Clinical predictors of major adverse cardiovascular events during long-term follow-up after carotid endarterectomy.

BACKGROUND: Those patients who undergo a carotid endarterectomy (CEA) will present a higher cardiovascular risk during follow-up than the general population. The objective of this study was to determine the prognostic factors and validate the accuracy of 3 cardiovascular risk scores as predictors of major adverse cardiovascular events (MACEs) during long-term follow-up after CEA. METHODS: Observational retrospective follow-up study with 416 CEAs conducted consecutively in 385 patients from 1994 to 2011. The primary end point was MACE, single event including myocardial infarction, stroke, and cardiovascular death. Preoperative risk factors and medical treatment at discharge were collected. A general cardiovascular risk score, the Revised Cardiac Risk Index (RCRI), was used, and 2 scores specific for CEA (Halm and Tu). Descriptive analysis and Cox regression were conducted. Informed consent from patients was obtained and approval by the ethics committee. RESULTS: The median follow-up was 4.94 years. MACEs appeared in 22.1% (95% confidence interval [CI], 18.0-26.2%) of the series during follow-up. The MACEs rate at 1 year, 3 years, and 5 years, was 3.1%, 9.3%, and 15.8%, respectively. In the Cox regression model, the MACE predictor variables were: the presence of peripheral artery disease (hazard ratio [HR], 1.69; 95% CI, 1.06-2.70) and RCRI (HR,1.61; 95% CI, 1.04-2.50). The RCRI area under the curve for predicting events, with a 2.5 cutoff point, was 0.59 with 85.9% sensitivity and a positive predictive value of 25.2%. CONCLUSIONS: Peripheral artery disease and high RCRI have an independent effect on predicting MACEs. The 3 different scores have a low ability for predicting MACEs during long-term follow-up.

Urgent endovascular treatment of a ruptured tibioperoneal pseudoaneurysm in Behçet's disease.

BACKGROUND: Behçet's disease is an autoimmune, systemic vasculitis disease that is characterized by oral aphthous and genital ulcerations and ocular lesions. Vascular manifestations in the form of aneurysms are the main predictors of mortality and morbidity in such cases. Normally, these aneurysms are located in the pulmonary arteries, the aorta, carotid, subclavia, and the femoropopliteal sector. Open surgery presents a maximum complication rate of 50%, principally in the form of anastomotic pseudoaneurysms. METHODS: We report the case of a 41-year-old man who was diagnosed with Behçet's disease 3 years before, and attended the emergency department after a 10-day history of pain and an infragenicular swelling edema in the right limb, without any previous record of trauma. RESULTS: An initial vascular exploration revealed a pusatile mass in the infrapopliteal region and absence of the posterior tibial pulse in the right limb. The rest of the exploration did not reveal any alterations. A Doppler ultrasound scan showed a ruptured infrapopliteal pseudoaneurysm. An emergency, selective arteriography of the popliteal artery was performed by using a contralateral femoral access approach, and a ruptured tibioperoneal pseudoaneurysm was embolized with three 5-mm metallic coils (Cook). The patient was discharged after 4 days and in the 2 years since then has remained asymptomatic. CONCLUSIONS: Aneurysms of the distal vessels in Behçet's disease are very infrequent and each case should be evaluated on an individual basis. Endovascular treatment is a good therapeutic alternative.

Tratamiento endovascular urgente de aneurisma esplénico roto / Urgent endovascular treatment of a rupture splenic aneurysm

Introducción. Los aneurismas de arteria esplénica (AAE) son los aneurismas viscerales más frecuentes. Su rotura provoca una mortalidad elevada. Existen técnicas endovasculares alternativas a la cirugía abierta. Se presenta un caso de AAE roto tratado de urgencia mediante embolización con coils. Caso clínico. Mujer de 58 años, con hepatopatía crónica por virus de la hepatitis C. Acudió a Urgencias por dolor abdominal de dos días de evolución. Al ingreso estaba consciente y aquejaba dolor en hipocondrio izquierdo. Constantes vitales: ritmo sinusal a 90/minuto, tensión arterial: 110/60 mmHg. Exploración vascular: normal. Hemograma: leucocitos 12.000, hematócrito 22%. Radiografía de abdomen: gran calcificación circular en hipocondrio izquierdo. Tomografía axial computarizada: hematoma retroperitoneal izquierdo. Arteriografía diagnóstica: aneurisma sacular de arteria esplénica de 8 cm. A las 3 horas de su llegada a Urgencias, se procedió a embolizar con coils los segmentos proximal y distal al aneurisma, hasta su exclusión. La paciente no tuvo complicaciones postintervención. En la angiografía de control, a las 24 horas, el aneurisma permanecía excluido. Al tercer día, tenía un mínimo relleno procedente de una colateral, que no se detectaba en el eco-Doppler previo al alta. Dos meses más tarde, la paciente continuaba bien y en una nueva angiografía el aneurisma seguía trombosado. Conclusiones. El tratamiento endovascular con coils de los aneurismas de AAE es eficaz, sin los riesgos de la cirugía abierta. Pueden obtenerse buenos resultados, incluso en situaciones de urgencia, en aneurismas rotos. La correcta exclusión del aneurisma debe comprobarse mediante imagen en sucesivos controles

INTRODUCTION. Splenic artery aneurysms (SAA) are the most frequently occurring visceral aneurysms. The mortality rate resulting from their rupture is high. A number of endovascular techniques can be used as alternatives to open surgery. We report a case of a ruptured SAA that was treated urgently by coil embolisation. CASE REPORT. Here, we describe the case of a 58-year-old female patient with chronic liver disease caused by hepatitis C virus who visited the Emergency department after a 2-day history of abdominal pain. On arrival she was conscious and suffering from pain in the left hypochondriac region. Vital signs: sinus rhythm 90/minute, arterial blood pressure: 110/60 mmHg. Vascular exploration: normal. Blood count: leukocytes 12,000, haematocrit 22%. X-ray of the abdomen: large circular calcification in the left hypochondriac region. Computerised axial tomography: haematoma in the left retroperitoneal region. Diagnostic arteriography: 8 cm saccular aneurysm in the splenic artery. Three hours after arrival at the Emergency department, coil embolisation of the segments lying proximal and distal to the aneurysm was carried out, until it was excluded. The patient had no post-operative complications. In the follow-up angiography performed at 24 hours, the aneurysm remained excluded. On the third day, she had a very small filling from a collateral vessel, which was not detected in the Doppler ultrasound recording carried out before her discharge from hospital. Two months later, the patient was still well and in a new angiography study the aneurysm was seen to be still thrombosed. CONCLUSIONS. Endovascular treatment of SAA with coils is effective and does not entail the risks involved in open surgery. Good results can be observed in ruptured aneurysms, even in urgent situations. Proper exclusion of the aneurysm must be confirmed by means of imaging techniques in later follow-ups