Search

Background: The aim of this study was to analyze the appropriateness of the type of repair (open or endovascular) performed for abdominal aortic aneurysm (AAA) in five university hospitals in Spain, according to evidence-based recommendations. Methods: A multicenter, retrospective cross-sectional study of patients with AAA who underwent elective open surgical repair (OSR) or endovascular aneurysm repair (EVAR). Data were collected on demographic and clinical variables and type of surgical repair. A pair of vascular surgeons from each participating hospital performed a blinded assessment based on GRADE recommendations. The concordance between the two evaluators and the agreement between their evidence-based recommendation and the procedure performed were assessed. Results: A total of 186 patients were selected; 179 were included. Mean age was 72.5 years (standard deviation [SD], 8.4), mean Charlson Comorbidity Index (CCI) was 2.04 (SD, 1.9). OSR was performed in 53.2% (N.=99) and EVAR in 46.8% (N.=87) of cases. Overall, 65.9% (118/179) of interventions performed were considered appropriate: 50% (47/94) of OSRs and 83.5% (71/85) of EVARs. The patient characteristics were similar for all the hospitals, but the chosen surgical technique did show significant differences among these centers. There were no significant differences among the hospitals in the proportion of cases judged as appropriate, either overall (P=0.346) or for each type of procedure (P=0.531 and P=0.538 for OSR and EVAR, respectively). Conclusions: In this study, most of the AAA repairs performed were appropriate according to GRADE recommendations. A higher proportion of EVARs were considered appropriate than OSRs. Choice of AAA repair should be standardized using evidence-based clinical practice guidelines, while incorporating patient preferences, to reduce the existing variability and ensure appropriate selection of AAA repair technique.

Background Primary aortic mural thrombus (AMT) is a rare entity. Asymptomatic AMT may be found in imaging studies for other disease studies. Symptomatic AMT as embolic events may localize in the arterial branches of the aorta; limb ischemia is the most usual clinical presentation, though. However, when proximal aorta is compromised, visceral branches occlusion and ischemia may determine morbidity and mortality in these patients. Methods We performed a retrospective study with collection of data from January 2011 to September 2016. Medical records of patients were reviewed for: demographic data, cardiovascular risk factors or any known prothrombotic predisposing condition, clinical presentation, vessel of embolism, localization of aortic thrombus, treatment of AMT and symptoms, follow-up, and computed tomography scan imaging findings. Results A total of 8 patients were included in the study. Mean age was 54.7 ± 11.5 years, with male/female ratio 3:1. Four (50%) patients had AMT at the arch or descending aorta, 3 (37.5%) patients in the infrarenal sector, and the remaining in the visceral aorta. All but one patient received anticoagulation alone for the aortic thrombus. Patient with femoral thromboembolectomy died in the early postoperative time due to severe massive embolism. Median follow-up was 23 months (range, 1–50). Five out of seven patients showed complete aortic thrombus resolution in imaging follow up. None of the patients presented recurrence of embolic events. Conclusions An anticoagulation first-approach treatment may be reasonable if mild organ damage is encountered. This strategy may be continued if no recurrences in embolic events are encountered, as high percentage of thrombus resolution is expected. Open or endovascular may be saved for life-threatening visceral or arch branches damage.

Objective: Cardiovascular autonomic neuropathy (CAN) is a common complication of type 1 diabetes (DM1). The risk of CAN is lower in middle-aged healthy women than in men, a fact that might be related to a more dominant parasympathetic regulation in the former. This sex-related effect in favor of women appears to disappear beyond 50 year-old. We assessed the effects of age and sex on CAN in patients with DM1. Research Designs and Methods: Cross-sectional study in 281 consecutive patients (158 males and 123 females) with DM1. CAN was assessed by the Ewing Score using the variability of heart rate (HR) in response to deep breathing, standing, and the Valsalva’s maneuver, and the response of blood pressure to active standing. A composite score ≥ 1 was diagnostic of CAN. CAN was classified as early or mild when the Ewing score was between 1-2, and definitive when ≥ 2. Results: The mean age of our study population was 36±12 years-old and their average duration of DM1 was 20±11 years. Their mean HbA1cwas 7.6±1.3%. The global prevalence of CAN was 30.6% (25.5-36.2). CAN was categorized as early/mild in 79 (92%) cases and definitive in 7 (8%) cases. CAN prevalence was not significantly different between men and women when analyzing all subjects regardless of age. When age was taken into account, the prevalence of CAN was independent of sex among individuals below 50 year-old, but in subjects aged ≥ 50 years (21 males and 19 females) the prevalence of CAN was larger in women than in men [63.2% (41.0-80.9) vs. 23.8% (10.6-45.1), respectively; χ2: 6.32, p= 0.012]. The OR of having CAN was 5.5 (1.4-21.6) in women aged ≥ 50 years compared to their male counterparts and 3.9 (1.4-10.7) compared to women under 50 years. Conclusions: The increase in CAN risk in subjects with type 1 DM may be greater in women over 50 years than in men of similar age. Moreover, women aged ≥ 50 years-old associate to a higher risk of CAN than younger women and men. This finding might be related to the menopausal-related decline in sex steroids. Disclosure L. Nattero-Chávez: None. S. Alonso Diaz: None. L. Montanez: None. E. Fernández: None. S. Redondo Lopez: None. M. Garnica Ureña: None. A. Bayona: None. H. Escobar-Morreale: None. M. Luque Ramírez: None. Funding Instituto de Salud Carlos III, Spanish Ministry of Economy and Competitiveness (PI1400649, PI151686, PIE1600050); Fondo Europeo de Desarrollo Regional

Context Cardiovascular autonomic neuropathy (CAN) appears to contribute to peripheral arterial stiffness (AS) in type 1 diabetes. Whether CAN in patients with AS is associated with concomitant asymptomatic peripheral arterial disease (aPAD) remains unclear. Objective To assess the risk of CAN in patients with type 1 diabetes and AS and its potential association with atherosclerosis. Design Cross-sectional study. Setting Type 1 diabetes clinic in an academic hospital. Patients Two hundred sixty-four patients with type 1 diabetes. Intervention AS was defined as an ankle-brachial index (ABI) >1.2, aPAD by the toe-brachial index and Doppler sonography, and CAN by blood pressure and heart rate responses to active standing and Ewing and Clarke tests. Main outcome measures Odds of having CAN among patients with AS. Odds for CAN were also calculated as a function of the presence of AS and concomitant aPAD. Results The study population's mean age was 35 ± 11 years, with a duration of disease of 19 ± 10 years and mean hemoglobin A1c of 7.5% ± 1.3%. Seventy-three patients (28%) had peripheral AS, of whom 28 showed aPAD. The prevalence of CAN among patients with AS was 48% but it was only 23% in subjects with normal ABI (OR: 3.1 [1.7; 5.4]). Concomitant aPAD increased the OR for CAN (OR: 4.5 [2.0; 10.1]). After adjustments for aPAD and relevant cardiovascular risk factors, AS remained associated with parasympathetic dysfunction. Conclusions In type 1 diabetes, both peripheral AS and atherosclerosis were associated with CAN. A simple method, such as the ABI, may identify a subset of patients with undiagnosed dysautonomia.

Background Abdominal aortic aneurysm (AAA) is an important cardiovascular (CV)-related disease that requires surgical treatment to prevent rupture. The elevation of arterial stiffness (AS) is an increasingly recognized independent determinant of CV morbidity and mortality and plays a special role in atherosclerosis. The importance of the surgical technique used for AAA repair in the long-term outcomes still needs to be clarified, and whether endovascular aortic repair (EVAR) or open surgical repair (OSR) confers high AS measurements and thus worse prognosis in terms of CV morbidity needs further investigation. Methods A prospective nonrandomized study that included consecutive patients requiring either EVAR or OSR for AAA disease between February 2015 and January 2016 was conducted. This study is registered on the National Institutes of Health website ( ClinicalTrials.gov ) and identified with NCT02642952. Several noninvasive measurements of AS and central aortic hemodynamics were obtained before surgery and in the first postoperative control (4–6 weeks), with change from baseline in heart rate–adjusted augmentation index (AIx@75) as main outcome. Likewise, inflammatory circulating biomarkers were also measured in the same time line. Results We included 44 patients, 25 in the EVAR group and 19 in the OSR group. Subjects who underwent EVAR were older and presented larger aneurysm diameter at baseline. There was a significant decrease in AIx@75 in the EVAR group after treatment (−4.1 ± 8.1%, P = 0.018), for a moderate effect size (d = 0.508), whereas the decreasing trend in the OSR group (−2.5 ± 6.7%, P = 0.127) was not statistically significant. No significant changes in carotid-radial pulse wave velocity (PWVCR) and central blood pressures were observed. The inflammatory markers increased after surgical repair, with significant changes in homocysteine in both EVAR (5.2 ± 6.9 μmol/L, P = 0.002) and OSR (1.8 ± 2.1 μmol/L, P = 0.002) groups. Conclusions Our study suggests that both treatments confer better postoperative values of AS measured by AIx@75 and produces no changes in PWVCR, in the early term. Whether this situation is maintained during follow-up needs further investigation.

Aims Epidemiological data on subclinical atherosclerotic disease in type 1 diabetes mellitus (DM1) are scarce. We aimed to estimate the subclinical atherosclerosis profile of asymptomatic patients with DM1 and an abnormal ankle-brachial index (ABI). Material and methods In a cross-sectional design (ClinicalTrials.gov Identifier: NCT02910271), we estimated ABI in 289 consecutive asymptomatic patients with DM1. An abnormal ABI led to measurements of toe-brachial index (TBI) and peripheral doppler ultrasound (DUS) to diagnose peripheral artery disease (PAD) and/or atherosclerotic carotid plaques (ACP). Results A reduced (≤0.9) or increased (>1.2) ABI was detected in 17 (6%) and 75 (26%) patients, respectively. PAD was confirmed by TBI and DUS in 9 (53%) patients with a reduced ABI and 28 (37%) patients with an increased ABI, resulting in a 12.8% (9.4-17.2) prevalence of asymptomatic PAD. Fourteen patients with an abnormal ABI also exhibited ACP [4.8% (2.9-7.9)], with 64% of these patients showing bilateral disease. Artery stenosis was mild or moderate in 21% and 29% of patients, respectively. Thus, 46 [16% (12-21)] patients showed asymptomatic PAD, ACP, or both. According to our data, we would have to explore three asymptomatic patients with DM1 and normal pulses to unmask one case of PAD, and seven asymptomatic patients showing abnormal ABI values to detect one carotid disease. Conclusions Peripheral artery disease is often undiagnosed in asymptomatic patients with DM1. However, its presence may change medical management in a substantial percentage of cases, highlighting the potential benefit of a thorough vascular assessment on these patients.