Long-term use of different doses of low-molecular-weight heparin versus vitamin K antagonists in the treatment of venous thromboembolism.

BACKGROUND: We evaluated whether the incidence of recurrent venous thromboembolic events (VTEs) during and after therapy differs for patients treated with full or reduced doses of low-molecular-weight heparin (LMWH) used long term compared with vitamin K antagonists (VKAs). METHODS: We identified randomized studies of long-term treatment with LMWH or VKA by searching MEDLINE, EMBASE, BIOSIS, and PASCAL. Seventeen studies were included, with 4,002 patients. RESULTS: In the assessment at 12 months of 1,957 patients without cancer, the recurrence rates of VTE in the LMWH/VKA groups were 8.3%/7.6% in the studies using full doses and 12.3%/12.1% in those using prophylactic doses. However, combined analysis after treatment to 1 year showed a nonsignificant (NS) trend to lower recurrent symptomatic VTE in favor of VKA (RR = 1.46, 95% CI 0.96-2.23). In 1,292 patients with cancer the recurrence rates of VTE in the LMWH/VKA groups were 6.5%/17.9% (p = 0.005) in the studies using full doses, 7.1%/13.4% (p = 0.002) in the studies using intermediate doses, and 14.3%/19.1% (p = NS) in the studies using prophylactic doses. Furthermore, the recurrences of VTE after discontinuation of treatment in the LMWH/VKA groups were 1.6%/9.5% (RR = 0.25, 95% CI 0.06-1.1) in 252 patients with full doses and 12%/7.4% (RR = 1.49, 95% CI 0.3-7.48) in 52 patients with prophylactic doses. In this population with cancer, the full-treatment LMWH regimen did not produce more major bleeding events than intermediate or prophylactic doses (5.1% vs. 6.3% or 8.1%, respectively). CONCLUSION: Full-dose LMWH for 3-6 months is as safe as intermediate and prophylactic doses for the long-term treatment of deep vein thrombosis. In patients with cancer it appears that there is an excess of VTE recurrence after treatment with prophylactic doses that does not occur with full therapeutic doses.

Análisis coste-efectividad del tratamiento del aneurisma de aorta abdominal mediante prótesis endovascular en España / Analysis of the cost-effectiveness of using stents to treat abdominal aortic aneurysms in spain

Objetivos. Determinar si el tratamiento endovascular (TEV) es una opción coste-efectiva en la terapia delaneurisma de aorta abdominal (AAA) respecto a la cirugía abierta, y evaluar el impacto presupuestario de una mayorutilización de estos dispositivos en el Sistema Nacional de Salud. Pacientes y métodos. Realizamos un análisis costeefectividady coste-utilidad del TEV frente a cirugía abierta utilizando un modelo de Markov de ciclos mensuales basadoen datos clínicos de la literatura (esencialmente el estudio EVAR-1) y la opinión de expertos. Tuvimos en consideraciónuna población española hipotética de pacientes con AAA igual o superior a 5 cm y tributarios de cirugía abierta. El análisislo realizamos desde la perspectiva del Sistema Nacional de Salud, y se descontaron costes y efectos futuros al 3,5%.Adicionalmente realizamos el impacto presupuestario y un análisis de sensibilidad probabilístico con la simulación deMonte-Carlo. Resultados. Los resultados mostraron que el TEV se asocia a una mayor efectividad que la cirugía abierta,con ganancias de entre 0,03 y 0,18 años de vida por paciente a uno y cuatro años, respectivamente (resultados similaressi se utilizan años de vida ajustados por calidad). El coste medio por paciente fue mayor en TEV, entre 2.879 y 3.492euros según distintos escenarios, el coste por años de vida ganado con TEV fue de 111.064 a 19.852 euros y el coste poraños de vida ajustados por calidad ganado fue de 137.206 a 27.077 euros (análisis a uno y cuatro años, respectivamente).El impacto presupuestario de aumentar la introducción de la endoprótesis evaluada en España durante los próximoscuatro años representa el 0,5-2,2% del coste total de las AAA. Conclusiones. El TEV es una alternativa coste-efectiva conrespecto a la intervención quirúrgica convencional, ya que a los cuatro años de seguimiento presenta valores por debajodel umbral de eficiencia usualmente aceptado en España(AU)

Aims. To determine whether endovascular treatment (EVT) is a cost-effective option for the treatment ofabdominal aortic aneurysm (AAA) with respect to open surgery, and to evaluate the budget impact of a more widespreadutilisation of these devices in the Spanish National Health Service. Patients and methods. We performed a costeffectivenessand cost-utility analysis of EVT versus open surgery using a Markov model of monthly cycles based onclinical data from the literature (essentially the EVAR-1 study) and the opinion of experts. The sample taken into accountwas a hypothetical Spanish population of patients with AAA equal to or larger than 5 cm and who were candidates foropen surgery. The analysis was performed from the perspective of the National Health Service, and future costs andeffects were discounted at 3.5%. Additionally we also examined the budget impact and performed a probabilisticsensitivity analysis with Monte-Carlo simulation. Results. The results showed that EVT is associated to a higher degreeof effectiveness than open surgery, with gains of between 0.03 and 0.18 years of life per patient at one and four years,respectively (similar results to those obtained if quality adjusted life years are used). The mean cost per patient wasgreater in EVT, between 2879 and 3492 euros, depending on the different scenarios, the cost-life years gained with EVTwas from 111 064 to 19 852 euros and the cost-quality adjusted life years gained was from 137 206 to 27 077 euros(analysis at one and four years, respectively). The budget impact of increasing the introduction of stents evaluated inSpain over the next four years represents 0.5-2.2% of the total cost of AAA. Conclusions. EVT is a cost-effectivealternative with respect to conventional surgical interventions, because at four years of follow-up it offers values thatare below the efficiency threshold that is usually accepted in Spain(AU)

Estudio epidemiológico para valorar la adhesión de los cirujanos vasculares españoles al documento de consenso TASC II para el tratamiento de la enfermedad arterial periférica / Retrospective study to evaluate the adherence to the document TASC II consensus on peripheral arterial disease in Spain

Introducción. La enfermedad arterial periférica (EAP) se considera la arteriopatía no cardíaca de mayor prevalencia.En la guía médica TASC II, publicada en 2007, se describen los procedimientos para el diagnóstico y tratamientode esta enfermedad. Objetivo. Evaluar la adhesión a la guía TASC II por parte de los médicos de los servicios decirugía vascular en los hospitales españoles. Pacientes y métodos. A partir de la historia clínica de pacientes dados dealta en los servicios de cirugía vascular diagnosticados de EAP, se recogieron datos sobre las características del paciente,diagnóstico, seguimiento y tratamiento de la EAP. Estos datos se compararon con las recomendaciones de la guíaTASC II. Resultados. Se incluyeron 1.456 pacientes tratados en 63 hospitales. Se observó un cumplimiento global con laguía TASC II del 62,43%, mientras que la adhesión a la guía en función de sus diferentes bloques varió, y los procesos derevascularización junto con el tratamiento de los factores de riesgo fueron los bloques con una adhesión superior (el 82,4y el 84,96%, respectivamente). El bloque de recomendaciones con el que menos se cumplió correspondió al tratamientode la claudicación intermitente (24,8%). Por último, respecto a los bloques relacionados con el tratamiento de la isquemiacrítica y la isquemia aguda de la extremidad se obtuvieron adhesiones del 78,46 y del 60,1%, respectivamente. Conclusiones.En este estudio se ha obtenido información valiosa sobre la práctica habitual médico-quirúrgica en el tratamientode los pacientes diagnosticados de EAP en España, y se ha observado un mayor cumplimiento con la guía TASCII en los bloques de revascularización y de control de los factores de riesgo(AU)

Introduction. Peripheral arterial disease (PAD) is considered the most prevalent non-cardiac arterial disease.The new TASC II guidelines (Inter-Society Consensus for the Management of Peripheral Arterial Disease) describes theprocedures for a proper diagnosis and treatment of the PAD. Aim. To evaluate the adherence of angiologists andvascular surgeons to the new TASC II guidelines in the main Spanish hospitals. Patients and methods. Each vascularsurgery department contributed their last 20 consecutive patients diagnosed with PAD and discharged from the hospital.The data were collected in to a CRF from the medical records, which included patient characteristics, diagnoses,treatments prescribed and follow-up. These data were compared with the recommendations of TASC II guidelines.Results. A total of 1,456 patients in 80 hospitals were included in the study during the year 2007, of which 60 patientsdid not fulfil with the selection criteria of the study. This is the reason why the statistical analysis has been done on 1,396patients. The global adherence to TASC II was observed in the 62.43%, whereas the adherence to the guideline bySections, varied being the revascularización processes and the management of the risk factors the Sections with greateradherence (82.4% and 84.96 respectively). The Section of recommendations that less adhesion obtained (24.8%)corresponded to management of the intermittent claudication. Finally the Section for the management of critical ischemiaand acute ischemia of the extremities obtained an adhesion of 78.46% and 60.1% respectively. Conclusions. The ENGUÍAstudy provides valuable information on the current medical practice in the management of patients diagnosed with PAD inSpain. A global adhesion of TASC II of 62.43% will help us to develop strategies to improve the management of PADaccording to guidelines(AU)

The importance of a standing position in the diagnosis of Nutcracker phenomenon by duplex sonography.

AIM: To determine the clinical usefulness of Doppler ultrasonography in the diagnosis of the Nutcracker phenomenon, as an alternative to computed tomographic scans (CT). METHODS: This study consisted of 52 patients that presented with intermittent hematuria of unknown origin between January 2006 to April 2008. Doppler ultrasonography was used to assess the left renal vein (LRV) by measuring the anteroposterior (AP) diameter and peak systolic velocity (PSV) in supine and standing positions, at the hilar and interaortomesenteric portions of the LRV. These data were compared with CT scans. The sensitivity and specificity of duplex sonography was determined using the AP diameter and PSV ratios to assess the cut-off levels. Kappa (k) statistic was also evaluated. RESULTS: mean AP diameters of the LRV measured by Doppler sonography were 8.38 mm at the hilar and 3.17 mm under the SMA, compared to 9.3 mm (hilar) and 3.2 mm (SMA) in the supine and standing position respectively. The PSV in the supine position was 25.77 cm/s and 115.48 cm/s, respectively, compared to 25.54 cm/s and 125.96 cm/s in the standing position. The cut-off levels were 3.85 (sensitivity: 61.5%, specificity: 80.8%, k:0.42) for the supine and 4.12 (sensitivity:61.5%, specificity: 65.4%, k: 0.27) for the standing AP diameter, 2.99 (sensitivity: 92.3%, specificity: 73.1%, k: 0.65) for the supine and 3.73 (sensitivity: 96.4%, specificity: 79.2%, k: 0.76) for the standing PSV. CONCLUSIONS: Our data show that the standing PSV ratio is the best parameter for to detecting entrapment of the LRV.

Early mobilisation in patients with acute deep vein thrombosis does not increase the risk of a symptomatic pulmonary embolism.

AIM: The purpose of the study was to determine if early mobilisation in patients with acute lower limb deep vein thrombosis (DVT) increases the incidence of symptomatic pulmonary embolism (PE) and to evaluate the predisposing factors for PE such as location of the thrombus and duration of symptoms. METHODS: The current study was a prospective randomised clinical trial. Between January 2005 and December 2007, 219 patients with acute lower limb DVT were enrolled in the study (118 males and 101 females); the mean age was 64.2 years. INCLUSION CRITERIA: <15 days of initial symptoms, life expectancy >1 year, no life-threatening clinical conditions, and signed informed consent. The patients were randomised into two groups. Group A, 105 patients (47.9%) were hospitalized and received 5 days of bed rest; Group B, 114 patients (52.1%) received care at home with early walking and compression stockings. The primary end point was the presence of symptomatic PE during the first 10 days of treatment. The relationships between the duration of symptoms, location of the thrombus, and symptomatic PE were also analysed. RESULTS: Five cases of symptomatic PE were detected (2.3%), three in Group B and two in Group A. There was no significant difference in the occurrence of new PE between the two groups (P=0.54). Likewise, no difference was detected based on the duration of symptoms (P=0.62) and the location of the thrombus (P=0.43). CONCLUSIONS: In acute DVT , early walking, thrombus location, and duration of the symptoms did not influence the incidence of symptomatic PE.

Non-cardiac arterial disease in Catalonia: patient profiles and quality of clinical records by characteristics of the Vascular Surgery Unit.

AIM: Non-cardiac arterial disease (NCAD) is a frequent cause of hospital admission. The aim of this study was to investigate differences in patient profiles and clinical records as a function of the size of the Vascular Surgery Unit (VSU). METHODS: Retrospective observational study. Stratified cluster sampling and selection of patients hospitalized for NCAD. ANALYSIS: 1) description of patient profiles, quality of clinical records, and VSU [availability of diagnostic (DR) and therapeutic (TR) resources, and of written protocols (WP)]; 2) association between these variables and size of VSU. RESULTS: The sample consisted of 14 hospitals, 6 with a VSU of 15 or fewer beds (VSU < or = 15B) and 8 with >15 beds (VSU >15B). The mean number of DRs, TRs and WPs was 9, 2.8 and 2 in VSUs < or = 15B, and 11.5, 6.5 and 3.3 in VSUs >15B. The proportion of patients older than 70, female, with ischemic disease, or with coexisting diabetes was significantly higher in VSUs < or = 15B (67%, 31%, 95% and 57%, respectively) than in VSUs >15B (58%, 22%, 69% and 48%). Comorbid conditions and treatment during admission and at discharge were documented significantly less frequently in the clinical records in VSUs < or = 15B. Risk factors were under-reported in the clinical records of both types of VSU. CONCLUSION: Patient profiles and the quality of clinical records vary by size of VSU. Under-reporting of risk factors may hinder the implementation of prevention and treatment measures.

Síndrome compartimental abdominal en el postoperatorio de un paciente con aneurisma de aorta abdominal infrarrenal fisurado. Caso clínico y revisión de la bibliografía / Abdominal compartment syndrome in the post-operative period in a patient with a fissured aneurysm in the infrarenal abdominal aorta. A case report and review of the literature

Introducción. El síndrome compartimental abdominal (SCA) representa una entidad clínica caracterizada por un aumento de la presión intraabdominal con potencial para provocar, si no se diagnostica y se corrige a tiempo, fallo multiorgánico progresivo y la muerte del paciente. En nuestra especialidad, el paradigma sería los enfermos con un aneurisma de aorta abdominal fisurado y tratados tanto con cirugía abierta convencional, como mediante técnicas endovasculares. Caso clínico. Varón de 79 años con factores de riesgo vascular habituales, que acudió a Urgencias por un cuadro de dolor lumbar con masa abdominal pulsátil en la exploración. Tras la realización de una tomografía axial computarizada, que confirmó el diagnóstico y descartó la terapéutica endovascular, fue intervenido mediante cirugía abierta, en la que se realizó una exclusión del aneurisma y una derivación aortobifemoral. En el postoperatorio precoz presentó deterioro clínico progresivo, oligoanuria y distensión abdominal grave por lo que, tras descartar otras causas de fallo multiorgánico, se realizó medición de la presión intravesical ante la sospecha de posible SCA. Tras confirmar la situación de hiperpresión intraabdominal fue reintervenido para realizar una laparotomía descompresiva. En la revisión de la bibliografía se discute la fisiopatología, los métodos diagnósticos y el tratamiento del SCA. Conclusión. Existe un grupo de pacientes en los que la identificación de las situaciones de riesgo de desarrollar un SCA resulta vital para evitar, mediante una intervención precoz, un desenlace fatal hacia el fallo multiorgánico y el fallecimiento

Introduction. Abdominal compartment syndrome (ACS) is a clinical entity characterised by an increase in the intra-abdominal pressure which can potentially lead to progressive multiple organ failure and the death of the patient, if it is not diagnosed and corrected in time. In our speciality, the paradigm would be patients with a fissured abdominal aortic aneurysm who have been treated with both conventional open surgery and by means of endovascular techniques. Case report. A 79-year-old male with the usual vascular risk factors, who visited the Emergency Department because of symptoms consisting in lower back pain and an abdominal pulsatile mass that was found in the examination. Following a computerised axial tomography scan, which confirmed the diagnosis and precluded the possibility of endovascular therapy, the patient was submitted to open surgery, which involved exclusion of the aneurysm and an aortobifemoral bypass. During the early phase of the post-operative period the patient showed progressive clinical deterioration, oligoanuria and severe abdominal distension. In consequence, after ruling out other causes of multiple organ failure and with the suspicion of possible ACS, the intravesical pressure was measured. After confirming the existence of high pressure within the abdomen, a second operation was performed to carry out a decompressive laparotomy. In the review of the literature, the pathophysiology, diagnostic methods and treatment of ACS are discussed. Conclusions. There is a group of patients in whom the identification of situations of higher risk of developing ACS is essential so that an early intervention can prevent a fatal outcome that leads to multiple organ failure and death

Estudio comparativo de dos técnicas quirúrgicas en el tratamiento de las varices de las extremidades inferiores: resultados tras cinco años de seguimiento / Comparative study of two surgical techniques in the treatment of varicose veins in the lower extremities: results from a five-year follow-up

Objetivo. Comparar los resultados tardíos de la fleboextracción convencional con la estrategia CHIVA en el tratamiento de las varices de las extremidades inferiores. Pacientes y métodos. Ensayo clínico sobre 100 pacientes con varices: 62 mujeres y 38 hombres con una edad media de 49 años (desviación estándar: 9,24 años). Los criterios de inclusión fueron los recomendados por la SEACV (varices más o menos evidentes con diferentes grados de insuficiencia venosa crónica), mientras que los criterios de exclusión fueron los antecedentes de tratamientos previos (esclerosis o cirugía), las alteraciones en el sistema venoso profundo, la obesidad mórbida y/o la edad superior a 70 años. Se practicó una cartografía hemodinámica mediante eco-Doppler. Los pacientes se dividieron en el grupo I (fleboextracción; n = 49) y el grupo II (CHIVA; n = 51). Ambos grupos eran homogéneos tanto demográfica como clínicamente (clasificación CEAP). Los controles clínicos y hemodinámicos se realizaron a la semana y al primer, tercer y sexto mes de la cirugía, y posteriormente cada año hasta los cinco años de seguimiento. Se analizaron la clínica y los resultados estéticos (objetivos y subjetivos), al igual que el número de reintervenciones y recidivas. Se aplicaron los tests de chi al cuadrado y t de Student para el análisis estadístico. Resultados. El 96% de los pacientes completó todo el seguimiento (cinco años). Los resultados clínicos y estéticos a los cinco años del postoperatorio no muestran diferencias significativas entre las dos técnicas. El número de reintervenciones fue similar en los dos grupos. No se detectaron diferencias estadísticamente significativas en cuanto a recidiva varicosa (p > 0,05). Conclusiones. En nuestra serie, las dos técnicas quirúrgicas presentan resultados clínicos y estéticos similares tras cinco años de seguimiento

Aim. To compare late outcomes of conventional vein stripping with the CHIVA strategy in the treatment of varicose veins in the lower extremities. Patients and methods. A clinical trial on 100 patients with varicose veins: 62 females and 38 males with a mean age of 49 years (standard deviation, SD: 9.24). Eligibility criteria were those recommended by the SEACV (varicose veins that were apparent to a greater or lesser extent with different degrees of chronic venous insufficiency). Exclusion criteria were the past history of previous treatments (sclerosis or surgery), disorders affecting the deep vein system, morbid obesity and/or the patient’s being over 70 years old. A blood map was performed using a Doppler ultrasound equipment. Patients were divided into group I (vein stripping; n = 49), and group II (CHIVA; n = 51). Both groups were demographically and clinically homogenous (CEAP classification). Haemodynamic and clinical controls were performed during the first week and at the first, third and sixth month after surgery and then every year until five years’ follow-up. The clinical features and the (objective and subjective) aesthetic outcomes were analysed, together with the numbers of reinterventions and recurrences. Chi squared and Student’s t tests were applied for the statistical analysis. Results. The whole (five-year) follow-up was completed by 96% of the patients. The clinical and aesthetic outcomes five years after the operation do not display any significant differences between the two techniques. The number of reinterventions was similar in the two groups. No statistically significant differences were detected as far as recurrence of the varicose syndrome was concerned (p > 0.05). Conclusions. In our series, both surgical techniques offered similar clinical and aesthetic outcomes after five years’ follow-up

Diagnóstico en Urgencias de la trombosis venosa de miembros inferiores: valor de los criterios clínicos unidos al dímero-D / The role of clinical signs in combination to the D-dimer in the diagnosis of deep vein thrombosis of lower limbs in an emergency room

Objetivo. Valorar la utilidad de criterios clínicos unidos a la determinación del dímero-D para el diagnóstico de la trombosis venosa profunda (TVP) de miembros inferiores (MMII) en un Servicio de Urgencias de un hospital de tercer nivel. Pacientes y métodos. Estudio retrospectivo-comparativo. Durante 6 meses (julio a diciembre de 2002) se examinaron 295 pacientes en el Servicio de Urgencias de nuestro centro por sospecha de TVP de MMII. Se les valoró siguiendo los criterios clínicos de Wells, y se estratificaron como pacientes de alta, media o baja probabilidad de TVP. Se les determinó el dímero-D. En todos se realizó eco-Doppler (ED) venoso de MMII como método de referencia diagnóstica. Analizamos los resultados obtenidos en función de sensibilidad, especificidad, valor pronóstico positivo (VPP) y negativo (VPN), y coeficiente kappa para comparar el grado de concordancia entre ambas pruebas diagnósticas, mediante sistema SPSS para Windows. Resultados. Sólo 53 (18%) casos tuvieron diagnóstico positivo de TVP según ED. Probabilidad alta/intermedia con dímero-D positivo: 49 con TVP, seis sin ella. Probabilidad baja o dímero-D negativo: 236 sin TVP, cuatro con TVP (los cuatro con dímero-D positivo). Sensibilidad 92%, especificidad 97%, VPP 89%, VPN 98%, con una exactitud de 96,6%, y el coeficiente kappa fue de 0,88, demostrando un alto grado de concordancia entre ambos procedimientos (p < 0,0001). Conclusiones. Los criterios clínicos de estratificación de Wells unidos a la determinación del dímero-D son muy útiles en un Servicio de Urgencias para el diagnóstico de TVP de MMII, permitiendo un inicio rápido de la terapéutica. En caso de baja probabilidad clínica y dímero-D negativo, se evita la realización de ED en un número elevado de casos, lo que agiliza la asistencia en Urgencias

Aim. To validate the role of clinical sings and D-dimer determination in evaluation of deep venous thrombosis (DVT) of lower limbs suspect in emergency room of high technology hospital. Patients and methods. Retrospective and comparative study since July 2002 to December 2002 about 295 patients looked after in emergency room in our hospital because of DVT of lower limbs suspect. We looked for Wells’ clinical signs, and stratified patients in high, middle and low probability of DVT. We determined D-dimer in all patients evaluated. We achieved venous duplex ultrasound of lower limbs like gold-standard diagnosis. We diagnosed 53 DVT with this method. We evaluated the results in sensibility, specificity, positive predictive value (PPV) and negative predictive value (NPV), and kappa coefficient, with program SPSS for Windows. Results. High and middle probability with D-dimer positive: 49 with DVT, 6 without. Low probability or D-dimer negative: 236 without DVT, 4 with it (these with D-dimer positive). Sensibility 92%, specificity 97%, PPV 89%, NPV 98%, with an exactitude of 96,6%, and kappa coefficient of 0,88. It was demonstrated a high degree of concordance between gold-standard and tests evaluated (p < 0,0001). Conclusions. Wells’ clinical signs and determination of D-dimer give good diagnosis approximation to DVT of lower limbs in emergency room. With low clinical probability of deep venous thrombosis and negative D-dimer determination is not necessary to achieve duplex for suspect deep venous thrombosis

Papel de la cartografía arterial con eco-Doppler en la toma de decisiones terapéuticas en la isquemia crítica de los miembros inferiores / The role of duplex arterial mapping in decision making in critical ischaemia in lower limbs

Introducción. La arteriografía hasta hoy se ha considerado como el patrón de referencia para la toma de decisiones terapéuticas en pacientes con isquemia crítica de los miembros inferiores (MMII). Ésta técnica invasiva no sólo no está exenta de efectos secundarios sino que además sólo aporta información morfológica. Por otra, mediante eco-Doppler se puede combinar la información morfológica y hemodinámica y realizar un mapa de la zona explorada, la llamada cartografía arterial (CA), que según algunos estudios ofrece similar fiabilidad a la angiografía. Objetivo. Evaluar la seguridad de la CA como método único de planificación terapéutica en la isquemia crítica de los miembros inferiores. Pacientes y métodos. Estudio prospectivo-comparativo no aleatorizado de pacientes con isquemia crítica de MMII reclutados durante 2002. Se incluyeron 112 pacientes consecutivos a quienes realizamos CA. En 56 pacientes, se realizó arteriografía para comprobar la imposibilidad de revascularización ante la única alternativa de amputación o bien en los casos en donde el explorador no consideró la CA como concluyente. Dividimos los pacientes en dos grupos de decisión terapéutica: grupo A, basado solamente en CA, y grupo B, basado en arteriografía. No hubo entre ellos diferencias estadísticamente significativas (p > 0,05). Registramos y comparamos permeabilidad acumulativa al mes y a los seis meses (mediante log-rank); grado de coincidencia en decisiones terapéuticas adoptadas por CAarteriografía en el grupo con ambas pruebas (grupo B), y grado de coincidencia de ambas respecto a la decisión quirúrgica intraoperatoria. Resultados. El grado de coincidencia CA-arteriografía fue de 92,8 por ciento (p 0,05). Conclusión. La CA es un método suficiente para tomar decisiones terapéuticas en la mayoría de pacientes con isquemia crítica de MMII; reduce un número significativo de angiografías. Sin embargo, ante la duda o la posibilidad de amputación recomendamos practicar angiografía (AU)

La formación del cirujano vascular en Europa: el problema de la armonización y su devenir futuro / The training of vascular surgeons in Europe: the problem of its harmonisation and development in the future

No disponible

Diagnóstico de la hipertensión arterial renovascular mediante Eco-Doppler

Objetivo: valorar la fiabilidad del eco-Doppler en la detección de estenosis renales en pacientes con sospecha de hipertensión renovascular. Material y método: estudio prospectivo durante cuatro años de 91 arterias renales en 47 pacientes hipertensos (tres monorrenos) con sospecha de hipertensión arterial renovascular. Edad media: 56 años (r = 25-77); 22 varones y 25 mujeres. Parámetros valorados por dúplex: velocidad sistólica máxima (VSM) y velocidad diastólica final (VDF) en arteria renal, cociente renal-aórtico e índice de resistencia periférica. Análisis estadístico: curvas ROC y análisis multivariante para la obtención del mejor parámetro diagnóstico de estenosis > 60 por ciento. A todos los pacientes se les realizó arteriografía de ambas arterias renales. Resultados: mediante análisis multivariante únicamente la VSM > 180 cm/sg (p = 0,01) y el cociente renal-aórtico > 3 (p = 0,04) son predictivos de estenosis > 60 por ciento. Así hemos identificado 60 de 65 estenosis inferiores al 60 por ciento, 20 de 21 estenosis superiores al 60 por ciento, y 5 de 5 oclusiones (Kappa = 0,85) (p 180 cm/sg es el mejor parámetro para detectar estenosis > 60 por ciento (AU)

[Vascular complications in the transplanted kidney: detection with Doppler ultrasonography]. / Complicaciones vasculares en el riñón transplantado: detección mediante Eco-Doppler.

OBJECTIVES: To determine the utility of renal duplex sonography in the detection of vascular complications in renal grafts. PATIENTS AND METHODS: 45 patients with a median post-transplant follow-up of 39.3 +/- 28.8 months were evaluated. The renal artery maximum systolic velocity (SVmax) and the renal artery/iliac artery Svmax ratio (RIR) were utilized to detect stenosis. RESULTS: The SVmax was > 200 cm/sec in 6 cases, indicating renal artery stenosis (RAS). Angiographic evaluation of 5 patients revealed 3 had RAS > 60% and 2 had RAS < 60%. The 3 patients with RAS > 60% had RIR > 2. Increased vascular resistance in renal parenchyma was detected in 8 patients (1 acute rejection, 1 acute tubular necrosis, 6 histopathologically confirmed chronic rejection). Seventeen patients had one or more biopsies done during the follow-up. Six patients had a Doppler pattern compatible with arteriovenous fistula; two were confirmed by arteriography and one of these was embolized. CONCLUSIONS: Duplex sonography is no substitute for the other methods utilized in the early detection of vascular complications in the renal graft, but it can identify those patients requiring angiographic assessment and can therefore reduce the number of biopsies for posttransplant evaluation.

[Aneurysms of the renal artery branches secondary to intimal fibrodysplasia]. / Aneurismas de ramas de la arteria renal secundarios a fibrodisplasia intimal.

We have a limited knowledge of the incidence, natural history and complications of aneurysms of the segmental branches of renal arteries. Two young female patients with intimal fibrodysplasia and aneurysms of the segmental branches of renal arteries are described. The presenting features were hypertension and hematuria. The diagnosis was achieved through an arteriogram. Both patients underwent aneurysmorrhaphy and one of them nephrectomy of a non-functioning kidney. Pathological examination revealed intimal fibrodysplasia; one of the specimens showed areas of calcification. The immediate postoperative period was uneventful. However, one of the patients died from cerebral haemorrhage 18 months from the operation. The other patient has remained asymptomatic 3 years postoperatively. The epidemiological aspects, risk factors and treatment are discussed.