Seminars in vascular surgery
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Vitamin-K antagonists have played a dominant role in the long-term management of patients with venous thromboembolism, and large trials from the past decade reinforced warfarin's effectiveness as an intermediate-duration and extended-duration anticoagulant. However, promising new oral direct thrombin inhibitors are proving to be at least as effective and as safe as the vitamin-K antagonists, without the associated hepatic toxicity that was seen with earlier orally administered direct thrombin inhibitors. This article reviews the recently published Dabigatran versus Warfarin in the Treatment of Acute Venous Thromboembolism clinical trial, and discusses the limitations and clinical applicability of the trial, especially in comparison with vitamin-K antagonists and the recently studied oral direct factor Xa inhibitors, rivaroxaban and apixaban.
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This article summarizes a differing interpretation of the long-term results of the Endovascular Aneurysm Repair (EVAR) 1 Trial. The EVAR 1 Trialists' conclusions regarding the equivalence of long-term outcomes of endovascular aneurysm repair (EVAR) with those of open repair (OR) are misleading and not applicable to patients currently treated by EVAR. ⋯ EVAR is a better treatment for infrarenal aortic aneurysms in anatomically suitable patients. We believe that current standards of practice should be altered accordingly, rather than preserving the nostrums that EVAR and OR are equivalent and that EVAR has more intrinsic disadvantages.
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Perhaps no recent trial in primary prevention of cardiovascular disease has resulted in more controversy than the JUPITER (Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin) trial, which was first published in 2008. The study evaluated a patient cohort previously considered to be "healthy," ie, men 50 years of age or older and women 60 years of age or older, who did not have a history of cardiovascular disease and, at the initial screening visit, had a low-density lipoprotein cholesterol level of <130 mg/dL (3.4 mmol/L) and a high-sensitivity C-reactive protein level ≥2.0 mg/L. ⋯ In the trial participants who achieved such lowering, major cardiovascular events, including venous thromboembolic events, were reduced even in the short term. Despite these results, many still question whether the trial results should influence high-sensitivity C-reactive protein testing or the prescription of statins for individuals at low risk for cardiovascular disease.
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Innominate and subclavian artery lesions run a wide spectrum of disease manifestation and treatment options. Since the first surgical treatment, multiple variances have been attempted with the desire to maintain high long-term patency rates while reducing perioperative morbidity and mortality. The advent of endovascular procedures in the 1970s provided the opportunity to seek alternative treatment options, but the fear of serious neurologic sequela stalled the adoption of these new techniques. The advancement in endovascular techniques and technology, along with proven clinical success and decreased morbidity and mortality, has led to their adoption as the first-line treatment.
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Management of vascular trauma has evolved tremendously since the turn of the 20(th) century. The lessons from each major military conflict over the past 100 years have refined our understanding of how to care for soldiers and civilians with vascular injuries. The recent wars in Iraq and Afghanistan have likewise improved our strategy for treating victims of vascular trauma. Understanding the principles that guide management of vascular injuries will result in preservation of life and limb.