ABSTRACT
AIMS: The occurrence of type I endoleaks represent an ominous sign after endovascular aneurysms repair (EVAR). We report our experience using balloon-expandable stents (BES) for the treatment of proximal Type I endoleaks at five high-volume hospitals in Argentina. METHODS AND RESULTS: Of 1,395 patients who underwent EVAR, we retrospectively collected data of 29 (2%) consecutive patients who underwent additional BES to repair proximal type I endoleaks. The mean age was 75.8 years old (range 63-87) and 93% were male. A hostile anatomy was found in 89.6% of the cases. BES oversize (balloon/neck diameter ration ≥ 30%) was frequent (69%); whereas, BES/prosthesis diameter ratio was less than 1 in 79% of the cases. Complete and partial sealing was obtained 72 and 28% of the cases, respectively. There were no immediate or late surgical conversion or major complications related with stent implantation. At a median time follow-up of 14.9 months (25-75% interquartiles: 4.5-17.5 months), there were no cardiovascular deaths, evidence of aneurysm sac enlargement or need for re-intervention. CONCLUSIONS: Our preliminary results suggest that BES implantation for the treatment of proximal type I endoleaks is feasible and safe with favourable mid-term results and may preclude the need for surgical conversion.
Subject(s)
Aortic Aneurysm, Abdominal/surgery , Blood Vessel Prosthesis Implantation/instrumentation , Blood Vessel Prosthesis , Catheterization , Endoleak/therapy , Endovascular Procedures/instrumentation , Stents , Aged , Aged, 80 and over , Aortic Aneurysm, Abdominal/diagnostic imaging , Aortography/methods , Argentina , Blood Vessel Prosthesis Implantation/adverse effects , Endoleak/diagnostic imaging , Endoleak/etiology , Endovascular Procedures/adverse effects , Feasibility Studies , Female , Humans , Male , Middle Aged , Retrospective Studies , Time Factors , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
Antecedentes: Los avances en la técnica quirúrgica y en los métodos de diagnóstico por imágenes redujeron los riesgos de colecistectomía. Sin embargo, tanto la técnica laparoscópica como la convencional pueden asociarse a lesiones de estructuras del hilio hepático. Objetivo:Presentar una serie de injurias vasculares derechas asintomáticas asociadas a lesiones canaliculares. Lugar de aplicación: Práctica hospitalaria y privada. Diseño: Observacional,prospectivo. Población: 39 pacientes con antecedentes de lesión quirúrgica de la vía biliar a los que se les realizó arteriografía previo al drenaje percutáneo. Método: Realizamos arteriografías a 39 pacientes con antecedentes de lesión quirúrgica de la vía biliar previo al drenaje pecutáneo. Practicamos ecodoppler previo a la arteriografía en 18 oportunidades. El seguimiento fue de 10 meses. Diagnosticamos 7 estenosis del colédoco, 15 a nivel del carrefour biliar y 17 por encima de la confluencia de los hepáticos. 29 pacientes presentaban estenosis de hepático yeyuno anastomosis, se les realizó biopsia hepática sistemática. Medidas de Evaluación:Se utilizó el test de Pearson y el test de Fisher. Resultados: La artgeriografía mostró variantes anatómicas en el 12,8% de los casos. Se observó lesión de la arteria hepática derecha sin sospecha clínica en el 33% de los casos. El ecodoppler fue patológico en sólo un caso. Conclusiones: Es imprescindible un angiografía digital o angiotomografía multicorte en el caso de una lesión quirúrgica de la vía biliar asociada a lesión vascular, especialmente cuando deba efectuarse una anastomosis biliodigestiva intrahepática, en canales separados, una hepatectomía central o izquierda.
Subject(s)
Humans , Male , Adult , Female , Middle Aged , Postoperative Complications , Hepatic Artery/injuries , Biliary Tract Surgical ProceduresABSTRACT
Antecedentes: Los avances en la técnica quirúrgica y en los métodos de diagnóstico por imágenes redujeron los riesgos de colecistectomía. Sin embargo, tanto la técnica laparoscópica como la convencional pueden asociarse a lesiones de estructuras del hilio hepático. Objetivo:Presentar una serie de injurias vasculares derechas asintomáticas asociadas a lesiones canaliculares. Lugar de aplicación: Práctica hospitalaria y privada. Diseño: Observacional,prospectivo. Población: 39 pacientes con antecedentes de lesión quirúrgica de la vía biliar a los que se les realizó arteriografía previo al drenaje percutáneo. Método: Realizamos arteriografías a 39 pacientes con antecedentes de lesión quirúrgica de la vía biliar previo al drenaje pecutáneo. Practicamos ecodoppler previo a la arteriografía en 18 oportunidades. El seguimiento fue de 10 meses. Diagnosticamos 7 estenosis del colédoco, 15 a nivel del carrefour biliar y 17 por encima de la confluencia de los hepáticos. 29 pacientes presentaban estenosis de hepático yeyuno anastomosis, se les realizó biopsia hepática sistemática. Medidas de Evaluación:Se utilizó el test de Pearson y el test de Fisher. Resultados: La artgeriografía mostró variantes anatómicas en el 12,8% de los casos. Se observó lesión de la arteria hepática derecha sin sospecha clínica en el 33% de los casos. El ecodoppler fue patológico en sólo un caso. Conclusiones: Es imprescindible un angiografía digital o angiotomografía multicorte en el caso de una lesión quirúrgica de la vía biliar asociada a lesión vascular, especialmente cuando deba efectuarse una anastomosis biliodigestiva intrahepática, en canales separados, una hepatectomía central o izquierda. (AU)
Subject(s)
Humans , Male , Adult , Female , Middle Aged , Postoperative Complications , Biliary Tract Surgical Procedures , Hepatic Artery/injuriesABSTRACT
PURPOSE: To report the use of an external common femoral to carotid artery shunt in the setting of acute type A aortic dissection associated with carotid occlusion and stroke. TECHNIQUE: The procedure is illustrated in a 52-year-old man who presented with a type A dissection extending into the innominate trunk, with associated occlusion of the right common carotid artery (CCA). Angiography showed no collateral circulation to the right cerebral hemisphere. To re-establish brain perfusion in this setting, a percutaneous external shunt was installed from the common femoral artery to the right CCA. The 5-F femoral sheath used during diagnostic angiography was replaced by an 8-F femoral introducer securely fixed to the skin with silk sutures. Ultrasound-guided percutaneous CCA access was obtained using an 18-G needle and a 6-F introducer, also sutured to the skin. The ICA and intracranial branches showed no evidence of thrombosis at this level. A plastic tube was used to connect the femoral and carotid sheath side arms to restore ICA flow. Transcranial Doppler showed normal flow at the right middle cerebral artery after shunt placement. The patient was immediately transferred to the operating room for aortic surgery, during which an intrapericardially ruptured aorta was found. The ascending aorta and proximal arch were replaced under cardiopulmonary bypass and circulatory arrest, but the patient died during the procedure due to uncontrolled bleeding. CONCLUSION: A temporary percutaneous external femoral-carotid shunt can restore blood flow to the brain whenever the carotid artery is occluded by the dissection flap and adequate collateral flow is absent.
Subject(s)
Aortic Aneurysm/surgery , Aortic Dissection/surgery , Carotid Artery, Common/surgery , Carotid Stenosis/surgery , Cerebrovascular Circulation , Femoral Artery/surgery , Stroke/etiology , Vascular Surgical Procedures , Anastomosis, Surgical , Aortic Dissection/complications , Aortic Dissection/diagnosis , Aortic Dissection/physiopathology , Aortic Aneurysm/complications , Aortic Aneurysm/diagnosis , Aortic Aneurysm/physiopathology , Aortic Rupture/physiopathology , Aortic Rupture/surgery , Aortography , Blood Vessel Prosthesis Implantation , Cardiopulmonary Bypass , Carotid Artery, Common/diagnostic imaging , Carotid Artery, Common/physiopathology , Carotid Stenosis/complications , Carotid Stenosis/diagnosis , Carotid Stenosis/physiopathology , Collateral Circulation , Fatal Outcome , Heart Arrest, Induced , Humans , Male , Middle Aged , Regional Blood Flow , Stroke/diagnosis , Stroke/physiopathology , Stroke/surgery , Suture Techniques , Treatment Outcome , Ultrasonography, Doppler, Transcranial , Ultrasonography, InterventionalABSTRACT
BACKGROUND: The features of pituitary ACTH-dependent Cushing syndrome are often indistinguishable from those of occult ectopic ACTH-dependent Cushing syndrome (CS). AIM: To assess the diagnostic accuracy of bilateral inferior petrosal sinus sampling (BIPSS) in the differential diagnosis of ACTH-dependent Cushing's syndrome as compared with ACTH levels and the overnight high dose dexamethasone suppression test (HDDST). MATERIAL AND METHODS: Retrospective review of medical records of 23 patients (aged 19 to 63 years, 16 women) with surgically proven CS, 20 pituitary microadenomas (CD) and 3 with occult ectopic ACTH secretion (EAS). RESULTS: No tumor was identifiable by imaging techniques. Mean plasma ACTH values were higher in patients with EAS than in CD (103+/- 110.2 and 73.1+/-41.98 pg/mL respectively, p=NS). Three patients with EAS and 3 patients with CD did not suppress cortisol with the HDDST. The sensitivity of the test was 86% and the specificity 100%. To improve the diagnostic outcome of BIPSS, an stimulation with Desmopressin (9 fig i.v) was performed in 9 patients. The threshold for a pituitary source, was defined as an inferior petrosal sinus to peripheral ACTH basal and post Desmopression ratio >2. BIPSS was successfully carried out in 22 patients and no complications occurred. In 6 patients BIPSS failed to meet the threshold criteria. In 3 patients, bronchial carcinoid tumors which proved to synthesize ACTH, were removed. The diagnostic sensitivity of BIPSS greatly improved from 86% to 100% after Desmopressin stimulation. BIPSS accurately predicted the inverted exclamation markateralization of the microadenoma in 8 of 12 patients (66%). CONCLUSIONS: The combination of Desmopressin stimulation with BIPSS was useful for the differential diagnosis of ACTH-dependent Cushing's Syndrome. However, the preoperative location of pituitary microadenomas was poorly predicted by BIPSS.
Subject(s)
ACTH Syndrome, Ectopic/diagnosis , Adenoma/diagnosis , Adrenocorticotropic Hormone/blood , Cushing Syndrome/diagnosis , Petrosal Sinus Sampling/methods , Pituitary Neoplasms/diagnosis , ACTH Syndrome, Ectopic/blood , Adenoma/blood , Adult , Antidiuretic Agents , Cushing Syndrome/blood , Deamino Arginine Vasopressin , Dexamethasone , Diagnosis, Differential , Female , Glucocorticoids , Humans , Male , Middle Aged , Pituitary Neoplasms/blood , Retrospective Studies , Sensitivity and SpecificityABSTRACT
Background: The features of pituitary ACTH-dependent Cushing syndrome are often indistinguishable from those of occult ectopic ACTH-dependent Cushing syndrome (CS). Aim: To assess the diagnostic accuracy of bilateral inferior petrosal sinus sampling (BIPSS) in the differential diagnosis of ACTH-dependent Cushing's syndrome as compared with ACTH levels and the overnight high dose dexamethasone suppression test (HDDST). Material and methods: Retrospective review of medical records of 23 patients (aged 19 to 63 years, 16 women) with surgically proven CS, 20 pituitarymicroadenomas (CD) and 3 with occult ectopic ACTH secretion (EAS). Results: No tumor was identifiable by imaging techniques. Mean plasma ACTH values were higher in patients with EAS than in CD (103± 110.2 and 73.1±41.98 pg/mL respectively, p=NS). Three patients with EAS and 3 patients with CD did not suppress cortisol with the HDDST. The sensitivity of the test was 86 percent and the specificity 100 percent. To improve the diagnostic outcome of BIPSS, an stimulation with Desmopressin (9 fig i.v) was performed in 9 patients. The threshold for a pituitary source, was defined as an inferior petrosal sinus to peripheral ACTH basal and post Desmopression ratio >2. BIPSS was successfully carried out in 22 patients and no complications occurred. In 6 patients BIPSS failed to meet the threshold criteria. In 3 patients, bronchial carcinoid tumors which proved to synthesize ACTH, were removed. The diagnostic sensitivity of BIPSS greatly improved from 86 percent to 100 percent after Desmopressin stimulation. BIPSS accurately predicted the ¡ateralization of the microadenoma in 8 of 12 patients (66 percent). Conclusions: The combination of Desmopressin stimulation with BIPSS was useful for the differential diagnosis of ACTH-dependent Cushing's Syndrome. However, the preoperative location of pituitary microadenomas was poorly predicted by BIPSS.
Subject(s)
Adult , Female , Humans , Male , Middle Aged , ACTH Syndrome, Ectopic/diagnosis , Adenoma/diagnosis , Adrenocorticotropic Hormone/blood , Cushing Syndrome/diagnosis , Petrosal Sinus Sampling/methods , Pituitary Neoplasms/diagnosis , ACTH Syndrome, Ectopic/blood , Adenoma/blood , Antidiuretic Agents , Cushing Syndrome/blood , Deamino Arginine Vasopressin , Dexamethasone , Diagnosis, Differential , Glucocorticoids , Pituitary Neoplasms/blood , Retrospective Studies , Sensitivity and SpecificityABSTRACT
The purpose of this study was to assess the safety and efficacy of stent-graft placement in the management of arteriovenous fistulae (AVF) and pseudoaneurysms (PAs) involving the carotid artery (CA). Twenty-two patients (16 men, 6 women) with a CA AVF (n = 5) or PA (n = 17) owing to a gunshot or stab wound, carotid endarterectomy, blunt trauma, a tumor, spontaneous dissection, or a central venous catheter were treated with percutaneous placement of stent grafts. The patients presented with tumor, bruit, headache, mouth and tracheostomy bleeding, transitory hemiparesis, seizure, or stroke. Diagnoses were made by using computed tomographic angiography (CTA) and digital subtraction angiography. Fourteen lesions were in the common CA; eight were in the internal CA. Homemade devices and stent grafts from a variety of manufacturers were employed. Follow-up evaluations included clinical, CTA, and Doppler ultrasound assessments. All patients had resolution of the PA or AVF. In one patient with a large petrous PA, acute occlusion of the CA developed after placement of three balloon-expandable stent grafts, but there were no neurologic complications because the circle of Willis was functional. During follow-up ranging from 2 months to 13 years, asymptomatic 90% stenosis owing to stent compression was observed on Doppler ultrasound and angiographic examinations in a patient with an autologous vein-covered stent graft in the internal CA. Three other patients died of causes unrelated to stent-graft placement. In all other patients, the stent graft remained patent. Our results indicate that stent grafting is an acceptable alternative to surgery in the treatment of AVF and PAs in the CA.
Subject(s)
Aneurysm, False/therapy , Arteriovenous Fistula/therapy , Blood Vessel Prosthesis , Carotid Artery Diseases/therapy , Carotid Artery Injuries/therapy , Stents , Adult , Aged , Aneurysm, False/diagnostic imaging , Aneurysm, False/etiology , Arteriovenous Fistula/diagnostic imaging , Arteriovenous Fistula/etiology , Carotid Artery Diseases/diagnostic imaging , Carotid Artery Diseases/etiology , Carotid Artery Injuries/diagnostic imaging , Carotid Artery Injuries/etiology , Female , Follow-Up Studies , Humans , Male , Middle Aged , Radiography , Treatment OutcomeABSTRACT
Percutaneous treatment of renal artery stenosis (RAS) is an accepted procedure and numerous reports have been published. However, experience with its use in RAS in the transplanted kidney in children is scarce. Since 1994 we have diagnosed RAS in seven children with the use of Doppler ultrasonography (US), confirming it with percutaneous angiography (PAG). In six of the seven patients percutaneous transluminal angioplasty (PTA) was performed. In one patient a metallic stent was placed due to the extension of the arterial lesion, and a second stent was placed in another child when a re-stenosis was diagnosed 1 month after the PTA. All patients presented with hypertension (de novo or 30% increase over previous values). After ruling out acute rejection, calcineurin inhibitor toxicity, and urinary obstruction, US was performed and, when an increase in arterial flux velocity was registered, PAG was also performed. Six children showed an increase in serum creatinine (Cr) and proteinuria. Blood pressure decreased after the procedure and Cr returned to previous levels in all children. One of the grafts was lost due to chronic transplant rejection 7 years later. The other children have a functioning kidney. Although this is a small group of patients, the consistently good results and the lack of reported experience prompted us to communicate our preliminary observation.
Subject(s)
Angioplasty, Balloon , Kidney Transplantation/adverse effects , Renal Artery Obstruction/therapy , Child , Humans , Renal Artery Obstruction/etiology , Retrospective StudiesABSTRACT
PURPOSE: To present a 2-device technique for cerebral protection during carotid stenting of the internal carotid artery (ICA) in patients with high-grade lesions, contralateral occlusion, and/or an aberrant or nonfunctioning circle of Willis. TECHNIQUE: A reverse flow system (Parodi Anti-Embolism System [PAES]) is first placed with a 260-cm exchange wire in the common carotid artery 3 cm below the carotid bifurcation. Flow reversal is obtained by inflating the balloons in the external and common carotid arteries. Via an external connector, a guidewire and E-Trap filter are delivered to the distal ICA with active suction from a syringe on the PAES catheter. Once the filter is above the stenosis, the reversed flow is discontinued, and the procedure proceeds under cerebral protection with the filter. CONCLUSIONS: The combination of 2 existing cerebral protection devices could, at least in theory, achieve what neither of them could independently. The "seat belt and air bag" approach may represent the ideal means of treating ICA stenoses in patients with a non-functioning circle of Willis.
Subject(s)
Angioplasty, Balloon/adverse effects , Angioplasty, Balloon/instrumentation , Balloon Occlusion/instrumentation , Carotid Stenosis/therapy , Intracranial Embolism/prevention & control , Stents , Angiography , Angioplasty, Balloon/methods , Balloon Occlusion/methods , Blood Flow Velocity , Carotid Artery, Internal/diagnostic imaging , Carotid Artery, Internal/physiopathology , Equipment Design , Equipment Safety , Humans , Intracranial Embolism/diagnostic imaging , Primary Prevention/instrumentation , Primary Prevention/methods , Sensitivity and Specificity , Vascular PatencyABSTRACT
El uso endovascular de resortes o espirales ("coils") de platino como agentes embolizantes han sido efectivos en malformaciones arteriovenosas como las fístulas carótidocavernosas y los aneurismas de la vena de Galeno. Su acción trombogénica radica en fenómenos obstructivos al flujo sanguíneo intraaneurismático y efectos electrostáticos sobre plaquetas y glóbulos. Se presentan 11 enfermos de aneurismas: seis gigantes intracavernosos, dos medianos y tres pequeños con seguimiento clínocoradiológico mayor a un año. En los aneurismas gigantes se comprobó trombosis completa en dos pacientes y subtotal en tres; falloeció uno por complicaciones del procedimiento. En los aneurismas medianos hubo trombosis completa en uno y revascularización en el otro. Rn los aneurismas pequeños se obtuvo oclusión completa en todos. En los aneurismas intracavernosas se observó mejoría en uno, estabilización clínica en tres y empeoramiento en el restante. En los cinco aneurismas medianos y pequeños no se ha evidenciado crecimiento a partir del cuello ni repetición de hemorragias subaracnoideas.
