Manejo endovascular de seudoaneurisma vertebral bilateral iatrogénico en paciente con ganglioneuroma / Endovascular management of an iatrogenic bilateral vertebral artery pseudoaneurysm in a patient with a ganglioneuroma

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Tratamiento primario con láser diodo en malformación venosa cervical de gran tamaño / Laser diode treatment of a giant lateral-neck venous malformation

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Incidencia y evolución del síndrome compartimental abdominal en aneurismas de aorta rotos tratados con endoprótesis / Incidence and outcomes of abdominal compartment syndrome after endovascular aneurysm repair in ruptured aortic aneurysms

OBJETIVO: Estudiar la incidencia, evolución y manejo del síndrome compartimental abdominal (SCA) en los aneurismas de aorta infrarrenal rotos (AAAr) tratados con endoprótesis en nuestro centro. Material y metodología: Estudio observacional retrospectivo. Analizamos todos los pacientes tratados con endoprótesis urgentes desde octubre de 2001 a diciembre de 2015. Incluimos solo pacientes con aneurismas de aorta infrarrenal rotos, excluyendo los AAA sintomáticos. Estudiamos la incidencia, evolución y tratamiento del SCA. Establecimos diagnóstico de SCA con una presión intraabdominal medida en vejiga > 20 mmHg, más el desarrollo de una nueva disfunción orgánica. Analizamos variables preoperatorias y postoperatorias para SCA. Utilizamos test exacto de Fisher y U de Mann-Whitney para el análisis estadístico. RESULTADOS: Durante el periodo analizado se implantaron 65 endoprótesis urgentes, de ellas 42 fueron por aneurismas de aorta infrarrenal rotos. La edad media fue 77 ± 8 años; el 98% fueron hombres. De los 42 pacientes estudiados, 9 (21,4%) fallecieron en quirófano. La incidencia de SCA en los 33 pacientes restantes fue 18,2% (6/33 pacientes). La mortalidad en SCA fue 66,7 frente 18,5% para los que no desarrollaron SCA (p = 0,034). Se realizó laparotomía descompresiva en 4 pacientes (4/6), siendo la mortalidad en estos pacientes del 50 frente al 100% para los que no se realizó laparotomía descompresiva (p = 0,4). Se asociaron con desarrollo de SCA la acidosis pre- y postoperatoria (57,7 vs. 7,7%, p = 0,01), coagulopatía preoperatoria (41,7 vs. 4,8%, p = 0,01), tensión sistólica <90mmHg preoperatoria (46,2 vs. 0%, p = 0,002) y administración > 3 litros de cristaloides/24 h en postoperatorio (38,5 vs. 5%, p = 0,02). Los pacientes con SCA recibieron intraoperatoriamente 8 ± 3,6 concentrados de hematíes vs. 2 ± 2,7 (p = 0,002). CONCLUSIONES: Estos hallazgos confirman que el SCA es una patología frecuente que asocia una elevada mortalidad en pacientes con AAAr tratados con endoprótesis. El compromiso hemodinámico importante y la administración de grandes cantidades de cristaloides intravenosos y politransfusión durante el manejo asocian mayor incidencia de este síndrome

OBJECTIVE: To study the incidence, evolution and management of abdominal compartment syndrome (ACS) in ruptured abdominal aortic aneurysms (RAAA) after endovascular aneurysm repair. MATERIAL AND METHODS: Retrospective observational study. We analyzed all emergency EVAR performed from October 2001 to December 2015. Only RAAA were included. Symptomatic aortic aneurysms were excluded. We studied the incidence, evolution and management of ACS. Diagnosis of ACS was established with intraabdominal pressure more than 20 mmHg plus the development of a new organic dysfunction. Preoperative and postoperative variables were analyzed for ACS. Fisher exact test and Mann-Whitney U-test were used for the statistical analysis. RESULTS: Sixty-five emergency EVAR were performed during the analyzed period, 42 were RAAA. The mean age was 77 ± 8 years; 98% were men. Nine of 42 patients (21.4%) died in the operating room. The incidence of ACS in the 33 remaining patients was 18.2% (6/33 patients). The mortality for ACS was 66.7% vs 18.5% (p = 0.034). Decompressive laparotomy was performed in 4 patients (4/6). The mortality after decompressive laparotomy was 50% vs 100% (p = 0.4). The incidence of ACS for postoperative acidosis was 57.7% vs 7.7% (p = 0.01), for preoperative coagulopathy 41.7% vs 4.8% (p = 0.01), for preoperative systolic blood pressure < 90 mmHg 46.2% vs 0% (p = 0.002). The incidence of ACS after overload of more than 3 liters of crystalloids per 24 hours in the postoperative period was 38.5% vs 5% (p = 0.02). Patients with ACS received intraoperatively 8 ± 3.6 packed erythrocytes vs 2 ± 2.7 (p = 0.002). CONCLUSIONS: These findings confirm that ACS is a common disease that is associated with a high mortality in patients with RAAA after EVAR. Patients with a compromise hemodynamic status, multiple transfusions and those with overload of intravenous crystalloids during management were associated with higher incidence of ACS

Incidencia y evolución del trombo intraprótesis tras reparación endovascular de aneurismas aortoilíacos infrarrenales / Incidence and outcome of intraprosthetic thrombus after endovascular infrarenal aortoiliac aneurysms repair

INTRODUCCIÓN Y OBJETIVOS: La formación de trombo intraprótesis (TI) tras reparación endovascular de aneurismas aortoilíacos infrarrenales (EVAR) es un hallazgo frecuente cuya repercusión clínica no está definida. OBJETIVO: Conocer la incidencia de formación de TI, su curso clínico y la existencia de factores predisponentes. MATERIAL Y MÉTODOS: Desarrollamos un estudio observacional retrospectivo. Entre febrero de 2009 y junio de 2014, realizamos 184 EVAR con endoprótesis Endurant II(R), excluyendo aquellos con seguimiento inferior a 5 meses. Recogimos factores de riesgo cardiovascular, antiagregación/anticoagulación, anatomía del aneurisma, configuración y tamaño del dispositivo, ratio de diámetros distal y proximal del dispositivo, presencia de endofuga y de TI durante el seguimiento, evolución del TI, complicaciones isquémicas y reintervenciones. Analizamos variables cualitativas con tablas de contingencia y chi-cuadrado y variables continuas, con t de Student. Análisis actuarial y log-rank para supervivencia, aparición de complicaciones y reintervención. RESULTADOS: Obtuvimos un seguimiento medio de 20,87 meses. Desarrollaron TI en 81 pacientes (44%). Solo encontramos relación con cáncer activo (p = 0,003; OR 3,639; IC 95%; 1,501-8,825), tratamiento anticoagulante (p = 0,006; OR 0,257; IC 95%; 0,092-0,715) y endofugas tipo II (p = 0,013; OR 0,406; IC 95%; 0,197-0,836). En 6 pacientes el trombo desapareció durante el seguimiento (7%). Las tasas de complicación y reintervención en función de presencia o ausencia de TI no mostraron diferencias significativas. CONCLUSIÓN: El TI es un hallazgo frecuente que no parece tener repercusión clínica significativa. La anticoagulación y la endofuga tipo II se presentan como factores protectores y el cáncer activo, como factor predisponente

INTRODUCTION: Although the appearance of intraprosthetic thrombus after endovascular infrarenal aortoiliac aneurysms repair is common, its clinical impact is not well defined. OBJECTIVE: Endoprosthetic thrombus prevalence, clinical impact and possible related factors. MATERIAL AND METHODS: A retrospective review was conducted on 184 Endurant type II stent grafts implanted between Feb/09 and Jun/14. Patients with a follow up less than 5 months were excluded. A record was made of cardiovascular risk factors, treatment, anatomy of aneurysms, endoprosthesis features, prosthetic thrombus appearance and behaviour, endoleaks, ischaemic events, and re-interventions. RESULTS: The mean follow up was 20.87 months. Intraprosthetic thrombus was observed in 81 patients (44%). Related factors: active cancer (P=.003; OR 3.639; 95% CI; 1.501-8.825), anticoagulation therapy (P=.006; OR 0.257; 95% CI; 0,092-0,715) and type II endoleaks (P=.013; OR 0.406; 95% CI; 0.197-0.836). The thrombus disappeared in 6 patients during follow up (7%). The thrombus group did not have a higher complication or re-intervention rate when compared with the non-thrombus group. CONCLUSION: Intraprosthetic thrombus occurs frequently. Its clinical behaviour seems benign. Risk factors: Active cancer. Protective factors: Anticoagulation therapy and type II endoleaks

Aplicabilidad de la escala de riesgo Finnvasc en pacientes con isquemia crítica tratados mediante revascularización infrainguinal / Usefulness of the Finnvasc risk score in patients with critical ischemia subjected to infrainguinal revascularization

OBJETIVOS: Múltiples estudios demuestran que la escala de riesgo Finnvasc tiene alto valor predictivo de mortalidad y amputación mayor precoces en pacientes con revascularización de miembros inferiores por isquemia crítica (IC). Se estudió la aplicabilidad de Finnvasc en nuestro centro. MATERIAL Y MÉTODOS: Se estudió a 190 pacientes tratados mediante revascularización infrainguinal por IC desde enero de 2012 hasta diciembre de 2013. Se estratificaron grupos según la puntuación Finnvasc y se midieron los eventos adversos postoperatorios. Mediante un análisis de la varianza (ANOVA) se estudió la asociación entre la puntuación obtenida y la ocurrencia de eventos adversos. Se utilizó la curva ROC para estimar el valor predictivo de la escala de riesgo. RESULTADOS: En los primeros 30 días postoperatorios, 6 pacientes (3,2%) fallecieron y 14 (7,4%) fueron amputados. Para los grupos con puntuación de 0, 1, 2 y ≥3, la incidencia de amputación fue de 0; 3,3; 10 y 15%. La mortalidad fue 0; 5; 1,3 y 7,7% y la mortalidad/amputación combinada fue de 0; 8; 11 y 23% respectivamente. El ANOVA para estas diferencias no obtuvo significación estadística (p = 0,08; p = 0,2; p = 0,057 respectivamente). Las curvas ROC muestran que el valor de la escala fue regular para predecir amputación mayor precoz (AUC = 0,694; 0,570-0,818) y malo para mortalidad precoz (AUC = 0,563; 0,316-0,811). La curva ROC para mortalidad/amputación combinada fue similar (AUC = 0,664; 0,543-0,785). CONCLUSIONES: La escala Finnvasc en la población de nuestro estudio no ha demostrado un valor predictivo aceptable para la mortalidad y la amputación. Además, no se objetivó una relación estadísticamente significativa para estas variables aisladas o combinadas

OBJECTIVES: Many studies show that the Finnvasc risk score predicts early mortality and major amputation in patients with critical lower limb ischemia (CI) after revascularization. A study is made on the applicability of the score in our center. MATERIAL AND METHODS: A total of 190 patients underwent infrainguinal revascularization for CI from January 2012 to December 2013. The patients were stratified into 4 groups according to the Finnvasc score. The incidence of postoperative adverse events was measured. Analysis of variance (ANOVA) was used to determine the association between the score and adverse events. The ROC curve was used to estimate the predictive value of the risk score. RESULTS: In the first 30 postoperative days, 6 patients (3.2%) died and 14 (7.4%) underwent major amputation. For groups with scores of 0, 1, 2 and ≥3, the incidence of amputation was 0, 3.3, 10 and 15%; the mortality rate was 0, 5, 1.3 and 7.7%, and the mortality/amputation combined was 0, 8, 11 and 23%, respectively. The ANOVA for these results did not achieve statistical significance (P=.08; P=.2; P=.057, respectively). The ROC curves showed that the score was average for predicting early major amputation (AUC=.694; 0.570-0.818) and poor for predicting mortality (AUC=.563; 0.316-0.811). The ROC curve for mortality/amputation combined was similar (AUC=.664; 0.543-0.785). CONCLUSIONS: The Finnvasc score in the studied population did not demonstrate an acceptable predictive value for early mortality and major amputation

Potential of mesenchymal stem cell in stabilization of abdominal aortic aneurysm sac.

BACKGROUND: In their origin, abdominal aortic aneurysms (AAAs) are related to an inflammatory reaction within the aortic wall, which can lead to weakness and degeneration of this structure. One of the most widely accepted treatment modalities for AAAs is the placement of stent grafts. Nevertheless, in some patients blood re-enters the aneurysm sac, creating so-called leaks, which constitute a renewed risk of rupture and death.This study explores the possibility of filling aneurysm sacs treated by endovascular aneurysm repair with adipose tissue-derived mesenchymal stem cells (ASCs) in a porcine model. METHODS: We developed a porcine model using 22 animals by creating an artificial AAA made with a Dacron patch. AAAs were then treated with a coated stent that isolated the aneurysm sac, after which we introduced allogeneic ASC into the sac. Animals were followed-up for up to 3 mo. The experiment consisted of the aforementioned surgical procedure performed first, followed by computed tomography and echo-Doppler imaging during the follow-up, and finally, after sacrificing the animals, histologic analysis of tissue samples from the site of cell implantation by a blinded observer and the detection of implanted cells by immunofluorescence detection of the Y chromosome. RESULTS: Our findings demonstrate the survival of ASCs over the 3 mo after implantation and histologic changes associated with this treatment. Treated animals had less acute and chronic inflammation throughout the study period, and we observed increasing fibrosis of the aneurysm sac, no accumulation of calcium, and a regeneration of elastic fibers in the artery. CONCLUSIONS: The combination of endovascular aneurysm repair and cell therapy on AAAs has promising results for the stabilization of the sac, resulting in the generation of living tissue that can secure the stent graft and even showing some signs of wall regeneration. The therapeutic value of such cell-based therapy will require further investigation.

Accidentes neurológicos tras esclerosis de varices: a propósito de un caso / Neurological accidents after sclerosis of varicose veins: Presentation of a case

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Tratamiento con trombina de seudoaneurisma femoral poscateterismo en neonato / Treatment of a postcatheter femoral pseudoaneurysm with thrombin in a newborn

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Uso de plasma rico en plaquetas para cicatrización de úlceras crónicas de miembros inferiores / Use of Platelet-Rich Plasma in the Healing of Chronic Ulcers of the Lower Extremity

INTRODUCCIÓN Y OBJETIVOS: El plasma rico en factores plaquetarios (PRP) ha sido utilizado como terapia adyuvante en el tratamiento de úlceras crónicas de miembros inferiores (UCMI), con resultados particularmente esperanzadores en las úlceras neuropáticas. Sin embargo, su uso en úlceras venosas e hipertensivas ha sido menos estudiado. Nuestro objetivo es valorar la seguridad y factibilidad del uso del PRP en UCMI y estimar sus beneficios en la cicatrización dirigida. MATERIAL Y MÉTODOS: Se trata de un estudio prospectivo. Fueron seleccionados 11 pacientes con úlceras en miembros inferiores de más de 6 semanas de evolución, de etiología no isquémica. Se administró PRP en inyección subcutánea perilesional y aplicación tópica, en 4 sesiones separadas por una semana. Se suministraron cuestionarios de calidad de vida (SF-12), se registró el dolor (escala visual analógica) y el perímetro de la úlcera antes y después de su aplicación. RESULTADOS: Hubo predominancia de mujeres (8/11 = 73%) y de úlceras venosas (7/11 = 64%) sobre las hipertensivas (4/11 = 36%). La mediana de edad fue de 79 años y el tiempo medio de evolución de la úlcera de 17 meses (6-108 meses). Se evidenció una disminución estadísticamente significativa del dolor (p < 0,05) y mejoría mental y física de la calidad de vida (p < 0,05). Se evidenció una reducción media en el área de las úlceras del 60%, con 5 cicatrizaciones completas. No se registraron eventos adversos. CONCLUSIÓN: La aplicación local de PRP en úlceras crónicas de miembros inferiores representa una herramienta válida, de uso práctico en la cicatrización dirigida, que puede mejorar la calidad de vida de estos pacientes, siendo particularmente útil en el control del dolor local

INTRODUCTION AND OBJECTIVES: Platelet-rich plasma (PRP) is used as an adjuvant in the treatment of chronic ulcers of the lower extremity and has shown particularly promising results in the case of neuropathic ulcers. There has been less research, however, into its use in venous and hypertensive ulcers. Our aim was to assess the safety and feasibility of using PRP in the treatment of chronic ulcers of the lower extremity and to evaluate its potential benefits in directed healing. MATERIAL AND METHODS: We prospectively selected 11 patients with nonischemic ulcers of the lower extremity that had been present for at least 6 weeks. PRP was injected subcutaneously into the perilesional tissue and applied topically in 4 sessions held at 1-week intervals. We assessed quality of life (SF-12 questionnaire), pain (visual analog scale), and the circumference of the ulcer before and after treatment. RESULTS: There was a predominance of women (8/11, 73%), and venous ulcers (7/11, 64%) were more common than hypertensive ulcers (4/11, 36%). The median age of the patients was 79 years and the median time since onset of the ulcer was 17 months (range, 6-108 months). We observed a significant reduction in pain (P < 0.05) and a significant improvement in the physical and mental components of the SF-12 (P < 0.05). The mean reduction in ulcer size was 60%, and complete healing was achieved in 5 cases. No adverse effects were observed. CONCLUSION: The local application of PRP is a valuable and practical procedure that promotes the healing of chronic ulcers of the lower extremity; it can improve patient quality of life and is particularly effective in local pain relief

Use of platelet-rich plasma in the healing of chronic ulcers of the lower extremity.

INTRODUCTION AND OBJECTIVES: Platelet-rich plasma (PRP) is used as an adjuvant in the treatment of chronic ulcers of the lower extremity and has shown particularly promising results in the case of neuropathic ulcers. There has been less research, however, into its use in venous and hypertensive ulcers. Our aim was to assess the safety and feasibility of using PRP in the treatment of chronic ulcers of the lower extremity and to evaluate its potential benefits in directed healing. MATERIAL AND METHODS: We prospectively selected 11 patients with nonischemic ulcers of the lower extremity that had been present for at least 6 weeks. PRP was injected subcutaneously into the perilesional tissue and applied topically in 4 sessions held at 1-week intervals. We assessed quality of life (SF-12 questionnaire), pain (visual analog scale), and the circumference of the ulcer before and after treatment. RESULTS: There was a predominance of women (8/11, 73%), and venous ulcers (7/11, 64%) were more common than hypertensive ulcers (4/11, 36%). The median age of the patients was 79 years and the median time since onset of the ulcer was 17 months (range, 6-108 months). We observed a significant reduction in pain (P<.05) and a significant improvement in the physical and mental components of the SF-12 (P<.05). The mean reduction in ulcer size was 60%, and complete healing was achieved in 5 cases. No adverse effects were observed. CONCLUSION: The local application of PRP is a valuable and practical procedure that promotes the healing of chronic ulcers of the lower extremity; it can improve patient quality of life and is particularly effective in local pain relief.

Evolución del uso de técnicas endovasculares para revascularización infrainguinal de miembros inferiores en el periodo 2005-2011. Experiencia de nuestro centro / Development in the use of endovascular techniques for the infrainguinal revascularisation of lower limbs in the period 2005-2011: Experience for a single center

Introducción: Las intervenciones endovasculares en el sector infrainguinal han experimentado una tendencia creciente. Objetivo: Describir la evolución que ha sufrido el uso de los procedimientos endovasculares infrainguinales en nuestro centro desde su introducción en el año 2005 hasta la actualidad. Material y métodos: De 6.867 procedimientos, fueron seleccionados los 391 de revascularización infrainguinal. Estudio de corte transversal, revisando los registros de quirófano a través de los protocolos quirúrgicos e historias clínicas, clasificándolos en procedimientos endovasculares y abiertos. Se revisó el compromiso clínico y el éxito técnico morfológico de los procedimientos endovasculares para compararlos durante el periodo. Resultados: El 81,32% fueron intervenidos por isquemia crítica. Se evidenció una tendencia al aumento global de procedimientos de revascularización infrainguinal, fundamentalmente a expensas de los endovasculares, los cuales se incrementan tanto en números absolutos como en proporción con los procedimientos abiertos (23,4 a 58,5%; p < 0,05). También se observó un leve aumento de la tasa de éxito técnico al comparar el inicio y el final del periodo, aunque no estadísticamente significativo (p = 0,37). Conclusiones: El uso de técnicas endovasculares en la revascularización de miembros inferiores en nuestro centro ha ido en claro aumento en los últimos años, presentando una tendencia a seguir incrementándose. Aunque no poseemos datos que nos permitan asegurarlo, pensamos que el uso de estos procedimientos puede ser un factor importante en el aumento de pacientes candidatos a revascularización de miembros inferiores observado en nuestra serie (AU)

Introduction: There is a growing trend in the number of infrainguinal endovascular revascularisations being performed in recent years. Objective: The primary aim of this study is to describe the development of the use of endovascular procedures for infrainguinal revascularisation in a hospital centre since its introduction in 2005 to the present date. Material and methods: A study was conducted on the 391 infrainguinal revascularisations performed out of a total of 6.867 procedures. A cross-sectional study was performed by reviewing surgery records, surgical protocols, and medical histories, and sorting them into endovascular and open surgery. Clinical compromise and morphological technical success were analysed in the endovascular procedures group in order to compare them over the study period. Results: A large majority (81.32%) presented as critical limb ischaemia. An increasing trend was observed in the number infrainguinal revascularization procedures performed, mainly at the expense of the endovascular group, which increased both in absolute numbers and proportionally compared to open surgery procedures (23.4% to 58,5%; P<0.05). A slight increase in the rate of technical success was also noted when comparing the beginning and the end of the period, although this was not statistically significant (P=0.37). Conclusions: The use of endovascular techniques in lower limb revascularisation in our institution has experienced a marked growth in recent years, with a tendency to increase further. Although we do not have the necessary data to ensure this, we believe that the use of these procedures may be an important factor in the increasing number of candidates for the lower limb revascularisations observed in our series (AU)

Serie de casos. Experiencia de un único centro en el tratamiento de fístulas aortoentéricas / A case series. Experience of a single centre in the treatment of aortoenteric fistulas

Objetivo: Analizar nuestra experiencia y resultados obtenidos en una patología infrecuente, compleja y grave como la fístula aortoentérica (FAE). Material y métodos: La patología aórtica previa y su tratamiento fueron: 4 síndromes de Leriche y 2 aneurismas de aorta y un aneurisma roto tratados con bypass aortobifemoral y dos endovascular aneurysms repair (EVAR). Otros datos recogidos fueron: factores de riesgo cardiovascular, patología y cirugía abdominal previa, la localización de FAE secundaria, periodo de tiempo hasta la FAE, evolución y recidivas. Nueve pacientes (7 hombres y 2 mujeres) con fístula secundaria aortoentérica tratados durante el periodo 2000-2010 se agruparon en función de la estabilidad hemodinámica: 3 hombres estables, 4 hombres y 2 mujeres inestables. Resultados: Las FAE secundarias aparecieron tras una media de tiempo de 85,8 meses (mediana: 104; rango: 5-204). Cuatro se trataron con bypass extra-anatómico, 3 inestables. Tres pacientes con reparación in situ, 2 inestables. Dos de forma endovascular, uno inestable. Hubo una muerte intra-quirófano, inestable, y durante los primeros 30 días fallecieron otros 4 pacientes, 3 inestables y uno estable. Los 4 pacientes que sobrevivieron sufrieron una recidiva de la FAE tras tres meses de media (intervalo: 2-5); solo dos se trataron, uno con endoprótesis y otro con bypass axilobifemoral. Conclusiones: La FAE secundaria es una complicación grave, rara y compleja, con una alta morbilidad y mortalidad. No existe un tratamiento estándar, aunque es fundamental el tratamiento urgente de la hemorragia, incluyendo la terapia endovascular, con o sin una nueva intervención para el tratamiento definitivo(AU()

Objective: To analyse our experience and results of a rare, complex and serious disease, aortoenteric fistula (AEF). Material and methods: Nine patients (seven males and two females) with secondary aortoenteric fistula treated during the period 2000-2010, were grouped according to hemodynamic stability: stable three males. Four males and two females were unstable. Previous aortic pathology and its treatment were: four Leriche syndrome, two aortic aneurysms and a ruptured aortic aneurysm treated by aortobifemoral bypass and two EVAR (endovascular aneurysms repair). Other data collected: cardiovascular risk factors, previous abdominal pathology and its surgery, the location of the secondary AEF, period of time until the appearance of AEF, evolution and recurrence. Results: The secondary AEF appeared after a mean time of 85.8 months (median 104, range 5-204). Four were treated with extra-anatomical bypass, and three were unstable. Three patients with in situ repair, two unstable. Two with endograft, one unstable. There was one death during surgery, unstable, and during the first 30 days, four patients died, 3 unstable, one stable. The four surviving patients had a recurrence of the AEF after a mean of three months (range, 2-5), only two were treated, one patient with endograft and one with axilobifemoral bypass. Conclusions: Secondary AEF is a serious, rare and complex complication, with high morbidity and mortality. No standard treatment exists, although the urgent treatment of bleeding is essential, including endovascular therapy, with or without a new intervention for definitive treatment(AU)

Tratamiento endovascular de la aorta torácica / Endovascular treatment of the abdominal aortic aneurysm

El tratamiento endovascular ha supuesto un cambio muy importante en las posibilidades terapéuticas que implican la aorta torácica. La disminución de la morbimortalidad gracias a los procedimientos menos invasivos hacen que este tratamiento se plantee como la primera opción terapéutica en el territorio que nos ocupa. En este trabajo se resumen las distintias entidades nosológicas que pueden afectar a la aorta torácica, los métodos diagnósticos más adecuados en cada caso y las distintas estrategias de tratamiento basándonos en una revisión actualizada de la literatura disponible(AU)

The endovascular approach has led to great changes in therapeutic possibilities involving the thoracic aorta. Low morbidity and mortality rates due to the less invasive procedures, tends to make this the first therapeutic option. This paper summarises the most important diseases involving the thoracic aorta, the most suitable diagnostic methods, and different treatment options based on an updated review of the literature(AU)

Análisis coste-efectividad del tratamiento del aneurisma de aorta abdominal mediante prótesis endovascular en España / Analysis of the cost-effectiveness of using stents to treat abdominal aortic aneurysms in spain

Objetivos. Determinar si el tratamiento endovascular (TEV) es una opción coste-efectiva en la terapia delaneurisma de aorta abdominal (AAA) respecto a la cirugía abierta, y evaluar el impacto presupuestario de una mayorutilización de estos dispositivos en el Sistema Nacional de Salud. Pacientes y métodos. Realizamos un análisis costeefectividady coste-utilidad del TEV frente a cirugía abierta utilizando un modelo de Markov de ciclos mensuales basadoen datos clínicos de la literatura (esencialmente el estudio EVAR-1) y la opinión de expertos. Tuvimos en consideraciónuna población española hipotética de pacientes con AAA igual o superior a 5 cm y tributarios de cirugía abierta. El análisislo realizamos desde la perspectiva del Sistema Nacional de Salud, y se descontaron costes y efectos futuros al 3,5%.Adicionalmente realizamos el impacto presupuestario y un análisis de sensibilidad probabilístico con la simulación deMonte-Carlo. Resultados. Los resultados mostraron que el TEV se asocia a una mayor efectividad que la cirugía abierta,con ganancias de entre 0,03 y 0,18 años de vida por paciente a uno y cuatro años, respectivamente (resultados similaressi se utilizan años de vida ajustados por calidad). El coste medio por paciente fue mayor en TEV, entre 2.879 y 3.492euros según distintos escenarios, el coste por años de vida ganado con TEV fue de 111.064 a 19.852 euros y el coste poraños de vida ajustados por calidad ganado fue de 137.206 a 27.077 euros (análisis a uno y cuatro años, respectivamente).El impacto presupuestario de aumentar la introducción de la endoprótesis evaluada en España durante los próximoscuatro años representa el 0,5-2,2% del coste total de las AAA. Conclusiones. El TEV es una alternativa coste-efectiva conrespecto a la intervención quirúrgica convencional, ya que a los cuatro años de seguimiento presenta valores por debajodel umbral de eficiencia usualmente aceptado en España(AU)

Aims. To determine whether endovascular treatment (EVT) is a cost-effective option for the treatment ofabdominal aortic aneurysm (AAA) with respect to open surgery, and to evaluate the budget impact of a more widespreadutilisation of these devices in the Spanish National Health Service. Patients and methods. We performed a costeffectivenessand cost-utility analysis of EVT versus open surgery using a Markov model of monthly cycles based onclinical data from the literature (essentially the EVAR-1 study) and the opinion of experts. The sample taken into accountwas a hypothetical Spanish population of patients with AAA equal to or larger than 5 cm and who were candidates foropen surgery. The analysis was performed from the perspective of the National Health Service, and future costs andeffects were discounted at 3.5%. Additionally we also examined the budget impact and performed a probabilisticsensitivity analysis with Monte-Carlo simulation. Results. The results showed that EVT is associated to a higher degreeof effectiveness than open surgery, with gains of between 0.03 and 0.18 years of life per patient at one and four years,respectively (similar results to those obtained if quality adjusted life years are used). The mean cost per patient wasgreater in EVT, between 2879 and 3492 euros, depending on the different scenarios, the cost-life years gained with EVTwas from 111 064 to 19 852 euros and the cost-quality adjusted life years gained was from 137 206 to 27 077 euros(analysis at one and four years, respectively). The budget impact of increasing the introduction of stents evaluated inSpain over the next four years represents 0.5-2.2% of the total cost of AAA. Conclusions. EVT is a cost-effectivealternative with respect to conventional surgical interventions, because at four years of follow-up it offers values thatare below the efficiency threshold that is usually accepted in Spain(AU)

[Treatment of an abdominal aorta aneurysms with endovascular stent grafts and embolizing materials: an experimental study]. / Tratamiento de un aneurisma de aorta abdominal con prótesis endovascular y materiales embolizantes: estudio experimental.

OBJECTIVE: To create an animal model to stabilize the aneurysmal sac and prevent type II leaks in the endovascular treatment of aneurysms of the abdominal aorta (AAA) by placing an endoprosthesis (stent-graft) and filling the aneurysmal sac. MATERIAL AND METHODS: AAA were experimentally induced in pigs and sheep; AAA were subsequently treated with endovascular stent grafts and stabilized in the same procedure by introducing ethibloc and onyx through a vascular catheter placed within the aneurysmal sac. All animals underwent aortography, and MR angiography and abdominal CT were performed on randomly selected animals. Histological studies included both macroscopic and microscopic examination. Two sheep were analyzed one year after the procedure. We evaluated the characteristics of the materials employed, their diffusion in the collateral arteries, and their efficacy in stabilizing the aneurysmal sac. RESULTS: The procedure was successfully carried out in all animals. Survival in the pigs was 100 %, whereas greater instability under anesthesia in the sheep led to 50 % perioperative mortality. Both ethibloc and onyx were considered easy to use and stable over time. CONCLUSION: The sac of an AAA treated with an endovascular stent graft and its collateral vessels can be treated in the same procedure with materials introduced through a catheter.

Tratamiento de un aneurisma de aorta abdominal con prótesis endovascular y materiales embolizantes: estudio experimental / Treatment of an abdominal aorta aneurysms with endovascular stent grafts and embolizing materials: an experimental study

Objetivo: estabilizar el saco aneurismático y evitar la formación de fugas tipo II en el tratamiento endovascular de los aneurismas de aorta abdominal (AAA), creando experimentalmente un modelo animal y tratándolo mediante la colocación de endoprótesis y la ocupación del saco aneurismático. Material y métodos: se crearon AAA de forma experimental en cerdos y en ovejas. Se trataron con prótesis endovasculares y se estabilizaron, en el mismo procedimiento, introduciendo ethibloc y onix a través de un catéter vascular situado dentro del saco aneurismático. En todos se realizaron controles con aortografía y, de forma aleatoria, con angiorresonancia magnética y tomografía computarizada abdominal. Se efectuaron estudios macroscópicos e histopatológicos. Se analizaron 2 ovejas 1 año después. Se valoraron las características de los materiales empleados, su difusión en las arterias colaterales y su eficacia para rellenar el saco del aneurisma. Resultados: en todos los animales se consiguió, con éxito, la realización del procedimiento. La supervivencia de los cerdos fue del 100 %, mientras que de una mayor labilidad de las ovejas para la anestesia, resultó una mortalidad perioperatoria del 50 %. De los materiales empleados, tanto ethibloc como onix son fáciles de utilizar y resultan estables con el paso del tiempo. Conclusión: es posible rellenar el saco de un AAA tratado con endoprótesis y sus colaterales, en el mismo procedimiento, con materiales introducidos a través de un catéter (AU)

Objective: to create an animal model to stabilize the aneurysmal sac and prevent type II leaks in the endovascular treatment of aneurysms of the abdominal aorta (AAA) by placing an endoprosthesis (stent-graft) and filling the aneurysmal sac. Material and methods: AAA were experimentally induced in pigs and sheep; AAA were subsequently treated with endovascular stent grafts and stabilized in the same procedure by introducing ethibloc and onyx through a vascular catheter placed within the aneurysmal sac. All animals underwent aortography, and MR angiography and abdominal CT were performed on randomly selected animals. Histological studies included both macroscopic and microscopic examination. Two sheep were analyzed one year after the procedure. We evaluated the characteristics of the materials employed, their diffusion in the collateral arteries, and their efficacy in stabilizing the aneurysmal sac. Results: the procedure was successfully carried out in all animals. Survival in the pigs was 100 %, whereas greater instability under anesthesia in the sheep led to50 % perioperative mortality. Both ethibloc and onyx were considered easy to use and stable over time. Conclusion: the sac of an AAA treated with an endovascular stent graft and its collateral vessels can be treated in the same procedure with materials introduced through a catheter (AU)

Acute iliac artery thrombosis and pulsatile femoral and popliteal veins in the same extremity: a case report.

Systemic venous pressure is elevated in right heart failure, and this elevation may be reflected in pulsatile venous flow when there is significant tricuspid regurgitation. The presence of this systolic reversed flow in the femoral and popliteal veins may result in major difficulties for diagnosis and treatment. We report the case of a patient with signs and symptoms of acute ischemia of the right lower limb with palpable pulse in the groin and popliteal fossa. Tricuspid regurgitation was suspected by clinical examination, and Doppler ultrasonographic examination of the extremity revealed pulsatile flow in the femoral and popliteal veins while the iliac arterial axis was occluded. A preoperative angiogram revealed an underlying iliac artery thrombosis, which was successfully treated.

Aortoenteric fistula arising as a complication of endovascular treatment of abdominal aortic aneurysm.

Estimates of the incidence of aortoenteric fistula as a sequela of surgery of the aorta range 1-2%. This complication is less common in patients who have had an aortic endograft implanted for aortoiliac aneurysm. We present three cases of aortoenteric fistula complicating endovascular treatment of abdominal aortic aneurysm (3/423 patients, 0.7% in our series).

Leiomiomatosis intravenosa con extensión cardíaca. Caso clínico y revisión de la bibliografía / Intravenous leiomyomatosis with extension into the heart. A case report and review of the literature

Introducción. La leiomiomatosis intravenosa (LIV) es un tumor poco frecuente que puede crecer a través devena cava inferior hasta extenderse a las cavidades cardíacas derechas. Es un tumor originado por las células de músculoliso y normalmente se encuentra confinado al sistema venoso pélvico. Se han descrito no más de 100 casos de LIV,de los cuales, tan sólo 30 presentaban afectación cardíaca. Aunque histológicamente es benigno, la afectación de las cavidadescardíacas derechas puede producir síntomas graves como síncopes y arritmias, y en algunos casos puede llegara producir la muerte súbita. Caso clínico. Mujer de 40 años con extensión cardíaca y que no presentaba síntomas previos.La extensión del tumor se producía tanto por ambas venas ilíacas internas como por la vena ovárica izquierda, algo quetan sólo se había descrito en otros dos casos anteriormente. La escisión quirúrgica se realizó en un único tiempo quirúrgicomediante circulación extracorpórea y abordaje abdominal y torácico. Conclusión. A pesar de ser un tumor poco frecuente,el retraso en la presentación de los síntomas (incluso 20 años) puede infravalorar su incidencia. Dado el gravecuadro clínico que puede provocar, su tratamiento es en todos los casos la extirpación quirúrgica, lo que supone un importantereto para el cirujano vascular. La escasa incidencia de la LIV y el tipo de extensión del tumor en este caso clínicolo hacen realmente excepcional

Introduction. Intravenous leiomyomatosis (IVL) is a rare tumour that may spread along the inferior venacava until it reaches the cavities on the right-hand side of the heart. It is a tumour that has its origins in smooth musclecells and is normally restricted to the pelvic venous system. No more than 100 cases of IVL have been reported, of whichonly 30 presented cardiac involvement. Although histologically it is benign, the involvement of the right cavities of theheart can give rise to severe symptoms such as syncopes and arrhythmias and in some cases it can even lead to suddendeath. Case report. A 40-year-old female with extension to the heart and who had no previous symptoms. The tumourspread along both the internal iliac veins and the left ovarian vein, something which had only previously been reportedin two other cases. Surgical excision was performed in a single session of surgery by means of a heart-lung bypass andusing an abdominal and thoracic approach. Conclusions. Despite being an infrequent tumour, its incidence may beunderestimated due to the fact that its symptoms often appear very late on in the course of the disease (up to 20 years).Given the severe clinical features that it may cause, its treatment always involves surgical removal, which is animportant challenge for the vascular surgeon. The low incidence of IVL and the type of extension of the tumour in thiscase make it truly exceptional