Cost-effectiveness analysis of the diagnosis of temporal arteritis.

Temporal arteritis (TA) is the most common form of systemic vasculitis. Its diagnosis is based on criteria proposed by the American College of Rheumatology (1990), and its treatment is high-dose corticosteroids. Our objective is to assess the cost of diagnosing TA, and secondarily, cost-effective analysis of different diagnostic strategies (clinical, biopsy, doppler ultrasound) and therapeutic strategies (corticosteroid suspension). MATERIAL AND METHOD: Observational, retrospective study has been carried out on patients with AT (2012-2021). Demographic data, comorbidities, signs and symptoms suggestive of AT were collected. AT was diagnosed with a score ≥ 3 according to American College of Rheumatoloy criteria (ACR-SCORE). The costs of diagnosis and treatment modification were analysed. RESULTS: Seventy-five patients have been included, median age 77 (46-87) years. Headache, temporal pain and jaw claudication were significant for the diagnosis of TA. Patients with a halo on Doppler ultrasound and a positive biopsy have significantly elevated ESR and CRP compared to patients who do not. The cost of the AT diagnosis was 414.7 euros/patient. If we use ACR-SCORE ≥ 3-echodoppler it is 167.2 є/patient (savings 59.6%) and ACR-SCORE ≥ 3-biopsy 339.75 є/patient (savings 18%). If the corticosteroid was removed and a biopsy was performed, 21.6 є/patient (94.7% savings), if the corticosteroid was removed and Doppler ultrasound was performed, 10.6 є/patient (97.4% savings). CONCLUSIONS: Headache, temporary pain and jaw claudication are predictors of AT. Elevated ESR and CRP are predictors of positive biopsy and presence of halo on ultrasound. The uses of ACR-SCORE ≥ 3 with Doppler ultrasound or biopsy, and with corticosteroid suspension, are cost-effective.

Análisis coste/efectivo del diagnóstico de la arteritis de la temporal / Cost-effectiveness analysis of the diagnosis of temporal arteritis

La arteritis de la temporal (AT) es la forma más frecuente de vasculitis sistémica, su diagnóstico está basado en criterios propuestos por el Colegio Americano de Reumatología (1990), y su tratamiento son corticoides a dosis elevadas. Nuestro objetivo es valorar el gasto del diagnóstico de la AT, y secundariamente análisis coste/efectivo de distintas estrategias diagnósticas (clínica, biopsia, eco-Doppler) y terapéuticas (suspensión del corticoide). Material y método: Estudio observacional, retrospectivo de pacientes con AT (2012-2021). Se recogieron datos demográficos, comorbilidades, signos y síntomas sugestivos de AT. Se diagnosticó AT con una puntuación ≥3 según los criterios del American College of Reumatology (ACR-SCORE). Se analizaron los gastos del diagnóstico y modificación de tratamiento. Resultados: Setenta y cinco pacientes, mediana edad 77 (6-87) años. Cefalea, dolor temporal y claudicación mandibular fueron significativos para el diagnóstico de AT. Los pacientes con halo en eco-Doppler y biopsia positiva, presentaron elevación de VSG y PCR de forma significativa en comparación con los pacientes que no. El gasto diagnóstico de AT fue de 414,7€/paciente. Si empleamos ACR-SCORE≥3-eco-Doppler serían 167,2€/paciente (ahorro del 59,6%) y ACR-SCORE≥3-biopsia 339,75€/paciente (ahorro del 18%). Si se retiraba corticoide y se realizaba biopsia hubiesen sido 21,6€/paciente (ahorro del 94,7%), si se retiraba corticoide y se realizaba eco-Doppler hubiesen sido 10,6€/paciente (ahorro del 97,4%). Conclusiones: Cefalea, dolor temporal y claudicación mandibular son predictores de AT. La elevación de VSG y PCR son predictores de biopsia positiva y presencia de halo en la ecografía.El empleo de ACR-SCORE≥3 con eco-Doppler o con biopsia, y con suspensión del corticoide son coste/efectivos.(AU)

Temporal arteritis (TA) is the most common form of systemic vasculitis. Its diagnosis is based on criteria proposed by the American College of Rheumatology (1990), and its treatment is high-dose corticosteroids. Our objective is to assess the cost of diagnosing TA, and secondarily, cost-effective analysis of different diagnostic strategies (clinical, biopsy, Doppler ultrasound) and therapeutic strategies (corticosteroid suspension).Material and method: Observational, retrospective study has been carried out on patients with TA (2012–2021). Demographic data, comorbidities, signs and symptoms suggestive of TA were collected. TA was diagnosed with a score ≥3 according to American College of Rheumatoloy criteria (ACR-SCORE). The costs of diagnosis and treatment modification were analysed. Results: Seventy-five patients have been included, median age 77 (46-87) years. Headache, temporal pain and jaw claudication were significant for the diagnosis of TA. Patients with a halo on Doppler ultrasound and a positive biopsy have significantly elevated ESR and CRP compared to patients who do not.: The cost of the TA diagnosis was 414.7 euros/patient. If we use ACR-SCORE≥3-echodoppler it is 167.2 €/patient (savings 59.6%) and ACR-SCORE≥3-biopsy 339.75 €/patient (savings 18%). If the corticosteroid was removed and a biopsy was performed, 21.6 €/patient (94.7% savings), if the corticosteroid was removed and Doppler ultrasound was performed, 10.6 €/patient (97.4% savings).Conclusions: Headache, temporary pain and jaw claudication are predictors of TA. Elevated ESR and CRP are predictors of positive biopsy and presence of halo on ultrasound. The uses of ACR-SCORE≥3 with Doppler ultrasound or biopsy, and with corticosteroid suspension, are cost-effective.(AU)

Estudio coste-efectividad del diagnóstico de trombosis venosa profunda en el medio hospitalario / Cost-effectiveness study of deep venous thrombosis diagnosis at the hospital setting

Introducción y objetivos: la trombosis venosa profunda (tVP) supone una importante carga económica. nuestro objetivo primario es comparar dos estrategias diagnósticas en cuanto a costes y a efectividad: la prueba del dímero d a todos los pacientes con sospecha con condicionarla a la probabilidad clínica pretest. el secundario, analizar el coste del diagnóstico en nuestro centro y los factores asociados a su presentación. Material y métodos: estudio prospectivo de los pacientes atendidos con sospecha de tVP de extremidad inferior entre mayo y octubre de 2019. Se analizaron las variables de la escala de Wells, el teP asociado, el dímero d, el resultado del eco Doppler y los costes (atención en urgencias, el reactivo del dímero d y la realización de un eco Doppler, obtenidos del Boletín oficial de la comunidad y de la unidad de cobros del hospital). el análisis estadístico se realizó con SPSS, pruebas de χ2 y el test exacto de Fisher. Resultados: se estudiaron 249 pacientes. 116 (46,59 %) presentaron tVP. La edad media fue de 70 años (21-95). aquellos con tVP presentaron con más frecuencia: sexo masculino (52,6 % frente a 39,8 %, p = 0,04), cáncer (29,3 % frente a 16,5 %, p = 0,016), dolor (80,2 % frente a 45,1 %, p < 0,001), edema (93,1 % frente a 57,1 %, p < 0,001), empastamiento (72,4 % frente a 14,3 %, p < 0,001), teP (25,9 % frente a 13,5 %, p = 0,014), menor diagnóstico alternativo (0,9 % frente a 62,4 %, p < 0,001) y menor obesidad (7,8 % frente a 18,8 %, p = 0,011). el gasto generado fue de 192,49 euros por paciente. Para el objetivo primario se analizaron a 144 pacientes (aquellos con dímero d). La estrategia 1 generó un gasto de 190,41 euros por paciente, con una sensibilidad del 100 % y una especificidad del 7,1 %; la estrategia 2, 188,51 euros por paciente, con una sensibilidad del 88,3 % y una especificidad del 78,5 %. ambas estrategias son un 1 % y un 2 % más económicas que el gasto generado, respectivamente...(AU)

Introduction and objective: deep venous thrombosis (dVt) is a significant economic burden. the study primaryendpoint is to compare two diagnostic strategies in terms of cost and effectiveness: d-dimer to all patients withsuspected dVt vs conditioning it to the pre-test clinical probability; the secondary endpoint is to analyze the costof dVt diagnosis in our center and the factors associated with its presentation. Material and methods: this was a prospective study of patients with suspected dVt of lower extremities con-ducted between may and october 2019. the variables of the Wells scale, associated Pte, d-dimer levels, dopplerechocardiography and costs (emergency care, d-dimer and doppler echocardiography obtained from the regionofficial Bulletin and the hospital billing unit) were analyzed. the statistical analysis was performed with SPSS, thechi-square test, and Fisher's exact test. Results: a total of 249 patients were studied, 116 of whom (46.59 %) presented with dVt. the mean age was70 years (21-95). those with dVt were predominantly men (52.6 % vs 39.8 %; p = .04), had cancer (29.3 %vs 16.5 %, p = 0.016), pain (80.2 % vs 45.1 %; p < .001), edema (93.1 % vs 57.1 %, p < .001), slurring (72.4 % vs14.3 %; p < .001), Pte (25.9 % vs 13.5 %, p = .014), less alternative diagnosis (0.9 % vs 62.4 %; p = .001) and lessobesity (7.8 % vs 18.8 %; p = .011). the cost generated was € 192.49 per patient. Regarding the primary endpoint,144 patients (those with d-dimer) were analyzed. Strategy #1 resulted in a cost of €190.41 per patient with100 % sensitivity and 7.1 % specificity; strategy # 2, resulted in a cost of €188.51/patient, with 88.3 % and 78.5 %sensitivity and specificity rates, respectively. Both strategies are 1 % and 2 % cheaper than the cost generated.Conclusion: the application of diagnostic algorithms for suspected dVt is cost-effective, so its use should begeneralized.(AU)

Clinical prediction rules in acute appendicitis: which combination of variables is more effective at predicting?

BACKGROUND: Clinical prediction rules have been designed to reduce variability and improve the diagnostic process. However, there are no unanimous criteria regarding which of them is the most efficient for the diagnosis of acute appendicitis. AIM: The primary aim of this study was to assess the diagnostic efficacy of the most commonly used clinical prediction rules. The second aim was to identify the combination of the smallest number of clinical and analytical variables that would allow a cost-effective diagnostic approach. METHODS: A retrospective observational study was conducted of 458 patients who were evaluated for right iliac fossa pain between January 2010 and December 2016. The scores tested were Alvarado, AIR, RIPASA, and AAS. Univariate and multiple regressions were used for validation. RESULTS: Alvarado one was the most efficient to establish a positive diagnosis of acute appendicitis. However, the most simplified and predictive combination variables included anorexia, white blood cell count > 8275 leukocytes/mL, neutrophilia (> 75%), abdominal pain < 48 h, migrating pain, and temperature out the range of 37-39ºC. CONCLUSIONS: A new and effective CPR (HMC score) for predicting appendicitis in patients presenting with the right iliac fossa pain has been established.

INTRODUCCIÓN: Las escalas de predicción diagnóstica (EPD) se han diseñado con el objetivo de reducir la variabilidad y mejorar el proceso de diagnóstico. Sin embargo, no existen criterios unánimes sobre cuál de ellas es la más el más eficiente para el diagnóstico de apendicitis aguda. OBJETIVO: El objetivo principal de este estudio fue evaluar la eficacia diagnóstica de las escalas de predicción diagnóstica más utilizadas. El segundo objetivo fue identificar la combinación del menor número de variables clínicas y analíticas que permitieran un enfoque diagnóstico más eficiente. MÉTODOS: Se realizó un estudio observacional retrospectivo de 458 pacientes que fueron evaluados por dolor en la fosa ilíaca derecha entre enero de 2010 y diciembre de 2016. Las escalas evaluadas fueron las de Alvarado, AIR, RIPASA y AAS. Se utilizaron la regresion univariada y la múltiple para la validación de los resultados. RESULTADOS: la escala de Alvarado fue la más eficiente para establecer un diagnóstico de apendicitis aguda. No obstante, la combinación de las siguientes variables: anorexia, recuento de leucocitos > 8275 leucocitos/mL, neutrofilia (> 75%), dolor abdominal < 48 horas, dolor migratorio y temperatura fuera del rango de 37-39ºC, demostró ser la más eficiente para establecer un diagnóstico positivo de apendicitis aguda. CONCLUSIONES: Se ha desarrollada una nueva EPD (escala HMDC) para determinar la presencia de apendicitis en pacientes evaluados por dolor en la fosa ilíaca derecha.

Clinical Characteristics and Surgical Outcomes of Carotid Body Tumors: Data from the Carotid Paraganglioma Cooperative International Registry (CAPACITY) Group.

BACKGROUND: This study's objective was to conduct a multinational registry of patients with carotid body tumors (CBTs) and to analyze patients' clinical characteristics, treatments, and outcomes. METHODS: Retrospective study from the Carotid Paraganglioma Cooperative International Registry involving eleven medical centers in Bolivia, Ecuador, Mexico, and Spain, of all patients with a CBT who underwent resection between 2009 and 2019. RESULTS: A total of 1432 patients with a CBT surgically treated were included. Median patient age was 54 years (range: 45-63 years), and 82.9% (1184) of the study cohort were female. While at low altitude, the proportion of female-to-male cases was 2:1, at high altitude, this proportion increased to 8:1, with statistically significant differences (p = .022). Median operative time was 139 min (range: 110-180 min), while median operative blood loss was 250 ml (range: 100-500 ml), with statistically significant difference in increased blood loss (p = .001) and operative time (p = .001) with a higher Shamblin classification. Eight (0.6%) patients suffered stroke. Univariate analysis analyzing for possible factors associated with increased odds of stroke revealed intraoperative vascular lesion to present an OR of 2.37 [CI 95%; 1.19-4.75] (p = 0.001). In 245 (17.1%), a cranial nerve injury was reported. Seven (0.5%) deaths were recorded. CONCLUSION: The most common CBT type on this cohort was hyperplasic, which might be partially explained by the high altitudes where these patients lived. Increased blood loss and operative time were associated with a higher Shamblin classification, and the risk of stroke was associated with patients presenting transoperative vascular lesions.

Effect of Remote Ischemic Preconditioning on the Incidence of Contrast-Induced Nephropathy in Patients Undergoing Endovascular Aneurysm Repair (Remote Ischemic Preconditioning-Endovascular Aneurysm Repair Study).

BACKGROUND: Contrast-induced nephropathy (CIN) is a major inconvenience in the use of iodinated contrast media (ICM) and it is associated with a significant increase in morbidity and mortality and cost of hospitalization. Remote ischemic preconditioning (RIPC) is a noninvasive and cost-effective tissue protection technique that has showed to be beneficial in decreasing renal insult in patients receiving intravascular contrast. AIM: The primary outcome of this study is to evaluate the impact of RIPC on the incidence of CIN in patients undergoing endovascular aneurysm repair. METHODS: Patients suffering from aortic aneurysm were recruited prior to the administration of ICM. Randomization was used to assign patients into the control/RIPC groups. Biochemical parameters determined renal function before and after surgery in immediate (24-72 hr) and at 30 days of follow-up. RESULTS: Of the 120 patients included in the study, 98,3% were male. Mean age was 73 years (range: 56-87 years). Diabetes and chronic renal failure (considering estimated glomerular filtration [eGFR] <60) was present prior to administration of ICM in 29.16% and 38.33%, respectively. RIPC was applied in 50% (n = 60) of the patients. A total of 24.17% developed CIN regardless of fluidotherapy, RIPC, and other protective strategies. RIPC did not influence outcomes in terms of incidence on CIN, serum creatinine, urea, eGFR, or microalbuminuria in immediate postoperative period. However, the group of RIPC patients showed a statistically significant benefit in renal function in terms of serum creatinine (1.46 ± 0.3 vs. 1.03 ± 0.5; P < 0.001), urea (61.06 ± 27.5 mg/dL vs. 43.78 ± 12.9 mg/dL; P = 0.003), and an increase in eGFR (56.37 ± 23.4 mL/min/1.73 m2 vs. 72.85 ± 17.7 mL/min/1.73 m2; P = 0.004) at 30 days of follow-up. CONCLUSIONS: RIPC seems to be a reasonable, effective, and low-cost technique to alleviate effects of ICM on the renal parenchyma in endovascular aneurysm repair procedures during short-term postoperative period.

Thirty-three vascular residency programs among 13 countries joining forces to improve surgical education in times of COVID-19: A survey-based assessment.

BACKGROUND: Academic interaction with mentors has almost become minimal due to the current pandemic of COVID-19. The objective of this study is to introduce how a group of vascular surgery residencies joined forces to improve surgical education in times of COVID-19. METHODS: On May 2020, a group of Hispanic American vascular residency programs created webinar sessions of arterial and venous clinical cases among vascular residents across Latin America and Europe. Participants were surveyed via email. Questions were about the perceived quality and utility of the webinars; answers were stratified into negative (disagree), neutral, and positive (agree). RESULTS: There have been 60 sessions and 118 clinical cases presented. The survey was answered by 106 participants, 82 males (78.8%) and 24 women (23.0%). Fifty-four (51.9%) were board-certified vascular surgeons, 49 (47.1%) vascular surgery residents, and 2 (1.9%) general surgery residents. Mean age of the participants was 41.5 years (range: 25-74 years). Mean years of vascular surgery practice or experience were 11.2 years (range: 0-45 years). The residency programs involved in this project were from 13 different countries. Most answers received were positive for both perceived quality and utility of the webinars. CONCLUSION: Globalization and technology provide an opportunity for international education, with the goal of building well-rounded and academic vascular surgeons. This group is just the beginning of a large collaborative group among Hispanic American countries, hoping that more residency programs will join, with the aim of breaking borders in the education of vascular surgery.

Impact of nutritional and inflammatory status in patients with critical limb-threatening ischemia.

BACKGROUND: A pro-inflammatory state and a poor nutritional status have been associated with severity and prognosis of patients with peripheral arterial disease (PAD). The clinical applicability of the different pre-operative nutritional and inflammatory biomarkers in patients with critical limb-threatening ischemia (CLTI) was analyzed. METHODS: A retrospective observational study was performed, that included all patients with CLTI revascularized from January 2016 to July 2019. The inflammatory state was calculated using neutrophil/lymphocyte (NLR), lymphocyte/monocyte (LMR) and platelet/lymphocyte ratios (PLR). For nutritional status, the Prognostic Nutritional Index (PNI) was calculated. Mortality and number of major amputations at 6 months and hospital length-of stay were studied. RESULTS: 310 patients were included. Higher levels of NLR and lower levels of PNI were associated with mortality (6.61±5.6 vs. 3.98±3.27, P=0.034; 40.33±7.89 vs. 45.73±7.48, P=0.05, respectively). Lower levels of PNI and LMR (42.57±7.82 vs. 45.44±7.65, P=0.036; 2.77±1.61 vs. 3.22±1.75, P=0.013, respectively) and higher levels of NLR (6.91±7.85 vs. 3.94±2.57, P=0.023) were associated with major amputations. The mean hospital length-of-stay was higher in patients with lower levels of PNI and LMR (P=0.000 and P=0.003) and higher levels of NLR and PLR (P=0.001 and P=0.002). A PNI<42.87 predicted short-term mortality with a 66.7% of sensitivity and a 66.8% of specificity (P=0.000). CONCLUSIONS: Our experience suggests that these inflammatory and nutritional biomarkers are independent predictors of short-term mortality and major amputations. In addition, our results suggest that PNI could be used to predict the short-term mortality with high sensitivity and specificity.

Leiomiosarcoma de vena cava / Vena cava leiomyosarcoma

Caso clínico: se presenta el caso de un varón de 64 años con sospecha de leiomiosarcoma de vena cava inferior (VCI) tratado con radioterapia neoadyuvante previa a resección quirúrgica en bloque tumoral y de VCI con reconstrucción mediante injerto de PTFE anillado, seguido de quimioterapia. Discusión: el leiomiosarcoma de VCI es una patología maligna muy infrecuente, de mal pronóstico y que requiere un manejo multidisciplinar. Representan la localización más frecuente de los leiomiosarcomas venosos, tienen predilección por el sexo femenino y una edad media de presentación entre 50 y 60 años. El síntoma más frecuente es el dolor abdominal, aunque muchos son asintomáticos. La prueba diagnóstica de elección es la RM y el tratamiento se basa en la resección quirúrgica, no estando aún claramente definido el papel de la radio y quimioterapia.(AU)

Case report: we present the case of a 64-year-old man with suspected inferior vena cava leiomyosarcoma (IVC) treated with neoadjuvant radiotherapy, tumor and IVC overall surgical resection with a ringshaped PTFE graft reconstruction, followed by chemotherapy. Discussion: IVC leiomyosarcoma is a very infrequent malignant disease, its prognosis is dark and requires multidisciplinary management. They represent the most frequent location of venous leiomyosarcomas, have a predilection for the female sex and a mean age of presentation between 50 and 60 years. The most frequent symptom is abdominal pain, although many are asymptomatic. The diagnostic test of choice is MRI and treatment is based on surgical resection, the role of radio and chemotherapy is not clearly defined yet.(AU)

Statistical techniques for predicting rupture risk in abdominal aortic aneurysms: A contribution based on bootstrap.

The morphometry of abdominal aortic aneurysms (AAA) has been recognized as one of the main factors that may predispose them to rupture. The need to quantify the morphometry of AAA on a patient-specific basis constitutes a valuable tool for assisting in rupture risk prediction. Previous results of this research group have determined the correlations between hemodynamic stresses and aneurysm morphometry by means of the Pearson coefficient. The present work aims to find how the AAA morphology correlates with the hemodynamic stresses acting on the arterial wall. To do so, the potential of the bootstrap technique has been explored. Bootstrap works appropriately in applications where few data are available (13 patient-specific AAA models were simulated). The methodology developed can be considered a contribution to predicting the hemodynamic stresses from the size and shape indices. The present work explores the use of a specific statistical technique (the bootstrap technique) to predict, based on morphological correlations, the patient-specific aneurysm rupture risk, provide greater understanding of this complex phenomenon that can bring about improvements in the clinical management of aneurysmatic patients. The results obtained using the bootstrap technique have greater reliability and robustness than those obtained by regression analysis using the Pearson coefficient, thus allowing to obtain more reliable results from the characteristics of the samples used, such as their small size and high variability. Additionally, it could be an indicator that other indices, such as AAA length, deformation rate, saccular index, and asymmetry, are important.

Off-Label Use of a Flared Endograft Limb for Treatment of a Complicated Anastomotic Abdominal Aortic Pseudoaneurysm: Reverse Deployment Throught Axillary Artery.

A case of complicated abdominal aortic pseudoaneurysm not suitable for open repair is described. It was treated by means of endovascular methods with a flared endograft limb. The uniqueness of this case is the absence of a suitable femoral access, requiring the deployment of the graft in a reversed configuration through axillary artery. The technique is described and the need of imaginative off label use of endovascular devices in such emergent cases is discussed.

Análisis volumétrico e influencia del trombo intraluminal tras la reparaciónendoluminal del aneurisma de aorta abdominal / Volumetric analysis and influence of intraluminal thrombus after endoluminal repair of abdominal aortic aneurysm

Objetivo: la precisión de la predicción del riesgo de rotura mediante control ultrasonográfico y angiotomografía computarizada está todavía lejos del método de diagnóstico óptimo para el aneurisma de aorta abdominal (AAA). El objetivo de este estudio es realizar un análisis volumétrico del saco aneurismático, comparar sus modificaciones con las del diámetro máximo, estudiar la evolución del volumen del trombo intraluminal (ILT) después de la reparación endovascular del AAA. Métodos: se analizaron un total de 144 AAA reparados por la EVAR electiva. Se realizó una angiotomografía en el periodo preoperatorio, 6-12 meses después de la intervención quirúrgica. Se calculó el diámetro máximo, el volumen del saco aneurismático y el volumen de la ILT en los tres momentos. Se determinó la modificación del diámetro, el volumen total y el volumen del trombo intraluminal (%). Se comparó la modificación del diámetro máximo con el volumen total de los aneurismas y entre el volumen total del aneurisma y el volumen del trombo intraluminal. Resultados: la media de los cambios en el diámetro máximo del AAA y el volumen después de la EVAR fue de -2,16 ± 8,20 mm y 84,4 ± 23,32 cc, respectivamente. Hubo un aumento en el volumen de AAA de 92,22 % y 57,34 % a los 6 y 12 meses en pacientes con endofugas (22.03 ± 19.03 cc a los 12 meses del periodo posoperatorio). La modificación media del ITL y del saco aneurismático fue de 0,59 ± 0,17 y 0,52 ± 1,8 para los pacientes con AAA presurizados y no presurizados, respectivamente (p = 0,308). Conclusión: el análisis volumétrico de los AAA reparados mediante tratamiento endovascular es una medida más preciso que la medición del diámetro máximo para determinar la expansión del saco aneurismático.(AU)

Purpose: the accuracy of risk prediction by ultrasonic control and computerized angiotomography is still far from the optimal diagnostic method for abdominal aortic aneurysm (AAA). The objective of this study is to perform a volumetric analysis of the AAA sac to detect alterations and to follow-up the evolution of the volume of the intraluminal thrombus (ILT) and its influence on the overall evolution after the EVAR. Methods: a total of 144 AAAs repaired by elective EVAR were analyzed. An angiotomography was carried out in the preoperative period, 6-12 months after the operation. The maximum-diameter, aneurysmal sac volume, and ILT volume were calculated each time. We determined the modification of the diameter, total-volume and intraluminal-thrombus volume (%). We made a comparison between the modification of the maximum-diameter and the total-volume of the aneurysms and between the total-volume of the aneurysm and the volume of ILT. Results: the average changes in the maximum diameter of AAA and the volume after EVAR was -2.16 ± 8.20 mm and 84.4 ± 23.32 cc, respectively. There was an increase in AAA-volume of 92.22 % and 57.34 % at 6 and 12 months in patients with endoleaks (22.03 ± 19.03 cc at 12 months of postoperative-period). The means of the ILT and AAA sac ratios were respectively 0.59 ± 0.17 and 0.52 ± 1.8 in AAA in sac growth and in stable or contracted AAA sac groups (p = 0.308). Conclusion: volumetric analysis of AAA repaired by EVAR is a more sensitive measure to determine the expansion of the aneurysm sac than the measurement of the maximum diameter of the aneurysm.(AU)

Celiac trunk segmental arterial mediolysis: a rare cause of arteriopathy

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Celiac trunk segmental arterial mediolysis: a rare cause of arteriopathy.

A 50-year-old male patient, without a previous medical history, presented sudden severe abdominal pain with no alterations in the blood analysis. A CT-Angiography (CTA) was performed that showed a wall thickening of the celiac trunk extended to the hepatic artery with a filiform lumen and no involvement of the splenic artery. There were no signs of intestinal or liver ischemia, therefore no further radiological tests were performed. The proteinogram and serology were normal, with no immunological and acute phase reactant markers, excluding vasculitis. It appeared as an isolated lesion with no signs of arterial dissection or pseudoaneurysms of the remaining abdominal vessels or the aorta. Therefore, it was considered as a Segmental Arterial Mediolisis (SAM).

Doppler Ultrasound as a Unique Diagnosis Test in Peripheral Arterial Disease.

BACKGROUND: The aim of this study was to analyze duplex ultrasound (DUS) and intraoperative angiography concordance for diagnosis of lower limb peripheral artery disease and its value for surgical planning. MATERIALS AND METHODS: This was a prospective, observational study, including patients who underwent revascularization of the lower limbs during 2018, diagnosed by DUS only or combined with preoperative computed tomography (CT) angiography. The concordance between preoperative DUS or CT angiography and the intraoperative angiography was studied using the Cohen kappa coefficient (k). The degree of agreement between the DUS-based surgical plan and the final surgical technique was also evaluated. RESULTS: Fifty-one patients were included, with mean age of 71.8 ± 11.96 years (46-94); 23 had chronic kidney disease (45%). In 17 patients (34%), preoperative CT angiography was also performed. DUS showed a sensitivity of 100% (95% confidence interval (CI) [83.3-100%]), 80% (95% CI [50.21-100%,]), and 100% (95% CI [96.43-100%]) at the iliac, femoral, and popliteal sector, respectively, and a specificity of 93.55% (95% CI [83.29-100%]), 95.45% (95% CI [84.48-100%]), and 90.48% (95% CI [75.54-100%]) at the iliac, femoral, and popliteal sector, respectively. The positive predictive value for DUS was 60% (95% CI [7.06-100%]), 88.9% (95% CI [62.8-100%]), and 87.5% (95% CI [68.17-100%]) for the iliac, femoral, and popliteal sectors, respectively, whereas the negative predictive value was 100% (95% CI [98.28-100%]), 91.3% (95% CI [77.61-100%]), and 100% (95% CI, [97.37-100%]). The concordance between DUS and intraoperative angiography showed a k index of 0.587 (P = 0.000) in the iliac sector, 0.799 in the femoral sector (P = 0.000), and 0.699 in the popliteal sector (P = 0.000). The concordance between CT angiography/intraoperative angiography had a k index of 0.71 in the iliac sector (P = 0.0093), 0.566 in the femoral sector (P = 0.006), and 0.5 in the popliteal sector (P = 0.028). DUS-based surgical plan was accurate in 86% of cases (n = 44). CONCLUSIONS: Our experience suggests that DUS arterial mapping of the femoral and popliteal areas is better than CT angiography and can be considered as a unique preoperative imaging test during the surgical planning in patients undergoing a lower limb revascularization procedure.

TAVI: disección aórtica iatrogénica tras retirada de balón / TAVI: iatrogenic aortic dissection during balloon retrieval

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Escala Anarcyl (aneurisma de aorta roto de Castilla y León) de predicción de mortalidad de aneurisma de abdominal roto / Anarcyl scale (ruptured aortic aneurysms Castilla y León) for predicting mortality in ruptured abdominal aortic aneurysms

INTRODUCCIÓN: el aneurisma de aorta abdominal roto (AAAr), a pesar de los avances diagnósticos y terapéuticos, continúa presentando una elevada mortalidad. Aunque la reparación endovascular (EVAR) incrementa el número de pacientes a los que se le ofrece tratamiento quirúrgico, no se encuentra exento de complicaciones. OBJETIVO: diseñar una escala de riesgo preoperatorio para los pacientes con AAAr intervenidos mediante EVAR. MATERIAL Y MÉTODOS: estudio prospectivo de 34 pacientes intervenidos mediante EVAR de AAAr en Castilla y León entre junio de 2016 y junio de 2019. Se recogieron variables de comorbilidad, preoperatorias de estabilidad hemodinámica y analítica al ingreso, así como de morbimortalidad intrahospitalaria. RESULTADOS: la mortalidad intrahospitalaria fue del 52,9%. El estudio univariante obtuvo como factores pronósticos de mortalidad la frecuencia cardíaca, la hemoglobina, la creatinina, el sodio, la GOT, la LDH y la troponina T ultrasensible. Tras la realización del estudio multivariante, resultaron significativas la frecuencia cardíaca (p = 0,011), la hemoglobina (p = 0,035) y la creatinina (p = 0,019). La escala resultante ofreció la siguiente fórmula de mortalidad: 0,440 + 0,560 (si hemoglobina < 7 mg/dl) + 0,169 (si frecuencia cardíaca < 70 latidos/min) + 0,084 (si creatinina > 2,8 mg/dl). El área bajo la curva del presente modelo asciende a 0,870 (Fig. 1). Una puntuación ≤ 0,440 se asoció con una mortalidad del 39,1%; una puntuación entre 0,441-0,644, con el 66,7%, y del 100%, si ≥ 0,644. CONCLUSIÓN: la frecuencia cardíaca al ingreso y los niveles analíticos de hemoglobina y creatinina constituyen factores predictores de mortalidad intrahospitalaria en pacientes con AAAr tratados mediante exclusión endovascular. La aplicación de la escala propuesta en el presente estudio permite conocer a los pacientes que no se beneficiarían del tratamiento quirúrgico endovascular del AAAr

INTRODUCTION: the ruptured abdominal aortic aneurysm (AAAr), despite diagnostic and therapeutic advances, continues to present a high mortality. Although endovascular repair (EVAR) increases the number of patients who are offered surgical treatment, it is not without complications.OBJECTIVE: design a preoperative risk scale for patients with AAAr treated by EVAR.MATERIAL AND METHODS: prospective study of 34 patients undergoing EVAR of AAAr in Castilla y León between June 2016 and June 2019. Comorbidities, preoperative variables of hemodynamic stability, analytical at admission, as well as in-hospital morbidity and mortality were collected. RESULTS: in-hospital mortality was 52.9%. The univariate predictors obtained were heart rate, hemoglobin, creatinine, sodium, GOT, LDH and ultrasensitive troponin T as prognostic factors. After completing the multivariate analysis, heart rate (p = 0.011), hemoglobin (p = 0.035) and creatinine (p = 0.019) were statistically different between the groups. The scale resulting from the following mortality formula: 0.440 + 0.560 (if hemoglobin < 7 mg/dl) + 0.169 (if heart rate < 70 beats/min) + 0.084 (if creatinine > 2.8). This model obtained an area under the curve of 0.870 (Fig. 1). A score < 0.440 is associated with a mortality of 39.1%, a score between 0.441-0.644 with 66.7% and 100% if > 0.644. CONCLUSION: the heart rate at admission and the analytical levels of hemoglobin and creatinine, are predictive factors of in-hospital mortality in patients with AAAr treated with endovascular exclusion. The application of the proposed scale allows the detection of patients who would not benefit from the endovascular surgical treatment of AAAr

Prospective Study of the Iliac Branch Device E-liac in Patients with Common Iliac Artery Aneurysms: 12 Month Results.

OBJECTIVES: At 12 months follow up of the PLIANT study, clinical success and efficacy of the E-liac Stent Graft System (JOTEC GmbH, Hechingen, Germany) were evaluated. Clinical success was defined as aneurysm exclusion (no type I, III, IV endoleak) with primary patency of the internal iliac artery (IIA) and external iliac artery (EIA) on the E-liac implantation side. METHODS: In this prospective multicentre European observational study, clinical and morphological data of 45 patients (93% male, mean age 72 y) were prospectively collected in 11 European centres between July 2014 and June 2016. Forty patients underwent an aorto-iliac (three patients bilaterally) treatment and five an isolated iliac treatment. RESULTS: At 12 months follow up, data were available for 42 patients. Overall clinical success at 12 months was 90%, with a survival rate of 100%. Four patients (10%) did not achieve clinical success, one with an internal iliac artery (IIA) occlusion on the E-liac implantation side, one with an infrarenal type Ia endoleak, and two with type Ib endoleaks in IIA. At 12 months the primary patency rate in the internal iliac artery on the iliac side branch implantation side was 98%. Two patients (5%) received E-liac related re-interventions: one caused by an edge stenosis at the distal end of the graft limb in the external iliac artery (EIA) and one caused by thrombo-embolism in the external iliac artery. Thus, for the EIA, primary and secondary patency rates were 98% and 100%, respectively. CONCLUSIONS: The low device related re-intervention rate of 5%, the high survival rate of 100%, and the high primary patency rates of 98% for the IIA and EIA at 12 month follow up demonstrate the safety and efficacy of the E-liac Stent Graft System. Long term 36 month results are awaited to confirm the efficacy and durability.

Enfermedad arterial periférica: la influencia de la etnia / Peripheral arterial disease: influence of ethnicity

INTRODUCCIÓN Y OBJETIVO: se han descrito diferencias en la prevalencia de la enfermedad arterial periférica (EAP) en distintas áreas geográficas. El objetivo es analizar los pacientes de Europa del este intervenidos en nuestro centro de isquemia crónica de extremidades inferiores y compararlos con los de origen español para describir cómo puede influir la etnia en el desarrollo de la EAP. MATERIALES Y MÉTODOS: se ha escogido una muestra de 337 pacientes intervenidos en nuestro centro desde el 2007 hasta el 2017 diagnosticados de isquemia arterial crónica de extremidades inferiores. Se han analizado los factores de riesgo cardiovascular (FRCV), la clínica al ingreso, las lesiones TASC y la estancia hospitalaria media. RESULTADOS: los pacientes de Europa del este representan el 7,7% de la muestra. La media de edad es de 67,9 años y un 79,8% son varones: el 70% presenta HTA; el 45,4%, DM; el 52,5%, DLP y el 40,7% son fumadores. Respecto a las comorbilidades, el 30,6% presenta cardiopatía isquémica; el 13,6%, EPOC y un 7,4%, accidentes cerebrovasculares. Los pacientes de Europa del este son más jóvenes (53,5 ± 10,53 frente a 69,09 ± 10,77; p = 0,0001), con menor prevalencia del resto de FRCV (HTA 30,7% frente al 73,3%, p = 0,001; DM 23,07% frente a 47,27%; p = 0,017; DLP 30,77% frente al 54,34%; p = 0,021). La prevalencia de fumadores es mayor (80,77% frente a 69,45%; p = 0,002). Presentan una clasificación Rutherford menor y un ITB más alto (3,19 ± 0,85 frente a 3,73 ± 1,19, p = 0,03, y 0,41 ± 0,21 frente a 0,26 ± 0,06, p = 0,028, respectivamente). La mayoría de los pacientes de Europa del este son claudicantes y presentan una estancia media superior que los pacientes claudicantes de origen español (12,31 frente a 6,3 días; p < 0,001). No existen diferencias significativas en el grado TASC. CONCLUSIONES: los pacientes de Europa del este intervenidos de isquemia arterial crónica de extremidades inferiores son más jóvenes, más fumadores y con menor prevalencia del resto de FRCV. La mayoría presenta claudicación intermitente y tiene una estancia hospitalaria media más elevada que los pacientes españoles

INTRODUCTION AND OBJECTIVE: differences in the prevalence of peripheral arterial disease (PAD) have been described in different geographical areas. These differences have been justified by life habits and socio-economic development of a country. The aim of this study is to analyze eastern Europe patients and Spanish patients, who underwent surgical procedures of lower limb chronic ischemia, to describe how can influence ethnicity in the PAD development. MATERIALS AND METHODS: a sample of 337 operated patients of lower extremities chronic ischemia in our center from 2007 to 2017 has been chose. Cardiovascular risk factors (CVRF), clinic at the beginning of admission, TASC lesions in imaging tests and hospitalization days were analyzed. RESULTS: eastern Europe patients represent 7.7% of the sample. The average age is 67.9 years (22-97) and 79.8% are males. 70% have HTA, 45.4% DM, 52.5% DLP and 40.7% are smokers. Regarding comorbidities: 30.6% have ischemic heart disease, 13.6% OCPD and 7.4% cerebrovascular disease. Eastern Europe patients are younger than Spanish patients (53.5 ± 10.53 vs. 69.09 ± 10.77) and with a lower prevalence of the rest of CVRF (HTA 30.7% vs. 73.3%; DM 23.07% vs. 47.27%; DLP 30.77% vs. 54.34%). In addition, the prevalence of smokers is higher (80.77% vs. 69.45%). They also present a lower Rutherford classification and a higher ABI (3.19 ± 0.85 vs. 3.73 ± 1.19 and 0.42 vs. 0.26, respectively). The average stay is higher in claudicants eastern Europe's patients (12.31 vs. 6.3 days). CONCLUSIONS: operated eastern European patients of lower limb chronic ischemia are young patients, smokers, and have a lower prevalence of the rest of CVRF. More than half of eastern Europe patients present intermittent claudication and they have a higher hospital stay than claudicant Spanish patients