Results From the United States Chronic Thromboembolic Pulmonary Hypertension Registry: Enrollment Characteristics and 1-Year Follow-up.

BACKGROUND: The United States Chronic Thromboembolic Pulmonary Hypertension Registry (US-CTEPH-R) was designed to characterize the demographic characteristics, evaluation, clinical course, and outcomes of surgical and nonsurgical therapies for patients with chronic thromboembolic pulmonary hypertension. RESEARCH QUESTION: What are the differences in baseline characteristics and 1-year outcomes between operated and nonoperated subjects? STUDY DESIGN AND METHODS: This study describes a multicenter, prospective, longitudinal, observational registry of patients newly diagnosed (< 6 months) with CTEPH. Inclusion criteria required a mean pulmonary artery pressure ≥ 25 mm Hg documented by right heart catheterization and radiologic confirmation of CTEPH. Between 2015 and 2018, a total of 750 patients were enrolled and followed up biannually until 2019. RESULTS: Most patients with CTEPH (87.9%) reported a history of acute pulmonary embolism. CTEPH diagnosis delays were frequent (median, 10 months), and most patients reported World Health Organization functional class 3 status at enrollment with a median mean pulmonary artery pressure of 44 mm Hg. The registry cohort was subdivided into Operable patients undergoing pulmonary thromboendarterectomy (PTE) surgery (n = 566), Operable patients who did not undergo surgery (n = 88), and those who were Inoperable (n = 96). Inoperable patients were older than Operated patients; less likely to be obese; have a DVT history, non-type O blood group, or thrombophilia; and more likely to have COPD or a history of cancer. PTE resulted in a median pulmonary vascular resistance decline from 6.9 to 2.6 Wood units (P < .001) with a 3.9% in-hospital mortality. At 1-year follow-up, Operated patients were less likely treated with oxygen, diuretics, or pulmonary hypertension-targeted therapy compared with Inoperable patients. A larger percentage of Operated patients were World Health Organization functional class 1 or 2 at 1 year (82.9%) compared with the Inoperable (48.2%) and Operable/No Surgery (56%) groups (P < .001). INTERPRETATION: Differences exist in the clinical characteristics between patients who exhibited operable CTEPH and those who were inoperable, with the most favorable 1-year outcomes in those who underwent PTE surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT02429284; URL: www.clinicaltrials.gov.

Pulmonary Endarterectomy in Latvia: A National Experience.

Background and objectives: Chronic thromboembolic pulmonary hypertension (CTEPH) is a hemodynamic state characterized by chronic obstruction in pulmonary circulation. The treatment of choice is pulmonary endarterectomy (PEA). The aim of our study was to compile and analyze the data of a small, national center, which has not yet been done in the Baltic states. Materials and methods: The data of Latvian CTEPH registry in timeframe from 1 September 2007 to 31 December 2016 was retrospectively analyzed and all patients who underwent PEA were included. Results: PEA was done for 7 patients. The in-hospital mortality was 14%. The 3-year survival rate was 86%. The procedure restored pulmonary blood pressure to normal values for three of the patients (42%). The remaining four patients (57%) had persistent pulmonary hypertension (mPAP > 30 mmHg), which required continuous therapy. There was a comparable decline in mean mPAP compared to baseline, 53.4 ± 14.4 mmHg to 44.3 ± 30 mmHg, respectively. At 12-month follow-up, there was a significant improvement in functional capacity, as seen by increased 6-min walk test distance and shifts in New York Heart Association functional class. Conclusions: Only 16% of all prevalent Latvian CTEPH patients have underwent PEA in the course of nine years, despite it being the treatment of choice for CTEPH. As PEA and other emerging treatment options, such as balloon pulmonary angioplasty, can only be done in expert centers, numerous organizational, logistical, and economic issues arise for patients of smaller countries, where such centers have not yet been created due to lack of experience and limited amount of patients.

Frequency of Coronary Endarterectomy in Patients Undergoing Coronary Artery Bypass Grafting at a Single Tertiary Texas Hospital 2010 to 2016 With Morphologic Studies of the Operatively Excised Specimens.

This study examines the frequency of coronary endarterectomy (CE) procedures during coronary artery bypass grafting (CABG), and determines the quantity of plaque in the specimens. Of the 2,268 CABG operations performed from January 2010 to June 2016, 35 patients had CE during CABG. The specimens were incised into 5-mm cross sections, stained by the Movat method, and examined. The number of CEs performed ranged from 0.21% to 4.01%. A total of 140 cm of specimens were examined, and all 140 cm contained considerable quantities of atherosclerotic plaque and narrowed lumens. The quantity of plaque present was similar to or greater than that observed in previously studied patients with fatal coronary artery disease. The frequency of CE during CABG varies greatly in surgeons. The quantity of plaque is enormous, and the lumens are severely narrowed.

Diagnosis and Treatment of Traumatic Cerebrovascular Injury: Pitfalls in the Management of Neurotrauma.

Traumatic cerebrovascular injury (TCVI) is an uncommon clinical entity in traumatic brain injury (TBI), yet it may cause devastating brain injury with high morbidity and mortality. Early recognition and prioritized strategic treatment are of paramount importance. A total of 1966 TBI patients admitted between 1999 and 2015 in our tertiary critical care center were reviewed. Screening of TCVI was based on the Guidelines for the Management of Severe Head Injury in Japan. TCVI was confirmed in 33 (1.7%) patients; 29 blunt and 4 penetrating injuries. The primary location of the injury included 16 cervical, 6 craniofacial, and 11 intracranial lesions. On arrival, 15 patients presented with hemorrhage, 5 of these arrived in shock status with massive hemorrhage. Ten presented with ischemic symptoms. Sixteen patients underwent surgical or endovascular intervention, 13 of whom required immediate treatment upon arrival. Surgical procedures included clipping or trapping for traumatic aneurysms, superficial temporal artery - middle cerebral artery bypass, carotid endarterectomy, and direct suture of the injured vessels. Endovascular intervention was undertaken in 7 patients; embolization with Gelfoam (Pharmacia and Upjohn Company, Kalamazoo, MI, USA) or coil for 6 hemorrhagic lesions and stent placement for 1 lesion causing ischemia. Patients' outcome assessed by the Glasgow Outcome Scale at 3 months were good recovery in 8, moderate disability in 3, severe disability in 9, persistent vegetative state in 1, and death in 12, respectively. In order to rescue potentially salvageable TCVI patients, neurosurgeons in charge should be aware of TCVI and master basic skills of cerebrovascular surgical and endovascular procedures to utilize in an emergency setting.

Time-dependent trends in cardiovascular adverse events during follow-up after carotid or iliofemoral endarterectomy.

BACKGROUND: Recent observations have suggested a decline in vulnerable carotid artery and iliofemoral atherosclerotic plaque characteristics over the past decade. The aim of this study was to determine whether, in the presence of clinically manifest carotid or peripheral artery disease, secondary adverse cardiovascular events decreased over this period. METHODS: Patients included in the Athero-Express biobank between 2003 and 2012 were analysed. During 3-year follow-up, composite cardiovascular endpoints were documented yearly, including: myocardial infarction, coronary interventions, stroke, peripheral interventions and cardiovascular death. The major cardiovascular endpoint consisted of myocardial infarction, stroke and cardiovascular death. RESULTS: Some 1684 patients who underwent carotid endarterectomy (CEA) and another 530 who had iliofemoral endarterectomy (IFE) were analysed. In total, 405 (25·2 per cent) and 236 (45·9 per cent) patients had a composite cardiovascular endpoint within 3 years after CEA and IFE respectively. Corrected for possible confounders, the percentage of patients with a secondary cardiovascular event after CEA did not change over time (hazard ratio (HR) 0·91, 95 per cent c.i. 0·65 to 1·28; P = 0·590, for 2011-2012 versus 2003-2004). In patients who had IFE, the incidence of secondary cardiovascular events significantly decreased only in the last 2 years (HR 0·62, 0·41 to 0·94; P = 0·024), owing to a decrease in peripheral (re)interventions in 2011-2012 (HR 0·59, 0·37 to 0·94; P = 0·028). No decrease in major cardiovascular events was observed in either group. CONCLUSION: In patients who had undergone either CEA or IFE there was no evidence of a decrease in all secondary cardiovascular events. There were no differences in major cardiovascular events.

[Effect of pulmonary endarterectomy on six-minute walking test and echocardiography in the early stage]. / Pulmoner endarterektominin erken dönemde alti dakika yürüme testi ve ekokardiyografi parametrelerine etkisi.

OBJECTIVE: Pre- and postoperative changes in echocardiographic parameters and results of 6-minute walking test (6-MWT) were investigated in the present study. METHODS: Seventy-six patients (32 males, 44 females; mean age 45.9±15.1 years) were included. Before and after surgery, 6-MWT and echocardiography were performed. Changes in postoperative parameters were compared to basal walking test and other basal parameters. RESULTS: Distance covered in 6-MWT significantly increased after surgery (p<0.001). Significant decrease in right ventricular diameter and pressure, and significant increase in left ventricular diameter were also observed. While changes in ejection fraction (EF) were not significant, significant reduction in systolic pulmonary artery pressure (sPAP) and tricuspid regurgitation were observed. No statistically significant correlation was observed between baseline 6-MWT results and echocardiographic parameters. CONCLUSION: The present study was the first to investigate the correlation between baseline 6-MWT results and right ventricular echocardiographic parameters. Myocardial performance index (MPI) and TAPSE were important parameters in follow-up after pulmonary endarterectomy. Improvement in quality of life parameters was also important.

Hospital Readmissions Following Endovascular Therapy for Critical Limb Ischemia: Associations With Wound Healing, Major Adverse Limb Events, and Mortality.

BACKGROUND: The significance of hospital readmission after endovascular therapy for critical limb ischemia (CLI) is not well established. We sought to investigate the incidence, timing, and causes of readmissions after endovascular therapy for CLI and whether readmission is associated with major adverse limb events (MALE) or mortality. METHODS AND RESULTS: This was a retrospective study of 252 patients treated with endovascular therapy for CLI. During median follow-up of 381 days (interquartile range [IQR], 115-718), 140 (56%) were readmitted, with median time to readmission of 83 days (IQR, 33-190). Readmission within 30 days occurred in 14% of patients (n=35; 25% of readmissions). Most readmissions occurred between 30 and 180 days (n=67; 48% of readmissions). The most frequent reason for readmission was unhealed wounds (n=63; 45% of readmissions). Independent predictors of readmission by Cox proportional hazards analysis were unhealed wounds, presence of multiple wounds, age ≥70, female sex, hemodialysis, and history of heart failure (P<0.05 for each). By Kaplan-Meier analysis, readmission was greatest in patients with unhealed wounds, followed by patients who never had a wound, and lowest in patients whose wounds completely healed (P<0.0001 overall, and P<0.01 between groups). After multivariable adjustment, readmission remained an independent predictor of composite MALE (major amputation, bypass, or endarterectomy) or mortality (adjusted hazard ratio, 3.1; 95% CI, 1.5-6.5; P=0.002). CONCLUSIONS: Most readmissions occur 30 and 180 days after endovascular therapy for nonprocedural reasons. Unhealed wounds are an independent risk factor for readmission. Readmission is associated with increased MALE and mortality after endovascular therapy for CLI.

Pulmonary thromboendarterectomy in 106 patients with chronic thromboembolic pulmonary hypertension.

INTRODUCTION: Pulmonary thromboendarterectomy is the treatment of choice in chronic thromboembolic pulmonary hypertension. We report our experience with this technique. METHODS: Between February 1996 and June 2014, we performed 106 pulmonary thromboendarterectomies. Patient population, morbidity and mortality and the long-term results of this technique (survival, functional improvement and resolution of pulmonary hypertension) are described. RESULTS: Subjects' mean age was 53±14 years. A total of 89% were WHO functional class III-IV, presurgery mean pulmonary pressure was 49±13mmHg and mean pulmonary vascular resistance was 831±364 dynes.s.cm(-5). In-hospital mortality was 6.6%. The most important post-operative morbidity was reperfusion pulmonary injury, in 20% of patients; this was an independent risk factor (p=0.015) for hospital mortality. With a 31-month median follow-up (interquartile range: 50), 3- and 5-year survival was 90 and 84%. At 1 year, 91% were WHO functional class I-II; mean pulmonary pressure (27±11mmHg) and pulmonary vascular resistance (275±218 dynes.s.cm(-5)) were significantly lower (p<0.05) than before the intervention. Although residual pulmonary hypertension was detected in 14 patients, their survival at 3 and 5 years was 91 and 73%, respectively. CONCLUSIONS: Pulmonary thromboendarterectomy offers excellent results in chronic thromboembolic pulmonary hypertension. Long-term survival is good, functional capacity improves, and pulmonary hypertension is resolved in most patients.

Preclinical atherosclerosis and metabolic syndrome increase cardio- and cerebrovascular events rate: a 20-year follow up.

BACKGROUND: Intima-media thickness (IMT) is a validated marker of preclinical atherosclerosis and a predictor of cardiovascular events. PATIENTS: We studied a population of 529 asymptomatic patients (age 62 ± 12.8 years), divided into two groups of subjects with and without Metabolic Syndrome (MetS). METHODS: All patients, at baseline, have had a carotid ultrasound evaluation and classified in two subgroups: the first one without atherosclerotic lesions and the second one with preclinical atherosclerosis (increased IMT or asymptomatic carotid plaque). Cardiovascular endpoints were investigated in a 20-years follow-up. RESULTS: There were 242 cardiovascular events: 144 among patients with MetS and 98 among in healthy controls (57.4% vs. 35.2%; P < 0.0001). 63 events occurred in patients with normal carotid arteries, while 179 events occurred in patients with preclinical atherosclerosis (31.8% vs. 54.1%; P < 0.0001). Of the 144 total events occurred in patients with MetS, 36 happened in the subgroup with normal carotid arteries and 108 in the subgroup with preclinical atherosclerosis (45% vs. 63.15%; P = 0.009). 98 events occurred in patients without MetS, of which 27 in the subgroup with normal carotid arteries and 71 in the subgroup with preclinical atherosclerosis (22.88% vs. 44.37%; P = 0.0003). In addition, considering the 63 total events occurred in patients without atherosclerotic lesions, 36 events were recorded in the subgroup with MetS and 27 events in the subgroup without MetS (45% vs. 22.88%; P = 0.0019). Finally, in 179 total events recorded in patients with preclinical carotid atherosclerosis, 108 happened in the subgroup with MetS and 71 happened in the subgroup without MetS (63.15% vs. 44.37%; P = 0.0009). The Kaplan-Meier function showed an improved survival in patients without atherosclerotic lesions compared with patients with carotid ultrasound alterations (P = 0.01, HR: 0.7366, CI: 0.5479 to 0.9904). CONCLUSIONS: Preclinical atherosclerosis leads to an increased risk of cardiovascular events, especially if it is associated with MetS.

[Vocal fold paralysis in the Medical University of Warsaw's Ambulatory of Phoniatry in years 2000-2011]. / Porazenia krtani w materiale Poradni Foniatrycznej Warszawskiego Uniwersytetu Medycznego w latach 2000-2011.

INTRODUCTION: Vocal fold paralysis it is an important problem in Phoniatrics' Ambulatory. There are a lot of difficulties in estimation a precise incidence of vocal fold paralysis in the population. As many as 50% of cases with paralysis might present nonspecific symptoms. AIM OF THE STUDY: The aim of the research it was to determine a vocal fold paralysis' epidemiology and etiology in material of the Medical University of Warsaw's Ambulatory of Phoniatry. MATERIAL AND METHODS: Authors present a group of 593 patients with vocal cord paralysis who were diagnosed and treated in The Ambulatory of Phoniatry from 2000 to 2011. The paralysis was observed in 439 women and in 154 men. In 488 patients paralysis was unilateral and in 105 - bilateral. RESULTS: In the study, surgery was responsible for most vocal fold paralysis (79.0%). In 357 patients, paralysis was caused by thyroid surgery. Other surgical causes of the paralysis there were: endarterectomy, thoracic surgery and skull base surgery. Of the total group, 1.2% of cases were diagnosed after intubation. In the review, in another 19.8% cases, paralysis was caused by thoracic, neck or brain tumors, by traumas and in 21 patients there was no obvious reason (idiopathic cases). CONCLUSIONS: Etiology of vocal fold paralysis seems to be affected by a character of institutions or hospitals who make a study and by geographic location. The most common etiology of vocal cord paralysis is iatrogenic.

Analysis of risk factors for amputation in 822 cases with acute arterial emboli.

BACKGROUND: We retrospectively examined the records of 822 patients who underwent a total of 901 operations for acute peripheral arterial occlusion of the upper or lower extremities between 1999 and 2009. We analyzed the effects of atherosclerotic structure, the time of admission to hospital, and re-embolectomies on amputation in the early postoperative period. METHODS: There were 466 (56.7%) men and 356 (43.3%) women. The time of admission to hospital was in the range of 58 hours. There were lower extremity emboli in 683 (83%). Bypass procedures were done in 27 (3.3%) patients. Fasciotomy, patchplasty, and endarterectomy were made in 19 (2.3%), 9 (1.1%), and 7 (0.8%) patients, respectively. RESULTS: Early revision (re-embolectomy) was performed in 77 (9.3%) patients. Amputation was performed in 112 (13.6%) patients. Delay after six hours from the onset of complaints and re-embolectomies increased the risk of amputation and rates. CONCLUSION: If the embolectomy, which is a rapid and easy technique for treatment of acute arterial emboli, is performed by experienced surgeons without delay, the complications associated with the emboli may be prevented. Otherwise, delayed operation and repeated re-embolizations in acute arterial play important roles in morbidity.

Hybrid procedures as a novel technique in the treatment of critical limb ischemia.

In hybrid reconstructions, patients are treated using both endovascular and open revascularization techniques simultaneously. In recent years, these multilevel reconstructions have been increasingly used especially by vascular surgeons as they have adopted new knowledge and endovascular skills and the endovascular techniques have evolved. The first reports of combined endovascular and open surgical procedures are from the 1970s. Since then, most reports have dealt with femoral endarterectomy or femoro-femoral bypass combined with inflow iliac percutaneous transluminal angioplasty (PTA) and stenting. Primary success rates have been high: 93%-100%. In our institution 213 hybrid procedures were performed during 2003-2011 with 98.6% technical success rate. The annual number of hybrid procedures ranged from 4 in 2004 to 73 in 2011. Inflow endovascular procedure was performed in 60% and outflow in 40 % of the cases. The proportion of the endovascular component performed by vascular surgeons increased from 0% in 2004 to 86.3% in 2011. In the current report we review the results published in the literature, report our own experience and present some technical notes and cases.

Gender differences in stroke care and outcomes in Ontario.

BACKGROUND: Studies of potential gender differences in stroke care and outcomes have yielded inconsistent findings. The Project for an Ontario Women's Health Evidence-based Report study measured established stroke care indicators in a large, representative sample of women and men with stroke or transient ischemic attack (TIA) admitted to acute care institutions in the province of Ontario, Canada. METHODS: The Registry of the Canadian Stroke Network performs a biennial audit on a random sample of 20% of patients with stroke or TIA seen at more than 150 acute care institutions across Ontario. We used data from the 2004/05 audit to compare stroke care by gender, with stratification by age and neighborhood income. RESULTS: The sample consisted of 4,046 patients (51% women). There were no significant gender differences in the use of thrombolysis, neuroimaging, carotid imaging, dysphagia screening, antithrombotic therapy, or neurology and other consultations. Women with ischemic stroke or TIA were less likely than men to be prescribed statins or undergo carotid imaging and endarterectomy within 6 months of stroke; women were more likely than men to receive antihypertensives. There were no significant gender differences in readmission or mortality rates after stroke. INTERPRETATION: In this population-based study, we found little evidence of gender differences in stroke care or outcomes other than lipid-lowering therapy, carotid imaging, and endarterectomy. Further study is needed to assess the contribution of the provincial stroke strategy in eliminating gender differences in management of acute stroke and to better understand and target remaining gender differences in management.

Propensity scored analysis of outcomes after ruptured abdominal aortic aneurysm.

BACKGROUND: This study examined the population outcome of ruptured abdominal aortic aneurysm (rAAA) in England, the role of endovascular repair (EVAR), and the relationship between outcome and hospital workload. METHODS: Data were retrieved from Hospital Episode Statistics between 1 April 2003 and 31 March 2008. Propensity scoring was used to compare the outcomes of stratified patients undergoing EVAR and open repair. The relationship between workload and outcome was determined. RESULTS: Some 3725 urgent and 4414 rAAA repairs were included. Mortality rates were 21.3 per cent for urgent repair and 46.3 per cent for rAAA repair. EVAR was employed for 16.3 and 7.6 per cent of urgent and rAAA repairs respectively. EVAR was associated with significantly reduced mortality for urgent repair (odds ratio (OR) 0.531, 95 per cent confidence interval 0.415 to 0.680; P < 0.001) and rAAA repair (OR 0.527, 0.416 to 0.668; P < 0.001). A propensity scored analysis confirmed the benefit of EVAR for rAAA repair (P < 0.001). Repair of rAAA at hospitals with a higher elective aneurysm workload was associated with lower mortality rates irrespective of the mode of treatment (P < 0.001). Higher-volume hospitals were more likely to operate on rAAA (P = 0.033). CONCLUSION: EVAR offered a survival advantage over open repair for non-elective aneurysm procedures. Services for the treatment of rAAA should incorporate access to EVAR and would benefit from being based in units with a high elective caseload.

Evaluación mediante mapas estadísticos paramétricos de los cambios de la perfusión cerebral en pacientes con estenosis de la arteria carótida sometidos a endarterectomía / Evaluation by “statistical parametric mapping” of the cerebral perfusion changes in patients with carotid artery stenosis after endarterectomy

La eficacia de la endarterectomía carotídea (EC) en los accidentes cerebrovasculares producidos por estenosis carotídea puede ser evaluada mediante la tomografía computarizada de emisión de fotón único de perfusión cerebral, utilizando SPM (statistical parametric mapping ‘mapas estadísticos paramétricos’).Material y métodosSe incluyeron en el estudio 12 pacientes con estenosis significativa de la arteria carótida que fueron sometidos a endarterectomía. A todos se les realizó un estudio de perfusión cerebral con 99mTc-etilen cisteinato dietilester (ECD) basal tras la endarterectomía. Mediante los SPM se comparó de forma independiente el estudio basal/poscirugía con el grupo control formado por 20 pacientes y se obtuvieron los correspondientes SPM. Se valoraron los cambios tanto en extensión (o número de vóxeles) como en intensidad (cambio en el valor de T) de las zonas significativamente hipoperfundidas y el sentido de estos cambios.ResultadosEn el grupo de 12 pacientes se observó una mejoría de la perfusión cerebral posquirúrgica, en 5 pacientes con disminución en la extensión de las zonas hipoperfundidas del 50,56% y de intensidad del 30,9% de media. Cuatro pacientes mostraron un aumento en la extensión de la hipoperfusión cerebral del 85,53% y de la intensidad del 34,21% de media. En tres pacientes no se apreciaron cambios significativos entre ambos estudios.ConclusionesEl SPM ha demostrado ser una herramienta útil que permite objetivar los cambios de flujo sanguíneo cerebral que se producen tras la intervención quirúrgica, valorando los cambios en extensión e intensidad de las zonas significativamente hipoperfundidas(AU)

The efficacy of carotid endartectomy (CE) in cerebrovascular accidents produced by carotid stenosis can be evaluated with the cerebral perfusion with single photon emission tomography, using statistical parametric mapping (SPM).Material and methodsTwelve patients with significant carotid stenosis who underwent endartectomy were included in the study. All underwent a cerebral perfusion study with 99mTc-etilen cisteinato dietilester (ECD) at baseline and after the endartectomy. Using SPM, the baseline/post-surgery study was compared independently with the control group made up of 20 patients and the corresponding parametric statistical mappings were obtained. Changes in extension (kE or voxel number) and intensity (change in the T value) of the significantly hypoperfused zones and direction of these changes were evaluated.ResultsIn the group of 12 patients, improvement of the post-surgical cerebral perfusion was observed in 5 patients with an average 50.56% decrease in the extension of the hypoperfused zones and average 30.9% decrease of intensity. Four patients showed an average 85.53% increase in the extension of cerebral hypoperfusion and of 34.21% in intensity. No significant changes between both studies were found in three patients.ConclusionsSPM has been shown to be a useful tool that makes it possible to objectify the cerebral brain flow changes produced after the surgical intervention, evaluating the changes in extension and intensity of the significantly hypoperfused zones(AU)

Pulmonary hypertensive medical therapy in chronic thromboembolic pulmonary hypertension before pulmonary thromboendarterectomy.

BACKGROUND: The currently recommended treatment for chronic thromboembolic pulmonary hypertension is pulmonary thromboendarterectomy (PTE). No convincing evidence for the use of pulmonary hypertensive medical therapy (PHT) exists in operable candidates. We sought to determine the prevalence of the use of PHT on referral for PTE and the effects on pre-PTE hemodynamics and post-PTE outcomes/hemodynamics. METHODS AND RESULTS: We performed a retrospective analysis of chronic thromboembolic pulmonary hypertension patients referred for PTE during 2005-2007. The prevalence of PHT was determined for all patients referred to our institution. Hemodynamic and outcomes analysis involved only those undergoing PTE. Data included baseline demographics, PHT medication(s), dosage, duration of therapy, and time to referral. Hemodynamic data were acquired from the time of diagnosis, the time of referral visit, and after PTE. Outcomes included intensive care unit, hospital, and ventilator days; bleeding and infection rates; incidence of reperfusion lung injury; and in-hospital mortality. The control group (n=244) was compared with the PHT group (n=111); subgroups included monotherapy with bosentan, sildenafil, or epoprostenol and combination therapy. The prevalence of PHT significantly increased from 19.9% in 2005 to 37% in 2007. There was minimal benefit of treatment with PHT on pre-PTE mean pulmonary artery pressure, but its use was associated with a significant delay in time to referral for PTE. Both groups experienced significant improvements in hemodynamic parameters after PTE. The 2 groups did not differ significantly in any post-PTE outcome. Similar results were obtained for each subgroup. CONCLUSIONS: Our results suggest that PHT use has minimal effect on pre-PTE hemodynamics and no effect on post-PTE outcomes/hemodynamics.

Early and late outcomes of multiple coronary endarterectomy.

OBJECTIVES: Coronary endarterectomy has been shown to be an effective adjunctive technique of revascularization for diffuse coronary artery disease. However, outcomes of multiple coronary endarterectomy (MCE) have not been well investigated. We sought to examine early and late results of this technique. METHODS: Between January 1992 and June 2006, 58 consecutive patients underwent coronary endarterectomy in more than one coronary artery territories, representing 6.5% of total coronary endarterectomy during the same period. Early and late outcomes were retrospectively analyzed. RESULTS: The mean age was 64 years. Forty-one patients (70.7%) had coronary endarterectomy in the left anterior descending artery and right coronary artery territories; five (8.6%) in the left anterior descending artery and circumflex artery territories; eight (13.8%) in the circumflex artery and right coronary artery territories; and four (6.9%) in the left anterior descending artery, circumflex artery, and right coronary artery territories. Operative mortality was 12.1% (7/58). The incidence of perioperative myocardial infarction was 25.9% (15/58). The median length of hospital stay was seven days. Actuarial five- and 10-year survivals were 64% and 36%, respectively. CONCLUSIONS: MCE may be a reasonable option for revascularization of multiple diffuse coronary artery disease. However, early and late outcomes are relatively poor and the indication should be carefully considered.

Current differences in referral patterns for pulmonary endarterectomy in the UK.

Pulmonary endarterectomy (PEA) surgery is the treatment of choice in surgically accessible chronic thromboembolic pulmonary hypertension and is potentially curative. The UK is served by seven specialist pulmonary hypertension centres and, consequently, there are regions which do not have a specialist unit. Since 2000, Papworth Hospital (Papworth Everard, UK) has been the sole PEA provider for the UK, offering the opportunity to study the national incidence of operable disease and give potential insight into factors that might affect geographical distribution within the UK. All 262 UK residents who underwent PEA surgery between April 2000 and May 2006 were included in the present study. The age-adjusted cumulative referral rates were compared between regions to test for uniformity. Overall, observed rates differed significantly from expected, with evidence of significant nonuniformity across the UK. The highest rates were observed in proximity to the nationally designated specialist centres and in particular in East Anglia and the West Midlands, nearest Papworth. These two regions differed by >2 x SD from the national mean rate. The present study demonstrates wide geographical variation in the number of patients referred for pulmonary endarterectomy surgery. This suggests that there may be patients who are not presently being offered this potentially curative option.

The role of surgery when endovascular treatment is considered the first choice therapy for ruptured intracranial aneurysms.

AIM: Nowadays endovascular therapy is more and more considered as first choice treatment for ruptured intracranial aneurysms. The aim of this study was to understand the impact that endovascular treatment (EVT), chosen as first therapeutic strategy, has had in the selection of ruptured intracranial aneurysms submitted to surgery at our Institution and what role neurosurgeons still play in this setting. METHODS: From 1998 to 2002, 272 consecutive patients were treated at the Hospital of Toulouse for ruptured intracranial aneurysms: 222 by embolization and 50 by surgery. The two groups were homogeneous for sex, age and aneurysms multiplicity. RESULTS: The patients of the surgical group had a worst clinical-radiological status at the treatment time than those treated by EVT. Clipping was performed for different reasons: 16% for failure of attempted EVT; 32% for intracranial hematoma requiring surgical evacuation; 30% for aneurysm morphology unsuitable for EVT and 22% for absence of the endovascular operator. Aneurysms of the middle cerebral artery (MCA) represented the main surgical group. The aneurysms judged unsuitable for EVT and addressed to surgery had often a complex morphology representing a challenge also for surgery. Mid-term outcome is significantly better for patients treated by EVT. CONCLUSION: The results show that microsurgery continues to have a role in the treatment of ruptured intracranial aneurysms even when EVT is the first choice. The precarious clinical conditions of the patients submitted to surgery and the frequent complexity of their aneurysms explain their worst outcome. This would advise training dedicated vascular Neurosurgeons to guaranty a high level treatment when EVT is not possible.