The importance of MDCT in the evaluation of risk factors before the TAVI procedure and its complications after implantation.

Transcatheter aortic valve implantation (TAVI) is the alternative to surgical valve replacement, expanding its indications in the latest guidelines. Multimodal CT (MDCT) is essential in patient selection and detection of complications. Vascular complications are frequent, so it is important to analyse the anatomy of the vessels before the procedure. Regarding annular ruptures and ventricular perforations, the volume and distribution of calcium and the ventricular diameter play an important role. Finally, valve migration is a rare complication that can occur both during and after TAVI. Proper planning of the MDCT procedure reduces the risk of complications and gives the interventional cardiologist security both before and during the procedure.

Multidetector computed tomography in planning the treatment of atrial fibrillation. / Tomografía computarizada multidetector en la planificación del tratamiento de la fibrilación auricular.

OBJECTIVE: To know the anatomy of the pulmonary veins (PVs) by multidetector computed tomography (MDCT) in patients with atrial fibrillation (AF) prior to ablation. MATERIALS AND METHODS: MDCT was performed in 89 patients with AF, analyzing the number of PVs, accessory variants and veins, diameter and ostial shape, distance to the first bifurcation and thrombus in the left atrial appendage. RESULTS: The most frequent venous pattern was 4 PVs (two right and two. left) in 49 patients (55.1%). The superior veins had a statistically significant greater mean ostial diameter than the inferior veins (Right Superior Pulmonary Vein (RSPV)> Right Inferior Pulmonary Vein (RIPV); p=0.001 and Left Superior Pulmonary Vein (LSPV)> Left Inferior Pulmonary Vein (LIPV); p<0.001). The right pulmonary veins ostial diameters were significantly larger than the left pulmonary veins ostial diameters (RSPV> LSPV; p<0.001 and RIPV> LIPV; p<0.001). The most circular ostium was presented by the VPID (ratio: 0.885) compared to the LIPV (p<00.1) and LSPV (p<0.001). The superior veins had a statistically significant greater mean distance to first bifurcation than the inferior veins (RSPV> RIPV; p=0.008 and LSPV> LIPV; p=0.038). Mean distance to first bifurcation has been greater in left PVs respect to the right PVs (LSPV> RSPV; p<0.001and LIPV> RIPV; p<0.001). Other findings found in AI: diverticula (30), accessory auricular appendages (5), septal aneurysms (8), septal bags (6) and 1 thrombus in the left atrial appendage. CONCLUSION: MDCT prior to ablation demonstrates the anatomy of the left atrium (LA) and pulmonary veins with significant differences between the diameters and morphology of the venous ostia.

Aortic root rupture and acquired intracardiac shunt after transcatheter aortic valve implantation. / Rotura de raíz aórtica con formación de shunt intracardíaco secundaria a implante valvular aórtico transcatéter.

Transcatheter aortic valve implantation (TAVI) is an alternative to surgical valve replacement in patients with high surgical risk. Although TAVI is becoming more and more common, it is not without complications. Rupture of the aortic root after implantation is an uncommon, but lethal complication; few cases have been described in the literature. Multidetector computed tomography is fundamental before TAVI to evaluate factors that predispose to complications; however, its role after the procedure is still controversial.

Multidetector computed tomography evaluation of candidates for transcatheter aortic valve implantation. / Evaluación de los pacientes candidatos a implante transcatéter de válvula aórtica mediante tomografía computarizada multidetector.

In transcatheter aortic valve implantation (TAVI), a biologic valve mounted in a stent is implanted without removing the native valve. This procedure was first done in humans by Alain Cribier in 2002 and was included in clinical guidelines after the multicenter PARTNER (Placement of AoRtic TraNscathetER) randomized clinical trial, which showed that TAVI obtained better outcomes than conservative medical treatment and is an alternative to surgery in patients with high surgical risk. Candidates for TAVI must be assessed to determine whether the procedure is feasible, because TAVI is not ideal for all patients who are considered inoperable. Multidetector computed tomography plays an important role in the anatomic evaluation of candidates and in guiding the procedure in those who are finally selected.

Complicaciones tras el empleo del dispositivo de cierre arterial StarClose® en punciones femorales / Complications after the use of a StarClose® vascular closure device for femoral punctures

El dispositivo de cierre arterial StarClose® (Abbot Vascular Devices, Abbot Laboratories,Redwood city, CA, EE.UU.) sella de forma rápida una punción arterial femoral mediante la colocación de un clip de nitinol en la adventicia de la arteria. Es un dispositivo seguro y efectivo, con ventajas respecto a la compresión manual, pero que no está exento de complicaciones. Presentamos dos casos con complicaciones tras utilización de StarClose® (AU)

The StarClose® arterial device (Abbot Vascular Devices, Abbot Laboratories, Redwood City, CA, USA) rapidly seals a femoral artery puncture by means of a nitinol clip in the adventitia of the artery. It is a safe and effective device, with advantages as regards manual compression, but is not free of complications. We present two cases with complications after using a StarClose® vascular device (AU)

[Complications after the use of a StarClose® vascular closure device for femoral punctures]. / Complicaciones tras el empleo del dispositivo de cierre arterial StarClose® en punciones femorales.

The StarClose(®) arterial device (Abbot Vascular Devices, Abbot Laboratories, Redwood City, CA, USA) rapidly seals a femoral artery puncture by means of a nitinol clip in the adventitia of the artery. It is a safe and effective device, with advantages as regards manual compression, but is not free of complications. We present two cases with complications after using a StarClose(®) vascular device.

Trombosis arterial secundaria a exostosis de tibia y peroné / Arterial thrombosis secondary to tibia and fibula exostosis

No disponible

Tratamiento híbrido de un aneurisma sintomático de un divertículo de Kommerell / Hybrid treatment of a symptomatic aneurysm of a Kommerell's diverticulum

El arco aórtico izquierdo con arteria subclavia derecha aberrante constituye la anomalía vascular congénita más común del arco aórtico. En el 60% de casos se origina de un segmento dilatado, denominado divertículo de Kommerell. El aneurisma de la arteria subclavia derecha aberrante es raro, puede ser clínicamente silente o cursar con síntomas inespecíficos y su rotura se asocia a una elevada mortalidad. No hay criterios precisos para el tratamiento, pero se recomienda su reparación cuando se producen síntomas por compresión o cuando alcanza 30-50mm. La radiografía puede hacer sospechar la malformación, pero la resonancia magnética (RM) o la tomografía computarizada (TC) son las pruebas de elección para realizar el diagnóstico y planificar el tratamiento. Presentamos un caso de una arteria subclavia derecha aberrante con un pequeño aneurisma calcificado en un divertículo de Kommerell que provocó dolor torácico y disfagia y fue tratado mediante un procedimiento combinado endovascular y quirúrgico (AU)

Left aortic arch with aberrant right subclavian artery is the most common congenital vascular anomaly involving the aortic arch. In 60% of cases, the aberrant right subclavian artery arises from a dilated segment of the aortic arch called Kommerell's diverticulum. Aneurysm of the aberrant right subclavian artery is rare; this condition could remain clinically silent or it could originate nonspecific symptoms. Rupture of an aneurysm of the aberrant right subclavian artery is associated with high mortality. Although there are no exact criteria to indicate the treatment of this condition, repair of the aneurysm is recommended when symptoms occur or when it reaches a size of 30mm to 50mm. The malformation can be suspected at plain-film X-ray examination, but magnetic resonance imaging (MRI) or computed tomography (CT) are the imaging tests of choice for the diagnosis and for planning treatment. We present the case of a patient with an aberrant right subclavian artery with a small calcified aneurysm in a Kommerell's diverticulum that caused chest pain and dysphagia; the patient underwent a procedure combining endovascular and surgical treatment (AU)

[Hybrid treatment of a symptomatic aneurysm of a Kommerell's diverticulum]. / Tratamiento híbrido de un aneurisma sintomático de un divertículo de Kommerell.

Left aortic arch with aberrant right subclavian artery is the most common congenital vascular anomaly involving the aortic arch. In 60% of cases, the aberrant right subclavian artery arises from a dilated segment of the aortic arch called Kommerell's diverticulum. Aneurysm of the aberrant right subclavian artery is rare; this condition could remain clinically silent or it could originate nonspecific symptoms. Rupture of an aneurysm of the aberrant right subclavian artery is associated with high mortality. Although there are no exact criteria to indicate the treatment of this condition, repair of the aneurysm is recommended when symptoms occur or when it reaches a size of 30 mm to 50mm. The malformation can be suspected at plain-film X-ray examination, but magnetic resonance imaging (MRI) or computed tomography (CT) are the imaging tests of choice for the diagnosis and for planning treatment. We present the case of a patient with an aberrant right subclavian artery with a small calcified aneurysm in a Kommerell's diverticulum that caused chest pain and dysphagia; the patient underwent a procedure combining endovascular and surgical treatment.

Tratamiento de fístulas carótido-cavernosas / Treatment of carotid-cavernous fistulas

Objetivos. Valorar los resultados del tratamiento de 33 pacientes con fístula carótido-cavernosa (FCC) de acuerdo con criterios clínicos y angiográficos. Material y métodos. De enero de 1993 a diciembre de 2003, 33 pacientes fueron diagnosticados y tratados de FCC en nuestro hospital. Se realizó examen clínico y angiografía antes y después del tratamiento. Las modalidades terapéuticas disponibles son el tratamiento conservador, mediante compresiones, y el tratamiento intervencionista, con distintos procedimientos según la vía de abordaje y el material de embolización empleados. Resultados. De las 11 FCC directas, una fue tratada de forma conservadora y 10 se sometieron a procedimientos de embolización. La vía de abordaje fue transarterial en 5, transvenosa en 2 y en 3 se utilizaron ambas, consiguiendo la desaparición de los síntomas en el 90% de los pacientes. De las 22 FCC indirectas o durales, 6 fueron tratadas de forma conservadora, con óptimo resultado, mientras que las 16 restantes se embolizaron, 11 por vía transarterial y 5 combinando los accesos transarterial y transvenoso. La terapia endovascular logró la desaparición completa de los síntomas en 9 pacientes y parcial en 7. Sólo se produjo una complicación transitoria. Conclusiones. La adecuada selección tanto del tipo de tratamiento (conservador o intervencionista), como del procedimiento (vía de abordaje y material de embolización), caso de que fuera necesario, optimiza los resultados en el manejo de pacientes con FCC

Objectives. To evaluate the results of the treatment of 33 patients with carotid-cavernous fistula (CCF) with respect to clinical and angiographic criteria. Material and methods. From January 1993 to December 2003, 33 patients were diagnosed with CCF and treated at our hospital. All patients underwent clinical examination and angiography before and after treatment. Available treatment modalities were conservative treatment, consisting of compressions, and interventional treatment, with different procedures depending on the approach and the materials employed for embolization. Results. Of the 11 direct CCFs, one received conservative treatment and 10 underwent embolization procedures. An arterial approach was used in 5 cases, a venous approach in 2, and a combined venous-arterial approach in the remaining 3, with symptoms disappearing in 90% of the patients. Of the 22 indirect or dural CCFs, 6 received conservative treatment, with optimal results, and the remaining 16 underwent embolization (11 using an arterial approach and 5 using a combined venous-arterial approach). Endovascular treatment brought about the complete disappearance of symptoms in 9 patients and partial disappearance in 7. Only one transitory complication was observed. Conclusions. The appropriate selection of both the type of treatment (conservative vs. interventional) and the interventional procedure (approach and material for embolization), yields optimal results in the management of patients with CCF

[Progression following the embolisation of 100 intracranial arteriovenous malformations]. / Evolución tras la embolización de 100 malformaciones arteriovenosas intracraneales.

INTRODUCTION: We analysed the characteristics, progression and outcomes observed following the embolisation of 100 intracranial arteriovenous malformations (AVM) that were performed in order to achieve complete obliteration of the AVM, the elimination of associated vascular risk factors and also to reduce their size with a view to increasing the effectiveness of later treatments. PATIENTS AND METHODS: The demographic and anatomical characteristics of 110 patients with AVM were analysed over a period of 13 years, and embolisation was performed in 100 of them. In all, 203 embolisation sessions were carried out with an average of 3 embolisations per patient. Of the 100 AVM that were embolised, 36 were AVM which were treated by embolisation with no later therapy, 48 required radiosurgery after the embolisation and the other 16 were submitted to surgery following the embolisation. The type of materials used included liquid adhesive embolic agents (Hystoacryl, Glubran), non-adhesive embolic agents (Onyx) and polyvinyl alcohol particles. Patients were examined clinically and arteriographically. RESULTS: Of the 100 AVM that were embolised, complete eradication was accomplished with just embolisation in 27 cases of AVM (27%). Of the 48 AVM in which radiosurgery was carried out at a later date, the average rate of obliteration was 78% and of the 16 AVM in which surgery was carried out some time later, the average rate of obliteration was 70%. Of the 100 AVM that were embolised, some residue remained in 16 cases. Embolisation eliminated most of the associated vascular risk factors, as can be seen by the fact that associated risk factors disappeared in 28 (65%) out of the 43 AVM with such factors. The morbidity and mortality rates with embolisation were 8% and 2%, respectively. CONCLUSIONS: Embolisation eliminated most of the vascular risk factors, with complete obliteration in 27 cases and size was satisfactorily reduced for later treatment; at the same time, morbidity and mortality rates were acceptable.

Evolución tras la embolización de 100 malformaciones arteriovenosas intracraneales / Progression following the embolisation of 100 intracranial arteriovenous malformations

Introducción. Analizamos las características, evolución y resultados tras la embolización de 100 malformaciones arteriovenosas (MAV) intracraneales con el objetivo de conseguir la obliteración completa de la MAV, la eliminación de los factores de riesgo vascular asociados y disminuir su tamaño para la efectividad de posteriores tratamientos. Pacientes y métodos. Analizamos las características demográficas y anatómicas de 110 pacientes portadores de MAV durante 13 años, y se realizó una embolización a 100de éstos. Se practicaron 203 sesiones de embolización con una media de 3 embolizaciones/paciente. De las 100 MAV embolizadas, hubo 36 MAV a las que sólo se realizó embolización sin otro tratamiento posterior, a 48 se les realizó radiocirugía postembolización y a los 16 restantes cirugía postembolización. El tipo del material usado fueron agentes embólicos líquidos adhesivos (Hystoacril, Glubran®), agentes embólicos no adhesivos (Onyx) y partículas de polivinil alcohol. Se revisó a los pacientes clínica y arteriográficamente. Resultados. De las 100 MAV embolizadas, hubo una erradicación completa con sólo embolización en 27 MAV (27%). De las48 MAV a las que se les realizó radiocirugía posterior, hubo una obliteración media del 78%. De las 16 MAV a las que se realizó cirugía posterior, hubo una obliteración media del 70%. De las 100MAV embolizadas, hubo 16 en las que quedaron restos. La embolización eliminó la mayoría de los factores de riesgo vascular asociados: de 43 MAV con factores de riesgo asociados, desaparecieron en 28 MAV (65%). Con la embolización se produjo una morbilidad del 8% y mortalidad del 2%. Conclusión. La embolización eliminó la mayoría de los factores de riesgo vascular, con una obliteración completa en 27 casos y se redujo el tamaño para posteriores tratamientos de manera satisfactoria, y todo ello con una morbimortalidad aceptable (AU)

Introduction. We analysed the characteristics, progression and outcomes observed following the embolisation of 100intracranial arteriovenous malformations (AVM) that were performed in order to achieve complete obliteration of the AVM, the elimination of associated vascular risk factors and also to reduce their size with a view to increasing the effectiveness of later treatments. Patients and methods. The demographic and anatomical characteristics of 110 patients with AVM were analysed over a period of 13 years, and embolisation was performed in 100 of them. In all, 203 embolisation sessions were carried out with an average of 3 embolisations per patient. Of the 100 AVM that were embolised, 36 were AVM which were treated by embolisation with no later therapy, 48 required radiosurgery after the embolisation and the other 16 were submitted to surgery following the embolisation. The type of materials used included liquid adhesive embolic agents (Hystoacryl, Glubran ®), non adhesiveembolic agents (Onyx) and polyvinyl alcohol particles. Patients were examined clinically and arteriographically. Results. Of the 100 AVM that were embolised, complete eradication was accomplished with just embolisation in 27 cases of AVM (27%). Of the 48 AVM in which radiosurgery was carried out at a later date, the average rate of obliteration was 78% and of the 16 AVM in which surgery was carried out some time later, the average rate of obliteration was 70%. Of the 100 AVM tha twere embolised, some residue remained in 16 cases. Embolisation eliminated most of the associated vascular risk factors, as can be seen by the fact that associated risk factors disappeared in 28 (65%) out of the 43 AVM with such factors. The morbidity and mortality rates with embolisation were 8% and 2%, respectively. Conclusions. Embolisation eliminated most of the vascular risk factors, with complete obliteration in 27 cases and size was satisfactorily reduced for later treatment; at the same time, morbidity and mortality rates were acceptable (AU)