El impacto de la enfermedad arterial periférica: propuesta de una nueva clasificación / The impact of peripheral arterial disease: A proposal for a new classification

La claudicación intermitente, estación evolutiva intermedia de la enfermedad arterial periférica, se ha considerado tradicionalmente como un estadio benigno, atendiendo al hecho exclusivo de la clínica de dolor que se produce durante la marcha. En este artículo pretendemos llamar la atención sobre las posibles consecuencias asociadas al dolor isquémico y el consiguiente estrés oxidativo desencadenado por su «sombra», el fenómeno isquemia/reperfusión. Durante el mismo se produce deficiente manejo del calcio y aparición incontrolada de radicales libres de oxígeno, con daño mitocondrial y aumento del fenómeno inflamatorio que podría estar asociado a una progresión acelerada de la arteriosclerosis sistémica con aumento del riesgo cardiovascular, directamente proporcional a la disminución del índice tobillo/brazo. Ante estos acontecimientos, proponemos una nueva clasificación integradora de las actuales de Fontaine y Rutherford, que considera las posibles consecuencias sistémicas expuestas y sirva para modificar nuestro manejo tradicional de la enfermedad arterial periférica

Clasically, intermittent claudication, an intermediate stage in peripheral arterial disease, has been considered as a benign condition when considering only the muscular pain on walking. In this paper our aim is to attract attention about the effects linked to ischemic pain and the oxidative injury resulting from episodes of ischemia/reperfusion. Throughout this process alterations in calcium homeostasis as well as uncontrolled generation of reactive oxygen species, in association with the mitochondrial dysfunction and inflammatory phenomena, could lead to accelerate atherosclerosis, with an increased cardiovascular risk stated by means of a reduced ankle-brachial index. Taking this idea into account we propose a possible new classification for the management of the peripheral arterial disease, combining the Fontaine and Rutherford classifications and thinking about the described systemic effects in order to change the traditional management of peripheral arterial disease

The impact of peripheral arterial disease: A proposal for a new classification. / El impacto de la enfermedad arterial periférica: propuesta de una nueva clasificación.

Clasically, intermittent claudication, an intermediate stage in peripheral arterial disease, has been considered as a benign condition when considering only the muscular pain on walking. In this paper our aim is to attract attention about the effects linked to ischemic pain and the oxidative injury resulting from episodes of ischemia/reperfusion. Throughout this process alterations in calcium homeostasis as well as uncontrolled generation of reactive oxygen species, in association with the mitochondrial dysfunction and inflammatory phenomena, could lead to accelerate atherosclerosis, with an increased cardiovascular risk stated by means of a reduced ankle-brachial index. Taking this idea into account we propose a possible new classification for the management of the peripheral arterial disease, combining the Fontaine and Rutherford classifications and thinking about the described systemic effects in order to change the traditional management of peripheral arterial disease.

Repair of bilateral true aneurysms of the dorsalis pedis artery.

Aneurysms of peripheral arteries are infrequent, with an incidence <1%. Dorsalis pedis artery (DPA) aneurysms are extremely rare, and most of them are pseudoaneurysms secondary to trauma or iatrogenic injuries. We report the first case of simultaneous (synchronous) bilateral DPA true aneurysms and how we repaired them. We review the literature on DPA true aneurysms and focus on the surgical management.

[Cerebral hyperperfusion syndrome in carotid revascularisation surgery]. / Síndrome de hiperperfusión cerebral en la cirugía de revascularización carotídea.

INTRODUCTION: Cerebral hyperperfusion syndrome (CHS) is a serious complication of carotid revascularisation surgery associated with both carotid endarterectomy and carotid stenting. AIM: To review the literature published to date on CHS with the aim of updating the data available on its incidence, pathophysiology, clinical features, risk factors, diagnosis, management and treatment. DEVELOPMENT: Carotid revascularisation surgery entails a transient increase in cerebral blood flow, and if this increase is more than 100% of the pre-operative value, then hyperperfusion occurs. Two pathophysiological mechanisms are involved in increasing cerebral blood flow: alteration of the cerebrovascular autoregulation mechanisms and increased post-operative systolic arterial pressure. CHS consists in the clinical triad headache, convulsions and focal neurological deficit, associated with arterial hypertension and the absence of cerebral ischaemia. If left undiagnosed, as it progresses it will lead to brain oedema, brain or subarachnoid haemorrhage and, finally, death. The main risk factors for CHS are: diminished haemodynamic reserve, post-operative arterial hypertension and hyperperfusion, which remains for several hours after the carotid recanalisation. Diagnosis is based on clinical suspicion and complementary tests, such as trans-cranial Doppler ultrasonography or single-photon emission tomography, which confirm the suspected hyperperfusion. The keystone on which treatment is based is prevention by strict control of the arterial pressure with drugs such as labetalol and clonidine. CONCLUSIONS: CHS is a serious, under-diagnosed complication of carotid revascularisation that the specialist must be aware of so that treatment can be established at an early stage, thereby reducing its high morbidity and mortality rate.

Isquemia aguda en extremidad superior secundaria a un mixoma / Acute ischemia in upper limb secondary to myxoma

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Carta dirigida a todos los socios de la Sociedad Española de Angiología y Cirugía Vascular (SEACV) / No disponible

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[Laparoscopy-assisted aortobifemoral bypass through the transperitoneal retrorenal approach]. / By-pass aortobifemoral con asistencia laparoscópica por vía transperitoneal retrorrenal.

The aim of laparoscopic vascular surgery in the aortoiliac segment is to replicate the excellent outcomes of open aortic surgery while providing the advantages of minimally invasive surgery. We report the case of a 49-year old man with disabling hip claudication and rest pain in his left lower extremity. On examination the patient had reduced right femoral pulse and absent pulses in his left lower extremity. Angiography revealed occlusive disease in the left aortoiliac segment and right common iliac artery stenoses. Laparoscopic aortobifemoral bypass was planned. The surgical technique included 70 degrees -right lateral decubitus position and retrorenal retrocolic dissection from the left common iliac artery to the left renal vein. Minilaparotomy consisted of aortic clamping, arteriotomy, and end-to-side aorto-prosthetic anastomosis with Dacron graft. Time to extubation was 5 hours; peristalsis was recovered 72 hours after surgery. The patient was discharged from hospital after cardiologic assessment 9 days after surgery.

By-pass aortobifemoral con asistencia laparoscópica por vía transperitoneal retrorrenal / Laparoscopy-assisted aortobifemoral bypass through the transperitoneal retrorenal approach

El objetivo de la cirugía vascular laparoscópica en el sector aortoilíaco es reproducir los excelentes resultados de la cirugía clásica minimizando la agresión quirúrgica. Presentamos el caso clínico de un varón de 49 años con claudicación invalidante en las caderas y dolor de reposo en el miembro inferior izquierdo (MII). A la exploración, el pulso femoral derecho era débil y había ausencia de pulsos en el MII. La aortoarteriografía demostró una oclusión ilíaca izquierda y un eje ilíaco derecho filiforme. Se consideró la opción quirúrgica de bypass aortobifemoral laparoscópico. La intervención quirúrgica se llevó a cabo con el paciente en decúbito lateral derecho de 70°; se realizó una disección aórtica retrocólica retrorrenal, desde origen de la arteria ilíaca primitiva izquierda hasta vena renal izquierda; la minilaparotomía consistió en pinzamiento aórtico, aortotomía y anastomosis aortoprotésica en terminolateral con dacron. Se extubó al paciente a las 5 h, que presentó peristalsis a las 72 h. Se le dio el alta ambulatoria tras revisión cardiología programada, al noveno día de la intervención (AU)

The aim of laparoscopic vascular surgery in the aortoiliac segment is to replicate the excellent outcomes of open aortic surgery while providing the advantages of minimally invasive surgery. We report the case of a 49-year old man with disabling hip claudication and rest pain in his left lower extremity. On examination the patient had reduced right femoral pulse and absent pulses in his left lower extremity. Angiography revealed occlusive disease in the left aortoiliac segment and right common iliac artery stenoses. Laparoscopic aortobifemoral bypass was planned. The surgical technique included 70°-right lateral decubitus position and retrorenal retrocolic dissection from the left common iliac artery to the left renal vein. Minilaparotomy consisted of aortic clamping, arteriotomy, and end-to-side aorto-prosthetic anastomosis with Dacron graft. Time to extubation was 5 hours; peristalsis was recovered 72 hours after surgery. The patient was discharged from hospital after cardiologic assessment 9 days after surgery (AU)

Cirugía vascular por laparoscopia: vías de abordaje de la aorta abdominal / Laparoscopic vascular surgery: access approaches to the abdominal aorta

Introducción. La posibilidad de aplicar técnicas mínimamente invasivas, como es la cirugía laparoscópica, a la patología de la aorta abdominal, isquémica o aneurismática, es una realidad para aquellos grupos que han sabido superar una curva de aprendizaje exigente y que han alcanzado tiempos totales prácticamente similares a los que se manejan en cirugía abierta tradicional. Objetivo. Divulgar el conocimiento de estas técnicas. Se ha descrito recientemente una serie de nuevas vías que facilitan y hacen más repetible estos abordajes, incluso en pacientes obesos y con enfermedades intercurrentes. Realizamos una revisión y una descripción detallada de todas ellas, así como un repaso de las empleadas anteriormente, para facilitar la difusión de éstas a todo el colectivo de cirujanos vasculares. Desarrollo. Describimos de forma sistemática las tres vías frontales, así como la dorsal retroperitoneal, con toda la información necesaria que posibilitará la disección de la aorta abdominal yuxta e infrarrenal. La disección y la sutura son las dos fases imprescindibles que permitirán la realización del bypass protésico de forma totalmente laparoscópica. Conclusiones. Las vías de abordaje descritas permiten una disección repetible de la aorta abdominal una vez superadas las exigencias de la curva de aprendizaje (AU)

Introduction. Applying minimally invasive techniques, such as laparoscopic surgery, to ischaemic or aneurysmal pathologies of the abdominal aorta is a real possibility for groups that have managed to overcome a demanding learning curve and which have reached total times that are practically the same as those usually required in traditional open surgery. Aims. Our aim was to report on these techniques and make them more widely known. Recent reports have described a series of new accesses that make these approaches more straightforward and easier to repeat, even in patients who are obese and with intercurrent diseases. We offer a review and detailed description of all of them, together with an appraisal of previously used techniques, in order to make them more widely known among vascular surgeons. Development. We provide a systematic description of the three frontal, as well as the retroperitoneal dorsal, accesses together with all the information needed to dissect the juxtarenal and infrarenal abdominal aorta. Dissection and suturing are the two crucial phases that will allow us to perform the bypass graft in a totally laparoscopic manner. Conclusions. The surgical approaches described here allow for repeatable dissection of the abdominal aorta once the requirements of the learning curve have been overcome (AU)

Estudio piloto de prevalencia de la enfermedad arterial periférica en atención primaria / A pilot study of the prevalence of peripheral arterial disease in primary care

Objetivo. Evaluar la prevalencia de la enfermedad arterial periférica (EAP) en atención primaria (AP), mediante un estudio piloto epidemiológico transversal basado en la medición del índice tobillo-brazo (ITB). Pacientes y métodos. Medición del ITB en pacientes que acuden a la consulta de AP. Criterios de inclusión: mayores de 65 años, o entre 50 y 65 años con factores de riesgo de aterotrombosis. Se han incluido 300 pacientes, cuya media de edad es de 69 años. Un paciente fue excluido por no cumplir los criterios de inclusión. De los 299, el 48% eran varones, y el 66%, mayores de 65 años. El 86% tenía factores de riesgo de aterotrombosis: hipertensión arterial (69%), hipercolesterolemia (50%), diabetes tipo I o II (28%) y consumo de tabaco de más de 15 cigarrillos al día (12%). El 5% tenía antecedentes de enfermedad cerebrovascular, el 13% de enfermedad coronaria y el 8% de EAP. Resultados. El 23% de los 299 pacientes presentó un ITB £ 0,9, es decir, EAP leve/moderada, frente al 77% con un ITB > 0,9. No se identificó ningún paciente con EAP grave (ITB < 0,4). La prevalencia de la EAP era más alta en mayores de 65 años (p < 0,05). El 31% de los ITB < 0,9 se derivó a Cirugía Vascular. Conclusión. La prevalencia de la EAP es del 23% en AP en mayores de 50 años y es más alta en mayores de 65 años (p < 0,05). El ITB es una prueba sencilla al alcance de personal entrenado y constituye el marcador más significativo de cribado de EAP

AIM. To evaluate the prevalence rate of peripheral arterial disease (PAD) in primary care (PC) by means of a cross-sectional epidemiological pilot study based on measurements of the ankle brachial index (ABI). PATIENTS AND METHODS. Measurement of the ABI in patients who visit PC centres. Eligibility criteria: over 65 years of age or between 50 and 65 with risk factors for atherothrombosis. A total of 300 patients were included, their mean age being 69 years. One patient was excluded because he did not satisfy the eligibility criteria. Of the remaining 299, 48% were males. 66% were over 65 years old. 86% had risk factors for atherothrombosis, namely, arterial hypertension (69%); hypercholesterolemia (50%); type 1 or 2 diabetes (28%); smoking more than 15 cigarettes a day (12%). The study showed that 5% of them had a history of cerebrovascular disease, 13% heart disease and 8% PAD. RESULTS. A total of 23% of the 299 patients had an ABI £ 0.9, that is to say mild or moderate PAD, versus 77% with an ABI > 0.9. No patients were found to have severe PAD (ABI < 0.4). The rate of prevalence of PAD was higher in those aged above 65 (p < 0.05). Of the cases of ABI < 0.9, 31% were referred to vascular surgery. CONCLUSION. The prevalence rate of PAD is 23% in PC in patients above the age of 50 and is higher in those over 65 years old (p < 0.05). The ABI is a simple test that can be utilised by trained members of staff and is the most powerful marker in screening for PAD