Reparación de aneurisma de aorta abdominal en paciente con riñón en herradura y oclusión ilíaca. ¿Es el tratamiento endovascular la única opción? / Repair of an abdominal aortic aneurysm in a patient with a horseshoe kidney and iliac occlusion. Is endovascular treatment the only option?

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Seudoaneurisma micótico de la arteria carótida interna / Mycotic pseudoaneurysm of the internal carotid artery

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Complicaciones de la arteria poplítea tras la artroplastia total de rodilla / Popliteal artery complications after total knee arthroplasty

Las complicaciones arteriales tras la artroplastia total de rodilla aparecen en el 0,25% de las intervenciones, pero su riesgo para la extremidad condiciona la necesidad de un manejo agresivo. Presentamos tres lesiones de la arteria poplítea tras dicha intervención: una trombosis, un pseudoaneurisma y una disección intimal. Los dos primeros casos se trataron con cirugía convencional y el último se manejó de manera conservadora. El resultado fue satisfactorio en los tres pacientes. Con los datos publicados consideramos necesario un diagnóstico precoz y un tratamiento agresivo ante una trombosis arterial aguda secundaria a artroplastia de rodilla, continuando con mejores resultados la cirugía de by-pass. Las técnicas intervencionistas para los pseudoaneurismas poplíteos presentan buenos resultados, aunque la falta de seguimiento a largo plazo no permite generalizar su indicación. Por último, existe un grupo de lesiones no oclusivas asintomáticas que permiten un manejo conservador(AU)

Arterial complications after total knee arthroplasty have an incidence of 0.25%, but the risk to the limb requires aggressive management. We present three cases of popliteal lesions after such surgery. One was a case of acute ischaemia due to popliteal thrombosis managed by an autologous vein by-pass. The second case consisted of a popliteal pseudoaneurysm with symptoms of knee pain and late functional impotence treated with a venous patch. The last case consisted of a non-occlusive intimal dissection managed with conservative treatment. In agreement with published data we believe that an early diagnosis and aggressive treatment of acute arterial thrombosis secondary to knee arthroplasty is necessary, surgical by-pass has the best results. Endovascular technics for popliteal pseudoaneurysm have good results, but due to the lack of long-term follow it is difficult to generalise their indication. Lastly, there is a group of non- occlusive, asymptomatic lesions which can be conservatively managed(AU)

Atrapamiento intravascular de un catéter de Swan-Ganz / No disponible

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Tratamiento endovascular de un pseudoaneurisma ilíaco postraumático: a propósito de un caso / Endovascular treament of a post-traumatic iliac pseudoaneurysm: A case report

Introducción. Los pseudoaneurismas ilíacos postraumáticos son un tipo poco frecuente de lesión arterial. Lareparación quirúrgica presenta dificultades técnicas y se asocia a una morbimortalidad que oscila entre el 10 y el 30%.La terapia endovascular tiene una morbimortalidad menor que la cirugía convencional con buenos resultados a medioplazo, por lo que es una alternativa que hay que tener en cuenta en pacientes con elevado riesgo quirúrgico o antecedentesde cirugía abdominal previa. Caso clínico. Varón de 64 años de edad con dolor lumbar irradiado a miembro inferiorizquierdo que presenta en la angiotomografía un aneurisma en la arteria ilíaca externa de morfología sacular y diámetromáximo de 10 cm. Como único antecedente de interés, refiere un traumatismo abdominal hace 20 años. La lesión seexcluyó con éxito mediante la colocación endovascular de dos stents recubiertos (Viabahn ® 8 × 10 y Advanta ® 8 × 59).El postoperatorio inmediato transcurrió sin incidencias. La angiotomografía a los seis meses muestra la exclusión adecuada,con una disminución de 6 cm del tamaño del saco aneurismático. Conclusión. Los pseudoaneurismas ilíacos postraumáticosson una patología poco frecuente. El tratamiento endovascular a este nivel tiene menor morbimortalidadque la cirugía convencional con unos resultados a medio plazo aceptables, por lo que, en el momento actual, la terapiaendovascular es una alternativa que hay que tener en cuenta en pacientes de alto riesgo o antecedentes de cirugía abdominalprevia(AU)

Introduction. Post-traumatic iliac pseudoaneurysms are a rare type of arterial injury. Surgical repair istechnically difficult and is associated to a morbidity and mortality rate that ranges between 10% and 30%.Endovascular therapy has a lower morbidity and mortality rate than conventional surgery with good medium-termoutcomes, which makes it an alternative that has to be taken into account in patients with a high surgical risk or ahistory of previous abdominal surgery. Case report. We report the case of a 64-year-old male with lower back pain thatirradiated to the lower left limb. The CT-angiography scan that was performed revealed the presence of an aneurysm inthe external iliac artery with a saccular shape and a maximum diameter of 10 cm. The only relevant past history was atraumatic injury to the abdomen 20 years earlier. The lesion was successfully excluded by endovascular placement oftwo covered stents (Viabahn® 8 × 10 and Advanta® 8 × 59). No adverse events occurred during the period immediatelyafter the operation. The CT-angiography scan at six months showed adequate exclusion, with a decrease of 6 cm in thesize of the aneurysmal sac. Conclusions. Post-traumatic iliac pseudoaneurysms are a rare pathology. Endovasculartreatment at this level has a lower morbidity and mortality rate than conventional surgery, with acceptable medium-termoutcomes. Therefore, today, endovascular therapy is an alternative that must be taken into account in patients with ahigh surgical risk or a history of previous abdominal surgery(AU)

Lesión de la arteria subclavia tras traumatismo torácico cerrado: a propósito de un caso / Lesion in the subclavian artery following closed thoracic traumatism: a case report

Introducción. Las lesiones traumáticas localizadas en la arteria subclavia son muy infrecuentes. La exposiciónquirúrgica presenta dificultades técnicas y se asocia a una morbimortalidad de entre el 5 y el 30%. El tratamientoendovascular es una alternativa a la cirugía convencional que puede ser aplicada en pacientes estables con un determinadotipo de lesiones, lo que representa aproximadamente el 50% de los casos. Caso clínico. Varón de 20 años politraumatizadocon sección transversal completa en el origen de la arteria subclavia derecha tras traumatismo torácico cerrado.Se reparó mediante cirugía abierta con la realización de un bypass entre el tronco innominado y la arteria subclavia;se empleó como abordaje una esternotomía media con una prolongación supraclavicular. La evolución postoperatoriafue favorable y no presentó secuelas vasculares ni neurológicas en dicho miembro. Conclusión. Las secciones transversalescompletas suponen una limitación en la terapia endovascular, por lo que la cirugía convencional sigue siendo elmejor tratamiento para este tipo de lesiones

Introduction. Traumatic injuries located in the subclavian artery are very infrequent. Operative exposure istechnically difficult and is associated to a morbidity and mortality rate of between 5% and 30%. Endovascular treatmentis an alternative to conventional surgery that can be applied in stable patients with a particular type of lesions, whichaccounts for around 50% of cases. Case report. A 20-year-old male with multiple traumatisms and complete transversalsectioning at the origin of the right subclavian artery following closed thoracic traumatic injury. It was repaired bymeans of open surgery with a bypass between the innominate artery and the subclavian artery; a median sternotomywith supraclavicular prolongation was used as the approach. Post-operative progression was favourable and the patientdid not present any vascular or neurological sequelae in the limb involved. Conclusions. Complete transversal sectionsrepresent a limitation for endovascular therapy, and conventional surgery therefore continues to be the best treatment for this kind of injuries (AU)

Cirugía del aneurisma de aorta abdominal en pacientes octogenarios / Surgical treatment of abdominal aortic aneurysm in octogenarian patients

Objetivo: Analizar las características de los pacientes octogenarios sometidos a cirugía convencional y valorar la experiencia y los resultados de este tipo de tratamiento en nuestro servicio. Pacientes y métodos. Estudio retrospectivo de todos los pacientes consecutivos mayores de 80 años con un aneurisma de aorta abdominal (AAA) tratados de forma quirúrgica convencional desde enero de 1993 hasta diciembre de 2006 en nuestro centro. Resultados. Se incluyeron 45 pacientes con una edad media de 83,4 +/- 3,4 años. La mayoría eran varones (40 pacientes, 88,9%). Veintiocho pacientes (62,2%) fueron clasificados como ASA (Asociación Americana de Anestesiología) IV. La media del diámetro de los AAA fue de 6,9 +/- 2 cm. Se trató de forma urgente a 29 pacientes (64,4), de los cuales, en 22 casos, la indicación fue por rotura aneurismática. Destacó entre los factores de riesgo cardiovascular la hipertensión, presente en 30 pacientes (66,7%). Treinta y un pacientes (68,9%) padecían alguna cardiopatía. La mortalidad operatoria fue del 6,3% en los pacientes tratados de forma electiva, mientras que en los tratados de forma urgente la mortalidad ascendió a 41,4% (p=0,01). La presencia de ictus previo (11,1%) a la intervención quirúrgica se asoció a mayor mortalidad (p=0,02). Conclusiones. Basándonos en estos resultados, el tratamiento quirúrgico electivo de los pacientes octogenarios parece justificado en nuestro centro cuando no existe una opción terapéutica alternativa menos invasiva

Aims. To analyse the characteristics of octogenaria patients submitted to conventional surgery and to evaluate our experience and the outcomes of this type of treatment in our department. Patients and methods. We conducted a retrospective study of all the consecutive patients over 80 years of age with an abdominal aortic aneurysm (AAA)who were treated using conventional surgery at our health centre beween January 1993 and December 2006. Results. The sample was made up of 45 patients, with a mean age of 83.4 +/- 3.4 years, most of whom were males (40 patients, 88.9%). Twenty-eight patiens (62.2%) were classified as ASA (American Society of Anaesthesiology) IV. The mean diameter of the AAA was 6.9 +/- 2 cm. The aneurysm was treated urgently in 29 patients (64.4%), and in 22 of these cases the indication was due to aneurismal rupture. The most common cardiovascular risk factor was hypertension, which was present in 30 patients (66.7%). Thirty-one patients (68.9%) had some kind of heart disease. The operative mortality rate was6.3% in patients treated electively, whereas among those treated urgently the mortality rate rose to 41.4% (p=0.01). The presence of a stroke (11.1%) prior to the surgical intervention is associated to a higher mortality rate (p=0.01). The presence of a stroke (11.1%) prior to the surgical intervention is associated to a higher mortality rate (p=0.02). Conclusions. On the basis of these results, elective surgical treatment in octogenarian patients seems to be justified in our health centre when no other less invansive therapeutic alternative is available

Disección y trombosis de arteria iliaca común secundaria a traumatismo abdominal cerrado: tratamiento endovascular / Dissection and thrombosis of the common iliac artery secondary to closed abdominal traumatic injury: endovascular treatment

Introducción. Las lesiones traumáticas de las arterias iliacas son poco frecuentes, constituyen alrededor del 10% de todas las lesiones vasculares abdominales y se deben en su mayoría a traumatismos penetrantes. La mayoría de los casos documentados de lesiones iliacas por traumatismos contusos fueron tratados mediante técnicas convencionales. Presentamos un caso de lesión traumática cerrada de la arteria iliaca común resuelta mediante un abordaje mínimamente invasivo. Caso clínico. Varón de 38 años que presenta traumatismo abdominal cerrado tras accidente laboral, con lesiones óseas y abdominales asociadas a disección y trombosis de la arteria iliaca común derecha, que se trata mediante trombectomía e implantación de un stent autoexpandible de nitinol. El control realizado con eco-Doppler a los tres meses demostró la permeabilidad del stent y el eje iliaco tratado. Conclusión. El tratamiento endovascular de lesiones arteriales iliacas secundarias a traumatismos cerrados es una opción válida y debe considerarse particularmente en pacientes politraumatizados con múltiples lesiones, en los que la cirugía abierta se asocia a elevadas tasas de morbimortalidad

Introduction. Traumatic injuries to the iliac arteries are infrequent; they account for about 10% of all injuries to abdominal blood vessels and are mainly due to stab wounds. Most of the cases of iliac injury caused by blunt trauma that have been described to date were treated using conventional techniques. We report a case of closed traumatic injury to the common iliac artery that was resolved by a minimally invasive approach. Case report. We describe the case of a 38-year-old male who presented a closed abdominal trauma as a result of a work accident, with bone and abdominal injuries associated to dissection and thrombosis of the right common iliac artery, which was treated by means of a thrombectomy and placement of a self-expanding nitinol stent. A control Doppler ultrasound scan performed at three months showed that the stent was patent and the iliac axis had been treated. Conclusions. Endovascular treatment of injuries to the iliac artery secondary to closed trauma is a valid option and should be taken into account particularly in the case of patients with multiple traumatic injuries, in whom open surgery is associated to high morbidity and mortality rates

Traumatismos arteriales abdominales. Diagnóstico y tratamiento actual / Traumatic injuries to the abdominal arteries. Their diagnosis and current treatment

Introducción. Los traumatismos arteriales abdominales continúan siendo una patología con elevada morbimortalidad, a pesar de la introducción de nuevas tecnologías tanto en su diagnóstico como en su tratamiento. Objetivos. Exponer los diferentes métodos diagnósticos que se usan en la actualidad, valorar sus resultados y realizar un algoritmo de manejo de estas lesiones. Desarrollo. Se describe el tratamiento quirúrgico clásico y el tratamiento endovascular, con mención tanto de los aspectos técnicos como de los resultados obtenidos. Conclusión. El tratamiento quirúrgico sigue siendo el tratamiento de elección para la mayoría de lesiones vasculares abdominales, aunque los nuevos tratamientos endovasculares incrementan las posibilidades terapéuticas

Introduction. Traumatic injuries to abdominal arteries continue to be a pathology with a high rate of morbidity and mortality, despite the introduction of new technologies both in their diagnosis and their treatment. Aims. To outline the different diagnostic methods currently in use, to evaluate their outcomes and to produce a management algorithm for these lesions. Development. Both the classical surgical and endovascular treatments are described, and their technical aspects and outcomes are discussed. Conclusions. Surgical treatment remains the preferred treatment for most injuries to blood vessels in the abdomen, although the latest endovascular treatments increase the therapeutic possibilities

The end-to-side peripheral nerve repair. Functional and morphometric study using the peroneal nerve of rats.

Morphologic and functional recovery following an end-to-side repair was studied comparatively with conventional end-to-end repair in a model of peroneal nerve lesion in rats. Twenty-eight rats were used and divided into four groups according to the reparative procedure following nerve division: (1) nerve stumps buried into neighboring muscles (n = 8); (2) conventional end-to-end repair (n = 7); (3) end-to-side repair onto the tibial nerve (n = 8); (4) sham operation (n = 5). The sciatic functional index (SFI) was evaluated at weekly intervals for 8 weeks, the peroneal nerve being resected on the 56th day for histologic and morphometric studies. The SFI progressively improved in Groups 2 (-16.9) and 3 (-22.7), although it did not reach normal values (around -8). The average nerve fiber density increased to normal values in both Groups 2 and 3, although accompanied by a marked decrease of average minimal and maximal nerve fiber diameter, myelin sheath area and G quotient. The differences between Groups 2 and 3 or Groups 2 and 4 were not significant. We conclude that, although resulting in significant morphologic and functional recovery, end-to-side repair is not as efficient as the conventional end-to-end nerve repair. However, end-to-side repair has a potential for application in selected cases in humans.

Semiautomated ultrasonographic measurement of fetal nuchal translucency using a computer software tool.

Nuchal translucency (NT) thickness measurement has been recently proposed as a part of routine ultrasound scanning during the late first trimester of pregnancy, for the early screening of chromosomal abnormalities. Manual determination of NT is currently performed using electronic calipers placed by the operator in the middle of two echogenic lines displayed on the screen. Therefore, intraobserver and interobserver repeatability can be questioned. This paper presents a software tool that has been developed for achieving this goal in a semiautomatic way, improving the reproducibility of the method.

Emerging state policy trends related to medical group practice: Alpha Center.

This article examines how state health care policy affects new ventures involving medical group practices. It will review briefly traditional state authorities related to the health care sector in general and physician organizations in particular. The article will then discuss state policies related to a range of physician organizations, including those aligned with larger provider systems. State policies related to physician organization in the competitive marketplace include several topics: referral practices, tax exemption, corporate practice of medicine, and antitrust and insurance regulation. Finally, it will discuss the implications of these trends for future enterprises undertaken by medical group practices.

Impact of purchasing strategies on local health care systems.

Efforts to control health care costs increasingly rely on purchasers to seek the best value for their investment. In this examination of purchasing strategies in fifteen communities, most purchasers employed traditional strategies to reduce their direct costs, such as shifting costs to employees and switching from indemnity to managed care plans. Fewer purchasers--mostly large companies, public agencies, and coalitions--were using more resource-intensive strategies such as direct contracting with providers or selecting plans based on quality to improve value or efficiency. Although both sets of strategies might help to reduce costs, they are not yet changing the delivery of health care in local communities.