Secondary medical prevention after primary vascular surgery between 1996 and 2006: a shift towards more evidence-based treatment.

OBJECTIVE: The implementation of evidence-based secondary medical prevention in peripheral arterial disease (PAD) patients has received increasing attention in recent years, but population-based data are sparse. This study examined the use of secondary medical prophylaxis in unselected symptomatic PAD patients in Denmark. DESIGN: A nationwide follow-up study based on individual-level record linkages of population-based healthcare registers was performed. PARTICIPANTS: All patients who underwent primary vascular reconstruction in Denmark between 1996 and 2006 with a minimum of 6 months of follow-up were included (n = 16,492). METHODS: Data were obtained from prescriptions that were filled six months after primary vascular reconstruction (±90 days). The use of secondary medical prevention was examined according to calendar year and place of residence. RESULTS: The use of lipid-lowering drugs increased from 32.2% in 1996 to 76.1% in 2006 (adjusted relative risk (RR) 1.95, 95% CI 1.81-2.10). The overall use of antihypertensive therapy was unchanged during the study period, but treatment shifted from diuretics/calcium antagonists towards angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists. The use of combination therapy (concomitant lipid-lowering, antiplatelet and any antihypertensive therapies) increased from 29.1% in 1996 to 67.6% in 2006 (adjusted RR 1.95, 95% CI 1.80-2.12). This shift in the use of secondary medical prevention was independent of sociodemographic and clinical factors. No substantial differences in pharmacological use based on place of residence were observed. CONCLUSION: The use of evidence-based secondary medical prevention, especially lipid-lowering drugs, increased substantially among symptomatic PAD patients in Denmark from 1996 to 2006. However, recommendations in current clinical guidelines suggest that room for improvement remains.

Use of angiotensin-converting enzyme inhibitors and cardiovascular outcomes following primary vascular surgery: a nationwide propensity score matched follow-up study.

OBJECTIVE: To examine the association between angiotensin-converting enzyme (ACE) inhibitor use and clinical outcome after primary vascular reconstruction in a population-based follow-up study. METHODS: All Danish patients undergoing primary vascular surgical reconstruction between 1996 and 2007 were included. For each ACE user up to 5 nonuser was identified using propensity score matching followed by Cox regression. All drugs were included as time-dependent variables. RESULTS: Totally 17 495 matched patients with a median follow-up period of 582 days were included. All-cause mortality was 20.4% for ACE users and 24.9% for nonusers (adjusted hazard ratio [adj HR] 0.88, 95% confidence interval [CI] 0.81-0.96). The cumulative risk of myocardial infarction was 6.2% for ACE users and 4.7% for nonusers (adj HR 1.20, 95%CI 1.03-1.39). Cumulative risk of new vascular surgery was 24.0% for ACE users and 23.1% for nonusers (adj HR 1.21, 95% CI 1.13-1.30). No differences were seen concerning stroke and major amputation. CONCLUSION: The ACE use was associated with lower all-cause mortality but also an increased long-term risk of recurrent vascular reconstruction.

Acute iliofemoral venous thrombosis in patients with atresia of the inferior vena cava can be treated successfully with catheter-directed thrombolysis.

PURPOSE: To assess the effectiveness and clinical outcomes of catheter-directed thrombolysis in patients with atresia of the inferior vena cava (IVC) and acute iliofemoral deep vein thrombosis (DVT). MATERIALS AND METHODS: From 2001 to 2009, 11 patients (median age, 32 y) with atresia of the IVC and acute iliofemoral DVT in 13 limbs were admitted for catheter-directed thrombolysis. Through a multiple-side hole catheter inserted in the popliteal vein, continuous pulse-spray infusion of tissue plasminogen activator and heparin was performed. Thrombolysis was terminated when all thrombus was resolved and venous outflow through the paravertebral collateral vessels was achieved. After thrombolysis, all patients received lifelong anticoagulation and compression stockings and were followed up at regular intervals. RESULTS: Ultrasound or computed tomography revealed absence of the suprarenal segment of the IVC in two patients, and nine were diagnosed with absence of the infrarenal segment of the IVC. Median treatment time was 58 hours (range, 42-95 h). No deaths or serious complications occurred. Overall, complications were observed in four patients, one of whom required blood transfusion. Three patients were diagnosed with thrombophilia. Median follow-up was 37 months (range, 51 d to 96 mo). All patients had patent deep veins and one developed reflux in the popliteal fossa after 4 years. No thromboembolic recurrences were observed during follow-up. CONCLUSIONS: Catheter-directed thrombolysis of patients with acute iliofemoral DVT and atresia of the IVC is a viable treatment option, as reasonable clinical outcomes can be obtained.