-
Journal of the American College of... May 2004Carotid endarterectomy for stroke prevention has been the standard of care for 50 years in patients with extra-cranial carotid bifurcation disease. Over the past decade,... (Review)
Review
Carotid endarterectomy for stroke prevention has been the standard of care for 50 years in patients with extra-cranial carotid bifurcation disease. Over the past decade, carotid stenting has emerged as a viable alternative to surgery. Combined with filter embolic protection devices, both a randomized control trial (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy registry [SAPPHIRE]) as well as registry data (ACCULINK for Revascularization of Carotids in High Risk Patients registry [ARCHeR] and Registry Study to evaluate the Neuroshield Bare-Wire Cerebral Protection System and X-Act Stent in patients at high risk for Carotid Endarterectomy [SECuRITY]) have compared favorably to endarterectomy in patients at high risk for operative revascularization. Conditions associated with high operative risk included patients with significant cardiac, pulmonary, and renal disease; previous neck operation; previous radiation; and anatomically difficult surgical access. On the basis of these results, a carotid stent system approved by the Food and Drug Administration (FDA) is anticipated in 2004. Although this will be a welcome addition to endarterectomy in the armamentarium of therapeutic options for patients with carotid disease, several challenges lie ahead. Coverage and reimbursement for the carotid stenting has been severely restricted to include only those procedures performed as part of an FDA investigational device exemption trial protocol, and a national noncoverage decision will have to be reckoned with before broader coverage can be put into place (assuming FDA approval). In addition, the level of national expertise in carotid endovascular intervention is limited, and training will need to be tailored to the three specialties likely to perform the procedure: cardiology, radiology, and vascular surgery. Each of these specialties will have specific, and different, requirements for their training, further complicating the task of education.
Topics: Blood Vessel Prosthesis Implantation; Cardiology; Carotid Artery Diseases; Endarterectomy, Carotid; Humans; Intracranial Embolism; Postoperative Complications; Stents; Stroke; United States
PubMed: 15120818
DOI: 10.1016/j.jacc.2003.11.051 -
International Angiology : a Journal of... Apr 2018Surgical procedures represent a risk for different complications which may appear during the perioperative period. Cardiac ischemic events and vascular complications are... (Review)
Review
Surgical procedures represent a risk for different complications which may appear during the perioperative period. Cardiac ischemic events and vascular complications are the most important causes of increased morbidity and mortality and they are much more frequent in patients with manifest cardiovascular disease. This is particularly seen in patients with peripheral arterial occlusive disease (PAD), which represents advanced atherosclerosis frequently accompanied by the presence of coronary artery disease. Therefore, patients with PAD need careful preoperative examination, including estimation of functional capacity and the presence of other co-existing atherosclerotic diseases. The perioperative risk of cardiac complications should be calculated by Apgar score. In patients with unstable coronary syndrome myocardial revascularization should be performed before vascular procedures, whereas in other coronary patients pharmacotherapy should be intensified. The latter includes beta-adrenergic receptor blockers, statin therapy, which significantly improves postoperative outcome and antiplatelet drugs, which do not significantly increase major bleeding complications but significantly reduce cardiovascular thromboembolic events. Postoperative strategy for prevention of complications should be focused particularly on identification of myocardial infarction which is frequently asymptomatic. Therefore, serial postoperative measurements of troponin levels allow close monitoring of postoperative myocardial damage and help to implement strategic choices for the treatment of postoperative adverse cardiac events.
Topics: Comorbidity; Health Status; Humans; Incidence; Perioperative Period; Peripheral Arterial Disease; Postoperative Complications; Risk Assessment; Risk Factors; Surgical Procedures, Operative; Treatment Outcome
PubMed: 29327897
DOI: 10.23736/S0392-9590.18.03897-X -
International Journal of Surgery... 2014Acute superior mesenteric venous thrombosis (ASMVT) is a rare but potentially lethal abdominal calamity. Outcome depends on prompt recognition and revascularization... (Review)
Review
Acute superior mesenteric venous thrombosis (ASMVT) is a rare but potentially lethal abdominal calamity. Outcome depends on prompt recognition and revascularization before progresses to bowel gangrene. Despite better understanding of pathogenesis and development of modern treatment technique, management of ASMVT remains a great clinical challenge. Transcatheter thrombolysis as the main revascularization method, combined with mechanical thrombectomy and other endovascular manipulations, alone or as a hybrid procedure, has got favorable outcomes. Thus on the basis of early diagnosis and close evaluation of intestinal ischemia and thrombus evolution, a coordinated stepwise management strategy involving a specialized approach of initial anticoagulation, preferred endovascular therapy, and damage-control surgery modality with surgical thrombectomy, may show benefits in rapid revascularization, prompt symptom improvement, and short bowel syndrome avoidance, with shortened hospitalization and less cost. This article presents an evidence-based review of the state-of-the-art advancements of this transcatheter thrombolysis centered stepwise management strategy for ASMVT.
Topics: Endovascular Procedures; Humans; Mesenteric Vascular Occlusion; Minimally Invasive Surgical Procedures; Thrombolytic Therapy
PubMed: 24704749
DOI: 10.1016/j.ijsu.2014.03.015 -
Archives of Cardiovascular Diseases Apr 2020Cardiogenic shock complicating acute myocardial infarction is challenging, and continues to be associated with high rates of in-hospital and long-term mortality.... (Review)
Review
Cardiogenic shock complicating acute myocardial infarction is challenging, and continues to be associated with high rates of in-hospital and long-term mortality. Coronary revascularization is critical for improving prognosis in CS. Thus, a systematic protocol-driven approach to cardiogenic shock, the development of specialized cardiac care centres, technical advances in interventional cardiology enabling treatment of more complex and severe lesions, the availability of recent antithrombotic therapies and the evolution of new haemodynamic support devices are important considerations in current management of cardiogenic shock complicating acute ischaemic heart disease. Despite these potentially meaningful developments, several substantial gaps in knowledge still exist regarding optimal coronary revascularization of patients with cardiogenic shock. This review will describe current principles in the revascularization of these patients, with a focus on: the time to transfer and revascularize; the choice of vascular access site; the need for complete revascularization or only a culprit lesion strategy; the optimal antithrombotic therapy; the type, place and timing of haemodynamic support; and the medical care system network.
Topics: Clinical Decision-Making; Coronary Artery Disease; Humans; Myocardial Infarction; Myocardial Revascularization; Patient Selection; Recovery of Function; Risk Factors; Shock, Cardiogenic; Treatment Outcome
PubMed: 32088156
DOI: 10.1016/j.acvd.2019.12.005 -
Neurology India 2021Indirect bypass surgeries for moyamoya disease have included modifications of procedures involving placement of the superficial temporal artery on the brain pial...
OBJECTIVE
Indirect bypass surgeries for moyamoya disease have included modifications of procedures involving placement of the superficial temporal artery on the brain pial surface. We evaluate the functional and angiographic outcomes of patients treated with encephaloduroarteriomyosynangiosis (indirect) revascularization and examine the outcome in relation to demographic and radiological factors.
MATERIALS AND METHODS
Patients treated surgically for moyamoya disease over a 14-year period were identified. Demographics, clinical presentation, and radiology were analyzed to assign a stage for the disease (Suzuki staging) and the extent of revascularization (Matsushima grade) at the last follow-up. A modified Rankin score was used to assess the clinical status at presentation and the functional outcome at follow-up.
RESULTS
There were 46 patients operated on by a single surgeon over a 14-year period. A higher incidence of motor deficits, seizures, and speech deficits was seen in the pediatric population. Age, sex, preoperative Suzuki disease stage, and hemispheric involvement had no bearing on angiographic outcome at last follow-up. Three of 46 patients (6.5%) developed immediate postoperative complications. Among 43 patients on follow-up, 39 had stable disease or showed improvement in clinical symptoms with 90% event-free status at last follow-up.
CONCLUSIONS
Indirect revascularization procedures are an effective alternative to direct cerebral revascularizations in the early or advanced stages of moyamoya disease. This is effective in a predominant ischemic presentation as noted in our series.
Topics: Cerebral Revascularization; Child; Humans; Moyamoya Disease; Retrospective Studies; Temporal Arteries; Treatment Outcome
PubMed: 34747793
DOI: 10.4103/0028-3886.329538 -
Annals of the Royal College of Surgeons... May 2021The increasing prevalence of diabetes mellitus and advances in endovascular therapies continue to have an impact on the epidemiology and management of lower extremity...
INTRODUCTION
The increasing prevalence of diabetes mellitus and advances in endovascular therapies continue to have an impact on the epidemiology and management of lower extremity arterial disease. This study describes trends in lower extremity revascularisation and major lower limb amputation in NHS England over the past two decades (2000-2019).
METHODS
Numbers of lower extremity endovascular interventions, open surgical procedures and major lower limb amputations performed in NHS England between 2000 and 2019 were extracted from publicly available hospital admitted patient care activity reports. Trends in intervention were assessed with linear regression models and chi-square tests for trend.
RESULTS
Over this period, 527,131 revascularisations and 92,053 amputations were performed. The mean age of patients was 67.5 years (standard deviation 1.6 years) and 65.3% were male. The number of lower limb revascularisation procedures increased by 402.4 units/year (95% confidence interval, CI, 290.1-514.6, < 0.001). The number of endovascular interventions rose by 43.5% (10,912 in 2000 vs 15,657 in 2019; β = 359.5.0, 95% CI 279.3-439.8, < 0.001) compared with no significant increase in the number of open surgical procedures (8,483 in 2000 vs 7,872 in 2019; β = 42.8, 95% CI -8.3 to 94.0, = 0.095). The number of major lower limb amputations has decreased by 9.4% (5,418 in 2000 vs 4,907 in 2019; β = -31.0; 95% CI -49.6 to -12.5, R = 0.42, = 0.003).
CONCLUSIONS
There has been a significant increase in the rate of lower limb revascularisation procedures associated with decreased numbers of major lower limb amputations over the past two decades. These changes in overall trends may affect both service provision and vascular surgery training planning.
Topics: Aged; Amputation, Surgical; Endovascular Procedures; England; Female; Humans; Limb Salvage; Lower Extremity; Male; Retrospective Studies
PubMed: 33852354
DOI: 10.1308/rcsann.2020.7090 -
VASA. Zeitschrift Fur Gefasskrankheiten Nov 2021Previous observational studies reported a wide variation and possible room for improvement in the treatment of patients suffering from symptomatic peripheral artery...
Previous observational studies reported a wide variation and possible room for improvement in the treatment of patients suffering from symptomatic peripheral artery disease (PAD). Yet, systematic assessment of everyday clinical practice is lacking. A General Data Protection Regulation (GDPR) compliant registry was developed and used to collect comprehensive data on clinical treatment and outcomes regarding PAD in Germany. Here, we report baseline characteristics of patients prospectively enrolled until the end of 2020. The GermanVasc registry study is a prospective longitudinal multicentre cohort study. Between 1 May 2018 and 31 December 2020, invasive endovascular, open-surgical, and hybrid revascularisations of patients suffering from chronic symptomatic PAD were prospectively included after explicit informed consent (NCT03098290). For ensuring high quality of the data, we performed comprehensive risk-based and random-sample external and internal validation. In total, 5608 patients from 31 study centres were included (34% females, median 69 years). On-site monitoring visits were performed at least once in all centres. The proportion of chronic limb-threatening ischaemia was 30% and 13% were emergent admissions. 55% exhibited a previous revascularisation. Endovascular techniques made 69% among all documented invasive procedures (n=6449). Thirty-five percent were classified as patients with severe systemic disease, and 3% exhibited a constant threat to life according to the American Society of Anaesthesiologists classification. The risk profile comprised of 75% former or current smokers, 36% diabetes mellitus, and in 30% a current ischemic heart disease was present. At discharge, 93% of the patients received antiplatelets and 77% received statins. The GermanVasc registry study provides insights into real-world practice of treatment and outcomes of 5,608 patients with symptomatic PAD in Germany. The cohort covers a broader range of disease severity and types of interventions than usually found in trials. In future studies, comparative outcomes will be analysed in more detail.
Topics: Cohort Studies; Endovascular Procedures; Female; Humans; Ischemia; Male; Peripheral Arterial Disease; Prospective Studies; Risk Factors; Treatment Outcome
PubMed: 34279120
DOI: 10.1024/0301-1526/a000966 -
Heart (British Cardiac Society) Sep 1996
Clinical Trial
Topics: Animals; Coronary Disease; Dogs; Humans; Laser Therapy; Myocardial Revascularization
PubMed: 8868972
DOI: 10.1136/hrt.76.3.191 -
Circulation. Cardiovascular... Feb 2016Critical limb ischemia (CLI) is a clinical syndrome of ischemic pain at rest or tissue loss, such as nonhealing ulcers or gangrene, related to peripheral artery disease....
Critical limb ischemia (CLI) is a clinical syndrome of ischemic pain at rest or tissue loss, such as nonhealing ulcers or gangrene, related to peripheral artery disease. CLI has a high short-term risk of limb loss and cardiovascular events. Noninvasive or invasive angiography help determine the feasibility and approach to arterial revascularization. An endovascular-first approach is often advocated based on a lower procedural risk; however, specific patterns of disease may be best treated by open surgical revascularization. Balloon angioplasty and stenting form the backbone of endovascular techniques, with drug-eluting stents and drug-coated balloons offering low rates of repeat revascularization. Combined antegrade and retrograde approaches can increase success in long total occlusions. Below the knee, angiosome-directed angioplasty may lead to greater wound healing, but failing this, any straight-line flow into the foot is pursued. Hybrid surgical techniques such as iliac stenting and common femoral endarterectomy are commonly used to reduce operative risk. Lower extremity bypass grafting is most successful with a good quality, long, single-segment autogenous vein of at least 3.5-mm diameter. Minor amputations are often required for tissue loss as a part of the treatment strategy. Major amputations (at or above the ankle) limit functional independence, and their prevention is a key goal of CLI therapy. Medical therapy after revascularization targets risk factors for atherosclerosis and assesses wound healing and new or recurrent flow-limiting disease. The ongoing National Institutes of Health-sponsored Best Endovascular Versus Best Surgical Therapy in Patients With Critical Limb Ischemia (BEST-CLI) study is a randomized trial of the contemporary endovascular versus open surgical techniques in patients with CLI.
Topics: Amputation, Surgical; Endovascular Procedures; Humans; Ischemia; Leg; Peripheral Arterial Disease
PubMed: 26858079
DOI: 10.1161/CIRCINTERVENTIONS.115.001946 -
Heart (British Cardiac Society) May 2006Coronary heart disease is the leading cause of death in men and women worldwide. It is still considered a disease of men and there has been little recognition of its... (Review)
Review
Coronary heart disease is the leading cause of death in men and women worldwide. It is still considered a disease of men and there has been little recognition of its importance in women. Gender differences exist in acute and chronic ischaemia in terms of clinical manifestations, investigations and treatment. There are clear gender differences in coronary revascularisation with a higher mortality seen in women. At the time a woman presents with coronary artery disease she is older and has more co-morbid factors. Furthermore, women have smaller coronary arteries making them more difficult to revascularise. In recent years there has been a general trend towards improved outcomes in women undergoing both surgical and percutaneous coronary intervention. The increasing use of drug eluting stents and adjunctive medical treatment as well as the use of off-pump bypass surgery needs further evaluation in terms of gender differences. This article reviews the current literature on coronary revascularisation in women.
Topics: Angioplasty, Balloon, Coronary; Coronary Artery Bypass; Coronary Disease; Female; Humans; Myocardial Infarction; Myocardial Revascularization; Risk Factors
PubMed: 16614263
DOI: 10.1136/hrt.2005.070359