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Carotid body tumors (CBTs), or chemodectomas, are rare, especially in the pediatric population. They often present with minimal symptoms, making timely diagnosis challenging. This case report and systematic review highlights a distinctive presentation and summarize the current evidence on pediatric CBTs. We report a case of a 13-year-old girl presenting with neck pain and a left-sided neck mass. After extensive evaluation, a Shamblin type III tumor was identified and removed surgically. Postoperatively, the patient experienced transient hypertension and significant dysphagia, both of which resolved within a few weeks with no permanent sequelae. Histology confirmed a benign paraganglioma. A systematic literature review of PubMed identified 29 cases from 23 published studies spanning from 1968 to 2024. The average age at diagnosis was 12.6 ± 3.6 years. The most common symptom was a neck mass or swelling, reported in 75% of cases (n = 21). Tumor sizes ranged from 1.3 to 8.0 cm, with Shamblin III being the most frequent classification. Gross total resection (n = 25 [89.3%]) alone or in combination with preoperative embolization (n = 10 [35.7%]) were the most common methods of management. In 62.1% of cases, there were no permanent complication or sequelae. The proximity to vital neurovascular structures and high vascularity in pediatric patients necessitates careful perioperative interdisciplinary management. Owing to their rarity and nonspecific presentation, CBTs often remain undiagnosed for years. They respond well to treatment, but can be fatal if untreated, underscoring the importance of including CBTs in the differential diagnosis of pediatric neck masses.

Background Transfemoral carotid artery stenting (TFCAS) carries important perioperative risks. Outcome prediction tools may help guide clinical decision‐making but remain limited. We developed machine learning algorithms that predict 1‐year stroke or death following TFCAS. Methods and Results The VQI (Vascular Quality Initiative) database was used to identify patients who underwent TFCAS for carotid artery stenosis between 2005 and 2024. We identified 112 features from the index hospitalization (82 preoperative [demographic/clinical], 13 intraoperative [procedural], and 17 postoperative [in‐hospital course/complications]). The primary outcome was 1‐year postprocedural stroke or death. The data were divided into training (70%) and test (30%) sets. Six machine learning models were trained using preoperative features with 10‐fold cross‐validation. The primary model evaluation metric was area under the receiver operating characteristic curve. The algorithm with the best performance was further trained using intra‐ and postoperative features. Model robustness was assessed using calibration plots and Brier scores. Overall, 35 214 patients underwent TFCAS during the study period and 3257 (9.2%) developed 1‐year stroke or death. The best preoperative prediction model was extreme gradient boosting, achieving an area under the receiver operating characteristic curve of 0.94 (95% CI, 0.93–0.95). In comparison, logistic regression had an AUROC of 0.65 (95% CI, 0.63–0.67). The extreme gradient boosting model maintained excellent performance at the intra‐ and postoperative stages, with area under the receiver operating characteristic curve values of 0.94 (95% CI, 0.93–0.95) and 0.98 (95% CI, 0.97–0.99), respectively. Calibration plots showed good agreement between predicted/observed event probabilities with Brier scores of 0.11 (preoperative), 0.11 (intraoperative), and 0.09 (postoperative). Conclusions Machine learning can accurately predict 1‐year stroke or death following TFCAS, performing better than logistic regression.

Abstract Lower extremity open revascularization is a treatment option for peripheral artery disease that carries significant peri-operative risks; however, outcome prediction tools remain limited. Using machine learning (ML), we developed automated algorithms that predict 30-day outcomes following lower extremity open revascularization. The National Surgical Quality Improvement Program targeted vascular database was used to identify patients who underwent lower extremity open revascularization for chronic atherosclerotic disease between 2011 and 2021. Input features included 37 pre-operative demographic/clinical variables. The primary outcome was 30-day major adverse limb event (MALE; composite of untreated loss of patency, major reintervention, or major amputation) or death. Our data were split into training (70%) and test (30%) sets. Using tenfold cross-validation, we trained 6 ML models. Overall, 24,309 patients were included. The primary outcome of 30-day MALE or death occurred in 2349 (9.3%) patients. Our best performing prediction model was XGBoost, achieving an area under the receiver operating characteristic curve (95% CI) of 0.93 (0.92–0.94). The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.08. Our ML algorithm has potential for important utility in guiding risk mitigation strategies for patients being considered for lower extremity open revascularization to improve outcomes.

Background Lower extremity endovascular revascularization for peripheral artery disease carries nonnegligible perioperative risks; however, outcome prediction tools remain limited. Using machine learning, we developed automated algorithms that predict 30‐day outcomes following lower extremity endovascular revascularization. Methods and Results The National Surgical Quality Improvement Program targeted vascular database was used to identify patients who underwent lower extremity endovascular revascularization (angioplasty, stent, or atherectomy) for peripheral artery disease between 2011 and 2021. Input features included 38 preoperative demographic/clinical variables. The primary outcome was 30‐day postprocedural major adverse limb event (composite of major reintervention, untreated loss of patency, or major amputation) or death. Data were split into training (70%) and test (30%) sets. Using 10‐fold cross‐validation, 6 machine learning models were trained using preoperative features. The primary model evaluation metric was area under the receiver operating characteristic curve. Overall, 21 886 patients were included, and 30‐day major adverse limb event/death occurred in 1964 (9.0%) individuals. The best performing model for predicting 30‐day major adverse limb event/death was extreme gradient boosting, achieving an area under the receiver operating characteristic curve of 0.93 (95% CI, 0.92–0.94). In comparison, logistic regression had an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.70–0.74). The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.09. The top 3 predictive features in our algorithm were (1) chronic limb‐threatening ischemia, (2) tibial intervention, and (3) congestive heart failure. Conclusions Our machine learning models accurately predict 30‐day outcomes following lower extremity endovascular revascularization using preoperative data with good discrimination and calibration. Prospective validation is warranted to assess for generalizability and external validity.

Background Carotid endarterectomy (CEA) is a major vascular operation for stroke prevention that carries significant perioperative risks; however, outcome prediction tools remain limited. The authors developed machine learning algorithms to predict outcomes following CEA. Methods and Results The National Surgical Quality Improvement Program targeted vascular database was used to identify patients who underwent CEA between 2011 and 2021. Input features included 36 preoperative demographic/clinical variables. The primary outcome was 30‐day major adverse cardiovascular events (composite of stroke, myocardial infarction, or death). The data were split into training (70%) and test (30%) sets. Using 10‐fold cross‐validation, 6 machine learning models were trained using preoperative features. The primary metric for evaluating model performance was area under the receiver operating characteristic curve. Model robustness was evaluated with calibration plot and Brier score. Overall, 38 853 patients underwent CEA during the study period. Thirty‐day major adverse cardiovascular events occurred in 1683 (4.3%) patients. The best performing prediction model was XGBoost, achieving an area under the receiver operating characteristic curve of 0.91 (95% CI, 0.90–0.92). In comparison, logistic regression had an area under the receiver operating characteristic curve of 0.62 (95% CI, 0.60–0.64), and existing tools in the literature demonstrate area under the receiver operating characteristic curve values ranging from 0.58 to 0.74. The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.02. The strongest predictive feature in our algorithm was carotid symptom status. Conclusions The machine learning models accurately predicted 30‐day outcomes following CEA using preoperative data and performed better than existing tools. They have potential for important utility in guiding risk‐mitigation strategies to improve outcomes for patients being considered for CEA.

Abstract After creation of a new arteriovenous fistula (AVF), assessment of readiness for use is an important clinical task. Accurate prediction of successful use is challenging, and augmentation of the physical exam with ultrasound has become routine. Herein, we propose a point-of-care tool based on machine learning to enhance prediction of successful unassisted radiocephalic arteriovenous fistula (AVF) use. Our analysis includes pooled patient-level data from 704 patients undergoing new radiocephalic AVF creation, eligible for hemodialysis, and enrolled in the 2014–2019 international multicenter PATENCY-1 or PATENCY-2 randomized controlled trials. The primary outcome being predicted is successful unassisted AVF use within 1-year, defined as 2-needle cannulation for hemodialysis for ≥90 days without preceding intervention. Logistic, penalized logistic (lasso and elastic net), decision tree, random forest, and boosted tree classification models were built with a training, tuning, and testing paradigm using a combination of baseline clinical characteristics and 4–6 week ultrasound parameters. Performance assessment includes receiver operating characteristic curves, precision-recall curves, calibration plots, and decision curves. All modeling approaches except the decision tree have similar discrimination performance and comparable net-benefit (area under the ROC curve 0.78–0.81, accuracy 69.1–73.6%). Model performance is superior to Kidney Disease Outcome Quality Initiative and University of Alabama at Birmingham ultrasound threshold criteria. The lasso model is presented as the final model due to its parsimony, retaining only 3 covariates: larger outflow vein diameter, higher flow volume, and absence of >50% luminal stenosis. A point-of-care online calculator is deployed to facilitate AVF assessment in the clinic.

Background: Artificial intelligence (AI) and machine learning (ML) are rapidly advancing fields with increasing utility in health care. We conducted a survey to determine the perceptions of Canadian vascular surgeons toward AI/ML. Methods: An online questionnaire was distributed to 162 members of the Canadian Society for Vascular Surgery. Self-reported knowledge, attitudes, and perceptions with respect to potential applications, limitations, and facilitators of AI/ML were assessed. Results: Overall, 50 of the 162 Canadian vascular surgeons (31%) responded to the survey. Most respondents were aged 30 to 59 years (72%), male (80%), and White (67%) and practiced in academic settings (72%). One half of the participants reported that their knowledge of AI/ML was poor or very poor. Most were excited or very excited about AI/ML (66%) and were interested or very interested in learning more about the field (83.7%). The respondents believed that AI/ML would be useful or very useful for diagnosis (62%), prognosis (72%), patient selection (56%), image analysis (64%), intraoperative guidance (52%), research (88%), and education (80%). The limitations that the participants were most concerned about were errors leading to patient harm (42%), bias based on patient demographics (42%), and lack of clinician knowledge and skills in AI/ML (40%). Most were not concerned or were mildly concerned about job replacement (86%). The factors that were most important to encouraging clinicians to use AI/ML models were improvements in efficiency (88%), accurate predictions (84%), and ease of use (84%). The comments from respondents focused on the pressing need for the implementation of AI/ML in vascular surgery owing to the potential to improve care delivery. Conclusions: Canadian vascular surgeons have positive views on AI/ML and believe this technology can be applied to multiple aspects of the specialty to improve patient care, research, and education. Current self-reported knowledge is poor, although interest was expressed in learning more about the field. The facilitators and barriers to the effective use of AI/ML identified in the present study can guide future development of these tools in vascular surgery.

Abstract Machine learning (ML) is a rapidly advancing field with increasing utility in health care. We conducted a systematic review and critical appraisal of ML applications in vascular surgery. MEDLINE, Embase, and Cochrane CENTRAL were searched from inception to March 1, 2021. Study screening, data extraction, and quality assessment were performed by two independent reviewers, with a third author resolving discrepancies. All original studies reporting ML applications in vascular surgery were included. Publication trends, disease conditions, methodologies, and outcomes were summarized. Critical appraisal was conducted using the PROBAST risk-of-bias and TRIPOD reporting adherence tools. We included 212 studies from a pool of 2235 unique articles. ML techniques were used for diagnosis, prognosis, and image segmentation in carotid stenosis, aortic aneurysm/dissection, peripheral artery disease, diabetic foot ulcer, venous disease, and renal artery stenosis. The number of publications on ML in vascular surgery increased from 1 (1991–1996) to 118 (2016–2021). Most studies were retrospective and single center, with no randomized controlled trials. The median area under the receiver operating characteristic curve (AUROC) was 0.88 (range 0.61–1.00), with 79.5% [62/78] studies reporting AUROC ≥ 0.80. Out of 22 studies comparing ML techniques to existing prediction tools, clinicians, or traditional regression models, 20 performed better and 2 performed similarly. Overall, 94.8% (201/212) studies had high risk-of-bias and adherence to reporting standards was poor with a rate of 41.4%. Despite improvements over time, study quality and reporting remain inadequate. Future studies should consider standardized tools such as PROBAST and TRIPOD to improve study quality and clinical applicability.

Objective:. We sought to confirm and extend the understanding of clinical outcomes following creation of a common distal autogenous access, the radiocephalic arteriovenous fistula (RCAVF). Background:. Interdisciplinary guidelines recommend distal autogenous arteriovenous fistulae as the preferred hemodialysis (HD) access, yet uncertainty about durability and function present barriers to adoption. Methods:. Pooled data from the 2014-2019 multicenter randomized-controlled PATENCY-1 and PATENCY-2 trials were analyzed. New RC-AVFs were created in 914 patients, and outcomes were tracked prospectively for 3-years. Cox proportional hazards and Fine-Gray regression models were constructed to explore patient, anatomic, and procedural associations with access patency and use. Results:. Mean (SD) age was 57 (13) years; 45% were on dialysis at baseline. Kaplan-Meier estimates of 3-year primary, primary-assisted, and secondary patency were 27.6%, 56.4%, and 66.6%, respectively. Cause-specific 1-year cumulative incidence estimates of unassisted and overall RC-AVF use were 46.8% and 66.9%, respectively. Patients with larger baseline cephalic vein diameters had improved primary (per mm, hazard ratio [HR] 0.89, 95% confidence intervals 0.81–0.99), primary-assisted (HR 0.75, 0.64–0.87), and secondary (HR 0.67, 0.57–0.80) patency; and higher rates of unassisted (subdistribution hazard ratio 1.21, 95% confidence intervals 1.02–1.44) and overall RCAVF use (subdistribution hazard ratio 1.26, 1.11–1.45). Similarly, patients not requiring HD at the time of RCAVF creation had better primary, primary-assisted, and secondary patency. Successful RCAVF use occurred at increased rates when accesses were created using regional anesthesia and at higher volume centers. Conclusions:. These insights can inform patient counseling and guide shared decision-making regarding HD access options when developing an individualized end-stage kidney disease life-plan.

Approximately 20% of vascular patients treated with acetyl salicylic acid (i.e., aspirin) demonstrate less than expected platelet inhibition – putting them at a four-fold increased risk of adverse cardiovascular events. Low-dose rivaroxaban (2.5 mg twice daily) in combination with low-dose aspirin has been shown to reduce adverse cardiovascular and limb events when compared to aspirin alone. In this study, light transmission aggregometry was used to measure arachidonic acid-induced platelet aggregation to evaluate the potential of combining low-dose rivaroxaban and aspirin in attenuating or overcoming aspirin non-sensitivity. In the discovery phase, 83 patients with peripheral arterial disease (PAD) taking 81 mg aspirin daily were recruited from the outpatient vascular surgery clinic at St Michael's Hospital between January to September 2021. 19 (23%) were determined to be non-sensitive to aspirin. After ex-vivo addition of 2.5 mg dosage equivalent of rivaroxaban, aspirin non-sensitivity was overcome in 11 (58%) of these 19 patients. In the validation phase, 58 patients with cardiovascular risk factors who were not previously prescribed aspirin were recruited. In this group, ex-vivo addition of 2.5 mg dosage equivalent of rivaroxaban significantly reduced arachidonic acid-induced platelet aggregation in the presence of aspirin. These results demonstrate the potential for low-dose rivaroxaban to overcome aspirin non-sensitivity in patients with PAD. Further studies are needed to evaluate and confirm these findings.

Abstract Background Aspirin is a key antiplatelet therapy for the prevention of thrombotic events in patients with cardiovascular disease. Studies suggest that ≈20% of patients with cardiac disease suffer from aspirin nonsensitivity, a phenomenon characterized by the inability of 81 mg aspirin to inhibit platelet aggregation and/or prevent adverse cardiovascular events. Objectives To investigate aspirin nonsensitivity in patients with vascular disease and assess the consequences of aspirin nonsensitivity. Methods One hundred fifty patients presenting to St. Michael’s Hospital’s outpatient clinics with evidence of vascular disease (peripheral arterial disease or carotid artery stenosis) and a previous prescription of 81 mg of aspirin were recruited in this study. Light transmission aggregometry with arachidonic acid induction was used to determine sensitivity to aspirin. Patients with a maximum aggregation ≥20% in response to arachidonic acid were considered aspirin nonsensitive, as per previous studies. Results Of the 150 patients recruited, 36 patients (24%) were nonsensitive to 81 mg of aspirin. Of these 36 nonsensitive patients, 30 patients provided a urine sample for urine salicyluric acid analysis (a major metabolite of aspirin). Urine analysis demonstrated that 14 patients were compliant and 16 were noncompliant with their aspirin therapy. Major adverse cardiovascular events and major adverse limb events were significantly higher in the nonsensitive patients compared to sensitive patients (hazard ratio, 3.68; P

Objective Many studies have analysed gender bias in academic medicine; however, no comprehensive synthesis of the literature has been performed. We conducted a pooled analysis of the difference in the proportion of men versus women with full professorship among academic physicians.Design Systematic review and meta-analysis.Data sources MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Education Resources Information Center and PsycINFO were searched from inception to 3 July 2020.Study selection All original studies reporting faculty rank stratified by gender worldwide were included.Data extraction and synthesis Study screening, data extraction and quality assessment were performed by two independent reviewers, with a third author resolving discrepancies. Meta-analysis was conducted using random-effects models.Results Our search yielded 5897 articles. 218 studies were included with 991 207 academic physician data points. Men were 2.77 times more likely to be full professors (182 271/643 790 men vs 30 349/251 501 women, OR 2.77, 95% CI 2.57 to 2.98). Although men practised for longer (median 18 vs 12 years, p

Surgical departments commonly rely on third-party quality improvement registries. As electronic health data become increasingly integrated and accessible within an institution, alternatives to these platforms arise. We present the conceptualization and implementation of an in-house quality improvement platform that provides real-time reports, is less onerous on clinicians and is tailored to an institution’s priorities of care.

Summary: The coronavirus disease 2019 (COVID-19) pandemic remains a source of considerable morbidity and mortality throughout the world. Therapeutic options to reduce symptoms, inflammatory response, or disease progression are limited. This randomized open-label trial enrolled 100 ambulatory patients with symptomatic COVID-19 in Toronto, Canada. Results indicate that icosapent ethyl (8 g daily for 3 days followed by 4 g daily for 11 days) significantly reduced high-sensitivity C-reactive protein (hs-CRP) and improved symptomatology compared with patients assigned to usual care. Specifically, the primary biomarker endpoint, change in hs-CRP, was significantly reduced by 25% among treated patients (−0.5 mg/L, interquartile range [IQR] [−6.9,0.4], within-group p = 0.011). Conversely, a non-significant 5.6% reduction was observed among usual care patients (−0.1 mg/L, IQR [−3.2,1.7], within-group p = 0.51). An unadjusted between-group primary biomarker analysis was non-significant (p = 0.082). Overall, this report provides evidence of an early anti-inflammatory effect of icosapent ethyl in a modest sample, including an initial well-tolerated loading dose, in symptomatic outpatients with COVID-19. ClinicalTrials.gov Identifier: NCT04412018.

Summary: Detection of vascular regenerative cell exhaustion is required to combat ischemic complications during type 2 diabetes mellitus (T2D). We used high aldehyde dehydrogenase (ALDH) activity and surface marker co-expression to develop a high-throughput flow cytometry–based assay to quantify circulating proangiogenic and proinflammatory cell content in the peripheral blood of individuals with T2D. Circulating proangiogenic monocytes expressing anti-inflammatory M2 markers were decreased in patients with T2D. Individuals with longer duration of T2D exhibited reduced frequencies of circulating proangiogenic ALDHhiCD34+ progenitor cells with primitive (CD133) and migratory (CXCR4) phenotypes. This approach consistently detected increased inflammatory cell burden and decreased provascular progenitor content in individuals with T2D. Key Words: aldehyde dehydrogenase, angiogenesis, ischemia, progenitor cells, type 2 diabetes

Doxorubicin (DOX) is an effective, broad-spectrum antineoplastic agent with serious cardiotoxic side effects, which may lead to the development of heart failure. Current strategies to diagnose, prevent, and treat DOX-induced cardiotoxicity (DIC) are inadequate. Recent evidence has linked the dysregulation and destruction of the vascular endothelium to the development of DIC. Autophagy is a conserved pro-survival mechanism that recycles and removes damaged sub-cellular components. Autophagy-related protein 7 (ATG7) catalyzes autophagosome formation, a critical step in autophagy. In this study, we used endothelial cell-specific Atg7 knockout (EC-Atg7−/−) mice to characterize the role of endothelial cell-specific autophagy in DIC. DOX-treated EC-Atg7−/− mice showed reduced survival and a greater decline in cardiac function compared to wild-type controls. Histological assessments revealed increased cardiac fibrosis in DOX-treated EC-Atg7−/− mice. Furthermore, DOX-treated EC-Atg7−/− mice had elevated serum levels of creatine kinase-myocardial band, a biomarker for cardiac damage. Thus, the lack of EC-specific autophagy exacerbated DIC. Future studies on the relationship between EC-specific autophagy and DIC could establish the importance of endothelium protection in preventing DIC.

Objective Trauma-related vascular injuries are major contributors to morbidity and mortality worldwide. We conducted a retrospective, population-based, cross-sectional study to examine temporal trends and factors associated with traumatic vascular injury-related in-hospital mortality in Ontario, Canada from 1991 to 2009. Methods We obtained data on Ontario hospital admissions for traumatic vascular injury, including injury mechanism and body region; and patient age, sex, socioeconomic status, and residence from the Canadian Institute for Health Information Discharge Abstract Database and Registered Persons Database from fiscal years 1991 to 2009. We performed time series analysis of vascular injury-related in-hospital mortality rates and multivariable logistic regression analysis to identify significant mortality-associated factors. Results The overall in-hospital mortality rate for trauma-related vascular injury was 5.5%. A slight but non-significant decline in mortality occurred over time. The likelihood of vascular injury-related in-hospital mortality was significantly higher for patients involved in transport-related accidents (odds ratio [OR[=2.21, 95% confidence interval [CI], 1.76–2.76), age ≥65 years (OR = 4.34, 95% CI, 2.25–8.38), or with thoracic (OR = 2.24, 95% CI, 1.56–3.20) or abdominal (OR = 2.45, 95% CI, 1.75–3.42) injuries. Conclusions In-hospital mortality from traumatic vascular injury in Ontario was low and stable from 1991 to 2009.

N-terminal pro B-type natriuretic peptide (NT-proBNP), a cardiac disease biomarker, has been demonstrated to be a strong independent predictor of cardiovascular events in patients without heart failure. Patients with peripheral arterial disease (PAD) are at high risk of cardiovascular events and death. In this study, we investigated levels of NT-proBNP in patients with PAD compared to non-PAD controls. A total of 355 patients were recruited from outpatient clinics at a tertiary care hospital network. Plasma NT-proBNP levels were quantified using protein multiplex. There were 279 patients with both clinical and diagnostic features of PAD and 76 control patients without PAD (non-PAD cohort). Compared with non-PAD patients, median (IQR) NT-proBNP levels in PAD patients were significantly higher (225 ng/L (120-363) vs 285 ng/L (188-425), p- value = 0.001, respectively). Regression analysis demonstrated that NT-proBNP remained significantly higher in patients with PAD relative to non-PAD despite adjusting for age, sex, hypercholesterolemia, smoking and hypertension [odds ratio = 1.28 (1.07-1.54), p-value

Summary: Bariatric surgery, in addition to the benefit of sustained weight loss, can also reduce cardiometabolic risk and mortality. Lifelong vessel maintenance is integral to the prevention of cardiovascular disease. Using aldehyde dehydrogenase activity, an intracellular detoxifying enzyme present at high levels within pro-vascular progenitor cells, we observed an association between chronic obesity and “regenerative cell exhaustion” (RCE), a pathology whereby chronic assault on circulating regenerative cell types can result in adverse inflammation and diminished vessel repair. We also describe that, at 3 months following bariatric surgery, systemic inflammatory burden was reduced and pro-angiogenic macrophage precursor content was improved in subjects with severe obesity, suggesting the restoration of a microenvironment to support vessel homeostasis. These data suggest that bariatric surgery may reverse deleterious events that predispose patients with morbid obesity to cardiovascular risk.

Summary: The clinical use of doxorubicin in cancer is limited by cardiotoxic effects that can lead to heart failure. Whereas earlier work focused on the direct impact of doxorubicin on cardiomyocytes, recent studies have turned to the endothelium, because doxorubicin-damaged endothelial cells can trigger the development and progression of cardiomyopathy by decreasing the release and activity of key endothelial factors and inducing endothelial cell death. Thus, the endothelium represents a novel target for improving the detection, management, and prevention of doxorubicin-induced cardiomyopathy. Key Words: cardiomyopathy, doxorubicin, endothelium, heart failure

Background and Objectives: Aspirin (acetylsalicylic acid—ASA) is a first-line antiplatelet therapy provided to patients with coronary artery disease (CAD). However, it has been demonstrated that 20–30% of these patients are non-sensitive to their ASA therapy. ASA non-sensitivity is a phenomenon where low-dose ASA (81–325 mg) does not completely inhibit arachidonic-acid-induced platelet aggregation, putting patients at risk of adverse cardio-thrombotic events. Ticagrelor is a P2Y12 receptor inhibitor and alternative antiplatelet that has been approved to reduce the risk of stroke, myocardial infarction, and overall cardiovascular-related death. In this study, we aimed to identify ASA non-sensitive patients and evaluate if they would be sensitive to ticagrelor. Materials and Methods: For this pilot study, thirty-eight patients with CAD taking 81 mg ASA were recruited. Blood samples were collected from each patient and platelet rich plasma (PRP) from each sample was isolated. Light-transmission aggregometry (LTA) was used to determine baseline ASA sensitivity in each patient using 0.5 mg/mL arachidonic acid as a platelet agonist. Patients with ≥20% maximal platelet aggregation after activation were considered ASA non-sensitive. Fresh PRP samples from all patients were then spiked with a clinical dosage of ticagrelor (3 μM—approximately equivalent to a loading dose of 180 mg ticagrelor). Sensitivity was determined using LTA and 5 μM ADP as a platelet agonist. Patients with ≥46% maximal platelet aggregation were considered ticagrelor non-sensitive. Results: Of the 38 CAD patients taking 81 mg ASA, 32% (12/38) were non-sensitive to their 81 mg ASA therapy. All 38 of the recruited patients (100%) were sensitive to ticagrelor ex vivo. In conclusion, we were able to identify ASA non-sensitivity using LTA and determine that ASA non-sensitive patients were sensitive to ticagrelor. Conclusions: Our results suggest that ticagrelor is a promising alternative therapy for patients who are non-sensitive to ASA.

Acetylsalicylic acid (ASA), also known as aspirin, appears to be ineffective in inhibiting platelet aggregation in 20–30% of patients. Light transmission aggregometry (LTA) is a gold standard platelet function assay. In this pilot study, we used LTA to personalize ASA therapy ex vivo in atherosclerotic patients. Patients were recruited who were on 81 mg ASA, presenting to ambulatory clinics at St. Michael’s Hospital (n = 64), with evidence of atherosclerotic disease defined as clinical symptoms and diagnostic findings indicative of symptomatic peripheral arterial disease (PAD), with an ankle brachial index (ABI) of n = 52) or had diagnostic features of asymptomatic carotid arterial stenosis (CAS), with >50% stenosis of internal carotid artery on duplex ultrasound (n = 12). ASA compliance was assessed via multisegmented injection-capillary electrophoresis-mass spectrometry based on measuring the predominant urinary ASA metabolite, salicyluric acid. LTA with arachidonic acid was used to test for ASA sensitivity. Escalating ASA dosages of 162 mg and 325 mg were investigated ex vivo for ASA dose personalization. Of the 64 atherosclerotic patients recruited, 8 patients (13%) were non-compliant with ASA. Of ASA compliant patients (n = 56), 9 patients (14%) were non-sensitive to their 81 mg ASA dosage. Personalizing ASA therapy in 81 mg ASA non-sensitive patients with escalating dosages of ASA demonstrated that 6 patients became sensitive to a dosage equivalent to 162 mg ASA and 3 patients became sensitive to a dosage equivalent to 325 mg ASA. We were able to personalize ASA dosage ex vivo in all ASA non-sensitive patients with escalating dosages of ASA within 1 h of testing.

Background There are no recognized pharmacological treatments for abdominal aortic aneurysms (AAA), although statins are suggested to be beneficial. We sought to summarize the literature regarding the effects of statins on human AAA growth, rupture, and 30‐day mortality. Methods and Results We conducted a systematic review and meta‐analysis of randomized and observational studies using the Cochrane CENTRAL database, MEDLINE, and EMBASE up to June 15, 2018. Review, abstraction, and quality assessment were conducted by 2 independent reviewers, and a third author resolved discrepancies. Pooled mean differences and odds ratios with 95% confidence intervals were calculated using random effects models. Heterogeneity was quantified using the I2 statistic, and publication bias was assessed using funnel plots. Our search yielded 911 articles. One case‐control and 21 cohort studies involving 80 428 patients were included. The risk of bias was low to moderate. Statin use was associated with a mean AAA growth rate reduction of 0.82 mm/y (95% confidence interval 0.33, 1.32, P=0.001, I2=86%). Statins were also associated with a lower rupture risk (odds ratio 0.63, 95% confidence interval 0.51, 0.78, P

Background Statins are commonly used for the prevention of cardiovascular events; however, statins are underutilized in patients with noncoronary atherosclerosis. We sought to establish the rates of statin use in patients with carotid artery disease and to examine the association between statin therapy and outcomes after carotid revascularization. Methods and Results In this population‐level retrospective cohort study, we identified all individuals aged ≥66 years who underwent carotid endarterectomy or stenting in Ontario, Canada (2002–2014). The primary outcome was a composite of 1‐year stroke, myocardial infarction, or death (major adverse cardiac and cerebrovascular events). Five‐year risks were also examined. Adjusted hazard ratios were computed using inverse probability of treatment weighting based on propensity scores. A total of 7893 of 10 723 patients (73.6%) who underwent carotid revascularization were on preprocedural statin therapy; moderate‐ or high‐dose therapy was utilized by 7384 patients (68.9%). The composite rate of 1‐year major adverse cardiac and cerebrovascular events was lower among statin users (adjusted hazard ratio: 0.76; 95% confidence interval, 0.70–0.83). Patients who were on persistent long‐term statin therapy after the carotid procedure continued to experience significantly lower risk of major adverse cardiac and cerebrovascular events at 5 years (adjusted hazard ratio: 0.75, 95% confidence interval, 0.71–0.80). The beneficial associations with statin use were observed regardless of type of carotid revascularization procedure, carotid artery symptom status, or statin dose. Conclusions Continuous statin therapy was associated with a 25% lower risk of long‐term adverse cardiovascular events in patients with significant carotid disease. Along with other supportive evidence, statins should be considered in patients undergoing carotid revascularization, and efforts are required to increase statin use in this undertreated population.

We present two cases of thoracic outlet decompression performed to facilitate hemodialysis through upper limb arteriovenous fistulas. In patients undergoing arteriovenous fistula formation for dialysis access, venous hypertension is a well-known complication. We used a supraclavicular approach in our two reported cases to remove the first rib to facilitate hemodialysis. Dialysis patients presenting with central venous stenosis should be assessed for evidence of extrinsic compression by the first rib as management options differ from those with central venous stenosis due to an intravenous catheter.

Objective. To evaluate the relationship between TGFβ signaling and endothelial lncRNA expression. Methods. Human umbilical vein endothelial cell (HUVECs) lncRNAs and mRNAs were profiled with the Arraystar Human lncRNA Expression Microarray V3.0 after 24 hours of exposure to TGFβ1 (10 ng/mL). Results. Of the 30,584 lncRNAs screened, 2,051 were significantly upregulated and 2,393 were appreciably downregulated (P

Mohammed Al-OmranDepartment of Surgery, King Khalid University Hospital, King Saud University, Riyadh, Saudi ArabiaBackground: Peripheral arterial disease (PAD) is a marker of advanced atherosclerosis with an elevated risk of cardiovascular mortality and morbidity. Although intensive risk reduction therapy is critical in reducing the adverse cardiovascular outcomes in patients with PAD, the awareness of this information among all physicians is felt to be low. Given the role of family physicians (FP), general internists (GI), cardiologists (C), and vascular surgeons (VS) in treating patients with PAD, we sought to determine their perceptions and knowledge of risk reduction therapy in these patients.Methods and results: We conducted a cross-sectional self-administered survey of 84 physicians who work at a major teaching hospital. FP, GI, C, and VS represent 39%, 33%, 16%, and 12% of the surveyed physicians, respectively. The recommended targets of LDL-cholesterol, blood glucose and blood pressure in PAD patients were known to 37.3%, 94.1% and 35.3% of physicians, respectively. The majority of physicians reported to screen for risk factors in PAD. Although 86.3% of physicians would recommend antiplatelets therapy in PAD, only 17.6% would recommend angiotensin converting enzyme (ACE) inhibitors; 25.5% would recommend nicotine replacement therapy for smokers and 62.7% would recommend statins. Compared to other specialties, cardiologists had the lowest threshold, whereas GI had the highest threshold for initiating antiplatelets and statins for patients with PAD.Conclusion: The perceptions towards risk reduction in PAD identify glaring knowledge and action gaps. Effective strategies to encourage health professionals to use risk reduction therapy are needed.Keywords: peripheral arterial disease, risk reduction, atherosclerosis

Background Peripheral Arterial Disease (PAD) is a marker of systemic atherosclerosis with an elevated risk of cardiovascular mortality and morbidity. This study was undertaken to identify the prevalence of PAD in patients presenting with acute coronary syndrome and do not have previous history of coronary artery disease in order to identify the missed opportunity in treating these patients and potentially avoiding such cardiovascular events. Methods We prospectively collected data from consecutive patients who presented with acute coronary events over 4 months. PAD was diagnosed if the Ankle-Brachial index was less than 0.90 and/or if the patient had signs or symptoms suggestive for PAD. Risk factors and risk reduction therapy were compared between patients with and without PAD. Results A total of 51 patients were recruited. The mean age for these patients was 62 years and 27% were women. Prevalence of PAD was 45%, of these, 61% were asymptomatic. Prevalence of PAD in patients with no previous history of CAD was 48%, of these, 64% were asymptomatic. There was no difference in atherosclerotic risk factors between patients with PAD compared to patients without PAD. Utilization of risk reduction was suboptimal in patients with PAD; only 61% were on aspirin, 48% were on statin therapy, 43% were on beta-blockers and 30% were on angiotensin converting enzymes inhibitors. Conclusion There is a great opportunity in preventing acute coronary events that we are missing. This is can be achieved by recognizing patients with PAD (symptomatic or asymptomatic) and aggressively control their risk factors.