Parâmetros dopplervelocimétricos na avaliação da perviedade da anastomose portossistêmica intra-hepática transjugular (TIPS): estudo prospectivo Doppler flowmeter parameters for evaluation of transjugular intrahepatic porto-systemic shunts (TIPS) patency: prospective study

OBJETIVO: Estudar as alterações hemodinâmicas consideradas normais após a realização da anastomose portossistêmica intra-hepática transjugular (TIPS) e a eficácia dos parâmetros sugestivos de estenose do TIPS com o ultra-som Doppler. MATERIAIS E MÉTODOS: Dezesseis pacientes foram avaliados de maneira prospectiva, no período de dezembro de 2001 a março de 2003. As avaliações foram realizadas 24-48 horas após o TIPS e a seguir em intervalos regulares de 30 dias, três meses, seis meses e um ano, com ultra-som modo B, Doppler pulsado, Doppler colorido e de amplitude em diferentes pontos da prótese relacionados ao TIPS. A angiografia foi realizada apenas para a confirmação dos resultados e terapêutica pertinente. RESULTADOS: Até o momento apenas os achados de fluxo contínuo no terço proximal da prótese e o gradiente de velocidade entre dois pontos da prótese apresentaram significância estatística para o diagnóstico de estenose do TIPS (p < 0,001), mas outros diferentes critérios também estiveram presentes, porém sem significância estatística. CONCLUSÃO: O ultra-som Doppler é uma ferramenta eficaz no diagnóstico da perviedade e das complicações secundárias à realização do TIPS, sobretudo da estenose. No entanto, é necessária casuística maior, a fim de determinar um conjunto de parâmetros que facilite o seguimento destes pacientes, reservando a angiografia apenas para o tratamento pertinente.<br>OBJECTIVE: To assess the hemodynamic changes considered normal after transjugular intrahepatic porto-systemic shunt (TIPS) placement and the efficacy of TIPS parameters suggestive of stenosis using Doppler sonography. MATERIALS AND METHODS: Sixteen patients were prospectively evaluated from December, 2001 to March, 2003 after TIPS placement. Evaluations were performed 24 to 48 hours after the procedure and then at intervals of 30 days, three months, six months and one year using B mode, color Doppler, power Doppler and spectral Doppler in different TIPS related sites. Angiography was performed only to confirm Doppler findings and treatment. RESULTS: To date the only statistically significant parameters for diagnosis of TIPS stenosis were continuous flow pattern in the proximal third of TIPS and the velocity gradient between the two sites (p < 0.001). Different non-statistically significant parameters were also observed. CONCLUSION: Doppler sonography is an efficient tool for the diagnosis of shunt patency and TIPS related complications such as stenosis. However, it is necessary to study a larger number of patients in order to determine a group of parameters that would help in the follow-up of these patients, thus using portal angiography only for indicated treatment

Parâmetros dopplervelocimétricos na avaliação da perviedade da anastomose portossistêmica intra-hepática transjugular (TIPS) Dopplerflowmetric patterns for evaluation of transjugular intrahepatic portosystemic shunt patency

A anastomose portossistêmica intra-hepática transjugular (TIPS) é um procedimento intervencionista minimamente invasivo realizado pela introdução de prótese metálica auto-expansível no parênquima hepático, via transjugular. Tem por objetivo tratar as complicações da hipertensão portal, principalmente a hemorragia digestiva alta e a ascite refratária. A estenose é complicação freqüente, embora o procedimento seja eficaz e com baixo índice de insucesso. O diagnóstico precoce da estenose é de fundamental importância, pois interfere no tipo de tratamento a ser realizado e o reaparecimento dos sintomas pode ser grave. O ultra-som Doppler é então utilizado para o seguimento dos pacientes portadores do TIPS, e vários parâmetros são descritos na literatura para o diagnóstico de estenose, como: as velocidades mínima e máxima no interior da prótese, a velocidade na veia porta, o gradiente de velocidade entre dois pontos da prótese, e outros. Infelizmente não há consenso sobre qual parâmetro ou conjunto de parâmetros é mais eficaz no diagnóstico, porque os protocolos de avaliação variam de instituição para instituição. Os autores realizaram uma revisão dos parâmetros de estenose descritos na literatura e de outros aspectos de fundamental importância na compreensão do procedimento, como as indicações, as contra-indicações e a fisiopatologia da estenose.<br>Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive interventional procedure that consists of placement of an auto expandable metallic stent in the hepatic parenchyma via transjugular. It is used to treat the complications of portal hypertension, particularly digestive bleeding of gullet varices and refractory ascites. Although TIPS is an efficient procedure with low rate of failure some complications such as stenosis are frequent. Early diagnosis of stenosis is mandatory since it interferes with the type of treatment and the reappearing symptoms can be serious. Doppler sonography is used in the follow-up of this patients and many parameters indicating TIPS stenosis are described in the literature such as the minimum and maximum velocity flow inside the stent, the velocity flow in portal vein, the velocity gradient between different sites of the stent, among others. Unfortunately there is no consensus on which parameter or group of parameters is more efficient for diagnosis because the evaluation protocols varied among institutions. The authors reviewed the parameters of stenosis reported in literature and other important aspects for comprehension of this procedure including indications, contraindications and physiopathology of stenosis

Transitional Flow in a Cylindrical Flow Chamber for Studies at the Cellular Level

Fluid shear stress is an important regulator of vascular and endothelial cell (EC) functions. Its effect is dependent not only on magnitude but also on flow type. Although laminar flow predominates in the vasculature, transitional flow can occur and is thought to play a role in vascular diseases. While a great deal is known about the mechanisms and signaling cascades through which laminar shear stress regulates cells, little is known on how transitional shear stress regulates cells. To better understand the response of endothelial cells to transitional shear stress, a novel cylindrical flow chamber was designed to expose endothelial cells to a transitional flow environment similar to that found in vivo. The velocity profiles within the transitional flow chamber at Reynolds numbers 2200 and 3000 were measured using laser Doppler anemometry (LDA). At both Reynolds numbers, the velocity profiles are blunt (non-parabolic) with fluctuations larger than 5% of the velocity at the center of the pipe indicating the flows are transitional. Based on near wall velocity measurements and well established data for flow at these Reynolds numbers, the wall shear stress was estimated to be 3–4 and 5–6 dynes/cm(2) for Reynolds number 2200 and 3000, respectively. In contrast to laminar shear stress, no cell alignment was observed under transitional shear stress at both Reynolds numbers. However, transitional shear stress at the higher Reynolds number caused cell elongation similar to that of laminar shear stress at 3 dynes/cm(2). The fluctuating component of the wall shear stress may be responsible for these differences. The transitional flow chamber will facilitate cellular studies to identify the mechanisms through which transitional shear stress alters EC biology, which will assist in the development of vascular therapeutic treatments