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)

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)

Tratamiento de la patología oclusiva de la arteria femoral superficial con el dispositivo Viabahn / Treatment of occlusive pathologies of the superficial femoral artery with a Viabahn device

Objetivos. Presentamos los resultados del tratamiento de la patología oclusiva de la arteria femoral superficial (AFS) con el stent recubierto autoexpandible Viabahn –grupo endovascular (EV)-. Comparamos dichos resultados con los obtenidos con el bypass (BP) protésico a primera porción de poplítea –grupo BP-. Pacientes y métodos. Diseño retrospectivo. 46 pacientes (46 extremidades) se han intervenido en 5 años. Indicación de tratamiento: claudicación intermitente o isquemia crítica. Lesiones tratadas: B o C de la clasificación TASC (TransAtlantic Inter. Society Consensus) II. Seguimiento clínico y mediante estudio hemodinámico. En el grupo EV también mediante eco-Doppler. Se ha realizado un estudio descriptivo de permeabilidad de la serie y un análisis de factores pronósticos. Resultados. Grupo EV, 20 pacientes (43,5%), y grupo BP, 26 pacientes (56,5%). La indicación clínica fue mayoritariamente (85%) isquemia crítica en ambos grupos. Hubo diferencias en el tipo de lesión intervenida, TASC-B (60%) en el grupo EV y TASC-C (85%) en el grupo BP (p=0,002). En el grupo EV, 3 pacientes presentaron fracaso hemodinámico y 4 oclusiones (1 amputación mayor). En el grupo-BP se ocluyeron 4 injerto (1 amputación mayor). La permeabilidad primaria y secundaria al año para ambos procedimientos ha sido: grupo EV, 50 y 75%; grupo BP, 87 y 91%. Conclusiones. El tratamiento EV con el dispositivo Viabahn en lesiones tipo B en el sector femoropoplíteo ofrece buenos resultados inmediatos durante el seguimiento. Si bien los resultados no son tan favorables en lesiones tipo C, el tratamiento EV podría ser una alternativa al BP supragenicular en estenosis largas o en tándem, especialmente si se precisa recanalización de la AFS

Aim. We present the outcomes of treatment of occlusive pathologies in the superficial femoral artery (SFA) using the Viabahn self-expanding covered stent – the endovscular (EV) group. We compared these results with those obtained using a prosthetic bypass (BP) in the first portion of the popliteal –the BP group. Patients and methods. The study followed a retrospective design. Over a period of 5 years, surgery was performed on 46 patients (46 limbs). Indication for treatment: intermittent claudication or critical ischaemia. Lesions that were treated: B or C on the TASC (TransAtlantic Inter Society Consensus) II classification. Clinical monitoring by means of haemodynamic studies. Doppler ultrasound was also used in the EV group. Both a descriptive study of the patency of the series and an analysis of prognostic factors were carried out. Results. EV group, 20 patients (43,5%), and BP group, 26 patients (56,5%). The clinical indication was mostly critical inchaemia (85%) in the two groups. There were differences in the type of lesion that was treated by surgery: TASC-B (60%) in the EV group and TASC-C (85%) in the BP group (p=0.002). In the EV group, 3 patients presented haemodynamic failure and there were 4 occlusions (1 major amputation). In the BP group 4 grafts became occluded (1 major amputation). Primary and secondary patency at one year for the two procedures was: EV group, 50 and 75%; BP group, 87 and 91%. Conclusions. EV treatment with a Viabahn device in type B lesions in the femoropopliteal segment offers food outcomes, both immediately and during the follow-up. Although the results are not as favourable in type C lesions, EV treatment could be and alternative to above-the-knee BP in long or tandem stenoses, especially if recanalisation of the SFA is required

[Immediate and long-term outcomes of carotid endarterectomies in eighty-year-olds]. / Resultados inmediatos y a largo plazo de la endarterectomía carotídea en octogenarios.

AIMS: To compare the immediate results obtained after performing a carotid endarterectomy (cEDA) in patients in their eighties with those of younger patients, and to determine survival and stroke-free times following carotid surgery in the two groups. PATIENTS AND METHODS: Retrospective data was collected regarding a series of 319 cases of cEDA (302 patients) performed between January 1998 and December 2004. Group 1: patients aged 80 or above. Group 2: the rest of the series. Sample follow-up: clinical and by means of carotid duplex. RESULTS: Mean age of the sample: 70.7 years (41-86). Group 1 was made up of 30 patients (9.4% of the series). Mortality rate: group 1, 3.3%; group 2, 1%; p=0.32. Major stroke-death incidence: group 1, 6.7%; group 2, 1.4%; p= 0.1. Median follow-up time: 36 months (1-87). Total mortality of the series throughout follow-up: 36 patients (12.6%). Mortality rate: group 1, 25%; group 2, 11.3%; p=0.04; relative risk: 2.6 (1.02-6.7). Stroke: group 1, 14.3%; group 2, 2.3%; p=0.01; relative risk: 7 (1.8-26.4). At five years, 96.7% were free of strokes (group 1: 84%; group 2, 97.7%; p=0.0001). At five years, 82.4% survived free of strokes (group 1: 61%; group 2, 84.4%; p=0.004). CONCLUSIONS: The risk of perioperative complications is higher in patients in their eighties than in younger patients, although the increase is not statistically significant. Even though the risk of a stroke during follow-up was higher in the eighty-year-olds, 84% of the subjects in this group remained stroke-free at five years. The high stroke-free survival rate in the medium to long term means that cEDA can be especially beneficial for patients in their eighties.

Resultados inmediatos y a largo plazo de la endarterectomía carotídea en octogenarios / Immediate and long-term outcomes of carotid endarterectomies in eighty-year-olds

Objetivos. Comparar los resultados inmediatos de la endarterectomía carotídea (EDAc) en pacientes octogenarios con los de pacientes de menor edad. Determinar la supervivencia y el tiempo libre de ictus tras la cirugía carotídea en ambos grupos. Pacientes y métodos. Se ha realizado una recogida prospectiva de una serie de 319 EDAc (302 pacientes) desde enero de 1998 a diciembre de 2004. Grupo 1: pacientes iguales o mayores de 80 años. Grupo 2: resto de la serie. Seguimiento de la muestra: clínico y mediante dúplex carotídeo. Resultados. Edad media de la muestra: 70,7 años (41-86). El grupo 1 está compuesto por 30 pacientes (9,4% de la serie). Mortalidad: grupo 1: 3,3%, grupo 2: 1%, p = 0,32. Incidencia de ictus mayor-muerte: grupo 1: 6,7%, grupo 2: 1,4%, p = 0,1. Tiempo mediano de seguimiento: 36 meses (1-87). Mortalidad total de la serie durante el seguimiento: 36 pacientes (12,6%). Mortalidad: grupo 1: 25%, grupo 2: 11,3%, p = 0,04, riesgo relativo: 2,6 (1,02-6,7). Ictus: grupo 1: 14,3%, grupo 2: 2,3%, p = 0,01, riesgo relativo: 7 (1,8-26,4). El 96,7% ha permanecido libre de ictus a los cinco años (grupo 1: 84%, grupo 2: 97,7%, p = 0,0001). El 82,4% de la serie ha sobrevivido libre de ictus a los cinco años (grupo 1: 61%, grupo 2: 84,4%, p = 0,004). Conclusiones. Los pacientes octogenarios presentan un mayor riesgo de complicaciones perioperatorias, aunque no estadísticamente significativas, con respecto a los pacientes más jóvenes. Si bien el riesgo de ictus durante el seguimiento ha sido mayor en los octogenarios, el 84% de los sujetos de este grupo permanecía libre de ictus a los cinco años. Los octogenarios se podrían beneficiar especialmente de la EDAc, con supervivencia libre de ictus elevada a medio-largo plazo

AIMS. To compare the immediate results obtained after performing a carotid endarterectomy (cEDA) in patients in their eighties with those of younger patients, and to determine survival and stroke-free times following carotid surgery in the two groups. PATIENTS AND METHODS. Retrospective data was collected regarding a series of 319 cases of cEDA (302 patients) performed between January 1998 and December 2004. Group 1: patients aged 80 or above. Group 2: the rest of the series. Sample follow-up: clinical and by means of carotid duplex. RESULTS. Mean age of the sample: 70.7 years (41-86). Group 1 was made up of 30 patients (9.4% of the series). Mortality rate: group 1, 3.3%; group 2, 1%; p = 0.32. Major stroke-death incidence: group 1, 6.7%; group 2, 1.4%; p = 0.1. Median follow-up time: 36 months (1-87). Total mortality of the series throughout follow-up: 36 patients (12.6%). Mortality rate: group 1, 25%; group 2, 11.3%; p = 0.04; relative risk: 2.6 (1.02-6.7). Stroke: group 1, 14.3%; group 2, 2.3%; p = 0.01; relative risk: 7 (1.8-26.4). At five years, 96.7% were free of strokes (group 1: 84%; group 2, 97.7%; p = 0.0001). At five years, 82.4% survived free of strokes (group 1: 61%; group 2, 84.4%; p = 0.004). CONCLUSIONS. The risk of perioperative complications is higher in patients in their eighties than in younger patients, although the increase is not statistically significant. Even though the risk of a stroke during follow-up was higher in the eighty-year-olds, 84% of the subjects in this group remained stroke-free at five years. The high stroke-free survival rate in the medium to long term means that cEDA can be especially beneficial for patients in their eighties

Recurrent carotid artery stenosis following endarterectomy: natural history and risk factors.

OBJECTIVES: To establish the incidence of restenosis (RES) following carotid endarterectomy (CEA) and evaluate clinical and technical factors related to its development. DESIGN: Prospective non-randomised cohort study. PATIENTS AND METHODS: Two hundred and twenty-four patients with 243 CEA between May 1998 and December 2002, were subjected to clinical and haemodynamic follow-up, median follow-up 23 months (1-56). There was selective use of a shunt (17.3%) and patch (61.7%). RES (> or =50%) and severe restenosis, > or =70%, (sRES) were defined as peak systolic velocities of > or =150 and > or =300cm/s (or > or =250cm/s with diastolic velocity >100cm/s), respectively. Rates of RES, symptom development and mortality were analysed using Kaplan-Meier curves. Cox's regression model (hazards ratio/95% CI) was used to evaluate prognostic factors. RESULTS: We detected 13 sRES (5.3%) (median time 6.1 months) and 30 (12.3%) moderate stenosis (mRES) (median time 3.7 months). Cumulative freedom from sRES at 23 months was 94.2%. Five sRES detected in the first 45 days after the procedure were deemed to be residual restenosis (rRES). Five (38.4%) sRES were symptomatic, 15.3% progressed to occlusion. Patient survival was 98.0 and 96.4% at 12 and 24 months, respectively. Independent risk factors for sRES: female sex (HR: 3.3, 95% CI 1.1-10 p=0.04) and diabetes (HR: 4.5, 95% CI 1.4-13.9 p=0.008). CONCLUSIONS: Carotid restenosis appears early, is usually low-grade and mostly asymptomatic. Although few stenoses progress to occlusion, women and diabetic patients were at highest risk.

Operative repair of popliteal aneurysms: effect of factors related to the bypass procedure on outcome.

The objective of this study was to compare patency rates following the repair of popliteal aneurysms according to the site of inflow, material of bypass graft and quality of distal runoff. Seventy bypasses were performed over an 11-year period. Autogenous saphenous vein was used in 53 procedures (75.7%) and prosthetic material was used in 17 (24.3%). Early mortality was 2.8%. Early primary and secondary patency rates were 95.7% and 97.1%, respectively. Autogenous vein showed better 10-year patency than prosthetic material (86% vs. 57%; p = 0.02). No significant differences in patency were observed according to the inflow site (87.8% groin vs. 74.7% supragenicular). Bypasses that originated in the groin showed improved patency when a saphenous vein was used (84.8% vs. 43.7%; p = 0.01). However, no influence of the graft material was noted in supragenicular bypasses (90.4% vs. 84.8%; p = 0.6). Bypasses in extremities with good runoff showed better patency than those in limbs showing poor runoff (86% vs. 55%; p = 0.003). The use of saphenous vein for the repair of popliteal aneurysms showed better results than those with prosthetic material, although in bypasses originating from the distal superficial femoral or above-knee popliteal artery, no significant differences in patency were observed. Good distal runoff was associated with improved overall outcome.

¿Cuál es el pronóstico de las derivaciones in situ reintervenidas por fracaso hemodinámico? / What is the prognosis of in situ bypass grafts submitted to revision because of hemodynamic failure?

Introducción. Hasta en un 20 per cent de las derivaciones in situ (BP) aparece un fracaso hemodinámico (FH) en su seguimiento, además de que existe aún controversia acerca de su manejo. Objetivo. Evaluar los resultados de BP reintervenidos por FH. Pacientes y métodos. Se han reintervenido 47 BP por estenosis grave en el trayecto o las anastomosis (19852001). Diagnóstico: clínico, hemodinámico, ecográfico. Localización de la lesión: anastomosis proximal (19,1 per cent), trayecto del injerto (42,6 per cent), anastomosis distal (38,3 per cent). El 70,2 per cent de las reintervenciones se realizaron dentro del primer año tras la intervención inicial, el 13 per cent en el segundo año y un 17 per cent más tarde. Se repararon seis casos mediante angioplastia percutánea (PTA) y 41 mediante cirugía. Resultados. Seguimiento medio tras la reparación: 35 meses. Permeabilidad primaria-asistida (PPA): 95,7 per cent al mes, 84,2 per cent al año y 72 per cent a los tres años. Porcentaje libre de eventos (PLE): 95,7, 70,5 y 53,2 per cent respectivamente. Salvación de la extremidad (SE): 100, 97,5 y 86,7 per cent. La localización del defecto o de la anastomosis distal y el diámetro del injerto no han influido en los resultados (p> 0,05). La PTA ha aumentado el riesgo de oclusión (riesgo relativo [RR]= 12,9; intervalo de confianza [IC] 95 per cent= 2,8-60; p= 0,002) y amputación tardías (RR= 14,3; IC 95 per cent= 1,3-157; p= 0,028).La reintervención dentro del primer año ha aumentado el riesgo de nuevo FH en el seguimiento (RR= 3,8; IC 95 per cent= 1,1-16,8; p= 0,034).Conclusiones. Se consiguen buenas PPA y SE tras la reparación de injertos en riesgo, aunque requieren una vigilancia estrecha por no ser rara la presentación de nuevos episodios en su seguimiento. El tratamiento quirúrgico es eficaz. Es recomendable el seguimiento indefinido por posible FH después del primer año (AU)

Popliteo-distal and tibio-tibial bypasses: a viable alternative for the revascularisation of the critically ischaemic limb.

BACKGROUND: The aim of the present study was to evaluate graft patency and limb salvage rates of popliteo-distal and tibio-tibial bypasses performed for critical ischaemia of the lower limb. METHODS: Thirty short bypasses performed during a five-year period (1994-1998) were reviewed. The inflow source was the supragenicular popliteal artery in 14 patients, the infragenicular popliteal artery in 12 patients and a tibial artery in four patients. Distal outflow was to a pedal vessel in 14 patients, and above the malleolus in 16 patients. Autogenous vein was used as conduit (saphenous vein in 28 patients and cephalic vein in two patients). RESULTS: Operative mortality was 3.3%. Early graft patency and limb salvage rates were 90 and 93%, respectively. Late primary and secondary patency, and limb salvage rates were 77%, 80 and 76% at 12 months, and 71, 74 and 76% at 24 months, respectively. These rates showed no differences attributable to diabetes, inflow or outflow site, surgical technique or slight proximal involvement. There was no progression of disease in the superficial femoral artery, even in the presence of moderate preoperative lesions. CONCLUSIONS: Popliteo-distal and tibio-tibial bypasses are durable procedures which yield good bypass patency and limb salvage rates.