Guía clínica española del acceso vascular para hemodiálisis / Spanish clinical guidelines on vascular access for haemodialysis

El acceso vascular para hemodiálisis es esencial para el enfermo renal tanto por su morbimortalidad asociada como por su repercusión en la calidad de vida. El proceso que va desde la creación y mantenimiento del acceso vascular hasta el tratamiento de sus complicaciones constituye un reto para la toma de decisiones debido a la complejidad de la patología existente y a la diversidad de especialidades involucradas. Con el fin de conseguir un abordaje consensuado, el Grupo Español Multidisciplinar del Acceso Vascular (GEMAV), que incluye expertos de las cinco sociedades científicas implicadas (nefrología [S.E.N.], cirugía vascular [SEACV], radiología vascular e intervencionista [SERAM-SERVEI], enfermedades infecciosas [SEIMC] y enfermería nefrológica [SEDEN]), con el soporte metodológico del Centro Cochrane Iberoamericano, ha realizado una actualización de la Guía del Acceso Vascular para Hemodiálisis publicada en 2005. Esta guía mantiene una estructura similar, revisando la evidencia sin renunciar a la vertiente docente, pero se aportan como novedades, por un lado, la metodología en su elaboración, siguiendo las directrices del sistema GRADE con el objetivo de traducir esta revisión sistemática de la evidencia en recomendaciones que faciliten la toma de decisiones en la práctica clínica habitual y, por otro, el establecimiento de indicadores de calidad que permitan monitorizar la calidad asistencial.

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support.

Polidocanol foam stability in terms of its association with glycerin.

OBJECTIVES: Foam sclerotherapy effectiveness mainly depends on the concentration of the sclerosing agent and foam stability. The objective of this study was to determine if the addition of glycerol at different concentrations contributes to the stability of polidocanol foam. CONTROL GROUP: 3% polidocanol. Group 1: polidocanol 3% + glycerin 1.66%. Group 2: polidocanol 3% + glycerin 3.3%. Group 3: polidocanol 3% + Glycerin 5%. Tessari standard method. Five recordings were made for each mixture. Early visual liquefaction time and half liquid time decay were recorded in seconds. Microscopic measurement of the foams. Mixtures surface tension measurement (N/m). RESULTS: Early visual liquefaction: CONTROL GROUP: 27 (±3.11); Group 1: 67.8 (±6.49); Group 2: 48.6 (±8.2); and Group 3: 35.8 (±4.49). Half-liquid time: CONTROL: 129.2 (±11.00); Group 1: 260.4 (±18.99); Group 2: 224.6 (±13.03); and Group 3: 189.2 (±8.52). Bubbles/mm(2)-diameter-wall thickness: CONTROL: 68-98 µm-7 µm; Group 1: 189-60 µm-9 µm; Group 2: 76-92 µm-12 µm; and Group 3: 49-112 µm-20 µm. Surface tension: CONTROL = 5.54 N/m; Group 1 = 5.45 N/m; Group 2 = 5.35 N/m; and Group 3 = 5.21 N/m. CONCLUSIONS: Small amounts of glycerin highly increase the stability and quality of polidocanol foam. This simple chemical method is easily reproducible and applicable.

Tratamiento médico de los aneurismas de aorta abdominal / No disponible

No disponible

Saccular aneurysms of the extracranial internal carotid artery. Experience and review of the literature.

The aim of this study was to describe the surgical technique employed and our results in the treatment of saccular aneurysms of the internal carotid artery at the extracranial level. We describe 3 cases of patients with saccular aneurysms of the extracranial internal carotid who underwent surgery at our unit within the last 3 years. We report on indications for treatment, surgical technique and results in terms of morbidity-mortality and also review the pertinent literature. Surgical treatment was indicated on the grounds of the patients being symptomatic: 2 had a history of cerebral ischemia, and 1 showed local compression symptoms. The surgical approach was presternocleidomastoid cervicotomy extended distally, and in 2 patients was accompanied by nasotracheal intubation to achieve adequate exposure. In 2 cases, we performed an aneurysmectomy with end-to-end anastomosis. In the third patient, the aneurysm neck was ligated from within the sac followed by aneurysmectomy. There was no mortality or neurological morbidity (local or general). The patients remain free from neurological symptoms with a patent carotid axis. Our clinical experience suggests that, despite the anatomically unfavorable location of this type of aneurysm and the greater complexity of the surgical technique, this patient group can be effectively treated. The frequent presence of an elongated carotid axis and an aneurysmal neck means the surgeon can easily restore arterial continuity by direct procedures.

Pie diabético / Diabetic foot

Todos los pacientes a los que se les ha realizado una amputación de miembro inferior (AMI) entre enero de 1989 y diciembre de 2003 en el Área 7 de Madrid se identificaron a través de los partes de quirófano. Los informes de alta del servicio de cirugía vascular y del servicio de endocrinología, así como los médicos de familia (prescriptores), se utilizaron como fuente secundaria. De acuerdo con la Declaración de San Vincent, se observó una reducción en las AMI y un retraso en la edad de presentación, y se relacionó con una mejoría en la asistencia dispensada a las personas con diabetes. A pesar de esta mejoría, se podría alcanzar una reducción más importante en las AMI con un cribado de neuropatía más temprano, con programas de intervención basados en una educación bien estructurada de forma continuada, y facilitando el acceso al podólogo cubierto por la Seguridad Social en pacientes con pie en riesgo. El coste económico ahorrable se ha estimado en más de 100.000 A anuales por cada 100.000 habitantes

All patients who underwent a lower extremity amputation (LEAs) between January 1989 and December 2003 in Area 7, Madrid, were identified through operating theatre records. Vascular surgery department and Endocrinology service discharge records, and prescribing family doctors were used as secondary sources. According to Saint Vincent Declaration, a substantial decrease in LEAs and a later presentation were observed and related to a series of improvements in diabetic treatment. Despite these figures, a more substantial reduction in LEAs in diabetic people could be achieved with an earlier neuropathy screening, and intervention programes based on a continuing and well-structured education. The potential cost saving per 100.000 inhabitants and per year was estimated to be about 100.000 A

DRB1-TNF-alpha-TNF-beta haplotype is strongly associated with severe aortoiliac occlusive disease, a clinical form of atherosclerosis.

Severe aortoiliac occlusive disease (AOD) is a clinical manifestation of peripheral arteriosclerosis. Atherosclerosis has been associated with some human leukocyte antigen (HLA)-DRB1 alleles, stressing its relationship with autoimmune or inflammatory disorders. Additionally, in rheumatoid arthritis patients, the DRB1*0404 allele is specifically associated with endothelial dysfunction. Our objective was to assess the role of class II HLA alleles in the susceptibility to AOD; a combined study of the nearby tumor necrosis factor (TNF) locus was also performed. We included 104 AOD patients and 504 healthy controls from Madrid. DRB1 typing and DRB1*04 subtyping was done by polymerase chain reaction amplification followed by hybridization with specific oligonucleotides. TNF-alpha and TNF-beta microsatellites were studied by polymerase chain reaction and capillary electrophoresis. None of the markers was associated with AOD, although a trend was observed for DRB1*0404 (OR = 2.18; p = 0.05). However, among DRB1*0404 individuals, the TNFa11-b4 pair was present more frequently in patients than in controls (OR = 16.0; p = 0.007). The combined appearance of TNFa11-b4 and DRB1*0404 was much more frequent in patients than in controls (OR = 5.92; p = 0.0013), a result enhanced by haplotypic estimates (OR = 10.0; p = 0.00017). Our results show that the HLA region modulates the predisposition to AOD. More specifically, they suggest that an extended haplotype encompassing DRB1*0404 and TNFa11-b4 carries a genetic factor conferring susceptibility to AOD.

Operative repair of popliteal aneurysms: effect of factors related to the bypass procedure on outcome.

The objective of this study was to compare patency rates following the repair of popliteal aneurysms according to the site of inflow, material of bypass graft and quality of distal runoff. Seventy bypasses were performed over an 11-year period. Autogenous saphenous vein was used in 53 procedures (75.7%) and prosthetic material was used in 17 (24.3%). Early mortality was 2.8%. Early primary and secondary patency rates were 95.7% and 97.1%, respectively. Autogenous vein showed better 10-year patency than prosthetic material (86% vs. 57%; p = 0.02). No significant differences in patency were observed according to the inflow site (87.8% groin vs. 74.7% supragenicular). Bypasses that originated in the groin showed improved patency when a saphenous vein was used (84.8% vs. 43.7%; p = 0.01). However, no influence of the graft material was noted in supragenicular bypasses (90.4% vs. 84.8%; p = 0.6). Bypasses in extremities with good runoff showed better patency than those in limbs showing poor runoff (86% vs. 55%; p = 0.003). The use of saphenous vein for the repair of popliteal aneurysms showed better results than those with prosthetic material, although in bypasses originating from the distal superficial femoral or above-knee popliteal artery, no significant differences in patency were observed. Good distal runoff was associated with improved overall outcome.

Clampaje suprarrenal y evolución de la función renal en los aneurismas yuxtarrenales / Renal function evolution after suprarenal cross-clamping in juxtarenal aneurysms

Introducción. Los aneurismas yuxtarrenales que requieren clampaje suprarrenal (CSR) se han asociado con una morbimortalidad mayor postoperatoria, que en algunos trabajos se ha relacionado con el deterioro de la función renal. Objetivo. Determinar la repercusión renal del CSR para la corrección del aneurisma de aorta abdominal (AAA). Pacientes y métodos. En el período 1992-2001, se ha intervenido electivamente a 374 pacientes con AAA. De ellos, 53 eran yuxtarrenales y requirieron un CSR. Se analizan los factores de riesgo generales y los datos de la función renal preoperatoria. No se utilizó ningún método de protección renal específico. Se midió la creatinina de forma seriada tras la operación y se relacionó con el tiempo de clampaje y la función renal previa. Resultados. La mortalidad fue del 5,6 por ciento (tres). Un 15,1 por ciento (ocho) de los pacientes presentaron insuficiencia renal (IR). El tiempo de clampaje fue de 30,2 min (15-75 min).La IR previa fue determinante para la elevación de la creatinina en el postoperatorio (p = 0,018). El tiempo de clampaje, cuando fue mayor de 35 min, alcanzó significación estadística para la elevación de la creatinina (p = 0,02) en los pacientes con una función renal previa normal. En los pacientes con función renal normal, la creatinina al alta no mostró diferencias significativas con la basal. El único factor determinante en la morbimortalidad fue la cardiopatía isquémica (p = 0,02).Conclusiones. En pacientes con función renal normal no se necesitan métodos de protección renal, si el tiempo de CSR es inferior a 35 min.En los pacientes con IR se espera un deterioro de la función renal siempre que se realice un CSR. La morbimortalidad en nuestra serie ha dependido de los factores de riesgo (AU)

Role of HLA-DR in the pathogenesis of abdominal aortic aneurysm.

OBJECTIVE: to establish a possible role for autoimmunity in the aetiology of abdominal aortic aneurysm (AAA) by examining human leukocyte antigen class II (HLA-II) immune response genes. MATERIALS AND METHODS: HLA-II typing was performed in a series of 72 AAA patients and a control group of 380 healthy subjects. RESULTS: a higher incidence of the allele subtype HLA-DR B1*0401 was detected in the AAA group with respect to the control group (12.5 vs 5.2%; p = 0.02, OR 2.59). In contrast, the HLA-DR B1*01 allele tended to behave as a protective factor for AAA (12.5% AAA vs 21.3% controls; p = 0.09, OR 0.5). CONCLUSIONS: the association observed here between HLA-DR B1*0401 and HLA-DR B1*01 and unspecific AAA is similar to that reported in several autoimmune diseases. This similarity suggests an essential role for autoimmune factors in the formation of the AAA.

Papel del hla en la patogenia de los aneurismas de aorta abdominal / Role of hla complex in the pathogenesis of abdominal aortic aneurysms

Introducción. En los últimos años, se han descrito alteraciones en el patrón de las metaloproteinasas en los aneurismas de aorta abdominal (AAA), secundarias a procesos inflamatorios que podrían estar implicados en la patogenia de los mismos; existen muy escasos estudios que valoren el papel de la autoinmunidad en la etiopatogenia de esta enfermedad. Objetivo. Estudiar el patrón HLA de clase II y III para valorar la participación de un proceso autoinmune en los AAA. Pacientes y métodos. Se realizó el tipaje de los HLA-II y las zonas del HLA-III correspondientes al factor de necrosis tumoral (TNF) y su promotor en un grupo de 72 pacientes con AAA, y se comparó con una muestra control de 380 personas sanas. Resultados. HLA-II: se encontró mayor incidencia de HLADR-4*401 en AAA respecto a controles (12,5 por ciento frente a 5,2 por ciento; p= 0,02; OR= 2,59). No hubo diferencias entre los demás alelos. TNF: la frecuencia de aparición del TNF a4b5 en el grupo de AAA mostró una tendencia a la significación (p= 0,055) sin encontrar otras diferencias respecto a los controles. Tampoco se encontraron diferencias en cuanto a los promotores del TNF. Haplotipos: el haplotipo HLA-DR3-TNF a2b3 fue significativamente más prevalente entre los AAA respecto a los controles (16,6 por ciento frente a 8,4 por ciento; p= 0 ,03; OR= 2,17). Conclusiones. La relación encontrada entre el HLA-DR4*401 y el haplotipo ancestral HLA-DR3-TNF a2b3 que se encuentra asociado a otras enfermedades autoinmunes, sugiere que fenómenos de autoinmunidad pueden desempeñar un papel importante en la patogenia de los aneurismas de aorta abdominal. (AU)

Comparison of peripheral arterial reconstruction in diabetic and non-diabetic patients: a prospective clinic-based study.

UNLABELLED: To assess the efficacy and safety of lower extremity arterial reconstruction in diabetic and non-diabetic subjects during a 3-year period. A prospective clinic-based study between 1994-1999 in Area 7, Madrid, with a population of 569307 and an estimated diabetic population of 37932 (15505 men and 22427 women). The level of arterial reconstruction and associated risk factors were ascertained. RESULTS: A total of 588 peripheral revascularization surgical procedures were performed in 481 patients. The diabetic patients (n=174, 36.2%) underwent 222 surgical procedures (including 48 follow-on operations, 21.6%), and 307 non-diabetic subjects underwent 366 surgical procedures (59 follow-on operations, 16.1%). The numbers of surgical procedures per 100000 people at risk and year were 18.8 and 1.8 for non-diabetic men and women, respectively, and 145.1 and 29.0 for men and women with diabetes mellitus (7.7- and 16.2-fold, respectively). Age at reconstruction surgery was 2 and 5 years earlier in non-diabetic than in diabetic men and women, respectively. Diabetic patients had a higher neuropathy score (P<0.05) and were less frequently smokers (P<0.05) than non-diabetic subjects. Diabetic subjects more frequently had distal reconstruction while proximal arterial reconstruction was more often performed in non-diabetic subjects. Between 64.6 and 80.4% of people with diabetes and 82.3 and 88.9% of non-diabetic subjects had no complications during their in-hospital stay. Distal amputation simultaneous to arterial reconstruction was the most frequent morbidity of people with diabetes during the study (P<0.05). Despite a graft occlusion rate after femoropopliteal revascularization significantly higher than in non-diabetic people (P<0.05), diabetic people more often required lower extremity amputations (LEAs) for the same level of bypass (P<0.01). Cumulative limb salvage rates were lower in diabetic patients than in non-diabetic subjects at femoropopliteal (49.2 vs. 89.7%; P<0.001), femorodistal (73.5 vs. 95.2%; P<0.01), and distal reverse (77.9 vs. 87.3%; P<0.05) arterial reconstruction, at the end of the third year, but similar after aorto-iliac reconstruction (93.1 vs. 97.5%). A higher neuropathy score and the presence of foot ulcers were associated to significantly lower limb salvage in diabetic patients (P<0.05), but not in non-diabetic people. Survival rates after 3 years were similar between diabetic and non-diabetic populations after aorto-iliac (93.1 vs. 97.5%), femoropopliteal (97.2 vs. 90.3%), and distal reverse (93.2 vs. 98.1%) revascularization, and slightly lower in diabetic compared to non-diabetic patients after femorodistal revascularization (82.1 vs. 96.3%; P<0.05). CONCLUSION: Although limb salvage after arterial reconstruction is lower in diabetic than in non-diabetic subjects, particularly in those with a higher neuropathy score, this surgical approach can be applied in both diabetic and non-diabetic subjects with otherwise similar outcome.

Should the cell saver autotransfusion system be routinely used in elective aortic surgery?

The objective of this study is to identify the aortic surgery procedures in which the use of the Cell Saver autotransfusion system is beneficial in terms of the amount of autologous blood recovered and the reduction in blood bank demands. An evaluation of the cost-effectiveness of the system is also presented. Four hundred and thirty-four elective aortic interventions were retrospectively reviewed to examine the use of intraoperative autotransfusion (IAT). Evaluation was made of risk factors, preoperative hematological variables, the volume of IAT-processed reinfused blood, and homologous transfusion requirements over the period of hospitalization. The routine use of the IAT system was cost-effective in the interventions for AAA and TAA. In patients subjected to aortobifemoral bypass for aortoiliac occlusive disease, IAT served to alleviate demands on blood bank inventories, although in our center its use led to a slight increase in net cost. The routine use of IAT during unilateral revascularization due to occlusive disease offered no benefits in terms of reduced homologous transfusion requirements or cost-effectiveness.