Leopoldo Mariné

Arterial Thoracic Outlet Syndrome: A 32-year Experience

BACKGROUND Clinical manifestations of thoracic outlet syndrome (TOS) differ depending on the compromised anatomic structure. Arterial TOS is the least common (1-5% of all cases of TOS), yet the most threatening, due to the risk of limb loss. METHODS We conducted a retrospective review of consecutive patients treated for arterial TOS between January 1979 and June 2012. Medical records and diagnostic images were reviewed, and follow-up was obtained. RESULTS Nineteen procedures were performed in 18 patients for symptomatic arterial TOS. The average age was 34 years (range 16-69 years), and 12 patients were female (63.2%). Surgical indications were upper limb critical ischemia in 8 (acute in 5 cases and acute-on-chronic in 3 cases) and claudication in 11. Imaging studies revealed a subclavian aneurysm in 7 patients, stenosis in 4 patients, and 2 patients with subclavian artery occlusion. The 6 remaining cases had symptoms caused by arterial compression in dynamic studies without arterial wall damage at rest. All limbs underwent surgery with outlet decompression; in addition, 13 underwent arterial reconstruction, and 7 were treated for distal embolic complications. There were no deaths, amputations, or early reoperations; 1 patient was readmitted 2 weeks after surgery for chylothorax, which resolved with conservative measures. During a mean follow-up of 155.8±103.1 months, 1 patient underwent successful reintervention at 4 months for bypass occlusion. CONCLUSIONS Arterial TOS is an infrequent but relevant manifestation of TOS. An accurate and early diagnosis allows for timely surgery and adequate results, as shown in this group of patients.

Antegrade Hypogastric Revascularization During Endovascular Aortoiliac Aneurysm Repair: An Alternative to Bilateral Embolization

Anatomy has been the major challenge to overcome to increase safe and durable applicability of endografting for the treatment of abdominal aortic aneurysm. Bilateral iliac aneurysm preventing an appropriate distal landing zone for the endograft is a common condition and can be managed by (a) increasing the diameter of the endograft, with limitations in available sizes, (b) bilateral hypogastric embolization, accepting an increased morbidity, (c) the use of a branched device, increasing the cost and currently with limited availability, (d) combined surgical hypogastric revascularization by the retroperitoneal approach, or (e) retrograde revascularization from the ipsilateral external iliac artery using an endograft. We describe the use of widely available devices to obtain stable antegrade revascularization of one hypogastric artery during aortic endografting. We report the case of a 68-year-old man, at high risk for an open procedure, who presented with bilateral iliac aneurysm and minor aortic ectasia; no iliac landing zone was available. A regular bifurcated graft was deployed and extended into one of the external iliac arteries, preceded by ipsilateral hypogastric embolization. Through an upper extremity approach, an endograft was deployed from the remaining bifurcated graft branch into the other hypogastric artery, followed by ipsilateral external iliac occlusion. Finally a femorofemoral crossover bypass was performed. The patient recovered event free, and patency of the endograft and absence of endoleak were demonstrated on computed tomography. Minor unilateral buttock claudication resolved in 6 weeks and sexual function was preserved. This technique is a reasonable alternative to consider in the endovascular treatment of patients with bilateral iliac aneurysm, allowing preservation of pelvic perfusion, limiting cost, and using available devices.

Endovascular Treatment of Cystic Adventitial Disease of the Popliteal Artery

Cystic adventitial disease of the popliteal artery is an uncommon cause of intermittent claudication in young patients. Several treatment options are available, oriented to either drainage of the cyst and/or arterial reconstruction. Endovascular techniques have been used in exceptional cases to treat this condition, mostly balloon angioplasty and only 2 cases of stenting, with mixed to poor results. We report the case of a 36-year-old female patient with claudication who was treated with primary stenting with long-term symptomatic relief and arterial patency.

Four-Limb Acute Ischemia Induced by Ergotamine in an AIDS Patient Treated With Protease Inhibitors

A 32-year-old man infected with HIV presented to the emergency department of our hospital reporting pain, coldness, paresthesias, and cyanosis in both feet and hands. The symptoms had started 3 days before, with lower extremities claudication at 200 m, which progressed to rest pain the day of admission; it was worse on the right foot. He was on chronic antiretroviral therapy with 300 mg QID tenofovir (Viread), 300 mg BID abacavir (Ziagen), and two 200/50 mg BID lopinavir/ritonavir (Kaletra). His CD4 cell count was 245 cells/mm and his HIV viral load was 45 copies/mL. When directly interviewed, the patient remembered that he had taken a single dose of ergotamine (1 mg) for migraine 24 hours before the onset of symptoms. He denied any recent drug intake. On examination, his 4 extremities were cold, cyanotic, and pulseless (Figure 1A). Only femoral pulses were weakly palpable. Plethysmography revealed bilateral multilevel ischemia, with severe proximal disease …

Uso de endoprótesis en el tratamiento de lesiones no oclusivas del territorio iliaco

OBJETIVO: La cirugia endovascular se ha establecido como una opcion eficaz en el tratamiento de la enfermedad oclusiva ateroesclerotica de las arterias iliacas. Sin embargo, el uso de estos procedimientos para tratar otro tipo de lesiones aun no ha sido bien estudiado. Nuestro objetivo es analizar indicaciones y resultados del uso de endoprotesis en lesiones iliacas no oclusivas. MATERIAL Y METODOS: Revisamos retrospectivamente los registros de 14 pacientes consecutivos, todos hombres, 61,6 anos de edad en promedio (rango: 25-80) tratados por via endovascular entre 2001 y 2006 por lesiones iliacas no oclusivas. El estudio pre y postoperatorio incluyo tomografia computada. El procedimiento se efectuo en quirofano, utilizando un angiografo digital. Se uso acceso femoral insertando endoprotesis tubulares. RESULTADOS: En 11 pacientes se asocio embolizacion de arteria hipogastrica ipsilateral. Las patologias tratadas fueron: ocho aneurismas ateroescleroticos, 3 disecciones, 2 lesiones traumaticas y un pseudoaneurisma anastomotico. La co-morbilidad mas frecuente fue la hipertension en 43% de los casos. No hubo mortalidad operatoria. Un paciente presento un pseudoaneurisma femoral tratado con compresion. Un paciente tratado por fistula arteriovenosa traumatica a nivel iliaco resuelve su insuficiencia cardiaca, con persistencia asintomatica de minimo flujo. La estadia postoperatoria fue de 3 dias (mediana). No se presentaron otras endofugas iniciales o tardias. Durante un seguimiento promedio de 20,5 meses (rango 1 a 49), un paciente fallece por cancer y ninguno ha requerido procedimientos complementarios. CONCLUSION: El tratamiento endovascular de lesiones iliacas mediante endoprotesis es seguro y permite un resultado durable en el manejo de un amplio espectro de patologias.

Correlación de valores de TTPa con anti factor Xa para establecer rango terapéutico en tratamiento anticoagulante con heparina sódica

Background: The therapeutic range (TR) of activated partial thromboplastin time (aPTT) for unfractionated heparin (UFH) dosing was established in the 1970 decade. Since then aPTT determination has changed. Current TR may be sub or supra-therapeutic depending on the reagents of the test, and therefore, responsible for complications of therapy. Aim: To establish the TR for UFH dosing in our institution using antifactor Xa analysis as reference standard. Material and methods: After obtaining an informed consent, 43 blood samples were obtained for aPTT determination and antifactor Xa assay in 23 patients treated with intravenous UFH. Samples were processed at Emergency and Hemostasis Labs. We excluded patients receiving other anticoagulants, with thrombophilia, pregnancy or liver disease. Results: Mean aPTT values in the Hemostasis and Emergency labs were 57.1±18.9 and 56.6±18.3 seconds, respectively (p=0.77). The squared correlation coefficients between aPTT and antifactor Xa at hemostasis and emergency labs were R2 0.5 and 0.45 respectively, p<0.001. Using a linear regression analysis, therapeutic aPTT range values in our laboratory were established between 50 and 80 seconds, corresponding to antifactor Xa values of 0.3 to 0.7 IU/mL. Conclusions: According to current recommendations, validation of aPTT determination with reference techniques should be done in every institution.BACKGROUND The therapeutic range (TR) of activated partial thromboplastin time (aPTT) for unfractionated heparin (UFH) dosing was established in the 1970 decade. Since then aPTT determination has changed. Current TR may be sub or supra-therapeutic depending on the reagents of the test, and therefore, responsible for complications of therapy. AIM To establish the TR for UFH dosing in our institution using antifactor Xa analysis as reference standard. MATERIAL AND METHODS After obtaining an informed consent, 43 blood samples were obtained for aPTT determination and antifactor Xa assay in 23 patients treated with intravenous UFH. Samples were processed at Emergency and Hemostasis Labs. We excluded patients receiving other anticoagulants, with thrombophilia, pregnancy or liver disease. RESULTS Mean aPTT values in the Hemostasis and Emergency labs ​​were 57.1 ± 18.9 and 56.6 ± 18.3 seconds, respectively (p = 0.77). The squared correlation coefficients between aPTT and antifactor Xa at hemostasis and emergency labs were R2 0.5 and 0.45 respectively, p < 0.001. Using a linear regression analysis, therapeutic aPTT range values ​​in our laboratory were established between 50 and 80 seconds, corresponding to antifactor Xa values of 0.3 to 0.7 IU/mL. CONCLUSIONS According to current recommendations, validation of aPTT determination with reference techniques should be done in every institution.

Trombolisis mecánica y fármaco-mecánica en el tratamiento de trombosis venosa profunda sin respuesta clínica con tratamiento médico convencional

BACKGROUND Conventional treatment of deep vein thrombosis (DVT) is anticoagulation, bed rest and limb elevation. Proximal DVT patients with persisting edema, pain and cyanosis of extremities despite of conventional therapy may develop ischemia. Direct treatment of thrombosis becomes necessary. AIM To report our experience with mechanical trombolysis of proximal lower extremity DVT. MATERIAL AND METHODS Retrospective review of medical records of proximal DVT patients treated with thrombolysis between March 2012 and August 2015. Thirteen patients, 14 limbs, median age 34 years (22-85), 8 women, were admitted with pain and swelling of recent onset; one patient with venous gangrene. All patients initially received heparin in therapeutic doses without clinical improvement. RESULTS In all 13 cases, mechanical thrombolysis was performed using AngioJet®, and associated with single dose thrombolytic agent in 9. Additional angioplasty for residual stenosis was performed in 12 (7 stents) and IVCF were implanted in 8. All patients were subsequently anticoagulated. Early outcomes with disappearance of pain and decrease of edema, with no mortality or bleeding complications. The patient with foot gangrene required amputation. CONCLUSIONS Mechanical thrombolysis with a single dose of a thrombolytic agent is safe and effective in patients with proximal DVT with an unfavorable evolution.Background: Conventional treatment of deep vein thrombosis (DVT) is anticoagulation, bed rest and limb elevation. Proximal DVT patients with persisting edema, pain and cyanosis of extremities despite of conventional therapy may develop ischemia. Direct treatment of thrombosis becomes necessary. Aim: To report our experience with mechanical trombolysis of proximal lower extremity DVT. Material and Methods: Retrospective review of medical records of proximal DVT patients treated with thrombolysis between March 2012 and August 2015. Thirteen patients, 14 limbs, median 34 years (22-85), 8 women, were admitted with pain and swelling of recent onset; one patient with venous gangrene. All patients initially received heparin in therapeutic doses without clinical improvement. Results: In all 13 cases, mechanical thrombolysis was performed using AngioJet®, and associated with single dose thrombolytic agent in 9. Additional angioplasty for residual stenosis was performed in 12 (7 stents) and IVCF were implanted in 8. All patients were subsequently anticoagulated. Early outcomes with disappearance of pain and decrease of edema, with no mortality or bleeding complications. The patient with foot gangrene required amputation. Conclusions: Mechanical Thombolysis with a single dose of a thrombolytic agent is safe and effective in patients with proximal DVT with an unfavorable evolution.

Reparación endovascular de Aneurisma aórtico abdominal: Estudio piloto de endoprótesis Ovation. Resultados comparativos

Introduccion: Las endoprotesis actuales para tratar aneurismas aorticos (AAA) requieren introductores de alto diametro (18-25F) y se sustentan excluyendo el aneurisma, mediante la fuerza radial de stents metalicos. Objetivo: protesis Ovation™ (TriVascular, EEUU) con aquellas disponibles en el mercado. Material y Metodo: Entre Noviembre 2009 y Agosto 2010 tratamos 47 AAA. En 10 pacientes usamos Ovation™ (Grupo 1). Grupo Control (2): diez pacientes tratados contemporaneamente con endoprotesis comerciales. Ovation™ es tri-modular, de PTFE y nitinol con un stent barbado para fijacion supra-renal. Sella bajo las arterias renales mediante 2 anillos llenados con un polimero durante el implante. Usa introductor 13-15F. Usa-Philips-Allura (Best, Holanda). Comparamos: duracion del procedimiento, hospitalizacion y complicaciones. Utilizamos test de Fisher exacto y t de student no pareado. Resultados: Exito tecnico 100%. Sin diferencia entre grupos (edad, sexo, tamano AAA, riesgo ASA, laboratorio preoperatorio). Tiempo operatorio (hrs): 2,12 ± 0,7 vs. 2,0 ± 0,6 (NS). Estadia postoperatoria (hrs): 44,5 ± 10,7 vs 49,5 ± 32,0 (NS). El cuello del AAA y la permanencia en UTI fueron mas cortos en grupo 1 (p= 0,035 y 0,0451). Seguimiento (4,5-12 meses) sin eventos adversos, endofugas tipo I ni III, ni re-intervenciones. Conclusiones: Los resultados con Ovation™ a corto plazo son comparables con los de otras endoprotesis, cumpliendo con estandares de eficacia y seguridad. Ovation ™ navega por vasos pequenos, permite un despliegue preciso y sellado efectivo en cuellos > 7 mm, ampliando el tratamiento endovascular del AAA.