In this study of patients with symptomatic carotid stenosis of 60% or more, the rates of death and stroke at 1 and 6 months were lower with endarterectomy than with stenting. (ClinicalTrials.gov number, NCT00190398 [ClinicalTrials.gov].).
Conclusion:The Talent thoracic stent graft appears effective in the treatment of both acute and chronic diseases of the thoracic aorta.Summary: This report derives from the Talent Thoracic Retrospective Registry. It includes treatment of patients in seven major European referral centers during an 8-year period. The Talent thoracic stent graft was used to treat thoracic aortic pathology in 457 consecutive patients, of which 113 were emergent cases and 344 were elective. Median follow-up was 24 Ϯ 19 months (range, 1 to 85.1 months). Follow-up was based on clinical and imaging findings. Adverse events were included, and all adverse events were reviewed by a single physician.In-hospital mortality was 5% (23 patients). Mortality was 8.5% during follow-up of the 422 patients who survived the initial procedure. Thirty-six patients died, and 11 of the deaths were related to aortic disease. Specific procedure-related complications included stroke in 3.7%, paraplegia in 1.7%, and local vascular access-site complications in 3.3%. Two patients died of aortic rupture during placement of the device.Persistent endoleak was documented in 64 cases, of which 43 demonstrated primary endoleak present at the end of the procedure, and 21 endoleaks were discovered during follow-up. There were 7 patients with persistent endoleak with aortic rupture during the follow-up period. Aortic rupture associated with persistent endoleak occurred from 40 days to 35 months. All patients with aortic rupture associated with persistent endoleak died. Stent graft migration occurred in seven cases, graft fabric failure in two, and known modular disconnection in three. Survival was 90.97% at 1 year, 85.36% at 3 years, and 77.49% at 5 years. Freedom from a second procedure, endovascular, or open conversion, at 1, 3 and 5 years was 92.41%, 81.3%, and 70.0%, respectively.Comment: These are registry data and are thus subject to all the limitations of such data. Patients were treated for a variety of acute and chronic conditions. Although patients were acquired during an 8-years period, only 95 patients had Ͼ3 years of clinical and imaging follow-up available. The data suggest the Talent thoracic aortic stent graft can be deployed with a reasonable rate of complications for a variety of thoracic aortic pathologies. Further follow-up is obviously required to establish long-term efficacy.
D-dimer testing to determine the duration of anticoagulation therapy
Conclusion:Physician judgment should be used in determining susceptibility to venous thromboembolism (VTE) and the need for VTE prophylaxis in patients undergoing major elective abdominal surgery.Summary: There were an estimated 900,000 VTE events in U.S. hospitalized patients in 2005 (Heit JA, et al. American Society of Hematology Annual Meeting Abstract 2005;106 abstract 910). However, pulmonary embolism (PE) after elective abdominal surgery seems very uncommon. Opponents of a "one size fits all" approach to VTE prophylaxis argue routine VTE prophylaxis for all patients increases cost and compromises resources to administer what is potentially a dangerous treatment for an infrequent event in certain categories of patients. They further argue that trials of VTE prophylaxis use some VTE events as end points for efficacy, such as calf vein thrombosis, that may not be clinically significant, at least in the short-term. In 2004 the Kentucky Surgical Care Improvement Project found a very low rate of PE in 5285 elective specialty surgery patients. There were 15 PEs detected in these patients, and none were fatal despite erratic and very limited use of VTE prophylaxis. The authors also queried the University Health System Consortium database from 2004 and also found a very low rate of VTE complication in patients undergoing elective operations (Surg 2008;144:654-660). It is possible, however, that American College of Chest Physicians (ACCP) recommendations may have altered practices of VTE prophylaxis in elective surgical patients, and rates of fatal and non-fatal PE could be influenced by changing indications for VTE prophylaxis. The authors' study was designed to assess and compare rates of VTE prophylaxis and PE from an 18-month consecutive period in 2003 to 2004 with an identical period of observation in 2007 to 2008. Their hope was to assess the effect of the ACCP recommendations advocating an increase in VTE prophylaxis.The authors queried the University Health System Consortium database comprising data from 123 academic teaching hospitals. They identified patients undergoing colorectal resections, total hip replacement, total knee replacement, and hysterectomies from two consecutive 18-month periods: 2003 to 2004 and 2007 to 2008. VTE rates ranged from 0.6% to 3.2%, and PE rates ranged from 0.28% to 1.09%. There was an increased use of VTE prophylaxis for all procedures between 2003 to 2004 and 2007 to 2008, except for hysterectomy. Comparing the two periods, the authors found VTE rates were not significantly affected among patients who received pharmacologic prophylaxis and actually decreased in patients who did not receive any pharmacologic prophylaxis, despite an absence of significant change of severity of illness in the patient populations.Comment: The author's arguments are a step backward from routine VTE prophylaxis to an approach where "the need for prophylaxis would be assessed on an individual basis, based on retrospective data, expert consensus, and clinical judgment." What the authors may have actu...
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