Association of polypharmacy scores with the long-term survival of patients with intact aortoiliac aneurysms and indication for repair.

OBJECTIVE/BACKGROUND: Our study analyzed the relationship between two polypharmacy scores (addition of chronic prescribed drugs [ACPDs] and Rx-Risk Comorbidity Index) and survival in patients with an intact abdominal aortic and/or common iliac aneurysm (AAA). METHODS: Consecutive retrospective, single-center cohort of patients attended for an intact AAA with indication for repair from 2008 to 2021. Demographic data, Charlson Comorbidity Index, AAA treatment, ACPD, and Rx-Risk polypharmacy scores were recorded at baseline. Main outcomes were the 5-year and long-term survival rates. The statistical analysis included Cox regression, area under the curve, and continuous net reclassification index. RESULTS: A total of 424 patients with AAA were evaluated (median age: 76 years; 92.2% male, median Charlson index 2), of whom 314 (74.1%) underwent intervention (80% endovascular and 20% open) and 110 (25.9%) did not. During follow-up (mean 4.6 years), 245 patients (57.8%) died, with 1-month, 1-year, and 5-year survival rates of 98.1%, 86.3%, and 52.7%, respectively. ACPD and Rx-Risk indices (median [interquartile range]: 6 [4-9] and 3 [0-5], respectively) were significantly and linearly associated (P < .001) with survival, with the best cutoff points at 5 and 0, respectively. An ACPD >5 (patients with >5 chronically prescribed drugs at baseline) and an Rx-Risk >0 were associated with a 45.2% (P = .038) and 102% (P = .002) increase in 5-year mortality, respectively, after adjustment for age, sex, Charlson index, and type of AAA treatment. Both polypharmacy indices improved significantly the discriminative power of the Charlson Comorbidity Index in predicting survival. CONCLUSIONS: Both ACPD and Rx-Risk polypharmacy scores are independently related to survival among patients with an intact AAA and indication for repair. Their behavior is similar, so the simple ACPD >5 appears to be sufficient to identify patients with lower survival rates.

Acute limb ischemia in nonagenarians: Characteristics and factors related to outcomes in a single-center consecutive series.

BACKGROUND: The increasing aging and frailty of the population make the management of acute limb ischemia (ALI) more difficult, with decision-making far from being guided by evidence. The aim of the study was to evaluate the characteristics and results of ALI treatment in nonagenarians. MATERIALS AND METHODS: Retrospective analysis of a consecutive series of nonagenarian patients with ALI attended at our institution between 2008 and 2021. The primary outcomes of the study were 1-year limb salvage and survival rates. RESULTS: A total of 102 patients were included (mean age 92.38, 78.4% women). In 83 cases (81.4%) ALI was attributed to embolism, and 19 (18.6%) to acute arterial thrombosis. One-month overall survival was 70.6%. Fifteen patients (14.7%) were treated palliatively, including 8 (53.3%) irreversible ALI with associated malignancy/advanced dementia, 5 (33.3%) with associated cerebral/intestinal ischemia and 2 (13.3%) with aortic occlusion and poor medical condition. None of these patients survived after 10 days. The remaining 87 patients (85.3%) were treated with isolated anticoagulation (n = 8, 9.1%), primary major amputation (n = 1, 1.1%) or revascularization (n = 78, 89.6%), including 69 (67.6%) embolectomies, 6 (5.9%) bypass and 3 (2.9%) endovascular techniques. One-year limb salvage and survival rates were 96% and 48%, respectively. Predictive factors of lower survival included anemia (HR = 1.81, p = 0.014) and ALI severity (HR = 1.73, p = 0.032), but not cognitive or functional status. Patients surviving the ALI episode had a 1-year survival rate significantly below that of a similar matched population. CONCLUSION: Although nonagenarians with an ALI are often functionally and cognitively impaired and have a limited life expectancy, most patients need revascularization for limb salvage and this can be done successfully with a low invasive surgery.

Comparison Between Several CT-Derived Psoas Muscle Sarcopenia Markers for Predicting Survival After Abdominal Aortic Aneurysm Repair.

BACKGROUND: Multiple CT-derived measurements of sarcopenia have been described yet their relationship with survival after abdominal aortic aneurysm (AAA) repair has not been properly assessed. We aimed to define and compare the relationship between several psoas CT-derived measurements and the 5-year survival after AAA repair and to evaluate their potential contribution to survival prediction. METHODS: Preoperative CT area (TPA) and density (MTPD) of the psoas muscle at L3 were measured in 218 consecutive AAA patients electively intervened. Additional measurements were obtained by normalizing TPA by anthropometric data or L3-vertebra surface or by TPAxMTPD multiplication (lean psoas muscle area-LPMA). The association of sarcopenia markers with survival was evaluated with Cox models adjusted by age, sex, type of intervention and the Charlson Comorbidity Index, and their contribution to survival prediction assessed with the C-statistic and the Continuous Net Reclassification Index (c-NRI). RESULTS: Sixty patients (27.5%) died during the first 5 years after surgery. There was a statistically significant and linear (spline analysis) relationship of sarcopenia markers with 5-year survival in all multivariate models, except that including LPMA. Despite this association, the inclusion of sarcopenia markers did not improve the C-statistic and moderately increased the c-NRI. None normalized sarcopenia markers performed better than TPA. CONCLUSION: The majority of CT-derived psoas muscle measurements of sarcopenia showed a significant and independent relationship with survival after elective AAA repair. Despite this association, they did not appear to improve sufficiently our survival prediction ability to become an efficient tool for decision-making.

Influence of Operative Time in the Results of Elective Endovascular Repair of Abdominal Aortic Aneurysms.

BACKGROUND: A prolonged operative time (OT) is a well-recognized risk factor of postoperative complications after many open surgical procedures, although little is known about its impact in less-invasive endovascular procedures. We aimed to define the characteristics related to a prolonged OT in the endovascular treatment of aorto-iliac aneurysms (EVAR) and to evaluate the influence of OT on postoperative outcomes. METHODS: Retrospective analysis of 284 consecutive patients (mean age 75 years, 95% male) who underwent an elective EVAR between 2000 and 2019. Operative characteristics related to OT and the impact of OT in postoperative results was studied using multiple lineal and logistic regression analyses, respectively. RESULTS: The mean surgical time was 200 min. OT was associated (regression model) with the implantation of straight endografts (-38 min, P = 0.007), femoral artery surgery (+80 min, P < 0.001), hypogastric preservation procedures (+70 min, P < 0.001), associated peripheral arterial disease (+22 min, P = 0.013), general anesthesia (+34 min, P < 0.001), and aneurysm diameter (+9 min/cm, P = 0.002). During the postoperative period (<30 days or at discharge), 21% presented a complication and 2.8% died. OT was independently associated with a higher incidence of postoperative complications (odds ratio [OR] for each additional 30' of surgery = 1.34, P < 0.001), such as immediate (OR = 1.48, P = 0.003) and 6-month mortality (OR = 1.28, P = 0.025). CONCLUSIONS: A prolonged OT is an independent risk factor for complications and mortality after EVAR. Surgeons must take this factor into consideration when defining the best therapeutic strategy for abdominal aortic aneurysms.

Kidney transplantation reduces the risk of chronic limb threatening ischemia and amputation among patients with end-stage renal disease on hemodialysis.

OBJECTIVE: This study aimed to analyze the risk of chronic limb threatening ischemia (CLTI) or amputation among patients with end-stage renal disease (ESRD) entering a hemodialysis (HD) program and to evaluate the protective effect associated with kidney transplantation (KT). DESIGN, MATERIAL AND METHODS: Retrospective cohort of all consecutive ESRD patients entering into a HD program at our institution between 2000 and 2010. Collected variables included baseline characteristics (pre-entry in hemodialysis), time on HD program, KT and the composite outcome of chronic limb threatening ischemia or need for any amputation (CLTI/AMP). Patients with previous symptomatic peripheral arterial disease or amputation were excluded. RESULTS: The study group included 336 patients (mean age 63 years, 66% male). The mean follow up was 6.7 years with an average time on HD of 4.2 years. Ninety two patients (27.4 %) underwent transplantation. CLTI free survival rates were 90.3 % and 82.6 % at 5 and 10 years, respectively. The episodes of CLT involved 28 revascularization procedures (17 endovascular and 11 open surgeries), 18 minor amputations and 20 major amputations. KT was associated with a protective effect over the development of CLTI (HR: 0.065; CI 95% 0.02-0.21) after adjustment for confounding factors. The long-term survival of non-transplanted patients was 45 % and 15 % at 5 and 10 years, respectively and the long-term survival in transplanted patients was 89% and 80% at 5 and 10 years, respectively; but decreased to 47 % at 1 year and 18.2 % at 5 years once CLTI occurred. CONCLUSION: Patients on HD program show a notorious risk of chronic limb threatening ischemia or amputation over time. Once this complication occurs, patient's survival is markedly reduced. Transplantation confers an independent protective effect over the development of chronic limb threatening ischemia or amputation.

Critical Limb Ischemia in Nonagenarians: A Challenge of Our Times.

BACKGROUND: As a result of the increasing life expectancy of the western population, the number of older patients with chronic limb-threatening ischemia (CLTI) seeking medical care is growing. Our objective was to describe the characteristics of a consecutive series of nonagenarian patients with CLTI and evaluate the outcomes of their management. MATERIALS AND METHODS: Retrospective analysis of a consecutive series of nonagenarian patients with CLTI attended at our institution between 2005 and 2019. Primary endpoints were 1-year limb salvage and survival rates. RESULTS: A total of 171 patients were included (mean age 92.7, 51.5% women), of which in 59 (34.5%) primary major amputation (n = 10) or palliative care (n = 49) was indicated at presentation because of severe dementia (n = 30, 50.8%), knee retraction (n = 17, 28.8%), terminal condition (n = 13, 22%) or a non-salvageable foot (n = 28, 47.4%). In the remaining 112 (65.5%), the need for a revascularization was further assessed finally performing A) conservative treatment/minor amputation (n = 57, 50.9%), B) revascularization (n = 50, 44.6%) or C) direct major amputation (n = 5, 4.4%), with 1-year limb salvage and survival rates of 93.1 and 57.4%, respectively. Predictive factors for lower survival included age >92 years (HR = 1,59, p = 0.041), hemoglobin <10.5 mg/dL (HR 2,34, p < 0.001), congestive heart failure (HR = 1.65, p = 0.036), non-severe dementia (HR 3,11, p < 0.001) and current mobility with wheelchair (HR 1,74, p = 0.014). CONCLUSION: Nearly one-third of nonagenarian patients with CLTI have a direct indication for amputation or palliative care at presentation. In the remaining, a judicious approach with conservative treatment, minor amputation or revascularization procedures yields excellent limb salvage rates. Survival is, however, the cornerstone of these patients. It can be predicted with certain clinical factors which may help decision-making.

Predictors of medium-term patency in percutaneous endovascular therapy of femoro-popliteal lesions.

BACKGROUND: The objective is to study the medium-term results of angioplasty and stenting in the femoro-popliteal sector in patients with critical limb ischemia (CLI), and identify angiographic predictive factors of primary patency. PATIENTS AND METHODS: Retrospective review of 98 patients with critical ischemia and angiographic lesions characterized as TASC A=13 (14%), B=38 (40%), C=24 (25%) or D=20 (21%). A total of 106 angioplasties and primary self-expanding stents (mean length of stent coverage of 19cm) were performed between January 2006 and January 2011. RESULTS: The immediate results of patency, limb salvage and survival were 95, 96 and 96%, respectively. Primary patency at 1 and 2 years was 54 and 38%, respectively. Twenty-seven cases (25%) required endovascular iterative procedures, providing an assisted patency at 1 and 2 years of 72 and 60%, and a secondary patency of 80 and 67%. A lower primary patency was observed (log rank) when stent length was >20cm (P<.001), popliteal artery was invloved (P=.004), and in TASC C and D lesions (P=.04). In multivariate analysis (Cox), only stent length>20cm was an independent negative predictor for primary patency (HR=5.7, P<.001). The limb salvage at 1 and 2 years was 83 and 81%, respectively. CONCLUSIONS: Angioplasty with stent in the femoro-popliteal sector is a safe technique, but with significantly lower permeability results in injuries that require stent coverage of more than 20cm. In these cases, vein bypass surgery should be the procedure of choice.

Comparative performance of three comorbidity scores in predicting survival after the elective repair of abdominal aortic aneurysms.

BACKGROUND: We aimed to study the discriminative power of 3 comorbidity scores for predicting 5-year survival after the elective repair of aorto-iliac aneurysms (AAA). METHODS: 444 patients with AAA undergoing elective repair (33% open and 67% endovascular) between 2000 and 2020 were reviewed. The Charlson Comorbidity Index (CCI) and subsequent adjustments by Schneeweiss, Quan and Armitage, the Modified Frailty Index (MFI) and the American Society of Anesthesiologists Score (ASA) were calculated from preoperative data. Their association with 5-year survival was analyzed using Cox regression models and their discriminative power and its changes with C statistics and Net Reclassification Index (NRI). RESULTS: All comorbidity scores were associated with survival after adjusting by age, sex and type of surgical repair: original CCI HR=1.24, P<0.001; Schneeweiss CCI HR=1.23, P<0.001; Quan CCI HR=1.27, P<0.001, Armitage CCI HR=1.46, P<0.001, MFI HR=1.39, P<0.001 and ASA HR=1.68 (P=0.04) and 2.86 (P=0.01) for classes III and IV, respectively. Associated C statistics were of 0.64, 0.65, 0.65, 0.64, 0.61 and 0.59, respectively. Compared with the original CCI, models based on Schneeweiss CCI and Armitage CCI provided minor improvements in NRI (0.32 and 0.23), and the model based on ASA showed lower C statistics (P=0.014) and NRI (-0.30). CONCLUSIONS: Established comorbidity scores, such as CCI, MFI or ASA, are all associated with 5-year survival after the elective repair of AAAs, being ASA the worst of them. However, their predictive power is in no case sufficient to identify, by themselves, those patients who may not be eligible for intervention on the basis of life expectancy.

Clinical characteristics and preoperative ultrasound parameters related to low patency in radio-cephalic arteriovenous fistulas.

INTRODUCTION: Our objective is to describe the clinical characteristics and preoperative ultrasound mapping parameters associated with primary and secondary patency of radio-cephalic arteriovenous fistulas (RCF). METHODS: A retrospective, single-center, descriptive study, including patients undergoing a RCF creation between 2015 and 2019. Socio-demographic data and ultrasound parameters were collected and an analysis of primary and secondary patency was performed. RESULTS: Eighty-four patients were included in this study. Mean age was 65.6 (±13.9) years; 76.6% were male. Mean preoperative ultrasound parameters: forearm cephalic vein diameter was 2.8 (±0.57) mm, radial artery diameter was 2.6 (±0.42) mm, radial artery systolic peak velocity was 68 (±14.3) cm/s radial artery resistance index was 0.76 (±0.9). At the end of the 4 years the follow-up, the mean primary and secondary patency were 47.2% and 80% respectively. Only female sex was significantly associated with a decrease in both primary patency (p = 0.043, HR = 0.48) and secondary patency (p = 0.021, HR = 0.023). Furthermore, radial artery systolic peak velocity (p = 0.007, HR = 2.6) showed a significant association with decreased primary patency and forearm cephalic vein diameter showed a borderline significant association with decreased secondary patency (p = 0.046, HR = 8.2). CONCLUSIONS: A standardized evaluation by a vascular surgeon or nephrologist represent a key in the preoperative assessment of AVF candidates. Based on our results, we will consider to avoid distal vascular access in both female patients with lower radial artery systolic peak velocity (less than 68 cm/s) and borderline forearm cephalic vein diameter (less than 2.8 mm) after initial assessment in our clinical practice. Our results could encourage new studies in order to stablish the potential role of these parameters in the RCFs patency rates.

A cost-effectiveness analysis of the introduction of a specialised consultation with duplex ultrasound assessment prior to vascular access surgery for haemodialysis.

INTRODUCTION: Duplex ultrasound (DUS) is increasingly used before vascular access (VA) surgery for haemodialysis. However, the cost-effectiveness of this approach is unknown. Our objective was to assess whether the introduction of a specialised consultation with DUS assessment modifies the cost and the time delay to achieve a first VA valid for haemodialysis. PATIENTS AND METHODS: Prospective cohort of patients undergoing a first VA (June 2014-July 2017) after a specialised consultation with DUS (ECO group). They were compared with a historical cohort (January 2012-May 2014) where VA was indicated exclusively by clinical evaluation (CLN group). We analysed the cost related to visits, DUS assessments, interventions, hospital admissions and graft materials to achieve a first VA valid for haemodialysis at least during 1 month. RESULTS: 86 patients in the CLN group were compared with 92 in the ECO group. Patients in the ECO group were younger (68.4 vs. 64.0 years; P=.038) but no other differences were seen among groups. The average cost to achieve a first AV valid for haemodialysis was significantly lower in the ECO group (2707 vs. 3347€; P=.024). There was a higher cost associated with DUS assessments in the ECO group yet the CLN group had a higher cost related to follow-up visits, successive surgical interventions, prosthetic material, days of hospital admission and catheters. The mean time needed to achieve a first AV valid for haemodialysis was also shorter in the ECO group (49.9 vs. 82.9 days, P=.002). CONCLUSION: The introduction of a specialised vascular access consultation with DUS prior to VA surgery has reduced the cost necessary to achieve a first VA valid for haemodialysis. From the patient's point of view this has meant less interventions and hospital admissions and a shortening of the time delay.

Are continued policies of prioritizing native vascular access in patients on hemodialysis programs useful?

The guidelines recommend establishing native vascular access as opposed to prosthetic or catheter-based access despite information relating to its effectiveness being scarce from a patient-orientated perspective. We analyzed the effectiveness of a continued policy of native vascular access (CPNVA) in patients undergoing hemodialysis. A retrospective, observational study, including 150 patients undergoing hemodialysis between 2006 and 2012 at our center, and who underwent a CPNVA. Statistical analysis was based on treatment intention. In 138 patients (92%), the first useful access (FUA) was native, and in 12 patients (8%), it was prosthetic. In 50 patients (33.3%), more than one procedure had to be carried out in to order to achieve FUA. The probability of dialysis occurring via a FUA was 67.1% and 45.3% at 1 and 5 years respectively. Over the follow-up period (mean time = 30 months), 84 patients (56%) required repairs or new access, extending the effectiveness of the CPNVA to 88.3% and 73.2% at 1 and 5 years respectively. The effectiveness of the CPNVA was reduced if the patient: required a catheter initially (HR: 3.6, p = 0.007); in cases of initially elevated glomerular filtration rate (HR: 1.1, p = 0.040); in cases of history of previous access failure before FUA (HR: 3.9, p = 0.001); and in female patients (HR: 2.4, p = 0.031). The long-term effectiveness of a CPNVA is high. However, the percentage of patients requiring diverse procedures in order to achieve FUA and the need for re-interventions yield the necessity to optimize preoperative evaluation and postoperative follow-up.

Outcome of elective endovascular repair of abdominal aortic aneurysms in octogenarians.

AIM: The need to adjust the indications of elective abdominal aortic aneurysm (AAA) repair among patients with a limited life-span deserves a specific evaluation for octogenarians. The aim of this study was to compare the postoperative results and the long-term survival after endovascular repair of abdominal aortic and/or iliac aneurysms (EVAR) in octogenarians compared with patients under 80 years of age. METHODS: Retrospective analysis of 241 consecutive patients who underwent an elective EVAR between 2000 and 2017. EVAR was not considered among patients with clear life-limiting conditions. Patients receiving other than commercially standard infra-renal endoprostheses were excluded. RESULTS: Seventy patients (29.0%) were octogenarians. They had a lower rate of active smoking (10.0% vs. 30.4%, P < 0.001) and a higher prevalence of previous cerebrovascular disease (21.4% vs. 11.7%, P = 0.055) than younger patients. Thirty-day/in-hospital complication and mortality rates were not significantly higher among octogenarians when compared with younger patients (24.3% vs. 16.9% and 2.9% vs. 2.4%, respectively). Octogenarians had a lower long-term survival at 1, 3 and 5 years (92.6% vs. 93.3%, 67.7% vs. 78.0% and 39.3% vs. 60.6%, P = 0.039) in the bivariate analysis. However, an age ≥ 80 years per se was not an independent predictor of survival after adjustment for confounding factors. CONCLUSION: An age above 80 years was not associated with an increased risk of postoperative complications or long-term mortality. Our results suggest that EVAR can be considered in elderly patients without a clear life-limiting condition and with a suitable aneurysm anatomy. Geriatr Gerontol Int 2021; 21: 392-397.

A cost-effectiveness analysis of the introduction of a specialised consultation with duplex ultrasound assessment prior to vascular access surgery for haemodialysis. / Impacto de la introducción de una consulta específica con valoración eco-doppler en el costo asociado a la obtención de un primer acceso vascular para hemodiálisis.

INTRODUCTION: Duplex ultrasound (DUS) is increasingly used before vascular access (VA) surgery for haemodialysis. However, the cost-effectiveness of this approach is unknown. Our objective was to assess whether the introduction of a specialised consultation with DUS assessment modifies the cost and the time delay to achieve a first VA valid for haemodialysis. PATIENTS AND METHODS: Prospective cohort of patients undergoing a first VA (June 2014-July 2017) after a specialised consultation with DUS (ECO group). They were compared with a historical cohort (January 2012-May 2014) where VA was indicated exclusively by clinical evaluation (CLN group). We analysed the cost related to visits, DUS assessments, interventions, hospital admissions and graft materials to achieve a first VA valid for haemodialysis at least during 1 month. RESULTS: Eighty-six patients in the CLN group were compared with 92 in the ECO group. Patients in the ECO group were younger (68.4 vs. 64.0 years; P=.038) but no other differences were seen among groups. The average cost to achieve a first AV valid for haemodialysis was significantly lower in the ECO group (2707 vs. 3347€; P=.024). There was a higher cost associated with DUS assessments in the ECO group yet the CLN group had a higher cost related to follow-up visits, successive surgical interventions, prosthetic material, days of hospital admission and catheters. The mean time needed to achieve a first AV valid for haemodialysis was also shorter in the ECO group (49.9 vs. 82.9 days, P=.002). CONCLUSION: The introduction of a specialised vascular access consultation with DUS prior to VA surgery has reduced the cost necessary to achieve a first VA valid for haemodialysis. From the patient's point of view this has meant less interventions and hospital admissions and a shortening of the time delay.

Natural History After Below-knee Amputation: Analysis of Survival and Prosthetic Fitting Over 2 Decades. / Historia natural del paciente sometido a una amputación infracondílea: análisis de la supervivencia y protetización durante 2 décadas.

INTRODUCTION: This study sought to evaluate the natural history of patients undergoing below-knee amputation (BKA) and compare their evolution over 2 decades, as well as survival predictors, prosthetic fitting, and contralateral amputation. METHODS: Retrospective study of 209 consecutive patients (mean age 72.9 years; 68% males) who underwent BKA in 2 periods: 1996-2005 and 2006-2015. The fitting of prostheses, risk of contralateral amputation and survival, as well as their predictive factors, were assessed by survival analysis. RESULTS: 133 BKA were performed from 1996-2005 and 106 from 2006-2015. The etiology that motivated the BKA was acute ischemia (4.3%), chronic ischemia (34.0%), infection (9.1%) or mixed (chronic+infection, 52.6%), with no differences found between periods. Survival: mortality within one month=9.2%, one year=31.9%, 2 years=43.8% and 5 years=63.9%, with no significant differences between the 2 periods. Prosthetic: the fitting rate was 44.5% throughout the follow-up, with no significant differences between the two periods. 41.1% patients managed to walk. Contralateral amputation: 20.1% of the patients later required a major contralateral amputation, with no significant differences between the two periods. CONCLUSIONS: In the last decade, fewer BKA have been performed probably, due to higher previous interventional revascularization. Despite this, the results of fitting, contralateral amputation or survival were not modified. In any case, the number of patients who are able to achieve ambulation is modest, so it emphasizes the need for an optimal selection of patients with BKA with the goal of prosthetic fitting.

Renal denervation for the treatment of resistant hypertension in Spain. The Flex-Spyral Registry.

INTRODUCTION AND OBJECTIVES: Renal denervation is a percutaneous intervention for the treatment of resistant hypertension. Randomized studies have shown contradictory results on its efficacy. We present the results of a renal denervation registry for the treatment of resistant hypertension in real-life patients in Spain. METHODS: Multicenter registry of consecutive patients with resistant hypertension treated with renal denervation in Spain between 2009 and 2018. RESULTS: We included 125 patients (mean age, 56 years; 41% female; mean onset of hypertension 14±9 years previously). Office systolic and diastolic blood pressure and ambulatory blood pressure monitoring decreased 6 months after the intervention (166±20/95±16 to 149±22/87±16 mmHg and 151±14/89±12 to 143±15/84±11, both P <.0001). At 12 months, the blood pressure reduction was maintained and the number of antihypertensive drugs decreased from 4.9±1.2 to 4.4±1.5 (P=.0001). There were no significant procedure-related complications. The response rate to denervation at 1 year was 80%, but there were wide differences between centers. CONCLUSIONS: In patients with resistant hypertension, treatment with renal denervation was related to a decrease in office blood pressure and, more importantly, in ambulatory blood pressure monitoring, with a significant reduction in pharmacological treatment.

Utility of doppler ultrasound in the preoperative evaluation of the first vascular access for haemodialysis. / Utilidad de la valoración ecográfica previa a la realización del primer acceso vascular para hemodiálisis.

INTRODUCTION: Traditionally, the indication of the type of vascular access (VA) has been based on the surgeon's physical examination, but it is now suggested that imaging methods could provide a clinical benefit. Our aim was to determine whether or not preoperative Doppler ultrasound modifies outcomes of the first VA for haemodialysis. PATIENTS AND METHODS: Prospective cohort of patients undergoing a first VA from June 2014 to July 2017 who had a preoperative Doppler ultrasound (ECO group). They were compared to a historical cohort (January 2012-May 2014) of first VA indicated exclusively by clinical assessment (CLN group). RESULTS: A total of 86 patients from the CLN group were compared to 92 from the ECO group, which was younger (68.4 vs 64.0, P=.038). The primary patency (CLN/ECO) at 1 and 2years was 59.5%/71.9% and 53.1%/57.8% respectively, marginally better in the ECO group (P=.057). The assisted patency at 1 and 2years was 63.2%/80.7% and 58.1%/70.2%, respectively, significantly better for the ECO group (P=.010). Due to lack of patency/utility of the initial VA, 26.7% in the CLN group and 7.6% in the ECO group (P<.001) required a new VA during the first 6months. An average of 1.39 interventions were performed to achieve a useful VA in the CLN group and 1.08 in the ECO group (P<.001), the first VA being useful at the radiocephalic level in 31.0%/45.1% (P=.039). CONCLUSION: The indication of the first VA according to a preoperative Doppler ultrasound examination could decrease the need for new VA, enable them to be made more distal, and significantly improve patency.

Bypass distal con vena autóloga invertida / Distal inverted autologous vein bypass

La derivación (bypass) con vena autóloga invertida es, sin lugar a dudas, uno de los procedimientos fundamentales en la revascularización de los miembros isquémicos de las extremidades inferiores. De hecho, fue el primero en desarrollarse (Jean Kunlin). Los autores de este artículo describen su forma tradicional de realizarlo y sus trucos, así como sus maneras de abordar y de evitar problemas, pero lo hacen con un lenguaje práctico (“cómo lo hago”) que ayude a entender el procedimiento a médicos jóvenes en formación. Durante la descripción se mencionan algunas técnicas alternativas, conscientes de que a buen seguro habrá otras y que otros cirujanos lo harán con pequeñas modificaciones.(AU)

The autologous distal vein bypass with an inverted vein is, without doubt, one of the main procedures in the revascularization of ischemic limbs of the lower extremities. In fact, it was the first to be developed (Jean Kunlin). The authors of this article describe their traditional way of doing it, their tricks, their ways of approaching and avoiding problems, but they explain their “how I do it” with a practical language that helps to understand the procedure by young doctors in training. During the description, some technical alternatives are mentioned, aware that there will surely be others and that others vascular surgeons will do so with minor modifi cations.(AU)

Modelo animal para la evaluación del sellado de colaterales venosas con dispositivos liberadores de energía en cirugía de revascularización / Animal model to assess collateral vein sealing with energy-based devices in revascularization surgery

Introducción: los dispositivos liberadores de energía permiten la hemostasia de los vasos mediante generación de calor y la coagulación de las proteínas de la pared. Sin embargo, se desconoce su comportamiento a medio plazo en la cirugía arterial con injertos venosos. Objetivos: desarrollar un modelo animal que permita evaluar la eficacia y seguridad del sellado a medio plazo tras el proceso de cicatrización. Comparar y evaluar qué modelo in vivo presenta menor morbilidad y mayor supervivencia a las 4 semanas. Material y métodos: estudio experimental animal de 16 conejos New Zealand a los que se interpuso un fragmento de vena safena humana (VS) con una colateral. Se desarrollaron dos modelos arteriales: bypass termino-terminal de VS en aorta infrarrenal (n = 5) y plastia de aorta con parche de VS (n = 11). La colateral venosa fue sellada, previa aleatorización, con electrocoagulación bipolar controlada por temperatura (EB) o bisturí armónico (BA). Todos los animales recibieron inmunosupresión y profilaxis antitrombótica. Se registró la tasa de paraplejia, de infección, de hemorragia y de supervivencia. Resultados: la supervivencia a los 7 días fue del 50 % (2/4) en el modelo de injerto de interposición. Sin embargo, ningún animal sobrevivió a las 4 semanas de seguimiento en este modelo. En el grupo de plastia de aorta, la supervivencia a los 7 días fue del 55,56 % (5/9) y del 44,44 % (4/9) a las 4 semanas (p = 0,5). La tasa de paraplejia en el grupo de interposición fue del 100 % e inferior en el modelo de plastia de aorta (25 %) (p = 0,03). El tiempo medio de isquemia en el modelo de plastia de aorta (37,11 ± 8,1 min) fue inferior al del grupo del bypass (42 ± 10,61 min) (p = 0,414). En ningún caso se objetivó hemorragia intraabdominal ni reacción adversa a la inmunosupresión. Conclusiones: el modelo arterial de plastia de aorta con parche de VS presentó menor tasa de paraplejia, así como menor mortalidad posoperatoria a los 7 días...(AU)

Introduction: energy sealing devices achieve hemostasis of the vessels through the heat generated and coagula-tion of the vascular wall proteins. However, the mid-term efficacy profile for venous graft sealing in arterial bypasssurgery remains unknown.Objectives: to create an animal model to compare the mid-term efficacy and safety profile at the sealing areaafter the healing process. To compare and assess which in vivo arterial models show lower morbidity and highersurvival rates after 4 weeks.Material and methods: this was an in vivo experimental study of 16 New Zealand rabbits. In each rabbit a humansaphenous vein (SV) with, at least, 1 venous collateral was implanted. Two arterial models were developed: infrarre-nal aorta bypass with SV (n = 5) and aortoplasty with SV patch (n = 11). In both models the collateral was randomizedand sealed with either 1 these 2 energy sealing devices: electrothermal bipolar vessel sealing (EBVS) or Harmonicscalpel (HS). Every animal was treated with antithrombotic prophylaxis and immunosuppressive medication. Therates of intraoperative mortality, paraplegia, infection, bleeding, and survival were all studied.Results: two animals (50 %) survive 7 days after surgery in the bypass model. However, no animal survived 4 daysafter surgery in this model. In the aortoplasty group, the 7-day survival rate was 55.56 % (5/9) while the 4-weeksurvival rate was 44.44 % (4/9) (p = 0.05). The rate of paraplegia was 100 % for the bypass model and much lowerfor the patch group (25 %) (p = 0.03). The mean ischemic time was lower for the aortoplasty model (37.11 ± 8.1 min)compared to the bypass group (42 ± 10.61 min) (p = 0.414). No animal showed intrabdominal hemorrhages oradverse drug reactions associated with the immunosuppressive medication.Conclusion: aortoplasty with the SV patch model showed lower rates of paraplegia and 7-day mortality in theanimal model...(AU)

Asociación entre metilación del ADN y tabaquismo en pacientes con isquemia crónica amenazante de extremidades inferiores / Association between DNA methylation and smoking in patients with chronic limb-threatening ischemia

Introducción y objetivo: estudiar la asociación entre tabaquismo y el nivel de metilación de dos regiones genómicas en pacientes con enfermedad arterial periférica (EAP). Método: estudio transversal de 297 pacientes (edad media: 69,6 años; varones: 78,5 %) diagnosticados de isquemia crónica de extremidades inferiores en diferentes estadios clínicos entre marzo de 2016 y diciembre de 2019en el servicio de cirugía vascular del Hospital del mar (Barcelona). Se analizó la metilación de Cg02156642 y deCg03636183 asociados en otros estudios al tabaquismo. Se realizó una regresión lineal múltiple para discriminar lasvariables asociadas al nivel de metilación. Se calculó el área bajo la curva ROC para discriminar el nivel de metilaciónentre fumadores y no fumadores. Resultados: de la muestra, 46 pacientes (15,5 %) eran no fumadores; 132 (44,4 %), exfumadores y 119 (40,1 %),fumadores. No se observó una asociación entre la exposición al tabaco y el nivel de metilación del Cg02156642,pero sí con el de Cg03636183: los fumadores presentaban menor nivel de metilación y, además, a más carga detabaco menos metilación (Rho de Spearman: -0,324; p < 0,001).Un nivel de metilación en este CpG del 80 % tiene una sensibilidad (S) del 90,0 % y una especificidad (E) del83,5 % para discriminar entre fumadores y nunca fumadores. Para discriminar entre fumadores y exfumadores,un nivel de metilación del 75 % tiene una S del 69 % y una E del 56,9 %.Al ajustar por todas las variables relacionadas con la metilación, la magnitud de esta asociación entre Cg03636183y tabaquismo se mantenía signifi cativa entre los nunca fumadores y los fumadores. Conclusiones: la metilación del cpg cg03636183 se asocia a tabaquismo en pacientes con eap y está directamenterelacionada con la carga de tabaco. Este biomarcador podría utilizarse en la práctica clínica para valorar el consumode tabaco de nuestros pacientes.(AU)

Introduction and objective: to study the association between smoking and the methylation level of 2 genomicregions in patients with peripheral artery disease (PAD). Method: cross-sectional study of 297 patients (mean age, 69.6 years; males, 78.5%) diagnosed with chronic lowerextremity ischemia at various clinical stages from march 2016 through December 2019 at the Vascular Surgery Unitof Hospital del mar, Barcelona, Catalonia, Spain. methylation analysis of Cg02156642 and Cg03636183, previouslyassociated with smoking in former studies was performed. multiple linear regression was conducted to identifyvariables associated with methylation levels. The area under the ROC curve was estimated to discriminate meth-ylation levels between smokers and non-smokers. Results: among the sample, 46 patients (15.5%) were non-smokers, 132 (44.4%) were former smokers, and 119(40.1%) were current smokers. No association was seen between tobacco exposure and methylation levels ofCg02156642. However, an association was found with Cg03636183: smokers had lower methylation levels, anda higher smoking load was associated with lower methylation (Spearman's Rho, -0.324; p < .001). A methylationlevel of 80% in this region showed a 90.0% sensitivity and an 83.5% specificity to discriminate between smokersand never smokers. To discriminate between smokers and former smokers, a methylation level of 75% had an 69%sensitivity and an 56.9% specificity. After adjusting for all variables associated with methylation, the associationbetween Cg03636183 and smoking remained significant among never smokers and smokers. Conclusions: methylation of the Cg03636183 region is associated with smoking in patients with PAD and is directlyassociated with the smoking load. This biomarker could be used in the routine clinical practice to assess tobaccouse in our patients.(AU)