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Concurrent venography during first rib resection and scalenectomy for venous thoracic outlet syndrome is safe and efficient.
Hawkins AT, Schaumeier MJ, Smith AD, de Vos MS, Ho KJ, Semel ME, Nguyen LL
(2015) J Vasc Surg Venous Lymphat Disord 3: 290-4
MeSH Terms: Adolescent, Adult, Angioplasty, Balloon, Decompression, Surgical, Female, Follow-Up Studies, Humans, Male, Middle Aged, Phlebography, Retrospective Studies, Ribs, Subclavian Vein, Thoracic Outlet Syndrome, Treatment Outcome, Young Adult
Show Abstract · Added September 27, 2016
OBJECTIVE - Surgical treatment of acute axillosubclavian vein thrombosis from venous thoracic outlet syndrome (VTOS) traditionally involves first rib resection and scalenectomy (FRRS) followed by interval venography and balloon angioplasty. This approach can lead to an extended need for anticoagulation and a separate anesthesia session. We present outcomes for FRRS with concurrent venography.
METHODS - Retrospective chart review was performed for consecutive patients undergoing FRRS with concurrent venography for VTOS from February 2007 to April 2014. Venography was performed immediately after FRRS with the arm in neutral and provocative positions. The primary outcomes of this study were primary and primary-assisted patency. Secondary outcomes included whether concurrent venography resulted in modification of the procedure, postoperative anticoagulation use, and postoperative complications.
RESULTS - Thirty patients underwent first rib resection with venography with a mean follow-up time of 24.4 months. The mean age was 29.5 years (range, 17-52 years), and 17 (56.7%) were female. All were maintained on anticoagulation before the procedure. Concurrent venography resulted in modification of the procedure in 28 patients (93.3%). Of these, 27 patients (96.4%) underwent balloon angioplasty and two patients (7.1%) underwent further rib resection. Twenty patients (66.7%) were discharged after the procedure with no anticoagulation. For those receiving postoperative anticoagulation for persistent minor thrombus, median time for anticoagulation duration was 5.0 months (range, 0.8 and 16.7 months). Two patients (6.7%) had postoperative bleeding requiring thoracentesis or video-assisted thoracoscopic evacuation of hemothorax. One patient (3.3%) suffered rethrombosis and was successfully lysed open, resulting in a 2-year subclavian vein (SCV) primary patency of 96.7% and primary-assisted patency of 100%. No patients required reoperation for VTOS, and all reported improvements in symptoms. Three patients (10.0%) later underwent prophylactic first rib resection on the contralateral side for symptoms and SCV stenosis.
CONCLUSIONS - FRRS with concurrent venography is a safe procedure for VTOS that allows effective intraoperative modification of the surgical plan, resulting in excellent patency of the SCV, early cessation of anticoagulation, and durable relief of symptoms.
Copyright © 2015. Published by Elsevier Inc.
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16 MeSH Terms
Epidural removal after perioperative myocardial infarction and coronary stent placement.
Hackney CW, Wilson SH, Abernathy JH, McEvoy MD
(2014) Reg Anesth Pain Med 39: 252
MeSH Terms: Aged, Angioplasty, Balloon, Coronary, Catheters, Device Removal, Epidural Space, Humans, Male, Myocardial Infarction, Stents
Added October 17, 2015
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9 MeSH Terms
When to call it a day: incremental risk of amputation and death after multiple revascularization.
Hawkins AT, Schaumeier MJ, Smith AD, Hevelone ND, Nguyen LL
(2014) Ann Vasc Surg 28: 35-47
MeSH Terms: Aged, Aged, 80 and over, Amputation, Angioplasty, Balloon, California, Chi-Square Distribution, Comorbidity, Critical Illness, Decision Support Techniques, Female, Humans, Ischemia, Kaplan-Meier Estimate, Lower Extremity, Male, Middle Aged, Multivariate Analysis, Patient Selection, Proportional Hazards Models, Reoperation, Retrospective Studies, Risk Assessment, Risk Factors, Smoking, Time Factors, Treatment Outcome, Vascular Surgical Procedures
Show Abstract · Added September 27, 2016
BACKGROUND - Patients with critical limb ischemia (CLI) often undergo revascularization before amputation. The exact relationship between multiple procedures and increased risk of amputation is unclear. We sought to determine the increased risk of amputation for each additional revascularization.
METHODS - The 2007-2009 California State Inpatient Database (SID) was used to identify a cohort of CLI patients undergoing revascularization and conduct a time-to-event analysis for patients undergoing one or more revascularization procedures. One-year estimates were generated with Kaplan-Meier curves and compared with the log-rank test. The Wei-Lin-Weissfeld (WLW) marginal proportional hazards model was used to assess independent effects of number of revascularization procedures on amputation and death.
RESULTS - A total of 11,190 patients with CLI underwent revascularization between July 2007 and December 2009. Their mean age was 71.0 years (interquartile range 62-80 years) and 6255 (55.9%) were male. Over half the subjects (55.2%) were smokers and there was a high burden of comorbidities in the cohort. One-year estimates of amputation by number of revascularizations (1: 23.3%; 2: 27.1%; 3: 30.3%; 4: 26.7%; 5(+): 28.6%; P < 0.001) and death (1: 18.7%; 2: 21.1%; 3: 26.3%; 4: 23.6%; 5+: 32.1%; P = 0.012) increased significantly as procedures increased. In the WLW model for amputation, the hazard increased significantly for patients with 2 revascularization versus 1 (HR = 1.22; 95% CI 1.09-1.37; P = 0.001) and 3 revascularizations versus 2 (HR = 1.33; 95% CI 1.10-1.62; P = 0.004). In the multivariable WLW models for death, the increase in revascularization procedures for 2 compared with 1 (HR = 1.18; 95% CI 1.04-1.34; P = 0.010) was significant.
CONCLUSIONS - The risk of amputation increases with each additional revascularization procedure. These findings hold true for both percutaneous transluminal angioplasty only and lower extremity bypass only subsets. In addition, increased revascularization procedures appear to result in an increased risk of death. We advocate for continued communication between clinicians and patients on the true risks and benefits of additional revascularization procedures.
Copyright © 2014 Elsevier Inc. All rights reserved.
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27 MeSH Terms
Sex-influenced association of nonalcoholic fatty liver disease with coronary heart disease.
Feitosa MF, Reiner AP, Wojczynski MK, Graff M, North KE, Carr JJ, Borecki IB
(2013) Atherosclerosis 227: 420-4
MeSH Terms: Aged, Alanine Transaminase, Angioplasty, Coronary Disease, Fatty Liver, Female, Humans, Inflammation, Insulin Resistance, Liver, Male, Middle Aged, Multivariate Analysis, Myocardial Infarction, Non-alcoholic Fatty Liver Disease, Oxidative Stress, Phenotype, Predictive Value of Tests, Risk Factors, Sex Factors
Show Abstract · Added February 15, 2014
OBJECTIVE - This study investigated whether nonalcoholic fatty liver disease (NAFLD) predicts prevalent coronary heart disease (CHD).
METHODS - Epidemiologic studies have used various definitions for NAFLD. Here, we considered both liver fat burden measured by CT (FL) and the non-specific measure of hepatic inflammation -alanine aminotransferase (ALT). The association of FL and ALT with CHD (self report of coronary bypass, myocardial infarction, or percutaneous transluminal coronary angioplasty) was investigated in 2756 European-American participants of the Family Heart Study.
RESULTS - FL (p = 0.0084) and ALT (≥40 U/L, p = 0.014) were each individually associated with prevalent CHD. However, when accounting for traditional metabolic risk factors in a multivariate model FL had no predictive value for CHD in either men or women; whereas ALT was a significant predictor of CHD in men, and the association strengthened among non-diabetic men. In non-diabetic women, neither FL nor ALT was associated with CHD.
CONCLUSIONS - ALT (≥40 U/L) was a predictor of prevalent CHD in men but not in women, while CT measured FL was not significant in either sex. The failure to account for traditional risk factors, heterogeneity by sex, and varying definitions of NAFLD may account for some of the conflicting evidence in the literature regarding the association between NAFLD and coronary disease.
Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
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20 MeSH Terms
Clopidogrel: a case for indication-specific pharmacogenetics.
Johnson JA, Roden DM, Lesko LJ, Ashley E, Klein TE, Shuldiner AR
(2012) Clin Pharmacol Ther 91: 774-6
MeSH Terms: Angioplasty, Balloon, Coronary, Aryl Hydrocarbon Hydroxylases, Clopidogrel, Cytochrome P-450 CYP2C19, Genotype, Humans, Pharmacogenetics, Platelet Aggregation Inhibitors, Ticlopidine
Show Abstract · Added June 26, 2014
The CYP2C19*2 loss-of-function allele is associated with reduced generation of active metabolites of clopidogrel. However, meta-analyses have supported or discounted the impact of genotype on adverse cardiovascular outcomes during clopidogrel therapy, depending on studies included in the analysis. Here we review these data and conclude that evidence supports a differential effect of genotype on protection from major adverse cardiovascular outcomes following percutaneous coronary intervention (PCI), but not for other clopidogrel indications.
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9 MeSH Terms
ST-segment-elevation myocardial infarction treatment and the seductive lure of observational analyses.
Muñoz D, Granger CB
(2011) Circulation 124: 2477-9
MeSH Terms: Angioplasty, Balloon, Coronary, Emergency Medical Services, Fibrinolytic Agents, Humans, Myocardial Infarction, Transportation of Patients
Added March 7, 2014
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6 MeSH Terms
Effect of intracoronary delivery of autologous bone marrow mononuclear cells 2 to 3 weeks following acute myocardial infarction on left ventricular function: the LateTIME randomized trial.
Traverse JH, Henry TD, Ellis SG, Pepine CJ, Willerson JT, Zhao DX, Forder JR, Byrne BJ, Hatzopoulos AK, Penn MS, Perin EC, Baran KW, Chambers J, Lambert C, Raveendran G, Simon DI, Vaughan DE, Simpson LM, Gee AP, Taylor DA, Cogle CR, Thomas JD, Silva GV, Jorgenson BC, Olson RE, Bowman S, Francescon J, Geither C, Handberg E, Smith DX, Baraniuk S, Piller LB, Loghin C, Aguilar D, Richman S, Zierold C, Bettencourt J, Sayre SL, Vojvodic RW, Skarlatos SI, Gordon DJ, Ebert RF, Kwak M, Moyé LA, Simari RD, Cardiovascular Cell Therapy ResearchNetwork
(2011) JAMA 306: 2110-9
MeSH Terms: Adult, Aged, Angioplasty, Balloon, Coronary, Bone Marrow Transplantation, Double-Blind Method, Female, Humans, Male, Middle Aged, Myocardial Infarction, Stroke Volume, Transplantation, Autologous, Treatment Outcome, Ventricular Dysfunction, Left, Ventricular Function, Left
Show Abstract · Added November 13, 2012
CONTEXT - Clinical trial results suggest that intracoronary delivery of autologous bone marrow mononuclear cells (BMCs) may improve left ventricular (LV) function when administered within the first week following myocardial infarction (MI). However, because a substantial number of patients may not present for early cell delivery, the efficacy of autologous BMC delivery 2 to 3 weeks post-MI warrants investigation.
OBJECTIVE - To determine if intracoronary delivery of autologous BMCs improves global and regional LV function when delivered 2 to 3 weeks following first MI.
DESIGN, SETTING, AND PATIENTS - A randomized, double-blind, placebo-controlled trial (LateTIME) of the National Heart, Lung, and Blood Institute-sponsored Cardiovascular Cell Therapy Research Network of 87 patients with significant LV dysfunction (LV ejection fraction [LVEF] ≤45%) following successful primary percutaneous coronary intervention (PCI) between July 8, 2008, and February 28, 2011.
INTERVENTIONS - Intracoronary infusion of 150 × 10(6) autologous BMCs (total nucleated cells) or placebo (BMC:placebo, 2:1) was performed within 12 hours of bone marrow aspiration after local automated cell processing.
MAIN OUTCOME MEASURES - Changes in global (LVEF) and regional (wall motion) LV function in the infarct and border zone between baseline and 6 months, measured by cardiac magnetic resonance imaging. Secondary end points included changes in LV volumes and infarct size.
RESULTS - A total of 87 patients were randomized (mean [SD] age, 57 [11] years; 83% men). Harvesting, processing, and intracoronary delivery of BMCs in this setting was feasible. Change between baseline and 6 months in the BMC group vs placebo for mean LVEF (48.7% to 49.2% vs 45.3% to 48.8%; between-group mean difference, -3.00; 95% CI, -7.05 to 0.95), wall motion in the infarct zone (6.2 to 6.5 mm vs 4.9 to 5.9 mm; between-group mean difference, -0.70; 95% CI, -2.78 to 1.34), and wall motion in the border zone (16.0 to 16.6 mm vs 16.1 to 19.3 mm; between-group mean difference, -2.60; 95% CI, -6.03 to 0.77) were not statistically significant. No significant change in LV volumes and infarct volumes was observed; both groups decreased by a similar amount at 6 months vs baseline.
CONCLUSION - Among patients with MI and LV dysfunction following reperfusion with PCI, intracoronary infusion of autologous BMCs vs intracoronary placebo infusion, 2 to 3 weeks after PCI, did not improve global or regional function at 6 months.
TRIAL REGISTRATION - clinicaltrials.gov Identifier: NCT00684060.
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15 MeSH Terms
Access survival amongst hemodialysis patients referred for preventive angiography and percutaneous transluminal angioplasty.
Chan KE, Pflederer TA, Steele DJ, Lilly MP, Ikizler TA, Maddux FW, Hakim RM
(2011) Clin J Am Soc Nephrol 6: 2669-80
MeSH Terms: Aged, Angioplasty, Balloon, Arteriovenous Shunt, Surgical, Blood Vessel Prosthesis Implantation, Case-Control Studies, Chi-Square Distribution, Constriction, Pathologic, Female, Graft Occlusion, Vascular, Humans, Kidney Failure, Chronic, Linear Models, Male, Medicare, Middle Aged, Proportional Hazards Models, Radiography, Regional Blood Flow, Renal Dialysis, Risk Assessment, Risk Factors, Time Factors, Treatment Outcome, United States, Vascular Patency
Show Abstract · Added May 20, 2014
BACKGROUND AND OBJECTIVES - Referring hemodialysis patients for elective access angiography and percutaneous transluminal angioplasty (PTA) is commonly done to prevent access failure, yet the effectiveness of this procedure remains unclear. DESIGN, SETTING, PARTICIPANTS, & MEASURES: An observational matched cohort analysis among 40,132 Medicare beneficiaries receiving hemodialysis with a fistula or graft was performed. Cox regression was used to determine whether access intervention was associated with improved 1-year access survival.
RESULTS - Nonsurgical access intervention was found to be frequent at a rate of 20.9 procedures per 100 access years. In the 1-year period after intervention using angiography and PTA, the overall access failure rate was 53.7 per 100 access years in the intervention group and 49.6 in the nonintervention group (HR = 1.02; 95% CI, 0.96 to 1.08). Similar findings were also seen when the analysis was repeated in only fistulas (HR = 1.06; 95% CI, 0.98 to 1.15) and grafts (HR = 0.95; 95% CI, 0.86 to 1.05). In patients with a low intra-access flow rate (HR = 0.86; 95% CI, 0.75 to 0.99) or a new access (HR = 0.79; 95% CI, 0.71 to 0.89), angiography and PTA significantly increased access survival when compared with nonintervention (P for interaction was <0.0001). Angiography-PTA-related upper-extremity hematoma, vessel injury, or embolism-thrombosis occurred in 1.1% of all patients.
CONCLUSIONS - Access characteristics significantly modify the survival benefits of angiography and PTA intervention where the benefits of these interventions are most seen in newer accesses or accesses with insufficient flow.
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25 MeSH Terms
Clinical Pharmacogenetics Implementation Consortium guidelines for cytochrome P450-2C19 (CYP2C19) genotype and clopidogrel therapy.
Scott SA, Sangkuhl K, Gardner EE, Stein CM, Hulot JS, Johnson JA, Roden DM, Klein TE, Shuldiner AR, Clinical Pharmacogenetics Implementation Consortium
(2011) Clin Pharmacol Ther 90: 328-32
MeSH Terms: Acute Coronary Syndrome, Alleles, Angioplasty, Balloon, Coronary, Aryl Hydrocarbon Hydroxylases, Clopidogrel, Cytochrome P-450 CYP2C19, Genotype, Humans, Pharmacogenetics, Platelet Aggregation Inhibitors, Ticlopidine
Added June 26, 2014
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11 MeSH Terms
LateTIME: a phase-II, randomized, double-blinded, placebo-controlled, pilot trial evaluating the safety and effect of administration of bone marrow mononuclear cells 2 to 3 weeks after acute myocardial infarction.
Traverse JH, Henry TD, Vaughan DE, Ellis SG, Pepine CJ, Willerson JT, Zhao DX, Simpson LM, Penn MS, Byrne BJ, Perin EC, Gee AP, Hatzopoulos AK, McKenna DH, Forder JR, Taylor DA, Cogle CR, Baraniuk S, Olson RE, Jorgenson BC, Sayre SL, Vojvodic RW, Gordon DJ, Skarlatos SI, Moyè LA, Simari RD, Cardiovascular Cell Therapy Research Network
(2010) Tex Heart Inst J 37: 412-20
MeSH Terms: Angioplasty, Balloon, Coronary, Bone Marrow Transplantation, Double-Blind Method, Echocardiography, Heart Failure, Humans, Magnetic Resonance Imaging, Myocardial Infarction, Myocardium, Pilot Projects, Placebo Effect, Research Design, Time Factors, Transplantation, Autologous, Treatment Outcome, United States, Ventricular Function, Left, Ventricular Remodeling
Show Abstract · Added November 18, 2010
A realistic goal for cardiac cell therapy may be to attenuate left ventricular remodeling following acute myocardial infarction to prevent the development of congestive heart failure. Initial clinical trials of cell therapy have delivered cells 1 to 7 days after acute myocardial infarction. However, many patients at risk of developing congestive heart failure may not be ready for cell delivery at that time-point because of clinical instability or hospitalization at facilities without access to cell therapy. Experience with cell delivery 2 to 3 weeks after acute myocardial infarction has not to date been explored in a clinical trial. The objective of the LateTIME study is to evaluate by cardiac magnetic resonance the effect on global and regional left ventricular function, between baseline and 6 months, of a single intracoronary infusion of 150 × 106 autologous bone marrow mononuclear cells (compared with placebo) when that infusion is administered 2 to 3 weeks after moderate-to-large acute myocardial infarction. The 5 clinical sites of the Cardiovascular Cell Therapy Research Network (CCTRN) will enroll a total of 87 eligible patients in a 2:1 bone marrow mononuclear cells-to-placebo patient ratio; these 87 will have undergone successful percutaneous coronary intervention of a major coronary artery and have left ventricular ejection fractions ≤0.45 by echocardiography. When the results become available, this study should provide insight into the clinical feasibility and appropriate timing of autologous cell therapy in high-risk patients after acute myocardial infarction and percutaneous coronary intervention.
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18 MeSH Terms