C. Vaquero-Puerta

Effect of the anticoagulant therapy in the incidence of post-thrombotic syndrome and recurrent thromboembolism: Comparative study of enoxaparin versus coumarin

OBJECTIVE We evaluated the effect of long-term anticoagulant treatment (enoxaparin vs coumarin) in patients with deep venous thrombosis (DVT) as to incidence of post-thrombotic syndrome (PTS) and recurrent venous thromboembolism. We also analyzed the impact of thrombus regression after the anticoagulant treatment for these two outcomes. METHODS A prospective study was designed in which 165 patients with symptomatic, unilateral, first-episode DVT were randomized to a long-term anticoagulant treatment with coumarin or enoxaparin during at least 3 months. The rate of thrombus regression was defined as the difference in Marder score after 3 months of treatment by venography. Follow-up was performed at 3, 6, and 12 months, and yearly thereafter for 5 years. Venous disease was related to pathologic severity of PTS according to the validated scale of Villalta as rated by a physician blinded to treatment. Recurrence of symptomatic venous thromboembolism was documented objectively. RESULTS The 5-year follow-up period was completed for 100 patients (enoxaparin, 56; coumarin, 44). A lesser incidence of PTS was observed in the enoxaparin group (39.3% absent, 19.6% severe) than in the coumarin group (29.5% absent, 29.5% severe), although this difference was not statistically significant. The accumulated recurrence rate was 19.3% with enoxaparin compared with 36.6% with coumarin (P = .02). Although the mean Marder score was significantly improved in both groups (49.1% for enoxaparin vs 24.0% for coumarin; P = .016), a lower reduction in thrombus size was associated with higher clinical events of recurrence (hazard ratio = 1.97; 95% CI, 1.06-3.66; P = .032). A significant inverse correlation was also found between the degree of thrombus regression at 3 months and the incidence at 5 years of PTS (P = .007). CONCLUSIONS Residual venous thrombosis is an important risk factor for recurrent thromboembolism and PTS. A greater reduction in thrombus size was associated with lesser clinical events of recurrence and consequently a lesser rate of PTS. However, despite a greater recanalization with enoxaparin, the incidence of PTS was similar between both treatment groups, probably because of the small sample size. Further investigations are needed to clarify the implication of the anticoagulant treatment in the severity of PTS.

Fístula aortoduodenal primaria: descripción de un caso y revisión de la bibliografía

Resumen Introduccion La fistula aortoenterica primaria es una excepcional, pero devastadora, etiologia de sangrado digestivo. El ser portador de un aneurisma de aorta abdominal constituye el mayor factor de riesgo. La triada clinica clasica es hemorragia digestiva alta, dolor abdominal y masa abdominal pulsatil. La prueba diagnostica con mas utilidad es la tomografia computarizada con contraste intravenoso, a pesar de que la endoscopia se indica en los casos con sangrado digestivo. El tratamiento quirurgico con injerto sintetico in situ es la tecnica de eleccion en casos sin elevado nivel de contaminacion. La reparacion endovascular es una alternativa factible en pacientes seleccionados. Caso clinico Presentamos un caso de fistula aortoenterica primaria en el que se sospecho ruptura inminente de un aneurisma de aorta abdominal con su hallazgo intraoperatorio. Describimos las caracteristicas etiologicas y clinicas, ademas de discutir el algoritmo diagnostico actual y el papel de las nuevas tecnicas endovasculares en su tratamiento.

Prognostic Significance of an Elevated Neutrophil–Lymphocyte Ratio in the Amputation-free Survival of Patients with Chronic Critical Limb Ischemia

BACKGROUND The aim of this study was to investigate the utility of admission neutrophil-lymphocyte ratio (NLR) in predicting the amputation-free survival (AFS) of patients with critical limb ischemia (CLI) who underwent an elective infrainguinal therapeutic intervention. METHODS All patients with CLI undergoing elective infrainguinal vascular surgery (open or endovascular) at a single university teaching hospital between January 2005 and December 2009 were retrospectively identified from a prospectively maintained database. The primary end point was AFS. The cut-off of NLR >5 was used to categorize patients into low- and high-NLR groups. Kaplan-Meier analysis and long-rank test were used to compare survival between both groups. Cox regression analysis was conducted to determine independent factors affecting the AFS. RESULTS During a median follow-up of 31 months, 561 patients with chronic CLI underwent infrainguinal revascularization. Five-year mortality was lower in the NLR <5 group (33%) than in the NLR >5 group (49%) (P ≤ 0.001), and the AFS was significantly higher in the NLR <5 group (50%) than in the NLR >5 group (26%) (P ≤ 0.001). In a multivariate analysis, preoperative NLR >5 was independently associated with 5-year AFS (hazard ratio 2.325, 95% CI 1.732-3.121). CONCLUSIONS Elevated NLR predicts a worse AFS in patients undergoing infrainguinal vascular revascularization with chronic CLI, suggesting that the NLR conveys powerful prognostic information that is independent of other conventional clinical risk factors.

Shotgun wound and pellet embolism to the intracranial carotid artery

Missile embolism into the cerebral circulation is a very unusual complication of shotgun wounds to the chest or neck. We report a case of an 11-year-old boy who sustained an air gunshot wound and pellet embolism to the intracranial carotid artery. The cerebral artery pellet embolus resulted in contralateral hemiplegia. The patient was successfully treated by emergency flow reversal and embolectomy. Because this injury is extremely rare, the literature is reviewed, and several principles are suggested to improve the management.

Influencia de la presencia de Staphylococcus aureus resistente a la meticilina en las complicaciones postoperatorias y en el pronóstico de los pacientes con amputación de extremidad inferior

Fundamento y objetivo: El aumento de la incidencia y la gravedad de las infecciones es actualmente un importante problema terapeutico. Staphylococcus aureus resistente a la meticilina (SARM) se asocia a un aumento en la morbimortalidad cuando se compara con otras infecciones bacterianas; sin embargo, esta asociacion no resulta clara debido a peores condiciones de comorbilidad en los pacientes con SARM. El objetivo de este estudio fue analizar las complicaciones postoperatorias y la mortalidad asociada a la presencia de SARM en pacientes con enfermedad vascular sometidos a amputacion (mayor o menor) de la extremidad inferior. Pacientes y metodo: Pacientes consecutivos sometidos a la amputacion de la extremidad inferior en nuestro Servicio durante el ano 2004 que presentaron cultivo microbiologico positivo de la herida. Se comparo a los pacientes con SARM frente a los que tenian un germen diferente. Se evaluaron sus caracteristicas generales, la indicacion quirurgica, la microbiologia de la herida quirurgica, la tasa de reamputacion, la morbimortalidad y la estancia media. Resultados: Se amputo a un total de 117 pacientes (edad media 73 anos, 68% varones) durante este periodo. De ellos, 82 mostraron cultivo positivo y en el 30% de estos se aislo SARM. Ambos grupos fueron comparables y no registraron diferencias estadisticamente significativas en relacion con la tasa de reamputacion, morbimortalidad y estancia media. Conclusiones: La presencia de SARM no predispone a un riesgo adicional de reamputacion ni a un incremento de las complicaciones postoperatorias. Hay que realizar la vigilancia de la herida, el desbridamiento quirurgico y la antibioterapia racional en todos los pacientes amputados, con independencia de la flora bacteriana aislada.

Impacto ambiental sobre la rotura de aneurisma de aorta abdominal

IMPACTO AMBIENTAL SOBRE LA ROTURA DE ANEURISMA DE AORTA ABDOMINAL Resumen Introduccion. Los factores ambientales habitualmente se han relacionado con la rotura de aneurismas de aorta abdominal (AAA). El objetivo de este estudio es analizar su influencia con la posible estacionalidad y rotura de los AAA. Pacientes y metodos. Se diseno un estudio ecologico retrospectivo estratificado por estaciones utilizando una serie de 106 AAA rotos registrados durante el periodo 2000-2007 y confirmados mediante tomografia computarizada y cirugia. Como variables ambientales se registraron la presion atmosferica, temperatura y humedad relativa al dia de la rotura, asi como la fase lunar correspondiente a ese dia. Todos estos datos fueron facilitados y procesados por el Centro Meteorologico Regional. Resultados. La edad media de la serie fue de 73 anos (rango: 50-91 anos), con un predominio franco de varones (98,1%). La tasa de mortalidad global fue del 58,5%. Mediante un histograma de frecuencias se observo una mayor incidencia de AAA rotos en otono (32,1%). La unica variable que presento diferencias estadisticamente significativas (p

Sarcomatous degeneration of an arteriovenous malformation

Introduction: The prevalence of vascular malformations is estimated at 1.5% in the general population. Sarcomas are a rare group of mesenchymal-origin malignant tumors that accounts for less than 1% of all tumors in adults. We present one case of sarcomatous degeneration in an arteriovenous malformation of 50 years’ evolution. Material: A 60-year-old male patient was admitted to our department presenting with soft tissue infection and hindfoot bleeding in the context of an arteriovenous malformation of 50 years’ evolution and unidentified etiology. The patient had bilateral distal pulses. A 5 x 6 cm ulcerated and over-infected hindfoot lesion, with mamelonated borders that collapsed on digital pressure, was observed at the right lower limb. Methods: Diagnostic arteriography revealed a vascular formation with angiomatous nidus on the medial surface of the talotibiofibular joint, arising from the posterior tibial artery. The arteriovenous malformation was embolized, with total exclusion thereof at final control. In spite of medical treatment and dressing, bad evolution persisted, with over-infection and appearance of new mamelonated formations, and infracondylar amputation was therefore decided. Results: Anatomic pathology revealed a malignant mesenchymal neoplasm suggestive undifferentiated pleomorphic sarcoma with giant cells (malignant fibrous histocytoma of the giant cell type). The patient passed away at 3 months of diagnosis due to tumor disease dissemination. Conclusion: Sarcomatous degeneration is a rare complication of arteriovenous malformations and, since clinical suspicion is low, the diagnosis is delayed, which entails poor results on the short-term. (creativecommons.org/licenses/by-nc-nd/4.0/). Si n co nt ar c on e l c on se nt im ie nt o pr ev io p or e sc ri to d el e di to r, no p od rá r ep ro du ci rs e ni f ot oc op ia rs e ni ng un a pa rt e de e st a pu bl ic ac ió n.

Disfunción sexual tras la reparación endovascular del aneurisma de aorta abdominal infrarrenal

DISFUNCION SEXUAL TRAS LA REPARACION ENDOVASCULAR DEL ANEURISMA DE AORTA ABDOMINAL INFRARRENAL Resumen. Introduccion. La cirugia abierta de AAA (CA) se asocia con un empeoramiento de la funcion sexual. A la reparacion endovascular (EVAR) se le ha supuesto una menor incidencia de disfuncion erectil. Objetivos. Analizar la incidencia de disfuncion sexual postoperatoria en pacientes tratados de AAA mediante CA o EVAR. Material y metodos. Estudio prospectivo mediante empleo de test IIEF-5 (International Index Erectile Function) para medicion de disfuncion sexual pre y postoperatoria desde enero de 2008 hasta junio de 2009. De 182 pacientes tratados, se incluyeron 112, 47 (42,0%) CA y 65 (58,0%) EVAR. Resultados. Edad media de 70 anos (64,3 CA vs 74,7 EVAR, p=0,032). La prevalencia de impotencia preoperatoria fue elevada en ambos grupos y significativamente mayor en los tratados endovascularmente (40,5% CA vs 66,2% EVAR, p=0,017). Aparecio en 5 pacientes (22,7%) tras EVAR y en 10 (35,7%) tras CA (p>0,05). Dentro del grupo EVAR, ambas iliacas internas fueron ocluidas a 3 pacientes (13,6%) y a 10 (45,5%) una. La oclusion unilateral de arteria hipogastrica no influyo en la aparicion de impotencia (p>0,05), todas las oclusiones bilaterales sufrieron disfuncion erectil. La disfuncion del grupo EVAR fue mas severa, tanto durante el pre como en el postoperatorio. Conclusiones. La incidencia de disfuncion sexual preoperatoria de los pacientes intervenidos de AAA es elevada. El tratamiento mediante EVAR no supone una proteccion significativa frente a la aparicion de impotencia. La oclusion bilateral de arterias hipogastricas es causa de disfuncion sexual, sin que la oclusion unilateral constituya un factor de riesgo significativo. [ANGIOLOGIA 2009; 61: 295-304]

Compresión de la arteria femoral profunda por safena interna aberrante e influencia en el desarrollo de claudicación intermitente

Summary Introduction. The relationship between vascular malformations and the appearance of intermittent claudication is rare. Case report. We describe the case of a 70-year-old male, a smoker, diabetic and dyslipidemic, who visited because of intermittent claudication at short distances with occasional rest pain in both lower limbs. Following a clinical and haemodynamic examination, an arteriographic study was performed. The right common iliac artery was found to be occluded, there was stenosis of both deep femoral arteries at the origins, and bilateral femoral-popliteal obstruction was also observed. After performing a right iliofemoral bypass, a thromboendarterectomy of the left common and deep femoral arteries was carried out. An incidental surgical finding was the unilateral anomalous drainage of the internal saphenous arch in the deep femoral vein, which crossed over the artery of the same name, constricting and displacing it, thus giving rise to a certain degree of fibrosis in surrounding tissue. The arteriotomy showed a severe reduction in the calibre of the arterial lumen at this level, caused by both an increase in the atherosclerotic plaque and the intrinsic compression due to the aberrant situation of the internal saphenous artery. Conclusions. This is the first description of this anatomical malformation in the great inguinal vessels and we were also able to observe directly the probable effect on the morphological and haemodynamic factors of aetiopathogenesis in the arteriosclerotic process and, consequently, in limb ischemia. [ANGIOLOGIA 2004; 56: 587-94]

Estudio de las repercusiones arteriales de la deprivación y aporte de hormonas femeninas. Estudio experimental

Summary Introduction . It has been generally accepted that female hormones protect against the development of cardiovascular diseases and more especially with regard to the development of degenerative disorders affecting the arteries. Aims . This study attempts to show the relationships between the hormonal component and the artery wall, and evaluates them from a histological and morphometric point of view. Materials and methods . We conducted an experimental study in rats using different groups of animals in order to provide an animal model in which to demonstrate the arterial repercussions of the different hormonal situations. The experimental design was structured in a number of study groups based on hormonal deprivation, followed by replacement that was implemented either pharmacologically or by means of ovarian transplant in the wall of the artery. Results and conclusions . The repercussions of hormone deprivation were not seen very clearly, but detection was possible using morphometric methods. Results show that hormone replacement neutralises the possible degenerative effects stemming from hormone deprivation. We discuss the interaction of estrogenic hormones and their involvement in the development of arterial pathologies, and the evidence that exists in the literature on this issue. [ANGIOLOGIA 2004; 56: 529-38]