Protocolo y algoritmo de diagnóstico, tratamiento y derivación ágil de las úlceras de la extremidad inferior / Protocol and algorithm for diagnosis, treatment and early referral of lower limb ulcers

Las úlceras venosas son una patología muy prevalente, especialmente en pacientes de edad avanzada. repercutennegativamente en la calidad de vida de los pacientes y conllevan un importante consumo de recursos. este artículopropone un práctico algoritmo para el diagnóstico y el tratamiento de las úlceras en la pierna con el objetivo deoptimizar su manejo. existe una amplia literatura sobre el tema, pero sigue existiendo una brecha entre la evidenciacientífi ca y la práctica clínica que seguimos tratando de minimizar. Laboratorios Urgo propuso al Capítulo español de Flebología y Linfología la creación de un comité de expertos deespaña y portugal para la elaboración de un algoritmo de diagnóstico, tratamiento y derivación ágil de las úlcerasen la extremidad inferior. Se realizó una búsqueda bibliográfica sistemática y se tuvieron en cuenta las guías depráctica clínica (GpC). Se diseñó un algoritmo sobre una regla nemotécnica alfabética que busca ayudar a memorizar los pasos clave deldiagnóstico y del tratamiento de estas úlceras. Se englobaron todos los aspectos prácticos, desde la valoración en atención primaria por médicos y enfermerashasta la atención especializada por el especialista en angiología y cirugía vascular. Con las letras del abecedario dela a hasta la F, resumimos los pasos necesarios para asegurar el diagnóstico de la úlcera, el mejor (best) tratamientolocal, terapia compresiva, tratamiento preventivo de recidiva después de la cicatrización de la úlcera y estrategiaquirúrgica y farmacológica.el diagnóstico preciso, la actuación correcta ajustada a las GpC y la derivación temprana para valorar estrategiasquirúrgicas o escleroterapia contribuyen a la resolución y a la reducción del tiempo de cicatrización de las úlcerasy la mejora de la calidad de vida de los pacientes. Seguir las GpC a través de un algoritmo reduce el consumo derecursos y de gasto, acelerando la cicatrización de la úlcera y previniendo su recidiva.(AU)

Venous ulcers are a prevalent disease, especially in elderly patients. they have a negative impact in patients’ qualityof life and carry a significant economic burden. this article suggests an algorithm for the diagnosis and treatment oflower extremity ulcers in order to optimize their management. there is huge evidence and multiple organizationshave published guidelines, consensus documents and treatment recommendations. nevertheless, there is still agap between evidence and clinical practice. Urgo Laboratories proposed the Spanish phlebology and Lymphology Chapter the creation of a Spanish andportuguese experts committee the elaboration of an algorithm for diagnosis and treatment and early referral oflower extremity ulcers. a systematic review was performed, considering the current clinical practice guidelines. the algorithm was designed on a simple alphabetic mnemonic rule aiming to easily memorize the key points andmost relevant issues of the diagnosis and treatment of these ulcers.all necessary steps from primary care nurses and physicians to Vascular Surgery were considered. With the alphabetletters from a to F in Spanish, all key points were summed up. to confirm ulcer diagnosis (asegurar el diagnóstico dela úlcera), best local treatment, compressive therapy, preventive treatment after healing (tratamiento preventivo derecidiva después de la cicatrización de la úlcera), surgical strategy (estrategia quirúrgica) and pharmacological strategy(estrategia farmacológica).an accurate diagnosis, a clinical practice according to the clinical practice guidelines and an early referral to thespecialist in order to determine if there is a surgical or interventional strategy are essential to effective resolutionand reduction of ulcer healing time, and finally to prevent its recurrence.(AU)

Results of endovascular treatment of venous anastomotic stenosis in prosthetic arteriovenous for hemodialysis PTFE grafts. Comparative analysis between patent and occluded grafts.

OBJECTIVE: To analyze the results of endovascular treatment of venous anastomotic stenosis (VAS) in humero-axillary arteriovenous grafts (HAG), comparing outcomes between patent and thrombosed HAG. MATERIAL AND METHODS: A retrospective cohort study was made of endovascular treated patients because of a VAS in a HAG between January 2009 and December 2019. Group A: Thrombosed HAG secondary to a VAS. Group B: Patent HAG with a VAS detected during follow-up. Technical success was defined as residual stenosis after treatment <30%, and clinical success as satisfactory immediate dialysis after surgery. After ET a biannual clinical and ultrasound follow-up was performed. STATISTICAL ANALYSIS: Survival analysis was performed for time-to-event data to assess patency. RESULTS: Group A: 55 patients. Group B: 22. There were no significative differences in demographic and anatomical factors between groups. Technical and clinical success were 100% in group B and 94.5% and 91% respectively in group A. Primary patency at 1, 6 and 12 months was: Group A: 81.8%, 22.4% y 15.7% respectively. Group B: 100%, 85.9%, 76,4% (p < 0.001). Secondary patency at 1, 6 and 12 months was: Group A: 85.2%, 45.8% y 31.3% respectively. Group B 100%, 95.3%, 95.2% (p < 0.001). Use of non-covered stents was associated with an increased risk of occlusion (HR 2.669 IC 95% 1.146-6.216, p = 0.010). CONCLUSION: A higher patency of EV performed on a patent HAG is expected. It is therefore advisable to develop surveillance programs that are capable to detect VAS before its occlusion.

Resultados del tratamiento endovascular de la estenosis de la anastomosis venosa en las fístulas arteriovenosas protésicas para hemodiálisis de PTFE. Análisis comparativo entre fístulas permeables y trombosadas / Results of endovascular treatment of venous anastomotic stenosis in prosthetic arteriovenous for hemodialysis PTFE grafts. Comparative analysis between patent and occluded grafts

Objetivo: Analizar los resultados del tratamiento endovascular (TEV) de las estenosis en las anastomosis venosas (EAV) de las fístulas arteriovenosas protésicas (FAVp), comparando su utilidad al realizarse sobre FAVp permeables frente a trombosadas.Material y métodosEstudio retrospectivo de pacientes intervenidos mediante TEV por EAV de fístulas humeroaxilares realizadas entre enero de 2009 y diciembre de 2019 en nuestro centro. Grupo A: FAVp trombosada secundaria a EAV; Grupo B: FAVp permeable con EAV detectada en seguimiento. Se definió éxito técnico como estenosis residual ≤ 30% y éxito clínico como diálisis efectiva inmediata. Tras el TEV se realizó un seguimiento clínico y con eco-Doppler semestral. Estudio estadístico: se realizó un análisis de supervivencia mediante el método Kaplan Meier para el estudio de permeabilidades.ResultadosGrupo A: 55 pacientes. Grupo B: 22 pacientes. No existieron diferencias significativas en las características demográficas ni anatómicas entre grupos.El éxito técnico y clínico fueron del 100% en el grupo B frente a un 94,5% y 91%, respectivamente, en el grupo A.La permeabilidad primaria a 1, 6 y 12 meses en el Grupo A fue: 81,8%, 22,4% y 15,7%, respectivamente, frente al Grupo B: 100%, 85,9%, 76,4% (p<0,001). Permeabilidad secundaria a 1, 6 y 12 meses en el Grupo A fue 85,2%, 45,8% y 31,3%, respectivamente, frente al Grupo B 100%, 95,3%, 95,2% (p<0,001). El uso de stents no cubierto se asoció a un mayor riesgo de oclusión (HR 2,669 IC 95% 1,146-6,216, p=0,010).ConclusiónEs esperable una mayor permeabilidad del TEV realizado sobre una FAVp permeable, por lo que es recomendable elaborar programas de seguimiento que sean capaces de detectar la EAV previo a su trombosis. (AU)

Objective: To analyze the results of endovascular treatment of venous anastomotic stenosis (VAS) in humero-axillary arteriovenous grafts (HAG), comparing outcomes between patent and thrombosed HAG.Material and methodsA retrospective cohort study was made of endovascular treated patients because of a VAS in a HAG between January 2009 and December 2019. Group A: Thrombosed HAG secondary to a VAS. Group B: Patent HAG with a VAS detected during follow-up. Technical success was defined as residual stenosis after treatment <30%, and clinical success as satisfactory immediate dialysis after surgery. After ET a biannual clinical and ultrasound follow-up was performed. Statistical analysis: Survival analysis was performed for time-to-event data to assess patency.ResultsGroup A: 55 patients. Group B: 22. There were no significative differences in demographic and anatomical factors between groups.Technical and clinical success were 100% in Group B and 94.5% and 91% respectively in Group A.Primary patency at 1, 6 and 12 months was: Group A: 81.8%, 22.4% and 15.7% respectively. Group B: 100%, 85.9%, 76.4% (p<0.001). Secondary patency at 1, 6 and 12 months was: Group A: 85.2%, 45.8% and 31.3% respectively. Group B 100%, 95.3%, 95.2% (p<0.001). Use of non-covered stents was associated with an increased risk of occlusion (HR 2.669 95% CI 1.146–6.216, p=0.010).ConclusionA higher patency of EV performed on a patent HAG is expected. It is therefore advisable to develop surveillance programs that are capable to detect VAS before its occlusion. (AU)

A dual pressure indicator, two-layer compression system for treatment of venous leg ulcers: a review.

OBJECTIVE: Venous leg ulcers (VLUs) are considered the most frequent category of hard-to-heal limb ulcers. Although evidence-based care of VLUs suggests that compression therapy plays a pivotal role in the standard of care, patient adherence is considered low, with at least 33% non-compliance, either due to perceived problems from clinicians regarding their own competency in applying the bandages, or from the patient finding the wrapping bothersome. For many years, four-layer bandaging has been considered the 'gold standard', but application can be difficult and may also prove uncomfortable for patients. Accurate application may be facilitated by a stretch indicator which has been engineered to act as a surrogate for appropriate pressure application that can address the skill concern, while fewer layers can save clinicians' time and improve the quality of life of patients. Here, we review the literature supporting a two-layer system which combines elastic (long stretch) and inelastic (short stretch) components as well as both layers having graphic markers to define that the dressing has been applied at the proper tension. METHOD: An initial search was conducted on PubMed and then followed up by a manual search of Google Scholar to retrieve evidence of different levels, in order to evaluate the outcomes of use of the specific two-layer compression system with pressure indicators in the management of patients presenting with VLUs. RESULTS: A total of four papers discussing the specific compression system in question were identified from 32 publications retrieved from PubMed, while a further six were retrieved from Google Scholar. These 10 publications were considered relevant to the two-layer system and were analysed for the outcomes of care, including wound healing, appropriate application, time-saving and better patient acceptance and adherence. CONCLUSION: Previous authors have demonstrated that two-layer systems are equivalent to four-layer systems. However, the ability to reproducibly apply appropriate compression has remained a question. The papers reviewed demonstrate that evidence suggests that the two-layer compression bandage system with indicators provides continuous, consistent and comfortable treatment that may be easier to apply with accurate pressure levels due to their indicator systems, and therefore, is a procedure that may increase patient adherence and acceptability to the wound therapy.

Results of endovascular treatment of venous anastomotic stenosis in prosthetic arteriovenous for hemodialysis PTFE grafts. Comparative analysis between patent and occluded grafts. / Resultados del tratamiento endovascular de la estenosis de la anastomosis venosa en las fístulas arteriovenosas protésicas para hemodiálisis de PTFE. Análisis comparativo entre fístulas permeables y trombosadas.

OBJECTIVE: To analyze the results of endovascular treatment of venous anastomotic stenosis (VAS) in humero-axillary arteriovenous grafts (HAG), comparing outcomes between patent and thrombosed HAG. MATERIAL AND METHODS: A retrospective cohort study was made of endovascular treated patients because of a VAS in a HAG between January 2009 and December 2019. Group A: Thrombosed HAG secondary to a VAS. Group B: Patent HAG with a VAS detected during follow-up. Technical success was defined as residual stenosis after treatment <30%, and clinical success as satisfactory immediate dialysis after surgery. After ET a biannual clinical and ultrasound follow-up was performed. STATISTICAL ANALYSIS: Survival analysis was performed for time-to-event data to assess patency. RESULTS: Group A: 55 patients. Group B: 22. There were no significative differences in demographic and anatomical factors between groups. Technical and clinical success were 100% in Group B and 94.5% and 91% respectively in Group A. Primary patency at 1, 6 and 12 months was: Group A: 81.8%, 22.4% and 15.7% respectively. Group B: 100%, 85.9%, 76.4% (p<0.001). Secondary patency at 1, 6 and 12 months was: Group A: 85.2%, 45.8% and 31.3% respectively. Group B 100%, 95.3%, 95.2% (p<0.001). Use of non-covered stents was associated with an increased risk of occlusion (HR 2.669 95% CI 1.146-6.216, p=0.010). CONCLUSION: A higher patency of EV performed on a patent HAG is expected. It is therefore advisable to develop surveillance programs that are capable to detect VAS before its occlusion.

Understanding the Basis of Radiation Protection for Endovascular Procedures: Occupational and Patients.

INTRODUCTION: Some concepts of radiation protection are not well understood and must be refreshed periodically. The basic knowledge that a vascular surgeon must have about radiation protection for patients and staff is summarised. REPORT: Diagnostic reference levels are a form of investigation into the medical exposure of patients during diagnostic and endovascular procedures that help to optimise them. Radiological quantities such as dose area product, also known as kerma area product and cumulative dose, are the most relevant to the patient. Equivalent dose, in mSv, determines the dose limits for staff. The effective dose (related to absorbed dose), also in mSv, represents the global risk of cancer and hereditary effects. For patient protection, the most important factors are fluoroscopy time, collimation, magnification, keeping the patient as near as possible to the image detector and as far as possible away from the tube, and trying to work in fluoroscope mode. Regarding occupational protection, distance, shielding, and dosimetry are the most important. DISCUSSION: With the increased use of endovascular procedures, radiation protection is an issue that has grown in importance. Radiation protection is based on three principles: justification; optimisation; and dose limits. Every action focused on reducing a patient's radiation dose will also reduce the dose to staff. Basic principles such as "the further away the better", "always use a lead apron, thyroid protector, and lead glasses", and "do not forget to wear personal dosimeters" must be remembered at all times.

Compression stockings attenuate the expression of proteins associated with vascular damage in human varicose veins.

OBJECTIVE: The objective of this study was to analyze whether compression stocking therapy in the human varicose vein wall may change the levels of biomarkers associated with vein insufficiency. METHODS: Dilated collateral varicose vein samples were obtained from patients showing chronic venous disease (class 2 of the Clinical, Etiology, Anatomy, and Pathophysiology classification). Before elective surgery, 12 patients underwent compression stocking therapy (for 1 month) and 9 patients did not (control group). Expression levels of biomarkers associated with endothelial functionality (nitric oxide synthase 3), inflammation (interleukin-6, interleukin-10), oxidative stress (Gp91phox subunit of NADPH oxidase), and coagulation (factor Xa) were determined. P-selectin, an inflammatory and thrombosis-related biomarker, was also measured. RESULTS: Compression stockings increased the content of nitric oxide synthase 3 (control, 16.48 [16.04-17.40] AU; compression, 83.71 [67.70-91.85] AU; P < .001) in the varicose vein wall that was accompanied by reduction of both interleukin-6 levels (control, 38.72 [33.48-48.52] pg/µg protein; compression, 14.49 [11.05-17.41] pg/µg protein; P = .001) and the expression of Gp91phox subunit of NADPH oxidase (control, 63.24 [53.79-77.03] AU; compression, 36.85 [35.66-52.27] AU; P < .010). P-selectin (control, 77.37 [61.86-85.00] AU; compression, 54.31 [49.60-67.50] AU; P = .017) and factor Xa (control, 90.78 [75.02-100.00] AU; compression, 14.50 [13.77-36.20] AU; P < .001) were also reduced in the varicose vein wall of compression stocking-treated patients. However, P-selectin lost its statistical significance after adjustment by dyslipidemia. CONCLUSIONS: In the varicose vein wall, compression stocking therapy improved the content levels of biomarkers associated with endothelial functionality, inflammation, oxidative stress, and coagulation.

National Diagnostic Reference Levels for Endovascular Aneurysm Repair and Optimisation Strategies.

OBJECTIVE: The International Commission on Radiological Protection (ICRP) has highlighted the large number of medical specialties using fluoroscopy outside imaging departments without programmes of radiation protection (RP) for patients and staff. Vascular surgery is one of these specialties and endovascular aneurysm repair (EVAR) is one of the most challenging procedures requiring RP guidance and optimisation actions. The recent European Directive on Basic Safety Standards requires the use and regular update of diagnostic reference levels (DRL) for interventional procedures. The objective of the study was to know the doses of patients undergoing EVAR with mobile Xray systems and with hybrid rooms (fixed Xray systems), to obtain national DRLs and suggest optimisation actions. METHODS: The Spanish Chapter of Endovascular Surgery launched a national survey that involved hospitals for 10 autonomous communities representing the 77% of the Spanish population (46.7 million inhabitants). Patient dose values from mobile Xray systems were available from nine hospitals (sample of 165 EVAR procedures) and data from hybrid rooms, from seven hospitals, with dosimetric data from 123 procedures. The initial national DRLs have been obtained, as the third quartile of the median values from the different centres involved in the survey. RESULTS: The proposed national DRLs are 278 Gy cm2 for hybrid rooms and 87 Gy cm2 for mobile Xray systems, and for cumulative air kerma (cumulative AK) at the patient entrance reference point, 1403 mGy for hybrid rooms, and 292 mGy for mobile systems. CONCLUSION: An audit of patient doses for EVAR procedures to identify optimised imaging protocol strategies is needed. It is also appropriate to evaluate the diagnostic information required for EVAR procedures. The increase by a factor of 3.2 (for kerma area product) and 4.8 (for cumulative AK) in the DRLs needs to be justified when the procedures are performed in the hybrid rooms rather than with mobile Xray systems.

Free skin micrografts with cyanoacrylate as outpatient treatment for venous leg ulcers.

OBJECTIVE: The present study describes an ambulatory, free skin micrograft technique with cyanoacrylate as a coadjuvant venous leg ulcer (VLU) healing strategy and its outcomes after one month. METHODS: This prospective study involved Comprehensive Classification System for Chronic Venous Disorders (CEAP) stage C6 patients with good granulation tissue and negative culture results, consecutively recruited in January 2017 in the Hospital Clinico San Carlos. A skin micrograft was harvested from the anterior surface of the patient's thigh with a 0.4cm punch (0.12cm2). The graft was adhered to the ulcer bed with cyanoacrylate. Anti-adherent dressing and double-layer bandaging was applied, with weekly replacements. Measurements were obtained of the surface of the VLU and graft progression (in cm2) using a photographic grid. RESULTS: A total of 12 VLUs in 12 patients were included, with a mean treated surface of 20.32±13.9cm2. A total of 18 grafts were placed and all were found to be viable after one week. Average graft growth was not noticeable after one week but was found to be 0.25±0.08cm2 after week two, 0.41±0.98cm2 after week three, and 0.70±0.15cm2 after week four (p<0.001). There were no complications in the donor zone. CONCLUSION: The findings of this study show that free skin micrografting with cyanoacrylate as outpatient treatment for VLUs was simple, rapid and without complication in this study, and may contribute to its wider application in clinical use.

[Stress echocardiography in the pre-operative evaluation of patients undergoing major vascular surgery. Are results comparable with dypiridamole versus dobutamine stress echo?]. / Ecocardiografía de estrés en el preoperatorio de cirugía vascular: son comparables los resultados con dipiridamol y dobutamina?

INTRODUCTION: [corrected] Perioperative cardiovascular complications are an important cause of post-surgical morbility and mortality in patients undergoing major vascular surgery. Dobutamine Stress Echo is considered one of the methods of choice in the detection of coronary artery disease in this subgroup of patients. OBJECTIVES: . Our aim was to analyze if dipyridamole stress echocardiography could be used as an alternative to Dobutamine Stress Echo in the perioperative evaluation of patients in need of major vascular surgery. PATIENTS AND METHOD: The result of consecutives dypiridamole and dobutamine stress exams prior to vascular surgery were reviewed. We analyzed if those patients with a positive stress echo presented a higher number of cardiac events during and after surgery than those with negative stress echo. The negative and positive predictive values were calculated for both techniques. RESULTS: 133 stress exams were analysed: 39 with dobutamine and 94 with dipyridamole. Of the 39 dobutamine studies 2 were positive, 29 negatives and 8 non conclusive. Of the 94 dypiridamole studies 13 were positive and 81 negatives. None of the patients with a positive dobutamine echo underwent surgery. The negative predictive value for dobutamine echo was 96.5%, quite similar to that of dypiridamole stress echo (97.5%). CONCLUSION: Dipyridamole stress echocardiography is a valid alternative to dobutamine echocardiography in the pre-surgical evaluation of patients undergoing major vascular surgery.

Ecocardiografía de estrés en el preoperatorio de cirugía vascular: ¿son comparables los resultados con dipiridamol y dobutamina? / Stress Echocardiography in the Pre-Operative Evaluation of Patients Undergoing Major Vascular Surgery. Are Results Comparable with Dypiridamole versus Dobutamine Stress Echo?

Introducción. Las complicaciones cardiovasculares perioperatorias son causa de morbimortalidad posquirúrgica en pacientes sometidos a cirugía vascular. La ecocardiografía de estrés se usa como cribado para la detección de enfermedad coronaria en estos pacientes. Objetivos. El propósito del estudio es analizar si la ecocardiografía de estrés con dipiridamol puede ser usada como alternativa a la ecocardiografía con dobutamina en la estratificación pronóstica de los pacientes que requieren cirugía vascular mayor. Pacientes y método. Se revisaron las ecocardiografías de estrés con dobutamina y dipiridamol realizadas antes de la cirugía vascular. Se analizó si los pacientes con resultado positivo presentaron un mayor número de acontecimientos cardíacos durante y tras la cirugía que aquellos con prueba negativa. Se calcularon los valores predictivos positivos y negativos de ambas técnicas.Resultados. Se han analizado 133 ecocardiogramas de estrés. De éstos, 39 se realizaron con dobutamina y 94 con dipiridamol. De los 39 estudios con dobutamina, dos fueron positivos, 29 negativos y ocho no concluyentes. De los 94 estudios con dipiridamol, 13 eran positivos y 81 negativos. Ninguno de los pacientes con ecocardiograma con dobutamina positivo fue intervenido. El valor predictivo negativo para la dobutamina fue de 96,5 por ciento, muy similar al del dipiridamol (97,5 por ciento).Conclusiones. La ecocardiografía de estrés con dipiridamol es una alternativa válida a la ecocardiografía con dobutamina en la valoración prequirúrgica de los pacientes que van a ser sometidos a cirugía vascular mayor (AU)