Comparing EVAR & Open Repair for Ruptured AAAs
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The Particulars: Case and single center reports have documented the feasibility of endovascular aneurysm repair (EVAR). Some investigations have reported the effectiveness of EVAR for ruptured abdominal aortic aneurysms (AAAs), but the role and value of such treatment remain controversial.
Data Breakdown: Investigators examined a collected experience with use of EVAR for the treatment of ruptured AAAs from 49 centers using data on patients treated by EVAR or by open repair. The 30-day mortality in the EVAR group was 19.7% compared with a 36.3% rate for those treated with open repair. Supraceliac aortic balloon control was obtained in 19.1% ± 12.0% of EVAR-treated patients. Abdominal compartment syndrome was treated by some form of decompression in 12.2% ± 8.3% of EVAR patients.
Take Home Pearls: EVAR of ruptured AAAs appears to be superior to open repair in patients with favorable anatomy and in centers with access to vascular surgeons. Adequate skills, facilities, and protocols must be available, and optimal strategies, techniques, and adjuncts should be employed.
A Promising Treatment for Chronic DVT [Back to Top]
The Particulars: DVT affects 600,000 patients each year and is accountable for approximately 100,000 deaths. About 30% of patients with DVT will suffer from a recurrent episode of it within 10 years, with the greatest risk occurring in the first 2 years. Therapy for lower extremity DVT has been aimed at preventing more thrombus and the occurrence of pulmonary embolism and recurrent DVT, but few treatment options are available for chronic DVT.
Data Breakdown: Researchers presented a series of 50 patients with chronic, hard, and occlusive DVT who were suffering from post-thrombotic syndrome (PTS). Patients were successfully treated with the EkoSonic ultrasound (EKOS Corp.), a device that utilizes endovascular techniques to restore flow and reduce symptoms related to PTS. The EKOS ultrasound assisted thrombolysis, in addition to standard angioplasty and stenting techniques, and appears to lead to successful venous recanalization and patency with improved venous outflow.
Take Home Pearl: The ability to successfully recanalize chronically occluded venous segments in DVT patients with PTS appears to benefit patients by reducing symptoms and improving quality of life.
Evaluating Safety of Carotid Procedures [Back to Top]
The Particulars: Carotid stenting (CAS) and carotid endarterectomy (CEA) are two procedures that have been used to treat patients with symptomatic carotid stenosis, but little data are available regarding which procedure is safer.
Data Breakdown: A randomized comparison of CAS and CEA in symptomatic patients was conducted in a multicenter, randomized trial. Aspirin plus clopidogrel were provided prior to stenting. The primary endpoint was the 30-day rate of any stroke, myocardial infarction, or death. An intention-to-treat analysis for primary short-term outcome found that 8.5% of the CAS group experienced any endpoint event compared with a 5.1% rate for the CEA group (hazard ratio, 1.73). There were twice as many strokes after CAS than after CEA in the per protocol analysis (7.0% vs 3.3%). This difference in outcome was largely driven by non-disabling stroke.
Take Home Pearl: CEA appears to be safer than CAS in patients with symptomatic carotid stenosis and is the treatment of choice for suitable individuals.
Managing Small AAAs [Back to Top]
The Particulars: The PIVOTAL trial (Positive Impact of Endovascular Options for Treating Aneurysms Early) involved 728 patients with small aortic abdominal aneurysms (AAAs)—ranging from 4 cm to 5 cm in diameter—to receive either early endovascular repair or ultrasound surveillance. The goal of the trial was to determine if small AAAs should be treated with less morbid methods of repair.
Data Breakdown: After a mean follow-up of 20 ± 12 months, there were 15 deaths in each of the randomized patient groups. Aneurysm rupture or aneurysm-related death occurred in two patients in the early endovascular repair group (0.6%) and two patients in the surveillance group (0.6%).
Take Home Pearls: The mortality rate of early endovascular repair for small AAAs appears to be similar to that of ultrasound surveillance. Until longer follow-up data become available, repair of small AAAs should be individualized. Decisions should be based on patient preference, endovascular expertise of surgical teams, and the likelihood that patients will comply with rigorous follow-up imaging.
Detecting Thoracic Aortic Aneurysms [Back to Top]
The Particulars: Thoracic aortic aneurysms (TAAs) are often asymptomatic and associated with high mortality rates. The ability to detect TAAs by a blood test could facilitate early intervention, thus preventing further growth and complications.
Data Breakdown: Researchers tested a new technique to detect TAAs using a blood test to examine gene expression in peripheral blood cells. A model consisting of 41 genes was constructed and applied to patients with and without TAAs. The system achieved an accuracy of 80% in the classification of patients with and without TAAs.
Take Home Pearls: Detection of TAAs using a blood test that examines gene expression in peripheral blood cells appears to accurately classify patients with and without these aneurysms. These genes appear to be potential diagnostic markers that could facilitate the early detection of TAAs.
Frank J. Veith, MD, has indicated to Physician’s Weekly that he owns stock, stock options, or bonds in Vascular Innovations.
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