Effectiveness and safety of 1470-nm diode laser fulguration in the management of diffuse venous malformations.

BACKGROUND: Venous malformations (VMs) are the most frequent congenital vascular malformations. Pain and deformity are the main symptoms and usually progressive in untreated patients. Current therapeutic options are surgery (frequently partial resections with an uncomfortable postoperative period), sclerotherapy (often limited because of the need for high doses and the potential subsequent toxicity), and percutaneous intralesional laser treatment. The main objective of our study was to analyze efficiency and safety of 1470-nm diode laser treatment in the management of diffuse VMs. METHODS: We included patients treated between 2012 and 2018 whose quality of life was severely impaired. Data regarding laser settings, previous and subsequent D-dimer and fibrinogen blood levels, preprocedural and postprocedural assessment of pain by means of a visual analog scale, and reported complications were collected. RESULTS: Twenty-six procedures were performed in 17 patients (76% women); 59% were sporadic VMs, 70% had previously undergone other treatments, and 53% needed continuous analgesic treatment. The median pain reduction after the intervention, measured on the visual analog scale, was 5 points (P < .001). A significant decrease in the postoperative D-dimer values (P = .003) was observed in all patients. There were five postoperative complications in four patients, and none was life-threatening. CONCLUSIONS: The diode laser appears to be effective for treatment of diffuse VMs. It allows a reduction of the volume and symptoms of the malformation and is well tolerated by the patients. There is no currently described limitation in terms of dosage or number of procedures, making this a good alternative therapeutic option for these malformations.

Results and complications of carotid endarterectomy in a hospital from Madrid, Spain.

OBJECTIVE: To study the incidence of cerebrovascular (transient ischemic attacks and stroke) and myocardial events (myocardial infarction) as well as early survival related to carotid endarterectomy. Our secondary aim is to establish possible risk factors associated with complications. METHOD: Retrospective observational case-control study within a cohort. All patients who underwent carotid endarterectomy by the angiology and vascular surgery service at the Hospital Universitario La Paz, in Madrid (Spain), in the period between January 2011 and December 2017 were included. Chi square was used to calculate differences. Kaplan-Meier and Cox regression was used for the survival analysis and patency. RESULTS: 111 procedures were performed on 108 patients, 95 (87,9%) male with an average age of 68.5 ± 8.75. The mean time of follow-up was 2.9 years. There was no 30-day post-surgical mortality, with a 30-day postoperative cerebral vascular event rate of 2.7%. Statistically significant correlation was found between the presence of 30-day postoperative cerebral vascular event and primary closure (p = 0.005) as well as between the smoking habit and 30-day postoperative myocardial infarction (p = 0.036) and restenosis (p = 0.008). In mid-term follow-up, the event rate for cerebral vascular events and myocardial infarction was 1.8%. CONCLUSION: carotid endarterectomy is the procedure of choice in carotid stenosis. The low rates of perioperative mortality, morbidity and complications have been demonstrated.

OBJETIVO: Conocer la incidencia de eventos cerebrovasculares y miocárdicos, y la supervivencia temprana, relacionados con la endarterectomía carotídea, y como objetivo secundario establecer los posibles factores de riesgo asociados a las complicaciones. MÉTODO: Estudio observacional de casos y controles anidado en una cohorte retrospectiva. Se incluyeron todos los pacientes que se sometieron a endarterectomía carotídea en el servicio de angiología y cirugía vascular del Hospital Universitario La Paz, de Madrid (España), en el periodo de enero de 2011 a diciembre de 2017. Para la estimación de diferencias se utilizó la prueba de ji al cuadrado. El análisis de supervivencia y permeabilidad se realizó mediante Kaplan-Meier y regresión de Cox. RESULTADOS: Se realizaron 111 procedimientos en 108 pacientes, 95 (87.9%) de ellos varones, con una edad media de 68.5 ± 8.75 años. La media de seguimiento fue de 2.9 años. No hubo mortalidad posquirúrgica a 30 días, y la tasa global de eventos vasculares cerebrales posoperatorios a 30 días fue del 2.7%. Se encontró asociación entre la presencia de eventos vasculares cerebrales posquirúrgicos a 30 días y el cierre arterial primario (p = 0.005), y del infarto agudo de miocardio posoperatorio a 30 días y la reestenosis carotídea con el hábito tabáquico (p = 0.036 y p = 0.008, respectivamente). En el seguimiento a mediano plazo se encontró una tasa de enfermedad vascular cerebral y de infarto agudo de miocardio del 1,8%. CONCLUSIÓN: La endarterectomía carotídea es el procedimiento de elección en la estenosis carotídea por enfermedad aterosclerótica. En nuestro estudio se demuestran sus bajas tasas de mortalidad, de morbilidad y de complicaciones perioperatorias.

Aneurisma periférico roto en paciente joven / Ruptured peripheral aneurysm in a young patient

No disponible

Effects of metformin versus ethinyl-estradiol plus cyproterone acetate on ambulatory blood pressure monitoring and carotid intima media thickness in women with the polycystic ovary syndrome.

OBJECTIVE: To compare the effects of metformin versus an antiandrogenic contraceptive pill on ambulatory blood pressure monitoring (ABPM) and carotid intima media thickness (CIMT) in women with polycystic ovary syndrome (PCOS). DESIGN: Clinical randomized trial. SETTING: Academic hospital. PATIENT(S): Thirty-four consecutive PCOS patients. INTERVENTION(S): PCOS patients randomized to oral treatment with metformin (n = 19) or with Diane(35) Diario pill (n = 15) for 24 weeks. MAIN OUTCOME MEASURE(S): ABPM recordings and ultrasound measurements of CIMT as marker of subclinical atherosclerosis obtained at baseline and after treatment. RESULT(S): Metformin resulted in reductions in daytime and 24-hour average systolic and diastolic blood pressure whereas Diane(35) Diario induced a slight increase in these parameters. Compared with a nonhyperandrogenic control group, the increased CIMT values of PCOS patients decreased to the normal range after treatment with either metformin or Diane(35) Diario. CONCLUSION(S): Metformin treatment decreased daytime ABPM recordings whereas Diane(35) Diario exerted the opposite effect. The safer blood pressure profile of metformin should be considered in PCOS patients who present with a history of hypertension or who are at risk for this disorder. Treatment with either Diane(35) Diario or metformin improved CIMT mean values.

Androgen excess is associated with the increased carotid intima-media thickness observed in young women with polycystic ovary syndrome.

BACKGROUND: We evaluated carotid intima-media thickness (CIMT) as an early marker of atherosclerosis, as well as its main determinants among androgen excess, obesity and insulin resistance, in patients with polycystic ovary syndrome (PCOS). METHODS: We selected 40 PCOS patients and 20 non-hyperandrogenic women who were similar in terms of age and grade of obesity. Complete clinical, metabolic and hormonal profiles and left common CIMT measurements were obtained. RESULTS: Patients with PCOS presented with increased mean CIMT values when compared with controls (F = 8.575; P = 0.005), and this was independent of obesity. Five PCOS patients but no controls had increased CIMT values. CIMT correlated directly with serum total and free testosterone, androstenedione and dehydroepiandrosterone-sulfate levels and mean 24-h heart rate (HR), and inversely with the insulin sensitivity index (ISI), but no correlation was observed with the body mass index (BMI). Multiple stepwise linear regression models showed that in PCOS patients, the main determinants of CIMT were serum total testosterone or androstenedione concentrations, with no influence of ISI or the mean 24-h HR. CONCLUSIONS: Compared with control women, PCOS patients present with an increased CIMT, independent of obesity and related directly to androgen excess; this suggests that hyperandrogenism is associated with atherosclerosis and cardiovascular risk in these women.

Obesity is the major determinant of the abnormalities in blood pressure found in young women with the polycystic ovary syndrome.

CONTEXT: Obesity and insulin resistance predispose patients with the polycystic ovary syndrome (PCOS) to abnormalities in blood pressure regulation. OBJECTIVE: Our objective was to evaluate the impact of obesity on the blood pressure profiles of PCOS patients. PATIENTS, SETTING, AND DESIGN: Thirty-six PCOS patients and 20 healthy women participated in a case-control study at an academic hospital. MAIN OUTCOME MEASURES: We conducted ambulatory blood pressure monitoring and office blood pressure determinations. RESULTS: Hypertension (defined as increased office blood pressure confirmed by ambulatory blood pressure monitoring or by masked hypertension) was present in 12 PCOS patients and eight controls (P = 0.618). No differences between patients and controls were found in office and ambulatory blood pressure monitoring values and heart rate, yet the nocturnal decrease in mean blood pressure was smaller in patients (P = 0.038). Obese women (13 patients and eight controls) had increased frequencies of office hypertension (29% compared with 3% in lean plus overweight women, P = 0.005), increased diastolic (P = 0.009) and mean (P = 0.015) office blood pressure values, and increased heart rate values during the daytime (P = 0.038), nighttime (P = 0.002), and 24-h (P = 0.009) periods, independently of having PCOS or not. The frequency of a nocturnal nondipper pattern was 62% in obese PCOS patients, compared with 26% in lean plus overweight PCOS patients (P = 0.036) and 25% in obese and in lean plus overweight controls. CONCLUSIONS: Abnormalities in the regulation of blood pressure are common in young women with PCOS, yet, with the exception of the nondipper pattern, these abnormalities result from the frequent association of this syndrome with obesity.

Dosis de radiación recibida por el paciente durante el tratamiento endovascular de los aneurismas de aorta abdominal / The radiation dose received by patients during endovascular treatment of abdominal aortic aneurysms

Introducción. Las técnicas endovasculares se utilizan cada vez con mayor frecuencia en el tratamiento de los aneurismas de aorta abdominal (AAA), para lo que es necesario emplear mayores dosis de radiación en los pacientes, tanto en el diagnóstico como en el procedimiento y su seguimiento posterior, que en el tratamiento quirúrgico convencional. Es imprescindible delimitar los niveles de referencia de dosis de radiación necesarios para la ejecución del procedimiento. Objetivo. Cuantificar la dosis total que reciben los pacientes sometidos a esta modalidad de tratamiento. Pacientes y métodos. Se analiza de forma observacional-prospectiva a 46 pacientes con AAA tratados mediante abordaje endovascular en el año 2004, de los cuales 27 reciben un montaje aortomonoilíaco y 19 bifurcado. Resultados. Se obtiene una dosis de radiación total de 48,62 mSv el primer año; esta dosis no difiere entre los pacientes a los que se les coloca una endoprótesis aortomonoilíaca o una bifurcada. Conclusiones. La dosis obtenida no produce un efecto nocivo apreciable el primer año en lo que respecta a efectos deterministas de la dosis empleada. La mayor parte de la dosis recibida se debe a los estudios con tomografía axial computarizada. La resonancia magnética puede jugar un papel muy importante para la reducción de la dosis necesaria en el futuro

Introduction. It is becoming increasingly more frequent to treat abdominal aortic aneurysms (AAA) using endovascular techniques and as a result the doses of radiation patients receive, both in the diagnosis and intervention as well as in the ensuing follow-up, are higher than in conventional surgical treatment. It is essential to define the reference radiation dosage levels that are needed to perform the operation. Aim. To quantify the total dose received by patients submitted to this kind of treatment. Patients and methods. An observational-prospective study was conducted to analyse 46 patients with AAA who were treated using an endovascular approach in the year 2004; aortomonoiliac devices were utilised in 27 cases and 19 received bifurcated stents. Results. A total radiation dose of 48.62 mSv was obtained in the first year; patients received the same dose regardless of whether an aortomonoiliac or a bifurcated stent had been placed. Conclusions. The dose obtained does not give rise to any appreciable adverse effects in the first year as far as dosage-determined effects are concerned. The greater part of the dose received by patients is due to the computerised axial tomography scans that are carried out. Magnetic resonance imaging can play an important role in reducing the doses that are required in the future

Tratamiento endovascular de fístula arteriovenosa y falso aneurisma poplíteos postraumáticos. Presentación de un caso / Endovascular treatment of post-traumatic popliteal arteriovenous fistula and false aneurysm. A case report

Introducción. La fístula arteriovenosa (FAV) postraumática que afecta a los vasos poplíteos es una patología de incidencia escasa cuyo tratamiento hasta ahora ha sido quirúrgico; no obstante, también se puede lograr la oclusión de la fístula mediante la implantación de un stent recubierto intraarterial, con reducción extraordinaria tanto del tiempo quirúrgico como de la estancia hospitalaria del paciente. Caso clínico. Varón de 29 años con una FAV en la segunda porción de poplítea derecha, así como falso aneurisma de dos años de evolución provocados por traumatismo por arma blanca. Tras el estudio preoperatorio correspondiente que incluía eco-Doppler y arteriografía, se decidió tratamiento mediante técnica endovascular, que consistió en la implantación de un stent recubierto en la arteria poplítea, con lo que se consiguió al mismo tiempo la oclusión de la fístula y de la comunicación con el falso aneurisma. El tiempo quirúrgico fue de 60 minutos, no se requirió transfusión sanguínea y se dio de alta al paciente en el quinto día de postoperatorio. El eco-Doppler realizado a los 90 días de la intervención muestra la arteria y la vena poplíteas permeables con ausencia de comunicación entre ellas, así como trombosis del falso aneurisma. Conclusión. Las técnicas endovasculares constituyen una alternativa a la cirugía en casos de FAV postraumáticas que afectan a vasos de calibre grande y mediano

Introduction. Post-traumatic arteriovenous fistula (AVF) involving the popliteal vessels is a pathology with a poor incidence being open surgery its treatment of choice. Nowadays however the total occlusion of the fistula can also be achieved by means of the implantation of a covered stent-graft, which implies an important reduction of both surgical time and hospital stay. Case report. A 29-year old man who had a stab wound in the right popliteal fossa two years earlier was admitted with a popliteal AVF involving the middle popliteal segment along with a false aneurysm. After echo-Doppler examination and arteriography the patient was assessed for endovascular treatment that consisted in the implantation of a covered stent-graft thus achieving the occlusion of both the fistula and the false aneurysm. The procedure lasted 60 minutes, blood transfusion was not required and the patient was discharged on the 5th postoperative day. 90 days after operation an echo-Doppler examination was performed that showed patency of both artery and vein, absence of fistula and thrombosis of the false aneurysm. Conclusion. Endovascular techniques are an alternative to open surgery in the treatment of post-traumatic AVF involving large or middle size vessels

Experiencia en nuestro centro en el tratamiento de aneurismas de la aorta infrarrenal rotos mediante prótesis endovasculares / Experience in the treatment of ruptured infrarenal aortic aneurysms by means of endovascular grafts in our centre

Introducción. La morbimortalidad perioperatoria asociada a la cirugía por la rotura de un aneurisma de la aorta abdominal (AAA) se ha venido manteniendo constante en las últimas décadas, alrededor del 50-70%. Con el desarrollo de las técnicas endovasculares disponemos de una alternativa terapéutica a la cirugía abierta que podría tener éxito para disminuir el número de complicaciones a corto plazo. Pacientes y métodos. Presentamos una serie de 16 pacientes intervenidos entre enero del 2001 y agosto del 2005 por rotura de un AAA. Se emplearon endoprótesis aortomonoilíacas y bifurcadas asociadas a diversos procedimientos como embolización del saco aneurismático o implantación de stents entre la hipogástrica y la ilíaca externa. Resultados. La mortalidad perioperatoria fue del 12,5%. Durante los primeros 30 días hubo cinco reintervenciones (31%), dos Friedrich, dos revisiones por sangrado inguinal y un bypass axilobifemoral. En el 37% de los casos se asoció la implantación de stents recubiertos entre la arteria ilíaca externa e hipogástrica. En el 31% de los casos se embolizó el saco aneurismático con Ethiblock®. En un caso hubo que realizar una interposición de un segmento de dacron en la arteria femoral común por desgarro durante la introducción de la endoprótesis. En los primeros 30 días postoperatorios se produjeron diez complicaciones sistémicas graves en cinco pacientes, incluidos un infarto agudo de miocardio, dos íleos prolongados, dos casos de insuficiencia respiratoria aguda, tres casos de insuficiencia renal aguda, y un caso de colitis isquémica que requirió una hemicolectomía. Conclusiones. El uso de técnicas endovasculares en el tratamiento de AAA rotos nos permite reducir la mortalidad a corto plazo a causa de éstos en pacientes seleccionados (AU)

INTRODUCTION. The rate of perioperative morbidity and mortality associated to surgery for rupture of an abdominal aortic aneurysm (AAA) has remained more or less constant over recent decades, with a value of around 50-70%. The development of endovascular techniques has provided us with an alternative to open surgery that could be successful in lowering the number of short-term complications. PATIENTS AND METHODS. We report on a series of 16 patients submitted to surgery between January 2001 and August 2005 to treat an AAA. Aortomonoiliac and bifurcated stents were employed in association with different procedures such aneurysmal sac embolisation or the placement of stents between the hypogastric and external iliac arteries. RESULTS. Perioperative mortality rate was 12.5%. During the first 30 days there were five reinterventions (31%), two Friedrich, two revisions due to inguinal bleeding and one axillobifemoral bypass. In 37% of cases placement of covered stent-grafts between the external iliac and hypogastric arteries was associated to the treatment. In 31% of cases the aneurysmal sac was embolised with Ethiblock®. In one case a segment of dacron had to be inserted in the common femoral artery due to a laceration that occurred during placement of the stent. In the first 30 days of the post-operative period ten severe systemic complications occurred in five patients. These included one acute myocardial infarction, two prolonged ileus, two cases of acute respiratory failure, three cases of acute renal failure, and one case of ischaemic colitis that required a hemicolectomy. CONCLUSIONS. The use of endovascular techniques in the treatment of ruptured AAA makes it possible to reduce the short-term mortality rates from this condition in selected patients (AU)

Evaluación de estenosis carotídea en pacientes subsidiarios de revascularización miocárdica / The evaluation of carotid stenosis in patients who can benefit from myocardial revascularisation

Introducción. La estenosis carotídea (EC) crítica es frecuente en pacientes pendientes de revascularización miocárdica (RM), aumenta el riesgo de ictus durante la cirugía y su diagnóstico es importante, aunque el tratamiento sea controvertido cuando coexisten ambas patologías. Objetivos. Estudiar la lesión carotídea en pacientes pendientes de RM y los factores asociados. Determinar la morbimortalidad de la cirugía combinada carotídea y la RM frente a cirugías separadas. Pacientes y métodos. Estudio prospectivo, observacional y consecutivo durante 16 meses; se realiza dúplex carotídeo en 140 candidatos a RM, y consideramos la EC crítica: lesión carotídea ≥ 70%, con un 72,9% varones y una edad media de 69,8 años. Realizamos análisis estadístico con SPSS 10.1, chi al cuadrado y test exacto de Fisher: p £ 0,05 es significativamente estadística. Resultados. Prevalencia de lesión carotídea: 16,5% EC ≥ 50%, 10% EC ≥ 70%, pero sólo 7,1% quirúrgicas, ya que cuatro casos fueron oclusión carotídea. 42,6% angor inestable, 5% fracción de eyección del ventrículo izquierdo < 30%. Encontramos asociación significativa entre EC crítica en este tipo de pacientes con las siguientes variables: enfermedad cerebrovascular en el 37,5% de los casos (p = 0,009); lesión de tronco coronario izquierdo (TCI) ≥ 50% en el 22,2% (p = 0,002) y no padecer diabetes (p = 0,028). Practicamos cinco cirugías secuenciales: endarterectomía carotídea (EAC) seguida de RM cuatro cirugías combinadas y una RM emergente sin EAC. La morbimortalidad de la RM en pacientes con EC < 70% fue: 0,61% mortalidad, 0,69% morbilidad –seis infartos agudos de miocardio (IAM) y tres ictus–. En EC quirúrgicas hubo un exitus, un IAM. Conclusiones. Consideramos indicación primaria el estudio con dúplex carotídeo en estos pacientes; es especialmente importante cuando existe lesión del TCI significativa (≥ 50%) y enfermedad cerebrovascular. Proponemos cirugía combinada en pacientes cardiológicamente inestables y es recomendable en lesión del TCI ³ 50%, aunque sean necesarios ensayos clínicos que mejoren la indicación

Introduction. Critical carotid stenosis (CS) is frequent among patients who are waiting for myocardial revascularisation (MR), it increases the risk of stroke during the operation and it is important to diagnose it, although when the two pathologies coexist there is some controversy about treatment. Aims. To study carotid lesions in patients waiting for MR and the associated factors. We also intended to determine the morbidity and mortality rates of combined carotid and MR surgery versus separate procedures. Patients and methods. The study was prospective, observational and consecutive over a period of 16 months; carotid duplex was performed in 140 candidates for MR and the CS was considered to be critical: carotid lesion ≥ 70%, with 72.9% males and a mean age of 69.8 years. Statistical analyses were performed with SPSS 10.1, chi squared and Fisher’s exact test. p £ 0.05 is statistically significant. Results. Prevalence rate of carotid lesions: 16.5% CS ≥ 50%, 10% CS ≥ 70%, but only 7.1% surgical, since four were cases of carotid occlusion. 42.6% unstable angina, 5% severe left ventricle ejection fraction < 30%. We found a significant association between critical CS in this kind of patients and the following variables: cerebrovascular disease in 37.5% of cases (p = 0.009); left coronary artery trunk (LCT) lesion ≥ 50% in 22.2% (p = 0.002) and not suffering from diabetes (p = 0.028). Five sequential surgical procedures were performed: carotid endarterectomy (CE) followed by MR four combined interventions and one emerging MR without CE. MR morbidity and mortality rates in patients with CS < 70% were: 0.61% mortality, 0.69% morbidity –six acute myocardial infarctions (AMI) and three strokes– and with surgical CS there was one death and one AMI. Conclusions. We consider the use of carotid duplex as a primary indication in the study of these patients; it is especially important when there is significant injury to the LCT (≥ 50%) and cerebrovascular disease. We propose combined surgery in cardiologically unstable patients and it is recommendable in LCT lesion ³ 50%, although further clinical trials are needed to improve the indication

Infragenicular bypass graft for limb salvage using polytetrafluoroethylene and distal vein cuff as the first alternative in patients without ipsilateral greater saphenous vein.

The objectives of this study were to evaluate the results of polytetrafluoroethylene infragenicular bypass grafts with a distal interposition vein cuff in patients with critical limb ischemia in the absence of ipsilateral greater saphenous vein. From January 1997 to June 2002, 58 consecutive below-knee bypass grafts with PTFE and distal interposition vein cuff were performed in 57 patients with a median age of 70.8 years. The distal anastomosis was located at the infragenicular popliteal artery in 18 cases and at tibial vessels in 40. Primary patency, secondary patency, and limb salvage were analyzed using the Kaplan-Meier method. During a median follow-up of 14.4 months (range, 1-50) 26 cases of graft occlusion and 19 major amputations were registered. The primary and secondary patency rates at 12, 24, and 36 months were 57%, 54%, and 47% and 61%, 58%, and 50%, respectively. Limb salvage rates reached 69%, 69%, and 59% at 12, 24, and 36 months. When below-knee revasculanzation is required in patients with limb-threatening ischemia, in the absence ipsilateral greater saphenous vein, PTFE grafts with a distal vein cuff are a reasonable substitute with acceptable long-term patency and limb salvage rates.