Results of surgical management of acute thromboembolic lower extremity ischemia

ObjectiveAcute lower extremity ischemia secondary to arterial thromboembolism is a common problem. Contemporary data regarding this problem are sparse. This report examines a 10-year single-center experience and describes the surgical management and outcomes observed.MethodsProcedural codes were used to identify consecutive patients treated surgically for acute lower extremity embolization from January 2002 to September 2012. Patients presenting >7 days after onset of symptoms, occlusion of grafts/stents, and cases secondary to trauma or iatrogenic injury were excluded. Data collected included demographics, medical comorbidities, presenting clinical characteristics, procedural specifics, and postoperative outcomes. Results were evaluated using descriptive statistics, product-limit survival analysis, and logistic regression multivariable modeling.ResultsThe study sample included 170 patients (47% female). Mean age was 69.1 ± 16.0 years. Of these, 82 patients (49%) had a previous history of atrial fibrillation, and four (2%) were therapeutically anticoagulated (international normalized ratio ≥2.0) at presentation. Presentation for 83% was >6 hours after symptom onset, and 9% presented with a concurrent acute stroke. Femoral artery exploration with embolectomy was the most common procedural management and was used for aortic, iliac, and infrainguinal occlusion. Ten patients (6%) required bypass for limb salvage during the initial operation. Local instillation of thrombolytic agents as an adjunct to embolectomy was used in 16%, fasciotomies were performed in 39%, and unexpected return to the operating room occurred in 24%. Ninety-day amputation above or below the knee was required during the index hospitalization in 26 patients (15%). In-hospital or 30-day mortality was 18%. Median (interquartile range) length of stay was 8 days (4, 16 days), and 36% of patients were discharged to a nursing facility. Recurrent extremity embolization occurred in 23 patients (14%) at a median interval of 1.6 months. The 5-year amputation freedom and survival estimates were 80% and 41%, respectively. Predictors of 90-day amputation included prior vascular surgery, gangrene, and fasciotomy. Predictors of 30-day mortality included age, history of coronary artery disease, prior vascular surgery, and concurrent stroke.ConclusionsDespite advances in contemporary medical care, lower extremity arterial embolization remains a condition that is associated with significant morbidity and mortality. Furthermore, the condition is resource-intensive to treat and is likely preventable (initially or in recurrence) in a substantial subset of patients

An Interesting Case Highlighting Management of Pelvic Congestion Syndrome

INTRODUCTION: The development of valvular incompetence and/or obstruction in the pelvic and gonadal veins causing disabling symptoms comprises Pelvic Congestion Syndrome (PCS). It is a less known pathologic condition commonly occurring in women of child bearing age, and diagnosis can be challenging due to a variety of clinical presentations. Nutcracker syndrome (NCS) is a potential cause of PCS and involves compression of the left renal vein between the superior mesenteric artery and the aorta. We report one such case of a woman who presented with chronic pelvic pain. CASE DESCRIPTION: Our patient is a 31-year-old woman evaluated in our clinic with 6 years of unbearable back and suprapubic pain associated with dyspareunia and dysuria. She underwent evaluation by her gynecologist, and a transvaginal ultrasound demonstrated vaginal varicosities. Computed tomography angiogram (CTA) showed dilated left ovarian vein contiguous with left greater than right pelvic varicosities. We then performed a diagnostic venogram that demonstrated left pelvic venous plexus consistent with pelvic varicosities in the left ovarian vein and NCS anatomy. We decided to treat the PCS first. The patient underwent foam sclerotherapy of the pelvic venous plexus using 3cc of foam sclerosing agent (polidocanol) followed by coil embolization of the left ovarian vein. Post embolization venogram demonstrated radiographically successful treatment with no flow in the ovarian vein and preserved flow in the left renal vein. DISCUSSION: Chronic pelvic pain due to pelvic congestion is often associated with a constellation of symptoms including pelvic pain, dyspareunia, dysmenorrhea, and dysuria causing negative cognitive, behavioral, sexual and emotional consequences. There are three types of chronic pelvic pain, categorized by etiology. Type I is secondary to valvular incompetence of pelvic or ovarian veins, Type II is secondary to obstruction of outflow, and Type III is due to local compression. Venography is the gold standard for diagnosis. Treatment is directed at providing symptomatic relief with medical therapy, and treating the underlying cause by either endovascular (sclerotherapy and embolization, left renal venous stent placement) or open surgical techniques (including gonadal vein transposition, left renal vein transposition, or saphenous vein bypass).N

Renal Artery Stenosis and Obstructive Uropathy: To Resect or to Stent?

INTRODUCTION: Atherosclerotic renal artery stenosis causes hypertension that is resistant to medical management and may eventually lead to loss of kidney function. The treatment options for uncontrolled hypertension include best medical therapy (BMT), renal artery stenting (RAS), or surgical intervention; however, the optimal modality remains uncertain. This is the case of a patient with renal artery stenosis complicated by concurrent obstructive uropathy. CASE DESCRIPTION: Our patient is a 66-year-old male with a long-standing history of hypertension uncontrolled with BMT (beta blocker, angiotensin II receptor blocker (ARB) and a thiazide diuretic) and progressive renal insufficiency which was presumed to be due to prostatic obstructive uropathy. Despite undergoing a transurethral prostatectomy, his renal function continued to decline. A pelvic magnetic resonance angiogram (MRA) was performed which showed bilateral renal artery stenosis with the left being worse than the right. Computed tomography angiogram (CTA) was then performed which confirmed significant bilateral renal artery stenosis of 80 percent and 60 percent of the left and right renal artery respectively. The patient then underwent balloon angioplasty followed by stenting of both vessels without complication. Post-stenting angiography showed less than 30 percent stenosis of either vessel. During hospitalization, he had some improvement in his blood pressure, and his renal function was improved from baseline. One month follow up showed no significant change in blood pressure from initial visit prior to stenting. DISCUSSION: In healthy subjects, reduced renal perfusion lowers the glomerular filtration rate (GFR), causing a response by the renin-angiotensin-aldosterone system (RAAS) which leads to a compensatory increase in blood pressure. Although the GFR is reduced, renal parenchyma is able to adapt to reduced blood flow if perfusion pressure is reduced by 40 percent. There are a number of ways to manage renal artery stenosis, including RAS versus BMT. Currently, the effects of stenting are controversial and not fully understood. Multiple randomized trails have shown confounding results. Some trails have shown benefit in RAS, while others have demonstrated increase adverse outcomes due to renal reperfusion. In this case, we decided to to proceed with RAS given the significant stenosis on imaging, the patient's clinical presentation of worsening renal function despite BMT, and having ruled out other causes of progressive renal failure. The decision to intervene in these patients is usually determined on a case-by-case basis after discussion between surgeon, nephrologist and patient and after educating the patient on the risks and benefits.N

Management of Endoleak After Abdominal Aortic Aneurysm Repair

INTRODUCTION: Abdominal aortic aneurysm (AAA) represents a potentially life-threatening condition that requires proper surveillance and treatment. While AAA was historically treated by open surgical repair, technologic advances have resulted in Endovascular Aortic Aneurysm repair (EVAR) becoming the primary repair technique for AAA. Persistent endoleaks are a known complication of EVAR that often require additional intervention. We present a case highlighting the management of a Type 1B endoleak post-EVAR. CASE DESCRIPTION: Our patient is a 66-year-old male with history of EVAR at outside facility, and was evaluated in clinic with an enlarging iliac artery aneurysm. Computed tomography angiogram (CTA) demonstrated a 5cm aneurysmal degeneration of the right common iliac artery, most likely due to an endoleak in the distal portion of the stent (Type 1B). Due to the existing aortic endograft with a high flow divider, this required a combined axillary and femoral artery approach. The patient underwent placement of iliac branch endoprosthesis (IBE) at the right common iliac artery bifurcation with limb extension into both the external iliac and hypogastric arteries. Completion angiogram demonstrated successful extension of the endograft with exclusion of both the AAA and iliac aneurysm, preserved patency of the right hypogastric artery, and no endoleak. DISCUSSION: Endoleaks are a known complication of EVAR and frequently require intervention. There are multiple type of endoleak. Type 1 endoleaks denote leaks due to inadequate seal, and are divided further into 1A (proximal seal zone) and 1B (distal seal zone). Type II are due to branch vessel, type III endoleak are due to graft connection, and type IV due to graft porosity. The identification of location and type is frequently challenging and requires an angiogram. The management is based on the type of leak. Our patient had a type IB, due to leakage around the distal right common iliac limb. Relining the endograft with placement of an IBE device and extension of the stents into the external iliac and hypogastric arteries ensured development of adequate seal while preserving blood flow distally. With extensive pre-operative case planning and an intricate knowledge of the vascular anatomy, the modern vascular surgeon is equipped to provide advanced endovascular treatment options for complex vascular conditions.N

Thoracic Endovascular Repair of Descending Thoracic Aortic Thrombus

INTRODUCTION: Penetrating atherosclerotic ulcers (PAU) develop in the internal elastic lamina and indicate severe aortic atherosclerosis. PAU can have an associated intraluminal aortic thrombus, with associated risk of thromboembolism with subsequent mesenteric infarct and limb loss. We present a case of persistent descending thoracic aortic thrombus, with embolic renal infarcts, necessitating repair. CASE DESCRIPTION: A 80-year-old woman with history of bilateral renal infarcts on Eliquis and uncontrolled hypertension was referred to our department for extensive aortic atherosclerosis and 6mm ulceration proximal to the celiac artery, demonstrated on a CT. A follow up Computed Tomography Angiogram (CTA) demonstrated a persistent descending thoracic aortic thrombus and thoracic endovascular repair (TEVAR) was indicated. Preoperative imaging demonstrated >50% stenosis of the distal left common femoral artery (CFA). We accessed the proximal left CFA and subsequently placed stent grafts in the descending thoracic aorta, distally to proximally. Completion aortogram revealed complete occlusion in left external iliac artery. Doppler signals to the left foot were diminished on prompt exam. Current intraoperative imaging showed thromboembolism vs. flow-limiting dissection in the left CFA and external iliac arteries. Given these findings, an open endarterectomy of the iliac arteries was indicated, along with stent graft deployment in the left external iliac artery and bilateral stents in the common iliac arteries. A complete angiogram revealed a flow-limiting thromboembolism in the left superficial femoral artery (SFA). This was treated with covered stent placement, excluding the thrombus. Subsequent imaging demonstrated brisk flow into the left foot. On exam, pulses were palpable in the feet bilaterally and she moved all extremities. This patient had an uneventful hospital course and was discharge on postoperative day three. DISCUSSION: PAUs are a collective part of Acute Aortic Syndrome (AAS), seen in 2-8% of patients with AAS. PAUs develop from aortic mural thrombi, located most frequently in the abdominal aorta. A PAU > 4mm thick with ulceration is categorized as a complex plaque and warrants surgical repair. Anticoagulation is not sufficient for complex plaques. Endovascular repair (EVAR) is preferred to open since operating time is shorter, involves smaller incisions, and decreased hospital stay, with improved perioperative morbidity and all-cause mortality. Employing quality vascular access and wire manipulation can reduce endoleaks, access complications, and peripheral embolization. If complications arise, prompt imaging to access the stenotic vessels is necessary. This case demonstrates the potential morbidity of aortic thrombus embolization and the attention to detail required for successful treatment.N

Challenging Endovascular Retrieval of Multiple Well Incorporated Inferior Vena Cava Filters

INTRODUCTION: Inferior Vena Cava (IVC) filters are placed in patients to prevent pulmonary embolism in patients with recurrent deep venous thromboembolism or in high risk patients who cannot tolerate anticoagulation at their initial event. IVC filters are designed as either optional (retrievable) or permanent, and filter selection is based on the indication for placement. We present a case of complex retrieval of two IVC filters from the same patient with a history of chronic venous thromboembolism and post thrombotic syndrome. CASE DESCRIPTION: Our patient is a 63 year-old male with a remote history of trauma that resulted in chronic venous thromboembolism and post thrombotic syndrome of left lower extremity. He presents a rare case where he had two separate IVC filters placed during his treatment; initially, a permanent filter was placed, with an additional retrievable filter placed due to recurrent pulmonary emboli. He eventually tolerated anticoagulation, and wanted these filters removed due to their possible contribution to his chronic leg swelling and pain. From a right internal jugular vein approach, the retrievable superior filter was removed with the conventional snaring technique. We were unable to remove the second filter using conventional snare technique, as well as a through and through “flossing” approach from both jugular and femoral vein access points. We then proceeded with using a 16Fr laser extractor sheath with multiple laser treatments, followed by large aortic balloon expansion from the femoral access site, in an attempt to loosen the filter from the IVC sidewall. This combination of approaches did free the filter from the IVC wall, but the filter remained outside the sheath. Under fluoroscopic visualization, we brought the dislodged filter into the internal jugular vein and, after surgically exposing the vein, successfully removed the filter. Completion venogram confirmed removal of both filters without venous extravasation. DISCUSSION: This case illustrates the complexity in removing permanent IVC filters in select patients wherein the legs of the filter have embedded into the IVC wall. In patients with higher complexity of IVC filter removal, various methods have been described. Two advanced modes of extraction which are popular are the Endobronchial Forceps Extractions and the Laser-Assist Snare Extraction. Different devices have their unique characteristics and different failure modes. In patients with filter legs embedded in the vessel wall, a more robust approach with laser-assist, balloon endotraction, and external traction to free it from the IVC sidewall may be required for successful retrieval, as in this patient.N

The everchanging epidemiology of meningococcal disease worldwide and the potential for prevention through vaccination.

Neisseria meningitidis is a major cause of bacterial meningitis and septicaemia worldwide and is associated with high case fatality rates and serious life-long complications among survivors. Twelve serogroups are recognised, of which six (A, B, C, W, X and Y) are responsible for nearly all cases of invasive meningococcal disease (IMD). The incidence of IMD and responsible serogroups vary widely both geographically and over time. For the first time, effective vaccines against all these serogroups are available or nearing licensure. Over the past two decades, IMD incidence has been declining across most parts of the world through a combination of successful meningococcal immunisation programmes and secular trends. The introduction of meningococcal C conjugate vaccines in the early 2000s was associated with rapid declines in meningococcal C disease, whilst implementation of a meningococcal A conjugate vaccine across the African meningitis belt led to near-elimination of meningococcal A disease. Consequently, other serogroups have become more important causes of IMD. In particular, the emergence of a hypervirulent meningococcal group W clone has led many countries to shift from monovalent meningococcal C to quadrivalent ACWY conjugate vaccines in their national immunisation programmes. Additionally, the recent licensure of two protein-based, broad-spectrum meningococcal B vaccines finally provides protection against the most common group responsible for childhood IMD across Europe and Australia. This review describes global IMD epidemiology across each continent and trends over time, the serogroups responsible for IMD, the impact of meningococcal immunisation programmes and future needs to eliminate this devastating disease

Automated telephone communication systems for preventive healthcare and management of long-term conditions

Background Automated telephone communication systems (ATCS) can deliver voice messages and collect health-related information from patients using either their telephone’s touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention. Objectives To assess the effects of ATCS for preventing disease and managing long-term conditions on behavioural change, clinical, process, cognitive, patient-centred and adverse outcomes. Search methods We searched 10 electronic databases (the Cochrane Central Register of Controlled Trials; MEDLINE; Embase; PsycINFO; CINAHL; Global Health; WHOLIS; LILACS; Web of Science; and ASSIA); three grey literature sources (Dissertation Abstracts, Index to Theses, Australasian Digital Theses); and two trial registries (www.controlled-trials.com; www.clinicaltrials.gov) for papers published between 1980 and June 2015. Selection criteria Randomised, cluster- and quasi-randomised trials, interrupted time series and controlled before-and-after studies comparing ATCS interventions, with any control or another ATCS type were eligible for inclusion. Studies in all settings, for all consumers/carers, in any preventive healthcare or long term condition management role were eligible. Data collection and analysis We used standard Cochrane methods to select and extract data and to appraise eligible studies. Main results We included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty-one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long-term conditions, and seven studies for appointment reminders. We downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. We judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. We considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear. For preventive healthcare, ATCS (ATCS Plus, IVR, unidirectional) probably increase immunisation uptake in children (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty). For screening, multimodal ATCS increase uptake of screening for breast cancer (RR 2.17, 95% CI 1.55 to 3.04; 2 studies, N = 462; high certainty) and colorectal cancer (CRC) (RR 2.19, 95% CI 1.88 to 2.55; 3 studies, N = 1013; high certainty) versus usual care. It may also increase osteoporosis screening. ATCS Plus interventions probably slightly increase cervical cancer screening (moderate certainty), but effects on osteoporosis screening are uncertain. IVR systems probably increase CRC screening at 6 months (RR 1.36, 95% CI 1.25 to 1.48; 2 studies, N = 16,915; moderate certainty) but not at 9 to 12 months, with probably little or no effect of IVR (RR 1.05, 95% CI 0.99, 1.11; 2 studies, 2599 participants; moderate certainty) or unidirectional ATCS on breast cancer screening. Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls (low certainty). For long-term management, medication or laboratory test adherence provided the most general evidence across conditions (25 studies, data not combined). Multimodal ATCS versus usual care showed conflicting effects (positive and uncertain) on medication adherence. ATCS Plus probably slightly (versus control; moderate certainty) or probably (versus usual care; moderate certainty) improves medication adherence but may have little effect on adherence to tests (versus control). IVR probably slightly improves medication adherence versus control (moderate certainty). Compared with usual care, IVR probably improves test adherence and slightly increases medication adherence up to six months but has little or no effect at longer time points (moderate certainty). Unidirectional ATCS, compared with control, may have little effect or slightly improve medication adherence (low certainty). The evidence suggested little or no consistent effect of any ATCS type on clinical outcomes (blood pressure control, blood lipids, asthma control, therapeutic coverage) related to adherence, but only a small number of studies contributed clinical outcome data. The above results focus on areas with the most general findings across conditions. In condition-specific areas, the effects of ATCS varied, including by the type of ATCS intervention in use. Multimodal ATCS probably decrease both cancer pain and chronic pain as well as depression (moderate certainty), but other ATCS types were less effective. Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and diabetes mellitus. ATCS have little or no effect on outcomes related to heart failure, hypertension, mental health or smoking cessation, and there is insufficient evidence to determine their effects for preventing alcohol/ substance misuse or managing illicit drug addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, hypercholesterolaemia, obstructive sleep apnoea, spinal cord dysfunction or psychological stress in carers. Only four trials (3%) reported adverse events, and it was unclear whether these were related to the intervention

Albiglutide and cardiovascular outcomes in patients with type 2 diabetes and cardiovascular disease (Harmony Outcomes): a double-blind, randomised placebo-controlled trial

Background: Glucagon-like peptide 1 receptor agonists differ in chemical structure, duration of action, and in their effects on clinical outcomes. The cardiovascular effects of once-weekly albiglutide in type 2 diabetes are unknown. We aimed to determine the safety and efficacy of albiglutide in preventing cardiovascular death, myocardial infarction, or stroke. Methods: We did a double-blind, randomised, placebo-controlled trial in 610 sites across 28 countries. We randomly assigned patients aged 40 years and older with type 2 diabetes and cardiovascular disease (at a 1:1 ratio) to groups that either received a subcutaneous injection of albiglutide (30–50 mg, based on glycaemic response and tolerability) or of a matched volume of placebo once a week, in addition to their standard care. Investigators used an interactive voice or web response system to obtain treatment assignment, and patients and all study investigators were masked to their treatment allocation. We hypothesised that albiglutide would be non-inferior to placebo for the primary outcome of the first occurrence of cardiovascular death, myocardial infarction, or stroke, which was assessed in the intention-to-treat population. If non-inferiority was confirmed by an upper limit of the 95% CI for a hazard ratio of less than 1·30, closed testing for superiority was prespecified. This study is registered with ClinicalTrials.gov, number NCT02465515. Findings: Patients were screened between July 1, 2015, and Nov 24, 2016. 10 793 patients were screened and 9463 participants were enrolled and randomly assigned to groups: 4731 patients were assigned to receive albiglutide and 4732 patients to receive placebo. On Nov 8, 2017, it was determined that 611 primary endpoints and a median follow-up of at least 1·5 years had accrued, and participants returned for a final visit and discontinuation from study treatment; the last patient visit was on March 12, 2018. These 9463 patients, the intention-to-treat population, were evaluated for a median duration of 1·6 years and were assessed for the primary outcome. The primary composite outcome occurred in 338 (7%) of 4731 patients at an incidence rate of 4·6 events per 100 person-years in the albiglutide group and in 428 (9%) of 4732 patients at an incidence rate of 5·9 events per 100 person-years in the placebo group (hazard ratio 0·78, 95% CI 0·68–0·90), which indicated that albiglutide was superior to placebo (p<0·0001 for non-inferiority; p=0·0006 for superiority). The incidence of acute pancreatitis (ten patients in the albiglutide group and seven patients in the placebo group), pancreatic cancer (six patients in the albiglutide group and five patients in the placebo group), medullary thyroid carcinoma (zero patients in both groups), and other serious adverse events did not differ between the two groups. There were three (<1%) deaths in the placebo group that were assessed by investigators, who were masked to study drug assignment, to be treatment-related and two (<1%) deaths in the albiglutide group. Interpretation: In patients with type 2 diabetes and cardiovascular disease, albiglutide was superior to placebo with respect to major adverse cardiovascular events. Evidence-based glucagon-like peptide 1 receptor agonists should therefore be considered as part of a comprehensive strategy to reduce the risk of cardiovascular events in patients with type 2 diabetes. Funding: GlaxoSmithKline