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Collaboration is Key When Treating PAD

Collaboration is Key When Treating PAD

In the United States, only about 25% of the general population is aware of peripheral arterial disease (PAD), a strikingly low percentage considering that the disease impacts an estimated 8 to 12 million Americans. Studies show that many cases of PAD go undiagnosed each year, reflecting that management of the disease remains suboptimal. Increasing physician awareness and adherence to guideline recommendations could potentially reduce the high rate of mortality and morbidity seen with PAD. Primary care physicians (PCPs) play an extremely critical role in the early diagnosis of PAD, often serving as the first point of contact for patients suffering from its symptoms. Unfortunately, time is at a premium for these general practitioners; they face increasing patient demands and greater time constraints, making it challenging for them to always give enough attention to holistic health issues. Simple PAD warning signs (eg, leg cramping or pain) are frequently attributed to other common, more benign, factors. Complicating matters is that about half of people with PAD do not show any major symptoms at all. As such, the partnership between PCPs and vascular surgeons is essential to making a swift diagnosis and developing an effective treatment plan. We owe it to each other and our patients to educate and collaborate as we care for PAD patients. Making a Concerted Effort My colleagues and I are committed to this partnership. Our vascular surgeons work closely with the PCPs throughout our network to identify PAD risk factors and symptoms as early as possible so that we can collaboratively determine the best course of treatment. To enhance this partnership, we’ve enabled real-time communication between providers...

Examining the Neurologic & Cognitive Effects of CABG

Although the mortality rate associated with CABG has been declining, research suggests that patients who undergo these procedures are increasingly older and sicker. Risk factors for complications after CABG are high, and adverse neurologic outcomes (eg, stroke and cognitive decline) remain a major concern. Efforts to reduce post-CABG-related neurologic events have been hindered by an incomplete understanding of the pathophysiology of these events. One of the justifications for developing off-pump CABG was the hope that rates of embolization, and therefore stroke, would be lower than those experienced with on-pump surgery. However, a number of large prospective ran­domized trials have failed to show a significant difference in rates of post-surgical stroke between on- and off-pump bypass. In light of these findings, strategies to reduce the incidence of adverse post-CABG neurologic and cognitive outcomes should focus more on patient-related risk factors rather than procedure-specific outcomes. (see also, Revised Guidelines for Evidence-Based PCI) Changing Perceptions on CABG & Cognitive Decline In the January 19, 2012 New England Journal of Medicine, my colleagues and I published a review article on neuro­cognitive outcomes following CABG. Studies in the past have suggested that CABG causes cognitive decline. For example, a Duke University study published about 10 years ago suggested a high rate of cognitive decline at 5 years after CABG. But this study was not randomized and had no control groups. In a more recent study (although not randomized), my colleagues at Johns Hopkins compared cognitive outcomes over 6 years in patients undergoing CABG, a group with the same vascular risk factors that did not undergo surgery, and a group of heart-healthy con­trols. Although those...

Keys to Transradial Access for Percutaneous Revascularization

Although the adoption of radial coronary angiography and radial PCI in the United States lags behind that of other countries, particularly those in Europe and Asia, transradial coronary intervention has seen an 8% to 10% increased utilization in the U.S., a trend that is expected to continue. The Society for Cardiovascular Angiography and Interventions (SCAI) published an executive summary on transradial access (TRA) for coronary and peripheral procedures in the November 2011 issue of Catheterization and Cardiovascular Interventions. The overview examined utility, utilization, and training aspects to consider when performing angioplasty via the radial artery. “Historically, the traditional route to access blocked coronary arteries has been through the larger femoral artery,” says Ronald P. Caputo, MD, FACC, FSCAI, lead author of the SCAI paper. “TRA is advantageous to transfemoral access because it’s less invasive and has been shown to decrease the risk of access site complications and bleeding.” TRA also is preferred by the vast majority of patients because, unlike the transfemoral approach, it causes less discomfort and allows them to stand up and ambulate immediately following the procedure. In addition, some patients undergoing TRA procedures can be discharged the same day. “These advantages ultimately can decrease length of stay and reduce hospitalization costs while still improving clinical outcomes,” adds Dr. Caputo. Avoiding Complications in Transradial Access Appropriate patient selection for TRA is the first important step in a successful procedure, says Dr. Caputo. Ideal patients for TRA include those with a palpably large radial artery with a strong pulse and a normal Allen’s test with no history of an ipsilateral brachial procedure. Contraindications include abnormal Allen’s test, a...

Managing Varicose Veins & More Advanced Chronic Venous Diseases

It is estimated that 20% to 25% of American adults have varicose veins, and 6% have more advanced chronic venous diseases (CVDs). While varicose veins were once considered a cosmetic problem, they are associated with discomfort, pain, and poor quality of life. Severe CVDs may also lead to loss of limb or life. In response to the rapid improvement in technology and results from recent randomized clinical trials, the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) jointly released new clinical practice guidelines for the care of patients with varicose veins. The guidelines, published in the May 2011 supplement to the Journal of Vascular Surgery, also provide recommendations for those with more advanced CVDs, including edema, skin changes, or venous ulcers. As the aging population continues to grow, so too will complications related to varicose veins and associated CVDs. Advancements in technology and surgical techniques have resulted in vast improvements in the prevention and management of varicose veins. “It is critical that surgeons are aware of the latest diagnostic strategies and the less invasive and more effective treatment techniques for treating the disease,” says Peter Gloviczki, MD, who chaired the SVS/AVF Venous Guideline Committee. New & Modified Recommendations Numerous recommendations for the management of varicose veins and more advanced CVDs are presented in the SVS/AVF guidelines (Table). The strength of each guideline varies based on the benefits as compared to the risks, burdens, and costs. A key recommendation offered by the new guidelines is duplex scanning of the deep and superficial veins to complement the standard history and physical examination in evaluation of patients with varicose veins...
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