Journal of vascular surgery
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Randomized Controlled Trial
Low-molecular-weight heparin for prevention of restenosis after femoropopliteal percutaneous transluminal angioplasty: a randomized controlled trial.
Restenosis after angioplasty is essentially due to intimal hyperplasia. Low-molecular-weight heparins (LMWHs) have experimentally been shown to have antiproliferative effects in addition to their antithrombotic properties. Their potential in reducing restenosis remains to be established. Therefore, we wanted to test the hypothesis that LMWH plus aspirin is more effective than aspirin alone in reducing the incidence of restenosis/reocclusion in patients undergoing percutaneous transluminal angioplasty (PTA) of femoropopliteal arteries. Further, different effects of LMWH in patients treated for critical limb ischemia (CLI) or claudication only should be investigated. ⋯ Treatment with 2500 IU dalteparin subcutaneously given for 3 months after femoropopliteal PTA failed to reduce restenosis/reocclusion at 12 months. However, dalteparin may be beneficial in the subgroup of patients with CLI at 12 months follow-up.
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Comparative Study
Appropriateness of learning curve for carotid artery stenting: an analysis of periprocedural complications.
Cerebral embolism is the first cause of neurologic complications of carotid artery stenting (CAS). A large debate has been raised to identify the caseload necessary for an appropriate learning curve before systematic use of CAS. This study examined (1) the timing of periprocedural complications during CAS and how these complications vary over time to identify factors that contribute to neurologic morbidity and (2) a sufficient number of procedures for adequate training. ⋯ A large proportion of major strokes (4/10) from CAS cannot be prevented by using CPD, because these strokes occur during catheterization (phase 1). This finding, together with the significant decrease in the overall stroke/death rate between the first and the last interval of the study period, enhances the importance of an appropriate learning curve that involves a caseload larger than that generally accepted for credentialing. The noticeable number of postprocedural cerebral embolizations leading to minor strokes and occurring in the early and late postinterventional phases (16/18) is likely due to factors less strictly related to the learning-curve effect, such as stent design and medical therapy. Moreover, expertise in selecting material and design of the stents according to different vessel morphology, in association with correct medical treatment, may be useful in reducing the number of minor strokes that occur in the later postinterventional phases of CAS.
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Multicenter Study
Access strategies for revision or explantation of the Charité lumbar artificial disc replacement.
Several lumbar disc prostheses are being developed with the goal of preserving mobility in patients with degenerative disc disease. The disadvantage of lumbar artificial disc replacement (ADR) compared with anterior interbody fusion (ALIF) is the increased potential for displacement or component failure. Revision or removal of the device is complicated by adherence of the aorta, iliac vessels, and the ureter to the operative site. Because of these risks of anterior lumbar procedures, vascular surgeons usually provide access to the spine. We report our experience with secondary exposure of the lumbar spine for revision or explantation of the Charité disc prosthesis. ⋯ Owing to vascular and ureteral fixation, anterior exposure of the lumbar spine for revision or explantation of the Charité disc replacement should be performed through an alternative approach unless the procedure is performed < or = 2 weeks of the index procedure. The L5-S1 level can be accessed through the contralateral retroperitoneum. Reoperation at L3-4 and L4-5 usually requires explantation and fusion that is best accomplished by way of a lateral transpsoas exposure.
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Pivotal and comparative trial data are emerging for stent graft (SG) vs open repair of the thoracic aorta. We reviewed procedure-related perioperative morbidity, mortality, and mid-term outcomes in a contemporary series of patients treated with SG of the thoracic aorta. The data were compared with those of a patient cohort concurrently treated with open surgical repair confined to the descending aorta. ⋯ Operative mortality was halved with SG, with similar late survival for both cohorts. Reinterventions were required at a nearly identical rate for open repair and SG, and both groups experienced similar rates of spinal cord ischemic complications.
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Primary varicose veins are commonly considered a progressive disease starting from the saphenous junctions and extending to tributaries in a retrograde fashion along the saphenous trunks. This theory has been criticized by studies indicating different patterns of development and progression of varicose veins. To contribute to the understanding of the pathogenesis of the disease, the anatomy of the venous bed was comparatively evaluated by duplex sonography in patients with varicose veins with a marked difference in age. ⋯ The frequent occurrence of normal SVs in varicose limbs of all patients does not support the crucial role commonly credited to SVs in the pathogenesis of primary varicosities. Moreover, the SV trunks were normal in most varicose limbs from young patients. These findings suggest that varicose disease may progressively extend in an antegrade fashion, spreading from the STVs to the SVs. This hypothesis suggests that the saphenous trunks could be spared in the treatment of a relevant number of varicose legs. Prospective longitudinal studies with serial duplex evaluations of large series of extremities are necessary to confirm this hypothesis.