Estudio multicéntrico de la reparación endovascular urgente de la aorta torácica: indicaciones y resultados / A multicenter study of emergency endovascular repair of the thoracic aorta: indications and outcomes

Objetivo Las técnicas endovasculares se han convertido en una herramienta esencial para el tratamiento de la patología de aorta torácica descendente (TEVAR). El objetivo es analizar las indicaciones y resultados del TEVAR urgente a nivel nacional en relación con la cirugía programada. Diseño y ámbito de estudio Registro multicéntrico retrospectivo de pacientes con patología de aorta torácica descendente tratados de urgencia mediante técnicas endovasculares entre los años 2012-2016 en 11 servicios clínicos. Pacientes, criterios de inclusión 1) Aneurismas de aorta torácica rotos, 2) roturas traumáticas de aorta torácica y 3) disecciones de aorta torácica tipo B (DATBc) complicadas. Variables principales Mortalidad, supervivencia y tasa de reintervenciones. Variables secundarias Datos demográficos, factores de riesgo cardiovasculares, datos específicos por indicación, datos técnicos y complicaciones postoperatorias. Resultados Se obtuvieron 135 TEVAR urgentes (111 varones, edad media 60,4 ± 16,3 años): 43 aneurismas aórticos rotos (31,9%), 54 disecciones tipo B (40%) y 32 roturas aórticas traumáticas (23,7%) y otras etiologías 4,4%. La mortalidad global a los 30 días fue del 18,5%, siendo superior en los aneurismas de aorta torácica rotos (27,9%). La supervivencia media actuarial ha sido del 67± 6% a los 5 años. La tasa de ictus postoperatoria fue del 5,2% y la tasa de isquemia medular del 5,9%. Las reintervenciones aórticas fueron necesarias en 12 pacientes (9%). Conclusiones La patología de aorta descendente urgente puede ser tratada mediante técnicas endovasculares con resultados óptimos y baja morbimortalidad, aunque ligeramente superior a los casos electivos. Este registro aporta por primera vez, información de la realidad clínica diaria del TEVAR urgente en España. (AU)

Objective Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. Study design and scope A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. Patients, inclusion criteria 1) Ruptured descending thoracic aortic aneurysms; 2) Blunt traumatic thoracic aortic injury; and 3) Complicated acute type B aortic dissections (TBADc). Primary variables Patient mortality, survival and reoperation rate. Secondary variables Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. Results A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ± 16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the ruptured descending thoracic aortic aneurysms group (27.9%). The mean actuarial survival rate was 67± 6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). Conclusions Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality – though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain. (AU)

A multicenter study of emergency endovascular repair of the thoracic aorta: Indications and outcomes.

OBJECTIVE: Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. STUDY DESIGN AND SCOPE: A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. PATIENTS, INCLUSION CRITERIA: 1) Ruptured descending thoracic aortic aneurysms (RTAA); 2) Blunt traumatic thoracic aortic injury (TAI); and 3) Complicated acute type B aortic dissections (TBADc). PRIMARY VARIABLES: Patient mortality, survival and reoperation rate. SECONDARY VARIABLES: Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. RESULTS: A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ±â€¯16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the RTAA group (27.9%). The mean actuarial survival rate was 67 ±â€¯6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). CONCLUSIONS: Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality - though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain.

A multicenter study of emergency endovascular repair of the thoracic aorta: indications and outcomes. / Estudio multicéntrico de la reparación endovascular urgente de la aorta torácica: indicaciones y resultados.

OBJECTIVE: Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. STUDY DESIGN AND SCOPE: A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. PATIENTS, INCLUSION CRITERIA: 1) Ruptured descending thoracic aortic aneurysms; 2) Blunt traumatic thoracic aortic injury; and 3) Complicated acute type B aortic dissections (TBADc). PRIMARY VARIABLES: Patient mortality, survival and reoperation rate. SECONDARY VARIABLES: Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. RESULTS: A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ± 16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the ruptured descending thoracic aortic aneurysms group (27.9%). The mean actuarial survival rate was 67± 6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). CONCLUSIONS: Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality - though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain.

Atención farmacéutica integral a los pacientes de un servicio de Cirugía Vascular / Comprehensive Pharmaceutical Care in a Vascular Surgery Department

Objetivo La actuación conjunta del farmacéutico con el resto del equipo sanitario durante todo el proceso asistencial es necesaria para el desarrollo de la atención farmacéutica y así mejorar la calidad de vida del paciente. En este estudio se presentan los resultados de un modelo continuo de atención farmacéutica en pacientes ingresados en un servicio de Angiología y Cirugía Vascular (ACV).Material y método Estudio prospectivo realizado durante 5 meses para evaluar el resultado de la actividad de un farmacéutico clínico en un servicio de ACV. El farmacéutico participa en el pase de visita de lunes a viernes y en la toma de decisiones con el equipo multidisciplinar, detectando y resolviendo errores de conciliación (EC) al ingreso y al alta y problemas relacionados con la medicación (PRM) durante la estancia hospitalaria. Resultados Se han detectado y resuelto 273 EC en 99 pacientes y 76 PRM en 46 pacientes. La aceptación global de las intervenciones farmacéuticas ha sido del 96%.ConclusionesUn 74% de los pacientes han presentado EC. La eficiencia de la actividad farmacéutica a lo largo del proceso hospitalario queda recogida en el alto grado de aceptación de las intervenciones realizadas (AU)

Objective The pharmacist must work with the clinical team across the continuum of care to develop and therefore improve the patient's quality of life. In this study, we present the results from a continuous pharmaceutical care programme for patients admitted to an angiology and vascular surgery department. Material and methods A 5-month prospective study to evaluate the results of a pharmaceutical care programme in an angiology and vascular surgery department. The pharmacist went on the rounds with the clinical team from Monday to Friday and helped make decisions on treatment, and detect and resolve conciliation discrepancies upon admission and discharge, and drug-related problems during the hospital stay. Results We detected and resolved 273 conciliation discrepancies in 99 patients and 76 drug-related problems in 46 patients. Global acceptance of pharmacist interventions was 96%.ConclusionsSeventy-four percent of patients presented conciliation discrepancies. Efficiency of pharmaceutical activity across the continuum of care is demonstrated by the high acceptance of the interventions (AU)

Comprehensive pharmaceutical care in a vascular surgery department.

OBJECTIVE: The pharmacist must work with the clinical team across the continuum of care to develop and therefore improve the patient's quality of life. In this study, we present the results from a continuous pharmaceutical care programme for patients admitted to an angiology and vascular surgery department. MATERIAL AND METHODS: A 5-month prospective study to evaluate the results of a pharmaceutical care programme in an angiology and vascular surgery department. The pharmacist went on the rounds with the clinical team from Monday to Friday and helped make decisions on treatment, and detect and resolve conciliation discrepancies upon admission and discharge, and drug-related problems during the hospital stay. RESULTS: We detected and resolved 273 conciliation discrepancies in 99 patients and 76 drug-related problems in 46 patients. Global acceptance of pharmacist interventions was 96%. CONCLUSIONS: Seventy-four percent of patients presented conciliation discrepancies. Efficiency of pharmaceutical activity across the continuum of care is demonstrated by the high acceptance of the interventions.

La cirugía abierta es el tratamiento de elección en los aneurismas de la arteria poplítea / No disponible

No disponible

Revascularización percutánea de angiosomas específicos en isquemia crítica de la extremidad / Percutaneous revascularisation of specifi c angiosome in critical limb ischaemia

Introducción y objetivos. Analizar si la adquisición de fl ujo directo al angiosoma isquémico delpie infl uye en la cicatrización y en el salvamento de la extremidad ante isquemia crítica tratadamediante terapia endovascular.Material y métodos. Análisis retrospectivo de 34 extremidades (32 pacientes) consecutivas conisquemia crónica categoría 5 (n = 21; 61,8 %) y 6 (n = 13; 38,2 %) de Rutherford y tratadas exitosamentemediante técnica endovascular, entre 2007 y 2009. Elaboramos dos grupos: el grupo derevascularización directa o RD (la arteria revascularizada nutre directamente el angiosoma isquémico)y el grupo de revascularización indirecta o RI (la arteria revascularizada no nutre directamenteel angiosoma isquémico). Se analizó la cicatrización completa, el tiempo de cicatrizacióny la tasa de salvamento de la extremidad. El análisis estadístico incluyó la prueba deChi-cuadrado y tablas de supervivencia.Resultados. Se incluyeron 34 extremidades sometidas a recanalización (n = 27; 79,4 %), angioplastiasimple (n = 3; 8,8 %) y angioplastia con stent (n = 4; 11,8 %). El grupo RD incluyó 18(52,9 %) extremidades y el grupo RI 16 (47,1 %). Al comparar comorbilidades, no se encontrarondiferencias significativas. El 76,5 % (n = 26) de las heridas cicatrizaron completamente y no resultódiferente el tiempo total de curación (RD 157,8 días frente a RI 124,5 días). Al comparar eléxito de cicatrización completa (RD n = 14 [77,8 %] frente a RI n = 12 [73,7 %]) y la tasa de salvamentode extremidad al año (RD 89 % frente a RI 84 %) tampoco hubo diferencias.Conclusión. En nuestra serie, la revascularización directa o indirecta del angiosoma no infl uyeen la tasa de cicatrización y de salvamento de la extremidad(AU)

Introduction and objectives. To determine whether the acquisition of direct fl ow to ischaemicfoot angiosome affects healing and limb salvage in critical limb ischaemia treated byendovascular therapy.Material and methods. Retrospective analysis of 34 consecutive limbs (32 patients) with chronicischaemia, Rutherford category 5 (n = 21, 61.8 %) and 6 (n = 13, 38.2 %) and successfully treatedwith endovascular technique, between 2007 and 2009. We created two groups: the directrevascularisation group or DR (revascularised artery directly feeds the ischaemic angiosome)and the indirect revascularisation group or IR (revascularised artery does not directly feed theischaemic angiosome). The variables analysed were: complete healing, healing time and limbsalvage rates. Statistical analysis included Chi-square test and survival tables.Results. We included 34 limbs who underwent recanalisation (n = 27, 79.4 %), simple angioplasty(n = 3, 8.8 %) and angioplasty with stents (n = 4; 11.8 %). The DR group included 18 (52.9 %) limbsand the IR group 16 (47.1 %). We did not find significant differences when comparingcomorbidities. There was complete healing in 76.5 % (n = 26) of the wounds and there were nodifference in the total healing time (157.8 days in DR against 124.5 days in IR). There wereno differences when comparing the success of complete healing (DR n = 14 [77.8 %] against IRn = 12 [73.7 %]) and the limb salvage rate per year (89 % DR against 84 % IR).Conclusion. In our series, the direct or indirect revascularisation angiosome does not affect therate of healing and limb salvage(AU)

Evolución del diámetro iliaco tras resección de aneurisma aórtico e interposición de injerto aorto-aórtico / Follow-up of iliac diameter in patients after open abdominal aortic aneurysm repair with an aorto-aortic prosthetic graft

Introducción: Los aneurismas de arteria iliaca después de la reparación de un aneurisma aórtico abdominal (AAA) son poco comunes y no se ha protocolizado el seguimiento del diámetro iliaco. Objetivo: Evaluar la evolución del tamaño de las arterias iliacas mediante eco-doppler en pacientes intervenidos de AAA e interposición de injerto recto. Material y métodos: Estudio transversal de pacientes intervenidos de AAA entre enero de 1999 y marzo de 2008 a los que se les realiza un eco-doppler para valorar el diámetro de las arterias iliacas. Se recogen 45 pacientes. Variables estudiadas: diámetro iliaco preoperatorio (angio-tomografía computarizada) y postoperatorio, así como factores de riesgo vascular y comorbilidades. Se realizan las pruebas de la t de Student, Chi 2 y tablas de supervivencia. Resultados: Media de edad: 69 años (desviación estándar [DE] 6,8). Seguimiento medio: 4,5 años (DE 1,89). Tamaño preoperatorio medio de arterias iliacas: 13 mm (DE 0,45), en el seguimiento: 17 mm (DE 0,52), p = 0,001. Un 19 % de las iliacas presentó crecimiento durante el seguimiento. Se observó un menor crecimiento en pacientes con diabetes mellitus (0/24 %, riesgo relativo [RR] 0,76; intervalo de confianza [IC] 95 %: 0,7-0,9). No se ha podido determinar una correlación tiempo/crecimiento. Ningún paciente precisó tratamiento durante el seguimiento. Conclusión: Aunque en nuestra serie se demuestra un crecimiento significativo durante el seguimiento, no está justificado un protocolo de seguimiento ecográfico de arterias iliacas en este contexto por la baja/nula necesidad de tratamiento quirúrgico posterior(AU)

Introduction: Iliac artery aneurysms are uncommon and there is current no protocol for the follow-up. Aim: To evaluate the progress of the diameter of the iliac arteries by echo-doppler in patients undergoing abdominal aortic aneurysm (AAA) open repair with an aorto-aortic prosthetic graft. Material and methods: A cross-sectional study of patients undergoing AAA between January 1999 and March 2008, on whom an echo-doppler was performed to assess the diameter of iliac arteries. A total of 45 patients were included. The variables studied were: pre- and post-operative iliac diameter (angio-computerized tomography), vascular risk factors and comorbidities. Student t test, Chi-square test were performed and survival tables constructed. Results: The mean age was: 69 years (SD 6.8). Follow-up: 4.5 years (1.89). Preoperative mean size of iliac arteries: 13 mm (0.45), follow-up: 17 mm (0.52), p = 0.001. Overall, the diameter increased in 19 % iliac arteries during growth monitoring. There was a lower expansion rate in diabetic patients (0 %/24 %, relative risk [RR] 0.76, 95 % confidence interval [CI]: 0.7-0.9). We were unable to determine a time/expansion rate correlation. No patient required a repeat operation during the follow-up. Conclusion: Although our series showed a significant growth, the iliac arteries ultrasound follow-up is not justified, in this context, due to the low/no need for a subsequent surgical procedure(AU)

¿Debemos ser más agresivos en el tratamiento revascularizador del paciente claudicante? En contra / No disponible

No disponible

No dispoinble

Safety and efficacy of therapeutic angiogenesis as a novel treatment in patients with critical limb ischemia.

BACKGROUND: In some patients with critical limb ischemia (CLI) the possibility of revascularizing treatment does not exist. In this case therapeutic angiogenesis (TA) using autologous endothelial progenitor cell (EPC) transplantation could be an alternative. The objective of our study was to evaluate the safety and efficacy of TA using EPC. METHODS: Twenty-eight patients with CLI who were not candidates for surgical or endovascular revascularization were included in a prospective study. To mobilize EPCs from the bone marrow, granulocyte colony-stimulating growth factor was injected subcutaneously at doses of 5 microg/kg/day for 5 days. Apheresis was performed, obtaining 50 mL of blood with a high rate of EPCs (CD34(+) and CD133(+) cells were counted). EPCs were implanted in the ischemic limb by intramuscular injections. Primary end points were the safety and feasibility of the procedure and limb salvage rate for amputation at 12 months. Other variables studied were improvement in rest pain, healing of ulcers, ankle-brachial pressure index (ABI), and digital plethysmography. All procedures were done pretreatment and every 3 months for a year on average. Postransplantation arteriography was done in selected cases. RESULTS: No adverse effects were observed. Mean follow-up was 14 months. Before treatment, mean basal ABI was 0.35+/-0.2 and at 18 months postimplantation, 0.72+/-0.51 (p=0.009). There was a mean decrease of five points in pain scale: basal 8.7+/-1, after TA 3.8+/-2.9 (p=0.01). Seven patients required major amputation. Kaplan-Meier analysis revealed a limb salvage rate of 74.4% after 1 year. CONCLUSION: Implantation of EPCs in CLI is a safe alternative, improves tissue perfusion, and obtains high amputation-free rates. Nevertheless, this is a small cohort and results should be tested with long randomized trials.

Valor pronóstico de la escala de Glasgow en aneurismas de aorta abdominal infrarrenal rotos / The prognostic value of the Glasgow scale in ruptured aneurysms in the infrarenal abdominal aorta

Introducción.La mortalidad del aneurisma dea orta abdominal roto (AAAr) intervenido varía en 26-62%, dependiendo del estado clínico del paciente previo a la cirugía. Objetivos. Aplicar la escala de Glasgow en pacientes invervenidos de AAAr, y utilizarla como herramienta pronóstica para determiancar la mortalidad perioperatoria y observar cómo se modificaría la indicación de cirugía para estos pacientes. Pacientes y métodos. Estudio retrospectivo de 103 pacientes intervenidos entre 1996 y 2007 de AAAr. Valoración mediante la escala de Glasgow del estadio clínico preoperatorio. Se obtuvieron las curvas ROC (punto de corte y área bajo la curva) y se compararon los grupos, establecidos según el punto de corte, mediante test de chi al cuadrado. Se determinó la sensibilidad, especificidad, valor pronóstico y positivo (VPP) y negativo (VPN) para el punto de corte. Se aplicó un estudio multivariable para los datos estudiados y se realizaron tablas de supervivencia de Kaplan-Meier. Resultados. Las frecuencias de presentación de las variables de Glasgow fueron: shock 71,8%, cardiopatía 34%, neuropatía 7,8% y nefropatía 36,9%. La mortalidad perioperatoria fue del 49,5% (n=51). El área bajo la curva estimada es 0,814 (intervalo de confianza, IC 95%: 0,725-0,883) y el putno de corte es 106 puntos (sensibilidad 45,1%, especificidad 94,2%; VPP: 88,5%; VPN: 63,6%). La mortalidad por encima y debajo del punto de corte fue del 88,5 y 36,4%, respectivamente (p<0,001; odds ratio: 13,4; IC 95%: 3,6-48,7). Por encima de 111 puntos la mortalidad fue del 100%. Conclusión. La escala de riesgo de Glasgow es una buena herramienta pronóstica de mortalidad en pacientes con AAAr, con la que se obtiene un punto de corte preciso a partir del cual la mortalidad se incrementa de forma significativa, pudiendo, de esta forma, realizar una mejor indicación de cirugía para este grupo de pacientes

Introduction. Mortality in cases of ruptured abdominal aortic aneurysm (rAAA) submitted to surgery ranges between 26-62%, depending on the clinical status of the patient before the operation. Aims. To apply the Glasgow scale in patients who underwent surgery for rAAA and to use it as a prognostic tool to determine the perioperative mortality rate and to observe how the indication for surgery wouyld be modified for these patients. Patients and methods. We conducted a retrospective study of 103 patients submitted to surgery for rAAA between 1996 and 2007. The preoperative clinical status was evaluated by means of the Glasgow scale. The ROC curves (cutt-off point and area below the curve) were obtained and the groups, which had been established according to the cutt-off point, were compared using the chi-square test. Sensitivity, specificity, and both the negative (NPV) and positive predictive value (PPV) were determined for the cutt-off point. A multivariable study was applied for the data under study and Kaplan-Meier survival charts were drawn up. Results. The frequencies of presentation of the Glasgow variables were: shock 71.8%, heart disease 34%, neuropathy 7.8% and nephropathy 36.9%. Perioperative mortality rate stood at 49.4% (n=51). The estimated are below the curve is 0.814 (95% confidence interval, CI: 0.725-0.883), the cut-off points is 106 (sensitivity 45.1%; specificity 94.2%; PPV: 88.5%; NPV: 63.6%). Mortality above and below the cut-off points was 88.5 and 36.4%, respectively (p<0.001; odds ratio, 13.4; 95% 95% CI: 3.6-48.7). Above 111 points mortality was 100%.Conclusions. The Glasgow risk scale is a good tool for predicting mortlity in patients with rAAA, which provides a precise cut-off point beyond which mortality increases significantly. As a result, a better indication for surgery can be achieved for this group of patients

Prospective study of the functional recovery after surgery for thoracic outlet syndrome.

OBJECTIVES: The aim of this study is to evaluate the functional recovery after Thoracic Outlet Syndrome (TOS) surgery, by the application of Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. MATERIAL AND METHODS: This was a prospective study of all patients operated on for TOS from January 1998 to December 2005. The DASH questionnaire was administered pre- and postoperatively. The scores were analysed according to TOS type, the associated comorbidity and the type of surgery performed. Results were assessed with Wilcoxon Test for continuous variables, and the Fisher Test for categories. RESULTS: Twenty-three consecutive patients were included in the study, the average age was 37 years (range: 22-54). Fourteen patients presented with venous TOS and 9 with neurogenic TOS. Patients with venous TOS had a preoperative score of 14.9 (SD 18.31) and a postoperative score of 14.8 (SD 15.6) (p>0.05). The preoperative score in patients with neurogenic TOS was 53.96 (SD 15.6) and the postoperative score was 17.8 (SD 15.3) (p=0.01). CONCLUSIONS: DASH questionnaire is a valid and objective test for evaluating the functional state after TOS surgery. Venous TOS is clinically less incapacitating than neurogenic. Surgically decompression of thoracic outlet leads to significant benefit in patients with neurogenic TOS.

Tratamiento endovascular de la patología arterial de los miembros inferiores / Endovascular treatment of arterial pathologies in the lower limbs

Introducción. La cirugía endovascular presenta un rápido desarrollo en todos los territorios, igualando e incluso mejorando los resultados de la cirugía convencional. Sin embargo, en los miembros inferiores todavía no se han alcanzado los niveles de seguridad y permeabilidad de otros territorios. Objetivo. Realizar una puesta al día de los procedimientos endovasculares aplicables en el sector femoral poplíteo y distal. Desarrollo. Nueve cirujanos vasculares con experiencia en terapéutica endoluminal han redactado este documento. En este trabajo se muestran desde los avances en los métodos diagnósticos, hasta los resultados y costes. Iniciamos esta guía con unas breves notas acerca de la biomecánica de la arteria femoral superficial. Cerramos esta monografía con dos capítulos dedicados al tratamiento endovascular del aneurisma poplíteo y pseudoaneurismas. Hemos intentado redactar un documento útil y práctico, siguiendo las directrices del Capítulo de Cirugía Endovascular de la Sociedad Española de Angiología y Cirugía Vascular. Al final de cada capítulo se ha incluido un apartado de recomendaciones basado en niveles de evidencia. Conclusiones. Este campo de la terapéutica vascular está teniendo un desarrollo veloz y cambiante. La intención de hacer una puesta al día sin duda queda desfasada en pocas semanas. Podría afirmarse que la mejor técnica sería la disponible ‘en nuestro medio’y según ‘nuestra experiencia, que aplicada para un ‘paciente individual’, logre la mayor duración con la menor morbimortalidad posible; y que en caso de fallo, pueda ser repetible o haya alternativas terapéuticas

Introduction. Endovascular surgery is developing quickly in all territories and the results being achieved are similar to, or even better than, those offered by conventional surgery. Yet, the levels of safety and patency of other territories have still not been attained in the lower limbs. Aim. To update our knowledge of the endovascular procedures that can be applied in the popliteal and distal femoral segment. Development. This article has been written by nine vascular surgeons with experience in endoluminal therapy and covers aspects ranging from the advances in the diagnostic methods to the outcomes and costs. We begin this guide with a few brief words about the biomechanics of the superficial femoral artery. The monograph ends with two chapters devoted to the endovascular treatment of popliteal aneurysms and pseudoaneurysms. We have tried to draw up a document that is both useful and practical, following the guidelines of the Endovascular Surgery Chapter of the Spanish Society of Angiology and Vascular Surgery. At the end of each chapter we have included a section offering recommendations based on levels of evidence. Conclusions. This field of vascular therapy is developing in a changeable and very swift manner. What we intend to offer as an update will undoubtedly become somewhat obsolete in a few weeks. As a final conclusion we could say that the best technique is the one that we have available ‘in our area’ and which, according our experience, when applied to an ‘individual patient’ achieves the greatest durability with the lowest possible morbidity and mortality rates: at the same time, in case of failure, it can be repeated or there exist therapeutic alternatives

Diagnóstico no invasivo mediante eco-Doppler de la disfunción eréctil por fuga venosa / Non-invasive diagnosis of erectile dysfunction due to venous leak using Doppler ultrasound

Introducción. El mecanismo patogénico más frecuente de la disfunción eréctil es el de origen vascular. Hasta la fecha, en el diagnóstico de la disfunción eréctil por fuga venosa, únicamente se disponía de pruebas diagnósticas invasivas, como la cavernosometría y la cavernosografía, con un riesgo potencial de yatrogenia para los pacientes. Caso clínico. Varón de 38 años de edad con disfunción eréctil de origen vascular por fuga venosa (disfunción del mecanismo corporovenooclusivo), diagnosticado únicamente mediante eco-Doppler e índice peneano en nuestro gabinete de diagnóstico vascular no invasivo. Conclusiones. La exploración hemodinámica mediante eco-Doppler de las arterias cavernosas, sobre todo desde la incorporación de la administración intracavernosa de fármacos vasoactivos, ha pasado a considerarse como la prueba de elección en el diagnóstico de disfunción eréctil en la fase arterial. De la misma forma, muchos autores también la consideran de elección en la valoración del mecanismo corporovenooclusivo (o fase venosa) y ha desplazado de forma paulatina a pruebas como la cavernosografía y la cavernosometría dinámicas

Introduction. The most common pathogenic mechanism causing erectile dysfunction has its origins in a vascular disorder. To date, in the diagnosis of erectile dysfunction due to venous leak, only invasive diagnostic tests, such as cavernosometry and cavernosography, have been available, and such methods naturally entail a potential iatrogenic risk for patients. Case report. A 38-year-old male with vascular erectile dysfunction due to venous leak (dysfunction of the corporal veno-occlusive mechanism), diagnosed using only Doppler ultrasonography and the penile index in our noninvasive vascular diagnosis clinic. Conclusions. Haemodynamic examination using Doppler ultrasound recording of the cavernous arteries has now become the preferred test for diagnosing erectile dysfunction in the arterial phase, and more so since the incorporation of intracavernous administration of vasoactive drugs. Likewise, many authors also consider it to be the preferred method for evaluating the corporal veno-occlusive mechanism (or venous phase) and it has gradually substituted dynamic tests such as cavernosography and cavernosometry

Inappropriate secretion of antidiuretic hormone: a rare complication after carotid endarterectomy.

The syndrome of inadequate secretion of the antidiuretic hormone (SIADH) is a very rare complication after carotid endarterectomy, characterized by hyponatremia, decrease of serum osmolarity as well as an increase in urinary osmolarity. We report the case of an 80-year-old woman who developed, 24 hours after the surgery, a picture of drowsiness and lethargy without neurological focality. The diagnosis of SIADH was suspected. We conclude that is important to have in mind this clinical entity in the differential diagnosis of non-focal neurological deficit after carotid endarterectomy.

Tratamiento quirúrgico de la arteritis de Takayasu con afectación de troncos supraaórticos. A propósito de dos casos clínicos / Surgical treatment of Takayasu´s arteritis with involvement of the supra-aortic trunks. Two clinical case reports

Introducción. La arteritis de Takayasu es una enfermedad inflamatoria muy poco frecuente en nuestro medio, que afecta principalmente a mujeres jóvenes de origen asiático o norteafricano. El fenómeno creciente de inmigración existente actualmente en nuestro país, hace que debamos tener presentes patologías que hasta ahora eran muy poco habituales. Casos clínicos. A través de los casos clínicos de dos pacientes jóvenes con enfermedad de Takayasu sintomática, cuyo estudio arteriográfico mostró una afectación grave de troncos supraaórticos, presentamos el diagnóstico y manejo terapéutico de esta patología. Se realizó a ambas pacientes un injerto desde aorta ascendente a carótida interna y subclavia izquierda con buena evolución, y remisión de la sintomatología isquémica. Conclusión. La revascularización de troncos supraaórticos es una opción válida en el tratamiento de la arteritis de Takayasu; se deben evitar siempre los procedimientos quirúrgicos en la fase aguda de la enfermedad, así como en los sectores arteriales que presentan una mayor incidencia potencial de afectación

Introduction. Takayasu’s arteritis is a very infrequent inflammatory disease in our milieu that chiefly affects young females of Asian or North African extraction.The growing phenomenon of immigration that currently exists in our country means that we now have to take into account a series of pathologies that, until recently, were very uncommon. Case reports. The clinical cases of two young patients with symptomatic Takayasu’s disease, in which an arteriography study revealed severe involvement of the supra-aortic trunks, are used here to describe the diagnostic and therapeutic treatment of this condition. A graft was carried out from the ascending aorta to the internal carotid and the left subclavian in both patients with good progress and remission of the ischaemic symptoms. Conclusions. Revascularisation of the supra-aortic trunks is a valid option in the treatment of Takayasu’s arteritis; surgical procedures must always be avoided during the acute phase of the disease, as well as in the arterial segments that are potentially more likely to become infected

[Buerger's disease with intestinal ischemic involvement]. / Isquemia intestinal en la enfermedad de Buerger.

Buerger's disease is uncommon arterial disease that affects mainly young people with heavy smoking history. Ischemic symptoms of upper and lower extremities are clearly defined as the most common kind of presentation. Visceral arteries are rarely affected. We report a case of a 44 year old young female with Buerger's disease and mesenteric ischemic involvement, and a revision of the literature about Buerger's disease with visceral affection. Due to the extreme rarity of the intestinal involvement of Buerger's disease, the early diagnosis is difficult, for this reason all patients affected by Buerger's disease who present intestinal symptoms should be carefully evaluated. Aortography and early laparoscopic revision are very important to limit ischemic intestinal injury and later complications. If hemodynamic instability is present emergency laparotomy at the operating theatre is recommended.

Isquemia intestinal en la enfermedad de Buerger / Buerger´s disease with intestinal ischemic involvement

La enfermedad de Buerger es una arteritis que afecta de forma predominante a pacientes jóvenes con gran habito tabáquico. La sintomatología isquémica a nivel de extremidades superiores e inferiores es la forma más habitual de presentación. La afectación visceral es muy poco frecuente y a menudo se infravalora. Presentamos el caso clínico de una mujer joven de 44 años con enfermedad de Buerger y afectación intestinal, y realizamos una revisión de la literatura de pacientes con enfermedad de Buerger que presentan afectación visceral. La afectación intestinal en la enfermedad de Buerger es extremadamente infrecuente y su diagnóstico precoz difícil, por eso ante un paciente con enfermedad de Buerger que presenta dolor abdominal de etiología no aclarada, debe evaluarse la posibilidad de una isquemia visceral. La arteriografía diagnóstica y una laparoscopia abdominal exploradora precoz ayudarán a delimitar la necrosis intestinal y el riesgo de complicaciones. En aquellos casos en que la situación hemodinámica del paciente no lo permita se procederá a la realización de una laparotomía con carácter de urgencia

Buerger’s disease is uncommon arterial disease that affects mainly young people with heavy smoking history . Ischemic symptoms of upper and lower extremities are clearly defined as the most common kind of presentation. Visceral arteries are rarely affected. We report a case of a 44 years old young female with Buerger’s disease and mesenteric ischemic involvement, and a revision of the literature about Buerger’s disease with visceral affection. Due to the extremely rarity of the intestinal involvement of Buerger’s disease, the early diagnosis is difficult, for these reason all patient affected by Buerger’s disease who presents intestinal symptoms should be carefully evaluated. Aortography and early laparoscopic revision are very important to limit ischemic intestinal injury and later complications. If hemodynamic instability is present emergency laparotomy at the operating theatre is recommended

Técnica DRIL como tratamiento del síndrome de robo arterial isquémico / The DRIL procedure as treatment for ischaemic arterial steal syndrome

Objetivo. El objetivo de nuestro estudio es evaluar la efectividad de la técnica DRIL (revascularización distal y ligadura intermedia) como tratamiento del síndrome de robo arterial isquémico secundario a fístulas arteriovenosas (FAV). Pacientes y métodos. Entre enero 1999 y diciembre 2003, 10 pacientes con accesos vasculares (AV) para hemodiálisis (HD) presentaron robo arterial isquémico clínico y hemodinámico (pletismografía aplanada e índices digitales menores de 0,4). En tres se presentó de forma inmediata tras la FAV y en siete de forma diferida. Tres pacientes eran portadores de FAV protésicas y los siete restantes de fístulas autólogas; en todos la arteria humeral era el origen de la FAV. Todos los casos se intervinieron realizándose un injerto humerohumeral con vena safena antóloga invertida y ligadura de la arteria humeral distal a la anastomosis arteriovenosa. Resultados. Se objetivó remisión de la sintomatología isquémica en todos los pacientes. Nueve normalizaron el estudio hemodinámico y recuperaron pulsos distales; el caso restante presentó un robo parcial de carácter asintomático. Dos pacientes precisaron de amputaciones transfalángicas, uno de ellos por presentar trombosis de arterias digitales. La permeabilidad primaria de los injertos y la FAV a un año fue del 60,5%. Conclusiones. La técnica DRIL es un método efectivo en el tratamiento del robo arterial isquémico producido por FAV para HD; ésta consigue los dos objetivos básicos: resolver la sintomatología isquémica y preservar el AV

Aims. The aim of our study is to evaluate the effectiveness of the DRIL (Distal Revascularisation and Interval Ligation) procedure as treatment for ischemic arterial steal syndrome secondary to arteriovenous fistulas (AVF). Patients and methods. Between January 1999 and December 2003, 10 patients with vascular accesses (VA) for haemodialysis (HD) were found to have clinical and haemodynamic ischaemic arterial steal syndrome (flattened plethysmography tracings and digital indices below 0.4). In three cases it appeared immediately after AVF set-up and in the other seven its appearance was delayed. Three patients had prosthetic AVF and the remaining seven had autologous fistulas; in all cases the AVF originated in the brachial artery. All interventions were performed with a brachial-brachial graft with inverted antologous saphenous vein and ligation of the distal brachial artery to the arteriovenous anastomosis. Results. The ischaemic symptoms were seen to remit in all patients. Nine showed normal results in the haemodynamic study and regained distal pulses; the remaining case had a partial, asymptomatic steal. Two patients required transphalangeal amputations, one of them owing to thrombosis of digital arteries. Primary patency of the grafts and the AVF at one year was 60.5%. Conclusions. The DRIL procedure is an effective method in the treatment of the ischaemic arterial steal produced by AVF for HD, since it accomplishes the two basic objectives, namely, resolution of the ischaemic symptoms and preservation of the VA