Aneurisma toracoabdominal tipo II de Crawford: resolución mediante un procedimiento híbrido complejo / Crawford type II thoracoabdominal aneurysms: resolution by means of a complex hybrid procedure

Introducción. La estrategia quirúrgica clásica en los aneurismas toracoabdominales sigue presentando ennuestros días un alto grado de complejidad técnica y unas elevadas tasas de morbimortalidad. En los últimos años se introducenlas técnicas endovasculares entre las alternativas terapéuticas, aunque, en algunos casos, precisan ser combinadascon cirugías abiertas para salvar el escollo que suponen las grandes arterias viscerales. Caso clínico. Varón de 62años, que se remite desde el Servicio de Otorrinolaringología por presentar disfonía y efecto masa en mediastino. En latomografía axial computarizada y la angiografía centimetrada se observan múltiples dilataciones aneurismáticas de todala aorta, comenzando en el cayado aórtico y con un diámetro máximo de 8 cm en el sector de la aorta torácica descendente.Se plantea una estrategia híbrida en dos tiempos; en primer lugar se realiza la corrección de la dilatación abdominaly la revascularización retrógrada de los troncos digestivos y arterias renales; y en segundo lugar, seis semanas mástarde, se realiza la ligadura de la arteria carótida común izquierda y la arteria subclavia izquierda y la revascularizaciónde éstas desde la arteria carótida derecha vía retroesofágica, y la exclusión endovascular de toda la aorta torácica y laabdominal desde la aorta ascendente a la prótesis aortobifemoral previa. Se da de alta al paciente dos semanas más tardesin secuelas. Conclusión. La accesibilidad actual de las técnicas endovasculares permite plantear estrategias deabordaje de aneurismas de alta complejidad menos agresivas para el paciente, aunque continúen siendo necesarias maniobrasquirúrgicas abiertas. La combinación de ambas parece suponer una mejora importante en los resultados inmediatosde todo el procedimiento

Introduction. Even today, the classic surgical strategy followed in cases of thoracoabdominal aneurysms stillentails a high degree of technical complexity as well as high morbidity and mortality rates. In recent years endovasculartechniques have been introduced as therapeutic alternatives, although, in some cases, they have to be combined withopen surgery in order to get round the obstacle of the major visceral arteries. Case report. A 62-year-old male who wasreferred from the Otorhinolaryngology Department because of dysphonia and a mass effect on the mediastinum. Acomputerised axial tomography and calibrated angiography scans showed multiple aneurysmal dilatations along thewhole of the aorta, which began in the aortic arch and had a maximum diameter of 8 cm in the segment of thedescending thoracic aorta. A two-stage hybrid strategy was proposed. First, correction of the abdominal dilatation andretrograde revascularisation of the digestive branches and renal arteries were performed. Second, six weeks later,ligation of the left common carotid artery and left subclavian artery was performed, together with revascularisation ofthese arteries from the right carotid artery with a retroesophageal approach. Likewise, endovascular exclusion of thewhole thoracic aorta and of the abdominal artery from the ascending aorta to the previous aortobifemoral graft wasalso carried out. The patient was discharged from hospital two weeks later with no sequelae. Conclusions. The currentavailability of endovascular techniques makes it possible to design highly complex strategies for approaching aneurysmsthat are less invasive for the patient, although open surgical manoeuvres continue to be necessary. The combination ofthe two seems to lead to a notable improvement in the immediate outcomes of the entire procedure

Tratamiento endovascular de aneurisma de aorta abdominal en paciente con distrofia polianeurismática / Endovascular treatment of an abdominal aortic aneurysm in a patient with polyaneurysmal dystrophy

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Acquired tracheoesophageal fistula and its management.

Tracheoesophageal fistulae (TEF) are severe lesions leading to serious and eventually fatal pulmonary complications. Currently, TEF are mainly iatrogenic, occurring in the course of tracheal intubation for resuscitation or malignant after invasion of both esophageal and tracheal walls. Difficulty in treatment results from the need to manage both the consequences of esophagotracheal communication and those of the illness responsible for fistula. Various carefully selected means may be used to achieve this aim: division and closure of the TEF, esophageal exclusion followed by gastric or colic bypass or push-through intubation. Abstention from treatment may be appropriate in hopeless situations.

Subchorionic placental cyst: a cause of fetal growth retardation--ultrasound and color-flow Doppler diagnosis and follow-up.

Subchorionic placental cysts are ominous findings. When attached near the umbilical cord insertion, the risk of umbilical cord constriction is increased. This may cause fetal growth retardation and intrauterine asphyxia. This article reports a case of subchorionic placental cyst diagnosed in the first trimester by transvaginal ultrasound. Color Doppler ultrasound demonstrated a reduction of the umbilical cord bloodstream as the cyst increased in size. Fetal growth retardation was evident in the third trimester.

Color flow Doppler: a useful instrument in the diagnosis of funic presentation.

Color Doppler sonography offers the opportunity to evaluate the umbilical cord and to study blood velocity wave forms within the cord. Funic (cord) presentation can be diagnosed unequivocally with color Doppler sonography. Because funic presentation is likely to be the harbinger of cord prolapse, the morbidity and mortality associated with cord prolapse can be prevented if funic presentation is diagnosed before membrane rupture. This article describes the first case in the obstetric literature of funic presentation diagnosed with color Doppler sonography. The potential complications associated with cord prolapse were avoided with a cesarean section.

Role of color flow Doppler ultrasonography in diagnosing velamentous insertion of the umbilical cord and vasa previa. A report of two cases.

BACKGROUND: Prenatal diagnosis of velamentous insertion of the umbilical cord is of practical importance since unsupported vessels in the amnion may be lacerated at the time of membrane rupture. Failure to diagnose ruptured vessels may lead to fetal death. The incidence of velamentous insertion of the umbilical cord is about 1% in singleton pregnancies. This mode of insertion occurs much more frequently with multifetal pregnancies. CASES: Two cases of velamentous insertion of the umbilical cord unrelated to vasa previa were diagnosed prenatally with color Doppler ultrasound in women with twin gestations. Both women delivered uneventfully by cesarean section. The velamentous insertion diagnosis was confirmed postnatally in both cases. CONCLUSION: Color flow Doppler ultrasonography can be used in the second and third trimesters of pregnancy to identify potentially lethal structural abnormalities of the umbilical cord.

Normal uterine arterial blood flow in postmenopausal women assessed by transvaginal color Doppler sonography: the effect of hormone replacement therapy.

We used transvaginal color Doppler sonography to study the effect of hormone replacement on the uterine arterial blood flow for 203 postmenopausal women. The regimens studied involved estrogen replacement alone, continuous combined estrogen and progestogen, and estrogen followed sequentially by combined estrogen-progestogen. The mean pulsatility index fell to 65% +/- 9% and the mean resistive index fell to 87% +/- 4% of baseline during the first month of therapy (P < 0.0001). The addition of a progestogen did not alter the effect of estrogen alone (P > 0.5). Our findings suggest that the increase in vascular flow occurs even in women who begin therapy long after menopause.

Normal uterine arterial blood flow in postmenopausal women assessed by transvaginal color Doppler ultrasonography.

We used transvaginal color Doppler sonography to study uterine artery blood flow velocity waveforms in 345 normal postmenopausal women who had never been on hormone replacement therapy. Our objective was to establish the standard baseline flow values for normal postmenopausal women. The mean pulsatility index was 3.38 +/- 1.04 and the mean resistive index was 0.93 +/- 0.09. There was a positive correlation between arterial blood flow impedance and number of years since menopause. We believe that these levels may become important screening parameters for the detection of endometrial carcinoma in postmenopausal women.

Transvaginal color Doppler assessment of endometrial status in normal postmenopausal women: the effect of hormone replacement therapy.

We used transvaginal color Doppler sonography to study the effects of hormone replacement therapy on the endometrial structure and vascular flow of 345 normal postmenopausal women. We studied women taking estrogen replacement alone, continuous combined estrogen and progestogen, and estrogen followed sequentially by estrogen-progestogen combination. Endometrial measurements prior to the initiation of hormone replacement therapy were used as baseline values. An increase in endometrial thickness was seen soon after initiation of hormone replacement therapy (P < 0.0001). Hyperplasia or adenocarcinoma was found only when endometrial thickness was greater then 9 mm. No correlation was found between hormone replacement therapy and the occurrence of endometrial hyperplasia or adenocarcinoma.

[Extra-amniotic pregnancy. Diagnosis with transvaginal color Doppler]. / Extraamniotische Schwangerschaft. Diagnose mittels transvaginalem Farbdoppler.

We report on the early diagnosis of two cases of extraamniotic pregnancy in the first trimester using transvaginal colour Doppler. The flow alterations in trophoblastic and corpus luteum vessels were of low diagnostic significance.

Early prenatal diagnosis of an ominous aneurysm of the vein of Galen by color Doppler ultrasound.

A case of an aneurysm of the vein of Galen detected by color Doppler ultrasound (CDU) at 25 weeks of pregnancy is presented. The initial finding was a small defect of the posterior cerebral vein. Sonographic follow-up demonstrated an enlargement of the cerebral lesion as well as severe hemodynamic consequences. Fetal demise finally occurred at 28 weeks. Necropsy findings confirmed the diagnosis. This is the first report describing the value of CDU in the early diagnosis of such aneurysms.

Early detection of embryonic malformations by transvaginal and color Doppler sonography.

A total of 834 women with uneventful pregnancies were followed prospectively until the 15th week of gestation by TVS to screen for early embryonic malformations. Twenty-eight embryonic anomalies were detected in this series (3.3%). The median gestational age at diagnosis was 11 (range, 8 to 15) weeks. Two neural tube defects were missed by early TVS screening. Two suspected abdominal wall defects were not confirmed by repeat mid-second trimester abdominal sonography representing 6.7% of all fetal malformations evident by 24 weeks of gestation. The sensitivity and specificity of TVS screening for fetal malformations in this series were 93.3 and 99.7%, respectively. In addition, the role of TCDU also was investigated in these 28 abnormal embryos. TCDU proved to be of limited value as it was useful only for evaluating those embryonic malformations with vascular involvement. In such cases, the diagnosis was greatly enhanced with this technique. Two previously undetected single umbilical arteries were also diagnosed by TCDU as well. This series included 11 aneuploid embryos (44%), most of them among the embryos with focal or generalized edema. This study demonstrates that screening for early embryonic malformations is feasible using TVS techniques, but a repeat mid-second trimester abdominal sonogram still is recommended.

Aetiological factors involved in the low response to gonadotrophins in infertile women with normal basal serum follicle stimulating hormone levels.

This study was designed to investigate possible aetiological factors involved in the low response to gonadotrophins in women with normal basal serum follicle stimulating hormone (FSH) concentrations, stimulated for assisted reproduction. Nine of these patients with normal basal serum FSH and 22 normal controls (five of whom had had a normal response to previous gonadotrophin stimulation) were prospectively subjected to: (i) transvaginal pulsed colour Doppler ultrasound evaluation of the vessels surrounding the dominant follicle for blood flow impedance analysis, (ii) the clonidine test to explore the ability of the pituitary to release growth hormone, and (iii) detection of anti-granulosa cell auto-antibodies in blood using an enzyme-linked immunosorbent assay (ELISA). The pulsatility and resistance indices (PI, RI) were significantly (P < 0.01) higher in the women with low responses as compared to the controls on days -1 and 0 (day 0 = ovulation). Seven out of the nine low responders were out of the range calculated for normal values after evaluation of the controls. A significant (P < 0.05) decrease in the secretion of growth hormone 60-90 min after clonidine ingestion was observed in the low responders as compared to five controls with previous normal response to ovarian stimulation. Six out of the nine low responders showed a negative clonidine test. No increase in anti-granulosa cell auto-antibodies was observed in the low responders as compared to the controls, including normal responders. In conclusion, an abnormal follicular blood flow impedance in the natural cycle may be related to low responses to gonadotrophins in patients with normal serum FSH concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of endometrial carcinoma: predictive value of transvaginal color Doppler.

The objective of this study was to determine whether transvaginal ultrasound plus color Doppler flow improve the ability to diagnose endometrial carcinoma and allow better discrimination between benign and malignant endometrial lesions. One hundred thirty women with abnormal uterine bleeding were evaluated with transvaginal color Doppler before fractional dilatation and curettage (D&C). The endometrial line thickness and endometrial characteristics were evaluated by endosonography. The resistive and pulsatile indices of the uterine arteries and of the endometrium were evaluated with transvaginal color Doppler. Following D&C and tissue diagnosis, women were divided into two groups, 62 with a histologic diagnosis of endometrial adenocarcinoma and 68 with benign endometrial tissue. All women with endometrial carcinoma underwent TAH and BSO. A complete histopathologic study was done an all surgical specimens. The International Federation of Gynecology and Obstetrics (FIGO) stage and tissue grading were determined in all cases. The histopathologic findings were correlated with ultrasound and transvaginal color Doppler results. Patients with adenocarcinoma had an average endometrial thickness of 26.13 mm (range 8-87 mm). The average thickness for functional endometrium (proliferative) was 10.5 mm (range 6-23 mm). There was no case of carcinoma where the endometrial thickness was less than 8 mm. Intraendometrial neovascularization was not observed in any case with functional or atrophic endometrium. The flow indices in patients with endometrial adenocarcinomas are significantly different from the flow indices of patients with benign endometrial tissue. Transvaginal color Doppler increases the sensitivity of endometrial malignancy diagnosis. The method is capable of detecting important differences in flow indices and endometrial line characteristics between benign and malignant endometrial tissue.

Is avoidance of surgery possible in patients with perimenopausal ovarian tumors using transvaginal ultrasound and duplex color Doppler sonography?

A total of 108 cases of small perimenopausal ovarian tumors (largest diameter, less than 7 cm) were evaluated by transvaginal sonography and duplex color Doppler sonography; 101 had criteria for benignity and 7 for malignancy. All cysts were punctured and aspirated to avoid unnecessary surgery (benign cases) and establish the cytologic diagnosis as well as to avoid the risk of leakage (malignant cases). Recurrence rate of benign punctured cysts was 25% within 1 year of follow up. No difference in recurrent rate was seen between pre- and postmenopausal patients (19 of 56 cases in the premenopausal group, and five of 28 cases in the postmenopausal group). The larger the cyst, the greater the risk of recurrence. Puncture and aspiration of seven sonographically established malignant tumors allowed cytologic diagnosis before surgery, and no evidence of leakage was noted at the time of surgery. No significant differences were observed between cytologic and histopathologic findings in cases that went to surgery. Puncture and aspiration of small endometriomas (17 cases) was found to be inefficient for therapeutic purposes. Finally, owing to the high percentage of unsatisfactory cytologic results (20%) with cyst aspiration, vaginal and color Doppler sonography seemed more efficient in distinguishing between benignity and malignancy.