Registro de actividades de la Sociedad Española de Angiología y Cirugía Vascular, año 2019 / Registry of activities of the Spanish Society of Angiology and Vascular Surgery, year 2019

Objetivo: describir la actividad asistencial del año 2019 de los servicios/unidades de angiología y cirugía vascular en España. Pacientes y métodos: estudio transversal con encuesta a 107 centros sobre procedimientos quirúrgicos y exploraciones vasculares realizados en 2019. Análisis descriptivo de resultados y comparación de la ratio de actividad /100 000 habitantes con 2018. Resultados: respondieron 44 servicios (41,1 %), 4 de ámbito privado. De los 42 servicios docentes, respondieron 29 (65,9 %), un 65,9 %. En los servicios que respondieron se produjeron 26 960 ingresos, el 46,4 % urgentes y el 53,5 % programados (estancia media: 6,8 días). En la mayoría de sectores no hubo cambios significativos en la ratio/100 000 habitantes, salvo un aumento moderado (10,7 frente a 9,4) en el sector distal, tanto en procedimientos quirúrgicos (3,3 frente a 2,8) como en endovasculares (7,3 frente a 6,6). Descenso moderado de procedimientos endovasculares en los troncos supraaórticos (1,4 frente a 1,6). Hubo una disminución moderada de procedimientos quirúrgicos en aorta torácica (0,17 frente a 0,20) y abdominal (2,38 frente a 2,78), que contrastó con un aumento moderado en procedimientos endovasculares abdominotorácicos (0,40 frente a 0,35). En las arterias viscerales se encontró una disminución relevante de procedimientos endovasculares (0,89 frente a 1,16) y un aumento moderado de los quirúrgicos (0,99 frente a 0,89). En el sector aortoilíaco hubo un aumento moderado de procedimientos endovasculares (6,8 frente a 5,8). En 2019 también se encontró una disminución relevante en el número de procedimientos endovasculares relacionados con los accesos de hemodiálisis (1,2 frente a 1,5), un descenso moderado en el número de amputaciones mayores (6,9 frente a 7,8) y un descenso relevante de actividad sobre las malformaciones (0,32 frente a 0,59). Se encontró un aumento moderado en la actividad global sobre el sector venoso con respecto a la de 2018 (93,3 vs. 80,3)...(AU)

Introduction and objective: to describe the healthcare activity of the Angiology and Vascular Surgery services/units in Spain in 2019.Patients and methods: cross-sectional study with a survey of 107 centers on surgical procedures and vascularexplorations performed in 2019. Descriptive analysis of results and comparison of the activity ratio / 100,000inhabitants with 2018.Results: 44 services responded (41.1 %), with only 4 being private. Of the 42 teaching services, 29 (65.9 %) respon-ded, representing 65.9 % of the total. In the services that responded, there were 26,960 admissions, 46.4 % urgentand 53.5% scheduled, with an average stay of 6.8 days. Global surgical activity in arterial surgery in 2019 was similarto that of 2018. In most sectors there were no significant changes in the ratio / 100,000 inhabitants, except for amoderate increase (10.7 vs. 9.4) in the distal sector , finding the increase in both surgical procedures (3.3 vs. 2.8) andendovascular procedures (7.3 vs. 6.6). Furthermore, a moderate decrease in endovascular procedures was foundin the supra-aortic trunks (1.4 vs. 1.6). There was a moderate decrease in surgical procedures in the thoracic aorta(0.17 vs. 0.20) and abdominal (2.38 vs. 2.78), which contrasted with a moderate increase in thoraco-abdominalendovascular procedures (0.40 vs. to 0.35). In visceral arteries, a relevant decrease in endovascular procedures wasfound (0.89 vs. 1.16) and a moderate increase in surgical procedures (0.99 vs. 0.89). In the aorto-iliac sector therewas a moderate increase in endovascular procedures (6.8 vs. 5.8). In 2019, a relevant decrease was also found inthe number of endovascular procedures related to hemodialysis accesses (1.2 vs. 1.5), and a moderate decreasein the number of major amputations (6.9 vs. 7.8)...(AU)

Radiation Exposure in Endovascular Surgery According to Complexity: Protocol for a Prospective Observational Study.

In the past decades, we have witnessed tremendous developments in endovascular surgery. Nowadays, highly complex procedures are performed by minimally invasive means. A key point is equipment improvement. Modern C-arms provide advanced imaging capabilities, facilitating endovascular navigation with an adequate open surgical environment. Nevertheless, radiation exposure remains an issue of concern. This study aims to analyze radiation used during endovascular procedures according to complexity, comparing a mobile X-ray system with a hybrid room (fixed X-ray system). This is an observational and prospective study based on a cohort of non-randomized patients treated by endovascular procedures in a Vascular Surgery department using two imaging systems. The study is planned for a 3-year duration with a recruitment period of 30 months (beginning 20 July 2021) and a 1-month follow-up period for each patient. This is the first prospective study designed to describe the radiation dose according to the complexity of the procedure. Another strength of this study is that radiologic variables are obtained directly from the C-arm and no additional measurements are required for feasibility benefit. The results from this study will help us determine the level of radiation in different endovascular procedures, in view of their complexity.

Multicenter Comparative Analysis of Late Open Conversion in Patients With Adherence and Nonadherence to Instructions for Use Endovascular Aneurysm Repair.

PURPOSE: The widespread adoption of endovascular aneurysm repair (EVAR) as preferred treatment modality for abdominal aortic aneurysm (AAA) has enlarged the number of patients needing open surgical conversion (OSC). The relationship between adherence to Instructions For Use (IFU) and EVAR long-term outcomes remains controversial. The aim of this study is to compare preoperative differences and postoperative outcomes between EVAR patients not adjusted to IFU and adjusted to IFU who underwent OSC. METHODS: This multicenter retrospective study reviewed 33 explanted EVARs between January 2003 and December 2019 at 14 Vascular Units. Patients were included if OSC occurred >30 days after implantation and excluded if explantation was performed to treat an endograft infection, aortic dissection, or traumatic transections. Variables analyzed included baseline characteristics, adherence to IFU, implant and explant procedural details, secondary reinterventions, and postoperative outcomes. RESULTS: Fifteen explanted patients (15/33, 45.5%) were identified not accomplished to IFU (out-IFU) at initial EVAR vs 18 explanted patients adjusted (in-IFU). During follow-up, a mean of 1.73±1.2 secondary reinterventions were performed, with more type I endoleaks treated in the subgroup out-IFU: 16.7% vs 6.3% in-IFU patients and more type III endoleaks (8.3% vs 0%). Patients out-IFU had shorter mean interval from implant to explant: 47.60±28.8 months vs 71.17±48. Type II endoleak was the most frequent indication for explantation. Low-flow endoleaks (types II, IV, V) account for 44% of indications for OSC in subgroup of patients in-IFU, compared with 13.3% in patients out-IFU and high-flow endoleaks (types I and III) were the main indication for patients out-IFU (33.3% vs 16.7% in-IFU). Total endograft explantation was performed in 57.5% of cases (19/33) and more suprarenal clamping was required in the subgroup out-IFU. Overall, 30-day mortality rate was 12.1% (4/33): 20% for patients out-IFU and 5.6% in-IFU. CONCLUSIONS: In our experience, type II endoleak is the most common indication for conversion and differences have been found between patients treated outside IFU with explantation taking place earlier during follow-up, mainly due to high-flow endoleaks and with higher mortality in comparison with patients adjusted to IFU. Ongoing research is required to delve into these differences.

COVID-19 and aorto-enteric fistula.

We present the case of a 72-year-old male with upper gastrointestinal bleeding. He had been discharged from hospital two weeks before after severe COVID-19 infection, treated with lopinavir-ritonavir (L-R), hydroxychloroquine, tocilizumab, and methylprednisolone. On presentation, he was in hypovolemic shock. Esophagogastroduodenoscopy showed an ulcer in the third duodenal portion, which was sclerosed and hemodynamic stability was recovered. A scan was performed as it was in an atypical location for ulcers, showing an aortic aneurysm in close relationship to the duodenum, suggesting a primary aortoenteric fistula (PAEF).

National Diagnostic Reference Levels for Endovascular Aneurysm Repair and Optimisation Strategies.

OBJECTIVE: The International Commission on Radiological Protection (ICRP) has highlighted the large number of medical specialties using fluoroscopy outside imaging departments without programmes of radiation protection (RP) for patients and staff. Vascular surgery is one of these specialties and endovascular aneurysm repair (EVAR) is one of the most challenging procedures requiring RP guidance and optimisation actions. The recent European Directive on Basic Safety Standards requires the use and regular update of diagnostic reference levels (DRL) for interventional procedures. The objective of the study was to know the doses of patients undergoing EVAR with mobile Xray systems and with hybrid rooms (fixed Xray systems), to obtain national DRLs and suggest optimisation actions. METHODS: The Spanish Chapter of Endovascular Surgery launched a national survey that involved hospitals for 10 autonomous communities representing the 77% of the Spanish population (46.7 million inhabitants). Patient dose values from mobile Xray systems were available from nine hospitals (sample of 165 EVAR procedures) and data from hybrid rooms, from seven hospitals, with dosimetric data from 123 procedures. The initial national DRLs have been obtained, as the third quartile of the median values from the different centres involved in the survey. RESULTS: The proposed national DRLs are 278 Gy cm2 for hybrid rooms and 87 Gy cm2 for mobile Xray systems, and for cumulative air kerma (cumulative AK) at the patient entrance reference point, 1403 mGy for hybrid rooms, and 292 mGy for mobile systems. CONCLUSION: An audit of patient doses for EVAR procedures to identify optimised imaging protocol strategies is needed. It is also appropriate to evaluate the diagnostic information required for EVAR procedures. The increase by a factor of 3.2 (for kerma area product) and 4.8 (for cumulative AK) in the DRLs needs to be justified when the procedures are performed in the hybrid rooms rather than with mobile Xray systems.

Registro de actividades de la Sociedad Española de Angiología y Cirugía Vascular, año 2018 / Register of activities of the Spanish Society of Angiology and Vascular Surgery, 2018

OBJETIVO: describir la actividad asistencial del año 2018 de los servicios/unidades de angiología y cirugía vascular en España. PACIENTES Y MÉTODOS: estudio transversal con encuesta a 107 centros sobre procedimientos quirúrgicos y exploraciones vasculares realizados en 2018. Análisis descriptivo de resultados y comparación de la ratio de actividad / 100 000 habitantes respecto al año 2016. RESULTADOS: respondieron 53 servicios (49,5%). De los 42 servicios docentes, respondieron 33 (78,5%), un 62,2% del total. En los servicios que respondieron se produjeron 36 321 ingresos, con una estancia media de 7,1 días. La actividad quirúrgica global en cirugía arterial en 2018 fue semejante a la de 2016. Hubo sectores sin cambios significativos en la ratio / 100 000 habitantes. En 2018 se encontró una disminución relevante en el número de procedimientos relacionados con los accesos de hemodiálisis (17,8 frente a 25,3). La actividad en amputaciones mayores fue semejante (7,8 frente a 7,5), con un aumento moderado de las menores (13,5 frente a 11,6). En la tasa de actividad sobre malformaciones se encontró una disminución relevante (0,5 frente a 1,5). Por otro lado, se encontró un aumento relevante en la actividad global sobre el sector venoso en 2018 con respecto a la de 2016 (80,3 frente a 66,6). CONCLUSIÓN: se encontró una disminución ligera de la actividad quirúrgica arterial global debido a la disminución moderada de procedimientos endovasculares, sobre todo aórticos. La actividad quirúrgica venosa global ha aumentado de forma relevante, con gran aumento de procedimientos endovasculares. Las exploraciones vasculares presentaron una disminución relevante. Con relación a 2016, aumentó la participación, lo que puede condicionar la interpretación de los resultados

OBJECTIVE: cross-sectional study using a questionnaire sent to 107 centres on surgical procedures and vascular examinations performed in 2018. A descriptive analysis of results and comparison of the activity ratio/100,000 population with 2016 is also presented. PATIENTS AND METHODS: cross-sectional study using a questionnaire sent to 107 centres on surgical procedures and vascular examinations performed in 2018. A descriptive analysis of results and comparison of the activity ratio/100,000 population with 2016 is also presented. RESULTS: responses were received from 53 department (49.5%), including only 3 private centres. Of the 42 teaching centres, 33 responses were received (78.5%), corresponding with a 62.2% of all centres. According to received data, in 2018 there were 36,321 admissions (of which 34.3% were emergency and 65.7% were elective), with a mean hospital stay of 7.1 days. The overall arterial surgery activity in 2018 was similar to 2016, although there was a moderate decrease in the endovascular procedures rate. In some segments there were no significant changes in the ratios/100,000 population: 8.9 vs. 9.3 in supra-aortic trunks; 23.6 vs. 23.5 in the femoropopliteal segment and 9.4 vs. 10.3 in infrapopliteal segment. A relevant increase of endovascular procedures in supra-aortic trunks was found (1.6 vs. 1.2). There was a moderate decrease in the activity rate in thoracic aorta (1.53 vs 1.90), thoracic-abdominal aorta (0.43 vs. 0.49) and abdominal aorta (8.7 vs. 10.8), whereas the decrease in obstructive pathology of aortic-iliac segmen twas relevant (9.2 vs. 13.1). In 2018 there was also a moderate increase of activity in the visceral arteries (2.05 vs. 1.81), in contrast to a relevant decrease in the number of hemodialysis access procedures (17.8 vs. 25.3). Compared to 2016, major amputations rate was similar (7.8 vs. 7.5), with a moderate increase of minor amputations (13.5 vs. 11.6). There was also a relevant decrease in malformations (0.5 vs. 1.5). On the other hand, a relevant increase in overall venous surgery activity was found in 2018 (80.3 vs. 66.6). There increase was found in varicous veins procedures and also in thrombotic disease procedures. A relevant decrease of the vascular examination ratio/10000 population was found (607.9 vs. 850.6). CONCLUSION: a mild decrease in the overall arterial surgical activity was found because of the moderate decrease in endovascular procedures, especially those related to the aorta. The overall venous surgical activity increased significantly because of a higher number in endovascular procedures. There was a relevant decrease of vascular examinations. Compared to 2016, there was an increase in participating centres, which may condition the interpretation of the results

Registro de actividades de la Sociedad Española de Angiología y Cirugía Vascular, año 2016 / Register of activities of the Spanish Society of Angiology and Vascular Surgery, 2016

OBJETIVO: describir la actividad asistencial del año 2016 de los servicios/unidades de angiología y cirugía vascular en España. PACIENTES Y MÉTODOS: estudio transversal con encuesta a 107 centros sobre procedimientos quirúrgicos y exploraciones vasculares realizados en 2016. Análisis descriptivo de resultados y comparación de la ratio de actividad / 100 000 habitantes con 2014. RESULTADOS: respondieron 41 servicios, ninguno en la medicina privada. La actividad quirúrgica global en cirugía arterial en 2016 fue semejante a la de 2014, con variaciones en la ratio / 100 000 habitantes según el sector. Hubo un aumento relevante de la tasa actividad en aorta torácica (1,9 frente a 1,1), aorta toracoabdominal (0,49 frente a 0,38) y arterias viscerales (1,8 frente a 1,3). Hubo también un aumento moderado de actividad en los aneurismas de aorta abdominal (10,8 frente a 9,5) y en la patología obstructiva del sector aortoilíaco (13,1 frente a 11,1). Prácticamente en todas ellas la ratio de procedimientos de cirugía convencional fue inferior, mientras que la de cirugía endovascular aumentó en algunos. En 2016 se encontró un aumento relevante en el número de accesos de hemodiálisis (25,3 frente a 20,6). La actividad en amputaciones mayores y menores fue semejante (7,5 frente a 7,3 y 11,6 frente a 10,7). No se encontró diferencia significativa en la actividad global sobre el sector venoso en 2016 con respecto a la de 2014 (66,6 frente a 65,4), si bien hubo un aumento moderado de procedimientos de cirugía endovascular para tratamiento de varices. También se encontró un aumento moderado de la ratio / 100 000 habitantes de exploraciones vasculares (850,6 frente a 760,5). CONCLUSIONES: se encontró un aumento ligero de la actividad quirúrgica arterial global, con un incremento de procedimientos en algunos territorios; la actividad venosa global se ha mantenido, con gran aumento de procedimientos endovasculares para el tratamiento de varices; también se encontró aumento de las exploraciones vasculares. Con relación a 2014, disminuyó de forma considerable la participación, lo que condiciona el sesgo en la interpretación de los datos

OBJECTIVE: to describe the assistant activity of the year 2016 of the services / units of Angiology and Vascular Surgery in Spain. PATIENTS AND METHODS: a cross-sectional study with a survey of 107 centers on surgical procedures and vascular examinations carried out in 2016. A descriptive analysis of results and comparison of the activity ratio/ 100,000 inhabitants with 2014 was performed. RESULTS: forty-one (38.3%) departments of vascular surgery (27 training units, 71%) in Spain answered this survey. None from private medicine. Regarding to these units there were 29,046 admissions, 36.3% being urgent and 63.7% scheduled, with an average stay of 6.7 days. On the waiting list there was a predominance of venous pathology over arterial (5,783 vs. 1,187). The global surgical activity in arterial surgery in 2016 was similar to that of 2014 with variations in the ratio/ 100,000 inhabitants according to the arterial sector: 9.39 vs. 9.35 in supraaortic trunks; 23.5 vs. 21.9 in the femoropopliteal arteries and 10.3 vs. 9.8 in the distal sector. There was a significant increase in the activity rate in thoracic aorta (1.9 vs. 1.1), thoracoabdominal aorta (0.49 vs. 0.38) and visceral arteries (1.8 vs. 1.3). There was also a moderate increase in activity in abdominal aortic aneurysms (10.8 vs. 9.5) and in obstructive pathology of the aorto-iliac sector (13.1 vs. 11.1). Practically in all of them the ratio of conventional surgery procedures was lower, while that of endovascular surgery increased in some. In 2016, a significant increase was found in the number of hemodialysis accesses (25.3 vs. 20.6). The activity in major and minor amputations was similar (7.5 vs. 7.3 and 11.6 vs. 10.7). There was no significant difference in the overall activity on the venous sector in 2016 compared to 2014 (66.6 vs. 65.4), although there was a moderate increase in endovascular surgery procedures for varicose veins. There was also a moderate increase in the ratio/ 100,000 inhabitants of vascular examinations (850.6 vs. 760.5). CONCLUSIONS: a slight increase in global arterial surgical activity was found, with an increase in procedures in some territories. Global venous activity has been maintained, with a large increase in endovascular procedures for the treatment of varicose veins. An increase in vascular examinations was also found. In relation to 2014, participation decreased considerably, which determines the bias in the interpretation of the results

Endovascular Treatment of Descending Thoracic Aortic Pathology: Results of the Regis-TEVAR Study.

BACKGROUND: Endovascular techniques have become an essential tool for treatment of thoracic aortic pathology. The objective of this study was to analyze indications and results of thoracic endovascular aortic repair (TEVAR) in vascular surgery units, through a retrospective and multicentric national registry called Regis-TEVAR. METHODS: From 2012 to 2016, a total of 287 patients from 11 vascular surgery units, treated urgently and electively, were recruited consecutively. The primary variables analyzed are mortality, survival, and reintervention rate. The following indications for TEVAR were also analyzed: aortic dissections, thoracic aneurysms, traumatisms, and intramural hematomas or penetrating ulcers, as well as results and postoperative complications in accordance with each indication. RESULTS: Of the 287 TEVAR performed (239 men, mean age 64.1 ± 14.1 years), 155 were because of aortic aneurysm (54%), 90 because of type B aortic dissection (31.4%), 36 because of traumatic aortic rupture (12.5%), and 6 because of penetrating ulcers or intramural hematomas (2.1%). Overall mortality at 30 days was 11.5% (18.5% in urgent and 5.3% in elective), being higher in dissections (13.3%). The median actuarial survival was 73% at 4 years. The stroke rate was 3.1%, and the rate of spinal cord ischemia was 4.9%. Aortic reoperations were necessary in 23 patients (8.1%). CONCLUSIONS: This registry provides complete and reliable information on real clinical practice of TEVAR in Spain, with results similar to international series of open surgery. In accordance with these data, TEVAR can be performed with acceptable morbidity and mortality and with low rates of postoperative complications.

Manejo de pseudoaneurisma de arteria cervical transversa / Management of transverse cervical artery pseudoaneurysm

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Contrast-Induced Nephropathy: A Fact or Fiction in Lower Limb Revascularization?

INTRODUCTION: Contrast-induced nephropathy (CIN) is defined as an increase >25% of serum creatinine from baseline, occurring in 24-48 hours after exposure to contrast, while alternative explanations for renal impairment have been excluded. The volume administered directly relates to risk, increasing by 12% per 100 mL of contrast. According to the series, its incidence varies between 3.3% and 8% in patients without renal damage and 12-50% in patients with chronic kidney disease (CKD) and/or diabetes mellitus (DM). The purpose of this study is to determine the incidence of CIN in endovascular revascularization of lower limbs in our center, where we apply the ALARA concept (As Low As Reasonably Achievable) to the use of contrast. MATERIAL AND METHODS: 163 patients who underwent endovascular revascularization procedures in lower limbs were included in this prospective observational study between February 2013 and April 2015. They were classified according to clinical stage and presence of DM and/or CKD. Data included serum creatinine values preoperative and postoperative, type and volume of contrast used. Patients on hemodialysis and those without sufficient analytical data were excluded. Chi-squared test and Student t-test were used for data analysis. P < 0.05 was considered statistically significant. RESULTS: 109 patients were enrolled, with 67% of DM and 31.5% of CKD. CIN incidence was 3.7% in patients without DM neither CKD, in DM was 6.8% and 12.5% in CKD. Mean creatinine presurgery was 97.96 and postsurgery 97.07, finding no significant differences between them (P = 0.753). Medium-contrast volume was 37.43 mL ± 22.3. The worsening variable (creatinine postsurgery minus creatinine presurgery) was evaluated according to clinical stage, DM, or CKD, being not significant in either group. CONCLUSIONS: In our experience, the dose administered of contrast was not related to the existence of postprocedure CIN, due to the policy of optimizing the use of contrast.