Synergistic influence of rivaroxaban on inflammation and coagulation biomarkers in patients with coronary artery disease and peripheral artery disease on aspirin therapy.

COMPASS study demonstrated efficacy of dual pathway inhibition with 2.5 mg twice daily rivaroxaban and aspirin in patients with polyvascular disease (coronary artery disease, peripheral arterial disease or both), the underlying mechanism of which is not clearly understood. In this Phase IV, prospective, open-label and randomized study, we hypothesize that treatment with rivaroxaban is associated with a reduction in platelet activation and aggregation, inflammation and coagulation markers. 30 patients will be randomly treated with aspirin (81 mg q.d.) or aspirin plus rivaroxaban (2.5 mg b.i.d.) for 12 weeks. Platelet aggregation, platelet activation and inflammation markers, thrombin generation kinetics and tissue factor-induced platelet-fibrin clot strength will be measured at baseline, and 4 and 12 weeks after randomization. Trial registration number: NCT04059679.

A Mysterious Cause of Gastrointestinal Bleeding Disguising Itself as Diverticulosis and Peptic Ulcer Disease: A Review of Diagnostic Modalities for Aortoenteric Fistula.

An 81-year-old male with a history of hypertension, hyperlipidemia, smoking, and peptic ulcer disease (PUD) presented with 2 episodes of maroon stools for 3 days and was found to be orthostatic. His PUD was thought to have accounted for a previous upper gastrointestinal (GI) bleed. A colonoscopy revealed 3 polyps and a few diverticuli throughout the colon that were considered to be the source of the bleeding. Two months later, the patient had massive lower GI bleeding and developed hypovolemic shock with a positive bleeding scan in the splenic flexure; however, angiography was negative. A repeat colonoscopy revealed transverse/descending colon diverticular disease and the patient was scheduled for a left hemicolectomy for presumed diverticular bleeding. Intraoperatively, an aortoenteric (AE) fistula secondary to an aorto-bi-iliac bypass graft placed during an abdominal aortic aneurysm (AAA) repair 14 years prior was discovered and was found to be the source of the bleeding. The patient had an AE fistula repair and did well postoperatively without further bleeding. AE fistulas can present with either upper GI or lower GI bleeding, and are universally deadly if left untreated. AE fistulas often present with a herald bleed before life-threatening bleeding. A careful history should always be elicited in patients with risk factors of AAAs such as hypertension, hyperlipidemia and a history of smoking. Strong clinical suspicion in the setting of a scrupulous patient history is the most important factor that allows for the diagnosis of an AE fistula. There are numerous diagnostic modalities for AE fistula, but there is not one specific test that universally diagnoses AE fistulas. Nuclear medicine scans and angiography should not be completely relied on for the diagnosis of AE fistulas or other lower GI bleeds for that manner. Although the conventional paradigm for evaluating lower GI bleeds incorporates nuclear medicine scans and angiography, there is evidence that early endoscopy with enteroscopy may have a better role in severe lower GI bleeding.

Can carotid angiography be performed by vascular surgeons? A critical evaluation of indications, technique, and results.

The purpose of this report is to examine the contemporary indications for diagnostic carotid arteriography and evaluate its utility and safety when performed by vascular surgeons. The records of all patients having selective carotid arteriography from September 2000 through March 2002 at our institution were reviewed. One hundred sixty-four consecutive patients had selective arteriography of the extracranial carotid arteries for the following indications: hemispheric symptoms with stenosis <80% by duplex ultrasound (20.6%), suspected brachiocephalic trunk stenosis (15.8%), unclear anatomy by duplex (10.3%), recurrent carotid stenosis (10.3%), symptomatic high-grade (>80% by duplex) internal carotid stenosis (9.8%), ipsilateral internal carotid artery occlusion (7.1%), bilateral high-grade internal carotid artery stenoses (7.1%), vertebral-basilar ischemia (7.0%), contralateral internal carotid occlusion (5.4%), duplex ultrasound from a nonaccredited vascular laboratory (3.3%), and evaluation of nonatherosclerotic carotid disease (3.3%). There were no transient ischemic attacks, strokes, or deaths related to the index procedure. Selective angiography of the extracranial carotid arteries remains an important adjunct in the evaluation of patients with carotid disease. This procedure can be performed safely by vascular surgeons.

Can the Perclose suture-mediated closure system be used safely in patients undergoing diagnostic and therapeutic angiography to treat chronic lower extremity ischemia?

PURPOSE: Mechanical closure devices for arterial hemostasis after angiography, such as the Perclose suture-mediated closure system, are designed to decrease time to ambulation and improve patient comfort. Although these devices are safe and efficacious, to date there has been little reported about use of the Perclose device in a cohort consisting exclusively of patients with lower extremity peripheral vascular disease. The purpose of this study was to determine the safety and efficacy of routine use of the Perclose system in patients with documented peripheral vascular disease undergoing angiography to treat chronic lower extremity ischemia. METHODS: The Perclose device was placed for arterial closure after femoral artery access in 500 consecutive patients with documented peripheral vascular disease (ankle-brachial index, <0.8) who underwent diagnostic angiography or percutaneous intervention because of chronic lower extremity ischemia. These 500 patients composed 91% of all patients who underwent angiography because of chronic lower extremity ischemia between January 1, 2001, and April 1, 2002. All complications associated with the Perclose device were identified and reviewed. RESULTS: Of the 500 arteries, 54% were accessed for diagnostic angiography and 46% for intervention. Perclose device placement was successful in 475 attempts (95%). Overall major complication rate was 1.4% (7 of 500 arteries). Complications included one death from retroperitoneal hemorrhage; three episodes of limb ischemia, two requiring operation and one requiring lytic therapy; two pseudoaneurysms; and one hematoma, which prolonged hospitalization. The hematoma was the only complication in the 25 patients with failed Perclose device placement. There were no infections requiring admission or operation. CONCLUSION: The Perclose suture-mediated closure device is efficacious and can be used safely in selected patients with documented peripheral vascular disease. Complications associated with this device tend to be more severe than those historically reported for manual compression. Substantial experience with use of this device is required to achieve excellent results in patients with difficult anatomy.

The LEGS score: a proposed grading system to direct treatment of chronic lower extremity ischemia.

OBJECTIVE: To prospectively compare the Lower Extremity Grading System (LEGS)-derived "recommended treatment" to the actual treatment performed and to analyze LEGS intergrader scoring consistency by comparing blinded scoring results between physician graders. SUMMARY BACKGROUND DATA: Due to technical advances and the increased medical complexity of the aging population, the most appropriate treatment for chronic lower extremity ischemia-open surgery versus endovascular-is again in flux. In an attempt to standardize management, the LEGS score, based on the best available outcomes data, was devised by the physicians of an established vascular service. METHODS: From March to June 2002, all chronically ischemic lower extremities that met standard indications for revascularization were prospectively enrolled and independently graded with the LEGS score by an "endovascular surgeon" and an "open surgeon" for comparative analysis. The results were then blindly evaluated to determine whether the LEGS-derived "recommended treatment" agreed with the actual treatment rendered and to assess for intergrader consistency. Agreement was assessed using kappa statistical analysis. RESULTS: Of the 137 presenting limbs (mean patient age 66.4 yo; 43% claudication, 57% limb-threatening ischemia), 107 were treated (65% endovascular, 30% open surgery, 5% amputation), 16 were pending treatment, and 14 were not treated because of patient refusal (n = 13) or death (n = 1). The LEGS score predicted the actual or offered clinical treatment in 90% of cases. The LEGS score comparison between physician graders resulted in identical "recommended treatment" in 116 of 128 cases for a 90.6% agreement. CONCLUSIONS: A reproducible scoring system to guide the treatment of patients with chronic lower extremity ischemia is possible. While systems like the LEGS score may have potential clinical application, their use as a treatment standardization tool for future prospective outcomes comparisons between open and endovascular surgery will be essential.

Serum leptin levels in acute protein deprivation.

BACKGROUND: Protein energy malnutrition (PEM) induces a host neuroendocrine response, reflected by significant elevations in circulating glucocorticoid levels and associated with metabolic and immune dysfunction. Leptin regulates food intake and body mass and has a significant impact on the hypothalamic-pituitary-adrenal axis (HPA). We hypothesized that leptin may be altered by and may play an important role in regulating the effects of PEM. METHODS: Female Balb/c mice were used. In experiment 1, mice were pair-fed either a protein-free (0% casein) or control (24% casein) diet for 7 days. In experiment 2, mice were implanted with either a placebo or corticosterone-releasing pellet and fed the control diet for 7 days. In experiment 3, adrenalectomized mice were pair-fed either the protein-free or control diet for 7 days. Serum corticosterone and leptin levels were measured in all experiments. RESULTS: PEM caused significant reductions in food intake, body weight, and total body fat, but not lean body mass. Serum corticosterone and leptin levels were significantly greater in mice fed the protein-free diet. Subcutaneous implantation of a corticosterone pellet in mice fed the control diet resulted in a significantly elevated serum leptin level compared with placebo-implanted controls. Bilateral adrenalectomy partially blunted the increased serum leptin in PEM. CONCLUSIONS: Leptin may be an important mediator of weight loss and decreased food intake in PEM. Elevated serum leptin in PEM may be secondary to elevated serum corticosterone, with other factors inherent in the host response to protein restriction also contributing to elevated serum leptin.

Management of renal artery stenosis: effects of a shift from surgical to percutaneous therapy on indications and outcomes.

The treatment of choice for renal artery occlusive disease has shifted from open repair to percutaneous angioplasty and stenting in many institutions. Whether this change in treatment modality will lead to altered and, perhaps, relaxed indications for intervention is unclear. We reviewed our experience to determine if a shift from open surgery to percutaneous management of renal occlusive disease was associated with changes in either indications for intervention or patient outcomes. Over an 8-year period, 165 patients had intervention for renal artery stenosis by our vascular surgery teaching service. Over the period there was a dramatic increase in interventions per year (4 patients 1994 to 57 patients 2001). There was also a shift from open to endovascular management. Patient demographics and indications for intervention showed no difference between open and endovascular groups. Outcome analysis revealed similar technical success rates between groups but a significantly higher morbidity and mortality rate in the surgical group. A shift from open to percutaneous treatment of renal artery occlusive disease led to a significant increase in patient volume. This increase occurred without a change in patient demographics or indications for therapy, and appeared to reflect an increase in patient referrals.