Utilidad de la ecografía en la punción retrógrada distal en la isquemia crítica de extremidades inferiores / Usefulness of ultrasound-guided tibio-pedal access in patients with critical limb ischemia

Introducción La punción retrógrada se puede realizar guiada mediante fluoroscopia o ecografía. Nuestro objetivo fue analizar la utilidad de la ecografía en la punción retrógrada distal de las extremidades inferiores. Métodos Estudio analítico observacional de diciembre del 2013 a junio del 2019. Se incluyeron todos los accesos retrógrados distales que fueron realizados guiados ecográficamente. Se analizaron datos demográficos y clínicos, vaso utilizado como acceso retrógrado, procedimiento efectuado, cantidad de contraste usada y tiempo de escopia, fallo en el acceso y complicaciones locales. Resultados De 715 procedimientos, se utilizó el acceso retrógrado ecoguiado en 25 pacientes (64% hombres). La edad media fue de 74,8 años (45 a 90), con un 92% de diabéticos y un 32% de insuficiencia renal crónica. La clínica inicial era estadio 4 de Rutherford en dos pacientes y estadios 5-6 en los restantes 23. En 24 (96%) pacientes la punción ecoguiada fue satisfactoria, mientras que en un caso (4%) no se consiguió entrar en el vaso diana. Posteriormente a la punción, el éxito técnico de la revascularización fue conseguido en 19 (79,2%) pacientes, con cinco (20,8%) en los que no se consiguió superar la lesión. Las arterias utilizadas como acceso retrógrado fueron: tibial anterior 11, tibial posterior 10 y peronea en cuatro. Se utilizó una media de 63mL (9 a 100 mL) de contraste con un tiempo medio de escopia de 43 minutos (15 a 76 min). No se observaron complicaciones relacionadas con el acceso retrógrado. Conclusiones El acceso retrógrado distal ecoguiado es un método seguro y efectivo, que supone un buen recurso en aquellos procedimientos endovasculares en los que no es posible su realización vía anterógrada (AU)

Introduction Retrograde access performed guided by fluoroscopy or ultrasound. We aimed to analyze the usefulness of ultrasound in retrograde access in patients with critical limb ischemia. Methods Observational analytical study. From December 2013 to June 2019. We included all retrograde accesses that were guided by ultrasound. Our register assesses demographic and clinical data, the vessel used as retrograde access, the procedure performed, the amount of contrast agent used and time of fluoroscopy, access failure, and local complications. Results On 715 procedures performed, was used ultrasound-guided retrograde access in 25 patients (64% men). The mean age was 74.8 years (45-90), with 92% of diabetics and 32% of chronic renal failure. Two patients with Rutherford stage 4 and 23 with stage 5-6. In 24 (96%) patients the ultrasound-guided puncture was successful, while in one (4%) of them, it was not possible to enter the target vessel. After the punch, was achieved the technical success of revascularization in 19 (79.2%) patients, with 5(20.8%) in whom did not the arterial injury was not overcome. The arteries used as retrograde access were: anterior tibial 11, posterior tibial 10, and peroneal in 4. The mean of contrast used was 63 mL (9-100 ml) with an average time of 43 minutes (15- 76 min). Complications related did not observe in retrograde access. Conclusions Ultrasound- guided retrograde distal access is an effective method that may use as a bailout method in those endovascular procedures in which it is not possible to cross the lesion anterogradely (AU)

Beneficios del ácido acetilsalicílico en la recurrencia de trombosis venosa profunda de miembros inferiores en pacientes mayores de 70 años / Benefits of acetylsalicylic acid in the recurrence of deep vein thrombosis of the lower limbs in patients over 70 years-old

Introducción: El riesgo de recurrencia, después de un episodio de trombosis venosa profunda, está entre el 7-20% en los 2 años posteriores a la retirada de la anticoagulación. El objetivo de este trabajo es valorar el papel del ácido acetilsalicílico (AAS) en la recurrencia de trombosis venosa profunda, una vez finalizado el tratamiento anticoagulante en pacientes de 70 años o mayores, en nuestra población. Material y métodos: Se realizó un estudio retrospectivo de casos y controles de pacientes que presentaron un primer episodio de trombosis venosa profunda de miembros inferiores, confirmado por ecografía-Doppler, durante el período de enero de 2008 hasta diciembre de 2009. Se valoró, mediante revisión de historias clínicas, la presencia de recidiva en los 3 años siguientes al tratamiento anticoagulante mediante los controles en consultas externas, y la presencia o no de tratamiento con AAS por cualquier enfermedad de base. Resultados: Incluimos en el estudio un total de 246 pacientes con una media de edad de 78,7 años. Se dividieron los pacientes en 2 grupos, el grupo A (n = 106) formado por pacientes que tomaban AAS por cualquier enfermedad de base; y el grupo B (n = 140) formado por pacientes que no tomaban AAS. Se observó recidiva de trombosis venosa profunda en 28 pacientes del estudio (11,5%), registrándose 13 en el grupo A (12,3%) y 15 en el grupo B (10,7%), sin observarse diferencias estadísticamente significativas (p = 0,70). Conclusiones: En nuestra población mayor de 70 años, el tratamiento con AAS no parece disminuir la tasa de recidivas de trombosis venosa profunda (AU)

Introduction: The risk of recurrence after an episode of deep vein thrombosis is between 7% and 20% in the 2 years after withdrawal of anticoagulants. The main objective of this article is to study the role of acetylsalicylic acid in the recurrence of deep vein thrombosis once the anticoagulation treatment has ended in patients of 70 years-old and over. Material and methods: A retrospective study was conducted on patients that presented with a first episode of lower limb deep vein thrombosis confirmed by Doppler-ultrasound between the period of January 2008 and December 2009. Their clinical charts were reviewed for the presence of recurrence in the three years following anticoagulation treatment whilst on outpatient follow-up, as well as whether they were on treatment with acetylsalicylic acid for any underlying disease. Results: The study included 246 patients, with a mean age of 78.7 years. The patients were divided into two groups: Group A (n = 106) consisted of patients who took acetylsalicylic acid; and Group B (n = 140) consisted of patients who did not take acetylsalicylic acid. Recurrence of deep vein thrombosis was observed in 28 patients (11.5%), 13 patients in Group A (12.3%) and 15 patients in Group B (10.7%), without observing any statistically significant differences (P = .70) Conclusions: In our population aged 70 years-old and over, it seems that the treatment with acetylsalicylic acid has no influence on deep vein thrombosis recurrence (AU)

Utilidad de los marcadores tumorales como cribado de neoplasia oculta en enfermedad tromboembólica / Role of tumour markers for occult neoplasia screening in thromboembolic disease

Objetivo: Evaluar la eficacia de los marcadores tumorales (MT) dentro del cribado avanzado para la detección de neoplasia oculta, en pacientes que han presentado enfermedad tromboembólica (ETE). Material y métodos: Estudio retrospectivo entre enero 2007 y diciembre de 2008 diagnosticados de ETE en nuestro centro. Se evaluaron los siguientes marcadores tumorales: antígeno carcinoso 19.9 (Ca 19.9), antígeno carcinoso 125 (Ca 125), antígeno carcinoso 15.3 (Ca 15.3), antígeno carcinoma embrionario (CEA), alfafetoproteína(AFP) y antígeno específico de próstata (PSA), tomando una determinación dentro del mes siguiente del diagnóstico de ETE. Criterios de inclusión: TVP de MMSS o MMII, TEP diagnosticados por prueba de imagen, clínica aguda. Criterios de exclusión: neoplasia previa conocida, TVP no idiopática, imposibilidad de seguimiento. Resultados: El 63,4% eran hombres, el 36,6% mujeres, con edad media de 62,8 años. El análisis estadístico se hizo en función de 122 pacientes, de los 199 iniciales, con un seguimiento medio de 38 meses. Al finalizar el estudio no se encontraron diferencias significativas en cuanto a la incidencia posterior de neoplasia respecto a los pacientes con valores de MT positivos de los negativos (Ca 125: p=0,161; Ca 15.3: p=0,930; CEA: p=0,703; PSA: p=0,382; AFP: 100% pacientes con valores negativos). Exceptuando el Ca 19.9 (p<0,000). Conclusiones: Como conclusión a nuestro estudio, el uso de MT como cribado de cáncer oculto posterior a un evento trombótico, no ha permitido la detección de los pacientes que desarrollaron una neoplasia durante el seguimiento (AU)

Objective: To evaluate the use of the tumour markers (TM) as part the advanced screening of occult neoplasia, in patients with thromboembolic disease (TED). Material and methods: A retrospective study was conducted between January 2007 and December 2008 on patients diagnosed with TED in our centre. The sample included 63.4% males, and 36.6% females, with a mean age of 62.8 years. The following TM were evaluated in a blood sample taken within one month after the diagnosis of TED: cancer antigen 19.9 (Ca 19.9), cancer antigen 125 (Ca 125), cancer antigen 15.3 (Ca 15.3), embryonic carcinoma antigen (CEA), alpha fetoprotein (AFP), and prostate specific antigen (PSA). The inclusion criteria were, DVT of lower and upper limbs, TEP diagnosed by imaging technique, acute clinic signs. Exclusion criteria: previous known neoplasia, non-idiopathic DVT, impossibility of follow-up. Results: The statistical analysis was performed on the basis of 122 patients out of 199 initially included, with an average follow-up of 38 months. At the end of the study no significant differences were found as regards the subsequent finding of a neoplasia in patients with positive TM values compared with those with negative values (Ca 125: P=0.161; Ca 15.3: P=0.930; CEA: P=0.703; PSA: P=0.382; AFP: 100% patients with negative values). Exempting the Ca 19.9 (P<0.000). Conclusions: As a conclusion of our study, TM as extensive screening of early stages of cancer after TED, is not useful for detecting an occult neoplasia during follow-up (AU)

Tratamiento de la trombosis venosa profunda asociada a agenesia de vena cava inferior. Revisión de las anomalías de vena cava inferior / Treatment of deep venous thrombosis associated with inferior vena cava agenesis. A review of inferior vena cava variants

La complejidad de la embriología de la vena cava inferior, con numerosas anastomosis entre pares de venas, puede conducir a multitud de variantes anatómicas. En la población general la agenesia de la vena cava inferior constituye una malformación poco frecuente (0,07%), pero su presencia representa el 5-9,5% de las trombosis venosas profundas idiopáticas en pacientes menores de 30 años y su tratamiento continúa siendo un tema controvertido(AU)

The development of the inferior vena cava is a complex embryological process, with numerous anastomoses among pairs of veins, which may result in many anatomic variants. In the general population, the absence of inferior vena cava is a rare anomaly (0.07%), but this represents 5-9.5% of idiopathic deep venous thrombosis in patients under 30 years-old and its treatment options remain (AU)

Long-term use of different doses of low-molecular-weight heparin versus vitamin K antagonists in the treatment of venous thromboembolism.

BACKGROUND: We evaluated whether the incidence of recurrent venous thromboembolic events (VTEs) during and after therapy differs for patients treated with full or reduced doses of low-molecular-weight heparin (LMWH) used long term compared with vitamin K antagonists (VKAs). METHODS: We identified randomized studies of long-term treatment with LMWH or VKA by searching MEDLINE, EMBASE, BIOSIS, and PASCAL. Seventeen studies were included, with 4,002 patients. RESULTS: In the assessment at 12 months of 1,957 patients without cancer, the recurrence rates of VTE in the LMWH/VKA groups were 8.3%/7.6% in the studies using full doses and 12.3%/12.1% in those using prophylactic doses. However, combined analysis after treatment to 1 year showed a nonsignificant (NS) trend to lower recurrent symptomatic VTE in favor of VKA (RR = 1.46, 95% CI 0.96-2.23). In 1,292 patients with cancer the recurrence rates of VTE in the LMWH/VKA groups were 6.5%/17.9% (p = 0.005) in the studies using full doses, 7.1%/13.4% (p = 0.002) in the studies using intermediate doses, and 14.3%/19.1% (p = NS) in the studies using prophylactic doses. Furthermore, the recurrences of VTE after discontinuation of treatment in the LMWH/VKA groups were 1.6%/9.5% (RR = 0.25, 95% CI 0.06-1.1) in 252 patients with full doses and 12%/7.4% (RR = 1.49, 95% CI 0.3-7.48) in 52 patients with prophylactic doses. In this population with cancer, the full-treatment LMWH regimen did not produce more major bleeding events than intermediate or prophylactic doses (5.1% vs. 6.3% or 8.1%, respectively). CONCLUSION: Full-dose LMWH for 3-6 months is as safe as intermediate and prophylactic doses for the long-term treatment of deep vein thrombosis. In patients with cancer it appears that there is an excess of VTE recurrence after treatment with prophylactic doses that does not occur with full therapeutic doses.

The importance of a standing position in the diagnosis of Nutcracker phenomenon by duplex sonography.

AIM: To determine the clinical usefulness of Doppler ultrasonography in the diagnosis of the Nutcracker phenomenon, as an alternative to computed tomographic scans (CT). METHODS: This study consisted of 52 patients that presented with intermittent hematuria of unknown origin between January 2006 to April 2008. Doppler ultrasonography was used to assess the left renal vein (LRV) by measuring the anteroposterior (AP) diameter and peak systolic velocity (PSV) in supine and standing positions, at the hilar and interaortomesenteric portions of the LRV. These data were compared with CT scans. The sensitivity and specificity of duplex sonography was determined using the AP diameter and PSV ratios to assess the cut-off levels. Kappa (k) statistic was also evaluated. RESULTS: mean AP diameters of the LRV measured by Doppler sonography were 8.38 mm at the hilar and 3.17 mm under the SMA, compared to 9.3 mm (hilar) and 3.2 mm (SMA) in the supine and standing position respectively. The PSV in the supine position was 25.77 cm/s and 115.48 cm/s, respectively, compared to 25.54 cm/s and 125.96 cm/s in the standing position. The cut-off levels were 3.85 (sensitivity: 61.5%, specificity: 80.8%, k:0.42) for the supine and 4.12 (sensitivity:61.5%, specificity: 65.4%, k: 0.27) for the standing AP diameter, 2.99 (sensitivity: 92.3%, specificity: 73.1%, k: 0.65) for the supine and 3.73 (sensitivity: 96.4%, specificity: 79.2%, k: 0.76) for the standing PSV. CONCLUSIONS: Our data show that the standing PSV ratio is the best parameter for to detecting entrapment of the LRV.

Early mobilisation in patients with acute deep vein thrombosis does not increase the risk of a symptomatic pulmonary embolism.

AIM: The purpose of the study was to determine if early mobilisation in patients with acute lower limb deep vein thrombosis (DVT) increases the incidence of symptomatic pulmonary embolism (PE) and to evaluate the predisposing factors for PE such as location of the thrombus and duration of symptoms. METHODS: The current study was a prospective randomised clinical trial. Between January 2005 and December 2007, 219 patients with acute lower limb DVT were enrolled in the study (118 males and 101 females); the mean age was 64.2 years. INCLUSION CRITERIA: <15 days of initial symptoms, life expectancy >1 year, no life-threatening clinical conditions, and signed informed consent. The patients were randomised into two groups. Group A, 105 patients (47.9%) were hospitalized and received 5 days of bed rest; Group B, 114 patients (52.1%) received care at home with early walking and compression stockings. The primary end point was the presence of symptomatic PE during the first 10 days of treatment. The relationships between the duration of symptoms, location of the thrombus, and symptomatic PE were also analysed. RESULTS: Five cases of symptomatic PE were detected (2.3%), three in Group B and two in Group A. There was no significant difference in the occurrence of new PE between the two groups (P=0.54). Likewise, no difference was detected based on the duration of symptoms (P=0.62) and the location of the thrombus (P=0.43). CONCLUSIONS: In acute DVT , early walking, thrombus location, and duration of the symptoms did not influence the incidence of symptomatic PE.

Pseudoaneurisma iliaco en injerto renal no funcionante tras diez años de su embolización / Iliac pseudoaneurysm in non-funtioning kidney allograft after ten years or empboliation

Los pseudoaneurismas arteriales son una complicación infrecuente en el trasplante renal. Según su localización se dividen en intrarrenales y extrarrenales. Los primeros se relacionan con la práctica de biopsias percutáneas del injerto. Los segundos se asocian a defectos de la anastomosis vascular o infección del lecho quirúrgico, presentándose por ello de forma relativamente precoz. Presentamos el caso de un pseudoaneurisma iliaco en un injerto renal afuncionante embolizado 10 años antes. Este tipo de patología, por la gravedad clínica que condiciona, precisa de tratamiento quirúrgico urgente (AU)

[Iliac pseudoaneurysm in non-functioning renal graft 10 years after embolization]. / Pseudoaneurisma iliaco en injerto renal no funcionante tras diez años de su embolización.

The arterial pseudoaneurysms are an infrequent complication or renal transplantation. Depending on her localization, are divided in intra and extrarenal. The first are relacionated with the practice of percutaneous needly biopsy. The seconds are associated with defects of vascular anastomose or infection onsurgical area (with relative precocious presentation). Presentation of case of a iliac pseudoaneurysm in non-functional kidney allograft embolizated ten years before. This pathology, for this clinic gravity, requires urgent surgical treatment.

Diagnóstico de la hipertensión arterial renovascular mediante Eco-Doppler

Objetivo: valorar la fiabilidad del eco-Doppler en la detección de estenosis renales en pacientes con sospecha de hipertensión renovascular. Material y método: estudio prospectivo durante cuatro años de 91 arterias renales en 47 pacientes hipertensos (tres monorrenos) con sospecha de hipertensión arterial renovascular. Edad media: 56 años (r = 25-77); 22 varones y 25 mujeres. Parámetros valorados por dúplex: velocidad sistólica máxima (VSM) y velocidad diastólica final (VDF) en arteria renal, cociente renal-aórtico e índice de resistencia periférica. Análisis estadístico: curvas ROC y análisis multivariante para la obtención del mejor parámetro diagnóstico de estenosis > 60 por ciento. A todos los pacientes se les realizó arteriografía de ambas arterias renales. Resultados: mediante análisis multivariante únicamente la VSM > 180 cm/sg (p = 0,01) y el cociente renal-aórtico > 3 (p = 0,04) son predictivos de estenosis > 60 por ciento. Así hemos identificado 60 de 65 estenosis inferiores al 60 por ciento, 20 de 21 estenosis superiores al 60 por ciento, y 5 de 5 oclusiones (Kappa = 0,85) (p 180 cm/sg es el mejor parámetro para detectar estenosis > 60 por ciento (AU)