Clopidogrel has no effect on D-dimer and thrombin-antithrombin III levels in patients with peripheral arterial disease undergoing peripheral percutaneous transluminal angioplasty

OBJECTIVE: Coagulation activation markers are significantly elevated in patients with peripheral arterial disease compared with healthy controls. The more severe the disease, the higher the markers. Increased coagulation activation may contribute to the disease process and the risk of complications in patients with peripheral arterial disease, particularly after endovascular intervention. Animal studies have shown that clopidogrel significantly inhibits coagulation activation. The aim of this study was to determine whether combination of aspirin and clopidogrel affects thrombin-antithrombin III and D-dimer in patients with intermittent claudication undergoing angioplasty, compared with aspirin alone. METHODS: This was a double blind, randomized placebo-controlled trial conducted in a vascular unit in a tertiary referral center. One hundred thirty-two patients with intermittent claudication were randomized to clopidogrel and aspirin or placebo and aspirin, with a loading dose 12 hours before endovascular intervention. D-dimer and thrombin-antithrombin III (TAT) levels were measured using enzyme-linked immunosorbent assay at baseline, 1 hour before, and 1 hour, 24 hours, and 30 days after intervention in 103 patients who underwent endovascular intervention. RESULTS: There was a significant rise in D-dimer levels at 1 hour and 24 hours after angioplasty in both groups (placebo group: 63.69, 141.45, 122.18 ng/mL; clopidogrel group: 103.79, 159.95, 134.69 ng/mL), but no difference between the two groups (P = .514). Similarly there was a significant rise in TAT levels at 1 hour after angioplasty in both groups (placebo group: 2.93, 6.16 microg/L; clopidogrel group: 3.39, 5.27 microg/L), with no significant difference between the two groups (P = .746). CONCLUSION: Endovascular intervention results in a significant increase in TAT and D-dimer. The addition of clopidogrel to aspirin has no effect on TAT and D-dimer before or after endovascular intervention.     

Safety and cost savings of endovascular procedures: are outpatient interventions feasible when combined with open surgery?

As increasing experience and comfort with endovascular interventions performed in an outpatient setting has occurred, the safety and cost effectiveness of performing these procedures without an overnight stay were analyzed, especially when endovascular procedures were combined with open vascular operations requiring an arteriotomy and surgical closure. Ninety patients underwent endovascular procedures alone or concomitantly with open, minor vascular operations to salvage a failing graft between February 1994 and June 1999. Patients undergoing endovascular interventions during primary lower extremity bypass or other major surgical procedures were not included in this review because they were not candidates for outpatient procedures. Balloon angioplasty alone (79) or angioplasty with stent placement (11) was performed to treat stenoses in 50 failing grafts, 16 iliac, 14 femoral, 5 tibial, and 5 axilla/subclavian arteries. A significant increase in outpatient procedures was accomplished as more experience was garnered with these techniques: 19% (8/42) between 1994 and 1996 vs 57% (28/48) between 1997 and 1999 (p = 0.001). Age and comorbidity did not play a role in determining the need for admission because there were no significant differences in patients with diabetes mellitus, hypertension, smoking, or hyperlipidemia and those admitted or discharged the same day (p > 0.05). Patients admitted for overnight observation tended to have longer mean operative times and more complex revascularizations than outpatients (110 vs 69 min, respectively; p < 0.0001). Twenty-seven patients underwent surgical exposure of the access vessel: 63% (17) were admitted and 37% (10) were discharged the same day. Sixty-three patients underwent a percutaneous procedure: 42% (27) were admitted and 58% (37) were discharged the same day. Outpatients were more likely to receive only local anesthesia (83%; 30/35) compared to patients admitted overnight (67%; 36/53); the remaining patients received spinal or epidural anesthesia. Complications included graft thrombosis within 30 days in 6% (5/90) of patients and arterial graft infection in 2% (2). No patient required surgery for bleeding. The average charges for outpatient interventions were $1980 compared to $10,026 for patients who stayed overnight (p < 0.0001). As vascular surgeons become more experienced and comfortable with outpatient endovascular procedures, especially when performed in combination with open minor vascular surgery, significant cost savings can be realized without sacrificing patient safety. Even when open surgical exposure is planned, patients should be instructed preoperatively to anticipate discharge the day of their procedure to minimize resistance to this strategy.     

Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions

Objective

Unplanned hospital readmissions following surgical interventions are associated with adverse events and contribute to increasing health care costs. Despite numerous studies defining risk factors following lower extremity bypass surgery, evidence regarding readmission after endovascular interventions is limited. This study aimed to identify predictors of 30-day unplanned readmission following infrainguinal endovascular interventions.

The use of the Angioseal device for femoral artery closure

BACKGROUND: As vascular surgeons perform increasing numbers of percutaneous catheter-based procedures, they will need to become familiar with varying methods of femoral artery closure. Few studies on closure devices have included significant numbers of patients with peripheral arterial disease. It is the purpose of this study to determine whether the Angioseal device (St. Jude Medical) is a satisfactory method of achieving femoral artery puncture site hemostasis in these patients. METHODS: The records of all patients undergoing Angioseal closure of femoral artery puncture by a single vascular surgeon were reviewed. Indication, type of intervention, and size of the vascular sheath employed were recorded. Times to mobilization and discharge were determined. Patients were seen before discharge and 1, 4, and 12 weeks after the procedure, and at 3- month intervals thereafter. Complications including hemorrhage, pseudoaneurysm, infection, and vessel occlusion were noted. RESULTS: Between February 1, 2002, and August 31, 2003, 220 Angioseal collagen plugs were deployed in 188 patients. Attempts were made to deploy Angioseal devices in 92% of patients undergoing percutaneous procedures during this time period. One hundred forty-four procedures were diagnostic and 74 procedures included 76 therapeutic interventions. One hundred forty-four 5F sheaths, 47 6F sheaths, and 29 7F sheaths were employed during the procedures. Time to mobilization and discharge was 58 +/- 19 minutes and 102 +/- 31 minutes in patients undergoing diagnostic studies, 68 +/- 22 minutes and 146 +/- 42 minutes following interventions using 6F sheaths, and 127 +/- 18 minutes and 219 +/- 37 minutes when interventions were performed using 7F sheaths. No patient developed a major hematoma or infection following the use of an Angioseal. There were 2 complications related to device deployment. One patient developed a 1.4-cm false aneurysm at the femoral artery puncture site that resolved spontaneously. A second patient required operation for vessel occlusion when an Angioseal was deployed in a markedly diseased femoral artery. These adverse events occurred early in our experience. CONCLUSIONS: The Angioseal provides a secure method of achieving hemostasis following femoral artery puncture. It is easy to deploy, has a high level of patient satisfaction, and allows for early ambulation and hospital discharge. When simple guidelines are observed, the device can be safely used in the great majority of patients with peripheral vascular disease. It offers considerable advantages over the traditional method of manual compression.     

Timing of postcarotid complications: a guide to safe discharge planning.

OBJECTIVES: Currently, our standard of practice is that patients undergoing carotid endarterectomy (CEA) may be safely discharged on the first postoperative day. Because many patients do not appear to require overnight observation, we wanted to determine the safety and feasibility of same-evening discharge by establishing the timing of postoperative complications, which may potentially require operative intervention. METHODS: A total of 835 consecutive patients undergoing CEA were retrospectively reviewed. Sixty-two patients had a postoperative wound hematoma or neurologic deficit (ND) (transient ischemic attack or stroke) within 24 hours of their operation, complications potentially requiring a second operation. Excluded were 64 patients not eligible for same-day discharge because of other reasons (eg, heparinization, CEA with coronary artery bypass grafting). RESULTS: Sixty-two patients (8.0%) had ND (26 [3.4%]) or neck hematoma (NH) (36 [4.7%]) within 24 hours of their CEA. Nineteen (73%) of the NDs were diagnosed in the operating room or recovery room, 5 (19%) within 8 hours of the operation, and 2 (7.7%) after 8 hours but in less than 24 hours. Of the NHs, 23 (66%) were diagnosed in the recovery room, 11 (31%) within 8 hours, and 1 (2.7%) after 8 hours. Of the outliers, one patient experienced a blowout of the vein graft occurring on postoperative day 1, one patient had a delayed ipsilateral stroke, and one had a vertebrobasilar stroke. Overall, only three of 773 (0.4%) patients undergoing CEA had a complication occurring more than 8 hours after operation. CONCLUSION: NDs and NHs in post-CEA patients occurred within 8 hours of operation in 95% of those patients experiencing these complications or 99.6% of all CEA patients. These data indicate that same-evening discharge may be safely performed without increasing the adverse effects of stroke or hematoma. This plan has cautiously been initiated at this institution.     

Success and safety of same-day kidney biopsy in children and adolescents

Renal biopsy is crucial for the diagnosis, management, and monitoring of many kidney diseases. Although percutaneous renal biopsy is considered a routine safe procedure in children, the optimal length of in-hospital observation following the procedure is not yet known. We prospectively studied two comparable groups of children to compare the success and safety of performing native renal biopsy as an outpatient procedure versus keeping the children hospitalized post biopsy. Doppler ultrasonography of the biopsied kidney was performed approximately 2 weeks after the procedure. For 40 children the biopsy was performed on a same-day basis (study group) and another 15 children were kept for overnight observation (control group). All biopsies yielded adequate tissue for histopathological diagnosis. There was no difference between the two groups in the amount of reported pain and analgesics used after the procedure. Only 1 child in the study group was readmitted 5 days after the biopsy for 48 h, but no major complications were detected. The incidence of post-biopsy intra- or perirenal hematoma detection by sonography was not statistically different between the two groups (39% study group, 43% control group). Follow-up imaging studies were performed on 10 of the 20 children who had an early post-biopsy hematoma and all were completely normal. Patients and their families appreciated being discharged home the same day. In addition, total charges for hospitalization were significantly less for the study group than the control group. We conclude that in selected patients, same-day discharge after renal biopsy may be performed safely without an increased risk of complications.     

Lower extremity endovascular interventions: can we improve cost-efficiency?

OBJECTIVE: Management of lower extremity arterial disease with endovascular intervention is on the rise. Current practice patterns vary widely across and within specialty practices that perform endovascular intervention. This study evaluated reimbursement and costs of different approaches for offering endovascular intervention and identified strategies to improve cost-efficiency. METHODS: The medical records of all patients admitted to a university health system during 2005 for an endovascular intervention were retrospectively reviewed. Procedure type, setting, admission status, and financial data were recorded. Groups were compared using analysis of variance, Student t test for independent samples, and chi2. RESULTS: A total of 296 endovascular interventions were completed, and 184 (62%) met inclusion criteria. Atherectomy and stenting were significantly more costly when performed in the operating room than in the radiology suite: atherectomy, dollars 6596 vs dollars 4867 (P = .002); stent, dollars 5884 vs dollars 3292, (P < .001); angioplasty, dollars 2251 vs dollars 1881 (P = .46). Reimbursement was significantly higher for inpatient vs ambulatory admissions (P < .001). Costs were lowest when the endovascular intervention was done in the radiology suite on an ambulatory basis and highest when done as an inpatient in the operating room (dollars 5714 vs dollars 12,278; P < .001). Contribution margins were significantly higher for inpatients. Net profit was appreciated only for interventions done as an inpatient in the radiology suite. Reimbursement, contribution margins, and net profit were significantly lower among private pay patients in both the ambulatory and inpatient setting. The 30-day hospital readmission after ambulatory procedures was seven patients (6%). CONCLUSIONS: Practice patterns for endovascular interventions differ considerably. Costs vary by procedure and setting, and reimbursement depends on admission status and accurate documentation; these dynamics affect affordability. Organizing vascular services within a hub will ensure that care is delivered in the most cost-efficient manner. Guidelines may include designating the radiology suite as the primary venue for endovascular interventions because it is less costly than the operating room. Selective stenting policies should be considered. Contracts with private insurers must include carve-outs for stent costs and commensurate reimbursement for ambulatory procedures, and Current Procedural Terminology (CPT; American Medical Association, Chicago, Ill) coding must be proficient to make ambulatory endovascular interventions fiscally acceptable.     

Improved Cumulative Survival in Fistulas Requiring Surgical Interventions to Promote Fistula Maturation Compared with Endovascular Interventions

Due to high nonmaturation rates, arteriovenous fistulas (AVF) frequently require intervention(s) to promote maturation. Endovascular or surgical interventions are often undertaken to salvage nonmaturing AVFs. The objective of this study was to compare the impact of surgical versus endovascular interventions to promote AVF maturation on cumulative AVF survival. We evaluated 89 patients with new AVF placement from a Veterans Affairs population over a 5‐year period. Of these, 46 (52%) required intervention(s) to achieve successful maturation for dialysis: 31 patients had surgical revisions and 15 patients had endovascular repairs. We compared cumulative survival between AVFs requiring no intervention, surgical revision, and endovascular intervention to promote AVF maturation. Cumulative survival was longer in AVFs receiving surgical intervention compared with angioplasty to promote AVF maturation (p = 0.05). One‐year cumulative survival was 86% vs. 83% vs. 40% for no intervention vs. surgery vs. angioplasty, respectively. In AVFs that required interventions to promote maturation, AVFs with surgical intervention had longer cumulative survival compared with those AVFs with endovascular intervention. AVFs with surgical intervention to promote maturation had similar 1‐year cumulative survival to those AVFs that did not require intervention to promote maturation.     

Long-term effects of endovascular angioplasty on orthostatic vasocutaneous autoregulation in patients with peripheral atherosclerosis

OBJECTIVE: To test the hypothesis that endovascular revascularization of femoropopliteal lesions improves the impaired venoarteriolar response (VAR) in patients with atherosclerosis. METHODS: We prospectively compared VARs in 15 healthy controls (18 legs) and 14 patients (17 legs) with mild to moderate peripheral arterial disease before and after successful peripheral endovascular angioplasty of femoropopliteal lesions. In all subjects, foot skin blood flow was assessed by laser Doppler flowmetry in the horizontal (HBF) and sitting (SBF) positions. VAR was calculated as (HBF - SBF)/HBF x 100. RESULTS: In patients with peripheral arterial disease, mean HBF (in arbitrary units [AU]; mean +/- SD) was similar before (25.6 +/- 15.3 AU) and after (27.0 +/- 16.4 AU) angioplasty (P = .67), whereas SBF was significantly lower after than before the endovascular procedure (11.6 +/- 7.7 AU to 18.4 +/- 14.1 AU; P < .05). Intragroup differences between SBF and HBF were significant before and after angioplasty (P < .001). VAR was higher after angioplasty (55.1% +/- 21.2%) compared with VAR before intervention (33.4% +/- 20.2%; P = .015). Although VAR increased after the intervention, VAR was still lower than in healthy controls (68.4% +/- 20.5%; P = .025). During the 6 months of follow-up, the ankle-brachial index and VAR remained unchanged (P > .05). CONCLUSIONS: Patients with mild to moderate peripheral arterial disease have an impaired orthostatic autoregulation that improves after successful endovascular revascularization of femoropopliteal obstructive lesions. The effect on VAR is sustained in the absence of restenosis.     

Revisiting outpatient tonsillectomy in young children.

OBJECTIVE: Postoperative same-day discharge is safe for most children undergoing tonsillectomy. However, young children with upper airway obstruction have a higher risk of postoperative complications. We review our tonsillectomy experience in children under 36 months to evaluate the safety of outpatient tonsillectomy in this population. STUDY DESIGN AND SETTING: We conducted a retrospective study of all children under 36 months who underwent tonsillectomy during a recent 2-year period at The Children's Hospital of Philadelphia. RESULTS: The indication for tonsillectomy in 96% of 421 children was upper airway obstruction. Eighteen percent required postoperative treatment to prevent respiratory compromise; 56% of these patients had no associated medical comorbidity. Patients younger than 24 months and those with medical comorbidities were more likely to require intervention. CONCLUSION AND SIGNIFICANCE: It is not possible to preoperatively anticipate which children will have postsurgical complications. We recommend planning an overnight admission for children younger than 36 months undergoing tonsillectomy.     

Surgical implications of early failed endovascular intervention of the superficial femoral artery

BACKGROUND: It is generally accepted that failed infrainguinal bypass with prosthetic material significantly compromises arterial run off, which may limit future revascularization. It is well known that the negative consequences of early vein graft thrombosis are limited, but the effect of failed peripheral angioplasty on the distal vasculature is poorly studied. The purpose of this study was to determine whether early failure after superficial femoral artery intervention influences subsequent revascularization options. METHODS: Between July 1, 1998, and June 30, 2006, 276 patients underwent endovascular intervention of the superficial femoral artery. A prospective analysis of angiograms done before the intervention and after early failure (相似文献   

Endovascular intervention for acute thromboembolic stroke in young patients: an ideal population for aggressive intervention?

OBJECT: Endovascular treatment of acute thromboembolic stroke is a rapidly developing field that appears to hold great promise. Young patients may be particularly suited to benefit from endovascular acute stroke therapy. The authors sought to identify outcomes in young patients with thromboembolic stroke who underwent endovascular intervention. METHODS: The authors retrospectively reviewed a prospectively collected endovascular intervention registry of patients with ischemic strokes treated at a single large-volume institution between December 2000 and June 2007 to identify patients 18-35 years of age who were treated for thromboembolic stroke. Data are presented as the mean +/- standard deviation unless otherwise noted. RESULTS: Seven young patients underwent 8 consecutive endovascular interventions for thromboembolic stroke (mean age 26 +/- 6 years; 5 women). The National Institutes of Health Stroke Scale score at presentation was 13 +/- 4.3 (median 13). All patients presented within 6 hours of symptom onset. Revascularization was attempted with mechanical thrombectomy/disruption, intraarterial thrombolysis, and/or angioplasty, with or without stent placement. The modified Rankin Scale (mRS) score at discharge was 2.2 +/- 1.5 (median 1.5), with 5 patients (62.5%) achieving independence at discharge (mRS Score 0-2). There were no deaths. Hospital length of stay was 6.5 +/- 3.7 days (4.4 +/- 1.5 days for patients with an mRS score of 0-2; 10 +/- 3.6 days for patients with an mRS score of 4). All patients became independent and had reached an mRS score of < or = 2 at last follow-up evaluation (29 +/- 25 months). CONCLUSIONS: The data demonstrate the relative safety of endovascular intervention in young patients with thromboembolic cerebral ischemia and may suggest a potential benefit in outcome. Further investigation is indicated with larger numbers of patients and an appropriate control population.     

Outpatient treatment of arterial inflow stenoses of dysfunctional hemodialysis access fistulas by retrograde venous access puncture and catheterization

OBJECTIVE: To determine the feasibility of endovascular treatment of inflow stenoses in arteriovenous fistulae (AVFs) through retrograde venous access catheterization. METHODS: We included all 22 dysfunctional AVFs with arterial inflow stenoses at access imaging between January 2002 and September 2006. Following retrograde venous access puncture, an interventional radiologist intended to cross the arteriovenous anastomosis and advance a catheter into the aortic arch. After depiction of the complete vascular access tree, angioplasty and/or stent placement was aimed for stenoses with a >50% luminal diameter reduction at digital subtraction angiography (DSA). RESULTS: In one radiocephalic AVF, a catheter could not be positioned into the aortic arch after retrograde venous access puncture. DSA depicted 28 inflow stenoses in the remaining 21 patients (11 radiocephalic AVFs and 10 brachiocephalic AVFs). Clinical improvement was obtained in 18 out of 19 patients with a technically successful intervention (<30% residual stenosis after angioplasty or stent placement). Following endovascular therapy, access flow of 12 patients with a low flow access improved from 431 +/- 150 ml/min to 818 +/- 233 ml/min, and four patients with steal symptoms became symptom free. One nonmaturing fistula could be salvaged by angioplasty, and access cannulation problems were solved in another patient following angioplasty. Brachial artery stent placement did not reduce steal symptoms in one case, whereas two patients, in whom stent placement was not thought desirable, showed a >30% residual arterial stenosis after angioplasty. No complications were observed at DSA and endovascular intervention. CONCLUSION: Retrograde venous access puncture and catheterization, as an alternative to a potentially more hazardous brachial artery or more invasive femoral artery approach, should be considered for the visualization of the arterial inflow and endovascular treatment of inflow stenoses.     

Patient selection and perioperative outcomes of bypass and endovascular intervention as first revascularization strategy for infrainguinal arterial disease

Objective

The optimal initial revascularization strategy remains uncertain for patients with peripheral arterial disease. The purpose of this study was to evaluate current nationwide selection and perioperative outcomes of patients undergoing bypass or endovascular intervention for infrainguinal disease in those with no prior ipsilateral revascularization.

Percutaneous superficial femoral artery interventions for claudication--does runoff matter?

Endoluminal therapy for superficial femoral artery (SFA) occlusive disease for claudication is commonplace, but the implications of tibial vessel runoff on long-term outcomes of these interventions in patients with claudication are unclear. Runoff is known to negatively affect graft patency, but no data are available on the impact of runoff on percutaneous SFA interventions and their implications during follow-up. We examined the impact of distal popliteal and tibial runoff on long-term outcomes of SFA interventions for claudication. A prospective database of patients undergoing endovascular treatment of the SFA between 1986 and 2007 was queried. Patients with Rutherford symptom classifications 1, 2, and 3 were selected; those with concomitant tibial interventions were excluded. Angiograms were reviewed preoperatively in all cases to assess distal popliteal and tibial runoff and scored according to modified Society for Vascular Surgery criteria for both vessels such that a higher score implies worse runoff (minimum 1, maximum 19). Three run-off score groups were identified: <5 (good), 5-10 (compromised), and >10 (poor). Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Multivariate and factor analyses were performed. There were 481 limbs in 347 patients (70% male, average age 66 years) that underwent endovascular SFA treatment for claudication: 87% had hypertension, 51% had diabetes mellitus, 67% had hyperlipidemia, and 16% had chronic renal insufficiency (1% on hemodialysis). Technical success was 92%, with 63% SFA undergoing angioplasty, 26% SFA undergoing primary stenting, and 3% SFA undergoing atherectomy. Overall mortality was 1.1% and overall morbidity was 17% at 90 days after the procedure. At 5 years, vessels with compromised and poor runoff had significantly lower freedom from recurrent symptoms and lower freedom from restenosis. Primary and assisted primary patency rates were significantly worse in patients with poor runoff. However, secondary patency was equivalent between the groups. Compromised or poor runoff was associated with incremental lower limb salvage. Following SFA percutaneous interventions for claudication, runoff can identify patients more likely to develop restenosis and recurrent symptoms and, more importantly, those at higher risk of limb loss. Defining such subgroups allows a clear risk stratification of patients with claudication and can guide the intensity of surveillance in the outpatient setting.     

Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission

Objective

Hospital readmissions after surgical operations are preventable and are now counted as a quality metric. Patients with peripheral arterial disease often have several serious medical comorbidities. With advancements in endovascular technology and increasing comfort level of vascular surgeons, more and more patients with peripheral arterial disease are being treated with endovascular therapy. Most of these interventions are done as same-day operations. This study retrospectively reviewed the factors associated with hospital readmission after lower extremity endovascular interventions.

希望理论用于癫痫患者住院期间干预研究

目的帮助癫痫患者消除自卑心理,提高自尊水平及希望指数。方法将120例住院癫痫患者随机分为观察组和对照组各60例。两组均给予常规入院介绍、治疗、护理、健康教育,观察组在此基础上将希望理论应用于全程护理干预中。干预前及干预后(出院前、半年后、1年后)采用Herth希望指数(Herth Hope Index,HHI)量表、自尊量表(SES)及自我接纳问卷(SAQ)对两组患者进行效果评价。结果干预后观察组SES、SAQ、HHI评分显著高于对照组(均P<0.05)。结论根据希望理论制定干预措施有利于癫痫患者提高自尊水平及希望指数,从而强化正性行为。     

Patients with moderate to severe strokes (NIHSS score >10) undergoing urgent carotid interventions within 48 hours have worse functional outcomes

ObjectiveIncreasing evidence suggests that urgent carotid intervention after a nondisabling stroke is safe. However, the functional outcome of such patients has not been quantified for various degrees of stroke. We aimed to determine whether increased presenting stroke severity and timing to intervention are associated with poor functional outcomes in patients undergoing urgent carotid endarterectomy (CEA) or carotid artery stenting (CAS) after an acute transient ischemic attack or stroke.MethodsWe reviewed all urgent carotid interventions from January 2013 through April 2017 at a single tertiary referral center. Preoperative variables analyzed included admission stroke severity, calculated by National Institutes of Health Stroke Scale (NIHSS). The primary end point was the patient's neurologic functional independence at discharge, quantified by the modified Rankin scale (mRS) score (≤2, functionally independent; ≥3, dependent). Primary complications were defined as new or worsened stroke, intracranial hemorrhage, and death.ResultsA total of 120 urgent carotid interventions (CEA, n = 96; CAS, n = 22; 1 CEA with middle cerebral artery aspiration thrombectomy and 1 carotid embolectomy) were performed. Bivariate analysis demonstrated a correlation between admission NIHSS score and mRS score when patients were divided into groups with an admission NIHSS score ≤10 and >10 (P = .0029). Patients presenting with larger strokes (NIHSS score >10) were 3.4 times more likely (95% confidence interval [CI], 1.2-9.6; P = .024) to have functional dependence (mRS score ≥3) at discharge than patients presenting with minor to moderate strokes (NIHSS score ≤10). Patients undergoing CEA or CAS before 48 hours were also associated with a worse discharge mRS score compared with those undergoing carotid interventions after 48 hours (odds ratio, 3.5; 95% CI, 1.4-8.7; P = .007). Even when emergent carotid interventions were excluded from the subgroup of patients undergoing CEA or CAS within 48 hours, discharge mRS correlated with time to procedure (days 1- 2 compared with >2 days). The odds of having discharge functional dependence (mRS score ≥3) were 3.4 times more likely for patients with the procedure performed at 1 to 2 days compared with >2 days (95% CI, 1.3-9.1; P = .014).ConclusionsUrgent carotid intervention performed in patients with moderate or severe strokes (NIHSS score >10) and before 48 hours is associated with functional dependence (mRS score ≥3) on hospital discharge. By demonstrating a clear correlation between admission NIHSS score and interval time to procedure with independent neurologic functional outcomes, these data aid in clinical decision-making for this high-risk subpopulation of patients who present with acute symptomatic carotid lesions.     

Randomized clinical trial of the antiplatelet effects of aspirin-clopidogrel combination versus aspirin alone after lower limb angioplasty

BACKGROUND: There is a high risk of reocclusion after successful lower limb angioplasty. Platelets play a central role in this process. The aim of this study was to investigate the antiplatelet effect of a combination of aspirin and clopidogrel compared with aspirin alone in patients with claudication undergoing endovascular revascularization. METHODS: This was a double-blind randomized placebo-controlled trial. Some 132 patients were randomized to clopidogrel and aspirin or placebo and aspirin, with a loading dose 12 h before endovascular intervention. Flow cytometric measurements of platelet fibrinogen binding and P-selectin expression were taken as measures of platelet function at baseline, 12 h after the loading dose, and 1 h, 24 h and 30 days after intervention. RESULTS: Within 12 h of the loading dose, platelet activation in the clopidogrel group had decreased (P-selectin by 27.3 per cent, P = 0.017; fibrinogen binding by 34.7 per cent, P = 0.024; stimulated fibrinogen binding by 49.2 per cent, P < 0.001). No change was observed in the placebo group. Platelet function in the clopidogrel group was significantly suppressed compared with baseline at 1 h, 24 h and 30 days after endovascular intervention (stimulated fibrinogen binding by 53.9, 51.7 and 57.2 per cent respectively; all P < 0.001). CONCLUSION: A combination of clopidogrel and aspirin inhibited platelet function more than aspirin alone in patients with claudication before and after angioplasty.     

Perioperative outcomes of infrainguinal bypass surgery in patients with and without prior revascularization

Objective

Although an increasing number of patients with peripheral arterial disease undergo multiple revascularization procedures, the effect of prior interventions on outcomes remains unclear. The purpose of this study was to evaluate perioperative outcomes of bypass surgery in patients with and those without prior ipsilateral treatment.