Francisco S. Lozano

Low-Molecular-Weight Heparin Versus Saphenofemoral Disconnection for the Treatment of Above-Knee Greater Saphenous Thrombophlebitis: A Prospective Study

The objective of this study was to assess the efficacy, safety, and cost of lowmolecularweight heparin compared to saphenofemoral disconnection for the treatment of internal saphenous proximal thrombophlebitis (SPT). Eighty-four consecutive patients diagnosed as presenting SPT alone (symptoms/echo-Doppler) were divided into 2 comparable groups treated with (1) saphenofemoral disconnection under local anesthesia with a short hospital stay (n=45) or (2) prospective enoxaparin on an outpatient basis for 4 weeks (n=39). Informed consent was obtained and inclusion, exclusion, and withdrawal criteria were established. Patients were followed up at 1, 3, and 6 months. Thirty patients per group completed the study requirements. In the disconnection group, 2 patients (6.7%) presented complications of the surgical wound, 1 (3.3%) had SPT recurrence (however, there was no deep venous thrombosis), and 2 (6.7%) had nonfatal pulmonary embolism confirmed by radionuclide scan. In the enoxaparin group, there were 2 cases (6.7%) of minor bleeding (epistaxis and rectal bleeding) and 3 (10%) recurrences of SPT. In the enoxaparin group there was no case of progression of the thrombosis to the deep venous system or pulmonary embolism. The study found no statistically significant differences between saphenofemoral disconnection and enoxaparin in the treatment of SPT, but the low-molecular-weight heparin group had socioeconomic advantages.

The comparative abilities of propofol and sevoflurane to modulate inflammation and oxidative stress in the kidney after aortic cross-clamping.

BACKGROUND:Propofol has been reported to provide protection against ischemia–reperfusion injury. Nuclear transcription factor kappa B (NF&kgr;B) plays a key role in oxidative stress and the inflammatory response during ischemia–reperfusion. We compared the effect of propofol with sevoflurane on kidney NF&kgr;B expression and systemic inflammatory responses induced by aortic clamping. METHODS:Twenty piglets were divided into four groups: sham surgery group with propofol (group SP, n = 5); sham group with sevoflurane (group SS, n = 5); and suprarenal clamping for 30 min with aorta–aortic bypass under propofol (group CP, n = 5) or sevoflurane (group CS, n = 5) anesthesia. Propofol was administered at 4 mg · kg−1 · h−1 IV and sevoflurane given at 1.5% inspiratory concentration. Peripheral blood and kidney biopsies were taken before the start of surgery, 15 min after unclamping the aorta, 24, 48, 72 h, and 7 days after surgery. Plasma creatinine, myeloperoxidase, tumor necrosis factor-&agr;, interleukin 1-&bgr;; and kidney superoxide anion and superoxidase dismutase were measured. The expression of inducible nitric oxide synthase and renal tissue NF&kgr;B was measured using Western blotting. RESULTS:Compared with the CS group, animals in the CP group had lower concentrations of myeloperoxidase, tumor necrosis factor-&agr;, interleukin 1&bgr;, superoxide anion, superoxidase dismutase (P < 0.05) from 24 to 72 h after surgery and diminished NF&kgr;B expression and inducible nitric oxide synthase activity (P < 0.05) at 48 and 72 h after surgery, respectively. CONCLUSIONS:Compared with sevoflurane, propofol administration during suprarenal aortic clamping and unclamping led to modulation of markers of inflammation and decreased NF&kgr;B expression.

Laboratory investigation: Effects of propofol on the systemic inflammatory response during aortic surgery

PurposeA laboratory investigation was undertaken to assess the effects of propofol on renal function, through modulation of the systemic inflammatory response, in anin vivo experimental model of aortic surgery in comparison with sevoflurane.MethodsTwenty young male piglets were anesthetized with either propofol 4 mg·kg-1·hr-1 (n = 10) or sevoflurane 1.5% end-tidal concentration (n = 10). Animals were subjected to aorta-aortic bypass with suprarenal aortic clamping for 30 min. At specific intervals (basal -before the start of surgery; reperfusion 15 min after unclamping the aorta; at 24, 48 and 72 hr after surgery, and on the seventh day after surgery) the levels of the following were determined: plasma creatinine, renal myeloperoxidase, tumour necrosis factor-α, interleukin 1-ß, and interferon-γ; kidney superoxide anion and its detoxifying enzyme superoxidase dismutase, kidney malondialdehyde and the activity of inducible nitric oxide synthase. Seven days after surgery, the animals were anesthetized using the described techniques, and after blood withdrawal and kidney sampling they were sacrificed.ResultsIn comparison with sevoflurane, propofol was associated with a lower concentration of plasma creatinine (P < 0.05) together with lower concentrations of myeloperoxidase, tumour necrosis factor-α, interleukin 1-ß, interferon-γ, super-oxide anion and superoxidase dismutase, malondialdehyde and inducible nitric oxide synthase (P < 0.05).ConclusionIn an experimental model of aortic reconstructive surgery, and compared with sevoflurane, propofol anesthesia is associated with less neutrophil infiltration, lower plasma proinflammatory cytokine levels, lower production of oxygen free radicals, less lipid peroxidation, and reduced inducible nitric oxide synthase activity. These observations suggest a possible renal protective effect of propofol in this surgical setting.AbstractObjectifUn essai en laboratoire a été entrepris pour évaluer les effets du propofol sur la fonction rénale, à travers la modulation de la réaction inflammatoire généralisée, chez un modèle expérimental in vivo de chirurgie aortique et en comparaison avec le sévoflurane.MéthodeVingt jeunes porcelets ont été anesthésiés avec 4 mg·kg1·h-1 de propofol (n = 10) ou de sévoflurane à une concentration télé-expiratoire de 1,5 % (n = 10). Ils ont subi un pontage aorto-aortique avec clampage aortique pendant 30 min. À des moments spécifiques (au départ — avant le début de l’opération ; pendant la reperfusion 15 min après le déclampage de l’aorte ; à 24, 48 et 72 h après l’opération et au septième jour postopératoire), les niveaux suivants ont été déterminés : la créatinine plasmatique, la myéloperoxydase rénale, le facteur-α nécrosant tumoral, l’interleukine 1-ß et l’interféron-γ ; l’anion de superoxyde rénal et son enzyme de détoxification superoxydase dismutase, la malondialdéhyde rénale et l’activité de l’oxyde nitrique synthase inductible. Sept jours après l’opération, les animaux ont été anesthésiés selon les techniques décrites et, après le retrait du sang et la prise d’un échantillon rénal, ont été sacrifiés.RésultatsComparé au sévoflurane, le propofol a été associé à une plus faible concentration plasmatique de créatinine, (P < 0,05) et à de plus faibles concentrations de myéloperoxydase, de facteur-α nécrosant tumoral, d’interleukine 1-ß, d’interféron-γ, d’anion de superoxyde et de superoxyde dismutase, de malondial-déhyde et d’oxyde nitrique synthase inductible (P < 0,05).ConclusionPour un modèle expérimental de reconstruction aortique, et comparé à l’anesthésie au sévoflurane, l’anesthésie au propofol est associée à moins d’infiltration de neutrophiles, à des niveaux plasmatiques inférieurs de cytokine pro-inflammatoire, à une plus faible production de radicaux libres d’oxygène, à moins de peroxydation lipidique et à une activité réduite de l’oxyde nitrique synthase inductible. Ces observations indiquent un effet rénal protecteur possible du propofol dans ce contexte chirurgical.

Risk of recurrent venous thrombosis in patients with G20210a mutation in the prothrombin gene or factor V Leiden mutation

The impact of the G20210A prothrombin mutation, factor V Leiden and 677T mutation of methylene tetrahydrofalate reductase (MTHFR) in recurrent deep venous thrombosis (DVT) is not so clear. We have prospectively monitored 259 patients following a first episode of DVT in order to determine which factors influence the development of a recurrent event. Several clinical and biological factors together with the genetic polymorphisms of factor V Leiden, G20210A prothrombin and 677T MTHFR were assessed. During a median follow-up of 786 patient-years, 27 patients (14%) developed one objective episode of recurrent venous thrombosis. The carriers of a double defect, homozygous or double heterozygous for factor V Leiden and G20210A, had an increased risk after a first episode of DVT, while patients who were isolated heterozygous for factor V Leiden or G20210 had a risk of recurrent DVT similar to patients who had neither mutation (annual incidence of 12.1, 3.1, 2.9 and 2.8%). The 677T MTHFR mutation alone or combined with hyperhomocysteinemia was not associated with an increased risk of recurrent events. The development of proximal DVT (P = 0.01) and the presence of a double defect (P = 0.01) were the only two risk factors independently associated with a high recurrence ratio in the multivariate analysis. Thus, the annual incidence of DVT recurrence in patients without any of these two risk factors was only 0.6% (95% confidence interval, 0.2–0.9). We have identified a group of patients with DVT but at very low risk of re-thrombosis in whom an extended secondary thromboprophylaxis should be carefully considered.

Primary aortoduodenal fistula: new case reports and a review of the literature.

A primary aortoduodenal fistula (PADF) is a communication between the lumen of the aorta and that of the gastrointestinal tract at duodenal level. Unlike primary fistulas, there are other so-called secondary ones, such as the complication of a previously implanted aortic prosthesis; these are far more frequent. Since their first description some 100 years ago, more than 200 PADFs have been reported. The location between the aorta and duodenum, mainly in its third portion, caused by the evolutionary complication of an aortic aneurysm is the most common situation. Although less frequent, communications also occur between other parts of the digestive tract (esophagus, jejunum, ileum, and colon). These are caused by other reasons (infection, tumor, radiation therapy, foreign bodies, etc.). Apart from their rarity, the interest in PADFs lies in the diagnostic and therapeutic difficulties involved in their handling, which clearly affect their prognosis. In the present work, we carried out a literature search on Medline using different key words (primary, aortoenteric, aortoduodenal, aortoesophagic, aorto-enteric, aorto-duodenal, aorto-oesophageal, and a combination of these with fistula) between January 2004 and December 2006. This allowed 34 new cases to be added, which together with those from previous reviews make a total of 366 primary aortoenteric fistulas, of which 267 (72.9%) are PADFs. In this paper, we report two new cases and comment on the historical evolution of this pathology.

Home versus in-hospital treatment of outpatients with acute deep venous thrombosis of the lower limbs

BACKGROUND Some physicians are still concerned about the safety of treatment at home of patients with acute deep venous thrombosis (DVT). METHODS We used data from the RIETE (Registro Informatizado de la Enfermedad TromboEmbólica) registry to compare the outcomes in consecutive outpatients with acute lower limb DVT according to initial treatment at home or in the hospital. A propensity score-matching analysis was carried out with a logistic regression model. RESULTS As of December 2012, 13,493 patients had been enrolled. Of these, 4456 (31%) were treated at home. Patients treated at home were more likely to be male and younger and to weigh more; they were less likely than those treated in the hospital to have chronic heart failure, lung disease, renal insufficiency, anemia, recent bleeding, immobilization, or cancer. During the first week of anticoagulation, 27 patients (0.20%) suffered pulmonary embolism (PE), 12 (0.09%) recurrent DVT, and 51 (0.38%) major bleeding; 80 (0.59%) died. When only patients treated at home were considered, 12 (0.27%) had PE, 4 (0.09%) had recurrent DVT, 6 (0.13%) bled, and 4 (0.09%) died (no fatal PE, 3 fatal bleeds). After propensity analysis, patients treated at home had a similar rate of venous thromboembolism recurrences and a lower rate of major bleeding (odds ratio, 0.4; 95% confidence interval, 0.1-1.0) or death (odds ratio, 0.2; 95% confidence interval, 0.1-0.7) within the first week compared with those treated in the hospital. CONCLUSIONS In outpatients with DVT, home treatment was associated with a better outcome than treatment in the hospital. These data may help safely treat more DVT patients at home.

Surgery of vagal paragangliomas: six patients and review of literature.

BACKGROUND AND AIMS Vagal paragangliomas (VPs) represent a rare pathology in which surgery is usually recommended, but where experience is crucial to reduce the number of post-operative complications. In this study, we present our experience and a review of the literature. METHODS Between 1991 and 2006 we have treated 42 patients with 50 paragangliomas of the head and neck (26 carotid, 18 jugular/tympanic and 6 vagal). Examination of the literature (Medline and non-indexed Spanish source) from the last 30 years has revealed 23 series that each reported more than three cases; reaching a total of 332 VPs. RESULTS VPs are infrequent among paragangliomas of the head and neck (6/50) presenting clinical peculiarities such as multiple tumours, and malignant evolution. Within this current series, surgery was possible in all cases. Post-operative dysfunction in cranial nerves was frequent (the cranial X nerve was systematically sacrificed). There were no bronco-aspirations or mortalities. The literature review reveals similar results. CONCLUSION To obtain the best results, it is important that the candidates for surgery be selected by experts within multidisciplinary groups.

Postoperative Evolution of Inflammatory Response in a Model of Suprarenal Aortic Cross-clamping with and without Hemorrhagic Shock. Systemic and Local Reactions

Surgery of the abdominal aorta generates a systemic inflammatory response (SIR), a source of operative morbidity-mortality. In the present work we attempted to evaluate the evolution of SIR in an experimental model that simulates elective and urgent surgery on the abdominal aorta. Fifteen mini-pigs divided into three groups were used. The animals were subjected to suprarenal aortic/iliac clamping and bypass with a Dacron-collagen prosthetic graft. Groups were as follows: (1) sham (only aortic dissection); (2) clamping and bypass; (3) hemorrhage of 40%, pre-clamping, and bypass. Determinations included (1) tumor necrosis factor-alpha (TNF-α) interleukin (IL)-1β, IL-6, IL-10, interferon-gamma; (2) myeloperoxidase (MPO), superoxide anion (SOA), superoxide dismutase (SOD), and malondialdehyde (MDA); (3) nitrites; (4) iNOS, (5) cell adhesion molecules (ICAM-1, VCAM-1) at 24 hours, 48 hours, and on day 7; and (6) NFκB at 48 hours. Our results point to an increase in all inflammatory variables, corroborated by their molecular regulators such as the expression of CAMs, iNOS, and NFκB. The alterations tended to normalize by day 7, after reperfusion. The results point to the great importance of SIR at all levels (molecular, nuclear, cellular, and systemic) in situations such as elective and urgent abdominal aorta surgery and the role that control of this response could represent for the future of vascular surgery.

Nuevos anticoagulantes orales

Resumen Despues de realizar una perspectiva historica de los anticoagulantes, se relatan los problemas y las limitaciones de los actuales, para posteriormente hacer una clasificacion de los nuevos. El presente articulo de revision focaliza su atencion en los nuevos anticoagulantes orales. Se trata de una apuesta importante de la industria farmaceutica por unos anticoagulantes de administracion oral, inicio de actividad precoz y una diana especifica y directa anti-Xa o anti-lla. Los productos que poseen el desarrollo clinico mas avanzado son dabigatran etexilato y rivaroxaban. Se concluye que aunque los nuevos anticoagulantes orales son muy atractivos por diversas razones, todavia no sabemos cuando reemplazaran a los anticoagulantes convencionales. Cada potencial indicacion especifica requerira de nuevas y numerosas investigaciones.

Open and Endovascular Treatment for Pseudoaneurysms of the Superior Mesenteric Artery

BACKGROUND Pseudoaneurysms of the superior mesenteric artery are rare, and their natural history is characterized by their tendency to rupture, thereby leading to a high mortality rate. Compared with classic surgical techniques (open), in recent years the possibility of endovascular treatment has increased. RESULTS We report the cases of two patients with a pseudoaneurysm of the superior mesenteric artery. Each case was successfully treated in a different way: open and endovascular surgery. CONCLUSION Despite the advantages (less risk for the patient) and good results obtained with endovascular surgery, this cannot completely replace open surgery. The choice of the most appropriate therapeutic option for pseudoaneurysms of the superior mesenteric artery depends on the state of the patient and the characteristics of the lesion. Open and endovascular surgical techniques are complementary, not mutually exclusive, techniques.