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Background: Endovascular thrombectomy has revolutionized treatment of ischemic stroke. Given the clinical and socioeconomic support for thrombectomy, new devices, procedures, and pharmaceuticals have emerged in recent years, and have been subject to a growing number of clinical trials worldwide., Objective: To define the current state of thrombectomy clinical trials, highlight recent trends, and help guide future research in this area., Methods: Current and previous clinical trials involving thrombectomy for ischemic stroke were queried from the Clinicaltrials.gov database. Trials were categorized by their current status, study design, funding type, exclusion criteria, study phase, enrollment, start and completion dates, country of origin, item of investigation, outcome metrics, and whether a peer-reviewed publication was linked to the trial., Results: Querying the ClinicalTrials.gov registry yielded 196 trials, of which 161 (82.1 %) were started within the past 5 years. The average time to completion was 30.6 months. A total of 62 studies (31.6 %) examined the safety or efficacy of a thrombectomy device, 29 (14.8 %) investigated a pharmacological intervention alone or in combination with a device, 59 (30.1 %) examined aspects of the endovascular procedure on patient outcomes, and 14 (7.2 %) examined diagnostic utility during thrombectomy. Most trials were funded by academic centers (53.1 %) or industry (34.7 %). Although the United States contributed the most studies overall (59; 30.1 %), studies from European and Asian countries have been increasing since 2015., Conclusion: These trends indicate an increasing number of trials starting the past few years, with most occurring in Europe and examining devices or aspects of the thrombectomy procedure., (Copyright © 2020. Published by Elsevier B.V.)

Objective: Removal of colloid cysts of the third ventricle using a purely endoscopic method has been established as a safe and advantageous technique. It is hypothesized that endoscopic removal in recurrent cases might pose more technical challenges and result in less success. The objective of this study was to assess the feasibility and outcomes of using a purely endoscopic approach for the management of recurrent colloid cysts compared to primary cysts., Methods: A retrospective cohort study was performed on patients who underwent purely endoscopic removal of their colloid cyst. Descriptive statistics were compared for patients undergoing surgery for a recurrent cyst and those for a control cohort undergoing surgery for a primary cyst. Bivariate analysis was conducted using a Fisher's exact test for categorical variables and Mann-Whitney U-test for continuous variables., Results: In total, 121 patients had a primary colloid cyst endoscopically removed and 10 patients had a total of 11 recurrent cysts removed. Recurrence or progression after surgery occurred in 3 (2.5%) cases in the primary cyst group and 2 (18.2%) cases in the recurrent cyst group. Symptomatic presentation during the follow-up period occurred in 6 (54.5%) cases in the recurrent cyst group versus 75 (62%) cases in the primary cyst group (p = 0.749). Two patients (20%) in the recurrent group had a second recurrence in a mean period of 30 months (1 patient at 15 and 1 patient at 45 months). One of these patients required a tertiary endoscopic removal 8 years after the second resection. No immediate postoperative complications or new morbidities were observed after repeat endoscopic surgery. The authors' findings indicated a nonsignificant trend toward a higher recurrence rate (18.2% vs 2.5%, p = 0.055) and a decreased proportion of complete removal (90.9% vs 81.8%, p = 0.296) in the recurrent cyst group compared to the primary cyst group. However, a significantly higher rate of preoperative hydrocephalus was observed in the primary cyst group compared with the recurrent cyst group (63.6% vs 18.2%, p = 0.007)., Conclusions: Purely endoscopic approaches for the removal of recurrent colloid cysts of the third ventricle are feasible and equally safe compared with endoscopic removal of primary cysts. The study's findings did not show a statistically significant difference in the rate of recurrence between the 2 groups. The proportion of patients with symptomatic cysts on presentation was lower in patients with recurrent cysts than in patients with primary cysts. Due to the high rate of complete removal with negligible morbidity, the authors continue to advocate for an endoscopic removal at the time of cyst recurrence.

Background: Even though low molecular weight heparins (LMWHs) have become the standard for venous thromboembolism (VTE) prophylaxis in most European countries and Canada, it was not until recently that LMWHs were approved for use in the United States. The main objective of this study was to assess the current preferences and attitudes of United States surgeons toward the prevention of VTE with particular reference to LMWH., Methods: A survey with questions relative to VTE awareness, risk factors, and prevention practices was mailed to 10,000 Fellows of the American College of Surgeons., Results: A total of 1,145 (11.45%) usable questionnaires were returned. The vast majority (96%) of respondents use prophylaxis against VTE. Although LMWHs were rated first regarding efficacy and second regarding simplicity of use, conventional unfractionated heparin at fixed doses remains the preferred pharmacological agent for VTE prevention (74%), followed by 2 LMWHs: enoxaparin (34%) and dalteparin (16%). Overall, 52% of surgeons preferred physical methods over pharmacological methods when used separately and 26% of surgeons utilize combined physical-pharmacological modalities., Conclusions: North American general surgeons have substantially modified their approach to VTE prevention in the last 4 years. Physical methods and unfractionated heparin remain the preferred prophylactic modalities, but LMWHs have gained rapid acceptance since their approval for use for VTE prevention in North America. Even though the results of this survey must be interpreted with caution because of the limited response rate and possible sampling bias, they still reflect the current preferences and attitudes of North American surgeons toward prophylaxis.

Purpose: The use of intermittent pneumatic compression, in addition to elastic bandages or stockings, accelerates the healing of leg ulcers in patients with severe chronic venous insufficiency (CVI). There is recent evidence that impulse compression of the plantar venous plexus reduces post-traumatic ankle swelling and prevents postoperative venous thromboembolism. The purpose of this study was to evaluate the clinical and hemodynamic responses after home use of impulse foot compression for 3 months in patients already using therapeutic compression stockings for the management of CVI., Methods: Twelve extremities from 9 patients with documented CVI, class 4 to 5 according to the Clinical, Etiology, Anatomy, Pathophysiology classification system, were included in this prospective cohort study. All patients were instructed to use a foot pump device at home for 2 hours a day for 3 months in addition to therapeutic compression stockings (30-40 mm Hg) worn during the day. The device was set to three cycles (3 seconds) of compression (120 mm Hg) per minute. A clinical scoring system was completed before foot compression and 1, 2, and 3 months thereafter. In addition, all patients underwent air plethysmography studies at the same time intervals, including venous volume, venous filling index, ejection fraction, and residual volume fraction., Results: Patients reported significant improvement in their scores for swelling (P <.05) and pain (P <.04). Air plethysmography showed a reduction in venous volume and venous filling index, although these differences were not significant. Ejection fraction remained unchanged and residual volume fraction was significantly reduced (P <.05) compared with baseline. The foot compression devices were well tolerated by all the patients in the study., Conclusions: The use of home foot impulse compression plus elastic stockings significantly reduced the residual volume fraction as measured by air-plethysmography in a group of patients with severe CVI. This favorable hemodynamic response could, in part, explain the clinical improvement achieved by this combined treatment. However, this represents a preliminary pilot study that needs to be confirmed in future randomized controlled studies with more patients included.

Effective and safe methods of preventing venous thromboembolism (VTE) are now widely available, but a significant proportion of patients develop VTE either because thromboprophylaxis has not been used or because the intensity of thromboprophylaxis is not matched to the level of risk. Thromboembolic risk varies widely according to the clinical setting and presence of underlying risk factors, but VTE may not be suspected even in high-risk patients. Clinical risk factors for VTE include recent surgery, cancer, stroke, previous VTE, immobilization, and advanced age. Recent attention has focused on the role of inherited and acquired molecular factors in determining overall thromboembolic risk. These factors include the classic thrombophilias-deficiencies of antithrombin III, protein C, and protein S-and several newly described molecular risk factors: factor V Leiden, the prothrombin 20210A gene mutation, and hyperhomocysteinemia. Based on emerging knowledge of risk factors, several risk assessment models (RAMs) have been devised that stratify patients according to overall VTE risk, allowing thromboprophylaxis to be tailored appropriately. Compared with older risk assessment formulas, current RAMs are simpler and include specific recommendations for thromboprophylaxis based on the available scientific evidence. Consensus documents on VTE prevention classify patients into low-, moderate-, and high-risk categories. More recently, a new risk group, very high risk, has been described. Very-high-risk patients are especially prone to thromboembolic complications and need intensive and in some cases prolonged thromboprophylaxis., (Copyright 2001 by W.B. Saunders Company.)

Patients undergoing orthopedic surgery are at increased risk of venous thromboembolic events. Proven prophylactic measures are available but are generally underused. However, even one of the most effective therapies available, low-molecular-weight heparin, fails to prevent deep vein thrombosis in approximately 15% of patients undergoing total hip replacement. Clinical outcomes and cost-effectiveness of venous thromboembolism prophylaxis may be optimized by tailoring the treatment to the level of risk of each patient. Overall thromboembolic risk depends on the interactions among multiple factors, such as those that relate to the current clinical status and underlying susceptibility of the patient. Presently, risk assessment models that consider these factors may be of practical assistance in stratifying patients. Improving identification of patients with additional risk factors is a goal of future models. Novel therapies, such as the recombinant hirudin desirudin, or strategies, such as prolonged postoperative prophylaxis, may provide improved protection in these patients and should be considered in the future.

Background: To evaluate the prevalence of thrombosis risk factors in a group of patients undergoing venous duplex scanning (VDS) and to design a risk factor stratification model with the ability to improve the diagnostic yield of VDS., Methods: Risk factor assessment and VDS were performed on 1,000 patients with clinically suspected lower extremity deep vein thrombosis (DVT) and patients were divided into two groups based upon the outcome of their scan: those with and those without confirmed DVT. Univariate and multivariate logistic regression analyses were performed in order to determine the significance of each risk factor in relation to having a confirmed DVT., Results: There were 181 patients (18.1%) with confirmed DVT. A prior history of DVT/pulmonary embolism, malignancy, prior immobilization, and age over 70 were the most important risk factors associated with having a DVT confirmed on VDS. A novel risk factor stratification model was created utilizing the odds ratios of those factors found to be significant and the prevalence of DVT was found to be 92.4% in the high risk category, 11.5% in the moderate risk category, and 3.2% in the low risk category using this model., Conclusions: Venous duplex scanning is established as the screening test of choice when one suspects the diagnosis of DVT despite the significant cost of performing and interpreting the test. We suggest that a better clinical model utilizing risk factor assessment may be the key to increasing the yield rate and cost-effectiveness of VDS by excluding low-risk patients from undergoing unnecessary testing.

Purpose: The purpose of this study was to assess the rate of postoperative deep vein thrombosis (DVT) as a function of oral anticoagulation therapy after total hip replacement surgery., Methods: A total of 125 patients completed the study. All the patients received sequential gradient pneumatic compression over elastic stockings until hospital discharge. In addition, all the patients underwent postoperative heparin therapy followed by oral warfarin therapy, adjusted in dose to maintain a goal international normalized ratio (INR) level of 2.0 to 3.0. Warfarin therapy and compression stockings were continued for 1 month after surgery. Bilateral duplex scanning was performed 1 and 4 weeks after surgery to assess the rate of DVT., Results: Nineteen of the 125 patients had DVT develop (15.2%). Of those thromboses, six (31.6%) and 13 (68%) were detected 1 week and 1 month after surgery, respectively. The rate of proximal DVT was 2.4% (3 of 125) 1 week after surgery and rose to 8.2% (10 of 122) 1 month after surgery. Most DVT cases (64%; 12 of 19) were asymptomatic. The patients in whom DVT developed had significantly lower INR values during the second to fourth postoperative weeks than did those patients without thrombosis, and no differences in INR values were found during the first postoperative week., Conclusion: The risk of the development of DVT extends beyond hospital discharge in patients who undergo total hip replacement, despite a regimen of prolonged oral anticoagulation therapy. This is particularly true in patients whose INR values did not reach therapeutic range during the first postoperative month. Therefore, thrombosis prophylaxis regimens on the basis of the administration of warfarin should try to maintain INR values within therapeutic range during the entire first postoperative month to minimize the incidence of DVT.

Objective: The purpose of this study was to assess the rate of deep vein thrombosis (DVT) resolution and DVT outcomes as functions of the level of oral anticoagulation therapy achieved with warfarin., Methods: In 33 consecutive patients, a series of 35 limbs with acute symptomatic DVT was followed throughout 1 year of anticoagulation therapy. All the patients underwent 5 days of intravenous unfractionated sodium heparin therapy that was adjusted in dose to prolong the activated thromboplastin time to 2.0 to 2.5 times the control. In addition, warfarin was administered for a period of 6 months, with a target international normalized ratio (INR) between 2.0 and 3.0. All the patients underwent venous duplex scanning and physical examination at the time of diagnosis and at 1 week, 1 month, 3 months, 6 months, and 1 year., Results: At the end of the 1-year study period, the rate of complete DVT resolution was 68%. The median INR values in patients with complete DVT resolution were significantly higher than those of patients with incomplete DVT resolution after 1, 3, and 6 months of treatment with warfarin. In addition, the proportion of patients with INR values below therapeutic range was significantly higher in patients with incomplete DVT resolution than in patients with complete DVT resolution after 1, 3, and 6 months of treatment with warfarin. The presence of occlusive thrombi was associated with incomplete DVT resolution. Of the patients with occlusive thrombi, 62% had chronic venous insufficiency symptoms develop, whereas only 11% of the patients with nonocclusive thrombi (P =.003) had these symptoms develop., Conclusion: Despite 6 months of oral anticoagulant therapy, almost one third of thrombi did not resolve completely. The INR values were significantly higher in those patients with complete DVT resolution. These results suggest that the maintenance of an INR level between 2.0 and 3.0 throughout oral anticoagulation therapy will minimize the rate of incomplete DVT resolution.

Successful and cost-effective prophylaxis against venous thromboembolism (VTE) depends on the availability of safe and effective antithrombotic methods, and the ability to match these to patients according to their level of thromboembolic risk. The last 20 years have seen significant developments in methods of thromboprophylaxis but, despite use of the best available methods, VTE still occurs in a significant proportion of patients. Efforts are now focused both on developing more effective pharmacological and physical methods, and improving assessment of thromboembolic risk in clinical practice, with the goal of avoiding unnecessary prophylaxis in low-risk patients and providing enhanced protection to high-risk patients. Factors known to exert a direct effect on thromboembolic risk include previous VTE, advancing age, surgery, malignancy, immobility, and the presence of thrombophilic states. Other less well-defined risk factors include obesity, pregnancy, and leg varicosities. Various risk assessment models (RAMs) have been devised based on these factors, but most of the resulting risk assessment formulae, some of them based on laboratory test results, have been too complicated to gain acceptance in routine clinical practice. Reflecting the need to refine the use of thromboprophylaxis in clinical practice, a number of RAMs have been developed recently, based on epidemiological evidence. Some models include specific recommendations for prophylaxis, based on evidence from randomized, controlled trials.

Background: Chronic venous insufficiency (CVI) affects a significant portion of the world's population, causing substantial morbidity and medical expenditure. Its pathophysiology is based on venous hypertension in the lower extremities, with vascular compression therapy remaining the foundation of its medical management., Objective: To evaluate the effectiveness of therapeutic compression stockings in the treatment of lower extremity CVI., Methods: A group of 112 patients with CVI received graduated-compression stockings and rated the severity of their symptoms on a five-point scale before wearing the stockings, and then again after 1 and 16 months of treatment. Patient complaints associated with stocking use and patient compliance rates were also recorded at 1 and 16 months., Results: A statistically significant improvement (p < 0.001) was reported in patient severity scores for lower extremity swelling, pain, skin discoloration, activity tolerance, depression and sleeping problems after 1 and 16 months of treatment with compression stockings., Conclusion: Therapeutic graduated-compression stockings are an effective treatment for CVI of the lower extremities.

Purpose: The purpose of this study was to evaluate the rate of resolution of deep vein thrombosis (DVT) in the leg, by means of duplex imaging, in patients with symptoms during a 6-month period after initial diagnosis., Methods: Seventy-three limbs in 69 patients with acute DVT diagnosed by duplex imaging received conventional heparin and warfarin treatment and underwent subsequent duplex studies 1, 4, 12, and 24 weeks after the initial diagnosis. The objectives of the study were to document (1) the rate or complete resolution of DVT, (2) the proportion of unstable, floating thrombi, and (3) the development of chronic damage as a result of vessel wall scarring., Results: The rate of normalization of DVT 6 months after diagnosis was 78% in the common femoral vein, 70% in the superficial femoral vein, 75% in the popliteal vein, and 70% in the calf veins examined at the scheduled intervals. Twenty-six percent of thrombi were considered unstable on the baseline examination. The average number of days necessary for these thrombi to become stable was 10.7 days. Damage to the vessel wall or valves was documented in 44% of the patients., Conclusions: Rates of resolution of DVT were similar for the different veins of the leg studied. There was a high proportion of unstable thrombi, which present a high potential risk of embolization. Serial duplex scanning after DVT renders important information with regard to thrombus resolution, propagation, and attachment to the vein wall.