E.M. San Norberto García

Patología venosa y linfática

Chronic venous disease is manifested by a spectrum of signs and symptoms, including cosmetic spider veins, asymptomatic varicosities, large painful varicose veins, edema, hyperpigmentation and lipodermatosclerosis of skin, and ulceration. Treatment options range from conservative (eg, medications, compression stockings, lifestyle changes) to minimally invasive (eg, sclerotherapy or endoluminal ablation), invasive (surgical techniques). Deep venous thrombosis of the lower limbs, ranges from asymptomatic, incidentally discovered emboli to massive embolism causing immediate death. Chronic sequelae of venous thromboembolism (deep venous thrombosis and pulmonary embolism) include the post-thrombotic syndrome. Diagnosis and treatment can reduce the risk of death, and appropriate primary prophylaxis is usually effective. Chronic limb swelling due to lymphedema is not only a marked cosmetic deformity but, in most patients, it is also a disabling condition. Complications can be severe and include bacterial and fungal infections, chronic inflammation, wasting, immunodeficiency, and, occasionally, malignancy.

Protocolo diagnóstico y terapéutico de la insuficiencia venosa crónica de las extremidades inferiores

The prevalence of chronic venous insufficiency (CVI) is very high. Etiologically CVI may be primary (varicose veins), or secondary (post-trombotic syndrome). The major clinical features of CVI are dilated veins, edema, cutaneous trophic lesions and venous leg ulcers. The fundamental diagnostic test of CVI is doppler ultrasound scan in deep and superficial venous system of the lower limbs. Phlebography has poor diagnostic use and is done only in complex clinical contexts. Conservative treatment involves lifestyle changes for the patient and compression stockings. Venotonic drugs have limited role to play in the symptomatic therapy. Treatment of choice for varicose veins is the venous ablative surgery either by traditional surgery (stripping of saphenous and/or phlebectomy) or radiofrequency ablation, laser or foam sclerotherapy.

Protocolo diagnóstico y terapéutico de la estenosis aterosclerótica de la bifurcación carotídea

Resumen La estenosis de carotida constituye una causa potencialmente tratable de ictus isquemico. El estudio mediante eco-Doppler esta indicado en pacientes con sintomatologia neurologica en el territorio carotideo, asi como en pacientes asintomaticos de grupos de riesgo. El control de los factores de riesgo vascular, asi como la antiagregacion plaquetaria, constituyen la base del tratamiento medico de estos pacientes. Si se indica tratamiento quirurgico, se debe confirmar el diagnostico mediante angiorresonancia, angio-TC o arteriografia. La endarterectomia carotidea sigue siendo el tratamiento de eleccion en pacientes con estenosis sintomaticas superiores al 50 % o asintomaticas superiores al 70 %. La angioplastia y el stent carotideo han surgido como una alternativa a la endarterectomia y por el momento solo estan indicados en determinadas situaciones clinicas en centros experimentados.

Patología de la aorta torácica y abdominal

Resumen El sindrome aortico agudo es una lesion de la pared aortica que afecta a la capa media. Dicho termino incluye la diseccion de aorta, el hematoma intramural y la ulcera penetrante. La coarta cion de aorta asciende al 7% de todos los defectos cardiovasculares congenitos. Los aneuris mas de aorta pueden dividirse en: toracicos, toracoabdominales, infrarrenales, yuxtarrenales y pararrenales. Los sindromes aorticos oclusivos engloban a patologias aorticas y aortoiliacas que se presentan con hipertension e isquemia visceral o de las extremidades. Causas comunes de oclusion aortica incluyen la enfermedad oclusiva aterosclerotica, la oclusion aguda aortica (embolica/trombotica/diseccion) y el sindrome aortico medio (arteritis de Takayasu, hipoplasia aortica congenita, displasia fibromuscular, neurofibromatosis). El desarrollo del tratamiento endovascular ha significado un nuevo abordaje para el manejo de estas patologias, aportando un posible mejor pronostico. El objetivo de esta actualizacion es revisar los recientes progresos en el diagnostico y el tratamiento de estos sindromes aorticos.

Isquemia aguda de las extremidades

Resumen A pesar de los avances en las terapias farmacologicas y endovasculares, la isquemia aguda de extremidades posee una morbilidad y una mortalidad significativas. Su incidencia se cifra entre 13–17 casos por 100.000 habitantes y ano, con una mortalidad aproximada del 18 % en algunas series. Esta condicion potencialmente catastrofica puede progresar rapidamente a la perdida de la extremidad y la invalidez si no se diagnostica y se trata prontamente. La evaluacion clinica incluye la valoracion del color y la temperatura de la extremidad, los pulsos y la funcion motora y sensorial. El manejo inicial depende de varios factores que incluyen la agudeza y gravedad de la isquemia, las condiciones de comorbilidad y la disponibilidad de procedimientos quirurgicos abiertos y endovasculares. Tras el restablecimiento del flujo sanguineo por estos metodos abier- tos o endoluminales es imperativo identificar y tratar la etiologia subyacente. Esta actualizacion valorara las actuales manifestaciones clinicas, diagnostico y tratamiento.

Protocolo diagnóstico y terapéutico del aneurisma de aorta abdominal infrarrenal

Infrarenal abdominal aortic aneurysm (AAA) are typically asymptomatic until the catastrophic event of ruptura. AAA rupture event is associated with an 80-90 % mortality rate. Scheduled surgery of AAA is associated with lower mortality rates (5 %). To reduce the mortality rate from ruptured AAA in men aged 65 years, abdominal ultrasonography screening is recommended. Elective surgery is indicated after the diameter of the aneurysm has reached or exceeded 5,5 cm. If the diameter of the aneurysm is such, surgical procedure is contemplated. CT is required before surgery. Elective repair of an abdominal aortic aneurysm can be carried. Elective repair of an abdominal aortic aneurysm can be carried out by open surgery or endovascular repair. Endovascular approach is associated with lower morbidity and mortality rates, but long-term imaging test assessment is required. Repair of symptomatic aneurysms should be carried out within 48 hours to prevent the imminent risk of rupture.

Síndrome de isquemia crónica de las extremidades inferiores

Chronic limb ischemia is growing in prevalence and its incidence increases with age and up to 20 % of people aged over 60. The incidence is also high in smokers, diabetes patients, and those with coronary disease. The most common initial symptom is intermittent claudication. More severe or critical limb ischaemia can present with pain at rest, ulceration, tissue loss and/or gangrene. This severe form is associated with high rates of limb loss, morbidity and mortality. A focused history should identify the presence and severity of intermittent claudication and any critical limb ischaemia. Examination should concentrate on the palpation of lower limb pulses and look for signs of critical ischaemia such as ulceration. The key primary care investigation in suspected peripheral arterial disease is measurement of the ankle brachial pressure index. Lifestyle interventions are a key component of management. Pharmacological treatment, open surgery and endovascular procedures are indicated in selected patients.