Sangrado digestivo masivo no objetivable con angiografía pero sí con TAC / Detection with computer tomography of massive gastrointestinal bleeding not detected with angiography

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[Percutaneous placement of covered stents for treatment of post discectomy arterial rupture]. / Rotura arterial posdiscectomía. Tratamiento mediante implante percutáneo de una endoprótesis cubierta.

INTRODUCTION: Vascular lesions produced as a consequence of surgical spinal treatment are rare, but serious. Fast diagnosis and treatment are essential in lesions that produce massive blood loss. Following the use of non covered stents in the treatment of peripheral vascular stenotic obstructive pathologies, the appearance of covered stents allowed aneurysms, pseudo aneurysms, fistulas or bleedings to be treated. Being able to graft a stent in serious patients, during diagnosis itself, with a minimum amount of aggression and local anaesthesia affords this technique huge advantages over others. CASE REPORT: In this work we report the case of an arterial rupture which came about as a complication of a discectomy. After the surgical intervention, there was an important haematocrit reduction within a short space of time. The patient s quickly becoming anaemic and the existence of a retroperitoneal mass of heterogeneous echogenicity pointed towards a postoperative haemorrhage. This was confirmed by arteriography, which revealed an important contrast extravasation. A covered stent was placed at the same time and, in the post graft follow up, it was confirmed that there was no bleeding. At 12 hours after the operation the patient was moved from the postoperative recovery unit to a hospital ward and, 5 days later, was discharged. In a check up carried out in the Neurosurgery unit 2 months after being sent home, the patient was found to be asymptomatic. CONCLUSION: The placement of covered stents is a valid therapeutic option for treating postoperative haemorrhagic lesions. It can be performed at the same time as diagnosis and does not require general anaesthesia. In the case we have described, the patient recovered quickly and ambulatory check ups showed he continued to be asymptomatic

Rotura arterial posdiscectomía. Tratamiento mediante implante percutáneo de una endoprótesis cubierta / Percutaneous placement of covered stents for treatment of post-discectomy arterial rupture

Introducción. Las lesiones vasculares como consecuencia de tratamientos quirúrgicos espinales son complicaciones raras, pero graves. La rapidez en el diagnóstico y el tratamiento son esenciales en lesiones que producen pérdidas hemáticas masivas. A la utilización de endoprótesis no cubiertas en el tratamiento de la patología estenosicoobstructiva vascular periférica, le siguió la aparición de las endoprótesis cubiertas, que abrieron la posibilidad de tratar aneurismas, pseudoaneurismas, fístulas o sangrados. El hecho de poder implantar una endoprótesis en pacientes graves, en el mismo acto diagnóstico, con una agresión mínima y con anestesia local, le confiere grandes ventajas a esta técnica. Caso clínico. En este trabajo se presenta una rotura arterial como complicación de una discectomía. Tras el acto quirúrgico, el paciente presentó una reducción importante del hematocrito, en un corto período. La anemización rápida y la existencia de una masa de ecogenicidad heterogénea retroperitoneal orientaron hacia una hemorragia posquirúrgica, que se confirmó mediante una arteriografía, que demostró un extravasado importante de contraste. Se liberó una endoprótesis cubierta en el mismo acto, y se observó, en el control postimplante, la inexistencia de sangrado. A las 12 horas posprocedimiento, el paciente se trasladó desde la Unidad de Reanimación a la planta de hospitalización y, a los cinco días se le dio el alta. En un control realizado en el Servicio de Neurocirugía, a los dos meses del alta, el paciente se encontraba asintomático. Conclusión. El implante de endoprótesis cubiertas es una opción terapéutica apropiada para el tratamiento de lesiones hemorrágicas posquirúrgicas. Puede realizarse en el mismo acto diagnóstico y no necesita anestesia general. En el caso aquí descrito, el paciente presentó una recuperación rápida y el control ambulatorio demostró que seguía asintomático (AU)

[Percutaneous treatment of peripheral vascular malformations]. / Tratamiento percutáneo de las malformaciones vasculares periféricas.

OBJECTIVE: Vascular malformations are uncommon pathologic entities in which surgery is usually not possible or is inefficient. Our experience with the percutaneous treatment of peripheral vascular malformations, by means of transarterial embolization or direct puncture is here reported. MATERIAL AND METHODS: During the 1993-1997 period a total of 35 patient, 20 females (57%) and 15 males (43%) aged 11 to 75 years, were treated at our Unit. Sixteen vascular malformations were hemodynamically active (45.7%) and 19 hemodynamically inactive (54.3%). A total of 126 embolizations (mean 3.6) were performed. Malformations were studied by means of doppler-echography, magnetic resonance, arteriography and direct puncture angiography. Considering location, size and hemodynamic characteristics a specific approach and therapy was performed in each case. In two cases (5.7%) a surgical exeresis after embolization was performed. RESULTS: A technical success, defined as the possibility of embolizing the malformation, was achieved in 100% of cases. No technical complications during the procedure occurred. The mean follow-up time was 23 months (6-69). All patients but one improved both objectively and subjectively and all but one have recovered their daily activities in the following days. The exception was one patient who developed a severe complication--cutaneous necrosis--a few days after the procedure which required repairing surgery. All patient had edema, pain and increased functional impairment after the embolization which subsided with medical treatment. CONCLUSIONS: Percutaneous embolization of vascular malformations is an effective method associated with a low complication rate. Our results are encouraging although more extensive investigation are required to draw definite conclusions.

[Wallstent endoprostheses implanted by fluoroscopic guidance in the palliative treatment of malignant esophageal obstructions and esophago-tracheal fistulas]. / Endoprótesis de Wallstent implantadas bajo control fluoroscópico en el tratamiento paliativo de las obstrucciones esofágicas malignas y fístulas esófago-traqueales.

PURPOSE: The objective of this study was to present our experience with metallic stents (Wallstent) for palliation of dysphagia due to malignant esophageal obstruction and esophagotracheal fistula. PATIENTS AND METHODS: From August 1994 to July 1996 20 uncovered and 6 covered stents were inserted in 16 consecutive patients with dysphagia grade 3 (n = 4) or grade 4 (n = 12) caused by incurable malignant obstructions. The obstruction was in the proximal (n = 4), in the middle (n = 3) and the distal (n = 9) third of the esophagus. Five patients presented with esophagotracheal fistula. The stent insertion was performed under fluoroscopic control. RESULTS: Exact positioning of the stent with reduction of the dysphagia was obtained in all patients. There were no complications related with the procedure. Esophagotracheal fistula was solved in those patients treated with covered stents. Six patients had recurrent dysphagia due to tumor ingrowth or overgrowth. In these patients an additional overlapping stent was placed. In latest evaluation 2 patients presented dysphagia grade I, 5 grade III, and 4 grade IV. CONCLUSION: Implantation of stents proved to be an effective and safe method of palliating dysphagia and occluding esofagotracheal fistula. Placement of stents was feasible without major procedure-related complications.

[The long-term results on arterial pressure and kidney function after the percutaneous transluminal dilatation of renal artery stenosis]. / Resultados a largo plazo sobre la presión arterial y la función renal después de la dilatación transluminal percutánea de la estenosis de la arteria renal.

BACKGROUND: The purpose of this study was to evaluate the clinical results analyzing the cure, improvement and failure rates of percutaneous transluminal angioplasty (PTA) in patients with the diagnosis of renovascular hypertension with special reference to those with atherosclerotic vascular disease, according to their age, and their effect on blood pressure control and renal function. PATIENTS AND METHODS: In 93 hypertensive patients with a mean age of 43.4 years 123 renal artery PTA were performed: Twenty-six patients older than 50 years and eleven with 50 years or less had atherosclerosis, 27 fibromuscular dysplasia and a mixed disease was found in one patient. Twenty-eight patients with renal transplant were diagnosed as having arterial graft stenosis. RESULTS: After renal PTA, there was a significant decrease in blood pressure in all cases. Patients with atherosclerotic renal vascular disease showed a decrease in systolic pressure (SP) from 168 +/- 19 before PTA to 154 +/- 8 mmHg at 96 months (p < 0.001) and diastolic (DP) from 113 +/- 10 before PTA to 90 +/- 4 mmHg at 96 months (p < 0.001) respectively after the procedure. Significant differences were also observed in patients with fibromuscular dysplasia. Most patients with renal transplant arterial stenosis had less than five years of follow-up and SP and DP decreased from 162 +/- 18 and 109 +/- 8 mmHg before PTA, to 147 +/- 10 (p < 0.001) and 91 +/- 7 mmHg (p < 0.001) at 12 months after dilation respectively. Clinical improvement was achieved in 91% of patients with atherosclerosis at 96 months and fifty percent of the patients with fibromuscular dysplasia were cured after the same period from the time of PTA. Twelve months after the renal transplant artery dilation was achieved a clinical improvement in 81% and a cure rate in 6% of the patients. Ostial lesions comprised the majority of blood pressure benefit failures. There was no significant improvement in renal function immediately after renal artery dilation except in those patients with fibromuscular dysplasia. Residual stenosis greater than 75% was present in 15 patients after the first PTA. Complications were seen in 4.8% and were related to renal failure and vessel dissection. CONCLUSION: Angioplasty is effective in the long-term management of high arterial blood pressure and may preserve renal function according to renal artery disease.

[Percutaneous implant of Hickman catheters and reservoirs. Long-term experience]. / Implante percutáneo de catéteres de Hickman y reservorios. Experiencia a largo plazo.

OBJECTIVE: To report our experience with long term external catheters and implantable ports in the last 8 years. MATERIAL AND METHODS: From December 1987 to August 1995 a total of 617 central venous catheters were implanted in 541 patients in our Interventionist Vascular Radiology Unit, 265 men (49%) and 276 women (51%), with a mean age of 46 years. A total of 335 (54%) were partially implantable external catheters and 241 (39%) implantable ports in chest and 41 (7%) in the forearm. RESULTS: A technical success--defined as the possibility of implanting the catheter--was achieved in 98% of cases. Immediate complications included 5 pneumothorax (0.8%), 11 accidental carotid artery puncture (2%) with no clinical relevance, 18 catheter misplacement (3%), and 8 vein spasm (1%). Fifty-two catheters (8%) were removed on account of infectious complications. Currently, 71 catheters are still in use (12%), 433 (70%) have been removed or the catheter was patent until patients's death. CONCLUSIONS: Partially implantable central venous catheters and totally implantable ports are a safe alternative in patients requiring a central venous access for prolonged treatments. The low number of immediate complications renders the Interventionist Vascular Radiology Unit the proper place where to perform these procedures.