Long-term treatment of deep venous thrombosis with a low molecular weight heparin (tinzaparin): a prospective randomized trial.

OBJECTIVES: Evaluation of the effectiveness and safety of the low molecular weight heparin (LMWH) tinzaparin versus unfractionated heparin (UFH) followed by acenocoumarol in proximal deep venous thrombosis (DVT). DESIGN: Prospective, randomized clinical trial. MATERIAL AND METHODS: Consecutive patients (n=108) with acute leg DVT, confirmed by duplex, were randomized to either tinzaparin alone or UFH and acenocoumarol for 6 months. Patients were evaluated ultrasonographically at entry, 1, 3, 6 and 12 months. Thrombus regression, reflux distribution and the incidence of complications were studied. A cost-analysis, comparing the two treatments, was performed. RESULTS: The overall incidence of major events (mortality, DVT recurrence, pulmonary embolism, major bleeding, heparin-induced thrombocytopenia) was significantly different (p=0.035) in favor of tinzaparin (7 versus 17 events). The ultrasonographic clot volume score (an index of recanalization) decreased significantly in both treatment groups. However, tinzaparin produced significantly more extended overall recanalization from 3 months onwards (p<0.02). Thrombus regression was equivalent or in favor of tinzaparin in the different DVT subgroups and venous segments, but the statistical significance varied. Reflux showed non-significant differences overall or in subgroups. A cost-analysis resulted in favor of LMWH. CONCLUSIONS: A fixed daily dose of tinzaparin for 6 months was at least as effective and safe as UFH and acenocoumarol. Regarding major events and recanalization, there was a significant benefit in favor of tinzaparin. Long-term DVT treatment with tinzaparin could represent an alternative to conventional treatment.

The limits of percutaneous intervention in aortoiliac occlusive disease.

Aortoiliac occlusive disease (AIOD) is a common manifestation of atherosclerosis that may lead to limb-threatening ischemia. Over the past two decades, considerable advances in the management of patients with AIOD have taken place. Conventional surgical reconstructive procedures, namely aortofemoral and extra-anatomic bypasses, tend to be replaced by newer emerging percutaneous techniques, such as angioplasty and stenting, initially employed to reduce morbidity, complications and cost of treatment. However, irrational application of these percutaneous techniques is not suggested, since these surgical procedures are not devoid of limitations. A careful evaluation of the various restraining parameters should precede the choice of surgical approach, to ensure the selection of the most suitable technique in each individual patient, on the grounds of clinical presentation of the disease and efficiency of the surgical procedure.

Vascular surgery training in Greece.

The aim of the study was to describe current training in vascular surgery in Greece. The method used was the presentation of data obtained by direct contact with the units. Vascular surgery has been a mono-specialty in Greece since 1989. The duration of training is 7 years (3 years common trunk in general surgery, 3 years in vascular surgery and 1 year in cardiothoracic surgery). However, its duration often exceeds 11 years due to lost time in waiting to start training. The latter happens because there has been a tremendous increase of the number of medical graduates during the last decade and thus the number of trainees has increased disproportionately to the demand for vascular surgeons nationwide. Greece has the second higher ratio of vascular trainees per million population in EU (3.6 trainees/million population). There are 14 accredited centres for training in vascular surgery, the majority of them being in Athens (9/14). In these centres there are a total of 52 trainers and 38 trainees (ratio 1.4/1). An average of 380 operations are performed per centre/year and 140 operations/trainee/year. In conclusion, there is a need for re-defining the training programme in vascular surgery in Greece. The main concern is the tremendous increase in medical graduates leading to a discrepancy between accredited training posts and fellows waiting to fill them.

Genetic amniocentesis in women 20-34 years old: associated risks.

The aim of this retrospective controlled study is to evaluate the impact of predisposing factors on amniocentesis-related fetal loss. It comprises 3910 consecutive cases of women, aged 20-34 years, who had genetic amniocentesis during the years 1992-97 (study group). The control group comprised 5324 women under 35, at low risk for Down syndrome, during the same period. The fetal losses in both groups were analysed, in respect of: (a) maternal historical conditions; and/or (b) bleeding during current pregnancy. The leading indication for amniocentesis in women 20-34 years was maternal anxiety, mainly for marginal age (33-34 years), which accounted for a remarkable 34.4% of the study group. Total fetal loss rate up to the 28th week was 2.1% in the study group versus 1. 5% in controls. A history of previous spontaneous or induced abortions, as well as bleeding during the current pregnancy, was associated with a substantial rise of fetal loss in both groups. In cases with no predisposing factors, the added fetal loss rate was 0.03%. Previous abortions and bleeding during the current pregnancy are associated with the most fetal losses after amniocentesis. In the absence of these, the added fetal loss rate (0.03%) is non-significant.

The effect of gestational age and placental location on the prediction of pre-eclampsia by uterine artery Doppler velocimetry in low-risk nulliparous women.

OBJECTIVE: To assess how placental position and gestational age can influence the value of a diastolic notch of the uterine arteries as a screening test for pre-eclampsia, in a low-risk population of healthy nulliparous women. METHODS: Color Doppler ultrasound was used to examine both uterine arteries in 654 healthy nulliparas at 4-week intervals between 20 and 32 weeks. The only criterion for an abnormal result was the presence of an early diastolic notch. In each subject the placental position was also recorded. The major end points were pre-eclampsia and pre-eclampsia requiring delivery before the 34th week. RESULTS: Ninety-eight women (15%) had abnormal flow velocity waveforms at their first visit. Twenty-one out of 654 women developed pre-eclampsia (3.2%). The sensitivity of the test became lower as gestational age advanced and ranged from 81% at 20 weeks, to 71.4% at 32 weeks. In contrast, the specificity and positive predictive value increased significantly. Eleven out of 12 women who delivered before 34 weeks had abnormal waveforms at the 24th week. In women with a full lateral placenta, the predictive value of the test was extremely low, especially in cases with unilateral notches. CONCLUSION: Pre-eclampsia can be more accurately predicted if, along with the presence of a notch, both gestational age and placental position are taken into account. At week 24 the test maintains a high sensitivity (76.1%), but also has an improved specificity (95.1%) and positive predictive value (34%), which allow the clinician to intervene with a potential preventive treatment.