Norman H. Kumins

Expanded indications for the treatment of postcatheterization femoral pseudoaneurysms with ultrasound-guided compression.

BACKGROUND The purpose of this study was to define the factors that predict successful ultrasound-guided compression repair (UGCR) of postcatheterization femoral pseudoaneurysms (PA) and to determine risks for recurrence, the most appropriate follow-up, and the optimal management of compression failures and recurrences. METHODS A retrospective chart review was made. RESULTS UGCR thrombosed 52 of 60 PA (87%). Predictors of compression failure were PA size of 8 cm and an associated arteriovenous fistula (AVF). AVF was the only predictor of recurrence. All seven recurrences (13%) were discovered on the first follow-up scan. Four were thrombosed with additional UGCR. Late rescanning after a mean of 264 days identified no recurrences. Four anticoagulated patients failed initial UGCR but were thrombosed in another session when their anticoagulation was briefly reversed. CONCLUSIONS UGCR should be the initial management of PA because it is safe, effective, and durable. Temporary discontinuation of anticoagulation and multiple prolonged compression sessions may help treat recalcitrant cases. One follow-up scan is adequate for most patients. Recurrences should be initially treated with repeat UGCR.

Comparison of jejunal and ileal surveillance biopsies in a porcine model of intestinal transplantation.

BACKGROUND The optimal biopsy site of bowel allografts for rejection surveillance remains controversial. We compared the results of jejunal (JBx) and ileal (IBx) biopsies after bowel transplantation in a porcine model. METHODS Eighteen Yorkshire-Landrace pigs served as donors. Eighteen recipient pigs underwent total enterectomy followed by orthotopic small bowel transplantation with or without the colon. A jejunostomy and a Bishop-Koop ileostomy were constructed for biopsies. Immunosuppression consisted of FK506 (target level 10-15 ng/ml by enzyme immunoparticle assay) and prednisone administered via the jejunostomy. Simultaneous JBx and IBx were performed twice weekly. Acute rejection was graded as mild, moderate, or severe based on previously published criteria. RESULTS Mean overall survival after the transplant was 17.4 days. A total of 162 specimens were collected and evaluated for rejection (JBx, 81; IBx, 81). Acute rejection was detected in 41 JBx cases (50.7%) and 40 IBx cases (49.4%). The presence or absence of rejection was concordant between JBx and IBx in 70 of 81 case pairs (86.4%). Of the 11 discordant case pairs, 6 were JBx positive/IBx negative, whereas 5 were JBx negative/IBx positive. A total of 35 case pairs were synchronously positive, 24 (68.8%) of which demonstrated the same degree of rejection. CONCLUSIONS The correlation between JBx and IBx of bowel allografts in diagnosing the presence of acute rejection is quite good. However, performing IBx alone would have missed about 7.5% of the rejection episodes. Because the early treatment of rejection in bowel transplantation is of paramount importance, in selected cases, biopsies from both the ileum and jejunum should be considered if technically feasible.

IP109. The Learning Curve of Transcarotid Artery Revascularization

Objective: This study evaluates the risk attributable to the hemodynamic events that occur during carotid angioplasty and stenting (CAS) and the impact that preprocedural and prophylactic medications have on mitigating this risk in a large, population-based cohort of patients. Methods: We studied all patients in the Vascular Quality Initiative who underwent CAS between January 2006 and December 2016. KaplanMeier, multivariable logistic, and Cox regression analyses were employed to evaluate the impact of periprocedural hypertension, hypotension, bradycardia, and medication use on immediate periprocedural, 30-day, and 1-year stroke. Results: There were 13,698 CAS procedures studied. Of these, 1239 (9.1%), 1824 (13.3%), and 1333 (9.7%) patients experienced periprocedural hypertension, hypotension, and bradycardia, respectively. Immediate periprocedural stroke was 3.2% vs 2.1% vs 0.65% (P < .001), comparing patients with periprocedural hypertension vs hypotension vs normotension, and 1.4% vs 1.0% for bradycardic vs nonbradycardic patients (P 1⁄4 .19). Periprocedural hypertension was associated with a fourfold increase in immediate periprocedural stroke (adjusted odds ratio [aOR], 3.97; 95% confidence interval [CI], 2.63-5.99; P < .001). Periprocedural hypotension and bradycardia were associated with 5.5-fold (aOR, 5.56; 95% CI, 3.249.52; P < .001) and 2.3-fold (aOR, 2.31; 95% CI, 1.26-4.25; P 1⁄4 .007) increases, respectively, in immediate periprocedural stroke among patients with carotid symptoms. There was a 76% decrease in immediate periprocedural stroke risk for patients who did not experience a periprocedural hemodynamic event (aOR, 0.24; 95% CI, 0.16-0.35; P < .001). Preprocedural beta blockers and angiotensin-converting enzyme inhibitors had no significant impact on immediate periprocedural stroke. However, prophylactic use of antibradyarrhythmic agents conferred a 58% reduction in immediate periprocedural stroke among patients with carotid symptoms (aOR, 0.42; 95% CI, 0.23-0.78; P 1⁄4 .006). The periprocedural differences in outcomes extended into the long term (Figs 1 and 2). Conclusions: Periprocedural hypertension in all patients and hypotension and bradycardia in patients with symptomatic carotid disease are associated with significant increase in immediate periprocedural stroke. Prophylactic administration of antibradyarrhythmic agents is associated with a decrease in the incidence of bradycardia and immediate periprocedural stroke. These results heighten the need to anticipate and promptly address these hemodynamic changes during and after CAS to further improve the risk profile of this procedure for the benefit of our patients.

A systematic review of the efficacy of aspirin monotherapy versus other antiplatelet therapy regimens in peripheral arterial disease

Background: Dual antiplatelet therapy (DAPT) usually refers to the administration of aspirin plus a platelet P2Y12 receptor blocker. This combination is commonly prescribed after revascularization procedures in patients with peripheral arterial disease (PAD) to prevent failure of the intervention. However, there is not a consensus among peripheral vascular specialists regarding whether the optimal treatment regimen for their patients is mono antiplatelet therapy (MAPT) or DAPT. Furthermore, there is no consensus regarding the optimal duration of DAPT. This study was undertaken to systematically and critically review the evidence for the use of DAPT after revascularization in PAD, hypothesizing that longer durations of DAPT will result in decreased rates of major adverse cardiac events, major adverse limb events, and mortality, without a significant increase in severe bleeding episodes compared with MAPT or shorter durations of DAPT. Methods: A systematic search strategy encompassing DAPT and PAD was deployed in two databases. Studies including arterial bypasses using venous or prosthetic conduits, endovascular procedures, diagnostic angiography of lower extremity arteries, and patients with high risk factors were included. Results: We included 14 studies, 10 of which were randomized controlled trials (RCTs). The overall risk of bias for the RCTs ranged from low to moderate, whereas nonrandomized studies had moderate to high risk of bias. The results of this review suggest that use of DAPT in patients with PAD reduces rates of major adverse cardiac events (risk ratio [RR], 0.79; 95% confidence interval [CI], 0.68–0.91; P = .002), major adverse cardiac and cerebrovascular events, and mortality (RR, 0.57; 95% CI, 0.45–0.72; P < .00,001) compared with those of patients treated with MAPT. Lower extremity‐specific end points, such as major adverse limb events and target lesion revascularization (RR, 0.70; 95% CI, 0.49–1.01; P = .06) were also decreased in the DAPT cohort. Rates of moderate bleeding, however, were increased in those treated with DAPT, whereas rates of major bleeding (RR, 0.98; 95% CI, 0.68–1.41; P = .92) remained similar in both treatment groups. The effects of DAPT duration on outcomes of revascularization in patients with PAD have yet to be studied in an RCT. Conclusions: DAPT appears to be beneficial for preventing complications after revascularization in PAD, including thrombotic failure of the intervention. However, the durations of DAPT use in these studies are heterogeneous, suggesting that additional data are needed to determine the optimal use of DAPT in PAD patients.