Polyvascular Atherosclerotic disease: Echocardiographic and metabolic determinants of adverse cardiac outcome

Peripheral Arterial Disease (PAD) is a multifactorial syndrome that most commonly affects people over 60 years of age. With the aging of the population, the prevalence of atherosclerotic disease and its associated adverse outcomes will increase. It has to be noted that the process of established atherothrombosis is not limited to a single arterial location, giving it the character of a systemic and generalized disease. The Reduction of Atherothrombosis for Continued Health (REACH) registry demonstrated that one out of six patients with (i) PAD, (ii) cerebrovascular disease, or (iii) coronary artery disease had involvement of one or two other arterial beds. Importantly, the presence of multiple affected arterial territories, called polyvascular disease, has been demonstrated to be an independent predictor of long-term cardiovascular outcome in the general population. In response to studies demonstrating the adverse prognosis of atherosclerotic disease, the need for adequate risk factor stratification and reduction has emerged. The importance of risk factor reduction in patients with PAD has resulted in universally recommended atherothrombotic risk factor reduction, with the objective of decreasing the high incidence of heart disease and cerebrovascular disease associated with PAD. In patients with PAD scheduled for vascular surgery, risk factor stratification is directed at the detection of (a)symptomatic atherosclerotic disease in other vascular beds than the primary symptomatic arterial location. Early detection of polyvascular atherosclerotic disease has important consequences for risk factor reduction strategies, including life-style interventions and medical therapy

Timing of Pre-Operative Beta-Blocker Treatment in Vascular Surgery Patients Influence on Post-Operative Outcome

ObjectivesThis study evaluated timing of β-blocker initiation before surgery and its relationship with: 1) pre-operative heart rate and high-sensitivity C-reactive-protein (hs-CRP) levels; and 2) post-operative outcome.BackgroundPerioperative guidelines recommend β-blocker initiation days to weeks before surgery, on the basis of expert opinions.MethodsIn 940 vascular surgery patients, pre-operative heart rate and hs-CRP levels were recorded, next to timing of β-blocker initiation before surgery (0 to 1, >1 to 4, >4 weeks). Pre- and post-operative troponin-T measurements and electrocardiograms were performed routinely. End points were 30-day cardiac events (composite of myocardial infarction and cardiac mortality) and long-term mortality. Multivariate regression analyses, adjusted for cardiac risk factors, evaluated the relation between duration of β-blocker treatment and outcome.ResultsThe β-blockers were initiated 0 to 1, >1 to 4, and >4 weeks before surgery in 158 (17%), 393 (42%), and 389 (41%) patients, respectively. Median heart rate at baseline was 74 (±17) beats/min, 70 (±16) beats/min, and 66 (±15) beats/min (p < 0.001; comparing treatment initiation >1 with <1 week pre-operatively), and hs-CRP was 4.9 (±7.5) mg/l, 4.1 (±.6.0) mg/l, and 4.5 (±6.3) mg/l (p = 0.782), respectively. Treatment initiated >1 to 4 or >4 weeks before surgery was associated with a lower incidence of 30-day cardiac events (odds ratio: 0.46, 95% confidence interval [CI]: 0.27 to 0.76, odds ratio: 0.48, 95% CI: 0.29 to 0.79) and long-term mortality (hazard ratio: 0.52, 95% CI: 0.21 to 0.67, hazard ratio: 0.50, 95% CI: 0.25 to 0.71) compared with treatment initiated <1 week pre-operatively.ConclusionsOur results indicate that β-blocker treatment initiated >1 week before surgery is associated with lower pre-operative heart rate and improved outcome, compared with treatment initiated <1 week pre-operatively. No reduction of median hs-CRP levels was observed in patients receiving β-blocker treatment >1 week compared with patients in whom treatment was initiated between 0 and 1 week before surgery

Colorectal liver metastases: Surgery versus thermal ablation (COLLISION) - a phase III single-blind prospective randomized controlled trial

Background: Radiofrequency ablation (RFA) and microwave ablation (MWA) are widely accepted techniques to eliminate small unresectable colorectal liver metastases (CRLM). Although previous studies labelled thermal ablation inferior to surgical resection, the apparent selection bias when comparing patients with unresectable disease to surgical candidates, the superior safety profile, and the competitive overall survival results for the more recent reports mandate the setup of a randomized controlled trial. The objective of the COLLISION trial is to prove non-inferiority of thermal ablation compared to hepatic resection in patients with at least one resectable and ablatable CRLM and no extrahepatic disease. Methods: In this two-arm, single-blind multi-center phase-III clinical trial, six hundred and eighteen patients with at least one CRLM (≤3cm) will be included to undergo either surgical resection or thermal ablation of appointed target lesion(s) (≤3cm). Primary endpoint is OS (overall survival, intention-to-treat analysis). Main secondary endpoints are overall disease-free survival (DFS), time to progression (TTP), time to local progression (TTLP), primary and assisted technique efficacy (PTE, ATE), procedural morbidity and mortality, length of hospital stay, assessment of pain and quality of life (QoL), cost-effectiveness ratio (ICER) and quality-adjusted life years (QALY). Discussion: If thermal ablation proves to be non-inferior in treating lesions ≤3cm, a switch in treatment-method may lead to a reduction of the post-procedural morbidity and mortality, length of hospital stay and incremental costs without compromising oncological outcome for patients with CRLM. Trial registration:NCT03088150 , January 11th 2017