Cirugía convencional del aneurisma tóraco-abdominal / Open surgical treatment of thoracoabdominal aortic aneurysm. Experience in 45 patients

BACKGROUND: Thoracoabdominal aortic aneurysm (TAAA) is an infrequent disease and demands a highly specialized and experienced management. Open repair (OR) is the gold standard but it is associated with significant morbidity and mortality. Paraplegia and renal failure are the most important complications. AIM: To report our results with OR treatment of TAAA. MATERIAL AND METHODS: Descriptive study including all patients with TAAA operated electively and consecutively by OR between 1983 and 2019. Main outcomes are operative mortality, renal and neurological morbidity, and long-term survival. RESULTS: We report 45 operated patients aged 33 to 84 years, 74% males. Aneurysm extension according to Crawford classification was I in 18%, II in 18 %, III in 36% and IV in 29%. Operative mortality was 4%. The frequency of paraplegia or paraparesis at discharge was 9%. No patient was discharged on hemodialysis. Survival at 5 and 10 years were 60% and 40% respectively. CONCLUSIONS: OR of TAAA is a complex procedure. Our results show perioperative mortality rates comparable to highly experienced centers. Although being a major procedure, OR remains an alternative to treat this serious condition.

Isquemia de extremidades inferiores secundaria a arteritis de la arteria temporal

Giant cell arteritis is more common in women older than 60 years, is associated with systemic inflammation symptoms and mainly involves the aortic arch and cranial arteries, specially the temporal artery. Symptomatic lower extremity arterial stenosis or occlusion is uncommon and can lead to limb loss. We report a 73-year-old woman presenting with a one-month history of lower extremity intermittent claudication of sudden onset. She also complained of fever, malaise, headache and weight loss. A non-invasive vascular study showed moderate femoral popliteal occlusive disease, with and abnormal ankle-brachial index (0.68 and 0.83 on right and left sides, respectively). An angio-computed tomography showed thickening of the aortic wall and severe stenosis in both superficial femoral arteries. Steroidal treatment was started, and a temporal artery biopsy was performed confirming giant cell arteritis. Six weeks after steroid therapy the patient had a complete remission of symptoms. A serologic exacerbation was subsequently treated with a humanized monoclonal antibody against the interleukin-6 receptor Tocilizumab, obtaining long time remission.

Dolor pélvico crónico secundario a síndrome de congestión pélvica: resultados del tratamiento endovascular de la insuficiencia venosa pelviana y várices genitales / Embolization of insufficient pelvic veins for pelvic congestion syndrome: analysis of 17 cases

Background: Pelvic venous insufficiency may cause pelvic congestion syndrome that is characterized by chronic pelvic pain exacerbated by prolonged standing, sexual activity or menstrual cycle. It may be treated by embolizing the dysfunctional pelvic venous drainage and sometimes resecting vulvar, perineal and thigh varices. Aim: To assess the results of embolization of insufficient pelvic or ovarian veins on pelvic congestion syndrome. Material and Methods: Analysis of 17 female patients aged 32 to 53 years, who underwent subjected to a selective coil embolization of insufficient pelvic and/or ovarian veins through the jugular, basilic or cephalic veins. In the preoperative period, all patients had a lower extremity venous duplex pelvic ultrasound examination and some had an abdominal and pelvic CT angiogram. Results: The technical success of the procedure was 100% and no complications were registered. During a 32 month follow up, no patient had symptoms of pelvic venous insufficiency or relapse of vulvar or thigh varices. Conclusions: Embolization of insufficient pelvic and ovarian veins is a safe and successful procedure for the treatment of pelvic venous insufficiency or vulvar varices.

Acalasia esofágica / Esophageal achalasia

La acalasia es una patología de baja frecuencia que afecta la motilidad esofágica producto de la denervación mientérica del esófago y también, en gran proporción de casos, de estómago. Sus causas permanecen aún poco esclarecidas y su diagnóstico sigue siendo tardío, reportándose un desfase de al menos 5 años desde el inicio de la sintomatología, confundiéndose muchas veces con patologías como la enfermedad por reflujo gastroesofágico, entre otras. Es por ello, que requiere un alto índice de sospecha y un estudio acabado, siendo la manometría esofágica el estándar de oro. El tratamiento no es curativo en la actualidad, y está centrado en el alivio de los síntomas. Las alternativas quirúrgicas que se disponen son, la miotomía de Heller, dilatación endoscópica, y la más reciente miotomía endoscópica peroral (POEM). El tratamiento médico no ha demostrado buenos resultados y hoy en día presenta restringidas indicaciones.

Achalasia is a rare disease that affects esophageal motility as result of myenteric denervation of the esophagus and in a large proportion of cases, stomach. Its causes remain still poorly elucidated and its diagnosis remains late, reporting a delay of at least 5 years from the onset of symptoms, often confused with conditions such as gastroesophageal reflux disease, among others. Therefore, it requires a high index of suspicion and a comprehensive study, being esophageal manometry the gold standard. There is no curative treatment today and is focused on the relief of symptoms. The surgical available options are, Heller myotomy, endoscopic dilation, and the most recent peroral endoscopic myotomy (POEM). Medical treatment has not proved successful and today has restricted indications.

Trauma vascular de extremidad superior: manejo en la etapa aguda / Vascular trauma of an upper extremity: management in the acute stage

El trauma vascular es una situación de emergencia a la cual podemos vernos enfrentados en la unidad de urgencia, la cual puede causar la muerte del paciente de no realizar un manejo oportuno. Las extremidades representan el principal sitio de lesión en la población civil y de éstas alrededor del 30 por ciento afectan la extremidad superior. La principal etiología es el trauma penetrante, específicamente por arma de fuego, existiendo además un aumento alarmante de las lesiones iatrogénicas. El cirujano de urgencia debe tener los conocimientos teóricos y prácticos que le permitan un adecuado diagnóstico, y manejo en la etapa aguda, siendo el objetivo fundamental la sobrevida del paciente y luego el salvataje de la extremidad. La indicación actual ante la presencia de signos duros es la exploración quirúrgica clásica, existiendo algunos pacientes que podrían ser resueltos por cirugía endovascular, específicamente pacientes estables hemodinámicamente con lesiones de la arteria axilar y braquial proximal. En el presente artículo se exponen las consideraciones básicas en el manejo de emergencia del paciente con trauma vascular de extremidad superior.

The vascular trauma is an emergency situation at which we may be confronted in the emergency unit. This may cause the patient’s death if not made a timely management. The limbs represent the main site of injury in civilian population. 30 percent affect the upper extremity. The main etiology is penetrating trauma, specifically gunshot. There is also an alarming increase of iatrogenic injuries. The emergency surgeon should have an appropriate theoretical and practical knowledge to allow a proper diagnosis, and management in the acute stage. The main objective is to keep the patient alive and then the rescue of the limb. The current indication in the presence of objective signs is the classic surgical exploration, and there are some patients who could be resolved by endovascular surgery, specifically hemodynamically stable patients with injuries of the proximal brachial and axillary artery. This article presents the basic considerations in the emergency management of patients with upper extremity vascular trauma.