Impact of nutritional and inflammatory status in patients with critical limb-threatening ischemia.

BACKGROUND: A pro-inflammatory state and a poor nutritional status have been associated with severity and prognosis of patients with peripheral arterial disease (PAD). The clinical applicability of the different pre-operative nutritional and inflammatory biomarkers in patients with critical limb-threatening ischemia (CLTI) was analyzed. METHODS: A retrospective observational study was performed, that included all patients with CLTI revascularized from January 2016 to July 2019. The inflammatory state was calculated using neutrophil/lymphocyte (NLR), lymphocyte/monocyte (LMR) and platelet/lymphocyte ratios (PLR). For nutritional status, the Prognostic Nutritional Index (PNI) was calculated. Mortality and number of major amputations at 6 months and hospital length-of stay were studied. RESULTS: 310 patients were included. Higher levels of NLR and lower levels of PNI were associated with mortality (6.61±5.6 vs. 3.98±3.27, P=0.034; 40.33±7.89 vs. 45.73±7.48, P=0.05, respectively). Lower levels of PNI and LMR (42.57±7.82 vs. 45.44±7.65, P=0.036; 2.77±1.61 vs. 3.22±1.75, P=0.013, respectively) and higher levels of NLR (6.91±7.85 vs. 3.94±2.57, P=0.023) were associated with major amputations. The mean hospital length-of-stay was higher in patients with lower levels of PNI and LMR (P=0.000 and P=0.003) and higher levels of NLR and PLR (P=0.001 and P=0.002). A PNI<42.87 predicted short-term mortality with a 66.7% of sensitivity and a 66.8% of specificity (P=0.000). CONCLUSIONS: Our experience suggests that these inflammatory and nutritional biomarkers are independent predictors of short-term mortality and major amputations. In addition, our results suggest that PNI could be used to predict the short-term mortality with high sensitivity and specificity.

Leiomiosarcoma de vena cava / Vena cava leiomyosarcoma

Caso clínico: se presenta el caso de un varón de 64 años con sospecha de leiomiosarcoma de vena cava inferior (VCI) tratado con radioterapia neoadyuvante previa a resección quirúrgica en bloque tumoral y de VCI con reconstrucción mediante injerto de PTFE anillado, seguido de quimioterapia. Discusión: el leiomiosarcoma de VCI es una patología maligna muy infrecuente, de mal pronóstico y que requiere un manejo multidisciplinar. Representan la localización más frecuente de los leiomiosarcomas venosos, tienen predilección por el sexo femenino y una edad media de presentación entre 50 y 60 años. El síntoma más frecuente es el dolor abdominal, aunque muchos son asintomáticos. La prueba diagnóstica de elección es la RM y el tratamiento se basa en la resección quirúrgica, no estando aún claramente definido el papel de la radio y quimioterapia.(AU)

Case report: we present the case of a 64-year-old man with suspected inferior vena cava leiomyosarcoma (IVC) treated with neoadjuvant radiotherapy, tumor and IVC overall surgical resection with a ringshaped PTFE graft reconstruction, followed by chemotherapy. Discussion: IVC leiomyosarcoma is a very infrequent malignant disease, its prognosis is dark and requires multidisciplinary management. They represent the most frequent location of venous leiomyosarcomas, have a predilection for the female sex and a mean age of presentation between 50 and 60 years. The most frequent symptom is abdominal pain, although many are asymptomatic. The diagnostic test of choice is MRI and treatment is based on surgical resection, the role of radio and chemotherapy is not clearly defined yet.(AU)

Doppler Ultrasound as a Unique Diagnosis Test in Peripheral Arterial Disease.

BACKGROUND: The aim of this study was to analyze duplex ultrasound (DUS) and intraoperative angiography concordance for diagnosis of lower limb peripheral artery disease and its value for surgical planning. MATERIALS AND METHODS: This was a prospective, observational study, including patients who underwent revascularization of the lower limbs during 2018, diagnosed by DUS only or combined with preoperative computed tomography (CT) angiography. The concordance between preoperative DUS or CT angiography and the intraoperative angiography was studied using the Cohen kappa coefficient (k). The degree of agreement between the DUS-based surgical plan and the final surgical technique was also evaluated. RESULTS: Fifty-one patients were included, with mean age of 71.8 ± 11.96 years (46-94); 23 had chronic kidney disease (45%). In 17 patients (34%), preoperative CT angiography was also performed. DUS showed a sensitivity of 100% (95% confidence interval (CI) [83.3-100%]), 80% (95% CI [50.21-100%,]), and 100% (95% CI [96.43-100%]) at the iliac, femoral, and popliteal sector, respectively, and a specificity of 93.55% (95% CI [83.29-100%]), 95.45% (95% CI [84.48-100%]), and 90.48% (95% CI [75.54-100%]) at the iliac, femoral, and popliteal sector, respectively. The positive predictive value for DUS was 60% (95% CI [7.06-100%]), 88.9% (95% CI [62.8-100%]), and 87.5% (95% CI [68.17-100%]) for the iliac, femoral, and popliteal sectors, respectively, whereas the negative predictive value was 100% (95% CI [98.28-100%]), 91.3% (95% CI [77.61-100%]), and 100% (95% CI, [97.37-100%]). The concordance between DUS and intraoperative angiography showed a k index of 0.587 (P = 0.000) in the iliac sector, 0.799 in the femoral sector (P = 0.000), and 0.699 in the popliteal sector (P = 0.000). The concordance between CT angiography/intraoperative angiography had a k index of 0.71 in the iliac sector (P = 0.0093), 0.566 in the femoral sector (P = 0.006), and 0.5 in the popliteal sector (P = 0.028). DUS-based surgical plan was accurate in 86% of cases (n = 44). CONCLUSIONS: Our experience suggests that DUS arterial mapping of the femoral and popliteal areas is better than CT angiography and can be considered as a unique preoperative imaging test during the surgical planning in patients undergoing a lower limb revascularization procedure.

Radioprotection Measures during the Learning Curve with Hybrid Operating Rooms.

BACKGROUND: Endovascular procedures come with a potential risk of radiation hazards both to patients and to the vascular staff. Classically, most endovascular interventions took place in regular operating rooms (ORs) using a fluoroscopy C-arm unit controlled by a third party. Hybrid operating rooms (HORs) provide an optimal surgical suit with all the qualities of a fixed C-arm device, while allowing the device to be controlled by the surgical team. The latest studies suggest that an operator-controlled system may reduce the radiation dose. The purpose of the present study is to determine the amount of absorbed radiation using an HOR in comparison with a portable C-arm unit and to assess whether the radioprotection awareness of the surgical team influences the radiation exposure. The primary end point was the effective dose in milliSievert (mSv) for the surgical team and the average dose-area product (ADAP) in Gray-meters squared (Gym2) for patients. METHODS: The values of absorbed radiation of the surgical team's dosimeters were collected from January 2015 to May 2016. The HOR was installed in June 2015, and a radioprotection seminar was given in October 2015. The HOR-issued radiation, measured by the maximum dose-area product, ADAP, average dose (AD) per procedure, maximum dose per procedure per month, maximum fluoroscopy time, average fluoroscopic time, peak skin dose, and average skin dose (ASD), was collected monthly from September 2015 to July 2016. The timeline was divided into 3 periods: 5 months pre-HOR (Pre-HOR), 5 months after the HOR installation (PreS-HOR), and 5 months after a radioprotection seminar (PostS-HOR). RESULTS: The average number of procedures per month was 22.55 (±4.9), including endovascular aneurysm repair/thoracic endovascular aneurysm repair, carotid, visceral, and upper and lower limb endovascular revascularization. The average amount of absorbed radiation by the surgeons during PreS-HOR was 1.07 ± 0.4 mSv, which was higher than the other periods (Pre-HOR 0.06 ± 0.03 mSv, P = 0.002; PostS-HOR 0.14 ± 0.09 mSv, P = 0.000, respectively). The ADAP during PreS-HOR was 0.016 ± 0.01 Gym2, which was lower than the PostS-HOR (0.001 ± 0.002 Gym2) (P = 0.034). The AD during PreS-HOR was 0.78 ± 0.3 Gy and 0.39 ± 0.3 Gy during PostS-HOR (P = 0.098). The ASD during PreS-HOR was 0.40 ± 0.2 Gy and 0.20 ± 0.1 Gy during PostS-HOR (P = 0.099). CONCLUSIONS: In our experience, the HOR increases the amount of absorbed radiation for both patients and surgeons. The radioprotection seminars are of utmost importance to provide a continued training and optimize the use of ionizing radiation while using an HOR. Despite the awareness of the surgical team in the radioprotection field, the amount of absorbed radiation using an HOR is higher than the one using a C-Arm unit.

Leiomiosarcoma intraluminal de vena femoral común / Intraluminal leiomyosarcoma of the common femoral vein

No disponible

[Incidence of contrast induced nephropathy in patients who underwent an aortic endovascular repair]. / Incidência De Nefropatia Induzida Por Contraste Em Pacientes Operados De Reparação Aórtica endovascular.

INTRODUCTION: Intravascular iodinated contrasts are essencial in endovascular therapy. One of their major inconveniences is contrast-induced nephropathy (CIN), which has been associated with an increase in complications and prolonged hospital stay. AIM: To analyze the incidence of CIN in patients undergoing endovascular aneurysm repair (EVAR) in our hospital. MATERIAL AND METHODS: A retrospective study including patients (n=129) treated with EVAR between January 2014 - September 2015. Information was gathered concerning age, history of diabetes, hypertension, pre-existing chronic kidney disease and previous treatment with diuretics or metformin. We analyzed serum levels of urea, creatinine, sodium, potassium and glomerular filtrate (GF), at baseline, at 24hours, peak levels during post-operative period and before discharge. The amount of intravascular contrast and periprocedureral hydration were correlated to creatinine and GF to determine their effect on CIN. RESULTS: Of 129 patients, 11 (8.53%) developed CIN. A significant difference was found between preoperative and postoperative levels of urea and sodium, both p<0.001.Volume of contrast was the only variable that presented a statistically significant association with increase of creatinine levels in postoperative period (p=0.032). Worsening of glomerular filtrate showed a statistically significant association with preoperative levels of urea (p=0.036) and GF (p= 0.019). Fluid-therapy before or after exposure to contrast did not show any influence on the outcome. CONCLUSIONS: The incidence of CIN depends mainly on baseline GF and amount of contrast, and it is barely associated with hydration during the perioperative period. Since there is no specific treatment for CIN, the best practice is its prevention.