Managing iliofemoral deep venous thrombosis of pregnancy with a strategy of thrombus removal is safe and avoids post-thrombotic morbidity.

BACKGROUND: Extensive deep venous thrombosis (DVT) during pregnancy is usually treated with anticoagulation alone, risking significant post-thrombotic syndrome (PTS) in young patients. Catheter-directed thrombolysis (CDT) and operative venous thrombectomy have been safely and effectively used in nonpregnant patients, demonstrating significant reduction in post-thrombotic morbidity. This report reviews short- and long-term outcomes of 13 patients with extensive DVT of pregnancy treated with a strategy of thrombus removal. METHODS: From 1999 to 2013, 13 patients with iliofemoral DVT during pregnancy were offered CDT, pharmacomechanical thrombolysis (PMT), and/or venous thrombectomy. Gestational age ranged from 8 to 34 weeks. Fetal monitoring was performed throughout hospitalization. Radiation exposure was minimized with pelvic lead shields, focal fluoroscopy, and limited angiographic runs. Follow-up included objective vein evaluation using venous duplex and PTS assessment using the Villalta scale. RESULTS: CDT and/or PMT were used in 11 patients. Two patients underwent venous thrombectomy alone, and one patient had operative thrombectomy as an adjunct to CDT and PMT. Each patient had complete or near-complete thrombus resolution and rapid improvement in clinical symptoms. Eight of 11 having CDT or PMT underwent venoplasty and stenting of the involved iliac veins. Twelve of the 13 delivered healthy infants at term. One patient opted for termination of her pregnancy. Mean patient and gestational ages were 26 years and 26 weeks, respectively. Mean follow-up was 1.3 years, with only one recurrence. Duplex ultrasonography demonstrated patent veins in all but one patient and normal valve function in 10 patients. Eleven patients had Villalta scores <5 (considered normal), with a mean score of 0.7. CONCLUSIONS: Extensive DVT of pregnancy can be effectively and safely treated with a strategy of thrombus removal, resulting in a patent venous system, normal valve function in many, prevention of PTS, and reduction in recurrence.

Reintervention after EVAR and open surgical repair of AAA: a 15-year experience.

OBJECTIVE: This study examined the frequency and reason for reinterventions and their impact on survival in contemporaneously treated cohorts of EVAR and open surgical repair (OSR) patients. BACKGROUND: EVAR has largely replaced OSR for anatomically appropriate AAA because of improved short-term outcomes. However, EVAR is associated with a notable reintervention rate. METHODS: Data for patients undergoing elective AAA repair between 1996 and 2011 were collected and analyzed to assess time from initial procedure to reintervention and rate of reintervention. Patient demographics, comorbidities, number and type of reinterventions, graft type, and timing of reintervention were analyzed. RESULTS: A total of 1144 patients underwent AAA repair; 558 had EVAR and 586 had OSR. In 76 EVAR patients, 123 reinterventions were performed; 46 reinterventions were performed in 30 OSR patients (P < 0.0001). Endoleak was responsible for 66% of EVAR reinterventions; colonic ischemia, bleeding, and incisional hernias caused 30%, 22%, and 22% of OSR reinterventions, respectively. Time to first reintervention was shorter in OSR patients (P < 0.001) and was related to AAA size (P < 0.001). Early reintervention at the index procedure in OSR patients had a 23% mortality rate. If reinterventions were not required, survival curves were similar. Current endografts require fewer reinterventions than earlier generation endografts. CONCLUSIONS: Reintervention was more common with EVAR and occurred later. Early reintervention after OSR is associated with significant mortality. If early reintervention in OSR patients can be avoided, there is no early survival advantage to EVAR. Current endografts require fewer reinterventions than earlier devices.

Has Data Quality of an Antimicrobial Resistance Surveillance System in a Province of Nepal Improved between 2019 and 2022?

An operational research study was conducted in 2019 to assess the quality of data submitted by antimicrobial resistance (AMR) surveillance sites in the Bagmati Province of Nepal to the National Public Health Laboratory for Global Antimicrobial Resistance and Use Surveillance System (GLASS). Measures were implemented to enhance the quality of AMR surveillance by strengthening capacity, improving infrastructure, implementing data sharing guidelines, and supervision. The current study examined reports submitted by surveillance sites in the same province in 2022 to assess whether the data quality had improved since 2019. The availability of infrastructure at the sites was assessed. Of the nine surveillance sites in the province, seven submitted reports in 2022 versus five in 2019. Completeness in reporting improved significantly from 19% in 2019 to 100% in 2022 (p < 0.001). Timely reports were received from two sites in 2019 and only one site in 2022. Specimen-pathogen consistency in accordance with the GLASS guidelines for urine, feces, and genital swab specimens improved, with ≥90% consistency at all sites. Overall, the pathogen-antibacterial consistency improved significantly for each GLASS priority pathogen. The study highlights the importance of dedicated infrastructure and institutional arrangements for AMR surveillance. Similar assessments covering all provinces of the country can provide a more complete country-wide picture.

A Randomized Study of Short Course (One Week) Radiation Therapy with or without Temozolomide in Elderly and/or Frail Patients with Newly Diagnosed Glioblastoma (GBM).

OBJECTIVE: Short-course radiotherapy (25 Gy in 5 fractions) has been shown to be non-inferior to standard course radiotherapy in elderly and frail patients (60 Gy in 30 fractions). The purpose of this study was to determine the effects of temozolomide combined with short-course radiotherapy on the outcome of elderly and frail patients. METHODS: Between January 2017 and November 2018, 90 patients (65 years old and KPS score of 50-70; 65 years old and KPS score of 80-100; and 65 years old and KPS score of 50-70) were assessed for eligibility. Nine patients were excluded because they did not meet the inclusion criteria, six patients declined to participate, and four patients were unable to complete the quality-of-life questionnaire. The remaining 71 patients were divided into two arms at random in a 1:1 ratio. Short-course radiotherapy with concurrent temozolomide and adjuvant temozolomide was given to Arm 1, while short-course radiotherapy alone was given to Arm 2. RESULTS: In terms of overall survival and progression-free survival, radiotherapy with concurrent temozolomide and adjuvant temozolomide outperformed short-course radiotherapy alone. The median overall survival in arm 1 was 146 days and 121 days in arm 2 (P=0.146). The median progression-free survival in arm 1 was 109.50 days, while it was 77 days in arm 2 (P=0.028). With a median follow-up time of 6 months, the quality of life at 4 weeks and 12 weeks after treatment was not different between the two arms. CONCLUSION: We concluded that adding temozolomide to short-course radiotherapy significantly improved progression-free survival and showed an increasing trend in overall survival without compromising the quality of life.

Quality Assessment of an Antimicrobial Resistance Surveillance System in a Province of Nepal.

Antimicrobial resistance (AMR) is a global problem, and Nepal is no exception. Countries are expected to report annually to the World Health Organization on their AMR surveillance progress through a Global Antimicrobial Resistance Surveillance System, in which Nepal enrolled in 2017. We assessed the quality of AMR surveillance data during 2019-2020 at nine surveillance sites in Province 3 of Nepal for completeness, consistency, and timeliness and examined barriers for non-reporting sites. Here, we present the results of this cross-sectional descriptive study of secondary AMR data from five reporting sites and barriers identified through a structured questionnaire completed by representatives at the five reporting and four non-reporting sites. Among the 1584 records from the reporting sites assessed for consistency and completeness, 77-92% were consistent and 88-100% were complete, with inter-site variation. Data from two sites were received by the 15th day of the following month, whereas receipt was delayed by a mean of 175 days at three other sites. All four non-reporting sites lacked dedicated data personnel, and two lacked computers. The AMR surveillance data collection process needs improvement in completeness, consistency, and timeliness. Non-reporting sites need support to meet the specific requirements for data compilation and sharing.

Bilateral nonthrombotic subclavian vein obstruction causing upper extremity venous claudication.

Venous complications of thoracic outlet obstruction are frequently the result of acute axillosubclavian vein thrombosis, leading to symptoms consistent with venous claudication, including pain, swelling, and cyanotic discoloration. Nonthrombotic subclavian vein obstruction, however, is an uncommon cause of veno-occlusive symptoms. We report the case of a patient who, while running, developed pain consistent with venous claudication in her left arm and subsequently in her right arm. Clinical and hemodynamic evaluation revealed nonthrombotic subclavian vein obstruction, which was relieved by thoracic outlet decompression following first rib resection.

Endovenectomy of the common femoral vein and intraoperative iliac vein recanalization for chronic iliofemoral venous occlusion.

Chronic postthrombotic occlusion of the iliofemoral venous segments produces severe morbidity, which can be alleviated if venous drainage is restored. The common femoral vein (CFV) cannot always be fully recanalized with percutaneous endovenous techniques alone. We report the technique combining operative endovenectomy and patch venoplasty of the CFV with intraoperative iliac vein venoplasty and stenting to restore unobstructed venous drainage from the infrainguinal venous system to the vena cava. This procedure led to reduced pain, edema, and healing of a long-standing venous ulcer, with a marked reduction in postthrombotic morbidity.

Heparin-induced thrombocytopenia after implantation of a heparin-bonded polytetrafluoroethylene lower extremity bypass graft: A case report and plan for management.

The proprietary heparin-bonded expanded polytetrafluoroethylene graft appears to be an attractive option for lower extremity revascularization in patients with compromised runoff and no autogenous vein. There is no detectable elution of heparin from the graft surface, but antithrombotic activity has been detected in devices implanted for >2 years. Although 15,000 Propaten (W. L. Gore and Associates, Flagstaff, Ariz) grafts have been implanted, to our knowledge, this is the first report of heparin-induced thrombocytopenia developing from this heparin-bonded graft. The heparin-induced thrombocytopenia responded promptly to graft explantation. A management plan is suggested for patients being considered for this graft.

Antiplatelet therapy for vascular interventions.

The role of platelets and the importance of platelet inhibition are well established in patients with vascular disease. When physicians perform revascularization procedures in these patients, who typically have the most advanced atherosclerotic disease, they should be aware of both the generic benefits of platelet inhibition on patients' long-term health as well as the specific benefits relative to operative or endovascular revascularization. Platelet inhibition has not been well studied in the aortoiliac system, renal vascular bed, or the mesenteric arterial bed. Peripheral vascular beds that have been studied are predominantly the carotid circulation and the infrainguinal vasculature. This article reviews the basic mechanisms of platelet inhibition and suggests antiplatelet strategies for vascular interventions, including carotid endarterectomy, carotid angioplasty and stenting, infrainguinal bypass, and peripheral angioplasty and stenting.

Management of anticoagulation and platelet inhibition in reconstructive vascular surgery.

The successful management of patients with arterial or venous vascular disease is increasingly dependent on the effective use of pharmacotherapeutic agents. Anticoagulation therapies for thromboembolic disease are continually improving, and platelet inhibition remains a cornerstone treatment for all patients with atherosclerotic disease. Early ischemic complications can be avoided by proper preoperative prescription, intraoperative management, and postoperative pharmacotherapy. Combination strategies for platelet inhibition and platelet inhibition with anticoagulation are beneficial in properly selected patients; however, combining platelet inhibitors with each other and with anticoagulation generally increases bleeding risk. Unfractionated or low-molecular-weight heparin, warfarin, and long-term platelet inhibition can improve survival, reduce the risk of other vascular bed ischemic events, and improve the long-term success of the target revascularization procedure. An overview of evidence-based antithrombotic strategies will include a discussion of patients who undergo the two most common open vascular reconstructive procedures, carotid endarterectomy and infrainguinal bypass. The appropriate use of antithrombotic therapy for vascular reconstructive surgery patients has important implications for both short- and long-term patient outcomes.