RESUMO
INTRODUCTION: Acute haemodynamic changes and/or loss of abdominal muscle tone can occur during induction of general anaesthesia and may be the Achilles' tendon in endovascular aneurysm repair (EVAR) of ruptured aortoiliac aneurysms (rAIA). The purpose of this study was to evaluate the use of local anaesthesia (LA) for EVAR to overcome these limitations. METHODS: Twenty-one consecutive patients with rAIA are included in this study. Twenty patients underwent EVAR under LA, and 1 patient was treated under general anaesthesia. Haemodynamics were stabilised during assessment of EVAR feasibility by CT-scan and during the procedure itself by controlled hypotension (MAP 50-60 mmHg) and moderate fluid resuscitation. RESULTS: Median procedure time was 120 min. Haemodynamics remained stable in all but 3 patients who required transfemoral balloon occlusion of the supra-renal aorta. Perioperative intubation was necessary in 5 patients because of respiratory distress (n = 3), or retroperitoneal access (n = 2). Temporary deterioration of renal function occurred in 6 patients, with 2 requiring hemofiltration. CT-scan confirmed sealing of the rAIA in all patients at discharge. 30-day mortality was 9.5% (2 deaths). In the median follow-up of 19 months, there were no deaths, but 3 endovascular re-interventions, 1 crossover femoro-femoral bypass, and 1 open surgical graft repair. DISCUSSION: Our series is the first to show that EVAR for rAIA can be safely performed under LA. This approach allows implantation of commercially available bifurcated SG and improves patient outcome.
RESUMO
We discuss the case of a young man presenting with "renal colic" whose flank pain however, turned out to be the result of renal infarction due to dissection of an accessory renal artery with fibromuscular dysplasia. The condition was diagnosed after exclusion of nephrolithiasis and work-up of new onset arterial hypertension developing in the later course. He was successfully treated by ethanol ablation (renal ethanol angioinfarction) and coiling of the accessory renal artery with resolution of hypertension in the absence of any antihypertensive medication.
Assuntos
Cólica/etiologia , Infarto/diagnóstico , Nefropatias/etiologia , Rim/irrigação sanguínea , Obstrução da Artéria Renal/diagnóstico , Adulto , Algoritmos , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/terapia , Aortografia , Cólica/terapia , Diagnóstico Diferencial , Embolização Terapêutica , Displasia Fibromuscular/diagnóstico , Displasia Fibromuscular/terapia , Humanos , Infarto/terapia , Nefropatias/terapia , Masculino , Artéria Renal/anormalidades , Obstrução da Artéria Renal/terapia , Tomografia Computadorizada por Raios XRESUMO
A 75-year old woman with essential hypertension presented two days after the onset of a sudden and strong thoracic pain. The pain did neither increase during breathing nor decrease after the ingestion of nitroglycerine, and could not be triggered by physical manipulation of the thoracic wall. Electrocardiogram showed a left bundle branch block, chest X-ray showed a widened upper mediastinum. Rupture/dissection of an aberrant right subclavian artery (a. lusoria) could be diagnosed by computed tomography. Successful implantation of an endovascular stent-graft was carried out. Evaluation of (sub)acute thoracic pain should include two-plane chest X-ray and, in case of a widened mediastinum, further investigation by computed tomography. In case of highly suspected rupture/dissection of an intrathoracic artery, a specific imaging procedure such as computed tomography is crucial.
Assuntos
Aneurisma Roto/diagnóstico , Dissecção Aórtica/diagnóstico , Dor no Peito/etiologia , Artéria Subclávia , Tomografia Computadorizada por Raios X , Idoso , Dissecção Aórtica/terapia , Aneurisma Roto/terapia , Angioplastia com Balão , Bloqueio de Ramo/diagnóstico , Eletrocardiografia , Feminino , Humanos , Stents , Artéria Subclávia/anormalidadesRESUMO
Computed tomography (CT) of the abdomen is a reliable method for evaluation of spleen injuries and has the potential to exclude further abdominal injuries. Blunt and penetrating injuries of the spleen have to be managed immediately due to a high mortality rate. Two therapeutical options, conservative or operative, are currently available. In general, a hemodynamic stable patient, no further injuries of the abdominal organs or the skull as well as no history of abdominal surgery of the abdomen are prerequisites for a non-surgical therapy. Catheter-based angiography gives the possibility to diagnose and to treat injuries of blood vessels of the spleen, which were seen on the CT scans. Gunshots are relatively rare in Europe, but the mortality of such traumas is high. The present case demonstrates a patient with a penetrating gunshot trauma of the left hemiabdomen with a bleeding injury of the spleen. Due to the stable hemodynamic conditions, absence of further injuries of the abdomen or the skull and, because of previous pancreas surgery a non-surgical therapy was chosen, consisting of proximal embolisation of the splenic artery.
Assuntos
Embolização Terapêutica , Baço/lesões , Artéria Esplênica/lesões , Ferimentos por Arma de Fogo/terapia , Adulto , Angiografia , Humanos , Imageamento Tridimensional , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Baço/diagnóstico por imagem , Artéria Esplênica/diagnóstico por imagem , Tomografia Computadorizada Espiral , Ferimentos por Arma de Fogo/diagnóstico por imagemRESUMO
The therapeutical approach to diseases of the descending thoracic and abdominal aorta has dramatically changed over the last decade due to new stent-graft-based endoluminal techniques. In particular elderly patients with a variety of diseases, such as ruptured and asymptomatic aneurysms, acute B-dissections, acute penetrating ulcers, mycotic aneurysms or traumatic aortic injuries will benefit from these minimally invasive alternatives, which can be performed under local anesthesia. As the durability of these devices is not yet proven the patients undergoing endoluminal aortic repair will need life-long clinical and imaging follow-up.
Assuntos
Aorta/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular , Stents , Idoso , Angiografia Digital , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Doenças da Aorta/diagnóstico por imagem , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/cirurgia , Seguimentos , Humanos , Estudos Multicêntricos como Assunto , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Tomografia Computadorizada por Raios XRESUMO
INTRODUCTION: acute haemodynamic changes and/or loss of abdominal muscle tone can occur during induction of general anaesthesia and may be the Achilles' tendon in endovascular aneurysm repair (EVAR) of ruptured aortoiliac aneurysms (rAIA). The purpose of this study was to evaluate the use of local anaesthesia (LA) for EVAR to overcome these limitations. METHODS: twenty-one consecutive patients with rAIA are included in this study. Twenty patients underwent EVAR under LA, and 1 patient was treated under general anaesthesia. Haemodynamics were stabilised during assessment of EVAR feasibility by CT-scan and during the procedure itself by controlled hypotension (MAP 50-60 mmHg) and moderate fluid resuscitation. RESULTS: median procedure time was 120 min. Haemodynamics remained stable in all but 3 patients who required transfemoral balloon occlusion of the supra-renal aorta. Perioperative intubation was necessary in 5 patients because of respiratory distress (n=3), or retroperitoneal access (n=2). Temporary deterioration of renal function occurred in 6 patients, with 2 requiring hemofiltration. CT-scan confirmed sealing of the rAIA in all patients at discharge. 30-day mortality was 9.5% (2 deaths). In the median follow-up of 19 months, there were no deaths, but 3 endovascularre-interventions, 1 crossover femoro-femoral bypass, and 1 open surgical graft repair. DISCUSSION: our series is the first to show that EVAR for rAIA can be safely performed under LA. This approach allows implantation of commercially available bifurcated SG and improves patient outcome.