Revascularización cerebral inusual tras la corrección de un pseudoaneurisma carotídeo recurrente / Unusual cerebral revascularisation following correction of a recurring carotid pseudoaneurysm

Introducción. La aparición de pseudoaneurismas tras endarterectomía carotídea es una complicación poco habitual.Su corrección se asocia a una notable morbimortalidad, y ante la imposibilidad de reestablecer la continuidad delflujo, puede ser incluso necesaria la ligadura arterial. Caso clínico. Varón de 73 años de edad con un pseudoaneurismadesarrollado tras once años de la corrección inicial de un primer pseudoaneurisma que precisó la ligadura de la arteria carótidaprimitiva. El estudio hemodinámico completo (dúplex y Doppler transcraneal) confirmó la presencia del pseudoaneurisma,la oclusión de la carótida primitiva y la permeabilidad de las arterias carótida interna (ACI) y externa (ACE).Además, se objetivó la correcta perfusión de la arteria cerebral media directamente a través del flujo invertido originado enla ACE. Ante estos hallazgos y la sospecha de un sustrato infeccioso, se practicó la resección del pseudoaneurisma y unaanastomosis terminoterminal ACE/ACI, y se desestimó una revascularización convencional (anatómica/extraanatómica) ola ligadura arterial distal. Cultivos perioperatorios positivos para Staphylococcus aureus. En el postoperatorio inmediato,no se observan eventos neurológicos ni lesión de pares craneales. El paciente se mantuvo con tratamiento antibiótico (cloxacilina)domiciliario durante seis semanas. El control ecográfico al mes y a los seis meses de seguimiento confirmó la permeabilidadde la técnica y la ausencia de signos de sobreinfección. Conclusiones. Este caso refleja el beneficio de realizarun estudio hemodinámico completo intra/extracraneal previo a establecer una estrategia de revascularización óptima en situacionesclínicas inusuales. Además, confirma la potencial viabilidad de la utilización de la ACE como fuente de flujo directopara la revascularización cerebral en presencia de oclusión de carótida primitiva(AU)

Introduction. The appearance of pseudoaneurysms following a carotid endarterectomy is an infrequentcomplication. Their correction is associated with a notable rate of morbidity and mortality, and if it becomes impossibleto re-establish a continuous flow, arterial ligation may even become necessary. Case report. A 73-year-old male with apseudoaneurysm that developed 11 years after the initial correction of a first pseudoaneurysm that required ligation ofthe primitive carotid artery. The full haemodynamic study (by duplex and transcranial Doppler) confirmed the presenceof a pseudoaneurysm, the occlusion of the primitive carotid and the patency of the internal and external carotid arteries(ICA and ECA, respectively). Moreover, correct perfusion of the middle cerebral artery was also observed directly by thereversed flow originated in the ECA. Given these findings and the suspicion of an infectious substrate, resection of thepseudoaneurysm and an end-to-end ICA/ECA anastomosis were performed; both conventional (anatomical/extraanatomical)revascularisation and distal arterial ligation were rejected. Perioperative cultures were positive forStaphylococcus aureus. In the immediate post-operative period, no neurological events or injuries to cranial nerveswere observed. The patient was kept on home treatment with antibiotics (cloxacillin) for six weeks. An ultrasonographyexamination at one month and at six months of follow-up confirmed the patency of the technique and the absence ofsigns of over-infection. Conclusions. This case reflects the benefits of performing a full intra/extracranial haemodynamicstudy prior to establishing an optimal revascularisation strategy in unusual clinical situations. Furthermore, it confirmsthe potential viability of utilising the ECA as a suitable direct entrance for cerebral revascularisation in the presence ofocclusion of the primitive carotid(AU)

Evaluation of complications due to percutaneous renal biopsy in allografts and native kidneys with color-coded Doppler sonography.

We studied 142 consecutive percutaneous renal biopsies (puncturing on 73 allografts and 69 native kidneys) which were performed under continuous ultrasonic guidance, on 133 adult patients. The patients were monitored, at least, during the next 24 hours. We compared the complication rate for biopsies recording clinical and biochemical data and, the day after the biopsy, the kidney was examined with a color-coded Doppler sonography (CCDS): in real-time survey of the kidney and with spectral wave form analysis. The diagnosis of arteriovenous (AV) fistula was achieved detecting increased color saturation toward white, high peak systolic flow velocity and low resistive index in the supplying artery. Three procedures were excluded of the analyses because of incomplete data recorded, although none of them showed any remarkable complication. There was a 94.3% rate of successful biopsies. The mean +/- SEM number of glomeruli under light microscopic examination was 8.5 +/- 0.6. Complications occurred 64 times in relation to 55 patients with a higher incidence in allografts (61%) than in native kidneys (31%). Renal transplant patients showed higher serum creatinine values (5.8 +/- 0.8 vs. 3.2 +/- 0.4; p > 0.0001) and lower hematocrit (31.3 +/- 1.1 vs. 34.4 +/- 0.9; p = 0.025) than the native-kidney patients at the time of biopsy. De novo hematuria occurred in 30% of the procedures. In transplant patients, the gross hematuria incidence (9.9%) more than doubled that showed by native-kidney patients. The incidence of serious complications (hematoma, hemoperitoneum and AV fistula) was 16.5% and these were more frequent in transplant than in native kidneys.(ABSTRACT TRUNCATED AT 250 WORDS)

Arteriovenous fistulas in the neck: diagnosis with color Doppler sonography.

We report the use of color Doppler imaging in the diagnosis of four arteriovenous fistulas in the neck region: two had a traumatic origin and two were spontaneous. A perivascular color artifact was the most common initial finding on color images to indicate the underlying abnormality. In all four cases, a low-resistance flow with high systolic and diastolic velocities was observed in the feeding artery. Although angiography remains essential before therapeutic embolization, color Doppler sonography may be an important tool for screening and follow-up of cervical arteriovenous fistulas.

Diagnostic utility of color Doppler ultrasound in lower limb deep vein thrombosis in patients with clinical suspicion of pulmonary thromboembolism.

The diagnosis of pulmonary thromboembolism is frequently based on ventilation-perfusion scintigraphy and ascending lower limb venography when pulmonary angiography is not available. The aim of this study is to compare color Doppler ultrasound against ascending venography in the evaluation of the lower limb deep vein system in patients with clinical suspicion of pulmonary embolism, with special attention to calf veins. We prospectively studied 30 patients with clinical suspicion of pulmonary embolism in whom a color Doppler ultrasound and venogram were performed with no more than a 3-h interval between both procedures. The diagnostic criteria was that of loss of venous compressibility. The 'color' ability was used to identify artery from vein. Out of 15 patients in whom a venogram proved positive (50%), 9 had isolated calf vein thrombosis (60%). In 5 patients, the color Doppler ultrasound of the calf was considered inconclusive. Overall sensitivity was 53%, specificity 100%, positive predictive value 100%, and negative predictive value 68%. In the femoropopliteal system, sensitivity was 83% and specificity 100%. Considering all patients, sensitivity in the calf system was 40%. Excluding the 5 patients who were difficult to assess, sensitivity increased to 60%. In conclusion, color Doppler ultrasound is not as sensitive as venography in dealing with patients with clinical suspicion of pulmonary embolism, due to its low sensitivity in the calf system when distal thrombi need to be excluded. However, a reasonable alternative is to begin by performing a compression ultrasonography of the femoropopliteal system. Color Doppler ultrasonography of the calf system represents a rarely sensitive and arduous task and does not seem justifiable in this type of patient.(ABSTRACT TRUNCATED AT 250 WORDS)