Impact of Diabetic Foot Multidisciplinary Unit on Incidence of Lower-Extremity Amputations by Diabetic Foot.

BACKGROUND: One of the most devastating complications of diabetes is diabetes-related foot disease (DFD), which is a priority for public health systems. The 2016-2020 Catalonia Health Plan aimed to reduce the incidence of total and major lower-extremity amputations (LEAs) due to DFD by 10% in the population aged 45-74 years. The aim of the present study was to compare the incidence of LEA-DFD 5 years before and after the creation of the Diabetic Foot Multidisciplinary Unit at our Hospital. METHODS: We prospectively collected all cases of LEA-DFD performed at Vall d'Hebron University Hospital from 1 January 2016 to 31 December 2020. Cases of LEA-DFD performed from 1 January 2011 to 31 December 2015 were retrospectively reviewed. The incidence of LEA-DFD between these periods was compared. RESULTS: A total of 457 LEAs due to DFD were performed in 316 patients. We observed a reduction of 27.9% [CI: 23.7-32.1%] in the incidence of total LEA in the 2016-2020 period in comparison with the period 2011-2016 (0.8 ± 0.1 vs. 1.1 ± 0.3 per 10.000 inhabitants/year, p < 0.001), as well as a reduction of 49.3% [CI: 44.6-53.9%] in the incidence of major LEA-DFD (0.15 ± 0.1 vs. 0.30 ± 0.1 per 10.000 inhabitants/year, p < 0.001). CONCLUSIONS: The implementation of a Diabetic Foot Multidisciplinary Unit resulted in a significant reduction in the rate of amputations due to DFD in the population with diabetes in North Barcelona.

Impact of thoracic endovascular aortic repair following blunt traumatic thoracic aortic injury on blood pressure.

BACKGROUND: Blunt traumatic thoracic aortic injuries (BTAIs) are associated with a high mortality rate. Thoracic endovascular aortic repair (TEVAR) is the most frequently used surgical strategy in patients with BTAI, as it offers good short- and middle-term results. Previous studies have reported an abnormally high prevalence of hypertension (HT) in these patients. This work aimed to describe the long-term prevalence of HT and provide a comprehensive evaluation of the biomechanical, clinical, and functional factors involved in HT development. METHODS: Twenty-six patients treated with TEVAR following BTAI with no history of HT at the time of trauma were enrolled. They were matched with 37 healthy volunteers based on age, sex, and body surface area and underwent a comprehensive follow-up study, including cardiovascular magnetic resonance, 24-hour ambulatory blood pressure monitoring, and assessment of carotid-femoral pulse wave velocity (cfPWV, a measure of aortic stiffness) and flow-mediated vasodilation. RESULTS: The mean patient age was 43.5 ± 12.9 years, and the majority were male (23 of 26; 88.5%). At a mean of 120.2 ± 69.7 months after intervention, 17 patients (65%) presented with HT, 14 (54%) had abnormal nighttime blood pressure dipping, and 6 (23%) high cfPWV. New-onset HT was related to a more proximal TEVAR landing zone and greater distal oversizing. Abnormal nighttime blood pressure was related to high cfPWV, which in turn was associated with TEVAR length and premature arterial aging. CONCLUSIONS: HT frequently occurs otherwise healthy subjects undergoing TEVAR implantation after BTAI. TEVAR stiffness and length, the proximal landing zone, and distal oversizing are potentially modifiable surgical characteristics related to abnormal blood pressure.

Geometric, Biomechanic and Haemodynamic Aortic Abnormalities Assessed by 4D Flow Cardiovascular Magnetic Resonance in Patients Treated by TEVAR Following Blunt Traumatic Thoracic Aortic Injury.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is widely used for the treatment of patients with blunt traumatic thoracic aortic injury (BTAI). However, aortic haemodynamic and biomechanical implications of this intervention are poorly investigated. This study aimed to assess whether patients treated by TEVAR following BTAI have thoracic aortic abnormalities in geometry, stiffness, and haemodynamics. METHODS: Patients with BTAI treated by TEVAR at Vall d'Hebron Hospital between 1999 and 2019 were compared with propensity score matched healthy volunteers (HVs). All subjects underwent cardiovascular magnetic resonance (CMR) comprising a 4D flow CMR sequence. Spatially resolved aortic diameter, length, volume, and curvature were assessed. Pulse wave velocity, distensibility, and longitudinal strain (all measurements of aortic stiffness) were determined regionally. Moreover, advanced haemodynamic descriptors were quantified: systolic flow reversal ratio (SFRR), quantifying backward flow during systole, and in plane rotational flow (IRF), measuring in plane strength of helical flow. RESULTS: Twenty-six BTAI patients treated by TEVAR were included and matched with 26 HVs. They did not differ in terms of age, sex, and body surface area. Patients with TEVAR had a larger and longer ascending aorta (AAo) and marked abnormalities in local curvature. Aortic stiffness was greater in the aortic segments proximal and distal to TEVAR compared with controls. Moreover, TEVAR patients presented strongly altered flow dynamics compared with controls: a reduced IRF from the distal AAo to the proximal descending aorta and an increased SFRR in the whole thoracic aorta. These differences persisted adjusting for cardiovascular risk factors and were independent of time elapsed since TEVAR implantation. CONCLUSION: At long term follow up, previously healthy patients who underwent TEVAR implantation following BTAI had increased diameter, length and volume of the ascending aorta, and increased aortic stiffness and abnormal flow patterns in the whole thoracic aorta compared with matched controls. Further studies should address whether these alterations have clinical implications.

Cauda Equina Syndrome Caused by Epidural Venous Plexus Engorgement in a Patient with May-Thurner Syndrome.

The purpose of this article is to present a case of cauda equina syndrome in a patient with incomplete motor and sensory deficits due to epidural venous plexus engorgement, owing to May-Thurner syndrome successfully treated with venous iliac stenting. A 40-year-old woman, with previous history of deep vein thrombosis and miscarriages, gradually developed right leg and back pain, with functional limitation, perineal hypoesthesia, and sphincter incontinence. Magnetic resonance imaging revealed epidural venous plexus engorgement and cauda equina roots involvement. Phlebography showed perimedullary venous enlargement and left common iliac vein stenosis, leading to the diagnosis of May-Thurner syndrome. Stenting of the left common iliac vein was performed resulting in pain improvement and disappearance of neurological symptoms. Thrombophilia study was positive to heterozygous factor V Leiden. Cauda equina syndrome as the first presentation of a May-Thurner syndrome is very rare. In this case, venous iliac stent placement was an effective and safe treatment.

Incidence and evolution of mural thrombus in abdominal aortic endografts.

BACKGROUND: The aims of this study were to analyze the predictive factors for intragraft mural thrombus formation and evolution during follow-up after endovascular treatment of abdominal aortic aneurysms and to evaluate its relationship with the subsequent appearance of complications. METHODS: A retrospective study was performed by selecting those patients who underwent endovascular repair of an abdominal aortoiliac aneurysm between June 1998 and September 2004, with a minimum follow-up of 24 months. Preoperative clinical data, anatomical characteristics of the aneurysm, and endograft type were analyzed. In addition, clinical evaluation and abdominal computed tomography angiography (CT scans) performed at 1, 6, 12, and 24 months after the surgery were reviewed. RESULTS: Eighty-nine patients were submitted for endovascular aneurysm repair in this period, and 75 completed the 24-month follow-up. Eighteen patients developed intragraft mural thrombus (24% incidence), 13 (72.2%) appearing at 1 month of follow-up, and up to 16 (88.9%) appearing during the first 6 months. Logistic regression analysis showed that the lumen percentage of mural thrombus in the native aorta and the use of aortouniiliac endografts were independent predictors of intragraft mural thrombus formation (odds ratio, 1.065; 95% confidence interval, 1.022-1.110, and odds ratio, 8.014; 95% confidence interval, 1.598-40.181, respectively). No spontaneous regression of the thrombus was observed. The area of intragraft mural thrombus had increased at 12 and 18-24 months after their diagnosis (Wilcoxon signed rank test, p = 0.028 and 0.028, respectively). The presence of intragraft mural thrombus was associated with a greater tendency to endograft body or branch occlusion (5 of 18 cases with intragraft mural thrombus (27.8%) versus 1 of 57 cases without it (1.8%), (p = 0.003). CONCLUSION: Intragraft formation of mural thrombus is a common finding during the follow-up of abdominal aortic endografts, particularly in aneurysms with large mural thrombus of the native aorta, and is associated with the use of aortouniiliac endografts. The area occupied by the mural thrombus was shown to gradually increase during follow-up and was associated with a greater tendency for endograft occlusion.

Tumor renal con trombosis de vena cava inferior intra-suprahepática / Renal tumour with thrombosis of the intra-suprahepatic inferior vena cava

Introducción. Se realiza la descripción de dos casos de tumor renal con trombosis de vena cava inferior (VCI) intra-suprahepática tratados de forma radical. Casos clínicos. El primer caso comenzó con dolor abdominal y edema en extremidades inferiores, el segundo caso con cuadro de microhematuria. En ambos casos se realizaron: ecografía abdominal, TC toracoabdominal y cavografía que revelaron tumor renal con trombosis de vena renal que se extiende a cava inferior hasta la zona intrahepática. Se descarta la presencia de metástasis y se realizó cirugía radical con la finalidad de mejorar el pronóstico mediante la resección del tumor más trombectomía de vena cava inferior con control proximal de vena cava intrapericárdica (AU)

Principios básicos de la cirugía endovascular del sector aortoilíaco / Basic concepts in endovascular surgery of the aortoiliac sector

Cuando un servicio de cirugía vascular inicia un programa de cirugía endovascular, suele empezar por tratar las lesiones ilíacas, ya que constituyen una patología frecuente, de aprendizaje sencillo, y que sin duda son el mejor banco de pruebas para abordar posteriormente procedimientos más complejos. Una vez escogido el tipo de lesiones a tratar, deberemos determinar las características del quirófano radiológico y los materiales para dicha cirugía. El quirófano radiológico deberá contar con una mesa radiotransparente y un arco digital (sustracción digital, roadmapping y vídeo). Además, deberá cumplir todas las normas de radioprotección que determine el Consejo Nacional de Seguridad Nuclear. Deberemos disponer de los siguientes materiales: introductores, guías (normales, hidrofílicas y rígidas), catéteres (Simons, Hockey stick, Pig tail y Cobra), balones y stents (autoexpandibles, expandidos con balón y cubiertos). Será importante dominar las diferentes vías para poder abordar dichas lesiones. La vía femoral ipsilateral y la contralateral serán las más usadas, mientras que la vía braquial se reservará para casos muy concretos. Empezaremos realizando angioplastias aisladas o asociadas a stenting (de elección, los stents autoexpandibles), para pasar luego a tratar lesiones más complejas (recanalizaciones y remodelaciones de la bifurcación aórtica -kissing balloon-). Por último, pasaremos a tratar aneurismas aórticos. Para la implantación de endoprótesis deberemos conocer una serie de técnicas asociadas; las más usadas serán las embolizaciones (lumbares, hipogástricas, polares renales...). Se recurrirá a la vía contralateral para hacer progresar la rama de las endoprótesis (AU)

Degeneración neoplásica de una úlcera venosa / Neoplasic degeneration of venous ulcer

La degeneración neoplásica de las úlceras flebostáticas crónicas de extremidades inferiores es una complicación infrecuente. Se presenta un caso de carcinoma epidermoide diagnosticado histológicamente en una paciente con úlceras venosas de 14 años de evolución tratada mediante amputación por la afectación local y las hemorragias frecuentes (AU)

Aneurismas de la arteria hepática. Descripción de cinco casos y revisión de la literatura / Hepatic artery aneurysms. Description of five cases and revision of the literature

Introducción. Exponemos la experiencia de nuestro grupo en la cirugía del aneurisma de arteria hepática, una entidad muy poco frecuente pero con morbimortalidad elevada debido a su alto índice de roturas. Pacientes y métodos. De 1989 a 1996 se han diagnosticado y tratado cinco aneurismas de arteria hepática en nuestro servicio, el 80 por ciento hombres con 59 años de edad media. Se indicó tratamiento quirúrgico en todos los casos. Las técnicas realizadas fueron una aneurismorrafia, una ligadura simple de la arteria hepática común y tres aneurismectomías con reconstrucción: dos bypass de vena safena invertida desde tronco celíaco a arteria hepática propia y un bypass con Dacron desde aorta a arteria hepática común en su bifurcación. El seguimiento se ha realizado mediante anamnesis y TAC en todos los pacientes y arteriografía complementaria en dos de los casos. Resultados. En el postoperatorio inmediato hubo una muerte en el 23º día por pancreatitis necrohemorrágica; en el seguimiento posterior hubo 1 muerte por causa neurológica a los dos años (en el último control se había hallado el injerto permeable) y 3 permanecen asintomáticos hasta la fecha, con arteria hepática propia permeable. Conclusión. Destacamos que la cirugía es un tratamiento adecuado para esta patología, considerando siempre un manejo terapéutico adaptado a cada caso, que depende básicamente de la localización, estructura del aneurisma y de la circulación colateral (AU)

Papel del Eco-Doppler en el control de las endoprótesis de aorta abdominal / Duplex ultrasound in abdominal aortic endograft follow-up

Objetivo: Comparar los resultados que ofrece el Eco-doppler respecto a la Agio-TAC en el estudio de las endoprótesis aórticas. Métodos: Estudio observacional de evaluación 'ciega' en el que cuatro observadores independientes (dos en TAC y dos ECO-Doppler) valoran 23 pacientes consecutivos portadores de una endoprótesis implantada en nuestro Servicio entre el 1/6/98 y el 30/11/99. Los parámetros evaluados fueron: cálculo de diámetros máximos (cuello, cuerpo e iliacas), permeabilidad de la prótesis y sus ramas y detección de fugas. Para comparar diámetros se utilizó la prueba t-student. Para comparar los resultados en la detección de fugas y permeabilidades se utilizó el Test exacto de Fisher y la prueba CHI-cuadrado con la corrección de Yates. Resultados: Las diferencias interobservador en el cálculo de diámetros fueron de 9'8 por ciento en la TAC y del 11'2 por ciento en el duplex, no significativas. Hubo diferencias en los resultados de diámetros entre las dos pruebas, con una 18 por ciento de discordancia. No existieron diferencias en la detección de fugas ni en la determinación de permeabilidades de la prótesis, sus ramas y arterias renales. Hubo un alto grado de resultados indeterminados en la valoración de hipogástricas (25 por ciento). Conclusiones: No existieron diferencias interobservador en cada prueba en la valoración de todos los parámetros. Los diámetros determinados mediante dúplex son sistemáticamente menores a los determinados por TAC, diferencias imputables al aparataje en sí. El dúplex es un método válido en la detección de fugas y permeabilidades respecto a la TAC (AU)