Tratamiento endovascular de aneurisma aórtico abdominal: resultados en 80 pacientes consecutivos / Endovascular repair of abdominal aortic aneurysm: Results in 80 consecutive patients

Background: Endovascular repair of abdominal aortic aneurysms (AAA) avoids laparotomy, shortens hospital stay and reduces morbidity and mortality related to surgical repair, allowing full patient recovery in less time. Aim: To report short and long term results of endovascular repair of AAA in 80 consecutive patients treated at our institution. Patients and Methods: Between September 1997 and February 2005, three women and 77 men with a mean age 73.6±7.7 years with AAA 5.8±1.0 cm in diameter, were treated. The surgical risk of 38 percent of patients was grade III according to the American Society of Anesthesiologists classification. Each procedure was performed in the operating room, under local or regional anesthesia, with the aid of digital substraction angiography. The endograft was deployed through the femoral artery (83.7 percent bifurcated, 16.3 percent tubular graft). A femoro-femoral bypass was required in 11.3 percent of cases. Follow-up included a spiral CT scan at 1, 6 and 12 months postoperatively, and then annually. Results: Endovascular repair was successfully completed in 79/80 patients (98.7 percent technical success). The procedures lasted 147±71 min. Length of stay in the observation unit was 20.6±13.5 h. Blood transfusion was required in 10 percent. Sixty two percent of the patients were discharged before 72 h. One patient died 8 days after surgery due to a myocardial infarction (1.3 percent). During follow-up (3-90 months), 1 patient developed late AAA enlargement due to a type I endoleak, requiring a new endograft. No AAA rupture was observed. Survival at 4 years was 84.2 percent (SE =9.2). Endovascular re-intervention free survival was 82.7 percent (SE =9.5). Conclusion: Endovascular surgery allows effective exclusion of AAA avoiding progressive enlargement and/or rupture and is a good alternative to open repair. Close and frequent postoperative follow up is mandatory.

[Partial or total replacement of the aortic arch. Experience in 23 patients]. / Reemplazo parcial o total del arco aórtico. Experiencia en 23 pacientes.

BACKGROUND: Surgery of the aortic arch is a very complex procedure since it requires protective strategies for the brain, heart and rest of the body. AIM: To communicate our experience in the first 23 total or partial replacements of aortic arch. MATERIAL AND METHODS: Retrospective search in the database of the Cardiovascular Surgery Unit for patients subjected to partial or total replacement of the aortic arch since 1998. RESULTS: Between 1988 and 2002, 23 patients were operated. Seventeen had aortic dissection (10 acute and 7 chronic), five had an atherosclerotic aneurysm and one had a traumatic lesion. Thirteen patients were subjected to a replacement of the arch plus ascending aorta, six to a replacement of the arch plus descending aorta and four to a replacement of the arch, ascending and descending aorta. Seven patients had previous operation of the thoracic aorta. Arterial perfusion was done via the femoral artery, axillary artery or a combination of both. A hypothermic circulatory arrest was induced in 22; it was associated with cerebral retro perfusion alone in 8 patients, antegrade cerebral perfusion in 5; isolated or associated axillary perfusion was used in five patients. In seven, procedures on the aortic or mitral valve, or coronary artery operations were added. Operative mortality was 26%, 3 of the 8 patients operated as an emergency and 3 of 15 elective operations. There was no mortality among those without dissection and of 7 chronic dissections, one died. All patients were followed for an average of 45 months. Two patients required reinterventions on the aorta and one for colon cancer. There was one late death of unknown cause. Postoperative complications were agitation, bleeding and temporary vocal cord dysfunction. CONCLUSIONS: There is a learning curve, where more extensive operations, particularly those done as emergency or for dissections, had an increased operative risk.

Reemplazo parcial o total del arco aórtico: Experiencia en 23 pacientes / Partial or total replacement of the aortic arch: Experience in 23 patients

Background: Surgery of the aortic arch is a very complex procedure since it requires protective strategies for the brain, heart and rest of the body. Aim: To communicate our experience in the first 23 total or partial replacements of aortic arch. Material and methods: Retrospective search in the database of the Cardiovascular Surgery Unit for patients subjected to partial or total replacement of the aortic arch since 1998. Results: Between 1988 and 2002, 23 patients were operated. Seventeen had aortic dissection (10 acute and 7 chronic), five had an atherosclerotic aneurysm and one had a traumatic lesion. Thirteen patients were subjected to a replacement of the arch plus ascending aorta, six to a replacement of the arch plus descending aorta and four to a replacement of the arch, ascending and descending aorta. Seven patients had previous operation of the thoracic aorta. Arterial perfusion was done via the femoral artery, axillary artery or a combination of both. A hypothermic circulatory arrest was induced in 22; it was associated with cerebral retro perfusion alone in 8 patients, antegrade cerebral perfusion in 5; isolated or associated axillary perfusion was used in five patients. In seven, procedures on the aortic or mitral valve, or coronary artery operations were added. Operative mortality was 26%, 3 of the 8 patients operated as an emergency and 3 of 15 elective operations. There was no mortality among those without dissection and of 7 chronic dissections, one died. All patients were followed for an average of 45 months. Two patients required reinterventions on the aorta and one for colon cancer. There was one late death of unknown cause. Postoperative complications were agitation, bleeding and temporary vocal cord dysfunction. Conclusions: There is a learning curve, where more extensive operations, particularly those done as emergency or for dissections, had an increased operative risk.

Oxigenación con membrana extracorpórea en pacientes pediátricos: Comunicación de los 3 primeros casos tratados / Extracorporeal membrane oxygenation (ECMO): Consolidation of a neonatal-pediatric program in Chile and report of three cases

Extracorporeal membrane oxygenation (ECMO) improves survival in neonatal and pediatric patients with reversible severe respiratory or cardiac failure, in whom intensive treatment fails. Since 1999, a multidisciplinary team is trained to form the first neonatal-pediatric ECMO center in Chile, according to the norms of the Extracorporeal Life Support Organization (ELSO). During 2003 the first three patients were admitted to the program: a male newborn with pulmonary hypertension, a 38 days old female operated for a total anomalous pulmonary venous connection and a 3 months old male with a severe pneumonia caused by respiratory syncytial virus. They remained in ECMO for five, seven and nine days respectively and all survived to the procedure. No neurological complications were observed after one and a half year of follow up. This consolidates the first national neonatal-pediatric ECMO program, associated to ELSO. Up to date, twelve patients have been admitted to the program.

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

Cirugía de revascularización miocárdica en los primeros 15 días de evolución del infarto / Miocardial revascularization surgery in the first 15 days of infarction evolution

Revascularization significantly improves early and late prognosis in acute myocardial infarction and has prompted substantial changes in therapeutic strategies. We report 140 patients aged 60.3 years old (123 male) operated within 15 days of sustaining an acute myocardial infarction, between january 1984 and december 1989. Coronary angiogram showed single vessel disease single vessel disease in 8 (6 percent), double vessel disease in 32 (23 percent), triple vessel disease in 85 (61 percent) and left main vessel disease in 13 (9 percent). Indications for surgery were ponstinfarction angina in 92 patients (66 percent), multiple severe coronary stenosis in 18 (13 percent), infarction of less than six hours from onset in 16 (11 percent), acute angioplasty failure in 7 (5 percent) and cardiogenic shock in 7 (5 percent). Thirty one patients were operated during the initial 24 h of infarction (16 with less than 6 h) 14 between the second and third day and 95 between the fourth and fifteenth day. Overall mortality was 4.3 percent (6/140). Among patients with failed angioplasty and cardiogenic shock, mortality was 23 percent (7/140), among patients with postinfarction angina this figure was 2.1 percent (2/92). Five years actuarial survival was 95 percent and the actuarial probability of being free of acute myocardial infarction, angioplasty or reoperation at five years was 99 and 100 percent respectively. It is concluded that early surgical revascularization in acute myocardial infarction is safe and has excellent long term results

Perfusión cerebral retrógrada durante paro circulatorio con hipotermia profunda: nueva técnica para la protección encefálica en cirugía de aorta ascendente y arco aórtico / Retrograde cerebral perfusion during circulatory arrest with deep hypothermia: new technique for encephal protection in aortic arch and ascendent aorta surgery

Between may 1993 and august 1994, 15 patients (10 men) with type A aortic dissection (9 acute) had a replacement of the ascending aorta and/or aortic arch with circulatory arrest with profound hypothermia and retrograde cerebral perfusion. Mean circulatory arrest time was 47.5 min (range 23 to 68 min). Three patients (20 percent) died in relation to postoperative bleeding. No patient had a new neurologic damage related to surgery. Ten patients were awake and oriented before 24 hours of the operation and another one before 48 hours; 4 patients required more than 48 hours to be completely awake and oriented. Two patients were operated on with a recent stroke. One of them recovered without sequelae before hospital discharge and the other one had a major regression of his brain damage. Two other patients had emergency surgery because of cardiac tamponade and cardiogenic shock. Both of them had a satisfactory recovery. Six patients presented azotemia but only 2 of them needed dyalisis. There was no case of Q wave infarction nor congestive heart failure in the perioperative period. Follow-up was 100 percent completed (12 patients) with a mean of 9.8 months (range 5 to 18 months). One patient died on the 10th postoperative month because of a late infectious process. Eight patients are in functional class I and 3 in II. Ten of them are back to their usual activities. Although retrograde cerebral perfusion is a new surgical technique, it seems to be a very valuable complement for brain protection in ascending aorta and/or aortic arch surgery with circulatory arrest with profound hypothermia

Inducción anestésica en cirugía carotídea: comparación entre dos técnicas / Anesthetic induction in carotid surgery: comparasion between 2 techniques

Los pacientes sometidos a cirugía carotídea tienen un mayor riesgo cardiovascular. Esto y las características de la cirugía hacen deseable una óptima estabilidad hemodinámica en el intra y posoperatorio. El objetivo fue comparar dos técnicas de inducción anestésica en pacientes sometidos a endarterectomía carotídea electiva, en relación a la respuesta hemodinámica durante los períodos: posinducción, posintubación, preincisión y posincisión estandarizados previamente y condiciones de extubación al final de la cirugía. Un total de 21 pacientes fueron aleatoriamente asignados a uno de dos esquemas de inducción. Grupo I (G I)(n=10) Fentanyl 5µgrùkg-1 más Tiopental 4 mgùkg-1 y Grupo II (G II)(n=11) Alfentanil 120 µgrùkg-1. Entre grupos hubo diferencia sólo en los valores de PA, IC y LVSWI en el período posinducción. En ambos grupos hubo un descenso significativo en PA, IC y LVSWI en los períodos preincisión y posincisión. En el G II disminuyó, además, la FC presentándose un caso de bricardia extrema de difícil tratamiento. Dos pacientes, uno de cada grupo, no fueron estubados por no cumplir los criterios prefijados. La inducción con Alfentanil mostró menos variabilidad hemodinámica entre los períodos de medición, aunque la tendencia en ambos grupos fue al descenso de la PA hacia los períodos finales de estudio. La extubación fue comparable

Tratamiento quirúrgico del síndrome de Wolff-Parkinson-White / Surgical treatment of Wolff-Parkinson-White syndrome

La sección quirúrgica de los haces paraespecíficos ha demostrado ser un tratamiento eficaz para las taquicardias del síndrome de Wolff-Parkinson-White. Comunicamos nuestra experiencia con el tratamiento quirúrgico de 9 pacientes, 7 mujeres y 2 hombres, con edad promedio de 30 años. Siete pacientes tuvieron haces laterales izquierdos, 2 posteroseptales y 1 anteroseptal (1 pt con 2 haces) diagnosticados mediante estudio electrofisiológico preoperatório. La intervención se realizó con circulación extracorpórea en normotermia para los haces derechos y con hipotemia sistémica y cardioplejía en los haces izquierdos. El mapeo intraoperatorio permitió la exacta ubicación de los haces responsables de la preexitación. No hubo mortalidad ni morbilidad perioperatoria. En el 100% de los pacientes se observó eliminación de la preexitación en el estudio electrofisiológico intra y postoperatorio antes del alta. Todos los pacientes mantuvieron ritmo sinusal. En el seguimiento alejado (promedio 7 meses), todos los pacientes están en buenas condiciones, sin medicamentos antiarrítmicos y libres de nuevas crisis de taquicardia, excepto 1 pt en quien reapareció la preexitación. Concluimos que el tratamiento quirúrgico tiene un riesgo bajo y éxito del 90% en la sección definitiva del haz paraespecífico. Postulamos que la cirugía constituye un excelente alternativa de tratamiento para el síndrome de Wolff-Parkinson-White