carotid artery disease carotid disease

Is 2016 the year to declare carotid stenting (CAS) as a safe procedure compared to carotid endarterectomy (CEA)?

01/28/2016

the answer is NO; no supporting evidence from major carotid registries in the world according to Prof Naylor’s report.

Ref. EJVES Jan 2016

Stroke/death rates for “average risk” asymptomatic patients undergoing CAS and CEA in various registries. #Results reported separately for patients aged <65 and ≥65 years.

1-s2.0-S1078588415005948-gr2

Stroke/death rates for “average risk” symptomatic patients undergoing CAS and CEA in various registries. #Stroke and death rates reported separately. ##Stroke/death rates reported separately for patients aged <65 and ≥65 years.

1-s2.0-S1078588415005948-gr3

carotid artery disease carotid disease stroke

Can we reverse a stroke once it happens?

01/28/2016

The answer is YES, we can in 1 out of 5 patients!!

Ref. EJVES Feb 2016

2015 will be remembered as the year in which intra-arterial thrombolysis (IAT) was established as a highly beneficial therapy for patients with acute ischaemic stroke affecting the anterior circulation. No other intervention in the cardiovascular field has been considered so important that the editors of the New England Journal of Medicine decided to publish the results of five trials on the same topic in the same volume.

In fact, if a stroke centre persistently failing in saving 1 stroke patient for every 5 stroke incidents, we should question the centre ability to be a stroke establishment.

the following meta-analysis of six RCTs shows clear unquestionable evidence of the effect of this treatment in reversing the stroke status, that has been long considered as irreversible.

Microsoft Word - yejvs_5834_Figure 1_V3

Few questions remains:

TIMING: within 6 hours after acute stroke onset in six randomized clinical trials

SHOULD WE DO CAROTID SURGERY/STENTING SIMULTANEOUSLY? no evidence for or against. we however should do the carotid procedure ASAP.

IS ACUTE CAROTID OCCLUSION TREATABLE? YES; occlusion may spontaneously recanalize in the early hours/days after stroke onset (observed in 16% of patients).

SHOULD PATIENT HAS INTRAVENOUS THROMBOLYSIS AS WELL? no evidence. Intracranial haemorrhage occurs in 6% of IV thrombolysis.

All in all, the practice should now change and a new mind set should start to establish among decision makers.

perforators Radiofrequency Ablation RFA varicose veins Venus eczema

Should you treat incompetent perforators during RFA to main trunk varicose veins, or should you leave them alone?

01/25/2016

The answer is: you have to make your own judgment!

what you need to know is that RFA induces numerous changes in calf perforators. These changes seem to result from flow offloading in ablation site and onloading in nonablation site in the early postablation period. The perforators would then either disappear or remain intact and be the origin of recurrence.

See this interesting article:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557325/

 

and this one:

New insights into perforator vein incompetence

http://www.ncbi.nlm.nih.gov/pubmed/10479629

http://www.ncbi.nlm.nih.gov/pubmed/17043608

 

critical ischaemia

Treatment of distal arterial runoff disease: a challenging task!

12/29/2015

Ref: Charing Cross Vascular Symposium 2015 + EndovascularToday

Atherosclerotic lesions affecting runoffs in diabetic patients are super challenging: crossing the lesion, debulking the calcified atheroma, and avoiding arterial dissection for the, commonly, only runoff artery are some of the many challenges that faces the treatment process.

Few tips and tricks have emerged over the years that can provide a good framework to approach those lesions, and avoid major limb amputation if possible.

Crossing the lesions-

  • This article describes some useful tips for crossing those lesions: http://evtoday.com/pdfs/et0513_FT_csi.pdf
  • Dilate the distal microvasculature with an infusion of 200 to 400 μg of nitroglycerin, administered through the sheath before initial treatment. Additional nitroglycerin boluses of up to 400 μg are suggested after every second treatment.
  • Administer systemic anticoagulation with intravenous heparin (100 IU/kg).
  • Possibly run heparin saline infusion through the supporting catheter to provide a jet stream with the GTN.
  • Can we consider using a vasodilator other than GTN? Currently, Iloprost is not licensed in the UK (even to be given intravenously). It should then be only allowed on an off-license basis under a specialist advice exclusively. Patient should be well informed. This is then accepted to be delivered as an IV (despite some RCTs delivering this from within the bypass graft). The efficiency of Iloprost is to be determined. There is currently no clear evidence that Iloprost will dilate the vasculature bed and help the cannulation process whatsoever. GTN is probably much better to use. Papaverine is also well known for its effect (unlicensed).
  • If doing popliteal/TPT endarterectomy before crossing the distal lesion, then ensure avoiding to reach the small arterial lumen with your dissection. Once reached, it would be so hard to keep the lumen open without a dissection flap, which can fully compromise the lumen access later on. You can complete your endarterectomy once an access to the true lumen is well established, and the perfusion started.
  • Cross the lesion with the 0.014-inch ViperWire Advance® guidewire and position the guidewire tip to make sure there is sufficient distance between the guidewire spring tip and the distal end of the shaft (10-cm minimum at all times). The ViperWire Advance® should be within the true lumen of the vessel; subintimal use of the device may be ineffective.
  • If the ViperWire Advance® cannot be placed as a primary guidewire, use a stepwise approach to cross the lesion with a specialized crossing guidewire. A support catheter, such as Quick-Cross (Spectranetics Corporation, Colorado Springs, CO), may facilitate guidewire placement.

Angioplasty +/- Drug Coated Balloons +/- Drug Eluting Stents –  what is the evidence so far?

  • The following few points explains the current understanding in performing distal endovascular procedures (Charing Cross Vascular Symposium 2015), delivered by Prof Thomas Zeller:
    • Use drug eluting stents (DES) in lesions < 10 cm ?PRIMARILY. Current trials support the superiority of Self-expanding (Nitinol) stents (SES) over PTA or Bare-Metal Stents only, for 12-24months follow up.
    • distal stents
    • stents2
    • For lesions >10cm, use drug coated balloons (DCB) primarily. RCTs (IN.PACT, DEBATE) supports their use over PTA or DES.
    •  Atherectomy – this is indicated in diffuse fibrotic and calcified lesions, and in preparation for DCBs.
    •    
    • The following presentation summarises the current understanding/evidence behind this area.
Yoga

5 principles of Yoga that can be used in a busy clinical life

12/24/2015

1- correct breathing .. Breathing is considered in yoga as a bridge between the mind and the body. Correct breathing requires both increasing the depth of breathing, and being in conscious control of the breath.

2- complete relaxation– a state of true relaxation is defined in yoga as existing when the body consumes the minimum amount of energy required to exist. Physical relaxation requires loosening areas of muscle tension (by massage sometimes); mental relaxation involves quieting the mind by using breathing techniques.

3- balanced diet – the rule is to eat in moderation, only when hungry, taking time to chew food properly, and eating at set times every day.

4- positive thinking – yoga uses mediation and relaxation to clear the mind, and employs positive affirmations to boost self-esteem.

 


Ref. A little course in yoga 2013 isbn 97840936523 5. This material is copyrighted and is used here for educational purposes only!

5- beneficial excercises– yoga excercises can, when practiced regularly and correctly, provide full cardiac workout and ensure all areas are worked on thoroughly.

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

Massage Therapy for patients with peripheral arterial diseases: is it scientifically useful?

12/20/2015

ref: Arch Phys Med Rehabil. 2014 Jun; 95(6): 1127–1134

This study, a randomised controlled one was conducted to determine if lower extremity exercise-induced muscle injury (EMI) reduces vascular endothelial function of the upper extremity and if massage therapy (MT) improves peripheral vascular function after EMI. Thirty-six sedentary young adults were randomly assigned to one of three groups: 1) EMI + MT (n=15; mean age ± standard error (SE): 26.6±0.3), 2) EMI only (n=10; mean age ± SE: 23.6±0.4), and 3) MT only (n=11; mean age ± SE: 25.5 ± 0.4). Brachial artery flow-mediated dilation (FMD) was determined by ultrasound at each time point. Nitroglycerin-induced dilation was also assessed (NTG; 0.4 mg). Brachial FMD increased from baseline in the EMI + MT group and the MT only group (7.38±0.18 to 9.02±0.28%, p<0.05 and 7.77±0.25 to 10.20±0.22%, p < 0.05, respectively) at 90 minutes remaining elevated until 72 hrs. In the EMI only group FMD was reduced from baseline at 24 and 48 hrs (7.78±0.14 to 6.75±0.11%, p<0.05 and 6.53±0.11, p<0.05, respectively) returning to baseline after 72 hrs. Dilations to NTG were similar over time.

 

Those are very interesting results to the importance of massage therapy in this group of patients, and deserve further in depth look to understand the implication of this in the real life practice. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4037335/

massage_RCT2

 

 

Structured_Exercises

Home-Based Structured Exercises: are they really effective?

12/20/2015

Ref: EJVES Dec 2013

This is a systematic review of the effectiveness of an almost self-directed structured exercise ‘activities’ on the IC patients.

The clear conclusion is that there is “low-level” evidence that Home based exercise programme (HEPs) can improve walking capacity and quality of life in patients with intermittent claudication, albeit probably to a lesser extent than supervised exercise training. The recommendation is that HEPs should be used to promote walking in patients with intermittent claudication when supervised training is unavailable or impractical.

http://www.ejves.com/article/S1078-5884(13)00562-5/pdf

 

AAA complex AAA; FEVAR; BEVAR complex EVARs EVAR familial AAA; laparoscopic aneurysm repair rupture risk ruptured aneurysm

Care for patients with AAA – a thorough approach.

12/20/2015

Ref.: Clinical Practice Council of the Society for Vascular Surgery

I found this thorough guidelines from the Clinical Practice Council of the Society for Vascular Surgery pretty useful. It is focused, thorough, and very well thought about. Issues such as operating on patients with 5.0 -5.4cm aneurysms, comparing older trials to new EVAR era, using statins to prevent expansion of AAA, are very well documented in here.

Here is the link:

http://goo.gl/G9Fkps

 

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