RESUMO
Las complicaciones cardiovasculares representan la principal causa de morbilidad y mortalidad en pacientes con enfermedad renal crónica, por lo que el objetivo de este artículo es demostrar la influencia de la permanencia de la fístula arteriovenosa sobre variables eco cardiográficamente mensuradas en el corazón izquierdo. Para ello, se definió un estudio multivariable, longitudinal, prospectivo y controlado de grupos independientes después de una intervención que incluyó 39 pacientes a los que se le cerró el angioacceso (grupo de estudio) y 42 que no fueron expuestos a la cirugía (grupo control). Ambos grupos exhibían trasplante renal funcionante. Los principales resultados surgenal comparar el predominio entre el grupo de estudio con el de control, la edad promedio; 45,6 y 44,1 años, el sexo masculino, 24 (60%) y 23 (53,5%) y el color de la piel blanca; 33 (82,5%) y 32 (74,4%). La etiología de la nefropatía originaria más frecuente fue la nefropatía vascular hipertensiva; 12 (30%) vs 14 (32,6%). Entre las manifestaciones clínicas, en el grupo de estudio se evidenció remisión de las palpitaciones y la disnea de esfuerzo. Respecto a la tensión arterial, para la sistólica oscilaba; de 123 ±13,4 a 120,5 ±9,2 vs de 125,6 ±8,4 a 128 ±8,3 mm Hg (p= 0,000), mientras la diastólica variaba de; 76,8 ±7,5 a 76,3 ±6,2 vs 78,6 ±4,9 a 82,4 ±3,9 mm Hg (p= 0,000). El hematocrito comportaba valores equivalentes; 0,43 ±0,06 y 0,45 ±0,06 vs 0,42 ±0,05 y 0,42 ±0,06 l/l (p= 0,035) y la creatinina sérica mostró descenso en los pacientes intervenidos de; 106,8 ± 26,2 hasta 99,8 ±23,9 µ Mol/l vs 114 ±27,8 a 120,3 ±31 µ Mol/l (p= 0,002). Las variables ecocardiográficas mensuradas comparativamente según la localización de los angioaccesos a nivel del codo izquierdo; diámetro del ventrículo izquierdo: 3,12 ±4,08 vs 1,48 ±3,46 mms (p=0,001), fracción de eyección del ventrículo izquierdo: 2,99 ±5,47 vs -1,98 ±6,23 % (p=0,018) y el volumen telediastólico: -23 ±33,41 vs 10,86 ±36,87 ml (p=0,006). El codo contralateral revelaba; para la fracción de eyección del ventrículo izquierdo: 3,32 ±3,42 vs -2,18 ±4,78 % (p=0,037) y para el gasto cardíaco: -1,29 ±0,88 vs -0,26 ±0,86 l/min (0,020). Las conclusiones demuestran que el cierre del angioacceso a pacientes con trasplante renal funcionante respecto a los no intervenidos, contribuye a la regresión de las alteraciones morfológicas y hemodinámicas constatadas por ecocardiografía transtorácica en el corazón izquierdo a nivel de las diferentes localizaciones de los accesos vasculares.
Cardiovascular complications represent the main cause of morbidity and mortality in patients with chronic renal disease, so the objective of this article is to demonstrate the influence of the patency of the arteriovenous fistula on echocardiographic variables measured in the left heart. For this, a multivariate study, longitudinal, prospective and controlled study of independent groups after an intervention that included 39 patients who had their angioaccess closed (study group) and 42 who were not exposed to surgery (control group). Both groups exhibited functional kidney transplantation. The main results emerge when comparing the prevalence between the study group and the control group, the average age; 45.6 and 44.1 years, the male sex, 24 (60%) and 23 (53.5%) and the white skin color; 33 (82.5%) and 32 (74.4%). The most frequent etiology of the original nephropathy was hypertensive vascular nephropathy; 12 (30%) vs 14 (32.6%). Among the clinical manifestations, remission of palpitations and dyspnea on exertion were evidenced in the study group. With regard to blood pressure, for the systolic it ranged from 123 ±13.4 to 120.5 ±9.2 vs. 125.6 ±8.4 to 128 ±8.3 mmHg (p= 0.000), while the diastolic varied from; 76.8 ±7.5 to 76.3 ±6.2 vs. 78.6 ±4.9 to 82.4 ±3.9 mmHg (p= 0.000). The hematocrit had equivalent values; 0.43 ±0.06 and 0.45 ±0.06 vs 0.42 ±0.05 and 0.42 ±0.06 l/l (p= 0.035) and the serum creatinine showed decrease in the operated patients from; 106.8 ±26.2 to 99.8 ±23.9 µMol/l vs 114 ±27.8 to 120.3 ±31 µMol/l (p= 0.002). The echocardiographic variables measured comparatively according to the location of the angioaccesses at the left elbow level; diameter of the left ventricle: 3.12 ±4.08 vs 1.48 ±3.46 mms (p=0.001), ejection fraction of the left ventricle: 2.99 ±5.47 vs -1.98 ±6.23 % (p=0.018) and the telediasolic volume: -23 ±33.41 vs 10.86 ±36.87 ml (p=0.006). The contralateral elbow revealed; for the left ventricular ejection fraction: 3.32 ±3.42 vs -2.18 ±4.78 % (p=0.037) and for cardiac output: -1.29 ±0.88 vs -0.26 ±0.86 l/min (0.020). The conclusions show that the our study has shown that closing the angioaccess to patients with functioning renal transplants with respect to those not operated, contributes to the regression of morphological and hemodynamic alterations observed by transthoracic echocardiography in the left heart at the different locations of the vascular accesses.
Assuntos
Humanos , Masculino , Feminino , Fístula Arteriovenosa/fisiopatologia , Diálise Renal , Insuficiência Renal Crônica , Estudos Longitudinais , Fístula Arteriovenosa/cirurgia , Transplante de Rim/efeitos adversos , Nefropatias/complicaçõesRESUMO
A 43-year-old male patient, who received a deceased donor liver transplant for background ethanol-related decompensated cirrhosis, presented 7 months after transplant with mild abdominal distension and pain. On evaluation, the patient had thrombocytopenia, high serum-ascites albumin gradient ascites, and deranged liver functions. The Doppler study of the splenoportal axis showed hepatofugal flow in the recipient's portal vein, normal hepatic veins, a normal liver, splenomegaly, mild ascites, and multiple periportal collaterals. A transjugular liver biopsy and a hepatic venous pressure gradient measurement were done, which suggested mild portal tract inflammation with portal tract fibrosis with prominent portal venous thickening and normal hepatic venous pressure gradient (4 mm). However, the patient had a progressive increase in ascites and a dramatic increase in serum bilirubin level. A triple-phase computed tomography was done that showed rapid contrast flow in both the portal and hepatic arterial phase, suggesting arterialization of the portal flow with possible suspicion of a communicating arterioportal fistula. The patient underwent digital subtraction angiography, which was followed by an embolization of the arterioportal fistula. After embolization, serum bilirubin gradually decreased and ascites resolved. A repeat Doppler of the portal venous system showed established hepatopetal flow with progressively rising portal flow velocities.
Assuntos
Fístula Arteriovenosa/etiologia , Artéria Hepática/fisiopatologia , Hipertensão Portal/etiologia , Transplante de Fígado/efeitos adversos , Pressão na Veia Porta , Veia Porta/fisiopatologia , Dor Abdominal/etiologia , Adulto , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/fisiopatologia , Fístula Arteriovenosa/terapia , Ascite/etiologia , Embolização Terapêutica , Artéria Hepática/diagnóstico por imagem , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/fisiopatologia , Masculino , Veia Porta/diagnóstico por imagem , Fatores de Risco , Resultado do TratamentoRESUMO
Ruptured thoracoabdominal aneurysms (rTAAAs) are rare and carry a significant rate of morbidity and mortality. Aortocaval fistula secondary to rTAAA is even more infrequent. We describe an urgent and staged endovascular treatment of a ruptured extent III thoracoabdominal aortic aneurysm with an aortocaval fistula by performing vena cava stenting to treat aortocaval fistula as a damage control maneuver prior to transfer and subsequent TAAA repair with a physician-modified endograft at a quaternary level hospital.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Ruptura Aórtica/cirurgia , Fístula Arteriovenosa/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Aneurisma Ilíaco/cirurgia , Veia Cava Inferior/cirurgia , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/fisiopatologia , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/instrumentação , Hemodinâmica , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Aneurisma Ilíaco/fisiopatologia , Masculino , Stents , Resultado do Tratamento , Veia Cava Inferior/diagnóstico por imagem , Veia Cava Inferior/fisiopatologiaAssuntos
Fístula Arteriovenosa , Artérias Carótidas/diagnóstico por imagem , Seio Cavernoso/diagnóstico por imagem , Embolização Terapêutica/métodos , Angiografia por Ressonância Magnética/métodos , Esclerite/diagnóstico , Fístula Arteriovenosa/complicações , Fístula Arteriovenosa/diagnóstico , Fístula Arteriovenosa/fisiopatologia , Fístula Arteriovenosa/cirurgia , Diagnóstico Diferencial , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
A ruptured abdominal aortic aneurysm (RAAA), complicated by an aortocaval fistula (ACF), is usually associated with high morbidity and mortality during open operative repair. We report a case of endovascular treatment of an RAAA with ACF. After accessing both common femoral arteries, a bifurcated aortic stent graft was placed. Subsequently, we accessed the fistula from the right femoral vein and a cava vein angiography showed a persistent massive flow from the cava to the excluded aneurysm sac. We proceeded by covering the fistula with an Excluder aortic stent-graft cuff to prevent pressurization of the aneurysm sac and secondary endoleaks. This procedure is feasible and may reduce the chances of posterior endoleaks.
Assuntos
Aorta/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Fístula Arteriovenosa/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Veia Cava Inferior/cirurgia , Idoso , Aorta/fisiopatologia , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/fisiopatologia , Ruptura Aórtica/diagnóstico , Ruptura Aórtica/etiologia , Ruptura Aórtica/fisiopatologia , Aortografia/métodos , Fístula Arteriovenosa/diagnóstico , Fístula Arteriovenosa/etiologia , Fístula Arteriovenosa/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/instrumentação , Hemodinâmica , Humanos , Masculino , Flebografia/métodos , Stents , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Veia Cava Inferior/diagnóstico por imagem , Veia Cava Inferior/fisiopatologiaRESUMO
Se comunican los casos de dos pacientes con síndrome de Bonnet, Wyburn-Mason en quienes existía un aneurisma cirsoide de la retina de diferente grado de desarrollo. En uno, el cuadro oftalmoscópico era obvio; en tanto que en el otro la manisfestación fundamental era una tortuosidad vascular acentuada y en quien solo la angiografía fluoresceínica del fondo ocular mostró sutiles cambios compatibles con una malformación arteriovenosa localizada. Otro elemento inusual en el comportamiento de este tipo de malformaciones fue la asociación a una coartación de la aorta torácica y multiples anomalías esqueléticas sencillas, así como la obstrucción de un segmento muy desarrollado de la malformación arteriovenosa con infarto hemorrágico retiniano e involución posterior de parte de ella
We communicate the cases of two patients with syndrome of Bonnet, Wyburn-Mason who had cirsoide aneurysms of the retina of differnt degrees of development. In one, the ophthalmoscopic picture was obvious, while on the other, The primary manifestation was a marked vascular tortuosity and in which only the ocular fundus fluorescein angiography showed subtle changes consistent with a located arteriovenous malformation. Another unusual element in the behavior of this type of malformations was a coarctation of the thoracic aorta and multiple skeletal anomalies simple associated, as well as the obstruction of a highly developed portion of the retinal arteriovenous malformation with hemorrhagic infarction and consecutive involution of part of it
Assuntos
Humanos , Masculino , Adolescente , Adulto , Feminino , Aneurisma/patologia , Cefaleia/etnologia , Convulsões/diagnóstico , Doença de von Hippel-Lindau/patologia , Epistaxe/etiologia , Exoftalmia/etiologia , Febre/etiologia , Fístula Arteriovenosa/fisiopatologia , Inconsciência/etnologia , Angiofluoresceinografia/métodos , Cefaleias Vasculares/patologia , Fundo de OlhoRESUMO
The experimental model of aortocaval fistula is a useful model of cardiac hypertrophy in response to volume overload. In the present study it has been used to investigate the pathologic subendocardial remodeling associated with the development of heart failure during the early phases (day 1, 3, and 7) following volume overload. Compared with sham treated rats, aortocaval fistula rats showed lower systemic blood pressure and higher left ventricular end-diastolic pressure This resulted in lower coronary driving pressure and left ventricular systolic and diastolic dysfunction. Signs of myocyte necrosis, leukocyte cell infiltration, fibroplasia and collagen deposition appeared sequentially in the subendocardium where remodeling was more prominent than in the non-subendocardium. Accordingly, increased levels of TNF-alpha, IL-1 beta, and IL-6, and enhanced MMP-2 activity were all found in the subendocardium of rats with coronary driving pressure ≤ 60 mmHg. The coronary driving pressure was inversely correlated with MMP-2 activity in subendocardium in all time-points studied, and blood flow in this region showed positive correlation with systolic and diastolic function at day 7. Thus the predominant subendocardial remodeling that occurs in response to low myocardial perfusion pressure during the acute phases of aortocaval fistula contributes to early left ventricular dysfunction.
Assuntos
Aorta Abdominal/fisiopatologia , Fístula Arteriovenosa/fisiopatologia , Pressão Sanguínea/fisiologia , Veia Cava Inferior/fisiopatologia , Função Ventricular Esquerda/fisiologia , Remodelação Ventricular/fisiologia , Doença Aguda , Animais , Aorta Abdominal/patologia , Fístula Arteriovenosa/metabolismo , Fístula Arteriovenosa/patologia , Circulação Coronária/fisiologia , Modelos Animais de Doenças , Hemodinâmica/fisiologia , Interleucinas/metabolismo , Masculino , Metaloproteinase 2 da Matriz/metabolismo , Peroxidase/metabolismo , Fluxo Pulsátil/fisiologia , Ratos , Ratos Wistar , Veia Cava Inferior/patologiaRESUMO
Arteriovenous anastomoses disrupt cardiovascular and renal homeostasis, eliciting hemodynamic adjustments, resetting the humoral pattern, and inducing cardiac hypertrophy. Because acute circulatory imbalance alters gut motor behavior, we studied the effects of arteriovenous fistula placement on the gastric emptying (GE) of a liquid meal in awake rats. After laparotomy, we created an aortocaval fistula (ACF) by aorta and cava wall puncture with a 21-, 23-, or 26-gauge needle. The ACF was not created in the control group, which underwent sham operation. After 12, 24, or 48 h, mean arterial pressure, heart rate, and central venous pressure were continuously recorded, and cardiac output was estimated by thermal dilution. The rats were then gavage fed a test meal (i.e., phenol red in glucose solution), and fractional dye retention was determined 10, 20, or 30 min later. The effect of prior bleeding on ACF-induced GE delay, the role of neuroautonomic pathways, and changes in plasma hormone levels (i.e., angiotensin II, arginine vasopressin, atrial natriuretic peptide, corticosterone, and oxytocin) were evaluated. When compared with the sham-operated group, ACF rats exhibited arterial hypotension, higher (P < 0.05) heart rate, central venous pressure, and cardiac output values and increased (P < 0.05) gastric dye retention, a phenomenon prevented by bilateral subdiaphragmatic vagotomy and hexamethonium treatment. Pirenzepine also impaired the occurrence of gastric delay in subjects with ACF. In addition to causing hyperkinetic circulation, ACF placement delayed the GE of liquid in awake rats, an effect that likely involves a parasympathetic pathway.
Assuntos
Aorta Abdominal , Fístula Arteriovenosa/fisiopatologia , Esvaziamento Gástrico/fisiologia , Veia Cava Inferior , Animais , Sistema Nervoso Autônomo/fisiologia , Gasometria , Débito Cardíaco , Eletrodos Implantados , Ganglionectomia , Trânsito Gastrointestinal/fisiologia , Hormônios/sangue , Laparotomia , Masculino , Vias Neurais/fisiologia , Ratos , Ratos Wistar , Receptores Nicotínicos/fisiologia , VagotomiaRESUMO
INTRODUCTION: The perimedullary arteriovenous fistulas are located on the pial surface and are usually supplied by spinal medullary arteries, that is, either by the anterior or posterior spinal arteries, with no intervening nidus between the feeder arteries and the venous drainage. The clinical findings are, more commonly, caused by progressive radiculomedullary ischemic processes secondary to steal vascular mechanism. As the vascular supply to the spinal cord and to the arteriovenous fistulas (AVF) is not shared with one another, the vascular steal phenomenon cannot be implicated in this case's physiopathology. Most probably, the mass effect caused by the giant venous dilatation was the pathophysiological mechanism involved in this lesion. CASE REPORT: The authors describe the case of a 6-year-old girl with an intradural ventral arteriovenous fistula, with a giant venous dilatation, fed directly by L2 and L3 radiculomedullary arteries at the conus medullaris. There was no arterial supply to the fistula from the anterior or posterior spinal arteries. Selective spinal angiography showed an arteriovenous fistula supplied directly by two radiculomedullary arteries, with a large draining vein caudally. Interposing the arterial and venous vessels was a giant venous aneurysmal dilatation located ventral to the conus medullaris and extending from L3 to T6. The patient was successfully treated by a surgical approach through a laminotomy from L3 to T11. CONCLUSION: The type IV-C spinal arteriovenous malformations or perimedullary AVFs are rare lesions predominately described at the conus medullaris with various types of angio-architecture and controversial treatment.
Assuntos
Fístula Arteriovenosa/patologia , Fístula Arteriovenosa/fisiopatologia , Malformações Vasculares do Sistema Nervoso Central/patologia , Malformações Vasculares do Sistema Nervoso Central/fisiopatologia , Doenças Vasculares da Medula Espinal/patologia , Fístula Arteriovenosa/cirurgia , Malformações Vasculares do Sistema Nervoso Central/cirurgia , Criança , Feminino , Humanos , Laminectomia , Imageamento por Ressonância Magnética , Medula Espinal/irrigação sanguínea , Doenças Vasculares da Medula Espinal/fisiopatologia , Doenças Vasculares da Medula Espinal/cirurgia , Procedimentos Cirúrgicos VascularesRESUMO
1. The role of haemodynamic changes in left ventricular remodelling has been poorly investigated, especially in the context of volume overload cardiac hypertrophy. Low diastolic blood pressure and high left ventricular filling pressure are expected to affect coronary driving pressure negatively and thereby put in jeopardy subendocardial perfusion in particular. The consequences to global left ventricular remodelling remain undetermined. The aim of the present study was to investigate the role of coronary driving pressure in the development of subendocardial remodelling and the conceivable effects on cardiac function, using a rat model of aortocaval fistula. 2. Wistar rats, weighing 330-350 g, were submitted to aortocaval fistula (ACF group) or sham (control group) operations. Two haemodynamic measurements were determined following surgery, the initial measurement at week 1 and the final measurement at week 8. Cytokine expression, myeloperoxidase (MPO) activity, metalloproteinase expression and activity and fibrosis were assessed in two distinct left ventricular myocardial layers: the subendocardium (SE) and the non-subendocardium (non-SE). 3. The ACF group showed lower initial and final coronary driving pressure and lower final +dP/dt and -dP/dt compared with the control group. Multivariate analyses disclosed initial coronary driving pressure as the only haemodynamic parameter independently associated with SE fibrosis (R(2) = 0.76; P < 0.0001) and with +dP/dt (R(2) = 0.55; P = 0.0004) and -dP/dt (R(2) = 0.91; P < 0.0001). Matrix metalloproteinase (MMP)-2 expression and activity predominated in the SE of ACF animals, particularly in those with low coronary driving pressure. Increased levels of interleukin (IL)-6 and IL-1beta also predominated in the SE of the ACF group. Otherwise, MPO activity and levels of tumour necrosis factor-alpha and IL-10 were similar in both groups. Final coronary driving pressure correlated with both the expression and activity of MMP-2. 4. Low coronary driving pressure early in the course of ACF determines SE damage and, by this mechanism, interferes negatively in left ventricular function.