Alternativas en la cirugía del origen de los troncos supraaórticos / Alternative surgical treatment of stenosis and occlusion of the supra-aortic trunks

Objetivos. Estudiar los resultados alternativos del tratamiento quirúrgico, de las estenosis y oclusiones del origen de los troncos supraaórticos.Pacientes y métodos. Un total de 47 pacientes fueron sometidos a técnicas de revascularización entre 1968 y 1998. De ellos, 38 fueron varones y 9 mujeres, con una edad media de 54 años (límites, 29-72). Siete fueron sometidos a tromboendarterectomía, 23 a bypass, 11 reimplantaciones y 10 a técnicas endovasculares. Diecinueve pacientes presentaron síntomas inespecíficos, 16 accidentes isquémicos transitorios, y 12 episodios vertebrobasilares. Las técnicas quirúrgicas fueron: 13 (27 por ciento) intratorácicas y 34 (73 por ciento) extratorácicas. La media de seguimiento fue de 86 meses.Resultados. La permeabilidad fue 94 por ciento el primer año, 82 por ciento a los cinco años y 75 por ciento a diez años. Dos bypass axiloaxilares se ocluyeron a los 2 y 5 meses. La morbilidad temprana fue muy pequeña y no hubo mortalidad en los primeros 30 días. La cardiopatía isquémica y el cáncer fueron las principales causas de muerte.Conclusiones. La permeabilidad de las técnicas anatómicas y reimplantaciones fue mayor que la permeabilidad de las técnicas extraanatómicas. La menor permeabilidad se obtuvo en los bypass subclaviosubclavios, seguido de los carotideosubclavios.Las técnicas endovasculares tienen un papel en este campo de la cirugía. (AU)

Traumatismos arteriales en los troncos supraaórticos / Traumatic injuries to the brachiocephalic vessels

Presentamos cuatro casos de lesiones arteriales en la carótida común y las subclavias. Las lesiones asociadas fueron escasas y cabe señalar una contusión del plexo braquial derecho, que recuperó, sin secuelas. En el caso 4, se observó un ensanchamiento mediastínico que indujo al diagnóstico. Las lesiones carotídeas fueron abordadas a través de incisiones verticales en cuello anteriores al esternocleidomastoideo.Se accedió a la arteria subclavia derecha a través de una incisión supra e intraclavicular, y a la subclavia izquierda a través de una toracotomía posterolateral izquierda e infraclavicular del mismo lado. Todas las reparaciones arteriales estuvieron permeables y sin complicaciones, al menos, por un período de 5 años. (AU)

[Prevention of cerebral ictus, of carotid origin]. / Prevención del ictus cerebral, de origen carotideo.

The current incidence of stroke in Europe and the USA is about 200 per 100,000 population per annum. Eighty percent of strokes are ischaemic and 20% are due to hemorrhage. Approximately half the patients with ischaemic strike have carotid artery stenosis and about one third (10% all stroke victims) have had no warning symptoms such as transient ischaemi attacks. The European Carotid Surgery Trial (ECST) and North American Symptomatic Carotid Endarterectomy Trial (NASCET) have effectively shown that carotid endarterectomy (CEA) can prevent strokes in symptomatic patients. The benefit of operation is, at present, confined to those with at least 70% stenosis; for 30-69%, the trials have not yet reported a result. In asymptomatic patients the Veterans Administration Study and the Asymptomatic Carotid Atherosclerosis Study (ACAS) have yielded promising results that surgery may reduce the risk of TIA and minor stroke. There is as yet no convincing evidence in asymptomatic patients that moderate or severe stroke (or death) can be prevented by CEA. The aim of this trial is to determine whether CEA and appropriate best medical treatment (BMT) can improve stroke free survival time when compared with BMT alone.

Tratamiento endovascular del síndrome de vena cava superior de etiología neoplásica / Endovascular treatment of superior vena cava syndrome of neoplastic etiology

Describimos el caso clínico de una paciente con una estenosis crítica de la vena cava superior producida por una neoplasia pulmonar, con repercusión clínica grave. El tratamiento se realizó mediante técnica endovascular, procediendo a la angioplastia de la lesión mediante un balón de dilatación, con la colocación posterior de un stent. El resultado fue bueno con mejoría clínica sin producirse recidiva de la misma (AU)

Intraluminal leiomyosarcoma of the superior vena cava: a cause of superior vena cava syndrome.

Intraluminal tumours of the superior vena cavae (SVC) are extremely rare. We report a 75 year old male who suffered an acute syndrome of the SVC. The CT scan and phlebogram showed thrombosis of the right internal jugular, subclavian and innominate veins and the SVC. Fibrinolysis was started with 250.000 U, of urokinase and maintained for 72 hrs (75.000 U/h). A control phlebogram showed a great filling defect of the SVC which was enhanced in a postcontrast CT scan. An intraluminal leiomyosarcoma was diagnosed. A long and narrow pedunculated tumour was resected through a medial sternotomy and the SVC closed by direct suture without either a patch or a graft. The histopatholoy study confirmed the diagnosis. We cosider this protocol to be the procedure of choice for the diagnosis and treatment of the SVC syndrome since it can demonstrate any intraluminal or extramural aetiology.

[An inflammatory aortic aneurysm ruptured into the retroperitoneum and an extensive communication of the aneurysm with the vena cava inferior]. / Aneurisma aórtico inflamatorio roto en retroperitoneo y amplia comunicación del aneurisma en vena cava inferior.

Aortocaval fistula is a rare complication of abdominal aortic aneurysms that occurs with a frequency of 1% of operative cases or less. In this report we present a case of aortocaval fistula associated with ruptured and inflammatory aortic aneurysm that became apparent after evacuation of the thrombus. The inferior cava was ligated. We discuss the clinical syndrome and the management of patients with aortocaval fistula secondary to an abdominal aortic aneurysm and the results of surgical repair.

[Inflammatory aneurysms of the abdominal aorta]. / Aneurismas inflamatorios de aorta abdominal.

Approximately 10 per cent of abdominal aneurysms have an excessively thick wall that sometimes involve duodenum, cava or colon by an inflammatory process. Between February 1986 and December 1992, 147 patients with abdominal aortic aneurysm (AAA) were treated surgically and in 13 (8.8%) the aneurysms were found to be inflammatory. Their mean age was 67.3 years (70.1 years in non inflammatory group) and all were symptomatics initially (abdominal pain in 53%, rupture in 23%, mass in 15%). The operative mortality for elective resection was 37% in patients with inflammatory abdominal aortic aneurysms (IAAA) decreasing to 9% in the AAA group without inflammatory involvement. We conclude that surgery is indicated in these patients to prevent rupture and to hasten the subsidense of inflammatory process ever with postoperative morbi-mortality increased.

[Ruptured aneurysms of the abdominal aorta. A study of their incidence and mortality]. / Aneurismas rotos de aorta abdominal. Un estudio de la incidencia y mortalidad.

Between 1986 and 1992, 133 patients with abdominal aneurysms presented to our Department of Vascular Surgery. Of these, 97 (73%) were elective cases and 36 (27%) had ruptured. In all these patients resections were undertaken. Postoperative complications occurred in 28 patients (28%) for elective resection and in 17 patients (47%) for ruptured aneurysms (p < 0.05), with mortality rates of 46 and 94%, respectively (p < 0.005). The postoperative mortality for elective resection was 13% and for rupture 44% (p < 0.001).

[Airway involvement in the postoperative period of carotid endarterectomy. Report of a case]. / Compromiso de la vía aérea en el postoperatorio de la endarterectomía carotídea. A propósito de un caso.

We report a case of a fifty-seven year old man that was diagnosed a bilateral carotid disease and a carotid endarterectomy was practiced on him in the left carotid, and afterwards in a 12 day lapsus of time, the same was done in the right carotid. In the course of the immediate post-operative period, the patient presented a neck haematoma which required its removal and afterwards he developed a glottis oedema which called for the realisation of a tracheotomy in order to control the airway.

[Obliteration of the juxtarenal abdominal aorta. 90% stenosis of the left renal artery. Thrombosis of the right renal artery and renal atrophy. Treatment with aortic deobliteration, aorto-bifemoral prosthesis, left aorto-renal bypass and right nephrectomy. A case report]. / Obliteración de aorta abdominal yuxtarrenal. Estenosis 90% de arteria renal izquierda. Trombosis arteria renal derecha y atrofia renal. Tratado con desobliteración aórtica, prótesis aorto-bifemoral, by-pass aorto-renal izquierdo y nefrectomía derecha. Presentación de un caso.

A case report of a juxtarenal abdominal aortic obliteration, associated to a annulated right kidney, a 90% left renal arterial stenosis, hypertension and chronic renal failure is presented. An aortic desobliteration was performed, with a termino-terminal aortobifemoral prosthesis, a left aortorenal by pass and a right nephrectomy. The result was successfully and allowed a satisfactory evolution of its renal failure and hypertension.

[Loco-regional fibrinolysis with urokinase in the treatment of deep venous thromboses]. / Fibrinólisis loco-regional con urokinasa en el tratamiento de las trombosis venosas profundas.

The importance of the fibrinolytic treatment in deep venous thrombosis, to avoid the mortal pulmonary embolism, among other complications, is commented on. The results in 32 patients, presenting deep venous thrombosis and treated with loco-regional Urokinase, are presented. Author carries out some commentaries about surgical and medical treatment.