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.

Análisis coste-efectividad del tratamiento del aneurisma de aorta abdominal mediante prótesis endovascular en España / Analysis of the cost-effectiveness of using stents to treat abdominal aortic aneurysms in spain

Objetivos. Determinar si el tratamiento endovascular (TEV) es una opción coste-efectiva en la terapia delaneurisma de aorta abdominal (AAA) respecto a la cirugía abierta, y evaluar el impacto presupuestario de una mayorutilización de estos dispositivos en el Sistema Nacional de Salud. Pacientes y métodos. Realizamos un análisis costeefectividady coste-utilidad del TEV frente a cirugía abierta utilizando un modelo de Markov de ciclos mensuales basadoen datos clínicos de la literatura (esencialmente el estudio EVAR-1) y la opinión de expertos. Tuvimos en consideraciónuna población española hipotética de pacientes con AAA igual o superior a 5 cm y tributarios de cirugía abierta. El análisislo realizamos desde la perspectiva del Sistema Nacional de Salud, y se descontaron costes y efectos futuros al 3,5%.Adicionalmente realizamos el impacto presupuestario y un análisis de sensibilidad probabilístico con la simulación deMonte-Carlo. Resultados. Los resultados mostraron que el TEV se asocia a una mayor efectividad que la cirugía abierta,con ganancias de entre 0,03 y 0,18 años de vida por paciente a uno y cuatro años, respectivamente (resultados similaressi se utilizan años de vida ajustados por calidad). El coste medio por paciente fue mayor en TEV, entre 2.879 y 3.492euros según distintos escenarios, el coste por años de vida ganado con TEV fue de 111.064 a 19.852 euros y el coste poraños de vida ajustados por calidad ganado fue de 137.206 a 27.077 euros (análisis a uno y cuatro años, respectivamente).El impacto presupuestario de aumentar la introducción de la endoprótesis evaluada en España durante los próximoscuatro años representa el 0,5-2,2% del coste total de las AAA. Conclusiones. El TEV es una alternativa coste-efectiva conrespecto a la intervención quirúrgica convencional, ya que a los cuatro años de seguimiento presenta valores por debajodel umbral de eficiencia usualmente aceptado en España(AU)

Aims. To determine whether endovascular treatment (EVT) is a cost-effective option for the treatment ofabdominal aortic aneurysm (AAA) with respect to open surgery, and to evaluate the budget impact of a more widespreadutilisation of these devices in the Spanish National Health Service. Patients and methods. We performed a costeffectivenessand cost-utility analysis of EVT versus open surgery using a Markov model of monthly cycles based onclinical data from the literature (essentially the EVAR-1 study) and the opinion of experts. The sample taken into accountwas a hypothetical Spanish population of patients with AAA equal to or larger than 5 cm and who were candidates foropen surgery. The analysis was performed from the perspective of the National Health Service, and future costs andeffects were discounted at 3.5%. Additionally we also examined the budget impact and performed a probabilisticsensitivity analysis with Monte-Carlo simulation. Results. The results showed that EVT is associated to a higher degreeof effectiveness than open surgery, with gains of between 0.03 and 0.18 years of life per patient at one and four years,respectively (similar results to those obtained if quality adjusted life years are used). The mean cost per patient wasgreater in EVT, between 2879 and 3492 euros, depending on the different scenarios, the cost-life years gained with EVTwas from 111 064 to 19 852 euros and the cost-quality adjusted life years gained was from 137 206 to 27 077 euros(analysis at one and four years, respectively). The budget impact of increasing the introduction of stents evaluated inSpain over the next four years represents 0.5-2.2% of the total cost of AAA. Conclusions. EVT is a cost-effectivealternative with respect to conventional surgical interventions, because at four years of follow-up it offers values thatare below the efficiency threshold that is usually accepted in Spain(AU)

Documento base sobre el tratamiento de la estenosis carotídea con stent / Core document about the treatment of carotid stenosis with stenting

Introducción. El tratamiento quirúrgico de la estenosis carotídea ha suscitado, desde sus inicios, gran número de estudios internacionales, que cuestionaban su indicación, beneficios, etc.; pero, cuando las cosas parecían en calma, las nuevas tecnologías endovasculares vuelven a introducir el dilema, hasta plantear el tratamiento endovascular como una alternativa a la endarterectomía. Objetivo. Presentar el estado actual del conocimiento para que sirva de punto de partida a futuras guías en el diagnóstico y tratamiento de esta patología lesional. Desarrollo. Se comentan las distintas exploraciones diagnósticas, desde la ecografía Doppler, la tomografía axial computarizada y la angiotomografía, la resonancia magnética y la angiorresonancia, la angiografía de los troncos supraaórticos, discutiendo sus ventajas e inconvenientes para el diagnóstico. La indicación del stenting carotídeo se evalúa teniendo en cuenta el riesgo anatómico para la endarterectomía, los riesgos de alto riesgo médico para la cirugía y los riesgos de tipo técnico para la endarterectomía. También se comentan las contraindicaciones del stenting. Se describen de forma bastante extensa y precisa las distintas técnicas actuales de angioplastia y stenting, comentando los accesos, los tipos de materiales para cada una de ellas, capítulo este muy completo. Los sistemas de protección cerebral también se describen comenzando por la oclusión distal hasta los sistemas de flujo inverso hacia un shunt arteriovenoso. Se describen las complicaciones inmediatas (trombosis, embolismo cerebral, disección, hemorragia, vasoespasmo, etc.), así como las complicaciones tardías, destacando la reestenosis y las maneras de prevenirla. Conclusión. El documento base es el punto de partida a raíz de los acontecimientos y conocimientos actuales para poder contar en el futuro con más evidencias que conviertan este documento en una auténtica guía

Introduction. From its early days, the surgical treatment of carotid stenosis has given rise to a large number of international studies that have questioned its indication, benefits, and so forth; yet, when things seemed to have calmed down, the new endovascular technologies have revived the dilemma, to the point where endovascular treatment is proposed as an alternative to endarterectomy. Aim. To outline the present state of the art as a starting point for future guidelines in the diagnosis and treatment of this lesional pathology. Development. The article considers the different diagnostic examinations, from Doppler ultrasound, computerised axial tomography and tomography angiography, magnetic resonance imaging and MR angiography, to angiography of the supra-aortic trunks; at the same time, their advantages and disadvantages for use in diagnosis are also discussed. The indication for carotid stenting is assessed taking into account the anatomical risk involved in endarterectomies, the high medical risk for surgery and the risks of a technical nature deriving from endarterectomies. The contraindications of stenting are also discussed. The different angioplasty and stenting techniques that are currently used are described at length in this comprehensive chapter, with detailed information about accesses and the types of materials for each kind of procedure. Cerebral protection systems are also described, these ranging from distal occlusion to systems of reverse flow towards an arteriovenous shunt. Immediate complications (thrombosis, cerebral embolism, dissection, haemorrhage, vasospasm, etc.) are described, as are late complications, with special attention given to restenosis and ways of preventing it. Conclusions. The core document is the starting point based on current knowledge and events that will allow us to use more evidence to make this document a real guide in the future

Estudio comparativo de dos técnicas quirúrgicas en el tratamiento de las varices de las extremidades inferiores: resultados tras cinco años de seguimiento / Comparative study of two surgical techniques in the treatment of varicose veins in the lower extremities: results from a five-year follow-up

Objetivo. Comparar los resultados tardíos de la fleboextracción convencional con la estrategia CHIVA en el tratamiento de las varices de las extremidades inferiores. Pacientes y métodos. Ensayo clínico sobre 100 pacientes con varices: 62 mujeres y 38 hombres con una edad media de 49 años (desviación estándar: 9,24 años). Los criterios de inclusión fueron los recomendados por la SEACV (varices más o menos evidentes con diferentes grados de insuficiencia venosa crónica), mientras que los criterios de exclusión fueron los antecedentes de tratamientos previos (esclerosis o cirugía), las alteraciones en el sistema venoso profundo, la obesidad mórbida y/o la edad superior a 70 años. Se practicó una cartografía hemodinámica mediante eco-Doppler. Los pacientes se dividieron en el grupo I (fleboextracción; n = 49) y el grupo II (CHIVA; n = 51). Ambos grupos eran homogéneos tanto demográfica como clínicamente (clasificación CEAP). Los controles clínicos y hemodinámicos se realizaron a la semana y al primer, tercer y sexto mes de la cirugía, y posteriormente cada año hasta los cinco años de seguimiento. Se analizaron la clínica y los resultados estéticos (objetivos y subjetivos), al igual que el número de reintervenciones y recidivas. Se aplicaron los tests de chi al cuadrado y t de Student para el análisis estadístico. Resultados. El 96% de los pacientes completó todo el seguimiento (cinco años). Los resultados clínicos y estéticos a los cinco años del postoperatorio no muestran diferencias significativas entre las dos técnicas. El número de reintervenciones fue similar en los dos grupos. No se detectaron diferencias estadísticamente significativas en cuanto a recidiva varicosa (p > 0,05). Conclusiones. En nuestra serie, las dos técnicas quirúrgicas presentan resultados clínicos y estéticos similares tras cinco años de seguimiento

Aim. To compare late outcomes of conventional vein stripping with the CHIVA strategy in the treatment of varicose veins in the lower extremities. Patients and methods. A clinical trial on 100 patients with varicose veins: 62 females and 38 males with a mean age of 49 years (standard deviation, SD: 9.24). Eligibility criteria were those recommended by the SEACV (varicose veins that were apparent to a greater or lesser extent with different degrees of chronic venous insufficiency). Exclusion criteria were the past history of previous treatments (sclerosis or surgery), disorders affecting the deep vein system, morbid obesity and/or the patient’s being over 70 years old. A blood map was performed using a Doppler ultrasound equipment. Patients were divided into group I (vein stripping; n = 49), and group II (CHIVA; n = 51). Both groups were demographically and clinically homogenous (CEAP classification). Haemodynamic and clinical controls were performed during the first week and at the first, third and sixth month after surgery and then every year until five years’ follow-up. The clinical features and the (objective and subjective) aesthetic outcomes were analysed, together with the numbers of reinterventions and recurrences. Chi squared and Student’s t tests were applied for the statistical analysis. Results. The whole (five-year) follow-up was completed by 96% of the patients. The clinical and aesthetic outcomes five years after the operation do not display any significant differences between the two techniques. The number of reinterventions was similar in the two groups. No statistically significant differences were detected as far as recurrence of the varicose syndrome was concerned (p > 0.05). Conclusions. In our series, both surgical techniques offered similar clinical and aesthetic outcomes after five years’ follow-up