Aneurismas das Artérias Viscerais: Alternativa Terapêutica

The authors report two cases in which stent grafts were used to treat visceral artery aneurysms. Case number 1 was a 42-year old woman with a history of renal colic who was found to have a right renal artery aneurysm. Two 6-mm x 20-mm Wallgraft endoprosthesis (Boston Scientific, Watertown, Mass) were placed across the aneurysm neck. Case number 2 was a 72 year-old woman with a past medical history significant for hepatic angioma and hypothyroidism. She was found to have a superior mesenteric artery aneurysm that was treated with a 6-mm x 17-mm Jostent stent graft (Jomed, GmbH, Ra). In both cases the aneurysm was completely excluded and distal end-organ flow preserved. Stent graft placement is a safe and effective treatment for visceral artery aneurysms. If this approach proves durable and reproducible, it can become the method of choice for the management of visceral artery aneurysms in selected patients.

Reparação Híbrida do Arco Aórtico: Experiência Inicial do Hospital de Santa Marta

Objectives: To retrospectively review the hybrid treatment of the aortic arch with supra-aortic debranching and endo- vascular stent-graft repair in a single institution. Methods: From 2007 to 2010, all patients submitted to aortic debranching procedures were entered into a prospective database analysis. For the present study, only patients with sealing zones 0 and 1, according to the Ishimaru classification, were included. Procedure-related morbimortality was analysed for the open and endovascular procedures. Results: During the study period, we electively performed 6 total aortic debranching and 4 partial aortic debranching procedures in 10 patients. According to the etiology the indications were: 6 aortic arch aneurysms, 2 post-dissection aneu- rysms, 1 false aneurysm and 1 type I endoleak following TEVAR. The proximal sealing zone was Ishimaru zone 0 in six patients and zone 1 in four patients. The TEVAR procedure was delayed in all patients with a completion success of 80% (1 patient died from ruptured aortic aneurysm; 1 patient denied the second procedure and was lost to follow-up). The 30d mortality rate was 10% (patient mentioned above). The main morbidity was: 1 axillar venous thrombosis, 1 case of subclinical myocardial infarction, 1 case of terminal renal insufficiency and 1 case of prolonged ventilation. No permanent cerebral or peripheral neurologic deficit was noted. Conclusions: The hybrid repair of the aortic arch is a feasible and reproducible procedure, and our results are similar to the previously published series. Medium and long-term results are necessary to confirm whether the technique can be regarded as a safe alternative to open surgery in high-risk patients.

Mid-Term Results of EVAR in Severe Proximal Aneurysm Neck Angulation.

OBJECTIVE: To determine if mid-term outcome following endovascular aneurysm repair (EVAR) with the Endurant Stent Graft (Medtronic, Santa Rosa, CA, USA) is influenced by severe proximal neck angulation. METHODS: A retrospective case-control study was performed using data from a prospective multicenter database. All measurements were obtained using dedicated reconstruction software and center-lumen line reconstruction. Patients with neck length >15 mm, infrarenal angle (β) >75°, and/or suprarenal angle (α) >60°, or neck length >10 mm with β >60°, and/or α >45° were compared with a matched control group. Primary endpoint was primary clinical success. Secondary endpoints were freedom from rupture, type 1A endoleak, stent fractures, freedom from neck-related reinterventions, and aneurysm-related adverse events. Morphological neck variation over time was also assessed. RESULTS: Forty-five patients were included in the study group and were compared with a matched control group with 65 patients. Median follow-up time was 49.5 months (range 30.5-58.4). The 4-year primary clinical success estimates were 83% and 80% for the angulated and nonangulated groups (p = .42). Proximal neck angulation did not affect primary clinical success in a multivariate model (hazard ratio 1.56, 95% confidence interval 0.55-4.41). Groups did not differ significantly in regard to freedom from rupture (p = .79), freedom from type 1A endoleak (p = .79), freedom from neck-related adverse events (p = .68), and neck-related reinterventions (p = .68). Neck angle reduction was more pronounced in patients with severe proximal neck angulation (mean Δα -15.6°, mean Δβ -30.6°) than in the control group (mean Δα -0.39°, mean Δβ -5.9°) (p < .001). CONCLUSION: Mid-term outcomes following EVAR with the Endurant Stent Graft were not influenced by severe proximal neck angulation in our population. Despite the conformability of the device, moderate aortic neck remodeling was identified in the group of patients with angulated neck anatomy on the first computed tomography scan after implantation with no important further remodeling afterwards. No device integrity failures were encountered.

Clinical Outcome and Morphologic Determinants of Mural Thrombus in Abdominal Aortic Endografts

OBJECTIVE:Endograft mural thrombus has been associated with stent graft or limb thrombosis after endovascular aneurysm repair (EVAR). This study aimed to identify clinical and morphologic determinants of endograft mural thrombus accumulation and its influence on thromboembolic events after EVAR. METHODS: A prospectively maintained database of patients treated by EVAR at a tertiary institution from 2000 to 2012 was analyzed. Patients treated for degenerative infrarenal abdominal aortic aneurysms and with available imaging for thrombus analysis were considered. All measurements were performed on three-dimensional center-lumen line computed tomography angiography (CTA) reconstructions. Patients with thrombus accumulation within the endograft's main body with a thickness >2 mm and an extension >25% of the main body's circumference were included in the study group and compared with a control group that included all remaining patients. Clinical and morphologic variables were assessed for association with significant thrombus accumulation within the endograft's main body by multivariate regression analysis. Estimates for freedom from thromboembolic events were obtained by Kaplan-Meier plots. RESULTS: Sixty-eight patients (16.4%) presented with endograft mural thrombus. Median follow-up time was 3.54 years (interquartile range, 1.99-5.47 years). In-graft mural thrombus was identified on 30-day CTA in 22 patients (32.4% of the study group), on 6-month CTA in 8 patients (11.8%), and on 1-year CTA in 17 patients (25%). Intraprosthetic thrombus progressively accumulated during the study period in 40 patients of the study group (55.8%). Overall, 17 patients (4.1%) presented with endograft or limb occlusions, 3 (4.4%) in the thrombus group and 14 (4.1%) in the control group (P = .89). Thirty-one patients (7.5%) received an aortouni-iliac (AUI) endograft. Two endograft occlusions were identified among AUI devices (6.5%; overall, 0.5%). None of these patients showed thrombotic deposits in the main body, nor were any outflow abnormalities identified on the immediately preceding CTA. Estimated freedom from thromboembolic events at 5 years was 95% in both groups (P = .97). Endograft thrombus accumulation was associated with >25% proximal aneurysm neck thrombus coverage at baseline (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.3), neck length ≤ 15 mm (OR, 2.4; 95% CI, 1.3-4.2), proximal neck diameter ≥ 30 mm (OR, 2.4; 95% CI, 1.3-4.6), AUI (OR, 2.2; 95% CI, 1.8-5.5), or polyester-covered stent grafts (OR, 4.0; 95% CI, 2.2-7.3) and with main component "barrel-like" configuration (OR, 6.9; 95% CI, 1.7-28.3). CONCLUSIONS: Mural thrombus formation within the main body of the endograft is related to different endograft configurations, main body geometry, and device fabric but appears to have no association with the occurrence of thromboembolic events over time.

Trombose Muito Tardia de Stent Coronário Após Suspensão de Terapêutica Antiagregante Plaquetária

Percutaneous transluminal coronary angioplasty (PTCA) with stent placement is widely used to achieve myocardial revascularization in patients with symptomatic ischemic heart disease and significant coronary artery stenosis. Drug-eluting stents are used in most patients undergoing percutaneous angioplasty. Stent thrombosis is an uncommon but serious complication, manifested mostly by sudden death or acute ST-elevation myocardial infarction. The authors report the case of a 68-year-old patient with acute anterior ST-elevation myocardial infarction. Five years previously, she had had a similar presentation and underwent primary angioplasty of the left anterior descending artery with implantation of a drug-eluting stent. The patient was discharged under antithrombotic therapy. She discontinued antiplatelet therapy and two days later suffered an acute anterior myocardial infarction. Primary angioplasty revealed stent thrombosis.

Abordagem Percutânea de Atresia Pulmonar com Septo Interventricular Intacto. Perfuração da Válvula Pulmonar com Catéter de Radiofrequência e Implantação de Stent no Canal Arterial

A atrésia pulmonar com septo interventricular intacto (AtrP-SI) é uma cardiopatia congénita rara e de prognóstico reservado. Apresenta grande variabilidade anatómica, com diversos graus de hipoplasia do ventrículo direito (VD) o que condiciona a abordagem terapêutica. Idealmente, o objectivo é a reconstituição de uma circulação de tipo biventricular. Para o efeito, dispomos de técnicas cirúrgicas e percutâneas. A perfuração da válvula pulmonar com energia de radiofrequência (RF) é um método válido para doentes com atresia de tipo membranoso, VD sem hipoplasia marcada (bipartido ou tripartido) e circulação coronária não dependente do VD. Por vezes, há necessidade de suplementar a circulação pulmonar implantando um stent no canal arterial. Desta forma é possível tratar alguns doentes com técnicas exclusivamente percutâneas. Relatamos o primeiro caso conhecido em Portugal de um recém-nascido com AtrP-SI submetido a perfuração com radiofrequência e, num segundo tempo, implantação de stent no canal arterial.

Fractura de Stent: Caso Clínico e Revisão da Literatura

Apresentamos o caso de um doente, previamente submetido a angioplastia coronária com um stent revestido com fármaco, com enfarte agudo do miocárdio (EAM) provocado por trombose tardia do stent, tendo sido detectada fractura do mesmo. Este caso vem reforçar o reconhecimento crescente da fractura como potencial mecanismo para a trombose tardia de stent, na era dos stents revestidos com fármaco. A propósito deste caso clínico, apresentamos uma revisão da literatura sobre fractura de stent, nomeadamente sobre a sua incidência, mecanismos subjacentes e complicações clínicas.

Zero-Time Kidney Histology Predicts Early Graft Function

Our purposes are to determine the impact of histological factors observed in zero-time biopsies on early post transplant kidney allograft function. We specifically want to compare the semi-quantitative Banff Classification of zero time biopsies with quantification of % cortical area fibrosis. Sixty three zero-time deceased donor allograft biopsies were retrospectively semiquantitatively scored using Banff classification. By adding the individual chronic parameters a Banff Chronic Sum (BCS) Score was generated. Percentage of cortical area Picro Sirius Red (%PSR) staining was assessed and calculated with a computer program. A negative linear regression between %PSR/ GFR at 3 year post-transplantation was established (Y=62.08 +-4.6412X; p=0.022). A significant negative correlation between arteriolar hyalinosis (rho=-0.375; p=0.005), chronic interstitial (rho=0.296; p=0.02) , chronic tubular ( rho=0.276; p=0.04) , chronic vascular (rho= -0.360;P=0.007), BCS (rho=-0.413; p=0.002) and GFR at 3 years were found. However, no correlation was found between % PSR, Ci, Ct or BCS. In multivariate linear regression the negative predictive factors of 3 years GFR were: BCS in histological model; donor kidney age, recipient age and black race in clinical model. The BCS seems a good and easy to perform tool, available to every pathologist, with significant predictive short-term value. The %PSR predicts short term kidney function in univariate study and involves extra-routine and expensive-time work. We think that %PSR must be regarded as a research instrument.

Safety and Effectiveness of the Genous™ Endothelial Progenitor Cell-Capture Stent in the First Year Following ST-Elevation Acute Myocardial Infarction: A Single Center Experience and Review of the Literature

PURPOSE: The Genous™ stent (GS) is designed to accelerate endothelization, which is potentially useful in the pro-thrombotic environment of ST-elevation acute myocardial infarction (STEMI). We aimed to evaluate the safety and effectiveness of the GS in the first year following primary percutaneous coronary intervention (PCI) and to compare our results with the few previously published studies. METHODS AND MATERIALS: All patients admitted to a single center due to STEMI that underwent primary PCI using exclusively GS, between May 2006 and January 2012, were enrolled. The primary study endpoints were major adverse cardiac events (MACEs), defined as the composite of cardiac death, acute myocardial infarction and target vessel revascularization, at one and 12months. RESULTS: In the cohort of 109 patients (73.4% male, 59 ±12years), 24.8% were diabetic. PCI was performed in 116 lesions with angiographic success in 99.1%, using 148 GS with median diameter of 3.00mm (2.50-4.00) and median length of 15mm (9-33). Cumulative MACEs were 2.8% at one month and 6.4% at 12months. Three stent thromboses (2.8%), all subacute, and one stent restenosis (0.9%) occurred. These accounted for the four target vessel revascularizations (3.7%). At 12months, 33.9% of patients were not on dual antiplatelet therapy. CONCLUSIONS: GS was safe and effective in the first year following primary PCI in STEMI, with an apparently safer profile comparing with the previously published data. SUMMARY: We report the safety and effectiveness of the Genous™ stent (GS) in the first year following primary percutaneous coronary intervention in ST-elevation acute myocardial infarction. A comprehensive review of the few studies that have been published on this subject was included and some suggest a less safe profile of the GS. Our results and the critical review included may add information and reinforce the safety and effectiveness of the GS in ST-elevation in acute myocardial infarction.

Safety and Effectiveness of the Genous Endothelial Progenitor Cell-Capture Stent: Follow-Up to 5 Years

AIMS: To evaluate the long-term clinical outcomes following percutaneous coronary intervention (PCI) with the Genous stent in an unselected population. METHODS: All patients admitted to a single center who underwent PCI using the GS exclusively, between May 2006 and May 2012, were enrolled, and a clinical follow-up of up to 60 months was carried out. The primary endpoint of major adverse cardiac event (MACE) rate was defined as the composite of cardiac death, acute myocardial infarction (AMI), and target lesion revascularization (TLR). RESULTS: Of the 450 patients included (75.1% male; 65.5 ± 11.7 years), 28.4% were diabetic and acute coronary syndrome was the reason for PCI in 76.4%. Angioplasty was performed in 524 lesions using 597 Genous stents, with angiographic success in 97.1%. At a median of 36 months of follow-up (range, 1-75 months), MACE, AMI, TLR, stent restenosis (SR), and stent thrombosis (ST) rates were 15.6%, 8.4%, 4.4%, 3.8%, and 2.2%, respectively. Between 12 and 24 months, the TLR, SR, and ST rates practically stabilized, up to 60 months. Bifurcation lesions were independently associated with MACE, TLR, and SR. CONCLUSION: This is the first study reporting clinical results with the Genous stent up to 60 months. The Genous stent was safe and effective in the long-term, in an unselected population.

Estenose Intra-Stent na Artéria Femoral Superficial: Soluções Actuais Para um Problema Crescente

Os últimos anos de tratamento da doença arterial obstrutiva periférica na artéria femoral superficial observaram uma mudança de paradigma, da cirurgia clássica para a endovascular, o que se traduziu na utilização progressiva de stents metálicos para a manutenção da permeabilidade a longo prazo. Apesar dos avanços tecnológicos, a restenose intra-stent é uma das principais limitações do tratamento endovascular, com um tratamento complexo e não consensual, traduzindo a escassez de resultados obtidos ou a sua manutenção no tempo. Os autores procuraram recolher os dados mais recentes sobre este tipo de patologia e as principais opções disponíveis para o seu tratamento.

Clinical Outcomes and Genetic Expression Profile in Human Liver Graft Dysfunction During Ischemia/Reperfusion Injury

Introduction. This study aims to compare the molecular gene expression during ischemia reperfusion injury. Several surgical times were considered: in the beginning of the harvesting (T0), at the end of the cold ischemia period (T1), and after reperfusion (T2) and compared with graft dysfunction after liver transplant (OLT). Methods. We studied 54 patients undergoing OLT. Clinical, laboratory data, and histologic data (Suzuki classification) as well as the Survival Outcomes Following Liver Transplantation (SOFT) score were used and compared with the molecular gene expression of the following genes: Interleukin (IL)-1b, IL-6, tumor necrosis factor-a, perforin, E-selectin (SELE), Fas-ligand, granzyme B, heme oxygenase-1, and nitric oxide synthetase. Results. Fifteen patients presented with graft dysfunction according to SOFT criteria. No relevant data were obtained by comparing the variables graft dysfunction and histologic variables. We observed a statistically significant relation between SELE at T0 (P ¼ .013) and IL-1b at T0 (P ¼ .028) and early graft dysfunction. Conclusions. We conclude that several genetically determined proinflammatory expressions may play a critical role in the development of graft dysfunction after OLT.

Nonlethal, Attenuated, Transfusion-Associated Graft-Versus-Host Disease in an Immunocompromised Child: Case Report and Review of the Literature

Transfusion-associated graft-versus-host disease (TA-GVHD) is a rare complication of transfusion of nonirradiated blood components. It usually affects children in high-risk groups, including those who have primary immunodeficiencies (PIDs). It usually presents with skin, hepatic, digestive, and hematologic involvement and is normally fatal.

Importância da Presença de Lesões Adicionais Complexas no Contexto de Angioplastia Primária no Enfarte Agudo do Miocárdio no Prognóstico a Médio-Prazo

Introdução: Existe alguma controvérsia respeitante ao tipo de revascularização a efectuar no contexto de angioplastia (PCI) primária no enfarte agudo do miocárdio (EAM). A presença de lesões coronárias adicionais, particularmente complexas, poderá ter impacto no prognóstico. Objectivos: Avaliar o prognóstico a médio-prazo (1 ano) face à presença de lesões adicionais complexas após PCI primária. População e Métodos: Estudaram-se retrospectivamente 138 doentes consecutivos admitidos na nossa Unidade por EAM com elevação do segmento ST e submetidos a PCI primária. Os doentes foram seguidos por um período de 1 ano e divididos em 2 grupos: sem lesões adicionais complexas (n=69, 61 ± 14 anos, 62% sexo masculino) e com lesões adicionais complexas (n=69, 65 ± 13 anos, 73% sexo masculino, p=NS). Avaliaram-se as características demográficas, factores de risco para doença coronária, história prévia cardíaca, e presença de sinais de insuficiência cardíaca na admissão. Foram também avaliadas características angiográficas, medicação efectuada e resultado da PCI. Avaliou-se o impacto das variáveis na ocorrência combinada de morte/re-enfarte/revascularização miocárdica ao primeiro ano. Resultados: A taxa de sucesso angiográfico foi de 96,4%. O grupo com idade igual ou superior a 75 anos representa 24% da população e 4,3% apresentaram-se em classe Killip IV. A localização anterior foi ligeiramente superior no grupo sem lesões adicionais complexas (60% vs. 44%, p=0,06), a inferior no grupo com lesões adicionais complexas (26% vs. 42%, p=0,07). A doença de 1 vaso foi mais prevalente no grupo sem lesões adicionais complexas como esperado (86% vs. 11%, p<0,001). A utilização de stent foi mais frequente no grupo sem lesões adicionais complexas (96% vs. 86%, p=0,08). Não houve diferenças nas restantes variáveis. A taxa de morte/re-enfarte/revascularização foi superior no grupo com lesões adicionais complexas (13% vs. 32%, p=0,014). Até aos 13 dias de seguimento, ocorreram 67% dos eventos. Na análise univariada, os factores predizentes de eventos foram a classe Killip 2, fluxo TIMI < 3 no vaso relacionado com enfarte após PCI, a não utilização de antagonistas da glicoproteína IIb/IIIa, bloqueadores beta e estatinas, doença multivaso e presença de lesões adicionais complexas (Log-rank, p=0,003). Na análise multivariável, os factores predizentes independentes de prognóstico a 1 ano foram a classe Killip 2 (Odds ratio 0,28%; IC 95% 0,08-0,93, p=0,037) e a presença de lesões adicionais complexas (OR 0,32; IC 95% 0,12-0,84, p=0,020). Conclusões: A presença de lesões adicionais complexas após PCI primária tem um pior prognóstico ao primeiro ano, sugerindo a necessidade de intervenção para a sua estabilização, particularmente nos primeiros 30 dias após enfarte.