Toward endovascular treatment of type A aortic dissection with smaller landing zones and more patient eligibility.

OBJECTIVE: Type A or ascending aortic dissection is an acute life-threatening condition with high morbidity and mortality. Open surgery remains the standard of care. The development of minimally invasive endografts for type A aortic dissection (TAAD) will require a detailed understanding of the dissection and aortic root anatomy to determine patient eligibility and optimal device specifications. METHODS: Computed tomography images of TAAD cases at our institution from 2012 to 2019 were identified, and three-dimensional reconstructions were performed using OsiriX, version 10.0 (Pixmeo SARL, Bernex, Switzerland). We analyzed key anatomic structures, including centerline length measurements, ascending aorta and aortic root dimensions, and the location and extent of dissection in relationship to the coronary ostia. RESULTS: A total of 53 patients were identified (mean ± standard deviation age, 60.4 ± 17.1 years; 36 men and 17 women), 46 of whom had undergone surgery for TAAD. Four patients had died within 30 days of surgery. In 47 patients (88.7%), the entry tear was distal to the highest coronary ostium. These cases were retrospectively considered for endovascular intervention using a nonbranched, single endograft stent. The proximal landing zone (LZ) was defined as the distance from the highest coronary ostium to the entry tear. Of the 53 patients, 35 (66.0%) had a proximal LZ length of ≥2.0 cm, 38 (71.7%) had a proximal LZ length of ≥1.5 cm, and 42 (79.2%) had a proximal LZ length of ≥1.0 cm. The median proximal and distal LZ diameters of the sinotubular junction (STJ) and distal ascending aorta regions were 3.29 cm (interquartile range [IQR], 2.73-4.10 cm) and 3.49 cm (IQR, 3.09-3.87 cm, respectively), with a median length from the STJ to the innominate takeoff of 8.08 cm (IQR, 6.96-9.40 cm). The median ascending aorta radius of curvature was 6.48 cm (IQR, 5.27-8.00 cm). Of the 53 patients, 25 (47.2%) could be treated with a straight tube graft with a ≤20% diameter mismatch between the proximal and distal LZs. CONCLUSIONS: Almost 80% of the patients with TAAD had had a proximal LZ of ≥1.0 cm. Of these patients, 47.2% had anatomy amenable for endovascular therapy with a nontapered straight tube graft using commercially available devices. To increase patient eligibility for TAAD endovascular intervention, enhanced precision deployment with an adequate seal in shorter LZs will be required. Our results can serve as a guide for endovascular device specifications designed to treat this devastating condition.

Efficiency of Percutaneous Stent Angioplasty in Renal Artery Stenosis - 15 Years of Experience at a Single Center.

PURPOSE: To determine the therapeutic efficiency of percutaneous revascularization in renal artery stenosis (RAS), as well as the role of comprehensive factors such as patient selection and degree of artery stenosis, on clinical outcome. METHODS AND MATERIALS: 101 patients with hemodynamically relevant RAS underwent percutaneous angioplasty (PTA). 65.7 % were male (mean age: 64 years; range: 18-84). The clinical data was retrospectively analyzed. The serum creatinine (Cr), glomerular filtration rate (GFR), and blood pressure (BP) levels pre- and postprocedural, between 6 months and 1 year, were retrospectively collected and statistically analyzed. RESULTS: Follow-up data was available in 34 (33.7 %) and 28 patients (27.7 %) for Cr and MAP, respectively. A significant drop in mean arterial pressure (MAP) was observed on follow-up (mean -5.27 mmHg). Higher baseline Cr and MAP values showed a more pronounced drop in the follow-up (Cr: p 0.002; difference to baseline -0.25 mg/dL, 95 %CI:-0.36, -0.07 and BP p < 0.001; diff. to baseline -0.72 mmHg; 95 %CI: -1.4, -0.40). There was no association between comorbidities, gender, and degree of stenosis with renal and BP outcome. No significant improvement in renal function was observed on follow-up (mean Cr drop: -0.015 mg/dL). The age group 51-60 years showed a significant improvement in BP (p 0.030; diff. to baseline -19.2 mmHg; 95 %CI: -34, -4.3). There was a slight reduction in antihypertensive medication following angioplasty (0.2 fewer). Minor complications were recorded in five procedures (4.9 %). CONCLUSION: Percutaneous renal artery revascularization in the presence of atherosclerotic RAS is a safe procedure associated with a significant drop in post-procedural BP. No significant improvement in renal function was observed. Further prospective studies focused on patient selection are necessary. KEY POINTS: · Percutaneous stent angioplasty in renal artery stenosis is associated with a significant improvement in post-procedural blood pressure control.. · There is no improvement in renal function after percutaneous stent angioplasty for renal artery stenosis (RAS).. · Percutaneous stent angioplasty is a safe procedure.. CITATION FORMAT: · Guerreiro H, Avanesov M, Dinnies S et al. Efficiency of Percutaneous Stent Angioplasty in Renal Artery Stenosis - 15 Years of Experience at a Single Center. Fortschr Röntgenstr 2021; 193: 298 - 304.

Management of cardiovascular emergencies during the COVID-19 pandemic.

BACKGROUND: It has been reported that patients attending the emergency department with other pathologies may not have received optimal medical care due to the lockdown measures in the early phase of the COVID-19 pandemic. METHODS: This was a retrospective study of patients presenting with cardiovascular emergencies to four tertiary regional emergency departments in western India during the government implementation of complete lockdown. RESULTS: 25.0% of patients during the lockdown period and 17.4% of patients during the pre-lockdown period presented outside the window period (presentation after 12 hours of symptom onset) compared with only 6% during the pre-COVID period. In the pre-COVID period, 46.9% of patients with ST elevation myocardial infarction underwent emergent catheterisation, while in the pre-lockdown and lockdown periods, these values were 26.1% and 18.8%, respectively. The proportion of patients treated with intravenous thrombolytic therapy increased from 18.4% in the pre-COVID period to 32.3% in the post-lockdown period. Inhospital mortality for acute coronary syndrome (ACS) increased from 2.69% in the pre-COVID period to 7.27% in the post-lockdown period. There was also a significant decline in emergency admissions for non-ACS conditions, such as acute decompensated heart failure and high degree or complete atrioventricular block. CONCLUSION: The COVID-19 pandemic has led to delays in patients seeking care for cardiac problems and also affected the use of optimum therapy in our institutions.

Pretreatment with P2Y12 receptor antagonists in ST-elevation myocardial infarction: a report from the Swedish Coronary Angiography and Angioplasty Registry.

AIMS: Pretreatment of patients with ST-elevation myocardial infarction (STEMI) with P2Y12 receptor antagonists is supported by guidelines and is a common practice despite the lack of definite evidence for its benefit. METHODS AND RESULTS: Using data from the Swedish Coronary Angiography and Angioplasty Registry on procedures between 2005 and 2016, we stratified all patients who underwent primary percutaneous coronary intervention due to STEMI in Sweden by whether or not they were pretreated with P2Y12 receptor antagonists. We investigated associations between pretreatment with P2Y12 receptor antagonists and the risk of adverse outcomes using propensity score-adjusted mixed-effects logistic regression, which accounted for clustering of patients within hospitals. The primary endpoint was all-cause death within 30 days. Secondary endpoints were infarct-related artery (IRA) occlusion, 30-day stent thrombosis, in-hospital bleeding, neurological complications, and cardiogenic shock. In total, 44 804 patients were included. They were treated with clopidogrel (N = 26 136, 58.3%), ticagrelor (N = 15 792, 35.3%), or prasugrel (N = 2352, 5.3%); 37 840 (84.5%) were pretreated, and 30 387 (67.8%) had IRA occlusion. At 30 days, there were 2488 (5.6%) deaths and 267 (0.6%) stent thrombosis. Pretreatment was not associated with better survival at 30 days [odds ratio (OR) 1.08, 95% confidence interval (CI) 0.95-1.24; P = 0.313], reduced IRA occlusion (OR 0.98, 95% CI 0.92-1.05; P = 0.608), decreased stent thrombosis (OR 0.99, 95% CI 0.69-1.43; P = 0.932), higher risk of in-hospital bleeding (OR 1.05, 95% CI 0.89-1.26; P = 0.526), or neurological complications (OR 0.72, 95% CI 0.43-1.21; P = 0.210). CONCLUSION: Pretreatment of STEMI patients with P2Y12 receptor antagonists was not associated with improved clinical outcomes.

First International Consensus on the diagnosis and management of fibromuscular dysplasia.

This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD), which was commissioned by the working group 'Hypertension and the Kidney' of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.

Evaluating the effectiveness and safety of the carotid Casper-RX stent for tandem lesions in acute ischemic stroke.

INTRODUCTION: A new generation of carotid artery stents that use a dual micromesh layer to reduce embolic events during carotid artery stenting has recently been introduced. We aimed to analyze the effectiveness and safety of the new Casper-RX stent in patients experiencing acute ischemic stroke with large vessel intracranial occlusion associated with a tandem lesion (another carotid occlusion or severe stenosis). METHODS: We retrospectively analyzed all consecutive patients treated with carotid Casper-RX stents from our stroke registry. We analyzed clinical, angiographic, and neuroimaging data. Endpoints included acute intra-stent thrombus formation, stent occlusion prior to hospital discharge, 3 month modified Rankin Scale score (mRS), and symptomatic intracranial hemorrhage. RESULTS: 21 patients were included: 10 patients had tandem carotid occlusions and 11 patients had severe carotid stenosis, 8 of whom had a hemodynamically significant stenosis. We observed acute in-stent thrombus formation in 11 patients. No stent occlusion occurred prior to hospital discharge. We report no stroke recurrence at 3 months but symptomatic intracranial hemorrhage in two patients. mRS score at 3 months was 0-2 (favorable) for 15 patients (71%), 3-5 for 3 patients, and 6 for 3 patients. CONCLUSIONS: In the present series, we frequently observed clot formation during the procedure with Casper-RX stents, which required periprocedural intravenous infusion of anticoagulant and antiplatelet treatment. This motivated us, in the absence of a prospective randomized controlled study demonstrating the non-inferiority of micromesh dual layer stents compared with the single layer design, to discontinue using this stent type in acute stroke requiring carotid angioplasty.

Novel surgical strategy for complicated pulmonary stenosis using haemodynamic analysis based on a virtual operation with numerical flow analysis.

OBJECTIVES: A novel surgical strategy using haemodynamic analyses based on virtual operations with computational simulations has been introduced for complicated pulmonary stenosis. We evaluated the efficacy of this strategy. METHODS: Six patients were enrolled. Before surgery, the optimal pulmonary arteries were constructed based on computational fluid dynamics using 3-dimensional computed tomography. Energy loss (EL, mW) and wall shear stress (WSS, Pa) were calculated. We compared the shapes of preoperative and optimal pulmonary arteries to determine the surgical strategy, including the incision line and the shape of the patch (virtual surgery). EL and WSS were compared between virtual and actual surgeries using flow analysis. RESULTS: In both the virtual and actual surgeries, postoperative EL tended to be lower than the preoperative EL, although there were no significant differences (P = 0.12 and P = 0.17, respectively). The mean WSS in the virtual surgery was significantly reduced from 112 ± 130 Pa to 25 ± 24 Pa (P = 0.028). After the actual surgery, the mean WSS was also significantly reduced to 30 ± 23 Pa (P = 0.047). There were no significant differences in the values for EL and WSS before and after surgery or between virtual and actual surgery (P = 0.94 and P = 0.85, respectively). CONCLUSIONS: Pulmonary artery plasty, using computational fluid dynamics based on virtual surgery, is an efficient surgical strategy. This novel strategy can easily and successfully provide an optimal pulmonary artery plasty equivalent to that using the conventional approach, which is based on the surgeon's personal experience and judgement.

[Efficacy of percutaneous mechanical thrombectomy combined with percutaneous transluminal angioplasty in treatment of iliofemoral deep vein thrombosis].

OBJECTIVE: To evaluate the clinical efficacy of percutaneous mechanical thrombectomy (PMT) combined with percutaneous transluminal angioplasty (PTA) in the treatment of iliofemoral deep vein thrombosis. METHODS: Ninety-four patients with iliofemoral deep vein thrombosis were identified in this retrospective study in our institution from November 2015 through December 2017. Patients were divided into two groups:PMT+PTA group (n=50) and PMT only group (n=44). Clot lysis rates, the retrieving and the embolism of the interior vena cava filter, as well as the incidence of complications were compared between two groups. The changes of serum creatinine, lactate dehydrogenase and hemoglobin were also measured perioperatively. RESULTS: All procedures were completed successfully. The average clot lysis rate was higher and the procedure time was shorter in PMT+PTA group than those in PMT group (both P<0.01). No significant differences were found in the rates of venous stenosis, catheter-directed thrombolysis and stent placement between two groups (all P>0.05). The interior vena cava filter was taken out in 82.0% (41/50) patients of PMT+PTA group and 81.8% (36/44) patients of PMT group (P>0.05). There were no significant differences of the changes in serum creatinine, lactate dehydrogenase and hemoglobin (all P>0.05). In PMT+PTA group, symptomatic pulmonary embolism and puncture bleeding occurred in 1(2.0%) and 2(4.0%) patients, while in PMT group, it was 0 and 2(4.5%), respectively (P>0.05). CONCLUSIONS: PMT combined with PTA is more effective than PMT alone for the treatment of iliofemoral deep vein thrombosis with less procedure time and without more incidence of pulmonary embolism.

The association of Carotid Revascularization Endarterectomy versus Stent Trial (CREST) and Centers for Medicare and Medicaid Services Carotid Guideline Publication on utilization and outcomes of carotid stenting among "high-risk" patients.

OBJECTIVE: Since the 2004 approval by the United States Food and Drug Administration of carotid artery stenting (CAS), there have been two seminal publications about CAS reimbursement (Centers for Medicare and Medicaid Services guidelines; 2008) and clinical outcomes (Carotid Revascularization Endarterectomy versus Stent Trial [CREST]; 2010). We explored the association between these publications and national trends in CAS use among high-risk symptomatic patients. METHODS: The most recent congruent data sets of the Nationwide Inpatient Sample (NIS) were queried for patients undergoing carotid revascularization. The sample was limited to include only patients who were defined as "high-risk" if they had a Charlson Comorbidity Score of ≥3.0. Subgroup analyses were performed of high-risk patients with symptomatic carotid stenosis. Utilization proportions of CAS were calculated quarterly from 2005 to 2011 for NIS. Three time intervals related to Centers for Medicare and Medicaid Services guidelines and CREST publication were selected: 2005 to 2008, 2008 to 2010, and after 2010. Logistic regression with piecewise linear trend for time was used to estimate different trends in CAS use for the overall high-risk sample and for neurologically asymptomatic and symptomatic cases. Multivariate logistic regression was used to compare odds of postoperative mortality and stroke between these two procedures at different time intervals independent of confounding variables. RESULTS: During the study period, 20,079 carotid endarterectomies (CEAs) and 3447 CAS procedures were performed in high-risk patients in the NIS database. CAS utilization constituted 20.5% of carotid revascularization procedures among high-risk symptomatic patients, with a significant increase from 18.6% to 24.4% during the study period (P < .001). There was an initial increase during 2005 to 2008 in the rate of CAS compared with CEA, CAS utilization significantly decreased during 2008 to 2010 by a 3.3% decline in the odds ratio (OR) of CAS per quarter (OR, 0.967; 95% confidence interval [CI], 0.943-0.993; P = .002), and after CREST (after 2010), CAS utilization continued to increase significantly from the prepublication to the postpublication time interval. The odds of in-hospital mortality (OR, 2.56; 95% CI, 1.17-5.62; P = .019) and postoperative in-hospital stroke (OR, 1.53; 95% CI, 1.09-3.68; P = .024) were independently and significantly higher for CAS patients in the overall sample. CONCLUSIONS: The use of CAS for carotid revascularization in a high-risk cohort of patients has significantly increased from 2005 to 2011. Compared with CEA, CAS independently increased the odds of perioperative in-hospital stroke in all high-risk patients and of in-hospital mortality in symptomatic high-risk patients.

[Choosing wisely recommendations in nephrology]. / Klug-entscheiden-Empfehlungen in der Nephrologie.

The German Society of Internal Medicine ("Deutsche Gesellschaft für Innere Medizin", DGIM) founded the Choosing wisely initiative in order to address diagnostic and therapeutic procedures that are frequently inappropriately applied, whether this be in terms of over-, under-, or misuse of health services. The German Society of Nephrology ("Deutsche Gesellschaft für Nephrologie," DGfN) strongly supports the initiative and has contributed five positive and five negative recommendations. These ten recommendations are discussed in the current publication. The positive recommendations reflect the importance of early recognition of renal disease via simple blood and urine tests, the use of radiocontrast media in cases of impaired renal function, as well as the problems associated with low vaccination rates. Three of the negative recommendations are focused on hydration and diuretics. The remaining two negative recommendations concern angioplasty in cases of renal artery stenosis and the unconsidered use of nonsteroidal anti-inflammatory drugs.

Current Status and Future Potential of Transcatheter Interventions in Congenital Heart Disease.

Percutaneous therapies for congenital heart disease have evolved rapidly in the past 3 decades. This has occurred despite limited investment from industry and support from regulatory bodies resulting in a lack of specific device development. Indeed, many devices remain off-label with a best-fit approach often required, spurning an innovative culture within the subspecialty, which had arguably laid the foundation for many of the current and evolving structural heart interventions. Challenges remain, not least encouraging device design focused on smaller infants and the inevitable consequences of somatic growth. Data collection tools are emerging but remain behind adult cardiology and cardiac surgery and leading to partial blindness as to the longer-term consequences of our interventions. Tail coating on the back of developments in other fields of adult intervention will soon fail to meet the expanding needs for more precise interventions and biological materials. Increasing collaboration with surgical colleagues will require development of dedicated equipment for hybrid interventions aimed at minimizing the longer-term consequences of scar to the heart. Therefore, great challenges remain to ensure that children and adults with congenital heart disease continue to benefit from an exponential growth in minimally invasive interventions and technology. This can only be achieved through a concerted collaborative approach from physicians, industry, academia, and regulatory bodies supporting great innovators to continue the philosophy of thinking beyond the limits that has been the foundation of our specialty for the past 50 years.

Long term durability and outcomes of carotid stenting and carotid endarterectomy.

PURPOSE: To evaluate the long term durability and outcomes of carotid angioplasty and stenting (CAS) compared with carotid endarterectomy (CEA). METHODS: Using multiple comprehensive databases, we searched for randomized controlled trials comparing CAS with CEA for carotid stenosis. Studies were classified according to symptom status: symptomatic, asymptomatic, or all inclusive stenosis. Postprocedural ipsilateral stroke, restenosis/occlusion after revascularization, procedural stroke/death/myocardial infarction (MI), and postprocedural ipsilateral stroke were evaluated. Subgroup analysis was performed according to follow-up duration. RESULTS: 22 studies were included and classified for meta-analyses in relation to specific outcomes. The maximum follow-up duration was 10 years. The risk of postprocedural ipsilateral stroke in CEA was equivalent to that in CAS, irrespective of symptom status or follow-up time points. The CAS group had a greater risk of restenosis/occlusion after revascularization compared with CEA in studies of all inclusive stenosis. A similar tendency was found in studies of symptomatic stenosis, but without statistical significance. However, subgroup analysis showed that the risk of restenosis/occlusion in CAS decreased gradually with time, to the extent that these risks became comparable 1 year after the procedure. Procedural stroke/death/MI and postprocedural ipsilateral stroke occurred more frequently in the CAS group in studies of symptomatic stenosis although not in studies of asymptomatic or all inclusive stenosis. However, this association did not persist when studies were divided according to follow-up time points. CONCLUSIONS: Although CAS may be more strongly associated with periprocedural stroke/death compared with CEA, it could be a good alternative to CEA in terms of long term durability and outcomes.

Durability of Treatment Effect Using a Drug-Coated Balloon for Femoropopliteal Lesions: 24-Month Results of IN.PACT SFA.

BACKGROUND: Evidence from large, randomized, controlled peripheral artery disease trials reporting long-term outcomes using drug-coated balloons (DCBs) is limited. Previously, the DCB showed favorable 1-year outcomes compared with conventional percutaneous transluminal angioplasty (PTA), yet durability of the treatment effect with DCBs remains unknown. OBJECTIVES: This study sought to investigate the longer-term outcomes of a paclitaxel-eluting DCB compared to PTA for femoropopliteal lesions. METHODS: We enrolled 331 patients with symptomatic (Rutherford 2 to 4) femoropopliteal lesions up to 18 cm in length. Patients were randomly assigned in a 2:1 ratio to treatment with DCB or PTA. The 24-month assessments included primary patency, freedom from clinically driven target lesion revascularization (CD-TLR), major adverse events, and quality of life and functional outcomes as assessed by the EuroQOL-5D quality-of-life questionnaire, walking impairment questionnaire, and 6-min walk test. RESULTS: At 24 months, patients treated with DCB showed significantly higher primary patency when compared with PTA (78.9% vs. 50.1%; p < 0.001). The rates of CD-TLR were 9.1% and 28.3% (p < 0.001) for the DCB and PTA groups, respectively. The overall mortality rate in the DCB group was 8.1% versus 0.9% in the PTA group (p = 0.008). There were no device- or procedure-related deaths and no major amputations in either group through 24-month follow-up. The rate of vessel thrombosis was low (1.5% DCB vs. 3.8% PTA; p = 0.243), with no new events reported between 1 and 2 years. Both groups showed similar functional improvement at 2 years, although DCB patients achieved this level of function with 58% fewer reinterventions. CONCLUSIONS: The 24-month outcomes from the trial demonstrate a durable and superior treatment effect of DCB versus PTA with significantly higher primary patency, lower CD-TLR, and similar functional status improvement with fewer repeat interventions. (Randomized Trial of IN.PACT Admiral Drug Eluting Balloon vs Standard PTA for the Treatment of SFA and Proximal Popliteal Arterial Disease [INPACT SFA I]; NCT01175850; and IN.PACT Admiral Drug-Coated Balloon vs. Standard Balloon Angioplasty for the Treatment of Superficial Femoral Artery [SFA] and Proximal Popliteal Artery [PPA] [INPACT SFA II]; NCT01566461).

[Treatment reality of internal carotid artery stenosis in Germany : requirement and reality in international comparison and in light of the current S3 guidelines]. / Versorgungsrealität von Karotisstenosen in Deutschland : Forderung und Wirklichkeit im internationalen Vergleich und im Lichte der aktuellen S3-Leitlinie.

BACKGROUND: Severe atherosclerotic extracranial carotid artery stenosis accounts for 5-10 % of all ischemic strokes. Currently, therapeutic recommendations are undergoing changes, particularly regarding the treatment of asymptomatic stenosis. Consolidated knowledge on the indications, nationwide distribution and numbers of cases are not available. Moreover, the impact and grade of implementation of the recently published national S3 guidelines on the reality of medical treatment remain unclear. METHODS: Analysis of administrative hospital data involving the diagnosis-related groups (DRG) statistics and structured quality reports for 2010 and 2013 to evaluate the procedural therapy trends concerning operative and interventional approaches for symptomatic and asymptomatic carotid artery stenoses. RESULTS: In Germany approximately 37,000 carotid endarterectomies (CEA) and approximately 5,000 carotid angioplasties with stenting (CAS) are carried out per year. Approximately 94 % of CEA and 62 % of CAS are performed in centers with more than 25 procedures per year. Only 33 % of CEA and 39 % of CAS are related to symptomatic stenosis. CONCLUSION: Mathematically, an undertreatment of symptomatic and an overtreatment of asymptomatic carotid artery stenoses become apparent. Efforts should be made to achieve inpatient medical treatment conforming to the national S3 guidelines, in particular to adequately reduce the risk of stroke recurrence in patients with atherosclerotic symptomatic carotid artery stenosis.

Stroke risk in the early period after carotid related symptoms: a systematic review.

Current guidelines recommend performing carotid endarterectomy in patients with symptomatic carotid disease as soon as possible after the neurological index event. However, early stroke risk has not been well documented for this patient group. We therefore conducted a systematic analysis of the current literature on the recurrent risk of ischemic events in patients with symptomatic carotid stenosis. Systematic review was performed by searching the MEDLINE® database from 1950 until June 8, 2015 (key words: cerebral ischemia, transient ischemic attack, amaurosis fugax, stroke, symptomatic carotid stenosis, recurrent risk, outcome, prognosis, follow-up, cohort and natural history). All studies reporting stroke risks in patients with symptomatic carotid stenosis after neurologic index events within a period of 7 days were included. Cumulative stroke risks with 95% confidence intervals after a neurologic index event were recalculated at 2-3, 7, 14 and 30 days and a meta-analysis including an analysis of heterogeneity were performed using the statistical package R and Excel for Mac 2003. Ten studies with a total number of 2634 patients were included. Results of an overall stroke risk were as follows: 2.0-17.2% at 2-3 days, 0-22.1% at 7 days, 0-29.6% at 14 days and 0-11.1% at 30 days in patients with a symptomatic extracranial carotid stenosis. The pooled stroke risk in the six studies with active follow-up was 6.0% (95% CI 2.4-14.4) at 2-3 days, 10.9% (6.1-18.7) at 7 days and 17.6% (9.7-29.9) at 14 days. Pooled stroke risk in the three studies with uncensored populations was even higher with 6.4% (1.5-23.8%) at 2-3 days, 19.5% (12.7-28.7) at 7 days and 26.1% (20.6-32.5%) at 14 days. Significant heterogeneity (P<0.001) could be explained by the different inclusion criteria and the study's design. Retrospective studies with passive follow-up had the lowest stroke risk whereas prospective studies with active follow-up and without bias through early intervention by carotid endarterectomy or carotid stenting had the highest stroke risk. The risk of recurrence of cerebrovascular events in patients with symptomatic carotid stenosis within the first days after a neurologic index event is as high as 6.4% (1.5-23.8), 19.5% (12.7-28.7) and 26.1% (20.6-32.5) after 2-3, 7 and 14 days respectively. Patients with a symptomatic carotid stenosis are therefore at a very high risk of a definitive stroke. Recommendations by current guidelines to perform carotid endarterectomy as soon as possible after the neurologic index event are therefore justified.

Can Patients Select the Best Hospital for Carotid Revascularization?

BACKGROUND: Public reporting of cardiac surgery outcomes has been available for many years in the USA. Whether public information regarding carotid endarterectomy or stenting outcomes is available has not been studied previously. METHODS: The Medicare Hospital Compare website was analyzed for carotid endarterectomy and stenting volume and complications data. RESULTS: Within a large metropolitan area, endarterectomy volume data was provided in less than half of hospitals, with no information provided on morbidity or mortality. No information was available on carotid stenting. CONCLUSIONS: The quality of information available to patients in the USA contemplating a carotid revascularization procedure is suboptimal. Considering the volume of these procedures, greater transparency with regard to outcomes is desirable. Adoption of carotid procedure reporting practices as used in the UK should be considered.

Tratamiento de la úlcera venosa con escleroespuma frente a un método convencional. Ensayo clínico, prospectivo y aleatorizado / Venous ulcer treatment with sclerofoam versus a conventional treatment: randomized prospective clinical trial

INTRODUCCIÓN: Las úlceras venosas (UV) son las úlceras más frecuentes de la extremidad inferior, ellas generan alta morbilidad con importantes costos para los sistemas de salud. OBJETIVO: Determinar el porcentaje de curación de UV mediante un tratamiento convencional frente al mismo tratamiento más oclusión venosa endoluminal con escleroespuma ecoguiada. MATERIAL Y MÉTODOS: Ensayo clínico prospectivo y aleatorizado, realizado en la consulta externa de cirugía vascular del Hospital Occidente de Kennedy-Bogotá, entre los años 2011 y 2012. Se incluye a 44 pacientes mayores de 18 años, portadores de una UV e índice tobillo-brazo mayor a 0,8. Se analizaron en total 48 extremidades. Los pacientes fueron aleatorizados en 2 grupos: a) control (cura local húmeda más vendaje no compresivo) y b) ensayo: al tratamiento del grupo control se asocia inyección de escleroespuma (técnica de Tessari) en el sistema venoso superficial insuficiente, guiado por ecodoppler. Se realizaron controles a las 3, 8, 12 y 24 semanas. RESULTADOS: Al final del seguimiento (24 semanas), la curación de UV fue del 83,3% (20 extremidades) en el grupo de oclusión endoluminal con espuma ecoguiada frente al 12,5% (3 extremidades) del grupo control o convencional (p = 0,0005). No se observaron complicaciones mayores, derivadas de los tratamientos, en ningún grupo. CONCLUSIÓN: La oclusión endoluminal venosa con escleroespuma ecoguiada es segura y efectiva. Las tasas de curación de UV con esta técnica, mínimamente invasiva, son superiores a las del tratamiento conservador con curas húmedas y vendaje no compresivo

INTRODUCTION: Venous ulcers (VU) are the most common ulcers of the lower limb. It has a high morbidity and is a financial strain on the health system. OBJECTIVE: The aim of this study was to determine the rate of healing VU with a conventional treatment versus the use of conventional treatment plus ultrasound-guided foam endoluminal occlusion. MATERIAL AND METHODS: A prospective randomized clinical trial was conducted on patients attending the Vascular Surgery clinics in the Hospital Occidente de Kennedy-Bogotá during 2011-2012. A total of 44 patients age 18 years and over, with venous insufficiency, VU, and an ankle-brachial index greater than 0.8, were included. A total of 48 extremities were analyzed in the two groups; one group a) Control: (conventional treatment with non-compressive bandages, vaseline gauze, and wound care) and b) Study group: control treatment plus endoluminal occlusion with ultrasound-guided foam in the superficial venous system by Tessari method using 1% lapidium hydrochloride (sklerol). Follow-up was carried out at week 3, 8, 12 and 24. RESULTS: The healing rate of the ulcer at week 24 was 20 (83.3%) extremities healed by the endoluminal occlusion with ultrasound-guided foam group vs. 3 (12.5%) extremities healed in the group using the conventional treatment (P=.0005). No major complications arising from treatment were observed in either group. CONCLUSION: The healing rates of the VU after endoluminal occlusion with ultrasound-guided foam is safe and effective. This minimally invasive technique is far superior to conventional treatment with non-compressive bandages, vaseline gauze, and wound care, exclusively. Registration number of this study: NCT01594658 in clinical trials

Carotid artery stenting: high-risk interventionist versus high-risk center.

Carotid artery stenting (CAS) is a less invasive alternative to carotid endarterectomy (CEA) for the management of carotid artery stenosis. Although early multicenter randomized controlled trials reported inferior results for CAS compared with CEA, recent advances in technology and increasing CAS operator expertise have lead to improved results. As with any procedure, a high caseload translates into increased experience and better outcomes. This article discusses the current shortfalls of CAS, as well as the various options available to improve CAS results. The majority of studies suggest that there is an inverse relationship between caseload volume and CAS outcomes that defines high-risk interventionists and high-risk centers. Centralizing CAS procedures to high-volume centers is essential for optimization of CAS outcomes.

The indications of carotid artery stenting in symptomatic patients may need to be reconsidered.

According to the 2011 and the 2014 updated American Heart Association/American Stroke Association Guidelines, carotid artery stenting (CAS) is indicated as an alternative to carotid endarterectomy (CEA) for the management of symptomatic carotid patients. According to these recommendations, CAS is preferred to CEA in symptomatic patients with specific technical, anatomic, or physiological characteristics that render these individuals at "high risk" for surgery (e.g., contralateral carotid occlusion, previous neck irradiation, recurrent carotid stenosis, and so forth). This article presents emerging data suggesting that most of these criteria do not comprise contraindications for CEA. In fact, CEA is associated with similar (or even better) outcomes compared with CAS in many such "high-risk" patients. Based on these results, the indications of CAS in symptomatic patients may need to be reconsidered.