Seguimiento de la estenosis carotídea en pacientes asintomáticos: ¿se debe llevar a cabo en todos los pacientes? / Monitoring asymptomatic patients with carotid stenosis: should it be conducted in every patient?

Introducción: El seguimiento de los pacientes asintomáticos con estenosis carotídea (EC) es una práctica clínica habitual pero continúa siendo controvertido dado el bajo riesgo de ictus anual. Objetivos: Conocer los niveles de progresión de la EC en pacientes asintomáticos en nuestra población y qué factores de riesgo pueden estar relacionados con la progresión de la enfermedad. Material y métodos: De forma retrospectiva, recogimos 177 estenosis carotídeas asintomáticas en 123 pacientes con una media de seguimiento de 44,65 meses realizado entre los años 2004 y 2010. Se analizaron los diferentes factores de riesgo vascular clásicos, así como la toma de tratamiento médico adecuado. El criterio de progresión se estableció en función de las velocidades pico sistólicas (VPS) iniciales y finales medidas por eco-Doppler. Finalmente, se realizó una comparación de frecuencias observadas entre los pacientes con estabilización y aquellos con progresión de la enfermedad utilizando el test de ji al cuadrado y se calcularon los riesgos relativos utilizando un modelo de Cox. Resultados: Se encontró una progresión en 42 casos (23,7%). De 56 carótidas con un grado de estenosis inicial 30-50%, 15 (26,8%) evolucionaron a 50-70% y 5 (8,9%) a >70%. De 84 que partían de 50-70%, evolucionaron a >70% 22 casos (26,2%). Del conjunto, fueron subsidiarias de cirugía 13 casos (7,3%), siendo sintomáticas 2 (1,1%). Ninguno de los factores de riesgo, incluida la toma de estatinas, demostró diferencias entre los grupos estudiados. Conclusiones: Dada la tasa de progresión media de un 23,7%, se recomienda el seguimiento con eco-Doppler en aquellos pacientes con estenosis carotídea asintomática >30%. En este estudio, ningún factor clínico o demográfico fue predictivo de progresión(AU)

Introduction: Monitoring asymptomatic patients with Carotid Stenosis (CS) is a standard dynamical practice but it still has controversy due to the low annual risk of strokes. Objectives: To know the levels of progression of CS in asymptomatic patients in our population and which factors of risk can be related with the progression of the disease. Material and methods: In a retrospective way, we collected 177 asymptomatic CS in 123 patients with a following average time of 44,65 months between the years 2004 and 2010. Different factors of classical vascular risks were analyzed and also the appropriate medical treatment was applied. The criterion of the progression was established based on the peak systolic velocities (PSV) at the beginning and at the end measured by Doppler ultrasonography. Finally, a comparison of the observed frequencies between patients with stabilization and patients with disease progression was realised using the Chi-squared test and the relative risks were calculated using a Cox model. Results: We found a progression in 42 cases (23,7%). Of 56 cases with an initial degree of 30-50%, 15 (26,8%) evolved to 50-70%, and 5 (8,9%) to more than 70%. Of 84 cases with an initial degree of 50-70%, 22 (26,2%) evolved to more than 70%. Of the group, 13 cases (7,3%) were candidates of surgery, being 2 (1,1%) symptomatic. None of the factors of risks, including taking statins, showed any difference between the groups. Conclusions: Given that the average of progression is 23,7%, it is recommended to follow it up with Doppler ultrasonography in those patients with more than 30% asymptomatic CS. In this study, no clinic or demographic factors were predictive of progression(AU)

Escalas de riesgo preoperatorio para el tratamiento endovascular de aneurismas aórticos / Preoperative risk scales for the endovascular treatment of aortic aneurysms

Introducción: El objetivo de este estudio es analizar la utilidad en nuestra práctica habitual de dos escalas de riesgo preoperatorio en la reparación endovascular de los aneurismas aórticos abdominales. Pacientes y métodos: Estudio retrospectivo sobre mortalidad y morbilidad a 30 días en 50 pacientes consecutivos con aneurisma de aorta, a los que se realizó tratamiento endovascular. Se aplicó a todos los pacientes la escala de riesgo de Egorova-Giacovelli (EE-G) y la escala de aneurismas de Glasgow (GAS). Análisis estadístico mediante el estudio de medias, curvas ROC y riesgo según el punto de corte principal publicado para ambas escalas. Resultados: La mortalidad a 30 días fue del 4%, y la morbilidad del 12%, presentando ambos grupos una puntuación media mayor en ambas escalas. El análisis de las curvas ROC mostró una buena exactitud, con un área bajo la curva (AUC) en la EE-G de 0,781 (IC 95%: 0,543-1,020; p = 0,181) para la mortalidad y 0,831 (IC 95%: 0,675-0,988; p = 0,009) para la morbilidad. El AUC en la GAS fue 0,839 (IC 95%: 0,684-0,993; p = 0,108) para la mortalidad y 0,917 (0,835-0,999; p = 0,001) para la morbilidad. Cuando se utilizaron los puntos de corte la mortalidad subía del 2 al 20% (OR: 11) con la EE-G y del 2 al 8% (OR: 3,36) con la GAS; la morbilidad pasaba de 6 al 60% (OR: 21) con la EE-G y de 2 al 41% (OR: 26,42) con la GAS. Conclusiones: Este tipo de escalas pueden ayudarnos a descubrir el grupo de pacientes con mayor riesgo de presentar complicaciones en este tipo de procedimientos(AU)

Introduction: The aim of this study is to analyse the usefulness of two preoperative risk scales in the endovascular repair of abdominal aortic aneurysms in routine clinical practice. Patients and methods: A retrospective study was conducted on the morbidity and mortality at 30 days in 50 consecutive patients with an aortic aneurysm repaired by endovascular treatment. The Egorova-Giacovelli scale (EE-G) and Glasgow Aneurysm Scale (GAS) were used on all patients. A statistical analysis of the means, ROC curves, and risk was performed using the published cut-off point for both scales. Results: The mortality at 30 days was 4%, and the morbidity 12%, with both groups having a medium to high score on both scales. The analysis of the ROC curves showed good agreement, with an area under the curve (AUC) in the EE-G of 0.781 (95% CI: 0.543-1.020; P = .181) for the mortality and 0.831 (95% CI: 0.675-0.988; P = .009) for the morbidity. The AUC in the GAS was 0.839 (95% CI: 0.684-0.993; P = .108) for mortality and 0.917 (0.835-0.999; P = .001) for the morbidity. When the cut-off points were used, the mortality increased from 2% to 20% (OR: 11) with the EE-G and from 2% to 8% (OR: 3.36) with the GAS; the morbidity increased from 6% to 60% (OR: 21) with the EE-G and from 2% to 41% (OR: 26.42) with the GAS. Conclusions: These types of scales may help to determine the patient group with a higher risk of having complications in these types of procedures(AU)

Asymptomatic carotid stenosis in patients with intermittent claudication: epidemiological study.

AIM: The aim of this paper was to determine the prevalence of extracraneal carotid artery disease in patients with intermittent claudication, to describe classic cardiovascular risk factors in those with hemodynamically significant stenosis and to try to define subgroups at high risk, improving therefore the performance of non invasive testing. METHODS: A prospective descriptive study was conducted, with 146 patients reporting an intermittent claudication of the lower limbs and without a previous cerebrovascular event or carotid surgery. An ultrasonography examination was done. Risk factors were registed (smoking, dislipemia, arterial hypertension, diabetes mellitus), also ischemic cardiopathy and myocardial revascularization procedures. Univariate and multivariate analysis was made to define the variables associated with hemodynamically significant stenosis. RESULTS: Prevalence of hemodynamically significant stenosis was 23.2%. Smoking, dislipemia, arterial hypertension and diabetes mellitus were not significantly associated with carotid stenosis; 24.2% of patients affected of ischemic cardiopathy present a severe stenosis, and myocardial revascularization was a risk factor for carotid stenosis. CONCLUSION: Patients with claudication and ischemic miocardiopathy, especially when myocardial revascularization is needed, must be explored with carotid ultrasonography. In this patients, probably of hemodynamically significant carotid stenosis that requires treatment is more frequent.

Tratamiento endovascular en lesiones complejas de troncos distales: experiencia inicial / Endovascular treatment in complex lesions in distal branches: an initial experience

Introducción. Los pacientes con isquemia crítica y afectación difusa de troncos distales, asociado a la ausenciade una vena adecuada y/o comorbilidades importantes, constituyen un grupo con escasas posibilidades de revascularizaciónquirúrgica. Presentamos nuestra experiencia inicial en el tratamiento endovascular de este tipo de pacientes.Pacientes y métodos. Desde febrero de 2006 hasta octubre de 2007, 23 pacientes con isquemia crítica y lesiones complejasde troncos distales fueron tratados mediante angioplastia transluminal percutánea (ATP):18 hombres y 5 mujeres,con una edad media de 73 años, un 67% de los cuales eran diabéticos. Longitud media del segmento arterial tratado,7 cm (rango: 4-19 cm), la mayoría obstrucciones. En cuatro casos se recanalizó más de un tronco distal (total: 29) y en15 se trataron también lesiones más proximales. Los procedimientos se realizaron en quirófano, bajo anestesia local, porcirujanos vasculares. Se aplicó el método de Kaplan-Meier para el análisis de salvamento de la extremidad. Resultados.Éxito técnico inicial del 86,9%. La tasa de salvamento de la extremidad a 6 y 12 meses fue del 83,33 y el 72,92%, respectivamente.Complicaciones: una embolización distal. Hubo tres fallecimientos no relacionados con el procedimiento.Conclusiones. En nuestra experiencia inicial, la ATP en lesiones complejas de troncos distales, de pacientes con escasasposibilidades de revascularización quirúrgica, presenta una buena tasa de salvamento de la extremidad, con escasa morbilidad(AU)

Introduction. Patients with critical ischaemia and diffuse involvement of the distal branches, associated withthe absence of a suitable vein and/or important comorbidities, make up a group with scant possibilities of surgicalrevascularisation. We report our initial experience in the endovascular treatment of this kind of patients. Patients andmethods. Between February 2006 and October 2007, 23 patients with critical ischaemia and complex lesions in distalbranches were treated by means of percutaneous transluminal angioplasty (PTA): 18 males and 5 females, with a meanage of 73 years, 67% of whom were diabetics. The mean length of the segment of artery treated was 7 cm (range: 4-19 cm),mostly obstructions. In four cases more than one distal branch was recanalised (total: 29) and in 15 more proximallesions were also treated. The procedures were carried out in theatre, under local anaesthesia, by vascular surgeons.The Kaplan-Meier method was applied to analyse limb salvage rates. Results. Initial technical success rate was 86.9%. Thelimb salvage rate at 6 and 12 months was 83.33 and 72.92%, respectively. Complications: one distal embolisation. Threedeaths occurred, although they were not related to the procedure. Conclusions. In our initial experience, in patients withscarce possibilities of surgical revascularisation, PTA in complex lesions in the distal branches presents a good rate oflimb salvage, with scant morbidity(AU)

Endovascular treatment of splenic and renal aneurysms.

Four cases (three women and one man) of embolization of visceral artery aneurysms are presented, of which two affected the splenic artery and two the renal artery. The two renal aneurysms were related to hypertension; one of the splenic aneurysms was diagnosed in the context of hypertension, and the other affected a woman of a fertile age. Microguides, microcatheters, and Guglielmi platinum coils, liberated by electrolysis, with different lengths and characteristics, were used. Also, one of the renal aneurysm cases was related to the placing of a stent due to the existence of a stenosis of the renal artery adjacent to the aneurysmatic neck. Immediate occlusion of the aneurysm was achieved in the four cases. Evaluation with nuclear magnetic resonance angiography carried out 3 months later confirmed the sealing of the aneurysm and the patency of the native artery. Currently available devices provide a good therapeutic option for the embolization of visceral aneurysms with low morbidity and mortality rates.

Comparación de estudios de prevalencia de arteriopatía periférica en población general o seleccionada / Comparative study of prevalence of peripheral arterial disease in general population or selected

INTRODUCCIÓN. La apertura del Servicio de Angiología y Cirugía Vascular del Hospital de Cabueñes impulsó la necesidad deconocer la prevalencia de la de la Isquemia Crónica (IC) en los pacientes mayores de 65 años que residían en el AreaSanitaria de Gijón, con el fin de concretar los recursos necesarios y planear la organización del trabajo, y comparar los resultadoscon los obtenidos en los trabajos ya realizados con los usuarios que acudían por cualquier motivo a un Centro de Salud.MATERIAL Y MÉTODOS. Se diseña un estudio descriptivo transversal, incluyendo finalmente 232 sujetos, 114 hombres y 118mujeres, seleccionados aleatoriamente a partir de los datos de la tarjeta sanitaria. Se les historia, explora, y se calcula elíndice tobillo-brazo. Se procede a la búsqueda bibliográfica, centrada en estudios sobre prevalencia de EAP en usuarios deCentros de Salud. RESULTADOS. La prevalencia global de la IC es del 9,9%, está 6 puntos por encima en el grupo de los mayoresde 75 años y 8 puntos por encima en los hombres, y estas diferencias son estadísticamente significativas. En los estudioscon que se compara este trabajo las cifras de prevalencia de un índice tobillo/brazo disminuido oscilan entre el 23 y el 27.4%CONCLUSIÓN. Los estudios basados exclusivamente en el ITB, y los realizados en aquellas personas que acuden a un Centrode Salud por uno u otro motivo, parecen sobrevalorar la prevalencia de la EAP. La incorporación de la anamnesis y la exploraciónal ITB eleva la certeza diagnóstica (AU)

INTRODUCTION. The opening of the Service of Angiology and Vascular Surgery of the Cabueñes Hospital impelled the necessityto know the prevalence the one of Chronic Ischaemia (CI) in the greater patients of 65 years than they resided in the SanitaryArea of Gijón, with the purpose of making specific the resources necessary and to plan the organization of the work, and tocompare the results with the obtained ones in the works already made with the users who went for whatever reason to aCenter of Health. MATERIAL AND METHODS. A cross-sectional descriptive study is designed randomly, including 232 subjects,114 men and 118 women, finally selected from the data of the sanitary card. Them history, explores, and the index calculatesankle-arm. It is come to the bibliographical search, centered in studies on prevalence of EAP in users of Centers ofHealth. RESULTS. the global prevalence of the IC is of 9.9%, it is 6 points superficially in the group of greater of 75 years and8 points superficially in the men, and these differences are statistically significant. In the studies whereupon east work is comparedthe numbers of prevalence of an index ankle/diminished arm oscillate between the 23 and the 27,4% CONCLUSION. Thestudies based exclusively on the ITB, and the made ones in those people who go to a Center of Health by one or another reason,seem to overvalue the prevalence of the EAP. The incorporation of the anamnesis and the exploration to the ITB elevatethe certainty diagnoses (AU)

Aneurisma de aorta abdominal causado por Mycobacterium tuberculosis / Abdominal aortic aneurysm caused by Mycobacterium tuberculosis

Introducción. Los aneurismas de aorta abdominal causados por Mycobacterium tuberculosis son una entidad muy poco frecuente, con una alta tasa de mortalidad. Caso clínico. Varón de 67 años de edad que presenta tuberculosis diseminada a tratamiento con tuberculostáticos. En los meses posteriores al inicio del tratamiento refiere clínica de dolor lumbar que irradia a miembro inferior derecho. En los meses posteriores al inicio del tratamiento refiere clínica de dolor lumbar que irradia a miembro inferior derecho. En la resonancia magnética de columna lumbar se observa un aneurisma de aorta abdominal; a continuación se realiza una tomografía computarizada con contraste intravenoso en la que se confirma el hallazgo de un aneurisma de aorta abdominal yuxtarrenal de morfología sacular y 6,7 cm de diámetro, que no presentaba en una tomografía computarizada hecha tres meses antes. Se practica la resección del aneurisma y la interposición de prótesis aortoaórtica impregnada en plata. El cultivo de la pared aórtica es positivo para M. tuberculosis. El paciente es dado de alta a las dos semanas con tratamiento con tuberculostáticos. El seguimiento aneurismas a un año y medio transcurre sin incidencias. Conclusiones. En los aneurismas tuberculosos de aorta se debe combinar el tratamiento médico con el quirúrgico, y éste debe realizarse a la mayor brevedad posible debido a la alta tasa de morbimortalidad que presentan

Introduction. Abdominal aortic aneurysms caused by Mycobacterium tuberculosis are a very rare entity, with a high mortality rate. Case report. We report the case of a 67-year-old male who presented disseminated tuberculosis that was being treated with tuberculostatic compounds. During the months following the start of treatment, the patient reported symptoms of lower back pain that irradiated to the right lower limb. Magnetic resonance imaging of the lumbar spine shoewed an abdominal aortic aneurysm; computerised tomography with intravenous contrast was then performed and this confirmed the finding of a juxtarenal abdominal aortic aneurysm with a sacular morphology and a diameter of and this confirmed the findings of a juxtarenal abdominal aortic aneurysm with a saccular morphology and a diameter of 6.7 cm. This aneurysm had not shown up on a previous computerised tomography scan performed three months earlier. The aneurysm was resectioned and a silver-coated aortoaortic grafts was introduced. The aortic wall culture was positive for M. tuberculosis. The patient was discharged two weeks after beginning therapy with tuberculostatic agents. No incidents occurred during the one and a half year follow-up. Conclusions. Incases of tuverculous aortic aneurysms medical treatment must be combined with surgery and this should be performed as soon as possible due to the high morbidity and mortality rates of such cases