bypass

Is it reasonable to use a stent inside the vein graft?

01/07/2017

Ref. Circumstances Cardiovascular Interv Nov 2016

This study allows us, as vascular surgeons, to conclude .. as it is not exactly applicable in a direct manner.

Sealing Intermediate Nonobstructive Coronary Saphenous Vein Graft Lesions With Drug-Eluting Stentsas a New Approach to Reducing Cardiac Events: A Randomized Controlled Trial.

Abstract

BACKGROUND:

The objective of this study was to assess the efficacy of sealing intermediate nonobstructive coronary saphenous veingraft (SVG) lesions with drug-eluting stents (DES; paclitaxel- or everolimus-eluting stents) for reducing major adverse cardiac events (MACE).

METHODS AND RESULTS:

This was a randomized controlled multicenter clinical trial that enrolled patients with a previous coronary artery bypass graft who had developed at least 1 intermediate nonobstructive SVG lesion (30%-60% diameter stenosis by visual estimation). Patients were randomized (1:1) to DES implantation (SVG-DES) or medical treatment (SVG-MT) of the target SVG lesion. The primary efficacy outcome was the first occurrence of MACE defined as the composite of cardiac death, myocardial infarction, or coronary revascularization related to the target SVG during the duration of follow-up (minimum of 2 years). Secondary efficacy outcomes included MACE related to the target SVG lesion and overall MACE. A total of 125 patients (mean age 70±9 years, 87% men) were included, with a mean time from coronary artery bypass graft of 12±5 years. Sixty and 65 patients were allocated to the SVG-DES and SVG-MT groups, respectively. There were no events related to the target SVG at 30 days. After a median follow-up of 3.4 (interquartile range: 2.8-3.9) years, the MACE rate related to the target SVG was not significantly different in the 2 groups (SVG-DES: 15.0%, SVG-MT: 20.0%; hazard ratio, 0.65; 95% confidence interval, 0.23-1.53; P=0.33). There were no significant differences between groups in MACE related to the target SVG lesion (SVG-DES: 10.0%, SVG-MT: 16.9%; hazard ratio, 0.53; 95% confidence interval, 0.20-1.43; P=0.21) or global MACE (SVG-DES: 36.7%, SVG-MT: 44.6%; hazard ratio, 0.73; 95% confidence interval, 0.42-1.27; P=0.26).

CONCLUSIONS:

Sealing intermediate nonobstructive SVG lesions with DES was safe but was not associated with a significant reduction of cardiac events at 3-year follow-up.

vascular curriculum

What makes vascular surgery so distinctive?

01/07/2017

Reflections from ‘know yourself’ – consultant interview preparation course

Vascular surgery is distinct in four main aspects when compared to almost all other branches of surgery:

  1. The level of complexity of cases is generally significantly higher than average.
  2. The age and comorbidities for vascular patients is huge
  3. There is a high level of potential complications, almost 30-50% of arterial cases will have a complication or more in the first 2 years.
  4. There is a continuous need for high attention to details ALL the time; one lost opportunity is a guarantee for a complication.

It is not therefore surprising that this branch of surgery:

  1. Result in a very high level of preoperative stress to the surgeon
  2. requires a high demand on creative thinking
  3. requires a huge demand on time, urgent, and duration of procedures.
  4. s very dynamic and changing
  5. is full of basic science
  6. is two specialties in one: surgery and targeted radiology; each requires to apply the 10,000 hour rule to master
  7. nd is the only surgical specialty that can intimately integrates both physics and physiology

 

Well .. not everyone is convinced though. This is what Br J Cardiol 2009;16:299–302 has to say:

We undertook a seven-year in-depth review of all reported obituaries of medical practitioners in the BMJ to assess the age and disease distribution of mortality of medical practitioners in order to identify relationships between mortality and discipline, ethnicity and other demographic factors. In total, 3,342 obituaries reported in the BMJ from January 1997 to December 2004 were reviewed.

The majority of obituaries were of male doctors. Doctors who qualified in the developed world appeared to live longer (mean age at death of 78 years) than those who qualified in Asia (mean age at death of 70 years). White-European doctors lived significantly longer than doctors from other ethnic groups. There was no significant difference in longevity between doctors working in the primary care sector and those in the secondary care sector. An eighth (12.5%) of doctors died between the ages of 60 and 70 years and, of these, nearly half died between the ages of 61 and 65 years. There were significantly more suicides and accidental deaths in Accident and Emergency (A&E) doctors compared with other specialties.