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Novel diagnostic and imaging techniques in endovascular iliac artery procedures.
De Boer, SW, Heinen, SGH, Goudeketting, SR, De Haan, MW, Mees, BM, Van Den Heuvel, DAF, De Vries, JPM
Expert review of cardiovascular therapy. 2020;(7):395-404
Abstract
INTRODUCTION Endovascular revascularization has become the preferred treatment for most patients with iliac artery obstructions, with a high rate of clinical and technical success. AREAS COVERED This review will describe novel developments in the diagnosis and treatment of iliac artery obstructions including the augmentation of preprocedural imaging with advanced flow models, image fusion techniques, and state-of-the-art device-tracking capabilities. EXPERT OPINION The combination of these developments will change the endovascular field within the next 5 years, allowing targeted iliac treatment without the need for radiographic imaging or iodinated contrast media.
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[The Multimorbid Patient: Use of New Oral Anticoagulants in Patients with Chronic Kidney Disease].
Mohebbi, N
Praxis. 2018;(13):683-687
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Abstract
The Multimorbid Patient: Use of New Oral Anticoagulants in Patients with Chronic Kidney Disease Abstract. Increasing life expectancy in Western countries is associated with a high prevalence of multiple chronic diseases which is defined by the term "multimorbidity". Many of these patients suffer from chronic kidney disease (CKD) and thrombogenic comorbidities such as atrial fibrillation with the need for oral anticoagulation. For decades vitamin K antagonists have been exclusively prescribed for oral anticoagulation. However, due to altered pharmacokinetics and bioavailability of these drugs in CKD, a significant risk of bleeding exists. The introduction of direct oral anticoagulants as a new and promising alternative to vitamin K antagonists was -especially for CKD patients - highly anticipated. However, data from randomized studies are missing for older patients with advanced CKD. Consequently, a careful evaluation of the risk-benefit ratio is recommended for this sensitive patient population.
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Vein arterialization for lower limb revascularization.
Houlind, K, Christensen, JK, Jepsen, JM
The Journal of cardiovascular surgery. 2016;(2):266-72
Abstract
Conventional bypass surgery is only possible when patent distal arterial outflow vessels are available. In patients with critical limb ischemia and occluded distal arteries, attempts have been made to establish retrograde perfusion through either deep or superficial pedal veins. Though historical results were disappointing, more recently limb salvage has been achieved after adopting a principle of 1) placing the anastomosis distally, and 2) actively destroying the distal valves. Experimental, para-clinical, and clinical data confirm that direct tissue nutrition is improved, angiogenesis stimulated, and collaterals opened. Only a limited number of cases have been reported in the literature and a number of different operative techniques have been described. The results in terms of limb salvage and wound healing vary widely. Generally, results are poorer than what would have been expected if femoro-distal arterial bypass had been possible. Recently, hybrid approaches have been developed to avoid extensive distal incisions by endovascular destruction of valves and closure of side branches. Also, a totally endovascular technique, including the position of a stent graft between the vein and artery, has been proposed and tested. These developments may in the future improve results by limiting incisional wound complications and make this treatment available to more patients who would otherwise have no other alternative than amputation.
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Drug coated balloons below-the-knee: just too early?
Fanelli, F, Cannavale, A
The Journal of cardiovascular surgery. 2016;(1):18-22
Abstract
Patients with infrapopliteal arterial disease are generally considered challenging due to the usual presence of multivessel atherosclerotic disease. Several treatment options have been used by different authors but none of them can be considered ideal. In the last few years drug coated balloons have gained popularity especially due to the extraordinary results in the femoro-popliteal region. Following the great success, physicians started to use this promising device also in the below-the-knee (BTK) region. The initial enthusiasm correlated to some studies is not confirmed by the largest randomized trial, IN.PACT Deep, comparing In.Pact DCB to standard PTA. This trial failed completely to show the superiority of drug coated balloon (DCB). The negative outcome was mainly correlated to safety issues with an amputation rate higher for the drug coated balloon when compared to the conventional balloon (8.8% DCB vs.3.6% PTA, P=0.08). A thorough evaluation has been performed to justify these negative outcomes, given the good results reported by other studies. But nowadays it is still difficult to find a clear explanation. Especially for this negative outcome and for the big difference, in term of results, between the different studies in the BTK region and also between the above and below the knee regions more trials are mandatory.
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What are the potential limitations of drug coated balloons and possible ways to overcome.
Werk, M
The Journal of cardiovascular surgery. 2016;(1):23-8
Abstract
In several independent randomized clinical studies, it has been shown that drug-coated balloons (DCBs) cause persistent clinically meaningful and statistically significant inhibition of restenosis in femoropopliteal arteries in comparison to percutaneous transluminal angioplasty with uncoated balloon catheters. The potential benefits of delivering an antiproliferative drug into the vessel wall using a balloon as transporter are manifold: 1) widespread applicability: balloon angioplasty is suitable for use in a wide range of lesions. The use of DCBs is technically less demanding and offers greater flexibility compared with stenting techniques. 2) Maintaining options: minimizing the use of durable implants is providing more options for following and complementary revascularization procedures; 3) proven efficacy: consistent, positive outcomes across studies and key subgroups have been demonstrated from the first preclinical studies to ongoing clinical trials. Beside the enthusiasm carried along with this novel technique and questioning if DCBs will become standard-of-care-therapy for the superficial femoral artery, the potential limitations have to be discussed.
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Garlic for peripheral arterial occlusive disease.
Jepson, RG, Kleijnen, J, Leng, GC
The Cochrane database of systematic reviews. 2013;(4):CD000095
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Abstract
BACKGROUND Commercially available preparations of garlic have been reported to have beneficial effects on some of the risk factors associated with atherosclerosis. OBJECTIVES To assess the effects of garlic (both dried and non-powdered preparations) for the treatment of peripheral arterial occlusive disease. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched January 2013) and CENTRAL (2012, Issue 12). SELECTION CRITERIA Randomised trials of garlic therapy in patients with lower limb atherosclerosis were included. The main outcomes were objective measures of progression of underlying atherosclerosis (e.g. ankle pressure measurements, treadmill testing) and subjective measures (e.g. symptom progression). DATA COLLECTION AND ANALYSIS Two review authors (RJ and JK) independently extracted data and assessed trial quality. One author (RJ) contacted investigators to obtain information needed for the review that could not be found in published reports. MAIN RESULTS One eligible trial with 78 participants was found. Both men and women (aged 40 to 75) were included. The follow-up period was short, 12 weeks only.After twelve weeks of treatment, pain-free walking distance increased from 161 to 207 metres in the group receiving garlic and from 172 to 203 metres in the placebo group. This was not a statistically significant difference. There was no difference in change of systolic or diastolic blood pressure, heart rate, ankle and brachial pressures. No severe side effects were observed and nine patients taking garlic (28%) and four patients taking placebo (12%) complained of a noticeable garlic smell.Three trials were excluded from the review because they did not include any clinical measurements. AUTHORS' CONCLUSIONS One small trial of short duration found no statistically significant effect of garlic on walking distance.
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Clinical studies on the efficacy and safety of Padma 28, a complex herbal formulation from Tibetan medicine: an overview.
Vennos, C, Melzer, J, Saller, R
Forschende Komplementarmedizin (2006). 2013;:25-30
Abstract
BACKGROUND Padma 28 is an herbal formula from Tibetan Medicine, which since 35 years has been registered in Switzerland as a drug for the symptoms of circulatory disorders. Over this time, a large body of scientific literature has accumulated. The aim of this article was to give an overview of the clinical studies. METHODS A systematic literature search was done in PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CCRCT). The clinical trials found were assessed regarding fields of application, efficacy, and safety, as well as methodological quality and level of evidence. RESULTS 29 trials (1 meta-analysis, 21 controlled trials, 7 open trials) and 3 retrospective case studies were found. They deal with different indications and include a total of 1,704 verum (of these, 697 children), 333 placebo, and 394 untreated or healthy patients. Dropouts and withdrawals were 2.5 and 3.5 times higher in the placebo than in the verum group, respectively. The highest level of evidence for the use of Padma 28 was found in the indication of intermittent claudication (11 trials). Indications of efficacy were also found in other vascular (6 trials) and different inflammatory diseases (12 trials). CONCLUSIONS The results suggest a favorable safety profile for Padma 28, also in the children examined (41% of the study population). Furthermore, the results show a broad field of applications. According to clinical evidence, Padma 28 has shown to be a safe and effective symptomatic treatment option for atherosclerosis-related diseases such as intermittent claudication. It also seems to have a potential for application in certain chronic inflammatory diseases such as recurrent respiratory tract infections, viral hepatitis, and multiple sclerosis. However, further randomized controlled trials (RCT) are needed to confirm these findings.
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Micronutrients and sickle cell disease, effects on growth, infection and vaso-occlusive crisis: a systematic review.
Dekker, LH, Fijnvandraat, K, Brabin, BJ, van Hensbroek, MB
Pediatric blood & cancer. 2012;(2):211-5
Abstract
Patients with Sickle cell disease (SCD) exhibit signs of poor growth, increased susceptibility to infection and recurrent episodes of painful vaso-occlusive crises. Micronutrient deficiencies may increase susceptibility to these outcomes. We conducted a systematic review to assess the strength of evidence for improved outcomes related to micronutrient interventions. Six randomized-controlled trials of moderate quality met the inclusion criteria. Zinc supplementation was associated with improved growth and decreased incidence of infection and is a promising intervention in the management of SCD patients. Omega-3 fatty acid supplementation was associated with limited reduction in vaso occlusive crises. This review identifies key knowledge gaps, which are important research priorities for nutritional interventions.
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Advances in below-the-knee drug-eluting balloons.
Ferraresi, R, Centola, M, Biondi-Zoccai, G
The Journal of cardiovascular surgery. 2012;(2):205-13
Abstract
The management of critical limb ischemia due to below-the-knee disease remains challenging due to the frequent patient comorbidities, diffuse vascular involvement, and high rates of restenosis and disease progression. The BASIL study has established the substantial equivalence between bypass surgery and percutaneous transluminal angioplasty in this setting, at least at mid-term follow-up, but percutaneous techniques and devices have seen major developments since the publication of this pivotal trial in 2005. A major breakthrough has indeed been the introduction of drug-eluting balloons, which have several theoretical advantages in comparison to standard balloons and metallic stents for infra-popliteal lesions. Two clinical trials have already been reported with favorable results for the In.Pact Amphirion paclitaxel-eluting balloon, when employed for below-the-knee lesions. We hereby discuss the rationale for the use of drug-eluting balloons in this complex setting and the main findings of the study by Schmidt et al. and the DEBATE-BTK trial.
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Chapter III: Management of cardiovascular risk factors and medical therapy.
Diehm, N, Schmidli, J, Setacci, C, Ricco, JB, de Donato, G, Becker, F, Robert-Ebadi, H, Cao, P, Eckstein, HH, De Rango, P, et al
European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2011;:S33-42
Abstract
Critical limb ischaemia (CLI) is a particularly severe manifestation of lower limb atherosclerosis posing a major threat to both limb and life of affected patients. Besides arterial revascularisation, risk-factor modification and administration of antiplatelet therapy is a major goal in the treatment of CLI patients. Key elements of cardiovascular risk management are smoking cessation and treatment of hyperlipidaemia with dietary modification or statins. Moreover, arterial hypertension and diabetes mellitus should be adequately treated. In CLI patients not suitable for arterial revascularisation or subsequent to unsuccessful revascularisation, parenteral prostanoids may be considered. CLI patients undergoing surgical revascularisation should be treated with beta blockers. At present, neither gene nor stem-cell therapy can be recommended outside clinical trials. Of note, walking exercise is contraindicated in CLI patients due to the risk of worsening pre-existing or causing new ischaemic wounds. CLI patients are oftentimes medically frail and exhibit significant comorbidities. Co-existing coronary heart and carotid as well as renal artery disease should be managed according to current guidelines. Considering the above-mentioned treatment goals, interdisciplinary treatment approaches for CLI patients are warranted. Aim of the present manuscript is to discuss currently existing evidence for both the management of cardiovascular risk factors and treatment of co-existing disease and to deduct specific treatment recommendations.