ABS-SMART (Aortic Balloon Supporting for Superior Mesenteric Artery Recanalization Technique): A New Technical Option for Recanalization of Complete Superior Mesenteric Artery Occlusion in Chronic Mesenteric Ischemia.

OBJECTIVE: To report our experience with a new technique for recanalization of the superior mesenteric artery (SMA)/celiac trunk (CT) with complete occlusion at the origin. TECHNIQUE: We describe our ABS-SMART (Aortic Balloon Supporting for Superior Mesenteric Artery Recanalization Technique) for recanalization of the CT and SMA in cases of complete occlusion of these arteries with a short or inexistent stump, which usually corresponds to chronic lesions with important calcification of the ostium. CONCLUSION: The ABS-SMART is an alternative for the recanalization of visceral arteries in cases where other conventional techniques have failed. It is particularly useful in scenarios characterized by a short occlusion at the origin of the target vessel, with no entry stump or severe calcification at the origin. CLINICAL IMPACT: Catheterization and recanalization of visceral stenoses may pose a challenge in some cases, as for example in the presence of a very narrow angle between the root or origin of the vessel and the aorta, as well as in the case of long and calcified stenoses, or when arteriography is unable to visualize the origin of the vessel. The present study describes our experience with the endovascular revascularization of visceral vessels using an aortic balloon-supported recanalization technique not previously described in the literature, that may be an effective alternative for the treatment of lesions of difficult access, such as total occlusion at the origin of the target vessel, with no entry stump or severe calcification at the origin of the SMA and CT, by improving the chances for technical success.

Efecto del alprostadil en los cultivos de músculo esquelético isquémico. Estudio proteómico comparativo frente a músculo sano / The effect of alprostadil on ischemic skeletal muscle cultures. Comparative proteomic study with healthy muscle

INTRODUCCIÓN: El alprostadil tiene efecto vasodilatador y antiagregante. Es bien conocido su efecto endotelial, pero se desconocen sus posibles efectos pleiotrópicos sobre el músculo esquelético y si estos difieren en el músculo isquémico. OBJETIVO: Determinar el efecto del alprostadil sobre el metabolismo del músculo esquelético y valorar diferencias en su acción sobre el músculo isquémico frente al sano. MATERIAL Y MÉTODOS: Se obtuvieron muestras de tejido de 10 pacientes con isquemia irreversible intervenidos de amputación supracondílea, tanto de músculo isquémico (extensor corto de los dedos del pie, grupo I) como de músculo sano (músculo cuádriceps del borde de amputación, grupo S). Ambos grupos se cultivaron basalmente y con 5 ng de alprostadil. Se analizó la expresión proteómica de las siguientes enzimas: triosa-fosfato-isomerasa (TPI), malato deshidrogenasa (MDH), lactato deshidrogenasa (LDH) y piruvato carboxilasa (PC). Se determinaron también sus productos, lactato y piruvato. RESULTADOS: La MDH presentó una disminución en el grupo I en las muestras basales (2.196 ± 348 grupo S vs 644 ± 192 grupo I, p < 0,05). La PC estaba aumentada en el grupo I en ambos tipos de muestras (basal: 1,80 ± 1,27 vs 3,16 ± 2,25; alprostadil: 6,72 ± 2,13 vs 8,16 ± 3,63, grupo S vs grupo I, respectivamente, p < 0,05). No hubo diferencias significativas en la concentración de lactato ni en la de piruvato. CONCLUSIONES: La reducción de MDH en el músculo isquémico sugiere una reducción del ciclo de Krebs. El alprostadil estimula la expresión de PC, que induce la formación de oxalacetato; este se introduce en el ciclo de Krebs, permitiéndole funcionar parcialmente en el músculo isquémico y mejorando la obtención de energía

INTRODUCTION: Alprostadil has vasodilator properties and inhibits platelet aggregation. Its effects on endothelial wall have been widely studied, but there is no knowledge about possible skeletal muscle effects, and differences with ischemic muscle. OBJECTIVE: To determine the effects of alprostadil on skeletal muscle metabolism, and to investigate possible differences with ischemic muscle. METHODS: Samples were obtained in 10 patients with leg above-knee amputation due to severe irreversible ischemia, of ischemic muscle (extensor digitorum brevis, group I), and healthy muscle (quadriceps femoris, amputation edge, group S). Muscle segments were incubated with alprostadil 5 ng, or without it (baseline). Proteomic analysis of metabolic enzymes was performed: Triose-phosphate isomerase (TPI), malate dehydrogenase (MDH), lactate dehydrogenase (LDH) and pyruvate carboxylase (PC). Lactate and pyruvate was also determined. RESULTS: A decrease in malate dehydrogenase was observed in group I in the baseline samples (2196 ± 348 group S vs 644 ± 192 group I, P < 0.05). PC was increased in both samples in group I (baseline: 1.80 ± 1.27 vs 3.16 ± 2.25; alprostadil: 6.72 ± 2.13 vs 8.16 ± 3.63, group S vs group I, respectively, P < 0.05). No changes were observed in pyruvate and lactate. DISCUSSION: Decreased MDH in ischemic muscle suggests a Krebs cycle reduction. Alprostadil stimulates the expression of PC, which leads to oxaloacetate production. This product is inserted in Krebs cycle, improving energy obtaining. In this manner, Krebs cycle can work partially in ischemic muscle

Tratamiento endovascular con stent recubierto de aneurisma de arteria esplénica / Endovascular treatment of a splenic artery aneurysm with a coated stent

No disponible

Nuevas opciones de embolización de aneurisma aortoilíaco asociado a aneurisma de hipogástrica. A propósito de un caso / New options for embolising aortoiliac aneurysms associated to aneurysms in the hypogastric artery. A case report

Introducción. El tratamiento de los aneurismas aortoilíacos asociados a aneurismas de hipogástrica es un retopara los cirujanos vasculares, que han de idear tácticas individualizadas según la anatomía del caso. Caso clínico. Varónde 78 años, exfumador, con antecedentes de hipertensión arterial, cardiopatía isquémica y dos episodios de accidentecerebrovascular, en seguimiento por un aneurisma aortoilíaco que alcanza rango quirúrgico, decidiéndose reparaciónendovascular. Se trata de un aneurisma de aorta abdominal de 40 mm, asociado a un aneurisma de arteria ilíaca comúnizquierda y de hipogástrica izquierda, de 30 y 40 mm de diámetro, respectivamente. Mediante abordaje contralateral, seimplanta oclusor Amplatzer Vascular Plug de 22 × 18 mm, desde el cuello del aneurisma de la hipogástrica izquierdahasta la bifurcación de la ilíaca común, con lo que se excluyen ambos aneurismas. Se coloca una endoprótesis aortomonoilíacaderecha de 26 × 14 × 155 mm tipo Talent y un bypass femorofemoral cruzado derecha-izquierda con Dacron de8 mm. En la arteriografía posprocedimiento, la endoprótesis se encuentra permeable, existe una endofuga tipo II a aneurismaaórtico por lumbares y el aneurisma de la hipogástrica está trombosado. Una angiotomografía al año muestrapermeabilidad de la endoprótesis y el bypass, exclusión del aneurisma aortoilíaco y de la hipogástrica, ausencia de endofugasy ningún cambio en el tamaño de los sacos aneurismáticos. Conclusión. El diseño de nuevos dispositivos de liberaciónsencilla y precisa, y de mayor flexibilidad, posibilita nuevas estrategias en el tratamiento de aneurismas complejosde afectación aortoilíaca. Los oclusores Amplatzer Vascular Plug permiten en un solo acto, con un único dispositivo,ocluir la bifurcación de la ilíaca común y sellar el ostium de la hipogástrica(AU)

Introduction. The treatment of aortoiliac aneurysms associated to aneurysms in the hypogastric artery is achallenge for vascular surgeons, who have to devise tailor-made tactics to fit the anatomy of each case. Case report. A78-year-old ex-smoking male, with a history of arterial hypertension, ischaemic heart disease and two strokes, who wasbeing followed up due to an aortoiliac aneurysm that reached the surgical range; the decision was made to carry outendovascular repair. The abdominal aortic aneurysm measured 40 mm and was associated to an aneurysm in the leftcommon iliac and left hypogastric arteries, with diameters of 30 and 40 mm respectively. A contralateral approach wasemployed to implant a 22 × 18 mm Amplatzer Vascular Plug occluder, from the neck of the aneurysm in the left hypogastricto the bifurcation of the common iliac artery, which resulted in exclusion of both aneurysms. A 26 × 14 × 155 mmTalent-type right aortomonoiliac stent was placed, together with a right-left crossed femorofemoral 8-mm Dacronbypass. In the post-operative arteriography, the stent is found to be patent, there is a type II endoleak due to an aorticaneurysm near the lumbar region and the aneurysm of the hypogastric artery is thrombosed. A tomography angiographyscan at one year shows patency of the stent and the bypass, exclusion of the aneurysms in the aortoiliac and thehypogastric arteries, absence of endoleaks and no change in the size of the aneurysmal sacs. Conclusions. The design ofnew devices that are precise and simple to release, as well as being more flexible, allows for new strategies in thetreatment of complex aneurysms that compromise the aortoiliac artery. The Amplatzer Vascular Plug occluders make itpossible to occlude the common iliac and seal the ostium of the hypogastric artery in one single procedure and with justone single device(AU)

Acute lower limb ischemia in a patient with aortic thrombus and essential thrombocytosis.

Aortic thrombus is rare in patients with essential thrombocytosis (ET), so the optimal treatment remains undefined. A 45-year-old man with history of ET, under chronic treatment with aspirin, presented to the emergency department complaining of acute onset in both the legs and abdominal pain. Physical examination revealed that both dorsalis pedis pulses were not palpable with cold and pale feet. His abdomen was soft and nondistended. The platelet count was 436 x 10(9)/L. The thoraco-abdominal computerized tomographic scanning revealed normal aortic diameter with supraceliac and infrarenal nonoccluding thrombus and infarction areas in spleen and left kidney. At the emergency department he presented with recurrent symptoms, losing bilateral posterior tibial pulses. A decision was made to perform a thoracoretroperitoneal incision. A longitudinal sequential aortotomy was performed in the distal thoracic and infrarenal aorta, and the thrombus was easily removed. Following this, he underwent bilateral crural thrombectomy and local intra-arterial thrombolytic therapy. The postoperative course was uneventful. The left toes were amputated because of necrosis. He was discharged and put on antiaggregants, anticoagulants and hydroxyurea. Aortic thrombus in patients with ET is unusual, but potentially lethal. There is complete relief from symptoms in recurrent cases following surgery. An appropriate medical treatment after intervention must be supported.

Aneurisma de aorta torácica con cuello distal corto: técnica para aumentar la zona de sellado. A propósito de un caso / Aneurysm of the thorqacic aorta with a short distal neck: a technique to increase the sealing zone. A case report

Objetivo. Describir la experiencia personal inicial con una técnica para conseguir aumentar la zona de selladodistal de las endoprótesis en el tratamiento endovascular de aneurismas de aorta torácica (AAT) con cuello distal corto,aprovechando los 4 mm distales festoneados de la endoprótesis Gore TAG. Caso clínico. Mujer de 63 años, con antecedentesde hipertensión arterial, diabetes mellitus, cardiopatía isquémica y dislipidemia. Intervenida de apendicectomíae histerectomía. Con seguimiento en consulta externa de cirugía vascular por AAT, con crecimiento rápido de 15 mmen un año, motivo por el que se decide el tratamiento. En angio-TC toracoabdominal: AAT 50 mm de diámetro máximo.Cuello proximal de 35 mm de longitud y distal hasta el tronco celíaco de 10 mm. Técnica quirúrgica: con anestesia generaly protección medular (drenaje de líquido cefalorraquídeo), se procedió a la cateterización del tronco celíaco con balónde 2,5 mm vía transfemoral derecha e implantación de dos endoprótesis tipo Gore TAG de 28 × 15 y 31 × 15, respectivamente,por vía ilíaca izquierda a través de una prótesis de dacrón de 8 mm suturada terminolateral a ésta. En el seguimientocon angio-TC, al año se comprueba la correcta exclusión del aneurisma, sin evidencia de fugas periprotésicas,con permeabilidad del tronco celíaco. Conclusiones. La técnica de tutorización de los troncos viscerales mediante infladointraluminal de balón de angioplastia no sólo asegura su preservación durante el despliegue de la endoprótesis torácica,sino que además permite, de una forma segura, aumentar la zona de sellado distal en AAT con cuellos distales cortos(AU)

Aim. To describe our initial personal experience with a technique for increasing the distal sealing zone ofstent-grafts in the endovascular treatment of thoracic aortic aneurysms (TAA) with a short distal neck, by takingadvantage of the 4 mm scalloped flare at the distal end of the Gore TAG endoprosthesis. Case report. A 63-year-oldfemale with a history of arterial hypertension, diabetes mellitus, ischaemic heart disease and dyslipidaemia. The patienthad undergone an appendectomy and a hysterectomy. She was also attending the vascular surgery outpatientdepartment to follow up a TAA with a rapid growth rate of 15 mm per year, which is what led to the decision being takento treat it immediately. In a thoracoabdominal CT-angiography scan: TAA with a maximum diameter of 50 mm.Proximal neck with a length of 35 mm and distally, to the celiac trunk, 10 mm. Surgical technique: with generalanaesthesia and spinal cord protection (cerebrospinal fluid drainage), the celiac trunk was catheterised with a 2.5-mmballoon via right transfemoral, and placement of two 28 × 15 and 31 × 15 Gore TAG type endoprostheses, respectively,via the left iliac through an 8-mm Dacron graft that was sutured end-to-side to it. In the next CT-angiography scan atone year, the aneurysm was seen to be correctly excluded, with no evidence of periprosthetic leaks, and patency in theceliac trunk. Conclusions. The technique of tutoring the main visceral arteries by inflating an intraluminal angioplastyballoon not only ensures their preservation during deployment of the thoracic endoprosthesis, but also makes it possibleto safely increase the distal sealing zone in TAA with short distal necks(AU)

Fracaso hemodinámico de bypass venoso infrainguinal por fístula arteriovenosa tras trombectomía / Haemodynamic failure of an infrainguinal venous bypass due to arteriovenous fistula following a thrombectomy

Introducción. El desarrollo de una fístula arteriovenosa tras embolectomía o trombectomía es infrecuente, peropuede suponer un riesgo para la viabilidad de la extremidad. Caso clínico. Varón de 75 años de edad que presentó unaoclusión de bypass femoropoplíteo en la tercera porción con la vena safena in situ en el postoperatorio inmediato; se realizótrombectomía del mismo e interposición de un segmento de la vena safena invertida en el tercio distal, y se recuperaronpulsos distales. En la primera revisión se objetiva un fracaso hemodinámico del bypass, con índice tobillo/brazo de0,5. El eco-Doppler muestra bypass permeable con flujo bifásico en toda su extensión y velocidades sistólicas elevadas.En la arteriografía se detecta fístula arteriovenosa a la altura del tercio medio de la arteria peronea, y se realiza tratamientoendovascular de la misma. Conclusión. El diagnóstico precoz de este tipo de complicaciones es importante. Eltratamiento puede realizarse de forma efectiva mediante técnicas endovasculares

Introduction. Development of an arteriovenous fistula following an embolectomy or thrombectomy isinfrequent, but can put the viability of the limb at risk. Case report. A 75-year-old male who presented an occlusion ofa femoropopliteal bypass in the third portion with the saphenous vein in situ in the immediate post-operative period; athrombectomy and placement of the segment of the inverted saphenous vein in the distal third were performed, and distalpulses were recovered. In the first control examination, haemodynamic failure of the bypass was observed, with anankle-brachial index of 0.5. A Doppler ultrasound recording showed the bypass to be patent with a two-phase flow alongthe whole of its length and high systolic velocities. An arteriography revealed an arteriovenous fistula in the middle thirdof the peroneal artery, which was treated by endovascular methods. Conclusions. An early diagnosis of this type ofcomplications is important. Treatment can be performed effectively by means of endovascular techniques

Pseudoaneurisma de la arteria poplítea como complicación de la cirugía de prótesis de rodilla: tratamiento endovascular / Psudoaneurysm in the popliteal artery as a complication in knee prosthesis surgery: endovascular treatment

Introducción. Las complicaciones vasculares como consecuencia de la cirugía de rodilla son poco frecuentes,pero pueden derivar en una importante morbilidad. Caso clínico. Mujer de 71 años obesa e hipertensa, que acudió a Urgenciasquince días después de una artroplastia total de rodilla derecha por persistencia de dolor, edema y hematomaen pantorrilla derecha. En la exploración presentaba edema duro en el miembro inferior derecho, con hematoma en elhueco poplíteo y la pantorrilla y pulso poplíteo expansivo. Se realizó eco-Doppler arterial y venoso del miembro inferiorderecho en el que se observó pseudoaneurisma de arteria poplítea con trombosis de vena poplítea asociada. Se trató concarácter de urgencia mediante abordaje femoral ipsilateral, arteriografía y colocación de stent recubierto. Control arteriográficoinmediato: exclusión del pseudoaneurisma con permeabilidad del stent recubierto. Se anticoaguló a la pacientedurante tres meses como tratamiento de la trombosis venosa poplítea asociada. Posteriormente se suspendió la anticoagulaciónoral y se continuó con tratamiento antiagregante. Seguimiento mediante eco-Doppler, con permeabilidadprimaria del stent recubierto a los 12 meses, siendo posible una amplitud de flexión de rodilla derecha de 120º. Conclusiones.La presencia de lesiones vasculares después de una cirugía de artroplastia de rodilla se debe tener siempre encuenta ante la persistencia de hematoma, dolor y edema en la fosa poplítea. El tratamiento mediante stents recubiertospermite minimizar las complicaciones asociadas al tratamiento quirúrgico, presentando una alternativa adecuada a cortoy medio plazo

Introduction. Vascular complications as a consequence of knee surgery are rare, but can result in a high rateof morbidity. Case report. A 71-year-old female with obesity and hypertension who visited the Emergency departmenttwo weeks after a total arthroplasty on her right knee because of persistent pain, oedema and haematoma in the rightcalf. Examination revealed a hard oedema in the right lower limb, with a haematoma in the popliteal fossa and calf, andan expansive popliteal pulse. Arterial and venous Doppler ultrasound recording was performed on the right lower limband results showed a pseudoaneurysm of the popliteal artery associated with thrombosis of the popliteal vein. Urgenttreatment was established by an ipsilateral femoral approach, arteriography and placement of a covered stent. Immediatearteriographic control: exclusion of the pseudoaneurysm with patency of the covered stent. The patient was put on anticoagulant therapy for three months as treatment for the associated popliteal vein thrombosis. Oral anticoagulation therapy was later withdrawn and treatment continued with antiaggregating agents. Follow-up with Doppler ultrasoundshowed primary patency of the covered stent at 12 months, and the patient was capable of bending the right kneethrough 120º. Conclusions. The presence of vascular lesions after knee arthroplasty surgery must always be considered in the presence of persistent haematoma, pain and oedema of the popliteal fossa. Treatment using covered stents makes it possible to minimise the complications associated with surgical treatment, and thus represents a suitable short and medium-term alternative (AU)

Surgical treatment of distal renal artery expansive pseudoaneurysm after blunt trauma.

Renal artery pseudoaneurysms are rare after blunt abdominal trauma. Pseudoaneurysms are caused by decelerating injuries of the renal artery after major falls or car accidents. Patients may be asymptomatic for months or years, and the pseudoaneurysm may expand and rupture before diagnosis or treatment. We report a case of distal renal artery pseudoaneurysm in a 51-year-old male patient, who had had a previous trauma while playing tennis 16 months ago. It was diagnosed by consecutive computed tomography-scans demonstrating a thrombosed pseudoaneurysm of the distal right renal artery, with progressive enlargement and involving persistent pain. Angiography showed right lower polar artery aneurysm and a small renal infarction due to a distal branch thrombosis. Open surgery was performed revealing a hole in a segmentary artery ostium, that was sutured with single stitches. The patient was discharged a few days late with normal renal function. Despite the development of endovascular techniques, sometimes surgical treatment is the only therapeutic alternative.