Direct Anticoagulants RIVAROXABAN Uncategorized

Direct anticoagulants & preop policy 

12/08/2015

The half life of RIVAROXABAN is 5-9h in healthy individuals and 11-13h in the elderly. Ref.drugs.con

In uptodate.com: RIV can be stopped 2-3days before a procedure, with shorter interval if procedure has low risk of bleeding, based on or with no renal failure who is receiving 20mg once daily doses, or moderate renal failure on 15mg od. 

RIV can only be checked if really needed usingantifactor 10 levels. 

In rare cases, bridging is required, such as pts with very high thromboembolic tendency. 

RIV can be reinstituted immediately after procedure once haemostats is achieved, at the same dose, providing there is no big risk of further bleeding. 

RIV costs £63 for 20mg 30-tab pack. 

Warfarin, in comparison, costs £1.07 for 5mg 28-tab pack

varicose veins

Which is better long-term: endovenous laser ablation or traditional surgery for varicose veins?

12/07/2015

Ref: EJVES Nov 2015

This is seriously interesting!! Most, if not all, surgeons have now ‘switched to’ endovenous thermal ablation (laser or RF). The endovenous therapy has proven safety and mid-term results. what about the long term recurrence? RELACS study has some logic : traditional surgery risks the recurrence to occur in the site of operation; the endothermic risks the recurrence to occur in other places. Here are the results:

Same Site Recurrence is More Frequent After Endovenous Laser Ablation Compared with High Ligation and Stripping of the Great Saphenous Vein: 5 year Results of a Randomized Clinical Trial (RELACS Study)

Interventions were performed on ambulatory and hospitalized patients at two vein centres, a university dermatology department (EVLA) and a specialized vein clinic (HLS). Four hundred patients suffering from GSV incompetence were assigned to EVLA or HLS of the GSV. One hundred and eighty five and 161 patients (=limbs), respectively, were treated per protocol. Main outcome measures were clinically recurrent varicose veins after surgery (REVAS classification, primary study objective), Duplex detected saphenofemoral recurrence, clinical venous severity scoring (Homburg Varicose Vein Severity Score), quality of life (Chronic Venous Insufficiency Questionnaire 2), side effects, and patient satisfaction 5 years after treatment.

Results

  • Two hundred and eighty one legs (81% of the study population) were evaluated with a median follow up of 60.4 (EVLA) and 60.7 months (HLS).
  • Overall, REVAS was similarly observed in both groups: 45% (EVLA) and 54% (HLS), p = .152.
  • Patients of the EVLA group showed significantly more clinical recurrences in the operated region (REVAS: same site): 18% vs. 5%, p = .002.
  • In contrast, more different site recurrences were observed in the HLS group: 50% vs. 31%, p = .002.
  • Duplex detected saphenofemoral refluxes occurred more frequently after EVLA: 28% vs. 5%, p < .001.
  • Both treatments improved disease severity and quality of life without any difference.

The results are summarised in this good figure:

Microsoft PowerPoint - yejvs_5830_EJVES 10179R rev 2 RELACS_5y_F

The figure is shown for educational purposes only and not for reuse.

Conclusion – don’t take it for granted!! need more work on best treatment options …

 

aortic surgery

CERAB technique to replace aorto-bifemoral bypass .. is heating up!

12/07/2015

Ref: EJVES Nov 2015

This is the editor’s choice for EJVES this month… and it deserves!! It is a new era in major vascular reconstruction, now been followed for 0-48 months with excellent results so far. The study took place in the Netherlands and in Belgium.

The procedure is simply to use covered stents after passing the iliac and aortic blockage with wires and catheters.

CERAB

picture taken from CERAB original description for educational purposes only. http://www.angiocare.nl/uploads/downloads/4.CERAB_ZNA_poster-(1).pdf

The idea resembles the EVAR technique, with three key differences: passing wires through blockages; landing in a less-than-average aortic diameter, and lack of further attachments (barbs, hooks, etc.).

Between 2009 and March 2014, 103 patients (51 male, 52 female) suffering from obstructive lesions at the level of the aortic bifurcation were treated with CERAB in two clinics. The median age was 61 years (range 36–85 years). Lesion morphology was evaluated by CT angiography. Six TASC-II B lesions, nine TASC-II C lesions, and 88 TASC-II D lesions were treated. Follow up was a median 12 months (range 0–49 months) and consisted of clinical examination, ankle brachial indices, and duplex ultrasound examination.

  • Technical success was obtained in 98 procedures (95.1%). In five cases lesions could not be recanalized.
  • Primary patency was 87.3% at 1 year and 82.3% at 2 years, while secondary patency was 95.0% at 1 year and 95.0% at 2 years.
  • Mean ankle brachial indices improved significantly from 0.64 ± 0.21 before to 0.91 ± 014, after the procedure (p < .001).
  • The overall 30 day complication rate was 23.3%, including 22 minor complications and two major complications (1.9%).
  • There was no 30 day mortality. Median hospital stay was 2 days (range 1–16 days).

What this paper adds

The study is an evaluation of the first (and largest) patient cohort, showing the safety and excellent patency of this technique when treating aortoiliac arterial occlusive disease. There seem to be a potential shift from open surgical bypass grafting to endovascular treatment for patients suffering from disabling intermittent claudication or critical limb schema. We need more info and longer term results to judge; but the astonishing 0% mortality and 2 day LOS is impressive so far, not to mention the 95% technical success rate.

 

Intermittent claudication; Exercise; Physical activity; Accelerometer; Energy expenditure

How efficient it is to use GPS in monitoring intermittent claudicants?

12/06/2015

ref: EJVES Nov 2015

Reports are emerging on using modern ‘wearable’ technologies in monitoring outcome for cluadicants. The number of patients is still low, but the idea and the statistical design and analysis are the interesting part.

In this French study, seventeen PAD patients performed two series of evaluations (T1 and T2) within a 1 month period. Each series included: a 1 hour stroll in the community with the calculation of the walking impairment questionnaire (WIQ) scores, the measurement of maximal walking distance on a treadmill (MWD on treadmill) and a 1 hour stroll in the community with GPS. Test-retest reliability of MWD on treadmill, WIQ, and GPS parameters were assessed with intraclass coefficient of correlation (ICC).

ICCs are almost perfect between T1 and T2 for greatest distance (ICC = 0.911), average speed (ICC = 0.905), and MWD on treadmill (ICC = 0.992), and substantial for the average WIQ (ICC = 0.794). Correlation of average stop durations was considered substantial (ICC = 0.691).

Microsoft Word - yejvs_5815_Figures_EJVES9959R_Rev5_V1

This figure provides an example of the recordings observed during the two strolls (Test 1 and Test 2) in the same patient. The figure is a copyrighted material and is not reusable. It has been used here for the sole purpose of education.

AAA aortic surgery Spinal cord ischaemia Thoracic aneurysm

Spinal cord ischaemia in thoracic aneurysm endovascular repairs – major centres are now saying it is ‘preventable’!

12/06/2015

Ref. EJVES Nov 2015

The work and results coming from ST Thomas’ Unit in London are, to say the least, very encouraging. SCIs are not only preventable, but they are SIGNIFICANTLY reversible! This is quite encouraging when advising patients. We of course has to remember one important point: attention to details by the WHOLE team, not only by the surgeon!

Here are some details:

  • Sixty-nine patients (median age 73 years, 52 male; Crawford classification type I [n = 4], type II [n = 11], type III [n = 33], type IV [n = 14], type V [n = 7]) underwent endovascular TAAA repair.
  • Twelve patients developed neurological symptoms/signs related to SCI
  • This was successfully reversed in eight patients, leaving four (5.8%) with permanent paraplegia.
  • The median length of aorta covered was not significantly different in the 12 patients who developed SCI compared with the cohort that did not. see picture!
  • Eleven of the patients who developed SCI had an intraoperative mean arterial pressure (MAP) below 80 mmHg. Cutaneous atheroemboli were noted in half of the patients in the SCI group compared with 11% of the non-SCI group (p < .05).
  • Strategies used to reverse SCI included raising MAP, cerebrospinal fluid drainage, angioplasty of stenosed internal iliac arteries, and restoring perfusion to the aneurysm sac.

Microsoft PowerPoint - yejvs_5843_EJVES10055 rev 1 figures_V1

Picture: notice the extent of aortic coverage. This did not affect the incidence of SCI. Picture for education purpose and news reporting only and is not reusable.

 

carotid artery disease carotid disease MRI

When should we consider carotid lesion as ‘highly vulnerable’ regardless of symptoms?

12/06/2015
Ref: EJVES Nov 2015

This question has no clear unquestionable answer unfortunately! If you pick up a ‘highly vulnerable’ lesion in asymptomatic patient, who has no stroke history and referred, electively, to your clinic, then you still have to think TWICE! Adding haemodynamic data to static ones may also help you in the decision: finding small ‘blebs’ on doppler scan for example, or from a more accurate dynamic imaging in the future, would certainly help convincing both you and the patient that there is a dangerous plaque here. If you adopt a policy in the centre to operate on asymptomatic patients with significant stenosis (or with highly vulnerable plaque), then your results should follow the major trial results, and you would be able to estimate how many have you helped before one was harmed!

 

In this work from Toby Richards and team at UCL, highly vulnerable lesions were considered as those having several structural plaque characteristics that distinguish the “vulnerable” from the “non-vulnerable” plaque, which includes plaque ulceration, intraplaque haemorrhage (IPH), thin or ruptured fibrous cap (FC), lipid-rich necrotic core, and the presence of calcification. (1) Inflammation may also play a role in the development and progression of disease as well as identifying the vulnerable plaque.(2)

(1) A.V. Finn, M. Nakano, J. Narula, F.D. Kolodgie, R. Vierman. Concept of vulnerable/unstable plaque. Arterioscler Thromb Vasc Biol, 30 (2010), pp. 1282–1292
(2)M. Marnane, S. Prendeville, C. McDonnell, I. Noone, M. Barry, M. Crowe,  et al. Plaque inflammation and unstable morphology are associated with early stroke recurrence in symptomatic carotid stenosis. Stroke, 45 (2014), pp. 801–806

The conclusion is even more interesting:

US, CT, MRI, and PET are non-invasive imaging techniques that show promise for identifying vulnerable plaque characteristics beyond the degree of stenosis.

Although the aforementioned imaging parameters are promising, at present there is no single imaging technique that can clearly identify the vulnerable plaque. This is because (a) there is no single imaging modality that can detect all vulnerable plaque features, (b) plaque imaging is expensive, time-consuming, and requires a reviewer with advanced experience, and (c) prospective natural follow-up studies analysing the value of these imaging modalities for future cerebral events are limited. It is therefore important to realise that even if we could reliable identify ulceration, LRC, thin FC, and IPH as characteristics of the vulnerable plaque, at this stage there is not enough evidence that these patients indeed have a higher risk of stroke.

MRI has the most potential, with good sensitivity and specificity for most plaque characteristics, of course, within the above limitations …

 

News

‘Fair’ usage of copyrighted material. How can we make a ‘fair’ judgement?

12/06/2015

Here are SEVEN key questions that helps you decide wether what you have included on your website that were taken from others, is considered a fair use. Generally speaking, Fair use allows you to use someone’s copyrighted work without permission. If you are to use this material, it must must be for “purposes such as criticism, comment, news reporting, teaching, scholarship, or research.” AND “the use of this copyrighted piece should not be within a material that is used for profit-generation, and/or in a volume from that work that is considerable, depending on the nature of the work”.

So if your specific blog that you used a copyrighted material is fit with the first part of the above equation (for example, people don’t pay you to read that specific blog), then the second part applies, including, of course, wether you used the material in an ad rich site that will generate profit for you by attracting people to the copyrighted material. Interesting!!

The SEVEN key questions are included in this article that is clear and really easy to digest: https://janefriedman.com/the-fair-use-doctrine/

Health and fitness

Happiness follows healthy life .. Almost always!!

12/06/2015

This story of the 15 habits to make life happier, and healthier, has been repeating itself again and again … Yet .. Miserable people don’t seem to be able to make ‘any’ move … I would say, if you can’t make it all, at least maximise one of them to counterbalance the others … I’m repeating again: Maximise one (that you can do) to counterbalanance the others (that you can not change) … Simple !!! 
Here is the article: 

http://uk.businessinsider.com/habits-that-can-make-you-happier-2015-11?r=US&IR=T

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