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Fuchs C, Scheer CS, Wauschkuhn S, Vollmer M, Meissner K, Hahnenkamp K, Gründling M, Selleng S, Thiele T, Borgstedt R, Kuhn SO, Rehberg S, Scholz SS. Continuation of chronic antiplatelet therapy is not associated with increased need for transfusions: a cohort study in critically ill septic patients. BMC Anesthesiol 2024; 24:146. [PMID: 38627682 PMCID: PMC11022363 DOI: 10.1186/s12871-024-02516-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 03/28/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND The decision to maintain or halt antiplatelet medication in septic patients admitted to intensive care units presents a clinical dilemma. This is due to the necessity to balance the benefits of preventing thromboembolic incidents and leveraging anti-inflammatory properties against the increased risk of bleeding. METHODS This study involves a secondary analysis of data from a prospective cohort study focusing on patients diagnosed with severe sepsis or septic shock. We evaluated the outcomes of 203 patients, examining mortality rates and the requirement for transfusion. The cohort was divided into two groups: those whose antiplatelet therapy was sustained (n = 114) and those in whom it was discontinued (n = 89). To account for potential biases such as indication for antiplatelet therapy, propensity score matching was employed. RESULTS Therapy continuation did not significantly alter transfusion requirements (discontinued vs. continued in matched samples: red blood cell concentrates 51.7% vs. 68.3%, p = 0.09; platelet concentrates 21.7% vs. 18.3%, p = 0.82; fresh frozen plasma concentrates 38.3% vs. 33.3%, p = 0.7). 90-day survival was higher within the continued group (30.0% vs. 70.0%; p < 0.001) and the Log-rank test (7-day survivors; p = 0.001) as well as Cox regression (both matched samples) suggested an association between continuation of antiplatelet therapy < 7 days and survival (HR: 0.24, 95%-CI 0.10 to 0.63, p = 0.004). Sepsis severity expressed by the SOFA score did not differ significantly in matched and unmatched patients (both p > 0.05). CONCLUSIONS The findings suggest that continuing antiplatelet therapy in septic patients admitted to intensive care units could be associated with a significant survival benefit without substantially increasing the need for transfusion. These results highlight the importance of a nuanced approach to managing antiplatelet medication in the context of severe sepsis and septic shock.
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Affiliation(s)
- Christian Fuchs
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Christian S Scheer
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Steffi Wauschkuhn
- Department of Psychosomatic Medicine and Psychotherapy, Ernst von Bergmann Hospital, Potsdam, Germany
| | - Marcus Vollmer
- Institute of Bioinformatics, University Medicine Greifswald, Greifswald, Germany
| | - Konrad Meissner
- Department of Anaesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Klaus Hahnenkamp
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Matthias Gründling
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Sixten Selleng
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Thomas Thiele
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Rainer Borgstedt
- Department of Anaesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and Pain Therapy, Medical School, Protestant Hospital of the Bethel Foundation, Bielefeld University, University Medical Center OWL, Burgsteig 13, 33617, Bielefeld, Germany
| | - Sven-Olaf Kuhn
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Sebastian Rehberg
- Department of Anaesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and Pain Therapy, Medical School, Protestant Hospital of the Bethel Foundation, Bielefeld University, University Medical Center OWL, Burgsteig 13, 33617, Bielefeld, Germany
| | - Sean Selim Scholz
- Department of Anaesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and Pain Therapy, Medical School, Protestant Hospital of the Bethel Foundation, Bielefeld University, University Medical Center OWL, Burgsteig 13, 33617, Bielefeld, Germany.
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Ku JC, Taslimi S, Zuccato J, Pasarikovski CR, Nasr N, Chechik O, Chisci E, Bissacco D, Larrue V, Rabinovich Y, Michelagnoli S, Settembrini PG, Priola SM, Cusimano MD, Yang VXD, Macdonald RL. Peri-Operative Outcomes of Carotid Endarterectomy are Not Improved on Dual Antiplatelet Therapy vs. Aspirin Monotherapy: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 63:546-555. [PMID: 35241374 DOI: 10.1016/j.ejvs.2021.12.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 12/01/2021] [Accepted: 12/28/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE A systematic review and meta-analysis of the peri-operative outcomes of carotid endarterectomy (CEA) on dual antiplatelet therapy (DAPT) vs. aspirin monotherapy was carried out, to determine optimal peri-operative management with these antiplatelet agents. DATA SOURCES The Web of Science, Pubmed, and Embase databases were searched from inception to July 2021. The corresponding authors of excluded articles were contacted to obtain additional data for possible inclusion. REVIEW METHODS The main outcomes included ischaemic complications (stroke, transient ischaemic attack [TIA], and transcranial Doppler [TCD] measured micro-emboli), haemorrhagic complications (haemorrhagic stroke, neck haematoma, and re-operation for bleeding), and composite outcomes. Pooled estimates using odds ratios (ORs) were combined using a random or fixed effects model based on the results of the chi square test and calculation of I2. RESULTS In total, 47 411 patients were included in 11 studies, with 14 345 (30.2%) receiving DAPT and 33 066 (69.7%) receiving aspirin only. There was no significant difference in the rates of peri-operative stroke (OR 0.87, 95% confidence interval [CI] 0.72 - 1.05) and TIA (OR 0.78, 95% CI 0.52 - 1.17) despite a significant reduction in TCD measured micro-emboli (OR 0.19, 95% CI 0.10 - 0.35) in the DAPT compared with the aspirin monotherapy group. Subgroup analysis did not reveal any significant difference in ischaemic stroke risk between patients with asymptomatic and symptomatic carotid artery stenosis. DAPT was associated with an increased risk of neck haematoma (OR 2.79, 95% CI 1.87 - 4.18) and re-operation for bleeding (OR 1.98, 95% CI 1.77 - 2.23) vs. aspirin. Haemorrhagic stroke was an under reported outcome in the literature. CONCLUSION This meta-analysis found that CEA while on DAPT increased the risk of haemorrhagic complications, with similar rates of ischaemic complications, vs. aspirin monotherapy. This suggests that the risks of performing CEA on DAPT outweigh the benefits, even in patients with symptomatic carotid stenosis. The overall quality of studies was low, and improved reporting of CEA outcomes in the literature is necessary.
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Affiliation(s)
- Jerry C Ku
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Kingston General Hospital, Toronto, ON, Canada.
| | - Jeffrey Zuccato
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | | | | | - Ofir Chechik
- Sackler Faculty of Medicine, Tel-Aviv Medical Centre, Tel Aviv University, Israel
| | - Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Daniele Bissacco
- School of Vascular Surgery, Università degli Studi di Milano, Milan, Italy
| | | | - Yefim Rabinovich
- Sackler Faculty of Medicine, Tel-Aviv Medical Centre, Tel Aviv University, Israel
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | | | - Stefano M Priola
- Division of Neurosurgery, Health Sciences North, Sudbury, ON, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada; Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Victor X D Yang
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada; Division of Neurosurgery, Sunnybrook Hospital, Toronto, ON, Canada
| | - R Loch Macdonald
- Department of Neurological Surgery, University of California San Francisco, Fresno Campus, Fresno, CA, USA
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Aboyans V, Bauersachs R, Mazzolai L, Brodmann M, Palomares JFR, Debus S, Collet JP, Drexel H, Espinola-Klein C, Lewis BS, Roffi M, Sibbing D, Sillesen H, Stabile E, Schlager O, De Carlo M. Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy. Eur Heart J 2021; 42:4013-4024. [PMID: 34279602 DOI: 10.1093/eurheartj/ehab390] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/27/2021] [Accepted: 06/03/2021] [Indexed: 12/24/2022] Open
Abstract
The aim of this collaborative document is to provide an update for clinicians on best antithrombotic strategies in patients with aortic and/or peripheral arterial diseases. Antithrombotic therapy is a pillar of optimal medical treatment for these patients at very high cardiovascular risk. While the number of trials on antithrombotic therapies in patients with aortic or peripheral arterial diseases is substantially smaller than for those with coronary artery disease, recent evidence deserves to be incorporated into clinical practice. In the absence of specific indications for chronic oral anticoagulation due to concomitant cardiovascular disease, a single antiplatelet agent is the basis for long-term antithrombotic treatment in patients with aortic or peripheral arterial diseases. Its association with another antiplatelet agent or low-dose anticoagulants will be discussed, based on patient's ischaemic and bleeding risk as well therapeutic paths (e.g. endovascular therapy). This consensus document aims to provide a guidance for antithrombotic therapy according to arterial disease localizations and clinical presentation. However, it cannot substitute multidisciplinary team discussions, which are particularly important in patients with uncertain ischaemic/bleeding balance. Importantly, since this balance evolves over time in an individual patient, a regular reassessment of the antithrombotic therapy is of paramount importance.
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Affiliation(s)
- Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and INSERM 1094 & IRD, University of Limoges, 2, Martin Luther King ave, 87042, Limoges, France
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt Germany, and Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - José F Rodriguez Palomares
- Department of Cardiology, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en RedCV, CIBER CV, Barcelona, Spain
| | - Sebastian Debus
- Department of Vascular Medicine, University Heart Centre Hamburg, University Medical Centre HamburgEppendorf, Hamburg, Germany
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group (www.actioncoeur.org), INSERM UMRS 1166, Institut de Cardiologie, Hôpital PitiéSalpêtrière (APHP), Paris, France
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Landeskrankenhaus Feldkirch, Austria
| | - Christine Espinola-Klein
- Section Angiology, Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, TechnionIsrael Institute of Technology, Haifa, Israel
| | - Marco Roffi
- Division of Cardiology, University Hospitals, Geneva, Switzerland
| | - Dirk Sibbing
- Ludwig Maximilians Universität München and Privatklinik Lauterbacher Mühle am Ostersee, Munich, Germany
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Eugenio Stabile
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples 'Federico II', Naples, Italy
| | - Oliver Schlager
- Division of Angiology, 2nd Department of Medicine, Medical University of Vienna, Austria
| | - Marco De Carlo
- Cardiothoracic and Vascular Department, Azienda OspedalieroUniversitaria Pisana, Pisa, Italy
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Rivolta N, Piffaretti G, Corazzari C, Bush RL, Dorigo W, Tozzi M, Franchin M. To drain or not to drain following carotid endarterectomy: a systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:347-353. [PMID: 33829744 DOI: 10.23736/s0021-9509.21.11767-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION A postoperative neck hematoma can be a life-threatening complication after carotid endarterectomy necessitating urgent surgical decompression to avoid airway compromise. The practice of routine incisional drain placement is variable with few published studies evaluating the "to drain versus not to drain" approach. We conducted a systematic review and meta-analysis of the safety and efficacy of neck drain placement for prevention of neck hematoma requiring re-exploration for decompression. EVIDENCE ACQUISITION This study is a systematic review and meta-analysis performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pooled odds ratios with 95% confidence intervals were calculated for the outcome of surgical re-exploration for neck decompression among patients receiving or not receiving wound drainage. EVIDENCE SYNTHESIS We identified 5 studies for inclusion, comprising 48,297 patients with 19,832 (41.1%) patients receiving a drain after carotid endarterectomy. Patients in the drain group had a significantly higher re-exploration rate after carotid endarterectomy compared to those who did not receive a drainage (OR=1.24, 95% CI: 1.03-1.49; P=0.02) with no heterogeneity (I2=0%). CONCLUSIONS Routine drain placement does not offer complete protection against neck hematoma development and may give the surgeon a false sense of security in wound drainage. Thus, we conclude that drain placement following carotid endarterectomy should be selective, not routine.
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Affiliation(s)
- Nicola Rivolta
- Unit of Vascular Surgery and Cardiac Surgery, Department of Medicine and Surgery, Universitary Teaching Hospital, ASST Settelaghi, University of Insubria School of Medicine, Varese, Italy
| | - Gabriele Piffaretti
- Unit of Vascular Surgery and Cardiac Surgery, Department of Medicine and Surgery, Universitary Teaching Hospital, ASST Settelaghi, University of Insubria School of Medicine, Varese, Italy -
| | - Claudio Corazzari
- Unit of Vascular Surgery and Cardiac Surgery, Department of Medicine and Surgery, Universitary Teaching Hospital, ASST Settelaghi, University of Insubria School of Medicine, Varese, Italy
| | - Ruth L Bush
- University of Houston College of Medicine, Houston, TX, USA
| | - Walter Dorigo
- Unit of Vascular Surgery, Department of Clinical and Experimental Medicine, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy
| | - Matteo Tozzi
- Unit of Vascular Surgery and Cardiac Surgery, Department of Medicine and Surgery, Universitary Teaching Hospital, ASST Settelaghi, University of Insubria School of Medicine, Varese, Italy
| | - Marco Franchin
- Unit of Vascular Surgery and Cardiac Surgery, Department of Medicine and Surgery, Universitary Teaching Hospital, ASST Settelaghi, University of Insubria School of Medicine, Varese, Italy
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Phair J, Futchko J, Trestman EB, Carnevale M, Friedmann P, Shukla H, Garg K, Koleilat I. Protamine sulfate use during tibial bypass does not appear to increase thrombotic events or affect short-term graft patency. Vascular 2020; 28:708-714. [PMID: 32393108 DOI: 10.1177/1708538120924149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES While the use of protamine sulfate as a heparin reversal agent has been extensively reviewed in patients undergoing carotid endarterectomy and coronary artery bypass grafting, there is a lack of literature on protamine's effects on lower extremity bypasses. The purpose of this study was to determine the risk of protamine sulfate dosing after tibial bypass on thrombotic or bleeding events, including early bypass failure. METHODS We performed a retrospective review of our institutional database for patients undergoing primary distal peripheral bypass from January 2009 through December 2015 (contralateral bypass was considered to be a new primary bypass). Primary endpoints include composite thrombotic events (myocardial infarction, stroke, amputation at 30 days and patency less than 30 days) and composite bleeding events (bleeding or transfusion). RESULTS A total of 152 tibial or peroneal bypasses in 136 patients with critical limb ischemia were identified. Of these, 78 (57.4%) patients received protamine sulfate intraoperatively and 58 (42.6%) did not. There were no differences in composite thrombotic or hemorrhagic outcomes. Protamine use had no effect on the rates of perioperative MI (9.0% versus 3.5%, p = 0.20), stroke (1.3% versus 1.7%, p = 0.83), or perioperative mortality (5.1% versus 3.5%, p = 0.64). There was no significant difference in composite post-operative bleeding events (20.7% versus 14.1%, p = 0.31) or composite thrombotic events (17.2% versus 18.0%, p = 0.91). Patients who received protamine undergoing bypass with non-autogenous conduit had significantly higher-recorded median operative blood loss (250 mL versus 150 mL, p = 0.0097) and median procedure lengths (265 min versus 201 min, p = 0.0229). No difference in 30-day amputation-free survival was noted (91.0% versus 91.4%, p = 0.94). Follow-up Kaplan-Meier estimation did not demonstrate a difference in 30-day patency (91.7% versus 88.5%, p = 0.52). CONCLUSIONS Heparin reversal with protamine sulfate after tibial or peroneal bypass grafting is not associated with higher cardiovascular morbidity, bypass thrombosis, amputation, or mortality. Additionally, there was no statistically significant difference in post-operative bleeding or thrombosis complications for patients who did not receive protamine, although the findings are suggestive of a potential difference in a more adequately powered study. Our results suggest that protamine sulfate is safe for intraoperative use without increased risk of thrombotic complications or early tibial bypass graft failure.
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Affiliation(s)
- John Phair
- Division of Vascular Surgery, Mount Sinai Medical Center, New York, NY, USA
| | - John Futchko
- Division of Vascular Surgery, Montefiore Medical Center, New York, NY, USA
| | - Eric B Trestman
- Division of Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Matthew Carnevale
- Division of Vascular Surgery, Montefiore Medical Center, New York, NY, USA
| | - Patricia Friedmann
- Division of Vascular Surgery, Montefiore Medical Center, New York, NY, USA
| | - Harshal Shukla
- Department of Pharmacy, Montefiore Medical Center, New York, NY, USA
| | - Karan Garg
- Division of Vascular Surgery, New York University Langone Health, New York, NY, USA
| | - Issam Koleilat
- Division of Vascular Surgery, Montefiore Medical Center, New York, NY, USA
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Jiang QL, Wang PJ, Liu HX, Huang LL, Kang XK. Dual versus Single Antiplatelet Therapy in Carotid Artery Endarterectomy: Direct Comparison of Complications Related to Antiplatelet Therapy. World Neurosurg 2020; 135:e598-e609. [PMID: 31870823 DOI: 10.1016/j.wneu.2019.12.070] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Dual and single antiplatelet therapies are routinely used in carotid artery endarterectomy (CEA). However, the efficacy and safety of these therapies are controversial. The present study aimed to comprehensively compare the clinical outcomes between dual and single antiplatelet therapies in CEA. METHODS This study retrieved available academic studies evaluating the complications related to antiplatelet therapy between dual and single antiplatelet therapies in CEA from the databases of ScienceDirect, the Cochrane Library, EMBASE, and PubMed. References to previous reviews and related clinical trials were manually checked to retrieve potential literature that was not included in our electronic search results. RESULTS A total of 10 articles (1 randomized controlled trial, 9 non-randomized controlled trials) were included in the study. The overall number of patients in the dual antiplatelet group was 14,280, and the number of patients in the single antiplatelet group was 125,850. The results revealed that the single antiplatelet group had a lower incidence of 30-day death (rate difference [RD] 0.002; 95% confidence interval [CI] 0.000-0.003; P = 0.014), neck hematoma (odds ratio [OR] 2.120; 95% CI 1.431-3.142; P < 0.001), myocardial infarction (RD 0.004; 95% CI 0.001-0.007; P = 0.003), and major bleeding (RD 0.005; 95% CI 0.002-0.008; P < 0.001). Meanwhile, the single antiplatelet group was associated with a shorter operation time (weighted mean difference 4.000; 95% CI= 2.564-5.436; P < 0.001). However, there was no significant difference in the rate of postoperative transient ischemic attack (P = 0.215), stroke (P = 0.130), or length of stay (P = 0.563). CONCLUSIONS Based on current evidence, using single antiplatelet therapy in CEA may reduce operation time and the incidences of 30-day death, neck hematoma, major bleeding, and myocardial infarction without increasing the risks of transient ischemic attack, stroke, or a longer operation time.
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Affiliation(s)
- Qun-Long Jiang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Pei-Jian Wang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Hui-Xin Liu
- Department of Medical Examination, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Li-Li Huang
- Department of Endocrinology, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Xiao-Kui Kang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China.
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Teveris V, Columbo J, Bartline P, Goodney P, Stone D, Suckow B. Selective Use of Anticoagulation or Dual Antiplatelet Therapy for Patients with Extra-anatomic Bypasses. Ann Vasc Surg 2020; 66:272-281.e1. [PMID: 31931126 DOI: 10.1016/j.avsg.2020.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/01/2019] [Accepted: 01/05/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The benefit of long-term anticoagulation or dual antiplatelet therapy (DAPT) for patients with extra-anatomic bypasses to the lower extremity remains poorly defined. Our study analyzed the real-world use of antithrombotic therapy in patients with extra-anatomic bypass grafts to the lower extremity and compared graft and patient outcomes by antithrombotic regimen. METHODS We studied patients who underwent axillofemoral or femoral-femoral bypass within the Vascular Quality Initiative with one-year follow-up data. Primary exposures were anticoagulation and DAPT, at the time of index procedure and one-year follow-up. Primary outcomes were major adverse limb events (MALE) defined as reintervention or above-ankle amputation, and primary patency. Secondary outcomes included perioperative blood transfusion requirements and the need for reoperation specifically for bleeding. We analyzed outcomes using the Kaplan-Meier estimation and examined factors associated with choice of antithrombotic therapy via logistic regression. RESULTS Our cohort included 2,760 patients (axillofemoral bypass, n = 857; femoral-femoral bypass, n = 1,903) across 168 centers from 2009 to 2018. Mean age was 66.5 ± 10.5 years and 59% were male. Patients were infrequently prescribed long-term anticoagulation (19%) or DAPT (22%). One-year primary patency was 86% and was similar by anticoagulation (log-rank P = 0.12) and DAPT status (log-rank P = 0.26). Freedom from MALE was 87% at 1 year and was slightly inferior for patients on anticoagulation (88 vs. 83%, log-rank P = 0.001) but was similar by DAPT (log-rank P = 0.19). Transfusion was more common in patients who were anticoagulated than those who were not (30 vs. 25%, P < 0.01), but there was no increase in reoperation because of bleeding (anticoagulation 0.8 vs. 0.8, P = 0.98). Anticoagulation was more commonly prescribed according to disease severity, such as rest pain (adjusted odds ratio (OR): 1.6 (95% confidence interval (CI): 1.20-2.20), tissue loss (OR: 1.9, CI: 1.28-2.73), or acute limb ischemia (OR: 1.9, CI: 1.35-2.71) or prior bypass graft (OR: 2.6, CI: 2.07-3.35). Patients were more commonly prescribed DAPT according to comorbidities, including hypertension (OR: 1.4, CI: 1.04-1.94) and coronary artery disease (OR: 1.6, CI 1.26-1.95). CONCLUSIONS Antithrombotics are selectively used in patients with extra-anatomic bypass to the lower extremity, the selection of which appears associated with disease severity for anticoagulants and patient comorbidities for DAPT. Primary patency and MALE rates are similar with focused utilization of anticoagulants or DAPT. Blood transfusions are more common among patients on antithrombotics without a difference in the need for reoperation for bleeding.
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Affiliation(s)
- Victoria Teveris
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Jesse Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | - Philip Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Bjoern Suckow
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Lu X, Han L, Golts E, Baradarian S, Kassab GS. Homologous and heterologous assessment of a novel biomaterial for venous patch. J Vasc Surg Venous Lymphat Disord 2019; 8:458-469.e1. [PMID: 31837973 DOI: 10.1016/j.jvsv.2019.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/11/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE This study evaluated swine and bovine pulmonary visceral pleura (PVP) as a vascular patch. Venous patches are frequently used in surgery for repair or reconstruction of veins. Autologous patches are often limited by the number and dimension of donor tissue and can result in donor complications. Bovine pericardium is the most common heterologous patch used by vascular surgeons. Researchers, however, are continually seeking to improve heterologous and synthetic patches for improved outcome. METHODS The PVP was peeled from swine and bovine lungs and cross-linked with glutaraldehyde. After sterilization and rinsing, the PVP patches were implanted in the jugular vein (10 × 35 mm) of pigs and dogs. Patency was evaluated by ultrasound, and animals were euthanized at 2 and 4 months. Neoendothelium and neomedia were evaluated by histologic analysis. RESULTS The jugular vein patched by PVP in pigs and dogs remained patent at 2 and 4 months with no adhesions, inflammation, or aneurysm in the patches. The biomarkers of endothelial cells-factor VIII, platelet/endothelial cell adhesion molecule 1, and endothelial nitric oxide synthase-were detected in the neoendothelial cells. The expression of vascular smooth muscle cell (VSMC) α-actin was robust in the neomedia at 2 and 4 months. Neomedia composed of VSMCs developed to nearly double the thickness of adjacent jugular vein. The circumferential orientation of VSMCs in neomedia further increased in the 4-month group. CONCLUSIONS The cross-linked swine and bovine PVP patch has a nonthrombogenic surface that maintains patency. The PVP patch may overcome the pitfall of compliance mismatch of synthetic patches. The proliferation of vascular cells assembled in the neoendothelium and neomedia in the patches may support long-term patency.
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Affiliation(s)
- Xiao Lu
- Division of Cardiovascular Bioengineering, California Medical Innovations Institute, San Diego, Calif
| | - Ling Han
- Division of Cardiovascular Bioengineering, California Medical Innovations Institute, San Diego, Calif
| | - Eugene Golts
- Division of Cardiovascular Surgery, University of California San Diego, San Diego, Calif
| | - Sam Baradarian
- Division of Cardiovascular Surgery, Scripps Clinic, San Diego, Calif
| | - Ghassan S Kassab
- Division of Cardiovascular Bioengineering, California Medical Innovations Institute, San Diego, Calif.
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Valentine EA, Ochroch EA. 2016 American College of Cardiology/American Heart Association Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Perioperative Implications. J Cardiothorac Vasc Anesth 2017; 31:1543-1553. [PMID: 28826846 DOI: 10.1053/j.jvca.2017.04.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Elizabeth A Valentine
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Illuminati G, Schneider F, Pizzardi G, Masci F, Calio' FG, Ricco JB. Dual Antiplatelet Therapy Does Not Increase the Risk of Bleeding After Carotid Endarterectomy: Results of a Prospective Study. Ann Vasc Surg 2017; 40:39-43. [DOI: 10.1016/j.avsg.2016.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/13/2016] [Accepted: 09/15/2016] [Indexed: 10/20/2022]
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11
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Jones DW, Schermerhorn ML, Brooke BS, Conrad MF, Goodney PP, Wyers MC, Stone DH. Perioperative clopidogrel is associated with increased bleeding and blood transfusion at the time of lower extremity bypass. J Vasc Surg 2017; 65:1719-1728.e1. [PMID: 28222991 DOI: 10.1016/j.jvs.2016.12.102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 12/06/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Controversy persists surrounding the perceived bleeding risk associated with perioperative clopidogrel use in patients undergoing lower extremity bypass (LEB). The purpose of this study was to examine the LEB bleeding risk and clinical sequelae associated with clopidogrel. METHODS All LEBs in the Vascular Quality Initiative (VQI) from 2008 to 2014 were studied. The exposure was perioperative clopidogrel. Primary outcomes were blood transfusion, estimated blood loss ≥500 mL, and reoperation for bleeding. Secondary outcomes included mean operative time, major cardiac events, respiratory complications, infectious complications, and in-hospital mortality. Univariate and multivariable analyses were used to analyze patients on the basis of clopidogrel use and its association with outcomes. Nonparametric test for trend and Mantel-Haenszel methods were used to analyze association of clopidogrel use with blood transfusion and secondary outcomes. RESULTS Among the LEB cohort (N = 9179), 28% (n = 2544) were taking clopidogrel and 72% (n = 6635) were not. Patients taking clopidogrel were more likely to have coronary disease, prior coronary intervention, abnormal findings on stress test, and aspirin use (P < .001 for all). Patients taking clopidogrel were more likely to receive blood transfusion (38% vs 24%; P < .001) and to have estimated blood loss ≥500 mL (21% vs 12%; P < .001). Reoperation for bleeding rates were similar (0.9% vs 1.1%; P = .9). Clopidogrel use was also associated with increased mean operative times (244 minutes vs 232 minutes; P < .001) as well as with cardiac complications (8.8% vs 6.5%; P = .001), respiratory complications (2.5% vs 1.6%; P = .007), and in-hospital mortality (1.3% vs 0.8%; P = .03). Multivariable analysis demonstrated that clopidogrel was associated with increased risk of 1- or 2-unit blood transfusion (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5-2.1; P < .001) and >2-unit blood transfusion (OR, 2.0; 95% CI, 1.7-2.5; P < .001). Major cardiac events (OR, 1.2; 95% CI, 1.0-1.5; P = .05) and respiratory complications (OR, 1.4; 95% CI, 1.0-2.0; P = .03) were also independently associated with clopidogrel use. Weighted Mantel-Haenszel ORs controlling for blood transfusion amount revealed no remaining effect of clopidogrel on major cardiac events (OR, 1.1; P = .4) or respiratory complications (OR, 1.0; P = .8). CONCLUSIONS Perioperative clopidogrel use in LEB surgery is associated with increased blood loss and blood transfusion. Associated clinical sequelae include increased cardiac and pulmonary complications. Accordingly, surgeons should consider discontinuation of perioperative clopidogrel when it is clinically appropriate unless it is strongly indicated at the time of LEB.
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Affiliation(s)
- Douglas W Jones
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Marc L Schermerhorn
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Benjamin S Brooke
- Section of Vascular Surgery, The University of Utah School of Medicine, Salt Lake City, Utah
| | - Mark F Conrad
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Mark C Wyers
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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12
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Barkat M, Hajibandeh S, Hajibandeh S, Torella F, Antoniou G. Systematic Review and Meta-analysis of Dual Versus Single Antiplatelet Therapy in Carotid Interventions. Eur J Vasc Endovasc Surg 2017; 53:53-67. [DOI: 10.1016/j.ejvs.2016.10.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/18/2016] [Indexed: 11/25/2022]
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13
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Strosberg DS, Corbey T, Henry JC, Starr JE. Preoperative antiplatelet use does not increase incidence of bleeding after major operations. Surgery 2016; 160:968-976. [DOI: 10.1016/j.surg.2016.05.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 04/26/2016] [Accepted: 05/19/2016] [Indexed: 11/28/2022]
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Mehaffey JH, LaPar DJ, Tracci MC, Cherry KJ, Kern JA, Kron I, Upchurch GR. Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy. Ann Vasc Surg 2016; 39:195-203. [PMID: 27554691 DOI: 10.1016/j.avsg.2016.05.126] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 04/11/2016] [Accepted: 05/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly even within institutions. In this study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed to establish modifiable factors associated with prolonged hospital stay. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between June 1, 2011 and November 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤1 day and >1 day. RESULTS Complete 30-day variable and cost data were available for 219 patients with an average follow-up of 12 months. Seventy-nine (36%) patients had an LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included preoperative creatinine (P = 0.02) and severe congestive heart failure (P = 0.05) with self-pay status (P = 0.02) and preoperative beta-blocker therapy (P = 0.04) being protective. Shunt placement (P = 0.04), arterial re-exploration, and postoperative cardiac (P = 0.001) or neurological (P = 0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (P = 0.04), drain placement (P = 0.05), prolonged operative time (101 vs. 125 min, P = 0.01), return to the operating room (P = 0.01), and postoperative hypertension (P = 0.02) or hypotension (P = 0.04). Of note, there was no difference in LOS associated with technique (conventional versus eversion), patch use (P = 0.49), protamine administration (P = 0.60), electroencephalogram monitoring (P = 0.45), measurement of stump pressure (P = 0.63), Doppler (P = 0.36), or duplex (P = 0.92). Both hospital charges (P = 0.0001) and costs (P = 0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (P = 0.10). Increased LOS after CEA was associated with an increase in 12-month mortality (P = 0.05). CONCLUSIONS Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Furthermore, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery.
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Affiliation(s)
- James H Mehaffey
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA.
| | - Damien J LaPar
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Margret C Tracci
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Kenneth J Cherry
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - John A Kern
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Irving Kron
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Gilbert R Upchurch
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
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15
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Jones DW, Goodney PP, Conrad MF, Nolan BW, Rzucidlo EM, Powell RJ, Cronenwett JL, Stone DH. Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy. J Vasc Surg 2016; 63:1262-1270.e3. [PMID: 26947237 DOI: 10.1016/j.jvs.2015.12.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 12/18/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Controversy persists regarding the perioperative management of clopidogrel among patients undergoing carotid endarterectomy (CEA). This study examined the effect of preoperative dual antiplatelet therapy (aspirin and clopidogrel) on in-hospital CEA outcomes. METHODS Patients undergoing CEA in the Vascular Quality Initiative were analyzed (2003-2014). Patients on clopidogrel and aspirin (dual therapy) were compared with patients taking aspirin alone preoperatively. Study outcomes included reoperation for bleeding and thrombotic complications defined as transient ischemic attack (TIA), stroke, or myocardial infarction. Secondary outcomes were in-hospital death and composite stroke/death. Univariate and multivariable analyses assessed differences in demographics and operative factors. Propensity score-matched cohorts were derived to control for subgroup heterogeneity. RESULTS Of 28,683 CEAs, 21,624 patients (75%) were on aspirin and 7059 (25%) were on dual therapy. Patients on dual therapy were more likely to have multiple comorbidities, including coronary artery disease (P < .001), congestive heart failure (P < .001), and diabetes (P < .001). Patients on dual therapy were also more likely to have a drain placed (P < .001) and receive protamine during CEA (P < .001). Multivariable analysis showed that dual therapy was independently associated with increased reoperation for bleeding (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.20-2.42; P = .003) but was protective against TIA or stroke (OR, 0.61; 95% CI, 0.43-0.87; P = .007), stroke (OR, 0.63; 95% CI, 0.41-0.97; P = .03), and stroke/death (OR, 0.66; 95% CI, 0.44-0.98; P = .04). Propensity score matching yielded two groups of 4548 patients and showed that patients on dual therapy were more likely to require reoperation for bleeding (1.3% vs 0.7%; P = .004) but less likely to suffer TIA or stroke (0.9% vs 1.6%; P = .002), stroke (0.6% vs 1.0%; P = .04), or stroke/death (0.7% vs 1.2%; P = .03). Within the propensity score-matched groups, patients on dual therapy had increased rates of reoperation for bleeding regardless of carotid symptom status. However, asymptomatic patients on dual therapy demonstrated reduced rates of TIA or stroke (0.6% vs 1.5%; P < .001), stroke (0.4% vs 0.9%; P = .01), and composite stroke/death (0.5% vs 1.0%; P = .02). Among propensity score-matched patients with symptomatic carotid disease, these differences were not statistically significant. CONCLUSIONS Preoperative dual antiplatelet therapy was associated with a 40% risk reduction for neurologic events but also incurred a significant increased risk of reoperation for bleeding after CEA. Given its observed overall neurologic protective effect, continued dual antiplatelet therapy throughout the perioperative period is justified. Initiating dual therapy in all patients undergoing CEA may lead to decreased neurologic complication rates.
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Affiliation(s)
- Douglas W Jones
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Mark F Conrad
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Brian W Nolan
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Eva M Rzucidlo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Richard J Powell
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jack L Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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Zhan HT, Purcell ST, Bush RL. Preoperative optimization of the vascular surgery patient. Vasc Health Risk Manag 2015; 11:379-85. [PMID: 26170688 PMCID: PMC4492637 DOI: 10.2147/vhrm.s83492] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
It is well known that patients who suffer from peripheral (noncardiac) vascular disease often have coexisting atherosclerotic diseases of the heart. This may leave the patients susceptible to major adverse cardiac events, including death, myocardial infarction, unstable angina, and pulmonary edema, during the perioperative time period, in addition to the many other complications they may sustain as they undergo vascular surgery procedures, regardless of whether the procedure is performed as an open or endovascular modality. As these patients are at particularly high risk, up to 16% in published studies, for postoperative cardiac complications, many proposals and algorithms for perioperative optimization have been suggested and studied in the literature. Moreover, in patients with recent coronary stents, the risk of non-cardiac surgery on adverse cardiac events is incremental in the first 6 months following stent implantation. Just as postoperative management of patients is vital to the outcome of a patient, preoperative assessment and optimization may reduce, and possibly completely alleviate, the risks of major postoperative complications, as well as assist in the decision-making process regarding the appropriate surgical and anesthetic management. This review article addresses several tools and therapies that treating physicians may employ to medically optimize a patient before they undergo noncardiac vascular surgery.
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Affiliation(s)
- Henry T Zhan
- Texas A&M Health Science Center College of Medicine, Bryan, TX, USA
| | - Seth T Purcell
- Texas A&M Health Science Center College of Medicine, Bryan, TX, USA ; Baylor Scott and White, Temple, TX, USA
| | - Ruth L Bush
- Texas A&M Health Science Center College of Medicine, Bryan, TX, USA
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17
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Should antiplatelet medications be held before cervical epidural injections? PM R 2015; 6:442-50. [PMID: 24863733 DOI: 10.1016/j.pmrj.2014.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 04/25/2014] [Indexed: 01/08/2023]
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Atturu G, Homer-Vanniasinkam S, Russell DA. Pharmacology in peripheral arterial disease: what the interventional radiologist needs to know. Semin Intervent Radiol 2014; 31:330-7. [PMID: 25435658 DOI: 10.1055/s-0034-1393969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Peripheral arterial disease (PAD) is a progressive disease with significant morbidity and mortality. Risk factor control, using diet and lifestyle modification, exercise, and pharmacological methods, improves symptoms and reduces associated cardiovascular events in these patients. Antiplatelet agents and anticoagulants may be used to reduce the incidence of acute events related to thrombosis. The armamentarium available for symptom relief and disease modification is discussed. Novel treatments such as therapeutic angiogenesis are in their evolutionary phase with promising preclinical data.
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Affiliation(s)
- Gnaneswar Atturu
- Leeds Vascular Institute, Leeds General Infirmary, Leeds, United Kingdom
| | | | - David A Russell
- Leeds Vascular Institute, Leeds General Infirmary, Leeds, United Kingdom
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Singh S, Maldonado Y, Taylor MA. Optimal perioperative medical management of the vascular surgery patient. Anesthesiol Clin 2014; 32:615-637. [PMID: 25113724 DOI: 10.1016/j.anclin.2014.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Perioperative medical management of patients undergoing vascular surgery can be challenging because they represent the surgical population at highest risk. β-Blockers should be continued perioperatively in patients already taking them preoperatively. Statins may be used in the perioperative period in patients who are not on statin therapy preoperatively. Institutional guidelines should be used to guide insulin replacement. Recent research suggests that measurement of troponins may provide some risk stratification in clinically stable patients following vascular surgery. Multimodal pain therapy including nonopioid strategies is necessary to improve the efficacy of pain relief and decrease the risk of side effects and complications.
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Affiliation(s)
- Saket Singh
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA.
| | - Yasdet Maldonado
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA
| | - Mark A Taylor
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA
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Friedell ML, Stark KR, Kujath SW, Carter RR. Current status of lower-extremity revascularization. Curr Probl Surg 2014; 51:254-90. [DOI: 10.1067/j.cpsurg.2014.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 02/25/2014] [Indexed: 11/22/2022]
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Stone DH, Nolan BW, Cronenwett JL. Regarding "Discontinuation of preoperative clopidogrel is unnecessary in peripheral arterial surgery". J Vasc Surg 2014; 59:1475. [PMID: 24767280 DOI: 10.1016/j.jvs.2013.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 12/18/2013] [Accepted: 12/18/2013] [Indexed: 11/18/2022]
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Abstract
Worldwide, cardiovascular events represent the major cause of morbidity and mortality. A key role in the pathogenesis of these events is played by platelets. Interventional procedures, with placement of coronary and vascular stents, often represent the preferred therapeutic strategy. Antiplatelet medications are considered first-line therapy in preventing cardiovascular thrombotic events. A wide array of antiplatelet agents is available, each with different pharmacological properties. When patients on antiplatelet agents present for surgery, the perioperative team must design an optimal strategy to manage antiplatelet medications. Each patient is stratified according to risk of developing a cardiovascular thrombotic event and inherent risk of surgical bleeding. After risk stratification analysis, various therapeutic pathways include continuing or discontinuing all antiplatelet agents or maintaining one antiplatelet agent and discontinuing the other. This review focuses on the pharmacological and pharmacokinetic properties of both older and novel antiplatelet drugs, and reviews current literature and guidelines addressing options for perioperative antiplatelet management.
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Affiliation(s)
- A D Oprea
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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