Infrapopliteal arterial occlusive disease in elderly men: a population based study.

AIM: The aim of this paper was to determine prevalence, cardiovascular risk factors and association with coronary heart disease (CHD) of isolated infrapopliteal arterial disease in old-adult men. DESIGN: cross-sectional; participants: population-based sample of 699 men aged 55 to 74 years, measurements: cardiovascular history and risk factors, electrocardiogram, segmental pressures and velocity waveforms in lower limbs. RESULTS: Peripheral arterial occlusive disease (PAOD) was observed in 13.4% subjects, of whom 39.4% (37 patients) had isolated infrapopliteal PAOD. Of these, 11 (29.7%) patients were symptomatic. Isolated infrapopliteal PAOD was significantly associated with increased age, smoking, diabetes and hypertriglyceridemia. Subjects with extended PAOD differed from those with isolated infrapopliteal PAOD in increased tobacco exposure, higher levels of LDL and lower levels of HDL cholesterol. Association between PAOD and CHD was almost always significant (odds ratio from 1.8 to 3.4) irrespective of PAOD topographic pattern and symptom characteristics of CHD subjects. CONCLUSION: Isolated infrapopliteal PAOD is a frequent asymptomatic disorder in old-adult men, clearly associated with both symptomatic and asymptomatic CHD. In contrast to an expected risk factor profile biased by clinical practice, these subjects only differed from those with PAOD significantly extended to proximal arteries in their smoking exposition and a more atherogenic lipid profile.

The use of the CUSUM chart method for surveillance of learning effects and quality of care in endovascular procedures.

INTRODUCTION: Quality of care and learning effect surveillance are two mandatory responsibilities within a changing therapeutical paradigm. We aimed to evaluate the feasibility and value of CUSUM chart method in assessing performance in consecutive endovascular procedures done by vascular surgeons of a single department on aorto-iliac, femoropopliteal and renal artery occlusive disease. MATERIAL AND METHOD: Data were collected in 405 consecutive patients, scheduled for endovascular intervention of aorto-iliac (n = 131, 32.3%), femoropopliteal (n = 142, 35%) and renal artery (n = 132, 32.7%) occlusive disease during a 6-year period. Quality indicators included inability to cross the lesion, peri- and post-procedural complications and significant residual stenosis or occlusion at 1 month. CUSUM curves were generated for each territory globally and according to each quality indicator. The relevance of curve upward inflections was evaluated with Fisher's Exact Test. RESULTS: Failure to cross the lesion occurred in 6.9% (aorto-iliac), 10.6% (femoropopliteal) and 2.3% (renal) of patients. One-hundredth twenty aorto-iliac, 127 femoropopliteal and 132 renal angioplasties were finally performed. Peri- and post-procedural complications appeared in 14.5% (aorto-iliac), 9.2% (femoropopliteal) and 2.3% (renal), while significant residual stenosis or occlusion was seen in 0.8%, 4.9% and 2.3% of patients, respectively. Aorto-iliac CUSUM curve showed two upward inflections at the beginning and the end of the period, both associated with peri- and post-procedural complications (p = 0.002 and p = 0.0013) and the latter also with failure to cross the lesion (p = 0.009). Femoro-popliteal CUSUM curve moved progressively upward during all the period, initially related to peri- and post-procedural complications (p = 0.038) and later to failure to cross the lesion (p = 0.004). Renal CUSUM curve didn't show any upward inflection during the analysed period. CONCLUSION: CUSUM curves are an excellent tool for measuring learning effect and quality of care within a changing paradigm, such it is the case of endovascular interventions. Curve upward inflections can be further interpreted according to the type of "failure" thus helping to evaluate their underlying causes.

Historia natural del paciente isquémico sometido a una amputación infracondílea: un largo camino hacia la deambulación autónoma / The natural history of ischaemic patients who undergo below-knee amputation: a long way to autonomus walking

Objetivo. Conocer la historia natural del paciente sometido a una amputación infracondílea (AIC), analizandolos factores pronósticos de reamputación precoz, protetización, supervivencia y deambulación al año. Pacientesy métodos. 140 amputaciones consecutivas en 124 pacientes (edad media 70,2, varones 64%), intervenidos entre 1995y 2004 por isquemia aguda (6%), crítica (86%) o infección (exclusiva 8%; concomitante 59%); practicándose una AIC(57% transversal, 43% sagital). Estadístico: regresión logística, Kaplan-Meier invertido, Cox. Resultados. Supervivencia:inmediata (< 30 días/alta) del 87,6% y al año del 67%, disminuyendo significativamente la primera con antecedentede enfermedad pulmonar obstructiva crónica (odds ratio, OR = 2,698; p = 0,087), y la segunda si accidentevascular cerebral (AVC) (OR = 2,86; p = 0,039) o edad > 80 años (OR = 2,94; p = 0,049). Evolución del muñón: 20reamputaciones proximales (14%) precoces, asociándose a antecedentes de AVC (OR = 3,675; p = 0,021), edad 60-69años (OR = 3,337; p = 0,027) e isquemia aguda (OR = 5,097; p = 0,051). El porcentaje acumulado de cicatrización delas restantes 120 fue a 30/60/90 días de 44/84/91%, respectivamente (mediana 47 días), siendo menor con antecedentede diabetes (OR = 1,654; p = 0,020). Protetización: 56/140 (40%) pacientes (a 90/180/365 días: 19/38/55%), siendomenor si antecedente de insuficiencia cardíaca congestiva (OR = 0,245; p = 0,002), AVC (OR = 0,217; p = 0,035)y deambulación limitada (OR = 0,154, p = 0,002) o nula (OR = 0,191, p = 0,085) previas. Deambulación al año:41/124 pacientes (35%: limitada = 37%, normal = 63%), siendo menor si antecedente de edad > 70 años (OR = 0,169;p = 0,006), insuficiencia renal crónica (OR = 0,035; p = 0,001), AVC (OR = 0,000; p = 0,998), deambulación limitada(OR = 0,154, p = 0,002) o nula (OR = 0,191, p = 0,085) previas. Conclusiones. A pesar de nuestra tendencia optimistaal indicar una AIC, el número de pacientes que llegan al final del camino es modesto y depende de factores quevan mucho más allá de que el paciente tenga nivel clínico para esta intervención. El conocimiento de estos factorespuede contribuir a un mejor proceso de selección, evitando expectativas, a veces, poco realistas

Aim. To determine the natural history of patients who undergo below-knee amputation (BKA) by analysingthe prognostic factors of early reamputation, prosthetics surgery, survival and walking at one year. Patients and methods.Our sample included 140 consecutive amputations in 124 patients (mean age 70.2; 64% males) who, between 1995 and2004, underwent surgery involving BKA (57% transversal, 43% sagittal) as a result of acute ischaemia (6%), criticalischaemia (86%) or infection (exclusive 8%; concomitant 59%). Statistics: logistic regression, inverted Kaplan-Meier,Cox. Results. Survival: immediate (< 30 days/discharge) 87.6% and at one year 67%; the former dropped significantlywith a history of chronic obstructive pulmonary disease (odds ratio, OR = 2.698; p = 0.087) while the latter decreasedwith cerebrovascular accident (CVA) (OR = 2.86; p = 0.039) or age > 80 years (OR = 2.94; p = 0.049). Progression ofthe residual limb: 20 early proximal reamputations (14%), which were associated with a history of CVA (OR = 3.675; p =0.021), an age of 60-69 years (OR = 3.337; p = 0.027) and acute ischaemia (OR = 5.097; p = 0.051). The accumulatedpercentage of scarring in the other 120 was 44/84/91% at 30/60/90 days, respectively (mean 47 days), and was lowerwith a history of diabetes (OR = 1.654; p = 0.020). Prosthetics surgery: 56/140 (40%) patients (at 90/180/365 days:19/38/55%), which was lower with a history of congestive heart failure (OR = 0.245; p = 0.002), CVA (OR = 0.217; p =0.035) and previous limited (OR = 0.154; p = 0.002) or null walking ability (OR = 0.191; p = 0.085). Walking at one year: 41/124 patients (35%: limited = 37%, normal = 63%), which were lower with a history of an age > 70 years (OR= 0.169; p = 0.006), chronic renal failure (OR = 0.035; p = 0.001), CVA (OR = 0.000; p = 0.998), previous limited(OR = 0.154; p = 0.002) or null walking ability (OR = 0.191; p = 0.085). Conclusions. Despite our tendency to beoptimistic when indicating a BKA, a relatively small number of patients reach the end of the way and the figure dependson factors that go far beyond the patient's having the clinical level required for this procedure. Knowledge of thesefactors can help improve the selection process and avoid what are sometimes unrealistic expectations

The association of peripheral arterial occlusive disease with major coronary events in a mediterranean population with low coronary heart disease incidence.

OBJECTIVES: The association of peripheral arterial occlusive disease (PAD) association with major coronary events (MCE) has been well documented, nevertheless data are lacking for populations with a low incidence of coronary heart disease (CHD). We aimed to assess the association of PAD with MCE in a Mediterranean population. DESIGN: Prospective survey of 699 55-74 year-old men representative of an urban district near Barcelona (Spain). METHODS: Baseline cardiovascular risk factors, CHD and PAD (ankle/brachial index<0.9) were recorded. MCE were evaluated during the 5-year follow-up. RESULTS: At recruitment 94 subjects (13.4%) had PAD. During follow-up (mean 69.3 months), 35 (5%) subjects suffered a MCE, of whom 12 had PAD, 9 previous symptomatic CHD and 1 subject both conditions. Higher CHD related mortality (8.6% vs 1.4%; p<0.001) and lower MCE-free survival (78.67% vs 93.26%; p<0.001) was observed for PAD subjects. On Cox regression analysis PAD (RR=3; p=0.003) and previous symptomatic CHD (RR=4.1; p<0.001) were associated independently with MCE during follow-up. CONCLUSIONS: Even in a population with a low incidence of CHD there is a strong relationship between PAD and future MCE. Screening for PAD may improve the selection of patients targeted for cardiovascular risk prevention.

Quantification and characterization of carotid calcium with multi-detector CT-angiography.

OBJECTIVE: The aim of this study was to assess the accuracy of CT-angiography for identification and measurement of calcification of carotid atherosclerotic plaques and to characterise the content and distribution pattern of mineral calcium (hydroxyapatite, Ca) in carotid bifurcations and investigate its relationship with neurological symptoms. METHODS: Twenty-six patients with ICA stenosis > 60% (13 symptomatic, 13 asymptomatic) were selected for study. Ca was estimated from the weight of the ashed remnants of carotid endarterectomy (CEA) specimens in 11 patients. Calcium content (calcification volume (mm3),CV), and average calcium density (Hounsfield units (HU),CD), were determined by CT-angiography. The distribution pattern of calcium within the lesion (base (posterior), shoulder or luminal surface) was assessed in all cases. RESULTS: CT-derived estimation of CV and Ca mass (modified Agatston Score, (mAS) = CV x CD) showed a good correlation with its direct measurement in CEA specimens (r = 0.911 and 0.993 respectively, p < 0,005). Asymptomatic patients with ICA stenosis > 60% showed statistically significant higher content of Ca than those who were symptomatic (mAS: 122.6 +/- 138.0 HU mm3 vs 42.8 +/- 59.1 HU mm3, p = 0.04). Calcification on the surface of the plaque was observed more commonly in asymptomatic patients (9/12 vs 3/15, p = 0.006). Non-calcified or plaques with posterior calcification were 12 times more likely to be symptomatic (OR: 12, 95%CI 1.5-91.1, p = 0.021). CONCLUSIONS: CT-angiography permits the reliable quantification of calcification of carotid plaques. A lower content of calcium in carotid plaques, as well as its distribution in the base of the lesion, was associated with a greater prevalence of neurological symptoms. These parameters may be useful to identify those patients at higher risk of stroke.

The vascular surgeon facing clinical ethical dilemmas (the VASCUETHICS Study): 'V'-shaped association between compassionate attitudes and professional seniority.

OBJECTIVE: To evaluate the association between compassionate attitudes and seniority in vascular surgeons facing clinical ethical dilemmas (CED). SUBJECTS AND METHODS: (1) DESIGN: Cross-sectional. (2) SUBJECTS: Vascular surgeons (residents included) from the 28 vascular teaching departments of one European country. (3) MEASUREMENTS: Multidisciplinary team-designed, structured and self-administered questionnaire consisting of five clinical ethical dilemmas, of which four had conflict between compassion towards a 'small' or 'very costly' beneficial action vs. a reasonable but more 'pragmatic' allocation of health resources. Participants stated their degree of agreement with eight answers representing the two attitudes on a continuous scale. (4) STATISTICS: Cluster analysis and logistic regression model adjusted by confounding factors. RESULTS: Two hundred and fifty three vascular surgeons (median age 37 years, 74% male) from the 26 participating teaching vascular departments (public hospitals) completed the questionnaire (88% surgeons/department). Cluster analysis identified two groups of surgeons according to their pattern of answers: Group I (n=63) were mainly compassionate whereas Group II (n=180) were mainly pragmatic. The multivariate analysis disclosed, after adjusting for additional private practice, on call services and career status, a significant V-shaped relationship between the compassionate behaviour and seniority. Surgeons with 8-15 years experience were the least compassionate. CONCLUSIONS: The youngest and the most senior vascular surgeons were more prone to favour compassionate attitudes when facing clinical ethical dilemmas. Although both compassionate and pragmatic attitudes may be legitimate ethically, physicians not favouring compassion may be at risk of leaving the patient without an advocate within the health care system.

Clinical ethical dilemmas for vascular surgeons (the VASCUETHICS study): are self-interest attitudes related to professional seniority?

OBJECTIVE: To evaluate the association between professional seniority and self-interest (PSI) attitudes in the resolution of vascular ethical dilemmas (VED). DESIGN: Cross-sectional. SUBJECTS: Vascular surgeons (residents included) from the 28 vascular teaching departments of Spain. Measurements. Multidisciplinary team-designed questionnaire of 5 VED. Each VED had 3 different answers (attitudes): 2 favouring legitimate ethical attitudes (LEA) and 1 favouring PSI. The questionnaire was self-administered and all participants stated their degree of agreement with each answer on a continuous Likert scale. PSI was evaluated by: (1) adding the magnitudes of the 5 answers favouring PSI (absPSI); and (2) by comparing in each case the magnitude of the PSI answer with that of the 2 LEA (relPSI). STATISTICS: Linear regression adjusted by confounding factors. RESULTS: Two hundred and fifty-three vascular surgeons from the 26 participating teaching vascular departments of public hospitals completed the questionnaire (87.5% surgeons/department). Surgeon characteristics were: (1) median age 37 years; (2) 187 (74%) male; (3) 59 (23%) brought up with a health professional relative; (4) 94 (38%) had additional private practice; (5) 133 (65%) professed religious beliefs; and (6) 1-10 years of experience in 116 (47%), 11-20 years in 58 (24%), 21-30 years in 57 (23%), and >30 years in 15 (6%). The multivariate analysis disclosed that for every 10-years rise in professional seniority there was a 3.2% increase in absPSI (p=0.007, adjusted by variables 3 and 4), and a 3.4% increase in relPSI (p=0.002, adjusted by variable 5). CONCLUSIONS: Professional seniority is associated with a slight increase in pro-PSI attitudes in cases of vascular ethical dilemma. Both vascular surgeons and health institutions should promote the reversal of this worrying tendency.

Cribado de neoplasia oculta en pacientes afectos de trombosis venosa profunda primaria / Diagnosis of occult neoplasia in patients with primary deep vein thrombosis

Objetivos. Establecer la incidencia de neoplasia oculta (NEO) tras un diagnóstico de trombosis venosa profunda (TVP) primaria y evaluar la eficacia de realizar un cribado de cáncer oculto en estos pacientes. Pacientes y métodos. Ámbito: hospital general, período 1995-1999; sujetos: 266 pacientes consecutivos con diagnóstico objetivo de TVP, excluyéndose 111 TVP secundarias y 16 TVP primarias con seguimiento inferior a un año (8 exitus no neoplásicos y 8 pérdidas de seguimiento); variables: edad, sexo, localización TVP, tromboembolismo pulmonar asociado, hemograma, función hepática (FH), marcadores tumorales (MT), radiografía de tórax (RxTx), ecografía o TAC abdominal. Resultados. En las 139 TVP primarias analizadas, a 17 (12,2 por ciento) pacientes se les diagnosticó NEO en el primer año (3 hematológicas, 13 adenocarcinomas y 1 carcinoma vesical). 16 casos (94 por ciento) se detectaron mediante cribado y 9 se trataron precozmente para mejorar la supervivencia. Los datos clínicos no guardaron relación con NEO. Los valores predictivos positivo y negativo de los exámenes efectuados fueron, respectivamente: hemograma, 16 y 89 por ciento; FH, 26 y 88 por ciento; MT, 34 y 90 por ciento; RxTx, 100 y 87 por ciento, y TAC, 69 y 93 por ciento. Una estrategia de cribado limitada (hemograma, FH, RxTx y antígeno prostático en varones) habría resultado sugestiva de NEO en el 69 por ciento de las TVP primarias, y habría permitido diagnosticar 13 (81 por ciento) de las neoplasias detectadas. Con este algoritmo se habrían ahorrado otras exploraciones (TAC y otros MT) en el 31 por ciento de las TVP primarias, impidiendo el diagnóstico precoz de 3 casos (19 por ciento) y el tratamiento precoz de 2/9 (22 por ciento) pacientes. Conclusiones. La incidencia de NEO en las TVP primarias requiere su cribado. Una estrategia diagnóstica limitada permite detectar gran parte, pero no todos los tumores tratables, a expensas de ahorrar exploraciones en un porcentaje limitado de casos. Un cribado más completo parece más conveniente. (AU)

¿Tienen nuestros resúmenes (abstracts) lo que deben tener? Un análisis de la década 1991-2000 / Are our abstracts up to scratch? An analysis of 1991-2000

Objetivo. Determinar la variación de calidad informativa de los resúmenes de las comunicaciones orales (CO) presentadas en los Congresos Nacionales de la SEACV en los últimos 10 años. Material y métodos. 150 resúmenes de CO del período comprendido entre 1991 y 2000 seleccionados aleatoriamente. Cuestionario de 20 ítems (estructuración 1, objetivos 2, material y métodos 9, resultados 4, y conclusiones 4 ítems) aplicado de forma ciega (al autor, institución y año) a los resúmenes seleccionados, y expresado en porcentajes respecto a la puntuación teórica máxima (20 puntos= 100 por ciento). Resultados. A partir de 1991 (puntuación media del 45 por ciento), la calidad de los resúmenes mejoró progresiva y significativamente (p< 0,001) hasta el año 1995, fecha a partir de la cual permaneció estable (65-70 por ciento). Los resúmenes estructurados se asociaron, con independencia del año, a puntuaciones significativamente superiores. Los resúmenes procedentes de unidades docentes de la especialidad o de hospitales de gran magnitud no presentaron una calidad informativa significativamente superior. Conclusiones. A lo largo de la última década, la calidad de los resúmenes de CO de los congresos de la SEACV ha mejorado de forma importante, si bien dicha progresión ha quedado estacionada en los últimos años. La estructuración de los resúmenes se asocia a una mejor calidad de los mismos. (AU)

Quemodectoma asociado a paraganglioma del vago: resección mediante subluxación mandibular / Chemodectoma associated with a paraganglioma of the vagus: resection involving subluxation of the mandible

Introducción. Los paragangliomas son tumores neuroectodérmicos poco frecuentes, de carácter neurosecretor en el 5 por ciento de los casos, que se asocian a otras tumoraciones endocrinas múltiples. Muestran tendencia a malignizar en un 10 por ciento de los casos y marcada presentación familiar. Presentamos un caso de paraganglioma localizado en el cuerpo carotídeo (quemodectoma) asociado a paraganglioma en territorio del nervio vago (con extensión hacia la base del cráneo) que requirió un abordaje laterocervical poco frecuente por medio de subluxación mandibular. Caso clínico. Paciente de 27 años de edad, sin antecedentes de interés, remitida con el diagnóstico de sospecha inicial de quiste branquial. En la exploración física por sistemas tan sólo destaca una tumoración no pulsátil en región laterocervical izquierda alta sin soplo.Las exploraciones complementarias preoperatorias incluyeron: ecografía Doppler carotídea, que mostró imagen ecogénica redondeada de 1,4 ¥ 1,86 cm en la bifurcación carotídea; TAC cervical: masa vascularizada en bulbo carotídeo izquierdo, que se extiende hacia triángulo cervical posterior compatible con tumoración glómica y vagal, y arteriografía selectiva de carótida externa izquierda, que muestra imagen de hipervascularización en bifurcación carotídea dependiente de rama posterior de la arteria carótida externa. El tratamiento quirúrgico consistió en la resección de dos tumoraciones (en bifurcación carotídea y cara posterior de la porción distal de la carótida interna izquierda, respectivamente) mediante subluxación mandibular con prótesis dentaria. El estudio inmunohistoquímico fue positivo (en ambas piezas) para cromogranina y enolasa específica en las células tumorales. Se confirmó el diagnóstico de doble paraganglioma. (AU)

Relationship of obesity distribution and peripheral arterial occlusive disease in elderly men.

OBJECTIVE: To examine the relationships between total body fatness and abdominal fat distribution with peripheral arterial disease. DESIGN: Cross-sectional. SUBJECTS: Population-based sample of 708 men aged 55-74. MEASUREMENTS: Body mass index (BMI) to estimate total body fatness and waist-to-hip ratio for abdominal fat distribution; peripheral arterial disease defined by ankle/brachial index <0.9; cardiovascular risk factors. RESULTS: Peripheral arterial disease was observed in 13.4% of subjects. BMI did not correlate with peripheral arterial disease, whereas an increased waist-to-hip ratio over 0.966 (median value) doubled the prevalence of arterial disease. After controlling for smoking, diabetes, hypertension, high-density lipoprotein cholesterol and triglycerides, increased waist-to-hip ratio was independently associated with peripheral arterial disease (odds ratio 1.68; 95% confidence interval 1.05-2.70). CONCLUSION: Abdominal fat distribution, but not total body fatness, is associated with peripheral arterial occlusive disease, independently of concurrent cardiovascular risk factors.

[Ureteral complications of retroperitoneal prosthetic vascular surgery]. / Complicaciones ureterales de la cirugía vascular protésica retroperitoneal.

OBJECTIVE: Ureteral obstruction following retroperitoneal vascular by-pass has rarely been reported in the international world literature (only 169 cases). That's why we present three new cases to contribute at best knowledge of this iatrogenic disease. MATERIAL AND METHOD: Our cases were diagnosed by symptoms (number 2 and 3) and incidentally (number 1). The case 3 is exceptional because only 6 cases were previously described. RESULTS: Three different treatments were applied in our cases. The urinary fistula resulted into nephrectomy and the others were treated by endourological and reconstructive methods. We noted that the added comorbidity factors in all these cases make the pronogstic hazardous.

Utilidad de la angiografía por resonancia magnética en el diagnóstico de la estenosis de la arteria renal / The usefulness of magnetic resonance angiography in diagnosis of renal artery stenosis

Objetivo. Evaluar la utilidad de la angiografía por resonancia magnética (ARM), con contraste de fase y adquisición tridimensional (PC 3D), en la detección de estenosis de la arteria renal (EAR), comparando sus resultados con los de la eco-Doppler (ED) y angiografía por sustracción digital intrarterial (ASDIA).Pacientes y métodos. Treinta y tres pacientes consecutivos con isquemia crónica de las extremidades inferiores, lesiones obliterantes del sector aortoilíaco, aneurisma de aorta abdominal o sospecha de hipertensión vasculorrenal fueron incluidos en el estudio. En tres pacientes tan sólo se valoró una de las arterias renales por nefrectomía contralateral. Todos los pacientes fueron sometidos a ARM, ED y ASDIA del sector aortorrenal. Esta última exploración fue utilizada como patrón de referencia para el análisis de precisión en términos de: sensibilidad (S), especificidad (E), exactitud global (Ex) e índice kappa (k). Resultados. El ED y la ARM permitieron el diagnóstico de 3 de 4 oclusiones de la arteria renal. En las 59 arterias renales restantes el análisis de precisión de la ARM y ED respecto a la ASDIA en la discriminación de estenosis de la arteria renal (EAR >60 por ciento) demostró una S similar en los métodos (84,6 por ciento). Sin embargo, el ED sobrestimó el grado de estenosis en 11/33 EAR< 60 por ciento frente a tan sólo 4/33 en la ARM (E= 66,7 por ciento frente a 93,9 por ciento, Ex= 74,6 por ciento frente a 89,3 por ciento y k= 0,79 frente a 0,49, respectivamente). Conclusiones. La ARM, con utilización de técnicas PC 3D para el estudio de la EAR ofrece resultados satisfactorios, con valores de precisión razonables frente a la ASDIA, siendo su E superior a la proporcionada por otros métodos como el ED. Puede plantearse su utilización como técnica de apoyo, en las técnicas ARM de la arteria renal previa al estudio ARM con contraste, en el estudio de la EAR, tras un despistaje inicial de las lesiones mediante ED, dada su similar S y bajo coste económico. No obstante, la secuencia ARM PC 3D con finalidad diagnóstica, presenta por el momento ciertas limitaciones, tales como la valoración de patología en ramas distales, accesorias o intraparenquimatosas, que deben ser tenidas en cuenta dada sus posibles implicaciones terapéuticas (AU)

Complicaciones ureterales de la cirugía vascular protésica retroperitoneal / Ureteral complications and retroperitoneal prothesic vascular surgery

OBJETIVO: Sólo 169 casos han sido, hasta hoy, publicados referidos a obstrucción ureteral tras by-pass de los vasos retroperitoneales. Por este motivo presentamos 3 nuevos casos con el ánimo de contribuir al mejor conocimiento de esta afección yatrógena. MATERIAL Y MÉTODO: Los casos que presentamos fueron diagnosticados por síntomas (casos número 2 y 3) y de forma incidental (caso 1). El caso 3 es realmente excepcional ya que sólo 6 casos de fístula urinaria han sido comunicados previamente. RESULTADOS: Hemos aplicado tres diferentes formas de tratamiento en nuestros casos. La fístula urinaria obligó a la nefrectomía. Los otros dos fueron tratados mediante métodos endourológicos y por cirugía reconstructora. Hemos constatado en los tres que la importante comorbilidad de estos pacientes hipoteca fuertemente el pronóstico (AU)

Screening for carotid and renal artery stenoses in patients with aortoiliac disease.

Patients with severe stenoses of the carotid and renal arteries define a population at high risk but most of them are asymptomatic. Here arises the question of who must be tested and what would be the actual utility of a screening program in the general or selected populations. The aim of this study was to assess the efficacy of a duplex-based screening for carotid and renal arteries stenoses, in a subset of patients with aortoiliac arterial disease, in terms of: (1) prevalence of occlusive disease of the carotid and renal arteries detected and surgical procedures generated; (2) analysis of clinical variables that could be useful to increase the suspicion index for the disease; and (3) predictive values of duplex scanning adjusted for the observed prevalence. One hundred sixty eight consecutive patients selected for elective aortoiliac surgery were included. Carotid duplex scanning, renal duplex scanning and/or aortorenal angiography, and recording of clinical predictive variables were obtained in all the patients. The statistical analysis included prevalence rates, multivariate analysis, and predictive values of carotid and renal duplex scanning adjusted for the observed prevalence. Greater than 50% asymptomatic stenosis in at least one of the internal carotid arteries (CAS > 50%) was detected in 47 (28%) patients [95% confidence interval (CI): 21.2%-34.8%]; 67 (39.9%) patients showed greater than 60% stenosis in one or both renal arteries (RAS > 60%) (95% CI: 32.5%-47.3%). Based on current surgical indications, carotid endarterectomy was performed in 24 (14.3%) patients and a bypass to the renal artery in 30 (17.8%) patients. Logistic regression analysis accepted the following variables, in this order: carotid bruit, age, and ankle/brachial index for predicting carotid artery stenosis; and hypertension and CAS for predicting renal artery stenosis. Based on previous validation studies of duplex scanning accuracy, estimated positive predictive values for significant stenosis of the carotid and renal arteries showed a range of 80.5%-89.1% and 82.3%-89.7%, respectively. Routine screening of the carotid and renal arteries may be justified in those patients with aortoiliac aneurysmal and occlusive disease, provided there is a high prevalence of clinically significant lesions and sufficient predictive values of duplex scanning are obtained.

Secondary prevention of coronary heart disease in patients with extracoronary atherosclerosis: a need for accuracy of low density lipoprotein determination.

According to the new guidelines of the National Cholesterol Education Program (NCEP) for secondary prevention in adults with evidence of coronary heart disease or other clinical atherosclerotic disease, lipoprotein analysis is required and classification is based on low density lipoprotein (LDL) cholesterol. The aim of the present study was to analyze the reliability of calculated LDL cholesterol by the Friedewald formula compared with measured LDL cholesterol after separation by ultracentrifugation in 202 male patients with extracoronary atherosclerosis (100 patients with ischemic cerebrovascular disease and 102 patients with peripheral vascular disease) and in 117 health control subjects. Calculated LDL cholesterol coincided with measured LDL cholesterol, with less than 10% error, in 118 patients (58.4%) with extracoronary atherosclerosis and in 87 controls (74.4%). Calculated LDL cholesterol was overestimated, with an error of 10% or more compared with measured LDL cholesterol, in 34.6% of patients and 22.2% of controls, and underestimated in 6.9% and 3.4% respectively. Despite a good correlation between calculated and measured LDL cholesterol, the intraclass correlation coefficients demonstrate a poor concordance between calculated and measured LDL cholesterol, both in patients and controls. The authors underline the need for caution in assessing the reliability of calculated LDL cholesterol.

Apolipoprotein(a) genetic polymorphism and serum lipoprotein(a) concentration in patients with peripheral vascular disease.

Serum lipoprotein(a) (Lp(a)) levels were measured in 89 men with peripheral vascular disease (PVD) and 129 (100 male and 29 woman) healthy controls. Apolipoprotein(a) genetic polymorphism was determined by immunoblotting in all subjects. Patients with PVD had significantly higher serum Lp(a) levels than controls. Apolipoprotein(a) phenotype frequencies in patients with PVD did not differ from those of the control group. Both patients and controls with phenotype S2 had higher serum Lp(a) levels than those with phenotype S4. It should be emphasized that serum Lp(a) levels were significantly higher in PVD patients than controls for those with phenotype S2, S3/S4 and S4. Raised serum Lp(a) levels together with other lipoprotein abnormalities in patients with PVD imply a high cardiovascular risk. Genetic polymorphism clearly influences serum Lp(a) levels both in patients and controls. In patients with PVD, environmental and/or other genetic factors must play a role in raising Lp(a) levels.

Lipoprotein profile in men with peripheral vascular disease. Role of intermediate density lipoproteins and apoprotein E phenotypes.

BACKGROUND: The role of lipoprotein disturbances in the development of peripheral vascular disease (PVD) has not been sufficiently clarified. METHODS AND RESULTS: The relations among concentrations of intermediate density lipoproteins (IDL), apoprotein (apo) B, apo E, and other lipoproteins were studied in 102 men with PVD and 100 healthy men who formed the control group. Patients with PVD had significantly higher levels of serum triglycerides, very low density lipoprotein (VLDL) cholesterol, VLDL triglycerides, VLDL proteins, IDL cholesterol, and IDL triglycerides and lower levels of high density lipoproteins (HDL) than controls. Serum cholesterol and triglycerides were normal in 30 patients (cholesterol, less than 5.2 mmol/l; triglycerides, less than 2.3 mmol/l), who had significant increases in IDL triglycerides and significant decreases in HDL cholesterol compared with the 47 controls, who had normal cholesterol and triglyceride levels. Patients with more severe distal involvement showed higher cholesterol and triglycerides carried by IDL and a greater reduction in HDL cholesterol. Smoking patients with PVD showed increased VLDL cholesterol and VLDL triglycerides and lower HDL concentrations. Apo E polymorphism in our study population does not differ from that reported for other European populations. Alleles epsilon 2 and epsilon 4 had a major impact on serum triglycerides and VLDL lipids in our patients with PVD. CONCLUSIONS: Lipoprotein disturbances are a major risk factor for PVD. IDL abnormalities play an important role in the development and severity of PVD and should also be considered a vascular risk factor in normocholesterolemic and normotriglyceridemic patients.

Serum lipoprotein (a) levels in men with peripheral vascular disease.

The authors quantified serum lipoprotein (a) (Lp) (a) by enzymo-immuno-analysis in 86 outpatient men suffering peripheral vascular disease (PVD) and in 53 age-matched healthy men. They further measured serum cholesterol, serum triglycerides, low density lipoproteins-cholesterol, high density lipoproteins (HDL)-cholesterol and serum apolipoprotein B. Serum triglycerides were significantly increased in patients with PVD versus controls (148 +/- 8 and 114 +/- 7 mg/dL, mean +/- SEM). HDL-cholesterol levels were significantly lower in patients versus controls (36 +/- 1 and 43 +/- 2 mg/dL, respectively). Serum Lp(a) levels in patients with PVD were 20 +/- 2 mg/dL, whereas in controls they were 16 +/- 3 (p: NS). Serum Lp(a) concentrations were identical in smoker and nonsmoker patients. There was no correlation between Lp(a) concentration and the other lipid parameters. Conversely, as occurs in coronary heart disease and in cerebrovascular disease, Lp(a) does not seem to be a marker for PVD, although a trend toward a higher mean levels was found.