Indications for Catheter-Directed Thrombolysis in the Management of Acute Proximal Deep Venous Thrombosis

Deep vein thromboses (DVTs) cause significant morbidity and mortality in the general population. Oral anticoagulation therapy may reduce thrombus propagation but does not cause clot lysis and therefore does not prevent postthrombotic syndrome (PTS). Catheter-directed thrombolysis (CDT) can be used to treat DVTs as an adjunct to medical therapy, but there is no consensus defining exact indications. Current evidence suggests that CDT can reduce clot burden and DVT recurrence and consequently prevents the formation of PTS compared with systemic anticoagulation. Appropriate indications include younger individuals with acute proximal thromboses, a long life expectancy, and relatively few comorbidities. Limb-threatening thromboses may also be treated with CDT, although the subsequent mortality remains high. A number of randomized controlled trials are currently under way comparing the longer-term outcomes of CDT compared with anticoagulation alone. Initial reports suggest that venous patency and valvular function are better maintained after CDT. The effectiveness of combined pharmacomechanical thrombectomy and the role of vena cava filters need to be investigated further before strong recommendations can be made. The reported short-term outcomes following catheter-based intervention for DVT are encouraging in selected patients. Further evidence is required to establish long-term benefits and cost-effectiveness

Effect of Endovascular Aneurysm Repair on the Volume-Outcome Relationship in Aneurysm Repair

Background— We aim to quantify the relationship between the annual caseload (volume) and outcome from elective endovascular (EVR) or open repair of abdominal aortic aneurysms (AAAs) in England between 2005 and 2007. Methods and Results— Individual patient data were obtained from the Hospital Episode Statistics. Statistical methods included multiple logistic regression models, mortality control charts, and safety plots to determine the nature of any relationship between volume and outcome. The case-mix between hospitals of different sizes was examined using observed and expected values for in-hospital mortality. Outcome measures included in-hospital mortality and hospital length of stay. Between 2005 and 2007, a total of 57 587 patients were admitted to hospitals in England with a diagnosis of AAA, and 11 574 underwent AAA repair. There were 7313 elective AAA repairs, of which 5668 (78%) were open and 1645 (22%) were EVR. In-hospital mortality rates were 5.63% for all elective AAA repairs with rates of 6.18% for open repair and 3.77% for EVR (odds ratio, 0.676; 95% CI, 0.501 to 0.913; P=0.011). High-volume aneurysm services were associated with significantly lower mortality rates overall (0.991; 0.988 to 0.994; P<0.0001), for open repairs (0.994; 0.991 to 0.998; P=0.0008), and EVR (0.989; 0.982 to 0.995; P=0.0007). Large endovascular units had low mortality rates for open repairs. Conclusion— A strong relationship existed between the volume of surgery performed and outcome from both open and endovascular aneurysm repairs. These data support the concept that abdominal aortic surgery should be performed in specialized units that meet a minimum volume threshold

Editor's Choice - Delays to Surgery and Procedural Risks Following Carotid Endarterectomy in the UK National Vascular Registry.

OBJECTIVE: Guidelines recommend that patients suffering an ischaemic transient ischaemic attack (TIA) or stroke caused by carotid artery stenosis should undergo carotid endarterectomy (CEA) within 14 days. METHOD: The degree to which UK vascular units met this standard was examined and whether rapid interventions were associated with procedural risks. The study analysed patients undergoing CEA between January 2009 and December 2014 from 100 UK NHS hospitals. Data were collected on patient characteristics, intervals of time from symptoms to surgery, and 30-day postoperative outcomes. The relationship between outcomes and time from symptom to surgery was evaluated using multilevel multivariable logistic regression. RESULTS: In 23,235 patients, the median time from TIA/stroke to CEA decreased over time, from 22 days (IQR 10-56) in 2009 to 12 days (IQR 7-26) in 2014. The proportion of patients treated within 14 days increased from 37% to 58%. This improvement was produced by shorter times across the care pathway: symptoms to referral, from medical review to being seen by a vascular surgeon, and then to surgery. The spread of the median time from symptom to surgery among NHS hospitals shrank between 2009 and 2013 but then grew slightly. Low-, medium-, and high-volume NHS hospitals all improved their performance similarly. Performing CEA within 48 h of symptom onset was associated with a small increase in the 30-day stroke and death rate: 3.1% (0-2 days) compared with 2.0% (3-7 days); adjusted odds ratio 1.64 (95% CI 1.04-2.59) but not with longer delays. CONCLUSIONS: The delay from symptom to CEA in symptomatic patients with ipsilateral 50-99% carotid stenoses has reduced substantially, although 42% of patients underwent CEA after the recommended 14 days. The risk of stroke after CEA was low, but there may be a small increase in risk during the first 48 h after symptoms

Endovascular Versus Open Repair For Chronic Type B Dissection Treatment: A meta-analysis.

BACKGROUND: The respective place of endovascular versus open surgery in thoracic dissecting aneurysm treatment remains debatable. This comprehensive review seeks to analyse the outcomes of endovascular repair (ER) compared to open surgery (OS) in chronic type B aortic dissection treatment. METHODS: Embase and Medline searches (2000 - 2017)were performed following Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Outcomes data extracted comprised firstly early mortality and major complications: stroke, spinal cord ischemia (SCI), dialysis, respiratory complications; secondly, late survival and reinterventions. Reintervention causes were divided into proximal, adjacent, distal. Comparative studies provided comparative meta-analyses. Non-comparative studies were analysed in pooled proportion meta-analyses for each group. RESULTS: 39 studies were identified: 10 OS, 25 ER, 4 comparative. Comparative studies meta-analyses revealed lower early mortality for ER (OR: 4.13, 95% CI: 1.10 - 15.4), stroke (OR: 4.33, 95% CI: 1.02-18.35), SCI (OR: 3.3, 95% CI: 0.97 - 11.25) and respiratory complications (OR: 6.88, 95% CI:1.52- 31.02), but higher reintervention rate (OR: 0.34, 95% CI: 0.16 - 0.69). Mid-term survival was similar (OR: 1.19, 95% CI:0.42 - 3.32). Non-comparative studies analyses showed distal causes as the principal reintervention indication in both groups: OS 73%; ER 59%. Reintervention procedures were mainly surgical for OS (85%), mainly endovascular for ER (75%). Rupture rates were: OS 1.2% , ER 3%. CONCLUSIONS: This recent non -randomised data shows early ER benefit, unsustained at mid-term. Reintervention is higher after ER, necessitating improved technique. However, OS is exempt neither from reintervention nor rupture. Both techniques have their place, but patient selection is key

Thresholds for Abdominal Aortic Aneurysm Repair in England and the United States.

Background Thresholds for repair of abdominal aortic aneurysms vary considerably among countries. Methods We examined differences between England and the United States in the frequency of aneurysm repair, the mean aneurysm diameter at the time of the procedure, and rates of aneurysm rupture and aneurysm-related death. Data on the frequency of repair of intact (nonruptured) abdominal aortic aneurysms, in-hospital mortality among patients who had undergone aneurysm repair, and rates of aneurysm rupture during the period from 2005 through 2012 were extracted from the Hospital Episode Statistics database in England and the U.S. Nationwide Inpatient Sample. Data on the aneurysm diameter at the time of repair were extracted from the U.K. National Vascular Registry (2014 data) and from the U.S. National Surgical Quality Improvement Program (2013 data). Aneurysm-related mortality during the period from 2005 through 2012 was determined from data obtained from the Centers for Disease Control and Prevention and the U.K. Office of National Statistics. Data were adjusted with the use of direct standardization or conditional logistic regression for differences between England and the United States with respect to population age and sex. Results During the period from 2005 through 2012, a total of 29,300 patients in England and 278,921 patients in the United States underwent repair of intact abdominal aortic aneurysms. Aneurysm repair was less common in England than in the United States (odds ratio, 0.49; 95% confidence interval [CI], 0.48 to 0.49; P<0.001), and aneurysm-related death was more common in England than in the United States (odds ratio, 3.60; 95% CI, 3.55 to 3.64; P<0.001). Hospitalization due to an aneurysm rupture occurred more frequently in England than in the United States (odds ratio, 2.23; 95% CI, 2.19 to 2.27; P<0.001), and the mean aneurysm diameter at the time of repair was larger in England (63.7 mm vs. 58.3 mm, P<0.001). Conclusions We found a lower rate of repair of abdominal aortic aneurysms and a larger mean aneurysm diameter at the time of repair in England than in the United States and lower rates of aneurysm rupture and aneurysm-related death in the United States than in England. (Funded by the Circulation Foundation and others.)

Endovascular aneurysm sealing for the treatment of ruptured abdominal aortic aneurysms.

PURPOSE: To assess the feasibility and report preliminary results of ruptured abdominal aortic aneurysm (rAAA) repair with endovascular aneurysm sealing (EVAS), a novel therapeutic alternative whose feasibility has not been established in rAAAs due to the unknown effects of the rupture site on the ability to achieve sealing. CASE REPORT: Between December 2013 and April 2014, 5 patients (median age 71 years, range 57-90; 3 men) with rAAAs were treated with the Nellix EVAS system at a single institution. Median aneurysm diameter was 70 mm (range 67-91). Aneurysm morphology in 4 of the 5 patients was noncompliant with instructions for use (IFU) for both EVAS and standard stent-grafts; the remaining patient was outside the IFU for standard stent-grafts but treated with EVAS under standard IFU for the Nellix system. Median Hardman index was 2 (range 0-3). Two patients died of multiorgan failure after re-laparotomy and intraoperative cardiac arrest, respectively. Among survivors, all devices were patent with no signs of endoleak or failed aneurysm sac sealing at 6 months (median follow-up 9.2 months). CONCLUSION: EVAS for the management of infrarenal rAAAs appears feasible. The use of EVAS in emergency repairs may broaden the selection criteria of the current endovascular strategy to include patients with more complex aneurysm morphology

Population-based study of mortality and major amputation following lower limb revascularization.

BACKGROUND: The aim of this study was to estimate separate risks of major lower limb amputation and death following revascularization for peripheral artery disease (PAD) using competing risks analysis. METHODS: Routinely collected data from Hospital Episode Statistics (HES) were used to identify patients who underwent endovascular or open lower limb revascularization for PAD in England from 2005 to 2015. The primary outcomes were major lower limb amputation and death within 5 years of revascularization. Cox proportional hazards and Fine-Gray competing risks regression were used to examine the competing risks of these outcomes. RESULTS: Some 164 845 patients underwent their first lower limb revascularization for PAD during the study interval. Most were men (64·6 per cent) and the median age was 71 (i.q.r. 62-78) years. Following endovascular revascularization, the 5-year cumulative incidence of amputation was 4·2 per cent in patients with intermittent claudication and 18·0 per cent in those with a record of tissue loss. The corresponding rates were 10·8 and 25·3 per cent respectively after open revascularization, and 8·1 and 25·0 per cent after combined procedures. The 5-year cumulative incidence of death varied from 24·5 to 39·8 per cent, depending on procedure type. Competing risks methods consistently produced lower estimates than standard methods. CONCLUSION: The 5-year risk of major amputation following lower limb revascularization for PAD appears lower than estimated previously. Patients undergoing revascularization for tissue loss and those who require an open procedure are at highest risk of limb loss

Long-term survival after endovascular and open repair of unruptured abdominal aortic aneurysm.

BACKGROUND: The aim of this study was to examine patterns of 10-year survival after elective repair of unruptured abdominal aortic aneurysms (AAAs) in different patient groups. METHODS: Patients having open repair or endovascular aneurysm repair (EVAR) in the English National Health Service between January 2006 and December 2015 were identified from Hospital Episode Statistics data. Postoperative survival among patients of different age and Royal College of Surgeons of England (RCS) modified Charlson co-morbidity score profiles were analysed using flexible parametric survival models. The relationship between patient characteristics and risk of rupture after repair was also analysed. RESULTS: Some 37 138 patients underwent elective AAA repair, of which 15 523 were open and 21 615 were endovascular. The 10-year mortality rate was 38·1 per cent for patients aged under 70 years, and the survival trajectories for open repair and EVAR were similar when patients had no RCS-modified Charlson co-morbidity. Among older patients or those with co-morbidity, the 10-year mortality rate rose, exceeding 70 per cent for patients aged 80 years. Mean survival times over 10 years for open repair and EVAR were often similar in subgroups of older and more co-morbid patients, but their survival trajectories became increasingly dissimilar, with open repair showing greater short-term risk within 6 months but lower 10-year mortality rates. The risk of rupture over 9 years was 3·4 per cent for EVAR and 0·9 per cent for open repair, and was weakly associated with patient factors. CONCLUSION: Long-term survival patterns after elective open repair and EVAR for unruptured AAA vary markedly across patients with different age and co-morbidity profiles

Association between statin-use and mobility and long-term survival after major lower limb amputation.

AIM: The aim of this study was to determine if there is an association between statin-use and prosthetic mobility and long-term survival in patients receiving rehabilitation after major amputation for lower limb arterial disease. METHODS: A retrospective analysis of prospectively maintained data (2008-2020) from a centre for rehabilitation was performed. Patients were grouped by statin-use status and sub-grouped by the combination of statin and antithrombotic drugs (antiplatelets or anticoagulants). Outcomes were prosthetic mobility (SIGAM score, timed-up-go and 2-min walking distance) and long-term survival. Regression, Kaplan-Meier and Cox-proportional hazard analyses were performed to test associations adjusted to confounders. RESULTS: Of 771 patients, 499 (64.7%) were on a statin before amputation or prescribed a statin peri-operatively. Rate of statin-use was significantly lower among female (53.3%) compared to male (68.2%) patients, P < 0.001. Statin-use was associated with significantly better prosthetic independence (53.1% vs 44.1%, P = 0.017), timed-up-go (mean difference of 4 s, P = 0.04) and long-term survival HR 0.59 (0.48-0.72, P < 0.001). Significance persisted after adjusting for confounding factors and in subgroup analyses. The combination of statin with antiplatelet was associated with the most superior survival, HR 0.51 (0.40-0.65, P < 0.001). Sensitivity analysis (exclusion of non-users of prosthesis) showed that statin-use remained a significant indicator of longer survival, maximally when combined with antiplatelet use HR 0.52 (0.39-0.68, P < 0.001). CONCLUSIONS: Statin-use is associated with better mobility and long-term survival in rehabilitees after limb loss, particularly when used in combination with antiplatelets. Significantly lower rates of statin-use were observed in female patients. Further research is warranted on gender disparities in statin-use and causality in their association with improved mobility and survival

Validity of Self-reported Healthcare Utilization Data in the Community Health Survey in Korea

To evaluate the sensitivity and specificity of Community Health Survey (CHS), we analyzed data from 11,217 participants aged ≥ 19 yr, in 13 cities and counties in 2008. Three healthcare utilization indices (admission, outpatient visits, dental visits) as comparative variables and the insurance benefit claim data of the Health Insurance Review & Assessment Service as the gold-standard were used. The sensitivities of admission, outpatient visits, and dental visits in CHS were 54.8%, 52.1%, and 61.0%, respectively. The specificities were 96.4%, 85.6%, and 82.7%, respectively. This is the first study to evaluate the validity of nationwide health statistics resulting from questionnaire surveys and shows that CHS needs a lot of efforts to reflect the true health status, health behavior, and healthcare utilization of the population