Current update of cerebral embolic protection devices

Carotid artery stenting (CAS) has evolved into a viable alternative to carotid endarterectomy. Although CAS outcomes have improved during the last decade, the associated stroke rate remains higher when compared with carotid endarterectomy. Therefore, the pivotal role of embolic protection devices (EPDs) in minimizing stroke risk cannot be underestimated as a vital component of CAS. As technology advances, EPDs continue to be refined, and each device currently on the market has its own advantages and disadvantages. This review provides an overview of the current status of EPDs and highlights the unique features of each device, followed by suggestions for application in specific clinical scenarios

Appropriate Use of Venous Imaging and Analysis of the D- Dimer/Clinical Probability Testing Paradigm in the Diagnosis and Location of Deep Venous Thrombosis

Background—The D-dimer (DD) level combined with the pretest Wells criteria probability (WCP) score can safely exclude deep venous thrombosis (DVT). The objective of this study was to examine the correlation between DD results alongside WCP score with findings on venous duplex ultrasound (VDU). The hypothesis is that VDU remains overutilized in low-risk patients with negative DD and that higher DD levels may correlate with thrombus burden and location. Methods—Patients who presented to a high-volume tertiary care center with lower limb swelling with or without associated pain were retrospectively examined through June and July for 4 consecutive years (2012 to 2015). After calculating WCP, patients were divided into low-, moderate-, and high-risk categories. Electronic DD results utilizing enzyme linked immunosorbent assay, WCP data, and VDU analysis data were merged and analyzed based on receiver operator characteristic curve to determine the DD cutoff point for each WCP. Abnormal DD with an average value ≥ 0.6 mg/L fibrinogen equivalent units (FEUs) was correlated to positive DVT to differentiate proximal DVT (above popliteal vein) from distal DVT (below popliteal vein). Results—Data of 1,909 patients were analyzed, and 239 (12.5%) patients were excluded secondary to serial repeat visits or follow-ups, surveillance screens, and if they had a previous history of DVT. The average age was 62.1 ± 16.3 years with more women (55.7%) and the majority presented with limb pain and edema (87%). DD studies were ordered and completed in 202 patients and correlated with all positive and negative DVT patients (100% sensitivity and negative predictive value, with specificity and positive predictive value of 14.9% and 15.9%, respectively). Twenty-six of 202 patients had DD that were in the normal range 0.1–0.59 mg/L (FEU), all of which were negative for DVT (100% sensitive). Fifty one of 202 patients had DD values of 0.6–1.2 mg/L FEU, of which only 3 DVTs were recorded, and all of them were distal DVTs. In addition, 685 patients with WCP Thus, 762 patients had an unnecessary immediate VDU (Wells ≤1 and –DD) study during their initial presentation. Potential charge savings for VDU for all patients are 762 × $1,557 =$1,186,434 and DD for all patients are 762 × $182 =$138,684, with total potential savings of $1,047,750 (USD 2016). Conclusions—This study suggests that DD is still underutilized, and DD in conjunction with WCP could significantly reduce the number of unnecessary immediate VDUs. Higher value of DD (\u3e1.2 mg/L FEU) may raise concern for proximal DVT. Concern on cost-effectiveness exists and raises the demand for a proposed algorithm to be followed

A 10-year experience of infection following carotid endarterectomy with patch angioplasty

ObjectiveAlthough infection following carotid endarterectomy is rare, consequences of this seldom seen complication can be devastating. Polyester, polytetrafluoroethylene (PTFE), and vein patches have all been used by many institutions for patch angioplasty, each with reported cases of infection following surgery. Our institution has preferentially used PTFE for the majority of cases, and here, we report our experience with postoperative infection following endarterectomy over the last decade.MethodsFrom January 2000 through July 2009, we treated infections following carotid endarterectomy in 25 patients.ResultsOf the 25 patients undergoing treatment for postoperative infection, 21 had PTFE patches placed during the initial surgery. The remaining four consisted of two polyester patches and two bovine pericardial patches. Twenty-three of the 25 initial endarterectomies were performed at our institution, and the other two were referrals. The majority of cases (56%) were due to gram-positive organisms, with only two cases being polymicrobial. The interval from the original surgery to clinical presentation ranged from 7 days to 85 months, with 20 patients (80%) presenting within 60 days of the first operation. Thirteen patients underwent incision and drainage with antibiotics, and 12 patients underwent definitive surgical treatment. Four received patch excision with vein patch angioplasty, four received patch excision with vein interposition, and four received sternocleidomastoid flaps. The 30-day stroke rate was 8%, and the freedom from recurrent infection was 100% at a mean follow-up of 32 months.ConclusionInfection following carotid endarterectomy occurs <1% of the time; however, the potential for morbidity is significant. Our results show that most infections following PTFE patch angioplasty occur in the early postoperative period (<60 days) and that simple drainage with antibiotics may be an adequate form of treatment in select cases

Management of Immediate Post- Endovascular Aortic Aneurysm Repair Type Ia Endoleaks and Late Outcomes

BACKGROUND—Post-endovascular aortic aneurysm repair (EVAR) endoleaks and the need for reintervention are challenging. Additional endovascular treatment is advised for type Ia endoleaks detected on post-EVAR completion angiogram. This study analyzed management and late outcomes of these endoleaks. STUDY DESIGN—This was a retrospective review of prospectively collected data from EVAR patients during a 10-year period. All post-EVAR type Ia endoleaks on completion angiogram were identified (group A) and their early (30-day) and late outcomes were compared with outcomes of patients without endoleaks (group B). Kaplan-Meier analysis was used for survival analysis, sac expansion, late type Ia endoleak, and reintervention. RESULTS—Seventy-one of 565 (12.6%) patients had immediate post-EVAR type Ia endoleak. Early intervention (proximal aortic cuffs and/or stenting) was used in 56 of 71 (79%) in group A vs 31 of 494 (6%) in group B (p \u3c 0.0001). Late type Ia endoleak was noted in 9 patients (13%) in group A at a mean follow-up of 28 months vs 10 patients (2%) in group B at a mean follow-up of 32 months (p \u3c 0.0001). Late sac expansion and reintervention rates were 9% and 10% for group A vs 5% and 3% for group B (p = 0.2698 and p = 0.0198), respectively. Freedom rates from late type Ia endoleaks at 1, 3, and 5 years for group A were 88%, 85%, and 80% vs 98%, 98%, and 96% for group B (p \u3c 0.001); and for late intervention, were 94%, 92%, and 77% for group A, and 99%, 97%, and 95% for group B (p = 0.007), respectively. Survival rates were similar. CONCLUSIONS—Immediate post-EVAR type Ia endoleaks are associated with higher rates of early interventions, late endoleaks and reintervention, which will necessitate strict post-EVAR surveillance