Avanzando en la toma de decisiones compartida: estenosis carotídea asintomática / Advancing in shared decision making: asymptomatic carotid stenosis

En las últimas décadas ha venido produciéndose un cambio de paradigma en la relación médico-enfermo, que ha pasado de una visión paternalista a una medicina más centrada en el paciente. La toma de decisiones compartidas (TDC) es un proceso que incluye el intercambio de información (personal y médica) entre el paciente y el sanitario respecto a la enfermedad, la deliberación sobre las distintas opciones y, finalmente, la toma de una decisión consensuada. Para facilitar este proceso se han desarrollado distintas herramientas mediante diversos medios y formatos (folletos, texto escrito, vídeos, aplicaciones informáticas...), utilizando en muchas ocasiones ayudas visuales tales como caras sonrientes u otros pictogramas. Desde nuestro grupo de trabajo nos unimos a este proceso evolutivo de la práctica médica y presentamos una herramienta de ayuda visual a la TDC en el caso de pacientes con estenosis carotídea asintomática mayor del 70%. Para su realización nos hemos basado en los cates plots, que ayudan a cuantificar riesgos y beneficios de una intervención de forma estandarizada

In the last decades there has been a paradigm change in the doctor-patient relationship, from a paternalistic model to a patient centered medicine. Shared decision making (SDM) is a process that involves bidirectional communication between physicians and patients about the illness, different treatment options, and, through the deliberation process, reaching an agreement in the ultimate decision made. Various different tools have been developed to promote shared decision making, through different types of support methods (leaflets, books, videos, websites or other interactive media), frequently using visual aids like smiley faces plots or other pictograms. Our Working Group would like to join this evolutionary process. Thus, we have developed a visual aid tool to help in the decision-making process in the case of asymptomatic carotid stenosis > 70%. We have based on Cates plots that help to quantify risks and benefits of specific interventions in a standardized manner

Comparison of Bypass with Endoscopically Harvested Internal Saphenous Vein versus Bypass with Surgically Harvested Internal Saphenous Vein for Lower Limb Arterial Disease.

BACKGROUND: Patients with lower limb arterial disease have a high risk for complications related with surgical wounds. The endoscopic extraction of the great saphenous vein (GSV) is a less invasive alternative to the conventional surgical extraction. METHODS: A clinical and ultrasonographic follow-up was carried out on the lower limb bypass with GSV performed in our institution between years 2007 and 2012. Patients were selected for open or endoscopic harvesting depending on the surgeon assigned (endoscopic or open surgeon). Follow-up was performed at 1, 3, 6, and 12 months after surgery and annually thereafter. All the GSV endoscopic harvestings (GSVEH) were performed by the same surgeon. Data for primary, assisted, and secondary patency and amputation-free survival were analyzed. Anatomopathalogic analysis were performed on pares of samples of the same vein dissected surgically and endoscopically from the same patient. RESULTS: Sixty bypass surgery has been performed on 60 patients (54 men and 6 women), 30 with GSVEH (50%), and 30 with GSV open harvesting (GSVOH). All patients were intervened for critical limb ischemia (Rutherford cathegory 4, 5, and 6). Significant differences were found between both groups for suture dehiscence (GSVEH 0%, GSVOH 20%, P = 0.01) and infection (GSVEH 3%, GSVOH 30% P, 0.006). No significant differences were found between both groups regarding to primary patency, assisted primary patency, or amputation-free survival. An anatomopathologic comparison of segments of veins extracted surgically and endoscopically of the same patients did not show any significant differences. CONCLUSIONS: Although no statistically significant differences were found between GSVOH and GSVEH bypass for lower limb revascularization, there is a trend toward poorer patency rates for the endoscopic technique. GSVEH lowers the risks for infection and dehiscence of surgical wounds.

A hybrid open and endovascular repair for treatment of bovine aortic arch aneurysm accompanied by aneurysm of patent ductus arteriosus with deployment of Amplatzer duct occluder.

A rare case of bovine aortic arch aneurysm accompanied by patent ductus Botalli aneurysm was treated using an off-pump hybrid procedure including supraaortic debranching combined with aortic stent grafting and oversewing of pulmonary artery end of the aneurysm. Postoperative computed tomography angiography showed persistent perfusion of the ductus Botalli aneurysm from pulmonary artery, which was successfully closed with an Amplatzer duct occluder. Twenty-two months of follow-up showed good general state of the patient's health status. This less invasive procedure is an alternative to aortic replacement under circulatory arrest and may be the only salvage option for patients in poor general condition.

Leiomyosarcoma of the deep femoral vein. A rare cause of venous obstruction in lower limbs and an alternative diagnosis to chronic venous thrombus.

Primary venous leiomyosarcoma of the extremities is an uncommon, but aggressive, tumoral entity with a high rate of local recurrence and early hematogenous metastasis. In the present article, we report a case of leiomyosarcoma of the vena profunda femoris. This pathology causes deep venous thrombosis-like symptoms. No improvement in lower limb status and a significant and progressive increase in the diameter of the vein as seen using ultrasonography could indicate tumor disease. Particular care must be taken to avoid biopsies due to the possible dissemination. We must complete the medical study with imaging techniques, and the tumor must be removed as soon as possible for histopathological diagnosis. After a follow-up of 12 months, there was no evidence of local or metastatic recurrence in our patient.

Compresión de la vena femoral asociada a quistes intra y extravasculares: a propósito de dos casos / Compression of the femoral vein associated with intra and extravascular cysts: two case reports

Introducción. La patología quística de origen articular en la región inguinal incluye entidades de localización intra y extravascular difíciles de clasificar debido a que su presentación clínica es poco específica. Presentamos dos casos de compresión sintomática de la vena femoral provocados por un higroma quístico y un quiste adventicial. Casos clínicos. Caso 1: mujer de 38 años que acude a urgencias por edema de la pierna izquierda de tres semanas de evolución. En el estudio ecográfico se evidencia una estructura quística en la región inguinal que produce la obstrucción de la vena femoral común. Tras el vaciamiento y la exéresis del quiste, se dio de alta a la paciente con desaparición de la clínica. El resultado del examen patológico fue un higroma quístico. Caso 2: varón de 61 años con clínica ortostática en la pierna izquierda de 20 años de evolución. El eco-Doppler objetivó la incompetencia del cayado de la safena interna y una masa quística, comunicada con la cadera, que comprime la vena femoral común. El tratamiento fue la quistectomía asociada a cirugía de varices con una buena evolución clínica. El material se etiquetó de quiste adventicial venoso. Conclusiones. Es importante tener en cuenta estas infrecuentes situaciones de aumento del perímetro unilateral, no doloroso, principalmente en pacientes que refieran esta clínica sin causa que lo justifique. Por ello, es primordial hacer un amplio diagnóstico diferencial para evitar errores diagnósticos y terapéuticos. En ambos casos, es necesario un diagnóstico preciso. El tratamiento de elección consiste en el vaciamiento y la resección de la lesión, con lo que se consigue restablecer el flujo venoso

Introduction. Cystic pathologies that originate in the joints in the inguinal region include conditions with intra and extravascular locations that are difficult to classify because of their unspecific clinical presentation. We report two cases of symptomatic compression of the femoral vein caused by a cystic hygroma and an adventitial cyst. Case reports. Case 1: a 38-year-old female who visited the emergency department after a three-week history of oedema in the left leg. The ultrasonography study showed a cystic structure in the inguinal region that produced obstruction of the common femoral vein. After emptying and excision of the cyst, the patient was discharged with no clinical symptoms. The result of the pathology examination was a cystic hygroma. Case 2: a 61-year-old male with a 20-year history of stance dysfunction in the left leg. The Doppler ultrasound recording revealed the incompetence of the saphenous-femoral junction and a cystic mass that communicated with the hip and compressed the common femoral vein. Treatment consisted in a cystectomy in association with varicose vein surgery; clinical progress was good. The material was labelled as a venous adventitial cyst. Conclusions. It is important to bear in mind these infrequent, painless, situations involving a unilateral increase in perimeter, especially in patients who report these clinical features without there being any justifying cause. It is therefore essential to carry out a wide-ranging differential diagnosis to prevent errors in the diagnosis and therapy. In both cases, the diagnosis must be precise. The preferred treatment consists in emptying and resection of the lesion, and venous flow is restored