Tumor rabdoide maligno extrarrenal como causa de apnea del sueño en un niño / Extrarenal malignant rhabdoid tumour as a cause of sleep apnoea in a child

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Manejo de la infección protésica inguinal mediante aloinjerto arterial criopreservado, flap muscular rotacional e injerto cutáneo parcial / Management of inguinal graft infections by means of a cryopreserved arterial allograft, rotational muscular flap and partial skin graft

Introducción. La infección protésica inguinal es una complicación grave que pone en riesgo la extremidad revascularizada, y su solución resulta compleja en muchas ocasiones, incluso en las mejores situaciones. Caso clínico. Varón de 56 años con varias cirugías revascularizadoras en ambos miembros inferiores y ausencia de vena autóloga. Presenta antecedente de infección precoz en una prótesis femoropoplítea tratada con retirada parcial. Acude por infección inguinal con bypass femoropoplíteo infragenicular compuesto (politetrafluoroetileno-vena safena interna) permeable. Se realizó un amplio desbridamiento de la zona, con la retirada de la prótesis residual, y se implantó un bypass ortoanatómico con aloinjerto arterial criopreservado y posterior cobertura con flap muscular rotacional (recto anterior-sartorio) e injerto cutáneo parcial. Visto en una revisión a los tres meses con permeabilidad del bypass y buena integración del injerto. Conclusión. En caso de infección protésica, asociada a gran afectación tisular, y ausencia de material autólogo para su sustitución, el empleo de un aloinjerto arterial criopreservado con posterior cobertura con un flap muscular y cutáneo se presenta como una opción válida en su manejo

Introduction. Inguinal graft infections constitute a severe complication that puts the revascularised limb at risk and they are often difficult to resolve, even in the best situations. Case report. A 56-year-old male who had previously undergone several revascularisation operations in both lower limbs and had no autologous veins. The patient had previously suffered early infection of a femoral-popliteal graft which was treated by means of partial withdrawal. He visited because of an inguinal infection with a compound (polytetrafluoroethylene-great saphenous vein) below-theknee femoral-popliteal bypass that was seen to be patent. The procedure consisted in wide debridement of the area, with removal of the residual graft, and an anatomic bypass was implanted with a cryopreserved arterial allograft and later covered with a rotational muscular (rectus femoris-sartorius) flap and partial skin graft. In a control visit at three months, the bypass was seen to be patent and the graft was well integrated. Conclusions. In cases of infection of a prosthetic graft, associated with widespread tissue involvement, and the absence of autologous material with which to replace it, use of a cryopreserved arterial allograft that is later covered with a muscle and skin flap has proved to be a valid management option

Reparación endovascular de la rotura aórtica torácica en traumatismos cerrados. Presentación de dos casos / Endovascular repair of ruptured thoracic aortas in closed traumatic injuries. Two case reports

Objetivo. Presentar nuestra experiencia en el manejo de la rotura traumática de la aorta torácica en los traumatismoscerrados. Introducción. La rotura de la aorta torácica en traumatismos cerrados es una entidad grave, asociadaa una elevada morbimortalidad con el tratamiento quirúrgico convencional. La cirugía endovascular se está imponiendoen el tratamiento de la patología vascular torácica, por lo que, dada su menor agresividad, parece estar aún másindicada en esta patología. Casos clínicos. Caso 1: varón de 34 años que, tras un accidente de motocicleta, presentabaun politraumatismo con múltiples fracturas óseas, lesiones abdominales y craneales. Fue trasladado a nuestro centrocon un diagnóstico de rotura aórtica torácica e intervenido de forma urgente mediante dos endoprótesis. El control a los24 meses se observó la exclusión completa de la lesión sin fugas. Caso 2: varón de 19 años que, tras un accidente de tráfico,presentaba un politraumatismo con múltiples fracturas óseas, lesiones abdominales y craneales. Fue trasladado anuestro centro con un diagnóstico de rotura aórtica e intervenido de forma urgente mediante una endoprótesis. El controla los seis meses se observó la exclusión completa de la lesión sin fugas. Conclusión. La rotura de la aorta torácica entraumatismos cerrados es una entidad de elevada morbimortalidad y la reparación endovascular, a nuestro juicio, constituyeuna opción válida

Aim. To present our experience in the management of traumatic rupture of the thoracic aorta in closed trauma. ;;Introduction. Rupture of the thoracic aorta due to closed traumatic injuries is a severe condition that is associated to ;;high morbidity and mortality rates with conventional surgical treatment. Endovascular surgery is becoming the ;;preferred technique in thoracic vascular pathologies and therefore, due to its being less aggressive, it seems to be even ;;more indicated in this pathology. Case reports. Case 1: a 34-year-old male who, following a motorcycle accident, had ;;multiple traumatic injuries including several fractured bones and abdominal and cranial injuries. He was brought to our ;;centre with a diagnosis of rupture of the thoracic aorta and was submitted to emergency surgical treatment involving the ;;placement of two stent-grafts. The control visit at 24 months revealed complete exclusion of the lesion with no leaks. ;;Case 2: a 19-year-old male who, following an automobile accident, had multiple traumatic injuries including several ;;fractured bones and abdominal and cranial injuries. He was brought to our centre with a diagnosis of rupture of the aorta and was submitted to emergency surgical treatment involving the placement of a stent-graft. The control visit at six ;;months revealed complete exclusion of the lesion with no leaks. Conclusions. Rupture of the thoracic aorta in closed ;;traumatic injuries is a condition with high morbidity and mortality rates and endovascular repair is, in our opinion, a valid therapeutic option

Historia natural de la disección aórtica / Natural history of aortic dissections

Objetivo: Se analiza con detenimiento la historia natural de la disección tipo B y sus distintas formas evolutivas e igualmente se sigue por separado la historia natural del hematoma de pared y de la úlcera de pared de aorta. Desarrollo. Se propone abandonar la clasificación en aguda y crónica ya que es arbitraria y basada en días naturales que no siempre tienen que ver con la evolución y la situación clínica del caso; en su contra se propone dividir las disecciones tipo B en progresivas y estabilizadas y además en complicadas y no complicadas. Se presenta un resumen de una serie propia de 91 disecciones de aorta, 59 de las cuales pertenecen a una serie histórica tratada médicamente y 32 corresponden a una serie realizada de forma prospectiva con tratamiento endovascular, se comparan los resultados de ambas. Se justifica este tratamiento en vistas a los resultados del tratamiento médico que sigue presentando un 13% de mortalidad, un 10% de afectación medular, un 22% de insuficiencia renal, un 28% de isquemia intestinal y/o periférica y un 30% de redisecciones. Conclusión. Concluimos estableciendo que ante lo impredecible de la evolución de la disección tipo B, el tratamiento médico podría sustituirse por el quirúrgico cuando a las 48 horas de su inicio no ha sido capaz de hacer desaparecer el dolor y controlar la hipertensión arterial

Aims: We perform a detailed analysis of the natural history of type B dissections and their different forms of progression. At the same time we also carry out separate examinations of the natural history of aortic wall haematomas and wall ulcers. Development. We propose giving up the practice of classifying them as acute and chronic since this is decided at random and is based on the number of days, which does not always have a clear relation to the progression and clinical situation of the case. In contrast, however, we suggest dividing type B dissections into progressive and stabilised, as well as into complicated and non-complicated cases. We report on a series of our own consisting of 91 aortic dissections, 59 of which belonged to a historical series that was treated medically and 32 from a prospective series with endovascular treatment; results from the two series are compared. This treatment is justified by the outcomes obtained with medical treatment, which continues to offer a 13% mortality rate, a 10% rate of spinal cord involvement, 22% renal failure, 28% intestinal and/or peripheral ischaemia and a 30% rate of redissections. Conclusions. We conclude by stating that, given the unpredictability of the progression of type B dissections, medical treatment could be replaced by surgery when, 48 hours after starting therapy, it has been unable to make the pain disappear and to control the high blood pressure

Nueva técnica de embolización de arteria hipogástrica / A new technique for embolisation of the hypogastric artery

Introducción. La embolización de arterias hipogástricas previa al implante de endoprótesis aortoilíacas paratratar aneurismas no siempre es posible. Objetivo. Presentar una nueva técnica de embolización de hipogástricas ‘hostiles’,simultánea al implante de endoprótesis aortoilíaca. Pacientes y métodos. Se ha tratado a seis pacientes con aneurismasaortoilíacos (4) e ilíacos (2) con este procedimiento. El seguimiento se realizó mediante tomografía computarizada(TC) en la primera semana, al mes y a los tres y seis meses. Técnica endovascular: a) Emplazamiento de un catéteracodado cerca de la hipogástrica o en el saco; mediante la misma arteriotomía, se introduce la endoprótesis; b) Desplieguede la endoprótesis y, antes de balonearla, liberación de coils; c) Inyección en ese saco de 100 a 200 cm3 de sueropara arrastrar los coils hacia el ostium de la hipogástrica; d) Retirada del catéter y baloneamiento del extremo distal dela endoprótesis. Resultados. En cuatro pacientes se comprobó la trombosis del aneurisma ilíaco en la TC de la semana yen los otros, al mes. No se han observado endofugas ni desplazamiento de los coils en el saco. Se presentó claudicaciónglútea en cuatro de seis pacientes. No hubo isquemia cólica. Conclusiones. Este método de embolización original se hamostrado eficaz y seguro en cuanto a la capacidad de trombosar arterias potencialmente productoras de endofuga deltipo II, dado que evita desplazamientos no deseados de los coils

Introduction. Embolisation of hypogastric arteries prior to the placement of aortoiliac stents to treat aneurysmsis not always possible. Aim. To present a new technique for the embolisation of ‘hostile’ hypogastric arteries which isperformed at the same time as the placement of the aortoiliac stent. Patients and methods. This procedure was used totreat six patients with aortoiliac (4) and iliac (2) aneurysms. Follow-up was carried out by computerised tomography(CT) in the first week and at one, three and six months. Endovascular technique: a) Placement of a coudé catheter nearthe hypogastric artery or in the sac; the stent is introduced through the same arteriotomy; b) The stent is deployed and,before ballooning it, the coils are released; c) 100 to 200 cm3 of serum are injected into the sac to wash the coils towardsthe ostium of the hypogastric artery; d) Withdrawal of the catheter and ballooning of the distal end of the stent. Results.The CT scan showed thrombosis of the iliac aneurysm in the first week in four of the patients and at one month in theothers. There were no signs of endoleaks or movements of the coils inside the sac. Buttock claudication was noted in fourof the six patients. There were no cases of colic ischaemia. Conclusions. This original method of embolisation has provedto be effective and safe with regard to its capacity to thrombose arteries that are potential producers of type II endoleaks,since it prevents unwanted movements of the coils

Bostezos y epilepsia del lóbulo temporal / Yawning and temporal lobe epilepsy

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Neurotoxicidad en el tratamiento con litio. Caso clínico y hallazgos electroencefalográficos / Neurotoxicity in treatment with lithium. A case report and EEG findings

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Alpha- and gamma-interferon versus alpha-interferon alone in chronic hepatitis B. A randomized controlled study.

Thirty-two patients with chronic hepatitis B were randomly assigned to two groups. Sixteen patients received 10 million units of alpha-interferon per square meter of body surface (MU/m2), three times weekly for 4 months. Sixteen patients were treated simultaneously with gamma-interferon at a dose of 2 MU/m2, and 10 MU/m2 of alpha-interferon. At the end of the study (13th month), hepatitis B virus DNA was negative in 50% of the patients treated with alpha-interferon and in only 25% of those treated with alpha- and gamma-interferon. A similar trend was observed with respect to the hepatitis B e antigen negativization (31% and 19% of HBeAg negativization in patients treated with alpha- and gamma-interferon, respectively). In summary, these data demonstrate that, at the doses used in this study, the combination of alpha- and gamma-interferon does not give better results than the administration of alpha-interferon alone. The tolerance to simultaneous alpha- and gamma-interferons is poor and may decompensate the liver disease.

High doses of recombinant alpha-interferon or gamma-interferon for chronic hepatitis C: a randomized, controlled trial.

Chronic hepatitis C is often a progressive liver disease for which there is no satisfactory treatment. We studied the efficacy of recombinant alpha-interferon or gamma-interferon in the treatment of this disease in comparison with a control group. Thirty patients were randomly assigned to three groups. Ten patients received 7.5 MU alpha-interferon/m2 body surface three times weekly for 3 mo, then 5 MU/m2 for 3 mo and 2.5 MU/m2 for 6 mo. Ten patients were treated with gamma-interferon at a dose of 2 MU/m2 for 6 mo and the other 10 served as controls without treatment. The mean serum ALT levels and liver histological findings improved significantly only in the patients treated with alpha-interferon. No changes were observed in patients treated with gamma-interferon or in controls. Five of 10 patients treated with alpha-interferon had complete responses (mean ALT normal during therapy). After treatment ALT returned to pretreatment levels in two of 5 patients. The long-term response rate after alpha-interferon therapy was 30% at 18 mo. We conclude that alpha-interferon is effective in controlling disease activity in a portion of patients with chronic hepatitis C. High doses of alpha-interferon do not appear to add further benefit in the response rate or relapse rate. gamma-Interferon therapy is ineffective.

Treatment of chronic delta infection with recombinant human interferon alpha 2c at high doses.

Superinfection by hepatitis delta virus (HDV) in hepatitis B virus chronic carriers is normally associated with a progressive liver injury. For this reason, the aim of the present study was to determine the efficacy of recombinant interferon alpha (rIFN-alpha) treatment of chronic delta hepatitis, by giving high doses of rIFN-alpha 2c during a prolonged period. A total of 20 HBsAg, anti-HD carriers with a chronic active hepatitis were randomly allocated in two groups: (I) n = 10, control and (II) n = 10, treated with 10 MU/m2 body surface of rIFN-alpha, twice weekly, intramuscularly (im) during 6 months. Basally, all patients presented HDAg in the liver and serum IgM anti-HD. Serum HDV-RNA was positive in 8 and 7 patients from groups I and II, respectively. The interferon therapy was well tolerated and all patients finished the treatment period. During the first 6 months, a decrease in ALT levels among treated patients (255 +/- 98 vs. 193 +/- 117) was observed. In addition, a transient drop in HDV-RNA levels was also observed. No changes in anti-HD titer, IgM anti-HD and HBsAg concentration were detected. At the end of the follow-up period (15 months) two treated patients had lost IgM anti-HD. In addition, another two patients were HDV-RNA negative. In conclusion, no permanent antiviral effects of rIFN-alpha 2c in chronic delta hepatitis, using this schedule, was achieved.