Grace C.Y. Cheung

Epidemiology of venous thromboembolism in a Chinese population.

Deep vein thrombosis (DVT) is uncommon in Asians and routine thromboprophylaxis for surgery is controversial. Despite recent reports of higher incidences in some Asian countries, population‐based data are lacking.

THE SATIR MODEL AND CULTURAL SENSITIVITY: A HONG KONG REFLECTION

This paper addresses cultural sensitivity in applying the Satir model in the Hong Kong Chinese cultural setting, focusing on congruent communication. The authors contend that Satir was sensitive to the demands of culture. Her focus on individuality, equality, and freedom responds aptly to the egalitarian individualist ethos of the United States. In Hong Kong the family is generally dominated by hierarchical collectivist values. Applying the Satir model as it is being practiced in the United States totally ignores prevailing cultural conditions. Following the spirit of Satir, the authors propose the adoption of an emic approach, drawing inspiration and resource from traditional Chinese culture and maintaining continuity with hierarchical collectivism while protecting individual quests for equality, freedom, and independence.

Primary stenting of femoropopliteal atherosclerotic lesions using new helical interwoven nitinol stents

BACKGROUND The Supera helical interwoven nitinol stent has enhanced flexibility in counteracting fractures when placed in the femoropopliteal arteries and may improve patency. The aim of this study is to assess the early results of the Supera stent in symptomatic patients with femoropopliteal atherosclerotic lesions. METHODS From October 2011 to April 2013, patients with symptomatic femoropopliteal lesions were treated with angioplasty and primary stenting using the Supera stent. They were followed up at 1, 3, 6, and 12 months with clinical, duplex, and radiographic assessments. Failure was defined as >50% restenosis of the target lesion on duplex ultrasound imaging or stent fracture on X rays. RESULTS A total of 78 consecutive patients (46 males, 32 females) with 82 legs, mean age of 78.5 years (range, 57-97 years) were included. Symptoms of claudication, rest pain, and tissue loss were 48 (59%), 8 (10.1%), and 30 (37%), respectively. Ninety-six Supera stents were inserted in total. In 44 (53.7%) of the legs, stents were extended to the popliteal segments. The mean stented length was 12.6 cm (range, 4.0-38.0 cm). The primary patency rates at 6 and 12 months were 83.5% and 78.6%, respectively. The ankle brachial index increased from 0.58 ± 0.16 preoperative to 0.87 ± 0.14 postoperative. There were no stent fractures. Patency rate was not affected by severity of symptoms, stent lengths, femoro/popliteal stents (log-rank test, P = .50, .13, .52). All the patients reported symptomatic improvement. There was no procedural- or device-related morbidity or mortality, no major amputation after revascularization, and 10 patients died of unrelated cardiopulmonary/renal causes on follow-up. CONCLUSIONS Our early experience shows that the Supera stents are effective in our cohort of elderly patients, with acceptable patency rates. There were no stent fractures so far even with stenting of the popliteal segments.

Ten-Year Epidemiological Review of In-Hospital Patients with Marfan Syndrome

Marfan syndrome is a connective tissue disorder with a worldwide prevalence of 1 in 5,000, without any racial predilection. Major cardiovascular manifestations of Marfan disease often require surgical intervention. The aim of this study was to examine the demographics of patients with Marfan syndrome admitted to Hong Kong hospitals over a 10-year period from 1997 to 2006. We retrospectively reviewed the prospectively collected Hong Kong Health Authoritys Clinical Data Analysis and Reporting System and Clinical Medical System. Statistical analysis was performed using SPSS, version 15. A total of 525 patients with Marfan syndrome (310 male, 215 female) were included in this study. For males, mean age at first hospital admission was 19.8 years (range 0-78) and for females, 18.7 years (range 0-60). One hundred and twelve (21.3%) patients (56 male, 56 female) had documented aortoiliac aneurysms and/or dissection, with 74 (66.7%) cases involving the thoracic aorta. Forty-nine (9.3%) patients had major cardiac or aortoiliac operations, with an operative mortality of 5/49 (10.2%). Thirty-seven (7.0%) patients (23 male, 14 female) died during this period, with a mean age at death of 41.0 years (range 0-83) for males and 29.9 years (range 0-59) for females. The majority of these patients died of cardiovascular causes, with four aortic dissections, two ruptured aneurysms, seven with sudden collapse and cardiac arrest, and five with heart failure. In addition, there were other causes of mortality: five perioperative, one congenital, and four pulmonary causes, three with malignancy and one of stroke. The cause of death was unknown in five patients. Patients with aortoiliac diseases have a statistically significant higher mortality rate (p < 0.05). This population-based study shows that significant numbers of patients with Marfan syndrome are admitted to hospital per year, with a significant proportion requiring admissions at a young age. Life span in Marfan patients is markedly shortened, and aortoiliac disease is probably underdiagnosed. A standardized diagnostic and therapeutic follow-up program should be offered to these patients and their families.

Clinical outcomes and changes in venous hemodynamics after subfascial endoscopic perforating vein surgery

Background: We evaluated the clinical results of subfascial endoscopic perforating vein surgery (SEPS) in patients with severe chronic venous insufficiency (CVI) (clinical class 4–6) and assessed the hemodynamic changes associated with SEPS using air plethysmography (APG). Methods: Forty-five patients with severe CVI who had undergone SEPS were evaluated. Clinical score and venous hemodynamics, as measured by APG before operation and at 1 month and 1 year after operation, were compared using the Wilcoxon signed rank test. Patient satisfaction (on a visual analogue scale of 0 to 100%) was also assessed. Results: There were 29 men and 16 women; their mean age was 60 years (range, 37–83). Thirty-five patients (78%) had active venous ulcers; the ulcers’ mean size was 7.8 ± 11.9 cm2 and the mean duration of ulceration was 9 ± 10 months. There were no hospital deaths. Postoperative complications were uncommon (one groin wound infection and one case of thrombophlebitis). At a mean follow-up of 15 ± 9 months, 34 ulcers (97%) had healed. The cumulative ulcer healing was 82% at 3 months. There were five recurrent ulcers (15%). Significant improvement was seen in the clinical scores (10 ± 3 before operation, 6 ± 4 at 1 month, and 4 ± 3 at 1 year after operation). The venous filling index was also significantly improved after operation; this improvement was maintained at 1-year follow-up (7.36 ± 6.23 ml/sec before operation, 3.63 ± 3.90 ml/sec at 1 month, and 3.14 ± 2.06 ml/sec at 1 year). The degree of patient satisfaction was also remarkable, with 74 ± 17% and 90 ± 12% satisfaction at 1-month and 1-year follow-up, respectively. Conclusions: SEPS is a safe and effective treatment for patients with severe CVI. It leads to hemodynamic improvement, with rapid ulcer healing, and it is associated with a high degree of patient satisfaction.

Air Plethysmography in Chronic Venous Insufficiency: Clinical Diagnosis and Quantitative Assessment

To define the role of air plethysmography (APG) in the clinical diagnosis and quantita tive assessment of chronic venous insufficiency (CVI), APG studies were performed on 582 limbs in 291 patients with signs and symptoms of CVI. One hundred and thirty- one limbs were classified into group I (no evidence of CVI), 291 into group II (mild CVI), and 160 into group III (advanced CVI). On APG, the mean venous filling index (VFI) was 1.45 mL/s, 3.90 mL/s, and 5.25 mL/s in groups I, II, and III respectively (p < 0.05). The mean ejection fraction (EF) and mean residual volume fraction (RVF) also showed significant differences between the limbs with CVI and the contralateral normal limbs, but the values were similar for the different severities of CVI limbs. The amount of overlap in VFI, EF, and RVF values among the clinical groups was consider able. Discrimination analysis derived a VFI value of 2.67 mL/s as a cutoff point between normal limbs and limbs with CVI, with a positive predictive value of 96%. In conclusion, APG is a simple and noninvasive test for quantitative assessment of the different compo nents of CVI, valvular reflux, and calf muscle pump function. However, only VFI corre lated significantly with the severity of CVI. VFI, with its high positive predictive value, may be useful in diagnosis of CVI, and it may serve as an objective quantitative measure ment for monitoring the effect of treatment.

Perioperative deep vein thrombosis in Chinese patients undergoing craniotomy

BACKGROUND We attempted to determine the incidence of perioperative deep vein thrombosis (DVT) in Chinese patients undergoing elective craniotomy for brain tumors and to assess the efficacy of clinical and serial calf circumference assessment in detecting DVT. METHODS Between June 1999 and February 2001, 100 consecutive patients who underwent elective craniotomy for brain tumors at the Department of Neurosurgery, University of Hong Kong Medical Centre were examined for perioperative DVT. The demographic data, Glasgow coma score (GCS), mobility status, and the operative details were recorded. Graduated compression stockings and intermittent pneumatic compression were applied perioperatively as prophylaxis against DVT. Serial duplex scans were performed before and after operation. Clinical examination was also performed daily to look for signs of DVT. The calf circumference was measured at fixed levels for both limbs before each duplex scan surveillance. RESULTS The study group consisted of 44 males and 56 females, with a mean age of 54 +/- 15 years (range, 20-81 years). There was no preoperative DVT. Postoperative DVT was detected on duplex scan in four patients (4%), two of whom had bilateral involvement. The thrombosis was confined to the calf veins in two limbs. The demographic data, neurologic status and operative details of patients with and without DVT were similar. Patients with DVT had no clinically recognizable signs. The change in calf circumference measurement was also not predictive of DVT. CONCLUSIONS The incidence of perioperative DVT in Chinese patients undergoing elective craniotomy for brain tumors appears to be low with the present mechanical prophylactic measures. Given the low incidence of proximal DVT as detected by duplex scan, the use of heparin prophylaxis may not be justified because of the increased risk of intracranial bleeding. Clinical assessment with calf circumference measurement is unreliable in the diagnosis of DVT.

Cyanoacrylate glue used to treat great saphenous reflux: Measures of outcome

Introduction This is a single-center clinical study for the evaluation of safety, efficacy, and performance of endovenous cyanoacrylate (Sapheon Venaseal Closure System, now Medtronic Medical) for the treatment of great saphenous vein (GSV) reflux. Methods Primary outcome measures included the GSV obliteration, with clinical recurrence on follow up as detected by serial clinical and duplex examinations of patients at 1 week, 1 month, 6 months, and 1 year. Venous clinical severity score (VCSS), Aberdeen varicose vein questionnaire (AVVQ), Short Form Health Survey 36 Item (SF-36) questionnaires were used at clinical follow up. Diameter of the GSV, treatment length of the GSV, and pretreatment clinical severity of the varicose vein were analyzed to predict recanalization using Cox regression analysis. Results Fifty-seven legs in 29 patients with primary varicose veins were included. One week follow-up duplex showed successful obliteration of the GSV in all except one of the legs. Two legs had minimal extension of thrombus to deep vein. None of the patients had deep venous thrombosis. All the patients were discharged the same day of operation. Median time to return to work was 1 day (range 1–16 days). Our VCSS, AVVQ, and the SF-36 physical and mental scores changed from a mean of 6.91, 23.66, 44.24, 54.26 at baseline to 2.43, 6.10, 43.85, 52.50 at 1 month post operation, respectively. Kaplan–Meier analysis showed that the GSV closure rates were 98.2%, 94.3%, 89.7%, and 78.5% at post-op 1 week, 1 month, 6 months, and 1 year, respectively. With median follow-up period of 9 months (range 1–13 months), no clinical recurrence of varicosity was observed. Mean GSV diameter ≥8 mm was a significant predictor for recanalization (hazard ratio 6.92, 95%CI 1.34–35.67, p = 0.021). Conclusion This study showed that the use of endovenous cyanoacrylate in the treatment of the GSV reflux was safe. All patients had symptomatic improvement as shown by the VCSS and AVVQ.

Plasma Fibrinogen Level: an Independent Risk Factor for Long-term Survival in Chinese Patients with Peripheral Artery Disease?

Fibrinogen, an inflammatory marker as well as a fundamental part of the coagulation cascade, is suggested to play a significant role in the pathogenesis of atherosclerosis and complications of atherothrombotic diseases. The aim of this study was to determine if plasma fibrinogen is an independent risk factor for long-term survival in patients with peripheral artery disease (PAD). Altogether, 139 Chinese patients (88 men, 51 women) with PAD were consecutively recruited for the study. Atherothrombotic risk factors and fibrinogen levels were determined at presentation, and all patients were followed up for mortality prospectively. The mean follow-up was 6 years. All variables were first correlated with survival rates using Kaplan-Meier analysis and compared by means of the log-rank test. Significant risk factors were identified, and multivariate Cox regression analysis was used to evaluate the independent contribution of the fibrinogen level to the risk of mortality. During follow-up, 95 patients (68.3%) died. The overall survival rate was 77.7% at 3 years, 56.8% at 5 years, and 31.2% at 10 years (standard errors 0.05, 0.06, and 0.07, respectively). All-cause mortality rate increased with an elevated fibrinogen level. Eighty percent of patients with a fibrinogen level > 3.4 g/L had a survival time of less than 3 years (p = 0.002). This relation was also demonstrated within patients with critical ischemia. The plasma fibrinogen level was thus identified as an independent risk factor for mortality in PAD patients after adjusting for confounding factors.

Mid- and long-term outcome of patients with permanent inferior vena cava filters: a single center review.

BACKGROUND Inferior vena cava (IVC) filters are used to prevent pulmonary embolism (PE), especially in patients with active contraindication to systemic anticoagulation. The aim of this study is to examine the outcomes of patients who received permanent IVC filters at our institution. METHODS This is a single-center retrospective observational study with review of a prospectively collected database for patients who had permanent IVC filters. Patient demographics, indications of filter placement, postprocedure clinical outcome and complications, as well as use of anticoagulant therapy were documented. Chi-squared test was used to test for statistically significant differences (IBM SPSS version 21; IBM Corp., Armonk, NY), while survival was calculated using Kaplan-Meier survival curves analysis. RESULTS Between February 1998 and December 2013, a total of 109 patients with a median age of 65 (47 men, range 19-97) years had IVC filters inserted at our institution. All of them had documented venous thromboembolism (VTE) before filter placement: 99 (90.8%) had lower extremity deep vein thrombosis (DVT) (including 34 iliac, 65 infrainguinal), 9 (8.3%) had massive PE without evidence of lower limb DVT, and 1 (0.9%) had isolated IVC thrombosis. Forty-seven (43.1%) patients had PE before filter insertion. There were 2 serious procedure-related complications: one access site thrombosis and one right ventricular perforation. With a mean follow-up of 36 ± 33 months, no patient had further symptomatic PE or paradoxical embolism. There were a total of 54 (49.5%) deaths, with a 30-day mortality of 8.3%; none of them was device or procedure related. Among the 92 patients followed up, 27 (29.3%) had further VTE-either DVT in the index or the contralateral lower limb (20 patients, 21.7%), or thrombus inside the filter or the IVC (14 patients, 15.2%). Forty-one (44.6%) patients reported post-thrombotic syndrome (PTS) symptoms. Anticoagulant therapy was given to 39 (42.4%) and 55 (59.8%) patients in the periprocedural period and at any time during the study period, respectively. It did not reduce the rate of postfilter VTE or PTS in both instances. None of the filters in this series was retrieved. CONCLUSIONS This observational study showed that IVC filters were effective in the prevention of PE, although symptomatic postfilter VTE and PTS were common, leading to significant morbidity. Patients who received permanent filters have high mortality on follow-up; however, none were procedure or device related.