Judith C. Lin

Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis

Background The post‐thrombotic syndrome frequently develops in patients with proximal deep‐vein thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheter‐directed thrombolysis (hereafter “pharmacomechanical thrombolysis”) rapidly removes thrombus and is hypothesized to reduce the risk of the post‐thrombotic syndrome. Methods We randomly assigned 692 patients with acute proximal deep‐vein thrombosis to receive either anticoagulation alone (control group) or anticoagulation plus pharmacomechanical thrombolysis (catheter‐mediated or device‐mediated intrathrombus delivery of recombinant tissue plasminogen activator and thrombus aspiration or maceration, with or without stenting). The primary outcome was development of the post‐thrombotic syndrome between 6 and 24 months of follow‐up. Results Between 6 and 24 months, there was no significant between‐group difference in the percentage of patients with the post‐thrombotic syndrome (47% in the pharmacomechanical‐thrombolysis group and 48% in the control group; risk ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.11; P=0.56). Pharmacomechanical thrombolysis led to more major bleeding events within 10 days (1.7% vs. 0.3% of patients, P=0.049), but no significant difference in recurrent venous thromboembolism was seen over the 24‐month follow‐up period (12% in the pharmacomechanical‐thrombolysis group and 8% in the control group, P=0.09). Moderate‐to‐severe post‐thrombotic syndrome occurred in 18% of patients in the pharmacomechanical‐thrombolysis group versus 24% of those in the control group (risk ratio, 0.73; 95% CI, 0.54 to 0.98; P=0.04). Severity scores for the post‐thrombotic syndrome were lower in the pharmacomechanical‐thrombolysis group than in the control group at 6, 12, 18, and 24 months of follow‐up (P<0.01 for the comparison of the Villalta scores at each time point), but the improvement in quality of life from baseline to 24 months did not differ significantly between the treatment groups. Conclusions Among patients with acute proximal deep‐vein thrombosis, the addition of pharmacomechanical catheter‐directed thrombolysis to anticoagulation did not result in a lower risk of the post‐thrombotic syndrome but did result in a higher risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute and others; ATTRACT ClinicalTrials.gov number, NCT00790335.)

Snoring and carotid artery intima‐media thickness

A growing body of evidence indicates that primary snoring (PS) may be the initial presentation of sleep‐disordered breathing and can adversely affect an individuals health. Individuals with the sole diagnosis of PS were evaluated to determine if a relationship exists between snoring and thickening of the intima media of the carotid arteries.

Clinical utility of carotid duplex ultrasound prior to cardiac surgery

OBJECTIVE Clinical utility and cost-effectiveness of carotid duplex examination prior to cardiac surgery have been questioned by the multidisciplinary committee creating the 2012 Appropriate Use Criteria for Peripheral Vascular Laboratory Testing. We report the clinical outcomes and postoperative neurologic symptoms in patients who underwent carotid duplex ultrasound prior to open heart surgery at a tertiary institution. METHODS Using the combined databases from our clinical vascular laboratory and the Society of Thoracic Surgery, a retrospective analysis of all patients who underwent carotid duplex ultrasound within 13 months prior to open heart surgery from March 2005 to March 2013 was performed. The outcomes between those who underwent carotid duplex scanning (group A) and those who did not (group B) were compared. RESULTS Among 3233 patients in the cohort who underwent cardiac surgery, 515 (15.9%) patients underwent a carotid duplex ultrasound preoperatively, and 2718 patients did not (84.1%). Among the patients who underwent carotid screening vs no screening, there was no statistically significant difference in the risk factors of cerebrovascular disease (10.9% vs 12.7%; P = .26), prior stroke (8.2% vs 7.2%; P = .41), and prior transient ischemic attack (2.9% vs 3.3%; P = .24). For those undergoing isolated coronary artery bypass grafting (CABG), 306 (17.8%) of 1723 patients underwent preoperative carotid duplex ultrasound. Among patients who had carotid screening prior to CABG, the incidence of carotid disease was low: 249 (81.4%) had minimal or mild stenosis (<50%); 25 (8.2%) had unilateral moderate stenosis (50%-69%); 10 (3.3%) had bilateral moderate stenosis; 9 (2.9%) had unilateral severe stenosis (70%-99%); 5 (1.6%) had contralateral moderate stenosis; 2 (0.7%) had bilateral severe stenosis; 4 (1.3%) had unilateral occluded with contralateral less than 50% stenosis, 1 (0.3%) had unilateral occluded with contralateral (70%-99%) stenosis; and 1 had bilateral occluded carotid arteries. Primary outcomes of patients who underwent isolated CABG showed no difference in the perioperative mortality (2.9% vs 4.3%; P = .27) and stroke (2.9% vs 2.6%; P = .70) between patients undergoing preoperative duplex scanning and those who did not. Primary outcomes of patients who underwent open heart surgery also showed no difference in the perioperative mortality (5.1% vs 6.9%; P = .14) and stroke (2.6% vs 2.4%; P = .85) between patients undergoing preoperative duplex scanning and those who did not. Operative intervention of severe carotid stenosis prior to isolated CABG occurred in 2 of the 17 patients (11.8%) identified who underwent carotid endarterectomy with CABG. CONCLUSIONS In this study, the correlation between preoperative duplex-documented high-grade carotid stenosis and postoperative stroke was low. Prudent use of preoperative carotid duplex ultrasound should be based on the presence of cerebrovascular symptoms and the type of open heart surgery.

Robotic-assisted aortic surgery with and without minilaparotomy for complicated occlusive disease and aneurysm

OBJECTIVE Published reports of robotic-assisted aortic surgery involve a combination of laparoscopy for aortic dissection and a robotic system for vascular reconstruction. The objective of this study is to determine the feasibility and advantage of a total robotic-assisted aortic dissection and vascular reconstruction vs robotic-assisted aortic procedures for aortoiliac occlusive disease (AIOD) and abdominal aortic aneurysm (AAA). METHODS From February 2006 to August 2010, 21 patients were selected for robotic-assisted aortic procedures: aortobifemoral bypass in 12, AAA repair in 6, iliac aneurysm repair in 1, and ligation of type II endoleak after endovascular aneurysm repair in 2. Inclusion criteria included AAA >5 cm, iliac aneurysm >3 cm, and AIOD TransAtlantic InterSociety Classification (TASC) C or D lesions. The da Vinci S Surgical System (Intuitive Surgical Inc, Sunnyvale, Calif) was used for the abdominal aortic dissection in all cases and for the aortic anastomosis in three cases. RESULTS The 21 patients (6 women, 15 men) were an average age of 65.7 years (range, 44-86 years), had a body mass index (BMI) of 27.23 kg/m(2), and 90.4% were American Society of Anesthesiologists (ASA) class 3 or 4. Robotic dissection of the abdominal aorta was successful in 20 patients (95.2%). One patient required full conversion to open AAA repair due to trocar injury. Of the remaining 20 patients, the average robotic dissection time of the infrarenal aorta was 113.1 minutes, and the average aortic clamp time was 86 minutes. The procedure in 15 patients was performed with a minilaparotomy using an average abdominal incision of 13 cm to implant the Dacron or polytetrafluoroethylene graft. Five patients underwent a total robotic-assisted procedure with robotic aortic reconstruction or ligation of a type II endoleak. The 30-day survival rate was 100%. Median length of stay was 7.5 days. All grafts were patent at a median follow-up of 32.0 months. CONCLUSIONS For aortic procedures completed total robotically without an abdominal incision, the estimated blood loss was significantly less than in robotic-assisted procedures with a minilaparotomy. In these selected patients, robotic-assisted technology may be part of the armamentarium for the vascular surgeon as another less invasive method for the treatment of complicated occlusive disease or aneurysm.

Snoring and carotid artery disease: A new risk factor emerges: Snoring and Carotid Artery Disease

Previous studies have identified a relationship between snoring, carotid intima media thickening, and the presence of atherosclerosis. This study examines the correlation between snoring and carotid artery disease through use of duplex ultrasound identifying greater than 50% internal carotid artery stenosis.

RS04. Natural History of Progression of Carotid Artery Stenosis

neurologic complications. Propensity score analysis was performed to verify the role of EMB in CBT surgery. Results: The number of CBT patients and CBT operations rapidly increased in recent years. The population was composed of 132 patients (74 males and 58 females) with 142 CBTs resected. Tumor classification was Shamblin I in 29 tumors, Shamblin II in 61, and Shamblin III in 52. Of these, 97 tumors underwent EMB, and significantly decreased vascularization was achieved in 99.0%. Intraoperatively, rupture of the internal carotid artery occurred in 29patients (20.4%) andwas successfully reconstructed in 28 patients (96.4%) and ligated in one patient (3.6%). After surgery, a transient cranial deficitwas identified in 44patients (31%), and strokewas found in four patients (2.8%). During a mean follow-up of 60.7 months, seven patients (4.9%) were lost to follow-up, and a permanent nerve deficit was found in 18 (13.3%). Multivariate regression analysis revealed that the incidence of neurologic complications was associated with Shamblin group III (P1⁄4 .005 for in-hospital complication; P1⁄4 .001 for permanent neurologic complication) and high-lying tumors (P1⁄4 .047 for in-hospital complication; P 1⁄4 .101 for permanent neurologic complication). In comparison with the non-EMBgroup, the EMBgroupdidnot exhibit decreased rates of in-hospital neurologic complications (9 vs 15; P1⁄4 .151) or persistent neurologic complications (4 vs 6; P 1⁄4 .502) but had decreased operation times (100.0 minutesvs 183.0minutes;P< .001) andblood loss (65mLvs 100mL;P1⁄4 .039). Conclusions: Surgical resection of CBTs is the gold standard. The rate of neurologic complications is acceptable. Shamblin group III and highlying tumors were vulnerable to neurologic complications. EMB did not decrease the risks of neurologic complications, although it decreased operation times and blood loss.

In response to snoring and carotid artery intima-media thickness

We would like to thank Sereflican et al. for their letter in response to our article “Snoring and Carotid Artery Intima-Media Thickening.” We are pleased that this area of sleep medicine is attracting the much needed attention that it deserves. In devising our study, we were hopeful that both clinicians and scientists would be interested in further investigating the relationship between primary snoring and other potentially serious medical conditions. These investigations could address a variety of issues surrounding the topic including disease manifestations of primary snoring, potential etiologies of these relationships, and possible synergistic effects of snoring and other disease conditions. Sereflican et al. have made the observation that the relationship between snoring and intima-media thickness could be the result of the autonomic nervous system. Although our study did not actually investigate this possibility, we do find this to be a very interesting theory, and their claim is supported by a variety of studies that they reference. One of the theories we put forth in our article is that vibratory mechanisms, given the proximity of the carotid artery to the source of the snoring, may have a contributing role. Like many things in medicine, the mechanism is likely very complicated and multifactorial. Our study did not specifically study possible etiologies but was intended to point out that a relationship exists. We believe that much more study is needed in this area. We are hopeful that studies can be designed that will strengthen the evidence for a causal relationship and identify possible mechanisms.

Is preoperative vein mapping beneficial for the creation of dialysis arteriovenous fistulas

Introduction The use of preoperative vein mapping for arteriovenous fistula creation has shown promise in multiple studies over the years. However, a definitive scanning technique has not been well described. Our center has developed a standard method of preoperative vein mapping performed by a select group of trained technologists. Together with a single surgeon, we believe that this technique is equivalent to if not better than previously described methods. Methods In a retrospective study of 88 patients, all patients underwent preoperative scanning according to our dialysis mapping protocol with subsequent operative intervention. Results Eighty-three of the 88 patients mapped correctly matched the surgeons findings. Seventy-five patients had successful fistula creation. Sixty-one patients (82%) who had fistulas placed were accurately predicted by their preoperative mapping. Of the 83 patients, 94% presented for a 2-week follow-up appointment. At this point, 81% of fistulas showed evidence of a good thrill and were developing at a sufficient rate. In addition, 89% of these patients presented for a long-term follow-up appointment at 60 days postoperatively. Approximately 6.7% of these patients required additional intervention to progress fistula maturation at this point. Conclusion Further prospective studies with additional centers to use as control groups would be helpful in evaluating this technique. However, this scanning protocol shows promise as a method of obtaining favorable results in a consistent fashion.