[Open and endovascular surgery for the treatment of abdominal aortic aneurysm. Review of the available evidence]. / Manejo del aneurisma de la aorta abdominal: estado actual, evidencias y perspectivas para el desarrollo de un programa nacional.

Open and endovascular surgery are therapeutic alternatives for the treatment of abdominal aortic aneurysm. The development of guidelines for its treatment requires a thorough analysis of available evidence to recommend the best treatment for each country's reality. Prospective randomized trials have shown best initial results with endovascular surgery, with higher hospital costs than open surgery. The requirement of anatomical suitability for the placement of endovascular prostheses limits the universal use of endovascular surgery. Moreover, this type of surgery needs a strict imaging and clinical follow up due to the high rates of late complications, which range from 20% to 40%. Many of these complications require further surgical interventions, elevating costs of treatment. The initial benefit of endovascular surgery is lost during long follow up as survival curves become similar to those of open surgery. Even for patients with a high surgical risk, the benefits of endovascular surgery are doubtful.

Filtros de vena cava inferior en posición suprarrenal / Suprarenal inferior vena cava filters: retrospective review of 30 cases

Background: Inferior vena cava (IVC) filters are used to prevent massive pulmonary embolism in cases where anticoagulation is contraindicated or has failed. It is usually implanted below the renal veins. In a few cases it is necessary to deploy the filter above them, with theoretical rísk of secondary renal failure. Aim: To report the experience with filters located above the renal veins. Patients and Methods: Medical records of all patients with percutaneous suprarenal filters are reviewed. Results: Between May 1993 and May 2007, 361 percutaneous IVC filter procedures were performed. In thirty patients aged 19 to 77 years (average 48years, 50 percent males), they were placed in suprarenalposition (8,3 percent). Suprarenal IVC filters were implanted in patients with extensive caval thrombosis, renal vein thrombosis extending to cava, displacement of previous IVC filters and double IVC system. Jugular vein approach was the access of choice. Technical success was 100 percent, no death or pulmonary embolism occurred. Patients were followed from 1 to 165 months (average 57 months). Eight deaths were recorded, five in patients with cáncer No patient had renal failure on follow up (average creatinine 0.90+0,26 mg/dL). Three patients developed a new deep vein thrombosis (10 percent), without pulmonary embolism. Conclusions: In this retrospective analysis of patients, suprarenal placement of IVC filters was not associated to secondary renal failure, and showed good short and long term results.

Tratamiento endovascular de aneurisma aórtico abdominal: resultados en 80 pacientes consecutivos / Endovascular repair of abdominal aortic aneurysm: Results in 80 consecutive patients

Background: Endovascular repair of abdominal aortic aneurysms (AAA) avoids laparotomy, shortens hospital stay and reduces morbidity and mortality related to surgical repair, allowing full patient recovery in less time. Aim: To report short and long term results of endovascular repair of AAA in 80 consecutive patients treated at our institution. Patients and Methods: Between September 1997 and February 2005, three women and 77 men with a mean age 73.6±7.7 years with AAA 5.8±1.0 cm in diameter, were treated. The surgical risk of 38 percent of patients was grade III according to the American Society of Anesthesiologists classification. Each procedure was performed in the operating room, under local or regional anesthesia, with the aid of digital substraction angiography. The endograft was deployed through the femoral artery (83.7 percent bifurcated, 16.3 percent tubular graft). A femoro-femoral bypass was required in 11.3 percent of cases. Follow-up included a spiral CT scan at 1, 6 and 12 months postoperatively, and then annually. Results: Endovascular repair was successfully completed in 79/80 patients (98.7 percent technical success). The procedures lasted 147±71 min. Length of stay in the observation unit was 20.6±13.5 h. Blood transfusion was required in 10 percent. Sixty two percent of the patients were discharged before 72 h. One patient died 8 days after surgery due to a myocardial infarction (1.3 percent). During follow-up (3-90 months), 1 patient developed late AAA enlargement due to a type I endoleak, requiring a new endograft. No AAA rupture was observed. Survival at 4 years was 84.2 percent (SE =9.2). Endovascular re-intervention free survival was 82.7 percent (SE =9.5). Conclusion: Endovascular surgery allows effective exclusion of AAA avoiding progressive enlargement and/or rupture and is a good alternative to open repair. Close and frequent postoperative follow up is mandatory.

Terapia endovascular en el síndrome de vena cava superior: caso clínico / Endovascular treatment of superior vena cava syndrome: report of 1 case

The treatment of superior vena cava syndrome is usually oriented to the underlying cause, that can be too slow in emergency cases. We report a 49 years old woman with a multiple myeloma that was admitted due to a superior vena cava syndrome caused by a central venous catheter used for chemotherapy for 20 weeks. She was successfully treated with thrombolysis, angioplasty and stent placement. The patient died 7 months later due to the underlying disease. Long term catheters are the responsible for 20 to 30 percent of superior vena cava syndromes. Endovascular treatment of the syndrome is successful in 60 to 100 percent of cases with a symptomatic relapse in 4 to 45 percent of patients

Interrupción de vena cava inferior mediante filtros: indicaciones y resultados en 111 pacientes / Inferior cava vein filters: indications and results in 111 patients

Background: Anticoagulation is the treatment of choice for deep vein thrombosis and pulmonary embolism. Occasionally this treatment is contraindicated or fails to prevent pulmonary embolism. In these patients, inferior cava vein interruption is indicated and filter insertion is the procedure commonly performed. Aim: To report the results of inferior cava vein filter insertions in 111 patients. Patients and methods: A retrospective review of patients in whom inferior cava vein filters were inserted was performed. Results: During the period 1983-1997, filters were inserted in 111 patients (56 female) aged 15 to 93 years old. Indications were pulmonary embolism with contraindication or failure of anticoagulation therapy or poor respiratory function (58 patients), deep vein thrombosis and contraindication for anticoagulation (32 patients) and other indications in 20 patients. In 47 patients, treated before 1993, the insertion required a cut-down. Since then, a percutaneous approach was used in the remaining 64 cases. Three insertion attempts failed, all using cut-down. One of these patients died due to a massive pulmonary embolism. In 88 per cent of the patients the jugular vein was the access site and in 10 patients, the filter was deliberately deployed above the renal veins. There was no mortality or complications. Patients were followed during a maximal period of 147 months and 27 died of unrelated disorders. Survival at 5 and 10 years was 63 and 47 per cent respectively. Symptomatic inferior cava vein obstruction was detected in 5 patients during the follow up period. Conclusions: Inferior cava vein filter insertion is a safe measure to prevent pulmonary embolism and its consequences

Aneurisma aórtico abdominal: evolución de la morbimortalidad de la cirugía electiva durante 20 años / Abdominal aortic aneurysm: morbimortality evolution of elective surgery during 20 years

Abdominal aortic aneurysms (AAA) usually undergo progressive dilatation and eventually may rupture,complication that caries a high mortality rate. If certain clinical conditions, like operative risk and aortic diameter are met, all patients should be considered for surgical repair. Analysis of our results with the surgical treatment of asymptomatic AAA prompted this stydy. Our of 479 consecutive patients operated because of AAA between 1976 and 1995, 378 (79 percent) were electively treated. Two decades: 1976-85 (101 patients) and 1986-95 (277 patients) were compared as far as associated medical conditions, surgical procedures, complications and mortality rate. There was no difference in age, sex, risk factors and aortic diameter. During the second decade we favoured the use of aortic tube grafts (53 percent vs 25 percent, p < 0.01) and epidural anesthesia (95 percent vs 35 percent, p < 0.01). During the last decade only 53.3 percent of the patients received blood transfusion, compared to 95.3 percent during the first period (p < 0.001). Operative mortality decreased from 5.94 percent to 0.72 percent (p < 0.05). Postoperative hospital stay diminished from 11.2 ñ 8.2 to 9.6 ñ 6.3 days (p < 0.05). These results compare favourable with those reported from other academic centers and support our therapeutic approach. Our contemporary surgical results serve as a reference for future clinical evaluation of endovascular procedures currently under investigation

La importancia de la reprogramación en la vida útil y costo de implante de los marcapasos bicamerales / The importance of adjusting parameters for the duration and cost of dual chamber pacemakers

Antecedentes: realizamos un estudio prospectivo de 236 pacientes sometidos a implante de marcapaso DDD bicameral. Los parámetros nominales de implante permiten márgenes de seguridad de estimulación más que suficientes. Las mejoras en la tecnología de marcapasos y electrodos han permitido reducir los umbrales de captura y, por lo tanto, la programación de los parámetros de salida. Dichos cambios pueden significar una reducción en el consumo de la batería a largo plazo, produciendo una mayor durabilidad del generador. Métodos y resultados: se estudió 236 pacientes consecutivos implantados con marcapasos Pacesetter DDD para determinar el impacto de la reprogramación en la durabilidad y costo del implante del marcapaso. Se excluyó a 36 pacientes, 19 murieron, 13 no tuvieron suficientes controles y 4 fueron reprogramados a modo VVI. Los 200 pacientes restantes completaron al menos 18 meses de seguimiento y se les implantó generadores capaces de medir umbrales de estimulación crónico, ancho de pulso, impedancia y energía de la batería. Comparamos la durabilidad estimada basada en la energía de la batería bajo parámetros de implante nominales, con aquella basada en los parámetros obtenidos tras la reprogramación durante el seguimiento. La estimación de durabilidad fue de 6,89 años bajo parámetros nominales y de 10,5 años bajo parámetros de programación final (p<0,001). Conclusiones: la reprogramación podría aumentar la durabilidad y reducir el costo de implante de los marcapasos. En nuestro estudio la reprogramación aumentó la durabilidad del marcapaso en 3,6 años y ocasionó una reducción promedio en sus costos de 330 dólares por año

Tratamiento del aneurisma aórtico abdominal por vía endovascular: experiencia inicial / Endovascular treatment of abdominal aortic aneurysm: initial experience

Background: Thirty day mortality of current surgical treatment of abdominal aortic aneurysm is 0.7 to 5 percent. Coronary artery disease is the main risk factor in this elderly population. An alternative procedure based on the transfemoral deployment of self expandable prostheses to exclude the aneurysm, avoids a laparotomy and major surgical trauma, reducing the risks of the conventional operation. Aim: To report our experience on endovascular repair of abdominal aortic aneurysms. Patients and methods: Nine consecutive patients aged 66 to 82 years old, possible candidates for the procedure, were studied. Results: Only four patients fulfilled the requirements for the procedure, which was technically successful in three. One patient was converted to an open surgical repair. Patients were discharged 72-96 hours after graft implantation. The postoperative CAT scan confirmed total exclusion of the aneurysm by the endovascular graft. All nine patients are alive at the time of this report. Conclusions: Given certain anatomical conditions, endovascular treatment of abdominal aortic aneurysms is an attractive alternative for high risk patients