Factores asociados a fenómeno de no reflujo coronario en pacientes adultos llevados a angioplastia

Introducción: La disminución de flujo en los vasos coronarios sin presencia de oclusión, es conocido como fenómeno de no reflujo, se observa después de la reperfusión, su presentación oscila entre el 5% y el 50% dependiendo de la población y de los criterios diagnósticos, dicho suceso es de mal pronóstico, aumenta el riesgo de morir en los primeros 30 días posterior a la angioplastia (RR 2,1 p 0,038), y se relaciona con falla cardiaca y arritmias, por eso al identificar los factores a los cuales se asocia, se podrán implementar terapias preventivas. Metodología: Estudio de casos y controles pareado por médico que valoró el evento, para garantizar que no existieron variaciones inter observador, con una razón 1:4 (18:72), realizado para identificar factores asociados a la presencia de no reflujo en pacientes llevados a angioplastia, entre noviembre de 2010 y mayo de 2014, en la Clínica San Rafael de Bogotá, D.C. Resultados: La frecuencia del no reflujo fue del 2.89%. El Infarto Agudo de Miocardio con elevación del ST (IAMCEST) fue la única variable que mostró una asociación estadísticamente significativa con este suceso, valor de p 0,002, OR 8,7, IC 95% (2,0 – 36,7). Discusión: El fenómeno de no reflujo en esta población se comportó de manera similar a lo descrito en la literatura, siendo el IAMCEST un factor fuertemente asociado.

Angiorresonancia versus angiografía por sustracción digital en el seguimiento de aneurismas intracraneales embolizados. Comparación del desempeño diagnóstico

Introducción: La DSA es el método de elección para el seguimiento de pacientes con aneurismas intracraneales embolizados; esta se puede asociar a complicaciones incapacitantes o mortales. La MRA se ha propuesto como método alternativo por menor costo y menos morbi-mortalidad, aunque su desempeño diagnóstico permanece en discusión debido al desarrollo de nuevos protocolos, resonadores más potentes y nuevas aplicaciones de la DSA. Metodología: Exploramos la literatura hasta la actualidad y comparamos el desempeño diagnóstico de la MRA con la DSA para detectar flujo residual posterior a la embolización terapéutica de aneurismas intracraneales. Realizamos una revisión sistemática de la literatura y meta-análisis basados en 34 artículos detectados en la búsqueda que incluyó las bases de datos PubMed, Scopus, ScIELO y BVS. Resultados: La TOF-MRA demostró sensibilidad de 86.8% (84.3%-89.1%) y especificidad de 91.2% (89%-93.1%); la SROC para TOF-MRA demostró un AUC de 0.95. El desempeño de la CE-MRA demostró sensibilidad de 88.1% (84.6%-91.1%) y especificidad de 89.1% (85.7%-91.9%); la SROC presentó una AUC de 0.93. El análisis estratificado por potencia del resonador encontró que la TOF-MRA tiene mejor desempeño con el resonador de 3T, aunque no es estadísticamente significativo. La concordancia interobservador con TOF-MRA y CE-MRA fue moderada a muy buena. Discusión: El desempeño diagnóstico de la MRA en el seguimiento de aneurismas intracraneales embolizados demostró ser bueno, con sensibilidad mayor a 84%, siendo ligeramente mejor con TOF-MRA, sin lograr reemplazar la DSA. Sin embargo, los resultados deben ser evaluados con precaución por la heterogeneidad de los resultados de los estudios incluidos. (Abreviaturas: DSA: Angiografía por Sustracción Digital; MRA: Angiografía por Resonancia Magnética; TOF-MRA: Angiorresonancia por Tiempo de Vuelo; CE-MRA: Angiorresonancia contrastada).

Uretero-uretero anastomosis: una alternativa para pacientes con patología asociada a doble sistema colector

Introducción El doble sistema colector es la alteración renal más frecuente y presenta una incidencia 1/500 individuos. Hay varias opciones de tratamiento para el uréter con reflujo o severamente dilatado cuando se asocia a un sistema duplicado, entre ellas la uretero-uretero anastomosis. El objetivo es dar a conocer nuestra experiencia en la realización de este procedimiento para pacientes pediátricos. Materiales y métodos: Se presenta una serie de casos entre Enero 2010 y Abril 2014, se revisaron 214 historias clínicas de pacientes con doble sistema colector y patologías asociadas; 10 fueron sometidos a uretero-uretero anastomosis. El Seguimiento posopertorio fue de 12 meses promedio. Resultados: Se incluyeron 10 pacientes. El 70% fueron género femenino, la edad promedio al momento de la cirugía fue 5 años . Todos cursaban con infección urinaria y 10% presentaban incontinencia urinaria. En el postoperatorio, en 40% se encontró uréter ectópico, 30% ureterocele intravesical y 30% reflujo vesicoureteral al sistema inferior. Se realizaron siete anastomosis del sistema superior al inferior y tres del inferior al superior, todos por una incisión de 2cm a nivel inguinal y fueron derivados con catéter doble J sin complicaciones postoperatorias. Al tiempo de seguimiento la totalidad de los pacientes se encontraron sin profilaxis antibiótica, con dilatación resuelta, sin infecciones urinarias ni incontinencia. Conclusión: La uretero-uretero anastomosis es una alternativa fiable, segura y con mínima morbilidad para el tratamiento de pacientes con patología asociada a doble sistema colector. Estudios adicionales, con mayor número de pacientes y seguimiento serán necesarios para ver evolución a largo plazo.

Ibuprofen inhibits migration and proliferation of human coronary artery smooth muscle cells by inducing a differentiated phenotype: role of peroxisome proliferator-activated receptor y

Objectives: The search for agents that are capable of preventing restenosis and reduce the risk of late thrombosis is of utmost importance. In this study we aim to evaluate the in vitro effects of ibuprofen on proliferation and migration of human coronary artery smooth muscle cells (HCASMCs) and on human coronary artery endothelial cells (HCAECs) migration. Methods: Cell proliferation was evaluated by direct cell counting using trypan blue exclusion. Cell migration was assessed by wound healing “scratch” assay and by time lapse video-microscopy. Protein expression was assessed by immunoblotting, and morphological changes were studied by immunocytochemistry. The involvement of the PPARγ pathway was studied with the selective agonist troglitazone, and the use of highly selective antagonists of PPARγ such as PGF2α and GW9662. Results: We demonstrate that ibuprofen inhibits proliferation and migration of HCASMCs and induces a switch in HCASMCs towards a differentiated and contractile phenotype, and that these effects are mediated through the PPARγ pathway. Importantly we also show that the effects of ibuprofen are cell type specific as it does not affect migration and proliferation of endothelial cells. Conclusions: Taken together, our results suggest that ibuprofen could be an effective drug for the development of novel drug eluting stents, which could lead reduced rates of restenosis and potentially other complications of DES stent implantation.

Análise morfométrica digital na parede aórtica de suínos após implante de stents não revestidos versus stents revestidos com dacron

Os stents são dispositivos intravasculares implantados com o objetivo de dilatar ou fixar a placa de colesterol contra a parede arterial. O objetivo avaliar dois tipos de stents de aço inoxidável, um recoberto com poliéster (dacron) e outro não recoberto, implantados na aorta infra-renal de suínos jovens, foram avaliados por morfometria digital para medir o espessamento intimal. Foi realizado um estudo experimental randomizado, separados em dois grupos(stents não revestidos e revestidos com dacron) e duas fases (I e II). Oito stents recobertos com dacron e oito stents de aço inoxidável (30mm de extensão e 8 mm de diâmetro), não revestidos, foram implantados através de abordagem retroperitoneal na aorta infrarenal normal de 16 suínos normolipêmicos. Para a passagem do sistema de implante, foi necessário uma pequena arteriotomia na aorta distal (fase I). Após quatro semanas, a aorta com os stents foram removidas em monoblocos (fase II). Os valores de hematimetria e do lipidograma foram coletados nas duas fases e não apresentaram alterações que pudessem influenciar o estudo. Amostras de tecido dos sítios de fixação (proximal e distal) dos stents foram retiradas, confeccionadas lâminas, que foram coradas pelas técnicas de hematoxilina e eosina de Verhoeff e enviadas para análise morfométrica digital. A camada intima distal não apresentou diferença estatística significativa. A camada média proximal das porções proximal e da porção distal não apresentaram diferença entre os grupos. Os dois tipos de stents apresentaram 100% de perviedade, boa biocompatibilidade e boa incorporação a parede aórtica de suínos normolipêmicos. A camada íntima proximal do grupo de stents revestidos com dacron apresentou espessura maior do que os stents não revestidos, mas com significância estatísitica limítrofe.

Detecção de bactérias periodontopatogênicas cultiváveis e não cultiváveis em placas ateromatosas

Periodontal infections consist of a group of inflammatory conditions caused by microorganisms that colonize the tooth surface through the formation of dental biofilm. Chronic infections such as periodontitis have been associated to the development and progression of atherosclerosis. AIM: Detect cultivatable and non-cultivatable periodontopathogenic bacteria in atheromatous plaques; search for factors associated to the presence of these bacteria in the atheromatous plaques and characterize the presence of cultivatable and non-cultivatable bacteria in these plaques. METHODOLOGY: A cross-sectional study was performed with a sample of 30 patients diagnosed with atherosclerosis in the carotid, coronary or femoral arteries and surgically treated with angioplasty and stent implant, bypass or endarterectomy. The plaques were collected during surgery and analyzed using the PCR molecular technique for the presence of the DNA of the cultivatable bacteria Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis and Treponema denticola and of the non-cultivatable Synergistes phylotypes. The patients were examined in the infirmary, after the surgery, where they also responded to a questionnaire aimed at determining factors associated to the presence of periodontopathogenic bacteria in the atheromatous plaques. RESULTS: All patients with tooth (66,7%) possessed disease periodontal, being 95% severe and 65% widespread. No periodontopathogenic bacteria were found in the atheromatous plaques. However, four samples (13.3%) were positive for the presence of bacteria. Of these, three participants were dentate, being two carriers of widespread severe chronic periodontite and one of located severe chronic periodontitis. None of them told the accomplishment of procedures associated to possible bacteremia episodes, as treatment endodontic, extraction the last six months or some procedure surgical dental. CONCLUSION: The periodontopathogenic bacteria studied were not found in the atheromatous plaques, making it impossible to establish the prevalence of these pathogens or the factors associated to their presence in plaques, the detection of positive samples for bacteria suggests that other periodontal and non-periodontal pathogens be studied in an attempt at discovering the association or not between periodontal disease and/or others infections and atherosclerosis, from the presence of these bacteria in atheromas

Urgent Endovascular Treatment of Thoraco-abdominal Aneurysms Using a Sandwich Technique and Chimney Grafts - A Technical Description

Introduction: So far the only endovascular option to treat patients with thoraco abdominal aortic aneurysms is the deployment of branched grafts. We describe a technique consisting of the deployment of standard off-the- shelf grafts to treat urgent cases.Material and Methods: The sandwich technique consists of the deployment of ViaBahn chimney grafts in combination with standard thoracic and abdominal aortic stent grafts. The chimney grafts are deployed using a transbrachial and transaxillary access. These coaxial grafts are placed inside the thoracic tube graft. After deployment of the infrarenal bifurcated abdominal graft a bridging stent-a short tube graft is positioned inside the thoracic graft further stabilizing the chimney grafts.Results: 5 patients with symptomatic thoraco abdominal aneurysms were treated. There was one Type I endoleak that resolved after 2 months. In all patients 3 stentgrafts had to be used When possible all visceral and renal branches were revascularized. A total number of 17 arteries were reconnected with covered branches. During follow up we lost one target vessel the right renal artery.Conclusion: The sandwich technique in combination with chimney grafts permits a total endovascular exclusion of thoraco abdominal aortic aneurysms. In all cases off-the shelf products and grafts could be used. The number of patients treated so far is still too small to draw further more robust conclusions with regard to long term performance and durability. (C) 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Total Endovascular Debranching of the Aortic Arch

Background: Significant morbidity and mortality are related to conventional aortic replacement surgery. Endovascular debranching techniques, fenestrated or branched endografts are time consuming and costly.Objective: We alternatively propose to use endovascular approach with parallel grafts for debranching of aortic arch.Methods: Under general anesthesia, 12 F sheaths were inserted in the femoral, axillary and common carotid arteries for vascular accesses. ViaBahn grafts 10 - 15 cm in length were placed into the aortic arch from right common carotid, left common carotid and left axillary arteries, until the tip of each graft reached into the ascending aorta. Through one femoral artery, the aortic stent-graft was positioned and delivered. Soon after, the parallel grafts were sequentially delivered. Self-spanding Wallstents(R) were used for parallel grafts reinforcement. Ballooning was routinely used for parallel grafts and rarely for aortic graft.Results: This technique was used in 2 cases. The first one was a lady with 72 years old, with an aortic retrograde dissection from left subclavian artery and involving remaining arch branches. Through right common carotid artery a stent-graft was placed in the ascending aorta and through the left common carotid artery a ViaBahn was inserted parallel to the former. A thoracic endograft then covered all the aortic arch dissection extending into the ascending aorta close to the sinu-tubular junction. The second case was a 82 year old male patient with a 7 cm aortic arch aneurysm. Through both common carotid arteries ViaBahn grafts were introduced and positioned into the ascending aorta. Soon after, the deployment of the thoracic stent graft covered all parallel grafts of the aortic arch, excluding the aneurysm. Both cases did not have neurologic or cardiac complications and were discharged 10 days after the procedure.Conclusions: This technique may be a good minimal invasive off-the-shelf technical option for aortic arch "debranching". More data and further improvements are required before this promising technique can be widely advocated. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Endovascular Treatment of Late Aortic Perforation due to Vena Cava Filter

Perforation of inferior vena cava (IVC) by filter struts ranges from 9% to 24%, and clinical sequelae and complications are unpredictable. The aim of this article was to report an unusual case of late complication of IVC filter that caused an IVC wall perforation and penetration of the filter's hooks in the aorta, which was treated by endovascular procedure. Molding strut tip by balloon angioplasty, its accommodation with a bare stent, and its coverage and protection with an endoprosthesis is probably the first technique reported so far in this situation.

Biomechanical and histologic analysis in aortic endoprosthesis using fibrin glue

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Intervenção coronariana percutânea em artéria coronariana única em paciente com angina instável de alto risco

No presente caso, relatamos a realização de angioplastia coronariana com implante de stent na artéria coronariana direita de paciente com quadro de angina instável de alto risco, portadora de artéria coronariana única com origem no seio coronariano direito. As artérias descendente anterior e circunflexa originavam-se isoladamente no terço proximal da artéria coronariana direita. Trata-se de rara anomalia coronariana com poucos relatos de intervenção coronariana percutânea na literatura. Este caso ilustra a necessidade da avaliação anatômica pormenorizada do trajeto das artérias coronarianas, precedendo a realização da angioplastia transluminal percutânea, objetivando-se a prevenção de complicações.

Treatment of atherosclerotic renovascular disease

Treatment of atherosclerotic renovascular disease is controversial and revascularization is not a beneficial approach to all patients. Conditions as progressive deterioration of renal function, refractory hypertension or accelerated cardiovascular disease, especially recurrent pulmonary edema, could profit from renal angioplasty with stent placement. Surgical revascularization is a good option for patients who will need concomitant surgical corrections of abdominal aortic lesions. Treatment of all other patients must be individualized. Medical therapy is indicated for all patients with atherosclerotic renovascular disease. Observational studies pointed out to the beneficial effect of controlling blood pressure (<130/80 mm Hg), glucose and lipids profile, lifestyle modifications, specific use of platelet antiaggregant therapy, Angiotensin Conversion Enzyme Inhibitors (ACEI) and statins. All others cardiovascular risk factors must be controlled. The evaluation and management of other systemic atherosclerotic vascular lesions is important, especially coronary, carotid and abdominal aortic. This paper presents a review of evidences to rationale the atherosclerotic renovascular disease treatment. © 2008 Bentham Science Publishers Ltd.

Fondaparinux em intervenção coronária percutânea no tratamento da síndrome coronária aguda

Background: Fondaparinux is considered an agent with a well-established safety and efficacy profile in the treatment of non-ST segment elevation acute coronary syndromes, but when used alone, is associated to a higher incidence of thrombotic complications during invasive coronary procedures, requiring the supplementation of an anti-IIa agent. This study aimed to evaluate the efficacy and safety of percutaneous coronary intervention (PCI) in patients with non-ST segment elevation acute coronary syndromes previously treated with fondaparinux. Methods: Prospective, controlled registry enrolling 127 consecutive patients submitted to an early invasive stratification during treatment with fondaparinux, with supplementation of intravenous unfractionated heparin at a dose of 85 U/kg at the time of PCI. Results: The rate of the composite primary endpoint including death, acute myocardial infarction, stroke, stent thrombosis or emergency myocardial revascularization was 3.2%. The cumulative incidence of major bleeding and vascular complications was 3.2%. There were no cases of guidecatheter thrombosis or abrupt vessel closure. Conclusions: PCI in patients with acute coronary syndromes receiving fondaparinux is associated with a low rate of major adverse cardiovascular ischemic events and severe hemorrhagic complications. Supplementation of unfractionated heparin during the invasive procedures eliminates the risk of catheter-related thrombosis.

Efeito da revascularização renal sobre a evolução da disfunção renal na nefropatia isquêmica aterosclerótica

Pós-graduação em Fisiopatologia em Clínica Médica - FMB

Colocação de endoprótese vascular versus cirurgia para coarctação de aorta: revisão sistemática

Pós-graduação em Bases Gerais da Cirurgia - FMB