Adjunctive abciximab improves patency and functional outcome in endovascular treatment of femoropopliteal occlusions: initial experience

PURPOSE: To prospectively evaluate the safety and effectiveness of adjunctive administration of abciximab observed within 30 days and at 6 months after randomization in patients undergoing endovascular revascularization of long-segment femoropopliteal occlusions. MATERIALS AND METHODS: The study was approved by the local ethical committee, and patients gave written informed consent. In a prospective, double-blind, placebo-controlled design, patients undergoing percutaneous treatment for long-segment (>5 cm) femoropopliteal occlusions were randomly assigned to receive abciximab or a placebo; all patients also received standard-dose heparin. Effectiveness and safety analyses were based on an intention-to-treat approach. Patency was calculated according to life-table analysis, and P values were derived from the log-rank statistic. The P values for dichotomous safety end points were calculated with the Fisher exact test. Odds ratios were calculated for subgroup analyses. Logistic regression modeling was used for analysis of the safety bleeding data. RESULTS: A total of 98 patients (103 limbs) were included: 47 patients received abciximab and 51 received a placebo. Patency with abciximab versus placebo was 95.7% versus 80.4% (relative risk, 0.21; 95% confidence interval: 0.05, 0.96; P = .02) at 30 days and was 61.7% versus 41.2% (relative risk, 0.57; 95% confidence interval: 0.32, 1.01; P = .03), coupled with a better clinical outcome according to the Rutherford score, at the end of follow-up (P = .03). Risk of major bleeding was not significantly increased, while access-site bleeding was significantly higher among patients receiving abciximab (odds ratio, 2.9; 95% confidence interval: 1.04, 8.2; P = .04). CONCLUSION: The data show that adjunctive administration of abciximab has a favorable effect on patency and clinical outcome in patients undergoing complex femoropopliteal catheter interventions not hampered by serious bleeding. Treatment effect of abciximab observed at 30 days was maintained at 6-month follow-up.     

Modulation of glycine receptor subunits and gephyrin expression in the rat facial nucleus after axotomy

In the last decade, numerous studies have investigated molecular changes in excitatory glutamatergic receptors in axotomized motoneurons, but few data are available concerning the modulation of inhibitory amino acid receptors. We report here the effect of axotomy on the expression of glycine receptors, gephyrin, vesicular inhibitory amino acid transporter (VIAAT) and synapsin I in rat facial motor neurons as demonstrated by in situ hybridization and immunohistochemistry. The facial nerve trunk was sectioned unilaterally and rats were killed 1, 3, 8, 30 or 60 days after surgery. We investigated the mechanisms underlying the changes in production of these proteins following axotomy by perfusing the facial nerve with colchicine or tetrodotoxin, and injecting cardiotoxin or botulinum toxin independently and unilaterally into the whisker pads of normal rats. Animals were killed 8 days later and processed for immunohistochemistry. The abundance of GlyR subunits and gephyrin fell sharply in the axotomized facial nucleus. This decrease began 1 day after axotomy and was lowest at 8 days, with protein levels returning to normal by day 60. Abnormal synapsin immunolabelling was also observed between days 8 and 60 after axotomy but we detected no change in VIAAT immunoreactivity. The effect of colchicine was similar to, but weaker than, that of axotomy. In contrast, tetrodotoxin, cardiotoxin and botulinum toxin had no significant effect. Thus, axotomy-induced changes probably resulted from a loss of trophic factor transported from the periphery or a positive injury signal, or both. They did not seem to depend on the disruption of activity.     

Trends in Warfarin Monitoring Practices Among New York Medicare Beneficiaries, 2006–2011

Anticoagulation with warfarin requires frequent evaluation of the international normalized ratio (INR), and less invasive testing devices are available for use by clinicians at the point-of-care (POC) and by patients who self-test (PST). Despite commercial availability and positive results of published studies, evidence suggests that adoption of less invasive (POC/PST) testing in the United States is slow. Considering the equivalence of results and logistical advantages of POC/PST testing, slow uptake may indicate a gap in quality of care warranting evaluation and possibly intervention. This study used Medicare fee for service claims data to explore the uptake of POC/PST INR monitoring across New York State over a 6 year time frame (2006–11), with additional analyses based on beneficiary age, sex, race and ethnicity and income by county. In 2006, only 28.3 % of 103,410 analyzable beneficiaries presumed to be chronic warfarin users based on INR testing patterns were monitored by POC/PST, and increased to only 37.6 % by 2011. Utilization of POC/PST testing varied widely by county (baseline range 1.2–89.4 %), and uptake of these testing modalities in New York State was significantly lower among the very elderly, women, and ethnic minorities. We hypothesize that poor penetration of these less invasive INR testing modalities into highly populated New York City and barriers to POC utilization in long term care facilities may account for a portion of the variability in INR testing patterns observed in this study. However, additional research is needed to further explore whether disparities in warfarin monitoring practices exist.     

Reversal of direct oral anticoagulants: Guidance from the Anticoagulation Forum

Two specific reversal agents for direct oral anticoagulants (DOACs) have been approved in the United States: idarucizumab for dabigatran reversal and andexanet alfa for apixaban and rivaroxaban reversal. Non-specific prohemostatic agents such as prothrombin complex concentrate (PCC) and activated PCC have also been used for DOAC reversal. The goal of this document is to provide comprehensive guidance from the Anticoagulation Forum, a North American organization of anticoagulation providers, regarding use of DOAC reversal agents. We discuss indications for reversal, provide guidance on how the individual reversal agents should be administered, and offer suggestions for stewardship at the health system level.     

Below-the-knee angioplasty in patients with end-stage renal disease.

PURPOSE: To determine clinical efficacy of below-the-knee (BTK) angioplasty in patients with end-stage renal disease (ESRD). METHODS: Interrogation of a prospectively maintained database containing 2,659 patients treated at a tertiary referral hospital between February 1995 and June 2004 identified 29 ESRD patients (21 men; median age 69 years, IQR 10.12) who had 73 infrapopliteal atherosclerotic lesions treated in 38 ischemic limbs. The indication for treatment was intermittent claudication in 13 (34%) and critical limb ischemia in 25 (66%) limbs. BTK angioplasty was attempted either alone (n=18) or combined with an endovascular inflow procedure (n=20). Primary clinical success was defined as hemodynamic improvement (ABI increase >or=0.1) and/or symptomatic improvement (at least one clinical category). Cumulative rates were calculated according to the Kaplan-Meier estimate. RESULTS: Primary technical success reached 97%, whereas hemodynamic improvement was obtained in only 50% (19/38) of the limbs treated. The pedal arteries were severely diseased in all, and complete occlusion of the pedal arch was found in 58% (18/31) of limbs on completion angiography. Median follow-up was 5.9 months (IQR 11.5). Primary clinical success was 17%, 11%, 11%, and 11% in patients with BTK angioplasty alone and 53%, 45%, 45%, and 45% in patients with inflow procedures after 3, 6, 9, and 12 months, respectively (p=0.017). Limb salvage was 73% at 12 months. Subgroup analyses showed significantly better clinical results in men (p=0.003) and in patients on hemodialysis compared to peritoneal dialysis (p=0.037). CONCLUSIONS: Clinical efficacy of BTK angioplasty is limited in patients with ESRD because of the severely diseased pedal arteries. Further studies are warranted to define subgroups of patients likely to experience a more favorable outcome.     

Renal artery stenting following acute aortic dissection: implantation and follow-up

Two patients with renal artery involvement in type B dissection of the aorta were treated by percutaneous stent implantation. Both of them were hypertensive and showed increasing serum creatinine levels. After stent implantation in the renal arteries blood pressure and renal function improved, and the renal arteries were patent in duplex ultrasound 15 and 30 months after treatment respectively.     

Acute hemorrhage in chronic pancreatitis: diagnosis and treatment options including superselective microcoil embolization

Acute hemorrhage in the course of chronic pancreatitis is the most serious and challenging complication, and its treatment has been the subject of controversy for years. We relate our experience in the management of this complication by superselective microcoil embolization. Five patients with acute hemorrhage resulting from chronic pancreatitis between 1994 and 1997 were included in this study. All patients were men with a median age of 44 years (range, 29-59 years). The bleeding occurred into a pseudocyst in all patients, with the splenic artery as feeding vessel. In all instances, the bleeding was successfully controlled by superselective microcoil embolization. Two patients underwent subsequent uneventful elective pseudocystojejunostomy. There was no mortality or morbidity, and no rebleeding occurred during a median follow-up of 22 months (range, 8-36 months). In appropriate patients, diagnostic angiography and superselective microcoil embolization may obviate the need for emergency surgery and should be considered as treatment alternative.