Abstract Phlegmasia cerulea dolens is a potentially limb-threatening complication of acute severe iliofemoral deep vein thrombosis. This case discusses the mode of presentation, the endovascular therapeutic options, and the technical aspects of carrying out these procedures, and presents a literature review of the supporting evidence.
Introduction: IHR PE management is challenging; thrombolysis reduces risk of haemodynamic collapse but increases bleeding risk1. We have shown safe use of half-dose systemic and catheter directed thrombolysis (CDT) in a cohort of 57 patients from 2014-2016. Aim: To review outcomes of IHR and high-risk (HR) PE from 2018-2019 and compare with our historical cohort. Methods: A retrospective review of PE cases admitted from 2018-2019. 126 patients were identified via thrombosis database and case notes were reviewed. PELT review (includes PESI, troponin/BNP, imaging and clinical/bleeding risk assessment) facilitates risk stratification and treatment selection. Standard care is unfractionated heparin infusion (UFH) & review at 24 hours unless the patient is very unwell. Any decision to thrombolyse is made by PELT in conjunction with informed patient consent. Results: 74 (59%) were formally referred to PELT (109 IHR, 17 HR). Table 1 shows the outcomes. 95% of CDT patients had a high bleeding risk. Thrombolysis had only 4 minor and no major bleeding complications. No mortality is related to treatment but to underlying disease or multiorgan failure. Conclusions: PELT referrals have increased. Conservative management with UFH in selected patients is effective in the majority of cases. Thrombolysis gives good outcomes in carefully chosen patients reviewed by PELT who are very unwell on admission or have failed to respond to standard care. Reference: 1) Meyer, G. et al. NEJM 2014;370:1402-11
Donor nephrectomy operative complexity and postoperative outcomes remain subject to large degrees of unexplained heterogeneity. This study assess the clinical correlation of CT based intrabdominal and perinephric fat content using 3 different fat calculation methods (1. % visceral fat at the umbilicus, 2. 3D visceral fat content of the whole abdomen and donated kidney and 3. perinephric fat in anterior, posterior, medial and lateral planes at the level of the renal vein) producing 15 separate data points for each donor. The study was performed in a single centre in 500 patients undergoing hand assisted laparoscopic donor nephrectomy between 2005 - 2014 who had CT angiography performed as part of their routine preoperative work up. Analysis of each fat measure was carried out with spearman correlations, test and ANOVA. Multivariate regression models of the predictors of a low post donation clearance state at one year (GFR <45mls/min) and operating time (as a marker of operative complexity) were also developed. The mean age of the cohort was 44.1 yrs, 17% were obese and 51% female. Abdominal visceral fat content (r2=0.12 coefficient 0.36 p=0.001) and perinephric fat content (r2=0.14, coefficient 0.07 p<0.001) were strong independent predictors of operating time when adjusted for operating surgeon, arterial multiplicity. Total abdominal visceral fat measures were also greater in those developing postoperative infection (1692cm2 v 1489cm2 p=0.04). Greater perinephric fat content was associated with incisional hernia development (235cm2 v 163cm2 p=0.04). The mean reduction in glomerular filtration rate (GFR) post renal donation at one year was 30.5mls/min (SD 9.6). Spearman rank correlation statistics demonstrated significant positive associations between GFR reduction at one year post donation and visceral fat content at the umbilicus (spearman rho=0.14, p=0.03) and total abdominal visceral fat content (spearman rho 0.13, p=0.04). There was no association with BMI (spearman rho 0.02, p=0.69). Similarly subcutaneous and perinephric fat measures demonstrated no relationship. 7% of the kidney donors studied had a one year post donation "low" GFR clearance state (<45mls/min). A logistic regression model adjusted for preoperative GFR and age demonstrated abdominal visceral fat content measured at the umbilicus to be an independent predictor of a low GFR state at one year (OR 1.1 p=0.001, LR chi2 = 68, p=0.001 r2 = 0.48). |In this the largest CT based anthropometric study of kidney donors to date; visceral and perinephric CT based fat measurements appear to be superior predictors of short and long term outcomes (when compared to BMI). In marginal cases of donation particulary where there is concern over residual renal function post donation, these measures may facilitate perioperative decision making.
There is a lack of consensus regarding which type of antiplatelet agent should be used in patients with peripheral arterial disease (PAD) and little is known on the advantages and disadvantages of dual antiplatelet therapy. We conducted a systematic review and network meta-analysis of available randomized controlled trials (RCT) comparing different antiplatelet drugs (Aspirin, Ticlopidine, Clopidogrel, Ticagrelor, Cilostazol, Picotamide and Vorapaxar as monotherapies or in combination with aspirin) in PAD patients (PROSPERO public database; CRD42014010299).We collated evidence from previous relevant meta-analyses and searched online databases. Primary efficacy endpoints were: (1) the composite rate of major adverse cardiovascular events (MACE; including vascular deaths, non-fatal myocardial infarction and non-fatal stroke), and (2) the rate of major leg amputations. The primary safety endpoint was the rate of severe bleeding events. Bayesian models were employed for multiple treatment comparisons and risk-stratified hierarchies of comparative efficacy were produced to aid medical decision making. Number-Needed-to-Treat (NNT) and Number-Needed-to-Harm (NNH) are reported in case of significant results. We analyzed 49 RCTs comprising 34,518 patients with 88,358 person-years of follow-up with placebo as reference treatment. Aspirin, Cilostazol, Vorapaxar and Picotamide were ineffective in reducing MACE. A significant MACE reduction was noted with Ticagrelor plus aspirin (RR: 0.67; 95%CrI: 0.46-0.96, NNT = 66), Clopidogrel (RR: 0.72; 95%CrI: 0.58-0.91, NNT = 80), Ticlopidine (RR: 0.75; 95%CrI: 0.58-0.96, NNT = 87), and Clopidogrel plus aspirin (RR: 0.78; 95%CrI: 0.61-0.99, NNT = 98). Dual antiplatelet therapy with Clopidogrel plus aspirin significantly reduced major amputations following leg revascularization (RR: 0.68; 95%CrI: 0.46-0.99 compared to aspirin, NNT = 94). The risk of severe bleeding was significantly higher with Ticlopidine (RR: 5.03; 95%CrI: 1.23-39.6, NNH = 25), Vorapaxar (RR: 1.80; 95%CrI: 1.22-2.69, NNH = 130), and Clopidogrel plus aspirin (RR: 1.48; 95%CrI: 1.05-2.10, NNH = 215). Clopidogrel monotherapy showed the most favourable benefit-harm profile (79% cumulative rank probability best and 77% cumulative rank probability safest). In conclusion, Clopidogrel should be the indicated antiplatelet agent in PAD patients. Dual antiplatelet therapy with aspirin and Clopidogrel can reduce the rate of major leg amputations following revascularization, but carries a slightly higher risk of severe bleeding.
Arteriovenous fistulae (AVF) provide superior primary vascular access for children on chronic dialysis compared to central venous catheters (CVC). However, AVFs inevitably develop complications and will require some intervention to maintain long-term functional patency.We report an 'endovascular-first' approach to the maintenance and rescue of paediatric AVFs. Thirty interventions targeting 46 lesions in 18 children (median age 11 years [range 5-17]) were performed. Sixty-eight percent of the AVFs were brachio-cephalic fistulae, 26% brachio-basilic fistulae and 5% radio-cephalic fistulae. Immediate functional success was 86% with good dialysis adequacy (mean urea reduction ratio > 70%) at 3 months post procedure.There was one significant complication, consisting of an AVF rupture which was managed with a covered stent.Repeated interventions may be necessary to maintain AVF patency and avoid central venous catheters. This is the largest series reported to date.
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