Management of bleeding ectopic varices

Introduction: Bleeding ectopic varices (EcV) are uncommon and a difficult conditions to manage. The clinical data of patients diagnosed and treated for bleeding EcV were reviewed to investigate the treatment strategy. Material and Methods: Patients diagnosed with bleeding EcV over a period of 10 years were identified from the comprehensive surgical database of our institution. Results: There were six patients (F-2, M-4) with the mean age of 46.8 ± 7.3 (20 to 76) years. The location of the EcV was: duodenal (DV, n=2), isolated gastric varices type 2 (IGV2) according Sarin classification (n=2), and rectal (RV, n=2). EcV were induced by liver cirrhosis (LC) - 2, posthrombotic portal cavernoma (PC) - 1, LC+PC - 1, hepatocelullar carcinoma (HCC) +PC-1 and left-sided portal hypertension -1. The EcV were managed as an emergency in 4 (DV-2, IGV2-2) and elective in 2 with RV. Bleeding EcV were managed by endoscopic ligation with HX-21L-1 (Olympus®, ET, Japan) device with mini-loop MAJ-339 (n=2, DV and IGV2) and endoscopic ligation with HMBL-4 (Wilson-Cook®, Winston-Salem, NC, SUA) (n=2, RV). Haemostatic efficacy was achieved in all cases. Surgery was performed in 2 pts: for IGV2 - stapling fundectomy with splenectomy and for DV - surgical ligation of affected vessels. Inhospital lethality was - 1/6 (16.6%). Conclusion: Bleeding EcV’s are a challenging emergency, haemostatic procedures depending on the site, bleeding activity and local expertise

Gallbadder varices

Introduction: Gallbladder varices (GBV) are relatively rare ectopic varices in patients with portal hypertension (PH). The aim of the study is to investigate clinical, imagistic and endoscopic data of patients diagnosed with GBV. Material and Methods: Patients diagnosed with GBV over a period of 10 years were identified from the comprehensive database of our institution. Results: There were seven patients (F-4, M-3) with the mean age of 27.9 ± 5.2 (10 to 51) years. PH was caused by portal vein thrombosis (portal cavernoma): after splenectomy for trauma and hematologic disease (n=4), antithrombin III deficiency (n=2) and protein S deficiency (n=l). At time of presentation GBV (n=6) were associated with bleeding esophageal varices (F3, RCS++-i-, Li+m) managed by endoscopic band ligation MBL-6,10 (Wilson-Cook®, Winston-Salem, NC, SUA) and bleeding duodenal varices managed surgically (n=l). Doppler imaging showed the existence of portal cavernoma and GBV. After complete eradication of esophageal varices no GBV enlargement neither other related complications were noticed. Conclusion: Color Doppler sonography is a valuable noninvasive imaging technique for assessment of portal hemodynamic profile in patients with portal cavernoma as well as a useful technique to detect GBV. Preoperative correct diagnosis of GBV should increase the surgeon’s vigilance during biliary tract surgery in patients with PH in order to avoid hazardous complications

Cohort profile. the ESC-EORP chronic ischemic cardiovascular disease long-term (CICD LT) registry

The European Society of cardiology (ESC) EURObservational Research Programme (EORP) Chronic Ischemic Cardiovascular Disease registry Long Term (CICD) aims to study the clinical profile, treatment modalities and outcomes of patients diagnosed with CICD in a contemporary environment in order to assess whether these patients at high cardiovascular risk are treated according to ESC guidelines on prevention or on stable coronary disease and to determine mid and long term outcomes and their determinants in this population

Rivaroxaban with or without aspirin in stable cardiovascular disease

BACKGROUND: We evaluated whether rivaroxaban alone or in combination with aspirin would be more effective than aspirin alone for secondary cardiovascular prevention. METHODS: In this double-blind trial, we randomly assigned 27,395 participants with stable atherosclerotic vascular disease to receive rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg once daily), rivaroxaban (5 mg twice daily), or aspirin (100 mg once daily). The primary outcome was a composite of cardiovascular death, stroke, or myocardial infarction. The study was stopped for superiority of the rivaroxaban-plus-aspirin group after a mean follow-up of 23 months. RESULTS: The primary outcome occurred in fewer patients in the rivaroxaban-plus-aspirin group than in the aspirin-alone group (379 patients [4.1%] vs. 496 patients [5.4%]; hazard ratio, 0.76; 95% confidence interval [CI], 0.66 to 0.86; P<0.001; z=−4.126), but major bleeding events occurred in more patients in the rivaroxaban-plus-aspirin group (288 patients [3.1%] vs. 170 patients [1.9%]; hazard ratio, 1.70; 95% CI, 1.40 to 2.05; P<0.001). There was no significant difference in intracranial or fatal bleeding between these two groups. There were 313 deaths (3.4%) in the rivaroxaban-plus-aspirin group as compared with 378 (4.1%) in the aspirin-alone group (hazard ratio, 0.82; 95% CI, 0.71 to 0.96; P=0.01; threshold P value for significance, 0.0025). The primary outcome did not occur in significantly fewer patients in the rivaroxaban-alone group than in the aspirin-alone group, but major bleeding events occurred in more patients in the rivaroxaban-alone group. CONCLUSIONS: Among patients with stable atherosclerotic vascular disease, those assigned to rivaroxaban (2.5 mg twice daily) plus aspirin had better cardiovascular outcomes and more major bleeding events than those assigned to aspirin alone. Rivaroxaban (5 mg twice daily) alone did not result in better cardiovascular outcomes than aspirin alone and resulted in more major bleeding events