Tratamiento híbrido de arteria ciática persistente / Hybrid treatment of a persistent sciatic artery aneurysm

Introducción: la arteria ciática persistente es una variante anatómica muy poco frecuente y en la mayoría de los casos presenta síntomas clínicos debido a la degeneración aneurismática del vaso.Caso clínico:presentamos un varón de 73 años, asintomático, que presenta una arteria ciática persistente con degeneración aneurismática como hallazgo en una angio-RMN. Se realizó un tratamiento híbrido mediante embolización de la arteria ciática persistente mediante dispositivo Amplatzer™ Vascular Plug II (AVP, St. Jude Medical, Plymouth, MN) y un bypass femoropoplíteo con una prótesis PTFE. El procedimiento transcurrió sin incidencias y el paciente no refiere clínica un año después de la intervención.Discusión:el tratamiento híbrido en estos casos es una opción sencilla que puede reducir la morbilidad quirúrgica del tratamiento quirúrgico convencional.(AU)

Introduction: a persistent sciatic artery is a very rare anatomic condition with frequently associated symptoms related with the aneurysmal degeneration of the vessel.Case report:we present a case of a 73-year-old patient with an aneurysmal persistent sciatic artery that was discovered on an MRI angiography. A hybrid surgical treatment was performed by embolization of the persistent sciatic artery using an Amplatzer™ Vascular Plug II (AVP, St. Jude Medical, Plymouth, MN) and a femoropopliteal bypass with a PTFE prosthesis. The procedure was uneventful and the patient reported no symptoms one year after the intervention.Discussion:hybrid treatment in these cases is a simple option that can reduce the surgical morbidity of conventional surgical treatment.(AU)

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.

Development of a Telemetric System for Postoperative Follow-up of Vascular Surgery Procedures: In Vitro Model.

BACKGROUND: Because of the unique electromagnetic characteristics of the magnetoelastic microwire, the changes in the pressure of a fluid will provoke a variation of the mechanical pressure on the sensor, which will cause a variation of its magnetization that will be detectable wirelessly. Thus, a wireless system can be developed for following up vascular surgery procedures. METHODS AND RESULTS: The sensor consists of a magnetoelastic microwire ring, which was integrated into an in vitro model with pulsatile flow. Different degrees of stenosis were simulated in different locations both in bovine artery as well as in a polytetrafluoroethylene anastomosis. A Fourier analysis of the registered signals and a statistical analysis using Pearson test and receiver operating characteristic (ROC) curves were made. A Pearson index of 0.945 (P<0.001) was obtained between the invasive pressure of the fluid and the power of the signal transmitted by the sensor in bovine artery. The sensor obtained very good ROC curves upon analyzing the signals registered, both in the case of preanastomotic stenosis (area under the curve [AUC], 0.98; 95% CI, 0.97-1.00), of anastomosis (AUC, 0.93; 95% CI, 0.86-0.99), as well as distal (AUC, 0.88; 95% CI, 0.79-0.98), compared to the control group. CONCLUSIONS: The magnetoelastic microwire has shown that it is capable of detecting, locating, and quantifying the degree of stenosis in bovine artery, as well as in a latero-terminal anastomosis, with a high statistical potency. For the first time, a wireless in vitro sensor has been developed for the postoperative follow-up of vascular surgery procedures.

Systematic nasogastric tube in aortic surgery: is it necessary?

BACKGROUND: Routine nasogastric tube (NGT) decompression has been traditionally used to prevent nausea and vomiting after abdominal surgery. Besides, many studies having demonstrated no benefits derived from this practice after an elective laparotomy, little evidence has been published regarding its use in aortic surgery. In this study, we analyze the effects of the selective use of the NGT in patients undergoing infrarenal aortic surgery in our center. METHODS: Prospective cohort study including patients who underwent elective infrarenal aortic surgery between January 2011 and December 2012. Patients were prospectively included in group A (systematic NGT placement) and group B (nonsystematic NGT). The main end point was the occurrence of postoperative nausea and vomiting (PONV). Secondary end points were postoperative complications, time to first oral intake, and hospital stay. RESULTS: One hundred patients were finally included in the study, 50 patients per group. Preoperative and intraoperative data were similar between both groups. Higher incidence of PONV (48% vs. 10%; relative risk, 2.4; 95% confidence interval [CI], 1.3-4.5; P = 0.003) was observed in group A. Selective NGT behaved as a protective factor regarding earlier first oral intake in first postoperative 48 hours (hazard ratio, 0.67; 95% CI, 0.45-0.99; P = 0.05). There were no differences in other adverse events although a trend toward fewer respiratory complications was observed in patients with nonsystematic NGT. CONCLUSIONS: This study demonstrates higher incidence of PONV and longer time to first oral intake in patients with systematic NGT with no benefits derived from this practice. Based on these results, selective NGT decompression should be encouraged in patients undergoing infrarenal aortic surgery.

Comparison of popliteal artery aneurysm therapies.

OBJECTIVE: Surgical treatment of popliteal artery aneurysms (PAAs) has advanced over time. Constant development of new endovascular techniques has converted these into the most attractive methods available today. However, results for each endovascular procedure are still limited, and available data have emerged from studies examining only a small number of cases. The present retrospective review was designed to examine early and late results for PAA treatment and to identify possible factors associated with graft patency. METHODS: This was a retrospective review of all PAAs treated from January 1993 to December 2013. Symptomatic and asymptomatic PAAs >2 cm treated using open surgery or an endovascular procedure were included. Kaplan-Meier curves and the Breslow test were used to analyze data. RESULTS: A total of 171 aneurysms were treated in 142 men (mean age, 69.3 years); of these, 53.3% were asymptomatic and 18.7% presented as acute ischemia. Saphenous vein was used for bypass in 57.9% of the patients, expanded polytetrafluoroethylene (ePTFE) in 23.4%, and a stent graft in 18.7%. In the open surgical group, a popliteal-popliteal bypass was performed in 37.4% and a distal anastomosis to a tibial vessel was required in 14.4%. Good runoff (two to three vessels) was present in 69%. Perioperative mortality (30 days) was 1.8%. Of eight early occlusions recorded, five (2.9%) underwent reoperations. Major amputations were needed in five patients (all with previous acute ischemia). Median follow-up for the entire cohort was 49 months (range, 1-228 months). Primary and secondary patency rates at 24, 36, and 60 months were 76.3% and 89.5%, 73.4% and 87.4%, and 68.3% and 80.9%, respectively. Popliteal-popliteal bypasses showed better primary patency at 24 months when saphenous vein was used vs ePTFE (94.9% vs 79%; P = .04); however, similar patency rates were recorded for short ePTFE bypasses and stent grafts (79% vs 79.7%). On multivariate analysis, only poor runoff emerged as an independent factor for worse primary patency (hazard ratio, 3.5; 95% confidence interval, 1.7-7.2; P = .001). CONCLUSIONS: The open repair of PAA offers good long-term results, especially in asymptomatic patients, those undergoing elective surgery, and those showing good runoff. Given the also good midterm outcomes of endovascular treatment, this may be a feasible option in selected patients.

Endovascular treatment of external iliac artery occlusive disease: midterm results.

PURPOSE: To report midterm outcomes for endovascular treatment of external iliac artery (EIA) occlusive disease and assess possible factors affecting patency. METHODS: A retrospective analysis was conducted of 99 consecutive patients (91 men; mean age 67.3 years) with claudication (n=70) or critical limb ischemia (n=29) owing to occlusive EIA disease treated at our center from January 2005 to June 2012. The majority of lesions (79/108) were TASC A/B. Lesions were a mean 42.2 mm long (range 10-125); 43/108 affected the distal third of the EIA. Balloon angioplasty alone was performed in 7 limbs, while the remaining 101 lesions were stented (65 self-expanding, 24 balloon-expandable, and 12 covered). Clinical and hemodynamic follow-up was performed at 1, 3, 6, and 12 months after therapy and yearly thereafter. The factors examined were procedure characteristics and patency rates. RESULTS: Over a median follow-up of 27.5 months (range 1-89), there were 2 (1.9%) early occlusions followed by a successful reintervention, 4 late occlusions, and 5 hemodynamic failures followed by 7 reinterventions. These events led to primary and secondary patency rates at 30 months of 89.7% and 94.1%, respectively. No differences in patency rates were detected according to age, clinical state, or comorbidity. Use of covered stents (p=0.006) was the only variable associated with lower primary patency rates. CONCLUSION: Endovascular therapy to treat TASC A/B lesions of the EIA yielded good short and midterm patency and low early morbidity and mortality. Lesions involving the distal third of the EIA treated by simple angioplasty ± stenting fared worse. No clinical factors could be correlated with patency.

Cystic adventitial degeneration of the popliteal artery: report on 3 cases and review of the literature.

BACKGROUND: Cystic adventitial disease (CAD) is a rare, nonatherosclerotic vascular condition predominantly seen in middle-aged men with no cardiovascular risk factors. Three cases have been diagnosed and treated in our institution during the past 8 years. The purpose of this report is to provide an updated literature review of this condition with the addition of 3 new cases. METHODS: Information about 3 new cases is presented along with data obtained from articles published between 1979 and 2012 from PubMed and Embase databases. Two hundred thirty-eight articles were found, and 98 were included in our review. RESULTS: All patients treated presented with rapidly progressive intermittent calf claudication. Diagnosis of CAD was confirmed by at least 2 imaging techniques, either duplex ultrasound or magnetic resonance imaging, with a preoperative angiography performed in all cases. Wall cyst resection was performed in the 3 cases reported here, after intraoperative confirmation that there was no arterial wall damage. All patients remained asymptomatic with no signs of recurrence after a median 36-month follow-up (24-60 month follow-up). CONCLUSIONS: CAD is a rare vascular condition usually affecting arteries that presents as a sudden onset of unilateral intermittent calf claudication. Diagnosis must be confirmed with imaging techniques, such as duplex ultrasonography and magnetic resonance imaging. On the basis of existing knowledge, surgery remains the treatment of choice, with cystic evacuation in cases with no arterial wall damage or resection and grafting. However, the follow-up algorithm for treated patients remains unclear.

¿Está justificado el seguimiento ecográfico de las fístulas arteriovenosas protésicas húmero-axilares para hemodiálisis? / Is ultrasound follow-up necessary in humero-axillary prosthetic arteriovenous fistulas for haemodialysis?

Objetivo: Evaluar el impacto de una consulta específica de accesos vasculares (C-FAV) con seguimiento intensivo en la permeabilidad de las fístulas húmero-axilares. Pacientes y método: Estudio retrospectivo. Entre enero de 2005 y diciembre de 2009 se realizan 108 fístulas húmero-axilares. Desde junio de 2007 se establece una C-FAV. Se realiza eco-doppler preoperatorio y seguimiento posterior al mes de la intervención y, después, cada 3 meses. Resultados: Se analizan las permeabilidades de 57 fístulas húmero-axilares realizadas desde junio de 2007 hasta diciembre de 2009 (grupo C-FAV), comparándolas con 51 realizadas durante los 30 meses previos (grupo control). No se encontraron diferencias en la permeabilidad obtenida entre ambos grupos a 12 y 24 meses, con una permeabilidad secundaria a los 12 meses de 49% en el grupo C-FAV y 52% en el grupo control. El porcentaje de pacientes reintervenidos fue inferior en el grupo C-FAV (35%) que en el grupo control (67%), p = 0,002. La media de reintervenciones realizadas por paciente fue menor en C-FAV que en grupo control (0,49 vs. 1,18, p = 0,01). Los pacientes del grupo C-FAV presentaron un menor número de reintervenciones por obstrucción frente al grupo control (0,42 vs. 1,04, p = 0,01). Conclusiones: En nuestra experiencia, el seguimiento intensivo no ha mejorado la permeabilidad de las fístulas húmero-axilares, disminuyendo no obstante las reintervenciones por obstrucción. El seguimiento de estos accesos debe ser clínico basado en datos de hemodiálisis, quedando la valoración ecográfica para aquellos casos con sospecha de malfunción (AU)

Aim: To evaluate the impact of a specific vascular access (arteriovenous fistula) unit (AVF-U) and intensive follow-up controls on the patency of humero-axillary fistulas (Hax-AVF). Patients and method: Retrospective study. Between January 2005 and December 2009, 108 Hax-AVF were implanted. From June 2007 an AVF-U was established. A preoperative Doppler ultrasonography analysis was performed and a follow-up control carried out a month after the intervention and subsequently every 3 months. Results: An analysis was made of the patency of 57 Hax-AVF performed between June 2007 and December 2009 (AVF-U Group), in comparison to 51 interventions performed during the previous 30 months (Control Group). No differences in the patency achieved were found at 12 or 24 months, with a secondary permeability at 12 months of 49% in the AVF-U Group and 52% in the Control Group. The percentage of patients needing to be reoperated was lower in the AVF-U Group (35%) than in the Control Group (67%) (P=.02). The mean number of re-operations per patient was lower in the AVF-U Group than in the Control Group (0.49 vs 1.18; P=.01). The patients of the AVF-U Group underwent fewer reoperations for obstruction as compared to the Control Group (0.42 vs 1.04; P=.01). Conclusions: In our experience, the intensive follow-up controls did not improve the patency of the Hax-AVF, although reoperations due to obstruction did diminish. The follow-up of these fistulas should be clinically based on haemodialysis data, leaving ultrasound evaluation for those cases where AVF failure is suspected (AU)