Effective instruction of vascular anastomosis in the surgical skills laboratory.

BACKGROUND: A greater emphasis has recently been placed on laboratory-based training of core surgical skills and tasks, such as vascular anastomosis. Despite this emphasis, little objective data exist regarding the effectiveness of vascular anastomosis instruction in the laboratory setting. METHODS: Residents of all postgraduate levels received laboratory-based vascular anastomosis training. Each individual fashioned an end-to-side anastomosis between synthetic graft and porcine aorta before instruction (pretest). All subjects then received standardized anastomosis training with practice time. After training, the anastomosis was then repeated (posttest). Metrics included time to completion, anastomotic leakage, and visual characteristics of the completed product. RESULTS: Postteaching improvement was demonstrated by all residents (n = 32). Posthoc analysis showed statistically significant improvements in junior residents only. CONCLUSIONS: Laboratory-based training can effectively improve the ability of residents to perform vascular anastomosis immediately after training. Junior residents may gain a greater advantage from laboratory teaching.

Effect of antiplatelet agents clopidogrel, aspirin, and cilostazol on circulating tissue factor procoagulant activity in patients with peripheral arterial disease.

Tissue factor (TF) is the physiological initiating mechanism for blood coagulation. Platelets play an important role in monocyte TF expression, thrombosis and inflammation. Aspirin, clopidogrel and cilostazol, which inhibit platelet responses by different mechanisms, are widely used in patients with arterial diseases. We tested the hypothesis that platelet-inhibiting agents inhibit the levels of circulating TF procoagulant activity (TF-PCA) in patients with peripheral arterial disease (PAD). Twenty-six patients with lower extremity PAD, average age 65.9 +/- 8.4 years (mean +/- SEM), were studied at baseline and following sequential two-week treatment regimens with aspirin (325 mg daily), clopidogrel (75 mg daily) or a phosphodiesterase inhibitor cilostazol (100 mg twice daily) singly, and with each possible combination of these agents. Circulating TF-PCA in whole blood, and plasma factor VIIa, prothrombin fragment F1.2, thrombin-antithrombin complexes (TAT), and P-selectin were measured. Baseline TF-PCA levels in the patients were elevated (131 +/- 19 U/ml) compared to control subjects (23 +/- 2, p < 0.0001). TF-PCA levels declined following treatment with clopidogrel alone, and with combinations of clopidogrel with aspirin or cilostazol, with the lowest levels being with the triple-drug combination. Plasma P-selectin declined in all treatment groups. No changes were noted in plasma factor VIIa, F1.2 or TAT. In conclusion, treatment of PAD patients with antiplatelet agents decreases circulating TF, a molecule with prothrombotic and proinflammatory effects. These findings suggest an unrecognized mechanism, beyond inhibiting aggregation responses, for the efficacy of antiplatelet drugs in patients with arterial diseases.

Managing PAD with multiple platelet inhibitors: the effect of combination therapy on bleeding time.

PURPOSE: Patients with lower-extremity peripheral arterial disease (PAD) face a high risk of cardiovascular morbidity and mortality. Platelet inhibition (PI) significantly reduces this risk. Combination PI is common and increasingly indicated in patients with PAD; however, the effect on platelet function has not been objectively evaluated. Aspirin (ASA), clopidogrel (Clop), and cilostazol (Cilo) are the three most commonly used PI drugs in patients with PAD. A prospective, sequential evaluation of platelet function using the template bleeding time (BT) was performed for PAD patients taking these medications singly and in combination. METHODS: Twenty-one patients with PAD, averaging 65.9 years of age, were studied. Patients were placed on sequential two-week regimens of the following therapies: washout (no PI), ASA (325 mg daily), ASA + Cilo (100 mg twice daily), washout, Cilo, Cilo + Clop (75 mg each day), washout, Clop, Clop + ASA, and Clop + ASA + Cilo. At the end of each phase, trained personnel measured the BT. RESULTS: Baseline bleeding time for the group was 4.29 +/- 1.69 minutes. ASA (BT = 6.64 +/- 3.52) and Clop (BT = 10.17 +/- 5.4) significantly prolonged bleeding time (P < 0.01); however, no significant effect was observed with Cilo alone (BT = 5.41 +/- 2.69). Combined treatment with ASA + Clop (BT = 17.39 +/- 4.59) had a more pronounced effect on BT compared with either agent alone (P < 0.01). The addition of Cilo to either ASA (BT = 8.3 +/- 4.27) or Clop (BT = 12.7 +/- 7.46) or the combination of ASA + Clop (BT = 17.92 +/- 4.69) did not prolong BT. CONCLUSION: All patients with PAD require platelet inhibition, and many require pharmacotherapy for intermittent claudication. The platelet inhibitors aspirin and clopidogrel are used for the reduction of ischemic events. They significantly prolong bleeding time individually and to a greater extent in combination. Cilo is used to improve walking distance in patients with intermittent claudication. When Cilo is added to ASA, Clop, or the combination of the two, there is no additional increase in bleeding time. Therefore, Cilo can be used in combination with other platelet inhibitors without an additional effect on platelet function as reflected by the bleeding time.

Occult cardiac lymphoma presenting with cardiac tamponade.

Subxiphoid pericardiostomy is the procedure of choice for treatment of a pericardial effusion with tamponade. We report a case in which this procedure not only failed to reveal the presence of an occult malignancy, but also resulted in a recurrent symptomatic effusion.