Trucos y consejos para optimizar el tiempo de cateterización de arterias visceralesen dispositivos fenestrados (FEVAR) / Tips and tricks to optimize catheterization time of target vessel in fenestrated devices (FEVAR)

Introducción: el tratamiento de aneurismas complejos mediante FEVAR incluye entre sus objetivos un tiempoquirúrgico reducido para poder alcanzar el éxito técnico y clínico. Sin embargo, la canulación y el implante de losstents puente en múltiples arterias viscerales pueden suponer un factor limitante. Para evitar un tiempo de escopia y una dosis de radiación prolongados existen algunas maniobras que pueden ayudar a optimizar el tiempo de cateterización. Material y métodos: se realiza una revisión de los últimos casos tratados mediante endoprótesis fenestradas custom made de Zenith Cook® durante el año 2021 en un servicio de angiología, cirugía vascular y endovascular. El objetivo es mostrar las técnicas que sirven para optimizar el tratamiento de aneurismas complejos y que el cirujano puede emplear con el material habitual. Para ello se muestran varios fragmentos de vídeos de estos procedimientos grabados con el sistema OneView. Resultados: el primer paso clave consiste en la liberación del dispositivo fenestrado. La endoprótesis de Cook® presenta una o varias ligaduras de reducción que la mantienen fruncida hasta garantizar una correcta orientación y un correcto posicionamiento. Asimismo, ofrece la opción de canular las arterias viscerales entre la pared arterial y el dispositivo. Con una planifi cación adecuada y un abordaje sistematizado, el uso de guías coaxiales, catéteres de punta simple o reversa e introductores es esencial. El techo de la endoprótesis permite el avance de guías y de introductores con el soporte sufi ciente para su canulación. Los sistemas precargados permiten la canulación desde el miembro superior o el inferior. En este último caso, se utiliza una guía buddy de 0,014" que ofrece soporte al introductor, ya que lo acerca más aún a la fenestración, de tal modo que potencia el momento de torsión (torque) y el empuje del catéter.

Introduction: the treatment of complex aneurysms using FEVAR includes among its objectives a reduced surgicaltime in order to achieve technical and clinical success. However, cannulation and implantation of bridging stentsin multiple visceral arteries can be a limiting factor. To avoid a protracted scope time and radiation dose, there aresome maneuvers that can help optimize catheterization time. Material and methods: a review of the last cases treated with custom made Zenith Cook® fenestrated endoprostheses during the year 2021 is performed in an angiology, vascular and endovascular surgery service. The objective is to show video clips recorded with the OneView system of these techniques that the surgeon can use with the usual material to optimize the treatment of complex aneurysms.Results: the first key step is the release of the fenestrated device. The Cook® endoprosthesis has one or morereduction ligatures that keep it puckered until it guarantees correct orientation and positioning, as well as theoption of cannulating the visceral arteries between the arterial wall and the device.With proper planning and a systematic approach, the use of coaxial guides with single or reverse tip cathetersand introducers are essential. The roof of the endoprosthesis allows the advancement of guides and introducerswith sufficient support for their cannulation. The preloaded systems allow cannulation from the upper or lowerlimb. In the latter case, a 0.014” buddy guide is used to provide support for the introducer, bringing it even closerto fenestration in such a way as to enhance the torque and thrust of the catheter.

Applicability of Zenith p-branch Standard Fenestrated Endograft in Our Series.

BACKGROUND: In the endovascular treatment of abdominal aortic aneurysm (AAA) with short or absent infrarenal neck, the delay in the availability of fenestrated device and its high cost, have led to the manufacture of standardized models. Another option is the endografts with stents in parallel; however, regulated criteria for their use and long-term studies are lacking. The aim of this study was to assessed whether the AAA treated with fenestrated device or stents in parallel in our department, complied with the characteristics for the placement of the new endograft p-branch(®). Furthermore, the differences between the p-branch and the implanted prosthesis were analyzed. METHODS: Single-center and descriptive study of 41 aneurysms treated consecutively from 2008 to 2015. The anatomic characteristics analyzed were: relative distances between the visceral arteries, time position, diameter in the sealing area and number of fenestrations, and its compatibility with the p-branch. RESULTS: The anatomic compatibility rate with the p-branch options was 73.2% (30 cases). Of the 11 incompatible cases, 6 were due to misalignment of the visceral branches, 2 due to the aortic neck diameter being greater, another because the femoral access was inappropriate, and 2 more due to the fenestration configuration. Of the 30 cases in which compatibility existed, in 12 (40%) the configuration used coincided with the p-branch. In 13 cases, the number of fenestrations was higher than those actually used, with 23 fenestrations carried out and 39 hypothetical fenestrations with the new endograft. In the 5 remaining cases, a fenestration for the celiac trunk was necessary to achieve an adequate seal. CONCLUSIONS: The p-branch could meet the needs of three-quarters of the aortic anatomies of our series, with favorable expectations on cost and waiting time. However, in most cases either a higher number of fenestrations are needed for visceral arteries or the proximal seal was shorter than would be ideal.

Predictors of cervical bleeding after carotid endarterectomy.

BACKGROUND: The aim of this study is to determine the incidence of severe cervical bleeding requiring reintervention after carotid endarterectomy (CEA), to identify its predictive parameters, and to find out the influence of these on major complications. METHODS: This was a retrospective review of 502 CEAs carried out in 455 consecutive patients between 1995-2011 in our institution. The end points were: postoperative cervical bleeding that required reoperation and major postoperative complications (i.e., stroke, myocardial infarction, and death). Patients' demographics, antiplatelet and anticoagulant treatment, anaesthetic technique, surgical details, and perioperative management were registered. The end point predictors were univariate and multivariate analyzed. RESULTS: Neck bleeding after CEA occurred in 42 cases (8.4%), requiring reoperation in 28 cases (5.6%). In the univariate analysis, chronic anticoagulation and anticoagulation 24 hours before surgery were associated with reoperation for bleeding (16.6% vs. 4.8% [P = 0.02] and 17.8% vs. 4.7% [P = 0.014], respectively). The agent used for antiplatelet treatment before surgery was related to reoperation in the univariate analysis and was the only factor with statistical significance in the multivariate analysis: acetylsalicylic acid (ASA) 100 mg (2.4%), ASA 300 mg (1.5%), clopidogrel 75 mg (7.8%), ASA 100 mg associated with clopidogrel (3.3%), triflusal (5.5%), and ticlopidine (2.2%); there was a higher incidence of reoperation only in the group of patients who had taken clopidogrel 24 hours before CEA (4.7% vs. 1.05% [P = 0.06], respectively) but without statistical significance (odds ratio: 2; 95% confidence interval: 0.95-4.84). No reoperations were registered using vein patch compared to prosthetic patch (0% vs. 6.1% [P = 0.028]). Conversion to general anesthesia (22.2% vs. 4.9% [P = 0.014]) and noncontrollable postoperative hypertension (6.9% vs. 2.5% [P = 0.028]) were associated with a higher rate of reoperation. There were no statistically significant differences in the reoperation rates related to bleeding for anesthetic technique (local versus general), surgical procedure (classic endarterectomy versus eversion technique), type of prosthetic patch (Dacron/politetrafluoroethylene), use of shunt, intraoperative dose of heparin, protamine reversal, activated clotting time monitoring, or surgeon qualification level. The combined rate of stroke mortality was 2.6%. Reoperation for bleeding was not associated with an increased rate of thrombosis, stroke, death, or injury of cranial nerves. CONCLUSIONS: Postoperative severe bleeding after carotid surgery in our institution is not an uncommon complication. Its incidence is within the range reported in the literature, but it is not associated with major complications or mortality. Antiplatelet treatment with clopidogrel is the main risk factor associated with reintervention. Other factors, such as coagulation control, postoperative hypertension management, and the use of an autologous patch, could help reduce its incidence.

Historia natural de la estenosis carotídea de grado moderado en pacientes con enfermedad arterial periférica / Natural history of moderate-degree carotid stenosis in patients with peripheral artery disease

Fundamento y objetivo: Conocer la evolución de la estenosis carotídea moderada asintomática, losfactores que influyen en la progresión y la morbimortalidad relacionada. Pacientes y método: Estudio observacional retrospectivo de 133 pacientes con estenosis carotídea asintomática entre 50-69% en una o ambas carótidas entre 2002 y 2009. Se incluyen pacientes sometidos a cribado por enfermedad arterial periférica (EAP), patología aneurismática o soplo carotíeo. El seguimiento se realiza mediante ecodoppler anual. Se valora el grado de progresión, variables relacionadas con esta, la aparición de episodios neurológicos y mortalidad global y cardiovascular. Se ha realizado un estudio descriptivo, análisis univariante (ji al cuadrado y t de Student), análisis multivariante (regresión logística) y curvas de supervivencia (test de Log-Rank). Resultados: Con un tiempo medio (DE) de seguimiento de 30,8 (1,7) meses, se observó progresión de la estenosis en el 33% de los pacientes, con un tiempo medio de progresión de 31 3 (2,7) meses. Se registró una mayor tasa de progresión en el subgrupo de pacientes que asociaban EAP y cardiopatía isquémica (odds ratio [OR] 2,84, intervalo de confianza del 95% [IC 95%] 1,14-7,03). En el análisis multivariante tan solo la EAP se presenta como un factor de riesgo de progresión (p = 0,043). El grupo de pacientes con progresión presentó mayores tasas de episodios neurológicos (15 frente a 1,6%, p = 0,01), mayor mortalidad global (15 frente a 3%, p = 0,04) y mayor mortalidad cardiovascular (12,1 frente a 1,5%, p = 0,03). Conclusiones: La progresión de estenosis carotídea asintomática entre el 50-69% es frecuente en pacientes sometidos a cribado, especialmente en aquellos con antecedentes de cardiopatía isquémica y/o EAP. Esta progresión se asocia a una mayor tasa de complicaciones cardiovasculares. Por ello recomendamos el seguimiento clínico y ecográfico de estos pacientes (AU)

Background and objective: To understand the evolution of moderate asymptomatic carotid stenosis, the factors that influence its progression and the related morbimortality. Patients and methods: Retrospective observational study of 133 patients with asymptomatic carotid stenosis between 50-69% in one or both carotids between 2002 and 2009. Included patients were subjected to screening for peripheral arterial disease (PAD), aneurysmal disease or carotid bruit. The monitoring was carried out using an annual duplex scan. The rate of progression, the variables related to this, the appearance of neurological events, and global and cardiovascular mortality were evaluated. Descriptive studies, univariate analysis (chi-squared test and Student’s t-test), multivariate analysis (logistic regression), and survival curves (Log-Rank test) were carried out. Results: With an average time of monitoring: 30.8 1.7 months, stenosis progression was observed in 33% of the patients, with an average progression time of 31.3 2.7 onths. Greater progression was observed in the subgroup of patients with PAD and ischemic heart disease (odds ratio [OR] 2.84, confidence interval [CI] 95% 1.14-7.03). In the multivariate analysis only the PAD was identified as a risk factor for progression (P = .043). The group of patients with progression showed greater rates of neurological events: 15 vs. 1.6% (P = .01), greater global mortality: 15 vs. 3% (P = .04), and greater cardiovascular mortality: 12.1 vs. 1.5% (P = .03). Conclusions: The progression of asymptomatic carotid stenosis between 50-69% is common in patients subjected to screening, especially in those with a history of ischaemic heart disease and/or PAD. This progression is associated with an increased rate of cardiovascular complications. For this reason, we recommend clinical and echographic follow-up of these patients (AU)

[Natural history of moderate-degree carotid stenosis in patients with peripheral artery disease]. / Historia natural de la estenosis carotídea de grado moderado en pacientes con enfermedad arterial periférica.

BACKGROUND AND OBJECTIVE: To understand the evolution of moderate asymptomatic carotid stenosis, the factors that influence its progression and the related morbimortality. PATIENTS AND METHODS: Retrospective observational study of 133 patients with asymptomatic carotid stenosis between 50-69% in one or both carotids between 2002 and 2009. Included patients were subjected to screening for peripheral arterial disease (PAD), aneurysmal disease or carotid bruit. The monitoring was carried out using an annual duplex scan. The rate of progression, the variables related to this, the appearance of neurological events, and global and cardiovascular mortality were evaluated. Descriptive studies, univariate analysis (chi-squared test and Student's t-test), multivariate analysis (logistic regression), and survival curves (Log-Rank test) were carried out. RESULTS: With an average time of monitoring: 30.8 ± 1.7 months, stenosis progression was observed in 33% of the patients, with an average progression time of 31.3 ± 2.7 months. Greater progression was observed in the subgroup of patients with PAD and ischemic heart disease (odds ratio [OR] 2.84, confidence interval [CI] 95% 1.14-7.03). In the multivariate analysis only the PAD was identified as a risk factor for progression (P=.043). The group of patients with progression showed greater rates of neurological events: 15 vs. 1.6% (P=.01), greater global mortality: 15 vs. 3% (P=.04), and greater cardiovascular mortality: 12.1 vs. 1.5% (P=.03). CONCLUSIONS: The progression of asymptomatic carotid stenosis between 50-69% is common in patients subjected to screening, especially in those with a history of ischaemic heart disease and/or PAD. This progression is associated with an increased rate of cardiovascular complications. For this reason, we recommend clinical and echographic follow-up of these patients.