A Systematic Review and Meta-analysis of 24 Month Patency After Endovenous Stenting of Superior Vena Cava, Subclavian, and Brachiocephalic Vein Stenosis.

OBJECTIVE: This systematic review and meta-analysis aimed to appraise recent evidence assessing patency outcomes at various time points in patients with superior vena cava, subclavian, and brachiocephalic vein stenosis who had undergone stenting. DATA SOURCES: PubMed, Scopus, and Cochrane Library databases were searched for studies up to December 2022. REVIEW METHODS: Measured outcomes included technical success rate, primary, primary assisted, and secondary patency at various time points. A subgroup analysis was also conducted to compare malignant and benign obstruction. GRADE was used to assess the certainty of evidence. RESULTS: Thirty nine studies reporting outcomes in 1539 patients were included in the meta-analysis. Primary patency up to 1 year after the procedure was 81.5% (95% CI 74.5 - 86.9%). Primary patency declined after 1 year to 63.2% (95% CI 51.9 - 73.1%) at 12 - 24 months. Primary assisted patency and secondary patency at ≥ 24 months were 72.7% (95% CI 49.1 - 88.0%) and 76.6% (95% CI 51.1 - 91.1%). In the subgroup analysis, primary patency was significantly higher in patients with a malignant stenosis compared with a benign stenosis at 1 - 3 and 12 - 24 months. No significant difference was seen for pooled secondary patency rates when comparing the malignant and benign subgroups. GRADE analysis determined the certainty of evidence for all outcomes to be very low. CONCLUSION: Stenting is an effective intervention for benign and malignant stenosis of the superior vena cava, subclavian, and brachiocephalic veins. Primary patency rates were good up to 1 year after the procedure, with 81.5% of stents retaining patency at 6 - 12 months. Patency rates declined after 1 year, to 63.2% primary and 89.3% secondary patency at 12 - 24 months, showing improved outcomes following re-intervention. High quality evidence is lacking. More research is needed to investigate patency outcomes and the need for surveillance or re-intervention programme.

Effect of thrombophilia on clinical outcomes of chronic post-thrombotic patients after iliofemoral stenting with nitinol venous stents.

OBJECTIVE: Thrombophilia is a prothrombotic condition that increases the risk of venous thromboembolism. It is unclear whether the presence of thrombophilia alters the clinical outcomes after deep venous stenting. The aim of the present study was to examine the relationship between thrombophilia and outcomes after stenting for post-thrombotic syndrome. METHODS: Consecutive patients (2012-2017) receiving a nitinol venous stent for chronic post-thrombotic venous occlusive disease with a minimum of 18 months of follow-up in one center using the same anticoagulation protocol were included. The clinical history and thrombophilia testing results were reviewed. The outcomes were stent patency, which was assessed using duplex ultrasonography at 24 hours, 2 and 6 weeks, 3 months, 6 months, and annually thereafter; and reinterventions, which were performed when the stent diameter was <50% or occluded. RESULTS: Of the 136 patients who had undergone intervention, 55 (40%) had had a provoked deep vein thrombosis (DVT) and 81 (60%) had had an unprovoked DVT and had therefore undergone thrombophilia testing. Of the 81 patients, 38 (47%) had had either inherited (n = 19; 50%) or acquired (n = 19; 50%) thrombophilia. Of the 136 patients who had undergone stenting, 68 had required reintervention (50%) during follow-up to maintain stent patency. Of the 55 patients with a provoked DVT, 29 (53%) had required reintervention. Of the 81 patients with an unprovoked DVT, 39 (48%) had required reintervention (P = .420). Of the 38 patients with unprovoked DVT and thrombophilia, 17 (45%) had required reintervention. Of the 43 patients with unprovoked DVT and no thrombophilia, 22 (51%) had required reintervention (P = .766). The cumulative patency rate was 80% for patients with provoked DVT and 88% for those with unprovoked DVT (P = .193). The presence of thrombophilia was not associated with patency loss (92% cumulative patency for patients with thrombophilia and 84% for patients without thrombophilia; P = .307). CONCLUSIONS: Using our anticoagulation protocol, patients with and without thrombophilia had similar clinical outcomes after deep venous stenting and should not be excluded from iliofemoral venous stenting. We found no significant differences in outcomes in conjunction with appropriate postoperative anticoagulation therapy.

VenaSeal closure despite allergic reaction to n-butyl cyanoacrylate.

The VenaSeal closure system (Medtronic, Minneapolis, Minn) is a nonthermal, minimally invasive method for the treatment of superficial venous insufficiency using a proprietary n-butyl cyanoacrylate. We report the case of a 45-year-old woman who underwent right great saphenous vein closure with VenaSeal and subsequently had a biphasic reaction to n-butyl cyanoacrylate, confirmed on patch testing that had negative results for other cyanoacrylates. Despite the initial allergic response, which settled with antihistamines, follow-up duplex ultrasound imaging confirmed successful great saphenous vein closure, and the affected vein remained in situ without further complication.

Time-to-death in chronic respiratory failure on home mechanical ventilation: A cohort study.

BACKGROUND AND OBJECTIVE: Home mechanical ventilation (HMV) is used in heterogeneous conditions underlying chronic hypercapnic respiratory failure, but there are sparse data on long-term clinical outcomes. The aim was to systematically analyse the time and the circumstances of death on HMV. METHODS: All-cause mortality data of HMV patients were prospectively collected between 2008 and 2018 in a large tertiary centre. Data were categorised into diagnostic groups including neuromuscular disease (NMD), chest wall disease (CWD), chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome (OHS), overlap syndrome of COPD and OSA (overlap) and other group. The primary outcome was time-to-death from initiation of HMV. RESULTS: 1210 deaths were recorded over a 10-year period. Median time-to-death was 19.5 [6-55] months and differed between groups (Kruskal Wallis p < 0.001). CWD (98.5 [23.5-120] months) and slowly progressive NMD (64.5 [28-120] months) had the longest time-to-death on HMV, while OHS (33 [13-75] months) and overlap syndrome (30.5 [14.5-68.5] months) had a longer median time-to-death than COPD (19.5 [7-42.5] months) and motor neurone disease (7 [3-14] months). Daily adherence to HMV of greater than 4 h/night was associated with better outcomes (10 [3-24] vs. 30 [10-76] months; p < 0.001). 43% with confirmed location of death died outside the hospital. CONCLUSIONS: The time-to-death on home mechanical ventilation varies widely across disease groups with chronic respiratory failure and seems to be associated with daily usage time. TRIAL REGISTRATION: researchregistry.com UIN: researchregistry4122.

Deathbed Confession: When a Dying Patient Confesses to Murder: Clinical, Ethical, and Legal Implications.

During an initial palliative care assessment, a dying man discloses that he had killed several people whilst a young man. The junior doctor, to whom he revealed his story, consulted with senior palliative care colleagues. It was agreed that legal advice would be sought on the issue of breaching the man's confidentiality. Two legal opinions conflicted with each other. A decision was made by the clinical team not to inform the police. In this article the junior doctor, the palliative medicine specialist, a medical ethicist, and a lawyer consider the case from their various perspectives.

Severe peri-renal sepsis in established renal failure masquerading as an acute abdominal catastrophe.

Severe worsening lactic acidosis in an elderly patient following an episode of atrial fibrillation, who is not haemodynamically compromised, usually indicates an intra-abdominal vascular catastrophe. We describe a unique case of severe peri-renal sepsis in a patient with long-standing dialysis-dependent chronic kidney disease unrelated to urolithiasis that masqueraded as an acute abdominal condition requiring emergency laparotomy and nephrectomy.

The emergency surgical team - the way forward in emergency care?

INTRODUCTION: With reduced working hours and shift patterns, surgical training and continuity of patient care is being put at risk. We have devised a system for managing the emergency surgical patients in an effort to counteract these perceived problems. This study describes the emergency surgical team and audits its activity. PATIENTS AND METHODS: The emergency surgery team concept is described in detail. Over a 2-week period, general surgical referral data, patient management and operative activity were audited. RESULTS: A total of 229 patients were referred to the emergency surgical team with 159 treated conservatively, 45 underwent operative intervention and 25 were discharged without admission. Of the emergency surgical team referrals, 58% had gallstone pathology, appendicitis or constipation/non-specific abdominal pain. Average daily number of patients under the care of the emergency surgical team was 26 (range, 10-40). CONCLUSIONS: The consultant-led emergency surgical team look after many of the acutely sick surgical patients. Our system not only provides good teaching opportunities but ensures optimal continuity of patient care in a busy district general hospital. Such an approach to emergency surgical care has been successfully developed to optimise training opportunities and improve patient care in a setting of reduced working hours and shift systems in our hospital.