A clinical guide to deep venous stenting for chronic iliofemoral venous obstruction.

BACKGROUND: An increase in endovenous interventions for deep venous pathologies has been observed. This article aims to provide an overview of the role of venous stenting in the management of chronic conditions affecting the deep venous system of the lower limbs, with a focus on intervention relating to the vena cava and iliofemoral venous segments. METHODS: An overview of the literature on the minimally invasive venous stenting procedures that are being increasingly used in the management of chronic conditions affecting the deep venous system of the lower limbs. RESULTS: We discuss key areas of interest to a venous specialist practicing in this area, including diagnostic imaging in chronic deep venous disease, with a focus on the use of intravascular ultrasound examination in this context; the treatment of chronic venous outflow obstruction, including the rationale and structural indications for stenting, current guidance regarding stent placement, and fundamental points to consider during decision-making (endophlebectomy and stenting, stenting across the inguinal ligament, optimal sizing of venous stents, extension of venous stenting to beyond the common femoral vein confluence, the role of thrombolysis useful in chronic venous disease, and arteriovenous fistulae); outcomes and initial reports of stenting; and the future of venous stents. CONCLUSIONS: Deep venous stenting has become a key treatment option for chronic (thrombotic or nonthrombotic) obstructive venous disease. Dedicated venous stents and intravascular ultrasound examination represent important technological advances in the minimally invasive treatment of symptomatic chronic deep venous obstruction, which previously required open surgical reconstruction.

A comparison of carotid surgery in northern Europe and northern Africa.

BACKGROUND: Although the indications for carotid endarterectomy (CEA) are clearly defined by major trials, CEA has not been properly implemented in many developing regions, including Northern Africa represented in this study by Upper Egypt. This study was designed to estimate the need for CEA in symptomatic patients with significant internal carotid artery stenosis in Upper Egypt. The estimated needs and actual provision of CEA in Upper Egypt were compared with those of Uusimaa (Finland) and Wessex (England) regions, representing Northern Europe. METHODS: Incidence rates were derived from a community-based door-to-door survey in Upper Egypt, Oxford Community Stroke Project, and epidemiological Finnish studies. The provision of CEA was derived from the local registry of Vascular Surgery Department, Assiut University Hospitals in Upper Egypt; HUSVASC data registry at Helsinki University Central Hospital, and the published data of the Wessex region. The estimated needs were calculated using previously published proportions of patients eligible for CEA. RESULTS: The population at risk of cerebral ischemic events (>or=65 years old) is 4% of the Egyptian population compared with 16% and 15% of the British and Finnish populations, respectively. The incidence of stroke and transient ischemic attack (TIA) is comparable in England and Finland but higher than the Egyptian rates (1.9 per thousand and 2.1 per thousand vs. 1.2 per thousand for stroke; 0.5 per thousand and 0.6 per thousand vs. 0.2 per thousand for TIA, respectively). The ratio of the actual provision of CEA to the estimated need in Wessex and Uusimaa is the same (0.5), whereas it is much lower (0.003) in Upper Egypt. CONCLUSIONS: Despite the low incidence of stroke and TIA, there is a huge unmet need for CEA in Upper Egypt. Yet, Wessex and Uusimaa also seemed to be at a suboptimal level compared with the estimated need. If CEA could be offered annually to those 1,650 patients with severe symptomatic ICA stenosis, 275 strokes could be prevented in Upper Egypt in 5-year duration, provided that the operative morbidity and mortality rates are equal to those reported in the large, randomized, controlled trials.