Stent carotídeo transcervical con flujo reverso

En los últimos años el stenting carotídeo ha emergido como una potencial alternativa a la endarterectomía carotídea en téminos de seguridad y eficacia. El estudio SAPPHIRE probó que en los pacientes de alto riesgo con estenosis carotídea grave, el stenting carotídeo realizado con protección cerebral mediante filtro distal no es inferior a la endarterectomía. Aunque los sistemas de protección cerebral que utilizan los filtros distales reducen las complicaciones tromboembólicas durante el stenting carotídeo, la protección parece ser insuficiente. Por el contrario, cuando la protección cerebral implica la oclusión de la arteria carótida común y la creación de un flujo reverso en la arteria carótida interna se consigue una importante ventaja: la protección cerebral se realiza antes de atravesar la lesión, uno de los pasos más embolígenos durante el stenting carotídeo. En nuestra experiencia, el flujo reverso a través de un acceso transcervical es un método simple y seguro que elimina los inconvenientes de la instrumentación del arco aórtico y el hecho de atravesar la lesión sin protección. Es además más barato que los métodos que requieren un filtro distal y los resultados a corto y medio plazo son comparables a los reportados para la endarterectomía. Se ha sugerido que los pacientes de edad avanzada podrian constituir un subgrupo de alto riesgo para el stenting carotídeo. Distintas experiencias individuales y particularmente los resultados del estudio CREST, parecen confirmar esta idea. Tradicionalmente y fuera de experiencias individuales de endarterectomía carotídea en octogenarios, este subgrupo de pacientes fueron excluidos de los estudios multicéntricos que compararaban la endarterectomía con el mejor tratamiento médico, por lo que la incidencia de complicaciones de la endarterectomía en estos pacientes no es bien conocida haciendo más dificil establecer la mejor opción de tratamiento en esta población. La hipótesis que podría explicar la mayor tasa de complicaciones con el stenting carotídeo por vía transfemoral en pacientes añosos es la mayor dificultad técnica debido a la mayor complejidad del arco aórtico y a la tortuosidad de los troncos supraórticos en este grupo de edad. El stent carotídeo trancervical con flujo reverso evita ambos pasos: permite el despliegue del stent en la lesión estenótica sin instrumentación del arco aórtico. Los resultados de nuestro estudio confirman que la revascularización carotídea mediante stenting carotídeo transcervical con inversión de flujo para la protección cerebral es tan seguro como la endarterectomía en pacientes octogenarios, en contraste con las consideraciones de la mayoría de los autores que no recomiendan stenting carotídeo en este subgrupo de pacientes. Además, en la actualidad, los resultados del meta-análisis y revisiones sistemáticas ponen de manifieso altas tasas de ictus y muerte en pacientes de edad avanzada (mayores de 70 años) sometidos a stenting carotídeo por vía transfemoral y sugieren que el stent carotídeo se debe evitar en esta población. En esta tesis doctoral se ha podido demostrar que en pacientes octogenarios el stent carotídeo realizado con abordaje transcervical y flujo reverso es tan seguro como la endarterectomía carotídea a corto plazo. El acceso transcervical evita las limitaciones anatómicas antes mencionados y la inversión del flujo reduce el número de microembolias que ocurren durante el procedimiento. Hemos podido además confirmar los mismos resultados en pacientes mayores de 70 años. Creemos que lo que se debe evitar en esta población es la instrumentación del arco aórtico y de los troncos supraórtcicos, no el stenting carotídeo y por tanto el uso de la vía transcervical y la creación del flujo reverso es una técnica segura y eficaz en este grupo de pacientes.In the last few years transfemoral carotid artey stenting has emerged as a potential alternative to endarterectomy in terms of both safety and efficacy. The SAPPHIRE trial proved that among high risk patients with severe carotid artery stenosis and coexisting conditions, carotid artey stenting with the use of an emboli-protection device is not inferior to carotid endarterectomy: Cerebral filtering devices reduce thromboembolic complications durins carotid artey stenting , however the degree of protection appears to be incomplete. Systems for cerebral protection that involve proximal common carotid artery occlusion and establishment of flow reversal in the internal carotid artery offer an important advantage: cerebral protection is established before crossing the lesion, which is one of the most emboligenic maneuvers in carotid stenting. The use of a transfemoral route to establish flow reversal presents the drawbacks related to femoral access. In our experience, flow reversal using a transcervical access route is a simple, safe method that eliminates the drawbacks of aortic arch instrumentation and crossing the target lesion without protection. In addition, it is less expensive than methods requiring a filter device, and the short- and long-term outcomes are comparable to the reported results for carotid vascularization by endarterectomy. It has been suggested that patients of advanced age may constitute a high-risk subgroup for carotid artery angioplasty and stenting .Various individual experiences, and particularly the preliminary results of the lead-in phase of the CREST study, seem to confirm this idea. Moreover, apart from individual experiences with carotid endarterectomy in octogenarians, this age group was historically excluded from multicenter trials comparing endarterectomy and the best medical therapy. Thus, the precise incidence of complications associated with carotid endarterectomy is not known, making even more difficult to establish the best treatment option in this population. The hypothesis that may explain the higher rate of complications with the use of transfemoral carotid artey stenting in elderly patients is the greater technical difficulty of the treatment due to frequent anatomical complexity of the aortic arch and tortuosity of the supraaortic trunks in this age group. Transcervical carotid stenting with flow reversal is a technique that allows stent deployment over the stenotic lesion without aortic arch instrumentation. The results of our study confirm that carotid revascularization by transcervical carotid artey stenting with flow reversal for cerebral protection is as safe as carotid endarterectomy in octogenarian patients in contrast to the considerations of most authors who do not recommend carotid artey stenting in this patient subgroup. Currently, the results of meta-analyses and systematic reviews have pointed to elevated rates of stroke/death in older patients ( over 70 years) undergoing transfemoral carotid artery angioplasty and stenting , and strongly suggest that carotid stenting should be avoided in this population. The hypotheses are the same as those discussed above. This thesis has been demonstrated that carotid stenting octogenarians performed with transcervical approach and reverse flow is as safe as carotid endarterectomy in the short term. Transcervical access anatomical avoids the limitations mentioned above and the reversal of the flow reduces the number of microemboli which occur during the procedure. We could also confirm the same results in patients over 70 years. We believe that what should be avoided in this population is the implementation of the aortic arch and supraórtcicos trunks, not carotid stenting and therefore the use of the transcervical and the creation of flow reversal is a safe and effective in this group patients

Eficacia de la monoterapia con piperacilina-tazobactam en las infecciones del pie diabético

Resumen. Introducción. Las infecciones en el pie diabético constituyen un motivo habitual de consulta para los especialistas quirúrgicos y son en la actualidad el motivo más frecuente por el que los diabéticos ingresan en los hospitales, así como la causa principal de amputación no traumática. Objetivo. Estas infecciones son frecuentemente polimicrobianas, por lo que el objetivo del presente estudio ha sido evaluar la eficacia y la seguridad de un antibiótico de amplio espectro como la piperacilina-tazobactam en pacientes con infecciones graves del pie diabético. Pacientes y métodos. Estudio multicéntrico y prospectivo en donde 150 pacientes con infecciones del pie diabético recibieron piperacilina-tazobactam como tratamiento antibiótico. Resultados. La evolución clínica fue favorable en un 92,3% de los pacientes y la eficacia microbiológica obtenida al final del tratamiento fue del 89,9%. Se presentaron reacciones adversas al tratamiento en 10 pacientes (6,6%), y 84 necesitaron amputación (56%); se realizaron amputaciones menores en 78 enfermos y mayores en 6. Conclusiones. La eficacia clínica y microbiológica, junto con la escasez de efectos adversos presentados, hace de la piperacilina-tazobactam una alternativa eficaz en el manejo de estas infecciones

Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients

Background: The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. Methods: Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2: 1). Results: Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). Conclusion: Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding

Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort.

Objective:To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL).Background:AL after RC resection often results in a permanent stoma.Methods:This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated.Results:This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76).Conclusions:The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies