Actualización sobre las características pronósticas y el manejo terapéutico de la úlcera aórtica penetrante / Prognosis and therapeutic management of penetrating aortic ulcer. An update

La úlcera aórtica penetrante es una entidad poco frecuente e infradiagnosticada con características propias respecto la disección clásica. Se presenta una revisión actualizada de la enfermedad centrándose sobre todo en las características pronósticas y el manejo terapéutico

Penetrating aortic ulcer is a rare and underdiagnosed condition, with its own characteristics regarding classical dissection. An updated review is presented, focusing on its prognosis and therapeutic management

Guía de práctica clínica en enfermedad venosa crónica del Capítulo de Flebología y Linfología de la Sociedad Española de Angiología y Cirugía Vascular / Practice guidelines in chronic venous disease from the Phlebology and Lymphology Working Group of the Spanish Society of Angiology and Vascular Surgery

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The best conditions for parallel stenting during EVAR: an in vitro study.

OBJECTIVES: The aim of this study is to identify which endograft, and to what degree of oversizing, in combination with what type of parallel stent, may result in the most adequate fit in a juxtarenal abdominal aneurysmal neck when using a parallel-stent technique. MATERIALS/METHODS: In-vitro silicon aneurysmal neck models of different diameters, with one side-branch, were constructed. Two different endografts (Medtronic-Endurant Abdominal Stent Graft and Gore-Excluder abdominal aortic aneurysm Endoprosthesis; three diameters each), and two stents (self-expanding Gore Viabahn Endoprosthesis and balloon-expandable Atrium Advanta V12; 6-mm diameter) were tested, applying three endograft-oversizing degrees (15%, 30% and 40%). After remodelling using the kissing-balloon technique at 37 °C, the 36 endograft-stent-oversizing combinations were scanned by computed tomography (CT). The size of the results in gutters, parallel-stent compression and main stent-graft infolding were recorded. RESULTS: Increasing oversizing (15%, 30% and 40%) significantly decreased gutter areas (11.5, 6.2, 4.3 mm(2), P < 0.001); nevertheless, main endograft infolding of most 40%-oversized stent grafts was detected, particularly with Excluder devices. Lower stent compression, but wider gutters, were observed with the Excluder when compared to Endurant stent grafts, and with V12 when compared to Viabahn parallel stents. The Endurant-Viabahn combination resulted in maximum stent compression (35%). CONCLUSIONS: Better endograft-stent apposition was achieved when using 30% endograft oversizing. Lower stent compression, but wider gutters, were observed with the Excluder stent-graft and V12 parallel stent, achieving maximum stent compression with the Endurant-Viabahn combination.

Early abdominal aortic endografts: a decade follow-up results.

OBJECTIVES: To report the results of long-term follow-up of abdominal aortic aneurysms (AAAs) treated with endografts more than a decade ago. DESIGN: Retrospective analysis of estimated long-term follow-up, mortality and morbidity in terms of complications and re-interventions, using the Kaplan-Meier survival analysis. MATERIALS/METHODS: Between March 1997 and January 2000, 61 patients with AAA (53 asymptomatic, four symptomatic and three ruptured) were treated with aortic endografts. All preoperative, operative and follow-up data were recorded according to the EUROpean collaborators on Stent graft Techniques for abdominal aortic Aneurysm (EUROSTAR) criteria. RESULTS: The primary technical success rate was 98.4%. The majority of used devices were Vanguard (65.0%), and in a bifurcated configuration (86.7%). At 10-year follow-up, the estimated cumulative follow-up rate was 82.0%; complications occurred in 74.6% of the patients and re-interventions were required in 56.9%. The Vanguard endograft was related to a higher incidence of re-interventions (P=0.012). The combined in-hospital or AAA-related mortality rate was 5.0% at 30 days and 8.2% at a 10-year follow-up (1.8% and 5.0% in elective cases, respectively). CONCLUSIONS: Early abdominal endografts are associated with high incidence of complications (74.6%) and re-interventions (56.9%) at a 10-year follow-up; however, the mortality rate related to the procedure or aneurysm is low (5.0% in elective cases). Early endografts need lifelong strict surveillance.

Cirugía endovascular de la disección aguda tipo B / Endovascular surgery for acute type B dissection

Introducción. La disección aguda tipo B de la aorta torácica es una entidad compleja y grave, asociada a una elevada morbilidad y mortalidad. Desarrollo. Tradicionalmente, el tratamiento médico se ha preferido para las disecciones no complicadas, y se ha reservado la reparación quirúrgica para las que presentan complicaciones isquémicas o rotura. El tratamiento endovascular con endoprótesis ha aportado mayores esperanzas para los casos complicados, a la vez que se ha postulado su aplicación en casos asintomáticos. Estos aspectos se revisan y se discuten a fondo en el presente documento. Asimismo, se analizan aspectos técnicos del tratamiento endovascular pertenecientes al pre, peri y posprocedimiento. Conclusión. Por el momento, el uso de endoprótesis sólo está justificado en el tratamiento de disecciones agudas complicadas o inestables, o en las crónicas con expansión aneurismática

Introduction. Acute type B dissection of the thoracic aorta is a complex, severe condition associated to a high rate of morbidity and mortality. Development. Medical treatment has traditionally been preferred for non complicated dissections while surgical repair has been reserved for those with ischaemic complications or rupture. Endovascular treatment with a stent has brought greater hope for complicated cases, and its application in asymptomatic cases has also been suggested. These issues are reviewed and discussed at length in this article. Likewise, technical aspects of the endovascular treatment belonging to the pre-, peri- and post-operative periods are also analysed. Conclusions. For the time being, the use of stents is only justified in the treatment of complicated or unstable acute dissections, or in chronic cases with aneurysmal expansion

Remodelación aórtica en la disección tipo B crónica tras la reparación con stents recubiertos / Aortic wall remodeling of the chronic type B dissection after stent graft repair

Objetivo. Estudiar los cambios morfológicos de la pared aórtica en la disección crónica tipo B de Stanford tratada mediante stents recubiertos. Pacientes y métodos. Fueron tratados 17 pacientes (edad media: 61 años; rango: 35-70 años) por disección crónica tipo B. Se implantaron endoprótesis Talent (n = 11) y Excluder (n = 6); abordaje femoral (n = 15) y retroperitoneal (n = 2); control intraoperatorio mediante fluoroscopia y ecocardiografía transesofágica; cobertura intencionada de la arteria subclavia en cinco casos. Resultados. Éxito técnico con cierre de la puerta de entrada (17/17); tiempo quirúrgico: 73 ± 22 min (rango: 55-160 min); sin conversiones ni paraplejía; estancia postoperatoria media: 48 horas; trombosis de la falsa luz torácica completa (n = 13) y parcial (n = 4). El diámetro mínimo de la luz verdadera (LV) aumentó de 18,1 ± 5,4 a 27,9 ± 5,06 mm (p < 0,01). La luz falsa (LF) se redujo de 39,22 ± 18 a 26,6 ± 12,7 mm (p < 0,01). Seguimiento medio: 18 meses (rango: 1-58 meses); sin migraciones, fugas u otras complicaciones relacionadas con la endoprótesis; tres pacientes necesitaron a posteriori cobertura de la reentrada distal. Conclusiones. El cierre de la puerta de entrada mediante stents recubiertos suele inducir la trombosis en la LF torácica, ello conlleva una remodelación aórtica: estabilización del diámetro aórtico máximo, con cambios estadísticamente significativos del índice LV/LF (reducción de la LF, aumento de la LV). La aorta abdominal suele permanecer inalterada por persistencia de reentradas paraviscerales. Los resultados preliminares sugieren que el tratamiento endovascular de la disección crónica tipo B es una opción terapéutica factible y efectiva, con excelentes resultados a medio plazo

Aim. To study the morphologic evolution in the aortic wall of the chronic aortic type B dissection treated by means of stent-graft. Patients and methods. 17 patients (average age: 61 years; range 35-70 years) were treated by chronic aortic type B dissection. The endoprosthesis implanted were Talent (n = 11) and Excluder (n = 6); femoral access (n = 15) and iliac (n = 2); intraoperative transesophageal ecocardiography; intentionally left subclavian artery coverture in five patients. Results. Closure of the entry tear in all cases; surgical time: 73 ± 22 min (range: 55-160 min); no conversions, no neurological complications; median postoperative length of stay 48 hours; thrombosis of the thoracic false lumen (FL), complete (n = 13) and partial (n = 4). The minimum diameter of the true lumen (TL) increase from 18.1 ± 5.4 to 27.9 ± 5.06 mm (p < 0.01). FL reduction from 39.22 ± 18 o 26.6 ± 12.7 mm (p < 0.01). Mean follow up: 18 months; no related graft complications. In the follow up three patients needed to seal distal thoracic re-entry. Conclusions. The clossure of the entry tear usually induces the thrombosis of the thoracic FL. It promotes a remodelling of the aortic wall consistent in the stabilization of the maximum aortic diameter with significant changes of the index TL/FL (reduction of the LF and increase of the TL). The abdominal aorta usually remains unchanged by persistence of paravisceral reentries. The preliminary results suggest that stent-graft repair of the aortic dissection B type is a feasible and effective therapeutic option with excellent mid-term results

Endovascular versus open surgical repair of abdominal aortic aneurysm: a comparison of early and intermediate results in patients suitable for both techniques.

PURPOSE: To assess early and intermediate results of endovascular repair of abdominal aortic aneurysms (EVAR), and to compare them with open surgery (OS) in concurrent patients suitable for both types of treatment. METHODS: During 3 years, 180 patients with AAA underwent repair. We excluded patients with ruptured aneurysms (33), juxtarenal aneurysms (11), iliac aneurysms (8), with peripheral embolization (2) and those treated with a cryopreserved homograft (2). From the remaining patients (n=124), we selected those suitable for both techniques (n=83), of which 53 were treated by EVAR and 30 by OS. Analysis was performed using Kaplan-Meier curves and Log Rank tests. RESULTS: Hospital mortality was not significantly higher in the OS group (6.6% OS vs. 3.7% EVAR), p=0.55. The EVAR group had significantly shorter operative time, length of hospital stay and less blood loss. The median follow up time was 2.18 years for OR and 1.58 years for EVAR. There were no conversions from EVAR to OS and no differences in late survival (p=0.255, Cox regression analysis) with a cumulative survival rate at 3 years of 89% for EVAR and 73% for OS. By 3 years 24% (95% CI, 11-47%) of EVAR patients had presented endoleaks with an endovascular re-intervention rate of 27% (95% CI, 13-50%). One patient in the OS group needed a late open intervention. CONCLUSIONS: EVAR compares favourably with OS in terms of reduction of operative time, hospital length of stay and blood loss. This study did not show a difference in early or late mortality. EVAR durability remains the most critical issue to be addressed.

[Vascular access surveillance with blood flow monitoring: a prospective study with 65 patients]. / Monitorización del acceso vascular mediante la determinación del flujo sanguíneo durante la hemodiálisis por el método de ultrafiltración. estudio prospectivo de 65 pacientes.

BACKGROUND: Periodic intra-access blood flow rate (QA) monitoring is the preferred method for vascular access (VA) surveillance (NKF-K/DOQI, update 2000). OBJECTIVES: 1) To determine the ultrafiltration (UF) method accuracy for early detection of VA stenosis. 2) To evaluate the hemodynamic effect of elective VA intervention (angioplasty or surgery). 3) To define the impact of periodic QA monitoring using the UF method combined by elective VA intervention on VA thrombosis. PATIENTS AND METHODS: We prospectively monitored QA during hemodialysis (HD) in 65 ESRD (mean age 64.9 +/- 11.4 years, 20% diabetes) patients over 1 year period. All patients undergoing HD in the Hospital de Mollet by arteriovenous fistula (89.2%) or graft 10.8%. QA was measured at least every 4 months by the UF method using the Crit Line III Monitor. Fifty (77%) patients were included at the beginning of the study period and the remaining 15 (23%) were added later when they started HD. All patients with absolute QA <700 ml/min or decreased >20% from baseline met criteria of positive evaluation (PE) and were referred for angiography (AG) plus subsequent preventive intervention (angioplasty or surgery) if VA stenosis >50%. We also studied 94 not QA monitored patients since the beginning of the study period (mean age 64.6 +/- 13.7 years; 12.8% diabetes) that undergoing HD simultaneous in the Institut Nefrològic Granollers. RESULTS: We performed 200 QA measurements in 509 months of follow-up. The overall mean QA was 1176.7 +/- 491.8 ml/min (range, 380.5-2904.0 ml/min). Three patients (4.6%) thrombosed VA. Nineteen (29.2%) patients had PE; none of them clotted VA. The AG was performed in 84.2% (16/19) patients with PE and all of them (16/16) showed VA stenosis > or =50%; 31.2% (5/16) were lost to follow-up (3 death, 2 transplantation); of the remaining explored patients (11/16), 72.7% (8/11) underwent intervention (3 angioplasty, 5 surgery). The mean QA increased from 577.2 +/- 108.2 ml/min to 878.1 +/- 264.4 ml/min postintervention (p=0.005). The positive predictive value, negative predictive value, sensitivity and specificity of UF method for VA stenosis were 84.2%, 93.5%, 84.2% and 93.5%, respectively. VA thrombosis rate in our 50 beginners QA monitored patients (mean age 64.5 +/- 1 1.4 years; 20% diabetes) was lower (2/50, 4%) compared to 94 not QA monitored patients (16/94, 17%) (p=0.024). CONCLUSIONS: 1) QA monitoring using the UF method allows an early diagnosis of VA stenosis. 2) Serial QA measurement by UF method can be used in assessing the functional response to corrective VA intervention. 3) Periodic VA surveillance by QA measurements using the UF method combined with elective intervention results in reduced VA thrombosis.

[Non-invasive monitoring of a humeral arteriovenous fistula with hemodynamic repercussions]. / Monitorización no invasiva de fístula arteriovenosa (FAVI) humeral con repercusión hemodinámica.

A 70-year-old woman, who undergoing hemodialysis due to chronic pyelonephritis, is reported. She suffered from dyspnea due to pulmonary artery hypertension secondary to volume overload as a complication of high-flow brachial AVF. The combined estimation of vascular access blood flow rate (QA) and systolic pulmonary artery pressure by noninvasive methods (ultrafiltration and Doppler echocardiography, respectively) allowed us the diagnosis, make a surgical indication and post-surgical follow-up of AVF with hemodynamic repercussion.

Monitorización no invasiva de fístula arteriovenosa (FAVI) humeral con repercusión hemodinámica / Noninvasive monitoring of arteriovenous fistula (avf) with hemodynamic repercussion

Presentamos el caso de una enferma de 70 años, en programa de hemodiálisis periódica por pielonefritis crónica, que presentó disnea en relación a hipertensión arterial pulmonar moderada secundaria a la sobrecarga volumétrica de FAVI humeral hiperdinámica. La estimación del flujo sanguíneo (QA) del acceso vascular y de la presión arterial pulmonar sistólica (PAPs) de forma conjunta por métodos no invasivos (ultrafiltración y ecocardiograma doppler, respectivamente) nos permitió diagnosticar, sentar la indicación quirúrgica y efectuar el seguimiento postoperatorio de la FAVI con repercusión hemodinámica

A 70-year-old woman, who undergoing hemodialysis due to chronic pyelonephritis, is reported. She suffered from dyspnea due to pulmonary artery hypertension secondary to volume overload as a complication of high-flow brachial AVF. The combined estimation of vascular access blood flow rate (QA) and systolic pulmonary artery pressure by noninvasive methods (ultrafiltration and doppler echocardiography, respectively) allowed us the diagnosis, make a surgical indication and post-surgical follw-up of AVF with hemodynamic repercussion

The association between co-morbidity and mortality after abdominal aortic aneurysm endografting in patients ineligible for elective open surgery.

OBJECTIVE: To investigate whether co-morbidity affects mortality after endovascular stenting in patients who are fit and unfit for open surgery. METHODS: Data were obtained from the EUROSTAR registry. The association between co-morbidity and mortality was examined by Cox proportional hazards models. RESULTS: Between 1994 and July 2000, 2862 patients underwent aneurysm stenting; 381 were unfit for open surgery. The early/late mortality rates for patients fit for surgery, patients unfit for surgery and patients unfit for anaesthesia were 2.7/5.2%, 5.1/11.4% (p=0.035/p<0.0001) and 3.7/11.0% (NS/p=0.016), respectively. The survival curves among patients with poor medical condition were significantly worse than in those patients with a good medical condition (p=0.001). The presence or absence of co-existing diseases did not affect the mortality rate in patients unfit for open surgery. The age-adjusted mortality risks of patients fit for open surgery and pulmonary disease or diabetes mellitus were 1.41 (1.02-1.95) and 1.75 (1.12-2.74), respectively. CONCLUSIONS: Patients with co-morbidity had a significantly higher mortality after aortic endografting compared with patients fit for open surgery. Co-morbidity did not increase mortality after endovascular abdominal repair in patients unfit for open surgery. Endovascular repair of abdominal aortic aneurysm seems to have a limited benefit in patients unfit for open surgery.