We evaluated whether the incidence of recurrent venous thromboembolic events (VTEs) during and after therapy differs for patients treated with full or reduced doses of low-molecular-weight heparin ...(LMWH) used long term compared with vitamin K antagonists (VKAs).
We identified randomized studies of long-term treatment with LMWH or VKA by searching MEDLINE, EMBASE, BIOSIS, and PASCAL. Seventeen studies were included, with 4,002 patients.
In the assessment at 12 months of 1,957 patients without cancer, the recurrence rates of VTE in the LMWH/VKA groups were 8.3%/7.6% in the studies using full doses and 12.3%/12.1% in those using prophylactic doses. However, combined analysis after treatment to 1 year showed a nonsignificant (NS) trend to lower recurrent symptomatic VTE in favor of VKA (RR = 1.46, 95% CI 0.96-2.23). In 1,292 patients with cancer the recurrence rates of VTE in the LMWH/VKA groups were 6.5%/17.9% (p = 0.005) in the studies using full doses, 7.1%/13.4% (p = 0.002) in the studies using intermediate doses, and 14.3%/19.1% (p = NS) in the studies using prophylactic doses. Furthermore, the recurrences of VTE after discontinuation of treatment in the LMWH/VKA groups were 1.6%/9.5% (RR = 0.25, 95% CI 0.06-1.1) in 252 patients with full doses and 12%/7.4% (RR = 1.49, 95% CI 0.3-7.48) in 52 patients with prophylactic doses. In this population with cancer, the full-treatment LMWH regimen did not produce more major bleeding events than intermediate or prophylactic doses (5.1% vs. 6.3% or 8.1%, respectively).
Full-dose LMWH for 3-6 months is as safe as intermediate and prophylactic doses for the long-term treatment of deep vein thrombosis. In patients with cancer it appears that there is an excess of VTE recurrence after treatment with prophylactic doses that does not occur with full therapeutic doses.
Objective. To determine the clinical usefulness of color duplex sonography in the diagnosis of giant cell arteritis as an alternative to temporal artery biopsy. Methods. From May 1998 to November ...2002, 68 consecutive patients seen in our hospital with a clinical suggestion of active temporal arteritis were included. Forty‐eight patients were female and 20 were male, with a mean age of 77 years. Color duplex sonography with a linear array transducer (5–10 MHz) was used to assess temporal artery morphologic characteristics before a biopsy was performed. The main sonographic criterion for a positive diagnosis was visualization of a hypoechoic halo around the temporal artery. These data were compared with pathologic findings. The κ statistic was used to determine the level of agreement. Sensitivity, specificity, positive and negative predictive values, and accuracy of duplex sonography as a diagnostic test were assessed. Results. The color duplex sonographic findings were positive in 25 of 68 patients with a clinical suggestion of giant cell arteritis. The diagnosis was confirmed by biopsy in 22 patients; there were 4 false‐positive results and 1 false‐negative result by duplex sonography. The κ value was 0.84. Sensitivity, specificity, positive and negative predictive values, and accuracy for duplex sonography were 95.4%, 91.3%, 84%, 97.6%, and 92.6%, respectively. Conclusions. The use of high‐resolution color duplex sonography may replace biopsy in the diagnosis of giant cell arteritis.
Non-cardiac arterial disease (NCAD) is a frequent cause of hospital admission. The aim of this study was to investigate differences in patient profiles and clinical records as a function of the size ...of the Vascular Surgery Unit (VSU).
Retrospective observational study. Stratified cluster sampling and selection of patients hospitalized for NCAD.
1) description of patient profiles, quality of clinical records, and VSU availability of diagnostic (DR) and therapeutic (TR) resources, and of written protocols (WP); 2) association between these variables and size of VSU.
The sample consisted of 14 hospitals, 6 with a VSU of 15 or fewer beds (VSU < or = 15B) and 8 with >15 beds (VSU >15B). The mean number of DRs, TRs and WPs was 9, 2.8 and 2 in VSUs < or = 15B, and 11.5, 6.5 and 3.3 in VSUs >15B. The proportion of patients older than 70, female, with ischemic disease, or with coexisting diabetes was significantly higher in VSUs < or = 15B (67%, 31%, 95% and 57%, respectively) than in VSUs >15B (58%, 22%, 69% and 48%). Comorbid conditions and treatment during admission and at discharge were documented significantly less frequently in the clinical records in VSUs < or = 15B. Risk factors were under-reported in the clinical records of both types of VSU.
Patient profiles and the quality of clinical records vary by size of VSU. Under-reporting of risk factors may hinder the implementation of prevention and treatment measures.
Arteriography is the gold-standard in decision making in patients with critical lower-limb ischemia. Such method is not bereft of side effects and only gives morphologic information about lesions. ...Duplex allows to evaluate hemodynamically the arteriosclerotic lesions of ischemic lower limbs non-invasivelly and with the same reliability, in some studies, as angiography. Aim of this study was to determine the value and safety of arterial ultrasonic mapping in decision making for treatment of critical lower-limb ischemia.
This was a prospective and comparative study in patients with critical lower-limb ischemia recruited from March 2005 to June 2006. Ultrasonic arterial mapping was performed in 130 patients. Arteriography was performed only in those patients with elevated risk of major amputation or if ultrasound was not feasible (44 patients). Patients were randomized into two groups according to decision making criteria: 1) group A based on mapping alone; 2) group B based on arteriography. There was no statistical difference between risk factors in the two groups (P>0.05). Cumulative patency was recorded and compared at one and three months (Log Rank) as well as degree of concordance of decision making using mapping and arteriography in the group with both tests (B); and degree of concordance of the two tests with decision making based on intraoperative findings.
The degree of concordance between mapping and arteriography was 84.1% (P<0.0001), and the degree of concordance between mapping and arteriography with respect to final decision according to intraoperative findings was 93.1% and 97.7%, respectively (P<0.0001). There were no statistically significative differences in patency rates at one and three months between the two groups (P>0.05).
Ultrasonic arterial mapping is sufficient and comparable to arteriography for purposes of decision making in patients with critical lower-limb ischemia.
The purpose of the study was to determine if early mobilisation in patients with acute lower limb deep vein thrombosis (DVT) increases the incidence of symptomatic pulmonary embolism (PE) and to ...evaluate the predisposing factors for PE such as location of the thrombus and duration of symptoms.
The current study was a prospective randomised clinical trial. Between January 2005 and December 2007, 219 patients with acute lower limb DVT were enrolled in the study (118 males and 101 females); the mean age was 64.2 years.
<15 days of initial symptoms, life expectancy >1 year, no life-threatening clinical conditions, and signed informed consent. The patients were randomised into two groups. Group A, 105 patients (47.9%) were hospitalized and received 5 days of bed rest; Group B, 114 patients (52.1%) received care at home with early walking and compression stockings. The primary end point was the presence of symptomatic PE during the first 10 days of treatment. The relationships between the duration of symptoms, location of the thrombus, and symptomatic PE were also analysed.
Five cases of symptomatic PE were detected (2.3%), three in Group B and two in Group A. There was no significant difference in the occurrence of new PE between the two groups (P=0.54). Likewise, no difference was detected based on the duration of symptoms (P=0.62) and the location of the thrombus (P=0.43).
In acute DVT , early walking, thrombus location, and duration of the symptoms did not influence the incidence of symptomatic PE.
Abstract
INTRODUCTION: A case of thoracic-abdominal dissection after open surgical exclusion of an infrarenal aortic aneurysm is presented.
CASE PRESENTATION: A 62-year-old woman was diagnosed with ...an infrarenal abdominal aortic aneurysm with a rapid increase in maximal diameter. She underwent surgery for aneurysm exclusion by an end-to-end aortoaortic bypass with Dacron collagen (Intervascular; WL Gore&Associates Inc, USA). After 15 days, she was admitted to the emergency department with intense epigastric and lumbar pain. Computed tomography angiography with contrast revealed an aortic dissection with origin in the proximal bypass anastomosis and cranial extension to the thoracic aorta. The true lumen at the level of the eighth thoracic vertebra was practically collapsed by the false lumen. The celiac trunk, and the mesenteric and renal arteries were perfused by the true lumen. After the acute phase of the aortic dissection, surgical repair was planned. Two paths of false lumen were found — one at the thoracic aorta and the second in the proximal bypass anastomosis. Surgical repair comprised two approaches. First, a Valiant Thoracic stent graft (Medtronic Inc, UK) was implanted distal from the left subclavian artery, expanding the collapsed true lumen and covering the false and dissected lumen. Second, an infrarenal Endurant abdominal stent graft (Medtronic Inc) was implanted. This second device was complemented with an aortic infrarenal extension using a Talent abdominal stent graft (Medtronic Inc) in the infrarenal aortic neck to achieve a hermetic seal. The postoperative clinical course was uneventful, and her symptoms were completely resolved in six months.
CONCLUSION: Arteritis must be taken into account in young patients with high inflammatory markers. Covered stents and endoprosthetic devices seem to be effective methods to seal the dissected lumen.
To determine the clinical usefulness of Doppler ultrasonography in the diagnosis of the Nutcracker phenomenon, as an alternative to computed tomographic scans (CT).
This study consisted of 52 ...patients that presented with intermittent hematuria of unknown origin between January 2006 to April 2008. Doppler ultrasonography was used to assess the left renal vein (LRV) by measuring the anteroposterior (AP) diameter and peak systolic velocity (PSV) in supine and standing positions, at the hilar and interaortomesenteric portions of the LRV. These data were compared with CT scans. The sensitivity and specificity of duplex sonography was determined using the AP diameter and PSV ratios to assess the cut-off levels. Kappa (k) statistic was also evaluated.
mean AP diameters of the LRV measured by Doppler sonography were 8.38 mm at the hilar and 3.17 mm under the SMA, compared to 9.3 mm (hilar) and 3.2 mm (SMA) in the supine and standing position respectively. The PSV in the supine position was 25.77 cm/s and 115.48 cm/s, respectively, compared to 25.54 cm/s and 125.96 cm/s in the standing position. The cut-off levels were 3.85 (sensitivity: 61.5%, specificity: 80.8%, k:0.42) for the supine and 4.12 (sensitivity:61.5%, specificity: 65.4%, k: 0.27) for the standing AP diameter, 2.99 (sensitivity: 92.3%, specificity: 73.1%, k: 0.65) for the supine and 3.73 (sensitivity: 96.4%, specificity: 79.2%, k: 0.76) for the standing PSV.
Our data show that the standing PSV ratio is the best parameter for to detecting entrapment of the LRV.
Introduction. Arteriography has been considered as the gold-standard in decision making for critical ischaemia of the lower limbs. However, angiography may produce complications, is invasive and only ...evaluates morphological information. Meanwhile, duplex is able not only to evaluate the morphology of the stenosis but to assess its haemodynamic effects. Duplex reliability has been proven in many diagnostic areas when compared to angiography. Aim. To determinate the value of ultrasound arterial mapping as single test in decision making for treating patient with critical ischaemia of lower limbs. Patients and methods. Prospective and comparative study in patients with critical ischaemia of lower limbs. In all, we performed ultrasound arterial mapping to 112 patients recruited in our department during the year 2002. We only performed arteriography in those patients with high risk of major amputation or in those in whom ultrasound was not conclusive. Patients were allocated in two groups of decision making: (A) those in whom the therapy was based on mapping alone, and (B) when arteriography was considered the test to make the therapeutical decision. Both groups were comparable as we found no statistical differences (p > 0.05). We recorded and compared the accumulative patency at 1 and 6 months (log-rank). Only in the group in which both test were performed (B) we could compare the degree of coincidence in decision making between mapping and arteriography; and degree of coincidence of the two tests with the intraoperative findings. Results. The degree of coincidence mapping-arteriography was 92,8% (p < 0.0001), and the degree of coincidence of mapping and arteriography related to the final decision made at the operating room was 92,3% and 89,5%, respectively (p < 0.0001). There were no statistically significant differences in patency neither at ome month and six months between two groups (p > 0.05). Conclusion. Ultrasound arterial mapping may be enough in the majority of patients for decision making in patients with critical lower limbs ischaemia; may reduce up to 50% the number of angiograms in this particular group of patients. ANGIOLOGÍA 2004; 56: 433-43
Introducción. La arteriografía hasta hoy se ha considerado como el patrón de referencia para la toma de decisiones terapéuticas en pacientes con isquemia crítica de los miembros inferiores (MMII). Ésta técnica invasiva no sólo no está exenta de efectos secundarios sino que además sólo aporta información morfológica. Por otra, mediante eco-Doppler se puede combinar la información morfológica y hemodinámica y realizar un mapa de la zona explorada, la llamada cartografía arterial (CA), que según algunos estudios ofrece similar fiabilidad a la angiografía. Objetivo. Evaluar la seguridad de la CA como método único de planificación terapéutica en la isquemia crítica de los miembros inferiores. Pacientes y métodos. Estudio prospectivo-comparativo no aleatorizado de pacientes con isquemia crítica de MMII reclutados durante 2002. Se incluyeron 112 pacientes consecutivos a quienes realizamos CA. En 56 pacientes, se realizó arteriografía para comprobar la imposibilidad de revascularización ante la única alternativa de amputación o bien en los casos en donde el explorador no consideró la CA como concluyente. Dividimos los pacientes en dos grupos de decisión terapéutica: grupo A, basado solamente en CA, y grupo B, basado en arteriografía. No hubo entre ellos diferencias estadísticamente significativas (p > 0,05). Registramos y comparamos permeabilidad acumulativa al mes y a los seis meses (mediante log-rank); grado de coincidencia en decisiones terapéuticas adoptadas por CAarteriografía en el grupo con ambas pruebas (grupo B), y grado de coincidencia de ambas respecto a la decisión quirúrgica intraoperatoria. Resultados. El grado de coincidencia CA-arteriografía fue de 92,8% (p < 0,0001), y de CA y arteriografía respecto a las decisiones finales intraoperatorias de 92,3% y 89,5% (p < 0,0001). No hubo diferencias significativas en la permeabilidad al mes y a los seis meses entre ambos grupos (p > 0,05). Conclusión. La CA es un método suficiente para tomar decisiones terapéuticas en la mayoría de pacientes con isquemia crítica de MMII; reduce un número significativo de angiografías. Sin embargo, ante la duda o la posibilidad de amputación recomendamos practicar angiografía. ANGIOLOGÍA 2004; 56: 433-43
Introdução. A arteriografia, até hoje, tem sido considerada como o padrão de referência para as decisões terapêuticas em doentes com isquemia crítica dos membros inferiores (MI). Esta técnica invasiva, não só, não está isenta de efeitos secundários, como também comporta apenas informação morfológica. Por outro lado, mediante eco Doppler pode combinar-se a informação morfológica e hemodinâmica e realizar um mapa da zona explorada, a chamada cartografia arterial (CA), que segundo alguns estudos oferece idêntica fiabilidade à da angiografia. Objectivo. Avaliar a segurança da CA como método único de planificação terapêutica na isquemia crítica dos membros inferiores. Doentes e métodos. Estudo prospectivo-comparativo, não aleatório de doentes com isquemia crítica dos MI recrutados durante 2002. Foram incluídos 112 pacientes consecutivos a quem realizámos CA. Em 56 pacientes, foi realizada arteriografia para comprovar a impossibilidade de revascularização perante a única alternativa de amputação ou nos casos em que o explorador não considerou a CA como conclusiva. Dividimos os doentes em dois grupos de decisão terapêutica: grupo A, baseado apenas na CA, e grupo B, baseado na arteriografia. Não houve entre eles diferenças estatisticamente significativas (p > 0,05). Registámos e comparámos a permeabilidade acumulativa ao mês e aos seis meses (mediante log-rank); grau de coincidência em decisões terapêuticas adoptadas por CA-arteriografia no grupo com ambas as provas (grupo B), e grau de coincidência de ambas no que respeita à decisão cirúrgica intra-operatória. Resultados. O grau de coincidência CA-arteriografia foi de 92,8% (p < 0,0001), e da CA e arteriografia no que respeita às decisões finais intra-operatórias de 92,3% e 89,5% (p < 0,0001) respectivamente. Não houve diferenças significativas na permeabilidade ao mês e aos seis meses entre ambos os grupos (p > 0,05). Conclusão. A CA é um método suficiente para tomar decisões terapêuticas na maioria dos doentes com isquemia crítica dos MI; reduz um número significativo de angiografias. Contudo, perante a dúvida ou a possibilidade de amputação recomendamos a angiografia. ANGIOLOGÍA 2004; 56: 433-43 Palavras chave. Cartografia arterial. Diagnóstico através da imagem. Eco-Doppler. Hemodinâmica arterial. Isquemia crítica. Revascularização.
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