Long-term outcome of abdominal aortic aneurysm repair via a retroperitoneal approach.

BACKGROUND: A retroperitoneal approach for abdominal aortic aneurysm repair has demonstrated similar short-term postoperative outcomes compared with the transperitoneal approach. However, there is no long-term survival data utilizing exclusively open repair via retroperitoneal approach. METHODS: We have conducted a retrospective analysis to evaluate the long-term survival of 142 patients with infrarenal aortic aneurysm undergoing elective open surgical repair via a retroperitoneal approach. RESULTS: Our cohort of patients consisted of 82% males, 59% whites, and a mean age of 72.6±7.7 years. The 30-day mortality rate was 3.5% for open repair via retroperitoneal approach. Post-operative complications were low, with renal failure (9.9%), pulmonary complication (9.9%), and limb ischemia (6.3%) being the most prevalent. Five years after surgery, the cumulative survival rate was 70.1%. CONCLUSIONS: The elective management of infrarenal aortic aneurysms with open repair via a retroperitoneal approach offers a good prognosis demonstrated with up to 5 year follow up.

Subclavian artery stenosis: a case series and review of the literature.

Subclavian artery stenosis (SAS) is a significant form of peripheral artery disease, which may be a marker of diffuse atherosclerosis and increased risk for cardiovascular events. SAS can lead to symptomatic ischemia affecting the upper extremities, the brain, and, in some cases, the heart. In general, asymptomatic subclavian artery disease is treated with medical therapy and invasive treatment is reserved for the more symptomatic patients. This article discusses the evaluation of four patients with varying presentations of subclavian artery disease.

Endovascular treatment of an acute ascending aortic intramural hematoma.

INTRODUCTION: Herein, we present a case of an elderly gentleman who presented with an extensive intramural hematoma of the aorta which was treated with a percutaneous placement of an endovascular stent. PRESENTATION OF CASE: A 79-year-old male with a history of hypertension presented to the emergency department because of sudden onset of substernal chest pain radiating to his back. A chest computerized tomography scan was performed that demonstrated a Type A aortic wall intramural hematoma involving the arch and ascending aorta dissecting both antegrade and retrograde from a penetrating ulcer located in the descending aorta, immediately distal to the left subclavian artery. No dissection flap was noted. The patient opted for an endovascular approach. He was treated with the placement of a stent just distal to the left subclavian artery, with good results noted on follow-up exam performed 3 months later. DISCUSSION: The treatment of a Type A IMH lacks consensus, but the majority do favor surgical management. The data are limited; however, there are reports of patients with Type A intramural hematoma treated with descending aortic endograft at the site of the culprit ulcerated plaque, with satisfactory results. CONCLUSION: In a select group of patients, an endovascular approach for the treatment of a Type A aortic wall intramural hematoma caused by an ulcerated plaque may be a viable treatment option.

Spontaneous uterine rupture caused by placenta percreta at 18 weeks' gestation after in vitro fertilization.

We report a case of spontaneous uterine rupture caused by placenta percreta at 18 weeks' gestation after in vitro fertilization. Spontaneous uterine rupture is an extremely infrequent obstetric complication that may compromise the lives of the fetus and the mother. We describe the case of a pregnant woman at 18 weeks' gestation who presented with sudden abdominal pain and severe hemoperitoneum. We noticed a uterine rupture and carried out an urgent obstetric hysterectomy. The patient died due to hypovolemic shock and severe generalized coagulopathy. The pregnancy had been obtained via in vitro fertilization techniques. The patient did not have any risk factor or antecedent. The anatomopathological study showed a fundus uterine rupture caused by placenta percreta.

Should saphenous vein grafts be the conduits of last resort for coronary artery bypass surgery?

There is overwhelming evidence that internal mammary artery grafts improve survival and clinical outcomes after coronary artery bypass graft surgery. It has therefore become standard practice to use the left internal mammary artery as the graft of first choice. Given the overwhelming evidence for the superiority of internal mammary artery grafts, the question that naturally follows is whether the conduit of second choice should be the contralateral internal mammary artery, rather than a saphenous venous graft. This article reviews the evidence supporting the superiority of internal mammary artery grafts over other available conduits and addresses the selection of the second conduit after the left internal mammary artery. The current body of evidence, encompassing multiple clinical studies and employing different methodologies consistently, demonstrates that bilateral internal mammary artery grafting improves survival and long-term clinical outcome. The increasing longevity of postcoronary bypass patients with modern advances in medical and electrical therapies would augment the benefit of this procedure and argue for its greater utilization. Higher patency of arterial grafts may translate to a decreased need for repeat target vessel revascularization and may increase the cost-effectiveness of bilateral internal mammary artery use. However, in 2003, only 3% to 4% of patients undergoing surgical coronary revascularization received bilateral internal mammary artery grafts. There appears to be a potential to increase utilization of this procedure above the current rate. Increased utilization of this procedure would need a concerted effort by the cardiology and cardiac surgery community.

Tumores borderline de ovario. Estudio retrospectivo de 60 casos / Borderline ovarian tumors. Retrospective study of 60 cases

Objetivo: Describir las características clínicas, diagnósticas, terapéuticas y evolutivas de las pacientes con tumor borderline de ovario (TBO) tratadas en nuestro servicio durante un período de 15 años. Sujetos y métodos: Estudio retrospectivo basado en 60 pacientes diagnosticadas y tratadas en el Servicio de Ginecología del Hospital Universitario Miguel Servet de Zaragoza entre los años 1990 y 2004. Resultados: Se confirma el valor pronóstico del estadio de la enfermedad y la utilidad de la cirugía conservadora en las pacientes que desean mantener su capacidad fértil. En las pacientes no estadificadas inicialmente y en aparente estadio I, la supervivencia global es del 100%. Conclusiones: Los TBO presentan un pronóstico excelente, con buenos resultados de la cirugía conservadora en pacientes jóvenes y con deseo de descendencia. En el caso de pacientes no estadificadas inicialmente y en aparente estadio I de la enfermedad no parece útil recurrir a la cirugía de restadificación

Objective: To describe the clinical findings, treatment, and outcome of borderline ovarian tumors in 60 patients admitted to the Miguel Servet hospital over a 15-year period. Subjects and methods: Sixty patients diagnosed and treated from 1990 to 2004 for borderline ovarian tumors were retrospectively evaluated. Results: The results of this study confirm the prognostic value of surgical staging and the utility of fertility-sparing surgery in patients wishing to preserve fertility. In unstaged patients with apparent stage I tumors, overall survival was 100%. Conclusions: Borderline ovarian tumors have an excellent prognosis. Good results are provided by conservative surgery in young patients wishing to preserve fertility. In initially unstaged patients with apparent stage I tumors, surgical restaging does not appear to be useful

Percutaneous coronary intervention for cardiac arrest secondary to ST-elevation acute myocardial infarction. Influence of immediate paramedical/medical assistance on clinical outcome.

BACKGROUND: Patients with cardiac arrest have been excluded from most randomized trials on percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). OBJECTIVE: The aim of the study was to evaluate the outcome of patients undergoing primary PCI for acute myocardial infarction who suffered from cardiac arrest prior to the procedure, focusing the study on the influence of immediate paramedical-medical assistance on the outcome. METHODS AND RESULTS: Sixty-three patients with ST-elevation AMI and previous cardiac arrest underwent primary PCI within 12 hours after symptom onset. Three groups of patients were defined: Group 1: Cardiac arrest before hospital admission, without immediate (< 1 minute) initiation of resuscitation maneuvers (n = 13); Group 2: Pre-hospital cardiac arrest with immediate initiation of resuscitation maneuvers (n = 14); Group 3: Cardiac arrest after hospital admission. The proportion of patients with ventricular tachycardia or fibrillation as documented initial rhythm was similar among the groups (77%, 79% and 83%, respectively), as well as the rate of angiographic success (92%, 93% and 86%, respectively). However, the incidence of cardiac events at 30 days was significantly higher in Group 1 than in Groups 2 or 3 (54%, 29% and 17%, respectively; p = 0.03), as well as the mortality rate at 30 days (46%, 21% and 18%, respectively; p = 0.06). Interestingly, the outcomes were not statistically different between Groups 2 and 3. In multivariate analysis, the independent predictors for mortality at 30 days for Group 1 were: multivessel disease, angiographic failure and cardiogenic shock. CONCLUSIONS: Combining immediate initiation of resuscitation maneuvers and primary PCI yields a very good clinical outcome in patients with AMI suffering from cardiac arrest.

Prognostic impact of a chronic occlusion in a noninfarct vessel in patients with acute myocardial infarction and multivessel disease undergoing primary percutaneous coronary intervention.

BACKGROUND: Among patients with acute myocardial infarction (AMI) referred for primary percutaneous coronary intervention (PCI), those with multivessel disease have worse clinical outcomes. This study sought to elucidate the impact of a chronic occlusion in a noninfarct vessel among patients with multivessel disease undergoing PCI for AMI. METHODS AND RESULTS: We studied 630 patients with AMI treated with PCI within 12 hours of symptom onset. Three groups of patients were defined: Group 1 (single-vessel disease; n = 345); Group 2 (multivessel disease with no chronic coronary occlusion in another vessel; n = 201); and Group 3 (chronic coronary occlusion in another vessel; n = 84). The probability of being free from events was lower in patients with multivessel disease than in Group 1 (84 +/- 2% vs. 92 +/- 1% at 30 days; 71 +/- 3% vs. 81 +/- 3% at 2 years; Log-Rank: p = 0.001; Breslow: p < 0.001 ), and in Group 3 than in Group 2 (76 +/- 5% vs. 87 +/- 2% at 30 days; 63 +/- 6% vs.75 +/- 4% at 2 years; Log-Rank: p = 0.014; Breslow: p = 0.008 ). Freedom from cardiac death was lower in patients with multivessel disease than in Group 1 (88 +/- 2% vs. 94 +/- 1% at 30 days; 84 +/- 2% vs. 91 +/- 2% at 2 years; Log-Rank: p = 0.003; Breslow: p = 0.002), and in Group 3 than in Group 2 (82 +/- 4% vs. 90 +/- 2% at 30 days; 77 +/- 5% vs. 88 +/- 3% at 2 years; Log-Rank and Breslow: p = 0.020). Among patients with multivessel disease, the presence of cardiogenic shock, left main disease and anterior location, but not the presence of a chronic occlusion in another vessel, were independent predictors of mortality. CONCLUSION: Among patients with AMI and multivessel disease, those with a chronic occlusion in a noninfarct-related vessel constitute a subgroup with very poor clinical outcomes.

Clinical variables related with in-stent restenosis late regression after bare metal coronary stenting.

UNLABELLED: In-stent restenosis (ISR) has an incidence between 20% and 30% using bare metal stents. ISR late regression phenomenon (ISRLR) has been previously described, but clinical variables related with this phenomenon remain unclear. The aim of the study was to identify the variables related with ISRLR. METHODS: We identified from our data base 30 patients between November 1995 and September 2002 that fulfilled the following criteria: 1) Documented ISR at follow-up angiography (CA-1); 2) treated medically; and 3) Referred for a second follow-up angiography (CA-2). at least 3 months after CA-1. ISRLR was defined as a > 0.2 mm increase in MLD between CA-1 and CA-2, calculated as the 2-fold of our inter-observer variability. ISR late progression was defined as a > 0.2 mm decrease in minimum lumen diameter (MLD) between CA-1 and CA-2. RESULTS: At the time of CA-2 only 2 patients (6.7%) had symptoms related with the previously stented vessel. We found a mean MLD of 1.03+/-0.34 mm and 1.54+/-0.48 mm at CA-1 and CA-2 respectively (AMLD = 0.51 +/-0.34 mm; p < 0.001). Twenty four patients (80.0%) had ISRLR. Two variables were related to the presence or absence ISRLR: Current smoking at the time of coronary stenting (70.8% vs 20.0% respectively, p = 0.026) and acute coronary syndrome as clinical indication for coronary stenting (and 83.5% vs 40.0% respectively, p = 0.029). CONCLUSION: ISRLR is a frequent phenomenon in patients with ISR treated medically, probably contributing to the benign long-term clinical outcome that has been previously described in patients with asymptomatic or mildly symptomatic ISR. Current smoking at the time of coronary stenting and acute coronary syndrome as clinical indication for coronary stenting are associated with this phenomenon.

Treatment and prevention of atrial fibrillation with non-antiarrhythmic pharmacologic therapy.

Atrial fibrillation is one of the most frequent heart rhythm disturbances found in clinical practice. Anticoagulation, rate control, cardioversion, and ablative procedures have been the mainstay of treatment. The frequent recurrence of atrial fibrillation and the side effects when antiarrhythmic drugs are used have led to dissatisfaction with available treatment of this arrhythmia. Pharmacologic therapy with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statins, and perhaps aldosterone and calcium channel blockers may have a role in the prevention of atrial fibrillation onset and recurrence. We summarize the possible biologic mechanisms and the clinical observations supporting the use of non-antiarrhythmic medications in the prevention of atrial fibrillation.

Enfermedades cardiovasculares en la postmenopausia / Cardiovascular diseases in postmenopause

Las enfermedades cardiovasculares son la causa de muerte mas frecuente en la posmenopausia. El incremento de la longevidad proyectada para los próximos cincuenta años para la población general con la mayor longevidad de las mujeres comparada con la de los varones, prevee un gran número de individuos que van a entrar en menopausia y sufriran sus complicaciones. Este periódo biológico de las mujeres se prolongará durante unos treinta años aproximadamente. La transición de la premenopausia a la posmenopausia ha sido definida tradicionalmente como una etapa de declincaión. Sin embargo, con los avances de la medicina en general y de la medicina cardiovascular en particular, el comienzo de la posmenopausia representa hoy una gran oportunidad para la prevención. Estos cambios biológicos se reconocen como los marcadores iniciales de los nuevos eventos que van a ocurrir. Si se establece una comunicación abierta y bilateral entre el médico y la paciente, se llegará a una adecuada educación y prevención de las dos complicaciones mas teminads durante la posmenopausia como son las complicaciones cardiovasculares y la osteoporosis. El objeto del presente trabajo es discutir los mecanismos envueltos en la fisiopatología de las manifestaciones cardiovasculares y su prevención.

Enfermedades cardiovasculares en la postmenopausia / Cardiovascular diseases in postmenopause

Las enfermedades cardiovasculares son la causa de muerte mas frecuente en la posmenopausia. El incremento de la longevidad proyectada para los próximos cincuenta años para la población general con la mayor longevidad de las mujeres comparada con la de los varones, prevee un gran número de individuos que van a entrar en menopausia y sufriran sus complicaciones. Este periódo biológico de las mujeres se prolongará durante unos treinta años aproximadamente. La transición de la premenopausia a la posmenopausia ha sido definida tradicionalmente como una etapa de declincaión. Sin embargo, con los avances de la medicina en general y de la medicina cardiovascular en particular, el comienzo de la posmenopausia representa hoy una gran oportunidad para la prevención. Estos cambios biológicos se reconocen como los marcadores iniciales de los nuevos eventos que van a ocurrir. Si se establece una comunicación abierta y bilateral entre el médico y la paciente, se llegará a una adecuada educación y prevención de las dos complicaciones mas teminads durante la posmenopausia como son las complicaciones cardiovasculares y la osteoporosis. El objeto del presente trabajo es discutir los mecanismos envueltos en la fisiopatología de las manifestaciones cardiovasculares y su prevención. (AU)

Muerte súbita cardíaca: mecanismo, clasificación según el riesgo y manejo / Cardiac sudden death: mechanism, classification according the risk and management

The current approach to the problem of sudden is that of a proactive interventional attitude and should lead us to the recognition of the potential candidates for these events, which will provide an impact in total survival in the community.

Muerte súbita cardíaca: mecanismo, clasificación según el riesgo y manejo / Cardiac sudden death: mechanism, classification according the risk and management

The current approach to the problem of sudden is that of a proactive interventional attitude and should lead us to the recognition of the potential candidates for these events, which will provide an impact in total survival in the community. (AU)