Complex Reoperation for Late Complications After Acute Type A Aortic Dissection Surgery.

The correct management of acute Type A dissection continues to be a challenge. The primary goal is to save the patient´s life. However, the decision regarding the surgical approach determines possible later complications. We present the case of a 59-year-old female patient with a past history of emergent surgery for acute Type A dissection treated by supracoronary ascending and aortic valve replacement 19 years previously. Later, in a second endovascular approach, the descending aorta was treated by a thoracic endoprosthesis. During follow-up a dilated aortic root and a Type I endoleak were observed, and complex reoperation was required. We performed a total aortic arch replacement with a 4-branched graft and a complete aortic root replacement using the Cabrol technique for the reinsertion of the coronary arteries. The mechanical aortic normally functioning valve was preserved. The patient was discharged 30 days postoperatively.

Surgery for papillary fibroelastoma with uncommon location in left ventricle.

Cardiac papillary fibroelastoma is a rare tumor. Its location in the left ventricular wall is uncommon. A 59-year-old woman with 2 previous strokes presented with a tumor in the left ventricular apex. The patient underwent tumor resection through a left ventriculotomy. The histopathologic diagnosis was papillary fibroelastoma.

New method of tunnelling for omental transposition in the treatment of a complex radionecrotic groin ulcer.

Omental transposition is often used for reconstruction of soft tissue in the groin. However, the potential for incisional hernia is a relative contraindication. We report the cure of a groin ulcer with omental transposition using a new method of tunnelling to avoid herniation.

Aneurisma de la aorta abdominal: Tratamiento endovascular con una endoprótesis fenestrada / Abdominal aortic aneurysm: Endovascular treatment with fenestrated endoprothesis

El tratamiento endovascular de los aneurismas de aorta abdominal es una alternativa a la cirugía abierta para pacientes de alto riesgo. Consiste en la exclusión del saco aneurismático mediante la interposición de una endoprótesis colocada por vía femoral. El tratamiento endovascular no puede ser utilizado en todos los pacientes. Una limitación frecuente la constituye el nacimiento de una arteria visceral desde el saco aneurismático. Para contrarrestar esta limitación recientemente se han desarrollado endoprótesis fenestradas que presentan orificios que se corresponden con el nacimiento de las arterias involucradas en el aneurisma evitando su oclusión, permitiendo de esta manera el tratamiento endovascular. En esta comunicación se presenta un caso de tratamiento endovascular de un aneurisma de aorta abdominal mediante la colocación de una endoprótesis fenestrada en un paciente cuya arteria renal izquierda nacía directamente del saco aneurismático.

Endovascular treatment of the abdominal aortic aneurysm is consider an alternative to open surgery for high risk patients. Its goal is to exclude the aneurysm from the circulation by using an endoprothesis introduced from a femoral approach. Patients must be strictly selected to avoid possible complications. The most frequent limitation is related to anatomic contraindications such as visceral arteries involved in the aneurysm. Fenestrated endograft have been recently developed to allow endovascular treatment when anatomic features contraindicate classic endovascular procedures. Fenestrated endograft have holes that match with the origin of the visceral arteries maintaining its potency. In this paper we report the endovascular treatment of an abdominal aortic aneurysm by using a fenestrated endoprothesis in a patient whose left renal artery is originated from the aneurysm.

Seguimiento a mediano plazo de pacientes sometidos a reemplazo valvular aórtico con prótesis mecánicas / Mid-term Follow-Up of Patients Submitted to Aortic Valve Replacement with Mechanical Prosthesis

Introducción La patología de la válvula aórtica es una de las causas más frecuentes de reemplazo valvular en nuestro medio. La falta de información actualizada sobre la evolución alejada de pacientes que recibieron prótesis mecánicas en posición aórtica motivó la realización del presente estudio. Objetivo Conocer la mortalidad, la morbilidad (complicaciones mayores) y los resultados funcionales (mejoría clínica) durante el seguimiento de pacientes portadores de una válvula mecánica en posición aórtica. Material y métodos Se seleccionaron 95 pacientes sometidos a reemplazo valvular aórtico con prótesis mecánicas. Todos los pacientes fueron operados entre enero de 1999 y diciembre de 2006. La media de seguimiento fue de 4,5 ± 2,3 años, percentiles 25-75: 2,5-6,3 años. El seguimiento total fue de 427,5 pacientes/año. Resultados La media de edad fue de 64,5 ± 12,3 años y el 61,1% de los pacientes eran de sexo masculino. Sesenta pacientes (63%) estaban en clase funcional (CF) III-IV antes de la cirugía. En el seguimiento, 67 pacientes (70,5%) se encuentran en CF I y 28 (29,5%) en CF II. No se observaron pacientes en CF III ni IV. La media del índice área valvular efectiva / área de superficie corporal fue de 1,06 cm²/m². La supervivencia actuarial (Kaplan-Meier) fue del 95% (IC 95% 88-98%) a un año y del 89% a los 5 años (IC 95% 76-95%). La mortalidad relacionada se registró en 9 pacientes (9,5%). La incidencia de tromboembolia fue del 0,2% paciente-año, la de hemorragia del 2,3% paciente- año y la de endocarditis del 0,7% paciente-año. La tasa de reoperación fue del 0,4% paciente-año. Conclusiones Los resultados obtenidos fueron similares a los comunicados en series internacionales en términos de supervivencia y complicaciones mayores. La frecuencia de eventos adversos observados a mediano plazo, como en todo el mundo, aún permanece elevada.

Background Aortic valve disease is one of the most frequent causes of valve replacement in our environment. This study was performed based on the lack of information related to late outcomes in patients submitted to aortic valve replacement with mechanical prosthesis. Objective To assess the mortality, morbidity (major complications) and functional outcomes (clinical improvement) during the follow- up of patients with mechanical prosthesis placed in the aortic position. Material and Methods Ninety five patients submitted to aortic valve replacement with mechanical prosthesis were selected. Surgeries were performed between January 1999 and December 2006. Mean follow-up was 4±2.3 years; percentiles 25-75: 2.5-6.3 years. Total follow-up was 427.5 patients/year. Results Mean age was 64.5±12.3 years, 61.1% were men. Sixty patients (63%) were in functional class (FC) III-IV prior to surgery. During follow-up, 67 patients (70.5%) were en FC I and 28 (29.5%) in FC II. No patients presented FC III or IV. Mean effective valve area/body surface area was 1.06 cm²/m². Actuarial survival (Kaplan-Meier) was 95% (95% CI 88-98%) at one year and 89% at 5 years (95% CI 76-95%). Nine deaths (9.5%) were related to this condition. The incidence of complications was as follows: thromboembolism 0.2% patient/ year, bleeding 2.3% patient/year, and endocarditis 0.7% patient/ year. Re-operation rate was 0.4% patient/year. Conclusions These results were similar to those reported in international series in terms of survival and major complications. The number of adverse events observed at mid-term is still high, as it is all around the world.

[Abdominal aortic aneurysm. Endovascular treatment with fenestrated endoprothesis]. / Aneurisma de la aorta abdominal. Tratamiento endovascular con una endoprótesis fenestrada.

Endovascular treatment of the abdominal aortic aneurysm is consider an alternative to open surgery for high risk patients. Its goal is to exclude the aneurysm from the circulation by using an endoprothesis introduced from a femoral approach. Patients must be strictly selected to avoid possible complications. The most frequent limitation is related to anatomic contraindications such as visceral arteries involved in the aneurysm. Fenestrated endograft have been recently developed to allow endovascular treatment when anatomic features contraindicate classic endovascular procedures. Fenestrated endograft have holes that match with the origin of the visceral arteries maintaining its potency. In this paper we report the endovascular treatment of an abdominal aortic aneurysm by using a fenestrated endoprothesis in a patient whose left renal artery is originated from the aneurysm.

Different clinical features of aortic intramural hematoma versus dissection involving the descending thoracic aorta.

OBJECTIVE: The objective of this study is to test the hypothesis that the absence of flow communication in aortic intramural hematoma (IMH) involving the descending aorta may have a different clinical course compared with aortic dissection (AD). METHODS: We prospectively evaluated clinical and echocardiographic data in AD (76 patients) and IMH (27 patients) of the descending thoracic aorta. RESULTS: Patients did not differ with regard to age, gender, or clinical presentation. IMH and AD had the same predictors of complications at follow-up: aortic diameter (>5 cm) at diagnosis and persistent back pain. Surgical treatment was more frequently selected in AD (39% vs. 22%, P < 0.01) and AD patients who underwent surgical treatment had higher mortality than those with IMH (36% vs. 17%, P < 0.01). There was no difference in mortality with medical treatment (14% in AD vs. 19% in IMH, P = 0.7). During follow-up, of 23 patients with IMH, 11 (47%) showed complete resolution or regression, 6 (26%) increased the diameter of the descending aorta, and typical AD developed in 3 patients (13%). No changes occurred in 14% of the group. Three-year survival rate did not show significant differences between both groups (82 +/- 6% in IMH vs. 75 +/- 7% in AD, P = 0.37). CONCLUSION: IMH of the descending thoracic aorta has a relatively frequent rate of complications at follow-up, including dissection and aneurysm formation. Medical treatment with very frequent imaging and timed elective surgery in cases with complications allows a better patient management.

Experiencia inicial con trasplante de páncreas e islotes asociado a trasplante renal en pacientes diabéticos / Clinical experience with pancreas and islet transplantation in diabetes patients treatment

Antecedentes: El trasplante de tejido pancreático es en la actualidad el sistema más fisiológico de aporte de insulina en pacientes diabéticos. Objetivo: Presentar los resultados con el trasplante de páncreas vascularizado e islotes en pacientes diabéticos. Diseño: Retrospectivo y discutido. Material y métodos: En un período de tres años se efectuaron 5 trasplantes de páncreas vascularizado y 3 trasplantes de islotes en pacientes diabéticos tipo I. Se evaluaron variables bioquímicas y clínicas de seguimiento postrasplante. Resultados: No se registró mortalidad postoperatoria. Dos pacientes fallecieron al 4º y 14º mes. El resto están vivos y con función de sus órganos a 22, 10 y 9 meses postrasplante en el caso de trasplante vascularizado. En el caso de islotes trasplantados mejoró notablemente el manejo metabólico, bajando los requerimientos diarios de insulina. Conclusión: El trasplante vascularizado de páncreas sigue siendo la mejor opción terapéutica, para revertir completamente la insuficiencia endocrina. El trasplante de islotes ofrece un menor riesgo y puede ser implementado en una población altamente seleccionada

Experiencia inicial con trasplante de páncreas e islotes asociado a trasplante renal en pacientes diabéticos / Clinical experience with pancreas and islet transplantation in diabetes patients treatment

Antecedentes: El trasplante de tejido pancreático es en la actualidad el sistema más fisiológico de aporte de insulina en pacientes diabéticos. Objetivo: Presentar los resultados con el trasplante de páncreas vascularizado e islotes en pacientes diabéticos. Diseño: Retrospectivo y discutido. Material y métodos: En un período de tres años se efectuaron 5 trasplantes de páncreas vascularizado y 3 trasplantes de islotes en pacientes diabéticos tipo I. Se evaluaron variables bioquímicas y clínicas de seguimiento postrasplante. Resultados: No se registró mortalidad postoperatoria. Dos pacientes fallecieron al 4º y 14º mes. El resto están vivos y con función de sus órganos a 22, 10 y 9 meses postrasplante en el caso de trasplante vascularizado. En el caso de islotes trasplantados mejoró notablemente el manejo metabólico, bajando los requerimientos diarios de insu