Resumo Contexto As fraturas de stents implantados na artéria femoral superficial (AFS) são uma complicação reconhecida pós-tratamento endovascular desse território arterial. Objetivos Este estudo objetivou determinar a presença de fraturas nos stents implantados na AFS e identificar fatores predisponentes para essas fraturas, juntamente com o impacto na perviedade desses dispositivos. Métodos Foram incluídos 39 pacientes (65,7±9,0 anos) previamente submetidos à angioplastia para colocação de 56 stents na AFS. Durante o seguimento, que variou de 7 a 46 meses, foram coletadas variáveis referentes às características das lesões tratadas e às características dos stents implantados. Dois examinadores analisaram radiografias digitais para verificar a presença de fraturas de stent e a perviedade dos dispositivos independentemente. Resultados Foi encontrada uma prevalência de 10,7% de fratura nos stents implantados. O implante de múltiplos stents foi identificado como fator predisponente significativo para fraturas. Foi observada uma tendência acentuada de fraturas em pacientes do sexo feminino e em lesões tratadas com stents mais longos (> 150 mm). As estenoses acima de 50% e as oclusões foram significativamente mais frequentes em stents fraturados. Conclusões Este estudo sugere que implantes de múltiplos stents ou de stents com extensão maior que 150 mm estão associados a maiores taxas de fraturas do dispositivo. No caso de fraturas de stents, as estenoses mais significativas que 50% e as oclusões foram consideravelmente mais frequentes.

Abstract Background Fractures in stents implanted in the superficial femoral artery (SFA) are recognized complications of endovascular management of this arterial territory. Objectives The objective of this study was to determine the prevalence of fractures in stents implanted in the SFA and to identify predisposing factors for these fractures together with their impact on the patency of these devices. Methods The study included 39 patients (65.7±9.0 years) who previously underwent angioplasty for delivery of 56 stents into the SFA. During follow-up, which ranged from 7 to 46 months, variables were collected on the characteristics of the lesions treated and characteristics of the stents implanted. Two examiners independently analyzed digital radiographs for the presence of stent fractures and the patency of the devices. Results We found a 10.7% prevalence of fracture of implanted stents. Implantation of multiple stents was identified as a significant predisposing factor for fractures. We observed a marked tendency for fractures in female patients and in lesions treated with longer stents (> 150 mm). Stenosis exceeding 50% and occlusions were significantly more frequent in fractured stents. Conclusions This study suggests that implants longer than 150 mm and multiple stents are associated with higher device fracture rates. In cases with stent fractures, stenoses exceeding 50% and occlusions were significantly more frequent.

Abstract Objective: Endovascular techniques to treat abdominal aortic aneurysms results in lower morbidity and mortality rates. However, dilation of the common iliac arteries prevents adequate distal sealing, which compromises the procedure success. The aim of this study is report the long-term outcomes of patients with abdominal aortic aneurysms associated with aneurysm of the common iliac artery following endovascular repair using a bifurcated bell-bottom stent graft. Methods: This is a retrospective study that evaluated patients treated with bifurcated bell-bottom extension stent grafts to repair an infrarenal abdominal aortic aneurysm and who had at least one common iliac artery with dilatation > 1.5 cm for at least 12 months after the endovascular intervention. Results: Thirty-eight patients with a mean age of 70.4±8.2 years were included. Stent graft placement was followed by dilation of the common iliac artery aneurysms in 35.3% of cases; endoleak and reoperation rates were 17.6% and 15.7%, respectively. Younger patients showed a higher rate of artery diameter increase following the procedure. The average arterial dilation was 16% in the first year, 29% in the second year, 57% in the third year and 95% from the fourth year until the end of follow-up. Conclusion: Repair of infrarenal abdominal aortic aneurysms with bifurcated bell-bottom type stents when there is common iliac artery dilation is a good therapeutic option to preserve hypogastric flow. The rate of endoleak was 17.6%, and 15.7% of cases required reoperation. Younger patients are more likely to experience dilation of the common iliac artery after the procedure.

A dissecção da aorta é um evento cardiovascular de alta mortalidade quando não diagnosticado precocemente e tratado adequadamente. Na dissecção de aorta do tipo A de Stanford há o envolvimento da aorta ascendente enquanto na do tipo B este a aorta ascendente não está acometida. O tratamento da dissecção de aorta do tipo A é predominantemente cirúrgico. A mortalidade hospitalar do tratamento cirúrgico da dissecção da aorta do tipo B é de aproximadamente 20%, enquanto a do tratamento clínico é de 10%. Entretanto, metade dos pacientes que recebem alta hospitalar após o tratamento clínico, evoluem com complicações aórticas nos anos subsequentes, sendo que a mortalidade em três a cinco anos pode atingir 25 a 50%. Além disto, o tratamento cirúrgico das complicações aórticas, após o tratamento clínico, também apresenta alta mortalidade. Desta forma, o tratamento endovascular surge como interessante alternativa para o tratamento menos invasivo desta doença. Inicialmente indicado apenas para os casos complicados, apresentavam mortalidade hospitalar menor que 10% com mais de 80% de sucesso de oclusão e trombose da falsa luz. O INSTEAD TRIAL, que randomizou pacientes com dissecção de aorta do tipo B não complicada para o tratamento médico otimizado e para o tratamento endovascular em adição ao tratamento médico otimizado, demonstrou que após três anos de acompanhamento, aqueles pacientes submetidos ao tratamento endovascular apresentaram menor mortalidade e complicações relacionados a aorta. Portanto, atualmente há uma tendência em se indicar o tratamento endovascular como padrão para o tratamento da dissecção de aorta do tipo B.

Aortic dissection is a cardiovascular event of high mortality if not early diagnosed and properly treated. In Stanford type A aortic dissection, there is the involvement of the ascending aorta, whereas in type B the ascending aorta is not affected. The treatment of type A aortic dissection is mainly surgical. The hospital mortality of type B aortic dissection surgical treatment is approximately 20%, while medical therapy is 10%. However, half the patients who are discharged from hospital after medical treatment, progress to aortic complications in the following years, and the mortality in three to five years may reach 25-50%. In addition, the surgical treatment of aortic complications after medical treatment, has also a significant mortality. This way, the endovascular treatment comes up as an interesting alternative of a less invasive treatment for this disease. They presented a mortality rate lower than 10% with more than 80% success rate of occlusion and thrombosis of the false lumen. The INSTEAD TRIAL, which randomized patients with uncomplicated type B aortic dissection for optimal medical therapy and endovascular treatment in addition to optimal medical therapy, showed that after three years of follow up, patients who underwent endovascular treatment had lower mortality and aorta-related complications. Therefore, there is a current tendency to recommend the endovascular treatment as a standard for the treatment of type B aortic dissection

Os aneurismas do segmento subclávio-axilar são de ocorrência rara e, uma vez diagnosticados, devem ser tratados. Neste trabalho, relatamos dois casos de aneurismas de membros superiores, sendo um da artéria subclávia e outro da artéria axilar. No primeiro caso, o paciente de 71 anos, sexo masculino, apresentava abaulamento pulsátil supraclavicular direito associado à fraqueza muscular no membro ipsilateral. Foram realizados duplex scan e arteriografia, que confirmaram o diagnóstico de aneurisma da artéria subclávia direita, sendo o paciente submetido à aneurismectomia com anastomose término-terminal. No segundo caso, uma paciente de 24 anos, do sexo feminino, sem antecedentes mórbidos ou comorbidades, apresentava queixa de massa pulsátil na região axilar direita associada à parestesia no membro ipsilateral. O duplex scan e a arteriografia confirmaram o aneurisma da artéria axilar direita, que foi tratado com aneurismectomia e anastomose término-terminal com sucesso. O diagnóstico anátomo-clínico foi de aneurisma aterosclerótico no primeiro caso e, no segundo caso, de aneurisma congênito.

Aneurysms of the subclavian-axillary segment are rare, but when diagnosed they must be treated. This article describes two cases of aneurysms of the upper extremities, one in a subclavian artery and the other in an axillary artery. The first case was a 71-year-old male with a pulsating supraclavicular bulge on the right and muscle weakness in the ipsilateral extremity. Duplex scanning and arteriography confirmed the diagnosis of aneurysm of the right subclavian artery and the patient underwent aneurysmectomy and end-to-end anastomosis. The second case was a 24-year-old female patient, with no history of comorbidities, who presented with a pulsating mass in the right axillary region and paresthesia of the ipsilateral extremity. Duplex scanning and arteriography confirmed an aneurysm in the right axillary artery, which was successfully treated with aneurysmectomy and end-to-end anastomosis. Pathology findings showed that the first case was an atherosclerotic aneurysm and the second was a congenital aneurysm.

Fistula between arteries and the gastrointestinal tract are a rare cause of gastrointestinal bleeding, but potentially fatal. The recognition and early treatment can modify the patient prognosis. We report a case of a patient with previous surgery for seminoma of cryptorchidic testicle, with massive lower gastrointestinal bleeding. We performed the diagnosis and surgical treatment of the fistula between left external iliac artery and sigmoid colon. The patient was successfully treated by external iliac artery ligation and left colectomy.

INTRODUÇÃO: O tratamento endovascular na dissecção de aorta é um procedimento relativamente novo e, embora aparentemente menos invasivo, a eficácia e a segurança dessa técnica não estão totalmente estabelecidas. OBJETIVO: Avaliar a mortalidade e complicações nos pacientes submetidos a tratamento endovascular na dissecção de aorta tipo B de Stanford. MÉTODOS: Foram revisados, a partir de novembro de 2004 a outubro de 2007, em estudo clínico, anatômico, de imagens e dados da autopsia de 23 pacientes com dissecção aórtica tipo B. As principais indicações para o procedimento foram: dor persistente apesar da terapia médica, sinais de isquemia distal do membro, sinais de ruptura da aorta, progressão da dilatação do aneurisma da aorta descendente, durante o seguimento (definida como um diâmetro > 5 cm) e descendente da aorta torácica de 40 mm ou mais de diâmetro no início da dissecção aórtica. Os dados foram analisados estatisticamente considerados erro alfa de 5%. As variáveis contínuas foram expressas como média (± dp) e medianas e comparadas pelo teste t Student. As diferenças entre os grupos em variáveis categóricas e analisadas pelo chi-quadrado ou teste exato de Fisher. RESULTADOS: O procedimento apresentou sucesso técnico primário em 82,6% dos pacientes. Quatro (17,4%) pacientes tinham um selo de entrada incompleto proximal. Três (13%) pacientes morreram antes de 30 dias e oito (34,8%), após 30 dias do procedimento. CONCLUSÃO: Os procedimentos endovasculares são factíveis na dissecção da aorta torácica tipo B, na qual as complicações das causas de mortalidades alertam sobre a gravidade da doença e de intercorrências das próteses como no caso das fistulas.

BACKGROUND: Endovascular stent-graft repair of aortic dissections is a relatively new procedure, and although apparently less invasive, the efficacy and safety of this technique have not been fully established. OBJECTIVE: To evaluate mortality in patients with complicated Stanford type B aortic dissections submitted to endovascular treatment. METHODS: Clinical, anatomical, imaging and autopsy data of 23 patients with complicated type B aortic dissections were reviewed from November 2004 to October 2007. The main indications for transluminal thoracic stent-grafting included: persistent pain in spite of medical therapy, signs of distal limb ischemia, signs of aortic rupture, progression of aneurismal dilation of the descending aorta during follow-up (defined as a diameter > 50 mm) and the diameter of descending thoracic aorta of 40mm or larger at the onset of aortic dissection. Data were analyzed statistically; all p-values were two-tailed and differences < 0.05 were considered to indicate statistical significance. Continuous variables were expressed as mean (± SD), and medians were compared by the Student's t test. Differences in categorical variables between the groups were analyzed by the Chi-square or Fisher's exact test. RESULTS: The procedure presented primary technical success in 82.6% of patients. Four patients (17.4%) had an incomplete proximal entry seal. Three patients (13%) died within 30 days of the procedure and eight patients (34.8%) died after 30 days. CONCLUSION: Endovascular correction of complicated Stanford type B aortic dissections is a feasible and effective treatment option.

OBJETIVO: Avaliar as características demográficas e de imagens da trombose endoluminal em uma série de pacientes submetidos a tratamento endovascular do aneurisma de aorta abdominal (TEAAA). MÉTODOS: Avaliamos as características de imagem que permitiram o diagnóstico da trombose endoluminal em uma série de 30 pacientes submetidos ao TEAAA, com seguimento de 5 a 29 meses, através de exames de tomografia computadorizada multidetectores (TCMD) de 64 canais. RESULTADOS: Foram diagnosticados dez casos de trombose luminal (33,3%), sendo que em três pacientes a trombose foi total de um ramo ilíaco. CONCLUSÃO: A TCMD permitiu o diagnóstico de diferentes tipos de trombose endoluminal em pacientes submetidos ao TEAAA. O uso desta modalidade diagnóstica minimamente invasiva deverá ser encorajado na prática clínica.

OBJECTIVE: Evaluate the imaging findings of thrombosis in a series of patients submitted to endovascular repair of aortic abdominal aneurysm. METHODS: MDCT images of 30 patients submitted to endovascular repair of aortic abdominal aneurysm were obtained by a 64 slice scanner, 5 to 29 months after the endovascular treatment. RESULTS: Thrombosis was diagnosed in 10 patients (33.3%), and in three patients thrombosis was total in an iliac branch. CONCLUSION: MDCT allowed diagnosis of different types of endoluminal thrombosis in patients submitted to endovascular repair of aortic abdominal aneurysm. Utilization of this minimally invasive diagnostic technique should be encouraged in clinical practice.

OBJECTIVE: The purpose of this study was to improve the use of 64-channel multidetector computed tomography using lower doses of ionizing radiation during follow-up procedures in a series of patients with endovascular aortic aneurysm repair. METHODS: Thirty patients receiving 5 to 29 months of follow-up after endovascular aortic aneurysm repair were analyzed using a 64-channel multidetector computed tomography device by an exam that included pre-and postcontrast with both arterial and venous phases. Leak presence and type were classified based on the exam phase. RESULTS: Endoleaks were identified in 8/30 of cases; the endoleaks in 3/8 of these cases were not visible in the arterial phases of the exams. CONCLUSION: The authors conclude that multidetector computed tomography with pre-contrast and venous phases should be a part of the ongoing follow-up of patients undergoing endovascular aortic aneurysm repair. The arterial phase can be excluded when the aneurism is stable or regresses. These findings permit a lower radiation dose without jeopardizing the correct diagnosis of an endoleak.

Paragangliomas is a pheochromocytoma of extra adrenal localization. The case report is a male, 55 years old who presented symptoms of adrenergic hyperstimulation associated to an abdominal mass diagnosed as paraganglioma by a biopsy. Because of its size, localization and vascularization, an aortography with embolization of the nutrient branches of the tumor was done pre-operatively. Four days later, a surgical ressection was performed, and the tumor was adhered to the duodenum, infra-renal aorta and inferior vena cava. We believe that an angiographic study pre-operatively with embolization makes possible an analysis of the anastomosis and arterial supplement, making the ressecability of the tumor safer, although it seems the surgical intervention should have been done earlier.

A correção endovascular da dissecção de aorta tipo B tem se mostrado como uma nova alternativa para reduzir o trauma cirúrgico. No entanto, as complicações de médio e longo prazo, tais como a fístula aortoesofágica, são ainda pouco conhecidas e pouco relatadas. O objetivo deste trabalho é descrever três casos de fístula aortoesofágica após o tratamento endovascular de 23 casos de dissecção de aorta descendente conduzidos pela equipe de Cirurgia Vascular da Santa Casa de São Paulo em um estudo retrospectivo. Esses pacientes apresentavam características em comum, como dissecção crônica, pós-operatório imediato sem intercorrências, necessidade de reintervenções, oclusão de troncos arteriais como a artéria subclávia, mesentérica, tronco celíaco, e, ainda, uma rápida evolução para o óbito após os primeiros sinais de fístula. Portanto, embora raramente descrita na literatura, a ocorrência de fístula aortoesofágica é uma complicação de causa até o momento indefinida do tratamento endovascular da dissecção de aorta descendente que merece atenção, dada sua recorrência e evolução fatal.

Endoluminal stent-graft for type B aortic dissection is a new alternative to reduce surgical trauma. However, medium- and long-term complications are still little known and poorly reported, such as the aortic-esophageal fistula. The objective of this study is to describe three cases of aortic-esophageal fistula after the endovascular treatment of 23 cases of descending aortic dissection conducted by the vascular surgery team of Santa Casa de São Paulo in a retrospective study. These patients presented some common characteristics: chronic dissection, successful early outcome, need of reinterventions, occlusion of arterial trunks such as subclavian artery, mesenteric artery, celiac trunk, and finally, a fast fatal course after the first fistula-related symptoms. Therefore, despite rarely described in the literature, aortic-esophageal fistula is a complication of the endovascular treatment of descending aortic dissection which demands attention due to its unpredictability, recurrence, and fatal outcome.

Contexto: A qualidade e a quantidade de partículas coletadas em filtros de proteção cerebral (FPC) durante angioplastia transluminal percutânea com stent (ATPS) podem esclarecer a importância desses dispositivos no tratamento de estenoses carotídeas. Objetivos: Analisar o conteúdo retido por FPC em pacientes submetidos a ATPS de artéria carótida interna com nova técnica de análise qualiquantitativa. Métodos: O material coletado em 10 FPC durante ATPS da bifurcação da carótida em pacientes com alto risco cirúrgico foi submetido a análise microscópica qualiquantitativa. Fotografias digitais das lâminas com material corado com hematoxilina e eosina foram analisadas com o programa Axio Vision LE Release 4.1, que calculou a área das partículas em micrômetros/metro quadrado (µm²). Resultados: O exame histopatológico evidenciou material em 100% dos filtros consistindo predominantemente de restos hemáticos, cristais de colesterol e cálcio. A área média de fragmentos coletados foi expressiva (1.570.310 µm²), e houve ampla variância desses valores. Conclusões: Os FPC coletam quantidade importante de fragmentos de placas de ateroma, e a grande variância nas quantidades de material coletado pode estar associada com a gravidade da lesão, motivo pelo qual se tornam relevantes estudos que utilizem técnica padronizada para a quantificação desses fragmentos e para a compreensão de seu real significado clínico.

Background: Quality and quantity of the content retained in embolic protection filters (EPFs) used in percutaneous transluminal angioplasty and stenting may possibly indicate the importance of EPFs in the management of carotid stenosis. Objectives: To analyze the content retained by EPFs in patients undergoing percutaneous transluminal angioplasty and stenting of the internal carotid artery using a new technique for qualitative and quantitative analysis. Methods: Material captured in 10 EPFs during percutaneous transluminal angioplasty and stenting in high-surgical-risk patients was examined to determine a qualitative and quantitative microscopic analysis. Digital photographs of the hematoxylin-eosin stained slides were analyzed using the Axio Vision LE Release 4.1 software in order to calculate the particles area in micra/square meter (µm²). Results: Histopathological examination identified particulate debris in 100% of the filters including predominantly blood residues, cholesterol crystals, and calcium Quantity of captured fragments was significant (mean of 1,570,310 µm²) with a wide range of these values. Conclusions: Significant quantity of fragments of atheromatous plaques is retained by EPFs and the wide range in the quantity of the retained debris can be associated with the lesion severity; therefore new studies using standardized technique for quantifying these fragments and for better understanding their real clinical meaning are necessary.

CONTEXTO: O tratamento cirúrgico convencional do aneurisma da aorta abdominal (AAA) infra-renal pode resultar em complicações graves. A fim de otimizar os resultados na evolução do tratamento, é importante que sejam identificados os pacientes predispostos a determinadas complicações e instituídas condutas preventivas. OBJETIVOS: Avaliar a taxa de mortalidade operatória precoce, analisar as complicações pós-operatórias e identificar os fatores de risco relacionados com a morbimortalidade. MÉTODO: Foram analisados 134 pacientes com AAA infra-renal submetidos a correção cirúrgica eletiva no período de fevereiro de 2001 a dezembro de 2005. RESULTADOS: A taxa de mortalidade foi de 5,2%, sendo secundária principalmente a infarto agudo de miocárdio (IAM) e isquemia mesentérica. As complicações cardíacas foram as mais freqüentes, seguidas das pulmonares e renais. A presença de diabetes melito (DM), insuficiência cardíaca congestiva (ICC), insuficiência coronariana (ICO) e cintilografia miocárdica positiva para isquemia estiveram associadas às complicações cardíacas. A idade avançada, a doença pulmonar obstrutiva crônica (DPOC) e a capacidade vital forçada reduzida aumentaram os riscos de atelectasia e pneumonia. História de nefropatia, tempo de pinçamento aórtico prolongado e níveis de uréia elevados aumentaram os riscos de insuficiência respiratória aguda (IRA). A isquemia dos membros inferiores esteve associada ao tabagismo e à idade avançada, e a maior taxa de mortalidade, à presença de coronariopatia, tempos prolongados de pinçamento aórtico e de cirurgia. CONCLUSÃO: A taxa de morbimortalidade esteve compatível com a literatura nacional e internacional, sendo secundária às complicações cardíacas, respiratórias e renais. Os fatores de risco identificados no pré e transoperatório estiveram relacionados com essas complicações.

BACKGROUND: Conventional surgical treatment of infrarenal abdominal aortic aneurysm (AAA) can result in serious complications. To optimize treatment outcome it is important to identify patients at risk of having complications and implement prophylaxis. OBJECTIVES: To analyze early surgical mortality rate and postsurgical complications, and to identify risk factors related to morbidity and mortality. METHOD: A total of 134 patients with infrarenal AAA submitted to elective surgical correction from February 2001 to December 2005 were analyzed. RESULTS: The mortality rate (5.2%) was secondary mainly to acute myocardial infarction and intestinal ischemia. Heart-related complications were the most frequent, followed by lung and kidney complications. Presence of diabetes mellitus, congestive heart failure, coronary artery disease, and scintigraphy suggestive of ischemia were related to cardiac complications. Advanced age, chronic obstructive lung disease and reduced forced vital capacity were related to higher risks of atelectasis and pulmonary infection. Presence of renal failure, prolonged aortic clamping and high urea rates were related to acute renal failure. Smoking and advanced age were associated with lower limb ischemia. Presence of obstructive coronary insufficiency and prolonged aortic clamping and surgery time were associated with higher mortality rate. CONCLUSION: The morbidity and mortality rate was compatible with data found in the national and international literature, secondary to cardiac, pulmonary and kidney complications. Identified risk factors before and during the surgery were related to these complications.

OBJETIVO: Analisar fatores prognósticos relacionados com a letalidade dos doentes com aneurisma de aorta abdominal roto. MÉTODO: Foram analisados, retrospectivamente, 72 doentes portadores de aneurisma de aorta abdominal roto, operados no período de 1976 a 2000 pela disciplina de Cirurgia Vascular da Santa Casa de São Paulo. RESULTADOS: A análise descritiva dos dados mostra média de idade de 67,93 anos, com desvio padrão de 11,58 anos, sendo 32% do sexo feminino e 68% do sexo masculino. Do total, 28% tinham história prévia de aneurisma e 72% desconheciam a doença. A pressão arterial sistólica na admissão foi de 96,53 mmHg. A dor esteve presente em 100% dos doentes, assim como massa abdominal pulsátil. O local de rompimento do aneurisma foi em 93% dos casos para o retroperitônio, 4% para o duodeno e 2% para peritônio livre. CONCLUSÃO: Os fatores prognósticos relacionados à letalidade que se mostraram com significância estatística foram: idade, pressão arterial admissional, diurese intra-operatória, volume infundido e creatinina admissional.

OBJECTIVE: To analyze the prognostic factors related to the mortality of ruptured abdominal aortic aneurysm. METHOD: Seventy-two patients who suffered ruptured abdominal aortic aneurysm and were operated in the period between 1976 and 2000 by the Vascular Surgery Unit of the Santa Casa de São Paulo - School of Medical Sciences were retrospectively analyzed. RESULTS: The descriptive analysis of the data shows a mean age of 67.93 years, with a standard deviation of 11.58, 32% female and 68% male. Of the total number, 28% had a previous history of aneurysm and 72% were not aware of the disease. Mean systolic blood pressure during hospital admission was 96.53 mmHg. Pain was present in 100% of the patients, as well as throbbing abdominal mass. In 93% of the cases the location of the aneurysm rupture was the retroperitoneum, 4% in the duodenum, and 2% in the free peritoneum. CONCLUSION: The prognostic factors related to mortality and morbidity that demonstrated statistical significance were: age, initial blood pressure at hospital admission, diuresis during surgery, volume infused, and creatinine levels.