Registro de actividades de la Sociedad Española de Angiología y Cirugía Vascular, año 2019 / Registry of activities of the Spanish Society of Angiology and Vascular Surgery, year 2019

Objetivo: describir la actividad asistencial del año 2019 de los servicios/unidades de angiología y cirugía vascular en España. Pacientes y métodos: estudio transversal con encuesta a 107 centros sobre procedimientos quirúrgicos y exploraciones vasculares realizados en 2019. Análisis descriptivo de resultados y comparación de la ratio de actividad /100 000 habitantes con 2018. Resultados: respondieron 44 servicios (41,1 %), 4 de ámbito privado. De los 42 servicios docentes, respondieron 29 (65,9 %), un 65,9 %. En los servicios que respondieron se produjeron 26 960 ingresos, el 46,4 % urgentes y el 53,5 % programados (estancia media: 6,8 días). En la mayoría de sectores no hubo cambios significativos en la ratio/100 000 habitantes, salvo un aumento moderado (10,7 frente a 9,4) en el sector distal, tanto en procedimientos quirúrgicos (3,3 frente a 2,8) como en endovasculares (7,3 frente a 6,6). Descenso moderado de procedimientos endovasculares en los troncos supraaórticos (1,4 frente a 1,6). Hubo una disminución moderada de procedimientos quirúrgicos en aorta torácica (0,17 frente a 0,20) y abdominal (2,38 frente a 2,78), que contrastó con un aumento moderado en procedimientos endovasculares abdominotorácicos (0,40 frente a 0,35). En las arterias viscerales se encontró una disminución relevante de procedimientos endovasculares (0,89 frente a 1,16) y un aumento moderado de los quirúrgicos (0,99 frente a 0,89). En el sector aortoilíaco hubo un aumento moderado de procedimientos endovasculares (6,8 frente a 5,8). En 2019 también se encontró una disminución relevante en el número de procedimientos endovasculares relacionados con los accesos de hemodiálisis (1,2 frente a 1,5), un descenso moderado en el número de amputaciones mayores (6,9 frente a 7,8) y un descenso relevante de actividad sobre las malformaciones (0,32 frente a 0,59). Se encontró un aumento moderado en la actividad global sobre el sector venoso con respecto a la de 2018 (93,3 vs. 80,3)...(AU)

Introduction and objective: to describe the healthcare activity of the Angiology and Vascular Surgery services/units in Spain in 2019.Patients and methods: cross-sectional study with a survey of 107 centers on surgical procedures and vascularexplorations performed in 2019. Descriptive analysis of results and comparison of the activity ratio / 100,000inhabitants with 2018.Results: 44 services responded (41.1 %), with only 4 being private. Of the 42 teaching services, 29 (65.9 %) respon-ded, representing 65.9 % of the total. In the services that responded, there were 26,960 admissions, 46.4 % urgentand 53.5% scheduled, with an average stay of 6.8 days. Global surgical activity in arterial surgery in 2019 was similarto that of 2018. In most sectors there were no significant changes in the ratio / 100,000 inhabitants, except for amoderate increase (10.7 vs. 9.4) in the distal sector , finding the increase in both surgical procedures (3.3 vs. 2.8) andendovascular procedures (7.3 vs. 6.6). Furthermore, a moderate decrease in endovascular procedures was foundin the supra-aortic trunks (1.4 vs. 1.6). There was a moderate decrease in surgical procedures in the thoracic aorta(0.17 vs. 0.20) and abdominal (2.38 vs. 2.78), which contrasted with a moderate increase in thoraco-abdominalendovascular procedures (0.40 vs. to 0.35). In visceral arteries, a relevant decrease in endovascular procedures wasfound (0.89 vs. 1.16) and a moderate increase in surgical procedures (0.99 vs. 0.89). In the aorto-iliac sector therewas a moderate increase in endovascular procedures (6.8 vs. 5.8). In 2019, a relevant decrease was also found inthe number of endovascular procedures related to hemodialysis accesses (1.2 vs. 1.5), and a moderate decreasein the number of major amputations (6.9 vs. 7.8)...(AU)

Extrathoracic Aneurysms in Marfan Syndrome: A Systematic Review of the Literature.

BACKGROUND: Marfan syndrome (MS) most often shows as thoracic aortic aneurysm (TAA) or aortic dissection, but it may also involve other vascular territories. This study aimed to identify those extrathoracic vascular manifestations most frequently associated with MS. METHODS: A systematic review of the literature with Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria was carried out. The following databases were included: MEDLINE, Embase, Web of Science, Cumulative Index of Nursing and Health Sciences Literature (CINHAL); Spanish database MEDESY Cochrane Central Register of Controlled Trials (CENTRAL). RESULTS: A total of 10,008 articles were identified, leaving 155 for the first stage of data analysis (total incidence of aneurysms) and 83 for the second (descriptive data analysis). Overall, 518 aneurysms were identified: 149 in the head and neck, 94 in the extremities, and 275 in the aortic, iliac, and visceral sectors. Mostly, they were simultaneously discovered during studies of the TAA. In the abdominal aorta, the presentation with rupture in 11 of 32 patients stands out. Resection and bypass were the most frequently used methods for repair in the treated cases. CONCLUSIONS: Although its frequency in the general population is unknown, this systematic review suggests that extrathoracic aneurysmal arterial involvement in the MS may be more frequent than expected. We believe screening for aneurysms in other vascular sectors may be advisable, especially in patients with MS and TAA.

Conservative Surgical Management of Late Carotid Patch Infection in a Patient with Subsequent Stenting for Restenosis.

Carotid patch infection is a rare but dreaded complication after endarterectomy. About 160 cases can be found in literature, but presentation in a patient with post-endarterectomy stenting has not been reported. Most frequent clinical manifestations include the occurrence of a sinus, a pseudoaneurysm, or neck swelling, but in severe cases it may present anastomosis dehiscence with hematoma or hemorrhage. Usually, patch removal and reconstruction is recommended, but there is not a standard protocol for management. Conservative surgical management with patch preservation has only been reported in a minority of cases. We report a patient with a history of carotid endarterectomy and subsequent carotid stenting 21 months later because of >80% restenosis. He presented a sinus in the scar 81 months after the former intervention. The patient underwent surgery, and during the procedure, a detachment of a small segment of the Dacron patch from the surrounding tissue was found. The sinus tract was resected, and after verifying the integrity of the patch, it was irrigated with rifampicin and preserved in situ. S. epidermidis was isolated from tissue cultures. Twenty-four months later, the patient remains asymptomatic and duplex ultrasound shows no signs of infection. Conservative surgical approach can be a valid option for treatment and may be considered in selected patients with limited infection.

Endotension: twenty years of a controversial term.

Use of the term endotension in the treatment of aortic aneurysm is currently controversial. Initially it was proposed to define the circumstance in which there is an enlargement of the aneurysm sac after endovascular repair without a demonstrable endoleak. The term was established with the aim of transmitting the possibility of causes other than pressure applying stress to the aneurysm wall. Twenty years have passed since the proposal of this terminology was published. The literature is reviewed with the purpose of providing an update on advances in the knowledge of the possible etiological mechanisms. The experimental studies call into question that causes other than pressure determine the increase of the aneurysm. On the basis of this review, the term `Sac Expansion Without Evident Leak´ (SEWEL) is proposed as a more accurate and precise denomination for what is aimed to be defined. Evidence suggests that the more likely mechanisms of persistent pressurization of the aneurysm sac are an unidentified endoleak (likely type I or low-flow Type II) or thrombus occluding wide and short channels that connects with the excluded aneurysm sac (at the attachment sites of the stent-graft or at the branch vessels orifices).

Registro de actividades de la Sociedad Española de Angiología y Cirugía Vascular, año 2018 / Register of activities of the Spanish Society of Angiology and Vascular Surgery, 2018

OBJETIVO: describir la actividad asistencial del año 2018 de los servicios/unidades de angiología y cirugía vascular en España. PACIENTES Y MÉTODOS: estudio transversal con encuesta a 107 centros sobre procedimientos quirúrgicos y exploraciones vasculares realizados en 2018. Análisis descriptivo de resultados y comparación de la ratio de actividad / 100 000 habitantes respecto al año 2016. RESULTADOS: respondieron 53 servicios (49,5%). De los 42 servicios docentes, respondieron 33 (78,5%), un 62,2% del total. En los servicios que respondieron se produjeron 36 321 ingresos, con una estancia media de 7,1 días. La actividad quirúrgica global en cirugía arterial en 2018 fue semejante a la de 2016. Hubo sectores sin cambios significativos en la ratio / 100 000 habitantes. En 2018 se encontró una disminución relevante en el número de procedimientos relacionados con los accesos de hemodiálisis (17,8 frente a 25,3). La actividad en amputaciones mayores fue semejante (7,8 frente a 7,5), con un aumento moderado de las menores (13,5 frente a 11,6). En la tasa de actividad sobre malformaciones se encontró una disminución relevante (0,5 frente a 1,5). Por otro lado, se encontró un aumento relevante en la actividad global sobre el sector venoso en 2018 con respecto a la de 2016 (80,3 frente a 66,6). CONCLUSIÓN: se encontró una disminución ligera de la actividad quirúrgica arterial global debido a la disminución moderada de procedimientos endovasculares, sobre todo aórticos. La actividad quirúrgica venosa global ha aumentado de forma relevante, con gran aumento de procedimientos endovasculares. Las exploraciones vasculares presentaron una disminución relevante. Con relación a 2016, aumentó la participación, lo que puede condicionar la interpretación de los resultados

OBJECTIVE: cross-sectional study using a questionnaire sent to 107 centres on surgical procedures and vascular examinations performed in 2018. A descriptive analysis of results and comparison of the activity ratio/100,000 population with 2016 is also presented. PATIENTS AND METHODS: cross-sectional study using a questionnaire sent to 107 centres on surgical procedures and vascular examinations performed in 2018. A descriptive analysis of results and comparison of the activity ratio/100,000 population with 2016 is also presented. RESULTS: responses were received from 53 department (49.5%), including only 3 private centres. Of the 42 teaching centres, 33 responses were received (78.5%), corresponding with a 62.2% of all centres. According to received data, in 2018 there were 36,321 admissions (of which 34.3% were emergency and 65.7% were elective), with a mean hospital stay of 7.1 days. The overall arterial surgery activity in 2018 was similar to 2016, although there was a moderate decrease in the endovascular procedures rate. In some segments there were no significant changes in the ratios/100,000 population: 8.9 vs. 9.3 in supra-aortic trunks; 23.6 vs. 23.5 in the femoropopliteal segment and 9.4 vs. 10.3 in infrapopliteal segment. A relevant increase of endovascular procedures in supra-aortic trunks was found (1.6 vs. 1.2). There was a moderate decrease in the activity rate in thoracic aorta (1.53 vs 1.90), thoracic-abdominal aorta (0.43 vs. 0.49) and abdominal aorta (8.7 vs. 10.8), whereas the decrease in obstructive pathology of aortic-iliac segmen twas relevant (9.2 vs. 13.1). In 2018 there was also a moderate increase of activity in the visceral arteries (2.05 vs. 1.81), in contrast to a relevant decrease in the number of hemodialysis access procedures (17.8 vs. 25.3). Compared to 2016, major amputations rate was similar (7.8 vs. 7.5), with a moderate increase of minor amputations (13.5 vs. 11.6). There was also a relevant decrease in malformations (0.5 vs. 1.5). On the other hand, a relevant increase in overall venous surgery activity was found in 2018 (80.3 vs. 66.6). There increase was found in varicous veins procedures and also in thrombotic disease procedures. A relevant decrease of the vascular examination ratio/10000 population was found (607.9 vs. 850.6). CONCLUSION: a mild decrease in the overall arterial surgical activity was found because of the moderate decrease in endovascular procedures, especially those related to the aorta. The overall venous surgical activity increased significantly because of a higher number in endovascular procedures. There was a relevant decrease of vascular examinations. Compared to 2016, there was an increase in participating centres, which may condition the interpretation of the results

Por qué es importante el registro / Why register is important?

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Registro de actividades de la Sociedad Española de Angiología y Cirugía Vascular, año 2016 / Register of activities of the Spanish Society of Angiology and Vascular Surgery, 2016

OBJETIVO: describir la actividad asistencial del año 2016 de los servicios/unidades de angiología y cirugía vascular en España. PACIENTES Y MÉTODOS: estudio transversal con encuesta a 107 centros sobre procedimientos quirúrgicos y exploraciones vasculares realizados en 2016. Análisis descriptivo de resultados y comparación de la ratio de actividad / 100 000 habitantes con 2014. RESULTADOS: respondieron 41 servicios, ninguno en la medicina privada. La actividad quirúrgica global en cirugía arterial en 2016 fue semejante a la de 2014, con variaciones en la ratio / 100 000 habitantes según el sector. Hubo un aumento relevante de la tasa actividad en aorta torácica (1,9 frente a 1,1), aorta toracoabdominal (0,49 frente a 0,38) y arterias viscerales (1,8 frente a 1,3). Hubo también un aumento moderado de actividad en los aneurismas de aorta abdominal (10,8 frente a 9,5) y en la patología obstructiva del sector aortoilíaco (13,1 frente a 11,1). Prácticamente en todas ellas la ratio de procedimientos de cirugía convencional fue inferior, mientras que la de cirugía endovascular aumentó en algunos. En 2016 se encontró un aumento relevante en el número de accesos de hemodiálisis (25,3 frente a 20,6). La actividad en amputaciones mayores y menores fue semejante (7,5 frente a 7,3 y 11,6 frente a 10,7). No se encontró diferencia significativa en la actividad global sobre el sector venoso en 2016 con respecto a la de 2014 (66,6 frente a 65,4), si bien hubo un aumento moderado de procedimientos de cirugía endovascular para tratamiento de varices. También se encontró un aumento moderado de la ratio / 100 000 habitantes de exploraciones vasculares (850,6 frente a 760,5). CONCLUSIONES: se encontró un aumento ligero de la actividad quirúrgica arterial global, con un incremento de procedimientos en algunos territorios; la actividad venosa global se ha mantenido, con gran aumento de procedimientos endovasculares para el tratamiento de varices; también se encontró aumento de las exploraciones vasculares. Con relación a 2014, disminuyó de forma considerable la participación, lo que condiciona el sesgo en la interpretación de los datos

OBJECTIVE: to describe the assistant activity of the year 2016 of the services / units of Angiology and Vascular Surgery in Spain. PATIENTS AND METHODS: a cross-sectional study with a survey of 107 centers on surgical procedures and vascular examinations carried out in 2016. A descriptive analysis of results and comparison of the activity ratio/ 100,000 inhabitants with 2014 was performed. RESULTS: forty-one (38.3%) departments of vascular surgery (27 training units, 71%) in Spain answered this survey. None from private medicine. Regarding to these units there were 29,046 admissions, 36.3% being urgent and 63.7% scheduled, with an average stay of 6.7 days. On the waiting list there was a predominance of venous pathology over arterial (5,783 vs. 1,187). The global surgical activity in arterial surgery in 2016 was similar to that of 2014 with variations in the ratio/ 100,000 inhabitants according to the arterial sector: 9.39 vs. 9.35 in supraaortic trunks; 23.5 vs. 21.9 in the femoropopliteal arteries and 10.3 vs. 9.8 in the distal sector. There was a significant increase in the activity rate in thoracic aorta (1.9 vs. 1.1), thoracoabdominal aorta (0.49 vs. 0.38) and visceral arteries (1.8 vs. 1.3). There was also a moderate increase in activity in abdominal aortic aneurysms (10.8 vs. 9.5) and in obstructive pathology of the aorto-iliac sector (13.1 vs. 11.1). Practically in all of them the ratio of conventional surgery procedures was lower, while that of endovascular surgery increased in some. In 2016, a significant increase was found in the number of hemodialysis accesses (25.3 vs. 20.6). The activity in major and minor amputations was similar (7.5 vs. 7.3 and 11.6 vs. 10.7). There was no significant difference in the overall activity on the venous sector in 2016 compared to 2014 (66.6 vs. 65.4), although there was a moderate increase in endovascular surgery procedures for varicose veins. There was also a moderate increase in the ratio/ 100,000 inhabitants of vascular examinations (850.6 vs. 760.5). CONCLUSIONS: a slight increase in global arterial surgical activity was found, with an increase in procedures in some territories. Global venous activity has been maintained, with a large increase in endovascular procedures for the treatment of varicose veins. An increase in vascular examinations was also found. In relation to 2014, participation decreased considerably, which determines the bias in the interpretation of the results

Guías de diagnóstico de la enfermedad cerebrovascular extracraneal / Diagnostic guidelines for extracranial cerebrovascular disease

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Adventitial cystic disease of radial artery. Apropos of a case and review of literature.

Adventitial cystic disease is an uncommon condition that is characterized by the collection of mucinous material that accumulates in the adventitial layer of the artery. Predominantly, this entity affects the popliteal artery, whereas it is extremely rare in the radial artery. We report a 72-year-old female patient that underwent surgical treatment of an adventitial cyst of the right radial artery. The involved arterial segment was resected, and reconstruction by means of the interposition of a saphenous vein graft was performed. Although the etiology is still debated, the finding of a pedicle through the superficial palmar branch of the radial artery connecting to the adjacent wrist joint reinforces the hypothesis of synovial origin. After 12 months, the patient is asymptomatic, and duplex ultrasound shows no signs of recurrence and patency of the bypass. This rare entity should be suspected when a pulsatile mass is noted in the radial artery because an early diagnosis and appropriate management may prevent further complications.

Arteriocutaneous Fistula Associated with Bilateral Femoral Pseudoaneurysms Caused by Bacillus Calmette-Guérin. Apropos of a Case and Review of Literature.

Vascular complications of intravesical instillation of bacillus Calmette-Guérin (BCG) are rare. BCG is an attenuated strain of Mycobacterium bovis that was initially developed for vaccination against tuberculosis, but it has also been used as an adjuvant treatment for bladder transitional carcinoma. We report a patient with a history of instillation of BCG 2 years before, who underwent surgical treatment of 2 pseudoaneurysms. The first, located in the left superficial femoral artery (SFA), was resected, and the artery was ligated because he had a history of femoropopliteal occlusion. After 4 weeks, he presented another one associated with hemorrhage by cutaneous fistula, in the right common femoral artery. In this case, revascularization was performed by means a common-to-deep femoral artery bypass with polytetrafluorethylene graft and reimplantation of SFA. Initially, bacterial cultures were negative, but bacilli cultures identified M. bovis after 3 weeks. Antituberculosis therapy was administered. After 13 months, the patient was asymptomatic and duplex ultrasound showed no signs of recurrent infection. This exposure should be considered if presentation of the false aneurysm is spontaneous and there is a history of bladder carcinoma.

Combined non-surgical treatment for Paget-Schröetter syndrome: a case report.

BACKGROUND: Paget-Schröetter syndrome is an uncommon form of venous thrombosis, which is related to thoracic outlet syndrome. Axillary-subclavian vein thrombosis typically presents in healthy young adults. We present this case of particular interest because it indicates that a combined treatment involving thrombolysis, anticoagulation therapy, rehabilitation, and elastic compression sleeves can be a valid non-surgical alternative for some patients with Paget-Schröetter syndrome. CASE PRESENTATION: This report describes a case of a 38-year-old white woman, a swimmer, who presented with a sudden episode of swelling and pain in her right upper extremity. After duplex ultrasound diagnosis of venous thrombosis, computed tomography (CT) showed extrinsic compression of the vessel. Catheter-directed thrombolysis was performed in the first 24 hours, followed by anticoagulant therapy with bemiparin at a dose of 7500 IU/24 hours for the first week, and then reduced to 3500 IU/24 hours for the next 3 months. After treatment there was restoration of her venous flow and she returned to work 2 weeks later. Anticoagulant treatment was continued for 3 months; decompression surgery was not performed. At 6 months she was asymptomatic. CONCLUSION: Combined treatment involving thrombolysis, anticoagulant therapy, rehabilitation, and elastic compression sleeves may be a valid non-surgical alternative for a selected subset of patients with Paget-Schröetter syndrome.

A Rare Complication After Endovascular Aneurysm Repair: Disconnection of the Suprarenal Stent of a Zenith Endograft.

PURPOSE: To report a disconnection between the bare suprarenal stent and the main body of a Zenith endograft. CASE REPORT: A 79-year-old man with a history of successful endovascular repair of an aortic aneurysm presented a sudden episode of hypotension and hematuria. He had undergone implantation of a Zenith bifurcated device 8 years earlier in 2006. Plain abdominal radiography and computed tomography showed disconnection of the uncovered proximal stent, which led to endograft migration and type Ia endoleak. The patient also presented with distal endoleaks at the attachment sites in both common iliac arteries. The aneurysm sac diameter had increased from 52 to 96 mm. A proximal aortic cuff and bilateral iliac extensions were deployed via a common femoral artery access. Completion angiography did not show endoleak. CONCLUSION: After publication of a few such cases with the older Zenith device, the union between the suprarenal stent and main body was reinforced in 2002 to prevent this complication. Since modification of the device, this sequela had not been described. The reappearance of this complication underscores the need for continued surveillance, considering that these late events may require a reintervention to maintain the clinical success of the procedure.

Mid-Term Outcomes of Endovascular Treatment for TASC-II D Femoropopliteal Occlusive Disease with Critical Limb Ischemia.

PURPOSE: The purpose of the study was to assess the safety and midterm effectiveness of endovascular treatment in Trans-Atlantic Inter-Society Consensus II (TASC-II) D femoropopliteal occlusions in patients with critical limb ischemia (CLI). METHODS: Patients with CLI who underwent endovascular treatment for TASC-D de novo femoropopliteal occlusive disease between September 2008 and December 2013 were selected. Data included anatomic features, pre- and postprocedure ankle-brachial index, duplex ultrasound, and periprocedural complications. Sustained clinical improvement, limb salvage rate, freedom from target lesion revascularization (TLR), and freedom from target extremity revascularization (TER) were assessed by Kaplan-Meier estimation and predictors of restenosis/occlusion with Cox analysis. RESULTS: Thirty-two patients underwent treatment of 35 TASC-D occlusions. Mean age was 76 ± 9. Mean lesion length was 23 ± 5 cm. Twenty-eight limbs (80 %) presented tissue loss. Seventeen limbs underwent treatment by stent, 13 by stent-graft, and 5 by angioplasty. Mean follow-up was 29 ± 20 months. Seven patients required major amputation and six patients died during follow-up. Eighteen endovascular and three surgical TLR procedures were performed due to restenosis or occlusion. Estimated freedom from TLR and TER rates at 2 years were 41 and 76%, whereas estimated primary and secondary patency rates were 41 and 79%, respectively. CONCLUSIONS: Endovascular treatment for TASC II D lesions is safe and offers satisfying outcomes. This patient subset would benefit from a minimally invasive approach. Follow-up is advisable due to a high rate of restenosis. Further follow-up is necessary to know the long-term efficacy of these procedures.

Rapidly expanding ulnar false aneurysm related to a tablet computer.

Aneurysms of the ulnar artery are rare, usually related to the hypothenar hammer syndrome and caused by repetitive blunt trauma over the hook of the hamate bone. However, rapidly expanding ulnar false aneurysms are extremely rare, and nearly all are caused by a penetrating injury. We report a singular case of rapidly expanding pseudoaneurysm caused by the repetitive use of the hypothenar eminence as the supporting point of a tablet computer. This tablet model has a notch on its posterior side that played an essential role in the pathogenesis. This report illustrate that even low-intensity trauma can be an exceptional cause of injury to the palmar portion of the ulnar artery, and subsequently, can lead to the development of these lesions. The false aneurysm was repaired by means of resection and reconstruction by an end-to-end anastomosis because a rapid diagnosis and surgical treatment can prevent further complications.

The Roadside Technique for Type II Endoleak Embolization 4 Years after Endovascular Aortic Aneurysm Repair.

Endoleaks are the most common cause of reintervention after endovascular aortic aneurysm repair (EVAR). Type II endoleaks have been implicated as a risk factor for expansion and rupture. Several techniques have been described to manage type II endoleaks, being transarterial catheterization the most commonly used. In some cases this technique can be difficult or impossible to achieve. We report the use of a technique that offers a direct access to the aneurysm sac and the possibility of catheterization of the involved vessels or the embolization of the communication between them, even 4 years after EVAR.

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.

[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)

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