Could prior endovascular interventions affect the results of lower extremity below the knee autologous vein bypasses?

BACKGROUND: Performing a non-selective primary endovascular approach involves risk of performing ineffective procedures and could compromise future treatments. The objective of this research is to determine if previous failed endovascular intervention could affect bypass results. METHODS: Retrospective cohort study including 77 below the knee (BTK) bypasses with great saphenous vein (GSV) in patients with critical limb ischemia, carried out between 2008-2018. Primary bypasses (P-BP) were compared with bypasses with history of previous failed endovascular intervention (Secondary bypasses [S-BP]). Primary outcomes included: primary, primary-assisted, and secondary patency, and major amputation-free survival (AFS). The quality of GSV used was evaluated as a potential confounding factor. RESULTS: Forty-six procedures were P-BP (59.7%) and 31 S-BP (40.3%). The mean follow-up was 35.4 (SD: 31) and 28 (DS: 30) months respectively. Univariate results showed an increased risk of loss of primary patency (HR=2.7), primary-assisted patency (HR=3.1) and secondary patency (HR=3.26) in S-BP (P<0.05). This group also presented a trend towards an increased risk of major amputation (HR=1.6; P>0.05). Suboptimal GSV was used in 29% of S-BP and 15% of P-BP. This factor was identified as confounding partially, as it decreased the influence assumed by the history of prior endovascular intervention in the analyzed variables. CONCLUSIONS: Secondary bypasses show inferior results to primary bypasses in our series. Although the cause could be a prior failed endovascular intervention, the frequent use of suboptimal GSV in this type of patients may also contribute to this effect.

Development of an individualized scoring system to predict mid-term survival after carotid endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) is a prophylactic surgery focused in preventing stroke in the mid-long term. The purpose of this study was to analyze mid-term mortality in patients undergoing CEA, identify predictors of 3-year mortality and design a score to estimate individual risk of mortality in this population. METHODS: A retrospective single-center study including consecutive patients undergoing CEA between 1997-2010. Demographic data and comorbidities, postoperative results and patient follow-up data were registered and evaluated. Kaplan Meier analysis was used to analyze survival. After multivariable COX regression analysis, a score based on the calculated Hazards Ratios (HR) was designed. The sum of all points performed the individual score for each patient for estimating 3-years mortality. Population was stratified into four groups according to percentiles of score obtained: Group A (-7 to 4 points), Group B (5-8 points), Group C (9-10 points), Group D (score greater than 11 points). RESULTS: A total of 453 patients with a mean follow-up of 53.4 months were included in the study. Overall 3-year survival was 88.4%. On the univariate analysis the variables associated with significant increasing in 3-year mortality were: female gender (OR 2.32), diabetes mellitus (OR 2.28), COPD (OR 2.98), ischemic heart disease (OR 2.29), critical carotid stenosis >90% (OR 2.16) and antiplatelet therapy as a protective factor (OR 0,23). Factors associated with mortality in multivariate analysis were age (HR 1.14 P=0.001), diabetes mellitus (HR 1.62, P=0.031), COPD (HR 1.88 P=0.022), ischemic heart disease (HR 1.59 P=0.05), critical stenosis >90% (HR 1.70 P=0.015) and antiplatelet therapy as a protective factor (HR 0.23 P=0.027). The scoring system includes the following items: female gender (+2 points), age (50-69 years +7 points, 70-79 years +12 points, >80 years +15 points), diabetes (+4 points), COPD (+5 points), ischemic heart disease (+4 points), carotid stenosis> 90% (+4 points). Antiplatelet (-7 points). The score range from -7 to 26 points. The 3-year mortality range was 5.6% (group A) versus 25.5% (group D). The incidence of stroke at 3-year folllow-up was not correlated with the score (99%, 100%, 97% and 94.5%, respectively groups A-D, P=0.11) CONCLUSIONS: The score developed based on the risk factors of mortality allows individualized risk prediction of 3-year mortality in patients with carotid stenosis. This represents a useful and practical tool for decision-making in the indication of the CEA, allowing surgeons to identify high-risk patients who would benefit from medical treatment due to their limited life expectancy, mainly in asymptomatic patients.

Applicability of Zenith p-branch Standard Fenestrated Endograft in Our Series.

BACKGROUND: In the endovascular treatment of abdominal aortic aneurysm (AAA) with short or absent infrarenal neck, the delay in the availability of fenestrated device and its high cost, have led to the manufacture of standardized models. Another option is the endografts with stents in parallel; however, regulated criteria for their use and long-term studies are lacking. The aim of this study was to assessed whether the AAA treated with fenestrated device or stents in parallel in our department, complied with the characteristics for the placement of the new endograft p-branch(®). Furthermore, the differences between the p-branch and the implanted prosthesis were analyzed. METHODS: Single-center and descriptive study of 41 aneurysms treated consecutively from 2008 to 2015. The anatomic characteristics analyzed were: relative distances between the visceral arteries, time position, diameter in the sealing area and number of fenestrations, and its compatibility with the p-branch. RESULTS: The anatomic compatibility rate with the p-branch options was 73.2% (30 cases). Of the 11 incompatible cases, 6 were due to misalignment of the visceral branches, 2 due to the aortic neck diameter being greater, another because the femoral access was inappropriate, and 2 more due to the fenestration configuration. Of the 30 cases in which compatibility existed, in 12 (40%) the configuration used coincided with the p-branch. In 13 cases, the number of fenestrations was higher than those actually used, with 23 fenestrations carried out and 39 hypothetical fenestrations with the new endograft. In the 5 remaining cases, a fenestration for the celiac trunk was necessary to achieve an adequate seal. CONCLUSIONS: The p-branch could meet the needs of three-quarters of the aortic anatomies of our series, with favorable expectations on cost and waiting time. However, in most cases either a higher number of fenestrations are needed for visceral arteries or the proximal seal was shorter than would be ideal.

Endograft-assisted coil embolization of a celiac trunk aneurysm.

BACKGROUND: Celiac trunk aneurysms are rare but potential life-threatening lesions. Endovascular techniques are more often used for their treatment because of low rates of morbidity and mortality. CASE REPORT: We describe a modification of stent-assisted coil embolization technique more commonly used in the treatment of intracranial aneurysm, to exclude a 50-mm diameter celiac trunk aneurysm. The patient was a 67-year-old man who had a previous exclusion of a symptomatic aortic aneurysm, with occlusion of the inferior mesenteric and both hypogastric arteries. Anatomic features of the celiac trunk aneurysm and its branches do not allow treatment with a straight endograft or maintain direct flow to the hepatic artery. We then performed an endograft-assisted coil embolization of the aneurysm, with a straight flow line to the splenic artery. CONCLUSION: Endograft-assisted coil embolization is a feasible and safe technique to allow selective embolization of the sac and the presence of direct flow to the splenic artery and indirect flow to the hepatic artery.

Historia natural de la estenosis carotídea de grado moderado en pacientes con enfermedad arterial periférica / Natural history of moderate-degree carotid stenosis in patients with peripheral artery disease

Fundamento y objetivo: Conocer la evolución de la estenosis carotídea moderada asintomática, losfactores que influyen en la progresión y la morbimortalidad relacionada. Pacientes y método: Estudio observacional retrospectivo de 133 pacientes con estenosis carotídea asintomática entre 50-69% en una o ambas carótidas entre 2002 y 2009. Se incluyen pacientes sometidos a cribado por enfermedad arterial periférica (EAP), patología aneurismática o soplo carotíeo. El seguimiento se realiza mediante ecodoppler anual. Se valora el grado de progresión, variables relacionadas con esta, la aparición de episodios neurológicos y mortalidad global y cardiovascular. Se ha realizado un estudio descriptivo, análisis univariante (ji al cuadrado y t de Student), análisis multivariante (regresión logística) y curvas de supervivencia (test de Log-Rank). Resultados: Con un tiempo medio (DE) de seguimiento de 30,8 (1,7) meses, se observó progresión de la estenosis en el 33% de los pacientes, con un tiempo medio de progresión de 31 3 (2,7) meses. Se registró una mayor tasa de progresión en el subgrupo de pacientes que asociaban EAP y cardiopatía isquémica (odds ratio [OR] 2,84, intervalo de confianza del 95% [IC 95%] 1,14-7,03). En el análisis multivariante tan solo la EAP se presenta como un factor de riesgo de progresión (p = 0,043). El grupo de pacientes con progresión presentó mayores tasas de episodios neurológicos (15 frente a 1,6%, p = 0,01), mayor mortalidad global (15 frente a 3%, p = 0,04) y mayor mortalidad cardiovascular (12,1 frente a 1,5%, p = 0,03). Conclusiones: La progresión de estenosis carotídea asintomática entre el 50-69% es frecuente en pacientes sometidos a cribado, especialmente en aquellos con antecedentes de cardiopatía isquémica y/o EAP. Esta progresión se asocia a una mayor tasa de complicaciones cardiovasculares. Por ello recomendamos el seguimiento clínico y ecográfico de estos pacientes (AU)

Background and objective: To understand the evolution of moderate asymptomatic carotid stenosis, the factors that influence its progression and the related morbimortality. Patients and methods: Retrospective observational study of 133 patients with asymptomatic carotid stenosis between 50-69% in one or both carotids between 2002 and 2009. Included patients were subjected to screening for peripheral arterial disease (PAD), aneurysmal disease or carotid bruit. The monitoring was carried out using an annual duplex scan. The rate of progression, the variables related to this, the appearance of neurological events, and global and cardiovascular mortality were evaluated. Descriptive studies, univariate analysis (chi-squared test and Student’s t-test), multivariate analysis (logistic regression), and survival curves (Log-Rank test) were carried out. Results: With an average time of monitoring: 30.8 1.7 months, stenosis progression was observed in 33% of the patients, with an average progression time of 31.3 2.7 onths. Greater progression was observed in the subgroup of patients with PAD and ischemic heart disease (odds ratio [OR] 2.84, confidence interval [CI] 95% 1.14-7.03). In the multivariate analysis only the PAD was identified as a risk factor for progression (P = .043). The group of patients with progression showed greater rates of neurological events: 15 vs. 1.6% (P = .01), greater global mortality: 15 vs. 3% (P = .04), and greater cardiovascular mortality: 12.1 vs. 1.5% (P = .03). Conclusions: The progression of asymptomatic carotid stenosis between 50-69% is common in patients subjected to screening, especially in those with a history of ischaemic heart disease and/or PAD. This progression is associated with an increased rate of cardiovascular complications. For this reason, we recommend clinical and echographic follow-up of these patients (AU)

[Natural history of moderate-degree carotid stenosis in patients with peripheral artery disease]. / Historia natural de la estenosis carotídea de grado moderado en pacientes con enfermedad arterial periférica.

BACKGROUND AND OBJECTIVE: To understand the evolution of moderate asymptomatic carotid stenosis, the factors that influence its progression and the related morbimortality. PATIENTS AND METHODS: Retrospective observational study of 133 patients with asymptomatic carotid stenosis between 50-69% in one or both carotids between 2002 and 2009. Included patients were subjected to screening for peripheral arterial disease (PAD), aneurysmal disease or carotid bruit. The monitoring was carried out using an annual duplex scan. The rate of progression, the variables related to this, the appearance of neurological events, and global and cardiovascular mortality were evaluated. Descriptive studies, univariate analysis (chi-squared test and Student's t-test), multivariate analysis (logistic regression), and survival curves (Log-Rank test) were carried out. RESULTS: With an average time of monitoring: 30.8 ± 1.7 months, stenosis progression was observed in 33% of the patients, with an average progression time of 31.3 ± 2.7 months. Greater progression was observed in the subgroup of patients with PAD and ischemic heart disease (odds ratio [OR] 2.84, confidence interval [CI] 95% 1.14-7.03). In the multivariate analysis only the PAD was identified as a risk factor for progression (P=.043). The group of patients with progression showed greater rates of neurological events: 15 vs. 1.6% (P=.01), greater global mortality: 15 vs. 3% (P=.04), and greater cardiovascular mortality: 12.1 vs. 1.5% (P=.03). CONCLUSIONS: The progression of asymptomatic carotid stenosis between 50-69% is common in patients subjected to screening, especially in those with a history of ischaemic heart disease and/or PAD. This progression is associated with an increased rate of cardiovascular complications. For this reason, we recommend clinical and echographic follow-up of these patients.

Endovascular repair of an iliac arteriovenous fistula secondary to perforation from a common iliac aneurysm in a patient with Ehler-Danlos syndrome.

BACKGROUND: Type IV Ehler-Danlos syndrome (EDS) patients are prone to life-threatening vascular complications. Surgical management of those complications is challenging owing to vessel wall fragility, which may result in hemorrhagic events and high mortality rates. Here we report a case of left common iliac aneurysm perforation of the ipsilateral iliac vein repaired using endovascular technique in a patient with EDS. METHOD AND RESULTS: A 54-year-old patient presented with heart failure symptoms that evolved over 1 week in association with left leg edema and steal syndrome due to a perforation of the left iliac vein caused by a left common iliac aneurysm. A thrombosed right common iliac aneurysm and several other visceral and peripheral aneurysms were discovered on computed tomographic scan at admission. An aortouniiliac stent graft was used to seal the fistula. After 18 months of follow-up, the patient remained asymptomatic. CONCLUSIONS: We suggest that endovascular therapy is useful to manage vascular complications in patients with EDS.

Interaction of cerebrovascular disease and contralateral carotid occlusion in prediction of shunt insertion during carotid endarterectomy.

INTRODUCTION: To assess the possible role and the interaction of cerebrovascular disease and vascular stenosis on the necessity of shunt insertion during carotid endarterectomy (CEA). MATERIAL AND METHODS: Eighty consecutive patients undergoing CEA under regional anaesthesia were prospectively enrolled. Patients were divided into two groups depending on whether they were shunted or not. The measured end-points were co-morbidities degree of contralateral and carotid stenosis and other intra- and postoperative outstanding parameters. ANOVA, Student's t and χ(2) tests were used (p<0.05). Variables differing significantly between groups and potential confounders were used in backward stepwise logistic regression to estimate the relative risk (RR, 95% CI) of shunt. In addition Wald's test (p<0.05) with and without adjustments for potential confounders was used with various different multivariate analysis models. RESULTS: Contralateral stenosis and cerebral vascular accidents (CVA) were more frequently observed in shunted patients. The RR for patients with contralateral stenosis ≥ 50% was 1.3 (95% CI 1.0-1.5) and for patients with previous CVA was 1.2 (95% CI 1.0-1.4). For contralateral stenosis and CVA together the RR increased to 7.7 (95% CI 1.0-14.4). A model based on contralateral stenosis and CVA was found to be statistically significant (p=0.003) for shunt (RR=1.1, 95% CI 1.0-2.1). Relative excess risk due to interaction of both factors was 6.2. CONCLUSIONS: The findings suggest that patients with contralateral stenosis ≥ 50% and previous CVA have a higher risk of requiring shunt use during CEA than patients with these risk factors separately.

Primary aortoduodenal fistula in a patient with pararenal abdominal aortic aneurysm.

Primary aortoenteric fistula is a rare and extremely serious condition. In most cases, it is caused by an abdominal aortic aneurysm presenting with symptoms of gastrointestinal bleeding. Diagnosis is difficult owing to its rarity and the fact that diagnostic tests are not definitive in many cases. Surgery is performed urgently in most cases and is associated with high mortality. We report a case of a 65-year-old man presenting with symptoms of abdominal pain and massive rectal hemorrhage. Computed tomography revealed a pararenal abdominal aortic aneurysm and suspected aortoenteric fistula. The patient underwent an emergency surgery, confirming the suspected diagnosis. The surgery performed was the traditionally recommended extra-anatomical bypass with aortic ligation and repair of the intestinal defect. We describe the clinical condition and provide an up-to-date overview of diagnosis and treatment by reviewing the literature. We believe the therapeutic decision should be personalized by assessing the anatomy of the aneurysm, the patient's clinical status, the degree of local contamination, and the surgeon's experience with each of the techniques.

Popliteal artery aneurysm in patient with Klippel--Trénaunay--Weber syndrome.

BACKGROUND: The association of Klippel-Trénaunay-Weber syndrome (KTWS) with artery aneurysms is very rare. METHODS AND RESULTS: A 61-year-old man, diagnosed with left lower limb KTWS, presented with a venous ulcer and a popliteal aneurysm measuring 3.5 cm in diameter in the same limb. Endovascular treatment with covered stent was applied with good morphological and clinical results. CONCLUSION: We report a singular case of the association of a popliteal aneurysm with KTWS and its endovascular treatment. This treatment enabled exclusion of the popliteal artery aneurysm with safety and effectiveness and reduced the number of arteriovenous fistulas.

Endovascular treatment of a ruptured iliac aneurysm previously excluded.

We report a case of an isolated ruptured iliac artery aneurysm that had previously been treated, 25 months before, with iliac endovascular exclusion. Urgent computed tomographic (CT) scan showed the retroperitoneal hematoma and a type IA endoleak. On an emergency basis, at the operating room, an aortouni-iliac graft and femorofemoral crossover bypass were performed, successfully. This is a very rare but serious complication and requires careful indication and close follow-up with CT. In isolated common iliac artery aneurysms, the common iliac artery and distal aorta may tend to enlarge with failure of the endograft proximal attachment site and migration, thus leading to a late aneurysm rupture. A safe length and width, especially of the proximal sealing zone, should be accurately defined and closely followed up, or otherwise complete exclusion of the aortoiliac arteries should be considered.

[Clinical and therapeutic characteristics of limb emboli]. / Características clínicas y terapéuticas de las embolias de extremidades.

INTRODUCTION: To treat an extremity embolus seems to be a simple and safe procedure. However, it is not exempt from potentially serious complications. We review our experience of treating acute peripheral arterial occlusion due to emboli. PATIENTS AND METHOD: We retrospectively analyzed the data of 127 embolectomies performed during the last five years, in 120 extremities in 116 patients. The mean age of the patients was 80 years and 66% were female. All cases were presented as acute threatened limb ischemia grades IIA or IIB, and the mean evolution time was 27 hours. The patency, limb salvage and morbidity-mortality rates in the postoperative period and the salvage and survival rates in the follow-up were analyzed. RESULTS: Of the embolectomies, 55% were femoral and 30% brachial. Although 90% of the cases improved, only 75% of them recovered distal pulses. In the postoperative period the patency, limb salvage, morbidity and mortality rates were 90%, 96%, 13% and 6.4%, respectively. The mean follow-up was 24 months. Up until this time, the patency and survival rates are 91% and 61%, respectively. The only factor related with an increase in the amputation rate was a clinical presentation, such as a threatened immediate ischemia. The factors related with an increase in survival rate were appropriate cardiological treatment and control, and long-term anticoagulation treatment. CONCLUSIONS: Suffering an embolus of the extremities and its treatment causes considerable morbidity-mortality and limb amputation rates. The extremity salvage is associated with the clinical presentation at the time of the treatment. Long-term anticoagulation treatment and appropriate cardiological control increase the survival of these patients.

Características clínicas y terapéuticas de las embolias de extremidades / Clinical and therapeutic characteristics of limb emboli

Introducción. Tratar una embolia arterial de las extremidades resulta un procedimiento sencillo, seguro y resolutivo. Sin embargo, no es un proceso exento de complicaciones potencialmente graves. Material y método. Se han analizado retrospectivamente las 127 embolectomías realizadas, en los últimos 5 años, en 120 extremidades de 116 pacientes. La media de edad fue 80 años y el 66% eran mujeres. La mayoría se manifestó como isquemias agudas con amenaza de la extremidad, de una media de 27 h de evolución. Se han analizado las tasas de permeabilidad, salvamento y morbimortalidad postoperatorias y de salvamento y supervivencia a medio plazo en el seguimiento. Resultados. El 55% de las embolectomías fueron femorales y el 30%, humerales. El 90% de los casos mejoraron clínicamente, aunque sólo el 75% recuperó pulsos distales. En el postoperatorio los resultados fueron: permeabilidad del 90%, salvamento del 96%, morbilidad del 13% y mortalidad del 6,4%. El seguimiento medio fue 24 meses. Al final del seguimiento medio, los resultados fueron: salvamento de extremidad del 91% y supervivencia del 61%. El único factor relacionado con un incremento en la tasa de amputación fue la presentación clínica como una isquemia aguda con amenaza inmediata (frente a amenaza inicial). Los factores relacionados con una mejor supervivencia fueron unos adecuados tratamiento y control cardiológico y una anticoagulación prolongada a dosis ajustadas. Conclusiones. Sufrir una embolia de extremidades y su tratamiento mediante embolectomía producen tasas de morbimortalidad y amputación no desdeñables. El salvamento de la extremidad está relacionado con la clínica en el momento del tratamiento. La anticoagulación prolongada y el control cardiológico aumentan la supervivencia de estos pacientes (AU)

Introduction. To treat an extremity embolus seems to be a simple and safe procedure. However, it is not exempt from potentially serious complications. We review our experience of treating acute peripheral arterial occlusion due to emboli. Patients and method. We retrospectively analyzed the data of 127 embolectomies performed during the last five years, in 120 extremities in 116 patients. The mean age of the patients was 80 years and 66% were female. All cases were presented as acute threatened limb ischemia grades IIA or IIB, and the mean evolution time was 27 hours. The patency, limb salvage and morbidity-mortality rates in the postoperative period and the salvage and survival rates in the follow-up were analyzed. Results. Of the embolectomies, 55% were femoral and 30% brachial. Although 90% of the cases improved, only 75% of them recovered distal pulses. In the postoperative period the patency, limb salvage, morbidity and mortality rates were 90%, 96%, 13% and 6.4%, respectively. The mean follow-up was 24 months. Up until this time, the patency and survival rates are 91% and 61%, respectively. The only factor related with an increase in the amputation rate was a clinical presentation, such as a threatened immediate ischemia. The factors related with an increase in survival rate were appropriate cardiological treatment and control, and long-term anticoagulation treatment. Conclusions. Suffering an embolus of the extremities and its treatment causes considerable morbidity-mortality and limb amputation rates. The extremity salvage is associated with the clinical presentation at the time of the treatment. Long-term anticoagulation treatment and appropriate cardiological control increase the survival of these patients (AU)

[Value of the Doppler-ultrasonography for the diagnosis of temporal arteritis]. / Valor de la ecografía Doppler en el diagnóstico de la arteritis de la temporal.

BACKGROUND AND OBJECTIVE: The aim of this study was to investigate the accuracy of color Doppler-ultrasonography (CDU) compared with biopsy for the diagnosis of temporal arteritis (TA). PATIENTS AND METHOD: Twenty-three patients with suspected TA on the basis of clinical criteria were evaluated with CDU prior to temporal artery biopsy. The presence of a hypoechoic halo, suggesting edema of the inflamed vessel, and inflammatory stenoses were registered. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and eficiency or global test value (GTV) were evaluated. RESULTS: All patients completed a bilateral CDU examination of temporal arteries, and in 72% of patients the biopsy was negative for TA. When the presence of an halo in CDU examination was regarded as determinant for disease, sensitivity, specificity, PPV, NPV and GTV compared with TA histologic confirmation were 80%, 92%, 80%, 92% and 88%, respectively. When the criteria used was presence of the halo sign with or without inflammatory stenosis, the values were 100%, 77%, 62.5%, 100% and 83% respectively. CONCLUSIONS: Because of the high sensitivity and NPV, we consider CDU as a good screening test for the diagnosis of TA.

Valor de la ecografía Doppler en el diagnóstico de la arteritis de la temporal / Value of the Doppler-ultrasonography for the diagnosis of temporal arteritis

Fundamento y objetivo: El objetivo del trabajo es investigar la precisión de la ecografía Doppler (ED) color comparada con la biopsia en el diagnóstico de la arteritis de la temporal (AT). Pacientes y método: Estudio prospectivo en 23 pacientes con sospecha de AT basada en criterios clínicos a los que se realizó ED y estudio histopatológico. Se evaluó la presencia de halo hipoecoico indicativo de edema de la pared y/o la presencia de estenosis. Se valoró la sensibilidad, la especificidad, el valor predictivo positivo (VPP), el valor predictivo negativo (VPN) y eficiencia o valor general del test. Resultados: En todos los pacientes se completó el estudio ED y en un 72% las biopsias fueron negativas para AT. Considerando la presencia de halo como determinante de AT, la sensibilidad, la especificidad, el VPP, VPN y VGT fueron del 80, el 92, el 80, el 92 y el 88%, respectivamente, mientras que con el criterio de la presencia de halo y/o estenosis inflamatoria, fueron del 100, el 77, el 62,5, el 100 y el 83%, respectivamente. Conclusiones: Dada la elevada sensibilidad y VPN, consideramos que la ED es un buen test de cribado para el diagnóstico de AT

Background and objective: The aim of this study was to investigate the accuracy of color Doppler-ultrasonography (CDU) compared with biopsy for the diagnosis of temporal arteritis (TA). Patients and method: Twenty-three patients with suspected TA on the basis of clinical criteria were evaluated with CDU prior to temporal artery biopsy. The presence of a hypoechoic halo, suggesting edema of the inflamed vessel, and inflammatory stenoses were registered. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and eficiency or global test value (GTV) were evaluated. Results: All patients completed a bilateral CDU examination of temporal arteries, and in 72% of patients the biopsy was negative for TA. When the presence of an halo in CDU examination was regarded as determinant for disease, sensitivity, specificity, PPV, NPV and GTV compared with TA histologic confirmation were 80%, 92%, 80%, 92% and 88%, respectively. When the criteria used was presence of the halo sign with or without inflammatory stenosis, the values were 100%, 77%, 62.5%, 100% and 83% respectively. Conclusions: Because of the high sensitivity and NPV, we consider CDU as a good screening test for the diagnosis of TA

Derivaciones femorodistales perimaleolares en pacientes en hemodiálisis / Perimalleolar femorodistal bypasses in haemodialysis patients

Introducción. El incremento en la prevalencia de la enfermedad renal terminal y el aumento de la supervivencia de los pacientes sometidos a hemodiálisis hace que cada vez sean más frecuentes las manifestaciones arterioescleróticas avanzadas en sus miembros inferiores. Objetivo. Comparar los resultados inmediatos y a medio plazo de las derivaciones femorodistales perimaleolares realizadas en pacientes sometidos a hemodiálisis con los de los pacientes sin tratamiento renal sustitutivo. Pacientes y métodos. Se comparan los resultados obtenidos en dos grupos de pacientes: 36 derivaciones en 29 pacientes en hemodiálisis frente a 96 derivaciones en 87 pacientes sin hemodiálisis, realizadas en los últimos 10 años. Las características demográficas y clínicas fueron similares entre ambos grupos, excepto en una mayor presencia de hipertensión arterial en el grupo de pacientes en hemodiálisis. Se analizaron los resultados en el postoperatorio inmediato y durante el seguimiento. Resultados. En ambos grupos, la técnica más utilizada fue la derivación femoropedia con la vena safena invertida. En el postoperatorio inmediato, los pacientes en hemodiálisis presentaron una morbilidad mayor que los pacientes sin hemodiálisis (p = 0,03), debido a una mayor incidencia de complicaciones generales. El seguimiento medio en ambos grupos fue de 36 meses y durante este período los pacientes en hemodiálisis presentaron una menor supervivencia media (p = 0,02), debida a una mayor mortalidad cardiológica. Conclusiones. Las derivaciones femorodistales perimaleolares son técnicas de salvamento de la extremidad factibles en pacientes en hemodiálisis, con resultados vasculares comparables a los de los pacientes sin hemodiálisis. Sin embargo, los pacientes en hemodiálisis presentan una mayor morbilidad postoperatoria y una menor supervivencia media

Introduction. The rise in the prevalence of terminal kidney disease and the increased survival of patients submitted to haemodialysis are making advanced arteriosclerotic manifestations in their lower limbs increasingly more frequent. Aim. To compare the immediate and medium-term outcomes of perimalleolar femorodistal bypasses carried out in patients submitted to haemodialysis with those of patients who do not require renal replacement therapy. Patients and methods. We compared the outcomes obtained in two groups of patients, namely, 36 bypasses in 29 haemodialysis patients versus 96 bypasses carried out in 87 patients who did not require haemodialysis, performed over the last 10 years. The demographic and clinical characteristics of the two groups were similar, except for a greater presence of arterial hypertension in the group of haemodialysis patients. Outcomes in the immediate post-operative period and during the follow-up were analysed. Results. In both groups the most widely used technique was a femoral-dorsalis pedis bypass with inverted saphenous vein. In the immediate post-operative period, patients undergoing haemodialysis presented a higher rate of morbidity than patients who did not require haemodialysis (p = 0.03), owing to a higher incidence of general complications. The mean follow-up time in the two groups was 36 months and during this period the haemodialysis patients presented a lower mean rate of survival (p = 0.02), due to a higher rate of mortality from heart pathologies. Conclusions. Perimalleolar femorodistal bypasses are limb salvage techniques that are feasible in haemodialysis patients, with vascular outcomes that are comparable to those of patients who do not require haemodialysis. Nevertheless, patients undergoing haemodialysis have a higher rate of post-operative morbidity and a lower mean rate of survival

[Effect of renal revascularization techniques on renal function and blood pressure control]. / Efecto de las técnicas de revascularización renal en la función del riñón y en el control de la presión arterial.

BACKGROUND AND OBJECTIVE: Our objective was to assess the effect of renal revascularization on renal function and blood pressure control. PATIENTS AND METHOD: Retrospective analysis of primary renal revascularization procedures performed during a 6-year period. Parameters of renal function and blood pressure control were assessed before and after the procedure. RESULTS: Forty consecutive renal artery revascularizations were performed in 36 patients (12 aorto-renal bypasses and 28 percutaneous transluminal angioplasties, 4 bilateral). At the first month, the renal function improved in 50% cases, but at the mean follow-up it improved only in 26%. At the first month, blood pressure control improved in 50% patients, but at the mean follow-up, it only improved in 28%. CONCLUSIONS: Renal revascularization does not offer a medium-term benefit in most patients.

Efecto de las técnicas de revascularización renal en la función del riñón y en el control de la presión arterial / Effect of renal revascularization techniques on renal function and blood pressure control

FUNDAMENTO Y OBJETIVO: Conocer el efecto de la revascularización renal sobre el control de la presión arterial y la función renal. PACIENTES Y MÉTODO: Se analizaron retrospectivamente las revascularizaciones renales realizadas durante 6 años. Se valoraron parámetros de función renal y del control de la presión arterial pre y posprocedimiento. RESULTADOS: Se realizaron 40 procedimientos en 36 pacientes (12 derivaciones aortorenales y 28 angioplastias, 4 bilaterales).Al primer mes del seguimiento la función renal mejoró en el 50 por ciento de los casos, pero al final del seguimiento medio sólo mejoró en el 26 por ciento. El control de la presión arterial mejoró al primer mes del tratamiento en el 50 por ciento de los pacientes, pero al final del seguimiento medio sólo mejoró el 28 por ciento. CONCLUSIONES: A medio plazo la revascularización renal no aporta ningún beneficio sobre el control de la presión arterial y de la función renal en la mayoría de los pacientes. (AU)

Tratamiento quirúrgico en el aneurisma poplíteo / Surgical treatment of a popliteal aneurysm

Introducción. La indicación de cirugía en el aneurisma poplíteo asintomático es controvertida, a pesar de que son frecuentes las complicaciones isquémicas asociadas al aneurisma y del riesgo elevado de amputación de la extremidad. Objetivo. Comparar los resultados del tratamiento quirúrgico del aneurisma poplíteo sintomático y asintomático. Pacientes y métodos. Serie retrospectiva de 57 aneurismas poplíteos en 45 pacientes, desde enero de 1991 a diciembre de 2000: 20 asintomáticos (grupo I) y 37 con isquemia aguda por trombosis o embolización distal (grupo II). Se utilizó un análisis univariante y tablas de Kaplan -Meier. La diferencia se consideró significativa si p< 0,05. Resultados. El número de troncos distales permeables mostró diferencias entre ambos grupos (p< 0,0001), mayor en el grupo asintomático. El procedimiento vascular fue la exclusión del aneurisma y derivación poplítea -poplítea con vena safena interna, excepto cuatro amputaciones primarias en el grupo II. La permeabilidad primaria al mes fue del 95 por ciento en el grupo I y del 72,7 por ciento en el grupo II (p= 0,04). A 39ñ29 meses de seguimiento, la permeabilidad secundaria fue del 92,8 y del 55,8 por ciento, respectivamente (p= 0,006). La tasa de salvamento de extremidad fue del 100 y del 80,8 por ciento (p= 0,04). La fibrinólisis preoperatoria (16 casos) en el grupo II no aportó diferencias en cuanto a la permeabilidad ni al salvamento de la extremidad.Conclusiones. Los mejores resultados en el tratamiento quirúrgico del aneurisma poplíteo se obtienen en el grupo asintomático. Este grupo presenta un mayor número de troncos distales permeables. La fibrinólisis locorregional preoperatoria no influye en la permeabilidad ni en el salvamento de la extremidad. [ (AU)

Síndrome del pellizco costoclavicular / Costoclavicular compression syndrome

Introducción. La utilización de catéteres implantados para la administración de quimioterapia es cada vez más frecuente. El síndrome del pellizco costoclavicular (SPCC) es una rara complicación de dichos catéteres, produce la obstrucción y finalmente la sección del catéter, y su eventual embolización a cavidades cardíacas derechas o a arterias pulmonares. Casos clínicos. Se presentan los casos de dos pacientes portadoras de sistemas reservorio-catéter implantados por vía subclavia que presentaron dicha complicación. El primer caso es una mujer de 42 años a la que se le implantó un sistema reservorio-catéter para la administración de quimioterapia adyuvante por una neoplasia de mama. A las seis semanas de su colocación se detectó su obstrucción y se retiró a las 15 semanas. Durante su retirada la porción proximal del catéter se fragmentó y quedó alojada en el ventrículo derecho, se extrajo por vía percutánea. El segundo caso es una mujer de 60 años en tratamiento paliativo por una neoplasia de mama diseminada. A las diez semanas de tratamiento, la paciente inició dolor infraclavicular durante la administración de la quimioterapia. En la radiografía, realizada con administración de contraste, se observó la extravasación del mismo. En el momento de su retirada se objetivó la sección parcial del catéter. Conclusiones. El SPCC es una complicación infrecuente de los catéteres implantados por vía subclavia. En este trabajo se describe dicha complicación, su incidencia, sus signos diagnósticos y las medidas sugeridas para evitarlo (AU)