Inferior vena cava thrombosis

Inferior vena cava thrombosis (IVCT), although rare, has a potential for significant morbidity and mortality. IVCT is often a result of IVC filter thrombosis, but it can also occur de novo. Although anticoagulation remains the standard of care, endovascular techniques to restore IVC patency have become key adjunctive therapies in recent years. This study examines a single-center experience with diagnosis and management of IVCT.

https://www.annalsofvascularsurgery.com/article/S0890-5096(18)30842-2/pdf

Methods

A retrospective Institutional Review Board-approved review of a single-center institutional database was screened to identify IVCT thrombosis using International Classification of Diseases code 453.2 over a 3-year period. Etiology of IVCT was separated into 2 groups: those with IVC thrombosis in the setting of prior IVC filter place and those in whom IVCT occurred de novo. Patient demographics, presenting characteristics, and management of IVCT were examined. Treatment options included expectant management with anticoagulation versus catheter-directed thrombolysis (CDT), mechanical thrombectomy, stenting, or a combination. For those who underwent intervention, technical success, defined as restoration of IVC patency, was assessed.

Results

Forty-one unique patients were identified with radiographically confirmed diagnosis of ICVT (mean age 61, range 25-91; 21 female, 51.2%). Eighteen (43.9%) patients presented with thrombosed IVC filter. Risk factors for venous thromboembolism included tobacco usage, current or prior smoking (n = 17, 41.5%), history of prior deep vein thrombosis (n = 25, 61.0%), malignancy (n = 17, 41.5%), use of hormonal supplements (n = 3, 7.3%), known thrombophilia (n = 4, 9.8%), and obesity (body mass index: mean 29, range 18.8-58.53). Eleven patients (26.8%) presented with pulmonary embolism (PE), and of those 63.6% had IVC filter thrombosis (n = 7). Risk of PE was not significantly different between those patients presenting with a thrombosed IVC filter compared to those with de novo IVCT (38.9% vs. 17.4%, P = 0.12) Management of IVCT included anticoagulation alone (n = 27, 65.9%), CDT (n = 5, 12.2%), mechanical thrombolysis (n = 10, 24.4%), and adjunctive IVC stent (n = 3, 7.3%). Among the 14 (34.1%) patients who had intervention for IVCT, patency was restored in 12 patients (85.7%).

Conclusions

IVCT is a rare event and is associated with known risk factors for venous thromboembolism. PE can occur in roughly 25% of patients presenting with IVCT. Presence of a filter does not appear to confer an advantage in preventing PE when IVCT occurs. Although majority of IVCT is managed with anticoagulation alone, endovascular interventions, including lysis and stenting, can safely restore patency in most properly selected patients.

Carotid body tumors and the outcomes

A Systematic Review and Meta-Analysis of the Presentation and Surgical Management of Patients With Carotid Body Tumours.

Vaux Robertson

, 

Federica Poli

, 

Ben Hobson

, 

Athanasios Saratzis

, 

A. Ross Naylor∗,Correspondence information about the author A. Ross NaylorEmail the author A. Ross Naylor

The Leicester Vascular Institute, Glenfield Hospital, Leicester UK

Objectives

The aim was to determine the mode of presentation and 30 day procedural risks in 4418 patients with 4743 carotid body tumours (CBTs) undergoing surgical excision.

Methods

This is a systematic review and meta-analysis of 104 observational studies.

Results

Overall, 4418 patients with 4743 CBTs were identified. The mean age was 47 years, with the majority being female (65%). The commonest presentation was a neck mass (75%), of which 85% were painless. Dysphagia, cranial nerve injury (CNI), and headache were present in 3%, while virtually no one presented with a transient ischaemic attack (0.26%) or stroke (0.09%). The majority (97%) underwent excision, but only 21% underwent pre-operative embolisation. Overall, 27% were Shamblin I CBTs; 44% were Shamblin II; and 29% were Shamblin III. The mean 30 day mortality was 2.29% (95% CI 1.79–2.93). The mean 30 day stroke rate was 3.53% (95% CI 2.91–4.29), while the mean 30 day CNI rate was 25.4% (95% CI 24.5–31.22). The prevalence of persisting CNI at 30 days was 11.15% (95% CI 8.42–14.64). Twelve series (544 patients) correlated 30 day stroke with Shamblin status. Shamblin I CBTs were associated with a 1.89% stroke rate (95% CI 0.92–3.82), increasing to 2.71% (95% CI 1.43–5.07) for Shamblin II CBTs and 3.99% (95% CI 2.34–6.74) for Shamblin III tumours. Twenty-six series (1075 patients) correlated CNI rates with Shamblin status: 3.76% (95% CI 2.62–5.35) for Shamblin I CBTs, 14.14% (95% CI 11.94–16.68) for Shamblin II, and 17.10% (95% CI 14.82–19.65) for Shamblin III tumours. The prevalence of neck haematoma requiring re-exploration was 5.24% (95% CI 3.45–7.91). The proportion of patients with a neck haematoma requiring re-exploration was not reduced by pre-operative embolisation (5.92%; 95% CI 2.56–13.08) vs. no embolisation (5.82%; 95% CI 2.76–11.88). Pre-operative embolisation did not reduce drainage losses (639 mL vs. 653 mL).

Conclusions

This is the largest meta-analysis of outcomes after CBT excision. Procedural risks associated with tumour excision were considerable, especially with Shamblin III tumours where 4% suffered a peri-operative stroke and 17% suffered a CNI.

A National Goal: Prevent a Million Heart Attacks and Strokes by 2022

With your cooperation and the support of the medical profession, insurance companies, government agencies and communities throughout the country, the agency hopes to prevent a million heart attacks and strokes by the year 2022.As the centers’ experts estimated last year, if 2016 trends remain constant through 2021, an estimated 16.3 million potentially preventable life-threatening or fatal events, or 3.3 million a year, are projected to occur, including 2.2 million emergency department visits, 2.2 million deaths and 11.8 million hospitalizations, at a projected cost of $170 billion. A third of these preventable events are likely to afflict people aged 35 to 64, these experts, Dr. Janet S. Wright, Hilary K. Wall and Matthew D. Ritchey, calculated.He and his colleagues cited 213 million opportunities to improve cardiovascular risk among Americans by addressing behaviors that are currently standing in the way of progress: 71 million people are physically inactive, participating in no leisure-time exercise. 54 million people are still smoking combustible tobacco products. 40 million adults have uncontrolled high blood pressure.39 million with high cholesterol are not using medication to lower it. 9 million people for whom a daily baby aspirin is appropriate are not taking it.
The as-yet unstoppable epidemic of obesity is most likely the leading cause of preventable cardiovascular disease and deaths. Excess weight can result in high blood pressure, high cholesterol levels, Type 2 diabetes and a reluctance to be physically active, all of which contribute to cardiovascular risk.

Doctors and Disclosures

Doctors work hard not only in diagnosing diseases and treating them but also conduct research and help in improving the understanding of the diseases and their origins. This is possible through their association with other scientists, organizations and other medical industries. But this process needs to be transparent and one has to disclose conflict of interest. There can be serious objections if there are undisclosed links between the doctors and medical industries. In the Western countries this is taken seriously if the doctors at the helm of affairs fail to disclose search associations and especially when they are receiving honorariums. This is going to be considered equally seriously in the developing nations also soon. 

Academic journals are the way the world learns about medical breakthroughs, and companies benefit greatly when research about their products is published in them. Prestigious journals require authors to list any potential conflicts of interest. But dozens of doctors have failed to disclose significant relationships with health care and drug companies that pay them for consulting work, sitting on corporate boards and other roles.

https://www.nytimes.com/interactive/2018/12/08/health/journal-conflicts-of-interest.html 

Can we reduce the Cardiovascular risk and cancer risk by supplementing omega-3 fatty acids 1gm per day and Vitamin D3 2000 units/day-?

When we were medical students, omega-3 fatty acids were talked about among the senior citizens as better nutritional supplements to protect them from the illnesses. Now, we are aware that the higher intake of these omega-3 fatty acids has been associated with reduced risks of cardiovascular disease and cancer in several observational studies. Similarly, in the last few years, vitamin D levels were found to be very low in many people in our society. Some association was also noted between the low levels of Vitamin D and CV disease and cancer. This leads us to think that supplementation of these (omega-3 fatty acids and vitamin D) may be more effective in reducing the CV disease and cancers. If that is proved we may be finding new medication (fixed drug combinations)

A study was conducted and the results were published by J E Manson et al (2019). In this study the benefits of using the combination (Vitamin D₃ 2000units/day + Omega -3 fatty acids 1gm per day) were assessed. This is a randomized placebo-controlled trial. This study focuses a primary prevention of CV disease and cancer among men older than 50 years and women older than 55 years. Primary endpoints were major CV events (a composite of myocardial infarction, stroke or death from cardiovascular causes) and invasive cancer of any type. Secondary end points included individual components of the composite cardiovascular end point, the composite end point plus coronary revascularization (expanded composite of cardiovascular events), site-specific cancers, and death from cancer. A total of 25,871 people participated in this trial, out of them 5106 were blacks. All these patients were followed for 5.3 years.

At the end, it is disappointing to note that  supplementation of this combination did not result in lower incidence of major cardiovascular events or cancer than placebo.

https://www.nejm.org/doi/full/10.1056/NEJMoa1811403?query=featured_home