V. Gutiérrez

Venographic comparison of subcutaneous low–molecular weight heparin with oral anticoagulant therapy in the long-term treatment of deep venous thrombosis

PURPOSE The primary objective of this study was to evaluate with venography the rate of thrombus regression after a fixed dose of low-molecular weight heparin (LMWH) per day for 3 months compared with oral anticoagulant therapy for deep venous thrombosis (DVT). Secondary endpoints were the comparisons of the efficacy and safety of both treatments. METHODS This study was designed as an open randomized clinical study in a university hospital setting. Of the 165 patients finally enrolled in the study, 85 were assigned LMWH therapy and 80 were assigned oral anticoagulant therapy. In the group randomized to oral anticoagulant therapy, the patients first underwent treatment in the hospital with standard unfractionated heparin and then coumarin for 3 months. Doses were adjusted with laboratory monitoring to maintain the international normalized ratio between 2.0 and 3.0. Patients in the LMWH group were administered subcutaneous injections of fixed doses of 40 mg enoxaparin (4000 anti-Xa units) every 12 hours for 7 days, and after discharge from the hospital, they were administered 40 mg enoxaparin once daily at fixed doses for 3 months without a laboratory control assay. A quantitative venographic score (Marder score) was used to assess the extent of the venous thrombosis, with 0 points indicating no DVT and 40 points indicating total occlusion of all deep veins. The rate of thrombus reduction was defined as the difference in quantitative venographic scores after termination of LMWH or coumarin therapy as compared with the scores obtained on the initial venographic results. The efficacy was defined as the ability to prevent symptomatic extension or recurrence of venous thromboembolism (documented with venograms or serial lung scans). The safety was defined as the occurrence of hemorrhages. RESULTS After 3 months of treatment, the mean Marder score was significantly decreased in both groups in comparison with the baseline score, although the effect of therapy was significantly better after LMWH therapy (49.4% reduction) than after coumarin therapy (24.5% reduction; P <.001). LMWH therapy and male gender were independently associated with an enhanced resolution of the thrombus. A lower frequency of symptomatic recurrent venous thromboembolism was also shown in patients who underwent treatment with LMWH therapy (9.5%) than with oral anticoagulant therapy (23.7%; P <.05), although this difference was entirely a result of recurrence of DVT. Bleeding complications were significantly fewer in the LMWH group than in the coumarin group (1. 1% vs 10%; P <.05). This difference was caused by minor hemorrhages. Coumarin therapy and cancer were independently associated with an enhanced risk of complications. Subcutaneous heparin therapy was well tolerated by all patients. CONCLUSION The patients who were allocated to undergo enoxaparin therapy had a significantly greater improvement in their quantitative venographic score, a significantly lower recurrence rate of symptomatic venous thromboembolism, and a significantly lower incidence of bleeding than patients who underwent treatment with coumarin. LMWH can be used on an outpatient basis as a safer and more effective alternative to classical oral anticoagulant therapy for the secondary prophylaxis of selected patients with DVT.

Femoral pseudoaneurysms post-cardiac catheterization surgically treated: evolution and prognosis

OBJECTIVES To analyze the postoperative complications of patients who have undergone surgical repair of femoral pseudoaneurysm after cardiac catheterization. DESIGN Prospective study. MATERIALS Cardiovascular risk factors, related to surgery and cardiac catheterization were collected prospectively in 79 patients from 2003 to 2006 in Valladolid University Hospital. The indications of surgery included necrosis of adjacent soft tissue, rapid growth, infection, bleeding, hemodynamic instability or failure of the percutaneous treatment (US-guided compression and US-guided percutaneous thrombin injection). METHODS Patient and management related predictors for 30-day outcome were analyzed. RESULTS Fifty-six patients (56/79, 71%) experienced some type of postoperative complication, the most frequent being the need for a transfusion. Infection (15/79, 19%) and dehiscence of the surgical wound (10/79, 12.7%) were the other two most common complications. The mortality related to the intervention was 3.8% (3/79). The mean hospital stay was 32.5 days (+/-28.4 days). Significant risk factors in logistic regression model were gender (P=0.023, OR=9.66), 70 years old (P=0.049, OR=0.15) and the concurrent use of anticoagulation or antiplatelet therapy after the cardiac catheterization (P=0.005, OR=0.03). CONCLUSION Patients who undergo surgical treatment of femoral pseudoaneurysm post-cardiac catheterization experience a high postoperative morbidity and hospital stay. Factors such as female gender, age over 70 years and treatment with anticoagulants or antiplatelets increase the postoperative morbidity. A seasonal influence was appreciated, with a higher frequency during the summer period.

Coil embolization of persistent false lumen after stent graft repair of type B aortic dissection

Patent false lumen after endovascular stent graft treatment of type B aortic dissection is a predictor for late death and retreatment. Between June 2008 and March 2010, five men with patent false lumen, due to a type B dissection previously treated with thoracic stent graft, underwent endovascular coiling treatment. Within a 30-day period, there were no deaths or major complications. The follow-up duration ranged from 1 to 22 months (mean 10.6 ± 8.5). Endovascular coiling of patent false lumen after endovascular stent graft treatment for type B aortic dissection avoided the risk of rupture or death due to secondary aneurysm formation.

Clinical and haemodynamic evolution of lesions treated by means of atherectomy with SilverHawk in the femoropopliteal sector

UNLABELLED The objective of the work is to study the clinical and haemodynamic evolution, over 1 year, in patients with femoropopliteal arterial pathology treated by means of atherectomy with the SilverHawk device. MATERIALS AND METHODS Nineteen (19) patients were treated between December 2008 and May 2009, collecting data on sex, age, comorbidity and clinical degree, with prospective monitoring over 12 months of clinical symptoms, physical examination and ecodoppler, obtaining results on diameter and peak systolic velocity at different arterial levels. RESULTS Of the 19 patients, 14 were men and 5 women, with a mean age of 70 years, hypertensive (73%), diabetic (63%) and smokers (63%). Six (6) presented disabling claudication and 13 critical ischemia with advanced distal trophic lesions in 5. A good arteriographic result was obtained in 12 cases, a stent was placed on the superficial femoral artery in 5 due to suboptimal outcome. Contrast extravasation was observed in 2, with femoropopliteal bypass performed and one exclusion with endoprosthesis for repair. In the ecodoppler after 1, 3, 6 and 12 months, a progressive reduction in lumen diameter and peak intraarterial systolic velocity was observed, particularly on the distal superficial femoral artery. After one year, 7 patients (36.8%) were symptom-free, 5 (26.3%) presented mild or moderate intermittent claudication and 1 patient (5.3%) presented localised distal trophic lesion. Four (4) major amputations were performed, in 2 the knee was preserved, there were 3 thromboses due to the procedure, a secondary endovascular procedure was performed in one case and a femoropopliteal bypass in another, and there were 2 non procedure-related deaths. DISCUSSION atherectomy with SilverHawk achieves an improvement in clinical degree, with a good rate of extremity salvage in patients with critical ischemia. In the first year, the ecodoppler shows evolution of the arteriopathy, without this necessarily meaning a clinical worsening.

Open Surgical Repair and Endovascular Treatment in Adult Coarctation of the Aorta

BACKGROUND The aim of this study was to compare the results of endovascular therapy (covered stenting) with surgical technique to repair aortic coarctation in adults. METHODS A prospective study of 11 patients who were treated during the past 10 years was carried out. Of these, five patients underwent endoprosthesis (group A) and six an open surgical repair (group B). Follow-up comprised monitoring of the blood pressure, echocardiography, and computed tomography and magnetic resonance angiographic studies. RESULTS The mean age of the patients was 46 years (range: 17-67 years) and the mean follow-up was 52.6 months (range: 1-117 months; 32.3 for group A vs. 69.7 for group B; p = 0.01). Two cases in group A were recoarctations after child angioplasty. The rate of postoperative complications was 27.7% (one hemothorax for group A vs. one pneumothorax and one hemothorax for group B); however, mortality did not occur. The success rate of the endovascular technique was 80%. The stay in the intensive care unit was 2.3 days with significant differences (one group A vs. three group B; p = 0.01), whereas length of hospital stay was 11 days (7.8 group A vs. 11.83 group B; p = 0.17). The pressure gradient across the stenosis decreased by 21.9 ± 3.7 mm Hg (24.5 ± 4.3 group A vs. 33 ± 3.2 group B). Six patients (54.5%) showed persistent hypertension (80% group A vs. 33% group B), with a mean residual pressure gradient of 23.4 ± 4.3 mm Hg (22.5 ± 5.4 group A vs. 22 ± 2.1 group B; p = 0.58). CONCLUSIONS Short- and medium-term results of the endovascular therapy are similar, with shorter stay in the intensive care unit and higher necessity of antihypertensive treatment. Echocardiography and Doppler aortic coarctation gradients slightly higher than 20 mm Hg are usual during follow-up.

Subclavian Venous Aneurysm: Endovascular Treatment

Few cases of venous aneurysm involving the subclavian vein have been reported in the literature to date, and all were treated conservatively or with surgical excision. The present report describes a 73-year-old woman with a pulmonary thromboembolism that likely originated from a large right subclavian vein aneurysm that was treated by percutaneous endovascular means. The technique involved placement of a self-expanding stent in the parent vein across the aneurysm, followed by filling of the lumen of the aneurysm with coils through a microcatheter. The patient has remained symptom-free at 18-month follow-up.

Endovascular treatment of thoracic aorta injury after spinal column surgery.

A 61-year-old woman with a history of left dorso-lumbar scoliosis and severe dorso-lumbar kyphosis underwent surgical treatment of a spinal deformity. Surgery was conducted on the patient by performing a dorso-lumbar spinal arthrodesis (T6-L5) by means of the insertion of two longitudinal rods and a number of pedicle-expander screws at different vertebral levels. Following the orthopedic surgery, the patient presented paraparesis of the lower limbs and anemia that required transfusion. In the immediate postoperative period, a noncontrast-enhanced computed tomography (CT) scan was obtained to assess the medullary canal. A deviation of the left screw placed at T6 was detected; this screw projected outward from the vertebral cortex, protruding into the descending thoracic aorta. A contrast-enhanced CT scan showed that the screw had been malpositioned, and the image was highly suggestive of a perforation of the aortic wall, despite a lack of evidence of a peri-aortic hematoma, extravasation of contrast medium, or pleural effusion. The patient remained hemodynamically stable, and the decision was to perform an endovascular repair electively within 24 hours (A, Cover). In the operating room, a transesophageal echocardiogram (TEE) showed a metal object in the uppermost portion of the descending aorta constricting the arterial wall and giving rise to a tent-shaped image. A turbulent flow beneath the arterial intima and an intramural hematoma without active bleeding were found at that level (B). The patient was placed in a right decubitus position in the operating room to simultaneously perform the endovascular surgery of the thoracic aorta and the removal of the screw by the orthopedic surgeon. A single 2828100-mm Medtronic Valiant (Medtronic, Santa Rosa, Calif) thoracic endoprosthesis was introduced through the left common femoral artery into the proximal descending thoracic aorta at the site of injury. Afterward, an orthopedic surgeon manually removed the screw placed at D6, and the endograft was then expanded with a Reliant Stent Graft Balloon Catheter (Medtronic). There was no evidence of any leakage or signs of bleeding by TEE and intraoperative angiographic control. During the postoperative period, the patient recovered lower limb strength and mobility, and she was discharged uneventfully within 72 hours. A follow-up contrastenhanced CT scan that did not show signs of complications was obtained 1 month after the repair (C).

Percutaneous Treatment of Liver Failure and Acute Mesenteric Ischaemia

INTRODUCTION Synchronous embolism to the superior mesenteric artery (SMA) and coeliac axis (CA) is a rare disease. REPORT A 67-year-old man with atrial fibrillation developed acute liver failure due to an embolic occlusion of the CA and SMA, with a severe coagulation disorder. He was successfully managed with percutaneous stent placement and an exploratory laparotomy was not needed. He remains symptom-free 1 year after the procedure, and duplex follow-up showed stent patency. CONCLUSION Endovascular techniques in patients with liver failure, no signs of peritonism, early diagnosis and high operative risk seem feasible and should be used if possible, as first-line option.

Retrograde Approach for Endovascular Salvage of an Infrapopliteal Vein Bypass

Endovascular treatment through femoropopliteal and infragenicular percutaneous transluminal angioplasty, both in native vessels and in bypass salvage, has been an emerging technique in recent years. However, in some cases, a difficult anterograde access in distal occlusions has limited the technical success of this procedure. Combined subintimal arterial flossing with antegrade-retrograde intervention is used as a resource technique to obtain precise recanalization in these cases. Here, we present the case of a retromalleolar access of the posterior tibial artery, based on subintimal arterial flossing with antegrade-retrograde intervention technique, to achieve femoral-posterior tibial bypass salvage.

Endovascular Management of Radiotherapy-Induced Injury to Brachiocephalic Artery Using Covered Stents

Actinic vascular lesions tend to be stenotic-occlusive lesions. In this article, we present 2 exceptional cases of pseudoaneurysms caused by radionecrosis of the supra-aortic trunks. Both patients were treated by a retrograde carotid approach and deployment of a self-expanding covered stent. Proper exclusion of the pseudoaneurysm was attained in both cases; the first patient remained asymptomatic 12 months later; the second patient died of mediastinitis. Compared with conventional surgery, endovascular management is a viable, less invasive alternative in select patients, especially in life-threatening cases.