Editor's Choice - Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials.

OBJECTIVE: Current guidelines recommending rapid revascularisation of symptomatic carotid stenosis are largely based on data from clinical trials performed at a time when best medical therapy was potentially less effective than today. The risk of stroke and its predictors among patients with symptomatic carotid stenosis awaiting revascularisation in recent randomised controlled trials (RCTs) and in medical arms of earlier RCTs was assessed. METHODS: The pooled data of individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in four recent RCTs, and of patients randomised to medical therapy in three earlier RCTs comparing CEA vs. medical therapy, were compared. The primary outcome event was any stroke occurring between randomisation and treatment by CAS or CEA, or within 120 days after randomisation. RESULTS: A total of 4 754 patients from recent trials and 1 227 from earlier trials were included. In recent trials, patients were randomised a median of 18 (IQR 7, 50) days after the qualifying event (QE). Twenty-three suffered a stroke while waiting for revascularisation (cumulative 120 day risk 1.97%, 95% confidence interval [CI] 0.75 - 3.17). Shorter time from QE until randomisation increased stroke risk after randomisation (χ2 = 6.58, p = .011). Sixty-one patients had a stroke within 120 days of randomisation in the medical arms of earlier trials (cumulative risk 5%, 95% CI 3.8 - 6.2). Stroke risk was lower in recent than earlier trials when adjusted for time between QE and randomisation, age, severity of QE, and degree of carotid stenosis (HR 0.47, 95% CI 0.25 - 0.88, p = .019). CONCLUSION: Patients with symptomatic carotid stenosis enrolled in recent large RCTs had a lower risk of stroke after randomisation than historical controls. The added benefit of carotid revascularisation to modern medical care needs to be revisited in future studies. Until then, adhering to current recommendations for early revascularisation of patients with symptomatic carotid stenosis considered to require invasive treatment is advisable.

Functional Assessment and Evaluation of Outcome After Endovascular Therapy With Coverage of the Left Subclavian Artery in Case of Blunt Thoracic Aortic Injury.

BACKGROUND: Patients suffering blunt thoracic aortic injury (BTAI) can be treated by use of thoracic endovascular aortic repair (TEVAR). In this setting, the coverage of the left subclavian artery (LSA) is frequently necessary. Nevertheless, the functionality of the upper left extremity after TEVAR had been rarely analyzed. Thus, this study intends to underline the safety of TEVAR as well as to determine the functionality of the left arm after coverage of the LSA. METHODS: All patients suffering from BTAI treated by endovascular means in 3 centers (Aachen [Germany], Maastricht [Netherlands], and Innsbruck [Austria]) between 1996 and 2009 were retrospectively analyzed. The safety of the procedure had been assessed by the morbidity and mortality rate. The mid-term functional status of the upper left extremity was evaluated by using the DASH score (disabilities of the arm shoulder and hand). RESULTS: Forty-six patients (40 male, 6 female), mean age 39.4 ± 16.9 years suffered from BTAI caused by traffic accident (n = 31 [67.39%]), by skiing injury (n = 8 [17.39%]), and by fall (n = 7 [15.21%]). All patients underwent TEVAR, the technical success rate was 100%; 1 carotid-carotid subclavian bypass implantation was necessary. LSA coverage was performed in 76% (35/46) of the cases. Total complication rate was 17.3% (8/46); the endoleak rate was 8.6% (4/46) (2 × Ib, 1 × IIa, 1 × IV). Further complications were bypass and endograft occlusion. The postoperative mortality rate was 6% (3/46), the DASH score was completed in 65% (30/46). The study population reached a mean value of 17 ± 20, which is comparable to a nonharmed reference group (10.10 ± 14.68). A significant correlation between the DASH score and patients age could be demonstrated (2-sided P value: 0.0213). CONCLUSIONS: Endovascular therapy of BTAI revealed a good primary success rate. An adequate mid-term functional status of the upper left extremity could be assessed in comparison to a nonharmed reference group.

Macro- and microcirculatory assessment of cold sensitivity after traumatic finger amputation and microsurgical replantation.

INTRODUCTION: Finger replantations after traumatic amputation are associated with good prognosis and acceptable functional results. However, cold sensitivity is a common and sometimes disabling sequelae after digital replantation. The exact causes of cold intolerance are still unclear; neural as well as vascular mechanisms have been discussed. We examined the macro- and microvascular performance of replanted fingers using high-resolution color-coded sonography for the assessment of skin vessel density of the fingertips as well as nailfold capillary microscopy and laser Doppler anemometry. Subsequently, we correlated these findings with the presence of cold sensitivity of the replanted digits. PATIENTS AND METHODS: Thirty-seven patients (mean age 45 years; range 19-72) with 40 traumatic finger amputations and microsurgical replantations were studied. The mean time interval between amputation and examination was 57.7 months (range 13-95). Macro- and microvascular examination consisted of electronic oscillograms of both arms, photoplethysmograms of all fingers before and after cold test, duplex ultrasound of the finger arteries, high-resolution color-coded sonography of the fingertips and nailfold capillary microscopy with laser Doppler anemometry. RESULTS: Cold sensitivity was present in 33 (83%) of the 40 replanted fingers. Peripheral arterial disease of the upper extremity could be excluded as all oscillograms showed normal findings. A vasospastic reaction after cold test was documented in 74% (30 of 38) of the replanted fingers, compared to 24% (9 of 38) of the contralateral uninjured fingers. Raynaud's phenomenon was restricted to replanted fingers and occurred in 10 of 40 patients (25%). Compared with the contralateral fingertips, reduced skin vessel density was found in 27 of 36 (75%) replants. Nailfold capillary microscopy revealed uncharacteristic morphologic patterns. The capillary flow velocity was 0.28 +/- 0.12 mm/s in the replanted fingers and 0.48 +/- 0.23 mm/s in their unaffected counterparts (P < 0.001). Correlating these findings with the presence of cold intolerance, reduced skin vessel density in the fingertips was significantly different between cold-sensitive replants and those without cold sensitivity (P = 0.05). Reduced skin vessel density was not related to the extent of reconstruction of nerves (P = n.s.), arteries (P = n.s.) and veins (P = n.s.). CONCLUSIONS: Our results do not confirm hypotheses that cold sensitivity after finger replantations is caused by macrovascular problems nor do they support assumptions of a primary capillary microcirculatory failure. Our findings of reduced vessel density point towards diminished thermoregulatory capacities in the fingertips of cold-sensitive replanted digits.

Microcirculatory assessment of vascular acrosyndrome in anorexia nervosa and analysis of manifestation factors.

OBJECTIVE: Acrocyanosis (AC) is a common manifestation of starving syndrome in anorexia nervosa. We characterized microvascular changes associated with AC and determined discriminating factors between acrally symptomatic and nonsymptomatic patients. METHODS: We examined 34 patients with anorexia nervosa (15 restrictive-anorectic type, 19 binge-eating/purging type, duration 1-25 years). Nineteen were symptomatic (SP) and 15 were nonsymptomatic (NSP). All underwent photo-pletysmography, sonography of the brachial artery, capillary microscopy and laboratory analysis. RESULTS: Disease characteristics and body mass index did not differ between SP and NSP. In SP more dilated efferent capillary loops and venoles were present (P<.001) and capillary flow velocities were reduced (0.21+/-0.12 ml/min vs. 0.34+/-0.15 ml/min; P=.015). Flow-mediated and nitroglycerin-induced dilatation showed no differences. Symptomatic patients had lower leukocyte counts (P=.008), lower eosinophils (P=.003) and lower LDL (P=.045) concentrations. A logistic regression model identified only leukocytes (P=.017) and eosinophils (P=.023) to be associated with AC. CONCLUSIONS: In acrally symptomatic patients the typical microvascular features of AC are present. AC is associated with lower leukocyte counts and lower eosinophils.