Effectiveness and Tolerability of Fondaparinux vs Enoxaparin in a Population of Indian Patients with Symptomatic Deep Vein Thrombosis: A Retrospective Real-World Study.

BACKGROUND: Fondaparinux is the first approved anticoagulant drug among factor Xa inhibitors, with proven effectiveness and safety in preventing deep vein thrombosis. However, limited data are available supporting the benefit-risk profile of fondaparinux vs enoxaparin in a real-world group of Indian patients with deep vein thrombosis. OBJECTIVE: To compare the effectiveness and tolerability of fondaparinux vs enoxaparin in patients with symptomatic deep vein thrombosis in a long-term real-world setting. METHODS: Data from the electronic medical records of adult patients diagnosed with deep vein thrombosis prescribed fondaparinux (n = 503) or enoxaparin (n = 508) as monotherapy were analyzed. Effectiveness was analyzed in terms of recurrence, duration, and type of deep vein thrombosis event, and tolerability as bleeding events at initial hospitalization and follow-up visits up to 3 months duration. Appropriate statistical methods were used to determine the significance (p < 0.05) between the two groups. RESULTS: The deep vein thrombosis recurrence in the fondaparinux group was non-inferior (2.78%) when compared with enoxaparin (3.76%), with a mean duration of 47 and 48 days, respectively. The number of events and mean duration of events (in days) were not significant (p > 0.05). Major bleeding events were higher in the enoxaparin group at 3.17% than the fondaparinux group at 2.19%, and the difference was not statistically significant (p > 0.05). CONCLUSIONS: The weight-based, once-daily subcutaneous fondaparinux dose showed non-inferior effectiveness and a comparable tolerability profile when compared with the twice-daily enoxaparin dose for the management of symptomatic deep vein thrombosis.

Indocyanine Green Angiography to Prognosticate Healing of Foot Ulcer in Critical Limb Ischemia: A Novel Technique.

BACKGROUND: To predict wound healing in patients with critical limb ischemia (CLI) is an ongoing issue. Current methods such as ankle-brachial index (ABI), color Doppler and transcutaneous oxygen pressure (TCPO2), and computed tomography angiography are lacking in demonstrating regional perfusion. Indocyanine green angiography (ICGA) has the potential to provide regional perfusion information lacking in other methods. This study was conducted to demonstrate successes of revascularization procedure in CLI patients based on ICGA data. METHODS: A total of 47 patients with grade 2 or grade 3 University of Texas Wound Classification System ischemic foot ulcer undergoing lower limb revascularization procedure were included in this study, from July 2014 to May 2016. ICGA with intravenous 0.1 mg/kg of 0.1% indocyanine green dye was performed before and after revascularization procedure. ICGA data maximum unit, blush time, and blush rate were compared between prerevascularization and postrevascularization data, along with ABI and TCPO2. RESULTS: Out of 47 patients (45 males and 2 females), 43 underwent endovascular revascularization and 4 underwent open procedure. Of all, 76.6% of patients were diabetic and 46.8% were hypertensive. Also, 31.9% had coronary artery disease, 21.2% had history of cerebrovascular disease, 23% had chronic kidney disease, and 74.4% were chronic smokers. A total of 37 patients' ulcer healed completely on follow-up with significant improvement (P < 0.05) in preoperative and postoperative ABI, TCPO2, and ICGA data. Ten patients' ulcer did not heal in the follow-up period. In those 10 patients, preoperative and postoperative ABI and TCPO2 improved, but ICGA data were not improved postoperatively (P > 0.05). CONCLUSIONS: ICGA is an evolving tool to quantify regional perfusion in CLI. ICGA parameters provide qualitative real-time visual images of perfusion in area of interest as well as quantitative information of perfusion.

A Rare Entity: Traumatic Thoracic Aortic Injury in a Patient with Aberrant Right Subclavian Artery.

BACKGROUND: Aberrant right subclavian artery is an uncommon entity incidence ranging from 0.5 to 2.5%. Management of thoracic aortic injury in the presence of such anomalies can be a challenge. We present here a case of traumatic aortic injury, which was incidentally found to have an asymptomatic aberrant right subclavian artery. The patient was managed by an endovascular repair of thoracic aortic injury with an endograft and a right carotid to subclavian artery bypass as a hybrid procedure. METHODS: A 40-year male patient was brought to the emergency in shock with an alleged history of road traffic accident an hour back. After initial resuscitation as per advance trauma life support protocol, imaging revealed thoracic aortic injury with aberrant right subclavian artery with multiple rib and bilateral humerus fracture. After primary stabilization of arm fractures, the patient was shifted to a hybrid operation room. As the aortic injury was within 10 mm of the origin of both subclavian arteries, it was decided to cover the origin of both subclavian arteries and land the endograft distal to the left carotid artery origin. Since there was a right dominant vertebral artery on imaging, right carotid to right subclavian artery bypass was done with expanded polytetrafluoroethylene graft to prevent posterior circulatory stroke along with thoracic endovascular aortic repair to seal the thoracic aortic injury. RESULTS: After endovascular repair of thoracic aortic injury, left subclavian artery perfusion was maintained through left vertebral artery; and hence, revascularization of left subclavian artery was deferred. After management of all fractures, the patient was discharged 3 weeks after the date of admission without any complications. At 6 months follow-up, patient was stable and images showed patent bypass graft and sealed aortic injury. CONCLUSIONS: In a trauma setting with multiple injuries, hybrid procedure with a thoracic endograft is associated with low mortality and morbidity; hence, it is the treatment of choice for thoracic aortic injury over open surgical repair. A hybrid suite can be life and time saving in situations which mandate simultaneous endovascular repair along with surgical revascularization when indicated, especially in cases with aberrant aortic arch anatomy.

Traditional polypropylene and lightweight meshes in totally extraperitoneal inguinal herniorrhaphy.

BACKGROUND: Placement of a prosthetic mesh is integral to successful totally extraperitoneal (TEP) herniorrhaphy. Available meshes have supported the surgical efforts well but search for an ideal mesh continues. Post-herniorrhaphy pain is an index of patient reported outcomes (PRO). The pain is attributable to balloon dissection, cautery, sutures, tackers and prosthesis. Reducing polypropylene content of the mesh is associated with attenuated inflammatory response by the host and improved compliance and comfort. We report the difference in PROs in TEP herniorrhaphy with either heavy polypropylene (PPM) or light weight mesh (LWM) being used for the repair. PATIENTS AND METHODS: From June 2004 to December 2005, consecutive candidates for TEP herniorrhaphy were enrolled for this prospective study with an informed consent and compliance to Ethics guidelines. They were operated under general anesthesia (GA) on a day care basis using either PPM or LWM meshes as per the patient's choice. Operative and postoperative PRO were statistically analyzed by an independent doctor using the Microsoft Office Excel 2003. RESULTS: One hundred fourteen (84 PPMs and 30 LWMs) TEP herniorrhaphies were performed under GA on 57 male patients without any exclusion, on a day care basis. There was no technical difficulty, operative complications, conversion or prolonged hospital stay in either group. Patients of LWM reported better outcome in regards to pain, NSAID usage, seroma and recurrence. All patients of LWM reported an earlier return to activity. CONCLUSION: Light weight meshes result in comparatively better "patient reported outcomes" in TEP inguinal herniorrhaphy as compared to heavy polypropylene meshes.