Isselbacher, E.M.

Nienaber, C.A.

Suzuki, T.

Elsevier - Publisher Connector 

Type-Selective Benefits of Medications in Treatment of Acute Aortic Dissection (from the International Registry of Acute Aortic Dissection [IRAD]) 

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JOURNAL OF VASCULAR SURGERY
April 20121220 Abstractsever, benefit is small and it has been calculated that to prevent one disabling
stroke over a 5-year period, approximately 32 CEAs need to be performed.
Current estimates are that with best medical treatment, stroke risk can be
reduced from approximately 2% per year, found in the randomized trials of
CEA for asymptomatic disease, to  1% per year with current best medical
management (Abbott AL. Stroke 2009;40:e573-e583; and Marquardt L.
Stroke 2010;41:e11-e17). The Asymptomatic Carotid Emboli Study
(ACES) found embolic signals detected with TCD on baseline recordings of
1 hour predicted stroke risk over a 2-year follow-up time (Markus HS.
Lancet Neurol 2010;9:663-71). The current study acknowledges embolic
signal detection is time consuming and sought to determine if similar
predictive information could be attained from simpler recording protocols.
This was a predefined secondary analysis of the ACES. The authors evaluated
temporal variation of embolic signals and attempted to determine predictive
yield associated with different recording protocols and/or a higher thresh-
old level of embolic signals to indicate increased risk ( two embolic
signals). Different recording protocols were compared using sensitivity and
specificity analysis from receiver operator characteristic curves. There were
477 patients in this study with asymptomatic carotid stenosis, 467 had
baseline TCD recordings adequate for analysis. Of these, 77 had embolic
signals on one or both of two 1-hour baseline recordings. Embolic signal
status on two recordings was significantly associated (P .0001). There was,
however, poor agreement between embolic signal positivity on the two
recordings (k  0.266). For the primary outcome of ipsilateral stroke or
transient ischemic attack, two baseline recordings lasting 1 hour had greater
predictive accuracy than either the first baseline recording alone (P 
.0005), a single 30-minute recording (P .0001), or two recordings lasting
30 minutes (P  .0001). For the outcome of ipsilateral stroke 2 recordings
lasting 1 hour had greater predictive accuracy when compared to all other
recording protocols (all P  .0001).
Comment: The elephant in the room is that if one decides to use TCD
embolic signal detection to predict stroke in patients with asymptomatic
carotid disease, application of the technique will be labor- and time-intensive
for vascular laboratories. It will also require experienced operators and
validation of commercially available embolic signal detection symptoms.
Given the low therapeutic index for CEA for patients with asymptomatic
stenosis, the time, effort, and cost may be worth it. However, it is unlikely
anyone is willing going to pay for this in the foreseeable future.
Adapted from Moneta G et al. 2012 Year Book of Vascular Surgery.
Philadelphia, PA: Elsevier; 2012; with permission.
Patients With Severe Asymptomatic Carotid Artery Stenosis Do Not
Have a Higher Risk of Stroke and Mortality After Coronary Artery
Bypass Surgery
Mahmoudi M, Hill PC, Xue Z, et al. Stroke 2011;42:2801-5.
Conclusion: Severe carotid artery stenosis is not a risk factor for
mortality or stroke in patients undergoing coronary artery bypass grafting
(CABG).
Summary: Strokes complicate CABG approximately 2% of the time
(Naylor AR, et. al. Eur J Vas Endovasc Surg. 2002; 23:283-294) and most
strokes complicating CABG occur within 24 hours of operation with mor-
tality rates of up to 25%. There is, therefore, controversy as to the preferred
management of patients undergoing CABG who have severe carotid artery
stenosis.
The authors performed a retrospective study of 778 patients with
carotid duplex ultrasound who underwent an isolated CABG procedure in
their institution from January 2003 to December 2009. There were 117
patients with severe carotid artery stenosis, defined as 75 % stenosis.
Patients with severe carotid artery stenosis were then compared to those
without severe carotid artery stenosis (n  761). Data were analyzed for
rates of stroke and mortality during hospitalization for CABG. 30 day
mortality was also recorded. Patients with severe carotid artery stenosis had
a higher prevalence of peripheral arterial disease, heart failure, and were
older. However, patients with severe carotid artery stenosis had similar rates
of in-hospital stroke (3.4% vs 3.6%; P  1.0) and mortality (3.4% vs 4.2%;
P  1.0) compared to patients without severe carotid artery stenosis. The
two groups also had similar 30-day mortality rates (3.4% for those with
severe carotid artery stenosis vs 2.9% for those without severe carotid artery
stenosis; P  .51).
Comment: Severe carotid artery stenosis was not associated with an
increased risk of in-hospital stroke, in-hospital mortality, or 30-day mortality
in this study following CABG. Ricotta et. al. determined the major morbid-
ity of combining carotid endarterectomy (CEA) with CABG relates to
patient comorbidities rather than the CEA (Ricotta JJ, et al. J Vasc Surg
2005;41:397-401). Others have found, however, similar to this study,
severe carotid artery stenosis does not significantly contribute to neurologic
complication rates following CABG. It would seem the preponderance of
the data would suggest CEA to increase safety of CABG is an ineffective, or
a t best a marginally effective, strategy. The decision to perform CEA is
probably best made on individual patient circumstances irrespective of the
need for coronary surgery.
p
cAdapted from Moneta G et al. 2012 Year Book of Vascular Surgery.
hiladelphia, PA: Elsevier; 2012; with permission.
ranscranial Doppler Ultrasounography for Diagnosis of Cerebral
asospasm After Aneurysmal Subarachnoid Hemorrhage: Mean Blood
low Velocity Ratio of the Ipsilateral and Contralateral Middle Cere-
ral Arteries
akae R, Yokota H, Yoshida D, et al. Neurosurgery 2011;69:876-82.
Conclusion:The ratio of the ipsilateral to contralateral middle cerebral
rtery (MCA) mean blood flow velocity has better correlation with clinical
eaningful consequences of cerebral vasospasm than absolute mean velocity
n the MCA.
Summary: Transcranial Doppler (TCD) is one of the areas of nonin-
asive testing subject to accreditation by the Intersocietal Commission for
ccreditation of Vascular Laboratories (ICAVL). Establishment of diagnos-
ic criteria for clinically meaningful end points is important in the accredita-
ion process. TCD is most frequently used to monitor for cerebral vaso-
pasm. Diagnostic criteria for cerebral vasospasm focus on absolute mean
elocities in the MCA or comparing of mean velocities in the ipsilateral MCA
ersus the ipsilateral extracranial internal carotid artery (ICA); the so called
indegaard ratio. A recent meta-analysis concluded TCD of the MCA has a
igh specificity (99%), a high positive predictive value (97%), but a low
ensitivity in detecting MCA vasospasm (Lysakowski C. Stroke 2001;32:
292-8). In an effort to improve sensitivity of TCD parameters in detecting
erebral vasospasm, the authors reviewed their patients with subarachnoid
emorrhage admitted to their institution from July 2003 to August 2009.
hey sought to determine the TCD parameter that was best associated with
elayed cerebral ischemia defined as a neurologic deficit or CT evidence of
erebral infarction secondary to vasospasm. They used both ipsilateral and
ontralateral MCA mean blood flow velocities with the ipsilateral mean flow
elocity defined as the side with the highest mean flow velocity and the
ontralateral side defined as the MCA with the lowest mean flow velocity.
eceiver operator characteristic (ROC) analysis was used to determine the
CD parameter best associated with delayed cerebral ischemia. There were
42 patients retrospectively analyzed with 1262 TCD studies. ROC curve
nalysis showed the overall predictive value for delayed cerebral infarction
ad an area under the curve of 0.86 (95% CI, 0.76-0.96) when the ipsilateral
ean blood flow velocity of the MCA was compared to the mean flow
elocity of the contralateral MCA. The area under the curve was 0.80 (0.71-
.88) when the absolute mean MCA flow velocity was used. Discrimination
etween patients with and without delayed cerebral infarction was best with
n ipsilateral to contralateral (I/C) mean blood flow velocity ratio of 1.5.
Comment: In this study, TCD had a higher sensitivity (77%) and
pecificity (80%) for detecting delayed cerebral ischemia when the I/C ratio
f mean blood flow velocities in the MCA was used. This ratio was more
losely related to clinically significant vasospasm than absolute mean blood
ow velocities. It would have been interesting if the authors had also
ompared the proposed I/C MCA mean blood flow velocity ratio with the
ore commonly employed Lindegaard ratio. Confirmation of vasospasm
ith angiography would also have contributed positively to the robustness
f the data. Nevertheless, the paper is valuable in purposing a new TCD
arameter that may have increased sensitivity in detection of cerebral vaso-
pasm.
Adapted from Moneta G et al. 2012 Year Book of Vascular Surgery.
hiladelphia, PA: Elsevier; 2012; with permission.
ype-Selective Benefits of Medications in Treatment of Acute Aortic
issection (from the International Registry of Acute Aortic Dissection
IRAD])
uzuki T, Isselbacher EM, Nienaber CA, et al. Am J Cardiol 2012;109:
22-7.
Conclusion: Beta blockers are associated with improved outcomes in
ll types of aortic dissection patients, including those managed operatively
nd nonoperatively. Calcium channel blockers are associated with improved
urvival overall in patients with type B dissection and those managed
onoperatively. Angiotensin converting enzyme inhibitors do not have an
ssociation with mortality.
Summary:Medical management of aortic dissection depends primarily
n opinion and historic observational studies (Hiratzka LF. Circulation
010;121:e266-e369). Beta blockers are generally regarded as first-line
edications and calcium channel blockers are also frequently employed.
ecent studies have also suggested benefit with inhibitors of the renin
ngiotensin system (Swada TE. Eur Heart J 2009;30:2461-9). The lack of
olid evidence of which drugs to employ for medical management of aortic
issection has led to disparate guidelines from various societies.
The authors analyzed data from the International Registry of Acute
ortic Dissection (IRAD) to try and better understand current approaches
o medical management and the effects of medications on outcomes in
atients with aortic dissection. IRAD is a multinational registry of 24 referral
enters in 12 countries. The authors used data from all patients with aortic
i
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JOURNAL OF VASCULAR SURGERY
Volume 55, Number 4 Abstracts 1221dissection who were enrolled in IRAD from December 26, 1995 with a
follow-up to 5 years who had follow-up data that included the use of
medications. There were records from 1301 patients available for analysis;
these included 722 with type A dissection and 572 with type B dissection.
Univariate analysis demonstrated beta blockers were associated with im-
proved survival in all patients (P  .03), in patients with type A dissection
overall (P  .02), and in patients with a type A dissection who receive
surgery (P  .006). Calcium channel blockers were associated with im-
proved survival in patients with type B dissection overall (P  .02) and in
patients with type B dissection receiving medical management (P  .03).
With multivariate modeling beta blockers were associated with improved
survival in those with type A dissection undergoing surgery (OR, 0.47; 95%
CI, 0.25 to 0.90; P  .02) and calcium channel blockers were associated
with improved survival in patients with type B dissection managed medically
(OR, 0.55; 95% CI, 0.35 to 0.88; P  .01). There was no association of
angiotensin converting enzyme inhibitors with mortality.
Comment: The bottom line, within the limitations of the data, is that
beta blockers are beneficial in all types of aortic dissection regardless of
operative or nonoperative management. However, calcium channel blockers
appear to be only beneficial in the medical management of type B dissection.
No benefit could be found for the use of ace inhibitors in patients with aortic
dissection. In patients with Marfan’s syndrome, however, recent studies
suggest benefit of ace inhibitors. A separate analysis of patients with Marfan’s
syndrome in IRAD was not performed in this study. The IRAD data predate
the more widespread use of angiotensin receptor blockers. The data also did
not allow authors to test the effects of drug combinations and varying
dosages on mortality.
Adapted from Moneta G et al. 2012 Year Book of Vascular Surgery.
Philadelphia, PA: Elsevier; 2012; with permission.
Vascular Trauma in Geriatric Patients: A National Trauma Databank
Review
Konstantinidis A, Inaba K, Dubose J, et al. J Trauma 2011;71:909-16.
Conclusion: In the geriatric patient, vascular trauma is uncommon
with most injuries being blunt and the thoracic aorta the most frequently
injured vessel. Vascular trauma in the geriatric patient is associated with a
fourfold increase in adjusted mortality compared to vascular trauma in the
nongeriatric patient. PSummary: There is little literature on the epidemiology of vascular
njuries in elderly patients with poor documentation of diagnosis, manage-
ent, and outcome of these injuries. In this study, the authors used the
ational Trauma Data Bank (NTDB), the largest trauma registry in the
nited States, to determine the epidemiology of vascular injuries in geriatric
atients and to compare geriatric vascular injuries to vascular injuries in
ounger adults. The authors compared incidence of injury, injury mecha-
ism, and outcome. Geriatric patients were defined as those 65 years or
lder. The “control” group was an adult cohort age 16 to 64 years. Vascular
njuries were determined from the NTDB, version 7.0, which contains
,861,779 medical records from 2002 to 2006. Patients were identified with
he use of the International Classification of Diseases, Ninth Revision
ICD9), codes 900.0 to 904.9. Patients of unknown age were excluded.
During this study period, there were 29,736 patients with a vascular
njury, 1.6% of the patients in the NTDB for the time considered. Of the
atients identified with vascular injury, geriatric patients accounted for 7.6%
n  2268) and nongeriatric adult patients accounted for 83.1% (n 
4,703). Geriatric vascular injury patients had a higher injury severity score
ompared to nongeriatric vascular injury patients (26.6 17 vs 21.3 16.7;
 .001). Geriatric patients were less frequently victims of penetrating
njuries (16.1% vs 54.1%; P  .001). The thoracic aorta, inominate and
ubclavian vessels, and other vessels of the chest were the most commonly
njured vessels in the elderly (n  637, 40.2%). The incidence of thoracic
ortic injuries was higher in geriatric patients compared to nongeriatric
atients (33.0% vs 13.9%; P  .001). This incidence increased linearly with
ge. Adjusting for confounding variables, geriatric patients had a fourfold
ncrease in mortality following vascular injuries (OR, 3.9; 95%CI, 3.32-4.58;
 .001). The most common mechanism of injury in the geriatric patient
as a motor vehicle accident, with falls being the second most common
echanism of injury.
Comment:This is likely the largest examination of the epidemiology of
eriatric vascular trauma available. There are obvious limitations. The study
s retrospective and dependent on accurate data from more than 900 trauma
enters in the NTDB. Nevertheless, we can conclude vascular trauma in the
lderly is infrequent compared to younger patients, there is predominately a
lunt mechanism of vascular trauma in the elderly, the thoracic aorta is the
ost frequently injured vessel, and there is the increased relative mortality of
ascular injury in the elderly.
Adapted from Moneta G et al. 2012 Year Book of Vascular Surgery.
hiladelphia, PA: Elsevier; 2012; with permission.


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Type-Selective Benefits of Medications in Treatment of Acute Aortic Dissection (from the International Registry of Acute Aortic Dissection [IRAD])

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