Contenido en filtros tras angioplastia y colocación de stent carotídeo: relación con lesiones isquémicas en la resonancia magnética de difusión / Filter content after carotid angioplasty and stenting: relation to ischemic lesions in diffusion-weighted imaging

Objetivos. Evaluar la relación entre el material recogido en filtros distales tras angioplastia y colocación de stent carotídeo (ASC) y la aparición de lesiones isquémicas cerebrales en la RM potenciada en difusión (RMD). Determinar la influencia que tienen variables demográficas, clínicas y del procedimiento en el proceso embolígeno y en la isquemia post-ASC. Material y método. Se analizó histológicamente el contenido de los filtros de 76 pacientes sometidos a ASC por estenosis grave de la arteria carótida interna (ACI) (60 hombres; edad media 68,39 años; rango: 46-82), valorándose el volumen (< 1 λ=0,001 ml=1μl; 1-10 λ; y > 10 λ) y la composición de las partículas. Se realizó RMD previa y 24h después del procedimiento, recogiéndose la aparición de lesiones, número, tamaño y distribución. Se correlacionaron estadísticamente los datos anteriores y con variables demográficas, clínicas y del procedimiento. Resultados. Cincuenta y ocho pacientes (76,3%) presentaron sintomatología previa al procedimiento. El 64,5% de los filtros (49) presentó partículas, la mayoría menores de 1 λ (77,5%), predominando los agregados fibrinoplaquetarios, restos celulares y cristales de colesterol. Doce pacientes (15,8%) demostraron lesiones en la RMD post-ASC, sin relación con el contenido en los filtros. No se encontró correlación estadística entre la presencia de material en los filtros y otras variables. Conclusiones. La isquemia post-ASC no depende únicamente de la carga embolígena y su naturaleza. La menor prevalencia de lesiones post-ASC en nuestra serie en comparación con otras indica que la adecuada selección de pacientes y la experiencia minimizan la influencia negativa de algunas variables, como la edad, en su aparición (AU)

Objectives. To evaluate the relation between the material retrieved from distal filters after carotid angioplasty and stenting and the development of ischemic brain lesions in diffusion-weighted imaging (DWI). To determine the influence of demographic, clinical, and procedural variables in the pathogenesis of emboli and in ischemia after carotid angioplasty and stenting. Material and methods. We submitted the contents of the filters of 76 patients (60 men; mean age, 68.39years; range, 46-82) who had undergone angioplasty and stenting for severe stenosis of the internal carotid artery for histologic analysis evaluating volume (< 1 λ=0.001ml = 1μl; 1-10 λ; and > 10 λ) and the composition of the particles. All patients underwent DWI before and 24hours after the procedure; we recorded whether lesions appeared and their number, size, and distribution. We correlated the findings with demographic, clinical, and procedural variables. Results. Symptoms were present before the procedure in 58 (76.3%) patients. Particles were present in 49 (64.5%) of the filters; most particles (77.5%) were 1 λ with a predominance of fibrin-platelet aggregates, cell remnants, and cholesterol crystals. DWI after the procedure detected lesions in 12 (15.8%) patients. We found no statistically significant correlation between filter contents and lesion detection after the procedure or between filter contents and other variables. Conclusions. Ischemia after carotid angioplasty and stenting does not depend solely on the embolic load and its nature. We consider that the lower prevalence of postprocedural lesions in our series compared to others suggests that appropriate patient selection and experience minimize the negative influence of some variables like age in their development(AU)

[Filter content after carotid angioplasty and stenting: relation to ischemic lesions in diffusion-weighted imaging]. / Contenido en filtros tras angioplastia y colocación de stent carotídeo: relación con lesiones isquémicas en la resonancia magnética de difusión.

OBJECTIVES: To evaluate the relation between the material retrieved from distal filters after carotid angioplasty and stenting and the development of ischemic brain lesions in diffusion-weighted imaging (DWI). To determine the influence of demographic, clinical, and procedural variables in the pathogenesis of emboli and in ischemia after carotid angioplasty and stenting. MATERIAL AND METHODS: We submitted the contents of the filters of 76 patients (60 men; mean age, 68.39 years; range, 46-82) who had undergone angioplasty and stenting for severe stenosis of the internal carotid artery for histologic analysis evaluating volume (< 1 λ = 0.001 ml = 1 µl; 1-10 λ; and > 10 λ) and the composition of the particles. All patients underwent DWI before and 24 hours after the procedure; we recorded whether lesions appeared and their number, size, and distribution. We correlated the findings with demographic, clinical, and procedural variables. RESULTS: Symptoms were present before the procedure in 58 (76.3%) patients. Particles were present in 49 (64.5%) of the filters; most particles (77.5%) were 1 λ with a predominance of fibrin-platelet aggregates, cell remnants, and cholesterol crystals. DWI after the procedure detected lesions in 12 (15.8%) patients. We found no statistically significant correlation between filter contents and lesion detection after the procedure or between filter contents and other variables. CONCLUSIONS: Ischemia after carotid angioplasty and stenting does not depend solely on the embolic load and its nature. We consider that the lower prevalence of postprocedural lesions in our series compared to others suggests that appropriate patient selection and experience minimize the negative influence of some variables like age in their development.

Intravascular ultrasound and virtual histology of basilar artery atherosclerotic lesion. A case report.

To our knowledge, this paper presents the first intravascular ultrasound and virtual histology (IVUS-VH) study in the basilar artery. IVUS-VH serves to characterize and determine the extension of the plaque and we also to check stent placement.

[Outcome of intraarterial procedures in acute ischemic stroke]. / Resultados del intervencionismo en el ictus isquémico agudo.

INTRODUCTION: In addition to the thrombolytic agents, mechanical devices are being used in intraarterial procedures in acute stroke patients. The intervention protocol and outcomes of intraarterial procedures performed in the Hospital Virgen del Rocío in 2003-2004 are described. METHODS: The results in each arterial occlusion site and case-control study of the middle cerebral artery (MCA), the placebo group in PROACT II study (Prolyse in Acute Cerebral Thromboembolism II) as historic control group, are described. RESULTS: A total of 32 procedures were performed: 18 MCA occlusions, 8 basilar thrombosis and 6 intracranial carotid occlusions. Urokinase, abciximab and mechanical devices were used in 60%, 26% and 60% of the cases, respectively. MCA occlusions: 60% of the cases improved in 24 hours (25% remained asymptomatic). Only 25% controls remained independent versus 55% of the treated patients (p=0.001). Recanalization and complete recanalization rates were 95 % and 45 %, respectively (18% and 2% in the control group). Symptomatic intracranial hemorrhage (SICH) rate was 18% vs 4% in cases and controls. Basilar thrombosis: only one patient died and 57% of the remaining patients were independent. Carotid occlusions: no complete recanalization was achieved and only one patient was independent. Evolution time in SICH patients was longer (p=0.04), with increased international normalized ratio (INR) for thromboplastin time (p=0.06) and old ischemic lesions in brain CT scan (p=0.02) and they were more dependent at three months (p=0.01). CONCLUSIONS: Intraarterial procedures in MCA occlusions achieve high rates of recanalization and better clinical outcomes than those described in isolated intraarterial thrombolysis. Long-term outcomes in basilar thrombosis were also excellent. Nevertheless, the natural evolution of carotid occlusions was not modified.

[Financial analysis of intraarterial procedures in acute stroke]. / Análisis económico del intervencionismo en el ictus agudo.

INTRODUCTION: Since the most decisive factor related to the cost of stroke is disability, any acute phase intervention to reduce disability will probably be cost-effective. The present acute stroke phase analysis is the first cost-benefit study on intraarterial procedures in acute stroke phase. METHOD: Case-control study focusing on the cost of stroke including acute stroke patients subjected to interventionism in Hospital Virgen del Rocío in 2003-2004 was conducted. The data obtained was subsequently extrapolated to the number of patients who would have been treated if intraarterial procedures could be performed on a 24 hour-day basis. RESULTS: 32 patients were treated in 2003-2004. Direct cost (devices and human resources) of each treated patient was 10,502 euros and global saving in hospital stay and rehabilitation was 11,069 euros, resulting in 567 euros net saving per patient. Nevertheless, 92 patients would have been treated if intraarterial procedures could have been performed on a 24 hour-day basis, resulting in better financial results with 5,792 saving for each treated patient. CONCLUSIONS: Intracraneal procedures in acute stroke has been shown to be cost-effective since cost of material and human resources is greatly exceeded by the saving in hospitalization and rehabilitation as a result of reduction in patient disability.

Análisis económico del intervencionismo en el ictus agudo / Financial analysis of intraarterial procedures in acute stroke

Introducción. El determinante más importante del coste del ictus es el estado de discapacidad, por lo que cualquier intervención en fase aguda que reduzca la discapacidad será probablemente coste-efectiva. El presente análisis es el primer estudio de coste-beneficio del intervencionismo en fase aguda del ictus. Métodos. Se ha realizado un estudio de casos y controles de costes de los pacientes con ictus agudo tratados mediante intervencionismo en el Hospital Virgen del Rocío en los años 2003-2004 y posteriormente se han extrapolado los datos obtenidos al supuesto del número real de pacientes que habrían sido tratados si hubiera estado organizado el intervencionismo como atención continua. Resultados. En los años 2003-2004 se han tratado a 32 pacientes. El coste directo (material fungible + recursos humanos) por cada paciente tratado fue de 10.502 euros y el ahorro global en estancia hospitalaria más rehabilitación resultó de 11.069 euros por paciente, resultando, por tanto, en un ahorro neto de 567 euros por paciente. Sin embargo, si el intervencionismo hubiese estado organizado de forma continua se habrían tratado a 92 pacientes, resultando la evaluación económica más favorable con un ahorro de 5.792 euros por cada paciente tratado. Conclusiones. El tratamiento intervencionista ha demostrado ser coste-efectivo, ya que el gasto derivado del material y los recursos humanos necesarios es superado con creces por el ahorro en tiempos de hospitalización y rehabilitación que se deriva de la reducción de la discapacidad de los pacientes

Introduction. Since the most decisive factor related to the cost of stroke is disability, any acute phase intervention to reduce disability will probably be cost-effective. The present acute stroke phase analysis is the first cost-benefit study on intraarterial procedures in acute stroke phase. Method. Case-control study focusing on the cost of stroke including acute stroke patients subjected to interventionism in Hospital Virgen del Rocío in 2003-2004 was conducted. The data obtained was subsequently extrapolated to the number of patients who would have been treated if intraarterial procedures could be performed on a 24 hour-day basis. Results. 32 patients were treated in 2003-2004. Direct cost (devices and human resources) of each treated patient was 10,502 euros and global saving in hospital stay and rehabilitation was 11,069 euros, resulting in 567 euros net saving per patient. Nevertheless, 92 patients would have been treated if intraarterial procedures could have been performed on a 24 hour-day basis, resulting in better financial results with 5,792 saving for each treated patient. Conclusions. Intracraneal procedures in acute stroke has been shown to be cost-effective since cost of material and human resources is greatly exceeded by the saving in hospitalization and rehabilitation as a result of reduction in patient disability

Resultados del intervencionismo en el ictus isquémico agudo / Outcome of intraarterial procedures in acute ischemic stroke

Introducción. Además de los agentes trombolíticos, se están empleando dispositivos mecánicos en el intervencionismo en pacientes con ictus agudo. Se describe el protocolo y resultados del intervencionismo en el Hospital Virgen del Rocío durante los años 2003-2004. Métodos. Descripción de resultados en cada tipo de oclusión y estudio caso-control de oclusiones de arteria cerebral media (ACM) tratadas empleando como control histórico el grupo placebo del estudio PROACT II (Prolyse in Acute Cerebral Thromboembolism II). Resultados. Se realizaron 32 procedimientos: 18 oclusiones ACM, 8 trombosis basilares y 6 carótidas intracraneales. Se empleó urocinasa, abciximab y disrupción mecánica en un 60, 26 y 60% de pacientes, respectivamente. Oclusiones ACM: el 60% mejoraron en 24 h (25% quedaron asintomáticos). Sólo el 25% de controles quedaron independientes frente a un 55 % de los tratados (p=0,001). La tasa de recanalización y recanalización completa fue del 95 y 45%, respectivamente (18 y 2% en el grupo control). La tasa de hemorragia intracraneal sintomática (HICS) fue del 18% en el grupo tratado y del 4% en el control. Trombosis basilares: un paciente falleció y el 57% de los restantes alcanzó la independencia. Oclusiones carotídeas: en ningún caso se consiguió la recanalización completa y sólo alcanzó la independencia un paciente. Los pacientes con HICS tenían un tiempo de evolución más prolongado (p=0,04), un international normalized ratio (INR) mayor para el tiempo de tromboplastina (p=0,06) e infartos antiguos en la tomografía computarizada cerebral (p=0,02) y quedaban más dependientes al tercer mes (p=0,01). Conclusiones. El intervencionismo en oclusiones de ACM consigue altas tasas de recanalización y mejores resultados clínicos que los descritos para la fibrinólisis intraarterial aislada. Los resultados a largo plazo en las trombosis basilares fueron también excelentes. Sin embargo, no se modificó la evolución natural de las oclusiones carotídeas

Introduction. In addition to the thrombolytic agents, mechanical devices are being used in intraarterial procedures in acute stroke patients. The intervention protocol and outcomes of intraarterial procedures performed in the Hospital Virgen del Rocío in 2003-2004 are described. Methods. The results in each arterial occlusion site and case-control study of the middle cerebral artery (MCA), the placebo group in PROACT II study (Prolyse in Acute Cerebral Thromboembolism II) as historic control group, are described. Results. A total of 32 procedures were performed: 18 MCA occlusions, 8 basilar thrombosis and 6 intracranial carotid occlusions. Urokinase, abciximab and mechanical devices were used in 60%, 26% and 60% of the cases, respectively. MCA occlusions: 60% of the cases improved in 24 hours (25% remained asymptomatic). Only 25% controls remained independent versus 55% of the treated patients (p=0.001). Recanalization and complete recanalization rates were 95 % and 45 %, respectively (18% and 2% in the control group). Symptomatic intracranial hemorrhage (SICH) rate was 18% vs 4% in cases and controls. Basilar thrombosis: only one patient died and 57% of the remaining patients were independent. Carotid occlusions: no complete recanalization was achieved and only one patient was independent. Evolution time in SICH patients was longer (p=0.04), with increased international normalized ratio (INR) for thromboplastin time (p=0.06) and old ischemic lesions in brain CT scan (p=0.02) and they were more dependent at three months (p=0.01). Conclusions. Intraarterial procedures in MCA occlusions achieve high rates of recanalization and better clinical outcomes than those described in isolated intraarterial thrombolysis. Long-term outcomes in basilar thrombosis were also excellent. Nevertheless, the natural evolution of carotid occlusions was not modified

[Internal carotid artery pseudoaneurysm and stenosis: treatment with stents and coils]. / Tratamiento con endoprótesis y espirales de un pseudoaneurisma asociado a una estenosis en la arteria carótida interna

PURPOSE: To describe the endovascular management of a patient with post-dissection internal carotid pseudoaneurysm and stenosis. CASE REPORT: A 45-year-old man presented with left hemyparesia; angiography showed right internal carotid artery occlusion, left carotid stenosis and pseudoaneurysm. A metallic uncovered stent was implanted by means of a femoral approach. Coils were delivered through the uncovered stent and the pseudoaneurysm was excluded. CONCLUSION: The internal carotid percutaneous implantation of a carotid uncovered stent, and embolization through stent in a patient with stenosis and pseudoaneurysm, appears to be a safe procedure without risk of coils migration.

[Congenital coronary fistula to right ventricle. Treatment with transcatheter coil embolization]. / Fístula coronaria congénita a ventrículo derecho. Tratamiento mediante embolización transcateter con coils.

We report the case of a 3 year old girl with a congenital right coronary artery-right ventricle fistula demonstrated by two dimensional echocardiography with color-flow Doppler and cardiac catheterization and angiography. The treatment was percutaneous transcatheter embolization by two detachable coils (7 mm x 20 cm and 6 mm x 20 cm) with successful complete occlusion. There were no complications.

[Posttraumatic high-flow priapism in prepubertal age]. / Priapismo de alto flujo postraumático en edad prepuberal.

High flow priapism is an infrequent entity, generally following traumatic injuries in the genito-perineal area. Anamnesis, cavernous bodies blood gasometry and Doppler are the basic diagnostic tools for these condition. Therapeutical management is considerably different from that used for low flow venous priapism. Selective arteriography of the internal pudendal artery allows to locate the arterial lesion and, at the same time, to perform supraselective embolization of the lacerated cavernous artery which is currently considered the choice treatment. This paper presents the case report of a ten-year old patient successfully resolved through application of angioradiologic procedures.