Trombolisis dirigida por catéter en paciente con oclusión arterial periférica aguda / Catheter-directed thrombolysis in patients with acute peripheral arterial occlusion

Introducción: Las oclusiones arteriales periféricas agudas de menos de 14 días y de causa embólica y trombótica están asociadas a una alta morbimortalidad. La trombólisis dirigida por catéter representa en la actualidad una modalidad de tratamiento efectivo para la oclusión de vasos distales infrageniculares, que históricamente ha tenido malos resultados mediante embolectomía convencional, debido a la oclusión preexistente de vasos colaterales y al daño mecánico al endotelio, que conlleva esta técnica tradicional. Se decidió presentar este caso por ser la primera vez que se practica esta modalidad de tratamiento en Cuba. Objetivo: Exponer los resultados obtenidos con la aplicación de la trombolisis fibrinolitica mediante catéter en un paciente afectado por trombosis arterial periférica aguda. Presentación del caso: Paciente masculino de 57 años de edad con diagnóstico de trombosis arterial aguda de la arteria poplítea del miembro inferior izquierdo, con más de 24 horas de evolución de la isquemia y del compromiso de la viabilidad de la extremidad. Se utilizó el tratamiento fibrinolítico, mediante infusión de 250 000 unidades de Heberkinasa® en tres horas y se logró la mejoría del nivel de amputación. Conclusiones: El tratamiento fibrinolítico con Heberkinasa® fue útil en el paciente tratado porque redujo el nivel de amputación en el paciente, que presentó isquemia irreversible y criterio inicial de amputación supracondílea alto, en la extremidad comprometida(AU)

Introduction: Acute peripheral arterial occlusions of less than 14 days and of embolic and thrombotic cause are associated with a high morbidity and mortality. Catheter-directed thrombolysis currently represents an effective treatment modality for the occlusion of infragenicular distal vessels, which has historically had poor results by conventional embolectomy, due to the pre-existing occlusion of collateral vessels and the mechanical damage to the endothelium, which this traditional technique entails. It was decided to present this case because it is the first time that this modality of treatment is practiced in Cuba. Objective: Present the results obtained with the application of fibrinolytic thrombolysis by catheter in a patient affected by acute peripheral arterial thrombosis. Case presentation: A 57-year-old male patient diagnosed with acute arterial thrombosis of the popliteal artery of the left lower limb, with more than 24 hours of evolution of ischemia and compromised viability of the limb. Fibrinolytic treatment was used, by infusion of 250,000 units of Heberkinase® in three hours and the improvement of the amputation level was achieved. Conclusions: Fibrinolytic treatment with Heberkinase® was useful in the treated patient because it reduced the level of amputation in the patient, who presented irreversible ischemia and initial criteria of high supracondylar amputation in the compromised limb(AU)

Comparison of different types of endovascular mechanical embolectomy in acute ischemic stroke

SUMMARY Background: To compare the treatment efficacy of different types of endovascular mechanical embolectomy in acute ischemic stroke (AIS). Material and Methods: A total of 89 patients with AIS were selected in our hospital from January 2014 to January 2016 and divided into tPA group (n=27), tPA+Trevo group (n=30) and tPA+Solitaire FR group (n=32) for different treatments. Treatment effectiveness was evaluated using NIHSS and mRS system. The NIHSS score, vascular recanalization rate and postoperative complications were compared among groups. Results: The NIHSS score of the tPA group was significantly lower than that of other two groups at 1 d after the operation (p < 0.05), but it was significantly higher than that of other two groups at 3 d and 3 w after the operation (p < 0.05). After the treatment, no significant difference in NIHSS score was found between the tPA+Trevo and tPA Solitaire FR groups. The revascularization rate was significantly higher, but the mortality rate in 90 d was significantly lower in the tPA+Trevo and tPA+Solitaire FR groups than that in the tPA group (p < 0.05), and no significant difference was found between the tPA+Trevo and tPA+Solitaire FR groups. The incidence rate of symptomatic intracranial hemorrhage was significantly lower in the tPA+Solitaire FR group than that in tPA+Trevo group (p < 0.05) or tPA group (p < 0.01). Significantly more patients with mRS no higher than 2 points were found in the tPA+Trevo and tPA+Solitaire FR groups than those in tPA group (p < 0.05), and no significant difference was found between the tPA+Trevo and tPA+Solitaire FR groups. Conclusion: TPA+Solitaire FR is a type of thrombectomy that is superior to tPA and tPA+Trevo in the treatment of patients with AIS.

RESUMO OBJETIVO Comparar a eficácia do tratamento de diferentes tipos de embolectomia mecânica endovascular em acidente vascular cerebral isquêmico agudo (AIS). MATERIAL E MÉTODOS Um total de 89 pacientes com AIS foi selecionado em nosso hospital de janeiro de 2014 a janeiro de 2016, e os pacientes foram divididos em: grupo tPA (n = 27), tPA + grupo Trevo (n = 30) e grupo tPA + Solitaire FR (n = 32) para diferentes tratamentos. A eficácia do tratamento foi avaliada usando NIHSS e sistema mRS. Escore NIHSS, taxa de recanalização vascular e complicações pós-operatórias foram comparados entre os grupos. RESULTADOS A pontuação NIHSS do grupo tPA foi significativamente menor do que a dos outros dois grupos em um dia após a operação (p < 0,05), mas foi significativamente maior do que nos outros dois grupos em três dias e três semanas após a operação (p < 0,05). Após o tratamento, não houve diferença significativa no escore NIHSS entre o grupo tPA + Trevo e o grupo tPA Solitaire FR. A taxa de revascularização foi significativamente maior, mas a taxa de mortalidade em 90 dias foi significativamente menor nos grupos tPA + Trevo e tPA + Solitaire FR do que no grupo tPA (p < 0,05) e não houve diferença significativa entre os grupos tPA + Trevo e tPA + Solitaire FR. A taxa de incidência de hemorragia intracraniana sintomática foi significativamente menor no grupo tPA + Solitaire FR do que no grupo tPA + Trevo (p < 0,05) ou no grupo tPA (p < 0,01). Significativamente mais pacientes com mRS não maiores que 2 pontos foram encontrados no grupo tPA + Trevo e tPA + Solitaire FR do que no grupo tPA (p < 0,05), e nenhuma diferença significativa foi encontrada entre os grupos tPA + Trevo e tPA + Solitaire FR. Conclusão O tPA + Solitaire FR é um tipo de trombectomia superior ao tPA e tPA + Trevo no tratamento de pacientes com EIA.

Embolectomía tardía en isquemia aguda de miembros inferiores / Late embolectomy in acute lower limb ischemia

La isquemia aguda es la interrupción brusca del aporte sanguíneo a un determinado territorio del organismo. Su causa más frecuente, la embolia arterial, consiste en la oclusión también brusca de una arteria sana por material trombótico formado en un territorio proximal al del accidente y que desencadena un cuadro que, de no diagnosticarse y tratarse adecuadamente, puede comprometer la vida del paciente. Existe una estrecha relación entre la gravedad del cuadro isquémico y el tiempo transcurrido de manera que si no se toman medidas agresivas a tiempo raramente se resuelve de manera satisfactoria. La revascularización es considerada menos efectiva después de 8 a 10 h de isquemia, tiempo después del cual muchos se abstienen de operar debido al temido síndrome de reperfusión; sin embargo, algunos refieren éxitos con embolectomías tardías. Se presenta un caso de embolismo arterial a miembro inferior derecho por arritmia cardiaca, que llegó al servicio de Cirugía Vascular del Hospital Provincial "Dr. Antonio Luaces Iraola", con 72 h de evolución. Se le realizó embolectomía femoral con catéter de Fogarty con resultados satisfactorios, lo que apoya la hipótesis de que se debe intentar reperfundir la extremidad siempre que se demuestre viabilidad de los tejidos y no exista gangrena, independientemente del tiempo transcurrido(AU)

Acute ischemia is the sudden interruption of the blood flow in a specific area of the body. Its most common cause is arterial embolism consisting of abrupt occlusion of a healthy artery by thrombotic residues formed in an area near the stroke and unleashing a clinical picture that should be adequately diagnosed and treated to avoid death. There is close relationship between the severity of ischemia and the time elapsed because if no aggressive actions are taken in due time, the results are rarely satisfactory. Revascularization is considered less effective 8 to 10 hours after ischemia. After this time many surgeons refrain from performing surgery due to the frightening reperfusion syndrome. However some had documented successful results with late embolectomy. Here is a case of arterial embolism in right lower limb owing to cardiac arrhythmia. The patient arrived to the Vascular Surgery service after 72 hours of the event; he was performed femoral embolectomy with Fogarty catheter and the achieved results were satisfactory, which supports the hypothesis of trying to reperfusing the affected limb whenever tissue viability exists and gangrene is not present, regardless of time elapsed(AU)

Tratamiento neuroquirúrgico de la isquemia cerebral / Neurosurgical treatment of cerebral ischemia

Introducción: El manejo actual de la isquemia cerebral aguda (IA) contempla el uso de r-tPA y terapia endovascular, mientrasque en la isquemia cerebral crónica (IC) la mejor terapia aún no está definida. La revascularización cerebral microquirúrgicaha sido descrita como tratamiento alternativo para pacientes con IA y contraindicación para r-tPA o terapia endovascular, asícomo para pacientes con IC en quienes la terapia médica ha fracasado. Objetivo: Comunicar la experiencia inicial en cirugíade revascularización cerebral, con énfasis en la utilidad de la embolectomía microquirúrgica y del bypass cerebral comoterapia de rescate en IA, así como del bypass cerebral en IC. Pacientes y Método: Serie prospectiva de 5 pacientes conisquemia cerebral tratados con cirugía de revascularización cerebral en el período 2013 a 2016. Se describe la técnica y resultadosquirúrgicos, así como el estado funcional a los 3, 6 y 12 meses de seguimiento según modified Rankin Scale (mRS)...

Background: Tissue Plasminogen Activator (t-PA) and mechanical thrombectomy are today the best treatment approachfor acute ischemic stroke (AIS). However, the best management for chronic cerebral ischemia (CCI) is still debated. Microsurgicalrevascularization has been described as alternative treatment for patients with AIS and contraindication for t-PA orendovascular therapy, and for patients with CCI and failure of maximal medical therapy. Aim: To describe the effectiveness ofmicrosurgical embolectomy and cerebral bypass as salvage therapy in AIS, as well as cerebral bypass in CCI. Methods: Fivepatients were treated by cerebral revascularization between 2013 and 2016. Surgical and functional results were analyzed.Neurological outcomes were assessed by modified Rankin Scale (mRS) at 3, 6 & 12 months...

Carbon dioxide as a substitute for iodine contrast in arteriography during embolectomy / Uso de dióxido de carbono como substituto ao contraste iodado em arteriografia durante embolectomia

Acute limb ischemia can be potentially harmful to the limb and life threatening. Renal failure is a possible outcome associated with release of products of ischemic limb reperfusion. Some authors reported the benefit of performing angiography after embolectomy, even though iodine contrast is also nephrotoxic. We report a case of embolectomy on a patient with renal insufficiency in whom carbon dioxide was used as a substitute for iodine contrast.

A isquemia aguda de membro pode ser danosa para o membro e para a vida. A insuficiência renal é um desfecho possível associado à liberação dos produtos da reperfusão do membro isquêmico. Alguns autores relatam o benefício de realização de angiografia após embolectomia, apesar do contraste iodado também ser nefrotóxico. Relatamos um caso de embolectomia em uma paciente com insuficiência renal, em que o dióxido de carbono foi utilizado como substituto para o contraste iodado.

Percutaneous Aspiration Embolectomy Using Guiding Catheter for the Superior Mesenteric Artery Embolism

OBJECTIVE: To evaluate the technical feasibility and clinical outcome of percutaneous aspiration embolectomy for embolic occlusion of the superior mesenteric artery (SMA). MATERIALS AND METHODS: Between January 2010 and December 2013, 9 patients with embolic occlusion of the SMA were treated by percutaneous aspiration embolectomy in 2 academic teaching hospitals. The aspiration embolectomy procedure was performed with the 6-Fr and 7-Fr guiding catheter. Thrombolysis was performed with urokinase using a multiple-sidehole infusion catheter. The clinical outcome was investigated retrospectively. RESULTS: Superior mesenteric artery occlusion was initially diagnosed by computed tomography (CT) in all patients, and all patients had no obvious evidence of bowel infarction on CT scan. Percutaneous aspiration embolectomy was primarily performed in 6 patients, and thrombolysis was initially performed in 3 patients. In 3 patients who received primary thrombolysis, percutaneous aspiration was undertaken because the emboli were resistant to urokinase. Complete angiographic success was achieved in 6 patients and partial angiographic success was accomplished in 3 patients. One patient underwent bowel resection. One patient died of whole bowel necrosis and sepsis, and 8 patients survived without complications. CONCLUSION: Percutaneous aspiration embolectomy is a useful tool in recanalization of embolic occlusion of the SMA in select patients.

Acute Upper Limb Ischemia due to Cardiac Origin Thromboembolism: the Usefulness of Percutaneous Aspiration Thromboembolectomy via a Transbrachial Approach

OBJECTIVE: To evaluate the usefulness of percutaneous aspiration thromboembolectomy (PAT) via a transbrachial approach in patients with acute upper limb ischemia. MATERIALS AND METHODS: From July 2004 to March 2008, eleven patients with acute upper limb ischemia were enrolled in this study. They were initially treated with thrombolysis (n = 1), PAT (n = 6), or both (n = 4) via a femoral artery approach. However, all of the patients had residual thrombus in the brachial artery, which was subsequently managed by PAT via the transbrachial approach for removal of residual emboli. RESULTS: Successful re-canalization after PAT via a transbrachial approach was achieved in all patients. Two patients experienced early complications: one experienced a massive hematoma of the upper arm due to incomplete compression and was treated by stent deployment. The other patient experienced a re-occlusion of the brachial artery the day after the procedure due to excessive manual compression of the puncture site, but did not show recurrence of ischemic symptoms in the artery of the upper arm. Clinical success with complete resolution of ischemic symptoms was achieved in all patients. CONCLUSION: PAT via a transbrachial approach is a safe and effective treatment for patients with acute upper limb ischemia.

Tratamento com sucesso de um caso de tromboembolismo pulmonar maciço com uso de cateter de aspiração a vácuo / Clinical case: massive pulmonary embolism successfully treated with aspiration catheter

Relatamos um caso de tromboembolismo pulmonar maciço em paciente idosa, com grande instabilidade clínica e hemodinâmica, que foi submetida a intervenção percutânea precoce. Realizamos embolectomia com cateter de aspiração. Pronto 0,035" 10 F e trombolise intra-arterial (dose reduzida), com excelente resultados.

We report here the use of the Pronto .035" 10 F aspirationcatheter and intra-arterial trombolysis (reduced dose) inthe successful treatment of an elderly patient with a massive acute pulmonary thromboembolism and hemodynamic collapse submitted to early percutaneous intervention.

Acute pulmonary embolism advances in treatment.

Recent advances in interventional cardiology, pharmacotherapeutics and modern surgical management in tertiary cardiac care centers have tremendously improved the present treatment of Pulmonary Embolism (PE). CT pulmonary angiography (CTPA), nuclear lung scan (V/Q scan), D-dimer test and modern echocardiography have revolutionized the diagnostic methodology and risk assessment criteria. Cardiogenic shock or systolic hypotension (BP < 90 mmHg) and presence of right ventricular dysfunction (or failure) are two principal criteria which govern the severity of pulmonary embolism. While all patients of pulmonary embolism require anticoagulation, systemic thrombolytic therapy is the mainstay of initial treatment in massive and submassive pulmonary embolism. When thrombolysis is contraindicated or has failed, urgent surgical embolectomy or catheter embolectomy may be life saving procedures in severe pulmonary embolism.

Isquemia mesentérica aguda / Acute mesenteric ischemia

La esquemia mesentérica aguda representa una emergencia vascular que requiere de alta sospecha clìnica y exámenes adecuados para su diagnósticos oportuno, ya que su resolución precoz disminuye significativamente la morbimortalidad. Comunicamos un caso de isquemia mesentérica aguda, secundario a una embolia de la arteria mesentérica superior, en un paciente de 69 años hipertenso y portador de una fibrilación auricular; que consultó por intenso y súbito dolor abdominal al servicio de urgencia de un hospital privado. Se realizó angio TAC que evidenció la embolia, se estabilizó su condición aguda y posteriormente fue trasladado para su resolución quirúrgica en el sistema público, acogiéndose a la Ley de Urgencia Vital. Se realizó la embolectomía mesentérica de urgencia que permitió la revascularización del sector comprometido y evolucionó favorablemente, siendo dado de alta del servicio de cirugía. Se analiza la importancía del diagnóstico y tratamiento oportuno de esta entidad, además de la vigente Ley de Urgencia Vital a la que se acogió en este caso.