Safety and efficacy of therapeutic angiogenesis as a novel treatment in patients with critical limb ischemia.

BACKGROUND: In some patients with critical limb ischemia (CLI) the possibility of revascularizing treatment does not exist. In this case therapeutic angiogenesis (TA) using autologous endothelial progenitor cell (EPC) transplantation could be an alternative. The objective of our study was to evaluate the safety and efficacy of TA using EPC. METHODS: Twenty-eight patients with CLI who were not candidates for surgical or endovascular revascularization were included in a prospective study. To mobilize EPCs from the bone marrow, granulocyte colony-stimulating growth factor was injected subcutaneously at doses of 5 microg/kg/day for 5 days. Apheresis was performed, obtaining 50 mL of blood with a high rate of EPCs (CD34(+) and CD133(+) cells were counted). EPCs were implanted in the ischemic limb by intramuscular injections. Primary end points were the safety and feasibility of the procedure and limb salvage rate for amputation at 12 months. Other variables studied were improvement in rest pain, healing of ulcers, ankle-brachial pressure index (ABI), and digital plethysmography. All procedures were done pretreatment and every 3 months for a year on average. Postransplantation arteriography was done in selected cases. RESULTS: No adverse effects were observed. Mean follow-up was 14 months. Before treatment, mean basal ABI was 0.35+/-0.2 and at 18 months postimplantation, 0.72+/-0.51 (p=0.009). There was a mean decrease of five points in pain scale: basal 8.7+/-1, after TA 3.8+/-2.9 (p=0.01). Seven patients required major amputation. Kaplan-Meier analysis revealed a limb salvage rate of 74.4% after 1 year. CONCLUSION: Implantation of EPCs in CLI is a safe alternative, improves tissue perfusion, and obtains high amputation-free rates. Nevertheless, this is a small cohort and results should be tested with long randomized trials.

Fístula humerohumeral como técnica de recurso en pacientes sin patrimonio venoso superficial / Brachiobrachial fistula as a last-resort technique in patients with no surface venous pool

Introducción. El constante incremento de la población renal crónica junto con su mayor supervivencia nosobliga a optimizar el patrimonio venoso para la realización de accesos vasculares autólogos, pues éstos presentan unamenor tasa de complicaciones y una mayor permeabilidad que los protésicos. Casos clínicos. Presentamos dos pacientescon insuficiencia renal crónica terminal en hemodiálisis, con múltiples antecedentes de fístulas arteriovenosas (FAV) antólogas,todas ellas trombosadas, que no presentaban un patrimonio venoso superficial válido para realizar nuevos accesosautológos. A ambos se les realizó una FAV humerohumeral con superficialización venosa y mostraron una buenapermeabilidad del acceso, lo que fue útil para poder proseguir con sus sesiones de diálisis periódicas, de manera que sepudo demorar la realización de un acceso vascular protésico. No hubo ninguna complicación relacionada con la técnicaquirúrgica ni para la canulación de ésta. Conclusión. A través de estos dos casos describimos esta técnica quirúrgica yla planteamos como una posible alternativa en aquellos pacientes que no presentan un patrimonio venoso superficial apto.En un futuro esta técnica puede llegar a formar parte del algoritmo de manejo de los pacientes con insuficiencia renalcrónica terminal que precisan la realización de un acceso vascular

Introduction. The steady increase in the population suffering from chronic renal failure together with longersurvival times means that it is necessary to optimise the venous pool for performing autologous vascular accesses, sincethese offer a lower rate of complications and greater patency than prosthetic accesses. Case reports. We report the casesof two patients with terminal chronic renal failure on haemodialysis who did not present a valid superficial venous poolfor performing new autologous accesses; both patients had a history of numerous antologous arteriovenous fistulas(AVF), all of which had thrombosed. Brachiobrachial AVF with venous superficialisation was performed and patency ofthe access was seen to be good in both cases. This was useful in enabling them to continue with their periodical dialysissessions and made it possible to delay having to create a prosthetic vascular access. There were no complicationsrelated to the surgical technique or to the cannulation that was carried out. Conclusions. This surgical procedure isdescribed through these two cases and we suggest it as a possible alternative in patients who do not have a suitablesuperficial venous pool. In the future this technique may become part of the management algorithm for patients withterminal chronic renal failure in whom it is necessary to carry out a vascular access

Valor pronóstico de la escala de Glasgow en aneurismas de aorta abdominal infrarrenal rotos / The prognostic value of the Glasgow scale in ruptured aneurysms in the infrarenal abdominal aorta

Introducción.La mortalidad del aneurisma dea orta abdominal roto (AAAr) intervenido varía en 26-62%, dependiendo del estado clínico del paciente previo a la cirugía. Objetivos. Aplicar la escala de Glasgow en pacientes invervenidos de AAAr, y utilizarla como herramienta pronóstica para determiancar la mortalidad perioperatoria y observar cómo se modificaría la indicación de cirugía para estos pacientes. Pacientes y métodos. Estudio retrospectivo de 103 pacientes intervenidos entre 1996 y 2007 de AAAr. Valoración mediante la escala de Glasgow del estadio clínico preoperatorio. Se obtuvieron las curvas ROC (punto de corte y área bajo la curva) y se compararon los grupos, establecidos según el punto de corte, mediante test de chi al cuadrado. Se determinó la sensibilidad, especificidad, valor pronóstico y positivo (VPP) y negativo (VPN) para el punto de corte. Se aplicó un estudio multivariable para los datos estudiados y se realizaron tablas de supervivencia de Kaplan-Meier. Resultados. Las frecuencias de presentación de las variables de Glasgow fueron: shock 71,8%, cardiopatía 34%, neuropatía 7,8% y nefropatía 36,9%. La mortalidad perioperatoria fue del 49,5% (n=51). El área bajo la curva estimada es 0,814 (intervalo de confianza, IC 95%: 0,725-0,883) y el putno de corte es 106 puntos (sensibilidad 45,1%, especificidad 94,2%; VPP: 88,5%; VPN: 63,6%). La mortalidad por encima y debajo del punto de corte fue del 88,5 y 36,4%, respectivamente (p<0,001; odds ratio: 13,4; IC 95%: 3,6-48,7). Por encima de 111 puntos la mortalidad fue del 100%. Conclusión. La escala de riesgo de Glasgow es una buena herramienta pronóstica de mortalidad en pacientes con AAAr, con la que se obtiene un punto de corte preciso a partir del cual la mortalidad se incrementa de forma significativa, pudiendo, de esta forma, realizar una mejor indicación de cirugía para este grupo de pacientes

Introduction. Mortality in cases of ruptured abdominal aortic aneurysm (rAAA) submitted to surgery ranges between 26-62%, depending on the clinical status of the patient before the operation. Aims. To apply the Glasgow scale in patients who underwent surgery for rAAA and to use it as a prognostic tool to determine the perioperative mortality rate and to observe how the indication for surgery wouyld be modified for these patients. Patients and methods. We conducted a retrospective study of 103 patients submitted to surgery for rAAA between 1996 and 2007. The preoperative clinical status was evaluated by means of the Glasgow scale. The ROC curves (cutt-off point and area below the curve) were obtained and the groups, which had been established according to the cutt-off point, were compared using the chi-square test. Sensitivity, specificity, and both the negative (NPV) and positive predictive value (PPV) were determined for the cutt-off point. A multivariable study was applied for the data under study and Kaplan-Meier survival charts were drawn up. Results. The frequencies of presentation of the Glasgow variables were: shock 71.8%, heart disease 34%, neuropathy 7.8% and nephropathy 36.9%. Perioperative mortality rate stood at 49.4% (n=51). The estimated are below the curve is 0.814 (95% confidence interval, CI: 0.725-0.883), the cut-off points is 106 (sensitivity 45.1%; specificity 94.2%; PPV: 88.5%; NPV: 63.6%). Mortality above and below the cut-off points was 88.5 and 36.4%, respectively (p<0.001; odds ratio, 13.4; 95% 95% CI: 3.6-48.7). Above 111 points mortality was 100%.Conclusions. The Glasgow risk scale is a good tool for predicting mortlity in patients with rAAA, which provides a precise cut-off point beyond which mortality increases significantly. As a result, a better indication for surgery can be achieved for this group of patients

Prospective study of the functional recovery after surgery for thoracic outlet syndrome.

OBJECTIVES: The aim of this study is to evaluate the functional recovery after Thoracic Outlet Syndrome (TOS) surgery, by the application of Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. MATERIAL AND METHODS: This was a prospective study of all patients operated on for TOS from January 1998 to December 2005. The DASH questionnaire was administered pre- and postoperatively. The scores were analysed according to TOS type, the associated comorbidity and the type of surgery performed. Results were assessed with Wilcoxon Test for continuous variables, and the Fisher Test for categories. RESULTS: Twenty-three consecutive patients were included in the study, the average age was 37 years (range: 22-54). Fourteen patients presented with venous TOS and 9 with neurogenic TOS. Patients with venous TOS had a preoperative score of 14.9 (SD 18.31) and a postoperative score of 14.8 (SD 15.6) (p>0.05). The preoperative score in patients with neurogenic TOS was 53.96 (SD 15.6) and the postoperative score was 17.8 (SD 15.3) (p=0.01). CONCLUSIONS: DASH questionnaire is a valid and objective test for evaluating the functional state after TOS surgery. Venous TOS is clinically less incapacitating than neurogenic. Surgically decompression of thoracic outlet leads to significant benefit in patients with neurogenic TOS.

Tratamiento quirúrgico de la arteritis de Takayasu con afectación de troncos supraaórticos. A propósito de dos casos clínicos / Surgical treatment of Takayasu´s arteritis with involvement of the supra-aortic trunks. Two clinical case reports

Introducción. La arteritis de Takayasu es una enfermedad inflamatoria muy poco frecuente en nuestro medio, que afecta principalmente a mujeres jóvenes de origen asiático o norteafricano. El fenómeno creciente de inmigración existente actualmente en nuestro país, hace que debamos tener presentes patologías que hasta ahora eran muy poco habituales. Casos clínicos. A través de los casos clínicos de dos pacientes jóvenes con enfermedad de Takayasu sintomática, cuyo estudio arteriográfico mostró una afectación grave de troncos supraaórticos, presentamos el diagnóstico y manejo terapéutico de esta patología. Se realizó a ambas pacientes un injerto desde aorta ascendente a carótida interna y subclavia izquierda con buena evolución, y remisión de la sintomatología isquémica. Conclusión. La revascularización de troncos supraaórticos es una opción válida en el tratamiento de la arteritis de Takayasu; se deben evitar siempre los procedimientos quirúrgicos en la fase aguda de la enfermedad, así como en los sectores arteriales que presentan una mayor incidencia potencial de afectación

Introduction. Takayasu’s arteritis is a very infrequent inflammatory disease in our milieu that chiefly affects young females of Asian or North African extraction.The growing phenomenon of immigration that currently exists in our country means that we now have to take into account a series of pathologies that, until recently, were very uncommon. Case reports. The clinical cases of two young patients with symptomatic Takayasu’s disease, in which an arteriography study revealed severe involvement of the supra-aortic trunks, are used here to describe the diagnostic and therapeutic treatment of this condition. A graft was carried out from the ascending aorta to the internal carotid and the left subclavian in both patients with good progress and remission of the ischaemic symptoms. Conclusions. Revascularisation of the supra-aortic trunks is a valid option in the treatment of Takayasu’s arteritis; surgical procedures must always be avoided during the acute phase of the disease, as well as in the arterial segments that are potentially more likely to become infected

[Primary aortoenteric fistula: a rare cause of gastrointestinal bleeding in young adults]. / Fístula aortoentérica primaria, causa infrecuente de hemorragia digestiva en el adulto joven.

Aortoenteric fistula is defined as a communication between the native aorta and any portion of the gastrointestinal tract. Depending on previous aortic grafting it can be classified as primary, without previous grafting, or secondary. Primary aortoenteric fistula is less frequent and usually arises from an abdominal aortic aneurysm. Clinical presentation is usually gastrointestinal bleeding. The main diagnostic procedures are gastroscopy and computed tomography. We report the case of a 46-year-old man who presented to the emergency room with gastrointestinal bleeding and an abdominal pulsatile mass. Although complementary tests and clinical signs suggested a diagnosis of primary aortoenteric fistula, the communication was not observed on gastroscopy and was confirmed by exploratory laparotomy. Despite aggressive surgical treatment, the prognosis of this entity is poor.

Fístula aortoentérica primaria, causa infrecuente de hemorragia digestiva en el adulto joven / Primary aortoenteric fistula: a rare cause of gastrointestinal bleeding in young adults

La fístula aortoentérica es una comunicación entre la pared del tubo digestivo y la aorta. Se clasifica en primaria y secundaria según la ausencia o presencia de antecedentes de cirugía previa de la aorta. La más infrecuente es la fístu- la primaria, generalmente asociada a la existencia de un aneurisma de aorta abdominal. El signo clínico principal es la hemorragia digestiva. La gastroscopia y la tomografía computarizada son las principales pruebas diagnósticas. Presentamos el caso clínico de un varón de 46 años que acude a un servicio de urgencias por un cuadro de hemorragia digestiva y el hallazgo de un aneurisma de aorta abdominal. La gastroscopia no fue diagnóstica; sin embargo, las pruebas complementarias sugieren la presencia de una fístula aortoentérica que se confirma mediante laparotomía exploradora. El pronóstico de esta enfermedad es infausto a pesar de un tratamiento quirúrgico enérgico

Aortoenteric fistula is defined as a communication between the native aorta and any portion of the gastrointestinal tract. Depending on previous aortic grafting it can be classified as primary, without previous grafting, or seconda- ry. Primary aortoenteric fistula is less frequent and usually arises from an abdominal aortic aneurysm. Clinical presentation is usually gastrointestinal bleeding. The main diagnostic procedures are gastroscopy and computed tomography. We report the case of a 46-year-old man who presented to the emergency room with gastrointestinal bleeding and an abdominal pulsatile mass. Although complementary tests and clinical signs suggested a diagnosis of primary aortoenteric fistula, the communication was not observed on gastroscopy and was confirmed by exploratory laparotomy. Despite aggressive surgical treatment, the prognosis of this entity is poor

Factores predictivos de colitis isquémica después de un aneurisma de aorta abdominal roto / Predictive factors of colitis after a ruptured abdominal aortic aneurysm

Objetivo. Analizar la presencia de factores predictivos que faciliten el diagnóstico precoz de la colitis isquémica en el postoperatorio de un aneurisma de aorta abdominal roto. Pacientes y métodos. Sobre un total de 49 pacientes con aneurisma de aorta ab dominal roto intervenidos en nuestro centro en el período comprendido entre 1997 y 2003, realizamos un estudio retrospectivo sobre los 38 pacientes que sobrevivieron más de 24 h. Análisis estadístico: univariante (prueba de chi al cuadrado y prueba de Fisher) y análisis multivariante (regresión logística y tendencia lineal) con las variables significativas en el estudio estadístico univariante. Resultados. La mortalidad del grupo que se estudió del 18,4 por ciento. Incidencia de colitis isquémica: 23,7 por ciento. A cinco pacientes se les practicó resección intestinal. En el análisis por regresión logística se identificaron las siguientes variables de riesgo: tensión arterial sistólica al ingreso 180 min (OR: 9,1; IC 95 por ciento: 1,1-82,4) y tensión arterial sistólica media intraoperatoria 70 min, pH intraoperatorio 70 min, pH intraoperatorio < 7,3, uso de más de un fármaco vasoactivo y acidosis las primeras 72 h (AU)