Aortic endarterectomy in patients with severe multivessel paravisceral and aortoiliac occlusive disease.

OBJECTIVE: Aortic endarterectomy (AE), once a treatment of choice for aortoiliac occlusive disease, is now rarely performed in favor of endovascular procedures or open aortobifemoral bypass. However, in select patients with paravisceral or aortoiliac occlusive disease, AE remains a viable alternative for revascularization, either as a primary procedure or after prior interventions have failed. Here, we evaluated outcomes for an extended series of patients undergoing paravisceral or aortoiliac endarterectomy, demonstrating that these procedures can be an excellent alternative with acceptable morbidity and mortality in properly selected patients. METHODS: A single institution retrospective review of 20 patients who underwent AE from 2017 to 2023 was performed. RESULTS: Five patients (25%) underwent paravisceral endarterectomy and 15 (75%) underwent aortoiliac endarterectomy. There were no perioperative mortalities. One paravisceral patient died 3 months postoperatively from complications of pneumonia. Three patients in the paravisceral group required reinterventions; one acutely due to thrombosis of the superior mesenteric artery (SMA) requiring extension of the endarterectomy and patch angioplasty on postoperative day 0, one due to stenosis at the distal edge of the endarterectomy 1 month postoperatively, successfully treated with SMA stenting, and one at 10-month follow-up due to SMA stenosis at the distal aspect of the endarterectomy, also successfully treated with SMA stenting. With these reinterventions, the 1-year primary patency in the paravisceral group was 40%, primary-assisted patency was 80%, and secondary patency was 100%. In the aortoiliac group, 1-year primary, primary-assisted, and secondary patency were 91%, 91%, and 100%, respectively. One patient developed iliac thrombosis 10 days postoperatively owing to an intimal flap distal to the endarterectomy site. She and one other patient, a young man with an undefined hypercoagulable disorder, ultimately required neoaortoiliac reconstructions at 18 and 32 months postoperatively, respectively (the latter in the setting of stopping anticoagulation). The remaining 13 patients experienced no complications. All patients had rapid resolution of clinical symptoms, and median postoperative ankle-brachial indexes of 1.06 on the right and 1.00 on the left, representing a median improvement from preoperative ankle-brachial indexes of +0.59 on the right and +0.56 on the left (P < .01 and P < .01). CONCLUSIONS: In this series of 20 patients undergoing paravisceral and infrarenal aortoiliac endarterectomy, AE was associated with no perioperative mortality, relatively low and manageable morbidity, and excellent clinical outcomes in patients with both paravisceral and aortoiliac occlusive disease. SMA-related early reintervention was not uncommon in the paravisceral group, and attention should be given particularly to the distal endarterectomy site. AE remains a viable treatment for severe multivessel paravisceral or aortoiliac occlusive disease isolated to the aorta and common iliac arteries in select patients.

[Consensus on the procedure of balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension].

Chronic thromboembolic pulmonary hypertension (CTEPH) is classified as group IV pulmonary hypertension, characterized by thrombotic occlusion of the pulmonary arteries leading to vascular stenosis or obstruction, progressive increase in pulmonary vascular resistance and pulmonary arterial pressure, and eventual right heart failure. Unlike other types of pulmonary hypertension, the prognosis of CTEPH can be significantly improved by surgery, vascular intervention, and/or targeted drug therapy. Pulmonary endarterectomy (PEA) is the preferred treatment of choice for CTEPH. However, PEA is an invasive procedure with high operative risks, and is currently only performed in a few centers in China. Balloon pulmonary angioplasty (BPA) is an emerging interventional technique for CTEPH, serving as an alternative for patients who are ineligible for PEA or with residual pulmonary hypertension after PEA. BPA is gaining traction in China, but its widespread adoption is limited due to its complexity, operator skills, and equipment requirements, a lack of standard operating procedures and technical guidance, which limit the further improvement and development of BPA in China. To address this, a multidisciplinary panel of experts was convened to develop the Consensus on the Procedure of Balloon Pulmonary Angioplasty for the Chronic Thromboembolic Pulmonary Hypertension, which fomulates guidelines on BPA procedural qualification, perioperative management, procedural planning, technical approach, and complication prevention, with the aim of providing recommendations and clinical guidance for BPA treatment in CTEPH and standardizing its clinical application in this setting. Summary of recommendations: Recommendation 1: It is recommended that physicians who specialize in pulmonary vascular diseases take the lead in formulating the diagnostic and treatment plans for CTEPH, using a multidisciplinary approach.Recommendation 2: Training in BPA technique is critical; novice operators should undergo standardized operative training with at least 50 procedures under the guidance of experienced physicians before embarking on independent BPA procedures.Recommendation 3: BPA requires catheterization labs, angiography systems, standard vascular interventional devices and consumables, drugs, and emergency equipment.Recommendation 4: Patient selection for BPA should consider cardiac and pulmonary function, coagulation status, and comorbid conditions to determine indications and contraindications, thereby optimizing the timing of the procedure and improving safety.Recommendation 5: In experienced centers, patients deemed likely to benefit from early BPA, based on clinical and imaging features of CTEPH and without elevated D-dimer levels, could bypass standard 3-month anticoagulation therapy.Recommendation 6: BPA is a complex interventional treatment that requires thorough pre-operative assessment and preparation.Recommendation 7: The use of perioperative anticoagulants in BPA requires a comprehensive risk assessment of intraoperative bleeding by the operator for individualized decision making.Recommendation 8: A variety of venous access routes are available for BPA; unless contraindicated, the right femoral vein is usually preferred because of its procedural convenience and reduced radiation exposure.Recommendation 9: For the different types of vascular lesion in CTEPH, treatment of ring-like stenoses, web-like lesions, and subtotal occlusions should be prioritized before addressing complete occlusions and tortuous lesions, in order to reduce complications and improve procedural safety.Recommendation 10: A targeted, incremental balloon dilatation strategy based on vascular lesions is recommended for BPA.Recommendation 11: Intravascular pulmonary artery imaging technologies, such as OCT and IVUS can assist in accurate vessel sizing and confirmation of wire placement in the true vascular lumen. Pressure wires can be used to objectively assess the efficacy of dilatation during BPA.Recommendation 12: Endpoints for BPA treatment should be individually assessed, taking into account improvements in clinical symptoms, hemodynamics, exercise tolerance, and quality of life.Recommendation 13: Post-BPA routine monitoring of vital signs is essential; anticoagulation therapy should be initiated promptly post-procedure in the absence of complications. In cases of intraoperative hemoptysis, postoperative anticoagulation regimen adjustments should be adjusted according to the bleeding severity.Recommendation 14: If reperfusion pulmonary edema occurs during or after BPA, ensure adequate oxygenation, diuresis, and consider non-invasive positive-pressure ventilation if necessary, while severe cases may require early mechanical ventilation assistance or ECMO.Recommendation 15: In cases of intraoperative hemoptysis, temporary balloon occlusion to stop bleeding is recommended, along with protamine to neutralize heparin. Persistent bleeding may warrant the use of gelatin sponges, coil embolization, or covered stent implantation.Recommendation 16: For contrast imaging during BPA, non-ionic, low or iso-osmolar contrast agents are recommended, with hydration status determined by the patient's clinical condition, cardiac and renal function, and intraoperative contrast volume used.

[Chronic thromboembolic pulmonary hypertension: current diagnostic and treatment options: A review].

The article reviews current approaches to diagnosing and treating chronic thromboembolic pulmonary hypertension (CTEPH). The definition of the CTEPH is given, and its main risk factors are described. It is shown that the modern algorithm of diagnostic search includes four stages; the examination methods used at each stage are characterized. The most rational approach to CTEPH therapy is provided; the possibilities and limitations of pulmonary endarterectomy, transluminal balloon angioplasty of the pulmonary arteries, and specific therapy of pulmonary hypertension in such patients are described. The clinical presentation and treatment of CTEPH according to the Russian Pulmonary Hypertension Registry are reviewed.

Does pulmonary endarterectomy improve the clinical conditions of patients with chronic thromboembolic pulmonary disease without pulmonary hypertension?

To verify whether the new hemodynamic definition of pulmonary hypertension (PH) has any implication in treatment of Chronic Thrombo-Embolic Pulmonary Disease (CTEPD) patients without PH, we retrospectively analysed the clinical and functional changes determined by pulmonary endarterectomy (PEA) in 63 CTEPD patients without PH who underwent surgery at our center, comparing those in whom the hemodynamic diagnosis of PH met recent guideline recommendations versus those in whom the diagnosis only met previous hemodynamic thresholds. The results show that the vast majority of CTEPD patients without PH operated at our center would now be defined as chronic thromboembolic pulmonary hypertension (CTEPH) patients. PEA did not result in any improvement in exercise capacity nor in right ventricular function or lung function test in patients with mean pulmonary artery pressure (mPAP) ≤ 20 mm Hg and pulmonary vascular resistance (PVR) ≤ 2 WU; on the contrary, hemodynamic parameters, exercise capacity, right ventricular function and lung function significantly improved in patients with mPAP between 21 and 24 mm Hg.

An old but still valuable technique for popliteal artery stenosis: Endarterectomy via the posterior approach.

Isolated popliteal artery occlusions are rare compared with femoropopliteal occlusive diseases. Although endovascular procedures have gained importance in treatment, conventional surgery remains the gold standard. In this study, we reviewed popliteal endarterectomy and patch plasty using a posterior approach. Fourteen patients who underwent surgery for isolated popliteal artery occlusions were retrospectively examined. Patients were assessed in terms of age, sex, and risk factors, such as accompanying diseases and smoking, surgical method and anesthesia, incision type, preoperative and postoperative pulse examination, ankle-brachial indices, patency, wound infection, postoperative complications, and the treatment applied. Twelve (85.7%) patients were male, and 2 (14.3%) were female. Limb ischemia was critical (ABI < 0.7) in 11 (78.5%) patients. The average duration of postoperative hospitalization was 8 ±â€…3.7 days on average, and the average length of follow-up was 17 ±â€…3.4 months. Thrombosis and complications requiring secondary intervention did not develop during the early postoperative period. While the patency rate in the first 6 months of follow-up was 100%, it was 92.8% in the 1st year and 85.7% in the 2nd year. Surgical treatment with the posterior approach in isolated popliteal artery lesions is preferred by vascular surgeons as a prioritized treatment method, with a sufficient recanalization rate and low perioperative morbidity and mortality rates. Furthermore, it is promising because it does not prevent below-knee femoropopliteal bypass, which is the subsequent stage of treatment. Moreover, the great saphenous vein was protected, and the acceptable early- and mid-term results were encouraging.

[Circulatory support with venovenous ECMO in a patient with reperfusion pulmonary edema after pulmonary artery thromboendarterectomy]. / Soporte circulatorio con ECMO venovenoso en paciente con síndrome de reperfusión pulmonar secundario a tromboendarterectomía arterial pulmonar.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a subtype of pulmonary hypertension characterized by the obstruction of pulmonary arteries secondary to chronic thromboembolism. Pulmonary thromboendarterectomy surgery (PTE) is the main treatment for patients with CTEPH, as it removes the chronic thrombi from the pulmonary arteries. Pulmonary reperfusion syndrome is a common complication of the surgery, which involves the development of pulmonary edema in the area where blood perfusion improves after the surgery. The incidence of this syndrome varies from 8 to 91% depending on the criteria used for diagnosis, and it is one of the most serious complications of pulmonary thromboendarterectomy. In such cases, circulatory support with extracorporeal membrane oxygenation (ECMO) has become a valuable therapeutic modality. We present the case of a 60-year-old woman with a history of acute pulmonary embolism due to deep vein thrombosis of the right pelvic limb who was diagnosed later with CTEPH who was admitted for scheduled surgical treatment involving bilateral PTE. However, during the immediate postoperative period, she developed cardiogenic shock and refractory hypoxemia secondary to pulmonary reperfusion syndrome following the surgical procedure. As a result, she required veno-venous ECMO circulatory support for 6 days, leading to resolution of the pulmonary condition and clinical improvement.

La hipertensión pulmonar tromboembólica crónica (HPTEC) es un subtipo de hipertensión pulmonar caracterizada por la obstrucción de las arterias pulmonares secundaria a tromboembolias crónicas. La cirugía de tromboendarterectomía pulmonar (TEAP) es el tratamiento principal para los pacientes con HPTEC, elimina los trombos crónicos de las arterias pulmonares. El síndrome de reperfusión pulmonar es una complicación común de la cirugía, se trata del desarrollo de edema pulmonar en el área en la que la perfusión sanguínea mejora después de la cirugía. La incidencia del síndrome varía del 8 al 91% según los criterios utilizados para diagnosticarlo y es una de las complicaciones más graves de la tromboendarterectomía pulmonar. En tales casos, el soporte circulatorio con oxigenación por membrana extracorpórea (ECMO) se ha convertido en una valiosa modalidad terapéutica. Presentamos el caso de una paciente de 60 años de edad con antecedente de tromboembolia pulmonar aguda secundaria a trombosis venosa profunda de miembro pélvico derecho a quien durante el seguimiento se realizó el diagnóstico de HPTEC e ingresó de manera programada para tratamiento quirúrgico con realización de TEAP bilateral, sin embargo durante el posquirúrgico inmediato presentó choque cardiogénico e hipoxemia refractaria secundarios a síndrome de reperfusión pulmonar, por lo cual requirió soporte circulatorio con ECMO venovenosa durante seis días, con resolución del cuadro pulmonar y mejoría clínica.

Continuous heart monitoring to evaluate treatment effects in pulmonary hypertension.

BACKGROUND: The treatment of pulmonary hypertension (PH) has improved rapidly in recent decades. There is increasing evidence to support the role of early intervention and treatment in affecting clinical outcomes in PH. OBJECTIVES: To assess treatment effects before and after the escalation of specific PH treatments using continuous heart monitoring with a Reveal LINQ loop recorder. METHODS: Patients were compared before and after treatment escalation. Treatment escalation was defined as an additional pulmonary arterial hypertension (PAH) drug, pulmonary endarterectomy, percutaneous balloon angioplasty or bilateral lung transplantation. Specifically, changes in heart rate variability (HRV), heart rate (HR) and physical activity were assessed. RESULTS: In this prospective study, 41 patients (27 with PAH and 14 with chronic thromboembolic pulmonary hypertension (CTEPH)) were enrolled. Among them, 15 (36.6%) patients underwent PH treatment escalation. Prior to escalation, patients were monitored for a median of 100 (range: 68-100) days and after therapy escalation for a median duration of 165 (range: 89-308) days. In the escalation group, there was a significant increase in HRV, physical activity indexed by daytime HR and a significant decrease in nighttime HR assessed at baseline and after treatment escalation in both the PAH and CTEPH groups. This was paralleled by significant improvements in WHO functional class, 6-min walking distance and N-terminal pro-b-type natriuretic peptide. CONCLUSIONS: This is the first study to demonstrate an association between specific PH therapies and changes in HRV, HR nighttime and physical activity. This indicates the potential of continuous monitoring in the evaluation of treatment effects in PH.

Atrial Arrhythmias Following Pulmonary Thromboendarterectomy: A Comprehensive Review Of Current Literature.

Chronic thromboembolic pulmonary hypertension (CTEPH) presents as a progressive vascular condition arising from previous episodes of acute pulmonary embolism, contributing to the development of pulmonary hypertension (PH). Pulmonary thromboendarterectomy (PTE) is the gold-standard surgical treatment for CTEPH; however, it may be associated with postoperative sequelae, including atrial arrhythmias (AAs). This comprehensive literature review explores the potential mechanisms for PTE-induced AAs with emphasis on the role of PH-related atrial remodelling and the predisposing factors. The identified preoperative predictors for AAs include advanced age, male gender, elevated resting heart rate, previous AAs, and baseline elevated right atrial pressure. Furthermore, we explore the available data on the association between post-PTE pericardial effusions and the development of AAs. Lastly, we briefly discuss the emerging role of radiomic analysis of epicardial adipose tissue as an imaging biomarker for predicting AAs.

Low nailfold capillary density in patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension: biomarker of clinical outcome?

Nailfold capillary density is lower in patients with pulmonary arterial hypertension (PAH). It is unclear whether this observation signifies a unique systemic manifestation of PAH, or reflects microcirculatory dysfunction secondary to pulmonary hypertension (PH). Capillary density and loop dimensions were measured by nailfold-capillaroscopy (NC) in 30 PAH (23 idiopathic, or iPAH, 7 hereditary, or hPAH), 17 chronic thromboembolic PH (CTEPH) patients and 48 controls. NC-Measurements were repeated after pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) in CTEPH patients. We examined whether NC-measurements were related to markers of disease severity and predictive of time to clinical worsening (TTCW) as tested by univariate linear/logistic regression and cox-regression analysis, respectively. Capillary density was significantly lower in PAH (7.5 ± 1.1, p < 0.001) and in CTEPH (8.4 ± 1.5, p < 0.001) compared to asymptomatic controls (10.3 ± 1.0 capillaries/mm). Capillary density was similar in iPAH and hPAH and unrelated to hemodynamics in either PAH or CTEPH. A lower capillary density was predictive of clinical worsening in PAH (p 0.05). After normalization of pulmonary artery pressures by PEA or BPA, capillary density remained reduced in CTEPH patients. Capillary loop apex, capillary and venous- and arterial limb diameter were increased in patients with PAH and CTEPH compared to controls. Nailfold capillary density is reduced to a similar extent in iPAH, hPAH and CTEPH. Normalization of hemodynamics by PEA or BPA does not lead to a restoration of capillary density in CTEPH. Capillary dimensions were increased in both patients with PAH and CTEPH. Lower capillary density was predictive of clinical worsening in PAH. Our findings indicate that a loss of peripheral capillaries is not specific to PAH and is not related to the hemodynamic disturbance per se, but that shared mechanisms may account for a simultaneous development of a systemic microangiopathy and pulmonary vascular remodeling.

Percutaneous intervention versus surgery in the treatment of common femoral artery lesions: study protocol for the prospective, multi-center, randomized PESTO-CFA trial.

BACKGROUND: Endovascular therapy has become established as a first-line therapy in most arterial regions. However, open vascular surgery (endarterectomy) remains the treatment of choice for common femoral artery (CFA) lesions. The aim of this study is to investigate the acute and mid-term results of directional atherectomy plus drug-coated balloon (DCB) in comparison to endarterectomy in treatment of de novo arteriosclerotic CFA lesions. METHODS: This prospective, randomized, multicenter non-inferiority study will enroll 306 participants with symptomatic (Rutherford category 1 to 5) de novo stenosis of the CFA including the bifurcation. Patients eligible for both treatment groups could be included in this 1:1 randomized trial. Primary efficacy endpoint is patency of the target lesion at 12 months defined as restenosis < 50% without the need of clinically driven target lesion revascularization (cdTLR). Primary safety endpoint is a combined endpoint including death, myocardial infarction, major or minor amputation of the target limb, and peri-procedural complications at 30 days. Secondary endpoints include primary patency of the target lesion at 6 and 24 months, secondary patency, cdTLR 6, 12, and 24 months, change in ankle-brachial index, and Rutherford-Becker class at 6, 12, and 24 months. Limb salvage, change in quality of life measured by Walking Impairment Questionnaire, and major adverse events including death, myocardial infarction, and minor or major amputation of the target limb will be determined at 6, 12, 24, and 36 months. DISCUSSION: Endovascular treatment of CFA lesions is still a matter of debate. Few studies compared modern endovascular therapy methods against the so-called gold standard surgical endarterectomy so far. Based on recent positive results, this study aims to confirm non-inferiority of a "leaving nothing behind" endovascular approach combining directional atherectomy and DCB compared to surgical therapy. TRIAL REGISTRATION: ClinicalTrials.gov NCT02517827.

Profundaplastia femoral como un proceder inusual en la "era endovascular" / Femoral deep plasty as an unfrequent procedure in the "endovascular era"

Introducción: La arteria femoral común y sus ramas suministran la mayor parte del flujo sanguíneo al muslo, así como a la totalidad de la pierna y el pie, lo que da lugar a la mayor rama del triángulo femoral: la arteria femoral profunda. Objetivo: Exponer la efectividad de la profundaplastia femoral en la "era endovascular". Reporte del caso: Se presenta un caso de enfermedad arterial periférica de múltiples sectores, sin criterio de cirugía revascularizadora (derivación protésica aorto bifemoral). El paciente manifestaba claudicación intermitente a menos de 30 metros, localizada en pantorrilla derecha. En el estudio hemodinámico se apreciaron los índices de presiones tobillo/brazo disminuidos en arteria tibial posterior (0,46) y pedia derecha (0,33). La ecografía doppler del sector femoral derecho evidenció una estenosis de la arteria femoral profunda en su origen, que producía aumento de las velocidades picos sistólicos (479 cm/s), con flujo desorganizado, dilatación posestenótica y oclusión de la arteria femoral superficial en su origen. Se realizó endarterectomía femoral común y profunda con colocación de parche de politetrafloroetileno. El paciente evolucionó sin complicaciones posoperatorias. En el seguimiento se observó mejoría clínica en relación con la distancia de claudicación y un aumento de los índices de presiones tobillo/brazo en arteria tibial posterior y pedia derecha (0,50), respectivamente. Conclusiones: La profundaplastia femoral, aún en la "era endovascular", permanece como un proceder eficaz que resulta alternativa de tratamiento revascularizador en la enfermedad arterial periférica de localización infrainguinal(AU)

Introduction: The normal femoral artery and its branches supply most of the blood flow to the thigh, as well as to the whole leg and foot, which forms the largest branch of the femoral triangle: the deep femoral artery. Objective: Show the effectiveness of femoral deep plasty in the "endovascular era". Case report: It is presented a case of peripheral artery disease in multiple sectors, without surgical criteria of revascularization (derivación protésica aortobifemoral). The patient presented intermittent claudication in less than 30 meters, and it was located in the right calf. In the hemodynamic study, the ankle-arm pressure indexes were dicreased in the posterior tibial artery (0,46) and right dorsalis pedis artery (0,33). The doppler echocardiography of the right femoral sector confirmed a stenosis in the deep femoral artery in its origin, which produced an increase in the peak systolic velocity (479 cm/s), unorganized flows, poststenotic dilatation and occlusion of the superficial femoral artery in its origin. It was performed a common and deep femoral endarterectomy with colocation of polytetrafluoroethylene patch. The patient evolved without post-surgical complications. In the follow-up, it was observed a clinical improvement in relation with the claudication distance and the increase of the ankle-arm pressure indexes in the posterior tibial artery and right dorsalis pedis artery (0,50), respectively. Conclusions: The femoral deep plasty, still in the ´´endovascular era´´, is an efficient procedure that is an alternative to the revascularization treatment in the peripheral artery disease with infrainguinal location(AU)

Hipertensión pulmonar crónica tromboembólica tromboendarterectomía pulmonar / Chronic thromboembolic pulmonary hypertension

A nivel mundial, la tercera causa de muerte por causa cardiovascular es el Tromboembolismo Pulmonar (TEP), después del Infarto agudo de Miocardio y el Accidente cerebrovascular, con una incidencia anual estimada de 40 casos por cada 100.000 habitantes. Se comunica el caso clínico de un paciente de 44 años con diagnóstico de TEP recurrente con Hipertensión pulmonar tromboembólica crónica (CTPH) que fue sometido a tromboendarterectomía pulmonar bilateral (PTE) bajo paro circulatorio con hipotermia profunda. Se informa de los resultados de los medios de diagnóstico y del tratamiento quirúrgico mediante la tromboendarterectomía. Se discute el tema en el contexto de la experiencia internacional y nacional.

Tratamiento quirúrgico de la enfermedad pulmonar tromboembólica crónica / No disponible

No disponible

Comentarios a la guía ESC 2017 sobre el diagnóstico y tratamiento de la enfermedad arterial periférica / Comments on the 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases

No disponible

Angioplastia percutánea con balón en hipertensión pulmonar tromboembólica crónica / Percutaneous balloon angioplasty for treatment of chronic thromboembolic pulmonary hypertension

La hipertensión pulmonar tromboembólica crónica se caracteriza por la presencia de material trombótico organizado dentro de las arterias pulmonares que genera elevación de la resistencia vascular pulmonar, insuficiencia cardíaca derecha y, eventualmente, la muerte. El tratamiento de elección es la tromboendarterectomía pulmonar, que suele ser curativa si la obstrucción es proximal. En algunos casos este tratamiento no es posible y surge como alternativa la angioplastia pulmonar con balón (APB), que está generando creciente interés. Se presentan tres casos de pacientes con hipertensión pulmonar tromboembólica a los que por diferentes circunstancias no pudo tratarse con tromboendarterectomía y se realizó APB comprobándose, en los tres casos, mejoría de la clase funcional, prueba de la caminata de seis minutos, además de parámetros hemodinámicos y angiográficos.

Chronic thromboembolic pulmonary hypertension is characterized by the presence of organized thrombotic material in the pulmonary arteries which causes elevation of the pulmonary vascular resistance, right heart failure, and death if not treated. Pulmonary thromboendarterectomy is the treatment of choice and can be curative when the obstruction is proximal. There are cases in which this therapy is not possible, and pulmonary angioplasty is a therapeutic alternative of growing interest. We present our experience with three patients diagnosed with chronic thromboembolic pulmonary hypertension in whom pulmonary endarterectomy was not possible and pulmonary angioplasty was performed. All patients showed improvement of functional class, six-minute walk distance, and hemodynamic as well as angiographic parameters.

Análisis de mortalidad y estancia hospitalaria en cirugía cardiaca en México 2015: datos del Instituto Nacional de Cardiología / Analysis of mortality and hospital stay in cardiac surgery in Mexico 2015: Data from the National Cardiology Institute

Resumen Objetivo: Analizar las causas de mortalidad hospitalaria de pacientes operados de cirugía cardiaca en México en el año 2015. Identificar los factores de riesgo de mortalidad y realizar una correlación con el tiempo de estancia hospitalaria en terapia intensiva cardiovascular. Método: Estudio de casos y controles. Se estudió la base de datos de la Terapia Intensiva Cardiovascular del Instituto Nacional de Cardiología. Se incluyeron todos los pacientes adultos operados de cirugía cardiaca en el año 2015. Resultados: Se operaron 571 pacientes. La indicación quirúrgica predominante fue la cirugía de cambio valvular único o múltiple, seguida de la cirugía de revascularización coronaria y corrección de cardiopatías congénitas del adulto. La mortalidad global fue de un 9.2% y el 8% falleció en terapia intensiva. Los principales factores de riesgo de muerte fueron la presencia de falla orgánica o hipertensión pulmonar prequirúrgica, y el tiempo prolongado de circulación extracorpórea. La principal causa de muerte fue el choque cardiogénico. La mortalidad hospitalaria observada en esta población fue mayor para los operados de tromboendarterectomía pulmonar, cirugía de enfermedad aórtica compleja y cirugía valvular. Conclusiones: La mortalidad de los pacientes operados de cirugía cardiaca en México difiere levemente de la reportada en la literatura mundial porque se trata mayormente de cirugía multivalvular y de procedimientos quirúrgicos mixtos complejos.

Abstract Objective: To analyse hospital mortality in patients subjected to cardiac surgery in Mexico during the year 2015, and identify the mortality risks factors, and its correlation with days of hospital stay in the cardiovascular intensive care unit. Method: The database of Cardiovascular Intensive Care of the National Institute of Cardiology was examined for this cases and controls study that included only adult patients subjected to cardiac surgery during the year 2015. Results: A total of 571 patients were subjected to a surgical procedure. The predominant indication was single or multiple valve replacement surgery, followed by coronary revascularisation surgery, and correction of adult congenital heart disease. Overall mortality was 9.2, and 8% died in intensive care. The main risk factors for death were preoperative organ failure or pulmo- nary hypertension, and prolonged time with extracorporeal circulation. The primary cause of death was secondary to cardiogenic shock. The hospital mortality observed in this population was higher for patients undergoing pulmonary thromboendarterectomy, complex aortic disease surgery, and valvular surgery. Conclusions: The mortality of patients undergoing cardiac surgery in Mexico differs slightly from that reported in the world literature, primarily because there were more multivalvular surgeries and mixed complex procedures performed.

Evolución y pronóstico de la insuficiencia tricuspídea moderada-grave tras tromboendarterectomía pulmonar o angioplastia de arterias pulmonares / Outcome of moderate-severe tricuspid regurgitation after pulmonary endarterectomy or balloon pulmonary angioplasty

Introducción y objetivos: No está definido el abordaje de la insuficiencia tricuspídea (IT) funcional moderada-grave en los pacientes con hipertensión pulmonar tromboembólica crónica tras la tromboendarterectomía pulmonar (TEA) o angioplastia con balón de las arterias pulmonares (ABAP). El objetivo de este estudio es analizar la evolución y los predictores de IT residual tras el procedimiento, así como su impacto pronóstico. Métodos: Estudio observacional unicéntrico. Se incluyó a 72 pacientes sometidos a TEA y 20 que completaron el programa de ABAP con diagnóstico de hipertensión pulmonar tromboembólica crónica y presentaban IT moderada-grave antes del procedimiento intervencionista. Resultados: La prevalencia de IT moderada-grave tras el procedimiento fue del 29%, sin diferencias entre los tratados con TEA o ABAP (el 30,6 frente al 25%; p=0,78). En el grupo con IT persistente se hallaron mayores presión arterial pulmonar media (40,2± 1,9 frente a 28,5±1,3mmHg; p<0,001), resistencia vascular pulmonar (472 [347-710] frente a 282 [196-408] dyn·s/cm5; p <0,001) y área de la aurícula derecha (23,0 [21-31] frente a 16,0 [14,0-20,0]; p <0,001) tras el procedimiento comparado con el de pacientes con IT ausente-ligera. La resistencia vascular pulmonar> 400dyn.s/cm5 y el área de la aurícula derecha> 22 cm2 tras el procedimiento se asociaron de manera independiente con la persistencia de la IT, pero no se identificaron predictores antes de la intervención. La IT moderada-grave residual y la presión pulmonar media> 30mmHg se asociaron con mayor mortalidad en 3 años de seguimiento. Conclusiones: La IT moderada-grave residual posterior a TEA o ABAP se asoció con la persistencia de una mayor poscarga y un persistente remodelado desfavorable de las cámaras cardiacas derechas tras el procedimiento. La IT moderada-grave y la hipertensión pulmonar residual se asociaron con un peor pronóstico a 3 años. (AU)

Introduction and objectives: The management of persistent moderate-severe tricuspid regurgitation (TR) in patients with chronic thromboembolic pulmonary hypertension after treatment with pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) is not well defined. This study aimed to analyze the progression and predictors of significant persistent postintervention TR and its prognostic impact. Methods: This single-center observational study included 72 patients undergoing PEA and 20 who completed a BPA program with a previous diagnosis of chronic thromboembolic pulmonary hypertension and moderate-to-severe TR. Results: The postintervention prevalence of moderate-to-severe TR was 29%, with no difference between the PEA- or BPA-treated groups (30.6% vs 25% P=.78). Compared with patients with absent-mild postprocedure TR, those with persistent TR had higher mean pulmonary arterial pressure (40.2±1.9 vs 28.5±1.3mmHg P <.001), pulmonary vascular resistance (472 [347-710] vs 282 [196-408] dyn.s/cm5; P <.001), and right atrial area (23.0 [21-31] vs 16.0 [14.0-20.0] P <.001). The variables independently associated with persistent TR were pulmonary vascular resistance> 400 dyn.s/cm5 and postprocedure right atrial area> 22cm2. No preintervention predictors were identified. The variables associated with increased 3-year mortality were residual TR and mean pulmonary arterial pressure> 30mmHg. Conclusions: Residual moderate-to-severe TR following PEA-PBA was associated with persistently high afterload and unfavorable postintervention right chamber remodeling. Moderate-to-severe TR and residual pulmonary hypertension were associated with a worse 3-year prognosis. (AU)

Caracterización de las variantes quirúrgicas realizadas en dos años a pacientes con enfermedad cerebrovascular extracraneal / Characterization of surgical varians performed in patients with extracranial cerebrovascular diseases in two years

Objetivo: Caracterizar las variantes quirúrgicas realizadas a los pacientes ingresados con enfermedad cerebrovascular extracraneal en un período de dos años. Métodos: Estudio descriptivo prospectivo en 27 pacientes, sin distinción de edad y sexo, operados por enfermedad cerebrovascular de origen extracraneal. Se tuvieron en cuenta los criterios de cirugía, además del estadio clínico, enfermedad cerebrovascular extracraneal que motivó la operación, localización de la lesión carotidea, variantes quirúrgicas realizadas, la permeabilidad de estas y las complicaciones poscirugía. Los pacientes fueron seguidos en consulta externa por dos años. Resultados: Se encontró que el 44,4 por ciento tuvo un ataque transitorio isquémico. Fueron más frecuentes las lesiones unilaterales (85,2 por ciento) y las de la carótida derecha (48,1 por ciento). Se halló una asociación significativa entre el sexo masculino con el estadio clínico y la localización de las lesiones carotideas. La endarterectomía por eversión fue la variante quirúrgica más realizada (44,4 por ciento). El 96,3 por ciento de las intervenciones se mantuvo permeable hasta los 18 meses poscirugía, mientras que tres pacientes presentaron reestenosis a los 24 meses. El 40,7 por ciento no desarrolló complicaciones, y entre estas el sangrado fue la de mayor frecuencia (33 por ciento). Conclusiones: Las variantes quirúrgicas realizadas se caracterizaron por altos porcentajes de permeabilidad durante el tiempo de estudio, con un mínimo de complicaciones posquirúrgicas(AU)

Objective: To characterize the surgical variants performed in hospitalized patients with extracranial cerebrovascular diseases in two years. Methods: Prospective and descriptive study of 27 patients, regardless of age and sex, who had been operated on from cerebrovascular disease of extracranial origin. Surgical criteria, clinical condition, extracranial cerebrovascular disease that required surgery, location of the carotid lesion, surgical variants, their permeability and the post-surgery complications were all taken into account. The patients were followed-up in the outpatient service during two years. Results: It was found that 44.4 percent of patients had had a transient ischemic attack. Unilateral lesions (85.2 percent) and right carotid lesions (48.1 percent) were the most common. Significant association was found between the male sex and the clinical staging and the location of carotid lesions. Eversion endarterectomy was the most performed surgical technique (44.4 percent). In the study, 96.3 percent of operations were kept permeable up to 18 months after the surgery whereas three patients presented with re-stenosis after 24 months. In the study group, 40.7 percent did not develop complications, being bleeding the most frequent one (33 percent). Conclusions: The surgical variants performed in the study time were characterized by high percentages of permeability and minimal postsurgical complications(AU)

Subluxação da mandíbula para abordagem de bifurcação carotídea alta em paciente com parotidite por contraste iodado: relato de caso e revisão de literatura / Subluxation of the mandible for access to figh carotid bifurcation in a patient with iodinated contrast induced parotitis: care report and literature review

A doença aterosclerótica das carótidas extracranianas pode resultar em complicações com alta morbidade e mortalidade. A avaliação pré-operatória com exames contrastados de imagem é associada a complicações como a parotidite, além das já bem conhecidas reações alérgicas e da disfunção renal. A bifurcação carotídea alta e a doença aterosclerótica de extensão cranial costumam ser fatores limitantes para o tratamento cirúrgico convencional. Entretanto, quando há contraindicação ao uso de contraste iodado ou impossibilidade do tratamento endovascular, há a necessidade do conhecimento de técnicas cirúrgicas que permitam a realização da endarterectomia com segurança. A subluxação da mandíbula se mostrou uma técnica adjuvante segura e efetiva, de fácil execução e reprodutibilidade, possibilitando o acesso a bifurcações carotídeas altas com boa exposição do campo cirúrgico e permitindo a realização da endarterectomia conforme a técnica padrão. Apresentamos o caso de uma paciente com bifurcação carotídea alta e com limitações para uso do contraste iodado que foi submetida a endarterectomia carotídea após subluxação de mandíbula

Atherosclerotic disease of the extracranial carotid arteries can cause complications with high morbidity and mortality rates. The contrast imaging examinations used in preoperative evaluation are associated with complications such as parotitis, in addition to well-known allergic reactions and renal dysfunction. A high carotid bifurcation or atherosclerotic disease that extends distally are often limiting factors for conventional surgical treatment. However, when iodinated contrast is contraindicated or endovascular treatment is not feasible, knowledge of surgical techniques that allow safe endarterectomy is required. Subluxation of the mandible has proven to be a safe and effective adjuvant technique that is easy to perform and reproducible, providing access to high carotid bifurcations with good exposure of the surgical field and allowing endarterectomy to be performed with a standard technique. We present the case of a patient with a high carotid bifurcation and limitations for use of iodinated contrast who underwent carotid endarterectomy after subluxation of the mandible

Ictus isquémico en pacientes en tratamiento anticoagulante por vía oral / Ischaemic stroke in patients treated with oral anticoagulants

Introducción: Los ictus cardioembólicos tienen peor pronóstico. Su prevención se basa en el tratamiento anticoagulante por vía oral (ACO), cuya principal complicación es el sangrado y, en ocasiones, su ineficacia. Pacientes y métodos: Se ha revisado retrospectivamente a 1.014 pacientes consecutivos que presentaron ictus isquémico entre 2011 y 2013. De ellos, hemos analizado a los 107 pacientes en tratamiento con ACO en el momento del ictus, con especial atención a su etiología, evolución y valor del INR en la fase aguda. Resultados: La edad media ± desviación estándar fue de 71,9 ± 10 años. Tomaba ACO desde hacía 5,9 ± 5,5 años el 98,1% por cardiopatía. Setenta y siete pacientes (72%) tenían INR < 2 y 30 (28%) un INR ≥ 2. Se encontraban en rango terapéutico 9 pacientes (8,4%). La etiología según TOAST fue cardioembólica en el 88,8% y aterotrombótica en el 1,9%. Se suspendió la anticoagulación en 48 pacientes (44,9%): 24 por transformación hemorrágica, 23 por infarto extenso y uno por endarterectomía. Se reintrodujo en 24 de ellos (50%), a los 36 días de media; en los restantes, no fue posible por fallecimiento o secuelas severas. En 9 pacientes (18,7% de potenciales candidatos) se iniciaron nuevos ACO (NACO). La evolución a los 3 meses fue mejor si el INR en la fase aguda > 1,7 respecto al INR ≤ 1,7 (mRS 0-2: 62% vs. 30,8% y fallecimiento 10% vs. 38.4%; p = 0,0004). Conclusiones: Algunos pacientes con ACO presentan ictus isquémicos, en general cardioembólicos, especialmente si el INR es infraterapéutico. Se pueden reintroducir ACO sin complicaciones, siendo el uso de NACO todavía escaso. A pesar de su ineficacia, la evolución es mejor si INR > 1,7 al inicio del ictus

Introduction: Cardioembolic stroke is associated with poorer outcomes. Prevention is based on oral anticoagulant (OAC) therapy. Haemorrhage is the main complication of OACs, which are sometimes ineffective. Patients and methods: We retrospectively reviewed 1014 consecutive patients who suffered an ischaemic stroke between 2011 and 2013, analysing those who were receiving OAC treatment at stroke onset (107 patients in total) with special attention to aetiology, outcomes, and INR value in the acute phase. Results: The mean age (SD) was 71.9 (10) years. Patients had been treated with OACs for 5.9 (5.5) years; 98.1% of them were being treated for heart disease. INR was <2 in 77 patients (72%), and 30 patients (28%) had an INR≥2. Nine patients (8.4%) had INR values within the therapeutic range. According to TOAST classification criteria, 88.8% of strokes were cardioembolic and 1.9% were atherothrombotic. Anticoagulation therapy was discontinued in 48 patients (44.9%) due to haemorrhagic transformation (24 patients), extensive infarction (23), or endarterectomy (1). Therapy was resumed in 24 patients (50%) after a mean lapse of 36 days. This was not possible in the remaining patients because of death or severe sequelae. New OACs (NOACs) were prescribed to 9 patients (18.7% of all potential candidates). At 3 months, patients with INR>1.7 in the acute phase exhibited better outcomes than patients with INR≤1.7 (mRS 0-2 in 62% vs 30.8%; death in 10% vs 38.4%; P=.0004). Conclusions: Some patients taking OACs suffer ischaemic strokes that are usually cardioembolic, especially if INR is below the therapeutic range. OACs can be resumed without complications, and NOACs are still underused. Despite cases in which treatment is ineffective, outcomes are better when INR is above 1.7 at stroke onset