Tratamiento endovascular de un pseudoaneurisma de arteria ilíaca primitiva postrasplante renal / Endovascular resolution of iliac artery pseudoaneurysm in a transplanted patient

Presentamos el caso de un paciente varón de 58 años que al año después de un trasplante renal presenta una tumoración pulsátil en fosa ilíaca derecha acompañado de dolor, motivo por el que ingresa en la unidad de nefrología. Tras el estudio mediante Eco-doppler y angiografía es diagnosticado de un pseudoaneurisma de arteria ilíaca común. Se le practica tratamiento endovascular mediante la colocación de un "stent" cubierto previa embolización de arteria hipogástrica como prevención para evitar una fuga o "endoleak". Resultado clínico y radiológico bueno, desaparición de la masa pulsátil a la exploración y en la imagen radiológica (AU)

Epidemiology of chronic venous insufficiency of the lower limbs in the primary care setting.

AIM: The objective of the study was to describe the general characteristics, risk factors and clinical symptoms of patients seeking medical care at the primary care setting because of chronic venous insufficiency. METHODS: A total of 606 general practitioners throughout Spain participated in this epidemiological, cross-sectional, multicenter study in which 6 695 patients were included. During a 3-month period, each participating physician filled out a questionnaire for all consecutive patients with venous leg complaints attended at his/her consultation. The following data were recorded: demographic features and anthropometric characteristics, level of physical activity, tobacco and/or alcohol consumption, number of pregnancies, other risk factors for chronic venous insufficiency, clinical manifestations, and signs on physical examination. RESULTS: Women accounted for 81.3% of the sample. Risk factors included tobacco smoking in 33.8% of cases, alcohol consumption in 25%, low physical activity in 55.7%, and family history in 47.2%. Patients recognized prolonged standing as the most frequent factor probably related to the origin of the symptoms (30.7%). Heaviness in the legs (84.8%) and itching (53.9%) were the most common symptoms, whereas ankle edema (43.6%) was the most frequent sign followed by telangiectases (37.6%). The presence of family history, a higher body mass index an age older than 45 years seems to be related with an increased frequency of clinical manifestations. CONCLUSION: Among patients seeking medical care because of chronic venous insufficiency, women seemed to ask for attention more frequently than men and the beginning of symptoms was mainly related to a prolonged orthostatic posture, being overweight the second cause stated. Heavy legs was the most frequent symptom followed by itching, and ankle edema was the most frequent sign.

[Endovascular resolution of iliac artery pseudoaneurysm in a transplanted patient]. / Tratamiento endovascular de un pseudoaneurisma de arteria ilíaca primitiva postrasplante renal.

A 58-year-old patient with end-stage idiopatic renal disease underwent kidney transplantation from a cadaveric donor. Approximately one year after the transplant he complained of abdominal pain and presented a pulsating mass in his right pelvic region. Dupplex study and arteriography were performed and showed a large pseudoaneurysm arising from the right common iliac artery. We report the case in which a covered stent placement and an embolization of the right internal iliac artery solved the problem with successful clinical and radiological results.

Rotura de aneurisma de arteria poplíteaseis años después de la intervención / Rupture of popliteal artery aneurysm six years after surgery

Introducción. Los aneurismas de arteria poplítea son los aneurismas periféricos más frecuentes. Su principal complicación es la isquemia aguda por trombosis del mismo; su rotura es rara. El caso que presentamos resulta excepcional porque la rotura tuvo lugar más de seis años después de la intervención. Caso clínico. Paciente de 90 años, intervenido en 1996 de un aneurisma poplíteo bilateral; se le practicó ligadura y by-pass, con prótesis de politetrafluroetileno expandido (PTFE) en la pierna derecha y con vena safena invertida en la izquierda. Sigue controles anuales en nuestras consultas, durante los cuales no se han detectado arteriomegalias y se han mantenido permeables las reconstrucciones. En junio de 2002 ingresó de urgencia por presentar gran tumoración en la cara interna del muslo izquierdo, según el paciente, de 2-3 semanas de evolución. No se apreciaba latido ni signos externos de hemorragia. Se practicó angiorresonancia magnética (angio-RM), que informó de `imagen compatible con pseudoaneurisma, posiblemente originado en la zona de la anastomosis proximal del injerto'. Se intervino al paciente y se encontró un falso aneurisma por rotura de la pared del aneurisma en el hueco poplíteo, con indemnidad de las anastomosis. Se practicó una nueva ligadura de la arteria poplítea distal al final del aneurisma, se resecó parcialmente el falso aneurisma, que estaba trombosado, y se envió una muestra a anatomía patológica. Cuatro meses después de la intervención, coincidiendo con tratamiento anticoagulante por sospecha de trombosis venosa poplítea, la tumoración volvió a crecer y en esta ocasión se practicó embolización de ramas distales de la femoral profunda y de la femoral superficial. Un año después, el paciente permanece estable, sin cambios en una nueva angio-RM (AU)

[Cost-effectiveness of and morbidity from digital subtraction angiography. A study of 5,817 cases]. / Coût--effectivité--morbidité de l'angiographie par soustraction numérique. Etude de 5817 cas.

This study was based on 5,817 patients examined by digital subtraction angiography (DSA) between 1984 and 1990. 5,209 patients received an intravenous injection of contrast agent and 608 received an intra-arterial injection. Digital subtraction angiography has become a routine procedure for the diagnosis of vascular disease in the various fields studied, as it provides images of diagnostic quality in 97% of cases: diagnostic quality of 95% after intravenous injection and 99% after intra-arterial injection. The morbidity is 1.65% for the intravenous route and 4.8% for the intra-arterial route. The morbidity of brachial artery catheterization is 5.5% DSA by intravenous injection is a low-risk angiographic technique which represents a major economy in terms of the cost of the examination and the examination time, a reduction of hospital stay and waiting lists; these advantages are very important in the current context of public health.

Takayasu's arteritis as a cause of renovascular hypertension in a non-Asian population.

Takayasu's disease (TD) is a chronic inflammatory arteritis which affects the aorta and its main branches and occasionally the pulmonary artery. Its cause is not known. Clinical manifestations are due to the intensity and location of arterial inflammation in the acute phase, as well as chronic arterial stenosis over time; 50% of patients have hypertension. Although TD appears to be more common in Asia, increasing numbers of patients of different races are observed in Western countries. The most important pathogenetic mechanism of hypertension seems to be through renal artery stenosis. We show here seven Caucasian hypertensive patients with TD and renovascular stenosis and arterial hypertension. One case was diagnosed in the acute phase of the disease, while in the others diagnosis was established in an advanced occlusive phase. Basic diagnosis was established by angiographic study, with biopsy confirmation in two cases. All patients had at least three of the six criteria listed as diagnostic of TD (by the American College of Reumatology). All patients had the following criteria: age of disease onset before 40 years (symptoms or findings related to TD), vascular bruits in different areas and all patients also had aortic and renal arterial stenosis with some lesions of the main aortic branches. Six of them had claudication of the extremities. We describe their clinical, analytical and angiographic features and also the therapeutic approach. We discuss the aetiopathogenic mechanisms of hypertension in this disease and suggest that TD is not an unusual cause of vasculorenal hypertension.

Recurrent pulmonary embolism in patients treated because of acute venous thromboembolism: a prospective study.

OBJECTIVE: To evaluate the risk of pulmonary embolism (PE) despite adequate heparin therapy in a large series of patients with acute deep venous thrombosis and/or pulmonary embolism. DESIGN: Prospective study. SETTING: University Hospital Germans Trias i Pujol, Badalona, Spain. MATERIALS: 348 patients admitted because of deep venous thrombosis in the lower limbs and/or pulmonary embolism. A baseline lung scan was obtained initially in every patient, whether the original diagnosis was PE or deep vein thrombosis (DVT). Repeat chest X-ray and lung scans were obtained routinely at 8 days of heparin onset. OUTCOME MEASURES: The primary trial endpoint was a finding of confirmed, clinically apparent recurrent PE; in addition, laboratory evidence of subclinical PE at the repeat scan was also considered. RESULTS: PE recurrences were found in 23/348 patients (7%). No significant differences were found in age and sex distribution, or in the degree of DVT proximity between patients who developed and those who did not develop recurrences. Recurrent PE was more commonly found in patients with scintigraphic evidence of PE on admission, irrespectively of the original diagnosis being DVT or PE (18/151 vs. 3/155; p = 0.0005, Fisher's exact test). Recurrences were also more common in patients in whom thrombosis developed in the absence of any known risk factor (10/70 vs. 13/278; p = 0.007). The logistic regression analysis confirmed the statistical significance of these two clinical variables. CONCLUSIONS: Pulmonary embolism despite adequate heparin therapy is not an uncommon event. It appears possible to identify a subgroup of patients at a higher risk, and, modify treatment accordingly.

[Surgical wound infection in patients undergoing extra-anatomical arterial surgery. A retrospective study]. / Infección de la herida quirúrgica en pacientes sometidos a cirugía arterial extraanatómica. Estudio retrospectivo.

We present a retrospective review of a series of patients from our Service submitted to surgical extra-anatomical grafts. Correlation between diverse variants and ulterior obliteration by thrombosis or infection of the surgical wounds is analyzed. The series included 133 patients surgically treated between 1986 and 1991. The studied variants were: sex, age, type of graft, the material used, length and type of anesthesia, presentation of hypotension during the surgical intervention, diabetes, platelet recount. Fourteen patients (11%) presented early graft obliteration and 15 (11%) presented an infection of their surgical wound. Only the platelet variant showed statistical differences in patients presenting infection. A high recount of platelets could be a factor risk of infection.

Venographic assessment of deep vein thrombosis and risk of developing post-thrombotic syndrome: a prospective study.

It is well known that patients with deep vein thrombosis (DVT) constitute a risk group for development of pulmonary embolism. However, the relation of DVT and the extent thereof with the subsequent sequelae (post-thrombotic syndrome) are insufficiently investigated. We have prospectively studied a series of consecutive patients admitted because of DVT on lower limbs, trying to correlate venographic findings during acute DVT with post-thrombotic (PTS) symptoms that develop later. Seventy-nine patients (84 limbs) with acute DVT were followed-up in our out-patient clinic at 4-monthly intervals for 3 years. At each visit patients were carefully examined regarding the appearance of PTS symptoms and/or signs from the DVT-affected leg. Three years after discharge, presence of PTS signs was assessed according to a simple scoring system. And then correlated to venographic findings during acute DVT. Patients were classified as having no (37 legs), mild (30 legs), or severe PTS signs (17 legs). Patients with popliteal vein involvement showed a significantly higher incidence of PTS 3 years later (P < 0.001). The risk of PTS also increased as DVT extent increased (P < 0.001). Nevertheless, the logistic regression analysis showed that DVT location explained all the differences (P < 0.001). In other words, DVT extent was overriden by the significance of DVT location, being popliteal the only location that showed a relevant contribution to the PTS incidence (95% confidence interval = 2.49-71.5).

[Complete reconstructions without intermediate anastomoses]. / Reconstrucciones completas sin anastomosis intermedias.

Results from 9 complete reconstructions without intermediate anastomosis (8 patients) are presented. In five cases a by-pass from femoral artery to the contralateral popliteal (infra or supra-rotuliar) arterial prosthesis was performed. In other case a by-pass from the aorta artery to the third popliteal section was placed. Other by-pass was performed from the branches of an axillo-bifemoral by-pass to the third popliteal section. The last case was an axillo-bi-popliteal by-pass. All the patients presented a severe ischemia (III and IV Fontaine stadii). Eight millimeter PTFE grafts were used. The distal anastomosis should always be performed in vessels with a low distal resistance.

[Arteriovenous fistulae of posttraumatic origin: apropos 7 cases]. / Fístulas arteriovenosas de origen postraumático: a propósito de siete casos.

We present our experience with arterio-venous traumatic fistulas. Seven cases, between 6 patients are reviewed. Respective etiologies were: 4 cases after an accidental traumatism, 2 cases produced by iatrogenicity and 1 case of idiopathic etiology. Respective localizations were: 6 cases at lower limbs (85.7%) and one case at cervical column (14.2%). All patients underwent surgical treatment. There was any case of mortality and treatment results were satisfactory in all cases. Patients were followed and, up to now, no recidives have been registered. follow-time ranged from 1.5 to more than 6 years.

Occult cancer in patients with deep venous thrombosis. A systematic approach.

The authors prospectively studied 113 consecutive patients with deep venous thrombosis of the lower extremities to determine the most appropriate workup study for searching for a hidden cancer. After a careful physical examination, the following routine tests were performed: erythrocyte sedimentation rate (ESR), whole blood counts, biochemistry, carcinoembryonic antigen (CEA) levels, chest radiograph, upper gastrointestinal endoscopy, abdominal ultrasound and computed tomography (CT) scan. If a malignant lesion was suspected, further appropriate studies were performed. After discharge, periodic follow-up was performed on all patients in the outpatient clinic. A malignant neoplasm was detected in 12 patients. Of these 12 patients, six were asymptomatic with the exception of experiencing thrombophlebitis. Cancer was found more commonly in patients with idiopathic deep vein thrombosis (DVT) (7 of 31 versus 5 of 82 patients with secondary DVT; P = 0.012), and in those patients with abnormal lactic dehydrogenase (LDH) levels (6 of 23 versus 6 of 90; P = 0.007). Abnormal CEA levels allowed diagnosis of two cases of colonic cancer (on colonoscopy). Both ultrasound and CT scan of the abdomen showed two cases of urinary bladder carcinoma at a very early stage. Furthermore, two cases of adenomatous polyps in colon were found, a condition considered by most authors to be a colorectal cancer precursor. In addition, there were five patients with large benign pelvic tumors, and two patients with absent inferior vena cava. The most striking finding was that some cases of cancer were at a very early stage. It was concluded that blood cell counts, LDH, CEA, chest radiograph, and abdominal ultrasonography (or CT scan) should be routinely performed on all patients with deep venous thrombosis (particularly those with idiopathic DVT). Malignancy would not have been recognized in some patients if these tests had not been performed.

Occlusive arterial disease as a form of presentation of homocystinuria.

Homocystinuria was first described in 1962. The disease affects several systems including the eyes, skeletal and nervous and vascular systems. We present the case of a 28-year old woman who presented with a severe occlusive arteriopathy. Screening for the most usual causes of arterial disease in young patients was negative, but a study of aminoaciduria and column chromatography confirmed the diagnosis of B6-responsive homocystinuria. Although it was necessary to amputate her left leg, the patient remains asymptomatic 16 months after B6 therapy was started.

[Heparin-induced hemorrhage in the treatment of venous thromboembolism]. / Hemorragias por heparina en el tratamiento del tromboembolismo venoso.

Retrospective study about the frequency of hemorrhagic complications (258 patients) in the treatment of venous thrombosis and/o pulmonary embolism, with heparin. Heparin was intermittently administered by endovenous way and controlled during the ten first days. Mostly of the big hemorrhages happened between the seventh and the tenth day, in digestive and urinary system mainly.

[Compression of the iliac vein and occult neoplasm]. / Compresión de la vena ilíaca y neoplasia oculta.

Three cases demonstrating the possible venous system compression by some neoplasias, feigning an nonexistent thrombosis, are presented. Author stands out the fitness of to investigate possible neoplasias in thrombosis without apparent causality.

Hydatid cyst fistula into the aorta.

A case is presented of fistula formation between a primary hydatid cyst and the abdominal aorta which we believe is the first in the world literature. The patient underwent surgery with a diagnosis of aneurysm of the coeliac trunk. During the operation the presence was discovered of a hydatid cyst opening into the aorta. It was dealt with by partial resection and closing of the communication. Three months later the patient was readmitted with a new bleeding episode which resulted in a fatal outcome.