Psoas muscle analysis as a surrogate marker of sarcopenia and frailty: A multicenter analysis of predictive capacities over short- and long-term outcomes after abdominal aortic aneurysm repair.

OBJECTIVES: Several predictive models exist for estimating the postoperative risks of abdominal aortic aneurysm (AAA) repair, although no particular tool has seen widespread use. We present the results of a multicenter, historic cohort study comparing the predictive capacity of the psoas muscle area (PMA), radiodensity (PMD), and lean muscle area (LMA) as surrogate markers of sarcopenia, over short- and long-term outcomes after AAA repair, compared to the mFI-5 and American Society of Anesthesiologists (ASA) scales. METHODS: Retrospective review was conducted of all consecutive AAA elective repair cases (open or endovascular) in three tertiary-care centers from 2014 to 2019. Cross-sectional PMA, PMD, and LMA at the mid-body of the L3 vertebra were measured by two independent operators in the preoperative computed tomography. Receiver operating characteristic (ROC) curves were used to determine optimal cutoff values. Bivariate analysis, logistic regression, and Cox's proportional hazards models were built to examine the relationship between baseline variables and postoperative mortality, long-term mortality, and complications. RESULTS: 596 patients were included (mean age 72.7 ± 8 years, 95.1% male, 66.9% EVAR). Perioperative mortality was 2.3% (EVAR 1.2% vs open repair 4.6%, p = .015), and no independent predictors could be identified in the multivariate analysis. Conversely, an age over 74 years old (OR 1.84 95%CI 1.25-2.70), previous heart diseases (OR 1.62 95%CI 1.13-2.32), diabetes mellitus (OR 1.61 95%CI 1.13-2.32), and a PMD value over 66 HU (OR 0.58 95%CI 0.39-0.84) acted as independent predictors of long-term mortality in the Cox's proportional hazards model. Heart diseases (congestive heart failure or coronary artery disease), serum creatinine levels over 1.05 mg/dL, and an aneurysm diameter over 60 mm were independent predictors of major complications. CONCLUSION: Surrogate markers of sarcopenia had a poor predictive profile for postoperative mortality after AAA repair in our sample. However, PMD stood out as an independent predictor of long-term mortality. This finding can guide future research and should be confirmed in larger datasets.

Preoperative predictive factors for type II endoleak: Trying to define high-risk patients.

OBJECTIVE: Type 2 endoleaks (T2E) continue to be the "Achilles Heel" of endovascular aneurysm repair (EVAR). The aim of this study is to analyze preoperative factors of patients who underwent EVAR to define risk factors for T2E. METHODS: From January 2015 to June 2020, 140 of 191 patients who underwent EVAR in our institution meet inclusion criteria for this study. Postoperative image control were performed using duplex ultrasound or CT scan. All T2E detected during follow-up were confirmed by angio CT. Preoperative anatomic and clinical variables were analyzed for T2E using t-test, Mann-Whitney U test and Fisher exact test. ROC curves and the corresponding area under the curve (AUC) were used to describe the predictive accuracy for endoleak. RESULTS: T2E was detected in 16 patients (11.43%)0.12 of them (75%) were persistent and 10 (62.5%) provoked sac enlargement. Predictive factors for T2E were a greater IMA diameter (2.5 ± 0.5 vs. 3.3 ± 0.5, p < 0.001) and an increasing number of LA (4.8 ± 1.6 vs. 6.7 ± 1.4, p < 0.001). ROC curve analysis stablished thresholds of 3.5 mm for IMA diameter (sensitivity 77%, specificity 86%) and 5.5 for patent LA (sensitivity 88%, specificity 59%) as risk factor to develop T2E. CONCLUSIONS: Preoperative aortic side branches embolization to avoid T2E is not still standarised. We tried to define a group of high-risk patients for T2E. According to our findings, patients with a preoperative IMA> 3 mm and more than 5 patent LA should be considered for pre-EVAR embolization.

Symptomatic Aortic Arch Floating Thrombus In A Patient With "Bovine Arch".

Bovine arch is an aortic arch variant in which the left common carotid artery and the brachiocephalic trunk share the same origin. Several vascular pathologies, as aneurysm, dissection or strokes have an increased prevalence in patients with this anatomic variant. We describe the first reported case of a young patient with a symptomatic aortic arch floating thrombus in association with a bovine arch.

¿Deberían las sociedades profesionales abstenerse de la autoría de las guías clínicas? / Should abstain professional societies from authorship of guidelines?

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Escala Anarcyl (aneurisma de aorta roto de Castilla y León) de predicción de mortalidad de aneurisma de abdominal roto / Anarcyl scale (ruptured aortic aneurysms Castilla y León) for predicting mortality in ruptured abdominal aortic aneurysms

INTRODUCCIÓN: el aneurisma de aorta abdominal roto (AAAr), a pesar de los avances diagnósticos y terapéuticos, continúa presentando una elevada mortalidad. Aunque la reparación endovascular (EVAR) incrementa el número de pacientes a los que se le ofrece tratamiento quirúrgico, no se encuentra exento de complicaciones. OBJETIVO: diseñar una escala de riesgo preoperatorio para los pacientes con AAAr intervenidos mediante EVAR. MATERIAL Y MÉTODOS: estudio prospectivo de 34 pacientes intervenidos mediante EVAR de AAAr en Castilla y León entre junio de 2016 y junio de 2019. Se recogieron variables de comorbilidad, preoperatorias de estabilidad hemodinámica y analítica al ingreso, así como de morbimortalidad intrahospitalaria. RESULTADOS: la mortalidad intrahospitalaria fue del 52,9%. El estudio univariante obtuvo como factores pronósticos de mortalidad la frecuencia cardíaca, la hemoglobina, la creatinina, el sodio, la GOT, la LDH y la troponina T ultrasensible. Tras la realización del estudio multivariante, resultaron significativas la frecuencia cardíaca (p = 0,011), la hemoglobina (p = 0,035) y la creatinina (p = 0,019). La escala resultante ofreció la siguiente fórmula de mortalidad: 0,440 + 0,560 (si hemoglobina < 7 mg/dl) + 0,169 (si frecuencia cardíaca < 70 latidos/min) + 0,084 (si creatinina > 2,8 mg/dl). El área bajo la curva del presente modelo asciende a 0,870 (Fig. 1). Una puntuación ≤ 0,440 se asoció con una mortalidad del 39,1%; una puntuación entre 0,441-0,644, con el 66,7%, y del 100%, si ≥ 0,644. CONCLUSIÓN: la frecuencia cardíaca al ingreso y los niveles analíticos de hemoglobina y creatinina constituyen factores predictores de mortalidad intrahospitalaria en pacientes con AAAr tratados mediante exclusión endovascular. La aplicación de la escala propuesta en el presente estudio permite conocer a los pacientes que no se beneficiarían del tratamiento quirúrgico endovascular del AAAr

INTRODUCTION: the ruptured abdominal aortic aneurysm (AAAr), despite diagnostic and therapeutic advances, continues to present a high mortality. Although endovascular repair (EVAR) increases the number of patients who are offered surgical treatment, it is not without complications.OBJECTIVE: design a preoperative risk scale for patients with AAAr treated by EVAR.MATERIAL AND METHODS: prospective study of 34 patients undergoing EVAR of AAAr in Castilla y León between June 2016 and June 2019. Comorbidities, preoperative variables of hemodynamic stability, analytical at admission, as well as in-hospital morbidity and mortality were collected. RESULTS: in-hospital mortality was 52.9%. The univariate predictors obtained were heart rate, hemoglobin, creatinine, sodium, GOT, LDH and ultrasensitive troponin T as prognostic factors. After completing the multivariate analysis, heart rate (p = 0.011), hemoglobin (p = 0.035) and creatinine (p = 0.019) were statistically different between the groups. The scale resulting from the following mortality formula: 0.440 + 0.560 (if hemoglobin < 7 mg/dl) + 0.169 (if heart rate < 70 beats/min) + 0.084 (if creatinine > 2.8). This model obtained an area under the curve of 0.870 (Fig. 1). A score < 0.440 is associated with a mortality of 39.1%, a score between 0.441-0.644 with 66.7% and 100% if > 0.644. CONCLUSION: the heart rate at admission and the analytical levels of hemoglobin and creatinine, are predictive factors of in-hospital mortality in patients with AAAr treated with endovascular exclusion. The application of the proposed scale allows the detection of patients who would not benefit from the endovascular surgical treatment of AAAr

¿Réquiem por la cirugía vascular? / Requiem for vascular surgery?

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Angioleiomiosarcoma de la arteria carótida / Angioleiomyosarcoma of the carotid artery

Introducción. Las neoplasias de la cabeza y el cuello pueden invadir los vasos cervicales. La mayoría son del área otorrinolaringológica y, excepcionalmente, de partes blandas. El tratamiento incluye su extirpación con resección y reconstrucción vascular. Se presenta un caso de angioleiomiosarcoma carotídeo. Caso clínico. Mujer de 48 años con tumoración laterocervical derecha de consistencia sólida y dura y de crecimiento progresivo, adherida al tiroides, que desplaza el paquete vasculonervioso del cuello y comprime la vena yugular interna. En una primera intervención se extirpa un tumor encapsulado que se extiende desde el espacio retroclavicular hasta el ángulo mandibular; dicho tumor se considera un angioleiomioma. Tres años más tarde se produce una recidiva tumoral, y la paciente es intervenida de nuevo, pues es necesario seccionar la arteria carótida primitiva infiltrada y realizar una anastomosis terminoterminal (con la colaboración del Servicio de Cirugía Vascular). La biopsia revela un nuevo angioleiomioma con un aumento del índice mitótico. Un año después la paciente presenta una gigantesca masa cervical y es de nuevo intervenida conjuntamente por el Servicio de Cirugía Maxilofacial y el Servicio de Cirugía Vascular. Debido al englobamiento carotídeo, se reseca en bloque toda la lesión con la interposición de un injerto de dacron terminoterminal desde la arteria carótida primitiva proximal hasta la bifurcación carotídea. El informe anatomopatológico comunica angioleiomiosarcoma. Conclusión. La colaboración de especialistas en cirugía vascular en intervenciones complejas de tumores cervicales puede permitir resecciones más amplias seguidas de reconstrucción vascular, y evitar así recidivas y mejorar el pronóstico

Introduction. Neoplasias of the head and neck can lead to invasion of the cervical vessels. Most of these occur in the ORL area and are, exceptionally, soft tissue tumours. Treatment involves removal with resection and vascular reconstruction. We report a case of carotid angioleiomyosarcoma. Case report. A 48-year-old female with a slow-growing, hard, solid tumour on the right side of the neck which was attached to the thyroid gland and displaced the neurovascular bundle of the neck and compressed the internal jugular vein. In the first intervention an encapsulated tumour that ran from the retroclavicular space to the mandibular angle was removed; this tumour was considered to be an angioleiomyoma. Three years later, a tumour reappeared, and the patient was submitted to surgery again, since it was necessary to perform the section of the primitive carotid artery under anaesthesia and also an end-to-end anastomosis (with the collaboration of the Vascular Surgery Service). A biopsy study revealed a new angioleiomyoma with an increased mitotic index. A year later the patient presented with a huge cervical mass and was newly submitted to surgery carried out by a joint team from the Maxillofacial Surgery and the Vascular Surgery Services. Due to the carotid ballooning, the whole lesion was excised and an end-to-end dacron graft was placed from the proximal primitive carotid artery to the carotid bifurcation. Pathological report: angioleiomyosarcoma. Conclusions. The collaboration between specialists in vascular surgery in complex procedures carried out to treat cervical tumours can make it possible to perform wider resections followed by vascular reconstruction, thus preventing recurrences and improve the patient’s prognosis

Tumores del glomus carotídeo: estudio de 11 años / Carotid glomus tumours: an 11-year study

Introducción. Los tumores del glomus carotídeo son lesiones de crecimiento lento, hipervascularizados, infrecuentes, derivados de células paraganglionares de la cresta neural y que representan casi la mitad de todos los paragangliomas. Objetivo. Estudio retrospectivo de los tumores del glomus carotídeo tratados en nuestro servicio en los últimos 11 años. Pacientes y métodos. Siete casos en seis pacientes (uno bilateral). Edad media: 68 años (59-93 años). Dos hombres y cuatro mujeres. La forma de presentación más común fue una masa cervical pulsátil. Ningún paciente refería antecedentes familiares de paragangliomas. Se descartó enfermedad diseminada en todos los casos. Diagnóstico mediante angio-TAC (tomografía axial computarizada) y angiografía en todos los casos. Seis casos intervenidos (uno bilateral), mediante abordaje cervical y extirpación completa (resección subadventicial). En los tres últimos casos se practicó embolización preoperatoria. Ningún caso requirió reconstrucción vascular. Un caso no se intervino debido a la edad avanzada de la paciente. Resultados. Según los criterios de clasificación de Shamblin, un caso era de tipo III, tres de tipo II y dos de tipo I. Tamaño medio: 2,8 cm (1-4 cm). Ningún caso presentó criterios de malignidad. Las determinaciones de catecolaminas fueron normales. No hubo eventos cerebrovasculares intraoperatorios ni postoperatorios. Complicaciones menores: una disfonía leve y un granuloma con una fístula cutánea resuelta. En el seguimiento, dos pacientes han fallecido por causas independientes al paraganglioma; el resto permanece asintomático. Conclusiones. A pesar de la baja incidencia de los paragangliomas carotídeos, es una patología de indicación quirúrgica, que debe ser tratada por cirujanos vasculares, a fin de proporcionar altas tasas de curación y baja morbimortalidad

INTRODUCTION. Carotid glomus tumours are rare, slow-growing, hypervascularised lesions that derive from the paraganglionic cells of the neural crest and account for almost half of all paragangliomas. AIM. We conducted a retrospective study of the carotid glomus tumours treated in our service over the past 11 years. PATIENTS AND METHODS. The study involved seven cases in six patients (one was bilateral). Mean age: 68 years (59-93 years). Two males and four females. The most common form of presentation was a pulsatile mass in the neck. None of the patients had a history of paragangliomas in the family. Disseminated disease was precluded in all cases. All cases were diagnosed using angiography-CAT (computerised axial tomography) and angiography. Surgery was performed in six cases (one bilateral) and involved a cervical approach and complete removal (subadventitial resection). Pre-operative embolisation was carried out in the last three cases. None of the cases required vascular reconstruction. One case was not submitted to surgery due to the advanced age of the patient. RESULTS. According to the Shamblin classification criteria, one case was type III, three were type II and two were type I. Mean size: 2.8 cm (1-4 cm). None of the cases met malignancy criteria. Tests for catecholamines were normal. There were no intraoperative or post-operative cerebrovascular events. Minor complications: a mild dysphonia and a granuloma with resolved cutaneous fistula. In the follow-up two patients died due to causes that were not related to the paraganglioma; the others remained asymptomatic. CONCLUSIONS. Despite the low incidence of carotid paragangliomas, it is a pathology that requires surgery and must be treated by vascular surgeons in order to ensure high cure rates and low morbidity and mortality rates

Extirpación de sarcoma fibromixoide de bajo grado con resección y reconstrucción de arteria femoral / Surgical excision of a low-grade fibromyxoid sarcoma with resection and reconstruction of the femoral artery

Introducción. El sarcoma fibromixoide de bajo grado (SFMBJ) es un sarcoma de partes blandas caracterizado por una histología aparentemente benigna y un curso clínico indolente y maligno, como consecuencia del desarrollo de recurrencias locales y metástasis a distancia. La cirugía constituye el tratamiento de elección. Caso clínico. Varón de 17 años que presenta tumoración indolora en ingle derecha de 3 meses de evolución. En la primera exploración se aprecia un nódulo duro y fijo en ingle derecha, que con angio-RM se encuentra por delante de los vasos femorales. La punción aspirativa con aguja fina (PAAF) es compatible con tumor mesenquimal benigno, por lo que se opta por un tratamiento conservador. Tres años después, la masa experimenta un crecimiento rápido. Una segunda PAAF emite el diagnóstico de tumor mesenquimal, mixoide y fusocelular de baja agresividad. Los estudios de imagen revelan que el tumor afecta a la arteria femoral común derecha. Para la resección completa se necesita extraer en bloque el tumor con la arteria femoral y su bifurcación, con la interposición de un injerto de vena safena. El estudio anatomopatológico establece el diagnóstico de SFMBJ. Al existir infiltración tumoral de los bordes quirúrgicos, el paciente recibe radioterapia local externa. Conclusión. Tras 6 años de control clínico, el injerto vascular está permeable y no existen indicios de recidiva tumoral, ni local ni a distancia

INTRODUCTION. Low-grade fibromyxoid sarcoma (LGFMS) is a sarcoma affecting soft tissues that is characterised by apparently benign histological features and an indolent, malign clinical course resulting from the development of local recurrences and distant metastasis. Surgery is the referred treatment. CASE REPORT. We report the case of a 17-year-old male who had had a painless tumour in the right-hand side of the groin for 3 months. An initial exploration revealed a hard, fixed nodule in the right groin, which MR-angiography showed to be lying in front of the femoral vessels. Fine needle aspiration (FNA) is compatible with benign mesenchymal tumours, and conservative treatment was therefore chosen. Three years later, the mass began to grow quickly. A second FNA provided a diagnosis of a mesenchymal, myxoid, spindle-cell tumour with a low level of aggressiveness. Imaging studies revealed that the tumour affected the right common femoral artery. To perform the complete resection, the whole tumour had to be extracted in one piece along with the femoral artery and its bifurcation, and placement of a saphenous vein graft was carried out. A pathological study confirmed the diagnosis of LGFMS. Because the tumour had infiltrated into the surgical margins, the patient was submitted to local external radiotherapy. CONCLUSIONS. After 6 years of clinical control, the vascular graft remains patent and there are no signs of recurrence of the tumour, either locally or at a distance

Trombosis venosa y cáncer oculto / Venous thrombosis and occult cancer

Objetivo. Búsqueda selectiva de cáncer oculto en pacientes ingresados por diagnóstico de trombosis venosa. Pacientes y métodos. Estudio retrospectivo de la aplicación de un protocolo diagnóstico consistente en ecografía abdominal y marcadores tumorales Ca 19,9 y PSA a 46 pacientes, entre 75 ingresados por trombosis venosa durante el año 1998, excluyendo las neoplasias ya conocidas, los mayores de 80 años y los postoperados recientes. Resultados. La ecografía abdominal indicó sospecha de cáncer en cinco ocasiones de los 46 estudios (10,8 por ciento); Ca 19,9 elevado, en dos ocasiones (4,3 por ciento); PSA elevado, en cuatro ocasiones (8,6 por ciento), y muy elevado, en dos ocasiones (4,3 por ciento). Se confirmó el diagnóstico de seis cánceres ocultos, que corresponde al 13,04 por ciento de los estudiados con el protocolo y al 8 por ciento del total de 75 pacientes ingresados por trombosis venosa. Conclusiones. La búsqueda selectiva de cáncer oculto, a través del protocolo diagnóstico referido, en pacientes con trombosis venosa ha permitido diagnosticar neoplasias que hubieran pasado desapercibidas. Creemos que nuestros resultados justifican el empleo sistemático de este protocolo con la selectividad indicada (AU)