P-643 Long-term pregnancy outcomes in women with normogonadotropic anovulation and clomiphene failure: follow-up study of the M-ovin trial

Study question

What are the long-term outcomes after gonadotrophins versus clomiphene citrate (CC) with or without intrauterine insemination (IUI) in women with normogonadotropic anovulation and clomiphene failure?

Summary answer

The long-term cumulative chance for delivering at least one live birth is 78% for continuing CC and 84% for switching to gonadotrophins.

What is known already

CC has long been used as first line treatment for ovulation induction in women with normogonadotropic anovulation, but the best treatment for CC failure was unknown. Between 2009 and 2015, 666 women with normogonadotropic anovulation and CC failure were randomised to gonadotrophins or continued treatment with CC for another six cycles, with or without IUI. Switching to gonadotrophins increased the chance of live birth by 11% over continued treatment with CC after six failed ovulatory cycles, at a cost of €15 258 per additional live birth, while the addition of IUI did not increase live birth rates.

Study design, size, duration

We asked women that had been included in the M-ovin trial 6 to 13 years ago for consent to participate in this follow-up study. In the M-ovin trial, 666 women that failed to conceive over 6 ovulatory cycles had been allocated to switching to gonadotrophins versus continuing treatment with CC.

Participants/materials, setting, methods

The participating women were asked to complete a web-based questionnaire. The primary outcome of this study was cumulative live birth. Secondary outcomes included fertility treatments, clinical pregnancies, multiple pregnancies, miscarriage, stillbirth, ectopic pregnancy, neonatal outcomes and pregnancy complications.

Main results and the role of chance

We managed to contact 570 women of the 666 (85.6%) and retrieved follow-up data for 347 women of whom 176 had been originally allocated to gonadotrophins and 171 to CC. After a median follow-up time of 8 years (range 6-13), 148 women had a live birth (84.1%) in the gonadotrophin group and 133 women had a live birth (77.8%) in the CC group (RR 1.40 95% CI 0.90 – 2.17). A second live birth occurred in 80 of 176 women (45.5%) in the gonadotrophin group and in 77 of 171 women in the CC group (45.0%) (RR 1.01, 95% CI 0.83 – 1.22). A third live birth occurred in 7 of 176 women (4.0%) in the gonadotrophin group and in 11 of 171 women (6.4%) in the CC group. The use of fertility treatments in the follow-up period was comparable between both groups. The number of twin pregnancies were also comparable.

Limitations, reasons for caution

In 10.7% of the women, most having a follow-up period above 10 years, contact details had been lost. Therefore, not all eligible women could be approached to participate in this study. It should be realised that preliminary results are presented.

Wider implications of the findings

In women with normogonadotropic anovulation and CC failure, continuous treatment with CC for another six cycles is an effective alternative in view of the long-term live birth rates, without the extra costs of gonadotrophins.

Trial registration number

This follow-up study was registered in the OSF Register, https://osf.io/pf24m. The original M-ovin trial was registered in the Netherlands Trial Register, number NTR1449.

POS1422 USE OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS AND RISK OF MULTIPLE MYELOMA IN PERSONS WITH RHEUMATOID ARTHRITIS

Background

Biologic therapies used in the management of rheumatoid arthritis (RA) target several cytokines that have been implicated in the pathogenesis of multiple myeloma (MM). Yet little is known about the association between use of biologic or targeted synthetic disease modifying anti-rheumatic drugs (b or tsDMARDs) in RA and the incidence of MM.

Objectives

Our objective was to estimate the association between b/tsDMARD use and the risk of MM among persons with RA using Veterans Health Administration (VHA) data. We hypothesized that b-/tsDMARD use is associated with a lower incidence of MM compared with conventional synthetic DMARDs (csDMARDs).

Methods

In this retrospective cohort study, we identified patients >18 years of age diagnosed with RA in any United States VHA facility from 1/1/2002 and 12/31/2018. All patients met the following inclusion criteria: 1) two or more International Classification of Diseases Version 9 or 10 (ICD9 or ICD10) codes for RA at least 7 days apart but no more than 365 days apart 2) a prescription for a csDMARD within 90 days of the first RA diagnosis 3) one inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating a regular user of VHA). Medication data was derived from the outpatient prescription fills, bar coded medication administration (BCMA), and intravenous (IV) data domains. The csDMARDs included in these analyses were: methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine. The bDMARDs included were tumor necrosis factor inhibitors (TNFi) and non-TNFi biologics such as tocilizumab, rituximab, abatacept, and biosimilars; tsDMARD was tofacitinib. Patients with MM before the diagnosis of RA were excluded. Incident MM was determined by 1 or more ICD9/10 code or ICD-oncology codes. Multivariable Cox proportional hazards model were performed to estimate the hazard ratio for developing MM among those during and following the use of a b-/tsDMARD relative to b-/tsDMARD-naïve persons adjusting for age, gender, race, and ethnicity.

Results

27,540 veterans with RA met study eligibility criteria, of whom 8,322 (30%) had taken a b-/tsDMARD. Over the study period there were 77 incident MM over a total of 192,000 person years. There were 55 events in users of csDMARDs, an incidence rate (IR) of 0.40 (95% CI 0.30-0.52) per 1000 person-years and 22 in persons currently or formerly using b-/tsDMARDs (IR 0.41, 0.25-0.61 per 1000 person years). The unadjusted hazard ratio for MM following bDMARD use relative to csDMARD only use was 1.04 (0.63, 1.73), which increased to 1.28 (0.76, 2.16) after adjusting for demographic characteristics (Table 1).

Table 1.

Multivariable Cox proportional hazards model for association between use of disease modifying anti-rheumatic drugs and incident multiple myeloma.

Clinical characteristicHazards ratio (95% CI)csDMARDReferenceb-/tsDMARD use1.28 (0.76-2.16)Age*1.04 (1.02-1.07)Female0.58 (0.20-1.62)RaceReferenceWhite2.11 (1.15-3.86)Black0.70 (0.10-5.08)OtherHispanic Ethnicity0.71 (0.17-2.92)

Abbreviations: b-/tsDMARD- biologic or targeted synthetic disease modifying anti-rheumatic drug; CI: confidence interval

*Hazards ratio reflects risk per every 1-year increase in age

Model adjusted for age, gender, race, and ethnicity

Conclusion

In this nationwide VA study, we did not observe an association between bDMARD use and the incidence of MM. Of note, the median interval from initiation of a bDMARD to the end of follow-up was approximately 5.8 years, which does not allow for an examination of a possible longer term influence.

Disclosure of Interests

None declared

POS1434 USE OF BIOLOGIC OR TARGETED SYNTHETIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS AND THE RISK OF LYMPHOMA IN RHEUMATOID ARTHRITIS

Background

Epidemiologic studies suggest that disease duration and degree of inflammatory activity of rheumatoid arthritis (RA) contribute to lymphoma development (1). Whether the decrease in inflammatory burden seen with use of biologic or targeted synthetic disease modifying anti-rheumatic drugs (bDMARDs or tsDMARDs) translates into a lower risk of lymphoma in RA needs to be studied.

Objectives

The objective of our study was to examine the effect of administration of b/tsDMARDS on the incidence of lymphoma relative to conventional synthetic DMARDs (csDMARDs) in an inception cohort of Veterans with RA.

Methods

We identified patients >18 years of age diagnosed with RA in any US Veterans Affairs (VA) facility from 1/1/2002 and 12/31/2018 using the VA Corporate Data Warehouse (CDW). To be included, each patient was required to meet the following criteria: 2+ RA diagnostic codes at least 7 days apart but no more than 365 days apart; 2) a prescription for a csDMARD within 90 days of the first RA diagnosis; and 3) an inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating they are a regular user of the VA). The csDMARDs included in these analyses were: methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine. The bDMARDs included were tumor necrosis factor inhibitors (TNFi) and non-TNFi biologics such as tocilizumab, rituximab, abatacept, and biosimilars; tsDMARD was tofacitinib. Patients with prevalent lymphoma were excluded. Lymphoma diagnoses were identified using International Classification of Diseases Version 9, 10 and Oncology (ICD9, ICD10, ICDO) codes.

We used marginal structural models as described by Hernan et al (2) and time-varying Cox models to control for confounding by indication while evaluating this association. We adjusted for baseline demographics (age, sex, race, ethnicity, year of cohort entry, rheumatology visits), and time-varying CRP and time-varying Rheumatoid Disease Comorbidity Index (RDCI) (3) to control for confounding.

Results

27,421 Veterans with RA met our eligibility criteria. Most of the Veterans (56%) were in the age range 61-80 years old; 89% male, 76% White, 14% African American. 8,225 (30%) patients were treated with a b-/tsDMARD. The crude incidence rates were 1.71 (95% CI 1.5-1.94) per 1000 person-years for those only on csDMARDs and 1.78 (95% CI 1.44-2.18) for patients during or following use of a b/tsDMARDs. After adjustment with both time-fixed and time-varying covariates using marginal structural models, the incidence of lymphoma was not different between patients who did and did not use a b/tsDMARD (hazard ratio=1.06, 95% CI= 0.82-1.37) (Table 1).

Table 1.

Estimates of Effect of bDMARD or tsDMARD use on Lymphoma relative to use of csDMARDs

Marginal Structural Models; adjusted for:@Demographics1.04(0.80, 1.34)#Demographics + CRP1.06(0.82, 1.37)

* per 1000 person-years

@Demographics = age, gender, race, ethnicity, rheumatology visits, and year of cohort entry

#Adjusts for CRP, baseline rheumatology visits (yes/no) and RDCI.

CRP = C-Reactive Protein, RDCI = Rhematic Disease Comorbidity Index, CI = Confidence Interval, b/tsDMARD = biologic or targeted synthetic DMARD, csDMARD = conventional synthetic DMARD

Conclusion

In this large study using the nationwide VA data, we did not observe an association between the use of b/ts DMARDs and an increased risk of lymphoma.

References

[1]Baecklund E, Iliadou A, Askling J, Ekbom A, Backlin C, Granath F, et al. Association of chronic inflammation, not its treatment, with increased lymphoma risk in rheumatoid arthritis. Arthritis Rheum. 2006;54(3):692-701.

[2]Robins JM, Hernan MA, Brumback B. Marginal structural models and causal inference in epidemiology. Epidemiology. 2000;11(5):550-60.

[3]England BR, Sayles H, Mikuls TR, Johnson DS, Michaud K. Validation of the rheumatic disease comorbidity index. Arthritis care & research. 2015;67(6):865-72.

Disclosure of Interests

None declared

Toxic-metabolic encephalopathy in adults: Critical discussion and pragmatical diagnostic approach

Toxic-metabolic encephalopathy (TME) results from an acute cerebral dysfunction due to different metabolic disturbances including medications or illicit-drugs. It can lead to altered consciousness, going from delirium to coma, which may require intensive care and invasive mechanical ventilation. Even if it is a life-threatening condition, TME might have an excellent prognosis if its etiology is rapidly identified and treated adequately. This review summarizes the main etiologies, their differential diagnosis, and diagnostic strategy and management of TME with a critical discussion on the definition of TME.

POS0287 USE OF BIOLOGIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS IN RELATION TO THE RISK OF LYMPHOMA: A COHORT STUDY OF US VETERANS WITH RHEUMATOID ARTHRITIS

Background:

Epidemiologic studies suggest that disease duration and degree of inflammatory activity of rheumatoid arthritis (RA) contribute to lymphoma development. However, the association of the use of biologic disease modifying anti-rheumatic drugs (bDMARDs) in patients with RA on lymphoma risk needs further evaluation.

Objectives:

Examine the effect of administration of bDMARDS on the incidence of lymphoma in an inception cohort of RA.

Methods:

We identified patients diagnosed with RA in any US Veterans Affairs (VA) facility from 1/1/2002 and 12/31/2018 using the Veteran’s Health Administration (VHA) databases. To be included, each patient was required to meet the following criteria: 1) 2+ RA diagnostic codes at least 7 days apart but no more than 365 days apart 2) a prescription for a conventional synthetic DMARD (csDMARD) within 90 days of the first RA diagnosis 3) One inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating they are a regular user of the VHA). We excluded patients for any of the following if they preceded the first RA diagnosis: 1) a prior single RA diagnostic code 2) a prescription for any DMARD medication 3) a concomitant diagnosis of another inflammatory arthritis (e.g. psoriatic arthropathy) 4) a diagnosis of lymphoma. Index date for the study is the date of the first qualifying RA diagnosis. Lymphoma diagnoses were identified through VHA records using the International Classification of Diseases-Oncology codes.

Results:

We identified 27,536 veterans with RA in the study period meeting the inclusion and exclusion criteria. Of these, 53% (n=14,705) were in the age range 60 to 80 years. The cohort was 89% male, 75.5% White, 13.7% African American. Over the study period, 1.2% (n=332) of the study population developed a lymphoma.

Conclusion:

Using the nationwide VHA we have identified a large inception cohort of patients with RA of whom 1.2% developed lymphoma over study follow-up. This data will be used in future analyses to produce estimates of the effect of biologic medications on lymphoma risk, adjusting for confounding by indication and other variables.

Table 1.

Baseline characteristics of the cohort based on bDMARD exposure status

CharacteristicbDMARD-naive (n= 19,095)bDMARD-exposed (n=8,441)Overall Lymphomas Age (years)171161 18-4046 40-606378 60-8010074 >8043 Males17,206 (90%)7,270 (86%)Race White14,150 (74%)6,627 (76%) Black2,674 (14%)1,090 (13%) Asian96 (0.5%)46 (0.5%) Native American or Pacific Islander371 (2%)187 (2.2%) Missing1,804 (9%)491 (6%)

Acknowledgements:

The work in this abstract is supported by Investigator Award from the Rheumatology Research Foundation to Dr Singh.

Disclosure of Interests:

None declared

Do European patients with peripeheral arterial disease receive optimal lipid lowering therapy and achieve LDL-C goals? Results from the DA VINCI study

Background

2016 and 2019 EAS/ESC dyslipidemia guidelines recommend lipid lowering therapy (LLT) to reduce LDL-C in patients with peripheral arterial disease (PAD) with or without established cardiovascular (CV) disease, and recommend target LDL-C goals based on individual CV risk. Data regarding the implementation of these guidelines in clinical practice across Europe is currently lacking.

Purpose

Describe LLT and achievement of the target LDL-C goals recommended in EAS/ESC dyslipidemia guidelines in patients with PAD.

Methods

The cross-sectional Da Vinci study enrolled consenting adults who had received LLT in the 12 months prior to the study visit and had at least one LDL-C measurement in the 14 months prior to the study visit, seen in a primary or secondary care setting across 18 European countries. Patients with coronary, peripheral and cerebral disease were enrolled at a ratio of 1:2:2. FH patients with prior CV events were excluded. Data were collected from medical records at a single visit between Jun '17–Nov '18, including LLT and most recent LDL-C. Primary outcome was LDL-C goal attainment ≥28 days after starting most recent LLT (treatment-stabilised LLT).

Results

Of 5888 patients enrolled, 2794 met our definition of atherosclerotic cardiovascular disease (ASCVD). Of these ASCVD patients, 1036 (37%) had PAD. 31% (323/1036) of PAD patients were female and mean (SD) age was 69 (9.4) years. Concomitant CV risk factors included diabetes mellitus (473/1036 patients [46%]), hypertension (809/1036 [78%]) and smoking (794/1036 [77%]). 26% (271/1036) of patients with PAD also had coronary vascular disease and 12% (122/1036) also had cerebrovascular disease. At the visit date, approximately half (497/1036 [48%]) of all PAD patients were receiving moderate intensity statins and 41% (421/1036) were receiving high intensity statins. 818 (73%) of the PAD patients had a treatment-stabilised LDL-C measurement (median, 2.20 mmol/L), of whom 40% (326/818) achieved the 2016 EAS/ESC LDL-C goal of 1.8 mmol/L and only 19% (159/818) achieved the 2019 goal of 1.4mmol/L.

Conclusions

European patients with PAD are not treated as per EAS/ESC recommendations, with a large proportion receiving suboptimal LLT and fewer than half achieving target LDL-C levels.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Amgen

Passage of uranium through human cerebral microvascular endothelial cells: influence of time exposure in mono- and co-culture in vitro models

PURPOSE

Depleted uranium (DU) has several civilian and military applications. The effects of this emerging environmental pollutant on human health raise some concerns. Previous experimental studies have shown that uranium (U) exposure can disturb the central nervous system. A small quantity of U reaches the brain via the blood, but the effects on the blood-brain barrier (BBB) remain unclear.

MATERIALS AND METHODS

In the present work, two cell culture models were exposed to DU for different times to study its cytotoxicity, paracellular permeability and extracellular concentration of U. The well-known immortalized human cerebral microvascular endothelial cells, hCMEC/D3, were cultured on the filter in the first model. In the second model, human primary cells of pericytes were cultured under the filter to understand the influence of cell environment after U exposure.

RESULTS

The results show that U is not cytotoxic to hCMEC/D3 cells or pericytes until 500 µM (1.6 Bq.L^-1). In addition, acute or chronic low-dose exposure of U did not disturb permeability and was conserved in both cell culture models. However, U is able to reach the brain compartment. During the first hours of exposure, the passage of U to the abluminal compartment was significantly reduced in the presence of pericytes. Electronic microscopy studies evidenced the formation of needlelike structures, like urchin-shaped precipitates, from 1 h of exposure. Analytical microscopy confirmed the U composition of these precipitates. Interestingly, precipitated U was detected only in endothelial cells and not in pericytes. U was localized in multilamellar or multivesicular bodies along the endo-lysosomal pathway, suggesting the involvement of these traffic vesicles in U sequestration and/or elimination.

CONCLUSIONS

We show for the first time the in vitro passage of U across a human cerebral microvascular endothelial cells, and the intracellular localization of U precipitates without any cytotoxicity or modification of paracellular permeability. The difference between the results obtained with monolayers and co-culture models with pericytes illustrates the need to use complex in vitro models in order to mimic the neurovascular unit. Further in vivo studies should be performed to better understand the passage of U across the blood-brain barrier potentially involved in behavioral consequences.

Atypical Deep Cerebral Vein Thrombosis with Hemorrhagic Venous Infarction in a Patient Positive for COVID-19

There is growing evidence that Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) has a neurotropic and neuroinvasive potential. In particular, neurologic complications associated with the infection by SARS-CoV-2 include strokes that may result from a dysregulated inflammatory response to the infection. We report an atypical deep cerebral vein thrombosis complicated with hemorrhagic venous infarction in a patient positive for SARS-CoV-2 with no risk factors for thrombosis.

[Metabolic encephalopathies]

Metabolic encephalopathies (ME) are a common cause of admission to emergency rooms, to hospitalization wards or to intensive care units. They could account for 10 to 20% of causes of comatose states in ICU and could be associated to a poor outcome especially in older patients. Nevertheless, they are often reversible and are associated with a favorable outcome when diagnosed and rapidly treated. They correspond to an altered brain functioning secondary to the deficiency of a substance that is mandatory for the normal brain functioning or to the accumulation of a substance that can be either endogenous or exogenous. It preferably occurs in co-morbid patients, complicating its diagnosis and its management. Altered brain functioning, going from mild neuropsychological impairment to coma, movement disorders especially myoclonus and the absence of any obvious differential diagnosis are highly suggestive of the diagnosis. Whereas some biological samplings and brain MRI are essential to rule out differential diagnosis, some others, such as electroencephalogram, may be able to propose important clues in favor of the diagnosis. Once simple symptomatic measures are introduced, the treatment consists mainly in the correction of the cause. Specific treatment options are only seldom available for ME; this is the case for hepatic encephalopathy and some drug-induced encephalopathies. We will successively describe in this review the main pathophysiological mechanisms, the main causes, favoring circumstances of ME, the differential diagnosis to rule out and the etiological work-up for the diagnosis. Finally, a diagnostic and therapeutic strategy for the care of patients with ME will be proposed.

An Assessment of the Primary Payer Variable among Breast and Colorectal Cancer Cases in the Massachusetts Cancer Registry, 2005-2009

The Massachusetts Cancer Registry (MCR) reviewed the medical charts of 5,348 randomly selected breast and colorectal cancer cases diagnosed from 2005 to 2009. The purpose of this study was to assess the reliability of primary payer at diagnosis in the MCR database and to examine primary payer and the first course of treatment of individual cancer patients. For the first period (2005-2006), private insurance (72.6% agreement) and Medicare (84.3% agreement) indicated strong agreement with kappa values of 0.62 and 0.72, respectively. Agreement for the later period was again stronger in the private insurance and Medicare categories (kappa= 0.63 and 0.74, respectively).

Factors Associated With Nutritional Risk Among Homebound Older Adults With Depressive Symptoms

OBJECTIVES

This study used the Evans model of public health determinants to identify factors associated with nutritional risk in older adults.

DESIGN

The Evans model domains (physical and mental well-being, social/environmental statuses, individual choice, and economic security) were measured in a sample of homebound older adults. Regularized logistic regression analysis with LASSO penalty function was used to determine the strongest domain of the Evans model. Using traditional logistic regression, individual variables across all domains were compared to identify the significant predictors.

SETTING

Older adults receiving home meal services were referred to the study by community program staff.

PARTICIPANTS

Participants included 164 homebound older adults (age > 60) who endorsed at least one gateway symptom of depression.

MEASUREMENTS

Measurements: Nutritional risk was determined using the Mini Nutritional Assessment. Domains of the Evans model were measured using the MAI Medical Condition Checklist, items from the IADL scale, the Structured Clinical Interview for DSM-IV Axis I Disorders, the Duke Social Support Index, living arrangements, marital status, the Alcohol Use Disorders Identification Test, items from the SCID Screening Module, and a self-report of perceived financial security.

RESULTS

Poor mental well-being, defined by a diagnosis of major depressive disorder, was identified as the strongest Evans model domain in the prediction of nutritional risk. When each variable was independently evaluated across domains, instrumental support (Wald’s Z=-2.24, p=0.03) and a history of drug use (Wald’s Z=-2.40, p=0.02) were significant predictors.

CONCLUSIONS

The Evans model is a useful conceptual framework for understanding nutritional health, with the mental domain found to be the strongest domain predictor of nutritional risk. Among individual variables across domains, having someone to help with shopping and food preparation and a history of drug use were associated with lower nutritional risk. These analyses highlight potential targets of intervention for nutritional risk among older adults.

[Two forms of familial hypercholesterolemia: differences in cardiovascular risk factors, cardiac and extracardiac atherosclerosis]

BACKGROUND AND AIM

The monogenetic hypercholesterolemias (HC) are associated with a very high risk of premature coronary heart disease (CHD). We sought to assess the influence of the genetic defect and the cardiovascular risk factors on the manifestation of atherosclerotic complications in two forms of genetic HC.

PATIENTS AND METHODS

Data of patients with genetically defined HC (54 LDL-receptor defective familial hypercholesterolemia (FH) and 54 familial defective apolipoprotein B (FDB)) were analysed retrospectively for cardiac and extracardiac atherosclerosis.

RESULTS

Total and LDL-cholesterol were significantly higher in FH men than in FDB men, but not so in women. 41.8% of FH patients had CHD (mean age 41 years), 5.6% of FDB (mean age 52 years). Stenoses (>50% narrowing) of the internal carotid artery were verified in 15% of FH and 4% of FDB patients. Peripheral arterial disease was found in 3 FH and 2 FDB patients. Hypertension and active smoking were allotted almost equally, body weight was normal in most of the patients (BMI ≤ 25 kg/m(2)). Conlusion: Patients with genetic HC suffer from early manifestation of cardiac disease. Patients with FH seem to be affected more often than patients with FDB. Early diagnosis and early and lifelong treatment are essential and, according to the literature, lead to a delay of disease manifestation.

[Endovascular treatment of thoracic aneurisms: indications, techniques and results]

CLINICAL ISSUE OF THORACIC ANEURYSMS: Aneurysms are among the most common diseases affecting the thoracic aorta, with a continuous increase in incidence over the recent decades. The main cause of thoracic aneurysms is atherosclerosis, which, due to the frequent lack of major symptoms and the potentially lethal complications such as ruptured aortic aneurysm, remains a challenge in clinical practice.

STANDARD RADIOLOGICAL METHODS

CT angiography remains the imaging method of choice for acute aortic aneurysms, with MR angiography being increasingly used for follow-up imaging. THRESHOLD FOR TREATMENT: In the ascending aorta a diameter larger than 5-5.5 cm (descending aorta 6.5 cm) is regarded as the threshold for treatment. THORACIC ENDOVASCULAR AORTIC REPAIR: The continuous evolution of aortic stent grafting (i.e., thoracic endovascular aortic repair [TEVAR]) since Parodi, Palmaz and Dake has led to a steep rise in stent grafting procedures in recent years.

PRACTICAL RECOMMENDATIONS

Particularly in elderly patients with multiple comorbidities, TEVAR is a valuable, less invasive option compared to open surgical repair.

Monitoring of gadolinium-BOPTA uptake into the vessel wall during magnetic resonance (MR)-guided angioplasty of the peripheral arteries with a paclitaxel/gadolinium-BOPTA-coated balloon: an experimental study at 3 Tesla

PURPOSE

The success of paclitaxel distribution within the vessel wall during paclitaxel-coated balloon angioplasty to prevent restenosis cannot be monitored under X-ray guidance. The aim of this pilot study was to demonstrate the feasibility of monitoring Gadolinium-BOPTA delivery within the vessel wall during magnetic resonance (MR)-guided paclitaxel/Gadolinium-BOPTA-coated balloon angioplasty of the peripheral arteries.

MATERIALS AND METHODS

6 pigs (47 ± 2 kg) were investigated. All experiments were performed using a 3 Tesla MR scanner. MR-guided bilateral angioplasty of the iliac arteries was performed using a paclitaxel/MR contrast agent-coated balloon catheter. The feasibility of monitoring the delivery of Gadolinium-BOPTA to the vessel wall was assessed in 4 animals. In two additional animals, bilateral stenosis was surgically induced in the iliac arteries. Delivery of paclitaxel to the vessel wall was monitored using a 3 D T1-weighted gradient echo (GE) sequence for delineation of the vessel wall. Normalized signal intensity (SI) of the vessel wall was measured before and repeatedly after the intervention for 45 min. in all animals.

RESULTS

Paclitaxel/gadolinium-BOPTA-coated balloon angioplasty was successfully accomplished in all iliac arteries (n = 12). In animals with stenosis MR-angiography demonstrated successful dilatation (n = 4). The normalized SI of the vessel wall on T1-weighted GE images significantly increased after the intervention in all animals with and without stenosis for more than 45 min. (p < 0.001).

CONCLUSION

Monitoring of Gadolinium-BOPTA into the vessel wall during MR-guided coated balloon angioplasty is feasible. This is a first step towards providing a tool for the online control of homogenous drug delivery after paclitaxel-coated balloon angioplasty.

KEY POINTS

• Monitoring of gadolinium-BOPTA uptake into the vessel wall during MR-guided coated balloon angioplasty is feasible.• Endovascular MR-guided interventions on a 3 Tesla MR scanner are feasible.• This is a first step towards providing a tool for online control of homogenous drug delivery after paclitaxel-coated balloon angioplasty.

[Update carotid artery stenosis]

Stenosis of the extracranial carotid artery is a treatable cause of ischemic stroke and can reliably be detected and graded by vascular ultrasound. The differentiation between symptomatic and asymptomatic stenosis, the perioperative risk and the estimated life expectancy of the patient guide the therapy. Therapy is based on an optimal treatment of cardiovascular risk factors and antiplatelet drugs. Revascularization using surgical carotid endarterectomy is efficient for the prevention of stroke in patients with a high grade symptomatic stenosis. Endovascular therapy using stent-protected angioplasty of the carotid artery is an alternative in patients with a higher surgical risk with low complication rates when performed in experienced centres. Patients with asymptomatic carotid artery stenosis are primarily treated conservatively and revascularization is indicated in patients with a low surgical and global cardiovascular risk.

Combined immunosuppressive therapy including a TNF-alpha blocker induces remission in a difficult to treat patient with Takayasu arteriitis and coronary involvement

A 40 year old woman presented with symptoms of a systemic inflammatory disease and obstruction of the left subclavian artery. Takayasu arteriitis (TA) was clinically diagnosed and confirmed by MR angiography and FDG-PET scan showing inflammation of the aortic arch and the left subclavian artery. Immunosuppression with glucocorticoids and methotrexate resulted in immediate clinical improvement and normalization of systemic markers of inflammation. Despite that the patient developed chest pain on exertion suggesting coronary involvement, which was confirmed by dobutamine stress echocardiography. After adding the TNF-alpha blocker infliximab coronary symptoms gradually improved and a clinically stable situation could be achieved for more than 6 months. Coronary angiography and aortography showed an occluded main stem of the left coronary artery, an occluded left subclavian artery, and stenoses of the brachiocephalic trunk and the left common carotid artery. Revascularization of the coronary artery and the aortic arch and its branches was performed. The patient returned to work two months after the operation. Immunosuppressive therapy with infliximab and methotrexate is continued, glucocorticoids were stopped after one year of treatment. This case shows that vascular progress in TA patients may occur even when systemic inflammation is controlled, therefore patients have to be carefully observed for new vascular manifestations. TNF-alpha blockers may be an additional treatment option in otherwise difficult to treat TA patients allowing to perform revascularization after a stable disease state has been achieved.

Integrated-optics-based swept-source optical coherence tomography

We designed, fabricated, and characterized an integrated-optics-based swept-source optical coherence tomography (SS-OCT) system in TriPleX technology. An external 1300 nm swept source is coupled to the chip, which contains waveguide structures for interferometric depth ranging and balanced detection. The complete OCT chip has a footprint of 0.4 cm × 1.8 cm. Light from the chip is focused onto the sample using an aspheric lens; the lateral resolution is 21±1 μm. OCT measurements, performed with a moveable mirror, demonstrate a sensitivity of -80 dB and imaging up to the maximum depth of 5.09 mm. Corrected for dispersion, the measured OCT axial resolution of 12.7±0.5 μm is in good agreement with the bandwidth limited resolution. Finally, we demonstrate cross-sectional OCT imaging of a multilayered tissue phantom over the whole depth range with the integrated-optics-based SS-OCT system.

[Antithrombotic therapy after peripheral vascular treatment: what is evidence-based?]

Peripheral arterial occlusive disease is one manifestation of the systemic disease atherosclerosis. The initial therapy for every arteriosclerotic disease is aimed at reducing cardiovascular risk factors by lifestyle modification and medication. Patients who require surgical revascularisation need long-term antiplatelet therapy or anticoagulation. This therapy has to be differentiated according to the vascular territory involved and the method used for revascularisation. After local thrombendarterectomy, alloplastic bypass graft surgery of the aortic, aorto-iliac, aorto-femoral or femoro-popliteal region above the knee, long-term ASA 100 mg/d or clopidogrel 75 mg/d should be initiated. After alloplastic bypass grafting below the knee the combination of ASA 100 mg/d and clopidogrel 75 mg/d should be used. In contrast, after venous grafts the patency rate is improved by anticoagulation with vitamin K antagonists (INR 2-3), if there is a low risk of bleeding. If there is a contraindication to vitamin K antagonists, ASA 100 mg/d should be used. After revascularisation, a structured surveillance programme should be implemented aiming at controlling cardiovascular risk factors and monitoring the vascular state, as well as the anticoagulation and the antiplatelet therapy.

Efficacy and safety of rivaroxaban or fondaparinux thromboprophylaxis in major orthopedic surgery: findings from the ORTHO-TEP registry

BACKGROUND

Thromboprophylaxis with rivaroxaban (R) is superior to enoxaparin in patients undergoing major orthopedic surgery (MOS). However, rivaroxaban has never been directly compared with fondaparinux (F), which also shows superior efficacy over enoxaparin. The clinical impact of switching from fondaparinux to rivaroxaban thromboprophylaxis is unclear.

OBJECTIVES

To evaluate the efficacy and safety of rivaroxaban or fondaparinux thromboprophylaxis in unselected patients undergoing MOS.

PATIENTS/METHODS

This is a monocentric, retrospective cohort study in 5061 consecutive patients undergoing MOS at our centre, comparing rates of symptomatic VTE, bleeding and surgical complications, length of hospital stay and risk factors for VTE.

RESULTS

Rates of symptomatic VTE were 5.6% (F) and 2.1% (R; P < 0.001), with rates for distal DVT being 3.9 vs. 1.1% (P < 0.001). Rates of major VTE were numerically higher with fondaparinux (1.8 vs. 1.1%), but not statistically significant. Rates of severe bleeding (bleeding leading to surgical revision or death, occurring in a critical site, or transfusion of at least two units of packed red blood cells) were statistically lower with rivaroxaban compared with fondaparinux (2.9 vs. 4.9%; P = 0.010). The mean length of hospital stay was significantly shorter in the rivaroxaban group (8.3 days, 95% CI 8.1-8.5 vs. 9.3 days, 9.1-9.5; P < 0.001).

CONCLUSION

Based on an indirect comparison of two consecutive cohorts, our data suggest that thromboprophylaxis with rivaroxaban is associated with less VTE and bleeding events than fondaparinux in unselected patients undergoing MOS. Prospective comparisons are warranted to confirm our findings.