[Cerebral haemodynamics during carotid angioplasty with flow interruption. The correlation between oximetry and transcranial Doppler ultrasonography]. / Hemodinamica cerebral durante la angioplastia carotidea con interrupcion de flujo. Correlacion de la oximetria y el Doppler transcraneal.

AIMS: To determine the correlation between oximetry and transcranial Doppler ultrasonography (TDU) during and following carotid stent-angioplasty with flow interruption, and to evaluate the level of hypoperfusion and its recovery during the procedure. PATIENTS AND METHODS: Records were made, prospectively, of the flow rates in the middle cerebral artery and the trans-cutaneous oxygen saturation of 18 patients who had undergone surgery to perform a carotid stent-angioplasty. Monitoring was basal and at 1, 3, 5, 10 and 15 minutes after stopping and opening the flow. Measurements, in units and percentages of change, were stratified by groups as mild, moderate and severe. The agreement between the two tests was studied. RESULTS: Occlusion time: 8.2 +/- 2.7 minutes. Two patients (11.1%) presented cerebral hypoperfusion. Flow was re-established in two patients due to its reaching critical values. Mean of the baseline values: 56.3 +/- 11.4 cm/s (TDU) and 67.6 +/- 7.1% (oximetry). The changes in the absolute values and percentages of change between TDU and oximetry were evaluated and results showed an agreement between them in occlusion (rho = 0.8-0.9; p < 0.05), with less association on re-establishing the flow (rho = 0.4-0.8; p < 0.05). In percentages of change there was very good agreement in occlusion (kappa = 0.8-1; p < 0.05). Agreement was good (kappa = 0.68; p < 0.05) at 1, 3 and 5 minutes after opening up the flow. CONCLUSIONS: A significant correlation was found between the methods during the interruption of carotid flow, which means they can be used independently. Overall, 88.9% remained below the safety threshold for cerebral ischaemia and, given that the procedure can be carried out with brief interruptions, control by oximetry or TDU can be just as safe in evaluating cerebral ischaemia.

Hemodinámica cerebral durante la angioplastia carotídea con interrupción de flujo. Correlación de la oximetría y el Doppler transcraneal / Cerebral haemodynamics during carotid angioplasty with flow interruption. The correlation between oximetry and transcranial Doppler ultrasonography

Objetivos. Determinar la correlación entre la oximetría y el Doppler transcraneal (DTC) durante y después de la angioplastia- stent carotídeo con interrupción de flujo, y valorar la hipoperfusión y su recuperación durante el procedimiento. Pacientes y métodos. En 18 pacientes intervenidos de angioplastia-stent carotídeo, se registraron, de forma prospectiva, la velocidad de flujo en la arteria cerebral media y la saturación del oxígeno transcutáneo. La monitorización fue basal y a los minutos 1, 3, 5, 10 y 15 tras la oclusión y apertura del flujo. Las medidas, en unidades y porcentajes de cambio, se estratificaron por grupos en leves, moderadas y graves. Se estudió la concordancia entre ambas pruebas. Resultados. Tiempo de oclusión: 8,2 ± 2,7 minutos. Dos pacientes (11,1%) presentaron hipoperfusión cerebral. En dos pacientes se reinstauró el flujo por valor crítico. Media de valores basales: 56,3 ± 11,4 cm/s (DTC) y 67,6 ± 7,1% (oximetría). Valorando los cambios de los valores absolutos y porcentajes de cambio entre el DTC y la oximetría, fueron concordantes en la oclusión (rho = 0,8-0,9; p < 0,05), con asociación menor al reinstaurar el flujo (rho = 0,4-0,8; p < 0,05). En porcentajes de cambio hubo concordancia muy buena en la oclusión (kappa = 0,8-1; p < 0,05). La concordancia fue buena (kappa = 0,68; p < 0 05) en los minutos 1, 3 y 5 tras la apertura del flujo. Conclusiones. Hubo correlación significativa entre los métodos durante la interrupción del flujo carotídeo, por lo que pueden utilizarse de forma independiente. El 88,9% se mantuvo en un umbral seguro de isquemia cerebral y, dado que el procedimiento puede realizarse con breves interrupciones, el control por oximetría o DTC puede resultar igualmente seguro en la valoración de la isquemia cerebral (AU)

Aims. To determine the correlation between oximetry and transcranial Doppler ultrasonography (TDU) during and following carotid stent-angioplasty with flow interruption, and to evaluate the level of hypoperfusion and its recovery during the procedure. Patients and methods. Records were made, prospectively, of the flow rates in the middle cerebral artery and the transcutaneous oxygen saturation of 18 patients who had undergone surgery to perform a carotid stent-angioplasty. Monitoring was basal and at 1, 3, 5, 10 and 15 minutes after stopping and opening the flow. Measurements, in units and percentages of change, were stratified by groups as mild, moderate and severe. The agreement between the two tests was studied. Results. Occlusion time: 8.2 ± 2.7 minutes. Two patients (11.1%) presented cerebral hypoperfusion. Flow was re-established in two patients due to its reaching critical values. Mean of the baseline values: 56.3 ± 11.4 cm/s (TDU) and 67.6 ± 7.1% (oximetry). The changes in the absolute values and percentages of change between TDU and oximetry were evaluated and results showed an agreement between them in occlusion (rho = 0.8-0.9; p < 0.05), with less association on reestablishing the flow (rho = 0.4-0.8; p < 0.05). In percentages of change there was very good agreement in occlusion (kappa = 0.8-1; p < 0.05). Agreement was good (kappa = 0.68; p < 0.05) at 1, 3 and 5 minutes after opening up the flow. Conclusions. A significant correlation was found between the methods during the interruption of carotid flow, which means they can be used independently. Overall, 88.9% remained below the safety threshold for cerebral ischaemia and, given that the procedure can be carried out with brief interruptions, control by oximetry or TDU can be just as safe in evaluating cerebral ischaemia (AU)

Aneurisma venoso iliaco primario: presentación de un caso y revisión de la bibliografía / Primary iliac venous aneurysm: a case report and review of the literature

Introducción. Los aneurismas venosos han aparecido esporádicamente en la bibliografía mundial en los últimos 90 años. La verdadera entidad clínica no fue establecida por Abbott hasta 1950. Pueden clasificarse según su etiopatogenia en primarios o adquiridos. Caso clínico. Varón de 70 años, con cuadro de trombosis venosa profunda en miembro inferior izquierdo de 24 horas de evolución. En el eco-Doppler se objetivó trombosis de vena femoral común e iliaca externa. En la tomografía axial y en la angiorresonancia magnética se apreció aneurisma trombosado en venas iliaca primitiva y externa de 4,2 cm de diámetro. Se pautó anticoagulación sistémica, con buena evolución clínica. Alta con dicumarínicos, soporte elástico, control con angiorresonancia y seguimiento ambulatorio con eco-Doppler. Conclusiones. Los aneurismas venosos iliacos están entre los menos frecuentes del sistema venoso. Encontramos siete casos primarios publicados en la bibliografía. Éste es el primer caso descrito de vena iliaca primitiva-externa trombosado desde que Hurwitz publicara el primero de aneurisma venoso iliaco. La mayoría de autores coinciden en que los de localización intraabdominal presentan un riesgo potencial de trombosis y embolismo pulmonar, por lo que estaría indicado, cuando el aneurisma es sintomático e incluso asintomático y no se encuentra totalmente trombosado, la resección quirúrgica profiláctica, realizando anastomosis terminoterminal, venorrafía lateral o reconstrucción mediante injerto. El diagnóstico y seguimiento se puede obtener correctamente por dúplex, pero creemos que en el momento de su detección, debe realizarse una angiorresonancia complementaria

Introduction. Venous aneurysms have appeared sporadically in medical literature around the world for the last 90 years. Yet, the true clinical picture was not established until 1950 by Abbott. According to their aetiopathogenesis they can be classified into two types: primary or acquired. Case report. We report the case of a 70-year-old male with a 24-hour history of symptoms of deep vein thrombosis in the left lower limb. A Doppler ultrasound recording revealed thromboses in the common femoral and external iliac veins. Axial tomography and magnetic resonance angiography scans showed a thrombosed aneurysm with a diameter of 4.2 cm in the common and external iliac veins. Systemic anticoagulation was established and clinical progress was good. The patient was discharged with dicumarols, elastic support, resonance angiography monitoring and outpatient follow-up with Doppler ultrasound. Conclusions. Iliac venous aneurysms are among the least frequent occurring in the venous system. We found seven primary cases reported in the literature. This is the first case of a thrombosed external-common iliac vein since Hurwitz reported the first aneurysm of the iliac vein. Most authors agree that the intra-abdominal location presents a potential risk of pulmonary embolism and thrombosis; thus, when the aneurysm is symptomatic and even asymptomatic and is not fully thrombosed, prophylactic surgical resection involving end-to-end anastomosis, lateral phleborrhaphy or repair by means of a graft would be indicated. The diagnosis and follow-up can be accomplished correctly by duplex, but we believe that the moment it is detected, a complementary MR angiography should also be performed

¿Es la oclusión contralateral un factor de riesgo para la endarterectomía carotídea? / Is contralateral occlusion a risk factor for carotid endarterectomy?

Objetivos. Valorar si hay justificación para considerar a los pacientes con oclusión contralateral (OC) como grupo de alto riesgo para la endarterectomía carotídea (EDA). Evaluar la influencia de la utilización del shunt en estos pacientes. Presentamos los resultados de la EDA, donde se compara el grupo de pacientes con OC y sin ella. Pacientes y métodos. Entre enero de 1992 y diciembre de 2002, se realizaron 328 EDA. Se llevó a cabo un estudio prospectivo en el que se revisaron los factores de riesgo, la sintomatología preoperatoria y la técnica quirúrgica. Resultados. Se intervinieron 328 pacientes, un 86,6% de varones. De éstos, el 12,5% presentaban OC. La presencia de OC en pacientes asintomáticos fue significativamente mayor que en los sintomáticos (p < 0,05). La utilización de shunt durante la cirugía fue superior en el grupo con OC (p < 0,001). La morbilidad neurológica en la serie global fue del 3,3%. No se apreciaron diferencias significativas en el porcentaje de ictus postoperatorio asociados al uso o no de shunt, así como tampoco en cuanto a la tasa de morbimortalidad general postoperatoria entre el grupo con OC y el grupo sin ella. Conclusiones. La presencia de OC no aumenta la morbimortalidad tras realizar una EDA, que se puede efectuar con aceptables resultados, comparables a los obtenidos en pacientes sin OC. El uso de shunt en estos pacientes no se asocia con una disminución de la posibilidad de ictus. El riesgo añadido de la OC no debe ser considerado factor de riesgo aislado para justificar otras alternativas terapéuticas

AIMS. To determine whether there is any justification for considering patients with contralateral occlusion (CO) as a group at high risk for carotid endarterectomy (CE). To evaluate the effects of using shunts in these patients. We report the outcomes of the CE, comparing two groups of patients with and without CO. PATIENTS AND METHODS. Between January 1992 and December 2002, 328 CE were performed. A prospective study was conducted in which the risk factors, pre-operative symptoms and surgical technique were reviewed. RESULTS. A total of 328 patients were submitted to surgery, 86.6% of whom were males. Of these, 12.5% had CO. The presence of CO in asymptomatic patients was significantly higher than in symptomatic subjects (p < 0.05). The rate of shunt use during surgery was higher in the group with CO (p < 0.001). Neurological morbidity in the overall series was 3.3%. No significant differences were observed in the percentage of post-operative strokes that were associated to the usage or failure to use shunts. Likewise, no significant differences were found with regard to the general post-operative morbidity and mortality rates between the group with CO and the group that did not have CO. CONCLUSIONS. The presence of CO does not increase the morbidity and mortality rates after carrying out a CE, which can be performed with acceptable results that are comparable to those obtained in patients without CO. The use of shunts in these patients is not associated to a decrease in the chances of suffering a stroke. The added risk of CO should not be considered to be an isolated risk factor in order to justify other therapeutic alternatives

Anticoagulación perioperatoria y hematoma epidural. Caso clínico / Perioperative anticoagulation and epidural hematoma. Case report

La aparición de un hematoma epidural es una complicación grave y muy poco frecuente de la anestesia epidural. Presentamos el caso de un varón de 90 años, que fue intervenido quirúrgicamente bajo anestesia epidural por cuadro de isquemia aguda en miembro inferior izquierdo. En el perioperatorio fue tratado con antiagregantes, anticoagulantes y fibrinolíticos. A las 24 horas de la cirugía, presentó hematoma epidural y paraplejía, a pesar de respetarse las pautas recomendadas respecto al uso de anticoagulación perioperatoria y anestesia locoregional. (AU)