Common carotid artery occlusion treatment: revealing a gap in the current guidelines.

OBJECTIVE: To review the literature on the management of common carotid artery occlusion (CCAO). METHODS: A review of English-language medical literature from 1965 to 2012 was conducted using the PubMed and EMBASE databases to find all studies involving management of CCAO. The search identified 21 articles encompassing 146 patients/arteries (73.2% men; mean age 65 ± 6.9 years). RESULTS: The majority of the patients (93.8%) were symptomatic. Most of the patients (61.5%) had ipsilateral internal carotid artery (ICA) and external carotid artery (ECA) patent, while an occluded ICA and a patent ECA were found in 26.6% of the patients. Eighty per cent of the patients treated underwent a surgical bypass procedure, with the subclavian artery as the most common inflow vessel (64.1%). During the first 30 days of the procedure two strokes (1.5%) were reported. During a follow-up period spanning an average of 25.6 ± 11.2 months nine patients (6.6%) experienced a clinical cerebrovascular event. Seven restenoses (5.1%) and two reocclusions (1.5%) also occurred-eight after open surgical and one after endovascular repair. CONCLUSION: The necessity to intervene to a CCAO remains controversial. This review shows that open surgical management of symptomatic CCA occlusive disease is a safe, durable, and effective therapeutic strategy with low perioperative cerebrovascular morbidity.

Novel Oral Anticoagulants in Peripheral Artery Disease: Current Evidence.

BACKGROUND: Peripheral artery disease is a common manifestation of systemic atherosclerosis which strongly correlates to cardiovascular morbidity and mortality. In addition, the progression of peripheral artery disease leads to an increased risk of limb loss. In order to reduce these events, the benchmark of treatment and research over the last years has been the antiplatelet therapy which aims at inhibition of platelet aggregation. Over the last years, new studies combining antiplatelet agents in different therapeutic schemes have been proven efficacious. Unfortunately, patients remain still at high risk of CV events. Novel Oral Anticoagulants have been introduced as alternatives to warfarin, in the prevention and treatment of venous thromboembolism. The rationale of using medication which acts on platelet activation and the coagulation pathway of thrombosis has led investigators to examine the role of Noac's in preventing CV events in patients with peripheral artery disease, stable or unstable. METHODS: The aim of this study is to review the current evidence with respect to recently published studies concerning the use of Novel anticoagulants in peripheral artery disease. RESULTS: The Compass trial has shown that a combination of rivaroxaban with traditional therapy may produce promising results in reducing amputation rates, stroke, cardiac events, and mortality, however, there are still safety issues with bleeding requiring acute care. The ePAD study has provided us with insight concerning safety and efficacy after peripheral angioplasty or stenting and actually the need for further research. The Voyager Pad study, following the steps of Compass, is studying the effect and safety of the addition of rivaroxaban to traditional therapy in the highest risk population aka patients undergoing peripheral revascularization. The evidence concerning patients with concomitant atrial fibrillation appears to be insufficient, however, recent guidelines propose the use of novel oral anticoagulants. CONCLUSION: For the time being, novel oral anticoagulants in combination with aspirin may provide an alternative treatment in PAD, however, it is deemed necessary to identify patient subgroups who will benefit the most.

Surgical and endovascular intervention on internal carotid artery near occlusion.

Therapeutic strategy for treating carotid artery near occlusion (CANO) has been controversial. The aim of this study was to review the literature concerning the invasive treatment of atherosclerotic CANO. A review was conducted of the English medical literature from 1980 to 2013 using PubMedand EMBASE database to find studies involving open or endovascular management of CANO. The search identified 20 reports describing invasive treatment of CANO encompassing 770 patients (77.7% men; mean age 66.3±5.2 years). A typical appearance of string sign was noted in nearly 60% of the patients. The vast majority (92.6%) were symptomatic. 479 (62.2%) patients underwent an open procedure, while 291 (38.8%) were treated endovascularly. The technical success rate for the endovascular procedures was 99%, while distal embolic protection devices were applied in most patients (66%). The 30 days procedural stroke rate was 2.1% and 2.4% for open and endovascular repair respectively. During a follow-up period spanning an average of approximately two years the ipsilateral cerebrovascular event rate was 5% and 1.2% for open and endovascular treatmentrespectively. Twenty five (5.2%) restenosis or occlusions were reported for the open procedures, while 13 (5.4%) were also documented for endovascular repair. The current literature concerning the invasive treatment of CANO is weak and cannot support any evidence based recommendation. The necessity to intervene as well as the best therapeutic strategy remains controversial. This review shows that the interventionon symptomatic CANO may consist a relatively safe and effective therapeutic strategy with low perioperative cerebrovascular morbidity for both treatment modalities, although durability and long-term outcomes should be further affirmed. The low incidence of this entity and the dearth of clear evidence support the need for a large multicenter registry to clarify the absolute indications for intervention and define the best therapeutic approach.

The effect of revascularization procedures on healing of mixed arterial and venous leg ulcers.

AIM: The optimal management of venous leg ulcers in patients with concomitant peripheral artery disease (PAD) remains unclear. The aim of the present study was to evaluate the effectiveness of revascularization procedures in healing of the ulcers of mixed etiology. METHODS: During a 6-year period a total of 20 patients with evidence of chronic venous insufficiency, impaired arterial perfusion (ABI<0.75) and active leg ulcer were treated. Patients with moderate PAD (0.5