¿Son los nuevos anticoagulantes orales iguales a las antivitaminas K para la isquemia aguda de los miembros inferiores? Revisión sistemática de la evidencia / Are the new oral anticoagulants the same as vitamin K antagonists for acute lower limb ischaemia? A systematic review of the evidence

INTRODUCCIÓN: Los nuevos anticoagulantes orales (dabigatran, ribaroxaban y apixaban) se presentan como alternativas a los antagonistas de la vitamina K (AVK) en la prevención de eventos embólicos en pacientes con fibrilación auricular (FA). No existen ensayos clínicos que comparen directamente estos fármacos para la prevención de la isquemia aguda (IA) de miembros inferiores. MATERIAL Y MÉTODOS: Este estudio presenta los ensayos clínicos aleatorizados (RE-LY, ROCKET-AF, ARISTOTLE) que describen la capacidad de prevención de IA entre estos nuevos fármacos. RESULTADOS: Los nuevos anticoagulantes orales han demostrado en diversos ensayos clínicos y metaanálisis una eficacia similar a los AVK en la prevención de accidente cerebrovascular y embolismo sistémico con un menor número de complicaciones en pacientes con FA no valvular. CONCLUSIONES: Todavía no disponemos de evidencia de calidad sobre el efecto de estos fármacos para la prevención de la IA de miembros inferiores. Son necesarios futuros ensayos clínicos en esta dirección

INTRODUCTION: New oral anticoagulants (apixaban, dabigatran, and rivaroxaban) are alternatives to vitamin-K antagonist (VKA) for preventing embolic events in patients withauricular auricular fibrillation. So far, direct comparative studies between agents in prevention of acute limb ischaemia are unavailable. MATERIAL AND METHODS: The present study shows the outcome from the 3 randomised clinical trials (RE-LY, ROCKET-AF, ARISTOTLE) regarding acute limb ischaemia risk prevention. RESULTS: Novel oral anticoagulant therapies have shown a non-inferior efficacy compared with VKAs in lowering cerebrovascular ischaemic events and systemic embolism risk in several randomised clinical trials as well as in meta-analysis. Moreover, they have been shown to have a decreased complication rate in non-valvularauricular auricular fibrillation. CONCLUSIONS: There is no high quality evidence available on the effect of these treatments in preventing acute limb ischaemia

Meta-analysis and adjusted indirect comparison of direct oral anticoagulants in prevention of acute limb ischemia in patients with atrial fibrillation.

BACKGROUND: Direct oral anticoagulants are being presented as alternatives to warfarin for preventing stroke in patients with atrial fibrillation. Yet direct comparative trials between these agents in prevention of acute limb ischemia (ALI) are unavailable so far. OBJECTIVE: To conduct an adjusted indirect comparison meta-analysis between direct oral agents for prevention of acute limb ischemia in atrial fibrillation. METHODS: We conducted a systematic literature review searching electronic databases (MEDLINE and Embase) and the Cochrane Library from January 1990 through November 2014. Two blinded investigators reviewed all potentially relevant articles in a parallel manner by using a priori defined criteria. To assess the long-term efficacy and safety of these agents, only randomized clinical trials (RCTs) with follow-up durations of >1 year were included. The primary efficacy outcome was the end point of acute limb ischemia and/or extremity embolism. RESULTS: A total of 44,563 patients from three RCTs met criteria for inclusion. Patients randomized to direct oral anticoagulants had a non-significant decreased risk for acute limb ischemia (risk ratio [RR]: 0.57, 95% confidence interval [CI]: 0.26-1.2). In the analysis between agents, however, rivaroxaban significantly lowered the risk of ALI compared to warfarin (RR: 0.23, 95% CI: 0.064-0.82), apixaban (RR: 0.26, 95% CI: 0.081-0.83), and dabigatran (RR: 0.24, 95% CI: 0.077-0.83). CONCLUSIONS: Significant differences in prevention of acute limb ischemia may exist between oral anticoagulant agents in patients with atrial fibrillation. Rivaroxaban lowers the risk of limb embolism versus warfarin, apixaban and dabigatran.

Expresión proteica de metaloproteinasa-2 (MMP-2) y su inhibidor tisular (TIMP-2) en aorta, fascia y plasma de pacientes con aneurisma de aorta abdominal / Protein expression of metalloproteinases-2 (MMP-2) and its tissue inhibitor (TIMP-2) in aorta, fascia and plasma of patients with abdominal aortic aneurysm

INTRODUCCIÓN: Existen datos que asocian los aneurismas de aorta abdominal (AAA) con un incremento de la prevalencia de la enfermedad herniaria. Una posible alteración estructural de la matriz extracelular puede ser común en el proceso degenerativo de la pared aórtica y de la fascia abdominal. OBJETIVO: Conocer la expresión de metaloproteinasas de matriz-2 (MMP-2) y el inhibidor tisular de metaloproteinasas-2 (TIMP-2) en pared aórtica, fascia abdominal y plasma de pacientes intervenidos de AAA frente a pacientes con enfermedad aórtica oclusiva (EAO). MATERIAL Y MÉTODOS: Estudio piloto, observacional prospectivo. Se analizó la expresión proteica de MMP-2 y TIMP-2 en 10 pacientes con AAA y 10 con EAO. Recogimos datos epidemiológicos, antecedentes de hernias y diámetros del AAA. El análisis se realizó por técnica de ELISA. RESULTADOS: En el subgrupo de AAA de mediano tamaño con antecedentes de hernia, encontramos sobreexpresión de MMP-2 en fascia y de TIMP-2 en aorta y fascia, respecto a EAO sin hernia (MMP-2 fascia: AAA = 4,53 [3,11-6,90]; EAO = 1,87 [1,45-2,90]; p = 0,04; TIMP-2 en aorta: AAA = 72,62 [9,26-161,12], EAO = 9,79 [5,55-25,61]; p = 0,04 y TIMP-2 en fascia: AAA = 35,24 [13,15-61,08], EAO = 4,98 [1,42-18,01]; p = 0,02). La MMP-2 y el TIMP-2 estaban aumentados en fascia de AAA con enfermedad herniaria frente a EAO sin hernia (MMP-2: 4,31 [3,35-6,35] versus 1,87 [1,45-2,90]; p = 0,009 y TIMP-2: 18,73 [7,76-57,97] versus 4,98 [1,42-18,01]; p = 0,08). En pared aórtica hubo aumento de TIMP-2 en AAA (29,27 [14,05-140,30] frente a EAO, 9,79 [6,19-32,74]; p = 0,06). CONCLUSIONES: La MMP-2 y el TIMP-2 están aumentados, en aorta y fascia de pacientes con AAA, sobre todo, en los de mediano tamaño, lo que indica cierto papel en la etiología. El incremento de MMP-2 y TIMP-2 en presencia de hernia potencia la idea de un mecanismo patogénico común

INTRODUCTION: There are data that associates abdominal aortic aneurysms (AAA) with an increased prevalence of hernia disease. A possible structural alteration of extracellular matrix may be common in the degenerative process of the aortic wall and the abdominal fascia. OBJECTIVE: Determine the expression of matrix metalloproteinases-2 (MMP-2) and tissue inhibitor of metalloproteinases-2 (TIMP-2) in aortic wall tissue, abdominal fascia, and plasma of patients undergoing AAA versus patients with aortic occlusive disease (EAO). MATERIAL AND METHODS: A pilot, prospective observational study was conducted, in which the protein expression of MMP-2 and TIMP-2 was analyzed in 10 patients with AAA, and in 10 with EAO, using an ELISA technique. Epidemiological data, history of hernias, and AAA diameters were collected. RESULTS: In the subgroup of medium sized AAA with a history of hernia, over-expression of MMP-2 was found in fascia, and of TIMP-2 in aorta and fascia. As regards EAO without hernia (MMP-2 fascia: AAA = 4.53 [3.11-6.90], EAO = 1.87 [1.45-2.90], P=.04; TIMP-2 in aorta: AAA = 72.62 [9.26-161.12], EAO = 9.79 [5.55-25.61], P=.04, and TIMP-2 in fascia: AAA = 35.24 [13.15-61.08], EAO =4.98 [1.42-18.01], P=.02).The MMP-2 and TIMP-2 was increased in AAA fascia hernia disease compared with EAO without hernia (MMP-2: 4.31 [3.35-6.35] versus 1.87 [1.45-2.90], P=.009, and TIMP-2: 18.73 [7.76-57.97] versus 4.98 [1.42-18.01], P=.08).There was an increased TIMP-2 in the aortic wall, AAA (29.27 [14.05-140.30] vs. EAO 9.79 [6.19-32.74], P=.06). CONCLUSIONS: The MMP-2 and TIMP-2 are increased in aorta and fascia of patients with AAA, especially in the medium size, suggesting a role in the etiology. The increase in MMP-2 and TIMP-2 in the presence of hernia, enhances the idea of a common pathogenic mechanism

Analysis of vascular endothelial growth factor gene expression in the tissues of patients with chronic venous insufficiency.

OBJECTIVE: Immunohistochemical techniques have revealed the presence of vascular endothelial growth factor (VEGF) in the epidermis of patients with chronic venous disease (CVD). Our objective was to perform a quantitative analysis of the VEGF gene transcription in tissues that are potential sources of this factor (skin, varicose veins [VV] and great saphenous vein [GSV]) in patients with CVD. METHODS: In all, 212 skin and venous tissue samples were collected from patients diagnosed with CVD and controls. The VEGF gene expression was analysed using quantitative realtime polymerase chain reaction (PCR). RESULTS: The skin VEGF expression was lower in the CVD group than in the control group (P = 0.04). There were no significant differences between the insufficient GSV of the CVD group and the control healthy vein (P = 0.22). There was a greater expression of VEGF in the VV of the CVD group than in the control healthy vein (P = 0.03). Comparison of the VEGF expression between the different tissue types in the CVD group revealed significant differences between the skin and GSV (P = 0.02) and between the skin and the VV (P = 0.004), and between the VV and the GSV (P = 0.02). CONCLUSIONS: The results of the present study show an over-expression of VEGF gene in the VV tissue of patients with CVD. Based on the data in patients with C2 disease, the VVs appear to be the source of increased VEGF expression.

Influence of surgical or endovascular distal revascularization of the lower limbs on ischemic ulcer healing.

AIM: Our aim is to analyze the ability of distal endovascular procedures, performed as first treatment option, to promote ischemic ulcer healing. METHODS: Retrospective analysis of 91 primary distal procedures, 49 (53.8%) surgical and 42 (46.2%) endovascular, performed consecutively between January 2005 and December 2007 in patients with critical limb ischemia (CLI) and ischemic ulcers. Patient comorbidities, intervention duration time, postoperative hospital stay and complications were recorded. Ischemic ulcer healing time, patency, limb salvage and survival rates were compared between both groups. Data were included in a Cox regression model to determine predictive factors for healing RESULTS: Endovascular therapy was associated with shorter intervention time (128±53 versus 301±91 min; P=0.001) and postoperative hospital stay (13±13 versus 19±14 days; P=0.05). Surgical procedures were associated with more local complications (28.6% versus 7.1% P=0.01), more readmissions for surgical wound complications (12.2% versus 0% P=0.03) and more early major amputations (16.3% versus 0% P=0.007). Ischemic ulcer healing in endovascular and surgical procedures was 80% versus 83% at 12 months (P=NS). Overall patency, limb salvage, survival and amputation-free survival with healed ulcers at 24 months in endovascular and surgical groups were 82% versus 82% (P=NS), 83% versus 72% (P=NS), 81% versus 79% (P=NS) and 63% versus 56% (P=NS). Diabetes mellitus (HR: 2.86 95% CI [1.44-5.68]), free ambulatory status (HR: 0.57 95% CI [0.33-0.98]) and the presence of severe wounds (HR: 2.73 95% CI [1.40-5.30]) were predictors for ulcer healing. CONCLUSION: Endovascular and surgical distal procedures had a similar ulcer healing rate and limb salvage. Our experience supports endovascular-first strategy for CLI with tissue loss.

Long-term pleiotropic effect of statins upon nitric oxide and C-reactive protein levels in patients with peripheral arterial disease.

OBJECTIVES: Peripheral arterial disease can be regarded as a systemic inflammatory disorder affecting the entire vascular system. In the early clinical stages, it is characterised by the deterioration of endothelial function, which does not progress with the development of the disease. This study analyses the pleiotropic effects upon the plasma nitrite and C-reactive protein (CRP) levels in claudicating patients after 12 months of treatment with statins. STUDY DESIGN: A prospective randomised controlled translational study was made in patients with Fontaine grade II ischaemia, treated with the best medical treatment with or without statins for 12 months from the time of diagnosis for assessing the pleiotropic effects of those statins. METHODS: Measurements of plasma high-sensitivity CRP (hsCRP), lipid profile and nitrites were made at baseline and after 1 month and 1 year of treatment with atorvastatin 40 mg/day. RESULTS: A significant reduction in nitrite levels was observed after 1 month of treatment (11.8±7.8 µM vs 5.7±1.8 µM, p=0.0001), but this effect did not persist after 1 year (11.8±7.8 µM vs 9.4±8.9 µM, p=0.27). HsCRP underwent a significant reduction after both 1 month (7 (2.2-12) vs 3.4 (1.6-5.5), p<0.01) and 1 year of treatment with atorvastatin (7 (2.2-12) vs 2.25 (1.67-6.7), p=0.02). Statin treatment reduced hsCRP levels in 9.64 (95% CI (1.60 to 17.68)) after 1 month and in 9.14 (95% CI (0.18 to 18.47)) after 1 year. CONCLUSIONS: The long-term biological pleiotropic effects of statins provide information on the role of endothelial function and systemic inflammation in the aetiopathogenesis of peripheral arterial disease. Statins slow endothelial degradation at the start of the disease, with no effects over the long term. These drug substances reduce progressive inflammation throughout the treatment period. This supports the novel hypothesis that endothelial dysfunction is only a disease-triggering phenomenon, while systemic inflammation would be responsible for both the origin and the maintenance of peripheral arterial disease.

En el origen de la enfermedad arterial periférica: papel de la endotelina en la disfunción endotelial / At the origin of peripheral arterial disease: the role of endothelin in endothelial dysfunction

Introducción. La etiopatogenia de la arterioesclerosis reúne una serie de factores condicionantes y procesosinflamatorios crónicos que originan un estado permanente de disfunción endotelial. La endotelina (ET) es una proteínarelacionada con la función de las células endoteliales, y que parece tener un papel en la enfermedad arterial periférica(EAP), como manifestación de la arterioesclerosis. Objetivo. Investigar el papel de la ET en la EAP, y su relación con lossíntomas, la función endotelial y los procesos inflamatorios. Sujetos y métodos. Realizamos un estudio transversal con141 sujetos: 66 pacientes con claudicación intermitente, 37 pacientes con isquemia crítica y 38 controles sanos. Medimoslos niveles de ET y proteína C reactiva (hsPCR) plasmática y la dilatación de la arteria braquial mediada por flujo(DABMF) en estos tres grupos. Resultados. Las concentraciones de ET son significativamente más altas en pacientescomparados con los controles sanos (8,76 ± 7,1 frente a 6,45 ± 0,89 pM/L; p = 0,002). Los pacientes con claudicaciónpresentan concentraciones de ET significativamente más altas que los pacientes con isquemia crítica (10,97 ± 7,9 frentea 4,82 ± 2,57 pM/L; p < 0,001). Los valores de hsPCR fueron mayores en los pacientes con isquemia crítica que en losclaudicantes (16,94 frente a 4,73 mg/L; p = 0,001). En la DABMF no obtuvimos diferencias significativas entre los dosgrupos (5,4 ± 3,7% en claudicantes, 5,85 ± 4,35% en críticos; p = 0,58). Las concentraciones de ET presentan una modestacorrelación negativa con los valores de hsPCR (–0,165; p = 0,095). Conclusión. Las concentraciones plasmáticasde ET en los pacientes con EAP son mayores en etapas iniciales de la enfermedad. Con la progresión de la enfermedad,se observa una disminución de los valores de ET, mientras que existe un incremento del marcador inflamatorio hsPCR

Introduction. The aetiopathogenesis of arteriosclerosis includes a series of conditioning factors and chronicinflammatory processes that give rise to a permanent state of endothelial dysfunction. Endothelin (ET) is a protein thatis involved in the functioning of endothelial cells and which seems to play a role in peripheral arterial disease (PAD), asa manifestation of arteriosclerosis. Aim. To examine the role of ET in PAD and its relation with the symptoms,endothelial functioning and inflammatory processes. Subjects and methods. We conducted a cross-sectional study with141 subjects: 66 patients with intermittent claudication, 37 patients with critical ischaemia and 38 healthy controls. Wemeasured the levels of ET and C-reactive protein (hsCRP) in plasma and the brachial artery flow-mediated dilation(BAFMD) in these three groups. Results. ET concentrations are significantly higher in patients than in healthy controls(8.76 ± 7.1 vs. 6.45 ± 0.89 pM/L; p = 0.002). Patients with claudication show significantly higher ET concentrationsthan patients with critical ischaemia (10.97 ± 7.9 vs. 4.82 ± 2.57 pM/L; p < 0.001). Patients with critical ischaemia hadhigher hsCRP values than those with claudication (16.94 vs. 4.73 mg/L; p = 0.001). No significant differences were observedin the BAFMD in the two groups (5.4 ± 3.7% in those with claudication, 5.85 ± 4.35%; p = 0.58). ET concentrationsshow a slight negative correlation with the hsCRP values (–0.165; p = 0.095). Conclusions. Plasma concentrations ofET in patients with PAD are higher in the early stages of the disease. As the disease progresses, the ET values diminishwhile the inflammatory marker hsCRP increases

Embolismo aortoilíaco de etiología multicausal en un paciente joven / Aortoiliac embolism with multiple causations in a young patient

Objetivo. Presentar una excepcional asociación, en un varón joven, entre pioderma gangrenoso, acné conglobata,infarto de miocardio y embolia aortoilíaca, analizando sus posibles relaciones etiopatogénicas. Caso clínico. Varónde 25 años con clínica de isquemia arterial aguda en la extremidad inferior derecha. Como antecedentes, presentabaacné conglobata diseminado en tórax, abdomen y extremidades, y pioderma gangrenoso con tratamiento crónico corticoideode más de 12 años de duración. En el electrocardiograma se apreciaron imágenes sugestivas de infarto de miocardioantiguo silente y trombos apicales intracavitarios en el ecocardiograma, confirmados en resonancia cardíaca. Sele practicó tromboembolectomía de ambos miembros inferiores, en dos tiempos, y se obtuvo un buen resultado morfológicoy clínico, por lo que se asumió el riesgo del acceso quirúrgico a través de las lesiones ulceradas, por la posibilidadde infección y del fenómeno de patergia, característico del pioderma. Conclusiones. Los procesos inflamatorios crónicoshan sido relacionados con estados de trombofilia, que podrían deberse a mecanismos autoinmunes. El pioderma está frecuentementeasociado a enfermedades sistémicas, como las enfermedades inflamatorias intestinales, que a su vez han sidorelacionadas con complicaciones trombóticas. El tratamiento crónico con corticoides, que mantenía el paciente, producealteraciones en el electrocardiograma y enfermedad isquémica cardíaca. Sea como asociación sistémica no descrita,o como proceso protrombótico multicausal, los trombos intracavitarios asociados al infarto de miocardio fueron loscausantes de la isquemia

Aims. To present an exceptional association, in a young male, of pyoderma gangrenosum, acne conglobata,myocardial infarct and aortoiliac embolism, and to analyse their possible aetiopathogenic relations. Case report. Westudied the case of a 25-year-old male with a clinical picture of acute arterial ischaemia in the right lower limb. Thepatient had a history of disseminated acne conglobata on his thorax, abdomen and limbs, and had been receivingcorticoid treatment for pyoderma gangrenosum for over 12 years. An electrocardiogram revealed images suggesting aprevious silent myocardial infarct and the echocardiogram showed intracavitary apical thrombi, which were confirmed inthe cardiac magnetic resonance scan. A thromboembolectomy was performed in both lower limbs, in two sessions, and agood morphological and clinical result was obtained; the decision was therefore made to risk taking a surgical approachvia the ulcerated lesions, due to the possibility of infection and the phenomenon of pathergy, which is characteristic inpyoderma. Conclusions. Chronic inflammatory processes have been related to thrombophilic states, which could be dueto autoimmune mechanisms. Pyoderma is often associated with systemic diseases, such as inflammatory bowel diseases,which have in turn been linked to thrombotic complications. Chronic treatment with corticoids, which is what maintainedthe patient, produces alterations in the electrocardiogram and ischaemic heart disease. Whether as a systemic associationthat has not yet been described or as a prothrombotic process with multiple causation, the intracavitary thrombiassociated with the myocardial infarct were the cause of the ischaemia

Tratamiento endovascular de trombo flotante sintomático de aorta torácica / Endovascular treatment of symptomatic floating thrombi in the thoracic aorta

Introducción. Los trombos en la aorta torácica son poco frecuentes y constituyen una importante fuente de embolismos.El tratamiento endovascular ha mejorado las opciones terapeúticas hasta ahora reservadas a la tromboendarterectomíay/o a la anticoagulación sistémica. Caso clínico. Mujer de 52 años, fumadora, derivada desde otro centro pordolor abdominal difuso, náuseas, vómitos y hallazgo en la tomografía computarizada abdominal de oclusión de la arteriailíaca común izquierda, infartos renales bilaterales y defecto de repleción en la porción inferior de la aorta torácica.En el ecocardiograma transesofágico se observaba un trombo móvil de 7 × 23 mm en la aorta torácica. Se instauró el tratamientocon anticoagulación en dosis terapéuticas y se realizó una angiorresonancia magnética y una arteriografía; comoresultado de estas pruebas se observó un trombo flotante en la aorta torácica de 3 cm de longitud, fijado a la placaateroesclerótica, oclusión de la arteria renal izquierda e ilíaca izquierda. La exclusión del trombo se realizó mediante laliberación en la aorta torácica de una endoprótesis de 32 × 112 mm (Relay ®, Bolton Medical España), con acceso aórticoabdominal a través de una prótesis de dacron de 8 mm y un bypass aortofemoral izquierdo posterior (arteria ilíacacomún < 0,7 cm de diámetro). En la arteriografía de control intraoperatoria no se objetivaron imágenes de fuga ni defectosde repleción en la aorta torácica. La angiotomografía postoperatoria confirmó la exclusión del trombo. Se dio de altaa la paciente con tratamiento antiagregante; seis meses después de la intervención se encontraba asintomática. Conclusión.El tratamiento endovascular de estas lesiones constituye una nueva alternativa de tratamiento efectiva y seguray con menores tasas de morbimortalidad perioperatoria

Introduction. Thrombi rarely occur in the thoracic aorta and constitute an important source of embolisms.Endovascular treatment has improved the therapeutic options, which until recently were limited to thromboendarterectomyand/or systemic anticoagulation. Case report. A 52-year-old female smoker, who was referred from another health centrebecause of diffuse abdominal pain, nausea and vomiting; the findings from a computerised tomography scan of theabdomen showed occlusion of the left common iliac artery, bilateral renal infarction and filling defect in the lowerportion of the thoracic aorta. A transthoracic echocardiogram showed a 7 × 23 mm mobile thrombus in the thoracicaorta. Anticoagulation treatment was established in therapeutic doses and magnetic resonance angiography andarteriography were performed. The results of these tests revealed a 3 cm long floating thrombus in the thoracic aorta,which was attached to the atherosclerotic plaque, and occlusion of the left renal and left iliac arteries. Exclusion of the thrombus was performed by deploying a 32 × 112 mm stent (Relay ®, Bolton Medical España) in the thoracic aorta, withabdominal aortic access via an 8 mm Dacron graft and a posterior left aortofemoral bypass (common iliac artery < 0.7 cmin diameter). In the intraoperative control arteriography, no leaks or filling defects were observed in images of thethoracic aorta. The post-operative angiotomography confirmed the exclusion of the thrombus. The patient was dischargedfrom hospital with antiplatelet treatment; six months after the operation she remained asymptomatic. Conclusions. Theendovascular treatment of these lesions represents a new therapeutic alternative that is safe and effective and which haslower perioperative morbidity and mortality rates (AU)

Resultados del tratamiento endovascular en el sector iliaco estratificado según TASC. Pronósticos de fallo / Results of endovascular treatment in the iliac sector as stratified by the tasc. Failure predictions

Introducción. El tratamiento endovascular en el sector iliaco, que comenzó a aplicarse en pacientes de alto riesgo,hoy día puede ser la primera opción terapéutica. Objetivo. Determinar los resultados de la angioplastia transluminalpercutánea en el sector iliaco, con o sin implantación de stent, estratificando el análisis según tipos de lesión TASC-2000 yestimar la influencia de factores pronósticos en la permeabilidad, la salvación de la extremidad y la supervivencia. Pacientesy métodos. Análisis retrospectivo de 101 procedimientos en 91 pacientes, 85/6 hombres/mujeres) con una edad media de61,54 ± 11,59 años. Factores de riesgo: diabetes, 41,6%; hipertensión, 41,6%; tabaquismo, 56,4%; cardiopatía isquémica,19,8%; insuficiencia renal, 9,9%. La indicación fue en 35,7% isquemia crítica y claudicación limitante en 61,4%. Lesión tipoTASC A: 44,6%, B: 42,6%, C: 10,9%, D: 1,98%. Técnica: angioplastia, 35,65% y stent, 64,35%. Todas las variables, métodosde evaluación clínica y hemodinámica se definieron según los criterios de la SVS/ISCVS. Resultados. A los 66 meses,las tasas de permeabilidad primaria fueron del 69,84%, secundaria del 80,64%, salvación de la extremidad del 81,5% y supervivenciadel 93,6%. Resultados precoces: 4 fracasos técnicos, éxito morfológico del 92,1% y clínico del 85,1%. No se registraronfallecimientos ni amputaciones. A los 66 meses, estratificando según TASC, las permeabilidades primarias morfológicasy clínicas, respectivamente, fueron: A: 75,09%, 63,65%; B: 68,07%, 69,66% y secundarias: A: 89,98%, 73,30%; B:81,03%, 83,14%. El factor pronóstico significativo de disminución de permeabilidad primaria fue la localización en iliacaexterna, y para tasas de salvación de extremidad y supervivencia la insuficiencia renal. Actualmente, el tratamiento endoluminaliliaco, gracias a los avances tecnológicos, los excelentes resultados y la baja morbimortalidad, puede ser la primeraalternativa terapéutica para estos pacientes. Conclusiones. El tratamiento endovascular en el sector iliaco es aplicable a estetipo de pacientes, con uso selectivo de stent, obteniendo resultados similares a otras series

Introduction. Endovascular treatment of the iliac sector, which was first applied to high-risk patients, cannow be the preferred therapeutic option today. Aim. To determine the outcomes of percutaneous transluminal angioplastyin the iliac sector, with or without stent placement, the analysis being stratified according to the TASC-2000 typesof lesion. We also sought to estimate the influence of prognostic factors on patency, limb salvage and survival. Patientsand methods. We conducted a retrospective analysis of 101 interventions in 91 patients (85/6 males/females), whosemean age was 61.54 ± 11.59 years. Risk factors: diabetes, 41.6%; hypertension, 41.6%; smoking, 56.4%; ischaemicheart disease, 19.8%; renal failure, 9.9%. The indication was critical ischaemia in 35.7% and limiting claudication in61.4%. TASC A-type lesion: 44.6%, B: 42.6%, C: 10.9%, D: 1.98%. Technique: angioplasty, 35.65% and stent, 64.35%.All the variables, methods of clinical and haemodynamic evaluation, were defined according to SVS/ISCVS criteria.Results. At 66 months, the primary patency rates were 69.84%, secondary rates were 80.64%, limb salvage was 81.5%and survival was 93.6%. Early results: there were 4 technical failures, morphological success was 92.1% and clinicalsuccess was 85.1%. No deaths or amputations were recorded. At 66 months, and stratifying according to the TASC, theprimary morphological and clinical patencies were, respectively: A: 75.09%, 63.65%; B: 68.07%, 69.66% and thesecondary ones were: A: 89.98%, 73.30%; B: 81.03%, 83.14%. The significant prognostic factor for decreased primarypatency was location in the external iliac, and for limb salvage and survival rates it was renal failure. At the presenttime, thanks to the technological advances being made, the excellent outcomes and the low morbidity and mortalityrates, endoluminal iliac treatment can be the preferred therapeutic alternative for these patients. Conclusions. Endovasculartreatment in the iliac sector is applicable in this type of patients, with selective use of stents; the resultsobtained are similar to those in other series

El Proyecto MADAI: un estudio epidemiológico sobre el abordaje y manejo del dolor agudo periquirúrgico / MADAI project: an epidemiologic study about the perioperative pain tnanagetnent and treattnent

Objetivo. Obtener información descriptiva sobre el abordaje y el manejo del paciente con dolor agudo periquirúrgico tratado con analgésicos parenterales en el ámbito hospitalario. Metodología. Estudio epidemiológico, descriptivo, multicéntrico. Pacientes ingresados en los servicios de cirugía general, torácica, cardiovascular, angiología y cirugía vascular, ginecología, traumatología y urología. Resultados. Participaron 76 hospitales distribuidos por las diferentes comunidades autónomas y un total de 439 investigadores. Se evaluaron 1972 pacientes de los que el 43.9% y 25.5%, respectivamente pertenecieron a los servicios de cirugía general y traumatología. El 52.8% de los pacientes tenían más de 60 años, un 31.2 % no presentaron ninguna enfermedad concomitante, el 36.7% padecían hipertensión y un 16.5% diabetes. En el 5.8% de los pacientes se utilizaron escalas para valorar la intensidad del dolor al ingreso. En las sucesivas visitas, este porcentaje oscila entre el 10 % y el 15%. En el postoperatorio, los principales analgésicos administrados son los AINE (sobre todo el metamizol, que utilizan del 63.6% al 40.5% del total de pacientes del estudio) y el paracetamol, que utilizan el 41.3% a las 0-12horas y el 27% el día 4. El porcentaje que recibe medicación de rescate va disminuyendo, desde el primer control (25.7%), al del cuarto día (6%), siendo la medicación más utilizada el paracetamol. Conclusiones. A pesar de que en el ámbito de la cirugía se considera importante el tratamiento del dolor, la utilización de protocolos no es habitual. La elaboración y utilización de guías terapéuticas para el tratamiento del dolor peri quirúrgico podría mejorar el confort del paciente y su recuperación (AU)

Objective. To obtain descriptive information about patient treatment with acute perioperative pain receiving parenteral analgesics in hospital environments. Methodology. Epidetniologic descriptive multicentre study. Patients admitted in the following Surgery services: General, Thoracic, Cardiovascular, Angiology, Gynaecology, Orthopaedic and Urology. Results. Participation of 76 hospitals, distributed along the country; and 439 investigators. 1972 patients were assessed. 43.9% and 25.5% were admitted in General and Orthopaedic surgery services respectively. 52.8% of patients were over 60 years oíd. 31.2% did not present any concomitant illness. 36.78% had arterial hypertension and 16.5% diabetes mellitus. Pain scales to measure pain intensity, were used by 5.8% of patients at admission. In the following visits, these percentages ranged from 10% to 15%. During postoperative period NSAIDs were the most widely used (specially metamizol, administrated from 63.6% to 40.5% of the patients) and acetaminophen which was used by 41.3% of the patients in the first 12 hours and 27% in the 4th day. The percentage of patients that received rescue medication decreases from 25.7 % at first control to 6% at 4th day control; being acetaminophen the most commonly used medication. Conclusions. Despite pain treatment is considered important in surgical environments, treatment protocols are seldom used. The elaboration and the use of therapeutics guidelines for perioperative pain treatment could improve the patient comfort and their recuperation (AU)

Paraganglioma carotídeo familiar / Familiar carotid paraganglioma

Introducción. Los paragangliomas son tumores raros cuya frecuencia oscila entre 1/30.000-100.000 habitantes en la población general, siendo los del cuerpo carotídeo los más frecuentes (60%). Se estima que en el 10-50% de ellos son hereditarios, habiéndose identificado cuatro anomalías genéticas causantes. Presentamos los casos de dos hermanas con paraganglioma debido a mutación en el gen SD (11q23). Casos clínicos. Caso 1: muer de 22 años con tumoración cervical bilateral, diagnosticada con resonancia magnética de paraganglioma carotídeo bilateral (tipo III de Shamblin), más extenso en el lado izquierdo. Caso 2: su hermana de 19 años presentaba paraganglioma carotídeo izquierdo tipo I de Shamblin, diagnosticado tras tomografía computarizada por absceso periamigdalino. La historia familar muestra presencia de paragangliomas en su rama paterna, estando afectados el abuelo, el padre y cinco tíos. El estudio genético demostró una mutación del gen SD (11q23) en todos los afectados, siguiendo un patrón de herencia autosómico dominante con imprintig materno. En el primer caso se decidió tratamiento quirúrgico del paraganglioma izquierdo, requiriendo resección en bloque del tumor de la carótida interna, con interposicón de bypass carótido-carotídeo. En el segundo caso, se realizó exéresis simple del tumor, sin secuelas posquirúrgicas. Conclusiones. El paraganglioma familiar es una patología rara cuya causa genética se ha descrito. La identificación de los genes relacionados con esta entidad en los miembros de familias de alto riesgo, permitiría la detección y tratamiento precoz de estos tumores, reduciendo potencialmente la incidencia de morbimortalidad, la cual se relaciona con el tamaño y extensión del tumor

Introduction. Paragangliomas are rare tumours with an incidence ranging between 1/30.000-100.000 inhabitants in the general population, the most frequent being those affecting the carotid body (60%). Estimates suggest that 10-50% of them are hereditary, and four genetic abnormalities have been identified as causal agents. We report the cases of two sisters with paragangliomas due to a mutation in the SDHD gene (11q23). Case reports. Case 1: a22-year-old female with bilateral cervical tumours, which were diagnosed by means of magnetic resonance imaging as bilateral carotid paragangliomas (Samblin type III); the tumour was larger on the left side. Case 2: the first patient´s 19-years-old sister presented with carotid paraganglioma (Shamblin type I) on the left side; computerised tomography scanning led to a diagnosis of a peritonsillar abscess. There was a family history of paragangliomas in the paternal branch, with the grandfather, father and five uncles all being affected by such tumours. The genetic study proved the existence of a mutation in the SDHD gene (11q23) in all those affected by the condition, which followed an autosomal dominant pattern of inheritance with maternal imprinting. In the first case, surgery was chosen to treat the left paraganglioma, involving resection of the whole tumour and the internal carotid, with no post-surgical sequelae. Conclusions. Familiar paraganglioma is a rare pathology with a genetic causation that has been described. Identifying the genes linked to this condition in members of high-risk families would allow for early detection and treatment of these tumours. This would result in a reduction in the incidence of surgical morbidity and mortality, which is related to the size and extent of the tumour

Hipoplasia de la vena cava inferior asociada a una trombosis venosa profunda de los miembros inferiores / Hypoplasia of the inferior vena cava associated to deep vein thrombosis in the lower limbs

Introducción. Las anomalías congénitas de la vena cava inferior (VCI), como la ausencia o la hipoplasia, sondefectos poco frecuentes resultado de un probable desarrollo aberrante durante la embriogénesis. Estas anomalías parecenfavorecer la estasis venosa y el desarrollo de una trombosis venosa profunda (TVP). Caso clínico. Mujer de 27 añoscon un episodio de TVP hace 10 años, sin alteraciones en el estudio trombofílico. El estudio posterior reveló una hipoplasiadel segmento perirrenal de la VCI con una hipertrofia del sistema ácigos y hemiácigos. La paciente no ha vuelto apresentar nuevos episodios de TVP a pesar de no estar anticoagulada. Conclusiones. La ausencia de VCI es una anomalíacongénita rara, considerada un factor de riesgo importante para el desarrollo de una TVP. Debe sospecharse su existenciaen casos de TVP en personas jóvenes sin otra causa aparente, y deben realizarse pruebas de imagen (tomografíacomputarizada o resonancia magnética) para su diagnóstico. El tratamiento y el pronóstico de estos pacientes no se hanesclarecido todavía

Introduction. Congenital abnormalities of the inferior vena cava (IVC), such as absence or hypoplasia, areinfrequent defects that are probably the result of aberrant development during embryogenesis. These abnormalities seemto favour both venous stasis and the development of deep vein thrombosis (DVT). Case report. A 27-year-old female withan episode of DVT 10 years before, and no alterations in the thrombophilic study. A later study revealed hypoplasia inthe perirenal segment of the IVC with hypertrophy of the azygos and hemiazygos system. The patient has had no newepisodes of DVT despite not being on anticoagulant therapy. Conclusions. The absence of IVC is a rare congenitalanomaly, and is considered to be an important risk factor for developing DVT. Its existence should be suspected in casesof DVT in young people where there is no other apparent cause; imaging tests (computerised axial tomography ormagnetic resonance) must be performed to be able to diagnose it. The treatment and prognosis of these patients are stilllargely unknown

Direct association between C-reactive protein serum levels and endothelial dysfunction in patients with claudication.

OBJECTIVES: To evaluate the relationship between C-Reactive Protein (hsCRP), a serum marker of inflammation, and endothelial dysfunction in patients with intermittent claudication. DESIGN, PATIENTS AND METHODS: Cross-sectional study with stratified sampling on dependent variables of age, genre, hypertension, hyperlipidemia, diabetes, smoking status and ankle-brachial index (ABI) to select 156 patients from a target population of 4,100 patients with claudication. We assessed the flow-mediated arterial dilation (FMAD) as a reporter of endothelial function and plasma levels of hsCRP and fibrinogen. RESULTS: Patients with a FMAD<3% (range for the lowest 5% of healthy subjects) had increased levels of plasma hsCRP (6.3 vs 2.3mg/L; p<0.05) and fibrinogen (351vs 302mg/L; p<0.05) in comparison to those with FMAD>3%. There was a negative correlation between hsCRP and FMAD(r=-0.465; p<0.05). CONCLUSION: Impaired endothelial dysfunction is association with increased plasma concentrations of inflammatory markers, and both may have a role in the aetiopathogenesis of peripheral arterial disease.

¿Cuál es el momento idóneo para la medición por ultrasonidos de la dilatación braquial mediada por flujo? / What is the ideal moment for ultrasound measurement of brachial artery flow-mediated dilation?

Introducción y objetivo. Las guías técnicas de medición de la dilatación braquial mediada por flujo (DBMF) recomiendan su medida en diástole para evitar la influencia de la distensibilidad (complianza) arterial en los resultados. Sin embargo, no existen estudios que corroboren esta hipótesis, por lo que éste es el objetivo primordial de nuestro trabajo. Sujetos y métodos. Se reclutaron dos grupos de sujetos con estos criterios: grupo I, sujetos sanos con índice tobillo/brazo (ITB) > 0,9 y menores de 30 años, y grupo II, pacientes con arteriopatía periférica sintomática definida por un ITB < 0,9. Se les realizó la medición de la dilatación de la arteria braquial mediada por flujo (DBMF) en el brazo derecho en sístole (S) y diástole (D). Se midió en el mismo acto el ITB y se recogieron los factores de riesgo y los tratamientos. Además, se determinó la dilatación mediada por flujo en ambas arterias femorales (DFMF). Resultados. Se reclutaron 36 y 33 sujetos de los grupos I y II, respectivamente. Se compararon los valores de dilatación en S y D y se representaron como grupo: S / D (valor p). DBMF: I + II: 8,1 ± 4,6% / 7,6 ± 4,9% (p = 0,3); I: 10,8 ± 2,9% / 9,9 ± 3,8% (p = 0,055); II: 5,2 ± 4,3% / 5,16 ± 4,8% (p = 0,3). DFMF: I + II: 3,13 ± 3,6% / 2,8 ± 3,6% (p = 0,35); I: 5,3 ± 2,9% / 4,8 ± 2,6% (p = 0,02); II: 0,6 ± 2,5% / 0,6 ± 3,4% (p = 0,9). Conclusiones. Si se asume la influencia de la complianza en la dilatación arterial, se observa que la dilatación mediada por flujo en sístole es superior a la diastólica en los sujetos sanos, mientras que en los enfermos esta diferencia es prácticamente inexistente. Aunque la diferencia en la arteria braquial de sujetos sanos no llega a la significación (p = 0,055), sí que lo hace en la femoral (p = 0,02), por lo que, al valorar los datos en conjunto, recomendamos utilizar la medición en diástole para evitar sesgos a la hora de realizar comparaciones entre sanos y enfermos

Introduction and aims. The technical guides to measuring the brachial artery flow-mediated dilation (BFMD) recommend that it should be measured in the diastolic phase in order to prevent results from being influenced by arterial distensibility (compliance). No studies have been conducted, however, to confirm this hypothesis and this is therefore the main purpose of our research. Subjects and methods. Two groups of subjects were recruited on the basis of the following criteria: group I, healthy subjects with an ankle-brachial index (ABI) > 0.9 and below 30 years of age, and group II, composed of patients with symptomatic peripheral arterial disease that was defined by an ABI < 0.9. Brachial artery flow-mediated dilation was measured in the right arm in both the systolic (S) and diastolic (D) phases. The ABI was measured at the same time and the risk factors and treatments were collected. Flow-mediated dilation was also determined in both femoral arteries (FFMD). Results. Groups I and II consisted of 36 and 33 subjects respectively. The dilation values in the S and D phases were compared and represented as a group: S / D (value p). BFMD: I + II: 8.1 ± 4.6% / 7.6 ± 4.9% (p = 0.3); I: 10.8 ± 2.9% / 9.9 ± 3.8% (p = 0.055); II: 5.2 ± 4.3% / 5.16 ± 4.8% (p = 0.3). FFMD: I + II: 3.13 ± 3.6% / 2.8 ± 3.6% (p = 0.35); I: 5.3 ± 2.9% / 4.8 ± 2.6% (p = 0.02); II: 0.6 ± 2.5% / 0.6 ± 3.4% (p = 0.9). Conclusions. If it is assumed that compliance influences arterial dilation, systolic flow-mediated dilation is seen to be higher than in the diastolic phase in healthy subjects, whereas this difference is practically inexistent in patients. Although the difference in the brachial artery of healthy subjects does not reach significance (p = 0.055), it does in the femoral artery (p = 0.02). Therefore, on appraising the data as a whole, we recommend measurement in the diastolic phase in order to avoid the occurrence of biases when comparing between healthy and sick subject

De todos ellos ¿quiénes son los autores?, ¿cuál fue su contribución? / Out of all those people... who are the authors?, what contribution did they make?

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Tratamiento endovascular de la arteria femoral superficial / No disponible

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Tratamiento endovascular de la patología arterial de los miembros inferiores / Endovascular treatment of arterial pathologies in the lower limbs

Introducción. La cirugía endovascular presenta un rápido desarrollo en todos los territorios, igualando e incluso mejorando los resultados de la cirugía convencional. Sin embargo, en los miembros inferiores todavía no se han alcanzado los niveles de seguridad y permeabilidad de otros territorios. Objetivo. Realizar una puesta al día de los procedimientos endovasculares aplicables en el sector femoral poplíteo y distal. Desarrollo. Nueve cirujanos vasculares con experiencia en terapéutica endoluminal han redactado este documento. En este trabajo se muestran desde los avances en los métodos diagnósticos, hasta los resultados y costes. Iniciamos esta guía con unas breves notas acerca de la biomecánica de la arteria femoral superficial. Cerramos esta monografía con dos capítulos dedicados al tratamiento endovascular del aneurisma poplíteo y pseudoaneurismas. Hemos intentado redactar un documento útil y práctico, siguiendo las directrices del Capítulo de Cirugía Endovascular de la Sociedad Española de Angiología y Cirugía Vascular. Al final de cada capítulo se ha incluido un apartado de recomendaciones basado en niveles de evidencia. Conclusiones. Este campo de la terapéutica vascular está teniendo un desarrollo veloz y cambiante. La intención de hacer una puesta al día sin duda queda desfasada en pocas semanas. Podría afirmarse que la mejor técnica sería la disponible ‘en nuestro medio’y según ‘nuestra experiencia, que aplicada para un ‘paciente individual’, logre la mayor duración con la menor morbimortalidad posible; y que en caso de fallo, pueda ser repetible o haya alternativas terapéuticas

Introduction. Endovascular surgery is developing quickly in all territories and the results being achieved are similar to, or even better than, those offered by conventional surgery. Yet, the levels of safety and patency of other territories have still not been attained in the lower limbs. Aim. To update our knowledge of the endovascular procedures that can be applied in the popliteal and distal femoral segment. Development. This article has been written by nine vascular surgeons with experience in endoluminal therapy and covers aspects ranging from the advances in the diagnostic methods to the outcomes and costs. We begin this guide with a few brief words about the biomechanics of the superficial femoral artery. The monograph ends with two chapters devoted to the endovascular treatment of popliteal aneurysms and pseudoaneurysms. We have tried to draw up a document that is both useful and practical, following the guidelines of the Endovascular Surgery Chapter of the Spanish Society of Angiology and Vascular Surgery. At the end of each chapter we have included a section offering recommendations based on levels of evidence. Conclusions. This field of vascular therapy is developing in a changeable and very swift manner. What we intend to offer as an update will undoubtedly become somewhat obsolete in a few weeks. As a final conclusion we could say that the best technique is the one that we have available ‘in our area’ and which, according our experience, when applied to an ‘individual patient’ achieves the greatest durability with the lowest possible morbidity and mortality rates: at the same time, in case of failure, it can be repeated or there exist therapeutic alternatives

Tratamiento endovascular de la coartación aórtica / Endovascular treatment of aortic coarctation

Introducción. El defecto congénito de la coartación de la aorta torácica se presenta en 1:10.000 habitantes, frecuentemente asociado a otros defectos congénitos del desarrollo cardíaco. Habitualmente se detecta y se repara en la infancia, y ocasionalmente se diagnostica en la adolescencia y la edad adulta, de novo o como complicación en la evolución de reparaciones previas (pseudoaneurismas, reestenosis, etc.). Estos pacientes requieren de intervenciones correctoras que se acompañan de una morbimortalidad significativa. La alternativa a ellas se ha desarrollado en los últimos años mediante técnicas endovasculares. Objetivo. Exponer el estado actual de la práctica clínica en el tratamiento endovascular de la coartación de la aorta torácica mediante angioplastia simple y angioplastia con stent. Desarrollo. Se discute la indicación de angioplastia en los niños menores de 3 años. La utilización de stents está limitada en la edad infantil por el desarrollo incompleto del niño. Puede ser el tratamiento de elección en el adolescente y el adulto, incluso mediante stent primario. Conclusión. Las reintervenciones con técnica endovascular de las reestenosis y las endoprótesis cubiertas para el tratamiento de los aneurismas poscoartación y de los pseudoaneurismas poscirugía ofrecen resultados satisfactorios

Introduction. Coarctation of the thoracic aorta presents as a connatal defect in 1:10,000 inhabitants, and is frequently associated to other congenital anomalies affecting the development of the heart. It is usually detected and repaired in infancy, but may be diagnosed during adolescence and in adulthood, either de novo or as a complication in the progress of previous repairs (pseudoaneurysms, restenosis, etc.). These patients require remedial interventions that are accompanied by a significant morbidity and mortality rate. An alternative to such procedures has been developed in recent years using endovascular techniques. Aim. To report the current state of the art of clinical practice in the endovascular treatment of coarctation of the thoracic aorta by means of simple stent angioplasty. Development. The indication for angioplasty in children under 3 years of age is discussed. The use of stents is limited in childhood because the child’s development is still incomplete. It can be the preferred treatment in adolescents and adults, even with the use of a primary stent. Conclusions. Reinterventions with endovascular techniques to treat restenosis and covered stents for the treatment of post-coarctation aneurysms and post-surgery pseudoaneurysms offer satisfactory results

Clínicas del pie diabético / The clinical features of diabetic foot

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