ABS-SMART (Aortic Balloon Supporting for Superior Mesenteric Artery Recanalization Technique): A New Technical Option for Recanalization of Complete Superior Mesenteric Artery Occlusion in Chronic Mesenteric Ischemia.

OBJECTIVE: To report our experience with a new technique for recanalization of the superior mesenteric artery (SMA)/celiac trunk (CT) with complete occlusion at the origin. TECHNIQUE: We describe our ABS-SMART (Aortic Balloon Supporting for Superior Mesenteric Artery Recanalization Technique) for recanalization of the CT and SMA in cases of complete occlusion of these arteries with a short or inexistent stump, which usually corresponds to chronic lesions with important calcification of the ostium. CONCLUSION: The ABS-SMART is an alternative for the recanalization of visceral arteries in cases where other conventional techniques have failed. It is particularly useful in scenarios characterized by a short occlusion at the origin of the target vessel, with no entry stump or severe calcification at the origin. CLINICAL IMPACT: Catheterization and recanalization of visceral stenoses may pose a challenge in some cases, as for example in the presence of a very narrow angle between the root or origin of the vessel and the aorta, as well as in the case of long and calcified stenoses, or when arteriography is unable to visualize the origin of the vessel. The present study describes our experience with the endovascular revascularization of visceral vessels using an aortic balloon-supported recanalization technique not previously described in the literature, that may be an effective alternative for the treatment of lesions of difficult access, such as total occlusion at the origin of the target vessel, with no entry stump or severe calcification at the origin of the SMA and CT, by improving the chances for technical success.

Estudio multicéntrico de la reparación endovascular urgente de la aorta torácica: indicaciones y resultados / A multicenter study of emergency endovascular repair of the thoracic aorta: indications and outcomes

Objetivo Las técnicas endovasculares se han convertido en una herramienta esencial para el tratamiento de la patología de aorta torácica descendente (TEVAR). El objetivo es analizar las indicaciones y resultados del TEVAR urgente a nivel nacional en relación con la cirugía programada. Diseño y ámbito de estudio Registro multicéntrico retrospectivo de pacientes con patología de aorta torácica descendente tratados de urgencia mediante técnicas endovasculares entre los años 2012-2016 en 11 servicios clínicos. Pacientes, criterios de inclusión 1) Aneurismas de aorta torácica rotos, 2) roturas traumáticas de aorta torácica y 3) disecciones de aorta torácica tipo B (DATBc) complicadas. Variables principales Mortalidad, supervivencia y tasa de reintervenciones. Variables secundarias Datos demográficos, factores de riesgo cardiovasculares, datos específicos por indicación, datos técnicos y complicaciones postoperatorias. Resultados Se obtuvieron 135 TEVAR urgentes (111 varones, edad media 60,4 ± 16,3 años): 43 aneurismas aórticos rotos (31,9%), 54 disecciones tipo B (40%) y 32 roturas aórticas traumáticas (23,7%) y otras etiologías 4,4%. La mortalidad global a los 30 días fue del 18,5%, siendo superior en los aneurismas de aorta torácica rotos (27,9%). La supervivencia media actuarial ha sido del 67± 6% a los 5 años. La tasa de ictus postoperatoria fue del 5,2% y la tasa de isquemia medular del 5,9%. Las reintervenciones aórticas fueron necesarias en 12 pacientes (9%). Conclusiones La patología de aorta descendente urgente puede ser tratada mediante técnicas endovasculares con resultados óptimos y baja morbimortalidad, aunque ligeramente superior a los casos electivos. Este registro aporta por primera vez, información de la realidad clínica diaria del TEVAR urgente en España. (AU)

Objective Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. Study design and scope A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. Patients, inclusion criteria 1) Ruptured descending thoracic aortic aneurysms; 2) Blunt traumatic thoracic aortic injury; and 3) Complicated acute type B aortic dissections (TBADc). Primary variables Patient mortality, survival and reoperation rate. Secondary variables Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. Results A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ± 16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the ruptured descending thoracic aortic aneurysms group (27.9%). The mean actuarial survival rate was 67± 6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). Conclusions Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality – though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain. (AU)

A multicenter study of emergency endovascular repair of the thoracic aorta: Indications and outcomes.

OBJECTIVE: Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. STUDY DESIGN AND SCOPE: A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. PATIENTS, INCLUSION CRITERIA: 1) Ruptured descending thoracic aortic aneurysms (RTAA); 2) Blunt traumatic thoracic aortic injury (TAI); and 3) Complicated acute type B aortic dissections (TBADc). PRIMARY VARIABLES: Patient mortality, survival and reoperation rate. SECONDARY VARIABLES: Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. RESULTS: A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ±â€¯16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the RTAA group (27.9%). The mean actuarial survival rate was 67 ±â€¯6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). CONCLUSIONS: Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality - though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain.

A multicenter study of emergency endovascular repair of the thoracic aorta: indications and outcomes. / Estudio multicéntrico de la reparación endovascular urgente de la aorta torácica: indicaciones y resultados.

OBJECTIVE: Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. STUDY DESIGN AND SCOPE: A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. PATIENTS, INCLUSION CRITERIA: 1) Ruptured descending thoracic aortic aneurysms; 2) Blunt traumatic thoracic aortic injury; and 3) Complicated acute type B aortic dissections (TBADc). PRIMARY VARIABLES: Patient mortality, survival and reoperation rate. SECONDARY VARIABLES: Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. RESULTS: A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ± 16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the ruptured descending thoracic aortic aneurysms group (27.9%). The mean actuarial survival rate was 67± 6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). CONCLUSIONS: Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality - though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain.

Prevalencia de aneurismas de aorta abdominal en una población de riesgo en una consulta de cirugía vascular / Prevalence of abdominal aortic aneurysms in a risk population seen in a vascular surgery department

OBJETIVO: conocer la prevalencia de los aneurismas de aorta abdominal infrarrenal (AAA) y factores de riesgo en pacientes remitidos a consultas externas de Angiología y Cirugía Vascular para valoración de enfermedad arterial periférica (EAP). MATERIAL Y MÉTODOS: entre febrero de 2012 y diciembre 2016 se realizó eco Doppler aortoilíaco a los pacientes mayores de 50 años remitidos para descartar arteriopatía de miembros inferiores. En todos los casos se realizó exploración física y recogida de factores de riesgo cardiovascular. Diseño observacional, longitudinal. Análisis univariante y multivariante. RESULTADOS: el estudio incluyó a 454 pacientes. De estos, se excluyeron 11 en los que no fue posible la medición del diámetro del aneurisma por obesidad/gas abdominal. El total de pacientes estudiados es de 443. La prevalencia en la población estudiada de aneurisma fue del 8,8% (n = 39). La media del diámetro de los aneurismas diagnosticados fue 4,1 cm (± 1,1). En los pacientes que presentaron ITB menor de 0,9 (EAP), la prevalencia fue del 11,2% (29) frente al 5,2% (10) en pacientes con ITB mayor de 0,9 (p < 0,05). Los pacientes con EAP presentaron un mayor porcentaje de hipertensión arterial y tabaquismo (p < 0,05). En el análisis univariante de los factores de riesgo asociados a presentar AAA (grupo 1) frente a no presentar AAA (grupo 2), que fueron estadísticamente significativos (p < 0,05), la diabetes mellitus (DM) apareció como factor protector (grupo 1: 28,2%; grupo 2: 71,8%), mientras que los pacientes con broncopatía crónica (EPOC) (grupo 1: 64,1%; grupo 2: 35,9%), EAP (grupo 1: 74,4%; grupo 2: 55,2%), tabaquismo (grupo 1: 100%; grupo 2: 82,2%) y los mayores de 65 años (grupo 1: 89,7%; grupo 2: 70%) presentaron mayor riesgo de AAA. En el análisis multivariante, EPOC (OR 4,7), edad > 65 años (OR 3,4) y el grupo de pacientes con EAP (OR 2,4) se mostraron como factores de riesgo, mientras que la DM se mostró como factor protector (OR 0,4). CONCLUSIONES: en nuestra población, EPOC, EAP y edad > 65 años son factores de riesgo de AAA, mientras que la DM es un factor protector. El análisis de estos datos puede ayudar a definir la población de riesgo para la realización de estudios de despistaje en una consulta de cirugía vascular

OBJECTIVE: to determine the prevalence of infrarenal abdominal aortic aneurysms (AAAs) and their risk factors in patients referred to the Angiology and Vascular Surgery outpatient clinic for the evaluation of peripheral arterial disease (PAD). MATERIAL AND METHODS: a longitudinal observational study was carried out involving aortoiliac echodoppler exploration of the patients over 50 years of age referred to our center for the exclusion of arterial disease of the lower extremities between February 2012 and December 2016. A physical examination was made in all cases, with the compilation of cardiovascular risk factors. The data obtained were subjected to univariate and multivariate statistical analysis. RESULTS: a total of 454 patients were initially included in the study. Of these, 11 were discarded because abdominal gas / obesity impeded measurement of the diameter of the aneurysm. The final sample thus consisted of 443 individuals. The prevalence of aneurysms was 8.8% (n = 39), with a mean diameter of 4.1 (± 1.1 cm). In the patients with an ankle-brachial index (ABI) < 0.9 (indicative of PAD), the prevalence was 11.2% (n = 29) versus 5.2% (n = 10) in those with ABI > 0.9 (p < 0.05). The patients with PAD presented a greater incidence of arterial hypertension and smoking (p < 0.05). In the univariate analysis, on contrasting the patients with factors significantly associated (p < 0.05) to a risk of AAA (group 1) versus those without such risk factors (group 2), diabetes mellitus (DM) was identified as 63 a protective factor (group 1: 28.2%; group 2: 71.8%), while chronic obstructive pulmonary disease (COPD) (group 1: 64.1%; group 2: 35.9%), PAD (group 1: 74.4%; group 2: 55.2%,), smoking (group 1: 100%, group 2: 82.2%) and age > 65 years (group 1: 89.7%; group 2: 70%) were associated to an increased risk of AAA. In the multivariate analysis, COPD (odds ratio [OR] 4.7), age > 65 years (OR 3.4) and PAD (OR 2.4) were identified as risk factors, while DM proved to be a protective factor (OR 0.4). CONCLUSIONS: in our population of patients COPD, PAD and age > 65 years were risk factors for AAA, while DM was identified as a protective factor. These findings may contribute to define the risk population with a view to conducting screening studies in a vascular surgery department

Endovascular Treatment of Descending Thoracic Aortic Pathology: Results of the Regis-TEVAR Study.

BACKGROUND: Endovascular techniques have become an essential tool for treatment of thoracic aortic pathology. The objective of this study was to analyze indications and results of thoracic endovascular aortic repair (TEVAR) in vascular surgery units, through a retrospective and multicentric national registry called Regis-TEVAR. METHODS: From 2012 to 2016, a total of 287 patients from 11 vascular surgery units, treated urgently and electively, were recruited consecutively. The primary variables analyzed are mortality, survival, and reintervention rate. The following indications for TEVAR were also analyzed: aortic dissections, thoracic aneurysms, traumatisms, and intramural hematomas or penetrating ulcers, as well as results and postoperative complications in accordance with each indication. RESULTS: Of the 287 TEVAR performed (239 men, mean age 64.1 ± 14.1 years), 155 were because of aortic aneurysm (54%), 90 because of type B aortic dissection (31.4%), 36 because of traumatic aortic rupture (12.5%), and 6 because of penetrating ulcers or intramural hematomas (2.1%). Overall mortality at 30 days was 11.5% (18.5% in urgent and 5.3% in elective), being higher in dissections (13.3%). The median actuarial survival was 73% at 4 years. The stroke rate was 3.1%, and the rate of spinal cord ischemia was 4.9%. Aortic reoperations were necessary in 23 patients (8.1%). CONCLUSIONS: This registry provides complete and reliable information on real clinical practice of TEVAR in Spain, with results similar to international series of open surgery. In accordance with these data, TEVAR can be performed with acceptable morbidity and mortality and with low rates of postoperative complications.

Avanzando en la toma de decisiones compartida: estenosis carotídea asintomática / Advancing in shared decision making: asymptomatic carotid stenosis

En las últimas décadas ha venido produciéndose un cambio de paradigma en la relación médico-enfermo, que ha pasado de una visión paternalista a una medicina más centrada en el paciente. La toma de decisiones compartidas (TDC) es un proceso que incluye el intercambio de información (personal y médica) entre el paciente y el sanitario respecto a la enfermedad, la deliberación sobre las distintas opciones y, finalmente, la toma de una decisión consensuada. Para facilitar este proceso se han desarrollado distintas herramientas mediante diversos medios y formatos (folletos, texto escrito, vídeos, aplicaciones informáticas...), utilizando en muchas ocasiones ayudas visuales tales como caras sonrientes u otros pictogramas. Desde nuestro grupo de trabajo nos unimos a este proceso evolutivo de la práctica médica y presentamos una herramienta de ayuda visual a la TDC en el caso de pacientes con estenosis carotídea asintomática mayor del 70%. Para su realización nos hemos basado en los cates plots, que ayudan a cuantificar riesgos y beneficios de una intervención de forma estandarizada

In the last decades there has been a paradigm change in the doctor-patient relationship, from a paternalistic model to a patient centered medicine. Shared decision making (SDM) is a process that involves bidirectional communication between physicians and patients about the illness, different treatment options, and, through the deliberation process, reaching an agreement in the ultimate decision made. Various different tools have been developed to promote shared decision making, through different types of support methods (leaflets, books, videos, websites or other interactive media), frequently using visual aids like smiley faces plots or other pictograms. Our Working Group would like to join this evolutionary process. Thus, we have developed a visual aid tool to help in the decision-making process in the case of asymptomatic carotid stenosis > 70%. We have based on Cates plots that help to quantify risks and benefits of specific interventions in a standardized manner

Preoperative mapping of the aortoiliac territory with duplex ultrasound in patients with peripheral arterial occlusive disease.

OBJECTIVE: Duplex ultrasound (DUS) arterial mapping of the aortoiliac area is limited by obesity, abdominal gas, and the need to use a low-frequency probe (and therefore poorer resolution) in the examination. The aim of this study was to analyze the degree of agreement between DUS mapping of the aortoiliac area and angiography or contrast-enhanced computed tomography angiography (CTA). METHODS: This was a retrospective observational study. Between November 2006 and June 2015, there were 173 patients with a surgical indication for aortoiliac occlusive disease included, with preoperative aortoiliac DUS mapping and subsequent CTA or intraoperative angiography. Sensitivity, specificity, positive predictive value, and negative predictive value of DUS as an arterial mapping test were analyzed, as was the degree of agreement with angiography/CTA and agreement between the surgical indication based on DUS and the final surgical technique performed. RESULTS: Of 173 DUS mapping tests, 155 were evaluated (89.6%); the remaining 18 were not able to be evaluated because of the patient's obesity or bowel gas. Overall accuracy of DUS for predicting significant artery lesions was as follows: 92% sensitivity (95% confidence interval [CI], 88%-95%), 96% specificity (95% CI, 95%-97%), 89% positive predictive value (95% CI, 86%-93%), and 97% negative predictive value (95% CI, 96%-98%). Agreement with angiography/CTA had a κ index of 0.81 (95% CI, 0.77-0.84), which reflects a good degree of agreement. Surgical indications based on DUS mapping were correct in 89% of cases (138/155). CONCLUSIONS: DUS mapping of the aortoiliac territory could be used as a single preoperative imaging test in aortoiliac occlusive disease in patients whose DUS examination is able to be evaluated.

Indicadores de calidad en patología vascular: estudio piloto multicéntrico nacional / Quality indicators in vascular disease: National multicentre pilot study

INTRODUCCIÓN: Desde hace más de una década ha surgido un interés creciente por evaluar la calidad de la atención sanitaria que prestamos. Los indicadores de calidad son la medida instrumental de esa calidad asistencial. Diferentes sociedades científicas internacionales están desarrollando iniciativas para monitorizar sus procesos quirúrgicos más frecuentes. OBJETIVOS: El Grupo de Calidad de la Sociedad Española de Angiología Cirugía Vascular consideró que sería de interés empezar a desarrollar una estructura básica de indicadores dentro de nuestra sociedad. Para ello se propuso como objetivo seleccionar 4-5 patologías vasculares frecuentes y elaborar 1-2 indicadores de esos procesos, para de esta forma demostrar que esta iniciativa es factible y puede dar lugar a unos resultados útiles para mejorar la calidad de nuestro trabajo diario y poder hacer «benchmarking» europeo. MATERIAL Y MÉTODOS: Se seleccionaron 17 Servicios de Cirugía Vascular, 5 de las patologías más frecuentes y 2 indicadores clave por cada una de ellas: aneurismas de aorta abdominal, patología arterial periférica, patología carotídea extracraneal, trombosis venosa profunda y fístulas arteriovenosas para hemodiálisis. Para seleccionar los indicadores clave (key performance indicators) se recurrió a las guías de práctica clínica, documentos de consenso y estudios publicados de gran relevancia científica. Por consenso de expertos se escogieron preferentemente indicadores de proceso y se elaboró una ficha para la recogida uniformada de información. RESULTADOS: Los resultados mostraron una gran variabilidad entre los centros, siendo alguno de ellos imposible de cuantificar, dada la ausencia de bases de datos informatizadas que permitieran su análisis. Los detalles concretos de cada indicador se describen exhaustivamente en el contenido de este artículo. CONCLUSIONES: Este trabajo nos ha permitido mostrar que la elaboración de indicadores de calidad es factible, útil y una oportunidad de mejora válida. Como en otras sociedades científicas internacionales, y después de esta positiva experiencia, deberíamos ampliar estos indicadores y crear una base de datos nacional para monitorizarlos

INTRODUCTION: There is growing interest in evaluating the quality of vascular care. The quality indicators are the tool to measure this. Different international vascular scientific societies are developing initiatives to monitor the most frequent surgical procedures. OBJECTIVES: The Quality Group of the Spanish Society of Angiology and Vascular Surgery considered it of interest to begin developing a basic structure of indicators in our Society. To this end, it was proposed to select 4-5 vascular diseases and 1-2 indicators of these processes, thus demonstrating that this initiative is feasible and can lead to useful results to improve the quality of our daily work. MATERIAL AND METHODS: Seventeen Spanish Vascular Surgery Units were selected, together with 5 of the most common diseases and two key indicators for each: abdominal aortic aneurysms, peripheral arterial disease, extracranial carotid disease, venous thrombosis and arteriovenous fistulas for haemodialysis. Practice guidelines, consensus documents and published studies of great scientific importance were used to select the indicators (key performance indicators). Through expert consensus process indicators were selected. RESULTS: The results showed a great variability between centres, few of them being impossible to quantify, because of the absence of computer databases to be able to analyse them. The specific details of each indicator are fully described in this article. CONCLUSIONS: This report has allowed us to show that the development of quality indicators is feasible, useful, and a valid opportunity to improve. As in other international scientific societies and after this positive experience, we should increase these indicators and create a national database to monitor them

Tratamiento endovascular con stent recubierto de aneurisma de arteria esplénica / Endovascular treatment of a splenic artery aneurysm with a coated stent

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Nuevas opciones de embolización de aneurisma aortoilíaco asociado a aneurisma de hipogástrica. A propósito de un caso / New options for embolising aortoiliac aneurysms associated to aneurysms in the hypogastric artery. A case report

Introducción. El tratamiento de los aneurismas aortoilíacos asociados a aneurismas de hipogástrica es un retopara los cirujanos vasculares, que han de idear tácticas individualizadas según la anatomía del caso. Caso clínico. Varónde 78 años, exfumador, con antecedentes de hipertensión arterial, cardiopatía isquémica y dos episodios de accidentecerebrovascular, en seguimiento por un aneurisma aortoilíaco que alcanza rango quirúrgico, decidiéndose reparaciónendovascular. Se trata de un aneurisma de aorta abdominal de 40 mm, asociado a un aneurisma de arteria ilíaca comúnizquierda y de hipogástrica izquierda, de 30 y 40 mm de diámetro, respectivamente. Mediante abordaje contralateral, seimplanta oclusor Amplatzer Vascular Plug de 22 × 18 mm, desde el cuello del aneurisma de la hipogástrica izquierdahasta la bifurcación de la ilíaca común, con lo que se excluyen ambos aneurismas. Se coloca una endoprótesis aortomonoilíacaderecha de 26 × 14 × 155 mm tipo Talent y un bypass femorofemoral cruzado derecha-izquierda con Dacron de8 mm. En la arteriografía posprocedimiento, la endoprótesis se encuentra permeable, existe una endofuga tipo II a aneurismaaórtico por lumbares y el aneurisma de la hipogástrica está trombosado. Una angiotomografía al año muestrapermeabilidad de la endoprótesis y el bypass, exclusión del aneurisma aortoilíaco y de la hipogástrica, ausencia de endofugasy ningún cambio en el tamaño de los sacos aneurismáticos. Conclusión. El diseño de nuevos dispositivos de liberaciónsencilla y precisa, y de mayor flexibilidad, posibilita nuevas estrategias en el tratamiento de aneurismas complejosde afectación aortoilíaca. Los oclusores Amplatzer Vascular Plug permiten en un solo acto, con un único dispositivo,ocluir la bifurcación de la ilíaca común y sellar el ostium de la hipogástrica(AU)

Introduction. The treatment of aortoiliac aneurysms associated to aneurysms in the hypogastric artery is achallenge for vascular surgeons, who have to devise tailor-made tactics to fit the anatomy of each case. Case report. A78-year-old ex-smoking male, with a history of arterial hypertension, ischaemic heart disease and two strokes, who wasbeing followed up due to an aortoiliac aneurysm that reached the surgical range; the decision was made to carry outendovascular repair. The abdominal aortic aneurysm measured 40 mm and was associated to an aneurysm in the leftcommon iliac and left hypogastric arteries, with diameters of 30 and 40 mm respectively. A contralateral approach wasemployed to implant a 22 × 18 mm Amplatzer Vascular Plug occluder, from the neck of the aneurysm in the left hypogastricto the bifurcation of the common iliac artery, which resulted in exclusion of both aneurysms. A 26 × 14 × 155 mmTalent-type right aortomonoiliac stent was placed, together with a right-left crossed femorofemoral 8-mm Dacronbypass. In the post-operative arteriography, the stent is found to be patent, there is a type II endoleak due to an aorticaneurysm near the lumbar region and the aneurysm of the hypogastric artery is thrombosed. A tomography angiographyscan at one year shows patency of the stent and the bypass, exclusion of the aneurysms in the aortoiliac and thehypogastric arteries, absence of endoleaks and no change in the size of the aneurysmal sacs. Conclusions. The design ofnew devices that are precise and simple to release, as well as being more flexible, allows for new strategies in thetreatment of complex aneurysms that compromise the aortoiliac artery. The Amplatzer Vascular Plug occluders make itpossible to occlude the common iliac and seal the ostium of the hypogastric artery in one single procedure and with justone single device(AU)

Acute lower limb ischemia in a patient with aortic thrombus and essential thrombocytosis.

Aortic thrombus is rare in patients with essential thrombocytosis (ET), so the optimal treatment remains undefined. A 45-year-old man with history of ET, under chronic treatment with aspirin, presented to the emergency department complaining of acute onset in both the legs and abdominal pain. Physical examination revealed that both dorsalis pedis pulses were not palpable with cold and pale feet. His abdomen was soft and nondistended. The platelet count was 436 x 10(9)/L. The thoraco-abdominal computerized tomographic scanning revealed normal aortic diameter with supraceliac and infrarenal nonoccluding thrombus and infarction areas in spleen and left kidney. At the emergency department he presented with recurrent symptoms, losing bilateral posterior tibial pulses. A decision was made to perform a thoracoretroperitoneal incision. A longitudinal sequential aortotomy was performed in the distal thoracic and infrarenal aorta, and the thrombus was easily removed. Following this, he underwent bilateral crural thrombectomy and local intra-arterial thrombolytic therapy. The postoperative course was uneventful. The left toes were amputated because of necrosis. He was discharged and put on antiaggregants, anticoagulants and hydroxyurea. Aortic thrombus in patients with ET is unusual, but potentially lethal. There is complete relief from symptoms in recurrent cases following surgery. An appropriate medical treatment after intervention must be supported.

Aneurisma de aorta torácica con cuello distal corto: técnica para aumentar la zona de sellado. A propósito de un caso / Aneurysm of the thorqacic aorta with a short distal neck: a technique to increase the sealing zone. A case report

Objetivo. Describir la experiencia personal inicial con una técnica para conseguir aumentar la zona de selladodistal de las endoprótesis en el tratamiento endovascular de aneurismas de aorta torácica (AAT) con cuello distal corto,aprovechando los 4 mm distales festoneados de la endoprótesis Gore TAG. Caso clínico. Mujer de 63 años, con antecedentesde hipertensión arterial, diabetes mellitus, cardiopatía isquémica y dislipidemia. Intervenida de apendicectomíae histerectomía. Con seguimiento en consulta externa de cirugía vascular por AAT, con crecimiento rápido de 15 mmen un año, motivo por el que se decide el tratamiento. En angio-TC toracoabdominal: AAT 50 mm de diámetro máximo.Cuello proximal de 35 mm de longitud y distal hasta el tronco celíaco de 10 mm. Técnica quirúrgica: con anestesia generaly protección medular (drenaje de líquido cefalorraquídeo), se procedió a la cateterización del tronco celíaco con balónde 2,5 mm vía transfemoral derecha e implantación de dos endoprótesis tipo Gore TAG de 28 × 15 y 31 × 15, respectivamente,por vía ilíaca izquierda a través de una prótesis de dacrón de 8 mm suturada terminolateral a ésta. En el seguimientocon angio-TC, al año se comprueba la correcta exclusión del aneurisma, sin evidencia de fugas periprotésicas,con permeabilidad del tronco celíaco. Conclusiones. La técnica de tutorización de los troncos viscerales mediante infladointraluminal de balón de angioplastia no sólo asegura su preservación durante el despliegue de la endoprótesis torácica,sino que además permite, de una forma segura, aumentar la zona de sellado distal en AAT con cuellos distales cortos(AU)

Aim. To describe our initial personal experience with a technique for increasing the distal sealing zone ofstent-grafts in the endovascular treatment of thoracic aortic aneurysms (TAA) with a short distal neck, by takingadvantage of the 4 mm scalloped flare at the distal end of the Gore TAG endoprosthesis. Case report. A 63-year-oldfemale with a history of arterial hypertension, diabetes mellitus, ischaemic heart disease and dyslipidaemia. The patienthad undergone an appendectomy and a hysterectomy. She was also attending the vascular surgery outpatientdepartment to follow up a TAA with a rapid growth rate of 15 mm per year, which is what led to the decision being takento treat it immediately. In a thoracoabdominal CT-angiography scan: TAA with a maximum diameter of 50 mm.Proximal neck with a length of 35 mm and distally, to the celiac trunk, 10 mm. Surgical technique: with generalanaesthesia and spinal cord protection (cerebrospinal fluid drainage), the celiac trunk was catheterised with a 2.5-mmballoon via right transfemoral, and placement of two 28 × 15 and 31 × 15 Gore TAG type endoprostheses, respectively,via the left iliac through an 8-mm Dacron graft that was sutured end-to-side to it. In the next CT-angiography scan atone year, the aneurysm was seen to be correctly excluded, with no evidence of periprosthetic leaks, and patency in theceliac trunk. Conclusions. The technique of tutoring the main visceral arteries by inflating an intraluminal angioplastyballoon not only ensures their preservation during deployment of the thoracic endoprosthesis, but also makes it possibleto safely increase the distal sealing zone in TAA with short distal necks(AU)

Fracaso hemodinámico de bypass venoso infrainguinal por fístula arteriovenosa tras trombectomía / Haemodynamic failure of an infrainguinal venous bypass due to arteriovenous fistula following a thrombectomy

Introducción. El desarrollo de una fístula arteriovenosa tras embolectomía o trombectomía es infrecuente, peropuede suponer un riesgo para la viabilidad de la extremidad. Caso clínico. Varón de 75 años de edad que presentó unaoclusión de bypass femoropoplíteo en la tercera porción con la vena safena in situ en el postoperatorio inmediato; se realizótrombectomía del mismo e interposición de un segmento de la vena safena invertida en el tercio distal, y se recuperaronpulsos distales. En la primera revisión se objetiva un fracaso hemodinámico del bypass, con índice tobillo/brazo de0,5. El eco-Doppler muestra bypass permeable con flujo bifásico en toda su extensión y velocidades sistólicas elevadas.En la arteriografía se detecta fístula arteriovenosa a la altura del tercio medio de la arteria peronea, y se realiza tratamientoendovascular de la misma. Conclusión. El diagnóstico precoz de este tipo de complicaciones es importante. Eltratamiento puede realizarse de forma efectiva mediante técnicas endovasculares

Introduction. Development of an arteriovenous fistula following an embolectomy or thrombectomy isinfrequent, but can put the viability of the limb at risk. Case report. A 75-year-old male who presented an occlusion ofa femoropopliteal bypass in the third portion with the saphenous vein in situ in the immediate post-operative period; athrombectomy and placement of the segment of the inverted saphenous vein in the distal third were performed, and distalpulses were recovered. In the first control examination, haemodynamic failure of the bypass was observed, with anankle-brachial index of 0.5. A Doppler ultrasound recording showed the bypass to be patent with a two-phase flow alongthe whole of its length and high systolic velocities. An arteriography revealed an arteriovenous fistula in the middle thirdof the peroneal artery, which was treated by endovascular methods. Conclusions. An early diagnosis of this type ofcomplications is important. Treatment can be performed effectively by means of endovascular techniques

Pseudoaneurisma de la arteria poplítea como complicación de la cirugía de prótesis de rodilla: tratamiento endovascular / Psudoaneurysm in the popliteal artery as a complication in knee prosthesis surgery: endovascular treatment

Introducción. Las complicaciones vasculares como consecuencia de la cirugía de rodilla son poco frecuentes,pero pueden derivar en una importante morbilidad. Caso clínico. Mujer de 71 años obesa e hipertensa, que acudió a Urgenciasquince días después de una artroplastia total de rodilla derecha por persistencia de dolor, edema y hematomaen pantorrilla derecha. En la exploración presentaba edema duro en el miembro inferior derecho, con hematoma en elhueco poplíteo y la pantorrilla y pulso poplíteo expansivo. Se realizó eco-Doppler arterial y venoso del miembro inferiorderecho en el que se observó pseudoaneurisma de arteria poplítea con trombosis de vena poplítea asociada. Se trató concarácter de urgencia mediante abordaje femoral ipsilateral, arteriografía y colocación de stent recubierto. Control arteriográficoinmediato: exclusión del pseudoaneurisma con permeabilidad del stent recubierto. Se anticoaguló a la pacientedurante tres meses como tratamiento de la trombosis venosa poplítea asociada. Posteriormente se suspendió la anticoagulaciónoral y se continuó con tratamiento antiagregante. Seguimiento mediante eco-Doppler, con permeabilidadprimaria del stent recubierto a los 12 meses, siendo posible una amplitud de flexión de rodilla derecha de 120º. Conclusiones.La presencia de lesiones vasculares después de una cirugía de artroplastia de rodilla se debe tener siempre encuenta ante la persistencia de hematoma, dolor y edema en la fosa poplítea. El tratamiento mediante stents recubiertospermite minimizar las complicaciones asociadas al tratamiento quirúrgico, presentando una alternativa adecuada a cortoy medio plazo

Introduction. Vascular complications as a consequence of knee surgery are rare, but can result in a high rateof morbidity. Case report. A 71-year-old female with obesity and hypertension who visited the Emergency departmenttwo weeks after a total arthroplasty on her right knee because of persistent pain, oedema and haematoma in the rightcalf. Examination revealed a hard oedema in the right lower limb, with a haematoma in the popliteal fossa and calf, andan expansive popliteal pulse. Arterial and venous Doppler ultrasound recording was performed on the right lower limband results showed a pseudoaneurysm of the popliteal artery associated with thrombosis of the popliteal vein. Urgenttreatment was established by an ipsilateral femoral approach, arteriography and placement of a covered stent. Immediatearteriographic control: exclusion of the pseudoaneurysm with patency of the covered stent. The patient was put on anticoagulant therapy for three months as treatment for the associated popliteal vein thrombosis. Oral anticoagulation therapy was later withdrawn and treatment continued with antiaggregating agents. Follow-up with Doppler ultrasoundshowed primary patency of the covered stent at 12 months, and the patient was capable of bending the right kneethrough 120º. Conclusions. The presence of vascular lesions after knee arthroplasty surgery must always be considered in the presence of persistent haematoma, pain and oedema of the popliteal fossa. Treatment using covered stents makes it possible to minimise the complications associated with surgical treatment, and thus represents a suitable short and medium-term alternative (AU)

Pseudoaneurisma de carótida común tras la canalización de la vena yugular interna / Pseudoaneurysm in the common carotid artery following cannulation of the internal jugular vein

Introducción. Los pseudoaneurismas de la arteria carótida son una complicación poco frecuente de la canalización de la vena yugular interna. El incremento de pacientes incluidos en diálisis ha conllevado el aumento de canalizaciones de catéteres de doble luz en dicha vena, y con ello la aparición de pseudoaneurismas carotídeos tras punción venosa; ésta es la complicación posterior a la canalización de la vena yugular interna más frecuentemente publicada. Caso clínico. Mujer de 25 años de edad, en diálisis, con un pseudoaneurisma de arteria carótida común derecha tras la canalización de la vena yugular interna. La lesión apareció tras la retirada del catéter, y se manifestó clínicamente por crecimiento rápido y síntomas compresivos. El diagnóstico se realizó mediante eco-Doppler, tomografía axial computarizada y arteriografía, y se observó un pseudoaneurisma dependiente de la carótida común derecha situado a 1 cm del origen del tronco braquicefálico. Se trató quirúrgicamente mediante esternotomía y cervicotomía y sutura directa del ostium, con evolución posquirúrgica satisfactoria. Conclusiones. Los pseudoaneurismas de carótida tras punción de la vena yugular son poco frecuentes. Puesto que no es posible predecir su formación tras la retirada de catéter venoso, es necesaria una observación cercana y, en caso de aparición, un tratamiento temprano. Según nuestra experiencia, el tratamiento quirúrgico ofrece unos resultados buenos con una morbilidad aceptable. El tratamiento endovascular puede ser una opción para casos seleccionados

Introduction. Pseudoaneurysms of the carotid artery are an infrequent complication that may arise as a result of cannulation of the internal jugular vein. The rise in the number of patients undergoing dialysis has brought with it an increase in the number of double lumen catheters inserted into the internal jugular vein, and at the same time the appearance of carotid pseudoaneurysms following venous puncture. This is the most frequently reported complication following cannulation of the internal jugular vein. Case report. A 25-year-old female, on dialysis, with a pseudoaneurysm in the right common carotid artery following cannulation of the internal jugular vein. The pseudoaneurysm appeared after withdrawal of the catheter, and clinical symptoms included fast growth and signs of compression. Diagnosis was performed using Doppler ultrasound, computerised axial tomography and arteriography, and a pseudoaneurysm dependent on the right common carotid that originated 1 cm away from the start of the brachiocephalic trunk. It was treated surgically by means of a sternotomy and cervicotomy and direct suturing of the ostium, with satisfactory post-operative progress. Conclusions. Carotid pseudoaneurysms following puncture of the jugular vein are infrequent. Since it is not possible to predict their formation after the withdrawal of a venous catheter, close observation and, should they appear, early treatment are necessary. In our experience, surgical treatment offers good results with an acceptable rate of morbidity. Endovascular treatment may be an option for certain cases

Surgical treatment of distal renal artery expansive pseudoaneurysm after blunt trauma.

Renal artery pseudoaneurysms are rare after blunt abdominal trauma. Pseudoaneurysms are caused by decelerating injuries of the renal artery after major falls or car accidents. Patients may be asymptomatic for months or years, and the pseudoaneurysm may expand and rupture before diagnosis or treatment. We report a case of distal renal artery pseudoaneurysm in a 51-year-old male patient, who had had a previous trauma while playing tennis 16 months ago. It was diagnosed by consecutive computed tomography-scans demonstrating a thrombosed pseudoaneurysm of the distal right renal artery, with progressive enlargement and involving persistent pain. Angiography showed right lower polar artery aneurysm and a small renal infarction due to a distal branch thrombosis. Open surgery was performed revealing a hole in a segmentary artery ostium, that was sutured with single stitches. The patient was discharged a few days late with normal renal function. Despite the development of endovascular techniques, sometimes surgical treatment is the only therapeutic alternative.

Disease progression in the contralateral carotid artery after endarterectomy.

Our objectives were to establish the incidence and progression of stenotic lesions in the contralateral carotid artery (CCA) after endarterectomy, to identify subpopulations of patients at risk of contralateral disease progression, and to evaluate the efficacy of duplex scanning surveillance at detecting these lesions. We performed a prospective study on 180 patients in whom the CCA to the operated artery was healthy or showed <70% stenosis. All patients had completed a clinical and hemodynamic follow-up program, including duplex scanning of both carotids, with sessions 3 and 6 months after surgery and then every semester until 2 years. Thereafter, examinations were scheduled according to the severity of stenosis. Mean follow-up time was 26.2 months (range 1.6-67.6). Disease progression was observed in 26 lesions (15%), nine of which (5.5%) progressed to severe stenosis (SS). Kaplan-Meier event-free rates of any disease progression were 89%, 88%, 82%, and 79% for 1, 2, 3, and 4 years, respectively. Event-free rates of progression to SS were 98%, 96%, 93%, and 90.6%, respectively, for 1, 2, 3, and 4 years. The risk of progression to SS was five times higher for stenoses that were moderate at the start of the study (p = 0.025). Severe contralateral stenoses were more common and appeared later during follow-up than ipsilateral restenoses. Progression of contralateral stenotic lesions is not uncommon and is essentially related to the presence of a moderate lesion at the start of follow-up. Indeed, moderate stenosis is a risk factor for progression to SS, which appears later and more frequently than ipsilateral restenosis. It therefore seems that patients with a moderate contralateral lesion would benefit from long-term duplex ultrasound surveillance.

Endarterectomía carotídea con anestesia locorregional. Estudio de factores clínicos y arteriográficos de riesgo de isquemia cerebral durante el clampaje carotídeo / Carotid endarterectomy with locoregional anaesthesia. A study of clinical and arteriographic risk factors for cerebral ischemia during carotid clamping

Objetivo. Determinar la relación de factores clínicos y arteriográficos preoperatorios con la aparición de intolerancia al clampaje carotideo durante la endarterectomía carotidea (EDC), que se realizó mediante anestesia locorregional, monitorizando la función neurológica del enfermo despierto. Pacientes y métodos. Estudio de cohortes clínicoprospectivo. 381 EDC con anestesia locorregional (1994-2002). Un 11,8 por ciento (n = 45) presentaba ictus homolateral previo, un 28,1 por ciento (n = 107) accidente isquémico transitorio (AI) o amaurosis homolateral y un 10,8 por ciento (n = 41) oclusión contralateral. Análisis uni y multivariante. Resultados. Un 11 (n = 42) de los pacientes presentaron intolerancia al clampaje carotídeo. La morbilidad neurológica global fue del 2 por ciento (n = 8) y la mortalidad de 0, 7 por ciento (n = 3). Factores asociados a intolerancia al clampaje carotideo: clínica neurológica previa ipsilaterales -accidente cerebrovascular (ACV), AIT o amaurosis; 15,1 frente al 8,3 por ciento; riesgo relativo (RR): 1,9; intervalo de confianza (IC) del 95 por ciento 1,13, 7, p = 0, 04- y pacientes con oclusión contralaleral y síntomas neurológicos previos ipsilaterales (28,6 frente al 10,4; RR: 3,4; IC 95 por ciento: 1,1-11,5; p = 0,04). La oclusión contralaleral de modo aislado no fue un factor de riesgo de intolerencia al clampaje (14,6 frente al 10,6 por ciento, p = 0,4). La selección de pacientes para shunt, en función de haber presentado síntomas neurológicos ipsilaterales, tiene una sensibilidad del 15,1 ?lá; para el grupo de pacientes con oclusión contralateral y síntomas ipsilaterales fue del 28 por ciento. La morbilidad neurológica en estos dos grupos de pacientes no mostró diferencias estadísticamente significativas respecto al resto de la serie. Conclusiones. La clínica ipsilateral, sobre todo asociada a oclusión contralaleral, incrementa el riesgo de intolerancia al clampaje carotideo. Este hecho no ha tenido influencia en la morbilidad neurológica ni en la mortalidad de la serie analizada. Los criterios clínicos de selección de shunt tienen poca sensibilidad para la predicción de intolerancia al clampaje carotídeo (AU)

Cirugía carotídea en pacientes de alto riesgo (no NASCET). ¿Está justificado un tratamiento alternativo? / Carotid surgery in high risk (non-NASCET) patients. Is an alternative treatment justified?

Introducción. La endarierectomía carotídea (EDAc) ha demostrado disminuir la morbimortalidad debida a la enfermedad carotidea extracraneal. Sin embargo, en los últimos años es creciente el número de autores que piensan que la angioplastia carotidea puede ser el tratamiento de elección en pacientes de riesgo elevado (AR). Objetivos. Determinar la morbimortalidad de la EDAc en pacientes que no cumplían los criterios NASCET Identificar grupos de riesgo elevado. Comparar con los resultados publicados para endoprótesis carotídea. Pacientes y métodos. Se partió de 423 EDAc (enero de 1994 a diciembre de 2002). El grupo de estudio estaba formado por 141 pacientes no NASCET. Criterios de inclusión: pacientes no NASCET y oclusión contralateral. Análisis estadístico: chi al cuadrado (p < 0, 05). Resultados. En los pacientes AR se empleó más frecuentemente anestesia general (12,1 por ciento frente al 5, 7 por ciento, p = 0,02) y shunt (22, 7 por ciento frente al 13,5 por ciento, p = 0,02). La morbimortalidad global de la serie fue del 1, 9 por ciento, sin que se encontraran diferencias entre los grupos de estudio (resto de la serie frente a no NASCET): ictus mayor (1,1 por ciento frente al 1,4 por ciento, p = 0,54). Mortalidad (1,1 por ciento frente al 0, 7 por ciento, p = 0, 59). Ictus/muerte (1, 8 por ciento frente al 2,1 por ciento, p = 0,49). En el análisis de subgrupos de riesgo se ha comprobado: a) Oclusión contralateral e ictus previo (n = 5): mayor riesgo de intolerancia al pinzamiento (60 por ciento frente al 10, 6916, p = 0, 01, RR =12, 6, IC 95 por ciento: 2-77,4); b) Cardiopatía isquémica preoperatoria (n = 130): más complicaciones cardiológicas (10 por ciento frente al 3,8 por ciento, p = 0, 01, RR = 2,6; IC 95 por ciento: 1,2-5,8), y c) Ictus previo a la cirugía (n = 69): más complicaciones neurológicas (4, 5 por ciento frente al 0, 6 por ciento, p = 0, 03, RR = 7, 9, IC 95 por ciento: 1,6-43,8); mortalidad mayor (4,5 por ciento frente al 0,3 por ciento, p = 0, 01, RR =16, IC 95 por ciento: 1,6160,9). Los resultados que se obtuvieron en nuestra serie en el grupo no NASCET (ictus/muerte: 2,1 por ciento) son similares a los que se publicaron para la endoprótesis carotídea en la mayoría de las series (1,2-1,8 por ciento). Conclusiones. El concepto de grupos de alto riesgo para la EDAc debe reevaluarse. En nuestra serie se han intervenido pacientes clásicamente considerados de alto riesgo (no NASCET), con resultados similares a los del grupo de riesgo normal. El ictus previo y la enfermedad coronaria se han asociado a mayores complicaciones tras la EDAc. Aunque los grupos anteriores son de mayor riesgo, la morbimortalidad que se registró se encuentra dentro de lo que se aconseja en la literatura médica (AU)