El acceso vascular sigue siendo un problema a resolver / Vascular access is still an unresolved problem

El acceso vascular para el tratamiento endovascular de los aneurismas de aorta puede ser una limitante o una causa grave de morbilidad o mortalidad. La presunción, la posibilidad de realizarmaniobras adyuvantes o la combinación con cirugía abierta pueden ser determinantes al momento de planear o finalizar el procedimiento. Se describen una variedad de procedimientos utilizados para modificar la anatomía desfavorable de las arterias ilíacas. La angioplastía con dilatadores o balón, la utilización de ciertas guías y accesos o la realización de conductos pueden ser claves al momento de realizar la cirugía.

O acesso vascular para o tratamento endovascular dos aneurismas da aorta pode ser uma limitante ou uma causa grave de morbilidade ou mortalidade. Como presunção, a possibilidade derealizar manobras adjuvantes ou a combinação com cirurgia aberta podem ser determinantes no momento de planejar ou finalizar o procedimento. Descrevem-se uma variedade de procedimentos utilizados para modificar a anatomia desfavorável das artérias ilíacas. A angioplastia com dilatadores ou balão, a utilização de certas guias e acessos ou a realização de canais podem ser fundamentais no momento de realizar a cirurgia.

The vascular access in the treatment of aortic aneurysms may be a limiting factor or a severe cause of morbidity and mortality. The possibility of carrying out adjuvant procedures or combiningthem with open surgery may be determining factors at the moment of planning or completing the procedure. A series of procedures used to modify the unfavourable anatomy of the iliac arteries are here in described. Dilator or balloon angioplasty, the use of certain guidewires and routes of access or the carrying out of conduits may be key at the moment of carrying out the surgery.

Aneurisma micótico de arteria axilar / Mycotic axillary artery aneurysm

Introducción. El aneurisma micótico de la arteria axilar es infrecuente y generalmente es consecuencia de untraumatismo arterial o de abuso de drogas intravenosas. La mayoría de las comunicaciones son de la etapa preantibiótica,cuando la etiología predominante era la endocarditis bacteriana y presentaban una evolución clínica fatal. Casoclínico. Mujer de 44 años con diagnóstico de endocarditis bacteriana de válvula mitral que presentó un aneurisma micóticode arteria axilar; se trató exitosamente mediante resección aneurismática y puente subclaviohumeral con vena safena,acompañado de antibioticoterapia sistémica específica. Conclusión. El aneurisma micótico de arteria axilar por endocarditisbacteriana es infrecuente. La resección aneurismática y la reconstrucción vascular con vena, sumada a la antibioticoterapiaespecífica, constituye el tratamiento de elección(AU)

Introduction. Mycotic axillary artery aneurysm is rare and usually follows arterial trauma or intravenousdrug abuse. Most of the reports are from the pre-antibiotic era when these cases were generally caused by bacterialendocarditis and were usually fatal. Case report. A 44 year-old female with mitral valve bacterial endocarditis presentedwith axillary artery mycotic aneurysm. Patient received an aneurismal resection and a subclavian-brachial bypass withsafenous vein. Conclusion. Resection of the aneurysm, bypass with vein and antibiotic therapy is the treatment of choiceof this rare disease(AU)

Bypass iliopoplíteo por el agujero obturador / No disponible

No disponible

Fístula aortobronquial por aneurisma de aorta: tratamiento endovascular / Aortobronchial fistula due to thoracic aorta aneurysm - endovascular approach

Introducción. El aneurisma de aorta torácica complicado con una fístula aortobronquial es una entidad poco común que, sin control de su evolución, posee baja supervivencia debido a la hemoptisis masiva. La cirugía convencional se asocia a una alta tasa de mortalidad perioperatoria. Actualmente, el tratamiento endovascular ofrece una solución menos invasiva para esta patología. Presentamos un caso clínico y realizamos una revisión bibliográfica de esta entidad infrecuente, así como de los métodos de diagnóstico y las alternativas terapéuticas. Caso clínico. Varón de 67 años con hemoptisis masiva y descompensación hemodinámica a causa de una fístula aortobronquial por aneurisma verdadero de la aorta torácica de 6,7 cm diagnosticado por tomografía computarizada (TC), angiorresonancia y angiografía. El paciente fue sometido a un tratamiento endovascular con endoprótesis autoexpandible de politetrafluoroetileno (TAG Excluder 40 × 200 mm), previa colocación de urgencia de un balón oclusor aórtico, hasta lograr la compensación hemodinámica. No se registraron episodios de hemoptisis en el seguimiento. Los estudios fibrobroncoscópicos en el período postoperatorio fueron negativos. La TC de tórax de control mostró la exclusión completa del aneurisma. Conclusión. El tratamiento endovascular es una alternativa terapéutica segura para la resolución de un aneurisma verdadero de la aorta torácica complicado con una fístula aortobronquial

Introduction. Aneurysm of the thoracic aorta complicated with acute haemoptysis due to aortobronchial fistula is a lifethreating uncommon pathology. Open surgery is associated to a high perioperative mortality rate. Actually, endovascular approach offers a less invasive solution for this problem. We present a case report, and perform a bibliographic review of this unusual disease, as well a diagnostic images methods and current therapy modalities. Case report. A 67 years old male patient with a history of massive haemoptysis and unstable hemodynamically due to aortobronchial fistula secondary to a 6.7 cm thoracic aorta aneurysm, diagnosed by CT scan, angioresonance, and angiography. The patient was treated successfully by endovascular approach with a PTFE endograft (TAG Excluder 40 × 200 mm) being previously treated with an aortic occlusion balloon catheter. There were no episodes of haemoptysis in the postoperative period, and the fibrobronchoscopy was normal. CT scan showed total aneurysm exclusion. Conclusion. Endovascular approach is a safe alternative treatment when dealing with complicated thoracic aorta aneurysm due to aortobronchial fistula

Recuperación posquirúrgica en revascularización infrainguinal / Post-surgical recovery after infrainguinal revascularization

Introducción. En la revascularización del miembro inferior, tradicionalmente se consideraban los resultados de permeabilidad del bypass y la salvación de extremidad. Sin embargo, dado que la enfermedad arterial es sistémica y progresiva, deben evaluarse otros aspectos como las reintervenciones quirúrgicas, las readmisiones hospitalarias, la recuperación funcional y la supervivencia. Objetivo. Analizar los resultados de recuperación posquirúrgica en pacientes sometidos a revascularización infrainguinal. Pacientes y métodos. Revisión de las historias clínicas y el seguimiento clínico de 245 pacientes revascularizados por isquemia crítica debida a arteriopatía obstructiva crónica del miembro inferior. Se utilizaron los programas SPSS 11.5 y MEDCALC 7.1. Se realizaron bypasses infrapatelares, suprapatelares y secuenciales en 137, 92 y 16 pacientes, respectivamente. Resultados. La salvación del miembro inferior fue del 71% a los seis meses, 66% al año y 60% a los tres años. El 66,1% de los pacientes requirió al menos una reoperación y el 69,5% fue reingresado una vez. Sólo 92 pacientes (38,9%) curaron las lesiones tróficas y 44 (18,64%) deambularon de forma independiente. La supervivencia actuarial fue de 80% a los seis meses, 73% al año y 56% a los tres años. Solamente 32 pacientes (13,55%) presentaron resultados posquirúrgicos ideales, es decir, salvaron el miembro inferior, curaron sus lesiones, deambularon y no requirieron reoperaciones ni readmisiones hospitalarias por patología cardiovascular. Conclusiones. Aun con buenos resultados de salvación de extremidad, la revascularización infrainguinal por isquemia crítica presentó una baja tasa de recuperación posquirúrgica, por la continua necesidad de reoperaciones y readmisiones hospitalarias, y la escasa posibilidad de deambulación y curación de lesiones en el seguimiento

Introduction. The outcome of infrainguinal bypass surgery for limb salvage has traditionally been assessed by graft patency rates and limb salvage rates. However, since the peripheral arterial occlusive disease is progressive and systemic, other aspects must be evaluated such as reoperation rate, hospital readmission rate, functional recovery and survival. Aim. To analyze the results of post-surgical recovery in patients with infrainguinal bypass surgery. Patients and methods. Review of clinical records of 245 patients who underwent infrainguinal bypass surgery for critical limb ischemia. Statistical programs SPSS 11.5 and MEDCALC 7.1 were used. Infrapatelar suprapatelar and sequential bypasses were performed in 137, 92 and 16 patients, respectively. Results. The limb salvage rates were 71% at six months, 66% at the first year and 60% at three years. After operation, 66.1% of patients required at least one reoperation and 69.5% of patients, hospital readmission. Complete wound healing was achieved in 92 patients (38.9%) and 44 patients (18.64%) lived in independent form. The survival rates were 80% at six months, 73% at 1 year and 56% at three years. Only 32 patients (13.55%) had ideal surgical results, which consisted on saving the limb, complete wound healing, lived in independent form and no required reoperation or hospital readmissions for cardiovascular pathology. Conclusions. Despite the good results of salvage, the infrainguinal revascularization for critical limb ischemia had a low rate of functional recovery, due to the continuous necessity of reoperation and hospital readmissions, the lack of autonomy and wound healing in the follow-up

A highly accurate method for monitoring histological recovery in patients with celiac disease on a gluten-free diet using an endoscopic approach that avoids the need for biopsy: a double-center study.

BACKGROUND AND STUDY AIM: Endoscopy with duodenal biopsy is often performed in order to assess histological recovery in patients with celiac disease who are on a gluten-free diet. Use of the "immersion" technique during upper endoscopy allows visualization of duodenal villi or detection of total villous atrophy. In this two-center study, we investigated the accuracy of the immersion technique in predicting histological recovery in patients on a gluten-free diet whose initial diagnosis of celiac disease had been made on the basis of total villous atrophy. PATIENTS AND METHODS: The immersion technique was performed in 62 patients with celiac disease who were being treated and who had been referred for follow-up (26 patients at the Rome center and 36 patients at the Vicenza center). All these patients had an initial diagnosis based on positive antibodies and biopsy-proved duodenal total villous atrophy. At the follow-up examination, the duodenal villi were re-evaluated as present or absent by one endoscopist at each center, and the results were compared with the histology. RESULTS: At the follow-up endoscopy, the duodenal villi were found to be present in 51 patients and absent in 11. The sensitivity, specificity, positive predictive value, and negative predictive value of the immersion technique for detecting the presence or absence of villi were all 100 %. CONCLUSIONS: This study demonstrated the feasibility and the high level of accuracy of the immersion technique in predicting the histological recovery of duodenal villi in patients with celiac disease who are following a gluten-free diet. An endoscopy-based approach that avoids the need for biopsy could be useful for monitoring the dietary adherence and/or response of patients with an initial diagnosis of celiac disease based on total villous atrophy.

Intra-aneurysmal pressure after incomplete endovascular exclusion.

PURPOSE: An endoleak results from the incomplete endovascular exclusion of an aneurysm. We developed an experimental model to analyze hemodynamic changes within the aneurysm sac in the presence of an endoleak, with and without a simulated open collateral branch. METHODS: With a latex aneurysm model connected to a pulsatile pump, pressures were measured simultaneously within the system (systemic pressure) and the aneurysm sac (intrasac pressure). The experiments were performed without endoleak (control group) and after creating a 3.5-mm (group 1), 4.5-mm (group 2), and 6-mm (group 3) diameter orifice in the endograft, simulating an endoleak. Pressures were also registered with and without a patent aneurysm side branch. RESULTS: In each endoleak group, the intrasac diastolic pressure (DP) and mean pressure (MP) were significantly higher than the systemic DP and MP (P =.01, P =.006, and P =.001, respectively), although the pressure curve was damped. The presence of an open side branch significantly reduced the intrasac DP and MP. CONCLUSION: In this model, intrasac pressures were significantly higher than systemic pressures in the presence of all endoleaks, even the smallest ones. Intrasac pressures higher than systemic pressure may pose a high risk for aneurysm rupture. Although patent side branches significantly reduce these pressures, the aggressive management of an endoleak should be pursued.

Initial evaluation of carotid angioplasty and stenting with three different cerebral protection devices.

OBJECTIVE: The purpose of the study was to assess the effectiveness of cerebral protection devices during carotid artery angioplasty and stent placement. METHODS: Between September 1998 and September 1999, carotid angioplasty and stenting were performed in 46 patients with symptomatic (39.1%) or asymptomatic (60.9%) severe carotid artery stenosis. Wallstents were used in all patients with selective predilatation. Cerebral protection devices were used in 25 of these patients. Primary end points were perioperative neurologic complications and mortality. Data were collected prospectively. RESULTS: The overall combined end point of all neurologic deficits and death rate was 4.34%. Two neurologic events (one transient ischemic attack and one minor stroke) occurred in the unprotected group (9.53%) versus none in the group with cerebral protection. This difference is not statistically significant. The mortality rate was 0% for both groups. On an intention to treat basis, the overall technical success rate for carotid angioplasty was 97.8%, and for placement of cerebral protection devices it was 100%. An important number of particles of different sizes were captured in all cases in which cerebral protection devices were used. CONCLUSION: Experience has shown that cerebral protection during carotid angioplasty and stenting is technically feasible and appears to be effective in preventing procedure-related neurologic complications. Further investigation is warranted.

Endovascular aortic devices: the Parodi and Palmaz system.

Based on the concept of endoluminal aneurysm exclusion, we began to develop a plan for endovascular treatment for abdominal aortic aneurysm (AAA) in 1976.Two prototypes have been developed and were marked by a high failure rate.' The first was a thin fabric graft mounted on a metallic cage-like structure composed by a self-expandable mesh with a zigzag configuration. The apparatus was compressed inside a tubular sheath, which acted as a vessel introducer and carrier. Experiments in normal canine aor- tas led to the abandonment of this prototype due to an inconsistent deployment of the metallic cage. The radial expansion properties of the cage were difficult to control and predict. Over-expansion resulted in aortic wall injury and subsequent rupture. Controversially, underexpansion led to leakage of blood be- tween the apparatus and the host aorta with subsequent device migrations. The second prototype involved a Dacron graft fitted on a Silastic bag with a cylindrical lumen, which could be distended by injection of silicone into the bag. Unfortunately, this method was associated with prompt graft thrombosis of the aorta in all experimental essays.

[Prophylaxis of acute gastroduodenal lesions in critically ill patients]. / Profilaxis de las lesiones agudas gastroduodenales en pacientes críticos.

There were 220 patients studied, of which 44 were considered "critical" according to pre-established factors. In all of them, intra-gastrical pH in serious forms was detected, establishing that 45% of the "non-critical" patients had a pH factor less than 4. In these 61 patients and in the 44 "critical" patients a gastric alkalinization was sought, using between 1.2 and 2.4 grams of cimetidina daily, to which alkalines were added when necessary. Nine percent of the critical patients (4 of 44) had H.D.A., while 11 of 33 (33%) of the critically ill from a previous series that had not been treated had pronounced gastro-intestinal bleeding lesions (p less than 0.01.) The potential difference of gastric mucous in critical patients was measured likewise, being significantly less (means = 17.37 +/- 1.13) than in the non-critical patients (means = 30.2 +/- 1.13) (p less than 0.005). The use of cimetidina as an inhibitor of gastric secretion in a dosage of 1.2 grams was effective in 73% of the non-critical patients and in only 29% of the critical patients. Despite an increase in the dosage up to 2.4 grams in 9% of the critical and 22% of the non-critical patients, it was necessary to add alkalines. This lack of response shows a correlation between the amount of risk factors (3 of 10 patients had 3 factors) and the existence of hepatitic insufficiency (5 out of 16 patients and 5 out of 26 of sepsis).

Efectos de los bloqueantes histaminicos H1 y H2 en la ulcera de sujecion en la rata. / Effects of histamine H1 and H2 receptor blockaders in stress ulcer in rats

Se estudio el efecto bloqueante de los receptores H1 y H2, solos o asociados, en ratas sometidas a "stress" por sujecion de 4 horas y frio. Se desprende de los resultados que la cimetidina disminuye significativamente el numero de ulceraciones (p<0.001), no asi los bloqueantes H1, ya sea en forma independiente o asociados a la cimetidina

Profilaxis de las lesiones agudas gastroduodenales en pacientes críticos. / [Prophylaxis of acute gastroduodenal lesions in critically ill patients]

There were 220 patients studied, of which 44 were considered [quot ]critical[quot ] according to pre-established factors. In all of them, intra-gastrical pH in serious forms was detected, establishing that 45

of the [quot ]non-critical[quot ] patients had a pH factor less than 4. In these 61 patients and in the 44 [quot ]critical[quot ] patients a gastric alkalinization was sought, using between 1.2 and 2.4 grams of cimetidina daily, to which alkalines were added when necessary. Nine percent of the critical patients (4 of 44) had H.D.A., while 11 of 33 (33

) of the critically ill from a previous series that had not been treated had pronounced gastro-intestinal bleeding lesions (p less than 0.01.) The potential difference of gastric mucous in critical patients was measured likewise, being significantly less (means = 17.37 +/- 1.13) than in the non-critical patients (means = 30.2 +/- 1.13) (p less than 0.005). The use of cimetidina as an inhibitor of gastric secretion in a dosage of 1.2 grams was effective in 73

of the non-critical patients and in only 29

of the critical patients. Despite an increase in the dosage up to 2.4 grams in 9

of the critical and 22

of the non-critical patients, it was necessary to add alkalines. This lack of response shows a correlation between the amount of risk factors (3 of 10 patients had 3 factors) and the existence of hepatitic insufficiency (5 out of 16 patients and 5 out of 26 of sepsis).

Efectos de los bloqueantes histaminicos H1 y H2 en la ulcera de sujecion en la rata. / Effects of histamine H1 and H2 receptor blockaders in stress ulcer in rats

Se estudio el efecto bloqueante de los receptores H1 y H2, solos o asociados, en ratas sometidas a "stress" por sujecion de 4 horas y frio. Se desprende de los resultados que la cimetidina disminuye significativamente el numero de ulceraciones (p<0.001), no asi los bloqueantes H1, ya sea en forma independiente o asociados a la cimetidina