McDonough, E.B.

Wojtys, E.M.

Elsevier - Publisher Connector 

JOURNAL OF VASCULAR SURGERY
Volume 50, Number 6 Abstracts 1527likely place them into the 2% of patients who have a “high” annual effective
dose of radiation. Diagnostic cardiac catheterization has an average effective
dose of 7 mSv and a percutanous coronary intervention an average of effect
of 15 mSv. It is obvious vascular surgical patients may be among those most
intensively exposed to radiation through medical imaging procedures.
Fluvastatin and Perioperative Events in Patients Undergoing Vascular
Surgery
Schouten O, Boersma E, Hoeks SE and the Dutch Echocardiographic
Cardiac Risk Evaluation Applying Stress Echocardiography Study Group.
N Engl J Med 2009;361:980-9.
Conclusion: Perioperative fluvastatin therapy is associated with an
improvement in post-operative cardiac outcome in patients undergoing
vascular surgery.
Summary: To investigate the effects of statin medications on patients
undergoing vascular surgery the authors conducted the Dutch Echocardio-
graphic Cardiac Risk Evaluation Applying Stress Echocardiography III trial
(DECREASE III). The hypothesis was that perioperative statin therapy
would reduce post-operative incidents of cardiac events in patients under-
going elective vascular surgery.
This was a double blind placebo controlled trial where patients not
previously treated with a statin were, in addition to a beta blocker, random-
ized to either 80 mg of extended-release fluvastatin, or placebo, once daily
prior to undergoing vascular surgery. Lipid levels, interleukin-6 levels, and
C-reactive protein were measured at randomization, before surgery and in
follow-up. The primary endpoint was the occurrence of myocardial ischemia
defined as a release of troponin-T, transient electrocardiographic abnormal-
ities, or both, within 30 days of surgery. Secondary endpoint was a compos-
ite of death from cardiovascular causes and myocardial infarction.
There were 250 patients assigned to the fluvastatin group and 247 to
the placebo group. Randomization was a median of 37 days before vascular
surgery. In the fluvastatin group levels of low-density lipoprotein choles-
terol, total cholesterol, C-reactive protein and interleukin-6 were signifi-
cantly reduced but were unchanged in the placebo group. Myocardial
ischemia postoperatively occurred in 27 patients (10.8%) of the fluvastatin
group, and 47 patients (19.0%) of the placebo group (hazard ratio 0.55; 95%
CI, 0.34 to 0.88; p0.01). Death from myocardial infarction or cardiovas-
cular causes occurred in 12 patients (4.8%) in the fluvastatin group and in 25
patients (10.1% in the placebo group (hazard ratio, 0.47; 95% CI, 0.24 to
0.94; p0.03). There was no increase in adverse events in the fluvastatin
group compared to the placebo.
Comment: This paper provides the strongest evidence to date of the
benefits of statin therapy in patients undergoing vascular surgery. Statins
were beneficial in patients undergoing carotid endarterectomy, lower ex-
tremity revascularization and in patients undergoing both open and endo-
vascular aortic surgery. For several years vascular surgeons have thought that
whenever possible their patients should be on a statin medication prior to
operation. The type of medication and dosage was unknown. The current
study provides us at least some guidelines for one particular drug and one
particular dosage for patients undergoing primarily elective vascular surgery.
We still need additional data as to the minimal time preoperatively that
patients can be treated with statins to achieve what appears to be a plaque
stabilization effect.
High-Dose B Vitamin Supplementation and Progression of Subclinical
Atherosclerosis: A Randomized Controlled Trial
Hodis HN, Mack WJ, Dustin L, the BVAIT Research Group. Stroke
2009;40:730-6.
Conclusion: Dietary supplementation with high-dose B vitamins re-
duces progression of carotid intima media thickness in individuals with a
fasting total homocysteine  9.1 mol/L and who are at low risk for
cardiovascular disease.
Summary:Bothmeta-analysis and observational studies have indicated
that elevated total plasma homocysteine (tHcy) is an independent risk factor
for cardiovascular disease with risk increasing 40-60% for each 3-5 mol/L
increase in tHcy. However, clinical trials have failed to show reduction of
cardiovascular events with homocysteine lowering therapy. The B-vitamin
atherosclerosis intervention trial (BVAIT) assessed the impact on subclinical
atherosclerosis, in a population presumably free of cardiovascular disease, of
reducing total plasma homocysteine with B-vitamin supplementation.
This was a randomized double-blind placebo controlled trial con-
ducted from November 2000 to June 2006. Subjects were men and post-
menopausal women more than 40-years of age with fasting total homocys-
teine levels 8.5 mol/L. All subjects had no clinical signs or symptoms of
cardiovascular disease. Patients with diabetes, systolic blood pressures 160
mmHg, diastolic blood pressure  100 mmHg and creatinine clearance 
70 mL/min were excluded. There were 506 participants randomized to
high-dose of B-vitamin supplementation (5 mg folic acid  0.4 mg vitamin
B12  50 mg vitamin B6) or matching placebo for 3.1 years. Subclinical
atherosclerosis was assessed using carotid artery intima media thicknessvalues obtained with duplex scanning, the primary outcome measure. Mea-
surements of aortic and coronary artery calcification with multidetector
spiral CT scanning were secondary outcome measures. At follow-up there
was no statistical significant difference in the primary or secondary outcomes
comparing the patients with B-vitamin supplementation to those treated
with the placebo. A post-hoc analysis showed that subjects with baseline
tHcy’s  9.1 mol/L and randomized to B-vitamin supplementation had
statistically significant lower average rates of carotid intima media thickness
progression compared to the placebo group, p  0.02. Subjects with
baseline total homocysteines  9.1 mol/L had no treatment effect.
Comment: The authors contend that despite this being a post-hoc
analysis, their findings that vitamin-B supplementation can decrease carotid
intemia media thickness in individuals with fasting total homocysteine 9.1
mol/L is “highly relevant”. Perhaps this is true for the basic biology of
atherosclerosis but it is unlikely to have any clinical effect. Patients who had
decreases in carotid intimamedia thickness were an average age of 61-years and
had no signs of cardiovascular disease, no decrease in cardiovascular events, and
“benefitted” only by reduction in a subclinical marker of atherosclerosis. The
public health impact of these findings is likely to be nothing.
High Risk of Early Neurologic Recurrence in Symptomatic Carotid
Stenosis
Ois A, Cuadrado-Godia E, Rodriguez-Campello A, et al. Stroke 2009;40:
2727-31.
Conclusion: Patients with first mild stroke or TIA and significant
carotid stenosis are at high risk for neurologic recurrence, especially within
the first 72 hours of presentation.
Summary: Data from sub analysis of the European Carotid Surgery
Trial and the North American Symptomatic Carotid Endarterectomy Trial
have been evaluated to assess the risk of early stroke, defined as within two
weeks, after TIA or a mild stroke. These trials recruited only patients with
non-disabling stroke and therefore the number of patients who were not
included because of early recurrence or subsequent disability before time of
randomization is unknown. Recent studies have suggested a high recurrence
risk of neurologic events after a TIA or minor stroke (Stroke 2004; 35:2855-
2861, Brit Med J 2004; 328:326-328, and Neurology 2004; 62:569-573).
The authors of this paper sought to analyze recurrence risk for ischemic
events 72 hours, 7 days and 14 days in an unselected series of patients with
symptomatic,50% carotid stenosis and a first ever, non-disabling stroke or
TIA evaluated within the first 6 hours from onset of symptoms. There were
163 patients evaluated. Of these, 121 had an initial mild stroke and 42 had
a TIA. All were evaluated within 6 hours from onset of symptoms at a tertiary
care hospital. Neurologic recurrence was defined as a new neurologic event
(TIA or stroke) or an increase of 4 points in the initial National Institutes of
Health Stroke Scale. Neurology recurrence rates were determined at 72
hours, 7 days and 14 days. Patients were defined as disabled from their stroke
if they had a Rankin scale at 14 days of 3 to 6.
There were 45 patients (27.6%) that had a new neurologic event. Six
patients had two episodes at different time periods. Thirty-four events
(20.9%) occurred within the first 72 hours; 11 events (6.9%) occurred
between 72 hours and 7 days, and 6 events (3.7%) occurred at 14 days.
Carotid stenosis of 70% was associated with neurologic occurrence. Dia-
betes was marginally associated. At 2 weeks there were 19 patients (11.7%)
who had disability. Fourteen of these 19 patients had experience neurologic
recurrence within the first 72 hours.
Comment: Traditionally surgeons have been reluctant to intervene
acutely in a patient with a new stroke. In this study, however, only 2 patients
experienced non-disabling neurologic recurrence beyond 72 hours of symp-
toms. The results suggest the necessity of testing pharmacologic or inter-
ventional strategies to use in the hyperacute phase in patients with their
first-ever TIA or non-disabling stroke. Uurgent endovascular/surgical pro-
cedures in the first hours following presentation, which is clearly accepted in
other vascular pathologies such as coronary disease, needs to be evaluated in
a rigorous fashion in patient with acute neurologic events.
Multiligamentous Injuries of the Knee and Associated Vascular Injuries
McDonough EB, Wojtys EM. Am J Sports Med 2009;37:156-9.
Conclusion: Physical examination alone is not sufficient to detect the
majority of vascular surgery injuries after suspected knee dislocation.
Summary: The rate of injury to the popliteal artery from knee disloca-
tion varies widely from 7 to 80%. Evaluation of a patient with multiligament
damage of the knee and/or knee dislocation for the presence of vascular
injury is somewhat controversial. Traditionally, routine arteriography had
been advocated but more recently elective arteriography basing the decision
to proceed on arteriography on an abnormal physical examination or an
abnormal ankle-brachial index has been advocated. The authors sought to
report the frequency of vascular injuries in their patients with multiligament
injured knees and examine the role of arteriography in their treatment
protocol. This was a retrospective analysis of 71 patients over a 12 year
period of patients who had a diagnosis of multiligamentous injury of the
JOURNAL OF VASCULAR SURGERY
December 20091528 Abstractsknee with tibial-femoral dislocation documented by physical examination
and MRI.
There were 72 knee injuries involving multiple ligaments. In these 72
injured extremities, 12 vascular injuries were identified. Four of these were
identified by physical examination and 5 by routine arteriography. There
were 3 additional vascular injuries not identified by either preoperative
physical examination or arteriography. In the 4 patients who had an abnor-
mal physical examination at presentation, all underwent immediate revascu-
larization. The remaining 8 patients had normal pulses on initial examina-
tion. All underwent arteriography and 5 had vascular injuries detected by
arteriography and underwent successful repair. There were 3 patients who had
a normal physical examination and an arteriogram interpreted as normal but
who subsequently proved to have a popliteal artery injury. Two of the 3 patients
who had normal pulses and angiograms interpreted as normal had their popli-
teal artery injury discovered during release of the tourniquet following the repair
of their ligamentous injuries. The third patient developed a pseudoaneurysm
that bled following arthroscopic repair of the knee injury.
Comment:This is a selective series. There were no limb losses reported
with popliteal artery injury in this group of patients, suggesting significant
referral bias. However, it is important to note that both physical examination
and arteriography may not detect a popliteal artery injury occurring in the
setting of a knee dislocation. Despite normal arteriography and a normal
physical examination, delayed presentation of a popliteal artery injury does
happen. The take-home message here is that a single arteriogram or a single
physical examination is not sufficient to rule out popliteal artery injury in a
patient with a knee dislocation. Patients with knee dislocation should, at the
very least, be followed by serial physical examinations.
Prehospital HMG Co-A Reductase Inhibitor Use and Reduced Mor-
tality in Ruptured Abdominal Aortic Aneurysm
Feeney JM, Burns K, Staff I, et al. J Am College Surg 2009;209:41-6.Conclusion: In patients with ruptured abdominal aortic aneurysms
prehospital statin use appears to be associated with increased survival.Summary: One of the pleotrophic effects of statins appears to be
reduction of inflammatory mediators. These mediators include heat shock
proteins, tumor necrosis factor , multiple interleukins, nuclear factor  b, as
well as nitric oxide. Statins likely have free radical scavenger activity. Statins
also appear to exert anti-inflammatory and antioxidant affects that improve
mortality in septic shock populations and patients with severe sepsis who
were taking statins appear to develop septic shock less frequently. Theoret-
ically, similar shock mechanisms could be active in the setting of a ruptured
abdominal aortic aneurysm (rAAA).
The authors performed a retrospective review of their patients with
rAAAs from January 2000 to December 2008. They compared hospital and
ICU lengths of stay, cardiac morbidity, and number of cardiac events per
patient between survivor groups with and without pre hospital statin use.
Mortality, cardiac morbidity, and gender were also compared. The Physio-
logic Operative Severity Score for the Enumeration of Mortality and Mor-
bidity (POSSUM) was also calculated for all patients analyzed.
There are 121 records screened with 40 patients excluded due to the
presence of active cancer, chronic immune suppression or living wills or
advanced directives against live sustaining treatment,. There were no statis-
tically significant differences between statin users and non-users with respect
to age, gender and POSSUM scores. Mortality in the group without pre
hospital statin use was 63.8%. In the group with pre hospital statin use
mortality was 34.8% (p0.018, odds ratio 0.30 to 0.11). Hospital and ICU
lengths of stay, cardiac morbidity, and number of cardiac events per patient
were not statistically different among survivors.
Comment: This study provides further evidence for the ever-widening
pleotrophic effects of statin medications. It does have several limitations
including its small sample size and the fact that endovascular repair of
ruptured aneurysms and the use of statins increased over the study period.
Patients were included in this study if they used any statin at any dose for any
period of time up to their time of admission for rAAA. What is now needed
is prospective studies on dose related response and time delays in the
generation of the pleotrophic effects of statin medications.


Multiligamentous Injuries of the Knee and Associated Vascular Injuries 

file:///data/core-remote/dit/data/elsevier/pdf/d3c/aHR0cDovL2FwaS5lbHNldmllci5jb20vY29udGVudC9hcnRpY2xlL3BpaS9zMDc0MTUyMTQwOTAyMjM2OA==.pdf

Multiligamentous Injuries of the Knee and Associated Vascular Injuries

Abstract

Similar works

Full text

Available Versions

Elsevier - Publisher Connector