Combination therapy with warfarin plus clopidogrel improves outcomes in femoropopliteal bypass surgery patients

Background: Patients having undergone femoropopliteal bypass surgery remain at significant risk of graft failure. Although antithrombotic therapy is of paramount importance in these patients, the effect of oral anticoagulation therapy (OAT) on outcomes remains unresolved. We performed a randomized, prospective study to assess the impact of OAT plus clopidogrel vs dual antiplatelet therapy on peripheral vascular and systemic cardiovascular outcomes in patients who had undergone femoropopliteal bypass surgery. Methods: Three hundred forty-one patients who had undergone femoropopliteal surgery were enrolled and randomized: 173 patients received clopidogrel 75 mg/d plus OAT with warfarin (C + OAT), and 168 patients received dual antiplatelet therapy with clopidogrel 75 mg/d plus aspirin 100 mg/d (C + acetylsalicylic acid [ASA]). Study end points were graft patency and the occurrence of severe peripheral arterial ischemia, and the incidence of bleeding episodes. Results: Follow-up ranged from 4 to 9 years. The graft patency rate and the freedom from severe peripheral arterial ischemia was significantly higher in C + OAT group than in C + ASA group (P =.026 and.044, respectively, Cox-Mantel test). The linearized incidence of minor bleeding complications was significantly higher in C + OAT group than in C + ASA group (2.85% patient-years vs 1.37% patient-years; P =.03). The incidence of major adverse cardiovascular events, including mortality, was found to be similar (P =.34) for both study groups. Conclusions: In patients who have undergone femoropopliteal vascular surgery, combination therapy with clopidogrel plus warfarin is more effective than dual antiplatelet therapy in increasing graft patency and in reducing severe peripheral ischemia. These improvements are obtained at the expenses of an increase in the rate of minor anticoagulation-related complications. © 2012 Society for Vascular Surgery

Ischaemic heart disease and peripheral arterial disease: Routinely coronary angiography as strategy to reduce global risk

Atherosclerotic change in extracoronary arteries (i.e. thoracic and abdominal aorta, and carotid and femoral arteries) are associated with the extent of coronary atherosclerosis. The incidence of coronary artery disease and the clinical outcome of 163 consecutive patients affected with peripheral arterial disease (PAD), all subjected to coronary angiography, were determined in a prospective observational study. Forty patients (24.5%) were found to have significant coronary atherosclerotic disease (CAD) with a normal exercise ECG test and/or dipyridamole-thallium scintigraphy. The overall rate of myocardial revascularization observed was 56.4%, with a perioperative mortality rate (30 days) of 3.6%. Wide consensus exists on considering PAD as a CAD equivalent: patients are currently under-treated with regard to atherosclerotic risk factor modification and surgical treatment. Cardiovascular physicians should assume a more proactive clinical role in encouraging a correct therapeutic approach to the treatment of arterial diseases affecting multiple vascular beds, including extensive coronary angiography. © 2007 Pharma Project Group srl

MAJOR COMPLICATIONS FOLLOWING ENDOVASCULAR SURGERY OF DESCENDING THORACIC AORTA

We evaluated the impact of major complications on clinical outcome in a series of patients undergoing endovascular repair (EVAR) of descending thoracic aorta. From March 2001 to June 2005, 51 patients underwent EVAR for descending aortic diseases. Thirty-five were treated in emergency (60.7%) and 41 (80.4%) were in III-IV ASA class. There were no deaths, surgical conversion or paraplegia. A neurologic complication occurred in one patient (1.9%). Eleven major systemic complications occurred in 5 patients. One patient showed a primary type I endoleak at discharge, resolved spontaneously after 9 months. Three (5.9%) vascular injuries occurred during the endovascular procedure, requiring an emergency rescue iliac-femoral artery bypass. At follow-up (29\uc2\ub114 months), there was an overall mortality rate of 5.1% (3/51); 2 deaths (3.9%) were procedure related. Two secondary EVARs (3.9%) were successfully performed, one for a late type I endoleak six months after EVAR in a traumatic patient, and a second for a late rupture distally to the stent-graft implanted 36 months before in an acute type-B dissected patient. EVAR for descending aortic diseases is associated with decreased mortality and complications, however, long-term follow-up and additional studies are mandatory to detect late failure and to confirm clinical safety of this procedure. \uc2\ua9 2006 Published by European Association for Cardio-Thoracic Surgery. All rights reserved

Systematic Strategy of Prophylactic Coronary Angiography Improves Long-Term Outcome After Major Vascular Surgery in Medium- to High-Risk Patients A Prospective, Randomized Study

ObjectivesThis study was undertaken to determine the impact of a strategy of systematic coronary angiography on immediate- and long-term outcome of patients at medium-high risk who were undergoing surgical treatment of peripheral arterial disease.BackgroundDespite pre-operative risk stratification according to the current guidelines, vascular surgery patients still represent a high-risk population, as 30-day cardiovascular complications and mortality rates still remain as high as 15% to 20% and 3% to 5%, respectively.MethodsIn all, 208 consecutive patients scheduled for elective surgical treatment of major vascular disease and with a revised cardiac risk index ≥2 were randomly allocated to either a “selective strategy” group (group A, n = 103), in whom coronary angiography was performed based on the results of noninvasive tests, or to a “systematic strategy” group (group B, n = 105), consisting of patients who systematically underwent pre-operative coronary angiography.ResultsThe 2 groups were similar with respect to baseline clinical characteristics, revised cardiac risk index, and type of vascular surgery performed. The myocardial revascularization rate in group B was higher than in group A (58.1% vs. 40.1%; p = 0.01). In-hospital major adverse cardiovascular event rate was not significantly lower in group B (p = 0.07). At 58 ± 17 months of follow-up, group B showed significantly better survival (p = 0.01) and freedom from death/cardiovascular events (p = 0.003).ConclusionsIn this study, a strategy of routine coronary angiography positively impacted long-term outcome of peripheral arterial disease surgical patients at medium-high risk. This is the first such demonstration in a randomized, prospective trial. Multicenter trials to confirm this finding in a larger population are warranted