The change in the atrial fibrillation type as a prognosis marker in a community study: long-term data from AFBAR (Atrial Fibrillation in the BARbanza) study.

BACKGROUND: The aim is to describe the prognosis role of the change in the atrial fibrillation (AF) type in an unselected population of patients with AF currently attending primary care in a single health-service area in Galicia, north-western Spain. METHODS: AFBAR is a cohort study that was carried out by 35 primary care providers in 2008. Participants were followed up for a mean of 2.8 ± 0.7 years. 798 patients with the diagnosis of AF who presented at their clinics during a three-month period were recruited. Primary endpoint was mortality or hospital admission. RESULTS: 778 patients (413 male) were analyzed; mean age 74.8 years old. Hypertension was the most prevalent risk factor (76.5%). Permanent AF was diagnosed in 529 patients (68.0%). Change of AF status occurred in 76 patients (9.8%). During follow-up 52.1% of the patients underwent a primary endpoint and the overall survival was 83.4%. The following independent determinants of primary endpoint were identified: change in AF status (Hazard Ratio (HR) 1.41 (95%-confidence interval (CI) 1.04-1.92); p=0.026); previous heart failure (HR 1.28 (95%-CI 1.00-1.65); p=0.050); previous cardiovascular admission (HR 1.54 (95%-CI 1.16-2.03); p=0.002); stroke (HR 2.02 (95%-CI 1.35-3.03); p=0.001);ischemic heart disease (HR 1.28 (95%-CI 1.00-1.65); p=0.050); chronic obstructive pulmonary disease (HR 1.28 (95%-CI 1.00-1.64);p=0.042); anemia (HR 1.37 (95% CI 1.08-1.75); p=0.010); or AF-related complications (HR 1.45 (95%-CI 1.18-1.78); p<0.001). CONCLUSIONS: The change in AF status showed to be an important prognosis marker for death or hospital admissions in a primary care cohort.

Una oportunidad para conocer la hipertensión arterial refractaria en nuestro medio / An opportunity to know about resistant hypertension in our area

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[Arterial trauma in hip arthroplasty]. / Traumatismos arteriales en artroplastia de cadera.

INTRODUCTION: Arterial injuries due to total hip arthroplasty can be a serious complication. The risk of vascular injury is related to proximity of the structures, tractions, and the aggressive use of instruments. OBJECTIVES: To analyze the frequency, injury mechanism, clinical presentation and therapeutic options in this kind of injury. PATIENTS AND METHOD: A group of 4162 patients subjected to total hip arthroplasty between 1986 and 2006 (reinterventions 7.2%). We describe 8 cases (5 women and 3 men) with a mean age of 61 years (reinterventions 50%). The vascular surgery was performed at less than 1 hour (n = 4), 6 hours (n = 2), 16 hours (n = 1) and 20 days (n = 1). RESULTS: The most frequent locations were external iliac artery (n = 3), common femoral (n = 3), internal iliac (n = 1) and deep femoral (n = 1). The clinical presentation was, internal bleeding (50%), acute limb ischemia (37%) and subacute limb ischemia (13%). The surgical interventions were bypass (50%), arteriorrhaphy (25%), primary repair (12.5%), and thrombectomy and patching (12.5%). One case was reoperated 6 years later, as we found a false anastomotic aneurism in a previous ilio-femoral bypass. The death and amputation rates were 0%. CONCLUSIONS: Although these injuries are rare, they involve a life-threatening complication. The external iliac artery/common femoral artery are the most frequent location. Most patients required a bypass, although the surgical technique depends on the injury location.

Traumatismos arteriales en artroplastia de cadera / Arterial trauma in hip arthroplasty

Introducción. Las lesiones arteriales tras artroplastia de cadera suponen una grave complicación. El riesgo de lesión vascular aumenta por la proximidad de las estructuras, las tracciones y el uso de instrumentos agresivos. Objetivos. Analizar la frecuencia, los mecanismos lesivos, clínica y opciones terapéuticas en estas lesiones. Pacientes y método. Serie de 4.162 pacientes intervenidos de artroplastia de cadera en 1986-2006 (reintervenciones, el 7,2%). Se produjeron 8 casos (5 mujeres y 3 varones), con edad media de 61 años (reintervenciones, el 50%). La intervención vascular fue de menos de 1 h (n = 4), 6 h (n = 2), 16 h (n = 1) y 20 días (n = 1). Resultados. Se produjeron lesiones en ilíaca externa (n = 3), femoral común (n = 3), hipogástrica (n = 1) y femoral profunda (n = 1). La clínica fue hemorragia interna (50%), isquemia aguda (37%) y subaguda (13%). Los mecanismos lesivos fueron: broca (3), cemento (2), tracción (1), abrazadera (1) y legrado (1). Se realizó derivación (50%), ligadura simple (25%), sutura primaria (12,5%) y trombectomía con parche (12,5%). Un caso fue reintervenido 6 años después por un falso aneurisma anastomótico del bypass iliofemoral previo. La mortalidad y la tasa de amputaciones fueron del 0%. Conclusiones. Aunque poco frecuentes, las lesiones arteriales tras artroplastia de cadera suponen una complicación de gravedad considerable; la localización más frecuente es la arteria ilíaca externa/femoral común, que en la mayoría requiere derivación, aunque la técnica depende de la localización de la lesión (AU)

Introduction. Arterial injuries due to total hip arthroplasty can be a serious complication. The risk of vascular injury is related to proximity of the structures, tractions, and the aggressive use of instruments. Objectives. To analyze the frequency, injury mechanism, clinical presentation and therapeutic options in this kind of injury. Patients and method. A group of 4162 patients subjected to total hip arthroplasty between 1986 and 2006 (reinterventions 7.2%). We describe 8 cases (5 women and 3 men) with a mean age of 61 years (reinterventions 50%). The vascular surgery was performed at less than 1 hour (n = 4), 6 hours (n = 2), 16 hours (n = 1) and 20 days (n = 1). Results. The most frequent locations were external iliac artery (n = 3), common femoral (n = 3), internal iliac (n = 1) and deep femoral (n = 1). The clinical presentation was, internal bleeding (50%), acute limb ischemia (37%) and subacute limb ischemia (13%). The surgical interventions were bypass (50%), arteriorrhaphy (25%), primary repair (12.5%), and thrombectomy and patching (12.5%). One case was reoperated 6 years later, as we found a false anastomotic aneurism in a previous ilio-femoral bypass. The death and amputation rates were 0%. Conclusions. Although these injuries are rare, they involve a life-threatening complication. The external iliac artery/common femoral artery are the most frequent location. Most patients required a bypass, although the surgical technique depends on the injury location (AU)

Prospective evaluation of carotid artery stenosis: elliptic centric contrast-enhanced MR angiography and spiral CT angiography compared with digital subtraction angiography.

BACKGROUND AND PURPOSE: Although digital subtraction angiography (DSA) is the reference standard for assessing carotid arteries, it is uncomfortable for patients and has a small risk of disabling stroke and death. These problems have fueled the use of spiral CT angiography and MR angiography. We prospectively compared elliptic centric contrast-enhanced MR angiography and spiral CT angiography with conventional DSA for detecting carotid artery stenosis. METHODS: Eighty carotid arteries (in 40 symptomatic patients) were assessed. Elliptic centric MR and spiral CT angiographic data were reconstructed with maximum intensity projection and multiplanar reconstruction techniques. All patients had been referred for DSA evaluation on the basis of findings at Doppler sonography, which served as a screening method (degree of stenosis > or = 70% or inconclusive results). Degree of carotid stenosis estimated by using the three modalities was compared. RESULTS: Significant correlation with DSA was found for stenosis degree for both elliptic centric MR and spiral CT angiography; however, the correlation coefficient was higher for MR than for CT angiography (r = 0.98 vs r = 0.86). Underestimation of stenoses of 70-99% occurred in one case with elliptic centric MR angiography (a 70% stenosis was underestimated as 65%) and in nine cases with spiral CT angiography, in comparison to DSA findings. Overestimation occurred in two cases with MR angiography (stenoses of 65-67% were overestimated as 70-75%). With CT, overestimation occurred in seven cases; a stenosis of 60% in one case was overestimated as 70%. Both techniques confirmed the three cases of carotid occlusion. With elliptic centric MR angiography, carotid stenoses of 70% or greater were detected with high sensitivity, 97.1%; specificity, 95.2%; likelihood ratio (LR) for a positive test result, 20.4; and ratio of LR(+) to LR(-), -0.3. With spiral CT angiography, sensitivity, specificity, LR(+), and LR(+):LR(-) were 74.3%, 97.6%, 31.2, and 0.3, respectively. CONCLUSION: Elliptic centric contrast-enhanced MR angiography is more accurate than spiral CT angiography to adequately evaluate carotid stenosis. Furthermore, elliptic centric contrast-enhanced MR angiography appears to be adequate to replace conventional DSA in most patients examined.

Inflammatory aneurysm in the infrarenal portion of thoracoabdominal aneurysms: an uncommon variant.

INTRODUCTION: We present an unusual variant of type IV thoracoabdominal aneurysm with inflammatory changes in part of the aortic wall. MATERIAL AND METHODS: Between January 1990 and December 2000, 5 male patients (mean age, 68 years) with inflammatory aneurysms of 29 with type IV thoracoabdominal aneurysms (17.2%) underwent surgery. All five had arterial hypertension. The diagnosis of inflammatory aneurysm was made on the basis of clinical suspicion supported by characteristic features on CT scans. Endoaneurysmorraphy was performed in all cases; a tube graft was inserted in three cases, and bifurcation was performed in 2. The macroscopic appearance of periaortic fibrosis was detected at the infrarrenal portion of the aneurysm in the 5 patients, but no retroperitoneal fibrosis was found at the level of the distal thoracic aorta in any case. RESULTS: There was no operative mortality. Paraparesis was not detected in any patient. One patient had acute kidney failure, and another required an extended stay in the intensive care unit because of respiratory insufficiency. Pathologic examination confirmed the diagnosis of inflammatory aneurysm in all 5 patients, with characteristic adventitial thickening caused by lymphoplasmacytic infiltrate and fibrosis around the ganglionic and nerve structures. CONCLUSIONS: Type IV thoracoabdominal aneurysm with inflammatory changes can be treated at surgery with a retroperitoneal approach. Usually the fibrotic response is confined to the infrarenal portion of the aneurysm.

Obstructive ARF caused by an inflammatory abdominal aortic aneurysm.

Inflammatory abdominal aortic aneurysms are rare entities characterized by dense fibrosis typically enveloping the aortic wall and adjacent structures with distinctive clinical features that differentiate them from typical atherosclerotic aneurysms. The inflammatory process can involve the renal excretory pathways, causing ureteral obstruction in 20% of cases. The authors report 2 cases of complete obstructive anuria secondary to inflammatory aneurysms and discuss the most appropriate management for these situations of hydronephrosis. Surgical repair of the aneurysm usually leads to regression of the inflammatory reaction.

Cirugía de revascularización en aneurismas extraparenquimatosos de arteria renal: indicaciones quirúrgicas y resultados / Revascularization of extraparenchymal renal artery aneurysms: surgical indications and results

Objetivos: Revisión retrospectiva del manejo quirúrgico de los aneurismas extraparenquimatosos de arteria renal. Material y métodos: Desde Enero de 1978 a Diciembre de 1998 hemos intervenido a 18 pacientes (13 hombres y 5 mujeres) de edad media 50 años (rango: 20-77), portadores de 22 aneurismas de arteria renal. 2 pacientes eran monorrenos. 16 pacientes (16118, 90 por ciento) eran hipertensos; en 11 de ellos (11116; 70 por ciento) un estudio selectivo de reninas ylo un test del captopril demostró hipertensión vasculorenal. 6 pacientes sufrían Insuficiencia Renal Crónica (6118; 33.3 por ciento). Se intervinieron 20 aneurismas en 18 pacientes. 8 pacientes precisaron cirugía aórtica asociada. La respuesta de la tensión arterial y de la función renal fue analizada. La tasa de permeabilidad acumulada se calculó a través de Tablas de Vida. Resultados: Ningún paciente falleció en la intervención ni en el postoperatorio. La permeabilidad primaria fue del 100 por ciento. Los dos pacientes monorrenos mejoraron clínicamente de su insuficiencia renal. La tasa de curación/mejoría de la hipertensión arterial a largo plazo fue del 70 por ciento. 2 reconstrucciones se ocluyeron en evolución a los 6 y 24 meses, obteniéndose una tasa de permeabilidad acumulada del 89.3 por ciento. Conclusiones: Los aneurismas de arteria renal constituyen una patología poco común, pudiendo ser intervenidos con una baja morbimortalidad con buena permeabilidad a largo plazo. Creemos que la cirugía estd indicada en caso de Hipertensión Renovascular o Nefropatía Isquémica asociada así como en caso de patología aórtica oclusiva o aneurismdtica (AU)