Comparative performance of three comorbidity scores in predicting survival after the elective repair of abdominal aortic aneurysms.

BACKGROUND: We aimed to study the discriminative power of 3 comorbidity scores for predicting 5-year survival after the elective repair of aorto-iliac aneurysms (AAA). METHODS: 444 patients with AAA undergoing elective repair (33% open and 67% endovascular) between 2000 and 2020 were reviewed. The Charlson Comorbidity Index (CCI) and subsequent adjustments by Schneeweiss, Quan and Armitage, the Modified Frailty Index (MFI) and the American Society of Anesthesiologists Score (ASA) were calculated from preoperative data. Their association with 5-year survival was analyzed using Cox regression models and their discriminative power and its changes with C statistics and Net Reclassification Index (NRI). RESULTS: All comorbidity scores were associated with survival after adjusting by age, sex and type of surgical repair: original CCI HR=1.24, P<0.001; Schneeweiss CCI HR=1.23, P<0.001; Quan CCI HR=1.27, P<0.001, Armitage CCI HR=1.46, P<0.001, MFI HR=1.39, P<0.001 and ASA HR=1.68 (P=0.04) and 2.86 (P=0.01) for classes III and IV, respectively. Associated C statistics were of 0.64, 0.65, 0.65, 0.64, 0.61 and 0.59, respectively. Compared with the original CCI, models based on Schneeweiss CCI and Armitage CCI provided minor improvements in NRI (0.32 and 0.23), and the model based on ASA showed lower C statistics (P=0.014) and NRI (-0.30). CONCLUSIONS: Established comorbidity scores, such as CCI, MFI or ASA, are all associated with 5-year survival after the elective repair of AAAs, being ASA the worst of them. However, their predictive power is in no case sufficient to identify, by themselves, those patients who may not be eligible for intervention on the basis of life expectancy.

Angioplastia guiada mediante eco Doppler en el tratamiento de las estenosis de fístula arteriovenosa para hemodiálisis / Ultrasound-guided angioplasty in the treatment of arterio-venous fistula stenosi

INTRODUCCIÓN: las estenosis en el trayecto de fístulas arteriovenosas (FAV) para hemodiálisis son un problema muy prevalente y existe una larga experiencia en su tratamiento mediante angioplastia percutánea (ATP). Estos procedimientos, sin embargo, implican unas necesidades no despreciables de aparataje, exposición a radiación y contraste intravenoso que no son beneficiosas para el paciente y hacen más compleja su realización. Este estudio revisa nuestra experiencia inicial en la angioplastia guiada mediante ecografía Doppler. MATERIAL Y MÉTODOS: cohorte prospectiva de pacientes con disfunción de la FAV nativa por estenosis venosas significativas tratados mediante una ATP guiada mediante eco Doppler. La punción de la FAV, la cateterización de la lesión, la localización y el inflado del balón y la comprobación del resultado se hicieron de forma ecoguiada. Tan solo se realizaron una fistulografía comprobatoria previa y otra posterior a la dilatación. Como control, se recogieron también los casos realizados durante el mismo periodo por el método angiográfico habitual. RESULTADOS: entre febrero de 2015 y septiembre de 2018 se realizaron 51 ATP sobre FAV nativa, de las que 27 fueron de forma ecoguiada (edad media, 65,3 años; 63% varones). El éxito técnico fue del 96%. En el 26% de los casos se repitió la ATP por estenosis residual tras la imagen angiográfica. Hubo un 7,3% de complicaciones periprocedimiento. El 92% de las FAV fueron puncionadas a las 24 h. La permeabilidad primaria a 1 mes, 6 meses y 1 año fue del 100%, 64,8% y 43,6%, y la asistida del 100%, 87,2% y 74,8%. No hubo diferencias significativas en los resultados inmediatos o tardíos respecto a las angioplastias de FAV guiadas mediante angiografía. CONCLUSIONES: la ATP-FAV puede realizarse de manera segura y eficaz guiada mediante ecografía Doppler, lo que permite simplificar la logística necesaria para su realización, si bien debemos mejorar todavía la capacidad de comprobación precoz del resultado con esta técnica de imagen

BACKGROUND: stenoses in the arterio-venous fistulae (AVF) for hemodialysis are a very common problem and there is a long experience in its treatment by percutaneous angioplasty (PTA). These procedures, however, imply important needs for equipment, exposure to radiation and intravenous contrast that are not beneficial for the patient and make it more complex to perform. This study reviews our initial experience in ultrasound-guided angioplasty. MATERIAL AND METHODS: prospective cohort of patients with native AVF dysfunction due to significant venous stenosis, undergoing a PTA ultrasound-guided. Puncture of the AVF, catheterization of the lesion, localization and inflation of the balloon and verification of the result were ultrasound-guided, with only a fistulography performed before and after the dilation. As a control-cases, patients intervened by the usual angiographic method were also collected. RESULTS: of the 51 ATP performed on native AVF between February 2015 and September 2018, 27 were ultrasound-guided (mean age 65.3 years, 63% males). The technical success was 96%. In 26% of the cases, ATP was repeated due to residual stenosis after the angiographic image. There were 7.3% peri-procedural complications. 92% of the AVF were punctured at 24 h. Primary patency rates at 1 month, 6 months and 1 year was 100%, 64.8% and 43.6% and Assisted 100%, 87.2% and 74.8%, respectively. There were no significant differences in the immediate or late results with respect to angioplasty of AVF guided by angiography. CONCLUSIONS: ATP-FAV can be safe and effectively performed by Doppler ultrasound guidance. This method simplifies the logistics of the procedure although further improvements are needed to ensure that ultrasound is adequate to ensure the correct patency of the vessel

Disease Progression in the Contralateral Carotid Artery is Still Common After Endarterectomy.

BACKGROUND: Disease progression in the contralateral carotid artery (CA) after a carotid endarterectomy (CEA) was common in the past. Current medication regimens for these patients are better and have probably modified this progression. We evaluated the rate of disease progression in the contralateral CA over the last decade. METHODS: A retrospective analysis of 291 consecutive patients undergoing a CEA between 2005 and 2014 was performed. Disease progression in the contralateral CA after CEA was determined by a duplex ultrasound. Statistics were calculated by Kaplan-Meier life-tables and Cox regression. RESULTS: Of the 291 patients, 246 (84.5%) received at baseline antiplatelet and/or anticoagulant agents, and 223 (77%) received statins. These proportions increased over the second half of the study. Disease progression in the contralateral CA was evaluated in 200 patients during a mean follow-up of 3.5 years. Progression-free survival rates from any disease progression at 1 and 5 years were of 89.3% and 68.6%, respectively. Free survival rates from <50% to >50% progression or from 50% to 69% to a higher category at 1 and 5 years were of 89.3% and 75.5%, respectively. Finally progression-free survival rates to a >70% stenosis or occlusion at 1 and 5 years were of 96.8% and 90.1%, respectively. Age (hazard ratio = 1.034, P = 0.048) and dyslipidemia (hazard ratio = 1.93, P = 0.045) were also associated with any disease progression. CONCLUSIONS: Current rates of disease progression in the contralateral CA after CEA are similar to those reported more than 1 decade ago. Further research will be needed to evaluate the impact of current medical regimens at these stages of disease.

Persistent cutaneous abdominal ulcerations secondary to diffuse dermal angiomatosis: an underestimated sign for severe atherosclerosis: A case report.

BACKGROUND: Diffuse dermal angiomatosis (DDA) is a rare, acquired, reactive vascular proliferation, clinically characterized by livedoid erythematous-violaceous plaques, which frequently evolve to ulceration and necrosis. Histopathologically, it is manifested by a diffuse proliferation of endothelial cells within the full thickness of the dermis. DDA has been mainly associated with severe peripheral atherosclerosis. METHODS: We report a 63-year-old woman who presented with multiple erythematous-violaceous plaques with central deep skin ulcers on thighs, lower abdomen, and perianal area, associated with intermittent claudication, low-grade fever, and weight loss. Initially, the clinical picture along with positive cultures for Klebsiella pneumoniae suggested a multifocal ecthyma gangrenosum; nevertheless, a skin biopsy showed a diffuse dermal proliferation of endothelial cells interstitially arranged between collagen bundles. A computed tomography scan revealed severe aortic atheromatosis with complete luminal occlusion of the infrarenal aorta and common iliac arteries. RESULTS: The diagnosis of DDA secondary to severe atherosclerosis was established. The patient underwent a left axillofemoral bypass surgery with a rapidly healing of the ulcers in the next weeks. CONCLUSIONS: DDA should be considered in the differential diagnosis of livedoid ischemic lesions. Recognition of DDA as a cutaneous sign of severe peripheral vascular disease is important for both dermatologists and internists. Recognition of risk factors and their management with an early intervention to correct tissue ischemia can be curative.

Long-Term Anticoagulant Therapy of Patients with Venous Thromboembolism. What Are the Practices?

Current guidelines of antithrombotic therapy suggest early initiation of vitamin K antagonists (VKA) in non-cancer patients with venous thromboembolism (VTE), and long-term therapy with low-molecular weight heparin (LMWH) for those with cancer. We used data from RIETE (international registry of patients with VTE) to report the use of long-term anticoagulant therapy over time and to identify predictors of anticoagulant choice (regarding international guidelines) in patients with- and without cancer. Among 35,280 patients without cancer, 82% received long-term VKA (but 17% started after the first week). Among 4,378 patients with cancer, 66% received long term LMWH as monotherapy. In patients without cancer, recent bleeding (odds ratio [OR] 2.70, 95% CI 2.26-3.23), age >70 years (OR 1.15, 95% CI 1.06-1.24), immobility (OR 2.06, 95% CI 1.93-2.19), renal insufficiency (OR 2.42, 95% CI 2.15-2.71) and anemia (OR 1.75, 95% CI 1.65-1.87) predicted poor adherence to guidelines. In those with cancer, anemia (OR 1.83, 95% CI 1.64-2.06), immobility (OR 1.51, 95% CI 1.30-1.76) and metastases (OR 3.22, 95% CI 2.87-3.61) predicted long-term LMWH therapy. In conclusion, we report practices of VTE therapy in real life and found that a significant proportion of patients did not receive the recommended treatment. The perceived increased risk for bleeding has an impact on anticoagulant treatment decision.

Aneurismas micóticos de ambos miembros inferiores secundarios a endocarditis infecciosa / No disponible

No disponible

Aneurismas poplíteos. Evolución y factores pronósticos en la trombosis del saco / Popliteal aneurysms. Their course and prognostic factors in thrombosis of the sac

Objetivos. Conocer la evolución de aneurismas poplíteos tratados quirúrgicamente y evaluar factores pronósticos en la trombosis del saco. Pacientes y métodos. Desde mayo de 1993 hasta junio del año 2005, 43 pacientes presentaron 64 aneurismas poplíteos (diámetro medio: 2,8 cm; intervalo: 1,2-8 cm); de ellos, 19 (29%) han recibido tratamiento médico (compensación tras trombosis), dos (3%) aneurismectomía más injerto terminoterminal vía posterior, 22 (34%) exclusión por ligadura más bypass poplíteo-poplíteo y, por último, 21 (32%) exclusión y bypass femoropoplíteo. Hemos realizado un estudio descriptivo transversal en los 43 aneurismas tratados mediante exclusión y bypass (67%). Mediante eco-Doppler de control se evaluó: diámetro, presencia de flujo o trombosis del aneurisma y permeabilidad del bypass. Se analizó, mediante regresión de Cox, si existía asociación estadísticamente significativa entre la trombosis postoperatoria del saco aneurismático y los siguientes factores: diámetro preoperatorio del aneurisma, edad, factores de riesgo cardiovascular, comorbilidad, tipo de tratamiento, run-off, permeabilidad del bypass y presencia de aneurisma contralateral o de aorta. Resultados. De 43 aneurismas intervenidos, se pudieron evaluar 25 (56%). Se detectó flujo Doppler intraaneurismático en cuatro casos (16%); de éstos, hubo crecimiento del saco en tres (12%), y en uno (4%) disminuyó. De los 21 casos (84%) con trombosis completa del saco, se detectó su crecimiento en dos (8%), y en los 19 restantes (76%) disminuyó. El control clínico medio fue de 65 meses (intervalo: 1-128 meses). No se detectaron roturas ni síntomas compresivos. El tipo de cirugía resultó ser el único factor estadísticamente significativo (p = 0,04). Conclusiones. La reparación quirúrgica no garantiza la trombosis del aneurisma. El bypass poplíteo-poplíteo muestra mayores garantías en la trombosis del saco aneurismático

Aims. To determine how surgically treated popliteal aneurysms progressed and to evaluate the prognostic factors for thrombosis of the aneurysmal sac. Patients and methods. Between May 1993 and June 2005, 43 patients presented with 64 popliteal aneurysms (mean diameter: 2.8 cm; interval: 1.2-8 cm), of which 19 (29%) received medical treatment (compensation following thrombosis), two (3%) underwent an aneurysmectomy plus an end-to-end graft inserted using a posterior approach, 22 (34%) were treated with exclusion by ligation plus popliteal-popliteal bypass and, lastly, 21 (32%) underwent exclusion and femoral-popliteal bypass. We conducted a cross-sectional descriptive study in the 43 aneurysms treated by means of exclusion and bypass (67%). A control Doppler ultrasound recording was used to evaluate diameter, presence of flow or thrombosis of the aneurysm and patency of the bypass. Cox regression was used to analyse whether there was a statistically significant association between post-operative thrombosis of the aneurysmal sac and the following factors: pre-operative diameter of the aneurysm, age, cardiovascular risk factors, comorbidity, type of treatment, run-off, patency of the bypass and the presence of a contralateral or aortic aneurysm. Results. Of the 43 aneurysms that were treated with surgery, we were able to evaluate 25 (56%). Intra-aneurysmal Doppler flow was detected in four cases (16%); of these, the sac was seen to have grown in three (12%) and it had diminished in one (4%). Of the 21 cases (84%) with complete thrombosis of the sac, growth was detected in two of them (8%) and it had diminished in the remaining 19 (76%). Mean clinical monitoring time was 65 months (interval: 1-128 months). No ruptures or symptoms of compression were detected. Findings showed that type of surgery is the only statistically significant factor (p = 0.04). Conclusions. Surgical repair does not guarantee thrombosis of the aneurysm. A popliteal-popliteal bypass offers a higher degree of safety in thrombosis of the aneurysmal sac