BEST OF Groupe Vasculaire Thrombose

Transcription

1 BEST OF Groupe Vasculaire Thrombose Serge Kownator (Thionville) Claire Mounier Vehier (Lille) Gérard Helft (Paris) Victor ABOYANS (Limoges) Boris ALEIL (Strasbourg) Serge COHEN (Marseille) Joseph EMMERICH (Paris) Marc FERRINI (Lyon) Florence LECLERC (Montpellier) Claire LEHELLO (Caen) Philippe LEGER (Toulouse) François LUIZY(Paris) Emmanuel Messas (Paris) Ulrique MICHON PASTUREL (Paris) Guillaume ROSEY (Lille) Marie Antoinette SEVESTRE PIETRI (Amiens) Dominique STEPHAN (Strasbourg) Denis WAHL (Nancy)

2 Carotids

3 Carotid Stenting vs CEA Up to 2 / 4 years FU shows similirar rates of ischemic stroke between Carotid Stenting and CEA after the 30 days outcomes Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA 3S) trial: results up to 4 years from a randomised, multicentre trial Results of the Stent Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial Mas JL et al. Lancet Neurol Oct;7(10): Eckstein HH et al. Lancet Neurol Oct;7(10):

4 Carotids (2): the ENHANCE Study Thinner than thin?

5 Aorta In women: Rate of events 184/ Smoking, age, vascular disease, Chol lowering Rx are RF for AAA related events. Diabetes and HRT are inversely related to events Lederle F et al. BMJ 2008;337:a1724

6 Aorta Open repair associated with more perioperative death and complications but less reinterventions. Endovascular, repair associated with more reintervention and late mortality. Same rate of late survival. Schermerhorn ML et al. N Engl J Med 2008;358:

7 Renal Artery Stenosis The ASTRAL Study The Impact of Renal Artery Revascularisation in Atherosclerotic Renovascular Disease: The Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) Trial Background: Outcomes after percutaneous renal revascularisation in atherosclerotic renovascular disease (ARVD) are still uncertain and the results of adequately powered randomised control trials (RCT) are awaited. Methods: The ASTRAL trial randomised patients equally between percutaneous revascularisation (angioplasty and/or stenting) plus medical therapy versus medical therapy alone. The sample size calculation required that 750 patients be recruited, giving 80% power to detect a 20% reduction in the primary end point of rate of decline of renal function as assessed by reciprocal serum creatinine over time. Secondary endpoints are blood pressure control, occurrence of renal events (e.g. acute renal failure, dialysis), serious vascular events and mortality. The trial had broad eligibility criteria so that these outcomes could be investigated in a clinically relevant population. Results: Between November 2000 and October 2007, ASTRAL recruited 806 ARVD patients from 56 centres (52 UK based and 4 in Australasia), making it over 7 times larger than any previous RCT in ARVD. Baseline data for the whole group at randomisation demonstrates mean age (range) of patients 70 years (42-88), 63% male, serum creatinine 179 mol/l (64-750), estimated GFR 40ml/min ( ) and blood pressure 151/76 mm Hg (87/45-270/130). 54% of patients were ex-smokers, 30% were diabetic and 49%, 40% and 19% had a previous history of CAD, PVD and CVA, respectively. Pooled data analysis of all patients shows that serum creatinine increased by 18 mol/l and both systolic and diastolic blood pressure decreased (13/7 mmhg) between baseline and 5 years. To date (December 2007), 37 (5%) patients have suffered acute renal failure, 53 (7%) a myocardial infarction, 41 (5%) a CVA and 145 (18%) patients have died. By March 2008, the complete analysis of a minimum 6 months follow-up by randomised treatment for all patients entered into ASTRAL will have been performed and these data will be presented. MI, STROKE, VASCULAR DEATH FLUID OVERLOAD OR CARDIAC FAILURE Conclusions: To date ASTRAL is by far the largest randomised trial in ARVD, and will provide the most reliable and timely evidence on the role, if any, of revascularisation in ARVD with which to guide the treatment of future patients. MORTALITY Karla PA et al. ACC 08

8 PAD: ABI still alive Conclusions When the higher ankle pressure is used for ABI calculation, a group of patients at high risk for cardiovascular events is overlooked. With a simple modification of ABI (use of the lower instead of the higher ankle pressure), more patients at risk could be identified. Espinola Klein et al Circulation Aug 26;118(9):961-7 Conclusions: Diabetes is the dominant risk factor for a high (>1.40) ABI. Occlusive PAD is highly prevalent in subjects with high ABI, and these subjects should be considered as PAD-equivalent. Aboyans V et al. J Vasc Surg 2008;48: )

9 PAD : IPSILON Study Cacoub P, Cambou JP, Kownator S et al.int J Clin Pract Jan;63(1):63-70.

10 PAD Asymptomatic patients have poorer functional performances then symptomatic IC. Asymptomatic PAD is frequently a severe disease. Mc Dermott MM et al. Circulation May 13;117(19):

11 CV risk & non cardiac surgery Lancet 2008; 371:

12 CV risk & non cardiac surgery Bangalore et al. Lancet 2008; 372:

13 CV risk & non cardiac surgery DECREASE III : Fluvastatin 80 mg, 37 days before non cardiac surgery and during 30 days TC: 20% LDL: 21% hscrp 21% Il 6: 33%. MI: 0.53 (95% CI: ) Non fatal MI: 0.55 (95% CI: ) Cardiovascular death: 0.33 (95% CI: ) Cardiovascular death or non fatal MI: 0.48 (95% CI: ) Poldermans D et al. ESC 2008

14 Ridker P et al. N Engl J Med Nov 20;359(21):

15 Belch J et al. BMJ 2008;337:a1840

16 Venous thrombosis D Dimer in the FU of DVT After 3 month of anticoagulation: Negative D dimer => 3.5 % annual rate of new DVT Positive D dimer => 8.9 % annual rate of new DVT DVT and cancers Verhovsek M AnnInternMed Oct 7;149(7):481 90, W % vs 50 % of cancers are depicted if extensive secreening after DVT. Up to 10 % of cancers 1 yr after DVT Carrier M et al: Ann Intern Med Sep 2;149(5): DVT and Influenza (the FARIVE study) Influenza vaccination reduces the risk of DVT Emmerich J et al. AHA 2008

17 ANTITHROMBOTIC AND THROMBOLYTIC THERAPY, 8TH ED: ACCP GUIDELINES June 1, 2008; 133 (6 suppl)