Veno-arterial extracorporeal membrane oxygenation (ECMO VA) as part of a multimodal approach for the protection of spinal cord ischemia in surgical repair of a thoracoabdominal aneurysm.

Spinal cord ischaemia leading to paraplegia or paraparesis is one of the most devastating complications of aortic surgery. The risk of ischaemia is particularly high in repairs involving both the thoracic and abdominal segments, because in these cases blood flow to the spinal arteries can be interrupted. Multimodal protocols have now been developed to reduce the incidence of this complication, and include measures such as cerebrospinal fluid (CSF) drainage, avoidance of hypotension and anaemia, systemic hypothermia, neuromonitoring, maintaining distal perfusion during proximal clamping of the aorta, and reimplantation of intercostal or lumbar arteries, whenever feasible. We describe a case in which, due to the special characteristics of the surgery, veno-arterial extracorporeal membrane oxygenation (VA ECMO) was used to maintain distal blood flow in the lumbar, inferior mesenteric, and hypogastric arteries during aortic clamping. This approach reduced the risk of spinal cord and visceral ischaemia, and also eliminated the need for thoracotomy because partial left bypass was not required.

Anaesthetic management of breast surgery in a patient with Eisenmenger syndrome. / Anestesia para cirugía de mama en una paciente con síndrome de Eisenmenger.

Eisenmenger syndrome (ES) is a complex combination of cardiovascular abnormalities defined as pulmonary hypertension with investment or bidirectional flow through an intracardiac or aortopulmonary communication, usually secondary to a congenital heart disease not resolved promptly. It carries a significant risk of perioperative mortality, with an incidence close to 30% for non-cardiac surgery. We report the anaesthetic management in a ES patient undergoing breast surgery, which was successfully performed under general anaesthesia combined with thoracic analgesic blocks. The main pathophysiological implications of this syndrome are discussed, emphasizing the importance of appropriate preoperative evaluation with thorough assessment of associated risks, careful intraoperative management, and postoperative care, which should be initially performed in a critical care unit. The need to individualize and tailor the choice of drugs and anesthetic technique to the hemodynamic condition of the patient and the surgical procedure is highlighted.

[Anesthetic management and experience in the transcatheter implantation of the CoreValve(®) self-expanding aortic valve]. / Experiencia y tratamiento anestésico en el implante transcatéter de la prótesis valvular aórtica autoexpandible CoreValve(®)

OBJECTIVE: To analyze the experience and anesthetic management in the transcatheter implantation of the CoreValve(®) self-expanding aortic valve, in a university tertiary hospital. MATERIAL AND METHODS: Observational analytical review of data incorporated into a prospectively maintained database of 142 patients diagnosed with severe aortic stenosis who underwent implantation of a CoreValve(®) aortic self-expanding aortic valve between December 2007 and December 2012. RESULTS: The mean age of patients was 82.5±6.1 years and the logistic EuroSCORE was 14.9±11.2. General anesthesia was used in 107 patients (75.3%), with local anesthesia with sedation in 35 (24.6%). Local anesthesia and sedation was associated with a lower requirement of vasoactive drugs (P=.003) during implantation. No statistically significant differences were found between the 2 anesthetic techniques in the duration of the procedure, hospital stay, or morbimortality. The success rate was 97.1%. The most common complication was conduction disorders that required implantation of a permanent pacemaker in 46 patients (32.3%). There was no intraoperative mortality, and all-cause mortality at 30 days was 6.3%, with a one-year survival estimated by the Kaplan-Meier of 83.1%. CONCLUSIONS: This study confirms that in patients with severe aortic stenosis and high surgical risk, transcatheter implantation of aortic valve is a safe and effective alternative. Both, general anesthesia and local anesthesia with sedation are valid options, depending on the experience of the team.

Cambios en el índice biespectral (bis) en una parada circulatoria durante la circulación extracorpórea / No disponible

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[Cerebrospinal fluid drainage to treat delayed paraplegia after stent grafting of the descending thoracic aorta]. / Drenaje de líquido cefalorraquídeo como tratamiento de una paraplejia tardía después de la colocación de endoprótesis en aorta torácica descendente.

Delayed onset of paraplegia secondary to spinal cord ischemia is a rare but serious complication that can appear after endovascular repair of an aneurysm in the descending thoracic aorta, although this complication is significantly less frequent after stent grafting than after conventional surgical repair. We report the case of a man who developed paraplegia 36 hours after insertion of 4 stents in the descending thoracic aorta. The paraplegia reversed after a spinal catheter was placed to monitor cerebrospinal fluid pressure and to provide drainage.

Drenaje de líquido cefalorraquídeo como tratamiento de una paraplejia tardía después de la colocación de endoprótesis en aorta torácica descendente / Cerebrospinal fluid drainage to treat delayed paraplegia after stent grafting of the descending thoracic aorta

La paraplejia tardía secundaria a isquemia medulares una rara pero grave complicación que puede presentarsetras la reparación endovascular de aneurismas deaorta torácica descendente, aunque con una frecuenciasignificativamente menor que con los procedimientosquirúrgicos convencionales.Presentamos el caso de un paciente que sufrió unaparaplejia 36 horas después de la colocación de cuatroendoprótesis en la aorta torácica descendente y querevirtió tras la colocación de un catéter subaracnoideopara la monitorización de la presión y drenaje del líquidocefalorraquídeo

Delayed onset of paraplegia secondary to spinal cordischemia is a rare but serious complication that canappear after endovascular repair of anaaneurysm in thedescending thoracic aorta, although this complication issignificantly less frequent after stent grafting than afterconventional surgical repair.We report the case of a man who developed paraplegia36 hours after insertion of 4 stents in the descendingthoracic aorta. The paraplegia reversed after a spinalcatheter was placed to monitor cerebrospinal fluid pressureand to provide drainage

[Beriberi after esophagectomy]. / Beriberi tras una esofaguectomía.

A 55-years-old man with a history of alcoholism, hypertension and obesity was diagnosed of epidermoid carcinoma of the middle third portion of the esophagus. He was treated with two cycles of cytostatics with cisplatin and 5-fluorouracil. Due to his poor general health an inability to swallow solids and liquids, he received parenteral nutrition for 20 days using a commercial formula lacking in vitamins and minerals. During distal esophagectomy we observed a tendency to hypotension and severe metabolic acidosis that was unexplained by the hemodynamic profile and that persisted throughout the first 24 hours after surgery. Once these complications were corrected, he was weaned from mechanical ventilation and the following neurological signs were observed: temporal and spacial disorientation, aphasia, ophthalmoplegia with divergent strabismus and later conduction aphasia, amnesia and confabulation. Circulation was hyperdynamic, requiring inotropics and vasoconstrictors. Korsakoff syndrome secondary to Wernicke's encephalopathy was diagnosed, and the response to thiamine treatment was favorable. Beriberi can be found in hospitalized patients and the anesthesiologist may be involved in their perioperative care. Symptoms resolve easily with vitamin B1 treatment, which is ideally provided along with other hydrosoluble vitamins. Treatment should be prompt because delay leads to greater morbiomortality.

Drenaje de líquido cefalorraquídeo e hipotermia profunda sistémica con parada circulatoria total como método de protección medular durante la cirugía de aorta torácica / Cerebrospinal fluid drainage and deep systemic hypothermia with total absence of circulation for spinal cord protection during surgery on the thoracic aorta

A un paciente de 53 años con aneurisma disecante tipo B de Stanford o tipo I de Crawford de 8,5 cm de diámetro se le realizó recambio de cayado aórtico distal y aorta torácica, usando como métodos de protección medular hipotermia profunda de 17 °C durante 38 min y parada circulatoria total, además de un catéter subaracnoideo lumbar para la monitorización de la presión del líquido cefalorraquídeo y drenaje del mismo cuando la presión superaba los 10 mmHg. El día de la intervención se drenaron 60 ml intraoperatoriamente y 95 ml en el postoperatorio y en los 3 días siguientes 325, 262 y 169 ml, sucesivamente. No se objetivó ningún déficit neurológico durante el postoperatorio. La evolución del paciente fue buena hasta que 27 días después de la intervención sufrió un shock hipovolémico por una hemorragia digestiva alta debida a 2 úlceras duodenales que perforaban la arteria gastroduodenal; se realizó antrectomía y vagotomía de urgencia. El paciente falleció 4 días después por fallo multiorgánico. La lesión de la médula espinal continúa siendo una de las complicaciones más temidas tras resecciones de aneurisma de aorta torácica y toracoabdominales. En la actualidad se utilizan diferentes métodos de protección medular como drenaje del líquido cefalorraquídeo, derivación parcial a la arteria femoral, reimplantación de arterias intercostales, fármacos e hipotermia medular local y/o sistémica que junto a un tiempo de pinzamiento corto han logrado reducir la incidencia de alteraciones medulares (AU)

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[Multiple cholesterol athero-embolisms after resection of an abdominal aortic aneurysm]. / Ateroembolismo múltiple de colesterol tras resección de un aneurisma de aorta abdominal.

A 72-year-old man underwent resection of an infrarenal aortic aneurysm; during postoperative recovery, multiorgan failure developed secondary to cholesterol emboli in several arteries. The initial sign consisted of patches of livedo in the lower limbs with pedal pulses, hematuria and hyperdynamic shock with high cardiac output and reduced vascular resistance. The clinical picture progressed to multiple organ failure with non-cardiogenic pulmonary edema, oliguric kidney failure, coagulopathy, necrotizing pancreatitis and colic ischemia. The patient died 15 days after surgery. The formation of multiple cholesterol emboli is a rare complication after aortic surgery, vascular catheterization or anticoagulant treatment. It is caused by cholesterol crystals measuring 100 to 200 mu that embolize and block small arteries. Diagnosis is difficult because the organs involved can be many and various. No specific treatment is available and the rates of morbidity and mortality are high.

[Acute pancreatitis after resection of abdominal aortic aneurysm]. / Pancreatitis aguda tras la resección de un aneurisma de aorta abdominal.

The case of a patient who developed acute pancreatitis following resection of a ruptured aneurysm of the abdominal aorta is presented. During the first postoperative days the patient evolved satisfactorily except for specific abdominal symptoms. On the sixth day the patient suddenly presented tachycardia, hypotension, increase in abdominal distension and anemia for which emergency laparotomy was performed with signs of diffuse peritoneal steatonecrosis with an increase in the size and inflammation of the pancreas with necrotic and hemorrhagic zones being observed. The patient developed multiorganic failure and died at 18 days later. In this case, as in others described in the literature the beginning was uneventful. Only the determination of amylase and/or lipase, and the performance of abdominal CAT when these are increased, may be useful to obtain early diagnosis.