Abstract Objective: To determine the effects of “prolonged” antiplatelet therapy (that is, given for one month or more) on “vascular events” (non-fatal myocardial infarctions, non-fatal strokes, or vascular deaths) in various categories of patients. Design: Overviews of 145 randomised trials of “prolonged” antiplatelet therapy versus control and 29 randomised comparisons between such antiplatelet regimens. Setting: Randomised trials that could have been available by March 1990. Subjects: Trials of antiplatelet therapy versus control included about 70 000 “high risk” patients (that is, with some vascular disease or other condition implying an increased risk of occlusive vascular disease) and 30 000 “low risk” subjects from the general population. Direct comparisons of different antiplatelet regimens involved about 10 000 high risk patients. Results: In each of four main high risk categories of patients antiplatelet therapy was definitely protective. The percentages of patients suffering a vascular event among those allocated antiplatelet therapy versus appropriately adjusted control percentages (and mean scheduled treatment durations and net absolute benefits) were: (a) among about 20 000 patients with acute myocardial infarction, 10% antiplatelet therapy v 14% control (one month benefit about 40 vascular events avoided per 1000 patients treated (2P< 0.00001)); (b) among about 20 000 patients with a past history of myocardial infarction, 13% antiplatelet therapy v 17% control (two year benefit about 40/1000 (2P<0.00001)); (c) among about 10 000 patients with a past history of stroke or transient ischaemic attack, 18% antiplatelet therapy v 22% control (three year benefit about 40/1000 (2P<0.00001)); (d) among about 20 000 patients with some other relevant medical history (unstable angina, stable angina, vascular surgery, angioplasty, atrial fibrillation, valvular disease, peripheral vascular disease, etc), 9% v 14% in 4000 patients with unstable angina (six month benefit about 50/1000 (2P<0.00001)) and 6% v 8% in 16 000 other high risk patients (one year benefit about 20/1000 (2P<0.00001)). Reductions in vascular events were about one quarter in each of these four main categories and were separately statistically significant in middle age and old age, in men and women, in hypertensive and normotensive patients, and in diabetic and non: diabetic patients. Taking all high risk patients together showed reductions of about one third in non-fatal myocardial infarction, about one third in non-fatal stroke, and about one sixth in vascular death (each 2P<0.00001). There was no evidence that non-vascular deaths were increased, so in each of the four main high risk categories overall mortality was significantly reduced. The most widely tested antiplatelet regimen was “medium dose” (75-325 mg/day) aspirin. Doses throughout this range seemed similarly effective (although in an acute emergency it might be prudent to use an initial dose of 160-325 mg rather than about 75 mg). There was no appreciable evidence that either a higher aspirin dose or any other antiplatelet regimen was more effective than medium dose aspirin in preventing vascular events. The optimal duration of treatment for patients with a past history of myocardial infarction, stroke, or transient ischaemic attack could not be determined directly because most trials lasted only one, two, or three years (average about two years). Nevertheless, there was significant (2P<0.00001) further benefit between the end of year 1 and the end of year 3, suggesting that longer treatment might well be more effective. Among low risk recipients of “primary prevention” a significant reduction of one third in non: fatal myocardial infarction was, however, accompanied by a non-significant increase in stroke. Furthermore, the absolute reduction in vascular events was much smaller than for high risk patients despite a much longer treatment period (4.4% antiplatelet therapy v 4.8% control; five year benefit only about four per 1000 patients treated) and was not significant (2P=0.09). Conclusions: Among a much wider range of patients at high risk of occlusive vascular disease than is currently treated routinely, some years of antiplatelet therapy - with aspirin 75-325 mg/day or some other antiplatelet regimen (provided there are no contraindications) - offers worthwhile protection against myocardial infarction, stroke, and death. Significant benefit is evident not only among patients with unstable angina, suspected acute myocardial infarction, or a past history of myocardial infarction, stroke, or transient ischaemic attack, but also among many other categories of high risk patients (such as those having vascular procedures and those with stable angina or peripheral vascular disease). There is as yet, however, no clear evidence on the balance of risks and benefits of antiplatelet therapy in primary prevention among low risk subjects.

Collaborative overview of randomized trials of antiplatelet therapy .1. prevention of death, myocardial-infarction, and stroke by prolonged antiplatelet therapy in various categories of patients

Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery,* Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation

/pdf/acc-aha-2005-practice-guidelines-for-the-management-of-4ltfid6e9i.pdf

ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)

Recommended standards for reports dealing with lower extremity ischemia: Revised version

Anesthesiology. First of two parts.

Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial.

PRESENTATION OF CASE A48-year-old man was referred to our plastic surgery service for the evaluation of a left thigh wound. The patient took lisinopril for hypertension and denied smoking. Five years before his presentation, the patient was diagnosed with a plasmacytoma of his left proximal femur. He was treated with curettage, internal fixation, and postoperative radiation therapy. One year later, he developed a nonunion that was managed by femur resection and prosthetic reconstruction. He subsequently suffered loosening of the implant and a periprosthetic infection. The prosthesis was replaced with a temporary cement spacer, and after 12 weeks of vancomycin therapy another prosthesis was placed. Three weeks later, he presented with an infected, dehisced proximal wound resulting in exposure of the femoral prosthesis. He underwent irrigation, debridement, and placement of a vacuum-assisted wound closure device. The Orthopedic Surgery Service consulted with the Division of Plastic and Reconstructive Surgery for wound management (Fig. 1). Because of previous irradiation, multiple infections, and several operative procedures, the wound could not be closed primarily. Consequently, a regional flap outside the zone of injury was chosen to obtain tension-free closure over the hardware. He underwent ipsilateral extended rectus abdominis musculocutaneous pedicled flap surgery to cover his 8 30-cm left thigh defect (Fig. 2).1–3 The flap was elevated based on the deep inferior epigastric artery and vein, transferred through a subcutaneous tunnel, and inset over the exposed femoral implant. Estimated blood loss was 300 cc. Postoperatively, the patient was hypotensive, with systolic blood pressures between 80 and 95 mmHg. In addition, he had a low urine output and a hematocrit of 22.7 percent. On postoperative day 1, the thigh was noted to be very edematous, the flap was cyanotic, and the drain output over the previous 12 hours was 600 cc of serosanguineous fluid (Fig. 3).

Flap ischemia after pedicled tissue transfer to a lateral thigh wound: an example of complication assessment using the end result system of E. A. Codman.

PURPOSE: The current circumstances of US healthcare mandate elimination of unnecessary costs while increasing efficiency in patient care. Traditional implant-based breast reconstruction encompasses multiple stages and using acellular dermal matrix (ADM); both increase cost. The senior author (WGA) has used absorbable knitted mesh (VicrylTM polyglactin 910) as an inferior pole sling in single-stage directto-implant (DTI) breast reconstruction since 2011. We report 3 year outcomes and cost savings data using this material.

Three Years Experience with Absorbable Mesh in Single-Stage Breast Reconstruction: A Cost-Effective Alternative.

The technic of prosthetic replacement of the aortic valve has developed rapidly. Long-term follow-up of 51 hospital survivors of valvuloplasty is presented, showing worthwhile results at three years following operation and, in a very few cases, at four, five or more years. A recent 15 months' experience with 84 valve replacements and 22 valvuloplasties shows an 18 per cent hospital mortality in each group. Results of valve replacement are immeasurably superior to those achieved with incision and debridement in patients with significant aortic regurgitation or heavily calcified valves.

William G. Austen

Papers

Flap ischemia after pedicled tissue transfer to a lateral thigh wound: an example of complication assessment using the end result system of E. A. Codman.

Three Years Experience with Absorbable Mesh in Single-Stage Breast Reconstruction: A Cost-Effective Alternative.

Surgical challenge of aortic valve disease; a follow-up study.

A new approach to rapid coronary anastomosis: onlay graft without intimal approximation.

Monitoring losses during isolated tumor perfusion.