Results of Infrainguinal Bypass in Acute Limb Ischaemia.

OBJECTIVE/BACKGROUND: To assess the outcomes of infrainguinal bypass performed for acute limb ischaemia, as well as the predictors of patency, mortality, and amputation. METHODS: This was a retrospective cohort study of patients undergoing infrainguinal bypass between 1998 and 2014. The cohort was stratified according to the indication for surgery into two groups: group A (acute limb ischaemia) and group B (chronic lower extremity ischaemia). Comparative analysis was performed on comorbidities, surgical technique, and outcomes, as well as prognostic factors in group A. RESULTS: In total, 702 bypasses were performed (group A, n = 107; group B, n = 595). Differences between groups were detected in age (65.9 vs. 70.9 years; p = .03), diabetes (16% vs. 49%; p < .01), renal insufficiency (6% vs. 13%; p = .05), stroke (7% vs. 14%; p = .04), and coronary artery disease (13% vs. 28%; p < .01). Patients with acute limb ischaemia more often required general anaesthesia (47% vs. 12%; p < .01) and a short bypass was more often performed (32% vs. 7%; p < .01). Median follow up was 23 and 24 months for groups A and B, respectively. No differences were found in patency rates at 1, 12, and 24 months between groups, but group B had a higher re-intervention rate during follow up. Primary patency in group A was 84%, 63%, and 58%, and in group B it was 88%, 62%, and 53% at 1, 12, and 24 months, respectively (p = .77). Assisted primary patency in group A was 85%, 72%, and 67%, and in group B it was 90%, 74%, and 66% at 1, 12, and 24 months, respectively (p = .61). Secondary patency in group A was 90%, 78%, and 75%, and in group B it was 94%, 80%, and 74% at 1, 12, and 24 months, respectively (p = .80). The freedom from re-intervention rate in group A was 91%, 74%, and 68%, and in group B it was 92%, 76%, and 71%, respectively (p = .04). Acute limb ischaemia was an independent risk factor for amputation (odds ratio [OR] 4.96, 95% confidence interval [CI] 1.74-14.09; p < .01) and mortality (OR 4.13, 95% CI 1.53-11.14; p = .01) at 30 days. In group A, female sex, prosthetic conduit, and need of distal thrombectomy were independently associated with worse patency rates. Poor intra-operative runoff was correlated with higher amputation rates. CONCLUSION: Among those undergoing infrainguinal bypass, patients who present with acute limb ischaemia constitute a subset showing higher early rates of amputation and death. In this subset of patients, worse outcomes may be expected for women, prosthetic conduits, need for distal thrombectomy, and patients with poor intra-operative runoff.

Evolución de la función renal en la cirugía del aneurisma de aorta abdominal con clampaje suprarrenal / Evolution of renal function in abdominal aortic aneurysm surgery with suprarenal cross-clamping

Objetivo: Analizar los efectos del clampaje suprarrenal (CSR) frente al clampaje infrarrenal (CIR) en la evolución de la función renal en la cirugía del aneurisma de aorta abdominal (AAA). Material y método: Estudio de cohortes retrospectivo de los AAA tratados mediante cirugía abierta electiva entre 1998 y 2011. Se analizó la creatinina sérica (mg/dl) preoperatoria y a las 24, 48, 72, 96 h postoperatorias y al alta. Se definió deterioro de la función renal como una creatinina > 2 mg/dl en los pacientes con una creatinina basal normal o un aumento del doble de la creatinina basal en los pacientes con IRC previa. Se definió deterioro del filtrado glomerular (FG) como una disminución > 25%. Análisis multivariable de la evolución de la función renal. Resultados: Se analizaron 464 AAA, 359 (77,4%) con CIR y 105 (22,6%) con CSR. La prevalencia de IRC preoperatoria fue similar entre ambos grupos. El tipo de clampaje no se asoció a deterioro de la función renal (CSR = 8,6% vs. CIR = 4,7%; p = 0,13) y sí al deterioro del FG (CSR = 27,6% vs. CIR = 13,4%; p = 0,001). El tiempo de clampaje, la pérdida sanguínea y la IRC preoperatoria fueron factores de riesgo independientes para deterioro de la función renal. El tipo de clampaje aumentó el riesgo de deterioro de la función renal a partir de los 30 min (p = 0,001), asociándose a deterioro del FG (OR 2,04; IC 95% 0,94-4,47) de forma independiente. Conclusión: Con CSR inferiores a 30 min, en pacientes con creatinina normal, no es previsible un deterioro de la función renal. Con IRC previa o si se espera un CSR prolongado, es esperable un deterioro de la función renal, por lo que deberían valorarse métodos de protección renal (AU)

Objective: To analyse the effects of suprarenal cross-clamping (SC) as opposed to the infrarenal position (IC) in the evolution of the renal function abdominal aorta aneurysm (AAA) surgery. Material and method: A retrospective cohort study of AAAs treated by elective open surgery between 1998 and 2011. The preoperative level of serum creatinine (mg/dL) was determined and compared to postoperative level at 24, 48, 72 and 96 hours, and on discharge. A deterioration in the renal function was defined as a creatinine > 2 mg/dL in patients with a normal baseline creatinine level or an increase of double the baseline creatinine in patients with a previous chronic renal insufficiency (CRI). A deterioration of the glomerular filtrate (GF) was defined as a > 25% decrease. Multivariable analysis was performed on the evolution of the renal function. Results: A total of 464 AAA’s were analysed, 359 (77.4%) with IC, and 105 (22.6%) with SC. The prevalence of preoperative CRI was similar in both groups. The type of clamp was not associated with a deterioration in the renal function (SC = 8.6% vs. IC = 5.7%; p = 0.13) but was associated with a deterioration of the GF (SC = 27.6% vs. IC = 13.4%; p = 0.001). The time the clamp was in place, the blood loss, and the preoperative CRI were independent risk factors for the deterioration of the renal function. The type of clamp increased the risk of deterioration of the renal function beyond 30 minutes (p = .001), being independently associated with a deterioration in the GF (OR 2.04; 95% CI: 0.94-4.47). Conclusion: With SC less than 30 min, in patients with a creatinine level, a deterioration in the renal function is not foreseeable. With prior CRI, or if a prolonged SC is foreseen, a deterioration in the renal function can be expected, thereby making it necessary to evaluate methods for renal protection (AU)

Paraplejía tardía transitoria tras reparación de aneurismas torácico y toracoabdominal / Transient delayed paraplegia after repair of thoracic and thoracoabdominal aneurysms

El aneurisma toracoabdominal requiere de un manejo multidisciplinar debido a su complejidad tanto en la técnica quirúrgica como en el tratamiento anestésico. La complicación postoperatoria más temida es la isquemia medular, que se presenta con una clínica e instauración variable, a su vez que su recuperación puede ser parcial o completa. El manejo postoperatorio de la isquemia medular se basa en medidas que aumentan la perfusión medular, principalmente la optimización hemodinámica y el drenaje de líquido cefalorraquídeo (LCR). Presentamos 2 casos de paraplejía tardía, uno tras reparación abierta de aneurisma aórtico toracoabdominal y otro después del tratamiento endovascular de aneurisma de la aorta torácica descendente, con recuperación completa del déficit neurológico tras drenaje de LCR (AU)

Thoracoabdominal aneurysm requires multidisciplinary management due to its complexity both in surgical technique and anesthetic considerations. One of the most feared postoperative complication is spinal cord ischemia. It can be presented as different clinical patterns, and its recovery may be partial or complete. The postoperative management of spinal cord ischemia is mainly based on techniques to increase spinal cord perfusion, above all, hemodynamic stability and cerebrospinal fluid drainage. We present two cases of delayed paraplegia after an open repair of a thoracoabdominal aneurysm and a descending thoracic aortic aneurysm repair using an endovascular stent graft. They both had a complete neurological recovery after cerebrospinal fluid drainage (AU)

La plaqueta como célula inflamatoria: modificación de la expresión proteica del citoesqueleto y sistema contráctil de la pared vascular / The platelet as a inflammatory cell: modification of cytoskeletal and contractile protein expression of the vascular wall

A pesar de su sencillez estructural, las plaquetas son células funcionalmente muy complejas debido a su capacidad para producir y liberar biomoléculas. De aquí su importancia en el desarrollo de la arteriosclerosis. Se realizó un experimento in vitro para estudiar la actividad de las plaquetas sobre la pared vascular observando los cambios en la expresión proteica del citoesqueleto en segmentos de aorta bovina incubados con plasma rico en plaquetas. Para intentar simular un estado inflamatorio (arteriosclerosis), se realizaron estas mismas determinaciones en segmentos preestimulados con factor de necrosis tumoral. Se observó una modulación de la expresión de la mayoría de las proteínas del citoesqueleto en los segmentos de aorta sana. Sin embargo, en los segmentos preestimulados el número de proteínas fue menor, pudiendo reflejar una capacidad dual de las plaquetas para alterar la contractilidad vascular en función del estado inflamatorio de la pared vascular (AU)

Despite its structural simplicity, platelets are functionally complex cells due to their ability to produce and release biomolecules. Hence its importance in the development of atherosclerosis. An in vitro experiment was conducted to study the effect of the platelets on the vascular wall by observing changes in the cytoskeletal protein expression in bovine aortic segments incubated with platelet rich plasma. With the aim of simulating an inflammatory state (atherosclerosis), these same measurements were performed on aortic segments pre-stimulated with tumour necrosis factor. We observed a modulation of the expression of most of the cytoskeletal proteins in healthy aorta segments. However, the number of modified proteins was less in pre-stimulated segments. These results may reflect a dual platelet capacity to alter vascular contractility in relation to the inflammatory condition of the vascular wall (AU)

Stent-graft repair for blunt traumatic aortic injury: functional and survival outcomes.

AIM: Traumatic aortic injury is usually lethal, most often because of serious associated wounds. The short- and midterm outcome of endovascular exclusion was assessed as the current treatment of choice due to a lower mortality and morbidity than open surgical treatment. METHODS: We reviewed the cases of 8 patients (5 male, mean age 33 years) undergoing endovascular repair of a traumatic thoracic aortic lesion, confirmed by computed tomographic angiography, at our centre. Most patients showed a contained lesion limited to the aortic isthmus and severe associated injuries. RESULTS: Intrahospital mortality was 37.5% (N.=3) and mostly due to posttraumatic brain injury (N.=2). Most patients were hemodynamically stable at the time of endovascular repair (N.=6). The median time to surgery was 12 hours (3-48 hours). The endografts used were TAG® (W.L. Gore and Associates, Flagstaff) in three patients, and Valiant® (Medtronic, Santa Rosa, CA) in four. The technical success rate was 100%. In one case, the left subclavian artery was occluded without signs of arm ischemia. There were no cases of paraplegia or stroke related to treatment. No revision procedures were needed during follow-up. CONCLUSION: Endovascular repair shortly after injury seems to be effective and safe with a low associated morbidity and mortality.

[Transient delayed paraplegia after repair of thoracic and thoracoabdominal aneurysms]. / Paraplejía tardía transitoria tras reparación de aneurismas torácico y toracoabdominal.

Thoracoabdominal aneurysm requires multidisciplinary management due to its complexity both in surgical technique and anesthetic considerations. One of the most feared postoperative complication is spinal cord ischemia. It can be presented as different clinical patterns, and its recovery may be partial or complete. The postoperative management of spinal cord ischemia is mainly based on techniques to increase spinal cord perfusion, above all, hemodynamic stability and cerebrospinal fluid drainage. We present two cases of delayed paraplegia after an open repair of a thoracoabdominal aneurysm and a descending thoracic aortic aneurysm repair using an endovascular stent graft. They both had a complete neurological recovery after cerebrospinal fluid drainage.

Pseudoaneurisma postraumático tardío de aorta torácica / Delayed pseudoaneurysm after thoracic aortic injury

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Fístula arteriovenosa poplítea y aneurisma ilíaco gigante secundarios a traumatismo antiguo / Popliteal arteriovenous fistula and a giant iliac aneurysm due to an old injury

No disponible

Resultados de la reparación quirúrgica de los aneurismas inflamatorios de aorta abdominal: evolución de los reactantes de fase aguda y de la reacción inflamatoria periaórtica / Results of the surgery of inflammatory abdominal aortic aneurysms: evolution of the acute phase reactants and the periaortic inflammatory reaction

Objetivos: Presentar los resultados del tratamiento quirúrgico electivo de los aneurismas inflamatorios de aorta abdominal (AIAA) y analizar la evolución de la inflamación periaórtica (IPA) y de los reactantes de fase aguda (RFA) tras la intervención. Material y método: Se ha realizado un análisis retrospectivo de los AIAA intervenidos de forma electiva entre 1990 y 2010 mediante cirugía abierta. El seguimiento mediano ha sido de 71 meses y se ha analizado la evolución de la IPA y de los RFA tras la intervención. Resultados: Se han tratado 38 pacientes, de los cuales 12 (31,5%) eran sintomáticos. Se evidenció hidronefrosis en 7 casos (18,4%), siendo necesaria la colocación de doble-J preoperatorio en 5 (13,1%). Un paciente (2,6%) falleció en el postoperatorio inmediato y se realizaron 3 reintervenciones por sangrado (7,8%). Durante el seguimiento la hidronefrosis mejoró en 5 pacientes (71%), siendo la supervivencia a los 12, 36 y 72 meses del 92, 85 y 81% respectivamente. En cuanto a los RFA, se produjo una reducción significativa tanto de la velocidad de sedimentación globular (VSG) (p 0,01), como de la proteína C reactiva (PCR) (p 0,01) tras la cirugía. De igual forma, se redujo de forma significativa la IPA durante el seguimiento, fundamentalmente a partir de los 9 meses tras la intervención (p 0,02). Conclusiones: La cirugía electiva del AIAA ofrece unos buenos resultados a corto y largo plazo, asociándose a una disminución de los RFA y de la IPA, esta última fundamentalmente a partir del noveno mes postoperatorio(AU)

Objectives: To show the results of selective surgical treatment of inflammatory abdominal aortic aneurysms (IAAA), and to analyse the evolution of periaortic inflammation (PAI) and acute phase reactants (APR) after surgery. Patients and method: A retrospective analysis was made of the IAAA electively operated on between 1990 and 2010 by means of open surgery. The median follow-up period was 71 months and an analysis was made of the PAI and APR after surgery. Results: A total 38 patients underwent treatment, of which 12 (31.5%) were symptomatic. Hydronephrosis was evident in 7 cases (18.4%). The implantation of a pre-operative double-J catheter was necessary in 5 cases (13.1%). One patient (2.6%) died in the immediate post-operative period, and 3 were re-operated on due to bleeding (7.8%). During the follow-up period the hydronephrosis improved in 5 patients (71%), with a survival rate at 12, 36 and 72 months of 92%, 85% and 81%, respectively. With regard to the APR, a significant reduction was produced both in the erythrocyte sedimentation rate (ESR) (P=.01) and in the C-reactive protein (CRP) (P=.01) after surgery. Likewise, the PAI was significantly reduced during the follow-up period, mainly from the ninth month following the surgery (P=.02). Conclusions: Selective surgery of IAAA offers good results in the short and long term, associated with a decrease in the APR and PAI, the latter mainly from the ninth month of the post-operative period(AU)

Prevalencia de enfermedad carotídea asintomática en pacientes con claudicación intermitente / Prevalence of asymptomatic carotid artery disease in patients with intermittent claudication

Introducción y objetivosDeterminar la prevalencia de estenosis-oclusión carotídea en pacientes remitidos a nuestro Servicio por claudicación intermitente de miembros inferiores desde mayo de 2007 hasta febrero de 2008, así como los factores asociados a mayor riesgo de enfermedad carotídea.Pacientes y métodosDiseño transversal. Criterios de exclusión: pacientes con clínica neurológica previa y pacientes con eco-doppler carotídeo (eco-TSA) previo. Se determinaron factores de riesgo cardiovascular, antecedentes personales de cardiopatía isquémica y presencia de soplo carotídeo. Se realizaron asimismo un índice tobillo-brazo (ITB) y eco-doppler carotídeo.ResultadosSe analizaron 173 pacientes, la mayoría varones (89,6%), con una edad media de 68,1 años. El 19,7% tenía soplo carotídeo. La prevalencia de estenosis > 30% y > 50% fue del 15 y del 9,8% respectivamente, y el ITB medio fue de 0,68. Se ha observado una asociación estadísticamente significativa entre el soplo y la presencia de cualquier grado de estenosis (OR=6; p=0,0001) y de estenosis > 50% (OR=5,9; p=0,0001). También ha habido diferencias significativas en el ITB de los pacientes con estenosis>50% y los que no la presentaban (0,59 vs 0,68; p=0,05). Los pacientes con un ITB menor de 0,7 tienen mayor prevalencia de estenosis severa-oclusión que los pacientes con un ITB mayor (10,6% vs 1,4%; p=0,029).ConclusionesLa presencia de estenosis carotídea asintomática no es infrecuente en pacientes con arteriopatía periférica. En nuestro estudio la presencia de soplo carotídeo y un ITB menor de 0,7 se comportan como marcadores de riesgo de enfermedad carotídea(AU)

Introduction and objectivesTo establish both the prevalence of carotid stenosis-occlusion in patients with lower limb intermittent claudication referred to our Department between May 2007 and February 2008, and the risk factors of carotid disease.Patients and methodsCross-sectional design. Exclusion criteria: patients with previous neurological symptoms and patients with previous carotid echographic Doppler (Echo-SAT). We recorded cardiovascular risk factors, personal history of ischaemic heart disease and the presence of carotid bruit. We also performed an ankle-brachial index (ABI) and a carotid echo-Doppler.ResultsWe analysed 173 patients, 89.6% of whom were male, with a mean age of 68.1 years and 19.7% of carotid bruit. The prevalence of >30 and >50% carotid stenosis was 15% and 9.8%, respectively, and the mean ABI was 0.68. We observed a statistically significant association between the presence of a carotid bruit and that of any degree of carotid stenosis (OR=6; P=.0001), or the diagnosis of >50% stenosis (OR=5.9; P=.0001). There were also significant differences in the ABI values of patients with carotid stenosis compared to patients without it (0.58 vs 0.69, P=.05). The patients with an ABI less than 0.7 had a higher prevalence of severe stenosis-occlusion than the patients with a higher ABI (10.6% vs 1.4%, P=.029).ConclusionsThe presence of asymptomatic carotid stenosis is not uncommon in patients with peripheral artery disease. In our study, the presence of a carotid bruit and an ABI <0.7 have shown to be markers of carotid disease(AU)

Tratamiento endovascular del aneurisma de aorta abdominal / Endovascular treatment of the abdominal aortic aneurysm

La publicación de la primera reparación endovascular de un aneurisma de aorta abdominal ha cumplido 20 años, y los estudios aleatorizados que comparan la cirugía abierta con la endovascular han completado los 10 años de seguimiento.La experiencia en la reparación endovascular ha crecido notablemente, así como su uso ampliado a anatomías complejas mediante endoprótesis estándar en unos casos o con fenestradas y/o ramificadas en otros. El empleo para aneurismas rotos se ha difundido, aunque su uso sistemático para ello cuenta aún con dificultades y diversos puntos de controversia que motivan estudios no aceptados por todos. Las novedades en nuevas endoprótesis son continuas, y actualmente asistimos a un boom de ofertas comerciales, frente a un reducido grupo establecido en el mercado desde hace años que, no obstante, también ha implementado modificaciones que deben demostrar su efectividad a largo plazo. Sociedades científicas internacionales destacadas en el ámbito europeo y mundial han publicado actualizaciones de sus guías entre 2010 e inicios de 2011, en un intento de plasmar la actualidad de un campo tan cambiante.En este momento parece razonable poner al día el documento publicado en el capítulo de Cirugía Endovascular de la Sociedad Española de Angiología y Cirugía Vascular (SEACV), que pretende ser un documento de base que, manteniendo la esencia del original, incorpora novedades, puntos de debate y propuestas razonadas de mejora a partir de las que establecer un acuerdo global en la reparación endovascular de AAA, tanto en aspectos clínicos como técnicos.Por ello las recomendaciones son genéricas, a falta de un consenso explícito y recomendaciones oficiales emanadas de la sociedad científica que nos agrupa(AU)

It is now twenty years since the publication of the first endovascular repair of an abdominal aortic aneurysm, and randomised studies comparing open surgery with endovascular surgery have completed 10 years of follow-up.Experience in endovascular repair has markedly increased, as well its widened use in complex anatomies using standard endoprosthesis in some cases, or fenestrated and/or branched in others. The use for ruptured aneurysms has spread, although its systematic use still for this still has difficulties and several points of controversy due to studies not accepted by everyone. The innovations in new stents are continuous, and we are currently experiencing a boom in commercial offer, due to a reduced group established in the market for years. These, however, have also implemented changes that still are to show their effectiveness in the long term. International scientific groups in Europe and worldwide have published updates of their guidelines between 2010 and the beginning of 2011, in an attempt to reflect the current situation in such a changing field.Up to this point, it seems reasonable to update the document published by the Endovascular Chapter of the Spanish Angiology and Vascular Surgery (SEACV), which attempts to be a reference document, that while maintaining the essence of the original, includes innovations, points for debate and reasoned proposals for improvement, from which to establish an overall agreement on the repair of abdominal aortic aneurysms, in both the clinical and technical aspects.For this reason the recommendations are generic, lack a clear consensus and official recommendations by the Scientific Society to which we belong(AU)

Eficacia del dispositivo Viabahn ® en el tratamiento de la enfermedad oclusiva del sector femoropoplíteo / Efficacy of Viabahn ® in the treatment of superficial femoral arterial occlusive disease

IntroducciónLos avances en la cirugía endovascular han aportado nuevas opciones terapéuticas en la enfermedad oclusiva del sector femoropoplíteo.ObjetivoEvaluar la eficacia del dispositivo Viabahn® para tratar la enfermedad oclusiva del sector femoropoplíteo.Material y métodosDesde 2005 hasta 2010 se han tratado 30 pacientes con oclusiones/estenosis de la femoral superficial y poplítea supragenicular mediante dispositivo Viabahn®. El seguimiento se ha realizado con datos clínicos, hemodinámicos y ecográficos al mes, a los 3, 6 y 12 meses y, posteriormente, al año.ResultadosSe han tratado 30 pacientes, con una edad media de 69 años (rango: 45-82), que incluyen un 87% de varones (26), 57% de diabéticos(17), 73% de hipertensos (22) y 87% de fumadores (26). Presentaban isquemia crónica en estadio de Fontaine IIb 13,3%, III 46,7% y IV 40%. Las lesiones tratadas fueron TASC II A 16,7% (5), B 60% (18) y C 23,3% (7). Veinticinco (83,3%) eran oclusiones crónicas. La longitud media de la lesión fue de 69mm (rango: 20-150mm). En dos casos se produjeron complicaciones derivadas del procedimiento (una trombosis precoz y una embolización). El seguimiento mediano fue de 16 meses. La permeabilidad primaria fue del 74,7, 65,4 y 56% a los 6, 12 y 24 meses. La permeabilidad primaria asistida fue del 80,7, 75,3, y 64,6% a los 6, 12 y 24 meses. Hubo 7 trombosis tardías (23,3%). La permeabilidad secundaria fue del 84,2, 78,9 y 69% a los 6, 12 y 24 meses.ConclusionesEl tratamiento de las lesiones crónicas del sector femoropoplíteo con endoprótesis tiene aceptables resultados clínicos en pacientes seleccionados. Sin embargo, es necesario un seguimiento estricto para mantener una correcta permeabilidad(AU)

IntroductionAdvances in endovascular therapy have provided new options for treatment of femoropopliteal disease.ObjectiveTo evaluate the safety and efficacy of Viabahn® for the treatment of femoral-popliteal artery disease.Materials and methodsFrom 2005 until 2010, a Viabahn® endoprosthesis was implanted in 30 limbs of 30 patients to treat superficial femoral artery and above-knee occlusive lesions. Follow-up evaluation with ankle-brachial indices and colour flow duplex imaging were performed at 1, 3, 6, 12 months, and then, each year.ResultsA total of 30 patients were treated, with a mean age of 69 years (range 45-82), including 87% (26) male, 57% (17) diabetic, 73% (22) hypertensive, and 87% (26) current or former smokers. Patients had chronic limb ischemia in Fontaine stages IIb 13.3%, III (46.7%), and IV (40%). The treated lesions were TASC II A 16.7% (5), B 60% (18) and C 23.3% (7). There were 25 chronic occlusions (83.3%) and 5 stenoses (16.7%). The average length of treated lesions was 69mm (range 20-150mm). In 2 cases, major complications (1 early thrombosis and 1 thromboembolism) required additional surgery. The mean follow-up was 16 months. The primary patency rates were 74.7%, 65.4%, and 56% at 6, 12 and 24 months. Four restenoses were successfully treated. The assisted primary patency rates were 80.7%, 75.3%, and 64.6% at 6, 12 and 24 months. Late thrombosis was observed in 7 cases (23.3%). The secondary patency rates were 84.2%, 78.9%, and 69% at 6, 12, and 24 months.ConclusionsManagement of femoro-popliteal arterial occlusive lesions with stent-grafts has acceptable clinical results in selected patients. However, strict monitoring is needed, and a high number of reoperations are expected to ensure proper patency(AU)

Efecto del bosentan en pacientes con úlceras digitales de etiología isquémica / Effect of bosentan in patients with ischaemic digital ulcers

Introducción. La isquemia tisular es el resultado fi nal de un proceso en el que interviene un grannúmero de moléculas que median la interacción endotelio-músculo liso vascular, entre las quese encuentra la endotelina-1 (ET-1), que es una molécula sintetizada por el endotelio vascular yque induce vasoconstricción, es proinfl amatoria y tiene acción mitógena.Objetivo. Evaluar el resultado del bosentan, un antagonista dual de receptores de endotelina,en el tratamiento de las úlceras digitales de etiología isquémica.Pacientes y método. Han sido tratados con bosentan 18 pacientes con úlceras digitales secundariasa esclerodermia o por otra causa (indicación fuera de guía), con afectación importante devasos distales e irrevascularizables.Resultados. La etiología ha sido arteriosclerosis en 11 pacientes, enfermedad de Buerguer en 5,ateroembolismo en 1 y esclerodermia en 1 paciente. El tiempo mediano de tratamiento ha sido90 días. Tres (16,7 %) pacientes precisaron de amputación menor, y un caso, de amputación infracondílea(5,5 %). No se produjo elevación de transaminasas en ninguno de los casos. En 16 pacientes(88,9 %) mejoró el dolor y en 11 (61,1 %) se redujo el tamaño de las lesiones.Conclusiones. En este estudio se presenta por primera vez que el tratamiento con bosentanpuede ser útil en pacientes irrevascularizables, mejorando el dolor y el tamaño de las lesiones,con una baja incidencia de amputaciones mayores a corto plazo(AU)

Introduction. Tissue ischaemia is the end result of a process involving a large number ofmolecules that mediate the endothelium-vascular smooth muscle interaction, among which isfound endothelin-1 (ET-1), a molecule synthesized by the vascular endothelium and inducesvasoconstriction, is proinfl ammatory, and has mitogenic action.Objective. To evaluate the use of bosentan, a dual endothelin receptor antagonist in thetreatment of ischaemic digital ulcers.Patients and method. A total of 18 patients were treated with bosentan for digital ulcerssecondary to scleroderma or other cause (outside indication guidelines), with severe involvementof distal vessels and non-revascularisable.Results. The aetiology was atherosclerosis in 11 patients, Buerguer disease in 5, embolism in 1,and scleroderma in 1 patient. The median length of treatment was 90 days. Three (16.7 %)patients required minor amputation and 1 case (5.5 %) below-knee amputation. There was noincrease in transaminases in any case. There was an improvement of pain in 16 patients (88.9 %)and 11 (61.1 %) had decreased the size of the lesions.Conclusions. This is the first study to show that treatment with bosentan may be useful innon-revascularisable patients, improving pain and lesion size, with a low incidence of majoramputations in the short term(AU)

Tratamiento de las oclusiones crónicas en el sector femoropoplíteo mediante técnicas endovasculares / Treatment of chronic femoropopliteal occlusions using endovascular techniques

Introducción. El avance de las técnicas endovasculares ha proporcionado nuevas opciones en eltratamiento de lesiones complejas en el sector femopoplíteo.Objetivo. Evaluar los resultados del tratamiento endovascular en la patología oclusiva crónicadel sector femoropoplíteo.Material y métodos. Desde febrero de 1997 hasta febrero de 2009 se han incluido todas las oclusionescrónicas limitadas a la arteria femoral superfi cial y primera porción de poplítea intervenidasmediante tratamiento endovascular. Se han analizado la comorbilidad y las variables quepudieron relacionarse con reestenosis y salvación de extremidad. Las modalidades de tratamientohan sido la angioplastia simple y la angioplastia asociada a stent recubierto o norecubierto.Resultados. Durante el periodo de estudio han sido tratados 52 pacientes, con una edad mediade 71,7 años (40-94), 69,2 % varones, 53,8 % diabéticos, 69,2 % fumadores y 67,3 % hipertensos.Las lesiones tratadas (TASC II) fueron: 25 % tipo A, 46,2 % tipo B y 28,8 % tipo C. La longitud mediade la lesión fue de 73,6 mm (20-150). Hubo tres embolizaciones distales peroperatorias y cuatrooclusiones precoces. El seguimiento mediano fue de 18 meses (1-115), basado en datos clínicos,hemodinámicos y ecográfi cos. Permeabilidad primaria (3, 6, 12 y 24 meses, respectivamente):85 %, 76,8 %, 60 % y 52,5 %; primaria asistida: 85 %, 82,3 %, 74 % y 74 %; secundaria: 91,4 %, 86 %,76,4 % y 76,4 %. Ocho oclusiones tardías no pudieron ser recanalizadas, por lo que se realizóbypass (6 casos) y amputación (2 casos).Conclusiones. El tratamiento de lesiones complejas del sector femoropoplíteo, como son lasoclusiones crónicas, mediante técnicas endovasculares es una opción segura y efi caz en pacientesseleccionados(AU)

Introduction. Advances in endovascular techniques have provided new options in the treatmentof complex infrainguinal occlusive lesions.Aims. To evaluate the effectiveness and patency of endovascular treatment in patients withfemoropopliteal occlusive disease.Methods. All patients undergoing endovascular interventions for superfi cial femoral artery andabove knee popliteal artery obstructions between February 1997 and February 2009 wereretrospectively reviewed and assessed for comorbidities, operative and follow-up variablespotentially associated with restenoses and limb salvage.Results. During the study period, 52 patients were treated. Patients were 71.7 years (range40 to 94), 69.2 % male, 53.8 % diabetic, 69.2 % current or former smokers, and 67.3 % hypertensive.Lesions were 28.8 % TASC II C, 46.2 % TASC II B, and 25 % TASC II A. Mean recanalization length was73.6 mm (range 20 to 150 mm). There were three embolizations, and four early thrombosis.Mean follow-up time was 18 months (range 1 to 115), based on clinical, hemodynamic,and ultrasound data. Primary patency rates were 85 %, 76.8 %, 60 % and 52.5 % at 3, 6,12 and 24 months. Ten restenoses were successfully treated. The assisted primary patency rateswere 85 %, 82.3 %, 74 % and 74 % at 3, 6, 12 and 24 months. Eight complete occlusions could notbe reverted by a second recanalization procedure, and were treated by surgical bypass (6 cases)and amputation (2 cases). The secondary patency rates were 91.4 %, 86 %, 76.4 % and 76.4 % at 3,6, 12, and 24 months.Conclusions. Endovascular recanalization is a viable and effective strategy for lower limbrevascularization in selected patients(AU)

Valor pronóstico de la fl ujometría intraoperatoria en las fístulas nativas para hemodiálisis / Prognostic value of intraoperative fl owmetry in autogenous fi stula for haemodialysis

Introducción. Las fístulas arteriovenosas (FAV) autólogas son los mejores accesos vasculares parahemodiálisis debido a su durabilidad y a su bajo porcentaje de complicaciones.Objetivo. Determinar la utilidad de la fl ujometría intraoperatoria como valor pronóstico en lapermeabilidad precoz prehemodiálisis de las FAV nativas.Pacientes y método. Se ha realizado la medición de fl ujos intraoperatorios (FIO) mediante fl ujómetro(Medi-Stim mod. Butterfl y Flowmeter, Noruega) en 204 FAV nativas, 106 radiocefálicas(FAV RC) (52 %) y 98 humerocefálicas (FAV HC) (48 %). Se registraron para su análisis otras variables,como el sexo, la edad, la presencia de diabetes o hipertensión arterial. Se ha valorado lafuncionalidad de la FAV dentro del primer mes, considerándose permeables aquellas que presentabansoplo y/o thrill.Resultados. Permeabilidad precoz global de 94,1 % (192), FAV RC 90,6 % (96) y FAV HC 98 % (96).Curva COR del FIO diastólico FAV RC: área bajo la curva 73,1 % (intervalo de confi anza 95 %, límites:0,58-0,89). Para un valor de 60 ml/min: sensibilidad 81 %, especifi cidad 60 %.Conclusiones. El fl ujo diastólico determinado mediante fl ujometría intraoperatoria muestra unabuena correlación con el pronóstico inicial de las FAV(AU)

Background. Autogenous arteriovenous fi stula (AVF) are the best vascular access for haemodialysis due to its durability and low complication rates. Objective. The purpose of this study is to determine the usefulness of intra-operative blood fl owmeasurement as a prognostic value with respect to pre-haemodialysis patency of the AVF.Patients and methods. Intra-operative blood fl ow (IOF) was measured by ultrasonic transit timeflowmetry (Medi-Stim mod. Butterfly Flowmeter, Norway) in 204 AVFs, 106 radiocephalic(RCAVFs) (52 %) and 98 brachiocephalic (BCAVFs) (48 %). Demographic variables such as sex, age,presence of diabetes or arterial hypertension were analysed. The functionality of the AVF duringthe first month was evaluated, considering as patent those having an audible bruit and/orpalpable thrill.Results. Early patency AVFs 94.1 % (192), RCAVFs 90.6 % (96) and BCAVFs 98 % (96). ROC analysisof the diastolic IOF of RCAVF: area under the curve 73.1 % (95 % confi dence interval: 0.58-0.89).For a value of 60 ml/min: sensitivity 81 %, specifi city 60 %.Conclusions. Diastolic intra-operative blood fl ow measurement shows a good correlation withthe initial outcome of AVF(AU)

Aneurisma poplíteo roto resuelto mediante tratamiento endovascular / Resolution of a ruptured popliteal aneurysm by endovascular treatment

Introducción. Los aneurismas poplíteos son los aneurismas periféricos más frecuentes, siendo habitualmenteasintomáticos. Las complicaciones más frecuentes son la trombosis y la embolización, mientras que la rotura no resultahabitual. El diagnóstico precoz es importante porque la rotura de un aneurisma poplíteo suele acompañarse de pérdidade la extremidad. Caso clínico. Varón de 75 años de edad con clínica inicial sugerente de trombosis venosa profunda, alcual se le diagnosticó un aneurisma poplíteo roto mediante eco-Doppler. El tratamiento del aneurisma pudo realizarsemediante la implantación de un stent recubierto de PTFE, con buen resultado técnico. La correcta exclusión del aneurisma,así como la ausencia de sintomatología, se mantienen un mes después del alta. Conclusión. Si bien el tratamientoclásico ha consistido en ligadura y exclusión del aneurisma y la realización de un bypass venoso o protésico, el tratamientoendoluminal con stent recubierto supone una alternativa poco invasiva y que puede resultar segura y eficaz paratratar a estos pacientes. El seguimiento permitirá comprobar si el tratamiento es también válido a largo plazo(AU)

Introduction. Popliteal aneurysms are the most common peripheral aneurysms, and are usually asymptomatic.The most frequent complications are thrombosis and embolisation, while rupture is not very usual. Early diagnosis isimportant because the rupture of a popliteal aneurysm is usually leads to loss of the limb. Case report. A 75-year-oldmale patient with clinical features that initially suggested deep vein thrombosis, in whom a ruptured popliteal aneurysmwas diagnosed by means of Doppler ultrasound. Treatment of the aneurysm was carried out by placement of a PTFEcoveredstent, with good technical results. Both correct exclusion of the aneurysm and absence of symptoms continueone month after discharge from hospital. Conclusions. Although the classic treatment has consisted in ligation andexclusion of the aneurysm and performing a venous or prosthetic bypass, endoluminal treatment with a covered stentrepresents an alternative that is barely invasive and may well constitute a safe and efficient method for treating thesepatients. The follow-up will make it possible to determine whether the treatment is also valid in the long term(AU)