J.A. Brizuela Sanz

Design of a New Risk Score in Critical Limb Ischaemia: The ERICVA Model

OBJECTIVES It is difficult to establish which patients suffering from critical lower limb ischaemia will benefit from revascularization. Risk scores can provide objectivity in decision making. The aim was to design a new risk score (ERICVA) and compare its predictive power with the PREVENT III and Finnvasc scores. METHODS An observational retrospective study of patients who underwent revascularization (open or endovascular) in Valladolids University Hospital between 2005 and 2010 was designed. The sample was divided into two subgroups (development and validation subsamples). After univariate analysis followed by a multivariate Cox regression, a number of variables associated with death and/or major amputation were selected, creating a weighed score called ERICVA, and a simplified version of it. The area under the curve (AUC) of receiver operating characteristic (ROC) curve analysis was performed and the AUC of these two scores were additionally compared with the AUC of the PREVENT III and Finnvasc scales. RESULTS Six hundred and seventy two cases with an average surveillance of 778 days were included in the study. Amputation free survival (AFS) was 84.8% at 30 days and 63.1% at 1 year. Variables associated with death and/or major amputation in the Cox regression were cerebrovascular disease, prior contralateral major amputation, diabetes mellitus, dialysis, chronic obstructive pulmonary disease, cancer, haematocrit less than 30%, neutrophil/lymphocyte ratio exceeding 5, absence of arterial Doppler signal at the ankle, emergency admission, and Rutherford stage 6; these variables were used for the ERICVA and simplified ERICVA score designs. Scores were applied to both subsamples; in the development sample the AUC of ERICVA and simplified ERICVA was significantly higher than the PREVENT III (p = .008 and p = .045) and Finnvasc (p < .0001 and p = .0013) scores; in the validation sample the AUC of ERICVA and simplified ERICVA were significantly higher than Finnvasc score (p = .0323 and p = .0017). CONCLUSIONS The ERICVA model has a good predictive capacity for death and/or major amputation in the clinical setting, and is better than the PREVENT III and Finnvasc scores.

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.

Tratamiento endovascular del síndrome de vena cava superior: nuestra experiencia clínica en la última década*

Resumen Introduccion El sindrome de vena cava superior (SVCS) esta causado por una dificultad del retorno venoso debido fundamentalmente a patologia tumoral maligna, siendo menos frecuente la etiologia benigna (marcapasos, cateteres permanentes, etc.). Objetivo Revisamos nuestra experiencia en el tratamiento endovascular de este sindrome y su manejo terapeutico. Pacientes y metodos Entre 1998 y 2008 se realizaron un total de 13 procedimientos endovasculares (angioplastia transluminal percutanea y stent autoexpandible) en pacientes con SVCS, 10 (77%) de los cuales eran hombres y tres (23%) mujeres, con una edad media de 63,5 ± 13 anos (42–80). La etiologia fue en 6 casos de carcinoma de pulmon (46,2%), en un caso de carcinoma de esofago (7,6%), en tres, de metastasis en mediastino (23,1%) y otros tres con presencia de via central para tratamiento con quimioterapia (23,1%). Resultados El procedimiento endovascular fue optimo en 12 casos y se produjo migracion del stent en un caso. El abordaje fue femoral en 10 casos (77%) y braquial en 3 (23%). Once pacientes (84,6%) fueron intervenidos con anestesia local y dos (15,4%) con general por sus problemas sistemicos. Ningun paciente murio en relacion con la intervencion. La mejoria clinica fue inmediata. Durante el seguimiento a 10 anos, 7 pacientes fallecieron como consecuencia de la progresion de su enfermedad y se observaron dos recurrencias (15,4%), que se trataron con angioplastia. La tasa de supervivencia de la serie fue del 46,2%. Conclusiones El tratamiento endovascular del SVCS es un procedimiento eficaz y seguro, que proporciona una rapida mejoria en la calidad de vida del paciente y en los sintomas compresivos. El regimen de anticoagulacion optimo debe ser definido.

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.