Monitoring the practice of vascular surgery: findings from a national registry (1996-2011).

BACKGROUND: The goal of this article is to present for the first time to the international community the detailed findings and outcomes of the Spanish Vascular Registry (SVR) after 16 years of experience. METHODS: We examined the nationwide registry promoted by the Spanish Society of Angiology and Vascular Surgery (1996-2011). The changes in vascular surgical activity in Spain during the period of study were examined. We evaluated the number of services, medical specialists, consultations, admissions, and operations that occurred in Spain. We also assessed the trends in therapeutic activity and the medical and social impact of vascular pathology. RESULTS: A mean of 60 centers (range = 32-83) participated in the SVR (79.3 % of the total). In the last year of the study period, 94.3 % centers (100 % of teaching centers) participated. The mean number of activities per hospital per year was 5,298 consultations, 2,625 vascular explorations, 630 hospital admissions (61 % elective and 31 % emergency), and 742 surgical procedures. A total of 29,289 carotid stenosis procedures had been registered over 16 years. Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) procedures have increased in frequency over time. In 2011, CAS constituted 19.3 % of all carotid procedures. A total of 31,703 abdominal aortic aneurysm (AAA) operations were registered during the study period. Surgery for ruptured AAA remained stable over time. Since its appearance in the year 2000, endovascular treatment (EVAR) increased steadily over time. Currently, EVAR represents about half of all AAA surgery (50.2 %). The total rate of in-hospital operative deaths was 1.1 %, but in-hospital mortality for open arterial surgery was 4 %. Mortality has decreased of late. CONCLUSIONS: The SVR has enabled us to understand the development and implementation of vascular surgery throughout Spain and to note the increased healthcare activity and the better overall results obtained as a consequence.

[Cerebral haemodynamics during carotid angioplasty with flow interruption. The correlation between oximetry and transcranial Doppler ultrasonography]. / Hemodinamica cerebral durante la angioplastia carotidea con interrupcion de flujo. Correlacion de la oximetria y el Doppler transcraneal.

AIMS: To determine the correlation between oximetry and transcranial Doppler ultrasonography (TDU) during and following carotid stent-angioplasty with flow interruption, and to evaluate the level of hypoperfusion and its recovery during the procedure. PATIENTS AND METHODS: Records were made, prospectively, of the flow rates in the middle cerebral artery and the trans-cutaneous oxygen saturation of 18 patients who had undergone surgery to perform a carotid stent-angioplasty. Monitoring was basal and at 1, 3, 5, 10 and 15 minutes after stopping and opening the flow. Measurements, in units and percentages of change, were stratified by groups as mild, moderate and severe. The agreement between the two tests was studied. RESULTS: Occlusion time: 8.2 +/- 2.7 minutes. Two patients (11.1%) presented cerebral hypoperfusion. Flow was re-established in two patients due to its reaching critical values. Mean of the baseline values: 56.3 +/- 11.4 cm/s (TDU) and 67.6 +/- 7.1% (oximetry). The changes in the absolute values and percentages of change between TDU and oximetry were evaluated and results showed an agreement between them in occlusion (rho = 0.8-0.9; p < 0.05), with less association on re-establishing the flow (rho = 0.4-0.8; p < 0.05). In percentages of change there was very good agreement in occlusion (kappa = 0.8-1; p < 0.05). Agreement was good (kappa = 0.68; p < 0.05) at 1, 3 and 5 minutes after opening up the flow. CONCLUSIONS: A significant correlation was found between the methods during the interruption of carotid flow, which means they can be used independently. Overall, 88.9% remained below the safety threshold for cerebral ischaemia and, given that the procedure can be carried out with brief interruptions, control by oximetry or TDU can be just as safe in evaluating cerebral ischaemia.

Meta-analysis of randomized, controlled clinical trials in angiogenesis: gene and cell therapy in peripheral arterial disease.

We aim to determine the efficacy and safety of gene and cell angiogenic therapies in the treatment of peripheral arterial disease (PAD) and evaluate them for the first time by a meta-analysis. We include in the formal meta-analysis only the randomized placebo-controlled phase 2 studies with any angiogenic gene or cell therapy modality to treat patients with PAD (intermittent claudication, ulcer or critical ischemia) identified by electronic search in MEDLINE and EMBASE databases (1980 to date). Altogether, 543 patients are analyzed from six randomized, controlled trials that are comparable with regard to patient selection, study design, and endpoints. We perform the meta-analysis regarding clinical improvement (improvement of peak walk time, relief in rest pain, ulcer healing or limb salvage) and rate of adverse events. At the end of treatment, therapeutic angiogenesis shows a significantly clinical improvement as compared to placebo in patients with PAD (odds ratio [OR] = 1.437; 95% confidence interval [CI] = 1.03-2.00; P = 0.033). The response rate (improvement of peak walk time) of the pooled groups according to clinical severity does not significantly differ for gene therapy as compared with placebo in the treatment of claudicating patients (OR = 1.304; 95% CI = 0.90-1.89; P = 0.16). Otherwise, we find significant efficacy of the treatment in critical ischemia (OR = 2.20; 95% CI = 1.01-4.79; P = 0.046). The adverse events rates show a slightly significantly higher risk of potential nonserious adverse events (edema, hypotension, proteinuria) in the treated group (OR = 1.81; 95% CI = 1.01-3.38; P = 0.045). We find no differences in mortality from any cause, malignancy, or retinopathy. The patients with PAD, and particularly those with critical ischemia, improve their symptoms when treated with angiogenic gene and cell therapy with acceptable tolerability.

Relationship between the plasma concentration of C-reactive protein and severity of peripheral arterial disease.

OBJECTIVE: To determine whether the increase in plasma levels of C-Reactive Protein (CRP), a non-specific reactant in the acute-phase of systemic inflammation, is associated with clinical severity of peripheral arterial disease (PAD). METHODS AND RESULTS: This is a cross-sectional study at a referral hospital center of institutional practice in Madrid, Spain. A stratified random sampling was done over a population of 3370 patients with symptomatic PAD from the outpatient vascular laboratory database in 2007 in the order of their clinical severity: the first group of patients with mild chronological clinical severity who did not require surgical revascularization, the second group consisted of patients with moderate clinical severity who had only undergone only one surgical revascularization procedure and the third group consisted of patients who were severely affected and had undergone two or more surgical revascularization procedures of the lower extremities in different areas or needed late re-interventions. The Neyman affixation was used to calculate the sample size with a fixed relative error of 0.1. A homogeneity analysis between groups and a unifactorial analysis of comparison of medians for CRP was done. The groups were homogeneous for age, smoking status, Arterial Hypertension HTA, diabetes mellitus, dyslipemia, homocysteinemia and specific markers of inflammation. In the unifactorial analysis of multiple comparisons of medians according to Scheffé, it was observed that the median values of CRP plasma levels were increased in association with higher clinical severity of PAD (3.81 mg/L [2.14-5.48] vs. 8.33 [4.38-9.19] vs. 12.83 [9.5-14.16]; p < 0.05) as a unique factor of tested ones. CONCLUSION: Plasma levels of CRP are associated with not only the presence of atherosclerosis but also with its chronological clinical severity.

Aortoiliac thrombosis in antiphospholipid syndrome-case report and literature review.

Antiphospholipid syndrome is accepted as one of the most important causes of hypercoagulable states. Thrombotic events in patients with antiphospholipid syndrome, predominantly women, occur at a younger age than in those suffering from atherosclerotic disease. The majority of the thrombotic events affect the deep venous system of the lower limbs and arterial thrombosis predominates in the cerebral territory. The use of anticoagulant therapy prevents recurrent thrombosis but the duration and intensity of treatment remain controversial. Aortic disease is an anecdotal fact in the literature. A case of infrarenal aortic occlusion involving both iliac arteries associated with primary antiphospholipid syndrome is presented.

Disc erosion in Models 103 and 104 of Beall mitral valve prostheses.

Three cases of severe disc variance and erosion of the Teflon-disc Beall mitral valve prosthesis (Models 103 and 104) are reported. In two patients, the Beall mitral valves were excised and replaced with two Björk-Shiley mitral valves. The remaining patient did not survive, and at autopsy, the lens was found at the aortic bifurcation level. Because of this potentially lethal complication, careful follow-up of patients with Beall mitral valve prostheses (Models 103 and 104) is recommended.