CUSUM analysis of brachial artery access for peripheral endovascular interventions.

AIM: Evaluate efficacy and safety of diagnostic and therapeutic endovascular interventions performed through transbrachial approach. Transbrachial artery catheterization has long been considered a secondary access site due to its related complication rate (7-11%). Low-profile and long-delivery endovascular systems, however, are reviving the interest in this approach. METHODS: We retrospectively analysed all endovascular interventions attempted through a brachial artery access from 2003 to 2010. Two hundredth thirty seven consecutive patients (mean age 68.5 years, 89.5% male) underwent 168 transbrachial diagnostic (70.9%) and 69 therapeutic procedures (29.1%), characterised by micropuncture access (100%), 4-to-7 Fr sheath delivery systems and final digital compression (100%). CUSUM curves were created to evaluate learning effects and quality of care. RESULTS: All but one procedure were completed according to their scheduled intention. The overall complication rate was 5.5% (5 pseudoaneurysms (2.1%), 4 transient ischemic attack (1.7%), 3 brachial artery thromboses (1.3%) and 1 cardiac tamponade (0.4%). Surgical intervention was required in four of these patients (30.8%). No significant differences were observed according to age or sex. CUSUM curves created at a 2% theoretical risk showed two statistically significant upward inflections: one early in the series associated with diagnostic procedures (P=0.043) and another at the end of the study related to therapeutic interventions (P=0.018). CONCLUSION: Transbrachial catheterization is an effective and relatively safe access site for endovascular procedures. Its complication rate, although lower than before, still deserve it as a secondary access site. CUSUM curves let identify learning effects in diagnostic and interventional procedures.

Cambios en la práctica clínica tras la introducción de los filtros de vena cava retirables / Changes in clinical practice after the introduction of removable inferior vena cava filters

Objetivos: Evaluar si la introducción de filtros de vena cava (FVC) retirables en nuestra institución ha comportado variaciones en el número de implantes, indicaciones o complicaciones inmediatas. Material y métodos: Pacientes consecutivos (n=88; edad media 68; varones 46%) con TVP (n=27, 30,7%), TEP (n=22, 25%) o ambos (n=39, 44,3%), en quienes se implantó un FVC por cirujanos vasculares entre 1996-2011. A partir de 2004 todos los FVC fueron potencialmente retirables (Optease/Cordis). Indicaciones: TVP/TEP recurrente/progresivo con anticoagulación correcta (n=22, 25%), TVP/TEP con contraindicación para anticoagulación (n=47, 53,4%), o retirada de anticoagulación tras TVP/TEP por cirugía mayor (n=19, 21,6%). Resultados: Se implantaron 88 FVC: 33 permanentes (20 Venatech-LGM/Braun, 13 Trapesase/Cordis) y 55 retirables (Optease/Cordis). Desde la introducción de los FVC retirables, han aumentado un 40% los implantes, las indicaciones por retirada de anticoagulación tras TVP/TEP para cirugía mayor (p=0,001), y disminuido las indicaciones por TVP/TEP recurrente/progresivo (p<0,001). No se retiraron 31 (65%) de los FVC retirables con indicación supuestamente temporal (n=48), siendo más probable la retirada si se implantaba por cirugía mayor (p<0,001) y menos si era por TVP/TEP recurrente/progresivo (p=0,06). No hubo complicaciones inmediatas asociadas al procedimiento. Conclusiones: La disponibilidad de FVC retirables ha comportado un aumento del número de implantes, sobre todo en pacientes con TVP/TEP en los que debe suspenderse la anticoagulación por cirugía mayor y en los que probablemente antes se demoraba esta hasta pasada la fase aguda del TEP/TVP. A pesar de que los FVC retirables son igualmente seguros a corto plazo, un porcentaje relevante de estos con supuesta indicación temporal no son finalmente retirados, por lo que no debería liberalizarse su indicación(AU)

Objectives: To assess whether the introduction of removable inferior vena cava filters (VCF) has led to variations in the number of implants, indications, and immediate complications in our hospital. Materials and methods: The study included consecutive patients (n=88, mean age 68 years, males 46%) with DVT (n=27, 30.7%), PE (n=22, 25%) or both (n=39, 44.3%) who had a VCF implanted by vascular surgeons between 1996-2011. Since 2004 all VCF were potentially removable (OptEase / Cordis). Indications DVT / PE recurrent / progressive with proper anticoagulation (n=22, 25%), DVT / PE with contraindication to anticoagulation (n=47, 53.4%), or removal of anticoagulation after DVT / PE for major surgery (n=19, 21.6%). Results: A total of 88 VCF were implanted: 33 permanent (20 Venatech-LGM/Braun, 13 Trapesase / Cordis), and 55 removable (OptEase / Cordis). Since the introduction of removable VCF, the number of implants increased by 40%, indications for anticoagulation after withdrawal of DVT / PE for major surgery increased (P=0.001) and the indications for DVT / PE recurrent / progressive (P<.001) decreased. Thirty-one (65%) of supposedly temporary VCF (n=48) were not removed. Removal was more likely if implanted in surgery (P<0.001) and less if it was for DVT / PE recurrent / progressive (P<0.06). There were no immediate complications associated with the procedure. Conclusions: The availability of removable FVC has resulted in a higher number of implants, especially in patients with DVT / PE where anticoagulation should be discontinued for major surgery, and probably before that it was delayed until after the acute phase of PE / DVT. Although removable VCF are equally safe in the short term, a significant percentage of those with suspected temporary indications are eventually withdrawn, so its indication should not be widened(AU)

¿Qué factores infl uyen en la predisposición terapéutica ante tratamientos de efi cacia demostrada pero discreta? El caso de la revascularización en la estenosis carotídea grave asintomática / Factors infl uencing the physician disposition to treat with a therapy with proven but low effi cacy: The case of endarterectomy for severe asymptomatic carotid stenosis

Objetivo. Considerar como “clínicamente relevante” una terapéutica de efi cacia demostradapero —cuantitativamente— discreta puede depender, en la práctica, de factores raramenteanalizados. Se evaluó la predisposición a tratar (PT) ante un escenario teórico y “ciego” basadoen los riesgos/benefi cios de la endarterectomía en estenosis carotídeas graves asintomáticas.Sujetos y métodos. Sujetos: 100 médicos escogidos aleatoriamente de un hospital universitario(edad media: 34,6 años, 48 % varones, 54 % staff, 63 % especialidades médicas). Mediciones:cuestionario multidisciplinar estructurado, evaluando (escala visual analógica [EVA]) la infl uenciade características propias del paciente, del tratamiento o del profesional sobre la PT.Resultados. Se observó una relación lineal entre PT y menor edad del paciente (p < 0,001), menoragresividad del tratamiento (p < 0,001) y mayor soporte empírico (p < 0,001), sin apreciarsediferencias signifi cativas entre especialistas médicos y quirúrgicos. El estatus de staff y el sexomasculino se correlacionaron con los niveles más altos de PT a cualquier edad del paciente(staff + varones, p = 0,05) o agresividad terapéutica (staff, p = 0,01; varones, p = 0,025). Asimismo,infl uyeron signifi cativamente sobre la PT: a) terapéuticas con interés docente en residentes(p = 0,04); b) experiencia previa del equipo en staff (p = 0,018); c) interés científi co-técnico deltratamiento en especialistas médicos (p = 0,041); y, marginalmente, el grado de comprensión delpaciente (p = 0,061) y su catalogación como VIP (p = 0,065)(AU)

Conclusiones. La discreta rentabilidad de determinados tratamientos, como la revascularizacióncarotídea en estenosis asintomáticas, tiende a favorecer que emerjan factores contingentes enla decisión que, probablemente, serían poco relevantes en terapéuticas con un benefi cio másmarcado. La identifi cación de subgrupos de pacientes con mayor benefi cio terapéutico limitaría,con toda seguridad, la infl uencia de estos imponderables(AU)

Factors influencing the physician disposition to treat with a therapy with proven butlow effi cacy: The case of endarterectomy for severe asymptomatic carotid stenosisAbstractObjective. Considering as “clinically relevant” a therapy with proven albeit low —quantitatively—effi cacy may depend, in practice, on atypical factors. This study evaluated the predisposition totreat (PT) in a theoretical and “blind” scenario based on the benefi ts and risks associated withendarterectomy in severe asymptomatic carotid stenosis.Participants and measurements. Participants: 100 physicians randomly selected from a teachinghospital (mean age: 34.6 years, 48 % male, 54 % staff, 63 % non-surgical speciality). Measurements:structured multidisciplinary survey, based on the aforementioned scenario, evaluating (VisualAnalogic Scale) the infl uence of patient, treatment or professional characteristics on PT.Results. Linear relationships between PT and younger age of patient (p < 0.001), lower treatmentinvasiveness (p < 0.001) and higher empirical support (p < 0.001) were observed. No statisticallysignifi cant differences were observed between non-surgical and surgical specialists. Staff andmale physicians showed higher PT levels at any patient age (staff + male, p < 0.05) and treatmentinvasiveness (staff, p < 0.01; male, p < 0.025). PT levels were also infl uenced by: a) residentsfavouring treatments with higher teaching interest (p < 0.04); b) staff promoting treatmentsaccording to their personal experience (p < 0.018); c) non-surgical specialists favouringtreatments with scientifi c-technical interest (p < 0.041). The level of patient comprehension(p < 0.061) and VIPs (p < 0.065) marginally infl uenced PT(AU)

Conclusions. The proven but low effi cacy of some treatments, such as carotid endarterectomyfor severe asymptomatic stenosis, seems to be due to contingent factors infl uencing the fi naldecision to treat. The identifi cation of subgroups of patients with higher therapeutic benefi twould probably decrease the importance of those factors in clinical decision-making(AU)