hyper-attenuating brain lesions on CT after ischemic stroke and thrombectomy are associated with final brain infarction.

Purpose Hyper-attenuating lesions, or contrast staining, on a non-contrast brain computed tomography (NCCT) scan have been investigated as a predictor for hemorrhagic transformation after endovascular treatment of acute ischemic stroke (AIS). However, the association of hyper-attenuating lesions and final ischemic areas are poorly investigated in this setting. The aim of the present study was to assess correlations between hyper-attenuating lesions and final brain infarcted areas after thrombectomy for AIS. Methods Data from patients with AIS of the anterior circulation who underwent endovascular treatment were retrospectively assessed. Images of the brain NCCT scans were analyzed in the first hours and late after treatment. The hyper-attenuating areas were compared to the final ischemic areas using the Alberta Stroke Program Early CT Score (ASPECTS). Results Seventy-one of the 123 patients (65.13%) treated were included. The association between the hyper-attenuating region in the post-thrombectomy CT scan and final brain ischemic area were sensitivity (58.3% to 96.9%), specificity (42.9% to 95.6%), positive predictive values (71.4% to 97.7%), negative predictive values (53.8% to 79.5%), and accuracy values (68% to 91%). The highest sensitivity values were found for the lentiform (96.9%) and caudate nuclei (80.4%) and for the internal capsule (87.5%), and the lowest values were found for the M1 (58.3%) and M6 (66.7%) cortices. Conclusions Hyper-attenuating lesions on head NCCT scans performed after endovascular treatment of AIS may predict final brain infarcted areas. The prediction appears to be higher in the deep brain regions compared with the cortical regions.

Evolución clínica y ultrasonográfica del síndrome postrombótico en su primer año de evolución / Clinical and ultrasonographic progression of posthrombotic syndrome in its first year

Introduccións: La insuficiencia venosa crónica es característica principal del síndrome postrombótico donde el estasis venoso es típico.Objetivos: Describir la evolución clínica y ultrasonográfica del síndrome postrombótico durante su primer año.Métodos: Estudio descriptivo prospectivo en 20 hombres (55,6 por ciento) y 16 mujeres (44,4 por ciento) con una edad promedio de 55,8 ± 14,2 años (IC95 por ciento: 41,6 70 años), ingresados en el Servicio de Flebolinfología del Instituto Nacional de Angiología y Cirugía Vascular con el diagnóstico de trombosis venosa profunda de los miembros inferiores. Las variables estudiadas fueron: tipos de síntomas clínicos, tipo de evolución ultrasonográfica por ecodoppler, estadios clínicos del síndrome postrombótico, tiempo y porcentaje de recanalización.Resultadoss: A los seis meses de evolución predominó la sintomatología severa (47,2 por ciento); en el sector fémoro–poplíteo la clasificación de buena. Al año, fue más frecuente la clasificación de moderada (52,8 por ciento) y de muy buena en el sector poplíteo; el edema pretibial fue el signo que predominó. En los sectores ocluidos fémoro-poplíteo el porcentaje de recanalización promedio aumentó al año y fue superior (p < 0,05) al obtenido a los seis meses. Se encontró asociación significativa entre el porcentaje de recanalización y el período de evolución(X2= 41,41; p= 0,0000); y entre el estadio clínico y el porcentaje de recanalización (X2= 32,95; p= 0,0000).Conclusións: durante el primer año de presentarse el síndrome postrombótico pueden ocurrir cambios clínicos y evolución favorable en la recanalización del sistema venoso profundo (AU)

Introduction: Chronic venous insufficiency is the main characteristic of the posthrombotic syndrome where the vein stasis is typical.Objective: to describe the clinical and ultrasonographic progression of the post-thrombotic syndrome in its first year.Methods: A descriptive prospective study was conducted in 20 men (55.6 percent) and 16 women (44.4 percent), with average age of 55.8 ± 14.2 years (IC95 percent: 41.6 70 years) diagnosed as deep venous thrombosis of the lower limb patients and hospitalized in the phlebolymphology service of the National Institute of Angiology and Vascular Surgery. The studied variables were types of clinical symptoms, type of ultrasonographic progression using Echodoppler device, clinical stagings of the posthrombotic syndrome, and time and percentage of re-canalization.Results: After six months of progression, severe symptoms predominated (47.2 percent); and in the femoral-popliteal area the classification was good. After a year, the moderate classification was more frequent (52.8 percent) and extremely good in the popliteal sector; the pretibial edema was the predominant sign (50 percent). In the occluded popliteal-femoral sector, the percentage of average re-canalization increased after a year, being higher (p< 0.05) than that of six months. A significant association was found between the percentage of re-channeling and the period of progression (X2= 41.41; p= 0.0000); and between the clinical staging and the percentage of re-canalization (X2= 32.95, p= 0.0000).Conclusions: During the first year of existence of the posthrombotic syndrome, clinical changes and favorable progression may occur in the re-canalization of the deep venous system

Evolución clínica y ultrasonográfica del síndrome postrombótico en su primer año de evolución / Clinical and ultrasonographic progression of posthrombotic syndrome in its first year

Introduccións: La insuficiencia venosa crónica es característica principal del síndrome postrombótico donde el estasis venoso es típico. Objetivos: Describir la evolución clínica y ultrasonográfica del síndrome postrombótico durante su primer año. Métodos: Estudio descriptivo prospectivo en 20 hombres (55,6 por ciento) y 16 mujeres (44,4 por ciento) con una edad promedio de 55,8 ± 14,2 años (IC95 por ciento : 41,6 ­ 70 años), ingresados en el Servicio de Flebolinfología del Instituto Nacional de Angiología y Cirugía Vascular con el diagnóstico de trombosis venosa profunda de los miembros inferiores. Las variables estudiadas fueron: tipos de síntomas clínicos, tipo de evolución ultrasonográfica por ecodoppler, estadios clínicos del síndrome postrombótico, tiempo y porcentaje de recanalización. Resultadoss: A los seis meses de evolución predominó la sintomatología severa (47,2 por ciento); en el sector fémoro­poplíteo la clasificación de buena. Al año, fue más frecuente la clasificación de moderada (52,8 por ciento) y de muy buena en el sector poplíteo; el edema pretibial fue el signo que predominó. En los sectores ocluidos fémoro-poplíteo el porcentaje de recanalización promedio aumentó al año y fue superior (p < 0,05) al obtenido a los seis meses. Se encontró asociación significativa entre el porcentaje de recanalización y el período de evolución (X2= 41,41; p= 0,0000); y entre el estadio clínico y el porcentaje de recanalización (X2= 32,95; p= 0,0000). Conclusións: durante el primer año de presentarse el síndrome postrombótico pueden ocurrir cambios clínicos y evolución favorable en la recanalización del sistema venoso profundo(AU)

Introduction: Chronic venous insufficiency is the main characteristic of the posthrombotic syndrome where the vein stasis is typical. Objective: to describe the clinical and ultrasonographic progression of the post-thrombotic syndrome in its first year. Methods: A descriptive prospective study was conducted in 20 men (55.6 percent) and 16 women (44.4 percent), with average age of 55.8 ± 14.2 years (IC95 percent : 41.6 ­ 70 years) diagnosed as deep venous thrombosis of the lower limb patients and hospitalized in the phlebolymphology service of the National Institute of Angiology and Vascular Surgery. The studied variables were types of clinical symptoms, type of ultrasonographic progression using Echodoppler device, clinical stagings of the posthrombotic syndrome, and time and percentage of re-canalization. Results: After six months of progression, severe symptoms predominated (47.2 percent); and in the femoral-popliteal area the classification was good. After a year, the moderate classification was more frequent (52.8 percent) and extremely good in the popliteal sector; the pretibial edema was the predominant sign (50 percent). In the occluded popliteal-femoral sector, the percentage of average re-canalization increased after a year, being higher (p< 0.05) than that of six months. A significant association was found between the percentage of re-channeling and the period of progression (X2= 41.41; p= 0.0000); and between the clinical staging and the percentage of re-canalization (X2= 32.95, p= 0.0000). Conclusions: During the first year of existence of the posthrombotic syndrome, clinical changes and favorable progression may occur in the re-canalization of the deep venous system(AU)

Percutaneous retrograde crossing of a near-occluded celiac trunk via the superior mesenteric artery as an adjuvant maneuver for antegrade stenting / Passagem retrógrada percutânea de uma lesão estenosante crítica do tronco celíaco via artéria mesentérica superior como manobra adjuvante na abordagem anterógrada

We describe the case of a 63-year-old woman with chronic mesenteric ischemia, persistent postprandial upper abdominal pain and progressive weight loss. Retrograde recanalization was performed via the superior mesenteric artery in order to achieve the goal of crossing the near-occlusion, showing that retrograde catheterization of the celiac trunk can be a feasible approach in challenging cases in which an antegrade approach fails as a single maneuver.

Descrevemos o caso de uma mulher de 63 anos de idade, com isquemia mesentérica crônica, dor abdominal pós-prandial e emagrecimento progressivo. A recanalização retrógrada foi realizada através da artéria mesentérica superior para transpassar a estenose crítica. Demonstra-se assim que o cateterismo retrógrado do tronco celíaco pode ser uma abordagem viável em casos difíceis, em que a abordagem anterógrada falha como manobra única.

Aspectos clínicos, ultra-sonográficos e venográficos da tromboflebite jugular experimental em equinos / Equine experimental thrombophlebitis: clinical, ultrasonographic and venographic evaluation

A tromboflebite jugular ocorre frequentemente em equinos, decorrendo geralmente de processos mórbidos associados à iatrogenia, podendo levar a perda de função, edema cefálico, diminuição do desempenho atlético e ainda causar o óbito. Esta enfermidade nos equinos apesar de frequente é pouco conhecida quanto à sua evolução e tratamentos. O objetivo deste trabalho foi avaliar a evolução da tromboflebite jugular experimental em equinos, quanto às alterações clínicas e estruturais envolvidas na enfermidade, observando-se os aspectos clínicos, ultra-sonográficos e venográficos no contexto do trombo e do vaso, quanto à possibilidade de recanalização do trombo produzido e da vascularização compensatória. A tromboflebite da veia jugular foi induzida, unilateralmente, em 05 equinos nos quais previamente à indução da tromboflebite e diariamente após foram observadas manifestações clínicas e realizados exames ultra-sonográficos. Venografias foram feitas nos momentos pré-indução, na indução e a cada seis dias após a indução da tromboflebite, verificando-se a recanalização do trombo oclusivo e a presença de vasos na drenagem sanguínea compensatória. Observou-se a ocorrência de edema moderado das regiões parotídea, massetérica e supra-orbitária e discreto edema submandibular que reduziram até o 6º dia, permanecendo apenas discreto aumento parotídeo. O ingurgitamento da jugular cranial a região da indução permaneceu durante todo o período de avaliação. A porção caudal à tromboflebite mostrou ingurgitamento frente ao garrote na entrada do tórax desde o primeiro dia após a indução. Os exames ultra-sonográficos mostraram formação de trombo oclusivo total durante todo o período de observação em 3 animais e o restabelecimento parcial do fluxo na jugular em 2 animais e a presença de vasos colaterais conduzindo o sangue da porção cranial para a porção caudal à obstrução. As venografias revelaram fluxo sanguíneo "linear" normal no momento pré-operatório, constatando nos momentos pós-operatórios a presença oclusiva do trombo, com o contraste preenchendo os vasos tributários compensatórios direcionados à porção caudal à oclusão da veia ou ainda estagnado cranialmente ao trombo. Conclui-se que a trombose oclusiva na tromboflebite jugular experimental e unilateral sofre recanalização e compensação vascular por vasos tributários de drenagem, com redução gradativa dos sinais decorrentes da estase sanguínea de retorno, especificamente as regiões cefálicas com edema. Estudos envolvendo a tromboflebite jugular nos equinos devem evoluir nos aspectos experimental e clínico.

Jugular thrombophlebitis is a common complication of disease processes associated with repeated venipuncture, injection of irritant solutions, and the use of indwelling catheters, especially with bacterial contamination. Bilateral thrombophlebitis may result in edema of the soft tissues of the head, reduction of athletic performance and even death of the animal. This disease, although common in horses, is not much known regarding its evolution and treatment. The aim of this study was to evaluate the clinical and structural changes of experimentally induced jugular thrombophlebitis in horses, through clinical examination, ultrasound and venography of the thrombus and the vessel, verifying the possibility of thrombus recanalization and compensatory produced blood flow. The jugular thrombophlebitis was induced unilaterally into 5 horses, monitored by clinical (general, regional and local) and ultrassonographycs exams. Venographs were made at pre-induction, induction and every 6 days after induction of thrombophlebitis, in order to observe recanalization of the occlusive thrombus and presence of blood vessels in the drainage allowance. Occurrence of moderate edema was observed in the parotid, masseter and supra orbital regions, and mild edema in the submandibular region. The jugular engorgement of the cranial region of induction persisted throughout the period of evaluation. The caudal portion to the thrombophlebitis showed engorgement with compression on the vein at the thorax entrance since the first day after induction. The ultrasound examinations showed total occlusive thrombus formation of 3 animals, partial recirculating flow in the jugular vein in 2 animals, and collateral blood vessels from the cranial obstruction to the caudal portion. The venography revealed normal linear blood flow in the preoperative and occlusive thrombus with contrast directed filling of the vessels to the compensatory portion caudal to the vein occlusion or cranial to the thrombus in the postoperative moments. After vein resection of the segment containing the thrombus, the cephalic edema was less intense than after the induction of the thrombophlebtits. The ultrassonography and venography post resection showed vascularity increase in this region. It was concluded that there is recanalization with endothelialization and vascular compensation made by pre-existing vessels necessary for drainage.

Aspectos clínicos, ultra-sonográficos e venográficos da tromboflebite jugular experimental em equinos / Equine experimental thrombophlebitis: clinical, ultrasonographic and venographic evaluation

A tromboflebite jugular ocorre frequentemente em equinos, decorrendo geralmente de processos mórbidos associados à iatrogenia, podendo levar a perda de função, edema cefálico, diminuição do desempenho atlético e ainda causar o óbito. Esta enfermidade nos equinos apesar de frequente é pouco conhecida quanto à sua evolução e tratamentos. O objetivo deste trabalho foi avaliar a evolução da tromboflebite jugular experimental em equinos, quanto às alterações clínicas e estruturais envolvidas na enfermidade, observando-se os aspectos clínicos, ultra-sonográficos e venográficos no contexto do trombo e do vaso, quanto à possibilidade de recanalização do trombo produzido e da vascularização compensatória. A tromboflebite da veia jugular foi induzida, unilateralmente, em 05 equinos nos quais previamente à indução da tromboflebite e diariamente após foram observadas manifestações clínicas e realizados exames ultra-sonográficos. Venografias foram feitas nos momentos pré-indução, na indução e a cada seis dias após a indução da tromboflebite, verificando-se a recanalização do trombo oclusivo e a presença de vasos na drenagem sanguínea compensatória. Observou-se a ocorrência de edema moderado das regiões parotídea, massetérica e supra-orbitária e discreto edema submandibular que reduziram até o 6º dia, permanecendo apenas discreto aumento parotídeo. O ingurgitamento da jugular cranial a região da indução permaneceu durante todo o período de avaliação. A porção caudal à tromboflebite mostrou ingurgitamento frente ao garrote na entrada do tórax desde o primeiro dia após a indução. Os exames ultra-sonográficos mostraram formação de trombo oclusivo total durante todo o período de observação em 3 animais e o restabelecimento parcial do fluxo na jugular em 2 animais e a presença de vasos colaterais conduzindo o sangue da porção cranial para a porção caudal à obstrução. As venografias revelaram fluxo sanguíneo "linear" normal no momento pré-operatório, constatando nos momentos pós-operatórios a presença oclusiva do trombo, com o contraste preenchendo os vasos tributários compensatórios direcionados à porção caudal à oclusão da veia ou ainda estagnado cranialmente ao trombo. Conclui-se que a trombose oclusiva na tromboflebite jugular experimental e unilateral sofre recanalização e compensação vascular por vasos tributários de drenagem, com redução gradativa dos sinais decorrentes da estase sanguínea de retorno, especificamente as regiões cefálicas com edema. Estudos envolvendo a tromboflebite jugular nos equinos devem evoluir nos aspectos experimental e clínico.(AU)

Jugular thrombophlebitis is a common complication of disease processes associated with repeated venipuncture, injection of irritant solutions, and the use of indwelling catheters, especially with bacterial contamination. Bilateral thrombophlebitis may result in edema of the soft tissues of the head, reduction of athletic performance and even death of the animal. This disease, although common in horses, is not much known regarding its evolution and treatment. The aim of this study was to evaluate the clinical and structural changes of experimentally induced jugular thrombophlebitis in horses, through clinical examination, ultrasound and venography of the thrombus and the vessel, verifying the possibility of thrombus recanalization and compensatory produced blood flow. The jugular thrombophlebitis was induced unilaterally into 5 horses, monitored by clinical (general, regional and local) and ultrassonographycs exams. Venographs were made at pre-induction, induction and every 6 days after induction of thrombophlebitis, in order to observe recanalization of the occlusive thrombus and presence of blood vessels in the drainage allowance. Occurrence of moderate edema was observed in the parotid, masseter and supra orbital regions, and mild edema in the submandibular region. The jugular engorgement of the cranial region of induction persisted throughout the period of evaluation. The caudal portion to the thrombophlebitis showed engorgement with compression on the vein at the thorax entrance since the first day after induction. The ultrasound examinations showed total occlusive thrombus formation of 3 animals, partial recirculating flow in the jugular vein in 2 animals, and collateral blood vessels from the cranial obstruction to the caudal portion. The venography revealed normal linear blood flow in the preoperative and occlusive thrombus with contrast directed filling of the vessels to the compensatory portion caudal to the vein occlusion or cranial to the thrombus in the postoperative moments. After vein resection of the segment containing the thrombus, the cephalic edema was less intense than after the induction of the thrombophlebtits. The ultrassonography and venography post resection showed vascularity increase in this region. It was concluded that there is recanalization with endothelialization and vascular compensation made by pre-existing vessels necessary for drainage.(AU)

Recanalization of femoropopliteal chronic total occlusion susing the ENABLER-P balloon catheter system

Purpose: To evaluate the safety and effectiveness of a new system to facilitate intraluminaladvancement of conventional guidewires through chronic total occlusions (CTO) of thesuperficial femoral artery (SFA) and popliteal artery.Methods: The ENABLER-P Balloon Catheter System uses a unique balloon-anchoringmechanism and an automated balloon inflation device for steady, controlled advancementof a standard non-hydrophilic guidewire. The system was evaluated in 37 patients (22 men;mean age 67 years (range 41–87) with femoropopliteal CTOs averaging 86 mm in length(range 10–340). The device was used in a variety of occlusions, including heavily calcified,long, and fibrotic lesions. After successful guidewire recanalization facilitated by thesystem, occluded arterial segments were treated conventionally with balloon angioplasty,atherectomy, and stents as appropriate.Results: The primary endpoint of successful crossing was achieved in 86% (32/37) of theoverall study population. The average activation time for successful crossing was5.3 minutes (range 0.4–22). Of the 32 cases successfully crossed with the ENABLER-PSystem, all but 1 was successfully recanalized. One (3%) device-related complicationoccurred when the wire was advanced into a side branch when treating a 300-mm-longflush ostial SFA occlusion; the resulting perforation was managed with a covered stentwithout further sequelae.Conclusion: This novel system, which provides enhanced force to a standard guidewire tipfor controlled intraluminal advancement, is a promising device for the treatment ofperipheral CTOs.

Spontaneous recanalization after complete occlusion of the common carotid artery with subsequent embolic ischemic stroke.

INTRODUCTION: Acute carotid artery occlusion carries a high morbidity and mortality. Acute angioplasty and stenting is a feasible option with little known about the long term outcome. Limiting factor for this approach is hyperperfusion syndrome or hemorrhagic infarction. Spontaneous early or late recanalization for extracranial vessel is in the range of 5% -30%, with no well defined clinical outcome data. We describe a case of spontaneous common carotid recanalization. CASE REPORT: An 88 year old man presented with right sided weakness, global aphasia and visual field loss and was discovered to have common carotid occlusion at its origin. Within 12 hours of symptom onset patient improved neurologically to his baseline exam and repeat imaging demonstrated spontaneous recanalization. This was followed symptomatic occlusion of left middle cerebral artery The patient was treated with multimodality approach resulting in complete revascularization of the middle cerebral artery and angioplasty and stent placement of the internal carotid artery. Patient had a good neurological outcome at 3 months followup. CONCLUSION: The present case report demonstrates the risk of spontaneous recanalization acutely in patients presenting with common carotid artery occlusion and associated risk of embolic strokes. In such a patient, concomitant treatment for intracranial occlusion and extracranial high grade stenosis may be performed safely after 30 hours from the initial symptom onset.

A recanalizaçäo coronária espontânea e a circulaçäo colateral coronária säo realmente importantes na preservaçäo ventricular esquerda no infarto agudo do miocárdio? / Are Spontaneous Coronary Artery Recanalization and Collateral Circulation Really Important in the Preservation of Left Ventricular Systolic Function in Acute Myocardial Infarction?

Objetivo - Determinar se a manutençäo de algum fluxo sangüíneo para artéria coronária culpada no infarto agudo do miocárdio (IAM) é importante na preservaçäo da funçäo sistólica do ventrículo esquerdo (VE). Métodos - Estudo prospectivo em 63 sobreviventes consecutivos da fase aguda de infarto do miocardio na era pré-trombólise e que foram submetidos a cinecoronariografia e cineventriculografia esquerda em OAD a 30º na 4§ semana de evoluçäo. Correlacionaram-se a patência da artéria coronária culpada e a presença da circulaçäo colateral (CC) para esse vaso com a contratilidade global e segmentar do VE. Resultados - A recanalizaçäo coronária espontânea relaciou-se significativamente a uma melhor contratilidade ventricular esquerda somente nos pacientes com infarto de parede anterior, sendo a relaçäo mais nítida na contratilidade segmentar do que na global. Além disso, mostrou que a näo recanalizaçäo da oclusäo pré-septal na artéria descendente anterior resulta em significativa pior funçäo diastólica global e segmentar do VE que na oclusäo pós-septal, levando à formaçäo de aneurisma ventricular em todos os casos (2/3 dos casos que recanalizam versus 1/3 dos com oclusäo pós-septal). Já a CC para a artéria culpada só se relacionou significativamente a uma melhor contratilidade gloal e segmentar do VE nos infartos de parede inferior. Conclusäo - No IAM de parede anterior, a recanalizaçäo coronária espontânea esté associada a melhor contratilidade global e segmentar do VE, principalmente se a oclusäo foir pré-septal, enquanto a CC näo se relaciona a uma melhor funçäo sistólica. No infarto de parede inferior, ocorre o inverso

Purpose - To determine if maintenance of residual blood flow to culprit coronary artery in acute myocardial infarction is important in preserving left ventricular systolic function. Methods - Prospective study of 63 consecutive survivors of acute myocardial infarction in the prethrombolytic era that were submitted to cinecoronary angiography and 30º RAO left ventriculography on the 4th week. Culprit coronary artery patency and collateral circulation were correlated with global and segmental left ventricular contractility. Results - Spontaneous coronary recanalization correlated significantly with better left ventricular systolic function only in patients with anterior wall myocardial infarction. This relationship was stronger with segmental than with global contractility. Besides, it was seen that absence of recanalization of pre-septal left anterior descending coronary artery occlusion resulted in significantly worse global and segmental left ventricular systolic function than post-septal occlusion, resulting in left ventricular aneurysm in all patients (2/3 of recanalized patients versus 1/3 of post-septal occlusions). Collateral circulation to culprit coronary artery correlated significantly with better global and segmental left ventricular contractility only in patients with inferior wall myocardial infarction. Conclusion - In acute anterior wall myocardial infarction spontaneous coronary artery recanalization is associated with better global and segmental left ventricular systolic function, specially if the occlusion is of pre-septal localization, while collateral circulation is not related to better contractility. In acute inferior wall myocardial infarction one sees the reverse

Segmento ST como indicador de recanalizaçäo arterial após terapêutica trombolítica no infarto do miocárdio / ST segment as an arterial recanalization indicator after thrombolytic therapy in acute myocardial infarction

Objetivo: Avaliar a importância do segmento ST como indicador de recanalizaçäo da artéria em pacientes com infarto do miocárdio submetidos a terapêutica trombolítica por via venosa. Casuística e Métodos: Setenta e quatro pacientes (62 homens, média de idade 52,6 ñ 10 anos) com oclusäo da artéria relacionada ao infarto (ARI) antes da infusäo venosa "in bolus" de rt-PA em doses de 50, 60 e 70 mg. Após 90 minutos realizou-se nova angiografia e o estado da ARI foi relacionado ao comportamento do segmento ST antes e após o tratamento. Resultados: Cinqüenta e seis (75,6%) pacientes apresentaram normalizaçäo ou diminuiçäo do segmento ST (grupo I e II). Destes, em 47 notou-se recanalizaçäo da ARI. Dos demais 18 pacientes que näo apresentaram alteraçöes no segmento ST (grupo III), a ARI estava ocluída em 13 e recanalizada em cinco. O comportamento do segmento ST apresentou sensibilidade de 90,3% especificidade de 59,1%, valor preditivo positivo de 83,9% e valor preditivo negativo de 72,9%. Conclusäo: O segmento ST constitui importante indicador de recanalizaçäo ou näo da ARI após terapêutica trombolítica

Purpose: To evaluate the importance of the segment ST in the identification of coronary recanalization in patients submitted to intravenous thrombolysis during acute myocardial infarction (MI). Patients and Methods: Seventy four patients with MI, 62 male with mean age of 52.6 ± 10 years. All patients had angiographically demonstrated occlusion of the infarct-related artery (IRA) before the thrombolytic treatment with intravenous in bolus infusion of 50 mg, 60 mg and 70 mg of rt-PA. The recanalization of the IRA was assessed 90 minutes later. The real status of the IRA in the angiograms was compared with the ST segment changes between the ECGs obtained before and after the thrombolytic therapy. Results: Fifty six (75.6% ) patients presented a significant reduction in the ST segment elevation (groups I and II). Of these, 47 possessed an openned IRA. From the 18 patients who did not show ST segment decrement (group III),13 had an occluded IRA, and 5 an openned one. The method presented sensitivity of 90.3% and a specificity of 59.1%, positive predictive value of 83.9% and negative predictive value of 72.2%. Conclusions: The ST segment is an important marker of coronary recanalization or not following intravenous thrombolytic therapy.