Estrategias de búsqueda de información sobre cirugía vascular en Internet / Strategies for searching for information about vascular sugery on the internet

Introducción. La asistencia clínica diaria genera múltiples preguntas que necesitamos responder con rapidezy con la mejor evidencia científica disponible. La abundancia de fuentes de información nos obliga a ser muy selectivos y prácticos. Objetivo. Ofrecer una serie de conocimientos básicos sobre cómo localizar fuentes de información médica en Internet con evidencia científica y en concreto de temas relacionados con cirugía vascular. Desarrollo. Ante una pregunta clínica no deberíamos ir directamente a PubMed o a Google a buscar artículos originales, sino que deberíamos acceder a fuentes prefiltradas de información. Es lo que se denomina metabuscadores: una clase de buscador que carece de base de datos propia y, en su lugar, usa las de otros buscadores y muestra una combinación de las mejores páginas. Estos metabuscadores son el Tripdatabase en inglés y Excelencia Clínica en español. Si lo que buscamos son revisiones sistemáticas, la Biblioteca Cochrane Plus ofrece la mejor base de datos disponible, aunque existen otras fuentes como el Centre for Reviews and Dissemination, Clinical Evidence o Bandolier. Y si nuestro problema es localizar una guía de práctica clínica, Internet puede ofrecer una impresionante fuente de guías validadas y avaladas por importantes centros y de acceso libre como la National Guideline Clearinghouse norteamericana, las guías NICE británicas o GuíaSalud en España. Si lo que queremos es facilitar a nuestros pacientes páginas web con información, lo mejor es dirigirlos a MedlinePlus, donde incluso encontrarán tutoriales interactivos sobre posibles intervenciones vasculares(AU)

Conclusiones. Las herramientas descritas en este artículo pueden ser útiles en determinados momentos y circunstancias, sin olvidar que la maestría clínica es la que debe decidir cuándo estas evidencias externas son aplicables al paciente individual y, sí así ocurriera, cómo deben integrarse en una decisión clínica. Evidentemente, son una importante y moderna herramienta detrabajo(AU)

Introduction. Daily clinical care gives rise to a number of questions that need answering quickly and with thebest scientific evidence available. The abundance of sources of information means that we have to be very selective andpractical. Aims. The aim of this study is to offer some basic knowledge about how to locate online sources of medicalinformation with scientific evidence, and more particularly about subjects related to vascular surgery. Development.When dealing with a clinical question, we should not go directly to PubMed or Google to search for original papers, butinstead we ought to access pre-screened sources of information. These are what are called meta-search engines, whichare a type of search engines that do not have their own database and, instead, use those of other search engines andshow a combination of the best websites. These meta-search engines are Tripdatabase in English and Excelencia Clínicain Spanish. If we are looking for systematic reviews, the Biblioteca Cochrane Plus offers the best database available,although there are other sources such as the Centre for Reviews and Dissemination, Clinical Evidence or Bandolier. Andif our problem lies in locating clinical practice guidelines, the Internet can provide an impressive source of guidelinesthat have been validated and endorsed by important centres and which can be freely accessed, such as the NorthAmerican National Guideline Clearinghouse, the British NICE guidelines or GuíaSalud in Spain. If what we are lookingfor is to provide our patients with informative websites, the best thing is to recommend the use of MedlinePlus, wherethey can even find interactive tutorials about vascular operations they might undergo at some stage(AU)

Conclusions. The tools described in this article can be useful at certain times and under certain circumstances. It should not be forgotten, however, that clinical proficiency is the key to deciding when this external evidence is applicable to the individual patientand, if this is the case, how it should be integrated within a clinical decision. It is obviously an important and up-to-datework tool(AU)

Medicina basada en la evidencia: concepto y aplicación / Evidence-based medicine: Its concept and applicability

Objetivo. Introducir el concepto de medicina basada en la evidencia (MBE) y su aplicabilidad en la práctica clínica.Desarrollo. La MBE se define como ‘el uso consciente, explícito y juicioso de la mejor evidencia científica disponiblepara tomar decisiones sobre los pacientes’. El acto médico se entiende como una experiencia de relación interpersonal en laque los valores y la experiencia del médico, junto con las preferencias de los pacientes, tienen un papel preeminente, a lo quedebe añadirse como elemento crucial la evaluación sistemática de la evidencia científica. La MBE considera el método científicocomo la mejor herramienta de que se dispone hoy día para conocer la realidad y expresarla de forma inteligible y sintética.Ayuda a desarrollar un razonamiento y un método que persigue transformar los datos clínicos en conocimiento científicamenteválido, estadísticamente preciso y clínicamente relevante para la moderna práctica médica. Pretende que los médicosasistenciales, además de su experiencia y habilidades clínicas, sepan aplicar de manera adecuada los resultados de lainvestigación científica, a fin de mejorar la calidad de la práctica médica. El proceso consiste en la identificación de lagunasde conocimiento, la formulación de preguntas clínicas bien estructuradas, la búsqueda sistemática y eficiente de la evidenciade la que se dispone, la evaluación crítica de su calidad, la interpretación de los resultados y la aplicación de los hallazgosde la investigación a la toma de decisiones. Conclusiones. La MBE aporta un marco conceptual para la resolución de problemasclínicos, acercando los datos de la investigación clínica a la práctica médica(AU)

Aim. To introduce the concept of evidence-based medicine (EBM) and its applicability to clinical practice.Development. EBM is defined as ‘the conscious, explicit and judicious use of the best available scientific evidence forclinical decision making’. The medical act is understood as an experience of interpersonal relationship in which thephysician’s values and experience, together with the patient’s preferences, have an eminent role, to which the systematicevaluation of scientific evidence must be added as a crucial element. EBM considers the scientific method to be the besttool available today to learn about reality and express it in an intelligible and synthetic way. It helps develop a reasoningand a method which tries to transform the clinical data into scientifically valid, statistically precise and clinicallyrelevant knowledge for modern medical practice. It intends for physicians to learn how to adequately apply the resultsof scientific investigation, in addition to their experience and clinical abilities, in order to improve the quality of medicalpractice. The process consists of the identification of gaps in knowledge, the formulation of well-structured clinicalquestions, the systematic and efficient search of the available evidence, the critical evaluation of its quality, theinterpretation of the results and the application of the investigation findings to clinical decision making. Conclusions.EBM supplies a conceptual framework for the solution of clinical problems, bringing data of clinical investigationcloser to medical practice(AU)

[Ischemic renal disease: revascularization or conservative treatment?]. / Nefropatía isquémica: revascularización o tratamiento médico conservador?

Ischemic nephropathy is recognized as a distinct cause of renal insufficiency and it is defined as a significant reduction in glomerular filtration rate in patients with hemodynamically significant renovascular occlusive disease. We argue the epidemiologic and clinical manifestations of atherosclerotic renovascular disease, and we evaluate the pronostic agents. Published studies of the outcome of revascularization for renal-artery stenosis have been excellent, offering a durable patency and functional improvement but they have had numerous limitations. The atherosclerosis is a systemic disease and it provides the general prognosis of patients. We conclude that ischemic renal disease is a nephropathy of smoker men, with proteinuria excretion similar to nephropathy with unilateral stenosis. The age of patients is the clinical feature that decide the treatment: surgery, angioplasty/stent or medical management. Comparative analysis of percutaneous transluminal angioplasty and operation for renal revascularization and medically treated patients have proved that the advanced chronic renal insufficiency is associated with an unfavourable response of treatment of the ischemic nephropathy. But, in this nephropathy the revascularization can be the better therapy for selected patients. The revascularization with angioplasty/stent for patients with unilateral renal stenosis and chronic renal insufficiency has a doubtful effectiveness, as the chronic renal failure is result of nephroangiosclerosis.

Nefropatía isquémica: ¿revascularización o tratamiento médico conservador? / Ischemic renal disease: revascularization or conservative treatment?

La nefropatía isquémica es la enfermedad renal que origina insuficiencia renala través de la reducción de filtrado glomerular, a consecuencia de la alteraciónsignificativa del flujo arterial renal principal.Se valoran los factores etiopatogénicos de la nefropatía isquémica y de otrasnefropatías vasculares como la nefroangiosclerosis. Se revisan también sus factorespronósticos.La revascularización tendría que ser el mejor tratamiento de la nefropatía isquémica.Sin embargo, cuando las estenosis de las arterias renales son consecuenciade lesiones arteriosclerosas, al incidir esta enfermedad de manera generalen todo el organismo, no está tan claro que la revascularización sea la mejoropción terapéutica.Partiendo de poblaciones seleccionadas, no equiparables entre sí, nos proponemosestablecer el mejor tratamiento para cada una de ellas. Hemos podidocomprobar que la afectación arteriosclerosa de las arterias renales en nuestro contextoes una enfermedad predominante en pacientes varones con hábito tabáquico,y que el daño parenquimatoso renal atendiendo a la determinación de proteinuriaes parecido entre la verdadera nefropatía isquémica y la nefropatía vascularcon afectación arterial unilateral.Nuestros datos muestran que la edad es el único factor determinante de la opciónterapéutica a seguir y que el grado de insuficiencia renal crónica en el momentodel diagnóstico es índice pronóstico independiente de la nefropatía isquémica.La revascularización renal tiende a ser la mejor opción terapéutica enpoblación seleccionada afecta de nefropatía isquémica. La revascularización renalendovascular, en casos de afectación renal unilateral con insuficiencia renal, ofreceresultados más dudosos de efectividad, ya que dicha insuficiencia renal crónicasería atribuible a la afectación renal intraparenquimatosa

Ischemic nephropathy is recognized as a distinct cause of renal insufficiencyand it is defined as a significant reduction in glomerular filtration rate in patientswith hemodynamically significant renovascular occlusive disease.We argue the epidemiologic and clínical manifestations of atherosclerotic renovasculardisease, and we evaluate the pronostic agents.Published studies of the outcome of revascularization for renal-artery stenosishave been excellent, offering a durable patency and functional improvement butthey have had numerous limitations. The atherosclerosis is a systemic disease andit provides the general prognosis of patients.We conclude that ischemic renal disease is a nephropathy of smoker men, withproteinuria excretion similar to nephropathy with unilateral stenosis. The age ofpatients is the clinical feature that decide the treatment: surgery, angioplasty/stentor medical management.Comparative analysis of percutaneous transluminal angioplasty and operation forrenal revascularization and medically treated patients have proved that the advancedchronic renal insufficiency is associated with an unfavourable response oftreatment of the ischemic nephropathy. But, in this nephropathy the revascularizationcan be the better therapy for selected patients. The revascularization withangioplasty/stent for patients with unilateral renal stenosis and chronic renal insufficiencyhas a doubtful effectiveness, as the chronic renal failure is result ofnephroangiosclerosis

[Diagnostic and therapeutic management of pseudo-occlusions of the carotid artery]. / Manejo diagnóstico y terapéutico de la pseudooclusién carotídea.

AIMS: The aim of this study was to evaluate the diagnostic attitude and the results obtained after surgery in cases of pseudo occlusions of the carotid artery. PATIENTS AND METHODS: Between 1995 and 2000, 13 cases of pseudo occlusion of the internal carotid artery were performed (3.06% of carotid surgery carried out). Diagnostic criteria were as follows. Echo Doppler: complete occlusion with its origin in the internal carotid artery, damped distal signal; arteriography: occlusion with its origin in the internal carotid artery, filiform distal part, string sign. Clinical presentation was: 53.84% cerebral infarction, 23.07% TIA and 23.07% were asymptomatic. The 13 patients were submitted to echo Doppler and nine were examined using arteriography. Two patients were operated on without arteriography because of unstable neurological clinical features. A surgical exploration was performed in 100% of the cases. RESULTS: In seven cases, revascularisation of the internal carotid artery was carried out (53.84%) and in six cases it was ligated (46.16%). Echographic monitoring (from 1 4 years, average 2 years) showed permeability in the seven revascularised cases; in one case restenosis was detected between 31 50% at 2 years follow up. In the clinical controls (from 2 months to 4 years, average 30 months), one patient who was not revascularised was seen to have symptoms of TIA at one year and two months. DISCUSSION: Since neither arteriography nor echo Doppler can predict when it will be possible to revascularise the internal carotid artery, and because we did not observe an increase in surgical morbidity mortality, we believe surgical exploration is useful. In our study 53.84% of the series were successfully revascularised.

Manejo diagnóstico y terapéutico de la pseudooclusión carotídea / Diagnostic and therapeutic management of pseudo-occlusions of the carotid artery

Objetivo. Valorar la actitud diagnóstica y los resultados de la cirugía en las pseudooclusiones carotídeas. Pacientes y métodos. Entre 1995 y 2000 se trataron 13 pseudooclusiones de carótida interna (3,06 por ciento de la cirugía carotídea). Los criterios diagnósticos fueron: eco-Doppler: oclusión completa origen carótida interna, señal distal amortiguada; arteriografía: oclusión origen carótida interna, parte distal filiforme, string-sign. La presentación clínica fue: 53,84 por ciento, infarto cerebral; 23,07 por ciento, AIT; y el 23,07 por ciento, asintomática. En los 13 pacientes se practicó eco-Doppler y en nueve se realizó arteriografía.Dos pacientes se intervinieron sin arteriografía por presentar clínica neurológica inestable. Se realizó exploración quirúrgica en el 100 por ciento de los casos. Resultados. En siete casos se pudo revascularizar la carótida interna (53,84 por ciento), en seis se procedió a la ligadura de la misma (46,16 por ciento). Los controles ecográficos (de 1-4 años, media 2 años) muestran permeabilidad de los siete casos revascularizados; en un caso se detectó reestenosis entre 31-50 por ciento a los 2 años de seguimiento. En los controles clínicos (de 2 meses a 4 años, media 30 meses), un paciente no revascularizado presentó clínica en forma de AIT al año y 2 meses. Comentarios. Ante el hecho de que ni la arteriografía ni el eco-Doppler nos pueden predecir cuándo la carótida interna podrá revascularizarse, y dado que no observamos un aumento de la morbimortalidad quirúrgica, consideramos indicada la exploración quirúrgica. Un 53,84 por ciento de la serie pudieron revascularizarse (AU)

Aims. The aim of this study was to evaluate the diagnostic attitude and the results obtained after surgery in cases of pseudo-occlusions of the carotid artery. Patients and methods. Between 1995 and 2000, 13 cases of pseudo-occlusion of the internal carotid artery were performed (3.06% of carotid surgery carried out). Diagnostic criteria were as follows. Echo-Doppler: complete occlusion with its origin in the internal carotid artery, damped distal signal; arteriography: occlusion with its origin in the internal carotid artery, filiform distal part, string-sign. Clinical presentation was: 53.84% cerebral infarction, 23.07% TIA and 23.07% were asymptomatic. The 13 patients were submitted to echo-Doppler and nine were examined using arteriography. Two patients were operated on without arteriography because of unstable neurological clinical features. A surgical exploration was performed in 100% of the cases. Results. In seven cases, revascularisation of the internal carotid artery was carried out (53.84%) and in six cases it was ligated (46.16%). Echographic monitoring (from 1-4 years, average 2 years) showed permeability in the seven revascularised cases; in one case restenosis was detected between 31-50% at 2 years’ follow up. In the clinical controls (from 2 months to 4 years, average 30 months), one patient who was not revascularised was seen to have symptoms of TIA at one year and two months. Discussion. Since neither arteriography nor echo-Doppler can predict when it will be possible to revascularise the internal carotid artery, and because we did not observe an increase in surgical morbidity-mortality, we believe surgical exploration is useful. In our study 53.84% of the series were successfully revascularised (AU)

Factors increasing the mortality rate for patients with ruptured abdominal aortic aneurysms.

The objective of this report was to analyze the current surgical results of operative treatment in patients suffering ruptured AAA (abdominal aortic aneurysms) and to define those independent predictive factors for mortality. During a period of 2 years, from January 1996 to December 1997, 144 patients operated on for ruptured AAA in 10 hospitals were included in a multicenter retrospective study. Among the collected variables concerning each patient, those with potential relation to surgical mortality were studied: gender, age, diabetes, hypertension, cardiopathy, pulmonary obstructive disease, preoperative renal dysfunction, symptomatic cerebrovascular disease, peripheral vascular disease, hematocrit on admission, preoperative hypotension < 80 mmHg, loss of consciousness, cardiac arrest, aortic aneurysm location (infrarenal versus non-infrarenal), iliac involvement, aneurysm size, type of rupture, left renal vein ligature, ligature of a patent inferior mesenteric artery, place of aortic cross-clamping, type of grafting, exclusion of both hypogastric arteries, venous technical complications, associated surgery, use of cell saver, intraoperative blood loss, and postoperative complications (renal failure, sepsis, coagulopathy, cardiac complications, pulmonary complications, colon ischemia, prosthetic graft complications, and need for reoperation). Those variables with statistical significance in the univariate analysis were introduced into a multivariate logistic regression model to determine the independent predictors of death. From our results we concluded that surgery for ruptured abdominal aortic aneurysms continues to have an excessively high mortality rate. Even though some preoperative variables could be identified as predictors of mortality, an absolute mortality risk has not yet been determined and the decision to negate surgery should be individualized rather than taken on that basis only. Early diagnosis and treatment of symptomatic aneurysms would improve mortality figures and selective screening should be contemplated.

Comparison of clinical outcome of stripping and CHIVA for treatment of varicose veins in the lower extremities.

The purpose of this nonrandomized case-review study was to compare the outcome of stripping and CHIVA for treatment of varicose veins in the lower extremities in our department. Outcome was evaluated by independent physicians. A total of 85 patients underwent saphenous vein stripping in association with phlebectomy and 90 patients underwent CHIVA cure. The duration of follow-up was 3 years. Study criteria were (1) presence of varicose veins as a cause of failure (1.1% in the CHIVA group vs. 15.3% in the stripping group), (2) appearance of telangiectasia (8.9% in the CHIVA group vs. 65.9% in the stripping group), (3) patient dissatisfaction rate (3.3% in the CHIVA group vs. 16.5% in the stripping group), (4) postoperative symptoms as a cause of failure (1.1% in the CHIVA group vs. 21.2% in the stripping group), and (5) saphenous nerve injury (1 patient in the CHIVA group vs. 16 in the stripping group). Differences between all five criteria were significantly in favor of the CHIVA group as compared to saphenous vein stripping with phlebectomy. Clinical results at 3 years are better for patients treated with CHIVA than stripping with regard to presence of varicose veins, clinical symptoms, presence of telangiectasia, cosmetic satisfaction, and neurologic complications. Data in our series of CHIVA treatments are comparable to those reported in the literature and better than those described in three series of stripping procedures with 3-year follow-up. A prospective randomized study is now underway to confirm these findings.

[Indications for carotid endarterectomy without arteriography. A validation study using eco-Doppler]. / Indicaciones de endarterectomía carotídea sin arteriografía. Estudio de validación mediante eco-Doppler.

INTRODUCTION: The possibility of diagnosing carotid stenosis and carrying out surgery without arteriography has increased with the use of different diagnostic methods. The eco-Doppler has been shown to be a useful method, although it requires previous individualised validation. OBJECTIVE: We aim to validate our Vascular Diagnostic Laboratory in the diagnosis of stenosis of the carotid bifurcation using eco-Doppler as compared with angiography, and the therapeutic indication thus obtained. PATIENTS AND METHODS: We made a prospective study for one year of 62 consecutive patients diagnosed on eco-Doppler as having carotid stenosis of over 70% and subsequent carotid arteriography. The treatment indicated is given, without waiting for the result of the angiography, on clinical evaluation, computerized tomography or cranial magnetic resonance and eco-Doppler, and subsequently on angiography. The degree of correlation of both methods, both for the therapeutic indication and for the degree of stenosis was determined. RESULTS: In five cases there was discrepancy and the therapeutic indication was different. Three of these were related to the diagnosis of carotid occlusion and in the other two cases there were bilateral lesions of over 50% on eco-Doppler, which were classified as minor on angiographic study. In the group with stenosis of over 70% with < 50% contralateral stenosis, eco-Doppler showed sensitivity and specificity of 100%, with a kappa correlation index = 1. CONCLUSION: It is possible to indicate carotid endarterectomy in patients with unilateral stenosis greater than 70% and contralateral stenosis < 50%, based on the eco-Doppler studies done in our Vascular Diagnostic Laboratory.

Indicaciones de endarterectomía carotídea sin arteriografía. Estudio de validación mediante eco-Doppler / Indications for carotid endarterectomy without arteriography. A validation study using eco-Doppler

Introducción. La posibilidad de diagnosticar la estenosis carotídea y realizar su cirugía sin arteriografía se ha extendido con la utilización de diferentes métodos diagnósticos. La eco-Doppler ha demostrado ser un método útil, aunque exige una validación previa individualizada. Objetivo. Pretendemos validar nuestro Laboratorio Diagnóstico Vascular (LDV) en el diagnóstico con eco-Doppler de la estenosis de la bifurcación carotídea, respecto a la angiografía, y la indicación terapéutica que genera. Pacientes y métodos. Realizamos un estudio prospectivo, durante un año, en 62 pacientes consecutivos con el diagnóstico por eco-Doppler de estenosis carotídea superior al 70 por ciento y posterior arteriografía carotídea. Se lleva a cabo la indicación terapéutica primero sin conocer el resultado de la angiografía, mediante valoración clínica, tomografía computarizada o resonancia magnética craneal y eco-Doppler y, posteriormente, con angiografía. Se determina el grado de correlación para ambos métodos tanto para la indicación terapéutica como para el grado de estenosis. Resultados. Hubo cinco casos de discrepancia que variaron la indicación terapéutica: tres de ellos relacionados con el diagnóstico de oclusión carotídea y los otros dos con lesiones bilaterales mayores del 50 por ciento según la eco-Doppler, que fueron catalogadas como menores en el estudio angiográfico. Para el grupo de estenosis superiores al 70 por ciento, con contralateral <50 por ciento, la eco-Doppler obtuvo una sensibilidad y especificidad del 100 por ciento, con un índice de correlación kappa= 1. Conclusión. Es posible la indicación de endarterectomía carotídea en pacientes con estenosis unilaterales superiores al 70 por ciento, con contralateral <50 por ciento, basada en estudios con eco-Doppler practicados en nuestro LDV (AU)