Ultrasound-accelerated thrombolysis in arterial and venous peripheral occlusions: fibrinogen level effects.

PURPOSE: This study retrospectively assesses whether significantly accelerating thrombolysis with ultrasound affects fibrinogen levels in the treatment of peripheral arterial occlusions. MATERIALS AND METHODS: Between December 2005 and August 2007, 38 limbs in 38 patients (17 women; mean age, 60.5 +/- 19.7 years; age range, 17-94 years) were treated with ultrasound-accelerated thrombolysis for peripheral arterial occlusion (PAO) and deep vein thrombosis (DVT), with serum fibrinogen levels measured at baseline and every 24 hours. All occlusions were treated with alteplase (0.5-1.0 mg/h). RESULTS: Complete or partial lysis was achieved in 92.1% of patients. All patients received thrombolytic therapy with mean infusion time of 42.3 hours (range, 20-96 hours). As part of standard clinical practice, patients were not assessed angiographically overnight. Mean total alteplase dose was 40.6 mg (range, 18-96 mg). Across all patients, the fibrinogen level at the end of infusion decreased by an average of 18.5% from baseline, and no patient exhibited a fibrinogen level < 100 mg/dL during treatment. Fibrinogen depletion was more pronounced among patients with venous occlusions (26.4% from baseline) than those with arterial occlusions (15.8% from baseline). No major hemorrhagic complications occurred. One patient (2.6%) experienced a minor bleeding event at the access site, and use of thrombolytics was discontinued; and one patient with a chronic arterial occlusion and underlying coronary disease who did not respond to thrombolytic therapy, experienced an acute myocardial infarction. Of documented 30-day clinical outcomes in 20 patients, 80.0% remained patent at 30 days. CONCLUSIONS: Ultrasound-accelerated thrombolysis for the treatment of PAO and DVT is associated with a very low complication rate and nominal fibrinogen depletion.

One-year cognitive outcomes associated with carotid artery stent placement.

PURPOSE: To assess relatively long-term (ie, 1 year) neurocognitive outcomes of patients undergoing carotid artery stent (CAS) placement with cerebral protection. MATERIALS AND METHODS: Sixty-two patients (19 symptomatic; mean age, 73 years) with significant carotid stenosis (> or = 70% for symptomatic patients, > or = 80% for asymptomatic patients) underwent CAS placement with embolic protection. Cognitive function was assessed prospectively with use of a battery of standardized tests administered at baseline (1-5 days before CAS endovascular therapy) and at 3, 6, and 12 months after CAS placement. Diffusion-weighted imaging (DWI) was performed before the procedure and within 24 hours after CAS placement. RESULTS: Results of statistical modeling across occasions of measurement indicated significant main effects of occasion for the Dementia Rating Scale (DRS)-2 concept formation (P < .001), memory (P = .029), and total scores (P = .001); the DRS-2 total age- and education-corrected Mayo Older Americans Normative Studies score (P < .001); and the North American Adult Reading Test IQ score (P = .003). The vast majority of patients showed improvement or no change relative to baseline DRS-2 total scores at all time points. No significant relationship between DWI outcomes and cognition scores over time was found. Age influenced improvement on cognitive tests, whereas baseline symptom status did not. CONCLUSIONS: Revascularization with a carotid stent and neuroprotection, at a minimum, left cognitive function unchanged in patients receiving a CAS, and in many instances improved it. The preliminary findings of this prospective pilot study should be confirmed with a larger, controlled trial.

Clinical evaluation of the Zilver vascular stent for symptomatic iliac artery disease.

PURPOSE: To evaluate the safety and effectiveness of the Zilver vascular stent in the treatment of de novo or restenotic lesions in the external and common iliac arteries. MATERIALS AND METHODS: Regardless of the results of an initial percutaneous transluminal angioplasty (PTA), 151 consecutive patients were implanted with Zilver vascular stents (Cook, Bloomington, Ind) in up to two stenotic (< or =10 cm) or occluded (< or =5 cm) atherosclerotic lesions of the external or common iliac arteries. The primary endpoint was the rate of major adverse events within 9 months after the procedure. Major adverse events were defined as death, myocardial infarction, target lesion revascularization, and limb loss. Secondary endpoints included acute procedural success, 30-day clinical success, 9-month patency rate, 9-month functional status (on the basis of the validated Walking Impairment Questionnaire), and ankle-brachial index (ABI). RESULTS: of 1-, 6-, and 9-month follow-up are reported. Results The 9-month device and/or procedural-related major adverse event rate (adjudicated by an independent clinical events committee) was 2.7%. The all-cause major adverse event rate was 7.5%. Both rates were substantially below the prespecified objective performance criterion of 16%. The acute procedure success rate and 30-day clinical success rate were 98.0% and 94.0%, respectively. The 9-month patency rate, measured with duplex ultrasonography, was 92.9%. Significant improvement in the ABI and walking distance and walking speed scores, relative to preprocedural values, was seen at 1 month and was maintained through 9-month follow-up. CONCLUSIONS: The Zilver vascular stent is safe and effective as an adjunct to PTA in the treatment of symptomatic disease of the iliac arteries.

Evaluation of Legs For Life National Screening and Awareness Program for Peripheral Vascular Disease: results of a follow-up survey of screening participants.

PURPOSE: The Legs For Life(R) National Screening and Awareness Program for Peripheral Vascular Disease (PVD) was launched in 1999. A critical component of the screening program was an independent evaluation to provide additional information about the results of the program. This evaluation considers the health education impacts of the screening program; participants' knowledge about appropriate providers; and some of the outcomes associated with the program. MATERIALS AND METHODS: The evaluation is based on a representative sample of 700 individuals who participated in the screening program and responded to a six-page closed-ended mail questionnaire 6 months after the screening. The sample was drawn in a two-stage cluster. A sample of 1,000 individuals was drawn using random selection of low-risk participants and oversampling of all high- and medium-risk participants from 22 sites. RESULTS: More than 80% of the respondents remembered the name of the test (ankle-brachial index) given during the screening program. More than half the respondents reported being informed during the screening that leg pain when walking was a symptom of PVD, and 40% reported being told that numbness in the leg was a symptom. The majority of respondents were able to identify ways to prevent or slow the progression of PVD, whereas just under 50% were able to identify those individuals that would be at higher risk for PVD. Respondents most frequently identified vascular surgeons (42%), family or primary care physicians (22%), and cardiologists (19%) as the type of doctor to see for PVD treatment, whereas only 4.8% of screening participants recognized interventional radiologists as specialists appropriate to dealing with PVD. CONCLUSION: Evidence from participants in the Legs For Life(R) National Screening Program suggests that the program has met its initial goals of education, identification, and treatment for those identified with PVD. While many specialties manage this condition, the evaluation indicates there is much to be done in increasing the awareness of interventional radiologists and their role in the diagnosis and treatment of PVD.