Antiplatelet therapy prior to carotid endarterectomy--still room for improvement.

BACKGROUND: Antiplatelet therapy is one of the most important modalities for secondary prevention of ischemic events. The aim of this prospective study was to evaluate the current practice of antiplatelet therapy in patients with high grade stenosis of the internal carotid artery (ICA), who were referred by neurologists, stroke physicians and cardiologists for carotid endarterectomy. PATIENTS AND METHODS: Patients referred to our department for carotid endarterectomy with ICA stenosis (> 70% according to NASCET criteria) were prospectively evaluated regarding atherosclerosis risk factors and current antiplatelet therapy. During a 7 month period, 235 patients were scheduled for carotid endarterectomy. Their mean age was 70 years (range 42 years to 95 years), 91 patients were female (39%), 144 male (61%). 122 patients (52%) had a symptomatic ICA stenosis, 113 (48%) an asymptomatic ICA stenosis. RESULTS: Of the 235 patients, 29 were either on low molecular weight heparin or vitamin K antagonists for reasons other than ICA stenosis and were therefore excluded from analysis. Therefore, 206 patients (88%) were evaluated for antiplatelet therapy prescribed by their admitting physicians. Of these patients, 77 (37%) (42 (41%) symptomatic and 35 (34%) asymptomatic patients) did not receive any antithrombotic therapy prior to admission for surgery. The majority of patients received aspirin preoperatively (106 patients, 51.5%) 13 (6%) patients were on clopidogrel and 10 (5%) on dual therapy with Aspirin and clopidogrel. CONCLUSIONS: More than one third of patients awaiting carotid endarterectomy did not receive any antiplatelet therapy, despite high grade ICA stenosis. Since this practice does not meet the current guidelines, campaigns to increase the awareness of this problem are urgently needed.

[Diagnostic viewpoints in deep leg-/pelvic venous thrombosis]. / Diagnostische Gesichtspunkte bei tiefer Bein-/Beckenvenenthrombose.

In 60 to 90% of patients with deep vein thrombosis, successful recanalization with prevention of postthrombotic syndrome and decreased risk of pulmonary embolism can be achieved through early diagnosis and aggressive treatment, thrombolysis or surgical correction. In our experience, if treatment is delayed more than four days after onset, the results are unfavorable; in the latter case, provided necrotizing inflammation is not present, we treat only with anticoagulation. The indication for surgery is considered established if thrombolytic treatment is contraindicated, in the presence of necrotizing inflammation, if thrombolysis is unsuccessful and for recurrent pulmonary embolism which is carried out mostly with a caval filter. Anticoagulation alone in most patients will not lead to successful results. Sixty percent of deep vein thromboses arise ascending from lower leg thromboses. Further points of predilection are the junctions of the popliteal vein, the veins in the inguinal region and the caval bifurcation. In principle, any calf pain should suggest the possibility of beginning lower leg thrombosis. With regard to the history, it is important to know if the event is the first of its kind or recurrent (Table 1). Additionally, deep vein thrombosis may be suspected in the presence of local trauma, in women on contraceptives, in patients with hemoblastoses, after surgery in the lower pelvic or leg region and, in particular in women, in the presence of pelvic venous impediment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of resistance to subcutaneous insulin with implanted insulin infusion pumps]. / Behandlung der Resistenz gegen subkutanes Insulin mit implantierten Insulin-Infusionspumpen.

Four female patients, resistant to insulin administered subcutaneously, were treated with an implanted insulin infusion pump (Infusaid; constant rate infusion). They had all experienced as many as four episodes of ketoacidosis per month despite extremely high doses of insulin injected subcutaneously or intramuscularly, and none of the treatment approaches attempted--insulin delivery via subclavian catheter, Schade-port, insulin infusion with an external portable pump or various insulin additives--had been successful. After implantation of the pump the daily insulin dose, which had been between 300 and 3000 units during subcutaneous therapy, was reduced to 30 to 70 units per day. The patients' condition improved, no further episodes of ketoacidosis occurred and hospital stays were reduced significantly. In the further course of treatment pump and catheter-related complications had to be overcome.