Comparison of haemodynamic parameters between the high and low spinal block in young healthy patients

Background. For some surgical procedures a higher sensory block is needed. However, it is complicated by a higher incidence of hypotension, more bradycardia and nausea and a higher use of vasoactive drugs. In elderly and obstetric population complications have been attributed to the decrease in cardiac output and systemic vascular resistance, especially in a high block (above Th6). The aim of our study was to find the incidence of hypotension and bradycardia after a spinal anaesthesia in young, healthy patients. As young patients compensate more, we aimed to find the difference in haemodynamic variables between the group with a high and the group with a low spinal block and the underlying mechanisms of hypotension. Methods. In a prospective, randomized study 44 American Society of Anaesthesiologists (ASA) 1 patients scheduled for knee arthroscopy under spinal anaesthesia were randomly distributed to a high (group H) and a low (group L) spinal block group. In a group H patients were placed into horizontal, whereas in a group L in 15-degree anti-Trendelenburg position immediately after the spinal block. Haemodynamic parameters were measured continuously noninvasively from 10 min before to 25 min after the spinal block using the CNAPTM device with the LiDCORapid monitor. Results. The differences in haemodynamic parameters between the groups were not statistically significant at all measured times despite a significant difference in the spinal block level (18.5 vs 13.3 dermatomes above S5, p<0.001) and a significant difference in haemodynamic variables inside each group compared to the baseline value. With cardiac index (CI) as a dependent variable, a significant correlation between CI and stroke volume index (SVI) was found (β=0.849, p<0.001) and also between CI and heart rate (HR) (β=0.573, p<0.001). In group H the incidence of hypotension was 35%, whereas in group L it was 10%. The same difference was seen in the use of phenylephrine between the groups, however the difference was not significant. Conclusion. In our study it was found that in young, healthy patients there are no significant differences in haemodynamic parameters and in incidence of hypotension between a high and low spinal block. Young, healthy patients compensate a decrease in systemic vascular resistance caused by the spinal anaesthesia with a compensatory increase in CI resulting from an increase in SVI and HR. However, a trend towards less hypotension, less bradycardia and less frequent phenylephrine use in a low spinal block was noted

Non-coronary atherosclerosis

During the last decades, the clinical and research interest in atherosclerosis has been mostly focused on coronary arteries. After the publications of the European Society Guidelines and AHA/ACC Guidelines on Peripheral artery diseases, and of the Registry REduction in Atherothrombosis for Continued Health Registry, there has been an increased interest in atherosclerosis of the lower extremity arteries and its presence in multifocal disease. However, awareness in the general population and the medical community of non-coronary artery diseases, and of its major prognostic implications remain relatively low. The aim of this general review stemming out of an ESC Working Group on Peripheral Circulation meeting in 2011 is to enhance awareness of this complex disease highlighting the importance of the involvement of atherosclerosis at different levels with respect to clinical presentation, diagnosis, and co-existence of the disease in the distinct arterial territories. We also emphasize the need of an interdisciplinary approach to face the broad and complex spectrum of multifocal disease, and try to propose a series of tentative recommendations and measures to be implemented in non-coronary atherosclerosi

Optimal management of asymptomatic carotid stenosis in 2021: the jury is still out. An International, multispecialty, expert review and position statement

Objectives: The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. Materials and methods: A literature review was performed with a focus on data from recent studies. Results: Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. Conclusions: Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients

Optimal Management of Asymptomatic Carotid Stenosis in 2021:The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement

Objectives: The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. Materials and methods: A literature review was performed with a focus on data from recent studies. Results: Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80–99% ACS indicate a higher stroke risk than 50–79% stenoses. Conclusions: Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients

Practical Recommendations for Optimal Thromboprophylaxis in Patients with COVID-19: A Consensus Statement Based on Available Clinical Trials.

Coronavirus disease 2019 (COVID-19) has been shown to be strongly associated with increased risk for venous thromboembolism events (VTE) mainly in the inpatient but also in the outpatient setting. Pharmacologic thromboprophylaxis has been shown to offer significant benefits in terms of reducing not only VTE events but also mortality, especially in acutely ill patients with COVID-19. Although the main source of evidence is derived from observational studies with several limitations, thromboprophylaxis is currently recommended for all hospitalized patients with acceptable bleeding risk by all national and international guidelines. Recently, high quality data from randomized controlled trials (RCTs) further support the role of thromboprophylaxis and provide insights into the optimal thromboprophylaxis strategy. The aim of this statement is to systematically review all the available evidence derived from RCTs regarding thromboprophylaxis strategies in patients with COVID-19 in different settings (either inpatient or outpatient) and provide evidence-based guidance to practical questions in everyday clinical practice. Clinical questions accompanied by practical recommendations are provided based on data derived from 20 RCTs that were identified and included in the present study. Overall, the main conclusions are: (i) thromboprophylaxis should be administered in all hospitalized patients with COVID-19, (ii) an optimal dose of inpatient thromboprophylaxis is dependent upon the severity of COVID-19, (iii) thromboprophylaxis should be administered on an individualized basis in post-discharge patients with COVID-19 with high thrombotic risk, and (iv) thromboprophylaxis should not be routinely administered in outpatients. Changes regarding the dominant SARS-CoV-2 variants, the wide immunization status (increasing rates of vaccination and reinfections), and the availability of antiviral therapies and monoclonal antibodies might affect the characteristics of patients with COVID-19; thus, future studies will inform us about the thrombotic risk and the optimal therapeutic strategies for these patients

Static and rotating active magnetic regenerators with porous heat exchangers for magnetic cooling

The operation behaviour of an active magnetic regenerator (AMR) with a wavy-structure, or a honeycomb-like regenerator bed was numerically investigated. The thermodynamic model was applied to a static regenerator and – in a generalized version – to a rotary type. The models take two-dimensional unsteady heat conduction in the magnetic material during the four basic processes of the AMR cycle into account. The numerical results were used to determine optimal arrangements of different magnetic materials in order to obtain larger temperature spans between both ends of the porous beds. Furthermore, a first study of magnetic flux lines in a porous rotary heat exchanger was performed

The Post-thrombotic Syndrome-Prevention and Treatment: VAS-European Independent Foundation in Angiology/Vascular Medicine Position Paper

Importance: The post-thrombotic syndrome (PTS) is the most common long-term complication of deep vein thrombosis (DVT), occurring in up to 40-50% of cases. There are limited evidence-based approaches for PTS clinical management. Objective: To provide an expert consensus for PTS diagnosis, prevention, and treatment. Evidence-review: MEDLINE, Cochrane Database review, and GOOGLE SCHOLAR were searched with the terms "post-thrombotic syndrome" and "post-phlebitic syndrome" used in titles and abstracts up to September 2020. Filters were: English, Controlled Clinical Trial / Systematic Review / Meta-Analysis / Guideline. The relevant literature regarding PTS diagnosis, prevention and treatment was reviewed and summarized by the evidence synthesis team. On the basis of this review, a panel of 15 practicing angiology/vascular medicine specialists assessed the appropriateness of several items regarding PTS management on a Likert-9 point scale, according to the RAND/UCLA method, with a two-round modified Delphi method. Findings: The panelists rated the following as appropriate for diagnosis: 1-the Villalta scale; 2- pre-existing venous insufficiency evaluation; 3-assessment 3-6 months after diagnosis of iliofemoral or femoro-popliteal DVT, and afterwards periodically, according to a personalized schedule depending on the presence or absence of clinically relevant PTS. The items rated as appropriate for symptom relief and prevention were: 1- graduated compression stockings (GCS) or elastic bandages for symptomatic relief in acute DVT, either iliofemoral, popliteal or calf; 2-thigh-length GCS (30-40 mmHg at the ankle) after ilio-femoral DVT; 3- knee-length GCS (30-40 mmHg at the ankle) after popliteal DVT; 4-GCS for different length of times according to the severity of periodically assessed PTS; 5-catheter-directed thrombolysis, with or without mechanical thrombectomy, in patients with iliofemoral obstruction, severe symptoms, and low risk of bleeding. The items rated as appropriate for treatment were: 1- thigh-length GCS (30-40 mmHg at the ankle) after iliofemoral DVT; 2-compression therapy for ulcer treatment; 3- exercise training. The role of endovascular treatment (angioplasty and/or stenting) was rated as uncertain, but it could be considered for severe PTS only in case of stenosis or occlusion above the inguinal ligament, followed by oral anticoagulation. Conclusions and relevance: This position paper can help practicing clinicians in PTS management.</p

Recent Advances and Controversial Issues in the Optimal Management of Asymptomatic Carotid Stenosis

Objective: The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of AsxCS patients. Methods: A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: "asymptomatic carotid stenosis", "carotid endarterectomy" (CEA), "carotid artery stenting" (CAS) and "transcarotid artery revascularization" (TCAR). Areas covered included: i) improvements in best medical treatment (BMT) for AsxCS patients and declining stroke risk, ii) technological advances in surgical/endovascular skills/techniques and outcomes, iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and, iv) the association between cognitive dysfunction and AsxCS. Results: BMT is essential for all AsxCS patients, regardless of whether they will eventually be offered CEA/CAS/TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These include patients with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound, silent infarcts on brain CTA/MRA scans, reduced cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration and intraplaque hemorrhage. Treatment of AsxCS patients should be individualized, taking into consideration individual patient preferences/needs, clinical/imaging characteristics, and cultural/ethnic/social factors. Solid evidence supporting/refuting an association between AsxCS and cognitive dysfunction is lacking. Conclusions: The optimal management of AsxCS patients should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA/CAS/TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs/preference, clinical/imaging characteristics, social/cultural factors and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression/reversal of cognitive dysfunction

International Union of Angiology (IUA) position statement on no-option chronic limb threatening ischemia

This position paper, written by members of International Union of Angiology (IUA) Youth Committee and senior experts, shows an overview of therapeutical approaches for patients with Chronic Limb-Threatening Ischemia (CLTI) and absence of 'standard' solutions for revascularization. The aim is to demonstrate the accurate management of the 'no-option' CLTI patient including the wound treatment and the rehabilitation, considering always the goal of the increase of quality of life of the patients