Two cases treated by different strategies for common carotid artery dissection with thrombosis due to a type a aortic dissection

Abstract Total arch replacement and stent trunk were performed for two patients. One of these underwent a total bilateral carotid artery replacement in anatomical position while the other underwent partial carotid artery dissection. The first patient demonstrated no neurological complication after surgery and a postoperative computed tomography angiography (CTA) showed bilateral common carotid artery patency. However, the second patient had neurological dysfunction after surgery, while a postoperative CTA showed occlusion of the left common carotid artery. Anatomical replacement for a common carotid artery dissection with thrombus has the potential to significantly improve cerebral perfusion and reduce postoperative neurological complications.

Neuroprotective effects of erythropoietin on rat retinas subjected to oligemia

OBJECTIVES: Erythropoietin may have neuroprotective potential after ischemia of the central nervous system. Here, we conducted a study to characterize the protective effects of erythropoietin on retinal ganglion cells and gliotic reactions in an experimentally induced oligemia model. METHODS: Rats were subjected to global oligemia by bilateral common carotid artery occlusion and then received either vehicle or erythropoietin via intravitreal injection after 48 h; they were euthanized one week after the injection. The densities of retinal ganglion cells and contents of glial fibrillary acidic protein (astrocytes/Müller cells) and cluster of differentiation 68 clone ED1 (microglia/macrophages), assessed by fluorescence intensity, were evaluated in frozen retinal sections by immunofluorescence and epifluorescence microscopy. RESULTS: Retinal ganglion cells were nearly undetectable one week after oligemia compared with the sham controls; however, these cells were partially preserved in erythropoietin-treated retinas. The contents of glial fibrillary acidic protein and cluster of differentiation 68 clone ED1, markers for reactive gliosis, were significantly higher in retinas after bilateral common carotid artery occlusion than those in both sham and erythropoietin-treated retinas. CONCLUSIONS: The number of partially preserved retinal ganglion cells in the erythropoietin-treated group suggests that erythropoietin exerts a neuroprotective effect on oligemic/ischemic retinas. This effect could be related to the down-modulation of glial reactivity, usually observed in hypoxic conditions, clinically observed during glaucoma or retinal artery occlusion conditions. Therefore, glial reactivity may enhance neurodegeneration in hypoxic conditions, like normal-tension glaucoma and retinal ischemia, and erythropoietin is thus a candidate to be clinically applied after the detection of decreased retinal blood flow.

Tratamento híbrido das doenças do arco aórtico / Hybrid treatment of aortic arch disease

Introdução: O manejo das doenças da aorta torácica que envolvem a aorta ascendente, arco aórtico e aorta torácica descendente constituem um desafio técnico e é uma área em constante desenvolvimento e inovação. Objetivo: Analisar os resultados iniciais e a médio prazo do tratamento híbrido das doenças do arco aórtico. Métodos: Estudo retrospectivo de procedimentos realizados no período de janeiro de 2010 a dezembro de 2012, em que foram analisados o sucesso técnico e terapêutico, a morbimortalidade, os desfechos neurológicos, a taxa de vazamentos e de reintervenções. Resultados: Em um total de 95 pacientes tratados por doenças da aorta torácica no período, 18 realizaram o tratamento híbrido e adentraram neste estudo. A idade média foi de 62,3 anos. O sexo masculino esteve presente em 66,7%. O sucesso técnico e terapêutico foi de 94,5% obe 83,3%, respectivamente. A mortalidade perioperatória foi de 11,1%. Não houve óbito durante o acompanhamento de 1 ano. A taxa de reintervenção foi de 16,6%, devido a 2 casos de endoleak tipo Ia e um caso de endoleak tipo 2. Não foi observada oclusão dos enxertos anatômicos ou extra-anatômicos durante o período de seguimento. Conclusão: O tratamento híbrido das doenças do arco aórtico demonstrou ser uma alternativa viável à cirurgia convencional. As taxas de sucesso terapêutico e de reintervenções demonstram a necessidade do seguimento clínico rigoroso desses pacientes a longo prazo. .

Introduction: The management of thoracic aortic disease involving the ascending aorta, aortic arch and descending thoracic aorta are technically challenging and is an area in constant development and innovation. Objective: To analyze early and midterm results of hybrid treatment of arch aortic disease. Methods: Retrospective study of procedures performed from January 2010 to December 2012. The end points were the technical success, therapeutic success, morbidity and mortality, neurologic outcomes, the rate of endoleaks and reinterventions. Results: A total of 95 patients treated for thoracic aortic diseases in this period, 18 underwent hybrid treatment and entered in this study. The average ages were 62.3 years. The male was present in 66.7%. The technical and therapeutic success was 94.5% e 83.3%. The perioperative mortality rate of 11.1%. There is any death during one-year follow- up. The reoperation rates were 16.6% due 2 cases of endoleak Ia and one case of endoleak II. There is any occlusion of anatomic or extra anatomic bypass during follow up. Conclusion: In our study, the hybrid treatment of aortic arch disease proved to be a feasible alternative of conventional surgery. The therapeutic success rates and re- interventions obtained demonstrate the necessity of thorough clinical follow-up of these patients in a long time. .

Face transplantation in rats. Reproducibility of the experimental model in Brazil

PURPOSE: To investigate the reproducibility of the experimental model of face allotransplantation in rats in Brazil. METHODS: Eighteen rats were operated, nine-nine donors recipients. Animals underwent transplantation of the left hemiface, with periorbital and scalp. Transplants were made from donor Wistar rats to recipients Lewis rats. Flaps were based on the common carotid artery and the external jugular vein of the donor animal and the anastomosis in the recipient area was performed in common carotid artery (end-to-side) and in external jugular vein (end-to-end). RESULTS: Of the nine recipient animals operated, six survived and three progressed to death in the first days after surgery (survival rate = 67%). The mean time of the procedure was 252 minutes and the mean time of flap ischemia was 95 minutes. The five surviving animals were sacrificed at 14 days, in good general condition and without signs of tissue rejection. CONCLUSIONS: The experimental model of face allotransplantation in rats is reproducible in our midst. Duration of surgery, time of flap ischemia, animal survival rate and complications observed were similar to those described in the literature. .

Estratégia híbrida combinando angioplastia carotídea e cirurgia cardiovascular / Hybrid strategy combining carotid stenting and cardiovascular surgery

Fundamentos: Lesões carotídeas estão presentes em 8% a 14% dos candidatos a cirurgia cardiovascular e aumentam o risco de acidente vascular cerebral perioperatório. Esse problema é particularmente importante em pacientes com doença coronária e/ou valvar grave que não são candidatos a procedimentos de revascularização em momentos diferentes. Avaliamos os resultados de uma estratégia híbrida de tratamento, na qual angioplastia carotídea e cirurgia cardiovascular foram realizadas de forma sequencial, com intervalo de algumas horas. Método: Foram tratadas lesões carotídeas > 70% em pacientes sintomáticos e > 80% nos assintomáticos. Ácido acetilsalicílico foi administrado antes da angioplastia carotídea e heparina, no momento do procedimento. Finalizada a intervenção percutânea, os pacientes foram transferidos para a sala de cirurgia para realização do procedimento cardiovascular. Clopidogrel foi administrado habitualmente 8 horas após o término da cirurgia...

Background: Carotid lesions are observed in 8% to 14% of cardiovascular surgery candidates and increase the risk of perioperative stroke. This is particularly important in patients with coronary disease and/or severe valve disease who are not candidate to revascularization procedures at different time points. We assessed the results of a hybrid strategy, where carotid angioplasty and cardiovascular surgery were performed sequentially with an interval of a few hours. Method: Carotid lesions > 70% in symptomatic patients and > 80% in asymptomatic patients were treated. Acetylsalicylic acid was administered prior to carotid stenting and heparin was administered at the time of the procedure. Once the percutaneous intervention was over, patients were transferred to the surgery room to carry out the cardiovascular procedure. Clopidogrel was administered 8 hours after the end of the surgery...

Disección espontánea de la carótida común como causa de sangramiento digestivo alto: a propósito de un caso / Spontaneous dissection of the common carotid as a cause of high digestive bleeding: on the purpose of a case

El sangramiento digestivo alto es una entidad de presentación frecuente en los servicios de urgencia hospitalaria y a pesar de los avances terapéuticos continúa teniendo una elevada mortalidad quirúrgica. Cuando se recibe, de inmediato nos damos a la tarea de constatar el sangrado, evaluar su intensidad y tomar medidas rápidas para su tratamiento. Se presenta un caso, en el que para orientarnos en su etiología encaminamos el interrogatorio hacia las principales causas que pueden originar este síndrome y es aquí donde ciertos detalles nos sorprenden y nos hace pensar que nos encontramos ante una causa poco frecuente de estos eventos.

High digestive bleeding is an entity of frequent presentation at the hospital emergency care services, and in spite of the therapeutic advances, it still presents a high surgical mortality. When a patient with high digestive bleeding enters the service, we take care of checking it, evaluating its intensity and taking fast measures to treat it. We present a case in which, to determine its etiology, we directed the inquiry to the main causes that may originate this syndrome, finding some details that surprised us and led to the conclusion that the cause was infrequent in these events.

Morbimortalidad de la endarterectomía carotídea extracraneana en el Hospital DIPRECA / Carotid endarterectomy at Dipreca Hospital: morbidity and mortality

Introducción: La estenosis grave de la arteria carótida es una causa importante de accidente vascular encefálico(AVE) y evento isquémico transitorio (TIA) (10-20 por ciento). La endarterectomía carotídea extracraneana (ECE) ha demostrado ser efectiva en reducir este riesgo en pacientes seleccionados, sintomáticos y asintomáticos. Objetivo: Presentar los resultados de una serie de pacientes sometidos a ECE. Métodos: Serie de 135 ECE en 121 sujetos (84 hombres y 37 mujeres), con mediana de 72,2 +/- 7,7 años, tratados con ECE en el Servicio de Cirugía Vascular del Hospital Dipreca entre enero de 1998 y diciembre de 2004. La operación consistió en endarterectomía carotídea (común e interna) luego de realizar arteriotomía longitudinal amplia y endarterectomía carotídea externa por eversión. En la mayoría de los casos se utilizó shunt y bloqueo anestésico cervical profundo y superficial; en todos se fijó la placa distal y arteriorráfia con parche. Se utilizó estadística descriptiva y se calculó porcentajes, medianas, promedios, desviaciones estándar y supervivencia. Resultados: El déficit neurológico central homolateral postoperatorio fue de 1,5 por ciento. La morbilidad general fue de 12,6 por ciento. No hubo mortalidad perioperatoria. Se obtuvo un 94 por ciento de seguimiento. La causa de muerte más frecuente fue la de origen cardíaco (74 por ciento) y hubo un 4,7 por ciento de eventos neurológicos tardíos (TIA o AVE). La supervivencia libre de re estenosis fue de 92 por ciento. Conclusión: La ECE sigue siendo una alternativa de tratamiento en nuestro Hospital con baja morbimortalidad en sujetos seleccionados con estenosis carotídea sintomática y asintomática.

Background: Critical carotid artery stenosis is an important cause of stroke (CVA) and transient ischemic attack (TIA). Extra cranial endarterectomy (ECE) has proven effective in reducing the risk of these complications in selected patients, both symptomatic and asymptomatic. Aim: To report the results of ECE at Dipreca Hospital in Santiago, Chile. Methods: From January 1998 to December 2004, 135 ECE procedures were performed in 121 patients (84 males and 37 females). Mean age was 72.2 years (SD 7.7). ECE consisted of common and external carotid artery endarterectomy with eversion. In most cases, superficial and deep anesthetic blockade and shunts were utilized. A patch and fixation of distal plaque were performed in all. Results are presented with standard statistics methods. Results: Homolateral postoperative neurologic deficit was observed in 1.5 percent. All cause morbidity was 12.6 percent. There was no perioperative mortality. Follow up data was obtained for 94 percent of patients. Seventy-four percent of late deaths were due to cardiac events and 4.7 percent of patients developed late neurologic events (CVA or TIA). Restenosis free survival was 92 percent. Conclusion: ECE is a safe procedure for patients with both symptomatic and asymptomatic carotid artery stenosis.

Common carotid artery bifurcation levels related to clinical relevant anatomical landmarks / Niveles de Bifurcación de la Arteria Carótida Común en Relación a Puntos de Referencia Anatómicos Relevantes en Clínica

En cirugías de cabeza y cuello, las arterias carótidas comunes son importantes puntos de referencia, para defnir el plano de disección, durante cirugías radicales de cuello. Los objetivos del presente estudio fueron agregar información sobre el diámetro de las arterias carótidas y correlacionar el nivel de bifurcación de la arteria carótida común (ACC) con importantes puntos de referencia usados regularmente en la práctica clínica. Para la obtención de los objetivos planteados, fueron evaluados 46 cadáveres formolizados de individuos de sexo masculino. Se obtuvieron los diámetros de las arterias carótidas común, externa (ACE) e interna (ACI), con el auxilio de un caliper digital. No hubo diferencias entre lados derecho e izquierdo, ni tampoco en los niveles estudiados. El nivel de bifurcación de la ACC fue medido en relación a puntos de reparos anatómicos relevantes en clínica (margen superior del cartílago tiroides, ángulo de la mandíbula y lóbulo del pabellón auricular), como también en relación al nivel vertebral. Nuestro estudio mostró que el margen superior del cartílago tiroides fue el punto de referencia más estable para inferir el nivel de bifurcación de la ACC. Es importante mencionar que, de todos los puntos de referencia estudiados, la vértebra cervical fue la única que mostró diferencias entre los lados, siendo más variable el nivel de bifurcación en el lado izquierdo.

In head and neck surgery, the common carotid arteries are important landmarks, defining dissection plane during radical neck surgeries. The objectives of the present study were to add information on the diameter of the carotid arteries and to correlate the common carotid artery (CCA) bifurcation level with important anatomical landmarks used regularly in clinical practice. Forty-six necks from male embalmed human cadavers were evaluated. The CCA as the external (ECA) and internal (ICA) carotid arteries diameters were studied with the aid of an electronic digital caliper. No differences were found between sides in any level studied. The CCA bifurcation level was measured in relation to clinically relevant anatomical landmarks (superior level of the thyroid cartilage, mandible angle and ear lobe) and the bifurcation level according to the cervical vertebra level was also investigated. Our study shows that the superior border of the thyroid cartilage was the most stable anatomical landmark for predicting the CCA bifurcation level. It is important to mention that from all the landmarks studied, the cervical vertebra was the only one to show differences between sides, with the left side bifurcation level more variable than the right side.

Comparison of economic bipolar vessel sealer and biclamp for the hemostasis of large-sized cadaver arteries.

OBJECTIVE: The purpose of the present study was to compare the bursting pressure of large arteries sealed with hand made bipolar vessel sealer (BVS) using flexible electrosurgical system (HemoSaccab) and the BiClamp. MATERIAL AND METHOD: Sixteen common carotid arteries from a fresh cadaver were sealed using BVS and BiClamp 4 times sequentially for burst testing. A catheter was placed into the open end of the specimen and secured with a purse-string suture. The catheter was connected to a pressure monitor and saline was infused until there was leakage from the sealed end defining the bursting pressure in mmHg. Both devices were used to seal an additional 2 vessels in each group, which were sent for histologic examination. Student's t-test was performed. RESULTS: The BVS's mean burst pressure was statistically higher than that of the BiClamp (573 vs 442 mmHg) (p < 0.001). CONCLUSION: The flexible system of BVS is superior to the BiClamp device for sealing the common carotid artery because the BiClamp automatically finished the sealing process before the sealing area was completely dessicated.

Carotid artery stenting with filter protection.

BACKGROUND: Neurologic events associated with distal embolization of debris during percutaneous carotid artery stenting complicate the procedure. Filter devices for cerebral protection potentially reduce the risk of embolization and other neurologic events. We studied the feasibility, safety, and efficacy of carotid artery stenting with a filter device. METHODS AND RESULTS: Between January 2002 and January 2003, a total of 22 consecutive patients (30 lesions) who had >70% diameter stenosis of the internal carotid artery underwent carotid artery stenting with filter protection at our institute. The mean age of the patients was 64+/-9 years; 14 were men and 8 women, and 15 had neurologic symptoms. A stent was successfully implanted in 29 lesions. It was possible to position a filter device in all the 29 lesions. Neurologic complications during the procedure, in the hospital, and at 30-day clinical follow-up occurred in 2 patients. One patient suffered a minor stroke that resolved within 24 hours. None of the patients had a major embolic stroke. There was one death from intracerebral hemorrhage related to hyperperfusion and the use of a glycoprotein IIb/IIIa inhibitor. CONCLUSIONS: Filter protection during carotid artery stenting seems technically feasible, safe, and effective. In the present study, the incidence of embolic neurologic events was low.

Experiencia en el tratamiento quirúrgico del tumor del corpúsculo carotídeo / Our experience in surgical treatment of carotid body tumor

Antecedentes: El tumor del corpúsculo carotídeo (TCC) es una lesión infrecuente del área de cabeza y cuello, con características clínicas y quirúrgicas que merecen especial consideración. Objetivos: Describir la metodología diagnóstica, técnica quirúrgica y evolución clínica de una serie de pacientes operados de un TCC. Lugar de aplicación: Servicio de cirugía oncológica. Diseño: Estudio observacional retrospectivo. Población: 9 pacientes consecutivos operados entre 1993 y 1997. Método: Revisión de historias clínicas. Resultados: Promedio de edad de 43 años; 5 fueron mujeres. El diagnóstico se basó en el examen físico y fue confirmado por arteriografía en todos los casos. Cinco pacientes fueron embolizados en el preoperatorio. Los 9 tumores fueron completamente resecados. En 3 casos fue necesario resecar el bulbo carotídeo previa colocación de shunt arterial. No hubo mortalidad, se presentaron complicaciones menores en 2 casos. Todas las lesiones fueron benignas y no se registraron recurrencias durante el seguimiento en la presente serie. Conclusión: A pesar de ser una lesión inusual, el TCC puede ser diagnosticado y satisfactoriamente resecado con una mínima morbilidad mientras se observen determinados detalles técnicos

Arteriorrafia de carótidas con anillo microvascular 3M / Carotid anastomosis using the 3M Precise microvascular anastomotic system

En el laboratorio de microcirugía del Hospital del Trabajador de Santiago efectuamos 12 arteriorrafias en carótidas de ratas, utilizando el Precise Microvascular Anastomotic System de 3M, usando el anillo de 1.0 mm en arterias de 0.9 mm de diámetro externo. Obtuvimos una permeabilidad inmediata del 100 por ciento evaluada con el test de vaciado. En el control a las tres semanas se logró la revisión de diez ratas, encontrándose un gran porcentaje de rechazo del anillo (60 por ciento) y trombosis a nivel de anastomosis (20 por ciento). Sólo dos de diez se mantuvieron permeables (20 por ciento)