Documento base sobre el tratamiento de la estenosis carotídea con stent / Core document about the treatment of carotid stenosis with stenting

Introducción. El tratamiento quirúrgico de la estenosis carotídea ha suscitado, desde sus inicios, gran número de estudios internacionales, que cuestionaban su indicación, beneficios, etc.; pero, cuando las cosas parecían en calma, las nuevas tecnologías endovasculares vuelven a introducir el dilema, hasta plantear el tratamiento endovascular como una alternativa a la endarterectomía. Objetivo. Presentar el estado actual del conocimiento para que sirva de punto de partida a futuras guías en el diagnóstico y tratamiento de esta patología lesional. Desarrollo. Se comentan las distintas exploraciones diagnósticas, desde la ecografía Doppler, la tomografía axial computarizada y la angiotomografía, la resonancia magnética y la angiorresonancia, la angiografía de los troncos supraaórticos, discutiendo sus ventajas e inconvenientes para el diagnóstico. La indicación del stenting carotídeo se evalúa teniendo en cuenta el riesgo anatómico para la endarterectomía, los riesgos de alto riesgo médico para la cirugía y los riesgos de tipo técnico para la endarterectomía. También se comentan las contraindicaciones del stenting. Se describen de forma bastante extensa y precisa las distintas técnicas actuales de angioplastia y stenting, comentando los accesos, los tipos de materiales para cada una de ellas, capítulo este muy completo. Los sistemas de protección cerebral también se describen comenzando por la oclusión distal hasta los sistemas de flujo inverso hacia un shunt arteriovenoso. Se describen las complicaciones inmediatas (trombosis, embolismo cerebral, disección, hemorragia, vasoespasmo, etc.), así como las complicaciones tardías, destacando la reestenosis y las maneras de prevenirla. Conclusión. El documento base es el punto de partida a raíz de los acontecimientos y conocimientos actuales para poder contar en el futuro con más evidencias que conviertan este documento en una auténtica guía

Introduction. From its early days, the surgical treatment of carotid stenosis has given rise to a large number of international studies that have questioned its indication, benefits, and so forth; yet, when things seemed to have calmed down, the new endovascular technologies have revived the dilemma, to the point where endovascular treatment is proposed as an alternative to endarterectomy. Aim. To outline the present state of the art as a starting point for future guidelines in the diagnosis and treatment of this lesional pathology. Development. The article considers the different diagnostic examinations, from Doppler ultrasound, computerised axial tomography and tomography angiography, magnetic resonance imaging and MR angiography, to angiography of the supra-aortic trunks; at the same time, their advantages and disadvantages for use in diagnosis are also discussed. The indication for carotid stenting is assessed taking into account the anatomical risk involved in endarterectomies, the high medical risk for surgery and the risks of a technical nature deriving from endarterectomies. The contraindications of stenting are also discussed. The different angioplasty and stenting techniques that are currently used are described at length in this comprehensive chapter, with detailed information about accesses and the types of materials for each kind of procedure. Cerebral protection systems are also described, these ranging from distal occlusion to systems of reverse flow towards an arteriovenous shunt. Immediate complications (thrombosis, cerebral embolism, dissection, haemorrhage, vasospasm, etc.) are described, as are late complications, with special attention given to restenosis and ways of preventing it. Conclusions. The core document is the starting point based on current knowledge and events that will allow us to use more evidence to make this document a real guide in the future

Estudio de la frecuentación por enfermedad vascular en atención primaria / Study of vascular diseases for primary attention units

Objetivos. Analizar la frecuentación de consulta, diagnósticos realizados y manejo de los pacientes por patología vascular, en el ámbito de la atención primaria (AP), en una población adulta. Pacientes y métodos. Estudio transversal observacional. Tamaño de muestra mínimo de 2.401 consultas, para poder estimar prevalencias diagnósticas, con una precisión del 2 por ciento. Realizamos un corte de dos semanas (10 días sucesivos), en mayo y noviembre de 1999, en una muestra estratificada de zonas urbanas y rurales de nuestra provincia. La encuesta se analizó previamente con los médicos, incluyendo: edad, sexo, arteriopatías (isquemia aguda, crónica y sus estadios, y otras), flebopatías (varices, trombosis venosa, secuela posflebítica, edema, úlcera, síndrome ortostático, y otras) y destino (centro de salud, ambulatorio, urgencias).Resultados. Consultas totales: 15.815. Consultas por patología vascular: 532 (3,4 por ciento). Edad media: 65 años. Mujeres: 299. Hombres: 233. Arteriopatías: 164 (30,8 por ciento). Flebopatías: 368 (69,2 por ciento) . Se adjunta el desglose completo por diagnósticos. Destino: centro de salud, 461(86,6 por ciento); ambulatorio, 43 (8,1 por ciento); urgencias, 28 (5,3 por ciento). Se realiza estudio comparativo de cada corte estacional y proyección al total provincial y nacional. Conclusiones. El número de consultas por patología vascular en relación al total es importante (3,4 por ciento del total). El 13 por ciento de las consultas por patología vascular de AP son derivadas a Especializada y Urgencias. El estudio comparativo de los dos cortes estacionales muestra resultados muy homogéneos en flujo de consultas, porcentaje de angiopatías y destino de pacientes, menos homogéneos en clasificación diagnóstica. Se precisan más estudios para aclarar las diferencias. (AU)

Multiple cholesterol embolization syndrome: a lethal complication of vascular procedures. Report of two histologically proven cases.

Two cases of multiple cholesterol embolization syndrome (MCES) leading to death are presented. Rarely described and labeled as a "great masquerader", its presence in the medical literature is growing, since it is best diagnosed, but despite the high frequency with which MCES may occur, only a few cases are reported. This syndrome is not universally recognised.

[Female gonadal venous insufficiency]. / Insuficiencia venosa gonadal femenina.

The varicocele is a disease recognized and studied in the man. Dilatation of the ovarian veins and the pelvic varicosities secondaries to a varicocele in the woman is a rarely described disease but, if it were researched, it could be more frequent. Diverse syndromes of chronic abdominal pain in the woman with unrecognized etiology and associated with urologic and/or gynecologic symptomatology could be caused by this pathology, but the absence of a clinical description difficult the diagnosis of the most part of cases. The practice of gonadal selective venographies shows a high percentage of dilatation of the gonadal veins associated to a dilatation of the pelvic veins and of the lower limbs veins. The study of the anatomy of the gonadal veins shows diverse anomalies respect to the classical descriptions. Furthermore, the varicocele could be the cause of a high part of the "essential" varicosities presents during the pregnancy. We present a case that instead of being treated by Services of Urology or Gynecology, it was treated by the Vascular Surgery Service. So, the literature about the respect was reviewed. We think that, some entities, like the feminine varicocele, ovarian vein syndrome, pelvic congestion syndrome chronic pelvic pain, pelvic varicosities, vulvar varicosities and some "essential" pregnant varicosities at the lower limbs could be enclosed into the same clinical entity (with a common etiology, physiopathology, clinical presentation and treatment). It should be intending to unify criteria (etiologic, diagnostic and therapeutics criteria) by the different Specialized Unities in such type of pathology.

[Ascending aorta-supraceliac++ aorta bypass. Correction of a case of atypical coarctation in the adult]. / By-pass aorta ascendente-aorta supracelíaca: corrección de un caso de coartación atípica en el adulto.

A case of atypic coarctation at the aortic arch in an adult patient is described. Coarctation was surgically treated by a retrosternal bypass from the ascendant aorta to the supra-celiac aorta. After a short prelude the clinical case is summarized. Furthermore, the etiopathogenic features of the disease, the different diagnostic methods and the multiple surgical procedures are discussed. Finally, we briefly review the literature.

[Arteriosclerotic aneurysms isolated from the internal iliac artery]. / Aneurismas arterioesclerosos aislados de la arteria ilíaca interna.

A case of an isolate, symptomatic, atherosclerotic aneurysm of the left internal iliac artery is presented. A review from this very rare type of pathology reveal that clinical symptoms depends on the comprised anatomical structures. Diagnosis was made by rectal or vaginal touch, ultrasonography and CT. The operatoire mortality rate is high when aneurysms are ruptured.

[Vascular diseases masking malignant tumors of soft tissues]. / Procesos vasculares enmascarando tumores malignos de partes blandas.

Two case reports with Myxoid and Pleomorphic varieties of Malign Fibrohistiocytoma are presented. In both cases, the first consult took place in an Angiology and Vascular Surgery Service, because their clinical symptoms were similar in the first case to such produced by the arteriovenous fistulas and in the second case, symptoms remaid to an hematoma secondary to a varicose vein rupture. Such rare and malign tumors often are diagnosed as vascular diseases, and they may be discovered in the usual clinical practice, so its important an accurate recognition as well as an adequate treatment.

[Gigantic aneurysm of the popliteal artery]. / Aneurisma gigante de arteria poplítea.

A giant popliteal aneurysm case, whose first symptom was an acute ischemia on the limb, caused by thrombosis, which was successfully treated, is reported. Although popliteal aneurysm is not a rare event, the interest of this case is focused on its extraordinary size and unique location.

[Popliteal and infrapopliteal vascular injuries. A surgical challenge]. / Traumatismos vasculares poplíteos e infrapoplíteos. Un reto quirúrgico.

Prospective study of 11 patients with lower limbs traumatisms, affecting vessels under Hunter canal. The results of surgical treatment (no prosthesis) are analyzed. In all cases there was bony and/o articular lesion.

[Inflammatory aneurysm of the abdominal aorta. Apropos of a case]. / Aneurismas inflamatorios de aorta abdominal. A propósito de un caso.

The presentation of a case of inflammatory aneurysm in abdominal aorta and its bibliographic revision, makes evident the short knowledge of its etiopathogenesis and the need of TAC for its differential diagnosis and its treatment and correct follow up.

[Vasculo-renal arterial hypertension. Apropos of 2 very representative cases]. / Hipertensión arterial vásculo-renal. A propósito de dos casos muy representativos.

Authors's presents two clinical cases representatives of vasculo-renal hypertension, as much by its etiology and physiopathological mechanisms, as the therapeutics solutions successfully applied.