Endarterectomía carotídea bajo anestesia regional: experiencia inicial / Carotid endarterectomy under regional anesthesia: initial experience

Background: Endarterectomy is the treatment of choice for internal carotid artery critical stenosis. Some authors have proposed that the use of regional anesthesia has advantages over general anesthesia. Aim: To report our initial experience with carotid endarterectomy under regional anesthesia. Patients and methods: Between 1998 and 1999, patients with critical carotid artery stenosis, asymptomatic or with transient and recovered symptoms, were selected. A C2, C3, C4 root deep cervical block and superficial block was performed, using a mixture of lidocaine and bupivacaine. A carotid endarterectomy with patch and without routine shunt insertion, with standard and neurological monitoring, was performed. Results: During the study period, 94 carotid endarterectomies were done, 22 under regional anesthesia in 21 patients (12 male, age range 58-90 years old). Ninety five percent had hypertension, 52 percent smoked and 38 percent had renal dysfunction. One patient was converted to general anesthesia. Seventeen patients were discharged within 48 hours of the procedure and the rest, within 72 hours. There was no mortality or complications. Conclusions: Endarterectomy under regional anesthesia is less invasive, has excellent results and is well accepted by patients

Aneurisma roto de aorta torácica descendente: tratamiento endovascular / Endovascular treatment of a ruptured thoracic aorta aneurysm

In 1991, a technique to exclude aortic aneurysms from circulation inserting an endoluminal graft through the femoral artery, was described. This procedure, usually used for elective abdominal aneurysms, can also be used in the thoracic aorta. We report a 41 years old male with a Marfan syndrome, presenting with a descending aorta aneurysm that ruptured to the mediastinum and pleural cavity. He was compensated hemodynamically and an endovascular stent-graft was deployed at the ruptured zone, through the femoral artery. The postoperative evolution of the patient was uneventful. This technique will allow a less invasive treatment of ruptured aortic aneurysms

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

Isquemia mesentérica aguda por disección espontánea y aislada de la arteria mesentérica superior / Mesenteric ischemia caused by a spontaneous and isolated dissection of the superior mesenteric artery

Spontaneous dissection of the superior mesenteric artery is an unusual cause of mesenteric ischemia. Diagnosis can be based on findings of the helicoidal computed tomography or selective angiography of the superior mesenteric artery. We report two male patients, aged 47 and 50 years, who were admitted for abdominal pain. Isolated superior mesenteric artery dissection was confirmed by angiography. Both patients were treated with anticoagulation, conservative measures and recovered uneventfully

Pseudoaneurisma traumático de troncos supra-aórticos: tratamiento endovascular: casos clínicos / Endovascular treatment of traumatic pseudoaneurysms of aortic arch branches: report of3 cases

The traditional treatment of traumatic lesions of the aortic arch branches requires extended surgical exposures, not exempt of morbidity and mortality. Over the last decade, devices that allow a minimally invasive treatment, have been developed. The vessel can be repaired without direct exposure, using an endovascular procedure. We report three patients with traumatic pseudoaneurysms of the left subclavian, brachiocephalic and left common carotid arteries, respectively. All lesions were successfully repaired with the insertion of an endograft. Although long term results of these procedure are unknown, repair of a future stenosis or occlusion is less complicated than the treatment required by the original lesion. Endoluminal repair appears as a safe, efficient and less invasive treatment for these lesions

Hipercoagulabilidad en fibrilación auricular y su relación con factores de riesgo para embolia sistémica / Hypercoagulable state in atrial fibrillation and its relationship with risk factors for systemic embolism

Background: Atrial fibrillation is associated to a high risk of systemic embolism and to hypercoagulability. Aim: To evaluate the activation of the coagulation cascade through determinations of the thrombin-antithrombin complex in patients with atrial fibrillation and to correlate this data with the clinical and echocardiographic risk factors for systemic embolism. Patients and Methods: In 53 patients with atrial fibrillation plasma levels of the thrombin-antithrombin complex were determined on admission to a coronary care unit and 30 days later. Using a univariate and multiple regression analysis, the association basal thrombin-antithrombin with the duration of the arrhythmia, age over 70 years, previous use of antiplatelet agents, history of hypertension, mitral valve disease, diabetes, heart failure, previous systemic embolism, left atrial diameter and the presence of spontaneous contrast echo or thrombus in the left atrial appendage, was studied. Results: Basal thrombin-antithrombin values were 40.1ñ69 mg/L (Median 8.34 [3.0-47.5]) compared to 2.7ñ3.3 mg/L in healthy controls (p <0.001). No significant correlation was found between activation of the coagulation cascade and risk factors for systemic embolism. There were no significant differences in thrombin-antithrombin values between patients with chronic or paroxysmal atrial fibrillation (29.5ñ43 mg/L and 49.4ñ83 mg/L respectively). Mean thrombin-antithrombin values in patients under antiplatelet agents were lower than in those without treatment (17.3ñ43 vs 66.8ñ127 mg/L; p=0.018). Conclusions: The activation of the coagulation cascade in patients with atrial fibrillation was confirmed. However, no association of this activation with well known clinical and echocardiographic risk factors for systemic embolism, was found. Previous antiplatelet treatment prevented a higher activation of the coagulation cascade

Transección traumática aguda de la aorta torácica: tratamiento endovascular / Endovascular treatment of acute traumatic rupture of the thoracic aorta: report of 1 case

Traumatic rupture of the aorta has a near 80 percent mortality. Most patients die on the site of the accident. Conventional surgical repair of these lesions has a high morbidity and mortality, generally associated to the severity of associated lesions. Over the last decade, endovascular treatment has become an effective therapeutic alternative. We report a 40 years old male, that suffered a traumatic rupture of the descending thoracic aorta in a car accident. A successful endovascular repair was performed, installing an endoprothesis on the site of the lesion, using a femoral artery approach. The patient had a good postoperative evolution and was discharged from the hospital once complete rehabilitation of his associated lesions was obtained

Aneurisma aórtico abdominal: tratamiento quirúrgico y tratamiento endovascular: estado actual / Abdominal aortic aneurysms: surgical and endovascular treatment: current state

El tratamiento convencional del aneurisma aórtico abdominal (AAA) es el reemplazo quirúrgico de la aorta dilatada por una prótesis de dacrón. En los últimos años, el control de los factores de riesgo y el progreso en el manejo perioperatorio ha disminuido la mortalidad quirúrgica al 0,7-5 por ciento. La sobrevida alejada alcanza a 70 por ciento a 5 años, con una muy baja incidencia de complicaciones relacionadas con el reemplazo protésico. La introducción en 1990 de una técnica alternativa que evita la laparotomía, reemplazando el AAA por una prótesis instalada por vía endovascular, ha alcanzado un grado de desarrollo que la convierte en una alternativa particularmente atractiva en pacientes que presentan condiciones anatómicas favorables. Los riesgos y complicaciones inicialmente elevados, se han reducido al seleccionar apropiadamente los candidatos y con el uso de las nuevas endoprótesis. Se desconocen los resultados alejados en el tiempo y ciertamente los costos resultan aún elevados. Sin embargo, esta nueva técnica constituye un aporte importante para el tratamiento del AAA

Revascularización infrapoplítea con prótesis de PTFE y fístula arteriovenosa distal / Infrapopliteal revascularization with prosthesis of PTFE and distal arteriovenous fistula

El tratamiento de la isquemia crítica de extremidad inferior es la revascularización. Si el vaso a revascularizar es distal a la arteria poplítea, el conducto ideal para la construcción del puente es la vena safena. Ocasionalmente no se cuenta con vena y debe utilizarse prótesis, obteniendo una permeabilidad alejada inferior. Para mejorar esto, se ha sugerido realizar una fístula arteriovenosa en la anastomosis distal. Durante 2 años hemos intervenido 4 pacientes, todos hombres y edad promedio 67 años. La indicación quirúrgica fue gangrena en 2 pacientes y dolor de reposo en los restantes. Las anastomosis distales se ubicaron en el tercio distal de la pierna, asociándose una fístula arteriovenosa localmente. No hubo complicaciones locales ni mortalidad operatoria. Todos cicatrizaron sus úlceras o resolvieron el dolor de reposo. El seguimiento ha sido completo (promedio 10,2 meses, rango 4-24), todos se rehabilitaron y sus puentes están permeables

Trombosis venosa ilio-femoral: complicación infrecuente del aneurisma aorto-ilíaco en dos casos / Ilio femoral venous thrombosis: an infrequent complication of the aortic-iliac aneurysm in 2 cases

Death due to rupture of and abdominal aortic or iliac aneurysm, is their most frequent complication. We report two male patients, both over seventy years old, who presented with unexplained unilateral ilio-femoral deep vein thrombosis. During diagnostic work up an aortic and iliac aneurysm, compressing the deep venous system with secondary thrombosis, was found. In both patients a prophylactic inferior vena caval filter was inserted and standard elective surgery was then performed. No perioperative complications occurred and both patients remain asymptomatic during follow up. Deep vein thrombosis due to compression by an abdominal aortic and iliac aneurysm is infrequent. It must be ruled out together with intrabdominal cancer, in the elderly patient presenting with unexplained deep vein thrombosis

Salvataje de extremidad inferior en diabéticos: trasplante muscular microquirúrgico con y sin reconstrucción vascular previa / Salvage of low extremity in diabetics: microsurgical muscular transplantation with and without previous vascular reconstruction

Soft tissue wounds with or without bony involvement are a common problem and a cause of limb loss in diabetics. Usually local care, antibiotics, minor debridement and skin grafting are enough for successful handling of these lesions. When there proximal bony involvement and tendom exposure, the incidence of primary amputation rises, frequently being considered the only alternative. Two cases of diabetic patients with indication of primary amputation of a lower limb for large infected ulcers are reported. A microvascularized muscle transplant wa sused to cover large defects of soft tissue, tendoms and infected bone. One patient presented also critical ischaemia of the limb, requiring iliac angioplasty and a femoro-distal by-pass with in situ greater saphenous vein previous to the muscle graft. Both patients had no postoperative complications, being able to walk two months after the operation with their useful limb. Microvascularized muscle transplant with or without revascularization is a very useful alternative to amputation in the management of complex wounds of selected diabetic patients

Aneurismas micóticos y embolías múltiples en una paciente con endocarditis infecciosa / Mycotic aneurysms and multiple emboli in a patient with infectious endocarditis

Sepsis from an infected cardiac value can lead to bacterial seeding and destruction of the arterial wall with formation of a mycotic aneurysm. The natural history of these lesions is the rupture. We report the case of a 20 year old female who was admitted to our institution with massive mitral regugirtation and emboli of the central nervous system and both lower extremities. She underwent emergency valve replacement and then, staged treatment of her ischmic legs and multiple asymptomatic mycotic aneurysms. Superior mesenteric, right common iliac and left superficial femoral arteries. A splenectomy was required to treat a splenic abscess. An aneurysm of a peripheral branch of the middle cerebral artery was medically treated, demonstrating reduction in size on subsequente angiogram.She recoverd uneventfully and remains asymptomatic after 20 months of follow up. The development of new diagnostic and therapeutic tools had led to a decrease ot these complications during infectious endocarditis. However, in the patient with late diagnosis and symptoms in different territories, the mycotic aneurysm must be kept in mind to provide the patient with appropriate treatment

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

Endartectomía carotídea simultánea con revascularización miocárdica: experiencia en 27 pacientes / Carotid endartectomy simultaneous with myocardial revascularization: experience in 27 patients

Atherosclerosis is a systemic disease that may involve more than one territory. Myocardial infarction can occur after carotid endartectomy and stroke is a well documented morbidity of coronary artery bypass grafting. To optimize results, we have performed concomitant carotid endartectomy and myocardial revascularization in selected cases, with severe disease in both territories. During a 13 year period, 27 patients were submitted for this procedure, 21 (77,8 percent) were male and the average age was 67.6 years (range 59-81). All patients had high grade internal carotid artery stenosis, 5 (18.5 percent) were symptomatic. Coronary artery disease symptoms were: unstable angina in 12 patients (44,4 percent) and effort angina in 15 (55.6 percent). Two patients (7.4 percent) required reintervention for postoperative bleedinng. Two patients (7.4 percent) had transient renal dysfunction. One patient, with multiple organ failure, died on the 16th postoperative day (3.7 percent). Follow up was obtained in 26 patients (96.3 percent). Survival at 5 years was 80.6 percent, 95.7 percent of those patients were free of any neurologic symptoms. Combined carotid and coronary surgery is a safe treatment option for atherosclerosis of multiple territories in selected patients, long term benefits are also obtained

Ritmo cardíaco y embolias sistémicas en la evolución alejada de pacientes con fibrilación auricular paroxística no valvular / Cardiac rhythm and systemic emboli during long term follow up of patients with non-valvular paroxysmal atrial fibrillation

Background: Paroxysmal atrial fibrillation may predispose to systemic embolism. There is little information about the evolution of cardiac rhythm and the occurrence of new embolic events in these patients. Aim: To report the results of a long term follow up of patients with paroxysmal atrial fibrillation. Patients and methods: Patients consulting for non valvular paroxysmal atrial fibrillation were followed for a mean period of 5 years. An EKG, 2D echocardiogram and brain CT scans were performed on admission and at the end of the follow up period to all patients. Results: Sixty eight patients aged 65 ñ 1.5 years were studied. Thirty two had an idiopathic atrial fibrillation, 28 had a history of mild hypertension and 8 had a history of coronary artery disease. Evidence of systemic emboli was found in 17 patients at entry (to the brain in 14 patients). During the follow up 87 per cent of patients required antiarrhythmics, 27 per cent were anticoagulated and 28 per cent received aspirin. Five patients had new embolic episodes. Of these, four had a history of prior embolism. Forty one percent of patients continued in sinus rhythm and remained asymptomatic, 32 per cent had at least one recurrence of paroxysmal atrial fibrillation and nine patients evolved to chronic atrial fibrillation. Five patients required a permanent pacemaker due to symptomatic bradycardia. Conclusions: Most patients with non valvular paroxysmal atrial fibrillation remain in sinus rhythm but one third have recurrences of the arrhythmia. A main risk factor for embolism is the history of previous embolic episodes

Aneurisma de la vena poplítea / Popliteal vein aneurysm: report of one case

The popliteal vein aneurysm is a rare condition that can lead to local symptoms, thrombosis and pulmonary embolism. We report the case of a 67 years old, otherwise healthy white male, who presented to us with localised swelling and pain in the left popliteal fossa. Duplex ultrasound and venography were obtained, confirming the diagnosis of popliteal vein aneurysm. The patient underwent tangential aneurysmectomy and lateral venorrhaphy, recovery was uneventful remaining asymptomatic. The reconstruction was demonstrated patent on a duplex scan. The popliteal vein aneurysm is a potentially fatal condition for which surgical treatment is recommended

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

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