CEA vs. stent in patients with acute strokes: are they equally effective?

INTRODUCTION: Stroke is the 3rd leading cause of death worldwide with 15 million strokes annually. Extracranial carotid stenosis contributes to major stroke morbidity and mortality as a significant etiology of ischemic strokes. For acute stroke, in addition to optimal medical management, patients may be candidates for carotid endarterectomy and/or carotid stenting for secondary stroke reduction. This paper set out to review the data currently available regarding equivalency of the two intervention options. EVIDENCE ACQUISITION: A comprehensive literature review was performed through PubMed and other sources using the key words carotid endarterectomy, carotid artery stent, acute stroke, symptomatic carotid stenosis, flow reversal, TCAR. Studies which solely evaluated patients with asymptomatic disease were ineligible for the study. EVIDENCE SYNTHESIS: Review of landmark trials such as NASCET and CREST in addition to more recent studies demonstrates the effectiveness of surgical management with carotid endarterectomy of acute stroke. Carotid stenting has also been shown to have acceptable outcomes in certain patient populations. CONCLUSIONS: Carotid endarterectomy continues to demonstrate effectiveness and safety for management of acute stroke, while carotid stenting has limitations. Carotid artery stenting has been shown to be non-inferior in some patient populations, but more recent and future technologic developments may expand the potential acceptable patient selection criteria.

Fibrinolytic activity of endothelial cells from different venous beds.

BACKGROUND: Little is known about the molecular biology of endothelial cells from different venous vascular beds. As a result, our treatment of deep vein thrombosis and pulmonary artery embolism remain identical. As an initial step in understanding venous thromboembolic disease in the trauma and surgical patients, this study sought to investigate the balance between coagulation and fibrinolysis in the pulmonary and deep venous vascular beds and how trauma might influence this balance. MATERIALS AND METHODS: Confluent human iliac vein endothelial cells (HIVECs) and human pulmonary artery endothelial cells (HPAECs), were cultured in the absence or presence of tumor necrosis factor (TNFα; 10 ng/mL) for 24 h. The expression of mediators of coagulation and fibrinolysis were determined by Western blot analysis, and plasminogen activator activity was determined by a fibrin clot degradation assay. RESULTS: After TNFα stimulation, there was decreased expression of endothelial protein C receptor and thrombomodulin in both HIVECs and HPAECs. TNFα stimulation increased urokinase plasminogen activator expression in both HIVECs and HPAECs. There was an increase in the expression of tissue plasminogen activator and plasminogen activator inhibitor-1 in response to TNFα in HPAECs, but not in HIVECs. There was significantly greater clot degradation in the presence of both the conditioned media and cell extracts from HIVECs, when compared with HPAECs. CONCLUSIONS: HPAECs and HIVECs react differently in terms of fibrinolytic potential when challenged with a cytokine associated with inflammation. These findings suggest that endothelial cells from distinct venous vascular beds may differentially regulate the fibrinolytic pathway.

The incidence of contralateral iliac venous thrombosis after stenting across the iliocaval confluence in patients with acute or chronic venous outflow obstruction.

OBJECTIVE: Percutaneous transluminal angioplasty with stenting of the iliac veins is the method of choice to treat patients with symptomatic lower extremity venous outflow obstruction. The optimal method of performing this technique remains to be solved, however. One question in particular is that when braided stainless steel stents (Wallstents; Boston Scientific, Natick, Mass) are used, should these venous stents extend into the vena cava or should they stop short of this for fear of causing thrombosis of the patient's normal contralateral iliofemoral vein? It has been our practice to extend our venous stents significantly into the vena cava to coapt with the inferior vena cava (IVC) wall in the majority of patients with disease of the common iliac vein at the iliocaval junction. The aim of this study was to assess whether this placement led to thrombosis of a normal contralateral common iliac vein. METHODS: We retrospectively reviewed prospectively collected data from 2008 to 2012 in patients with symptomatic acute or chronic iliocaval venous obstruction who underwent percutaneous angioplasty and stenting at our institution. Data were collected by use of the American Venous Forum venous stent database variables. Stent patency rates and the incidence of contralateral iliac vein thrombosis were analyzed. RESULTS: In 65 patients (median age, 48 years; range, 15-80 years), 200 iliocaval stents were placed. Of these patients, 41 received ipsilateral stents that extended into the IVC and completely across the contralateral common iliac vein orifice; 39 (95%) of these had venous outflow obstruction as a result of thrombotic disease. In 22 patients (54%), post-thrombotic disease involved the IVC. All patients had stents that extended into the IVC, crossing the normal contralateral iliac vein orifice completely. Most patients (97.5%) were maintained by full anticoagulation with warfarin or low-molecular-weight heparin. Four patients (9.7%) suffered new thrombosis of the nonstented contralateral iliofemoral vein; two patients had initial involvement of the IVC, and three were totally noncompliant with their postoperative anticoagulation. Thus, 2.4% of compliant patients had new contralateral thrombosis after stenting across a normal contralateral common iliac vein and into the vena caval wall. In this select patient population, univariate analysis of patient compliance with the postoperative anticoagulation strategy showed a strong correlation with postoperative contralateral iliofemoral venous thrombosis (P = .0004). CONCLUSIONS: From these data, it appears that stenting across the iliocaval confluence can be done safely in the majority of patients maintained with therapeutic anticoagulation. In post-thrombotic patients, however, stenting across the iliocaval confluence can result in a small number of new contralateral thromboses, more often if the patients are noncompliant with anticoagulation after stenting. Current stent technology limits the ability of practitioners to treat common femoral venous obstruction precisely. Future stent development is likely to eliminate the need to cross the iliocaval confluence and risk contralateral venous thromboses.

Sensitivity of computed tomography in detection of perirectal abscess.

Most patients with anorectal abscess are diagnosed clinically based on pain, erythema, warmth, and fluctuance. Some patients, however, present with subtle or atypical signs. CT is easily accessible and is commonly used for diagnosis and delineation of anorectal abscess. The purpose of this study is to determine the sensitivity of CT scan in detecting perirectal abscesses and to see if immune status impacts the accuracy of CT. A retrospective study was conducted to identify patients from 2000 to 2009 with International Classification of Diseases, 9th Revision code 566 (anal or rectal abscess). Patients included had a CT scan less than 48 hours before drainage. Patients with CT-positive abscess were compared with patients with CT-negative abscess. Patients were categorized as either immunocompetent or immunosuppressed based on documentation of diabetes mellitus, cancer, human immunodeficiency virus, or end-stage renal disease. One hundred thirteen patients were included in this study. Seventy-four (65.5%) were male and the average age was 47 years. Eighty-seven of 113 (77%) patients were positive on CT for anorectal abscess. Sixty of 113 (53%) patients included in this study were immunocompromised. CT missed 26 of 113 (23%) patients with confirmed perirectal abscess. Eighteen (69%) of these patients were immunocompromised compared with CT-positive patients (42 [48%], P = 0.05). The overall sensitivity of CT in identifying abscess was 77 per cent. CT lacks sensitivity in detecting perirectal abscess, particularly in the immunocompromised patient.

Do donor characteristics really matter? Short- and long-term impact of donor characteristics on recipient survival, 1995-1999.

We reviewed the impact of multiple donor characteristics on recipient mortality by univariate and multivariate analyses in a cohort of heart donors from 1995 to 1999. A sub-cohort of donors was also selected who met "marginal" criteria, and the early and late survival of these patients was then compared. Surrogates of donor size (donor weight, donor body mass index [BMI], BMI mismatch >20%), under-resuscitation (hematocrit, 24-hour fluid intake) and age >56 years were significantly associated with peri-operative mortality in the univariate analysis; in the multivariate analysis, only average donor heart rate at procurement (p =.001), donor hematocrit (p =.02) and donor weight (p =.05) were significantly associated. Few donor characteristics actually impact significantly on recipient outcome, and thus recipient characteristics may figure more prominently than those of the donor toward the risk of death after transplantation.

Heparin-bonded cardiopulmonary bypass circuits reduce cognitive dysfunction.

OBJECTIVE: To determine the incidence of cerebral dysfunction in cardiac surgical patients exposed to heparin-bonded cardiopulmonary bypass (HB-CPB) versus nonheparin-bonded cardiopulmonary bypass (NH-CPB) circuits through neuropsychometric testing and to correlate these findings with markers of the systemic inflammatory response to CPB. DESIGN: Prospective, randomized, blinded clinical trial. SETTING: University hospital. PARTICIPANTS: Sixty-one patients undergoing elective cardiac surgery. INTERVENTIONS: A cohort of 61 patients scheduled for elective coronary artery bypass graft surgery were prospectively randomized to receive either HB-CPB or NH-CPB circuits during surgery. Patients were evaluated for cerebral injury using a battery of neuropsychometric tests at the following 3 time points: (1) before surgery as a baseline examination, (2) postoperative day 5, and (3) postoperative week 6. Blood samples were drawn to measure inflammatory markers at the following time points: (1) preincision, after induction of anesthesia, (2) 15 minutes after onset of CPB, (3) 30 minutes after CPB, (4) 6 hours postoperatively, and (5) 24 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Neuropsychometric performance was evaluated by group-rate and event-rate analyses. By group-rate analysis, patients undergoing surgery with HB-CPB performed significantly better at 5 days after surgery on 2 neuropsychometric tests (trails A [p < 0.01] and finger tapping with the dominant hand [p < 0.01]) and at 6 weeks after surgery on one neuropsychometric test (trails A [p < 0.01]). By event-rate analysis, at 5 days, patients undergoing surgery with HB-CPB circuits had less cognitive dysfunction (p < 0.05) compared with patients undergoing surgery with NH-CPB circuits. Serum samples were analyzed to evaluate markers of complement activation (C3a), proinflammatory cytokines (tumor necrosis factor-alpha, interleukin-1 beta, and interleukin-6), and coagulation (thrombin-antithrombin complex [TAT]) using the quantitative sandwich enzyme immunoassay technique. Although there were no significant differences in cytokine activation in either group, C3a was significantly higher in the NH-CPB group intraoperatively at 1 hour after CPB (p < 0.05), and TAT was higher in the HB-CPB group at 24 hours after surgery (p < 0.05). CONCLUSIONS: Patients undergoing cardiac surgery with CPB have less postoperative cognitive dysfunction during CPB when HB-CPB circuits are employed. Although there was a relationship, this finding did not correlate with decreased complement activation intraoperatively and activation of coagulation postoperatively.