Tomografía computarizada multidetector en la planificación del tratamiento de la fibrilación auricular / Multidetector computed tomography in planning the treatment of atrial fibrillation

OBJETIVOS: Conocer la anatomía de las venas pulmonares (VVPP) mediante tomografía computarizada multidetector (TCMD) en pacientes con fibrilación auricular (FA) antes de la ablación. MATERIAL Y MÉTODOS: Realizamos TCMD a 89 pacientes con FA analizando número, variantes y venas accesorias pulmonares, diámetro y forma ostia, distancia a la primera bifurcación y trombo en la orejuela izquierda. RESULTADOS: El patrón venoso pulmonar más frecuente fue 4 VVPP (dos derechas y dos izquierdas) en 49 pacientes (55,1%). Las VVPP superiores presentaron mayor diámetro ostial que las inferiores [vena pulmonar superior derecha (VPSD)> vena pulmonar inferior derecha (VPID); p = 0,001 y vena pulmonar superior izquierda (VPSI)> vena pulmonar inferior izquierda (VPII); p <0,001]. El diámetro ostial de las VVPP derechas era mayor que el de las izquierdas (VPSD> VPSI; p <0,001 y VPID> VPII; p <0,001). El ostium más circular lo presentó la VPID (ratio: 0,885) respecto a la VPII (p <0,001) y a la VPSI (p <0,001). La distancia a la primera bifurcación ha sido mayor en las venas superiores (VPSD> VPID; p = 0,008 y VPSI> VPII; p = 0,038). La distancia a la primera bifurcación fue mayor en las VVPP izquierdas (VPSI> VPSD; p <0,001 y VPII> VPID; p <0,001). Otros hallazgos fueron: divertículos (30), apéndices auriculares accesorios (5), aneurismas septales (8), bolsas septales (6) y 1 trombo en la orejuela izquierda. CONCLUSIÓN: La TCMD antes de la ablación demuestra la anatomía de la aurícula izquierda (AI) y de las VVPP con diferencias significativas entre los diámetros y morfología de los ostia venosos

OBJECTIVE: To know the anatomy of the pulmonary veins (PVs) by multidetector computed tomography (MDCT) in patients with atrial fibrillation (AF) prior to ablation. MATERIALS AND METHODS: MDCT was performed in 89 patients with AF, analyzing the number of PVs, accessory variants and veins, diameter and ostial shape, distance to the first bifurcation and thrombus in the left atrial appendage. RESULTS: The most frequent venous pattern was 4 PVs (two right and two left) in 49 patients (55.1%). The superior veins had a statistically significant greater mean ostial diameter than the inferior veins (Right Superior Pulmonary Vein (RSPV)> Right Inferior Pulmonary Vein (RIPV); p = 0.001 and Left Superior Pulmonary Vein (LSPV)> Left Inferior Pulmonary Vein (LIPV); p < 0.001). The right pulmonary veins ostial diameters were significantly larger than the left pulmonary veins ostial diameters (RSPV> LSPV; p < 0.001 and RIPV> LIPV; p < 0.001). The most circular ostium was presented by the VPID (ratio: 0.885) compared to the LIPV (p<00.1) and LSPV (p < 0.001). The superior veins had a statistically significant greater mean distance to first bifurcation than the inferior veins (RSPV> RIPV; p = 0.008 and LSPV> LIPV; p = 0.038). Mean distance to first bifurcation has been greater in left PVs respect to the right PVs (LSPV> RSPV; p < 0.001and LIPV> RIPV; p < 0.001). Other findings found in AI: diverticula (30), accessory auricular appendages (5), septal aneurysms (8), septal bags (6) and 1 thrombus in the left atrial appendage. CONCLUSION: MDCT prior to ablation demonstrates the anatomy of the left atrium (LA) and pulmonary veins with significant differences between the diameters and morphology of the venous ostia

Multidetector computed tomography in planning the treatment of atrial fibrillation. / Tomografía computarizada multidetector en la planificación del tratamiento de la fibrilación auricular.

OBJECTIVE: To know the anatomy of the pulmonary veins (PVs) by multidetector computed tomography (MDCT) in patients with atrial fibrillation (AF) prior to ablation. MATERIALS AND METHODS: MDCT was performed in 89 patients with AF, analyzing the number of PVs, accessory variants and veins, diameter and ostial shape, distance to the first bifurcation and thrombus in the left atrial appendage. RESULTS: The most frequent venous pattern was 4 PVs (two right and two. left) in 49 patients (55.1%). The superior veins had a statistically significant greater mean ostial diameter than the inferior veins (Right Superior Pulmonary Vein (RSPV)> Right Inferior Pulmonary Vein (RIPV); p=0.001 and Left Superior Pulmonary Vein (LSPV)> Left Inferior Pulmonary Vein (LIPV); p<0.001). The right pulmonary veins ostial diameters were significantly larger than the left pulmonary veins ostial diameters (RSPV> LSPV; p<0.001 and RIPV> LIPV; p<0.001). The most circular ostium was presented by the VPID (ratio: 0.885) compared to the LIPV (p<00.1) and LSPV (p<0.001). The superior veins had a statistically significant greater mean distance to first bifurcation than the inferior veins (RSPV> RIPV; p=0.008 and LSPV> LIPV; p=0.038). Mean distance to first bifurcation has been greater in left PVs respect to the right PVs (LSPV> RSPV; p<0.001and LIPV> RIPV; p<0.001). Other findings found in AI: diverticula (30), accessory auricular appendages (5), septal aneurysms (8), septal bags (6) and 1 thrombus in the left atrial appendage. CONCLUSION: MDCT prior to ablation demonstrates the anatomy of the left atrium (LA) and pulmonary veins with significant differences between the diameters and morphology of the venous ostia.

Rotura de raíz aórtica con formación de shunt intracardíaco secundaria a implante valvular aórtico transcatéter / Aortic root rupture and acquired intracardiac shunt after transcatheter aortic valve implantation

El implante transcatéter de válvula aórtica, más conocido por su acrónimo en inglés TAVI (Transcatheter Aortic Valve Implantation) es una alternativa al recambio valvular quirúrgico en pacientes inoperables o con alto riesgo quirúrgico. Sin embargo, es una técnica cada vez más utilizada, que no está exenta de complicaciones. La rotura de la raíz aórtica postimplante es una complicación infrecuente, pero letal, y con pocos casos descritos en la bibliografía. La tomografía computarizada multidetector es fundamental antes del procedimiento TAVI para valorar factores predisponentes a la aparición de complicaciones, mientras que su papel posprocedimiento sigue siendo controvertido

Transcatheter aortic valve implantation (TAVI) is an alternative to surgical valve replacement in patients with high surgical risk. Although TAVI is becoming more and more common, it is not without complications. Rupture of the aortic root after implantation is an uncommon, but lethal complication; few cases have been described in the literature. Multidetector computed tomography is fundamental before TAVI to evaluate factors that predispose to complications; however, its role after the procedure is still controversial

Aortic root rupture and acquired intracardiac shunt after transcatheter aortic valve implantation. / Rotura de raíz aórtica con formación de shunt intracardíaco secundaria a implante valvular aórtico transcatéter.

Transcatheter aortic valve implantation (TAVI) is an alternative to surgical valve replacement in patients with high surgical risk. Although TAVI is becoming more and more common, it is not without complications. Rupture of the aortic root after implantation is an uncommon, but lethal complication; few cases have been described in the literature. Multidetector computed tomography is fundamental before TAVI to evaluate factors that predispose to complications; however, its role after the procedure is still controversial.

Evaluación de los pacientes candidatos a implante transcatéter de válvula aórtica mediante tomografía computarizada multidetector / Multidetector computed tomography evaluation of candidates for transcatheter aortic valve implantation

El implante transcatéter de válvula aórtica, más conocido por su acrónimo en inglés TAVI (Transcatheter Aortic Valve Implantation), consiste en la implantación de una válvula biológica montada en un stent sin retirar la válvula nativa. El primer procedimiento lo realizó Alain Cribier en 2002 y la inclusión de esta técnica en las guías clínicas se produjo gracias al ensayo multicéntrico aleatorizado PARTNER (Placemente of Aortic Transcatheter Valves), que demostró que el TAVI obtiene mejores resultados que el tratamiento médico conservador y que es una alternativa a la cirugía en pacientes con alto riesgo quirúrgico. Los pacientes candidatos a TAVI deben completar un protocolo de evaluación para valorar si es factible, porque no todos los pacientes rechazados para cirugía son idóneos para TAVI. La tomografía computarizada multidetector desempeña un papel importante en la valoración anatómica de los candidatos, y en los pacientes finalmente seleccionados guía el procedimiento (AU)

In transcatheter aortic valve implantation (TAVI), a biologic valve mounted in a stent is implanted without removing the native valve. This procedure was first done in humans by Alain Cribier in 2002 and was included in clinical guidelines after the multicenter PARTNER (Placement of AoRtic TraNscathetER) randomized clinical trial, which showed that TAVI obtained better outcomes than conservative medical treatment and is an alternative to surgery in patients with high surgical risk. Candidates for TAVI must be assessed to determine whether the procedure is feasible, because TAVI is not ideal for all patients who are considered inoperable. Multidetector computed tomography plays an important role in the anatomic evaluation of candidates and in guiding the procedure in those who are finally selected (AU)

Multidetector computed tomography evaluation of candidates for transcatheter aortic valve implantation. / Evaluación de los pacientes candidatos a implante transcatéter de válvula aórtica mediante tomografía computarizada multidetector.

In transcatheter aortic valve implantation (TAVI), a biologic valve mounted in a stent is implanted without removing the native valve. This procedure was first done in humans by Alain Cribier in 2002 and was included in clinical guidelines after the multicenter PARTNER (Placement of AoRtic TraNscathetER) randomized clinical trial, which showed that TAVI obtained better outcomes than conservative medical treatment and is an alternative to surgery in patients with high surgical risk. Candidates for TAVI must be assessed to determine whether the procedure is feasible, because TAVI is not ideal for all patients who are considered inoperable. Multidetector computed tomography plays an important role in the anatomic evaluation of candidates and in guiding the procedure in those who are finally selected.

Solución del caso 18: Hidrocele del canal de Nuck / No disponible

No disponible

Lesión medular traumática en el síndrome de Klippel-Feil / No disponible

No disponible

Mujer con hipotensión y fallo renal agudo / No disponible

No disponible

[Primary mesenchymal chondrosarcoma of the mediastinum]. / Condrosarcoma mesenquimal primario en el mediastino.

Cartilaginous lesions of the mediastinum are quite rare and primary cartilage forming tumors arising within the mediastinum are even more exceptional. Radiologic findings are unspecific. However, certain characteristics can orient the diagnosis. They are presented one mediastinal chondrosarcoma case in adult patient of patho-anatomical diagnosis. The findings described entail chest radiography, computed tomography and magnetic resonance.

Condrosarcoma mesenquimal primario en el mediastino / Primary mesenchymal chondrosarcoma of the mediastinum

Las lesiones cartilaginosas en el mediastino son muy infrecuentes y los tumores primarios formadores de cartílago que asientan en el mediastino son incluso más excepcionales. Los hallazgos radiológicos a menudo son inespecíficos. No obstante, existen ciertas características que nos pueden orientar hacia el diagnóstico.Presentamos un caso de condrosarcoma mediastínico en un paciente adulto cuyo diagnóstico se realizó por anatomía patológica. Describimos los hallazgos en la radiografía de tórax, tomografía computarizada y resonancia magnética

Cartilaginous lesions of the mediastinum are quite rare and primary cartilage forming tumors arising within the mediastinum are even more excepcional. Radiologic findings are unspecific. However, certain characteristicscan orient the diagnosis.They are presented one mediastinal chondrosarcoma case in adult patient of patho-anatomical diagnosis. The findings described entail chest radiography, computed tomography and magnetic resonance

Tratamiento de fístulas carótido-cavernosas / Treatment of carotid-cavernous fistulas

Objetivos. Valorar los resultados del tratamiento de 33 pacientes con fístula carótido-cavernosa (FCC) de acuerdo con criterios clínicos y angiográficos. Material y métodos. De enero de 1993 a diciembre de 2003, 33 pacientes fueron diagnosticados y tratados de FCC en nuestro hospital. Se realizó examen clínico y angiografía antes y después del tratamiento. Las modalidades terapéuticas disponibles son el tratamiento conservador, mediante compresiones, y el tratamiento intervencionista, con distintos procedimientos según la vía de abordaje y el material de embolización empleados. Resultados. De las 11 FCC directas, una fue tratada de forma conservadora y 10 se sometieron a procedimientos de embolización. La vía de abordaje fue transarterial en 5, transvenosa en 2 y en 3 se utilizaron ambas, consiguiendo la desaparición de los síntomas en el 90% de los pacientes. De las 22 FCC indirectas o durales, 6 fueron tratadas de forma conservadora, con óptimo resultado, mientras que las 16 restantes se embolizaron, 11 por vía transarterial y 5 combinando los accesos transarterial y transvenoso. La terapia endovascular logró la desaparición completa de los síntomas en 9 pacientes y parcial en 7. Sólo se produjo una complicación transitoria. Conclusiones. La adecuada selección tanto del tipo de tratamiento (conservador o intervencionista), como del procedimiento (vía de abordaje y material de embolización), caso de que fuera necesario, optimiza los resultados en el manejo de pacientes con FCC

Objectives. To evaluate the results of the treatment of 33 patients with carotid-cavernous fistula (CCF) with respect to clinical and angiographic criteria. Material and methods. From January 1993 to December 2003, 33 patients were diagnosed with CCF and treated at our hospital. All patients underwent clinical examination and angiography before and after treatment. Available treatment modalities were conservative treatment, consisting of compressions, and interventional treatment, with different procedures depending on the approach and the materials employed for embolization. Results. Of the 11 direct CCFs, one received conservative treatment and 10 underwent embolization procedures. An arterial approach was used in 5 cases, a venous approach in 2, and a combined venous-arterial approach in the remaining 3, with symptoms disappearing in 90% of the patients. Of the 22 indirect or dural CCFs, 6 received conservative treatment, with optimal results, and the remaining 16 underwent embolization (11 using an arterial approach and 5 using a combined venous-arterial approach). Endovascular treatment brought about the complete disappearance of symptoms in 9 patients and partial disappearance in 7. Only one transitory complication was observed. Conclusions. The appropriate selection of both the type of treatment (conservative vs. interventional) and the interventional procedure (approach and material for embolization), yields optimal results in the management of patients with CCF

[Progression following the embolisation of 100 intracranial arteriovenous malformations]. / Evolución tras la embolización de 100 malformaciones arteriovenosas intracraneales.

INTRODUCTION: We analysed the characteristics, progression and outcomes observed following the embolisation of 100 intracranial arteriovenous malformations (AVM) that were performed in order to achieve complete obliteration of the AVM, the elimination of associated vascular risk factors and also to reduce their size with a view to increasing the effectiveness of later treatments. PATIENTS AND METHODS: The demographic and anatomical characteristics of 110 patients with AVM were analysed over a period of 13 years, and embolisation was performed in 100 of them. In all, 203 embolisation sessions were carried out with an average of 3 embolisations per patient. Of the 100 AVM that were embolised, 36 were AVM which were treated by embolisation with no later therapy, 48 required radiosurgery after the embolisation and the other 16 were submitted to surgery following the embolisation. The type of materials used included liquid adhesive embolic agents (Hystoacryl, Glubran), non-adhesive embolic agents (Onyx) and polyvinyl alcohol particles. Patients were examined clinically and arteriographically. RESULTS: Of the 100 AVM that were embolised, complete eradication was accomplished with just embolisation in 27 cases of AVM (27%). Of the 48 AVM in which radiosurgery was carried out at a later date, the average rate of obliteration was 78% and of the 16 AVM in which surgery was carried out some time later, the average rate of obliteration was 70%. Of the 100 AVM that were embolised, some residue remained in 16 cases. Embolisation eliminated most of the associated vascular risk factors, as can be seen by the fact that associated risk factors disappeared in 28 (65%) out of the 43 AVM with such factors. The morbidity and mortality rates with embolisation were 8% and 2%, respectively. CONCLUSIONS: Embolisation eliminated most of the vascular risk factors, with complete obliteration in 27 cases and size was satisfactorily reduced for later treatment; at the same time, morbidity and mortality rates were acceptable.