Síndrome isquémico de la mano secundario a acceso vascular para hemodiálisis. Estrategias terapéuticas / Ischemic hand syndrome after vascular access for hemodialysis. Therapeutic strategies

El síndrome isquémico de la mano inducido por un acceso vascular para hemodiálisis es una complicación poco frecuente, pero que en los casos invalidantes requiere tratamiento quirúrgico. Los síntomas isquémicos serán importantes solo si la perfusión distal es insuficiente para mantener los requerimientos metabólicos básicos. Esta perfusión es dependiente de la resistencias vasculares periféricas y de la circulación colateral con sus mecanismos de autorregulación. Porque muchos de los signos y síntomas son inespecíficos, la confirmación diagnóstica debe venir mediante la realización de pruebas no invasivas. Un índice digital/braquial < 0,45 es sugestivo de un síndrome isquémico grave y suele estar asociado a dolor de reposo o a lesiones tróficas en los dedos. El objetivo inicial del tratamiento es conservar el acceso vascular, del que depende la hemodiálisis del paciente, y corregir la situación isquémica de la mano. Una variedad de técnicas han sido descritas en la literatura que incluyen la corrección de lesiones arteriales proximales, la ligadura simple, la plicatura o banding de la fístula, el distal revascularization-interval ligation (DRIL), el revascularization using distal insertion(RUDI) o el proximalization of the arterial inflow (PAI). La elección de la técnica más apropiada debería basarse en los mecanismos hemodinámicos que determinaron la isquemia, la gravedad de los síntomas, la morbilidad del paciente y la localización de la fístula arteriovenosa. En este artículo de revisión se analiza la fisiopatología y se discuten las distintas opciones quirúrgicas. Aunque el DRIL aparece como el procedimiento más efectivo y duradero en el seguimiento a largo plazo, las circunstancias particulares de cada caso hacen necesaria una individualización del tratamiento

Access-induced ischemia is an uncommon but devastating complication for patients maintained on hemodialysis. The construction of an arteriovenous access results in a predictable decrease in the perfusion pressure distal to the anastomosis, which can result in ischemia if the compensatory mechanisms are inadequate. Because many of the signs and symptoms are nonspecific, the diagnosis can be aided in equivocal cases with non-invasive vascular laboratory studies. A digital/brachial index < 0.45 is suggestive of severe ischemic syndrome, and is usually associated with pain at rest and/or trophic lesions on the fingers. The aims of the treatments are to reverse the hand ischemia and to preserve the access. There are a variety of treatments, including correction of the inflow lesion, access ligation, limiting the flow through the access (banding), distal revascularization with interval ligation (DRIL), revision using distal inflow (RUDI), or proximalization of arterial inflow (PAI). The optimal choice should be based on hemodynamic mechanisms and severity of symptoms, in conjunction with the access type and patient comorbidities. A review of the underlying pathophysiology and treatment options will be presented. To date, the DRIL procedure has been the most consistently successful strategy. However, the particular circumstances of each case demand an individualization of treatment

Design of a New Risk Score in Critical Limb Ischaemia: The ERICVA Model.

OBJECTIVES: It is difficult to establish which patients suffering from critical lower limb ischaemia will benefit from revascularization. Risk scores can provide objectivity in decision making. The aim was to design a new risk score (ERICVA) and compare its predictive power with the PREVENT III and Finnvasc scores. METHODS: An observational retrospective study of patients who underwent revascularization (open or endovascular) in Valladolid's University Hospital between 2005 and 2010 was designed. The sample was divided into two subgroups (development and validation subsamples). After univariate analysis followed by a multivariate Cox regression, a number of variables associated with death and/or major amputation were selected, creating a weighed score called ERICVA, and a simplified version of it. The area under the curve (AUC) of receiver operating characteristic (ROC) curve analysis was performed and the AUC of these two scores were additionally compared with the AUC of the PREVENT III and Finnvasc scales. RESULTS: Six hundred and seventy two cases with an average surveillance of 778 days were included in the study. Amputation free survival (AFS) was 84.8% at 30 days and 63.1% at 1 year. Variables associated with death and/or major amputation in the Cox regression were cerebrovascular disease, prior contralateral major amputation, diabetes mellitus, dialysis, chronic obstructive pulmonary disease, cancer, haematocrit less than 30%, neutrophil/lymphocyte ratio exceeding 5, absence of arterial Doppler signal at the ankle, emergency admission, and Rutherford stage 6; these variables were used for the ERICVA and simplified ERICVA score designs. Scores were applied to both subsamples; in the development sample the AUC of ERICVA and simplified ERICVA was significantly higher than the PREVENT III (p = .008 and p = .045) and Finnvasc (p < .0001 and p = .0013) scores; in the validation sample the AUC of ERICVA and simplified ERICVA were significantly higher than Finnvasc score (p = .0323 and p = .0017). CONCLUSIONS: The ERICVA model has a good predictive capacity for death and/or major amputation in the clinical setting, and is better than the PREVENT III and Finnvasc scores.

Tratamiento endovascular de la aorta torácica / Endovascular treatment of the abdominal aortic aneurysm

El tratamiento endovascular ha supuesto un cambio muy importante en las posibilidades terapéuticas que implican la aorta torácica. La disminución de la morbimortalidad gracias a los procedimientos menos invasivos hacen que este tratamiento se plantee como la primera opción terapéutica en el territorio que nos ocupa. En este trabajo se resumen las distintias entidades nosológicas que pueden afectar a la aorta torácica, los métodos diagnósticos más adecuados en cada caso y las distintas estrategias de tratamiento basándonos en una revisión actualizada de la literatura disponible(AU)

The endovascular approach has led to great changes in therapeutic possibilities involving the thoracic aorta. Low morbidity and mortality rates due to the less invasive procedures, tends to make this the first therapeutic option. This paper summarises the most important diseases involving the thoracic aorta, the most suitable diagnostic methods, and different treatment options based on an updated review of the literature(AU)

La trombosis venosa profunda sural: ¿deben estos pacientes recibir anticoagulación terapéutica? / No disponible

No disponible

Isquema de la extremidad superior secundaria a acceso vascular para hemodiálisis / No disponible

La aparición de isquemia en la extremidad superior secundaria a un acceso vascular para hemodiálisis es una complicación seria por el riesgo de amputación. Su incidencia se está incrementando por el aumento del número de pacientes en hemodiálisis, cada vez con una edad más elevada. En este trabajo revisamos los procedimientos más adecuados para su diagnóstico y tratamiento (AU)

Upper limb ischemia secondary to haemodialysis vascular access is a serious complication due to amputation risk Incidenceis increasing because of the ascending number of patients in haemodialysis programs, every time older. In this paper wereview the more appropriate diagnostic and therapeutic procedures for it (AU)