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      Relación de factores clínico-bioquímicos con el estadio clínico y tipo de cirugía en una muestra de pacientes con isquemia crítica de miembros inferiores Translated title: Relation of clinical and biochemical factor with clinical stage and type of surgery in a sample of patients with critical ischemia of limbs

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          Abstract

          Objetivo: El término isquemia crítica de miembros inferiores se utiliza en aquellos pacientes con isquemia crónica y dolor en reposo, úlcera o gangrena atribuible a la demostración objetiva de la enfermedad arterial oclusiva. Con el presente estudio observacional se pretende identificar los factores relacionados con el estadío clínico y el tipo de cirugía reparadora empleada en una población intervenida por arterioslerosis severa de miembros inferiores. Material y métodos: Se ha realizado un estudio observacional durante un período de dos años, comprendido entre enero de 1999 y diciembre del 2000, con 330 pacientes intervenidos por enfermedad aterosclerótica severa de miembros inferiores, con isquemia crítica. A todos los pacientes se les recogieron, en el momento del ingreso para la cirugía, los siguientes datos: edad, sexo, tensión arterial, glucemia, colesterol total, LDL colesterol, HDL colesterol triglicéridos, topografia de la lesión, tipo de tratamiento quirúrgico, índice tobillo brazo, así como el tratamiento farmacológico prescrito para los factores de riesgo cardiovascular. Se realizó un analisis de regresión logistica para evaluar la influencia de las diferentes variables en la presencia de un estadio clinico IV frente al un estadío III. Así como, la utilización de amputación como técnica quirúrgica frente a revascularización. Resultados: La edad media fue de 74, 78 ± 10,35 años, siendo la edad de las mujeres mayor (78,88 ± 10,45 años) que la de los hombres (73,70 ± 10,07) (p <0,0001), con una distribución por sexos, de 261 hombres (79,1%) y 69 mujeres (20,9%). El modelo de regresión logística construido para explicar el estadio clínico dicotomizado en III/IV, ajustado para la edad y sexo, las variables que mayor influencia tienen en el riesgo de padecer un estadio IV frente al III son la diabetes mellitus, la localización de la lesión arterial, y las cifras bajas de colesterol total. Un paciente con diabetes mellitus tipo 2 tiene 3,322 (IC 95%: 1,881-5,866) veces más riesgo de presentar al ingreso un estadio clínico IV que una persona que no lo es. En cuanto al colesterol total, la OR es de 0,990 lo cual puede interpretarse como que el riesgo de presentar un estadio clínico IV frente al estadio clínico III se multiplicaría por 0,990 por cada mg/dl de aumento del nivel de colesterol total. La localización de la lesión arterial distal (por debajo del ligamento inguinal) incrementa el riesgo de presentar un estadio clínico IV en 6,897 (IC 95%: 3,509 -13,557) veces más que la localización de la lesión arterial en otro sector. El modelo de regresión logística construido para explicar el tipo de cirugía dicotomizado en amputaciones/derivaciones ajustado para la edad y sexo, la presencia de diabetes mellitus tipo 2 presenta una Odds Ratio (OR) de 3,37 lo que significa que el padecimiento de esta enfermedad multiplica por 3,37 (IC 95%: 1,940-5,866) el riesgo de ser sometido a una amputación frente a una revascularización. Con respecto del colesterol total, la OR es de 0,986 lo cual puede interpretarse como que el riesgo de amputación frente a intervenciones de revascularización se multiplicaría por 0,986 por cada mg/dl de aumento del nivel de colesterol total. En cuanto al sitio de la lesión aunque la variable entra globalmente en el modelo, las diferencias significativas se sitúan en la comparación entre lesión distal y proximal siendo la OR de la primera de 2,585 en relación a la segunda. Las personas que han sufrido más de una intervención quirúrgica presentan una OR de 3,013 (1,602-5,666) para sufrir una amputación frente a aquellas que han sido intervenidas una sola vez. Cada día de ingreso hospitalario aumenta en un 0,8% el riesgo de amputación frente a intervenciones de revascularización. Conclusión: En el análisis multivariante la presencia de diabetes mellitus, lesiones distales, sexo femenino y edad mayor de 75 se relaciona con la presencia de un estadio IV, presentando los niveles de colesterol una relación inversa. La presencia de diabetes mellitus, lesion distal, más de una cirugía reparadora, edad mayor de 75 años, los días de ingreso se relacionan con al realización de amputaciones como técnica reparadora, presentando los niveles de colesterol una relación inversa.

          Translated abstract

          Objective: The term of critical ischemia of legs is used in patients with chronical ischemia and pain in rest, ulcer or tisular necrosis secondary to oclussive arterial disease. The objective of our work was to identify factors related with clinical stage and type of surgery in these patients. Material and methods: An observational study was performed during two years, from january 1999 to december 2000, with 330 patients with surgery secondary to critical ischemia of legs. The next parameters were recorded during the Hospital stance; age, sex, blood pressure, glycaemia, total colesterol, LDL colesterol, HDL colesterol, triglycerides, location of disease, type of surgery, arm-ankle index, and farmacological treatment to cardiovscular risk factors. A regression logistic analyze was realized to study the influence of diferents variables in the clinical stage and in the type of surgery. Results: The mean age was 74.78 ± 10.35 years, with a higher age in females (78.88 ± 10.45 years) than males (73.70 ± 10.07) (p <0,0001), with 261 males (79.1%) and 69 females (20.9%). Logistic regression model to investigate clinical stage III/IV (adjusted by age and sex) showed that the independent variables related with stage IV were diabetes mellitus, location of arterial lesion, and low colesterol levels. A patient with diabetes mellitus type 2 has 3,322 (CI 95%: 1,881-5,866) times more risk of stage IV than a non diabetic patient. Odds ratio of total colesterol was 0,990, the risk to develop a IV stage is increased 0,990 times for each mg/dl of cholesterol. Distal lesion increased the risk of stage IV en 6,897 times (CI 95%: 3,509 - 13,557). Logistic regression model to investigate type of surgery (amputation/bypass) (adjusted by age and sex) showed that diabetes mellitus type 2 had Odds Ratio (OR) of 3,37, this means that diabetes increase 3,37 times (CI 95%: 1,940-5,866) the risk of amputation. Total cholesterol showed a OR of 0,986, this jeans an increase of amputation 0,986 time with each mg/dl of cholesterol. Distal location increase risk of amputation 2,585 times. Patients with more than one surgery had an OR of 3,013 (1,602-5,666) to increase amputation. Each day of hospital stance increase 0,8% risk of amputation. Conclusion: In multivariant análisis, diabetes mellitus, distal lesion, male sex and age over 75 years were positive related with stage IV, and colesterol levels were inverse related . Diabetes mellitus, distal lesion, age over 75 years, days of hospital stance, number of surgeries were positive related with amputation as surgery technic and colesterol levels were negative related.

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          Most cited references 26

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          Peripheral Arterial Disease in Diabetic and Nondiabetic Patients: A comparison of severity and outcome

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            Clinical outcome and its predictors in 1560 patients with critical leg ischaemia. Chronic Critical Leg Ischaemia Group.

            to assess the predictivity of clinical variables in patients with chronic critical leg ischaemia (CLI). Design observational prospective cohort study. the i.c.a.i. (ischemia critica degli arti inferiori) trial database was used to assess the impact of patients' history, cardiovascular risk, manifestations of the disease and specific invasive and pharmacological interventions on mortality, amputation rate and persistence of CLI. of 1560 patients, 298 died within one year; at six months 187 were amputees and 746 still suffered from CLI. Prior major vascular events doubled the risk of dying within one year. Previous revascularisation was associated with a lower mortality, but also with a higher probability of amputation. Among cardiovascular risk factors, only diabetes affected prognosis, in terms of increased mortality and lower probability of recovery from CLI. Patients with tissue loss had a higher amputation rate and less probability of recovery. Ankle pressure was predictive of mortality and amputation only when unmeasurable. Patients requiring revascularisation had better chances of recovering from CLI, but not of longer-term survival or limb salvage compared to those in whom surgery was deemed unnecessary. Antiplatelet drugs caused resolution of CLI and decreased the amputation rate by about 1/3, while the advantage of the test treatment (alprostadil-alpha-cyclodextrine) was confined to CLI resolution only. this study documents the high mortality and heterogeneity of patients with CLI. It provides stratification criteria for reliably estimating the achievable benefit in routine practice and for clinical trials. Copyright 1999 Harcourt Publishers Ltd.
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              Age at onset of smoking is an independent risk factor in peripheral artery disease development.

              The potential effects of age at onset of smoking on cardiovascular diseases have been studied little, in contrast to the well-established evidence supporting a causal role of cigarette smoking in these diseases. We sought to analyze the relationship between age at smoking onset and development of symptomatic peripheral arterial occlusive disease (PAOD). A population-based sample of 573 active or former male smokers aged 55 to 74 years were studied. Present or previous symptomatic PAOD was confirmed by noninvasive testing. Sixty-one subjects (10.6%) had symptomatic PAOD. Prevalence of disease increased with earlier starting age (15.6% if 16 years) of smoking. After controlling for risk factors that meet confounding factor criteria (ie, subject age and number of pack-years), men who started smoking at age 16 or earlier had a substantially higher risk for development of PAOD (odds ratio, 2.19; 95% CI, 1.15-4.15; P =.016) than men who began to smoke at a later age. A starting age for smoking of 16 years or earlier more than doubles the risk of future symptomatic PAOD regardless of the amount of exposure to cigarette smoking.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                ami
                Anales de Medicina Interna
                An. Med. Interna (Madrid)
                Arán Ediciones, S. L. (Madrid )
                0212-7199
                January 2006
                : 23
                : 1
                : 19-25
                Affiliations
                [1 ] Universidad de Valladolid Spain
                Article
                S0212-71992006000100004
                10.4321/s0212-71992006000100004
                Product
                Product Information: website
                Categories
                MEDICINE, GENERAL & INTERNAL

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