Current treatment strategies for primary upper extremity deep venous thrombosis; a retrospective observational multicenter case series.

Introduction: Current treatment strategies for primary upper extremity deep venous thrombosis (pUEDVT) range from conservative treatment with anticoagulation therapy to invasive treatment with thoracic outlet decompression surgery (TOD), frequently combined with catheter directed thrombolysis, percutaneous transluminal angioplasty, or stenting. Due to a lack of large prospective series with uniform data collection or a randomized trial, the optimal treatment strategy is still under debate. We conducted a multicenter observational study to assess the efficacy and safety of both the conservative and invasive treatment strategies for patients with pUEDVT. Methods: We retrospectively collected data from patients treated in five vascular referral and teaching hospitals in the Netherlands between 2008 and 2019. Patients were divided into a conservative (Group 1), an invasive treatment group (Group 2) and a cross-over group (Group 3) of patients who received surgical treatment after initial conservative therapy. Follow-up consisted of outpatient clinic visits and an electronic survey. Primary outcome was symptom free survival defined as absence of any symptom of the affected arm reported at last follow-up regardless of severity, or extent of functional disability. Secondary outcomes were incidence of bleeding complications, recurrent venous thromboembolism, surgical complications, and reinterventions. Results: A total of 115 patients were included (group 1 (N = 45), group 2 (N = 53) or group 3 (N = 27). The symptom free survival was 35.6%, 54.7% and 48.1% after a median follow-up of 36, 26 and 22 months in groups 1, 2 and 3 respectively. Incidence of bleeding complications was 8.6%, 3.8% and 18.5% and recurrent thrombosis occurred in 15.6%, 13.2% and 14.8% in groups 1-3 respectively. Conclusion: In this multicenter retrospective observational cohort analysis the conservative and direct invasive treatments for pUEDVT were deemed safe with low percentages of bleeding complications. Symptom free survival was highest in the direct surgical treatment group but still modest in all subgroups. Perioperative complications were infrequent with no related long term morbidity. Of relevance, pUEDVT patients with confirmed VTOS and recurrent symptoms after conservative treatment may still benefit from TOD surgery. However, symptom free survival of this delayed TOD seems lower than direct surgical treatment and bleeding complications seem to occur more frequently.

Risk Chart for Future Mortality and Ischaemic Events Following Peripheral Bypass Surgery.

OBJECTIVES: A prediction model to identify determinants and quantify the risk of future ischaemic events in patients with peripheral arterial disease (PAD) provides a personal risk profile to offer individualized patient care. A risk chart was derived and validated in patients who received infrainguinal bypass surgery. METHODS: The Bypass Oral anticoagulants or Aspirin Risk Chart (BOA-RC2) was based on a pre-defined subgroup of the Dutch BOA trial (N = 482), the derivation cohort. The primary outcome event for BOA-RC2 was the composite of all cause death, non-fatal myocardial infarction, or non-fatal ischaemic stroke during a 10 year follow up. Determinants and long-term risk were identified with multivariate Cox regression analyses. Validation of the BOA-RC2 was performed in the remaining patients of the complete BOA trial cohort (N = 2,650 - 482 = 2,168), the validation cohort. RESULTS: The primary outcome event occurred in 67% (321/454) of the derivation cohort and in 66% (1,371/2,083) of the validation cohort during a median follow up of 6.6 years. The BOA-RC2 included the following determinants: age, critical limb ischaemia, diabetes, and a prior vascular intervention. The performance of the BOA-RC2 was good with a Brier score of 0.19, an area under the curve of 0.73, and a Hosmer-Lemeshow statistic of p = .9. CONCLUSIONS: The BOA-RC2 proves to be fit for the prediction of mortality and major ischaemic events in patients after peripheral bypass surgery. The BOA-RC2 can be used to adequately inform the patient about his/her risk of future events in an illustrative manner and stress the necessity of preventative measures, such as lifestyle adjustments, screening for risk factors, and drug treatments. In the future, the BOA-RC2 may be of interest to identify patients at high risk of mortality and ischaemic events for clinical research on new therapeutic options.

Young women with PAD are at high risk of cardiovascular complications.

OBJECTIVES: Prognostic research in patients with peripheral arterial disease (PAD) is scarce and determinants of outcome are mainly studied in males. The current management of PAD in women is based on evidence from, at best, mixed populations. We therefore assessed risk and prognostic factors in 313 men and 169 women from the Dutch Bypass Oral anticoagulants or Aspirin Study of whom long-term follow-up data were available. METHOD: The primary composite outcome event was vascular death, myocardial infarction, stroke, or major amputation during 5 years of follow-up. Variables with a p-value <0.2 in the univariate analyses were added to the multivariate Cox proportional hazards model. RESULTS: Females were older (71 vs. 68 years; p < 0.01), had more advanced PAD (critical limb ischemia (CLI) 52.1 vs. 42.2%; p = 0.04), more often had peripheral bypass surgery as primary intervention (50.5 vs. 32.5%; p < 0.01), and had more often hypertension (48.5 vs. 33.2%; p < 0.01) than males. Males were more often smokers (63.6 vs. 53.3%; p = 0.03) and had more prior myocardial infarctions (18.5 vs. 10.1%; p = 0.02). In total 170 events occurred, 74 (44%) in females and 96 (31%) in males. Overall, independent risk factors for the primary outcome event were age and critical limb ischemia. Independent risk factors in males were: age (HR: 1.06, 95% CI: 1.03-1.09), critical limb ischemia (HR: 1.7, 95% CI: 1.05-2.7), and diabetes mellitus (HR: 1.7, 95% CI: 1.01-2.8) and in females critical limb ischemia (HR: 3.5, 95% CI: 2.0-6.1), ABI≤0.9 (HR: 2.8, 95% CI: 1.2-6.1), and femorocrural bypass (HR: 1.9, 95% CI: 1.1-3.3). Although sex was not an independent risk factor in the overall analysis, women younger than 60 years had an increased risk for cardiovascular events compared to men of that age (HR: 4.9, 95% CI: 1.8-13.6), whereas no difference was seen above 60 years of age. CONCLUSIONS: Risk factors for cardiovascular events in patients with PAD differ between men and women. To our knowledge, this is the first study that shows such a bad outcome in female patients younger than 60 years of age. More awareness leading to early diagnosis and optimal treatment might improve long-term clinical outcome in (young) women with PAD.

Medical treatment after peripheral bypass surgery over the past decade.

OBJECTIVE: The Dutch Bypass and Oral anticoagulants or Aspirin (BOA) Study demonstrated that in patients with peripheral arterial disease after bypass surgery oral anticoagulants were more effective in preventing venous graft occlusions than aspirin, while aspirin was more effective in non-venous grafts. We evaluated if this finding was implemented in the clinical practice of former BOA participants by reconstructing a 10-year overview of their applied various drug treatments including anti-hypertensive and lipid-lowering drugs. METHODS: In 482 patients from six centers that contributed most patients anti-thrombotic, anti-hypertensive, and lipid-lowering drug use was recorded at baseline (n = 478), retrospectively up to two years after BOA (n = 388), and prospectively for patients still alive between 2005 and 2009 (n = 209). RESULTS: At baseline, 54% of patients received anti-thrombotics which increased to 96% at follow-up. At baseline 15% of patients were treated with lipid-lowering drugs and 49% with anti-hypertensives. This increased over time to 65% and 76%, respectively. CONCLUSION: After the BOA Study its recommendations were applied marginally. Despite improvements over time, current lipid-lowering and anti-hypertensive drug use remained suboptimal. Our trend analyses, however, should be interpreted with caution, because drug use and compliance in survivors might be better than average.

Does folate therapy reduce the risk of coronary restenosis?

BACKGROUND.: A high homocysteine level is associated with an increased risk of ischaemic heart disease. Folate therapy has shown to reduce the homocysteine blood level, but does it decrease the risk of coronary restenosis in patients with coronary arterial disease? METHODS.: A systematic online literature search followed by a critical appraisal resulted in three suitable articles to provide an evidence-based evaluation of this clinical query. RESULTS.: The rate of coronary restenosis was reduced after folate therapy, except in patients who have had coronary stenting. An adverse effect of folate therapy on in-stent coronary restenosis was observed. CONCLUSION.: The effects of folate therapy on the rate of coronary restenosis after balloon angioplasty are contradicting. Until more clinical research has been preformed we recommend a conservative attitude towards folate therapy. (Neth Heart J 2007;15:12-5.).

Adenoidectomy and/or tonsillectomy in childhood is not associated with atopic disease later in life.

OBJECTIVE: To investigate the association between adenoidectomy and/or tonsillectomy in childhood and asthma, allergic rhinitis (AR), and eczema in adolescence. METHODS: Longitudinal birth cohort study of 1328 members born in the city of Nijmegen. Information on ear-nose-throat surgery was documented at 2, 4, and 8 years of age. In 1055 cohort members the incidence of asthma, AR, and eczema at 21 years of age was determined using the International Study of Asthma and Allergic disease in Childhood Core Questionnaire. To analyse the association between adenoidectomy and/or tonsillectomy in childhood and asthma, AR, and eczema at age 21 years, relative risks (RR) were calculated. RESULTS: Six hundred and ninety-three (66%) members completed the questionnaire at age 21 years, of whom 104 (15%) had undergone adenoidectomy and/or tonsillectomy and 262 (38%) reported atopic disease. Children who underwent adenoidectomy and/or tonsillectomy before the age of 8 years were not more likely to develop asthma, AR, or eczema at the age of 21 years than children who did not; RR 0.93 (95% confidence limits (CL) 0.52-1.64), RR 0.94 (CL 0.68-1.30), and RR 1.00 (CL 0.59-1.68), respectively. CONCLUSIONS: Our data show no association between adenoidectomy and/or tonsillectomy in childhood and the incidence of atopic disease in young adults.