[Risk factors and screening for cardiac disease, carotid stenosis and aortic aneurysms in Sicily (Italy): a population-based cross sectional survey]. / Screening per malattie cardiache, stenosi carotidee e aneurismi aortici in Sicilia: uno studio trasversale di popolazione.

A cross-sectional survey was performed among 50 to 75 year-old residents in the town of Regalbuto in Sicily (Italy), to evaluate risk factors and prevalence of cardiovascular diseases (CVD) in this geographically- defined population. Subjects were invited to participate by letter and those accepting to participate were asked to complete a questionnaire collecting personal data and information regarding the presence of risk factors for CVD. All participating subjects aged >50 years and with a minimum of four risk factors for CVD (smoking, hypertension, diabetes, obesity) were screened for cardiac disease and carotid stenosis (> 50% stenosis). Screening for aortic aneurysms was performed only in male participants aged >65, regardless of the presence or absence of risk factors. Screening was performed by electrocardiography, bi-dimensional echography and ecodoppler. Overall 3,073 subjects were invited to participate, of whom 564 (18%) accepted to participate, 54% of whom female. Mean age of responders was 64 years. No differences were found in the prevalence of risk factors amongst men and women. Twenty-seven percent had one risk factor for CV disease, 35% had two risk factors, 19% had three and 6% had four or more risk factors. Hypertension was the most common risk factor detected (62%), followed by dyslipidemia (57%), obesity (26%), tobacco smoke (23%) and diabetes mellitus (17%). Overall, 134 responders (24%) underwent screening, of whom 38 were screened for cardiac diseases and carotid stenosis and 126 for aortic aneurysms. Screening identified 14 new cases of cardiovascular disease: three cases of carotid stenosis, eight of ischemic cardiopathy, and three aneurysms. In conclusion, screening in high risk subjects identified a high percentage of subects with CVD.

ADAM-10 could mediate cleavage of N-cadherin promoting apoptosis in human atherosclerotic lesions leading to vulnerable plaque: a morphological and immunohistochemical study.

Atherosclerosis remains a major cause of mortality. Whereas the histopathological progression of atherosclerotic lesions is well documented, much less is known about the development of unstable or vulnerable plaque, which can rupture leading to thrombus, luminal occlusion and infarct. Apoptosis in the fibrous cap, which is rich in vascular smooth muscle cells (VSMCs) and macrophages, and its subsequent weakening or erosion seems to be an important regulator of plaque stability. The aim of our study was to improve our knowledge on the biological mechanisms that cause plaque instability in order to develop new therapies to maintain atherosclerotic plaque stability and avoid its rupture. In our study, we collected surgical specimens from atherosclerotic plaques in the right or left internal carotid artery of 62 patients with evident clinical symptoms. Histopathology and histochemistry were performed on wax-embedded sections. Immunohistochemical localization of caspase-3, N-cadherin and ADAM-10 was undertaken in order to highlight links between apoptosis, as expressed by caspase-3 immunostaining, and possible roles of N-cadherin, a cell-cell junction protein in VSMCs and macrophages that provides a pro-survival signal reducing apoptosis, and ADAM-10, a "disintegrin and metalloproteases" that is able to cleave N-cadherin in glioblastomas. Our results showed that when apoptosis, expressed by caspase-3 immunostaining, increased in the fibrous cap, rich in VSMCs and macrophages, the expression of N-cadherin decreased. The decreased N-cadherin expression, in turn, was linked to increased ADAM-10 expression. This study shows that apoptotic events are probably involved in the vulnerability of atherosclerotic plaque.

Computerized tomography and 3-D rendering help to select surgical strategy in leiomyosarcoma of the inferior vena cava.

Leiomyosarcoma of the inferior vena cava is a rare tumor that is usually fatal. The tumor may grow very slowly or occasionally very rapidly, shows extensive local invasion, and metastasizes more frequently than previously believed. Complete surgical resection remains the only potential curative therapeutic option. The aim of this study was to report the clinical experience in the management of a patient with leiomyosarcoma. A 65-year-old woman with a history of vague abdominal pain and leg swelling underwent computed tomography which demonstrated an occlusion of the inferior vena cava. The patient received a complete excision of the tumor without reconstruction and histological analysis confirmed the diagnosis of leiomyosarcoma type 1. At 3 years, the patient is still doing well with minimal leg edema and a contrast-enhanced CT demonstrates no evidence of recurrence locally or in distant sites. Leiomyosarcoma is a rare and aggressive tumor that presents with non-specific symptoms. Computerized tomography with 3-D reconstruction is a useful tool to define the presence and entity of the collateral circulation and therefore to decide on the surgical strategy. Resection probably offers the best opportunity for long-term survival.

Work-related effort thrombosis in a millwright: a case report.

BACKGROUND: Effort thrombosis refers to axillosubclavian vein thrombosis secondary to physical activities of the upper extremity. METHODS: This report describes the clinical presentation of effort thrombosis in a millwright and reviews the literature for occupational reports of this condition. RESULTS: While there is a paucity of literature reporting an occupational association, work related physical demands on the upper extremity appears to increase the risk of axillosubclavian impingement and thrombosis in certain patients. CONCLUSION: Effort thrombosis is a rare vascular condition of the upper extremity that may be seen in workers with repetitive, forceful, or overhead arm activities.

A survey evaluating surgeons' peri-operative usage of acetyl-salicylic acid (ASA) and their willingness to enroll their patients in a perioperative ASA randomized controlled trial.

PURPOSE: Major cardiovascular complications associated with noncardiac surgery represent a substantial population health problem for which there are no established efficacious and safe prophylactic interventions. Acetyl-salicylic acid (ASA) represents a promising intervention. The objective of this study was to determine surgeons' perioperative usage of ASA, and if they would enroll their patients in a perioperative ASA randomized controlled trial (RCT). METHODS: Cross-sectional survey of all practicing Canadian general, orthopedic, and vascular surgeons. Our mailed, self-administered survey asked surgeons to consider only their patients who were at risk of a major perioperative cardiovascular complication. RESULTS: The response rate was 906/1854 (49%). For patients taking ASA chronically, there was marked variability regarding ASA continuation prior to surgery amongst the general and orthopedic surgeons, whereas 76% of vascular surgeons continued ASA in 81-100% of their patients. For patients not taking ASA chronically, approaches to starting ASA prior to surgery were variable amongst the vascular surgeons, whereas 70% of general and 82% of orthopaedic surgeons did not start ASA. For patients taking ASA chronically, 73% of general surgeons, 70% of orthopaedic surgeons, and 36% of vascular surgeons would allow at least 40% of their patients to participate in a perioperative RCT comparing stopping versus continuing ASA. For patients not taking ASA chronically, most general (76%), orthopaedic (67%), and vascular (51%) surgeons would allow at least 40% of their patients to participate in a perioperative RCT comparing starting ASA versus placebo. CONCLUSION: This national survey demonstrates that perioperative ASA usage as reported by surgeons is variable, identifying the need for, and community interest in, a large perioperative ASA trial.

Morphometric analysis of anatomic variables affecting endovascular stent design in patients undergoing elective and emergency repair of endovascular abdominal aortic aneurysm.

BACKGROUND: Our objective was to identify morphologic trends in elective and emergency endovascular aneurysm repair (EVAR). This work will inform hospitals with endovascular programs about the diameters and lengths of endostents that should be available to efficiently care for patients with these conditions. METHODS: We performed a retrospective review of patients undergoing elective (n = 127) and emergency (n = 17) EVAR. Using computed tomography and 3-dimensional reconstructions, we evaluated the following: diameters of the aneurysm (D3), the aorta at the superior mesenteric (D1) and renal (D2a,b,c; 3 levels) levels, the iliac arteries (D5a,b; right and left) and the aortic bifurcation (D4); lengths from the lowest renal artery to the distal aspect of the aortic neck (H1), to the aortic bifurcation (H3), to the right and left iliac bifurcations (H4a,b); and angles of the origin of the common iliac arteries on the transverse plane (A1). We used descriptive statistics of trends within groups and independent sample t tests. RESULTS: In elective and emergency aneurysm repair, D2max (26, standard deviation [SD] 3, mm v. 30.7 [SD 3] mm), D5a (16 [SD 4.7] mm v. 19.3 [SD 5] mm), D5b (15.3 [SD 4] mm v. 18.1 [SD 3.6] mm), H1 (25.6 [SD 8.6] mm v. 18 [SD 2] mm), H4a (173 [SD 22] mm v. 189.5 [SD 22] mm) and H4b (174 [SD 25] mm v. 190 [SD 14] mm) were significantly different between the 2 groups (p = 0.001, p = 0.006, p = 0.007, p < 0.001, p = 0.05 and p = 0.01, respectively). H3 (118 [SD 17] mm v. 121.5 [SD 13.5] mm) was not significantly different (p = 0.40). In elective patients, A1 identified the right common iliac more frequently anterior relative to the left common iliac (mean 23 degrees , SD 16 degrees). CONCLUSION: Significant anatomic differences between elective and emergency patients will require hospitals to stock separate endovascular devices to treat abdominal aortic aneurysms in both groups.

Endovascular repair of popliteal aneurysms.

Endovascular repair is an established modality of treatment for abdominal aortic aneurysms. It is therefore reasonable to expect its application to other less common aneurysmal conditions, including isolated iliac and popliteal artery aneurysms (PAA). There are, however, essential differences between aortic aneurysms and peripheral aneurysms: smaller arterial caliber, mobility of the arterial segment, associated occlusive disease, and devices that have not been specifically designed for peripheral applications. Due to these differences, results obtained in abdominal aortic aneurysms cannot be extrapolated to peripheral aneurysms. The attraction of the endovascular repair for PAA is its minimally invasive nature. The literature, however, provides only case reports, case series and small cohorts, and one small randomized, controlled trial. A cumulative summary of these studies provides the clinician with information upon which to base the choice of treatment on a specific patient. Endovascular repair for PAA with suitable anatomy and good run-off can be considered safe, and medium term results appear comparable with those of open repair.

Relationship between access side used to deliver the main body of bifurcated prostheses for endovascular aneurysm repair and speed of cannulation of the contralateral limb.

OBJECTIVES: To examine the relationship between the orientation of the iliac arteries in infrarenal aortic aneurysms and its effect on the cannulation of the contralateral limb of a bifurcated stent graft system (SGS) used for endovascular aneurysm repair (EVAR). METHODS: This is a retrospective review of prospectively collected data in 100 consecutive patients treated with EVAR using the Zenith device (Cook Medical Inc., Bloomington, Indiana, USA). We collected data on reciprocal orientation between the origins of the common iliac arteries (OOCIA) on an axial plane, the common femoral artery (right or left) used to deliver the main body of the SGS (access side), and the cannulation time of the contralateral limb. The latter was defined as the time elapsed between the introduction of the selective catheter in the contralateral iliac artery to the time of successful cannulation of the contralateral limb of the SGS. Using an Aquarius workstation (v. 3.5; TeraRecon Inc, San Mateo, Calif), the OOCIA was measured establishing the center of the origin of the right and left common iliac arteries and joining them using a straight line. A horizontal line was then drawn through the origin of the right common iliac artery. The angle created by these two lines was defined as "zero," "positive," or "negative." We examined the relations between cannulation time, access side, and OOCIA using t tests and a multivariate regression analysis. RESULTS: In 84 patients, the origin of the right common iliac artery was in an anterior position compared with the left; in 16, the origin of the right and left were on the same horizontal line; and the right common iliac artery was posterior in none of the patients. The main body of the prosthesis was delivered using the left femoral artery in 52 patients and the right in 48. When all patients were considered, cannulation time was shorter when the main body of the bifurcated prosthesis was delivered through the left femoral artery (9.3 +/- 5.8 minutes vs 15.4 +/- 7.2 minutes, P < .0001). This effect was more pronounced when only patients with the left common iliac artery located posteriorly were examined (9.3 +/- 5.80 minutes vs 16.4 +/- 7.6 minutes, P < .0001). There was no correlation between increasing negativity of the OOCIA angle and cannulation time, regardless of access side. CONCLUSION: We have shown that in patients with infrarenal aortic aneurysms, the origin of the right iliac artery is often anterior compared with the left and that cannulation time of the contralateral limb is shorter when the main body of the prosthesis is delivered from the left.

The effect of thoracoabdominal aneurysm repair on quality of life.

OBJECTIVE: The objective of this study is to assess the impact of surgery on quality of life (QOL) in patients who underwent thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: This is a prospective single center cohort study using two quality of life questionnaires administered before surgery, at 6 months, and 1 year after surgery. The Illness Intrusiveness Rating Scale (IIRS) is a tool that on a 7-point Likert scale assesses the impact of disease on each of 13 domains of quality of life. The Karnofsky Activity Scale (KAS) uses a single rating to assess the impact on overall quality of life. At each visit, participants completed the IIRS and KAS. Healthy, nonaneurysmal individuals also completed the IIRS to form a control group. RESULTS: From 1998 to 2006, 297 patients underwent thoracoabdominal aneurysm repair at a tertiary care hospital. Quality of life was measured on 80 patients in total. Preoperative data was available in 45 patients (7 completed the IIRS and 3 the KAS only, and 35 both); 6-month postoperative data in 25 (1 completed the KAS only, and 24 both); and 1-year data postoperative in 35 (4 completed the IIRS and 2 the KAS only, and 29 both). Internal consistency was established for IIRS (Cronbach's alpha 0.85) and KAS (0.81). The mean preoperative IIRS score was 32.10 (SD 17.91). After surgery, there was no change at the 6-month and 1-year postoperative intervals: at 6 months, the mean IIRS score was 33.17 (SD 17.66) and at 1 year the mean was 28.09 (SD 13.61). Total IIRS in nonaneurysmal controls was 13.5 (SD 0.7). The mean preoperative Karnofsky Activity Scale score was 80.0 (SD 15.07), which corresponds to an ability to perform normal activity with effort and some signs or symptoms of disease. After surgery, there was no change as patients reported a 6-month mean score of 79.60 (SD 21.89), and a 1-year postoperative mean score of 86.94 (SD 13.94). CONCLUSIONS: Quality of life for patients undergoing TAAA repair who survive to attend follow-up in an ambulatory setting can be measured using reliable and valid instruments. Preoperatively, QOL is poor compared with healthy controls. After surgery, at 6- and 12-month follow-up, QOL seems to return to the preoperative levels. Further research is necessary to address responsiveness and sensitivity of QOL measuring tools.

Progression of internal carotid artery stenosis in patients with peripheral arterial occlusive disease.

OBJECTIVES: To study the risk factors and rate of progression of asymptomatic carotid stenosis in patients with peripheral arterial occlusive disease. METHODS: Between July 1999 and September 2003, we studied consecutive patients referred to a vascular laboratory for peripheral arterial occlusive disease who had not experienced neurologic symptoms within the previous 3 years. Carotid duplex ultrasound scan (DUS) was performed at baseline and at 6 to 12-month intervals. The internal carotid artery peak systolic velocity (PSV) was used to determine severity of carotid stenosis. Multilevel linear regression modeling (MLM) was used to identify the rate of progression and risk factors for progression. RESULTS: For 614 consecutive patients, median follow-up by DUS was 30 (2-42) months. Patients were 73 +/- 10-years-old, and 62% were men. Mean ankle-brachial index (ABI) was 0.79 +/- 0.24. The baseline prevalence of carotid stenosis >or=50% (PSV >or=125 cm/second) was 22%. During follow-up, ipsilateral amaurosis fugax, transient ischemic attacks, and strokes occurred in 3 (0.4%), 7 (1.1%), and 5 (0.8%) patients, respectively. Overall, there was little progression in carotid stenosis. Female gender, low ABI, and smoking were risk factors for progression of disease regardless of severity of carotid stenosis. Patients with >or=50% carotid stenosis were at greatest risk of progression if they continued smoking and were diabetic. Prediction models for progression of carotid stenosis given a baseline PSV and patient risk factors were constructed. CONCLUSION: There are few neurologic events in patients with asymptomatic carotid stenosis. The average rate of progression of stenosis over 2 years is not significant but greater in diabetic patients with baseline stenosis >50% who continue smoking. Rescreening by serial DUS should be limited to high-grade stenosis and follow-up performed at an interval of 1-2 years.

Anaconda endovascular limbs for the treatment of isolated iliac artery aneurysms.

The purpose of this article is to report the feasibility and preliminary results of the treatment of isolated iliac artery aneurysms (IAAs) with Anaconda limbs (Vascutek Ltd., Inchinnan, Renfrewshire, Scotland). A prospective cohort is reported of consecutive IAAs treated by two senior surgeons from May to December 2006. One or more Anaconda limbs were used, and internal iliac arteries were embolized if necessary. Twelve IAAs in 11 patients were treated. The average IAA diameter was 4.3 +/- 1.1 cm, and the average diameter of stent used was 14 +/- 2.5 mm, with an average total length of 97 +/- 25 mm. At a mean follow-up of 12 +/- 4 months, there were no graft-related complications, graft occlusions, or requirements for reintervention. Endovascular treatment for isolated IAAs under local anesthesia using Anaconda limbs is feasible, safe, and effective. However, as with all new technology, longer follow-up data are necessary.

Open versus endovascular repair of abdominal aortic aneurysm: a survey of Canadian vascular surgeons.

OBJECTIVE: The aim of this survey was to determine Canadian vascular surgeons' experience with elective endovascular aortic repair (EVAR) and traditional open repair and their interest in participating in an expertise- based randomized controlled trial (RCT) as opposed to a conventional RCT comparing these 2 procedures. METHODS: A single-page questionnaire was developed and sent by fax, email or post to all vascular surgeons in Canada. Nonresponders were recontacted on 2 additional occasions to improve the response rate. The questionnaire had 2 sections. The first inquired about current and past practice patterns, including experience in both open and endovascular techniques. The second investigated the surgeons' belief in the value of open as opposed to endovascular repair and the value of expertise-based RCT methodology; it also canvassed their interest in participating in a future trial. Definitions of expertise in open and endovascular repair were drawn from the published literature. Criteria to determine the feasibility of conducting an expertise-based RCT were established a priori. RESULTS: The questionnaire was sent to 259 surgeons who appeared in multiple vascular surgery databases, and the overall response rate was 56% (95% confidence interval [CI] 50%-62%). The mean career experience was 406 cases (standard deviation [SD] 359) for conventional open abdominal aortic aneurysm (AAA) repair and 24 cases (SD 48) for endovascular repair. Of the responding surgeons, 51% (95% CI 41%-60%) ranked conventional open repair as "probably superior." Respondents were equally interested in participating in an RCT using either expertise-based methodology (54%, 95% CI 44%-63%) or conventional design (51%, 95% CI 41%-60%). CONCLUSION: Uncertainty exists among vascular surgeons in Canada as to the role of endovascular surgery in the repair of AAA. A national RCT comparing open with endovascular repair in the elective setting is potentially feasible with either expertise-based or conventional design. Increases in the number of surgeons who are willing to participate and have expertise in EVAR, in addition to high recruitment rates among eligible patients, will be necessary to make such a trial feasible in Canada.

Preoperative intra-aortic balloon pump in patients undergoing coronary bypass surgery: a systematic review and meta-analysis.

OBJECTIVES: To assess the effectiveness of preoperative intra-aortic balloon pump (IABP) placement in high-risk patients undergoing coronary bypass surgery (CABG). The primary outcome was hospital mortality and secondary outcomes were IABP-related complications (bleeding, leg ischemia, aortic dissection). METHODS: MEDLINE, EMBASE, Cochrane registry of Controlled Trials, and reference lists of relevant articles were searched. We included randomized controlled trials (RCTs), and cohort studies that fulfilled our a priori inclusion criteria. Eligibility decisions, relevance, study validity, and data extraction were performed in duplicate using pre-specified criteria. Meta-analysis was conducted using a random effects model. RESULTS: Ten publications fulfilled our eligibility criteria, of which four were RCTs and six were cohort studies with controls. There were statistical as well as clinical heterogeneity among included studies. A total of 1034 patients received preoperative IABP and 1329 did not receive preoperative IABP. The pooled odds ratio (OR) for hospital mortality in patients treated with preoperative IABP was 0.41 (95% CI, 0.21-0.82, p = 0.01). The number needed to treat was 17. The pooled OR for hospital mortality from randomized trials was 0.18 (95% CI, 0.06-0.57, p = 0.003) and from cohort studies was 0.54 (95% CI, 0.24-1.2, p = 0.13). Overall, 3.7% (13 of 349) of patients who received preoperative IABP developed either limb ischemia or haematoma at the IABP insertion site, and most of these complications improved after discontinuation of IABP. CONCLUSION: Evidence from this meta-analysis support the use of preoperative IABP in high-risk patients to reduce hospital mortality.

Endovascular repair of ruptured abdominal aortic aneurysms: a systematic review and meta-analysis.

OBJECTIVES: The perioperative mortality for people with ruptured abdominal aortic aneurysms (RAAA) has not changed for two decades. Of patients who survive long enough to undergo open repair for ruptured aneurysms, half die (48%; 95% confidence interval [CI] 46 to 50). Randomized trials have shown that endovascular aneurysm repair (EVAR) for nonruptured abdominal aortic aneurysms decreases perioperative mortality compared with open repair. EVAR may similarly benefit patients with RAAA. We aimed to summarize studies of patients undergoing EVAR for ruptured aneurysms. METHODS: Two reviewers searched Medline and EMBASE databases from 1994 to July 2006, Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effectiveness, the Cochrane Central Register of Controlled Trials, Best Evidence 1994 to 2006, reference lists, clinical trial registries, and conference proceedings; we also contacted authors. All published and unpublished studies in which a group of people with ruptured aneurysms, assessed objectively by imaging, was treated with EVAR (REVAR) were eligible. We used the generic inverse variance function of the REVMAN software to pool results for death in hospital. Sensitivity analyses, using prespecified subgroups, explored heterogeneity between studies. RESULTS: Pooled mortality in 18 observational studies describing 436 people who underwent REVAR was 21% (95% CI 13 to 29); however, 90% of the heterogeneity between studies was not explained by chance alone. Surgical volume explained substantial heterogeneity. According to study-specific criteria, 47% (95% CI 39 to 55) of people with ruptured aneurysms were potentially eligible for REVAR. CONCLUSIONS: Mortality in people who underwent REVAR is lower than that in historical reports of unselected people undergoing open repair. Further investigation is needed to determine whether the difference in mortality is attributable to patient selection alone or to this new approach to treatment.

Oral anticoagulant and antiplatelet therapy and peripheral arterial disease.

BACKGROUND: Atherosclerotic peripheral arterial disease is associated with an increased risk of myocardial infarction, stroke, and death from cardiovascular causes. Antiplatelet drugs reduce this risk, but the role of oral anticoagulant agents in the prevention of cardiovascular complications in patients with peripheral arterial disease is unclear. METHODS: We assigned patients with peripheral arterial disease to combination therapy with an antiplatelet agent and an oral anticoagulant agent (target international normalized ratio [INR], 2.0 to 3.0) or to antiplatelet therapy alone. The first coprimary outcome was myocardial infarction, stroke, or death from cardiovascular causes; the second coprimary outcome was myocardial infarction, stroke, severe ischemia of the peripheral or coronary arteries leading to urgent intervention, or death from cardiovascular causes. RESULTS: A total of 2161 patients were randomly assigned to therapy. The mean follow-up time was 35 months. Myocardial infarction, stroke, or death from cardiovascular causes occurred in 132 of 1080 patients receiving combination therapy (12.2%) and in 144 of 1081 patients receiving antiplatelet therapy alone (13.3%) (relative risk, 0.92; 95% confidence interval [CI], 0.73 to 1.16; P=0.48). Myocardial infarction, stroke, severe ischemia, or death from cardiovascular causes occurred in 172 patients receiving combination therapy (15.9%) as compared with 188 patients receiving antiplatelet therapy alone (17.4%) (relative risk, 0.91; 95% CI, 0.74 to 1.12; P=0.37). Life-threatening bleeding occurred in 43 patients receiving combination therapy (4.0%) as compared with 13 patients receiving antiplatelet therapy alone (1.2%) (relative risk, 3.41; 95% CI, 1.84 to 6.35; P<0.001). CONCLUSIONS: In patients with peripheral arterial disease, the combination of an oral anticoagulant and antiplatelet therapy was not more effective than antiplatelet therapy alone in preventing major cardiovascular complications and was associated with an increase in life-threatening bleeding. (ClinicalTrials.gov number, NCT00125671 [ClinicalTrials.gov].).

Patterns of medical therapy in patients with peripheral artery disease in a tertiary care centre in Canada.

BACKGROUND: Patients with peripheral artery disease (PAD) of the lower extremities are among the highest risk vascular patients for fatal and nonfatal myocardial infarction and stroke, and have been traditionally undertreated from a medical perspective. Recent evidence suggests that the incidence of cardiovascular death, myocardial infarction and stroke can be substantially reduced among PAD patients if they are treated with antiplatelet therapy, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins), angiotensin-converting enzyme inhibitors (ACEIs) and in some instances, beta-blockers. OBJECTIVES: To characterize practice patterns of drug therapy (antiplatelet, statin, ACEI and beta-blocker) among PAD patients admitted to a tertiary care hospital and to determine the 'care gap', defined as the proportion of patients who did not receive therapy among those who were eligible for it. DESIGN AND METHODS: Patients with PAD (International Classification of Diseases code 440.2) admitted to the Hamilton General Hospital (Hamilton, Ontario) from January 2001 to January 2002 were considered for inclusion into the present study. Information was collected during hospitalization and by chart review. RESULTS: Data from 217 patients were used. The mean (+/- SD) age of participants was 68.6+/-11.9 years, and 41% were women. The primary reason for admission to hospital was peripheral artery bypass surgery (67%). Of these patients, 79% were current smokers or had a prior history of tobacco use, 60% had at least two cardiovascular risk factors (hypertension, cholesterol, diabetes or smoking) and 45% had undergone prior peripheral artery bypass surgery, amputation or carotid endarterectomy. Three-quarters of the patients had established coronary or cerebrovascular disease, or at least two cardiovascular risk factors. At the time of discharge, of those patients eligible for medical therapies, 16% did not receive antiplatelet or anticoagulant agents, 69% did not receive statins, 48% did not receive ACEIs and 49% did not receive beta-blockers. CONCLUSIONS: Patients with PAD represent a high-risk group in which more than 75% have established coronary or cerebrovascular disease, or multiple cardiovascular risk factors. Although the use of antiplatelet agents is common, the use of statins, ACEIs and beta-blockers may be improved.

Fenestrated endovascular grafts for juxtarenal aortic aneurysms: a step by step technical approach.

Fenestrated endovascular aortic aneurysm repair is a valuable alternative for patients who are at high risk for open surgery, but have unsuitable anatomy for infrarenal endovascular repair due to a short aneurysmal neck. Recognizing that this is an evolving and complex technology, we present a step by step approach to the surgical technique that may be useful for endovascular therapist interested in the management of these complex patients.