Alergia al níquel y colocación de endoprótesis aórticas con nitinol / Nickel allergy and placement of aortic endoprostesis with nitinol

Introducción: las alergias al níquel son muy frecuentes. En diversos materiales implantables utilizado en cirugía endovascular, la estructura metálica es de nitinol. Caso clínico: se presenta el caso de un paciente con alergia conocida al níquel y que necesitó una endoprótesis aórtica con ramas en cuya fabricación se sustituyó el níquel por el acero inoxidable. Discusión: a raíz del caso, se recomienda ser estrictos con las instrucciones de uso y se alerta sobre algunas reacciones posoperatorias.(AU)

Introduction: nickel allergies are very common. In various implantable material used in endovascular surgery, the metal structure is made of nitinol. Case report: We present a case of a patient with known nickel allergy who needed an aortic endoprosthesis with branches in which manufacture nickel was replaced with stainless steel. Discussion: as a result of this case it is recommended to be strict with the instructions and to be alert in case of postoperative reactions.(AU)

Inter-observer agreement of the Wagner, University of Texas and PEDIS classification systems for the diabetic foot syndrome.

BACKGROUND: The aim of this cohort study was to assess the inter-observer agreement of three diabetic foot classification systems: the Wagner, the University of Texas and the PEDIS. METHODS: We included 250 consecutive patients diagnosed of diabetic foot syndrome in 2009-2013. Wound scores were recorded at admission and a reevaluation was performed simultaneously or 24h later by a different evaluator. Demographical, laboratory data and associated risk factors were obtained from the patients' medical records. RESULTS: The Kappa coefficient showed a moderate inter-observer agreement between the first evaluation and the reevaluation for Wagner scale (Kappa=0.55; 95% CI: 0.507-0.593), University of Texas scale (Kappa=0.513; 95% CI: 0.463-0.563) and for PEDIS scale (Kappa=0.574; 95% CI: 0.522-0.626). CONCLUSIONS: This moderate agreement shows that these scales should not be used alone for management decisions regarding diabetic foot syndrome and should, therefore, be integrated with other clinical data to ensure an adequate handover.

Evaluación de la capacidad de difusión tisular de antibióticos en isquemia de miembros inferiores / Evaluation of the tissue diffusion capacity of antibiotics in lower limb ischaemia

INTRODUCCIÓN: El objetivo principal del estudio ha sido valorar si la penetración de antibióticos se ve influenciada por la perfusión tisular disminuida en pacientes con isquemia de miembros, reduciendo la concentración alcanzada en tejidos por debajo de los puntos de corte (breakpoints) de la concentración mínima inhibitoria (CMI) de los antimicrobianos utilizados para diferentes patógenos. MÉTODOS: Estudio prospectivo. Se incluyeron candidatos a amputación mayor con isquemia crítica de miembro inferior e infección en tratamiento antibiótico. Se determinaron 3 niveles de perfusión en el miembro inferior, midiendo la presión transcutánea de oxígeno (TcPO2). Se extrajo una muestra de sangre de vía central así como biopsias de piel, músculo y hueso de cada uno de los niveles de perfusión. Se determinó la concentración del antibiótico mediante HPLC. RESULTADOS: El número total de casos es de 61 (46 pacientes): 6 clindamicina, 9 vancomicina, 8 linezolid, 18 levofloxacino, 9 ceftazidima y 11 meropenem. Se encuentran diferencias estadísticamente significativas entre todos los niveles de TcPO2 (ANOVA, p = 0,000). La concentración en piel de vancomicina, levofloxacino y ceftazidima depende del nivel de perfusión. Vancomicina y levofloxacino difunden peor en hueso que en el resto de tejidos. La concentración de ceftazidima no supera el punto de corte de Pseudomonas aeruginosa en tejidos isquémicos. CONCLUSIONES: Linezolid y meropenem difunden en todos los tejidos independientemente de la perfusión, alcanzando concentraciones superiores a la CMI de los microrganismos diana, asegurando su efectividad en tejidos isquémicos

INTRODUCTION: The aim of the study was to assess whether the penetration of antibiotics is affected by decreased tissue perfusion in patients with limb ischaemia, thus reducing its concentration in tissues below the minimum inhibitory concentration (MIC) breakpoints of antibiotics for different microorganisms. METHODS: rospective study. Candidates for major amputation with critical lower limb ischaemia and an infection on antibiotic treatment, were included. Three levels of perfusion in the lower limb were determined by measuring the transcutaneous oxygen pressure (TcPO2). A central line blood specimen, as well as biopsies of the skin, muscle, and bone, were taken at each perfusion level. The antibiotic concentration was determined using HPLC. RESULTS: The total number of cases was 61 (46 patients): 6 clindamycin, 9 vancomycin, 8 linezolid, 18 levofloxacin, 9 ceftazidime, and 11 meropenem. Statistically significant differences were found in TcPO2 at all levels (ANOVA, P=.000). The vancomycin, levofloxacin and ceftazidime skin concentration depends on perfusion. Vancomycin and levofloxacin diffusion in bone is worse than in other tissues. Ceftazidime concentration does not exceed the MIC breakpoint of Pseudomonas aeruginosa in ischaemic tissues. CONCLUSIONS: Meropenem and linezolid diffuse in all tissues, regardless of perfusion, reaching concentrations above the MIC of the target microorganisms, ensuring its effectiveness in ischaemic tissues

Resultados clínicos de una nueva estrategia quirúrgica (CHIVA modificado) en el tratamiento de las varices dependientes de la vena safena magna accesoria anterior / Clinical results of a new strategy (modified CHIVA) for surgical treatment of anterior accessory great saphenous varicose veins

INTRODUCCIÓN: Tradicionalmente la insuficiencia de safena anterior se trataba mediante crosectomía y resección de los paquetes varicosos. El objetivo del trabajo es mostrar la seguridad y eficacia de una nueva estrategia terapéutica en las varices dependientes de la vena safena magna accesoria anterior. MÉTODOS: Estudio prospectivo no ramdomizado que incluyó 65 pacientes con varices dependientes de la safena anterior con safena interna anterógrada. La modificación en la técnica consiste en hacer solamente flebectomía de los paquetes varicosos, sin ligar el cayado de la safena. Se realizó un estudio hemodinámico venoso preoperatorio, al mes y al año, y para la valoración clínica se utilizó la escala de Fligelstone. RESULTADOS: Clasificación clínica basal CEAP: C2 58%, C3 26% y C4-6 15%. Complicaciones: 3 hematomas, 7 casos de trombosis parciales asintomáticas de safena anterior. Se observó una reducción del diámetro medio inicial de safena anterior de 6,4 mm a 3,4 mm al año (p < 0,001). A los doce meses mantenían un flujo anterógrado el 82% de los casos. Hubo una recidiva de varices visibles en el 8% de los casos. Todos los pacientes han reflejado una mejoría clínica en la escala de Fligelstone. El diámetro de safena anterior mayor de 7,5 mm y la obesidad se identifican como predictores de un peor resultado clínico y hemodinámico. CONCLUSIONES: La modificación de la estrategia quirúrgica sobre las varices dependientes de la safena anterior presenta un resultado clínico favorable al año de la intervención

INTRODUCTION: Traditionally, anterior accessory great saphenous vein insufficiency was managed by crossectomy and resection of varicose veins. The aim of this paper is to show the safety and efficacy of a new therapeutic strategy for anterior accessory great saphenous varicose veins. METHODS: This non-randomised prospective study included 65 patients with varicose veins from the anterior accessory great saphenous vein. The novelty of the technique is to avoid the great saphenous vein crossectomy and perform just flebectomy of the visible veins. Venous duplex studies were performed preoperatively, a month and a year postoperatively. The clinical assessment was done by the Fligelstone scale. RESULTS: The baseline CEAP clinical classification was: 58% C2, 26% C3 and 15% C4-6. The new strategy was applied to all cases. Complications: 3 haematomas, 7 cases of asymptomatic partial anterior saphenous thrombosis. Reduction of the initial average diameter was from 6.4 mm anterior saphenous to 3.4 mm by one year (p < 0.001). At twelve months a forward flow is maintained in 82% of cases. Recurrence of varicose veins was 8%. All patients improved their clinical status based on the Fligelstone scale. Cases with saphenous diameter bigger than 7.5 mm and obesity were identified as predictors of worse clinical and hemodynamic outcome. CONCLUSIONS: This modified surgical strategy for anterior saphenous varicose veins results in better clinical outcomes at one year postoperatively

Clinical results of a new strategy (modified CHIVA) for surgical treatment of anterior accessory great saphenous varicose veins.

INTRODUCTION: Traditionally, anterior accessory great saphenous vein insufficiency was managed by crossectomy and resection of varicose veins. The aim of this paper is to show the safety and efficacy of a new therapeutic strategy for anterior accessory great saphenous varicose veins. METHODS: This non-randomised prospective study included 65 patients with varicose veins from the anterior accessory great saphenous vein. The novelty of the technique is to avoid the great saphenous vein crossectomy and perform just flebectomy of the visible veins. Venous duplex studies were performed preoperatively, a month and a year postoperatively. The clinical assessment was done by the Fligelstone scale. RESULTS: The baseline CEAP clinical classification was: 58% C2, 26% C3 and 15% C4-6. The new strategy was applied to all cases. COMPLICATIONS: 3 haematomas, 7 cases of asymptomatic partial anterior saphenous thrombosis. Reduction of the initial average diameter was from 6.4 mm anterior saphenous to 3.4 mm by one year (p <0.001). At twelve months a forward flow is maintained in 82% of cases. Recurrence of varicose veins was 8%. All patients improved their clinical status based on the Fligelstone scale. Cases with saphenous diameter bigger than 7.5 mm and obesity were identified as predictors of worse clinical and hemodynamic outcome. CONCLUSIONS: This modified surgical strategy for anterior saphenous varicose veins results in better clinical outcomes at one year postoperatively.

Influence of wound scores and microbiology on the outcome of the diabetic foot syndrome.

AIMS: To establish if the microbiology and the TEXAS, PEDIS and Wagner wound classifications of the diabetic foot syndrome (DFS) predict amputation. METHODS: Prospective cohort study of 250 patients with DFS from 2009 to 2013. Tissue samples for culture were obtained and wound classification scores were recorded at admission. RESULTS: Infection was monomicrobial in 131 patients (52%). Staphylococcus aureus was the most frequent pathogen (76 patients, 30%); being methicillin-resistant S. aureus in 26% (20/76) Escherichia coli and Enterobacter faecalis were 2nd and 3rd most frequent pathogens. Two hundred nine patients (85%) needed amputation being major in 25 patients (10%). The three wound scales associated minor amputation but did not predict this outcome. Predictors of minor amputation in the multivariate analysis were the presence of osteomyelitis, the location of the wound in the forefoot and of major amputation elevated C reactive proteine (CRP) levels. A low ankle-brachial index (ABI) predicted major amputation in the follow-up. Overall, 74% of gram-positives were sensitive to quinolones and 98% to vancomycin and 90% of gram-negatives to cefotaxime and 95% to carbapenems. CONCLUSIONS: The presence of osteomyelitis and the location of the wound in the forefoot predict minor amputation and elevated CRP levels predict major amputation. In the follow-up a low ABI predicts major amputation.

[Evaluation of the tissue diffusion capacity of antibiotics in lower limb ischaemia]. / Evaluación de la capacidad de difusión tisular de antibióticos en isquemia de miembros inferiores.

INTRODUCTION: The aim of the study was to assess whether the penetration of antibiotics is affected by decreased tissue perfusion in patients with limb ischaemia, thus reducing its concentration in tissues below the minimum inhibitory concentration (MIC) breakpoints of antibiotics for different microorganisms. METHODS: Prospective study. Candidates for major amputation with critical lower limb ischaemia and an infection on antibiotic treatment, were included. Three levels of perfusion in the lower limb were determined by measuring the transcutaneous oxygen pressure (TcPO2). A central line blood specimen, as well as biopsies of the skin, muscle, and bone, were taken at each perfusion level. The antibiotic concentration was determined using HPLC. RESULTS: The total number of cases was 61 (46 patients): 6 clindamycin, 9 vancomycin, 8 linezolid, 18 levofloxacin, 9 ceftazidime, and 11 meropenem. Statistically significant differences were found in TcPO2 at all levels (ANOVA, P=.000). The vancomycin, levofloxacin and ceftazidime skin concentration depends on perfusion. Vancomycin and levofloxacin diffusion in bone is worse than in other tissues. Ceftazidime concentration does not exceed the MIC breakpoint of Pseudomonas aeruginosa in ischaemic tissues. CONCLUSIONS: Meropenem and linezolid diffuse in all tissues, regardless of perfusion, reaching concentrations above the MIC of the target microorganisms, ensuring its effectiveness in ischaemic tissues.

Clinical and health costs impact of progress in diagnosis and treatment in venous thromboembolic disease: evolution in 15 years.

BACKGROUND: The therapeutic and diagnostic approach in deep vein thrombosis (DVT) has changed enormously in the last two decades with the introduction of ultrasound, low-molecular-weight heparin (LMWH), and premature motion. The aim of this study is to evaluate these changes and analyze their clinical and economic aspects. METHODS: We registered all inpatients with a diagnosis of DVT during 1994 (n=110) and 2009 (n=75) and their sociodemographic and clinical features in a descriptive observational design. We performed a comparison of diagnostic techniques, length of stay, inpatient complications, and costs thus derived for both series, based on 2009 prices, so that we could get comparable results. RESULTS: Ninety-one percent of inpatients in 1994 were diagnosed by venography, whereas, in 2009, the diagnosis was based on clinical features, D-dimer, and ultrasound in 100% of patients. Inpatient treatment went from 7% LMWH in 1994 to 96% in 2009, and as outpatient from 82% acenocumarol to 90.6% LMWH. Complications decreased by 13.3%. Length of stay was 2.7 higher in 1994. Globally, the cost per patient decreased by 63.39%, based primarily on reduced length of stay. CONCLUSIONS: The current diagnostic and therapeutic approach in DVT allows for effective treatment, fewer complications, and a drastic reduction in inpatient costs.

Sensibilidad, especificidad y fiabilidad de la ecografía Doppler arterial en el diagnóstico de la isquemia crítica de los miembros inferiores con relación a la arteriografía / The sensitivity, specificity and reliability of arterial Doppler ultrasonography in the diagnosis of critical ischaemia of the lower limbs compared to arteriography

Introducción. La arteriografía sigue considerándose como el patrón estándar en el diagnóstico de la isquemia crítica. Sin embargo, puede ocasionar daños arteriales locorregionales, así como cuadros alérgicos y nefrotoxicidad; además, no valora hemodinámicamente las lesiones. La ecografía Doppler arterial (EDA) ha demostrado validez y fiabilidad en miembros inferiores y troncos supraaórticos, pero es necesaria una validación individual y del laboratorio, por ser una técnica dependiente del explorador. Objetivo. Analizar y validar la EDA como prueba diagnóstica en pacientes con isquemia crítica, en comparación con la arteriografía. Pacientes y métodos. Diseño transversal y aleatorio, con EDA aplicada de forma ciega e independiente con respecto a la arteriografía, en una muestra de 60 pacientes con isquemia crítica de miembros inferiores en estudio preoperatorio. La fiabilidad se determina mediante el porcentaje de acuerdo global e índice kappa. La validez se determina por la sensibilidad, especificidad, valores pronósticos positivos (VPP) y razón de probabilidad diagnóstica (RPD). Resultados. Tiempo medio de exploración por extremidad: 39 min. Índices kappa buenos o muy buenos en todos los sectores, salvo en la arteria peronea (moderada). Alta sensibilidad en territorios proximales. Especificidad por encima del 90%, excepto en la arteria peronea (88%). VPP siempre superior al 90%. Altos valores de RPD. Conclusión. La EDA, a tenor de los resultados obtenidos en nuestro laboratorio, es una prueba diagnóstica muy útil como alternativa a la arteriografía, ya que su fiabilidad es buena o muy buena y su validez, en términos de sensibilidad, especificidad, VPP y RPD, es muy alta. No obstante, en el sector distal, con especial atención sobre la arteria peronea, resulta necesaria en todo caso otra prueba de imagen antes de sentar una indicación quirúrgica

Introduction. Arteriography is still considered to be the gold standard in the diagnosis of critical ischaemia. Nevertheless, it can cause locoregional arterial damage, as well as allergic reactions and nephrotoxicity, and it does not evaluate the lesions haemodynamically. Arterial Doppler ultrasonography (ADU) has proved to be valid and reliable in the lower limbs and supra-aortic trunks but, because it is an examiner-dependent technique, individual and laboratory validation of findings is required. Aim. To analyse and validate ADU as a diagnostic test in patients with critical ischaemia, as compared to arteriography. Patients and methods. A cross-sectional random design, with ADU applied blind and independently with respect to arteriography conducted in a sample of 60 patients with critical lower limb ischemia undergoing their preoperative study. Reliability is determined by means of the percentage of overall agreement and the kappa index. Validity is determined by the sensitivity, specificity, predictive positive value (PPV) and diagnostic likelihood ratio (DLR). Results. Mean examination time per limb: 39 min. Good or very good kappa indexes in all sectors, except in the fibular artery (moderate). Highly sensitive in proximal territories. Specificity above 90%, except in the fibular artery (88%). PPV always above 90%. High DLR values. Conclusions. In the light of the results obtained in our laboratory, ADU can be considered to be a diagnostic test that is very useful as an alternative to arteriography, since its reliability is good or very good and its validity, in terms of sensitivity, specificity, PPV and DLR, is very high. Yet, in the distal sector, with special attention to the fibular artery, another imaging test must always be carried out before setting an indication for surgery

Revascularización infragenicular con aloinjerto arterial criopreservado / Below-the-knee revascularisation with a cryopreserved arterial allograft

Objetivo. Valorar los resultados preliminares obtenidos en nuestro servicio en revascularización infragenicular con aloinjerto arterial criopreservado (AAC) en caso de ausencia de injerto autólogo. Pacientes y métodos. Entre junio de 2001 y agosto de 2005, realizamos ocho procedimientos en ocho pacientes (dos mujeres y seis varones) con una edad media de 73 años (rango: 55-82 años). En dos casos los injertos fueron compuestos AAC-segmento venoso residual. En otros dos casos se emplearon dos AAC. Las indicaciones para intervenir fueron isquemia crítica (siete) e infección protésica (uno). En cinco casos había al menos una revascularización previa. Los AAC se obtuvieron de donante cadáver. La anastomosis distal se realizó sobre poplítea (dos), arteria tibial (cinco) o arteria perimaleolar (uno). En todos los casos se descartó la existencia de segmento venoso autólogo suficiente mediante eco-Doppler. El seguimiento fue clínico y ecográfico. Resultados. Durante el primer mes se produjeron una rotura de AAC y una trombosis precoz, ambas con reparación satisfactoria. Durante un seguimiento medio de 14 meses (rango: 1-46 meses), cuatro injertos sufrieron un fallo primario: dos trombosis, una estenosis y una degeneración aneurismática. Ello derivó en una amputación mayor, una trombectomía y una sustitución del injerto. La permeabilidad global fue del 75% (6/8) y la salvación de extremidad del 87,5% (7/8). Una paciente falleció a los cuatro y otro a los 46 meses, ambos con injerto permeable. Conclusión. A pesar de ser una serie pequeña, los AAC pueden ser una opción en las revascularizaciones infrageniculares en caso de ausencia de injerto autólogo suficiente para ésta

Aim. To assess our preliminary results of infrapopliteal bypass grafting performed with cryopreserved arterial allografts (CAA) in case of absence of alternate autologous veins. Patients and methods. Between June 2001 and August 2005, eight procedures were performed in eight patients (two female and six male), with a mean age of 73 years (range: 55-82 years). In two cases a composite CAA-residual vein bypass was realized. In another two cases two segments of CAA were used. Indications for operation were critical leg ischaemia in seven cases and infection in the other. In five cases, there was at least one previous revascularization on the same limb. CAA were obtained from cadaveric donors in a multidisciplinary organs explant program. Distal anastomosis was to the bellow knee popliteal artery in two cases, to a tibial artery in five cases and to a perimaleolar artery in one case. In all cases we searched for the existence of alternate autologous vein with Doppler scan. The surveillance was clinic and with Doppler scan. Results. During follow-up (mean: 14 months; range: 1-46 months), four grafts failed. These failures were two thrombosis, one stenosis and one aneurysmatic degradation. Due to this, a major amputation and a CAA-prosthetic replacement were performed. The global patency rate was 75% (6/8) and the limb salvage rate was 87.5% (7/8). One patient died at four month after procedure, with patent bypass. Conclusion. Even knowing that this is a small group of patients, we think CAA could be an option in infrapopliteal bypass surgery in case of absence of autologous vein

A new technique for hypogastric artery embolization.

We report a new procedure for embolization of hypogastric arteries simultaneously with aortoiliac stenting. Eight patients with aortoiliac (n = 6) and iliac (n = 2) aneurysms have been treated with this procedure. The technique involves the placement of a hook catheter near the hypogastric artery or in the sac, and the endoprosthesis insertion is done by using the same arteriotomy. The endoprosthesis is deployed and the coil is released. Saline is injected into the sac. The catheter is removed and the balloon at the distal end of the endoprosthesis is inflated. Computed tomography images showed periprosthesis or aneurysm thrombosis. No endoleaks or coils displacement in the sac were found.