M.A. de Gregorio

Guía para el diagnóstico, tratamiento y seguimiento de la tromboembolia pulmonar

La tromboembolia pulmonar (TEP) es la manifestación más grave de la enfermedad tromboembólica venosa. Hasta la década de los ochenta, tanto en el diagnóstico como en el tratamiento o el seguimiento, no hubo cambios sustanciales. Sólo desde hace poco más de una década asistimos al desarrollo de múltiples herramientas que mejoran el rendimiento diagnóstico, así como a nuevas opciones terapéuticas que pueden permitir modelos distintos de manejo de la enfermedad. La Sociedad Española de Neumología y Cirugía Torácica pretende a través de esta guía establecer unas recomendaciones actualizadas que, basándose en la evidencia científica disponible, sean útiles para el diagnóstico, tratamiento y seguimiento de la TEP.

Animal experience in the Günther Tulip retrievable inferior vena cava filter.

AbstractPurpose: To assess the retrievability of the Gunther Tulip temporary inferior vena cava filter from a technical viewpoint, and consider the histopathologic changes that occur at the anchoring site of the filter prongs to the vein endothelium in Landrace pigs. Methods: Twenty-two Gunther Tulip retrievable filters were inserted in 22 experimental Landrace pigs via the jugular vein. Device implantation time was 0, 3, 7, 12, 14, 15, 16, 20, 30, 35 and 56 days. Study subjects were divided into two groups. In one group the filter was retrieved percutaneously via the jugular vein whereas in the other group it was removed surgically. The specimens obtained (vena cava and filter) were histopathologically examined. Prior to filter retrieval, a venacavography was obtained in all cases. Degree of retrieval difficulty was rated as follows: no difficulty (N), slight (S), mild (M), high (H) and unretrievable (U). Results: Of the 22 implanted filters, 11 should have been removed percutaneously but this was impossible in three cases (U). In four cases the device was retrieved with no difficulty (N); in two cases the degree of difficulty was mild (M) and in other two it was high (H) and slight (S) respectively. Retrieval difficulties were observed after 16 days. Starting from day 20, there was evidence of fibrosis with thick intimal proliferation and total filter prong involvement, which accounts for the difficulty in retrieving the device. Conclusions: It is advisable not to exceed a filter retrieval time of 16 days in view of the fibrotic changes reported. It might be necessary to perform a larger study with more animals and with retrieval times between 14 and 20 days.

Experimental study and constitutive modelling of the passive mechanical properties of the porcine carotid artery and its relation to histological analysis: Implications in animal cardiovascular device trials

The present study focusses on the determination, comparison and constitutive modelling of the passive mechanical properties of the swine carotid artery over very long stretches in both proximal and distal regions. Special attention is paid to the histological and mechanical variations of these properties depending on the proximity to the heart. The results can have clinical relevance, especially in the research field of intravascular device design. Before the final clinical trials on humans, research in the vascular area is conducted on animal models, swine being the most common due to the similarities between the human and swine cardiovascular systems as well as the fact that the swine size is suitable for testing devices, in this case endovascular carotid systems. The design of devices usually involves numerical techniques, and an important feature is the appropriate modelling of the mechanical properties of the vessel. Fourteen carotid swine arteries were harvested just after sacrifice and cyclic uniaxial tension tests in longitudinal and circumferential directions were performed for distal and proximal samples. The stress-stretch curves obtained were fitted with a hyperelastic anisotropic model. Stress-free configuration states were also analyzed. Finally, human and swine samples were processed in a histological laboratory and images were used to quantify their microconstituents. The statistical analysis revealed significant differences between the mechanical behavior of proximal and distal locations in the circumferential but not in the longitudinal direction. Circumferential direction samples show clear differences both in residual stretches and tensile curves between the two locations, while the features of longitudinal specimens are independent of the axial position. The statistical analysis provides significant evidence of changes depending on the position of the sample, mainly in elastin and SMC quantification.

Radiation myelopathy in over-irradiated patients: MR imaging findings

Abstract. The objective of this work is to report the MRI findings in patients with radiation myelopathy due to accidental local over-irradiation syndrome. Eight patients (seven males and one female) were suffering from over-irradiation syndrome as a result of treatments from a malfunctioning linear electron accelerator. The mean accidental estimated dose was 136 Gy delivered to the “open-neck” (seven cases) and to the thoracic wall (one case), during a mean of 5.4 sessions (range 1–9 sessions). Paresthesia and weakness in the upper extremities were the earliest symptoms (87.5 %), with evolution to paralysis in all patients. No patient is alive (mean survival time 64 days). In all cases MRI was negative for neurologic lesions in the acute phase ( < 90 days from irradiation; Radiation Therapy Oncology Group scoring system). Late signs of radiation myelitis manifested as high-intensity signals on T2-weighted images in three patients, and as Gd-DTPA enhancement of T1-weighted images in one case. Autopsies performed on four patients who died in acute phase showed morphologic alterations in white matter: edema in 75 %, and necrosis and glial reaction as well as obliterative vasculitis in all cases. In cases of over-irradiation, MRI may be normal in acute phase even if the patients have severe neurologic deficit, as positive MRI findings appear only in delayed radiation myelitis.

Subcutaneous ports in the radiology suite: an effective and safe procedure for care in cancer patients

The purpose of the study is to present our experience and compare the results of the three types of ports used as a central venous access and performed in the radiology suite. Between March 1989 and November 1993 we performed 288 implantations (100 Implantofix Seldinger, 100 plastic Hickman port, and 88 stainless steel Port-a-cath) for chemotherapeutic treatment on the same number of patients diagnosed as having cancer. In all cases access was obtained via a subclavian vein (the left one in 185 cases and the right one in 103). All the system ports were implanted in the radiology suite. In all cases the procedure was successfully performed. Complications occurred in 26.3% of cases, most notably thrombosis in 13 cases (4.5%) and infection in 12 cases (4.1%). Duration of the port systems placement varied between 17 and 1467 days (a mean of 315 days). A total of 133 systems have been removed to date, 80 (60.%) due to termination of chemotherapy, and 53(40%) for treatment of complications. Significant differences (complications and port duration time) were not observed between the three types of reservoir used. Subcutaneous ports are safe, comfortable, and effective devices for central venous access.

Percutaneous treatment of intrabdominal abscess: urokinase versus saline serum in 100 cases using two surgical scoring systems in a randomized trial

The purpose of this study was to assess whether regular instillation of urokinase during abscess drainage leads to an improved outcome compared to saline irrigation alone. One hundred patients referred for image-guided abdominal abscess drainage were randomized between thrice daily urokinase instillation or saline irrigation alone. At the end of the study, patient medical records were reviewed to determine drainage, study group, Altona (PIA II) and Mannheim (MPI) scoring, duration of drainage, procedure-related complications, hospital stay duration, and clinical outcome. The technical success rate of the percutaneous abscess drainage was 100%. The success or failure of abscess remission did not differ significantly between groups (success rate of 91.5% in the urokinase group vs. 88.8% in the saline group; failure rate was of 8.5 vs. 21.2%, respectively); however, days of drainage, main hospital stay, and overall costs were significantly reduced in patients treated with urokinase compared to the control group (P < 0.05). No adverse effects from urokinase were observed. Surgical scores were a useful homogeneity factor, and MPI showed a good correlation with prognosis, while PIA results did not have a significant correlation. For drainage of complex abscesses (loculations, hemorrhage, viscous material), fibrinolytics safely accelerate drainage and recovery, reducing the length of the hospital stay and, therefore, the total cost.

Endovascular Treatment of Massive Hemoptysis by Bronchial Artery Embolization: Short-Term and Long-Term Follow-Up Over a 15-Year Period

OBJECTIVE To present our experience of using arterial embolization for the endovascular treatment of massive hemoptysis along with the results of follow-up over a 15-year period. PATIENTS AND METHODS A total of 401 patients with hemoptysis were referred to the minimally invasive surgery unit of the Hospital Universitario Lozano Blesa de Zaragoza between April 1989 and September 2004 for diagnosis and possible endovascular treatment. Of those patients, 314 met criteria for massive hemoptysis and treatment was attempted using embolization in 287 (91.4%). The most common cause of hemoptysis was bronchiectasis (n=99, 31.5%), followed by lesions due to tuberculosis (n=57, 18.1%) and chronic bronchitis (n=47, 14.9%). RESULTS Angiography of the bronchial arteries provided evidence to account for the hemoptysis in 287 patients (91.4%). The affected arteries were satisfactorily embolized in 281 (97.9%). Endovascular treatment was clinically successful in 256 of those patients (91.1%). Embolization had to be repeated during the hospital stay in 19 patients (6.7%) and was effective in 52.6% of those cases. The 6 patients in whom embolization was not satisfactory underwent thoracotomy. The mean follow-up in 201 patients (71.5%) was 2372.5 days (range, 61-5475 days). Eighty patients (28.4%) were lost to follow-up for various reasons and at different points. Recurrence of hemoptysis occurred on 1 or more occasions in 45 patients (22.3%) but only 21 (10.4%) required repeat embolization. Minor complications that did not require treatment were observed in 88 patients (28.0%). CONCLUSIONS Embolization of bronchial arteries is a nonsurgical treatment that is safe and effective in patients with massive hemoptysis.

Fragmentación mecánica y fibrinólisis intrapulmonar en el tratamiento del tromboembolismo pulmonar masivo con repercusión hemodinámica

Objetivos Evaluar la eficacia y seguridad de la fragmen-tacion mecanica asociada a trombolisis intrapulmonar en el tromboembolismo pulmonar (TEP) masivo con alteracion hemodinamica. Material y metodo Un total de 51 pacientes diagnosti-cados de TEP masivo con repercusion hemodinamica. Se in-cluyeron bajo este epigrafe pacientes con TEP agudo con un indice de Miller superior a 0,50 y una presion medida en la arteria pulmonar principal superior 30 mmHg. Cuadro cli-nico de inicio: 19 shock, 6 sincope y 26 disnea intensa de reposo. La saturacion de O 2 medida por pulsioximetria: 71,4%. Presion media en arteria pulmonar: 46,1 mmHg. Se realizo fragmentacion de los tromboembolos mas importan-tes. Durante la fragmentacion se administro un bolo de fi-brinolitico. A traves del cateter se administro infusion de fibrinolitico. El seguimiento se realizo con valoracion clini-ca, gammagrafica pulmonar y ecocardiografica. Resultados Tras la fragmentacion y administracion del bolo de trombolitico se observo mejoria clinica en 49 pacien-tes (97,2%). La presion media postratamiento mecanico y farmacologico fue de 24,1 mmHg. Exito tecnico del 100%. Conclusiones Los datos aportados avalan la eficacia y se-guridad de la fragmentacion mecanica y trombolisis farma-cologica en el tratamiento del TEP masivo con afectacion hemodinamica, mejorando la sintomatologia y disminuyen-do la presion arterial pulmonar.

Seguimiento clínico y por medios de imagen a largo plazo de los filtros de vena cava inferior. Estudio transversal

Hemos realizado un estudio transversal con el fin de evaluar los hallazgos morfologicos, incidencias y complicaciones observadas en 77 filtros de vena cava inferior implantados en 75 pacientes desde abril de 1990 hasta enero de 1994. El tiempo de seguimiento de los pacientes oscilo entre los 3 y los 61 meses (media, 38,5 meses), realizando encuesta telefonica, evaluacion clinica, iliocavografia y, en algunos casos, ecografia-Doppler y tomografia computarizada (TC). Los hallazgos observados demostraron trombosis de vena cava en el 38% de los casos, edemas en EE1I en el 63,4% de los casos, angulacion > 15° en 8 pacientes, defecto de apertura en 4 pacientes, fibrosis de vena cava con estenosis en 2 casos y perforacion de vena cava inferior en 3 pacientes. Segun nuestro estudio si bien la incidencia de la trombosis de VCI posfiltro es mas alta que la sospechada habitualmente, la trascendencia clinica resulta irrelevante.

La puncion aspirativa transtoracica (PAT) como metodo de diagnostico en las enfermedades pulmonares

Se presenta nuestra experiencia en la puncion aspirativa transtoracica (PAT) con aguja fina tipo Franseen. Se han realizado 247 punciones en pacientes con diversa patologia pulmonar, con un indice de positividad del 81,7%. Se comentan los resultados, resenando las indicaciones, contraindicaciones mas importantes asi como las principales complicaciones.