Search

24th Biennial International Congress on Thrombosis – EMLTD Congress 2016 4–7 May 2016, Istanbul, Turkey

Platelet aggregation inhibitors, also known as antiplatelet therapy (APT), are prescribed for the prevention of secondary cardiovascular events (CVE) after endovascular revascularization procedures.- Platelet aggregation inhibitors are not equally effective in all patients. The phenomenon of high residual platelet reactivity despite APT is called 'high on-treatment platelet reactivity' (HTPR); it bears an increased risk of secondary CVE.- Platelet function tests (PFT) can be used to diagnose HTPR. There are various tests available; of those, light transmission aggregometry (LTA) is considered the gold standard. Some tests are only suitable for determining the effect of a certain category of APT.- Research into the usefulness of PFTs to optimise treatment with APT has not yet produced an unambiguous conclusion.- Currently there is not yet an indication for routine use of PFT in clinical practice. However, for the treatment of certain categories of patients with thromboembolic disease - such as those with renal failure or a history of kidney transplant - PFT can be considered.

Introduction In patients with carotid stenosis receiving medical treatment, carotid plaque echolucency has been thought to predict risk of future stroke and of other cardiovascular events. This study evaluated the prognostic value of pre-operative plaque echolucency for future stroke and cardiovascular death in patients undergoing carotid endarterectomy in the first Asymptomatic Carotid Surgery Trial (ACST-1). Methods In ACST-1, 1832/3120 patients underwent carotid endarterectomy (CEA), of whom 894 had visual echolucency assessment according to the Gray-Weale classification. During follow-up patients were monitored both for peri-procedural (i.e. within 30 days) death, stroke, or MI, and for long-term risk of stroke or cardiovascular death. Unconditional maximum likelihood estimation was used to calculate odds ratios of peri-procedural risk and Kaplan-Meier statistics with log-rank test were used to compare cumulative long-term risks. Results Of 894 operated patients in whom echolucency was assessed, 458 plaques (51%) were rated as echolucent and peri-procedural risk of death/stroke/MI in these patients was non-significantly higher when compared with patients with non-echolucent plaques (OR 1.48 [95% CI 0.76–2.88], p = .241). No differences were found in the 10 year risk of any stroke (30/447 [11.6%] vs. 29/433 [11.0%], p = .900) or cardiovascular (non-stroke) death (85/447 [27.9%] vs. 93/433 [32.1%], p = .301). Conclusion In ACST-1, carotid plaque echolucency assessment in patients undergoing CEA offered no predictive value with regard to peri-operative or long-term stroke risk or of cardiovascular (non-stroke) death.

Objectives A remarkable variation exists in the cardiometabolic consequences of obesity. We evaluated the separate and combined effects of adiposity and cardiometabolic dysfunction on the occurrence of cardiovascular events and mortality in patients with vascular disease. Methods We prospectively followed 5231 patients with a history of clinical cardiovascular disease without diabetes from the Second Manifestations of ARTerial disease (SMART) study. Patients were classified according to body mass index and cardiometabolic function. The presence of cardiometabolic dysfunction was defined as ≥3 of the modified National Cholesterol Education Program (NCEP) metabolic syndrome criteria (waist circumference replaced by elevated C-reactive protein). Cox proportional-hazards analysis was used to estimate HRs for cardiovascular events and mortality. Results The prevalence of cardiometabolic dysfunction was 40% in normal weight, 58% in overweight and 75% in obese patients. During a median follow-up of 6.1 years, 769 patients died and 705 patients experienced a major cardiovascular event. In the absence of cardiometabolic dysfunction, overweight (HR 1.18, 95% CI 0.90 to 1.55) and obese patients (HR 0.93, 95% CI 0.53 to 1.64) were not at increased risk of recurrent major cardiovascular events compared with normal weight patients without cardiometabolic dysfunction. An increased cardiovascular risk was observed in patients with cardiometabolic dysfunction and normal weight (HR 1.58, 95% CI 1.23 to 2.04), overweight (HR 1.35, 95% CI 1.07 to 1.70) and obesity (HR 1.50, 95% CI 1.12 to 2.00) compared with normal weight patients without cardiometabolic dysfunction. A similar pattern was observed for vascular and all-cause mortality. Conclusions In patients with vascular disease, the cardiometabolic consequences of adiposity rather than adiposity per se increase the risk of recurrent cardiovascular events and mortality.

Objective/Background Carotid endarterectomy (CEA) prevents future stroke, but this benefit depends on detection and control of high peri-operative risk factors. In symptomatic patients, diastolic hypertension has been causally related to procedural stroke following CEA. The aim was to identify risk factors causing peri-procedural stroke in asymptomatic patients and to relate these to timing of surgery and mechanism of stroke. Methods In the first Asymptomatic Carotid Surgery Trial (ACST-1), 3,120 patients with severe asymptomatic carotid stenosis were randomly assigned to CEA plus medical therapy or to medical therapy alone. In 1,425 patients having their allocated surgery, baseline patient characteristics were analysed to identify factors associated with peri-procedural ( 90 mmHg) most strokes occurred during the procedure (67% vs. 20%; p = .02). Conclusion In ACST-1, diastolic blood pressure was the only independent risk factor associated with peri-procedural stroke or death. While the underlying mechanisms of the association between lower diastolic blood pressure and peri-procedural risk remain unclear, good pre-operative control of blood pressure may improve procedural outcome of carotid surgery in asymptomatic patients.

Introduction The apolipoprotein E gene ( APOE ) is associated with coronary heart disease and stroke, but the relation with peripheral artery disease (PAD) is unknown. We investigated the relation of APOE genotype with PAD and other types of vascular disease. Methods The cross-sectional association between APOE genotype and ankle-brachial index (ABI) and vascular disease prevalence; and the prospective relation with incident PAD and other types of vascular disease (coronary artery disease, stroke and vascular mortality) were evaluated in 7418 patients from the Secondary Manifestations of ARTerial disease (SMART) study. This is a prospective cohort study in patients with cardiovascular disease or a cardiovascular risk factor. Analyses were adjusted for age and sex. Results Mean age was 56.7 ± 12.4 years and 68% of the patients was male. APOE genotype frequencies were e2e2 1.3%; e2e3 9.9%; e2e4 2.4%; e3e3 56.9%; e3e4 26.7% and e4e4 2.8%. Median follow-up time was 8.1 years (IQR 5.4–11.4) in which 452 new PAD events occurred. The e2e2 genotype was significantly associated with a lower ABI (regression coefficient −0.04, 95%CI −0.07 to −0.01), increased PAD prevalence (prevalence ratio 1.54, 95%CI 1.01–2.17) and a higher risk of incident PAD (HR 2.31, 95%CI 1.29–4.12) compared with e3e3. No relations between APOE genotypes and other vascular disease were observed. Conclusion Of the six APOE genotypes, the e2e2 variant is associated with an increased risk for PAD in patients at high risk for cardiovascular disease. No association was observed between APOE genotype and coronary artery disease, stroke or vascular mortality in this population.

The present paper summarizes the similarities and differences between recent and ongoing randomized controlled trials on optimal treatment of patients with severe but asymptomatic carotid stenosis. Protocol details will be discussed as well as needs for outcome and especially differentiation between patients with a low versus high risk for future events.

Acute nontraumatic upper extremity ischemia has significant chronic disability when not treated adequately and timely. As surgical treatment can be challenging, this study evaluates catheter-directed thrombolysis as first-line treatment for acute upper extremity ischemia.Between January 2006 and December 2010, 28 patients (22 women; mean age, 63±16 years) underwent catheter-directed thrombolysis for acute upper extremity ischemia, Rutherford class I or IIa. Proximal extent of the occlusion was in the subclavian (32%), axillary (7%), brachial (25%) and forearm arteries (36%). Median occlusion length was 18 cm (range, 12-43). Causes were embolus (14%), thrombus (39%), thoracic outlet syndrome (14%), paraneoplastic (4%), or unknown (29%).Technical success was 96%, radiologic success (95% clot lysis) 61%, and clinical success 68%. Median duration of thrombolysis was 24 hours (range, 18-96). Of the 11 radiologically unsuccessful patients (39%), five were treated conservatively and six underwent surgical intervention. In-hospital amputation-rate was 7%. Four complications occurred: embolization to the lower extremity, a transient ischemic attack, a subcapsular splenic hematoma and a pseudoaneurysm. Cumulative amputation-free survival at six months was 93%, standard error (SE) 4.87 and at one year 88%, SE 6.50.These results show that catheter-directed thrombolysis is effective in over 60% of patients as first-line treatment of extensive acute upper extremity ischemia and can prevent surgical intervention in these patients.

Carotid artery revascularization by endarterectomy is an effective means of stroke prevention in selected patients with carotid stenosis. With the development of endovascular techniques, carotid artery stenting (CAS) has been proposed as a viable alternative to carotid endarterectomy (CEA), particularly in patients considered at high risk for CEA. Guidelines have established criteria that outline these patients who are considered at "high risk" for complications after CEA, to whom CAS may provide benefit. The validity of these theoretical high-risk criteria, however, is yet unproven, and, as a consequence, there is no clear evidence suggesting that the risk with CAS is lower in these high-risk patients compared with CEA. This manuscript summarizes the role of "high risk" within recent trials and discusses why the optimal treatment for these patients with deemed high risk for surgery remains a matter of debate.

Antiplatelet therapy has reduced the incidence of thromboembolic events for patients undergoing carotid revascularization. However, the platelet inhibitory effect of aspirin and clopidogrel, the most commonly used P2Y12 receptor inhibitors, is variable among patients. Patients displaying high platelet reactivity despite aspirin or clopidogrel treatment are at higher risk for thromboembolic events during and after carotid revascularization. In order to reduce the incidence of high platelet reactivity, more potent P2Y12 receptor inhibitors as prasugrel are used. However, this strategy increases the risk of bleeding. As there is evidence of a therapeutic window for platelet inhibition, platelet function tests could be helpful for tailoring antiplatelet therapy based on the patient's thrombotic and bleeding risk. This evidence overview describes the most commonly used platelet inhibitors, platelet function tests and the current evidence for tailoring of antiplatelet therapy to patients undergoing carotid revascularization.

The optimal operation technique for groin hernia repair has not been established. This study evaluates the long-term recurrence rate and perioperative complications after posterior inguinal mesh hernia repair using a gridiron incision described by Frans Ugahary. A retrospective analysis was performed of the medical records of 366 patients who underwent Ugahary hernia repair. Operative results and perioperative morbidity were evaluated retrospectively. Follow-up was done by clinical examination. The main outcome measure was recurrence rate at a mean follow-up of 2 years. Of the 386 groin hernia repairs, 263 hernia repairs were examinated in the outpatient clinic. The overall recurrence rate was 6.5% with a mean follow-up of 2 years, and 10.1% of the patients had minor complications. This retrospective study demonstrates that the repair according to Ugahary is a safe technique for operating on groin hernia. However, the procedure is difficult to reproduce in nonexpert hands. This technique must be compared to other inguinal hernia operation techniques in the near future.

Carotid endarterectomy has been shown to reduce the risk for stroke in patients with symptomatic or selected asymptomatic severe internal carotid artery stenosis. Although the basic aims of surgery are always the same, the exact techniques used to achieve them vary between surgeons. This paper summarizes the current evidence based optimal technical management of patients with an indication for carotid surgery, focusing on shunt use, patching, eversion versus longitudinal endarterectomy, and type of anesthesia applied. For each subtopic discuss, the text is accompanied by a table summarizing the key points.

Background: Atherosclerosis is a chronic systemic inflammatory disease in which many immune cells participate. Recently we have shown that mast cell numbers are associated with atherosclerotic plaque vulnerability and interestingly with future cardiovascular events (S. Willems et.al. 2013). The endogenous trigger that activates mast cells within the lesion remains unidentified. We hypothesized that mast cells are activated via receptors for IgG and/or IgE. In this study we aimed to establish whether specific immunoglobulin levels in plasma of atherosclerotic patients were related to intraplaque mast cell numbers. In addition, the levels were related to other vulnerable plaque characteristics and baseline clinical data. Results: Serum levels of total IgG, total IgE and oxLDL specific IgG were determined in 135 patients that underwent carotid endarterectomy. The studied patient population with a mean age of 67 and a male prevalence (71%) reflects a relatively typical population of patients with vascular occlusive diseases. The majority of patients were symptomatic (74%) as illustrated by the incidence of amaurosis fugax, a TIA or a stroke. No associations were observed between either the serum immunoglobulin levels or the total mast cell numbers in atherosclerotic plaques (total IgG vs. total mast cells r= -0,038, p=0.664) (tIgE vs total mast cells r=-0.038, p=0.664) (oxLDL-IgG vs total mast cells r=0.137 p=0.114). Furthermore, no associations were found between immunoglobulin levels and the following plaque characteristics: lipid core size, degree of calcification, number of macrophages or smooth muscle cells, amount of collagen and number of microvessels. Interestingly, we observed a negative association between statin use and total IgE (97.5 [43.1-276.8] vs. 157.3 [75.2-545.4] ng/mL, p=0.012) and statin use and oxLDL-IgG (288 [224-406] vs. 399 [282-584] mU/mL, p=0.004). Conclusions: In patients suffering from carotid artery disease, total IgG or IgE and oxLDL-IgG levels do not associate with plaque mast cell numbers or vulnerable plaque histopathological characteristics These data may indicate that other endogenous factors activate mast cells within the atherosclerotic plaque.

Aortic graft infection (AGI) is a dreaded complication in vascular surgery. Research on AGI is hampered by its rarity combined with a broad range of clinical presentation in critically ill patients. This report aims to explore the various current opinions on the diagnosis and treatment of AGI.A questionnaire was sent to all members of the Dutch Society of Vascular Surgery. Six weeks after the initial questionnaire a reminder was sent. A total of 306 questionnaires were sent. Data were analyzed for 124 vascular surgeons (VS) and 19 vascular surgeons in training (VT). Data analysis was performed in a descriptive manner.Total response rate was 51.3%, Response rate of the VS and VT combined was 47%. 85% of the VS versus 58% of VT rely on computed tomography scanning (CT) scanning for diagnosing AGI. Positron emission tomography scanning with CT fusion was used by 40% of VS versus 58% of VT. Antibiotic treatment was started at the first suspicion of AGI by 52% of VS and 58% of VT. 13 different opinions were noted on total antibiotic duration. Extra-anatomic bypass (EAB) was used by and 42% of VT. In-situ reconstructions were used by 59% of VS versus % of VT. Venous reconstructions were the first reconstruction choice in 63% VS and 52% of VT. Antibiotic-bonded grafts were used by 17% of VS and 16% of VT.This survey shows highly mixed opinions about clinical diagnosis, diagnostic imaging, and treatment of AGI, reflecting available literature. Further research is therefore desperately needed. More research and development of treatment guidelines is needed to reach uniformity and consensus for patients with infected vascular grafts.

The benefit of carotid revascularization is hampered by occurrence of periprocedural cerebrovascular complications. Cerebral hyperperfusion syndrome (CHS) is a potentially life threatening complication occurring in approximately 3% of all patients following either carotid endarterectomy (CEA) or carotid angioplasty with stenting (CAS). CHS generally is defined as a transcranial Doppler (TCD) derived increase in cerebral blood flow of100% over baseline. To reduce related morbidity and mortality early identification of patients at risk is essential. As such, TCD offers a technique for cerebral blood flow measurement that is nowadays the only applied and useful clinical monitoring tool for CHS prediction. Several studies have assessed the diagnostic value of TCD in the prediction of CHS and found promising results. However, results were based on a small number of cases and different definitions have been used to diagnose CHS. Moreover, the role of TCD in the onset of CHS has been studied most extensively following CEA, and it is unclear whether the findings of these studies can be generalized to patients undergoing CAS. Therefore we conclude that further studies in larger cohorts are required to assess the changes in cerebral hemodynamic in patients undergoing either CAS or CEA.

The benefit of carotid revascularization in long term stroke prevention is hampered by the occurrence of restenosis at the site of surgery, which is associated with a modestly increased risk of stroke. Preventing restenosis is an important part in the overall treatment and prevention of stroke in patients with carotid artery disease. The site of recurrent stenosis is primarily situated at the ends of, or within the confines of the original endarterectomy site and the suture lines. Several etiological factors but also surgical technique play a key role in the development of carotid recurrent stenosis. However, the exact pathophysiology of recurrent disease is not fully understood. The morphogenesis of recurrent lesions is a process of ongoing thrombogenesis beginning immediately after blood flow is restored across the endarterectomized surface. The early lesion is subsequently formed as the thrombus organizes and smooth muscle cell ingrow occurs, creating a supposed morphologic distinction between early (within 2 years of CEA) and late (over 2 years) recurrent carotid disease. Further, plaque composition at primary CEA is an independent predictor of restenosis after CEA and dissection of a lipid-rich and macrophage infiltrated plaque is associated with a reduced risk of stenosis. CEA of stable atherosclerotic plaques has been associated with an increased risk for restenosis. In addition, stable atherosclerotic plaque characteristics with low macrophage content and small lipid core size are associated with an increased incidence of restenosis compared with unstable inflammatory lesions. The implication of these findings is that macrophage infiltration and lipid core size are the plaque characteristics that should be targeted with noninvasive plaque imaging to assess the risk of patients with recurrent carotid stenosis to become symptomatic. Furthermore, the longer the delay from stroke until revascularization, the more the lesion stabilizes and the higher the risk for restenosis. Thus, operating on symptomatic patients within a few weeks after the index event could potentially reduce the risk of restenosis. The optimal treatment strategy for restenosis has yet to be defined. Optimally, one would strive to a "tailor-made" treatment comprising of best medical therapy, surgery or CAS including regular follow-up. With the ongoing developments and insights in histological plaque characterization this tailor-made treatment might be available in the near future, thereby reducing the risk of, or maybe even avoiding the development of restenosis.

Lower self-rated health status has been associated with worse prognosis in patients with coronary artery disease (CAD). We investigated the influence of self-rated physical and mental health status on the risk of future vascular events and mortality for various locations of symptomatic atherosclerotic disease and asymptomatic disease.Patients with CAD (n = 2547), cerebrovascular disease (n = 1061), peripheral arterial disease (PAD; n = 648), abdominal aortic aneurysm (AAA; n = 272) and asymptomatic atherosclerotic disease (n = 1933) were followed for a median of 4 years for the occurrence of a new vascular event or death. Self-rated health status was assessed with the Short Form-36 physical and mental component summary scales. Cox regression models were used to estimate associations between health status and vascular events and death, adjusted for age, sex, vascular risk factors and intima-media thickness.In the total population, lower self-rated physical health status (per 10-point decrease) increased the risk of vascular events [hazard ratio (HR) = 1.37, 95% confidence interval (CI) 1.24-1.52], and all-cause (HR = 1.45, 95% CI 1.29-1.63) and vascular mortality (HR = 1.40, 95% CI 1.20-1.64). A 10-point decrease in mental health status was associated with a modest increase in the risk of vascular events (HR = 1.19, 95% CI 1.08-1.32), and all-cause (HR = 1.19, 95% CI 1.05-1.34) and vascular mortality (HR = 1.28, 95% CI 1.09-1.49). Risk estimates of physical and mental health status were highest in patients with asymptomatic atherosclerotic disease and lowest in those with PAD.Poorer self-rated physical and mental health status increases the risk of vascular events and mortality in a broad population of patients with symptomatic and asymptomatic atherosclerotic disease.

Three patients, three women aged 40, 64 and 75, suffered from a trocar hernia, a specific complication of laparoscopic surgery. This type of hernia may result in small bowel obstruction and normally appears within two weeks after laparoscopy. The usual presentation is that of abdominal pain with nausea and vomiting. Trocar herniation implicates the necessity of reposition and might result in bowel resection with prolonged hospital stay. The advice for prevention is to use a trocar with a diameter as small as possible, as the chance of a hernia occurring increases withthe use of larger trocars. Fascial closure is advised for trocars to mm and larger. With a growing number of procedures being performed laparoscopically, the importance of recognizing and preventing this complication is evident. Three cases illustrate the importance of early recognition of small bowel obstruction resulting from trocar herniation.

Comparison of restenosis in patients who underwent both carotid artery angioplasty with stenting (CAS) and contralateral carotid endarterectomy (CEA).From our CAS data registry (1998-present) all patients with a history of contralateral CEA at any other time were selected (n = 63). Mean age was 70.6, SD = 6.8 for CAS and 68.2, SD = 6.1 for CEA and symptomatic carotid artery stenosis was present in 24% of patients pre-CAS and 40% pre-CEA. All CEAs were primary interventions, 19% of CAS were secondary to restenosis after previous ipsilateral CEA. All patients were followed up prospectively with duplex at 1 year (CAS: n = 58, CEA: n = 59), 2 years (CAS: n = 44, CEA: n = 53), 3 years (CAS: n = 27, CEA: n = 41), and every year thereafter. Within each patient we compared restenosis (50%) between CAS and CEA procedures.After a follow-up of 28.7 months for CAS (SD = 16.9) and 54.4 months for CEA (SD = 39.5) the rate of = or50% restenosis for CAS vs CEA at 1, 2, and 3 years was 23% vs 10%; 31% vs 19%; and 34 vs 24%, respectively (log rank P = NS).Our intrapatient comparison of patients who underwent both CAS and contralateral CEA did not reveal significant difference in restenosis between both procedures.