Impact of nutritional and inflammatory status in patients with critical limb-threatening ischemia.

BACKGROUND: A pro-inflammatory state and a poor nutritional status have been associated with severity and prognosis of patients with peripheral arterial disease (PAD). The clinical applicability of the different pre-operative nutritional and inflammatory biomarkers in patients with critical limb-threatening ischemia (CLTI) was analyzed. METHODS: A retrospective observational study was performed, that included all patients with CLTI revascularized from January 2016 to July 2019. The inflammatory state was calculated using neutrophil/lymphocyte (NLR), lymphocyte/monocyte (LMR) and platelet/lymphocyte ratios (PLR). For nutritional status, the Prognostic Nutritional Index (PNI) was calculated. Mortality and number of major amputations at 6 months and hospital length-of stay were studied. RESULTS: 310 patients were included. Higher levels of NLR and lower levels of PNI were associated with mortality (6.61±5.6 vs. 3.98±3.27, P=0.034; 40.33±7.89 vs. 45.73±7.48, P=0.05, respectively). Lower levels of PNI and LMR (42.57±7.82 vs. 45.44±7.65, P=0.036; 2.77±1.61 vs. 3.22±1.75, P=0.013, respectively) and higher levels of NLR (6.91±7.85 vs. 3.94±2.57, P=0.023) were associated with major amputations. The mean hospital length-of-stay was higher in patients with lower levels of PNI and LMR (P=0.000 and P=0.003) and higher levels of NLR and PLR (P=0.001 and P=0.002). A PNI<42.87 predicted short-term mortality with a 66.7% of sensitivity and a 66.8% of specificity (P=0.000). CONCLUSIONS: Our experience suggests that these inflammatory and nutritional biomarkers are independent predictors of short-term mortality and major amputations. In addition, our results suggest that PNI could be used to predict the short-term mortality with high sensitivity and specificity.

Celiac trunk segmental arterial mediolysis: a rare cause of arteriopathy

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Doppler Ultrasound as a Unique Diagnosis Test in Peripheral Arterial Disease.

BACKGROUND: The aim of this study was to analyze duplex ultrasound (DUS) and intraoperative angiography concordance for diagnosis of lower limb peripheral artery disease and its value for surgical planning. MATERIALS AND METHODS: This was a prospective, observational study, including patients who underwent revascularization of the lower limbs during 2018, diagnosed by DUS only or combined with preoperative computed tomography (CT) angiography. The concordance between preoperative DUS or CT angiography and the intraoperative angiography was studied using the Cohen kappa coefficient (k). The degree of agreement between the DUS-based surgical plan and the final surgical technique was also evaluated. RESULTS: Fifty-one patients were included, with mean age of 71.8 ± 11.96 years (46-94); 23 had chronic kidney disease (45%). In 17 patients (34%), preoperative CT angiography was also performed. DUS showed a sensitivity of 100% (95% confidence interval (CI) [83.3-100%]), 80% (95% CI [50.21-100%,]), and 100% (95% CI [96.43-100%]) at the iliac, femoral, and popliteal sector, respectively, and a specificity of 93.55% (95% CI [83.29-100%]), 95.45% (95% CI [84.48-100%]), and 90.48% (95% CI [75.54-100%]) at the iliac, femoral, and popliteal sector, respectively. The positive predictive value for DUS was 60% (95% CI [7.06-100%]), 88.9% (95% CI [62.8-100%]), and 87.5% (95% CI [68.17-100%]) for the iliac, femoral, and popliteal sectors, respectively, whereas the negative predictive value was 100% (95% CI [98.28-100%]), 91.3% (95% CI [77.61-100%]), and 100% (95% CI, [97.37-100%]). The concordance between DUS and intraoperative angiography showed a k index of 0.587 (P = 0.000) in the iliac sector, 0.799 in the femoral sector (P = 0.000), and 0.699 in the popliteal sector (P = 0.000). The concordance between CT angiography/intraoperative angiography had a k index of 0.71 in the iliac sector (P = 0.0093), 0.566 in the femoral sector (P = 0.006), and 0.5 in the popliteal sector (P = 0.028). DUS-based surgical plan was accurate in 86% of cases (n = 44). CONCLUSIONS: Our experience suggests that DUS arterial mapping of the femoral and popliteal areas is better than CT angiography and can be considered as a unique preoperative imaging test during the surgical planning in patients undergoing a lower limb revascularization procedure.

Celiac trunk segmental arterial mediolysis: a rare cause of arteriopathy.

A 50-year-old male patient, without a previous medical history, presented sudden severe abdominal pain with no alterations in the blood analysis. A CT-Angiography (CTA) was performed that showed a wall thickening of the celiac trunk extended to the hepatic artery with a filiform lumen and no involvement of the splenic artery. There were no signs of intestinal or liver ischemia, therefore no further radiological tests were performed. The proteinogram and serology were normal, with no immunological and acute phase reactant markers, excluding vasculitis. It appeared as an isolated lesion with no signs of arterial dissection or pseudoaneurysms of the remaining abdominal vessels or the aorta. Therefore, it was considered as a Segmental Arterial Mediolisis (SAM).

Reparación del arco aórtico mediante stent XL en Marfan / Aortic arch in Marfan syndrome repaired using the XL-stent

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Retrograde approach for endovascular salvage of an infrapopliteal vein bypass.

Endovascular treatment through femoropopliteal and infragenicular percutaneous transluminal angioplasty, both in native vessels and in bypass salvage, has been an emerging technique in recent years. However, in some cases, a difficult anterograde access in distal occlusions has limited the technical success of this procedure. Combined subintimal arterial flossing with antegrade-retrograde intervention is used as a resource technique to obtain precise recanalization in these cases. Here, we present the case of a retromalleolar access of the posterior tibial artery, based on subintimal arterial flossing with antegrade-retrograde intervention technique, to achieve femoral-posterior tibial bypass salvage.

Valor diagnóstico de la ecografía Doppler color en el control clínico de la reparación endovascular de los aneurismas de aorta abdominal / The diagnostic value of colour Doppler ultrasonography in the clinical monitoring of endovascular abdominal aortic aneurysm repair

Introducción. El control clínico del tratamiento endovascular de la enfermedad aneurismática de la aorta abdominal se basa en la valoración de la evolución del tamaño del aneurisma, la permeabilidad de la endoprótesis y la detección de fugas. Objetivo. Comparar la ecografía Doppler (ED) color con la tomografía axial computarizada (TAC) en la evaluación del tamaño del aneurisma y la detección de fugas en el tratamiento endovascular de aneurismas de aorta abdominal. Pacientes y métodos. Estudio prospectivo entre enero y diciembre de 2005. En 14 pacientes sometidos a tratamiento endovascular se realizó ED color y TAC a 1, 6 y 12 meses. Se compararon los tamaños del aneurisma mediante la prueba t para muestras dependientes y estudio de correlación. Sensibilidad, especificidad, valor predictivo positivo y valor predictivo negativo y el coeficiente de concordancia kappa se calcularon para la detección de fugas. Resultados. El control clínico medio fue de 9,4 meses y se compararon 49 exploraciones. El diámetro medio del aneurisma a los tres meses de control clínico fue de 51,2 cm con ED color y de 52,5 cm con TAC (p = no significativo). El coeficiente de correlación ascendió a 0,97 (p < 0,001). Todos los dispositivos se mantuvieron permeables. En detección de fugas, el estudio ED color obtuvo una sensibilidad, especificidad, valor predictivo positivo y valor predictivo negativo de 75, 61, 20 y 95%, respectivamente (kappa = 0,61). Conclusiones. El estudio ED color obtiene una excelente correlación con la TAC en la medida del tamaño de los aneurismas. En cambio, posee un valor predictivo positivo muy bajo para la detección de fugas

Introduction. Clinical monitoring of the endovascular treatment of aneurysmal disease of the abdominal aorta is based on evaluating the progression of the size of the aneurysm, the patency of the stent and the detection of leaks. Aim. To compare colour Doppler ultrasonography (DU) with computerised axial tomography (CAT) for evaluating the size of the aneurysm and the detection of leaks in the endovascular treatment of abdominal aortic aneurysms. Patients and methods. A prospective study between January and December 2005; colour DU and CAT scans were conducted in 14 patients submitted to endovascular treatment at 1, 6 and 12 months. Sizes of the aneurysms were compared by means of the t test for dependent samples and correlation studies. Sensitivity, specificity, predictive positive value and predictive negative value and the kappa coefficient of agreement were calculated for leak detection. Results. The mean period of clinical monitoring was 9.4 months and 49 examinations were compared. The mean diameter of the aneurysm at three months’ clinical monitoring was 51.2 cm with colour DU and 52.5 cm with CAT scanning (p = non-significant). The correlation coefficient was 0.97 (p < 0.001). Patency was maintained in all the devices. In the detection of leaks, the results of the colour DU study for sensitivity, specificity, predictive positive value and predictive negative value were 75, 61, 20 and 95%, respectively (kappa = 0.61). Conclusions. The colour DU study correlates very well with CAT in the measurement of the size of aneurysms. In contrast, it has a very low predictive positive value for the detection of leaks

Efecto de la trombosis carotídea en el comportamiento hemodinámico de la estenosis contralateral: criterios para su determinación / The effect of carotid thrombosis on the haemodynamic behaviour of contralateral stenosis: criteria for its determination

Objetivo. Comparar la precisión diagnóstica de varios parámetros hemodinámicos en la graduación de la estenosis carotídea en pacientes con oclusión contralateral. Pacientes y métodos. Se diseñó un estudio prospectivo de 76 pacientes con oclusión carotídea unilateral, en el que se correlacionaron de manera ciega los hallazgos de eco- Doppler color y arteriografía. Cada carótida se clasificó, según el grado estenótico angiográfico, en: 1-29% (n = 39), 30-49% (n = 15), 50-69% (n = 14), >= 70% (n = 8). Se consideraron cinco criterios hemodinámicos para valorar una estenosis > 50%: Universidad de Washington (estándar); AbuRahma (pico de velocidad sistólica, PSV > 140 cm/s; velocidad diastólica final, EDV 140 cm/s; EDV 1,5; y método nuevo (ratio de la ICA/CCA > 1,3; PSV > 115 cm/s). Se calcularon la sensibilidad, la especificidad, los valores predictivos positivo y negativo, el valor diagnóstico y el índice de concordancia κ. Resultados. La mejor concordancia arteriografía/eco-Doppler se dio para el método nuevo (κ = 0,59), con una precisión diagnóstica del 84,2, seguida del método estándar (que obtuvo una κ = 0,53 y una precisión de 82,8). Los métodos específicos para pacientes con trombosis carotídea unilateral (AbuRahma y Fujitani) fueron los menos eficaces, mientras que el método de la ratio presentó resultados intermedios. Conclusiones. La presencia de oclusión produce una sobreestimación o infraestimación del grado estenótico ipsilateral según los criterios clásicos admitidos. Este problema puede reducirse mediante la utilización de una ratio > 1,3 y un PSV > 115 cm/s. Para evaluar el grado de progresión de la enfermedad carotídea cada laboratorio ha de validar sus propios criterios, los cuales deben permitir diferenciar entre lesiones hemodinámicamente significativas y aquellas que no lo son (AU)

Aim. To compare the accuracy of various duplex hemodynamic criteria in grading ipsilateral carotid stenosis in patients with contralateral occlusion. Patients and methods. A prospective study was designed with 76 patients who had unilateral carotid occlusion, the results of duplex were correlated in blind fashion to arteriography. Each carotid was classified in order to the angiographic stenotic grade in: 1-29% (n = 39), 30-49% (n = 15), 50-69% (n = 14), ≥ 70% (n = 8). Five duplex ultrasonography classification criteria for discriminate > 50% stenosis were used: Washington University (standard), AbuRahma (peak systolic velocity, PSV > 140 cm/s; diastolic velocity, EDV 140 cm/s; EDV 1.5; new method (ratio ICA/ CCA > 1.3; PSV > 115 cm/s). The sensibility, specificity, positive predictive value, negative predictive value, accuracy and κ index were calculated. Results. Best concordance between angiography and duplex was for the new method, providing a κ = 0.59 and an accuracy of 84.2, followed by standard method that obtained κ = 0.53 and an accuracy of 82.8. Specific methods for patients with unilateral occlusion of ICA (AbuRahma and Fujitani) provided inferior efficacy in detecting carotid stenosis >= 50%, although the ratio method obtained intermediate results. Conclusions. The fact of having a contralateral occlusion of the ICA produces some overestimation or underestimation of the ipsilatral carotid stenosis degree following the classic criteria. This problem can be reduced using a ratio > 1.3 and a PSV > 115 cm/s. Each laboratory should perform an objective evaluation of their own criteria of diagnosis to discriminate hemodynamically significant lesions (AU)