Background: The ATTRACT Trial previously reported that pharmacomechanical catheterdirected thrombolysis (PCDT) did not prevent the post-thrombotic syndrome (PTS) in patients with acute proximal deep vein thrombosis (DVT). In the current analysis, we examine the effect of PCDT in ATTRACT patients with iliofemoral DVT. Methods: Within a large multicenter randomized trial, 391 patients with acute DVT involving the iliac and/or common femoral veins were randomized to PCDT with anticoagulation versus anticoagulation alone (No-PCDT) and were followed for 24 months to compare short-term and long-term outcomes. Results: Between 6 and 24 months, there was no difference in the occurrence of PTS (Villalta scale ≥5 or ulcer: 49% PCDT versus 51% No-PCDT; risk ratio (RR)=0.95; 95% confidence interval (CI), 0.78-1.15; p=0.59). PCDT led to reduced PTS severity as shown by: lower mean Villalta and Venous Clinical Severity Scores [VCSS] (p<0.01 for comparisons at 6, 12, 18, and 24 months); and fewer patients with moderate-or-severe PTS (Villalta scale ≥10 or ulcer: 18% versus 28%; RR 0.65; 95% CI 0.45-0.94, p=0.021) or severe PTS (Villalta scale ≥15 or ulcer: 8.7% versus 15%; RR 0.57; 95% CI 0.32-1.01, p=0.048; and VCSS ≥8: 6.6% versus 14%; RR 0.46; 95% CI 0.24-0.87, p=0.013). From baseline, PCDT led to greater reduction in leg pain and swelling (p<0.01 for comparisons at 10 and 30 days) and greater improvement in venous diseasespecific QOL (VEINES-QOL unit difference 5.6 through 24 months, p=0.029), but no difference in generic QOL (p > 0.2 for comparisons of SF-36 mental and physical component summary scores through 24 months). In patients having PCDT versus No-PCDT, major bleeding within 10 days occurred in 1.5% versus 0.5% (p=0.32), and recurrent VTE over 24 months was observed in 13% versus 9.2% (p=0.21). Conclusions: In patients with acute iliofemoral DVT, PCDT did not influence the occurrence of PTS or recurrent VTE. However, PCDT significantly reduced early leg symptoms and, over 24 Comerota et al.

Thrombosis of the inferior vena cava (IVC) is an under-recognized entity that is associated with significant short- and long-term morbidity and mortality. In absence of a congenital anomaly, the most common cause of IVC thrombosis is the presence of an unretrieved IVC filter. Due to the substantial increase in the number of IVC filters placed in the United States and the very low filter retrieval rates, clinicians are faced with a very large population of patients at risk for developing IVC thrombosis. Nevertheless, there is a paucity of data and societal guidelines with regards to the diagnosis and management of IVC thrombosis. This paper aims to enhance the awareness of this uncommon, but morbid, condition by providing a concise, yet comprehensive, review of the etiology, diagnostic approaches, and treatment strategies in patients with IVC thrombosis.

The role of catheter-directed thrombolysis (CDT) in the treatment of acute proximal deep vein thrombosis (DVT) is controversial, and the nationwide safety outcomes are unknown.OBJECTIVES The primary objective was to compare in-hospital outcomes of CDT plus anticoagulation with those of anticoagulation alone. The secondary objective was to evaluate the temporal trends in the utilization and outcomes of CDT in the treatment of proximal DVT. DESIGN, SETTING, AND PARTICIPANTSObservational study of patients with a principal discharge diagnosis of proximal or caval DVT from 2005 to 2010 in the Nationwide Inpatient Sample (NIS) database. We compared patients treated with CDT plus anticoagulation with the patients treated with anticoagulation alone. We used propensity scores to construct 2 matched groups of 3594 patients in each group for comparative outcomes analysis. MAIN OUTCOMES AND MEASURESThe primary study outcome was in-hospital mortality. The secondary outcomes included bleeding complications, length of stay, and hospital charges.RESULTS Among a total of 90 618 patients hospitalized for DVT (national estimate of 449 200 hospitalizations), 3649 (4.1%) underwent CDT. The CDT utilization rates increased from 2.3% in 2005 to 5.9% in 2010. Based on the propensity-matched comparison, the in-hospital mortality was not significantly different between the CDT and the anticoagulation groups (1.2% vs 0.9%) (OR, 1.40 [95% CI, 0.88-2.25]) (P = .15). The rates of blood transfusion (11.1% vs 6.5%) (OR, 1.85 [95% CI, 1.57-2.20]) (P < .001), pulmonary embolism (17.9% vs 11.4%) (OR, 1.69 [95% CI, 1.49-1.94]) (P < .001), intracranial hemorrhage (0.9% vs 0.3%) (OR, 2.72 [95% CI, 1.40-5.30]) (P = .03), and vena cava filter placement (34.8% vs 15.6%) (OR, 2.89 [95% CI, 2.58-3.23]) (P < .001) were significantly higher in the CDT group. The CDT group had longer mean (SD) length of stay (7.2 [5.8] vs 5.0 [4.7] days) (OR, 2.27 [95% CI, 1.49-1.94])

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The objective of this study was to perform a hemodynamic evaluation of moderate (50-90%) renal artery stenosis (RAS) under conditions of rest and maximum hyperemia. Identifying patients with RAS who have hemodynamically significant stenoses and are most likely to benefit from revascularization is clinically important. Current methods used to evaluate RAS, including angiography, have limitations. Physiologic evaluation of RAS may have a role in identifying patients with hemodynamically significant stenosis. Patients with suspected renovascular hypertension due to aorto-ostial RAS were included in the study. Hyperemia was induced by administration of intrarenal papavarine. Translesional pressure gradients were measured and renal fractional flow reserve (FFR) was calculated using a 0.014'' pressure guidewire. Thirteen patients and 14 arteries with moderately severe (50-90%) RAS were studied. The mean translesional pressure gradient rose from a baseline of 6.3 +/- 3.9 to 17.5 +/- 10.8 mm Hg with maximal hyperemia. The renal FFR ranged from 0.58 to 0.95. There was a poor correlation between angiographic stenosis measurement and the renal FFR (r = -0.18; P = 0.54) and the hyperemic translesional mean pressure gradient (r = 0.22; P = 0.44). There was an excellent correlation between renal FFR and the resting mean translesional pressure gradient (r = -0.76; P = 0.0016) and the hyperemic mean translesional pressure gradient (r = -0.94; P < 0.0001). Selective renal arterial papavarine administration induces maximum hyperemia, permitting the calculation of renal FFR in renal arteries with aorto-ostial stenoses. The renal FFR correlates well with other hemodynamic parameters of lesion severity, but poorly with angiographic measures of lesion severity.

Radiation therapy is a cause of cardiovascular morbidity and mortality. This is due to the significant degree of atherosclerosis seen in the vessels in the vicinity of the area being irradiated. Radiation-induced peripheral arterial disease is increasingly being recognized as large populations of cancer patients survive longer, yet it is a problem that is often under reported. Although it has most commonly been associated with carotid artery disease, all vascular beds are prone to this form of injury. The injury is accelerated by usual risk factors for atherosclerosis. Developing a healthy lifestyle, dietary prudence and the aggressive treatment of hypertension, diabetes mellitus, and dyslipidemia should all be encouraged in this patient population. When revascularization strategies are warranted, the percutaneous approach may be superior to open surgery as technical difficulties may arise in the fibrotic, scarred tissue. Stenting with distal embolic protection devices should be considered as the treatment of choice for patients with radiation-induced carotid artery disease. Several reports also suggest good results with balloon angioplasty with or without stenting in the case of radiation-induced renal, iliac, and femoral artery disease. Lifelong antiplatelet therapy may be appropriate.

SUMMARYWe present a normal 13-year old female who developed left cerebral infarction following envenomation by the carpet viper (Echis car inat us). We have read of only one other case of cerebral infarction following viper envenomation (Viperi russelli). Possible mechanisms for cerebral infarction in these circumstances are discussed. It is believed that this complication may be more common than is reported in the literature. Stroke Vol 16, No 2, 1985ECHIS CARINATUS, the saw-scaled viper, occurs throughout the Middle East and there have been sightings in many areas of Saudi Arabia. 1 Envenomation by this snake causes local swelling and severe tissue necrosis. Systemic complications are primarily related to bleeding due to blood depleted of fibrinogen and factors V, VII, II and XIII. This is manifested as hemorrhage in different parts of the body including the gums, nasopharynx, gastrointestinal tract, urinary tract and central nervous system. 2 The neurological symptoms include drowsiness, confusion and convulsions. Subarachnoid hemorrhage was seen in three of 115 patients reported from Nigeria, two of whom died. 2Arterial thrombotic complications in vessels near the site of some viper bites have been well described, 3 but arterial thromboses at distant sites are quite rare. We are aware of only two such instances reported in the literature. -5 In this communication, a Saudi Arabian patient who had cerebral infarction after a bite from Echis carinatus is described, and possible mechanisms for this phenomenon are discussed. Case HistoryA 13-year old right-handed Saudi Arabian female was clearing the ground for her sheep when she was bitten on her hand by a snake. She described the snake as being 50 centimetres long. When we showed her colored pictures of different snakes, she consistently pointed out Echis carinatus. A few minutes after the bite the patient developed severe pain and swelling in the right arm. She was taken to a nearby infirmary where she was given three 10 ml intravenous injections of polyvalent anti-snake serum (Behringwerke). She showed no immediate reaction to the antivenom and was subsequently transferred to a local hospital. On examination, the vital signs were stable. Two deep fang marks were seen on the right middle finger and the right arm was markedly swollen. A neurological examination was normal. Four hours after admission (ten hours after envenomation), she developed right hemiplegia with aphasia which evolved over one to two hours. Complete blood count including platelets, bleeding studies and prothrombin time, were normal. She received two more 10 ml injections of polyvalent anti-snake serum with no change in condition. Seventeen days later she was transferred to the King Faisal Specialist Hospital for investigation. The fang marks on the right middle finger were visible and healing, and there was mild swelling of the right arm. She had non-fluent aphasia with difficulty in expression and understanding. She also had right spastic hemiparesis involving the face and the arm, and to a...

In a contemporary national registry, BAV is associated with significant morbidity and mortality that are similar to TAVR. With the substantial increase in BAV utilization and the continuous improvement in TAVR outcomes, these data have important implications to aid clinicians in the selection of appropriate BAV candidates.