Results of Infrainguinal Bypass in Acute Limb Ischaemia.

OBJECTIVE/BACKGROUND: To assess the outcomes of infrainguinal bypass performed for acute limb ischaemia, as well as the predictors of patency, mortality, and amputation. METHODS: This was a retrospective cohort study of patients undergoing infrainguinal bypass between 1998 and 2014. The cohort was stratified according to the indication for surgery into two groups: group A (acute limb ischaemia) and group B (chronic lower extremity ischaemia). Comparative analysis was performed on comorbidities, surgical technique, and outcomes, as well as prognostic factors in group A. RESULTS: In total, 702 bypasses were performed (group A, n = 107; group B, n = 595). Differences between groups were detected in age (65.9 vs. 70.9 years; p = .03), diabetes (16% vs. 49%; p < .01), renal insufficiency (6% vs. 13%; p = .05), stroke (7% vs. 14%; p = .04), and coronary artery disease (13% vs. 28%; p < .01). Patients with acute limb ischaemia more often required general anaesthesia (47% vs. 12%; p < .01) and a short bypass was more often performed (32% vs. 7%; p < .01). Median follow up was 23 and 24 months for groups A and B, respectively. No differences were found in patency rates at 1, 12, and 24 months between groups, but group B had a higher re-intervention rate during follow up. Primary patency in group A was 84%, 63%, and 58%, and in group B it was 88%, 62%, and 53% at 1, 12, and 24 months, respectively (p = .77). Assisted primary patency in group A was 85%, 72%, and 67%, and in group B it was 90%, 74%, and 66% at 1, 12, and 24 months, respectively (p = .61). Secondary patency in group A was 90%, 78%, and 75%, and in group B it was 94%, 80%, and 74% at 1, 12, and 24 months, respectively (p = .80). The freedom from re-intervention rate in group A was 91%, 74%, and 68%, and in group B it was 92%, 76%, and 71%, respectively (p = .04). Acute limb ischaemia was an independent risk factor for amputation (odds ratio [OR] 4.96, 95% confidence interval [CI] 1.74-14.09; p < .01) and mortality (OR 4.13, 95% CI 1.53-11.14; p = .01) at 30 days. In group A, female sex, prosthetic conduit, and need of distal thrombectomy were independently associated with worse patency rates. Poor intra-operative runoff was correlated with higher amputation rates. CONCLUSION: Among those undergoing infrainguinal bypass, patients who present with acute limb ischaemia constitute a subset showing higher early rates of amputation and death. In this subset of patients, worse outcomes may be expected for women, prosthetic conduits, need for distal thrombectomy, and patients with poor intra-operative runoff.

Evolución de la arteria ilíaca ectásica no tratada tras la reparación endovascular del aneurisma de aorta / Evolution of the untreated ectactic iliac artery after endovascular aortic aneurysm repair

OBJETIVOS: Determinar el crecimiento de la arteria ilíaca común (AIC) ectásica no tratada durante la reparación endovascular del aneurisma aórtico (EVAR), por existir zonas de anclaje proximales más favorables. MATERIAL Y MÉTODOS: Estudio de cohortes retrospectivo, incluyendo pacientes tratados por aneurisma de aorta abdominal de forma electiva, con un seguimiento de 5 años. Se estudiaron los casos con anclaje en AIC, registrando los diámetros máximos basales y a 1, 2, 3, 4 y 5 años en el segmento de AIC no tratado, excluyendo aquellos casos con anclaje en la arteria ilíaca externa. Se analizó la muestra en función de: A) Diámetro basal AIC: grupo 1 (G1) (n = 67): < 16 mm; grupo 2 (G2) (n = 23): ≥16 mm. B) Zona de anclaje: 2/3 proximales de AIC (n = 40); 1/3 distal (n = 50). RESULTADOS: Un total de 56 pacientes incluidos en el estudio, con 90 ilíacas analizadas. A) Los diámetros medios en G1 y G2 (basal, 3, 5 años) fueron: 12,8; 13,1; 13,3 vs. 18,0; 19,4; 20,3 mm, con un crecimiento 1,8 mm mayor a 5 años en G2 (p < 0,001). No se registraron fugas tipo IB durante el seguimiento. B) Existió una interacción significativa (p = 0,01) entre la localización del anclaje y el diámetro basal para el crecimiento ilíaco: en AIC ≥ 16 mm el anclaje en el tercio distal fue protector para crecimiento (p = 0,04). CONCLUSIONES: El crecimiento tras EVAR de la AIC no tratada es mayor en las AIC ectásicas. En estos casos, el anclaje en el tercio distal puede disminuir la tasa de crecimiento. No obstante, si el anclaje es más favorable en los 2/3 proximales de la AIC dicho crecimiento no se traduce en mayor número de complicaciones

OBJECTIVE: To assess the enlargement of ectatic common iliac arteries (CIA) which are not covered during endovascular aortic aneurysm repair (EVAR) due to the existence of more favorable proximal sealing zones. MATERIAL AND METHODS: Patients who underwent elective EVAR, with a 5 year follow up were included in a retrospective cohort study. Only cases with distal sealing zones in CIA were studied, recording a maximum basal diameter at the non-covered segment of CIA, and at 1, 2, 3, 4 and 5 years. Cases with distal sealing on external iliac artery were excluded. The sample was analyzed according to: A) CIA baseline diameter: group 1 (G1) (n = 67): < 16 mm; group 2 (G2) (n = 23): ≥16 mm. B) Sealing zone: proximal two thirds of CIA (n = 40); distal third (n = 50). RESULTS: A total of 56 patients were included in the study, with 90 CIA analyzed. A) Mean diameters in G1 and G2 (baseline, 3, 5 years) were: 12.8, 13.1, 13.3 versus 18.0, 19.4, 20.3 mm, respectively, with a 1.8 mm greater enlargement for G2 (P<.001) at 5 years. No type IB endoleaks were registered during follow up. B) A significant interaction was observed (P=.01) between the distal sealing zone and basal diameter for iliac enlargement: in CIA ≥16 mm distal sealing in the distal third of the CIA was protective for iliac enlargement (P=.04). CONCLUSIONS: Iliac enlargement in non-treated segments of CIA after EVAR is greater in ectatic arteries. In these cases, distal sealing on the distal third of the CIA can decrease enlargement rate. However, if a more favorable zone for sealing exists proximally, the enlargement of the ectatic CIA does not result in a higher rate of complications

Resultados del bypass infrainguinal protésico en isquemia crítica: factores asociados a permeabilidad y salvamento de la extremidad / Outcomes of prosthetic bypass grafts in critical limb ischemia: Predictors of patency and limb salvage

OBJETIVOS: Los objetivos de este estudio son analizar los resultados del bypass protésico en isquemia crítica, así como evaluar posibles factores asociados a la permeabilidad y el salvamento de la extremidad. MATERIAL Y MÉTODOS: Estudio de cohortes retrospectivo de pacientes con isquemia crítica de miembros inferiores tratados mediante bypass infrainguinal protésico entre 1997-2013 en nuestro centro. Registramos factores preoperatorios e intraoperatorios, dividiendo la muestra en 3 grupos según la localización de la anastomosis distal: primera porción de la arteria poplítea (POP1), tercera porción de la arteria poplítea (POP3) o vaso distal. Analizamos permeabilidad primaria, primaria asistida, secundaria, salvamento de la extremidad y supervivencia. El análisis estadístico de variables se realizó por grupos según test habituales, Kaplan-Meier para permeabilidad, salvamento de la extremidad y supervivencia. El análisis univariable y multivariable de factores asociados a los resultados se llevó a cabo mediante regresión de Cox. RESULTADOS: Se analizaron 154 bypass protésicos, divididos en POP1 36,4% (n = 56), POP3 50% (n = 77) y vaso distal 13,6% (n = 21). Encontramos diferencias en la edad media (POP1 68,9 años, POP3 77,2 años, distal 76,8 años; p < 0,001). Seguimiento mediano: 11 meses. Obtuvimos mejores resultados en POP1 y peores en vaso sural para permeabilidad y salvamento de la extremidad (Log Rank P1 0,004, P1A 0,001, P2 0,001 y SE 0,025), sin diferencias en la supervivencia (Log Rank 0,068). Identificamos cardiopatía isquémica y anastomosis en vaso distal como factores de riesgo independientes para permeabilidad y salvamento de la extremidad. Los pacientes con mayor edad y aquellos con insuficiencia renal crónica presentaron mayor mortalidad. CONCLUSIONES: El bypass infrainguinal protésico ofrece resultados aceptables en isquemia crítica, siendo esperable un peor pronóstico en pacientes con cardiopatía isquémica y en bypass realizado a vasos distales

OBJECTIVES: To assess the outcomes of prosthetic bypass grafts in critical limb ischemia, as well as to determine the predictors of patency and limb salvage. MATERIALS AND METHODS: Retrospective cohort study of patients with critical limb ischemia undergoing a prosthetic infrainguinal bypass graft between 1997 and 2013 in a single centre. The pre- and post-operative data were collected, and the cohort was divided into 3 groups according to the location of the distal anastomosis: Above-knee popliteal artery (POP1), below-knee popliteal artery (POP3), or femorodistal. An assessment was made of the primary patency, assisted primary patency, secondary patency, limb salvage, and survival. Stratified statistical analysis using the Kaplan-Meier for patency, limb salvage and survival. Univariate and multivariate analysis of risk factors associated with the results using Cox regression. RESULTS: A total of 154 prosthetic graft bypass, divided into POP1 36.4% (n = 56), POP3 50% (n = 77), and femorodistal 13.6% (n = 21). Differences were found in mean age (POP1 68.9 years, POP3 77.2 years, femorodistal 76.8 years; P < .001). Median follow-up was 11 months. The best outcomes were found in POP1, and the worse in femorodistal in terms of patency and limb salvage (Log Rank P1 0.004, P1A 0.001, P2 0.001 and SE 0.025), with no differences in survival time (Log Rank 0.068). Coronary artery disease and femorodistal bypass were independent risk factors in patency and limb salvage. Older patients and those with chronic renal failure had higher mortality rates. CONCLUSIONS: Prosthetic infrainguinal bypass graft has fairly good outcomes in critical limb ischemia. The worst outcomes may be expected in patients with coronary artery disease and femorodistal bypass

Evolución de la función renal en la cirugía del aneurisma de aorta abdominal con clampaje suprarrenal / Evolution of renal function in abdominal aortic aneurysm surgery with suprarenal cross-clamping

Objetivo: Analizar los efectos del clampaje suprarrenal (CSR) frente al clampaje infrarrenal (CIR) en la evolución de la función renal en la cirugía del aneurisma de aorta abdominal (AAA). Material y método: Estudio de cohortes retrospectivo de los AAA tratados mediante cirugía abierta electiva entre 1998 y 2011. Se analizó la creatinina sérica (mg/dl) preoperatoria y a las 24, 48, 72, 96 h postoperatorias y al alta. Se definió deterioro de la función renal como una creatinina > 2 mg/dl en los pacientes con una creatinina basal normal o un aumento del doble de la creatinina basal en los pacientes con IRC previa. Se definió deterioro del filtrado glomerular (FG) como una disminución > 25%. Análisis multivariable de la evolución de la función renal. Resultados: Se analizaron 464 AAA, 359 (77,4%) con CIR y 105 (22,6%) con CSR. La prevalencia de IRC preoperatoria fue similar entre ambos grupos. El tipo de clampaje no se asoció a deterioro de la función renal (CSR = 8,6% vs. CIR = 4,7%; p = 0,13) y sí al deterioro del FG (CSR = 27,6% vs. CIR = 13,4%; p = 0,001). El tiempo de clampaje, la pérdida sanguínea y la IRC preoperatoria fueron factores de riesgo independientes para deterioro de la función renal. El tipo de clampaje aumentó el riesgo de deterioro de la función renal a partir de los 30 min (p = 0,001), asociándose a deterioro del FG (OR 2,04; IC 95% 0,94-4,47) de forma independiente. Conclusión: Con CSR inferiores a 30 min, en pacientes con creatinina normal, no es previsible un deterioro de la función renal. Con IRC previa o si se espera un CSR prolongado, es esperable un deterioro de la función renal, por lo que deberían valorarse métodos de protección renal (AU)

Objective: To analyse the effects of suprarenal cross-clamping (SC) as opposed to the infrarenal position (IC) in the evolution of the renal function abdominal aorta aneurysm (AAA) surgery. Material and method: A retrospective cohort study of AAAs treated by elective open surgery between 1998 and 2011. The preoperative level of serum creatinine (mg/dL) was determined and compared to postoperative level at 24, 48, 72 and 96 hours, and on discharge. A deterioration in the renal function was defined as a creatinine > 2 mg/dL in patients with a normal baseline creatinine level or an increase of double the baseline creatinine in patients with a previous chronic renal insufficiency (CRI). A deterioration of the glomerular filtrate (GF) was defined as a > 25% decrease. Multivariable analysis was performed on the evolution of the renal function. Results: A total of 464 AAA’s were analysed, 359 (77.4%) with IC, and 105 (22.6%) with SC. The prevalence of preoperative CRI was similar in both groups. The type of clamp was not associated with a deterioration in the renal function (SC = 8.6% vs. IC = 5.7%; p = 0.13) but was associated with a deterioration of the GF (SC = 27.6% vs. IC = 13.4%; p = 0.001). The time the clamp was in place, the blood loss, and the preoperative CRI were independent risk factors for the deterioration of the renal function. The type of clamp increased the risk of deterioration of the renal function beyond 30 minutes (p = .001), being independently associated with a deterioration in the GF (OR 2.04; 95% CI: 0.94-4.47). Conclusion: With SC less than 30 min, in patients with a creatinine level, a deterioration in the renal function is not foreseeable. With prior CRI, or if a prolonged SC is foreseen, a deterioration in the renal function can be expected, thereby making it necessary to evaluate methods for renal protection (AU)

Fístula arteriovenosa poplítea y aneurisma ilíaco gigante secundarios a traumatismo antiguo / Popliteal arteriovenous fistula and a giant iliac aneurysm due to an old injury

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Resultados de la reparación quirúrgica de los aneurismas inflamatorios de aorta abdominal: evolución de los reactantes de fase aguda y de la reacción inflamatoria periaórtica / Results of the surgery of inflammatory abdominal aortic aneurysms: evolution of the acute phase reactants and the periaortic inflammatory reaction

Objetivos: Presentar los resultados del tratamiento quirúrgico electivo de los aneurismas inflamatorios de aorta abdominal (AIAA) y analizar la evolución de la inflamación periaórtica (IPA) y de los reactantes de fase aguda (RFA) tras la intervención. Material y método: Se ha realizado un análisis retrospectivo de los AIAA intervenidos de forma electiva entre 1990 y 2010 mediante cirugía abierta. El seguimiento mediano ha sido de 71 meses y se ha analizado la evolución de la IPA y de los RFA tras la intervención. Resultados: Se han tratado 38 pacientes, de los cuales 12 (31,5%) eran sintomáticos. Se evidenció hidronefrosis en 7 casos (18,4%), siendo necesaria la colocación de doble-J preoperatorio en 5 (13,1%). Un paciente (2,6%) falleció en el postoperatorio inmediato y se realizaron 3 reintervenciones por sangrado (7,8%). Durante el seguimiento la hidronefrosis mejoró en 5 pacientes (71%), siendo la supervivencia a los 12, 36 y 72 meses del 92, 85 y 81% respectivamente. En cuanto a los RFA, se produjo una reducción significativa tanto de la velocidad de sedimentación globular (VSG) (p 0,01), como de la proteína C reactiva (PCR) (p 0,01) tras la cirugía. De igual forma, se redujo de forma significativa la IPA durante el seguimiento, fundamentalmente a partir de los 9 meses tras la intervención (p 0,02). Conclusiones: La cirugía electiva del AIAA ofrece unos buenos resultados a corto y largo plazo, asociándose a una disminución de los RFA y de la IPA, esta última fundamentalmente a partir del noveno mes postoperatorio(AU)

Objectives: To show the results of selective surgical treatment of inflammatory abdominal aortic aneurysms (IAAA), and to analyse the evolution of periaortic inflammation (PAI) and acute phase reactants (APR) after surgery. Patients and method: A retrospective analysis was made of the IAAA electively operated on between 1990 and 2010 by means of open surgery. The median follow-up period was 71 months and an analysis was made of the PAI and APR after surgery. Results: A total 38 patients underwent treatment, of which 12 (31.5%) were symptomatic. Hydronephrosis was evident in 7 cases (18.4%). The implantation of a pre-operative double-J catheter was necessary in 5 cases (13.1%). One patient (2.6%) died in the immediate post-operative period, and 3 were re-operated on due to bleeding (7.8%). During the follow-up period the hydronephrosis improved in 5 patients (71%), with a survival rate at 12, 36 and 72 months of 92%, 85% and 81%, respectively. With regard to the APR, a significant reduction was produced both in the erythrocyte sedimentation rate (ESR) (P=.01) and in the C-reactive protein (CRP) (P=.01) after surgery. Likewise, the PAI was significantly reduced during the follow-up period, mainly from the ninth month following the surgery (P=.02). Conclusions: Selective surgery of IAAA offers good results in the short and long term, associated with a decrease in the APR and PAI, the latter mainly from the ninth month of the post-operative period(AU)