Multicenter Comparative Analysis of Late Open Conversion in Patients With Adherence and Nonadherence to Instructions for Use Endovascular Aneurysm Repair.

PURPOSE: The widespread adoption of endovascular aneurysm repair (EVAR) as preferred treatment modality for abdominal aortic aneurysm (AAA) has enlarged the number of patients needing open surgical conversion (OSC). The relationship between adherence to Instructions For Use (IFU) and EVAR long-term outcomes remains controversial. The aim of this study is to compare preoperative differences and postoperative outcomes between EVAR patients not adjusted to IFU and adjusted to IFU who underwent OSC. METHODS: This multicenter retrospective study reviewed 33 explanted EVARs between January 2003 and December 2019 at 14 Vascular Units. Patients were included if OSC occurred >30 days after implantation and excluded if explantation was performed to treat an endograft infection, aortic dissection, or traumatic transections. Variables analyzed included baseline characteristics, adherence to IFU, implant and explant procedural details, secondary reinterventions, and postoperative outcomes. RESULTS: Fifteen explanted patients (15/33, 45.5%) were identified not accomplished to IFU (out-IFU) at initial EVAR vs 18 explanted patients adjusted (in-IFU). During follow-up, a mean of 1.73±1.2 secondary reinterventions were performed, with more type I endoleaks treated in the subgroup out-IFU: 16.7% vs 6.3% in-IFU patients and more type III endoleaks (8.3% vs 0%). Patients out-IFU had shorter mean interval from implant to explant: 47.60±28.8 months vs 71.17±48. Type II endoleak was the most frequent indication for explantation. Low-flow endoleaks (types II, IV, V) account for 44% of indications for OSC in subgroup of patients in-IFU, compared with 13.3% in patients out-IFU and high-flow endoleaks (types I and III) were the main indication for patients out-IFU (33.3% vs 16.7% in-IFU). Total endograft explantation was performed in 57.5% of cases (19/33) and more suprarenal clamping was required in the subgroup out-IFU. Overall, 30-day mortality rate was 12.1% (4/33): 20% for patients out-IFU and 5.6% in-IFU. CONCLUSIONS: In our experience, type II endoleak is the most common indication for conversion and differences have been found between patients treated outside IFU with explantation taking place earlier during follow-up, mainly due to high-flow endoleaks and with higher mortality in comparison with patients adjusted to IFU. Ongoing research is required to delve into these differences.

National Diagnostic Reference Levels for Endovascular Aneurysm Repair and Optimisation Strategies.

OBJECTIVE: The International Commission on Radiological Protection (ICRP) has highlighted the large number of medical specialties using fluoroscopy outside imaging departments without programmes of radiation protection (RP) for patients and staff. Vascular surgery is one of these specialties and endovascular aneurysm repair (EVAR) is one of the most challenging procedures requiring RP guidance and optimisation actions. The recent European Directive on Basic Safety Standards requires the use and regular update of diagnostic reference levels (DRL) for interventional procedures. The objective of the study was to know the doses of patients undergoing EVAR with mobile Xray systems and with hybrid rooms (fixed Xray systems), to obtain national DRLs and suggest optimisation actions. METHODS: The Spanish Chapter of Endovascular Surgery launched a national survey that involved hospitals for 10 autonomous communities representing the 77% of the Spanish population (46.7 million inhabitants). Patient dose values from mobile Xray systems were available from nine hospitals (sample of 165 EVAR procedures) and data from hybrid rooms, from seven hospitals, with dosimetric data from 123 procedures. The initial national DRLs have been obtained, as the third quartile of the median values from the different centres involved in the survey. RESULTS: The proposed national DRLs are 278 Gy cm2 for hybrid rooms and 87 Gy cm2 for mobile Xray systems, and for cumulative air kerma (cumulative AK) at the patient entrance reference point, 1403 mGy for hybrid rooms, and 292 mGy for mobile systems. CONCLUSION: An audit of patient doses for EVAR procedures to identify optimised imaging protocol strategies is needed. It is also appropriate to evaluate the diagnostic information required for EVAR procedures. The increase by a factor of 3.2 (for kerma area product) and 4.8 (for cumulative AK) in the DRLs needs to be justified when the procedures are performed in the hybrid rooms rather than with mobile Xray systems.

Prevalencia de aneurismas de aorta abdominal en una población de riesgo en una consulta de cirugía vascular / Prevalence of abdominal aortic aneurysms in a risk population seen in a vascular surgery department

OBJETIVO: conocer la prevalencia de los aneurismas de aorta abdominal infrarrenal (AAA) y factores de riesgo en pacientes remitidos a consultas externas de Angiología y Cirugía Vascular para valoración de enfermedad arterial periférica (EAP). MATERIAL Y MÉTODOS: entre febrero de 2012 y diciembre 2016 se realizó eco Doppler aortoilíaco a los pacientes mayores de 50 años remitidos para descartar arteriopatía de miembros inferiores. En todos los casos se realizó exploración física y recogida de factores de riesgo cardiovascular. Diseño observacional, longitudinal. Análisis univariante y multivariante. RESULTADOS: el estudio incluyó a 454 pacientes. De estos, se excluyeron 11 en los que no fue posible la medición del diámetro del aneurisma por obesidad/gas abdominal. El total de pacientes estudiados es de 443. La prevalencia en la población estudiada de aneurisma fue del 8,8% (n = 39). La media del diámetro de los aneurismas diagnosticados fue 4,1 cm (± 1,1). En los pacientes que presentaron ITB menor de 0,9 (EAP), la prevalencia fue del 11,2% (29) frente al 5,2% (10) en pacientes con ITB mayor de 0,9 (p < 0,05). Los pacientes con EAP presentaron un mayor porcentaje de hipertensión arterial y tabaquismo (p < 0,05). En el análisis univariante de los factores de riesgo asociados a presentar AAA (grupo 1) frente a no presentar AAA (grupo 2), que fueron estadísticamente significativos (p < 0,05), la diabetes mellitus (DM) apareció como factor protector (grupo 1: 28,2%; grupo 2: 71,8%), mientras que los pacientes con broncopatía crónica (EPOC) (grupo 1: 64,1%; grupo 2: 35,9%), EAP (grupo 1: 74,4%; grupo 2: 55,2%), tabaquismo (grupo 1: 100%; grupo 2: 82,2%) y los mayores de 65 años (grupo 1: 89,7%; grupo 2: 70%) presentaron mayor riesgo de AAA. En el análisis multivariante, EPOC (OR 4,7), edad > 65 años (OR 3,4) y el grupo de pacientes con EAP (OR 2,4) se mostraron como factores de riesgo, mientras que la DM se mostró como factor protector (OR 0,4). CONCLUSIONES: en nuestra población, EPOC, EAP y edad > 65 años son factores de riesgo de AAA, mientras que la DM es un factor protector. El análisis de estos datos puede ayudar a definir la población de riesgo para la realización de estudios de despistaje en una consulta de cirugía vascular

OBJECTIVE: to determine the prevalence of infrarenal abdominal aortic aneurysms (AAAs) and their risk factors in patients referred to the Angiology and Vascular Surgery outpatient clinic for the evaluation of peripheral arterial disease (PAD). MATERIAL AND METHODS: a longitudinal observational study was carried out involving aortoiliac echodoppler exploration of the patients over 50 years of age referred to our center for the exclusion of arterial disease of the lower extremities between February 2012 and December 2016. A physical examination was made in all cases, with the compilation of cardiovascular risk factors. The data obtained were subjected to univariate and multivariate statistical analysis. RESULTS: a total of 454 patients were initially included in the study. Of these, 11 were discarded because abdominal gas / obesity impeded measurement of the diameter of the aneurysm. The final sample thus consisted of 443 individuals. The prevalence of aneurysms was 8.8% (n = 39), with a mean diameter of 4.1 (± 1.1 cm). In the patients with an ankle-brachial index (ABI) < 0.9 (indicative of PAD), the prevalence was 11.2% (n = 29) versus 5.2% (n = 10) in those with ABI > 0.9 (p < 0.05). The patients with PAD presented a greater incidence of arterial hypertension and smoking (p < 0.05). In the univariate analysis, on contrasting the patients with factors significantly associated (p < 0.05) to a risk of AAA (group 1) versus those without such risk factors (group 2), diabetes mellitus (DM) was identified as 63 a protective factor (group 1: 28.2%; group 2: 71.8%), while chronic obstructive pulmonary disease (COPD) (group 1: 64.1%; group 2: 35.9%), PAD (group 1: 74.4%; group 2: 55.2%,), smoking (group 1: 100%, group 2: 82.2%) and age > 65 years (group 1: 89.7%; group 2: 70%) were associated to an increased risk of AAA. In the multivariate analysis, COPD (odds ratio [OR] 4.7), age > 65 years (OR 3.4) and PAD (OR 2.4) were identified as risk factors, while DM proved to be a protective factor (OR 0.4). CONCLUSIONS: in our population of patients COPD, PAD and age > 65 years were risk factors for AAA, while DM was identified as a protective factor. These findings may contribute to define the risk population with a view to conducting screening studies in a vascular surgery department

Reflexión y prudencia: paclitaxel en el tratamiento de la enfermedad de la arteria femoral superficial / Reflection and prudence: paclitaxel in the treatment of superficial femoralartery disease

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Preoperative mapping of the aortoiliac territory with duplex ultrasound in patients with peripheral arterial occlusive disease.

OBJECTIVE: Duplex ultrasound (DUS) arterial mapping of the aortoiliac area is limited by obesity, abdominal gas, and the need to use a low-frequency probe (and therefore poorer resolution) in the examination. The aim of this study was to analyze the degree of agreement between DUS mapping of the aortoiliac area and angiography or contrast-enhanced computed tomography angiography (CTA). METHODS: This was a retrospective observational study. Between November 2006 and June 2015, there were 173 patients with a surgical indication for aortoiliac occlusive disease included, with preoperative aortoiliac DUS mapping and subsequent CTA or intraoperative angiography. Sensitivity, specificity, positive predictive value, and negative predictive value of DUS as an arterial mapping test were analyzed, as was the degree of agreement with angiography/CTA and agreement between the surgical indication based on DUS and the final surgical technique performed. RESULTS: Of 173 DUS mapping tests, 155 were evaluated (89.6%); the remaining 18 were not able to be evaluated because of the patient's obesity or bowel gas. Overall accuracy of DUS for predicting significant artery lesions was as follows: 92% sensitivity (95% confidence interval [CI], 88%-95%), 96% specificity (95% CI, 95%-97%), 89% positive predictive value (95% CI, 86%-93%), and 97% negative predictive value (95% CI, 96%-98%). Agreement with angiography/CTA had a κ index of 0.81 (95% CI, 0.77-0.84), which reflects a good degree of agreement. Surgical indications based on DUS mapping were correct in 89% of cases (138/155). CONCLUSIONS: DUS mapping of the aortoiliac territory could be used as a single preoperative imaging test in aortoiliac occlusive disease in patients whose DUS examination is able to be evaluated.

Pseudoaneurisma de carótida común tras la canalización de la vena yugular interna / Pseudoaneurysm in the common carotid artery following cannulation of the internal jugular vein

Introducción. Los pseudoaneurismas de la arteria carótida son una complicación poco frecuente de la canalización de la vena yugular interna. El incremento de pacientes incluidos en diálisis ha conllevado el aumento de canalizaciones de catéteres de doble luz en dicha vena, y con ello la aparición de pseudoaneurismas carotídeos tras punción venosa; ésta es la complicación posterior a la canalización de la vena yugular interna más frecuentemente publicada. Caso clínico. Mujer de 25 años de edad, en diálisis, con un pseudoaneurisma de arteria carótida común derecha tras la canalización de la vena yugular interna. La lesión apareció tras la retirada del catéter, y se manifestó clínicamente por crecimiento rápido y síntomas compresivos. El diagnóstico se realizó mediante eco-Doppler, tomografía axial computarizada y arteriografía, y se observó un pseudoaneurisma dependiente de la carótida común derecha situado a 1 cm del origen del tronco braquicefálico. Se trató quirúrgicamente mediante esternotomía y cervicotomía y sutura directa del ostium, con evolución posquirúrgica satisfactoria. Conclusiones. Los pseudoaneurismas de carótida tras punción de la vena yugular son poco frecuentes. Puesto que no es posible predecir su formación tras la retirada de catéter venoso, es necesaria una observación cercana y, en caso de aparición, un tratamiento temprano. Según nuestra experiencia, el tratamiento quirúrgico ofrece unos resultados buenos con una morbilidad aceptable. El tratamiento endovascular puede ser una opción para casos seleccionados

Introduction. Pseudoaneurysms of the carotid artery are an infrequent complication that may arise as a result of cannulation of the internal jugular vein. The rise in the number of patients undergoing dialysis has brought with it an increase in the number of double lumen catheters inserted into the internal jugular vein, and at the same time the appearance of carotid pseudoaneurysms following venous puncture. This is the most frequently reported complication following cannulation of the internal jugular vein. Case report. A 25-year-old female, on dialysis, with a pseudoaneurysm in the right common carotid artery following cannulation of the internal jugular vein. The pseudoaneurysm appeared after withdrawal of the catheter, and clinical symptoms included fast growth and signs of compression. Diagnosis was performed using Doppler ultrasound, computerised axial tomography and arteriography, and a pseudoaneurysm dependent on the right common carotid that originated 1 cm away from the start of the brachiocephalic trunk. It was treated surgically by means of a sternotomy and cervicotomy and direct suturing of the ostium, with satisfactory post-operative progress. Conclusions. Carotid pseudoaneurysms following puncture of the jugular vein are infrequent. Since it is not possible to predict their formation after the withdrawal of a venous catheter, close observation and, should they appear, early treatment are necessary. In our experience, surgical treatment offers good results with an acceptable rate of morbidity. Endovascular treatment may be an option for certain cases