Diagnostic reference levels and complexity indices in interventional radiology: a national programme.

OBJECTIVES: To propose national diagnostic reference levels (DRLs) for interventional radiology and to evaluate the impact of the procedural complexity on patient doses. METHODS: Eight interventional radiology units from Spanish hospitals were involved in this project. The participants agreed to undergo common quality control procedures for X-ray systems. Kerma area product (KAP) was collected from a sample of 1,649 procedures. A consensus document established the criteria to evaluate the complexity of seven types of procedures. DRLs were set as the 3rd quartile of KAP values. RESULTS: The KAP (3rd quartile) in Gy cm2 for the procedures included in the survey were: lower extremity arteriography (n = 784) 78; renal arteriography (n = 37) 107; transjugular hepatic biopsies (THB) (n = 30) 45; biliary drainage (BD) (n = 314) 30; uterine fibroid embolization (UFE) (n = 56) 214; colon endoprostheses (CE) (n = 31) 169; hepatic chemoembolization (HC) (n = 269) 303; femoropopliteal revascularization (FR) (n = 62) 119; and iliac stent (n = 66) 170. The complexity involved the increases in the following KAP factors from simple to complex procedures: THB x4; BD x13; UFE x3; CE x3; HC x5; FR x5 and IS x4. CONCLUSIONS: The evaluation of the procedure complexity in patient doses will allow the proper use of DRLs for the optimization of interventional radiology. KEY POINTS: • National DRLs for interventional procedures have been proposed given level of complexity • For clinical audits, the level of complexity should be taken into account. • An evaluation of the complexity levels of the procedure should be made.

Guía de acceso vascular en hemodiálisis / Vascular access guideliness for hemodialysis

Introducción. La calidad del acceso vascular (AV) condiciona los resultados clínicos de los enfermos tratados mediante hemodiálisis periódicas. Las complicaciones originadas por la disfunción del AV constituyen una de las principales causas de morbimortalidad de estos pacientes y contribuyen de forma sustancial al aumento del coste sanitario. La Sociedad Española de Nefrología considera que este problema requiere una atención prioritaria, y ha decidido realizar una revisión de las guías de actuación de este capítulo, con la finalidad de mejorar nuestros estándares colectivos y elevar la calidad de nuestra práctica asistencial. Objetivos. La finalidad esencial ha sido la de elaborar un informe que pueda proporcionar una ayuda para la comprensión y tratamiento de los problemas relacionados con el AV y obtener una homogeneización de actuaciones con el propósito de alcanzar tres objetivos principales: aumentar la utilización de fístulas arteriovenosas autólogas como AV inicial, detectar la disfunción de AV permanente antes de la trombosis y racionalizar la utilización de catéteres venosos centrales (CVC). Desarrollo y conclusiones. Se presenta un documento consensuado de forma multidisciplinar en la que han participado nefrólogos, cirujanos vasculares, radiólogos intervencionistas, especialistas en enfermedades infecciosas y diplomados en enfermería nefrológica. En él se define el estado de la situación en seis capítulos: preparación del paciente, creación del AV, cuidados, vigilancia, tratamiento de las complicaciones y CVC. Estas guías constan de una serie de enunciados con diferentes grados de evidencia según la literatura disponible, que no pretenden ser normas de obligado cumplimiento, sino referentes del estado actual del problema y sus soluciones. La práctica clínica diaria, al depender de las condiciones intrínsecas, no siempre nos permite alcanzar el ideal, pero sí dirigir nuestros esfuerzos a una mejora de resultados. Cada recomendación se complementa con la exposición de su razonamiento. El documento se acompaña de una serie de indicadores de calidad

Introduction. Quality of vascular access (VA) has aremarkable influence in hemodialysis patients outcomes. Dysfunction of VA represents a capital cause of morbi-mortality of these patients as well an increase in economical. Aims. Spanish Society of Nephrology, aware of the problem, has decided to carry out a revision of the issue with the aim of providing help in comprehensión and treatment related with VA problems, and achieving an homogenization of practices in three mayor aspects: to increase arteriovenous fistula utilization as first vascular access, to increment vascular access monitoring practice and rationalise central catheters use. Development and conclusions.We present a consensus document elaborated by a multidisciplinar group composed by nephrologists, vascular surgeons, interventional radiologysts, infectious diseases specialists and nephrological nurses. Along six chapters that cover patient education, creation of VA, care ,monitoring, complications and central catheters, we present the state of the art and propose guidelines for the best practice, according different evidence based degrees, with the intention to provide help at the professionals in order to take aproppiate decissions. Several quality standars are also included

[Vascular access guidelines for hemodialysis]. / Guías de acceso vascular en hemodiálisis.

Quality of vascular access (VA) has a remarkable influence in hemodialysis patients outcomes. Dysfunction of VA represents a capital cause of morbi-mortality of these patients as well an increase in economical. Spanish Society of Neprhology, aware of the problem, has decided to carry out a revision of the issue with the aim of providing help in comprehensión and treatment related with VA problems, and achieving an homogenization of practices in three mayor aspects: to increase arteriovenous fistula utilization as first vascular access, to increment vascular access monitoring practice and rationalise central catheters use. We present a consensus document elaborated by a multidisciplinar group composed by nephrologists, vascular surgeons, interventional radiologysts, infectious diseases specialists and nephrological nurses. Along six chapters that cover patient education, creation of VA, care, monitoring, complications and central catheters, we present the state of the art and propose guidelines for the best practice, according different evidence based degrees, with the intention to provide help at the professionals in order to make aproppiate decissions. Several quality standars are also included.

Early detection and treatment of hemodialysis access dysfunction.

PURPOSE: To assess the usefulness of a program for the early detection of hemodialysis graft dysfunction and the impact on graft survival of percutaneous transluminal angioplasty (PTA) and stent implantation to correct venous stenosis. METHODS: A program for the early detection of hemodialysis access graft dysfunction was carried out in 110 patients over a period of 80 months. Detection was based on physical examination, flow rate measurements, venous pressure, and analytical determinations performed at dialysis. The stenoses detected were treated by PTA or PTA plus stent deployment. Survival curves compared primary and assisted patency rates for the different graft types. RESULTS: The most important indicators of dysfunction were increased venous pressure and difficulty in cannulation of the graft. Significant stenoses were revealed by 227 (92.2%) of the 246 fistulography procedures performed. PTA results were satisfactory in 100% of the Thomas grafts, 74% of the Brescia-Cimino (BC) grafts, and 53% of the polytetrafluoroethylene (PTFE) grafts. Technical success rates for stent deployment were 92% for BC grafts and 100% for PTFE grafts, while functional success rates were 96% and 97%, respectively. The difference in the primary patency (P1) and assisted patency (AP) values was statistically significant for all three graft types. There was no significant difference in the patency rates for grafts treated by PTA alone or by PTA and stent deployment. CONCLUSION: A surveillance program helped prevent graft thrombosis, and intervention as required achieved excellent primary and assisted patency rates. Stent deployment salvaged a considerable number of accesses but did not significantly extend access survival time.

[Venography and percutaneous embolization of the spermatic vein with spring coil as treatment of the varicocele in childhood]. / Flebografía y embolización percutánea de la vena espermática mediante espiral metálica, como tratamiento del varicocele en la infancia.

The treatment of varicocele is controversial in boys and it is a contributing factor to male infertility. Recently it has been proposed that earlier therapy of a varicocele during this period may improve the prognosis of infertility. We review our experience with the diagnosis and management of left varicocele in 30 pediatric patients 6 to 15 years old. All patients had clinically palpable varicocele. All were managed under local anesthesia by spermatic venography and percutaneous transcatheter embolization of the internal spermatic vein with spring coils. All achieved satisfactory occlusion, and during the follow up from 13 years to 9 months there was only one recurrence, noted in a patient 6 months after the procedure. Internal spermatic venograms allowed precise coil placement relative to collateral veins which could cause recurrence. Complications developed were phlebitis of the pampiniform plexus, leading to swelling and erythema of the left scrotum and mild flank pain, these symptoms resolved without sequelae. This a safe and effective nonsurgical method of obliterating varicoceles in children.

[Addition of ritanserin to the treatment with propranolol in cirrhotic patients: effects on portal pressure]. / Adición de ritanserina al tratamiento con propranolol en enfermos cirróticos: efectos sobre la presión portal.

The use of vasodilators to prevent the rupture of esophagic varices (EV) due to portal hypertension (PH) would reduce the portal pressure (PP) as the result of increased portocolateral flow. Rinsaterine, a 5-HT2 receptor blocker, reduces PP in experimental models of PH. This pilot study was designed to verify if ritanserine has a sustained and additive effect to propranolol on PP in cirrhotic patients with PH. Ten chronic patients with EV, under prophylactic therapy with propranolol and with a suprahepatic venous pressure gradient (SVPG) > 12 mm Hg, received ritanserine (0.11-0.14 mg/kg/day). One patients completed one month of treatment due to drug intolerance. Nine patients completed one month of treatment; SVPG did not show any significant variation in four patients and decreased 3 mm Hg in five patients, which were treated during 70 days more. After then, HVPG returned to its previous values except in one patient. The long-term association between ritanserine and propranolol does not improve the results of propranolol. However, the initial response observed in all of these patients supports the role of the serotoninergic system in the PH and states the need for further studies on 5-HT2 blocking for the prophylaxis of EV rupture.

[Hemoptysis caused by a bronchial artery aneurysm. Apropos a case]. / Hemoptisis por aneurisma de la arteria bronquial. A propósito de un caso.

We discuss the case of a right bronchial artery aneurysm in its intrapulmonary trajectory which manifested itself by repeated mild hemoptysis. Diagnosis was made through selective angiography of bronchial artery and during the same procedure it was treated through transcatheter embolization. We have reviewed the literature and found 17 cases of bronchial artery aneurysms with intrapulmonary or mediastinal localization.

[Effort thrombosis of the subclavian-axillary vein: a report of 3 cases and the individualization of treatment]. / Trombosis de esfuerzo de la vena subclavioaxilar: descripción de tres casos e individualización del tratamiento.

The previous history, clinical evolution, diagnostic procedure and treatment in three cases of effort thrombosis of the subclavian-axillary vein are described. Only one patient presented on admittance signs compatible with thoracic outlet syndrome. We insist on the importance of individualizing treatment. A patient presented on admittance an advanced clinical picture and underwent anticoagulant treatment for six months, showing important clinical and phlebographic alterations during this time. The other two patients presented an acute picture of a few hours of evolution and initially underwent fibrinolytic treatment followed by anticoagulant treatment during three months. The clinical data as well as phlebography was normal in these patients six months after admission.