External iliac artery endofibrosis - male cyclists

Exercise-induced external iliac artery endofibrosis (EIAE) is rare and has been described primarily in endurance male cyclists. This is difficult to recognize and investigate in the clinical practice. Clinically, it presents as claudication during maximal exercise with quick resolution after exercise. Most patients have fibrotic changes within the external iliac artery (EIA). This can be easily confused as a case of vasculitis or proximal vessel involvement in TAO.

This series highlights a possible mechanism to explain the claudication associated with EIAE. Vasospasm may be more important than wall thickening for the reduction of blood flow during extreme exercise in affected athletes. Routine duplex ultrasound imaging to measure EIA diameter and flow velocities before and after maximal exercise is needed to confirm this phenomenon. Exercise-induced external iliac artery endofibrosis (EIAE) is an uncommon condition affecting high-end endurance athletes in the absence of classic risk factors for atherosclerosis. These athletes are asymptomatic at rest and become symptomatic, with complaints of thigh claudication and loss of power during maximal effort. This was first reported in 1984 in two competition cyclists. 

Since then, EIAE has been described not only among cyclists but also in long-distance runners, triathletes, and speed skaters. EIAE has been described mostly in men, with women accounting for only 7% of the cases. The diagnosis is made by having the athlete exercise to the point of symptoms and obtaining ankle-brachial indices (ABIs) and duplex scanning after exercise. Multiple mechanisms have been proposed to explain EIAE, including increased cardiac output and adaptive systolic hypertension during strenuous effort, psoas muscle hypertrophy, presence of collaterals from the EIA to the psoas muscle, and repeated direct mechanical trauma on the fixed iliac arterial segment by the psoas muscle during hip flexion, and kinking as a result of excessive iliac arterial length. The final pathway is wall thickening, reduction in arterial lumen caliber, and restriction of blood flow during maximal exertion. We describe our experience with EIAE, our method of diagnosis, and propose a hypothesis for the mechanism involved in claudication associated with EIAE.

Re-admissions after lower extremity revascularization procedures

Less invasive endovascular procedures were not associated with decreased readmission rates compared with open surgery. The overall readmission rate for claudicant patients was 10.7%, which was unexpectedly high. Predictors of readmission included male sex, longer hospital stays, hospital infection, elevated aspartate aminotransferase, and high numbers of medications ordered and dispensed. Further examination exploring reasons for readmission are required to decrease readmission rates in the vascular surgery population.

Dramatic changes in health care delivery and rising interest in cost containment have increased concern regarding readmission and its cost to the health care system. In USA, in the Medicare population, the readmission rate after vascular surgical procedures is almost 24%, substantially higher than the average rate of 15.6% for other surgical procedures.¹ At the same time there has been a dramatic shift in the use of endovascular procedures for the management of lower extremity (LE) occlusive disease.² Endovascular interventions are now performed much more commonly than bypass surgery in the treatment of LE peripheral artery disease (PAD), and the use of percutaneous transluminal angioplasty (PTA) for claudication has dramatically increased.^2 and 3

Despite increased use of more minimally invasive procedures, there is a paucity of information evaluating if less invasive procedures are associated with decreased morbidity and also specifically with decreased use in the form of readmission. This analysis evaluated the readmission rates after LE interventions to specifically compare rates between procedure type and to evaluate factors associated with readmission, because identifying patients with increased risk for readmission after vascular procedures may lead to more effective, higher-quality care. 

We are facing this problem in providing the vascular surgical care for the patients under the ARSR scheme. They are not understanding this fact that the readmission rate is much higher in vascular surgery patients compared to the other surgical patients in the hospitals. I am sure papers of this nature will help us make the administrators of the ARSR scheme in andhra pradesh to recognize these difficulties in providing care to vascular patients.

• http://dx.doi.org/10.1016/j.jvs.2012.12.031, How to Cite or Link Using DOI
• Jl of Vascular surgery Volume 58, Issue 1, July 2013, Pages 90–97.e4

Drug Eluting Stents and Bare metal stents - which one? What about the longterm results? Are we there still to decide which one is better ?

We know that  the Angioplasty alone is helpful in some lesions, angioplasty and stenting is helpful in some patients. But now we have an option to use the drug eluting stents or bare metal stents. The consensus is evolving and there seem to be still serious concerns about the use of the drug eluting stents and long term results. Recently long term results comparing the DES and BMS are examined and published in the JACC interventions.

DEDICATION trial showed that

Complete clinical status was available in 623 patients (99.5%) at 5 years follow-up. The combined MACE rate was insignificantly lower in the DES group (16.9% vs. 23%), mainly driven by a lower need of repeat revascularization (p = 0.07). Whereas the number of deaths from all causes tended to be higher in the DES group (16.3% vs. 12.1%, p = 0.17), cardiac mortality was significantly higher (7.7% vs. 3.2%, p = 0.02). The 5-year stent thrombosis rates were generally low and similar between the DES and the BMS groups. No cardiac deaths occurring within 1 month could be clearly ascribed to stent thrombosis, whereas stent thrombosis was involved in 78% of later-occurring deaths.

Conclusions  The 5-year MACE rate was insignificantly different, but the cardiac mortality was higher after DES versus BMS implantation in patients with STEMI. Stent thrombosis was the main cause of late cardiac deaths.

So, in the coming periods, how one can make an informed decision about using the drug eluting stents in clinical practice if these results are taken seriously. The drug eluting stents are expensive and we may say that BMS ( the less expensive) may be getting preference in the developing nations. But does that means there is a possibility that the absorbable drug eluting stents may stand a good chance as they not be associated with the late effects of drug eluting non absorbable stents. 

Long-Term Outcome After Drug-Eluting Versus Bare-Metal Stent Implantation in Patients With ST-Segment Elevation Myocardial Infarction5 Years Follow-Up From the Randomized DEDICATION Trial (Drug Elution and Distal Protection in Acute Myocardial Infarction)

Lene Holmvang, MD; Henning Kelbæk, MD; Anne Kaltoft, MD; Leif Thuesen, MD; Jens Flensted Lassen, MD; Peter Clemmensen, MD; Lene Kløvgaard, RN; Thomas Engstrøm, MD; Hans E. Bøtker, MD; Kari Saunamäki, MD; Lars R. Krusell, MD; Erik Jørgensen, MD; Hans-Henrik Tilsted, MD; Evald H. Christiansen, MD; Jan Ravkilde, MD; Lars Køber, MD; Klaus Fuglsang Kofoed, MD; Christian J. Terkelsen, MD; Steffen Helqvist, MD

J Am Coll Cardiol Intv. 2013;6(6):548-553. doi:10.1016/j.jcin.2012.12.129

Venous thrombosis in Cancer patients - are there any special features!

The risk of venous thrombosis is higher in cancer patients. But we do not know if there are specific features for the venous thrombosis in cancer patients. We believe that the thrombosis is dependent on the circulating procoagulant factors associated with or released by the cancer tissues. Is the proximal deep vein thrombosis  (iliac vein) more common in cancer patients? 

In a study conducted on - For 3263 patients with cancer, the venous thrombosis incidence was: total 31.4% (n=1026), proximal 14.5% (n=472), bilateral 8.5% (n=278) and multiple venous sites 4.6% (n=149). The rate of clinical suspicion of pulmonary embolism was 49.9% (n=1628). For 1026 patients withthrombosis, proximal thrombi were nearly as frequent as distal thrombi, with 17.6% (n=181) iliocaval thrombi. Gastrocnemial, popliteal and femoral veins were almost equally concerned by thrombosis with respective rates of 28.7% (n=278), 27.1% (n=294) and 25.6% (n=263). Superficial veins were concerned in 23.5% (n=241). Partial or floating clots occurred frequently in 4 localizations: common femoral, external iliac, femoral and popliteal veins. J Mal Vasc. 2013 Jun 18. pii: S0398-0499(13)00131-5. doi: 10.1016/j.jmv.2013.05.001. [Epub ahead of print]

This results of this study point out that - Proximal, multiple, partial, mobile thrombi, and such unusual locations as gastrocnemial or superficial thromboses, are potentially indicators for selecting patients that may benefit from a cancer check-up because their venous thrombosis could be due to cancer.

It may not be cost effective to screen all patients for cancer in our clinical practice - in addition to the above factors related to venous thrombosis, we should remember that recurrence of DVT requiring admissions ( 2 or 3 times) in last 6 months should also prompt us to think and investigate for the cryptogenic malignancies. We found this very useful in our clinical practice not to miss the hidden malignancies.  

30th June 2013

Will there be a role for Atorvastatin in acute deep vein thrombosis?

In the recent past it was observed that aspirin would be beneficial in the prevention of recurrent DVT and cardiovascular events if given as a secondary thromboprophylactic agent after initial anticoagulation. It was opined that this benefit of aspirin in the long run is due to the protection from the actions of cytokines circulating in the blood which seem to be higher in the group of patients. 
Can we consider that the statins such as Atorvastatin, Rosuvastatin are helpful in the acute DVT to protect the patients from effects of cytokines?
In a recent study it was observed that IL-6, IL-8, P selectin were reduced by the 3 day course of 40 mg of atorvastatin. Thromb Res. 2013 Jun 20. pii: S0049-3848(13)00183-7. doi: 10.1016/j.thromres.2013.04.026. [Epub ahead of print]
This  point needs to be studied further to determine role of statins in the acute deep vein thrombosis patients. If it is proved that we may be adding the statin to the heparin in the management of venous thromboembolism.

Can we patent Human Genes?

Superficial venous thrombosis (SVT)

Superficial vein thrombosis (SVT) is regarded a self-limiting disorder, although the authors of recent studies showed that ultrasonographically diagnosed SVT is a precursor for venous thrombosis. We would like to know whether the same holds true for clinically diagnosed SVT and to what extent it is associated with thrombophilia in a population-based case-control study (ie, Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis). 
It was found that a history of clinical SVT was associated with a 6.3-fold (95% confidence interval [CI] 5.0-8.0) increased risk of deep-vein thrombosis and a 3.9-fold (95% CI 3.0-5.1) increased risk of pulmonary embolism. Blood group non-O and factor V Leiden showed a small increase in SVT risk in controls, with odds ratios of 1.3 (95% CI 0.9-2.0) and 1.5 (95% CI 0.7-3.3), respectively. 

In conclusion, clinically diagnosed SVT was a risk factor for venous thrombosis. Given that thrombophilia was only weakly associated with SVT, it is likely that other factors (varicosis, obesity, stasis) also play a role in its etiology.

http://bloodjournal.hematologylibrary.org/content/118/15/4239.full?sid=78553d12-afe0-439a-bc3c-e96aa64324a1

"Hormonal contraception and venous thrombosis."

Background. New studies about the influence of hormonal contraception (HC) on the risk of venous thromboembolism (VTE) have been published. 

Material and methods. Studies assessing the risk of specific types of hormonal contraception were evaluated, compared and set into a clinical perspective. 

Results. The majority of newer studies have demonstrated a three fold increased risk of VTE in current users of middle- and low-dose combined oral contraceptives (COCs) with norethisterone, levonorgestrel or norgestimate compared with non-users. 

The same studies have demonstrated a six-fold increased risk of VTE in users of combined pills with desogestrel, gestodene, drospirenone or cyproteroneacetate, and in users of the contraceptive vaginal ring, compared with non-users. The rate ratio of VTE between COCs with newer progestogens as compared with users of COCs with levonorgestrel was 1.5-2.8 in seven and 1.0 in two studies. Progestogen-only contraception did not confer an increased risk of VTE in any study.

The incidence rate of VTE in non-pregnant non-HC using women 15-49 years is 4 per 10 000 years. 

Recommendations. For starters on hormonal contraception, we recommend middle or low-dose combined pills with norethisterone, levonorgestrel or norgestimate as 1(st) choice preparations. For the many women who are users of COCs with newer progestogens, although the absolute risk of VTE is low, a change to combined pills with norethisterone, levonorgestrel or norgestimate may half their risk of VTE. Finally, we recommend COCs with 20 μg estrogen combined with the older progestogens to be launched in the Scandinavian countries. Women at an increased risk of VTE should consider progestogen-only contraception or non-hormonal contraception.

DVT in Orthopedic and Abdominal surgery patients - is due to different types of pathophysiological changes?

Why should there be a difference in the incidence of DVT in Orthopedic and abdominal surgery patients in post operative period?

Lower preoperative fibrinolytic activation observed in patients undergoing orthopedic surgery compared with abdominal surgery might have pathophysiological consequences. This may explain why Without prophylaxis, patients subjected to major abdominal surgery have a risk of deep vein thrombosis of approximately 30%, while the rate varies between 40% and 60% in orthopedic surgery. Pinjala R K

http://link.springer.com/article/10.1007/BF02912463