Management of Superior Vena Cava Occlusion Causing Bleeding "Downhill" Esophageal Varices.

The health care system in Peru treats 15,000 dialysis patients annually. Approximately 45% of patients receive therapy using catheters. The incidence of catheter-induced superior vena cava (SVC) occlusion is increasing along with its associated significant morbidity and vascular access dysfunction. One of the unusual manifestations of this complication is bleeding "downhill" esophageal varices caused by reversal of blood flow through esophageal veins around the obstruction to the right atrium. Herein is presented the case of an 18-year-old woman on hemodialysis complicated by SVC occlusion and bleeding esophageal varices who underwent successful endovascular recanalization of the SVC. Bleeding from "downhill" esophageal varices should be considered in the differential diagnosis of dialysis patients exposed to central venous catheters. Aggressive endovascular treatment of SVC occlusion is recommended to preserve upper extremity access function and prevent bleeding from this complication.

Tratamiento mediante dilatación con balón de un paciente con estenosis subaórtica por membrana: a propósito de un caso / Percutaneous balloon dilatation in a patient with membrane subaortic stenosis: a propos of a case

La estenosis subaórtica es una lesión cardiaca poco frecuente, en el cual el tracto de salida del ventrículo izquierdo está estrechado por la presencia de un anillo fibroso o fibromuscular. Constituye 8 a 20% de todas las formas de obstrucción al tracto de salida del ventrículo izquierdo. La cirugía ha sido considerada el tratamiento de elección cuando el gradiente pico es mayor de 50 mmHg o en pacientes que, con gradientes menores, presentan progresión de la insuficiencia aórtica o dilatación de los diámetros ventriculares, disfunción ventricular o síntomas. Presentamos el caso de un paciente menor de edad, portador de estenosis subaórtica por membrana, con síntomas de insuficiencia cardiaca y función ventricular izquierda muy comprometida, en la que se realizó el tratamiento percutáneo, alternativo al quirúrgico, con resultado exitoso. Constituye el primer caso reportado en el país de tratamiento percutáneo con balón y con evolución favorable.

Discrete subaortic stenosis is a rare cardiac lesion with left ventricle outflow narrowed by the presence of a muscular or fibrous ring. It accounts for 8-20% of all forms of left ventricle outflow tract obstruction. Surgery is considered the treatment of choice when the peak gradient is over 50 mmHg or in patients with lower gradients and either progression of aortic regurgitation, dilated ventricular diameters, left ventricular dysfunction or symptoms. We report the case of a child with membrane subaortic stenosis and symptoms of heart failure and compromised left ventricular function, in whom percutaneous balloon dilatation was performed as an alternative to surgery. This is the first case reported in the country with successful outcome.