Abordaje quirúrgico del síndrome de vena cava superior asociado a neoplasia maligna: revisión narrativa / Surgical approach to superior vena cava syndrome associated with malignant neoplasm: A narrative review

Introducción: El síndrome de vena cava superior (SVCS) es una patología poco frecuente, asociado en la mayoría de los casos a neoplasias de origen maligno; la cual en estadios avanzados representa una urgencia médico-oncológica que compromete la vida del paciente. Propósito de la revisión: El objetivo de la revisión es delinear el rol de las diferentes alternativas quirúrgicas y percutáneas para el tratamiento del SVCS. Buscamos reportes en donde se incluye los resultados de mejor supervivencia para los distintos tratamientos actuales. Recientes hallazgos: La literatura médica describe tratamientos como la radioterapia, la quimioterapia, el bypass, la terapia endovascular y la reconstrucción vascular para el manejo del SVCS, sin embargo, no todos responden con la misma eficacia al momento de presentarse una urgencia vital por SVCS; esto producto de los factores intrínsecos y extrínsecos del paciente. Dentro de los factores extrínsecos destaca la condición social la cual, se convierte en un reto al momento de realizar un manejo integral del paciente en ciudades fronterizas, donde los datos que conoce el médico sobre el paciente son limitados o el paciente no tiene un diagnóstico previo que permita orientar el manejo. Conclusiones: El punto de partida del tratamiento del paciente con SVCS consiste en diferenciar la emergencia y la estabilidad mediante la tabla de clasificación de gravedad. En casos emergentes se tiene 2 alternativas: la terapia endovascular y la radioterapia. El abordaje quirúrgico con Baypass está contraindicado y el tratamiento definitivo con reconstrucción vascular con prótesis tiene ventajas y desventajas que deben definirse en forma individual considerando la etiología del cáncer asociado.

Introduction: Superior vena cava syndrome (SVCS) is a rare pathology, associated in most cases with neoplasms of malignant origin; which in advanced stages represents a medical-oncological emergency that compromises the patient's life. Purpose of the review: The objective of the review is to outline the role of the different surgi-cal and percutaneous alternatives for the treatment of SVCS. We look for reports that include the best survival results for the different current treatments. Recent findings: The medical literature describes treatments such as radiotherapy, chemo-therapy, bypass, endovascular therapy and vascular reconstruction for the management of SVCS, however, not all respond with the same efficacy at the time of a vital emergency. by SVCS; this product of the intrinsic and extrinsic factors of the patient. Among the extrinsic fac-tors, the social condition stands out, which becomes a challenge when carrying out an integral management of the patient in border cities, where the data that the doctor knows about the patient is limited or the patient does not have a previous diagnosis. to guide management. Conclusions: The starting point of the treatment of the patient with SVCS consists in differentiating the emergency and the stability by means of the severity classification table. In emergent cases there are 2 alternatives: endovascular therapy and radiotherapy. The surgical approach with Baypass is contraindicated and the definitive treatment with vascular reconstruc-tion with a prosthesis has advantages and disadvantages that must be defined individually considering the etiology of the associated cancer.

Comparación de métodos de diagnóstico para el tratamiento hemodinámico en recién nacidos y prematuros utilizando la medición de la vena cava, lactato y criterios clínicos / Comparison of diagnostic methods for hemodynamic treatment in unborn and pre-term infants using the measurement of vena cava, lactate, and clinical criteria

Introducción: no existe un criterio único para evaluar el estado hemodinámico de los recién nacidos y prematuros y las diferentes variables en el grupo de recién nacidos, como la edad gestacional, el peso al nacer y los períodos de nacimiento. Métodos: Se trata de un estudio observacional descriptivo, transversal, epidemiológico con dos cohortes de pacientes. Los recién nacidos a término y Pretérmino, atendidos en la Unidad de Neonatal del Hospital Pablo Arturo Suárez, participan durante los meses comprendidos entre Noviembre de 2019 a enero de 2020. Resultados: la medición ecográfica del flujo de la vena cava inferior (FVCI) es útil para el tratamiento de manejo del paciente neonatal hemodinámicamente inestable. La muestra estuvo conformada por 110 recién nacidos atendidos en el servicio de neonatología del Hospital Pablo Arturo Suárez desde noviembre de 2019 a enero de 2020. Quito, Pichincha, Ecuador. Las variables bajo peso al nacer y prematuridad moderada tienen un valor estadística-mente significativo para el uso de inotrópicos. Las demás variables no presentan valor esta-dísticamente significativo. La frecuencia cardíaca, el gasto urinario, la presión arterial media, el ácido láctico, el llenado capilar, el flujo de la vena cava superior y el flujo de la vena cava inferior tienen valores estadísticamente significativos. Las comparaciones de FVCI y superior (FVCS) con frecuencia cardíaca, gasto urinario, presión arterial media, ácido láctico, llenado capilar tienen un valor estadísticamente significativo, excepto para el llenado capilar >3 segundos en FCVI. Se utilizó el análisis multivariado de Componentes Principales Categóricos (CATPCA) para caracterizar el estado hemodinámico e inotrópico, que resultaron significativos en el análisis bivariado. Dimensión, uno de los gráficos bidimensionales, discrimina el uso o no de inotrópicos y las categorías de parámetros hemodinámicos TAM <35 mmHg, ácido láctico, llenado capilar, FVCI y FVCS. La dimensión dos discrimina entre las categorías de gasto urinario y FC. Conclusión: En recién nacidos a término y prematuros con bajo peso y adecuado peso al nacer con inestabilidad hemodinámica en general, que fueron evaluados con ecografía para medir el flujo de la vena cava, la concordancia entre los criterios clínicos y la valoración ecográfica del flujo fue de 0.4 cm / seg en ambos métodos. Esta situación significa que la medición de los flujos cava venosos por ecografía es útil para evaluar el estado hemodinámico de los pacientes neonatales.

Introduction: There is no single criterion available to assess the hemodynamic state of new-born in-fants and preterm infants and the different variables in the group of newborns, such as gestational age, birth weight, and periods of birth. Methods: This is an epidemiological, cross-sectional, descriptive observational study with two patient cohorts. Newborn-to-term and preterm neonates assisted at the Neonatal Unit of the Pablo Arturo Suarez Hospital participated during the months between November 2019 to January 2020. Results: Ultrasound measurement of the vena cava (FVC) flow is useful for the management treatment of hemodynamically unstable neonatal patients. The sample was made up of 110 newborns treated in the Pablo Arturo Suarez Hospital's neonatology service from November 2019 to January 2020. Quito, Pichincha, Ecuador. The variables low birth weight and moder-ate prematurity have a statistically sig-nificant value for inotropic use.The other variables do not present statistically significant values. Heart rate, urinary output, mean blood pressure, lactic acid, capillary filling, upper vena cava flow, and lower vena cava flow had statistically significant values. FVCI and FVCS comparisons with heart rate, urinary output, mean blood pressure, lactic acid, and capillary filling had statistically significant values, except for capil-lary filling >3 sec in FCVI. Multivariate analysis of categorical main components (CATPCA) was used to characterize the hemodynamic state and inotropic state, which were significant in the bivariate analysis. Dimension, one of the two-dimensional graphs, discriminates the use or not of inotropics and the categories of hemodynamic parameters TAM <35 mmHg, lactic acid, capillary filling, FVCI, and FVCS. Dimension IIdiscriminates between the categories of urinary expenditure and HR. Conclusion: In term and preterm infants with low weight and adequate birth weight with hemody-namic instability in general, who were evaluated with ultrasonography to measure the flow of the vena cava, the agreement between the clinical criteria and the ultrasound assessment of the flow was 0.4 cm/sec in both methods. This situation means that the measurement of venous cava flows by echo sonography is useful for assessing neonatal patients' hemodynamic status.

Abdominal aortic aneurysms ruptured to the vena cava: a case series and literature review / Aneurismas de aorta abdominal rotos para a veia cava: uma série de casos e revisão de literatura

Abstract Ruptured abdominal aortic aneurysms (RAAA) evolving aortocaval fistula (AF) can have catastrophic hemodynamic effects. Surgical repair is imperative, but the optimal technical approach is still under debate. Our objective is to present 3 cases treated with endovascular repair (EVAR) at a University Hospital. Case #1, a 71-year-old man presenting a 7.1cm RAAA with AF, repaired with a monoiliac stent graft and femoral-femoral bypass; Case #2, a 76-year-old man presenting a 9.9cm RAAA with AF, repaired with a bifurcated stent graft; Case #3, a 67-year-old man with previous history of EVAR, presenting a type 3 endoleak with late rupture related to AF, repaired with a tubular stent graft. All cases unfolded with delayed recovery and significant complication rates, although AF symptoms had resolved by hospital discharge. EVAR techniques for AF may require secondary interventions but are feasible, despite the lack of consensus, considering the rarity of this RAAA presentation.

Resumo Aneurismas de aorta abdominal rotos (AAAR) com evolução para fístula aorto-cava (FAC) podem apresentar consequências hemodinâmicas catastróficas. A correção cirúrgica é mandatória, embora não haja consenso sobre a técnica operatória. Apresentamos uma série de três casos operados em hospital universitário pela técnica endovascular. No primeiro caso, um homem de 71 anos apresentou AAAR de 7,1 cm com FAC, submetido a correção por endoprótese monoilíaca e enxerto femoral cruzado. No segundo, um homem de 76 anos apresentou AAAR de 9,9 cm com FAC submetido a colocação de endoprótese bifurcada. O terceiro caso era de um homem de 67 anos com histórico de EVAR e endoleak tipo 3, com ruptura tardia para veia cava, tratado com extensão aórtica. Todos apresentaram evolução pós-operatória prolongada com significativas complicações, entretanto com boa resolução dos sintomas à alta hospitalar. A EVAR é uma técnica promissora para o tratamento de FAC, embora com taxa de reintervenção significativa.

Caudal vena cava collapsibility index in healthy cats by ultrasonography / [Índice de colapsibilidade da veia cava caudal em gatos domésticos Saudáveis, obtido por meio de ultrassonografia]

The objective of this study was to calculate the collapsibility index (CI) in a group of 15 healthy adult mixed breed cats via right hepatic intercostal ultrasound view. The minimal and the maximal diameters of the caudal vena cava (CVC) were obtained during inspiration and expiration, respectively, then CI was calculated. The mean diameter of the CVC was 0.5cm. The mean CI was 28±3% and CI was not significantly associated with gender. As in human medicine, there is a growing need for less invasive monitoring in small animal practice. The CI enables the assessment of estimated volemia without the need for a central venous catheter. This is the first reported study investigating CI in cats.(AU)

O objetivo deste estudo foi calcular o índice de colapsabilidade (IC) em um grupo de 15 gatos adultos, saudáveis e SRD, por meio da janela ultrassonográfica hepática intercostal direita. Os diâmetros mínimo e máximo da veia cava caudal (VCC) foram obtidos durante a inspiração e a expiração, respectivamente. O IC foi calculado, posteriormente. O diâmetro médio da VCC foi de 0,5cm. O diâmetro médio do IC foi de 28±3%, e o IC não foi significativamente associado ao gênero. Como na medicina humana, há uma necessidade crescente de monitoramento menos invasivo na prática de pequenos animais. O IC possibilita a avaliação da volemia estimada sem a necessidade de um cateter venoso central. Este é o primeiro estudo relatado sobre IC em gatos domésticos.(AU)

Ruptura de vena cava inferior secundaria a uso de sonda de ecografía intracardiaca tratada de manera exitosa con balón de alta distensibilidad / Inferior vena cava rupture associated with the use of an intracardiac echocardiography probe and successfully treated with a high-compliance balloon

Resumen La ruptura de la vena cava inferior durante los procedimientos de intervencionismo percutáneo es una complicación infrecuente que se asocia con alta tasa de mortalidad aunque sea detectada a tiempo y se realice reparo quirúrgico, el cual es hoy el estándar de manejo. No existen hasta el momento casos reportados de manejo percutáneo de perforación de la vena cava durante procedimientos de electrofisiología. Se describe el caso de una paciente llevada a aislamiento eléctrico de venas pulmonares para el manejo de fibrilación auricular paroxística, en quien, durante el procedimiento, se produjo perforación accidental de la vena cava inferior con la sonda de ecocardiografía intracardiaca, la cual fue tratada exitosamente mediante el uso de un balón de alta distensibilidad con lo que se logró adecuada hemostasia sin necesidad de intervención quirúrgica. Se considera que el uso de un balón de alta distensibilidad puede ser una herramienta útil en el control del sangrado asociado a lesiones vasculares iatrogénicas, y que por consiguiente todo intervencionista debería tener presente.

Abstract Rupture of the inferior vena cava during percutaneous intervention procedures is an uncommon complication. It is associated with a high rate of mortality, even when it is detected at the time and the current standard management, surgical repair is performed. At present there are no cases reported of the percutaneous management of a vena cava perforation during electrophysiology procedures. The case is described of a patient subjected to electric ablation of pulmonary veins for the management of paroxysmal atrial fibrillation. During the procedure there was an accidental rupture of the inferior vena cava with the echocardiography cardiac catheter. She was successfully treated using a high-compliance balloon, with adequate haemostasis being achieved without surgical intervention. The use of a high-compliance balloon is considered as a useful tool in the control of bleeding associated with iatrogenic vascular injuries, and for this reason all interventionist should be aware of it.

Management of a bi-caval dual lumen cannula clot obstruction after TEE guided diagnosis: a case report / Conduta em obstrução por coágulo em cânula de duplo lúmen bicaval após diagnóstico guiado por ETE: relato de caso

Abstract Background: Veno-venous extracorporeal membrane oxygenation is an established therapy for patients with refractory acute respiratory distress syndrome (ARDS). One complication related to the use of veno-venous extracorporeal membrane oxygenation is thrombosis despite proper anticoagulation. We report the diagnosis and management of a clot-obstruction in a single site cannula placed through the internal jugular vein, guided by transesophageal echocardiography. Case report: A 39 year-old male developed acute respiratory distress syndrome and hemodynamic instability after an episode of pulmonary aspiration in the ICU. Eight hours after placement of a single site veno-venous extracorporeal membrane oxygenation, suddenly the perfusionist noticed a reduction in flow. TEE showed a thrombus-like mass obstructing the inflow port in SVC and inflow at IVC was intact. After unsuccessful attempts to reposition the cannula, the team decided to insert additional femoral inflow cannula through the IVC. The single site catheter was then pulled out until its tip was positioned in the right atrium and all three ports of the catheter were switched to the infusion ports. After this, flows and oxygenation improved significantly. Unfortunately, despite all of the efforts, the patient died 2 days later. Discussion: The diagnosis of veno-venous extracorporeal membrane oxygenation cannula obstruction is based on reduced inflow rates, hemodynamic instability and poor oxygenation of blood. TEE allows evaluation of the flows inside the cannula and in this case, an obstruction was found. The management presented points to the fact that in a situation of catheter obstruction caused by a clot, there is a feasible alternative to assure minimal interruption of the hemodynamic support offered by the veno-venous extracorporeal membrane oxygenation.

Resumo Justificativa: A oxigenação por membrana extracorpórea veno-venosa é terapia estabelecida para pacientes com a síndrome do desconforto respiratório agudo. Uma complicação relacionada ao uso da oxigenação por membrana extracorpórea veno-venosa é trombose apesar de anti-coagulação adequada. Relatamos o diagnóstico e conduta em obstrução por coágulo em cânula de acesso único inserida pela veia jugular interna, guiada por ecocardiografia transesofageana. Relato de caso: Paciente do sexo masculino de 39 anos desenvolveu síndrome do desconforto respiratório agudo e instabilidade hemodinâmica após episódio de aspiração pulmonar na UTI. Oito horas após a instalação de oxigenação por membrana extracorpórea veno-venosa de acesso único, o perfusionista notou repentina redução no fluxo. A ETE revelou massa semelhante a um trombo obstruindo o portal de fluxo de entrada na VCS e o fluxo de saída na VCI estava intacto. Após tentativas sem sucesso para reposicionar a cânula, a equipe decidiu inserir cânula de entrada de fluxo adicional pela VCI. O catéter de acesso único foi, então, puxado até que sua ponta se posicionasse no átrio direito e todos os três portais do catéter fossem transferidos para os portais de infusão. A seguir, os fluxos e oxigenação melhoraram significativamente. Infelizmente, apesar dos esforços, o paciente foi a óbito 2 dias depois. Discussão: O diagnóstico de obstrução de cânula da oxigenação por membrana extracorpórea veno-venosa se baseia em velocidades reduzidas de entrada de fluxo, instabilidade hemodinâmica e oxigenação pobre do sangue. A ETE permite a avaliação dos fluxos dentro da cânula, e nesse caso foi encontrada obstrução. A técnica apresentada aponta para o fato de que em situação de obstrução de catéter causada por coágulo, existe alternativa factível para garantir interrrupção mínima do suporte hemodinâmico oferecido pela oxigenação por membrana extracorpórea veno-venosa.

Embolização para veia cava inferior de cateter totalmente implantável para quimioterapia / Totally implantable chemotherapy catheter embolization in inferior vena cava

A fratura com embolização de cateter inserido perifericamente em pacientes que receberam quimioterapia representa uma complicação grave e rara, constituindo menos de 1% das complicações relacionadas a esse procedimento. Relatamos aqui um caso de embolização de cateter totalmente implantável em uma paciente de 57 anos submetida a laparotomia por lesão anexial complexa devido a um câncer de ovário com carcinomatose intraperitoneal disseminada diagnosticado no intraoperatório. A paciente foi submetida a histerectomia e salpingooforectomia bilateral, não sendo realizada cirurgia oncológica radical. A análise histopatológica revelou adenocarcinoma de ovário G3. Em outubro de 2013, exame radiológico de rotina diagnosticou fratura e embolização de segmento distal do cateter para veia cava inferior retro e supra-hepática. A paciente não apresentou nenhuma sintomatologia. Procedeu-se à retirada do cateter através da veia femoral pela técnica do laço, sem complicações. Paciente está sem evidência de doença 24 meses após a realização do procedimento

Fracture of a peripherally inserted catheter causing embolization in patients on chemotherapy is a serious and rare complication, constituting less than 1% of complications related to this procedure. We report here a case of fully implantable catheter embolization in a 57-year-old female who had undergone laparotomy for complex adnexal lesion due to ovary cancer with disseminated peritoneal carcinomatosis, diagnosed intraoperatively. The patient was treated with hysterectomy and bilateral salpingo-oophorectomy, and radical oncological surgery was not performed. Histopathological analysis revealed G3 ovarian adenocarcinoma. In October 2013, a routine radiological examination diagnosed fracture and embolization of the distal segment of the catheter into the retrohepatic and suprahepatica inferior vena cava. The patient did not present any symptoms. The catheter was withdrawn through the femoral vein using the snare technique, without complications. The patient has no evidence of disease 24 months after the procedure

Ultrastructural analysis and residual DNA evaluation of rabbit vein scaffold

Abstract Purpose: To investigate the ultrastructural characteristics and analysis of residual DNA in scaffold models, produced with decellularized vena cava in an experimental model with rabbits. Methods: Three groups were created for ultrastructural and residual DNA analysis: group 1 - control, consisting of samples of vena cava in natura; group 2 - SD, consisting of vein fragments submitted to 2% sodium deoxycholate decellularization by shaking (160rpm - Shaker News Brunswick Scientific®) for 1 hour at controlled temperature shaker at 37°C; group 3 - SDS, consisting of vein fragments submitted to 1% sodium dodecyl sulfate decellularization under the same previous condition, for 2 hours. Results: The ultrastructural matrix of the blood vessel maintained its vintegrity after either decellularization models. The results of the two quantification methods demonstrated a significant decrease in the DNA content of the decellularized vena cava samples as compared to the control samples and, differed statistically from each other, p <0.05. Conclusion: The 2% DS protocol for vein decellularization, in this experimental model, was considered the best protocol because it presented less amount of residual DNA without causing substantial destruction of the extracellular matrix.

Persistencia de la vena cava superior izquierda: Presentación de un caso / Persistent Left Superior Vena Cava: Case Report

La vena cava superior izquierda persistente es una variante anatómica poco común, pero su conocimiento por parte de los médicos es importante para algunos procedimientos, como inserción de catéteres, entre otros. Se ha descrito desde 1950 y se asocia con anomalías cardiacas. Esta estructura venosa tiene varios sitios donde drenar los cuales se deben conocer. Casi siempre es un hallazgo incidental, pero se ha asociado a accidente cerebrovascular y muerte. Para su diagnóstico se han utilizado varias modalidades de imagen, como ecocardiografía, tomografía computarizada (TC) y resonancia magnética (RM).

Persistent left superior vena cava is a rare anatomical variant, which should be known by physicians, since it is relevant for some procedures such as insertion of catheters and pacemakers. Described in the literature since 1950, it has been associated with several cardiac anomalies. This venous structure drains towards several places, which must be known. Although most of the time it is an incidental finding, it has been associated with stroke and death. Imaging modalities such as CT, MRI and echocardiography are helpful for its diagnosis.

Unusual caudal vena cava thrombosis in a cow, secondary to Trueperella (Arcanobacterium) pyogenes infection / Rara trombose da veia cava caudal em bovino, secundária à infecção por Trueperella (Arcanobacterium) pyogenes

The caudal vena cava thrombosis, or pulmonary thromboembolism, in cattle is correlated with lactic acidosis, caused by diets rich in grains and highly fermentable, associated or not to septic situations, used in feedlots of beef or high-producing dairy cattle. This paper reports an unusual caudal vena cava thrombosis in a cow, secondary to Trueperella (Arcanobacterium) pyogenes infection, resulting in reduced milk production, anorexia, pale mucous membranes, ruminal atony, sternal decubitus and autoauscultation position. The heart was enlarged at necropsy, presence of clots distributed along the thoracic cavity, adherence between lung and pleura, abscesses, emphysema, petechiae, suffusions and ecchymosis in lungs, thickening of the caudal vena cava wall, hepatomegaly with chronic passive congestion ("nutmeg" aspect), and rumenitis. In lab, the actinomycete Trueperella (Arcanobacterium) pyogenes was isolated from liver and lung samples, probably resulting through dissemination of the bacteria of the rumen content, what reaffirms the opportunistic behavior of this actinomycete.(AU)

A síndrome da veia cava caudal ou tromboembolismo pulmonar bovino está relacionada à acidose láctica causada por dietas ricas em grãos e altamente fermentáveis, associados ou não a quadros sépticos, usadas em confinamentos de bovinos de corte ou para vacas leiteiras de alta produção. O presente artigo reporta caso raro de trombose da veia cava caudal em uma vaca, secundária a infecção por Trueperella (Arcanobacterium) pyogenes, apresentando reduzida produção de leite, anorexia, palidez de mucosas, atonia ruminal, decúbito esternal e posição de autoauscultação. À necrópsia observou-se coração aumentado de tamanho, coágulos distribuídos por toda cavidade torácica, aderência entre os pulmões e pleura, abscessos, enfisema, petéquias, sufusões, equimoses nos pulmões, espessamento da parede da veia cava caudal com trombo, hepatomegalia com congestão passiva crônica (aspecto de "noz moscada"), e ruminite. Em laboratório isolou-se o actinomiceto Trueperella (Arcanobacterium) pyogenes a partir de amostras de fígado e pulmão, provavelmente resultando da disseminação da bactéria proveniente do conteúdo ruminal, e reafirma o comportamento oportunista deste actinomiceto.(AU)

Major intrahepatic veno-venous fistula after fontan operation treated by transcatheter implantation of amplatzer septal occluder through internal jugular vein

Abstract Six months after undergoing a Fontan operation, a 7-year-old boy with right atrial isomerism and a single functional ventricle was admitted to our emergency department with cyanosis. Emergency cardiac catheterization revealed a large veno-venous fistula that began in a left hepatic vein, connected to the left accessory hepatic veins, and drained into the common atrium, resulting in desaturation. The fistula was occluded proximally with an Amplatzer septal occluder, with satisfying results; the patient's systemic arterial saturation decreased during his hospital stay. Three weeks after the first intervention, a second procedure was performed to retrieve the first device and to close the fistula distally. Multiple attempts with different types of gooseneck snares and a bioptome catheter failed to retrieve the first device, so a telescopic method was used to re-screw it. Using a Mullins long sheath and delivery sheath, the delivery cable was manipulated to fit into the slot of the end screw, and the cable was rotated gently in a clockwise direction to re-screw the device. Then, another Amplatzer septal occluder was placed at the distal end of the fistula. In conclusion, distal transcatheter occlusion of intrahepatic veno-venous fistulas might lead to better clinical outcomes in selected patients. Amplatzer septal occluder device can be retrieve without any complication within three weeks.

Morphometric study of the areolar space between the great vessels and the lumbar spine / Estudo morfométrico do espaço areolar entre os grandes vasos e a coluna lombar / Estudio morfométrico del espacio areolar entre los grandes vasos y la columna lumbar

Objective: This work aims to study the areolar space anterior to the lumbar spine, and also the positioning of the large vessels focusing a lateral approach. Methods:This is a morphometric study of 108 cases based on T2 weighted-MRI images in the supine position. The following measurements were performed: lumbar and segmental lordosis; anteroposterior disc diameter; space between the disc/vertebral body and the vessels; bifurcation between the abdominal aorta and the common iliac veins confluence in relation to the lumbar level. Results:The areolar space with respect to the iliac veins, and with the vena cava increased cranially (p<0.001), starting from average 0.6mm at L4-L5 and reaching 8.4mm at L2, while the abdominal aorta showed no increase or decrease pattern across the different levels (p=0.135) ranging from 1.8 to 4.6mm. The diameter of the discs increased distally (p<0.01) as well as the lordosis (p<0.001). The disc diameter was 11% larger when compared to the adjacent vertebral bodies (p<0.001) and that resulted in a smaller distance of the vessels in the disc level than in the level of the adjacent vertebral bodies (p<0.001). The aortic bifurcation was generally ahead of L4 (52%) and less frequently at L3-L4 (28%) and L4-L5 (18%). The confluence of the veins was usually at the L4-L5 level (38%) and at L5 (37%), and less frequently at L4 (26%). Conclusions: There is an identifiable plane between the great vessels and the lumbar spine which is particularly narrow in its distal portion. It is theoretically feasible to reach this plan, handle the anterior complex disc/ALL and protect the great vessels by lateral approach, however, it is challenging.

Objetivo: Estudar o espaço areolar localizado anteriormente à coluna lombar e também o posicionamento dos grandes vasos com enfoque em abordagem lateral. Métodos: Estudo morfométrico com 108 casos com base em exames de ressonância magnética com ponderação T2 em posição supina. Foram realizadas as seguintes medidas: lordose lombar e segmentar; diâmetro discal anteroposterior; espaço entre o disco/corpo vertebral e os vasos; bifurcação da aorta abdominal e confluência das veias ilíacas comuns em relação ao nível lombar. Resultados: O espaço areolar com relação às veias ilíacas e à veia cava aumentou no sentido cranial (p < 0,001), partindo de média de 0,6 mm em L4-L5 e chegando em 8,4 mm em L2, e a artéria aorta abdominal não apresentou padrão ao longo dos diferentes níveis (p = 0,135), variando de 1,8-4,6 mm. O diâmetro dos discos aumentou distalmente (p < 0,01), assim como a lordose (p < 0,001). O diâmetro discal foi 11% superior ao dos corpos vertebrais adjacentes (p < 0,001) e isso refletiu na menor distância dos vasos no nível discal do que no nível dos corpos vertebrais (p < 0,001). A bifurcação aórtica estava geralmente à frente de L4 (52%) e com menos frequência, em L3-L4 (28%) e L4-L5 (18%). A confluência das veias foi, em geral, no nível de L4-L5 (38%) e de L5 (37%), e menos frequentemente em L4 (26%). Conclusões: Existe um plano identificável entre os grandes vasos e a coluna lombar, que é especialmente estreito em sua porção distal. Através de acesso lateral é teoricamente factível, porém desafiador, atingir este plano, manipular o complexo anterior do disco/LLA e proteger os grandes vasos.

Objetivo: El trabajo tiene como objetivo estudiar el espacio areolar situado anteriormente a la columna lumbar y también el posicionamiento de los grandes vasos con enfoque de abordaje lateral. Métodos: Estudio morfométrico de 108 casos basados en MRI con ponderación T2 en la posición supina. Se realizaron las siguientes mediciones: lordosis lumbar total y segmentaria; diámetro anteroposterior del disco; espacio entre disco/cuerpo vertebral y los vasos; bifurcación de la aorta abdominal y la confluencia de las venas ilíacas comunes en relación con el nivel lumbar. Resultados: El espacio areolar con respecto a las venas ilíacas y la vena cava inferior aumentó cranealmente (p < 0,001), a partir de un promedio de 0,6 mm en L4-L5, llegando a 8,4 en L2, y la aorta abdominal no ha presentado un patrón a lo largo de los diferentes niveles (p = 0,135) que van desde 1,8 a 4,6 mm. El diámetro de los discos aumentó distalmente (p < 0,01) así como la lordosis (p < 0,001). El diámetro del disco fue 11% mayor que el diámetro de los cuerpos vertebrales adyacentes (p < 0,001) y esto resultó en la distancia más corta de los vasos en el nivel del disco que en el nivel de los cuerpos vertebrales (p < 0,001). La bifurcación aórtica fue en general por delante de L4 (52%) y con menor frecuencia en L3-L4 (28%) y L4-L5 (18%). La confluencia de las venas fue generalmente en L4-L5 (38%) y L5 (37%), y menos frecuentemente en L4 (26%). Conclusiones: Hay un plano identificable entre los grandes vasos y la columna vertebral lumbar que es especialmente estrecho en su parte distal. En teoría, es posible alcanzar este plan, manejar el complexo anterior disco/LLA y proteger los grandes vasos por abordaje lateral, sin embargo, es un desafío.

Canulación alternativa para cirugía mínimamente invasiva de cavidades cardiacas derechas / Alternative cannulation for minimally invasive surgery of right heart chambers

La cirugía mínimamente invasiva pasó de ser una alternativa, a un posible método de primera elección en cirugía valvular debido a sus beneficios en cuanto a infección, sangrado, estancia hospitalaria y funcionalidad. La canulación de ambas venas cavas, sin alterar los parámetros de la mínima invasividad, puede significar una disminución efectiva de los riesgos descritos con otras opciones y permite realizar procedimientos efectivos, tanto en cavidades izquierdas como derechas.

Minimally invasive surgery became more than an alternative, but a possible first election method for valve surgery because of its benefits in terms of infection, bleeding, hospital stay and functionality. The cannulation of both cava veins without altering the parameters of the minimal invasiveness may mean an effective reduction of the risks described in other options and allows us to perform procedures in both left and right cavities effectively.

Leiomiosarcoma de la vena cava inferior: reporte de un caso y revision de la literatura / Leiomyosarcoma of the inferior vena cava: a case report and review of the literature

Los sarcomas originados en las paredes de los grandes vasos son tumores de escasa presentación. El leiomiosarcoma de la vena cava es una enfermedad compleja que requiere ser manejado por un grupo multidisciplinario. Su tratamiento es quirúrgico. Poco se conoce de sus resultados oncológicos. Se presenta el caso de una paciente de 56 años, con diagnóstico de leiomiosarcoma de la vena cava inferior, su evaluación, manejo quirúrgico y seguimiento a corto plazo. Se hace una revisión de la literatura existente hasta la fecha, evaluando además la fisiopatología y la necesidad de reconstruir la vena cava inferior.

Sarcomas Sarcomas originating in the walls of the large vessels are tumors of unusual presentation. Leiomyosarcoma of the vena cava is a complex disease that needs to be managed by a multidisciplinary team. Its management is surgical. Little is known of their oncologic results. We report the case of a 56 year-old patient, diagnosed with leiomyosarcoma of the inferior vena cava, including her evaluation, surgical management, and short-term follow-up. An updated review of the literature is presented, along with an evaluation of the pathophysiology and the need for reconstruction of the inferior vena cava.

Utilidad de la Endoprótesis en Síndrome de vena cava superior / Benefits of the endoprosthesis in superior vena cava syndrome

El síndrome de vena cava superior, se corresponde a la obstrucción de la misma, siendo su causa más frecuente la etiología neoplásica. Objetivos: Se realiza el análisis y la presentación del siguientecaso clínico con el objetivo de considerar la utilidad de laendoprótesis. Caso Clínico: Paciente de 61 años, masculino que ingresa porsíndrome de vena cava superior. Se le realiza Tac Torácica con presencia de tumor hiliar derecho en ubicación retrocavopretraqueal que estenosa a la vena cava superior. Con mala evolución del cuadro se decide colocación de endoprotesis vascular. Aliviando la sintomatología para luego realiza eldiagnostico. Discusión: dado que el tratamiento de esta entidad es tratar lacausa de la obstrucción, se debe tener en cuenta la repercusión que genera, llevando inclusive a la muerte del paciente. Por lo que es de utilidad resolver la dificultad con la colocación de una endoprotesis, para luego estudiar y diagnosticar la etiología y asícondicionar un tratamiento adecuado...

The superior vena cava syndrome, corresponds to the obstruction of the superior vena cava, and its most common cause neoplastic etiology. Objectives: Analysis and presentation of the following case inorder to consider the usefulness of the endoprosthesis is made. Case presentation: A 61 year old male was admitted with superior vena cava syndrome. He takes Tac Thoracic presence of right hilar tumor location retrocavopretraqueal stenosing thesuperior vena cava. With bad symptom onset vascular endoprosthesis placement is decided. Relieving the symptoms and then performs the diagnosis. Discussion: Because the treatment of this entity is to treat thecause of the obstruction, must take into account the impact it creates, even leading to death. It is useful to solve the difficulties with the placement of a stent, and then study and diagnose theetiology and thus an appropriate treatment...

Implantación de catéteres translumbares: experiencia de seis años en el Hospital Universitario San Ignacio / Translumbar Catheter Placement. Six Years' Experience at Hospital Universitario San Ignacio

Introducción: La implantación de catéteres translumbares es un tipo de abordaje venoso que constituye una de las últimas opciones en pacientes sin disponibilidad de accesos venosos centrales convencionales. Objetivos: Revisar la literatura, describir la técnica y comunicar la experiencia de seis años en la realización de este procedimiento. Métodos: Se realizó una búsqueda de la literatura disponible sobre la implantación de catéteres translumbares en MedLine, Ovid y Liliacs; asimismo, se obtuvo una base de datos sobre los pacientes en quienes se implantó un catéter translumbar en el Hospital Universitario San Ignacio en el periodo entre 2008 y 2013. Finalmente, se ejecutó un estudio retrospectivo descriptivo. Resultados: Se realizaron 98 procedimientos en 66 pacientes (41 hombres y 25 mujeres). Se observó la incidencia de complicaciones hasta 72 horas posprocedimiento y se identificaron solo tres complicaciones (4,6 %) Conclusiones: El implante de catéteres translumbares constituye una alternativa eficaz y segura en pacientes que necesitan hemodiálisis y han agotado otros accesos venosos convencionales. Los resultados se hallan dentro de los indicadores publicados en la literatura.

Introduction: In recent years the Hospital Universitario San Ignacio has become a local and national reference center for translumbar catheter placement. This procedure is one of the last options to achieve effective central venous access in patients without other possible alternatives. Objectives: To review the literature, describe the technique and report the experience of six years in the making of this procedure. Methods: Search of the available literature about translumbar catheter placement was performed in MEDLINE, OVID and LILIACS. Additionally, it was obtained a database on patients with translumbar catheter placement at Hospital Universitario San Ignacio in the 2008-2013 period. Finally a retrospective study was made. Results: 98 Procedures were performed in 66 patients (41 men and 25 women). The incidence of complications up to 72 hours post-procedure was observed, identifying only 3 complications (4.6%) Conclusions: Translumbar catheter placement is an effective and safe alternative in patients requiring hemodialysis and have exhausted other conventional venous accesses. Our results are according to those reported in the available literature.

Estrutura, ultraestrutura e morfometria da veia cava de paca (Cuniculus paca Linnaeus, 1766) criada em cativeiro / Structure, ultrastructure and morphometry of the Vena cava in the paca (Cuniculus paca Linnaeus, 1766) raised in captivity

A paca (Cuniculus paca) é o segundo maior roedor da fauna brasileira. Apresenta carne de excelente qualidade, o que incentiva a criação comercial. Além disso, este animal pode tornar-se uma opção válida em experimentação embora poucas sejam as informações detalhadas sobre sua morfologia. Assim, objetivou-se descrever a morfologia, morfometria e ultraestrutura de segmentos das porções cranial e caudal da veia cava de quatro pacas (Cuniculus paca) adultas excedentes do plantel do Setor de Animais Silvestres do Departamento de Zootecnia da FCAV-Unesp. Os segmentos venosos foram analisados à microscopia de luz e à microscopia eletrônica de varredura. Foram mensuradas as espessuras do complexo formado pelas túnicas íntima e média, além da túnica adventícia e analisou-se os resultados pela estatística descritiva, teste "T" pareado (p<0,05). Em relação à espessura das túnicas estudadas, comprovou-se que os valores da espessura das túnicas íntima, média e adventícia, para todos os animais, foram significativamente maiores no segmento cranial. As camadas das paredes dos vasos apresentaram variações entre si quanto à estrutura e espessura, supostamente devido a uma adaptação à exigência funcional.

The paca (Cuniculus paca) is the second largest rodent of the Brazilian fauna. The excellent meat quality of this specie encourages the development of their commercial production. Moreover, this animal can become a viable alternative for animal experimentation although there exists scarce detailed information concerning their morphology. Therefore the purpose of this study is to describe the morphology, morphometry and ultrastructure in segments of the cranial and caudal portions of vena cava in four adult males and females of Cuniculus paca from the squad of Wild Animals Sector of Animal Science Department of FCAV-Unesp. Parts of the segments were examined by light microscopy and part by scanning electron microscopy. Thickness measures of the tunica intima and media complex and tunica adventitia of the vena cava were taken and analyzed using "T" test (p<0.05). In vena cava the thickness values of the intima, media and adventitia, for all animals, were significantly higher in the cranial segment. The layers of the vessel walls showed variations in structure and thickness, presumably due to an adaptation to functional demand.