Role of Botulinum Toxin in Pectoralis Minor Syndrome.

BACKGROUND: Thoracic outlet syndrome (TOS) causes neurogenic symptoms in 95% of the cases due to neurovascular bundle compression. The treatment goal is the decompression of the neurovascular structures. In the last decade, non-surgical treatments have been evaluated as a treatment option for spastic syndromes and thoracic outlet syndrome. In this study we report the use of botulinum toxin (BTX-A) injection as a diagnostic tool to identify the pectoral minor syndrome, and as a less aggressive treatment-option. METHODS: An observational cohort study of patients with neurogenic thoracic outlet syndrome who underwent sonographically guided chemodenervation of pectoral minor muscle with botulinum toxin. Follow-up includes clinical evaluation at one month, 3 months and 6 months after the procedure. Clinical evaluation was made with clinical questionnaire. In case of patients with partial improvement of the symptoms, a second infiltration of BTX-A was performed. The categorical variables were shown as percentages, and the continuous variables as mean and standard deviation (SD). For the comparison of categorical variables, the Fisher's exact test was used. Statistical analysis was performed using the SPSS version 20.0 program. We consider P <0.05 to be statistically significant. RESULTS: A total of twenty-six patients were diagnosed with thoracic outlet syndrome in this period, and 20 accomplished the inclusion criteria. 7 patients were excluded (1 due to neoplasia, 2 did not sign the informed consent, 1 due to neoplasia, 2 did not sign the informed consent, 1 was lost during the follow-up and 3 due to anomalies of the first rib secondary to fractures and cervical rib and 1 was lost during the follow-up), therefore a sample of 13 patients aged between 24 and 55 years was obtained. The most common type of procedure performed was the single injection of 50 IU of botulinum toxin. 4 patients were infiltrated in 2 occasions due to partial improvement in symptoms at 1month follow-up. Clinical stability was found at three months and at 6 months follow-up. CONCLUSION: The ultrasound-guided botulinum injection of the pectoralis minor muscles provides symptoms relief in patients with pectoral minor syndrome, and could be considered a safe tool in the diagnosis of the pectoralis minor syndrome within the spectrum of thoracic operculum syndrome.

Comparación entre amputaciones menores primarias respecto a amputaciones menores con revascularización previa en patología del pie diabético / Comparison between primary minor amputations and minor amputations with previous revascularization in diabetic foot pathology

INTRODUCCIÓN: la realización de amputaciones menores primarias en pacientes diabéticos es una práctica aún frecuente en servicios de cirugía vascular. El objetivo de este estudio es comparar la evolución de las amputaciones menores primarias respecto a las realizadas con revascularización previa, considerando la presencia o no de angiosoma directo que revascularice la zona del muñón que vamos a crear. MATERIAL Y MÉTODOS: se realizó un estudio observacional y comparativo sobre la población de pacientes diabéticos que requerían amputaciones menores de miembros inferiores ingresados en nuestro servicio durante el periodo comprendido entre enero y diciembre de 2018. La revascularización previa (o no) a la amputación menor se decidía con base en estudios hemodinámicos y posibilidades según pruebas de imagen. La muestra se dividió en cuatro grupos tomando en cuenta la necesidad-posibilidad de revascularización previa a la amputación menor y la presencia de vascularización basada en angiosoma directo o indirecto a la zona del muñón que íbamos a crear. Se valoró en cada grupo la tasa de amputaciones mayores, la tasa de curación de las amputaciones menores y la mortalidad. Consideramos significativa p < 0,05. RESULTADOS: se reclutaron 106 pacientes de enero a diciembre de 2018. Las tasas de curación de los muñones de amputación en los cuatro grupos no presentaron diferencias estadísticamente significativas (p = 0,085). Los pacientes no revascularizados mostraron una tasa de pérdida de extremidad más alta que el grupo previamente revascularizado, con una diferencia estadísticamente significativa entre los grupos (p = 0,002). CONCLUSIONES: la tasa de pérdida de extremidad es mayor en los pacientes que no son sometidos a cirugía de revascularización previa a la amputación menor, así como en los pacientes cuya vascularización depende de angiosomas indirectos al muñón creado

INTRODUCTION: the performance of primary minor amputations in diabetic patients is a frequent practice in vascular surgery services. The aim of this study is to compare the evolution of minor primary amputations, with those performed with previous revascularization, considering the presence or not of a direct angiosome that revascularizes the stump area that we are going to create. MATERIAL AND METHODS: an observational and comparative study was performed on diabetic patients who required minor lower limb amputations admitted to our department during the period from January to December 2018. The revascularization prior, or not, to minor amputation, was decided based on hemodynamic studies and possibilities according to imaging tests. Patients were divided into 4 groups considering the need-possibility of revascularization prior to minor amputation, and vascularization based on direct or indirect angiosome to the area of the stump that we were going to create. The rate of major amputations, the healing rate of minor amputations, and mortality were assessed in each group. We consider significant p < 0.05. RESULTS: 106 patients were recruited, from January to December 2018. The healing rate of the amputation stumps in the four groups did not show statistically significant differences (p = 0.085). Non-revascularized patients showed a higher rate of limb loss respect the previously revascularized group, with a statistically significant difference between the groups (p = 0.002). CONCLUSIONS: the rate of limb loss is higher in patients who do not undergo revascularization surgery prior to minor amputation, as well as in patients whose vascularization depends on indirect angiosomes to the created stump

Manejo de la enfermedad tromboembólica venosa en la era COVID-19. Recomendaciones del capítulo español de Flebología y Linfología de la SEACV / Management of venous thromboembolic disease in the era COVID-19. Recommendations of the Spanish phlebology and lymphology chapter of the SEACV

Los pacientes infectados por el nuevo coronavirus COVID-19 presentan un riesgo incrementado de enfermedad tromboembólica venosa (ETEV). La presente guía de práctica clínica del Capítulo Español de Flebología y Linfología y la Sociedad Española de Angiología y Cirugía Vascular pretende dar una serie de recomendaciones sobre profilaxis y tratamiento de la ETEV en los pacientes infectados por COVID-19, tanto a nivel hospitalario como ambulatorio, y consejos sobre su seguimiento clínico y ecográfico. Se recomienda que todos los pacientes con infección por COVID-19 hospitalizados, tengan o no factores de riesgo protrombótico asociados, reciban profilaxis antitrombótica, si no existe contraindicación. En caso de pacientes ambulatorios, según perfil clínico e historial médico, se recomienda valorar tromboprofilaxis con heparina de bajo peso molecular (HBPM), en ausencia de contraindicación. Ante el diagnóstico de TVP en paciente con COVID-19, tanto hospitalizado o ambulatorio, debe iniciarse el tratamiento anticoagulante con HBPM a dosis terapéuticas. No existen interacciones farmacológicas descritas de las HPBM con los fármacos empleados contra el COVID-19. Los niveles elevados de dímero-D son un hallazgo común en pacientes con COVID-19, por lo que este parámetro, de forma aislada, no es indicativo para realizar una ecografía Doppler de rutina. Se aconseja la realización de ecografía Doppler a un paciente COVID-19 positivo (con las medidas de protección necesarias) para descartar TVP solo en pacientes con alta sospecha clínica de TVP y cuando se dé una de las dos situaciones clínicas: alto riesgo de sangrado, o que exista un incremento brusco e inesperado de los niveles de dímero-D

Patients infected with the new coronavirus COVID-19 have an increased risk of venous thromboembolic disease (VTEV). The present clinical practice guide of the Spanish Chapter of Phlebology and Lymphology and the Spanish Society of Angiology and Vascular Surgery, aims to give a series of recommendations on prophylaxis and treatment of VTE in patients infected with COVID-19, both at the hospital and outpatient, and advice on their clinical and ultrasound monitoring. It is recommended that all hospitalized patients with COVID-19 infection, whether or not they have associated prothrombotic risk factors, should receive antithrombotic prophylaxis, if there is no contraindication. In the case of outpatients, according to clinical profile and medical history, it is recommended to evaluate thromboprophylaxis with low molecular weight heparin (LMWH), in the absence of contraindication. Given the diagnosis of DVT in a patient with COVID19, both hospitalized and outpatient, anticoagulant treatment with LMWH should be started at therapeutic doses. There are no described pharmacological interactions of HPBMs with the drugs used against COVID19. High levels of D-dimer are a common finding in patients with COVID-19, so this parameter, in isolation, is not indicative for routine Doppler ultrasound. Doppler ultrasound is recommended for a COVID-19 positive patient (with the necessary protective measures), to rule out DVT, only in patients with high clinical suspicion of DVT, and when one of the two clinical situations occurs: high risk of bleeding, or a sudden and unexpected increase in D-dimer levels

Manejo de pseudoaneurisma de arteria cervical transversa / Management of transverse cervical artery pseudoaneurysm

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