Badr Aljabri

Impact of Clinical Trial Results on the Temporal Trends of Carotid Endarterectomy and Stenting From 2002 to 2014

Background and Purpose— Randomized trials provide conflicting data for the efficacy of carotid-artery stenting compared with endarterectomy. The purpose of this study was to examine the impact of conflicting clinical trial publications on the utilization rates of carotid revascularization procedures. Methods— We conducted a population-level time-series analysis of all individuals who underwent carotid endarterectomy and stenting in Ontario, Canada (2002–2014). The primary analysis examined temporal changes in the rates of carotid revascularization procedures after publications of major randomized trials. Secondary analyses examined changes in overall and age, sex, carotid-artery symptom, and operator specialty–specific procedure rates. Results— A total of 16 772 patients were studied (14 394 endarterectomy [86%]; 2378 stenting [14%]). The overall rate of carotid revascularization decreased from 6.0 procedures per 100 000 individuals ≥40 years old in April 2002 to 4.3 procedures in the first quarter of 2014 (29% decrease; P<0.001). The rate of endarterectomy decreased by 36% (P<0.001), whereas the rate of carotid-artery stenting increased by 72% (P=0.006). We observed a marked increase (P=0.01) in stenting after publication of the SAPPHIRE trial (Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy) in 2004, whereas stenting remained relatively unchanged after subsequent randomized trials published in 2006 (P=0.11) and 2010 (P=0.34). In contrast, endarterectomy decreased after trials published in 2006 (P=0.04) and 2010 (P=0.005). Conclusions— Although the overall rates of carotid revascularization and endarterectomy have fallen since 2002, the rate of carotid-artery stenting has risen since the publication of stenting-favorable SAPPHIRE trial. Subsequent conflicting randomized trials were associated with a decreasing rate of carotid endarterectomy.

Surgical Management of Vascular Thoracic Outlet Syndrome: A Teaching Hospital Experience

OBJECTIVES Thoracic outlet syndrome (TOS) consists of a group of distinct disorders that are caused by compression of the brachial plexus and/or subclavian artery and vein. The aim of this study was to highlight the different modalities of diagnosing and treating vascular TOS and evaluate outcomes. METHODS We conducted a retrospective cohort study between 1999 and 2011 using the medical records database from a teaching hospital. RESULTS During the study period, 54 cases with vascular TOS were identified in 38 patients. Bilateral TOS was in 16 patients. The median age of the patients was 33 years (range 12-49), and the majority (79%) were female. Arterial TOS represented forty-nine cases (90.7%). Preoperative information derived from plain x-ray, duplex scanning and in selected cases computed tomography (CT) and/or angiography. Decompression of the TOS was performed through a supraclavicular approach in all cases with scalenectomy coupled with either cervical rib excision (70%), 1st rib excision alone (15%) and excision of both cervical and 1st ribs (15%). Adjunctive vascular reconstructive procedures were done in 11 cases (20.3%); 9 arterial cases and 2 venous cases. There was no mortality; however, postoperative complications occurred in 7 cases (13%). CONCLUSION The use of advanced radiological imaging and careful surgical planning for Vascular TOS in a high volume center resulted in good outcomes.

Vascular Thoracic Outlet Syndrome.

Two distinct terms are used to describe vascular thoracic outlet syndrome (TOS) depending on which structure is predominantly affected: venous TOS (due to subclavian vein compression) and arterial TOS (due to subclavian artery compression). Although the venous and arterial subtypes of TOS affect only 3% and <1% of all TOS patients respectively, the diagnostic and management approaches to venous and arterial TOS have undergone considerable evolution due to the recent emergence of minimally invasive endovascular techniques such as catheter-directed arterial and venous thrombolysis, and balloon angioplasty. In this review, we discuss the anatomical factors, etiology, pathogenesis and clinical presentation of vascular TOS patients. In addition, we use the most up to date observational evidence available to provide a contemporary approach to the diagnosis and management of venous TOS and arterial TOS patients.

Effects on duration of post-operative ischemia and patterns of blood flow recovery in different conditions of mouse hind limb ischemia

BackgroundCurrent limitations to the experimentation on patients with peripheral arterial disease push the development of different preclinical strategies. We investigated both duration of ischemia and blood flow recovery in mouse models of partial femoral artery ligation.MethodsMale BALB/c mice were used. The ligation over needle method involved placing a suture needle over the femoral artery, ligating over it and then removing the needle. The transfixation method involved transfixing the approximate center of the femoral artery and then tying the suture. Laser Doppler Perfusion Imaging was used to assess perfusion every 3rd day until 42 days after the procedure.ResultsLigation over needle method: Immediately post procedure, mean perfusion was -71.87% ± 4.43. Then mean difference in perfusion remained below the base line reading on days 3, 6, 9, and 12. From day 15 on wards mean perfusion progressively improved remaining near base line. Transfixation Method: Immediately post procedure mean perfusion was -70.82% ± 4.73. Mean perfusion improved following the procedure on days 3 and 6; a plateau followed this on days 9, 12 and 15. From day 15 onwards perfusion progressively improved remaining well below base line until crossing it on day 36.ConclusionThe currently described models do not pose major improvements over previously described methods.

Peripheral Arterial Disease Evaluation in the Saudi Project for Assessment of Coronary Events Registry Reveals a Missed Opportunity in Preventing the Adverse Cardiovascular Outcomes: A Pilot Study (SPACE-PAD-I)

Background Peripheral Arterial Disease (PAD) is a marker of systemic atherosclerosis with an elevated risk of cardiovascular mortality and morbidity. This study was undertaken to identify the prevalence of PAD in patients presenting with acute coronary syndrome and do not have previous history of coronary artery disease in order to identify the missed opportunity in treating these patients and potentially avoiding such cardiovascular events. Methods We prospectively collected data from consecutive patients who presented with acute coronary events over 4 months. PAD was diagnosed if the Ankle-Brachial index was less than 0.90 and/or if the patient had signs or symptoms suggestive for PAD. Risk factors and risk reduction therapy were compared between patients with and without PAD. Results A total of 51 patients were recruited. The mean age for these patients was 62 years and 27% were women. Prevalence of PAD was 45%, of these, 61% were asymptomatic. Prevalence of PAD in patients with no previous history of CAD was 48%, of these, 64% were asymptomatic. There was no difference in atherosclerotic risk factors between patients with PAD compared to patients without PAD. Utilization of risk reduction was suboptimal in patients with PAD; only 61% were on aspirin, 48% were on statin therapy, 43% were on beta-blockers and 30% were on angiotensin converting enzymes inhibitors. Conclusion There is a great opportunity in preventing acute coronary events that we are missing. This is can be achieved by recognizing patients with PAD (symptomatic or asymptomatic) and aggressively control their risk factors.

Aneurysms of the foot arteries

Aneurysms of the foot arteries are uncommon but can lead to devastating complications such as acute foot ischemia or arterial rupture if left untreated. In this case series, we present four cases of aneurysms of the foot: one true dorsalis pedis artery aneurysm and three cases of post-traumatic plantar artery pseudoaneurysms with arteriovenous fistulas. All four patients were successfully managed with surgical excision of the aneurysm with or without arteriovenous fistulas ligation. Our case series is followed by discussion on the etiology, clinical presentation and management strategy of patients with aneurysms of the foot arteries.