Effects of atherectomy on major adverse limb events for femoropopliteal interventions: Vascular Quality Initiative registry.

BACKGROUND: Atherectomy use in treatment of femoropopliteal disease has significantly increased despite scant evidence of benefit to long-term clinical outcomes. AIMS: We investigated the clinical benefits of atherectomy over standard treatment for femoropopliteal interventions. METHODS: Using data from the Society of Vascular Surgery's Vascular Quality Initiative (VQI) registry, we identified patients who underwent isolated femoropopliteal interventions for occlusive disease. We compared 13,423 patients treated with atherectomy with 47,371 receiving standard treatment; both groups were allowed definitive treatment with a drug-coated balloon or stenting. The primary endpoint was major adverse limb events (MALEs), which is a composite of target vessel re-occlusion, ipsilateral major amputation, and target vessel revascularization. RESULTS: Mean age was 69 ± 11 years, and patients were followed for a median of 30 months. Overall rates of complications were slightly higher in the atherectomy group than the standard treatment group (6.2% vs. 5.9%, p < 0.0001). In multivariable analysis, after adjusting for demographic and clinical covariates, atherectomy use was associated with a 13% reduction in risk of MALEs (adjusted odds ratio [aOR]: 0.87; 95% confidence interval [CI]: 0.77-0.98). Rates of major and minor amputations were significantly lower in the atherectomy group (3.2% vs. 4.6% and 3.3% vs. 4.3%, respectively, both p < 0.001), primarily driven by a significantly decreased risk of major amputations (aOR 0.69; 95% CI: 0.52-0.91). There were no differences in 30-day mortality, primary patency, and target vessel revascularization between the atherectomy and standard treatment groups. CONCLUSIONS: In adults undergoing femoropopliteal interventions, the use of atherectomy was associated with a reduction in MALEs compared with standard treatment.

A legal perspective on athlete screening and disqualification.

Physicians participate in the screening, routine medical supervision, and disqualification of student-athletes. In doing so, they should understand that eligibility/disqualification decisions inevitably have associated liability issues. It is the responsibility of physicians to take the lead role in the student-athlete medical assessment process to allow for optimum safety in sports programmes. The first duty of the physician is to protect the health and well-being of the student-athlete. However, because there is potential liability associated with the screening/disqualification process, physicians are wise to develop sound and reasonable strategies that are in strict compliance with the standard of care. This article focusses on cardiac screening and disqualification for participation in sports.

Early Thoracic Endovascular Aortic Repair of Uncomplicated Type B Thoracic Aortic Dissection: An Aorta Team Approach.

BACKGROUND: Although uncomplicated Type B aortic dissection (uTBAD) is traditionally treated with optimal medical therapy (OMT) as per guidelines, recent studies, performed primarily in interventional radiology or surgical operating rooms, suggest superiority of thoracic endovascular aortic repair (TEVAR) over OMT due to recent advancements in endovascular technologies. We report a large, single-center, case control study of TEVAR versus OMT in this population, undertaken solely in a cardiac catheterization laboratory (CCL) with a cardiologist and surgeon. We aimed to determine if TEVAR for uTBAD results in better outcomes compared with OMT. METHODS: This was a retrospective chart review of all patients with uTBAD during the last 13 years, with 46 cases (TEVAR group) and 56 controls (OMT group). RESULTS: In the TEVAR group, the procedure duration of 2.5 hours resulted in 100% procedural success for stent placement, with 63% undergoing protective left subclavian artery bypass, 0% mortality or stroke, and a lower readmission rate (1 vs. 2%; p = 0.04 in early TEVAR cases), but a longer length of stay (12.9 vs. 8.5 days: p = 0.006). The risk of all-cause long-term mortality was markedly reduced in the TEVAR group (RR = 0.38; p = 0.01), irrespective of early (<14 days) versus late intervention. On follow-up computed tomography imaging, the false lumen stabilized or decreased in 85% of cases, irrespective of intervention timing. CONCLUSION: TEVAR performed solely in the CCL is safe and effective, with lower all-cause mortality than OMT. These data, in collaboration with previous data on TEVAR in different settings, call for consideration of an update of practice guidelines.

The ABCs of left ventricular assist device echocardiography: a systematic approach.

Echocardiography is an important imaging modality used to determine the indication of left ventricular assist device (LVAD) implantation for patients with advanced heart failure (HF) and for serial follow-up to make management decisions in patient care post-implant. Continuous axial-flow LVAD therapy provides effective haemodynamic support for the failing left ventricle, improving both the clinical functional status and quality of life. Echocardiographers must develop a systematic approach to echocardiographic assessment of LVAD implantation and post-LVAD implant cardiac morphology and physiology. This approach must include the evaluation of left and right heart chamber morphology and physiology and the anatomy and physiology of the inflow and outflow cannulas and the rotor pump, and the determination of the degree of tricuspid regurgitation and the presence of interatrial shunts and aortic regurgitation. Collaboration among the echocardiography and HF/transplant teams is essential to obtain this comprehensive evaluation. We outline a systematic approach to evaluating patients with HF who have failed conventional therapy and require LVAD therapy as a bridge to cardiac transplantation or destination therapy.

Abnormal cardiac structure and function in the metabolic syndrome: a population-based study.

OBJECTIVE: To measure the association between cardiac structure and function abnormalities and isolated metabolic syndrome (metabolic syndrome excluding established hypertension or diabetes mellitus). PARTICIPANTS AND METHODS: We collected data prospectively on a population-based random sample of 2042 Olmsted County, Minnesota, residents aged 45 years or older who underwent echocardiography between January 1, 1997, and September 30, 2000. Metabolic syndrome was defined by National Cholesterol Education Program Adult Treatment Panel III criteria. RESULTS: The prevalence of isolated metabolic syndrome was 21.7% (214/984) in men and 16.7% (177/1058) in women. Left ventricular (LV) mass index was greater (91.7 vs 87.9 g/m2; P=.04) and LV diastolic dysfunction more prevalent (28.2% [50/177] vs 14.9% [81/544]; P<.001) in women with isolated metabolic syndrome than in women without metabolic syndrome; no difference was found in men. When patients with hypertension or diabetes mellitus were included in the cohort, there was a stepwise increase in LV mass index and LV diastolic dysfunction from no metabolic syndrome to isolated metabolic syndrome to metabolic syndrome in women and men. CONCLUSION: Isolated metabolic syndrome, which is associated with increased LV mass index and LV diastolic dysfunction in women, identifies women with evidence of early ventricular dysfunction.