Trauma de arteria vertebral: difícil solución para el cirujano vascular / Vertebral artery trauma: difficult solution for the vascular surgeon

Los traumatismos de la arteria vertebral son relativamente infrecuentes si se los comparan con las otras estructuras vasculares del cuello. Esto, debido a que esta arteria ocupa la parte más profunda del cuello, siendo protegida además por estructuras musculares y óseas. Al mismo tiempo, no dan ninguna sintomatología específica, por lo que muchos de estos traumatismos pueden pasar desapercibidos. Sin embargo, en ocasiones, pueden dar hemorragias masivas que ponen en riesgo la vida del enfermo, especialmente cuando se asocian a otras lesiones de vasos de gran calibre y dependiendo de la ubicación de la lesión, es extremadamente difícil detener esta hemorragia. Se presenta un paciente portador de trauma cervical abierto por arma blanca con hemisección de carótida común y sección completa de arteria vertebral que debió ser operado de urgencia

Neoplasia colorrectal: tratamiento de la obstrucción con endoprótesis metálicas autoexpandibles / Colorectal neoplasm: treatment of obstructing with expandable metal stents

Background: Expandable metal stents can be used as a palliative or pre surgical method to decompress obstructing colonic carcinomas. Aim: To assess the effectiveness of these stents in the treatment of obstructive colonic carcinoma. Patients and methods: Expandable metal stents were placed in nine patients with the diagnosis of colorectal carcinoma and with clinical and radiographic signs of intestinal obstruction. Stents were placed under fluoroscopic guidance in nine patients and with endoscopic help in 2. The indications were palliative treatment in 7 and pre surgical decompression in 2 patients. Results: Stent placement was successful in all patients. One patient presented a self limited rectal bleeding after the procedure. Obstruction was relieved in less than 24 hours after the procedure. Conclusion: Expandable metal stent placement is an effective means of relieving intestinal obstruction caused by colorectal carcinoma

Tratamiento de la ascitis refractaria mediante derivación transyugular intrahepática portosistémica: caso clínico / Treatment of refractory ascites using a transjugular intrahepatic portosystemic shunt TIPS: clinical case

Approximately, 10 percent of cirrhotic patients with ascites become refractory to medical treatment, a condition that reduces overall survival. TIPS is a therapeutic alternative for the management of refractory ascites. It corrects sinusoidal portal hypertension, becoming a rational and relatively safe therapeutic approach. The most frequent complications of TIPS are the development of hepatic encephalopathy and a high incidence of shunt stenosis or occlusion after one year of follow-up. We report a 43 years old alcoholic cirrhotic male with ascites refractory to medical treatment, that required multiple large volume paracentesis, whose clinical condition deteriorated progressively. A TIPS was successfully placed with a rapid and complete resolution of ascites and marked improvement of his clinical condition. During the ensuing six months the patient remained in excellent conditions, but was lost from follow-up and resumed excessive alcohol intake. Eight months after TIPS placement he had an upper gastrointestinal bleeding and died

Recanalización percutánea de oclusiones crónicas de arterias ilíacas con instalación primaria de stent / Percutaneous revascularization of chronic iliac artery occlusions and primary stent placement

Background: Percutaneous transluminal angioplasty is a well established treatment method for aorto iliac stenoses. However its success is limited in arterial occlusions and vascular stent placement can improve the results. Aim: To assess the effectiveness of percutaneous revascularization with stent placement in patients with chronic iliac artery occlusions. Patients and methods: twenty six patients (18 male) aged 47 to 82 years, with iliac artery occlusions lasting six or more weeks were treated. Fourteen had involvement of common iliac artery, five had involvement of external iliac artery and seven of both. The occluded segment length ranged from 3.5 to 12 cm. According to the Society of Cardiovascular Surgery/International Society for Cardiovascular Surgery classification, 22 patients had category 1 claudication, 10 were in category 2, 12 in category 3 and two in category 4. Results: A technical success was obtained in 23 patients and clinical success in 21. After the intervention, the anklearm index improved from 0.49 ñ 0.12 to 0.88 ñ 0.18 (p < 0.001). Permeability after 12 months of follow up was 81 percent and after 36 months, 65 percent. Four patients had complications; one had a vascular perforation, two had an acute occlusion and one had an asymptomatic distal embolization. All these were solved using endovascular techniques. Conclusions: Percutaneous revascularization with stent placement is a valid alternative to surgery in selected patients with chronic iliac artery occlusion

Tratamiento del aneurisma aórtico abdominal por vía endovascular: experiencia inicial / Endovascular treatment of abdominal aortic aneurysm: initial experience

Background: Thirty day mortality of current surgical treatment of abdominal aortic aneurysm is 0.7 to 5 percent. Coronary artery disease is the main risk factor in this elderly population. An alternative procedure based on the transfemoral deployment of self expandable prostheses to exclude the aneurysm, avoids a laparotomy and major surgical trauma, reducing the risks of the conventional operation. Aim: To report our experience on endovascular repair of abdominal aortic aneurysms. Patients and methods: Nine consecutive patients aged 66 to 82 years old, possible candidates for the procedure, were studied. Results: Only four patients fulfilled the requirements for the procedure, which was technically successful in three. One patient was converted to an open surgical repair. Patients were discharged 72-96 hours after graft implantation. The postoperative CAT scan confirmed total exclusion of the aneurysm by the endovascular graft. All nine patients are alive at the time of this report. Conclusions: Given certain anatomical conditions, endovascular treatment of abdominal aortic aneurysms is an attractive alternative for high risk patients

Anglioplastía transluminal percutánea (ATP) y endoprótesis en el tratamiento de estenosis venosas centrales y periféricas, de fístulas arteriovenosas para hemodiálisis crónica / Percutaneous transluminal angioplasty and endoprosthesis in the treatment of the central and peripheral venous stenoses of arteriovenous fistula for chronic hemodialysis

We studied retrospectively 48 patients with arteriovenous fistulae stenoses, that were followed during 24 months. When the fistulography disclosed an stenosis, a percutaneous thrombolysis was done. These procedures were repeated as needed. Twenty four patients had a peripheral vein stenoses, 20 had subclavian vein stenosis and 4 had both veins compromissed. All were dilated with percutaneous transluminal angioplasty. Five stents were installed in the subclavian vein and five in peripheral veins. Two patients required thrombolysis. The procedure was succeful in 96 percent of peripheral lesions and 92 percent of central lesions. There was regression of superior limb edema in 16 of 20 patients. Five patients had an subclavian treated veins remained patent. The use of percutaneous transluminal angioplasty and intravascular stents, maintains long term arteriovenous fistulae permeability and has similar results to surgical procedures

Tromboendarterectomía pulmonar: tratamiento quirúrgico del tromboembolismo pulmonar crónico bajo paro circulatorio con hipotermia profunda en un caso / Pulmonary thromboendarterectomy: surgical treatment of chronic pulmonary thromboembolism under circulatory arrest and with deep hypothermia in 1 case

Pulmonary thromboendarterectomy under circulatory arrest and deep hypothermia is presently a curative treatment for pulmonary hypertension secondary to chronic pulmonary artery thromboembolic occlusion, but is still not frequently performed around the world. We report here the first successful pulmonary thromboendarterectomy under circulatory arrest performed in Chile. The patient was a 37 years old white man, high school teacher, with a 5 months history of effort dyspnea and cough. Pulmonary hypertension secondary to chronic pulmonary thromboembolism was confirmed by angiography and echocardiography. The patient was operated on april 27, 1995. After the operation the patient had an enmediate and maintained normalization of his pulmonary hemodynamics. He presented periods of delirium that postponed mechanical ventilation disconnection until the 7th postoperative day, after which he had an uneventful neurological recovery. Before hospital discharge a control angiography showed complete patency of the pulmonary artery system with no evidence of residual thrombi. Presently he is enjoying a normal life and back to his teaching activities

Rol diagnóstico de la combinación tomografía computada - angiografía en lesiones traumáticas de la aorta torácica / Diagnostic role of the combination of computed tomography and angiography in traumatic injury of thoracic aorta

Aim: To assess tha diagnostic value of the combination of computed tomography and angiography in aptients with blunt thoracic trauma and suspicion of aortic injury. Patients and methods: restrospective analysis of six patients, aged 22 to 72 years old, with traumatic thoracic aorta injury secondary to severe trauma, specially car accidents, seen between 1985 and 1994. Results: an early diagnosis was done in 3 patients. One patient, in whom diagnosis was delayed, died before surgery. In 3 cases, CAT scan showed indirect evidence of aortic rupture, consisting in alterations of aortic outline. In other 3 patients, it showed hemomediastinum, associated to a left hemothorax in one case. Angiography confirmed the diagnosis, localized and characterized yhe injury in all patients. Conclusions: the delay in the diagnosis of aortic injury may be fatal. The combination of CAT scan and angiography has a high sensitivity and specificity to localize and characterize lesions of the aorta or its branches or associated organs, essential step for surgical planning. CAT scan restrict the use of angiography, avoiding false negative studies, but cannot be used as the sole diagnostic procedure

Disolución de cálculos vesiculares de colesterol por infusión percutánea transhepática con Metil-Tert-Butil-Eter / Gallstones dissolution with metil-butil-eter via percutaneous transhepatic infusion

Se evaluó el tratamiento de colelitiasis sintomática de cálculos de colesterol o mixtos con escaso contenido de calcio, mediante infusión directa de metil-tert-butil-éter (MTBE) a través de colecistostomía transhepática en 10 pacientes con extracción complementaria de fragmentos residuales en 3 de ellos. La colecistostomía se realizó por vía transhepática bajo visión ecográfica o fluoroscópica. Se infundió MTBE durante 2 a 15 horas, en uno a cinco días, hasta lograr disolución de todos los cálculos, controlando el procedimiento con colecistografía directa, determinación colorimétrica de colesterol en el líquido recuperado y ecografías horarias. Se logró disolución completa en 7 pacientes (70 ciento por ciento). En los 3 restantes, portadores de cálculos que contenían calcio, se extrajeron fragmentos residuales con canastillo de Dormia. Sólo hubo complicaciones menores durante el procedimiento en 2 pacientes (náuseas y vómitos), que cedieron espontáneamente al suspender la infusión. A todos los pacientes se les indicó tratamiento de mantención con ácido Ursodeoxicólico. Se realizó seguimiento ecográfico cada 3 meses por un período de 10 meses, sin observar recurrencias. Esta técnica demuestra ser efectiva y de baja morbilidad en pacientes con indicaciones específicas, aunque su rol como tratamiento definitivo está aún por dilucidar