9 Contents EDITORIAL International cooperation between vascular surgery programs to optimize education in the United States and Latin America: the time is right Luis R. Leon Jr. - Miguel F. Montero-Baker 11 ORIGINALS High Flow Iatrogenic Arteriovenous Fistula after Brachial Artery Puncture for Iliac Intervention Xiaoyi Teng, MD, Mireille A Moise, MD, Lisa Mican, et al. 15 Aortic athero-thrombotic formation that morphologically and clinically mimics an Aortic sarcoma. Ortiz, I.; Llasat N1. Riambau, V. 19 Intraoperatory Conic Beam Tomography (O-ARMTM) and Navigation assistance to Percutaneous Transgluteal Type II endoleak embolization: clinical and technical report. NJ. Mosquera, J. Castro. 24 Uterine arterio-venous malformation combined with aortic coarctation in a pregnant lady. Endovascular therapy and histerectomy. Case Report and literatura review. Dr. Jesús García Pérez, Dr. Jorge Arellano Sotelo, et al. 31 Pseudoaneurisma de arteria peronea asociado a fistula arteriovenosa: Tratamiento endovascular Dr. Diego López García 44 CONGRESS CALENDARY 48 The information and opinions expressed in the articles are exclusively those of the authors who are solely responsible of their contents. Técnicas Endovasculares is edited 3 times a year. Copyright NEWS FROM THE INDUSTRY INSTRUCTIONS FOR THE AUTOR No part of the articles of this publication may be reproduced without the prior written permission of the editor. SUBSCRIPTION FORM 09 62
11 Luis R Leon Jr. Miguel F Montero-Baker Editorial Dr. Luis R. Leon Jr. Dr. Miguel F. Montero-Baker 11
12 Luis R Leon Jr. Miguel F Montero-Baker Editorial A sad reality of most Latin American developing countries is caused the model by which most US-based endovascular companies have attempted to engage the market: the distributorship model. This complex model acts as a safety-net for large companies, since the local distributor assumes most of the risk involved in developing the business in uncharted seas; the unfortunate repercussion is the resulting ridiculous product overpricing (i.e. a angioplasty balloon in the US may cost $US 200, whereas in an emerging market the same product may be as high as $US 1,500). Due to the latter, vascular surgical interventions remain by large, open complex interventions, which, in many occasions, are what patients need, but in many other instances, these open interventions prove to be too invasive for patients that are often frail and in very poor medical condition. Patients then, if financially able, are tasked with finding a practitioner abroad that is capable and willing to perform the endovascular procedure needed, with ensuing multiple financial and logistic hurdles to overcome. Or the practitioner is asked to travel to a Latin country to perform this intervention, which is often complicated by similar financial and logistic hurdles, but also fails to overcome the availability restriction of certain endovascular tools to perform these procedures. This is an important component of the ever growing, unsupervised and non-regulated medical tourism. In the US, costs are less of a problem in terms of our ability to obtain medical devices such stents, balloons or catheters. In fact, this country has experienced a technological explosion during the last years, currently performing most vascular interventions through minimally invasive techniques. In a typical vascular practice, it is not uncommon to hear that a practitioner performs over 80% of his/her entire caseload through endovascular, minimally invasive methods. In our practice, the only areas in vascular surgery still dominated by open interventions are carotid and hemodialysis access interventions. Such a practice requires the use of devices and tools that are often quite expensive. Our restrictions are more set by the Food and Drug Administration and the speed at which new devices and technologies are approved for use in this country. Far from being an ideal situation, this has also caused tremendous implications for surgical training. The number of open cases that are performed nowadays in the US has dramatically dropped to alarming levels, making surgical training in standard procedures such as an open repair of an abdominal aortic aneurysm or a femoropedal arterial bypass a rare event. In current vascular practice, there is a real and strong need for proficiency with open procedures. Endovascular interventions have not completely replaced open procedures, and in my opinion we are far from this hypothetical situation. Therefore, graduates from current surgical training programs are in a disadvantageous position when joining established surgical practices. 12
13 Luis R Leon Jr. Miguel F Montero-Baker Editorial This discrepancy in access to resources has enormous implications on vascular surgery training, while creating an evident need for advanced training in peripheral interventions and vascular surgery education in Latin American countries. A surgeon is ultimately the sum of his or her cumulative operative experience, whether as the operating surgeon or assistant surgeon. Therefore it is imperative to utilize any possible opportunity to maximize this experience. Several alternatives for a solution have been sought. For instance, conducting surgical tutorials via videoconferencing or telemedicine undertaking at remote hospitals has been suggested, with positive results. For surgeons however, the hands-on experience is irreplaceable. We herein propose to incorporate away rotations overseas, in an exchange fashion between trainees in the US and those in Latin countries, for a number of months in order to improve the experience of US trainees in open vascular procedures and the endovascular experience of physicians overseas. As vascular practitioners in the US of Latino origin, our mission must be to take our strength in education and knowledge to those in need internationally. Guided by the belief that unnecessary amputations increase mortality and have a drastic negative economic impact, proper education and training will greatly improve the lives of the patients, their families and the communities in which they live. This could be accomplished by training and mentoring leading physicians and their team of healthcare providers. The ultimate goal is to create a network of physicians who can exchange ideas, new technologies and rely on each other as resource for vascular care. There are several examples of similar educational vascular surgical programs between the US and foreign countries, such as for instance China, that have been recently instituted, with enormous success. We must direct our efforts to the implementation of similar exchange programs between our region and the US. This will require significant dedication of time and financial resources. Fortunately, the recent economic growth of several Latin American countries has attracted the attention of several vascular device companies, and they have expressed their interest in supporting our mission. We have contacted several industry company officers as well as vascular surgery opinion leaders in both the US and Latin America in order for this to happen, and the level of interest is quite high. We believe that this is a project that has an enormous potential to change vascular training and to impact positively the care of vascular patients worldwide. The potential positive effects on vascular surgery education and care are limitless. This process would test the trainee s individual resilience and ability to adapt to new 13
14 Luis R Leon Jr. Miguel F Montero-Baker Editorial and sometimes strange-seeming situations, which could prove to be a major determinant in whether the future surgeon would thrive in his or her place of employment. This could have the benefit of producing surgeons who can work comfortably in any setting. Their surgical volume experience will be for sure enriched. Several professional networks of vascular practitioners would be created, which would serve as a constant source of future consulting. Several caveats to our proposal could be cited. For instance, the negative effects of social displacement, insufficient means to assert operative skills and quality of overseas faculty, language barriers and/or the potentially unsafe situation of some places in Latin America. This must be balanced against the positive results cited above. Away rotations from main campuses within the US have been the mainstay of training in this country. Globalization mandates at least to explore this possibility in this time of uncertainty in vascular surgery training. Our position in the vascular map and the timing is ideal. This is an opportunity that we cannot let pass by. Luis R Leon Jr., 1-5 Miguel F Montero-Baker1-2, 4-5 University of Arizona Health Science Center, Tucson, Arizona 1 Vascular and Endovascular Surgery Section - Tucson Medical Center, Tucson, Arizona 2 Arizona College of Osteopathic Medicine, Midwestern University, Phoenix, Arizona 3 Pima Heart Physicians - Vascular and Endovascular Surgery Section 4 Pima Vascular PC 5 14
15 Xiaoyi Teng, MD, Mireille A Moise, MD, Lisa Mican, et al. Fistula arteriovenosa yatrogénica de alto flujo secundaria a una punción braquial para intervencionisoo ilíaco. ORIGINALES Fistula arteriovenosa yatrogénica de alto flujo secundaria a una punción braquial para intervencionisoo ilíaco. High Flow Iatrogenic Arteriovenous Fistula after Brachial Artery Puncture for Iliac Intervention Xiaoyi Teng, MD, a Mireille A Moise, MD, b Lisa Mican, RVT, a Javier A Alvarez- Tostado, MD a From the Department of Vascular Surgery, Marymount Hospital, Cleveland Clinic,a and the Department of Vascular Surgery, Metrohealth Medical Center.b Javier A Alvarez-Tostado, MD, Department of Vascular Surgery, Marymount Hospital, Heart and Vascular Institute, Cleveland Clinic McCracken Road Suite 351, Garfield Hts., Ohio Tel Fax Resumen La arteria humeral ha sido establecida como un buen acceso para numerosas intervenciones endovasculars periféricas. Las complicaciones relacionadas con el acceso percutáeno braquial and sido escasamente reportadas en la literature. Informamos de un caso clínico con la presencia de una gran fistula arteriovenosa secundaria al abordaje arterial para una intervención ilíaca endovascular. Abstract: The brachial artery has been established as an important access site for a number of peripheral endovascular interventions. Complications from brachial percutaneous accesses have been sparsely reported in the literature. In this report, we present a case of a large, high flow brachial arteriovenous fistula secondary to sheath access for endovascular iliac intervention. Introduction The brachial artery has been established as an important access site for a number of peripheral endovascular interventions, as well as coronary and neurological interventions. (1,2) It has given interventionalists increased capacity and flexibility in the treatment of complex vascular problems and inaccessible vasculature. Complications from brachial percutaneous accesses have, however, been sparsely reported in the literature. Here we present a case of a large, high flow arteriovenous fistula (AVF) formation following sheath placement for arterial access for thrombolysis and subsequent intervention. Case Report: A 63-year-old male with a past medical history significant for hyperlipidemia, severe hypertension and heavy tobacco use presented to our department
16 Xiaoyi Teng, MD, Mireille A Moise, MD, Lisa Mican, et al. Fistula arteriovenosa yatrogénica de alto flujo secundaria a una punción braquial para intervencionisoo ilíaco. ORIGINALES Figure 1. Arteriovenous fistula duplex showing large fistula with high flow. for follow up after endovascular intervention for the treatment of acute ischemia of his left lower extremity. Three years prior, the patient was successfully treated with catheter directed thrombolysis and subsequent percutaneous angioplasty with stent placement in the left common and external iliac arteries. Left brachial access was obtained during his initial thrombolysis, and a 6-French sheath was placed without complications, over the point of maximal pulsation one finger breadth above the antecubital crease. The patient underwent a total of 48 hours of thrombolysis followed by angioplasty and left common and external 16 iliac stent placement. The patient tolerated all procedures well during his hospitalization, and his initial post-operative follow up was uneventful. The patient presented for follow up again after two years without any specific complaints. At that time, a palpable thrill was felt slightly proximal to his left antecubital fossa over the initial brachial access puncture site. The patient had no pain, edema or symptoms of steal syndrome in the left upper extremity. Radial pulses were 2+ bilaterally without significant difference between the two extremities. He denied any symptoms suggestive of heart ischemia or
17 Xiaoyi Teng, MD, Mireille A Moise, MD, Lisa Mican, et al. Fistula arteriovenosa yatrogénica de alto flujo secundaria a una punción braquial para intervencionisoo ilíaco. ORIGINALES Duplex ultrasound of the left upper extremity was performed which revealed a large arteriovenous fistula between the brachial artery and one of the brachial veins. The fistula was located approximately 2cm proximal to the brachial artery bifurcation. Flow within the arteriovenous fistula was measured using duplex and estimated to be 1091ml/min. (Figure 1) As stated above; the patient did not have systemic or local symptoms related to this fistula. However, due to the high flow as well as the low probability of spontaneous resolution, surgical repair was planned. The patient underwent open repair of the fistula, and was found to have a large, well-formed arteriovenous fistula approximately 5mm in diameter and almost 10mm in length. The affected brachial vein was located medial and anterior to the brachial artery. After proximal and distal control of both vessels was gained, the fistula was clamped and transected. Both the artery and the vein were both primarily repaired with 6-0 Prolene. (Figure 2) Subsequent follow up have been unremarkable with no sequelae from the repair up to 21 months after his surgical procedure. Duplex ultrasound revealed successful repair with no evidence of complications. Discussion: Iatrogenic injuries including occlusion, thrombosis and pseudoaneurysm formation have all been reported in the past decade as the usage of the brachial artery as an access site for vascular interventions has increased. In the coronary literature, the local complications have been reported to be approximately 0.4-3%, (3,4) with thrombosis of the brachial artery as the most reported complication. These percentages increase in cases of larger sheath size (7%) or in patients with smaller vessel sizes such as women (1,2,3). One notable peri-operative risk factor for injury included increased sheath length of >10cm for interventions. (2) 17 Figure 2. Operative findings and surgical repair.
18 Xiaoyi Teng, MD, Mireille A Moise, MD, Lisa Mican, et al. Fistula arteriovenosa yatrogénica de alto flujo secundaria a una punción braquial para intervencionisoo ilíaco. ORIGINALES In review of current literature, the occurrence of iatrogenic AVF formation following brachial artery puncture seem to be rare. (2,5) Most iatrogenic AVF have been reported following lower extremity puncture sites, namely the femoral artery and vein. (6) Prospective studies within the cardiac literature where all patients underwent post-operative femoral artery duplex exams document the overall incidence of AVF formation was <1%. (7,8) Most arteriovenous fistulas (90%) were asymptomatic and resolved without a surgical procedure within the first few months following intervention. The 10% that did require operative repair was usually due to large size or symptomatology, including swelling of affected limb, or in extreme cases, heart failure. Risk factors for the development of arteriovenous fistula after lower extremity punctures have included female gender and hypertension. Perioperative anticoagulation has also been attributed to an intrinsic decreased ability to thrombose small AVFs in the acute setting. (4) In our particular case, the patient had a history of hypertension and underwent thrombolysis and perioperative anticoagulation. Although the size of the sheath used was not large, it remained in place for 48 hours, making it a lengthy intervention. Operative findings showed that the affected brachial vein was located medial and anterior to the brachial artery. This particular anatomy, along with previously mentioned factors, increased the patient s risk for the development of vascular injury. Ultrasound-guided access possibly would have helped us prevent this complication. The lack of symptoms of most arteriovenous fistulas following arterial puncture often leads to spontaneous thrombosis before a diagnosis can be made. This may account for the limited amount of documentation of this complication seen within the literature. In our patient, the lack of symptoms resulted in an almost two year delay in diagnosis and repair, even though the fistula was large with high volume flow. If occurrence of brachial AVF can be inferred from the femoral literature, then even in the asymptomatic patient, the physician should carry a reasonable level of suspicion for the possibility of brachial arteriovenous fistula formation after access, especially if there are notable risk factors. References : 1. Criado FJ, Wilson EP, Abul-Khoudoud O, et al. Brachial artery catheterization to facilitate endovascular grafting of abdominal aortic aneurysm: safety and rationale. J Vasc Surg 2000;32: Alvarez-Tostado JA, Moise MA, et al. The brachial artery: a critical access for endovascular procedures. J Vasc Surg. 2009;49: Armstrong PJ, Han DC, Baxter JA, et al. Complication rates of percutaneous brachial artery access in peripheral vascular angiography. Ann Vasc Surg 2003;17: Tonnessen, BH. Iatrogenic injury from vascular access and endovascular procedures. Perspectives in Vascular Surgery and Endovascular Therapy, 2011;23(2): Khoury M, Batra S, Berg R, et al. Influence of arterial access sites and interventional procedures on vascular complications after cardiac catheterizations. Am J Surg Sep;164(3): Lazarides, MK, Tsoupanos, SS, Georgopoulos, SE, et al. Incidence and patterns of iatrogenic arterial injuries. A decade's experience. Journal of Cardiovascular Surgery, 1998; 39: Perings SF, Kelm M, Jax T, Strauer BE. A prospective study on incidence and risk factors of arteriovenous fistulae following transfemoral cardiac catheterization. Int J Cardiol. 2003;88: Ohlow MA, Secknus MA, von Korn H, et al. Incidence and outcome of femoral vascular complications among 18,165 patients undergoing cardiac catheterisation. Int J Cardiol Jun 12;135(1):66-71.
19 Ortiz, I.; Llasat N1. Riambau, V. Aortic athero-thrombotic formation that morphologically and clinically mimics an Aortic sarcoma. ORIGINALES Aortic athero-thrombotic formation that morphologically and clinically mimics an Aortic sarcoma. Aortic pseudo-sarcoma: confounding clinical and morphological findings Aortic Tumor-like lesion: endovascular solution Ortiz, I.; Llasat N 1. Riambau, V. División de Cirugía Vascular. Instituto del Tórax. 1 Enfermera quirofanista. Hospital Clínico. Universidad de Barcelona. Resumen Se presenta el caso de una mujer de 63 años de edad, con síndrome constitucional grave, claudicación intermitente de ambas extremidades inferiores y ausencia de pulsos femorales. Los estudios de imagen revelaron la presencia de una masa intraluminal que ocasinaba ocupación del 70% de la luz del segmento viscereal aórtica. Con la sospecha de angiosarcoma se sometió a biopsia endovascular y a tratamiento paliativo con stent aórtico no cubierto. Abstract We report a 63 year-old lady, with anorexia-cachexia, and asthenia syndrome, intermittent claudication, and femoral pulseless. Medical imaging revealed an intraluminal mass that let to a 70% of aortic stenosis at the visceral level. Angio-sarcoma was suspected and an endovascular biopsy and a palliative treatment with a aortic bare stent was applied. 19 Reporte Mujer de 63 años, antecedentes de interés alérgica al níquel, intolerancia a las estatinas, ciclopegicos, Hipertensa de reciente evolución que ha precisado el uso de drogas, dislipidemia, Fumadora de 2 paquetes de cigarrillos al día, Epoc, enfisema moderado, refiere que durante el otoño, después de vacunación para gripe estacional, inicia con astenia, adinamia, pérdida de peso, acompañado en una ocasión con febrícula. Además de presentar dolor abdominal inespecífico, autolimitado, con sabor fétido en la boca, claudicación de extremidades inferiores. Se le realiza angio Tc, donde se observa imagen calcificada pediculada que ocupa la luz de la aorta en su cara posterior que ocluye más del 70% de la luz(fig. 1,2); PET no capta, además de neumatosis gástrica e intestinal, a la exploración no hay pulsos femorales palpables, ante la presentación de la clínica se sospecha de síndrome constitucional por oclusión aortica a descartar sarcoma vs aterotrombosis, se le propuso tratamiento quirúrgico, sin embargo no aceptó abordaje abierto,
20 Ortiz, I.; Llasat N1. Riambau, V. Aortic athero-thrombotic formation that morphologically and clinically mimics an Aortic sarcoma. ORIGINALES por lo que se programó intervención endovascular, por vía percutánea a través de acceso femoral izquierdo, se practicó biopsias con forceps miocárdicos de material que obstruía la luz de la aorta, se enviaron restos a estudio histopatológico, la angioplastia se hizo con Stent aórtico E XL (Jotec,Hechingen Germany),(fig.3,4), previa protección de ramas viscerales con balones de oclusión para evitar embolias, la arteriorrafia de la A.femoral fue con parche de colageno, por hallarse placa de ateroma que condicionaba una estenosis de más del 50% a su salida, durante el postoperatorio inmediato se exploran pulsos femorales, los cuales se encuentran palpables en ambas extremidades y tibiales posteriores, se normaliza tensión arterial inmediatamente, no precisando continuar con medicación hipotensora, sin molestias abdominales, tolera la dieta oral y deambula sin claudicación. Figura 1 y 2. Lesión ocupativa de aorta. 20 El reporte de examen anatomopatológico, describe fragmento de coloración blanquecina de 7 mm de diámetro máximo, en la tinción con hematoxilina-eosina, se observó tejido fibroso a-celular entremezclando calcificaciones y ocasionales células endoteliales periféricas. Reporte final trombo y áreas calcificadas.
21 Ortiz, I.; Llasat N1. Riambau, V. Aortic athero-thrombotic formation that morphologically and clinically mimics an Aortic sarcoma. ORIGINALES Fig. 3. angioplastia de aorta con stent E-XL. (Jotec,Hechingen Germany) Discusion Las neoplasias primarias de aorta comprometen de igual manera a la aorta torácica y a la abdominal. La mayoría son clasificadas como sarcomas, entre ellos se encuentran el sarcoma intimal de la aorta, el angiosarcoma y el sarcoma de partes blandas. Los tumores no sarcomatosos benignos son extremadamente raros y se presentan más frecuentemente en adultos jóvenes y a los niños, localizados principalmente sobre la adventicia. Los paragangliomas, forman parte del diagnostico diferencial con los tumores de pared aórtica. La mayoría de los sarcomas se originan en la íntima, manifestándose con síntomas de obstrucción vascular por estrechamiento de la luz aórtica o incluso más común con embolización aterotrombotica periférica. 1 Los síntomas del angiosarcoma primario de aorta, simulan a los de la enfermedad oclusiva aterosclerótica y el patrón radiomorfológico a menudo es inespecífico. 2 21
22 Ortiz, I.; Llasat N1. Riambau, V. Aortic athero-thrombotic formation that morphologically and clinically mimics an Aortic sarcoma. ORIGINALES Las neoplasias primarias de aorta no tienen predilección por determinado sexo y aparecen en la edad media de la vida; su tratamiento requiere la exéresis del segmento vascular comprometido y tienen, en general, un pobre pronóstico. 3 El síndrome consuntivo o constitucional se ha identificado en el Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, España con una prevalencia (aproximadamente 20 %).se caracteriza por astenia, adinamia y la pérdida involuntaria de peso con etiología orgánica, funcional e idiopática. Los tumores son las principales causas orgánicas representan aproximadamente 25 % de las causas, siguen los trastornos gastrointestinales y por último, las múltiples enfermedades crónicas cuando llegan a situaciones de máximo deterioro. Entre las causas psicosociales está la depresión y la demencia, aunque por lo general se tienen poco en cuenta al momento de la evaluación clínica en un paciente con pérdida de peso involuntaria sin aparente causa orgánica. 4 Tratamos de compartir esta experiencia en donde el diagnostico organizado, no nos condujo a la patología mas frecuente, sino al diagnostico diferencial este último, nos sirve para hacer una correcta valoración de una enfermedad con respecto a otras parecidas. Como en el caso clínico expuesto se consideró como diagnostico diferencial la patología ateroesclerótica ya que los signos y síntomas manifiestos por la frecuencia de la enfermedad, nos obligaron a realizar estudios complementarios para descartar y al mismo tiempo confirmar el diagnostico. Conclusion. El diagnóstico clínico es un arte, y sigue siendo un reto intelectual importante además de ser origen de satisfacciones en nuestra vida profesional, es la tarea fundamental de los médicos y la base para el tratamiento adecuado. No es una tarea fácil, ya que se conforma con la práctica diaria, conocimientos y sobretodo experiencia clínica. References: 1.- Higgins R, Posner MC, Moosa HH y col: Mesenteric infarction secondary to tumor emboly from primary aortic sarcoma. Cancer 1991; 68: Secondary Procedures After Infrarenal Abdominal Aortic Aneurysms Endovascular Repair With Second-Generation Endografts Michel A. Bartoli, Benjamin Thevenin, Gabrielle Sarlon, Roch Giorgi, Jean Noël Albertini, Gilles Lerussi, Alain Branchereau, Pierre-Edouard Magnan Annals of Vascular Surgery,Volume 28, Pages 490.e1 490.e4, February Primary angiosarcoma of the abdominal aorta: multi-row computed Tomography, Leopold Winter, Jan Langrehr, Enrique Lopez Hänninen, abdominal imaging August 2010, Volume 35, pp Bilbao-Garay J, Barba R, Losa-García JE, Martín H, García-de Casasola G, Castilla V, González-Anglada I, et al. Assessing clinical probability of organic disease in patients with involuntary weight loss: a simple score. Eur J Intern Med. 2002;13(4):
24 NJ. Mosquera, J. Castro, Intraoperatory Conic Beam Tomography (O-ARMTM) and Navigation assistance to Percutaneous Transgluteal Type II endoleak embolization: clinical and technical report. ORIGINALES Intraoperatory Conic Beam Tomography (O-ARMTM) and Navigation assistance to Percutaneous Transgluteal Type II endoleak embolization: clinical and technical report. NJ. Mosquera, 1 J. Castro, 2 1 Angiology and Vascular Surgery Department. Complexo Hospitalario Universitario de Ourense. Ourense. Spain. 2 Neurosurgery Department. Complexo Hospitalario Universitario de Ourense. Ourense. Spain. Corresponding author: NJ. Mosquera, Angiology and Vascular Surgery Department, Complexo Hospitalario Universitario de Ourense, 52-54, Ramon Puga St, 32005, Ourense, Spain. Abstract Image guided surgery is a general description that can be applied to any surgical procedure, referenced by images, associated with specific surgical navigation devices. There has beeen a huge development of navigation systems to guide neurosurgical procedures. This technology can also be used to assist certain endovascular procedures such as the percutaneous translumbar / transgluteal embolization we are reporting. Case report: a type II endoleak with sac diameter enlargement related to patent hypogastric and gluteal artery and no direct access options was treated with a novel intraoperative image system 24 guidance, the Conic Beam Tomography (O-ARM), to acquire preoperative study combined with Navigation system and to guide the percutaneous transgluteal retrograde puncture of this artery. After the access was granted, we performed a coil embolization of the endoleak nidus plus Onyx TM embolization of hypogastric trunk. Successfull embolization and exclusion of the endoleak and hypogastric trunk was achieved with no intra or perioperative complications. The patient was discharged 18h later with no other complication. The procedure length was 55 minutes and the retrograde access puncture, guided by navigation, was achieved at first attemp.
25 NJ. Mosquera, J. Castro, Intraoperatory Conic Beam Tomography (O-ARMTM) and Navigation assistance to Percutaneous Transgluteal Type II endoleak embolization: clinical and technical report. ORIGINALES Discusion and Conclusions: The combination of Conic Beam Intraoperative Technology and Navigation system, as we are reporting, seems to be a promising approach to direct access to aneurysm sac when a translumbar embolization is needed. This was an easy, safe and fast procedure to solve a concerning complication related to EVAR. The accuracy of this approach is great as we demonstrated with the gluteal artery puncture. Key words: EVAR, embolization, endoleak, aneurysm, navigation Introduction Image guided surgery (IGS) is a developed concept wich includes any surgical procedure, performed under image assistance, with specifically designed medical devices, combined with anatomical images obtained previously or during the procedure. IGS, when is related to Neurosurgery, is usually designed Neuronavigation or just intraoperative navigation. These navigated procedures require specific medical devices (Navigators) which provide three dimensional orientation during the procedure, based on a previous computed tomography scan(ct), magnetic resonance image (MRI) or any other available image study accurate enough to give the system the proper anatomical references of the patient 1-3. Surgical Navigation step by step. 1. Image gathering: the most usual medical image study is CT or MRI performed previously to the procedure. These images can be fused with other image studies such as PET, SPECT, etc. 2. Image transfer process from regular source (usually Hospital PACS) to a computer or Navigator. 3. Matching technique; compare previous images with patient position on the operation table. Those images must be referenced with the actual position of the patient. There are different possible techniques to obtain an optimal match between image study and real anatomy of the patient: stickers with references applied to skin; bone reference, attached to patient percuteneously (screwed to patient s bone) or facial recognition as used in craneal surgery. These references will be identified by the navigator by optical (LEDs) or magnetic sensors. 4. Proper IGS: using different surgical devices, also with references the navigator is 25 capable to identify, the previous image study, actual patient s anatomy and surgical instruments are integrated by the navigator, displaying a virtual reconstruction of the surgical device position and its relation with actual anatomy. This system produces a virtual image, this image will guide the surgical procedure. Navigation systems are widely used in Neurosurgery for spine and craneal diseases such as tumors. These disesase have two common features; they are usually deeply located in high sensible áreas, where accuracy is critical, and they are also located in relativelly fix position in terms of anatomy. When craneal surgery is going to be performed, navigation references are glued to scalp. A facial anatomy recognition technique can be used also for the same aim. When Spine surgery is going to be performed, references will be fixed to the bone itself. This particular condition, the reference process, wich is completely neccesary to perform IGS, has been a limitation in the development of this technique to guide other surgical procedures such as Vascular or Endovascular procedures 4. O-ARM system & Stealth Station Treon Plus The O-ARM TM System (Medtronic, Minneapolis, US.) is an