A Comprehensive Review of Risk Factors and Thrombophilia Evaluation in Venous Thromboembolism.

Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant cause of morbidity and mortality worldwide. There are many factors, both acquired and inherited, known to increase the risk of VTE. Most of these result in increased risk via several common mechanisms including circulatory stasis, endothelial damage, or increased hypercoagulability. Overall, a risk factor can be identified in the majority of patients with VTE; however, not all risk factors carry the same predictive value. It is important for clinicians to understand the potency of each individual risk factor when managing patients who have a VTE or are at risk of developing VTE. With this, many providers consider performing a thrombophilia evaluation to further define a patient's risk. However, guidance on who to test and when to test is controversial and not always clear. This comprehensive review attempts to address these aspects/concerns by providing an overview of the multifaceted risk factors associated with VTE as well as examining the role of performing a thrombophilia evaluation, including the indications and timing of performing such an evaluation.

Carotidynia: revisiting an unfamiliar entity.

Carotidynia (unilateral neck pain reproducible with light pressure on the carotid artery) is a controversial and poorly understood vascular condition. This review provides important historical information, several representative case reports, and a comprehensive summary of the literature. The authors also propose an algorithm for the care of these patients.

Does a standardization tool to direct invasive therapy for symptomatic lower extremity peripheral arterial disease improve outcomes?

OBJECTIVES: While decision analysis and treatment algorithms have repeatedly been shown to improve quality of care in many areas of medicine, no such algorithm has emerged for the invasive management of lower extremity peripheral arterial disease. Using the best available evidence-based outcomes data, our group designed a standardization tool, the Lower Extremity Grading System (LEGS) score, which consistently directs limbs to a specific treatment on the basis of presentation. The purpose of this study was to examine whether use of such a tool improves outcomes by directing treatment of lower extremity peripheral arterial disease. METHODS: Over 18 months (July 2001-December 2002) our group intervened in 673 limbs (angioplasty, open surgery, primary limb amputation) with lower extremity peripheral arterial disease. During this time we developed the LEGS score, and implemented its prospective use for the final 362 limbs. For the purpose of this study, all 673 limbs were retrospectively scored with the LEGS score to determine the LEGS recommended best treatment. Of the 673 limbs, 551 (81.9%) received the same treatment as recommended with LEGS and 122 (18.1%) received treatment contrary to LEGS. Limbs treated contrary to LEGS (cases) were then compared with matched control limbs (treated according to LEGS), with similar angiographic findings, clinical presentation, preoperative functional status, comorbid conditions and operative technical factors. Outcomes measured at 6 months included arterial reconstruction patency, limb salvage, survival, and maintenance of ambulatory status and independent living status. Kaplan-Meier curves were used to assess patency, limb salvage, and survival; associated survival curves were compared with the log-rank test. Functional outcomes were compared with the Fisher exact test. RESULTS: After matching case limbs with control limbs, 9 limbs had no control match. Thus 113 limbs in 100 patients treated contrary to LEGS were compared with 113 limbs in 100 patients treated according to LEGS. Limbs treated contrary to LEGS resulted in significantly inferior outcomes at 6 months for measures of primary patency (57.5% vs 84.3%; P < .001), secondary patency (73.2% vs 96.2%; P < .001), limb salvage (89.7% vs 97.2%; P = .04), and maintenance of ambulatory status (78% vs 92%; P = .02). As an additional finding, 29.6% (92 of 311) of interventions performed before implementation of the algorithm were treated contrary to LEGS, and thus contrary to objectively determined best therapy, compared with 8.3% (30 of 362) after LEGS implementation (P < .001). CONCLUSIONS: Limbs treated according to our standardization tool resulted in better outcomes compared with limbs treated contrary to the algorithm. These data suggest that routine use of an appropriately validated treatment standardization algorithm is capable of improving overall results for invasive treatment of lower extremity peripheral arterial disease.

An analysis of standard open and endovascular surgical repair of abdominal aortic aneurysms in octogenarians.

While elective open abdominal aortic aneurysm (AAA) repair has been shown to be safe in selected octogenarians, very little is known about the role of endovascular AAA exclusion in this high-risk cohort. A retrospective review of our vascular surgical registry from January 1996 to December 2001 revealed 51 octogenarians that underwent infrarenal AAA repair. Since 1999 all octogenarians who presented for AAA repair were evaluated for preferential endovascular stent graft placement. Over the 6-year period, 35 patients underwent standard open repair while 16 patients were found to be anatomic candidates for and were treated with an endovascular stent graft. Hospital and office charts were reviewed to compare the endovascular cohort to the standard open cohort. Factors considered included patient comorbidities, perioperative data, and operative outcomes. Statistical analysis was done using Wilcoxon rank sum test and Fisher exact test. The median age for the entire group was 83 years. There were 11 females in the open group and 1 female in the endovascular group. There were no statistically significant differences in preoperative patient comorbidities between groups. Total mortality for the entire series was 11.8 per cent but this included 5 ruptured AAAs, all of which patients died, and 11 additional AAAs that were symptomatic, of which 1 patient died. Total nonruptured mortality for the entire series was 2.2 per cent (0% for the endo-group and 3.3% for the open group). There were statistically significant differences between the endovascular versus the open groups when comparing aneurysm diameter (5.6 cm vs. 6.2 cm; P = 0.016), estimated blood loss (225 cc vs. 2100 cc; P < 0.001), ICU days (0 vs. 3; P < 0.001), length of hospital stay (2 days vs. 12 days; P < 0.001), and patients with blood transfusions (1 vs. 27; P < 0.001). When comparing postoperative morbidities, 4 of the endovascular patients (25%) and 25 of the open patients (68.6%) had a complication (P = 0.006). In conclusion, endovascular stent graft treatment of nonruptured infrarenal AAAs in octogenarians led to significantly better outcomes and should probably be considered the preferred treatment whenever anatomically appropriate. Endovascular exclusion of ruptured AAAs may potentially improve future outcomes in this high-risk group.

The LEGS score: a proposed grading system to direct treatment of chronic lower extremity ischemia.

OBJECTIVE: To prospectively compare the Lower Extremity Grading System (LEGS)-derived "recommended treatment" to the actual treatment performed and to analyze LEGS intergrader scoring consistency by comparing blinded scoring results between physician graders. SUMMARY BACKGROUND DATA: Due to technical advances and the increased medical complexity of the aging population, the most appropriate treatment for chronic lower extremity ischemia-open surgery versus endovascular-is again in flux. In an attempt to standardize management, the LEGS score, based on the best available outcomes data, was devised by the physicians of an established vascular service. METHODS: From March to June 2002, all chronically ischemic lower extremities that met standard indications for revascularization were prospectively enrolled and independently graded with the LEGS score by an "endovascular surgeon" and an "open surgeon" for comparative analysis. The results were then blindly evaluated to determine whether the LEGS-derived "recommended treatment" agreed with the actual treatment rendered and to assess for intergrader consistency. Agreement was assessed using kappa statistical analysis. RESULTS: Of the 137 presenting limbs (mean patient age 66.4 yo; 43% claudication, 57% limb-threatening ischemia), 107 were treated (65% endovascular, 30% open surgery, 5% amputation), 16 were pending treatment, and 14 were not treated because of patient refusal (n = 13) or death (n = 1). The LEGS score predicted the actual or offered clinical treatment in 90% of cases. The LEGS score comparison between physician graders resulted in identical "recommended treatment" in 116 of 128 cases for a 90.6% agreement. CONCLUSIONS: A reproducible scoring system to guide the treatment of patients with chronic lower extremity ischemia is possible. While systems like the LEGS score may have potential clinical application, their use as a treatment standardization tool for future prospective outcomes comparisons between open and endovascular surgery will be essential.