Coarctation of the Aorta: An Atypical Case Treated by a Double Layer Stent Technique.

Introduction: Coarctation of the aorta (CoA) is one of the more common congenital heart defects that usually manifests in adults as poorly controlled hypertension. When technically possible, the treatment of choice for adult CoA is an endovascular approach with covered stent placement. A case is presented with atypical clinical onset, treated endovascularly with a double layer stent technique. Report: A 41 year old previously asymptomatic woman with an unremarkable past medical history presented with sudden dyspnoea, unstable blood pressure and pulse, and a radial femoral systolic pressure difference of 53 mmHg. A computed tomography scan showed coral reef aorta: aortic stenosis from a highly calcified lesion located distal to the origin of the left subclavian artery, compatible with CoA. Within a few hours, the patient went rapidly into cardiogenic shock with multiple organ failure requiring urgent intervention. Using a dual left iliac conduit and right brachial artery access, the lesion was pre-dilated with an 8 × 60 mm balloon. A double layer technique was then applied by coaxially deploying a BeGraft aortic stent (expanded to 18 mm) followed by a Conformable GORE® TAG® thoracic stent graft (26 × 26 × 100 mm). The patient's symptoms improved and the radial femoral systolic gradient decreased to 12 mmHg. Discussion: Sudden onset CoA is a rare condition in adults that can lead to refractory cardiogenic shock and multiple organ failure. In anatomically complex cases, a double layer technique may be beneficial because it has high radial force and good wall apposition with lower risk of stent collapse than single stent deployment.

Impact of socioeconomic status on the clinical profile of patients with non-traumatic lower-limb amputation. / Impacto del nivel socioeconómico sobre el perfil del paciente amputado de miembro inferior por causa no traumática.

INTRODUCTION: To analyse the influence of socioeconomic status on the clinical profile of patients undergoing non-traumatic lower-limb amputation. METHODS: Retrospective study of 697 lower-limb amputee patients in an Angiology and Vascular Surgery Department during a 5-year period. Patients were classified according to their socioeconomic status (low, medium and high). We analysed demographic (age and gender) and clinical variables (cause of amputation, comorbidity, cardiovascular risk factors and amputation level). RESULTS: Mean age was 70.5 ± 11.9 years, and the median was 72 years. The low socioeconomic status group presented a higher frequency of amputations in men. Cardiovascular risks factors were more frequent in this socioeconomic group, and the difference was statistically significant for diabetes (85.8% low, 69.3% medium, 65% high; P<.01) and obesity (31.4% low, 22.6% medium, 12.5% high, P<.01). Diabetic retinopathy was the only comorbidity with a significant association with low socioeconomic status (21.1% low, 15.3% medium, 12.5% high, P<.03). Regarding the cause for amputation, there was no difference in terms of socioeconomic status. The low socioeconomic level showed a higher frequency of major amputation, which was a significant difference (63.6% low, 41.2% medium, 55% high, P<.04) and a higher predisposition for this amputation level. CONCLUSIONS: The low socioeconomic status has been shown to determine an unfavourable vascular risk profile in lower-limb non-traumatic amputees and a higher predisposition of a major amputation. This socioeconomic level demonstrates a negative influence on these patients' diabetes, obesity and diabetic retinopathy.

Inter-observer agreement of the Wagner, University of Texas and PEDIS classification systems for the diabetic foot syndrome.

BACKGROUND: The aim of this cohort study was to assess the inter-observer agreement of three diabetic foot classification systems: the Wagner, the University of Texas and the PEDIS. METHODS: We included 250 consecutive patients diagnosed of diabetic foot syndrome in 2009-2013. Wound scores were recorded at admission and a reevaluation was performed simultaneously or 24h later by a different evaluator. Demographical, laboratory data and associated risk factors were obtained from the patients' medical records. RESULTS: The Kappa coefficient showed a moderate inter-observer agreement between the first evaluation and the reevaluation for Wagner scale (Kappa=0.55; 95% CI: 0.507-0.593), University of Texas scale (Kappa=0.513; 95% CI: 0.463-0.563) and for PEDIS scale (Kappa=0.574; 95% CI: 0.522-0.626). CONCLUSIONS: This moderate agreement shows that these scales should not be used alone for management decisions regarding diabetic foot syndrome and should, therefore, be integrated with other clinical data to ensure an adequate handover.

Direct Oral Anticoagulants in the Treatment of Venous Thromboembolic Disease.

BACKGROUND: Anticoagulation is the treatment of choice in the management of venous thromboembolic disease. This approach is applied to reduce mortality and the risk of recurrences and associated complications. Standard therapy for non-oncologic patients has traditionally been based on parenteral anticoagulation followed by vitamin K antagonists. However, this approach has many limitations. METHODS: The aim of this manuscript was to critically review current evidence on the use of direct oral anticoagulants in the treatment of venous thromboembolic disease by analyzing the specific characteristics of each drug. RESULTS: Direct oral anticoagulants have many advantages over standard therapy. While they are equally effective as standard therapy for reducing the possibility of recurrence of venous thromboembolic disease, they carry a lower risk of major bleeding. CONCLUSIONS: Direct oral anticoagulants are an attractive alternative to standard therapy for the treatment of venous thromboembolism.

Genetic polymorphisms influence on the response to clopidogrel in peripheral artery disease patients following percutaneous transluminal angioplasty.

AIM: To study the association of ABCB1 and CYP2C19 polymorphisms and the clopidogrel response in Spanish peripheral artery disease patients following percutaneous transluminal angioplasty (PTA) and to perform a meta-analysis. MATERIALS & METHODS: 72 patients were recruited and 122 patients included in the meta-analysis. We evaluated the effect of ABCB1 3435 C>T, CYP2C19*2 and CYP2C19*3 and primary end point (restenosis/occlusion of the treated lesions) during 12 months after PTA. RESULTS: CYP2C19*2 and/or ABCB1 TT patients were associated with primary end point (OR: 5.00; 95% CI: 1.75-14.27). The meta-analysis confirmed the association of CYP2C19*2 and new atherothrombotic ischemic events (OR: 5.40; 95% CI: 2.30-12.70). CONCLUSION: The CYP2C19 and ABCB1 polymorphisms could be genetic markers of cardiovascular events in peripheral artery disease patients following PTA treated with clopidogrel.