Conclusion:Stripping of the greater saphenous vein (GSV) abolishes deep venous reflux in a significant proportion of limbs. Continued GSV insufficiency may be associated with development of new deep venous reflux.Summary: The authors examined the effect of GSV stripping on known deep venous reflux and development of new deep venous reflux. The study included 62 consecutive patients who underwent saphenofemoral junction disconnection, multiple stab avulsions of varicosities, and who may or may not have undergone successful stripping of the GSV to the knee. Duplex ultrasound scanning was performed to detect venous reflux preoperatively and at a median of 24 months postoperatively. Completely stripped limbs were defined as those in which complete stripping of the GSV to the knee was confirmed on postoperative duplex scans. Duplex scanning-Detected reflux time greater than 0.5 seconds was considered abnormal.Preoperatively, 42% of limbs had deep venous reflux. Follow-up postoperative duplex scans indicated that the GSV had been completely stripped in only 38% of limbs. In patients with preoperative deep venous reflux, complete stripping was associated with a significant reduction in the prevalence of superficial femoral vein reflux (P Ͻ .001) and popliteal vein reflux (P Ͻ .016). In patients without preoperative deep venous reflux, incomplete stripping of the GSV was associated at follow-up with development of superficial femoral vein reflux (P Ͻ .031) and popliteal vein reflux (P Ͻ .008).Comment: The authors; data suggest that successful stripping of a refluxing GSV may improve reflux in the femoral and popliteal veins. Incomplete stripping may lead to development of new deep venous reflux in the femoral and popliteal veins. This study affirms the growing realization that deep venous reflux may derive from the presence of superficial venous reflux. The results suggest that patients with a combination of deep and superficial venous reflux may benefit from stripping of the refluxing GSV and, in fact, may be harmed by leaving a refluxing GSV in situ. Aspirin plus clopidogrel compared with clopidogrel alone after recent ischemic stroke or transient ischemic attack in patients at high risk patients (MATCH): Randomized double-blind placebo-controlled trialHans-Christoph D, Bogousslavsky J, Brass LM, and the MATCH Investigators. Lancet 2004;364:331-7. Conclusion:The combination of aspirin and clopidogrel in patients with recent ischemic stroke or transient ischemic attack (TIA) is associated with a nonsignificant difference in reducing major vascular events, compared with clopidogrel alone. The risk for life-threatening or major bleeding is, however, increased with the addition of aspirin to clopidogrel in this patient group.Summary: The CAPRIE study (Lancet 1996;348:1329-39) demonstrated that clopidogrel is superior to aspirin in reducing cardiovascular end points in patients with previous manifestations of atheroembolic disease. The clopidogrel benefit was amplified in some subgroups of patients at high risk. In this stu...

Summary. Although several authoritative, evidence-based, guidelines for the prevention of venous thromboembolism (VTE) have been published, the use of VTE prophylaxis in routine clinical practice varies markedly. Even in orthopedic surgery, the indication for which prophylaxis is used most often, a signi®cant proportion of surgeons do not use routine prophylaxis. When prophylaxis is used, guideline recommendations are often not followed. A number of factors may contribute to the under-use of guidelines. Physician-related factors include: a lack of awareness of, or familiarity with, the guidelines; a perception that VTE is not a signi®cant problem or that VTE prophylaxis is ineffective; and concern about potential bleeding risks. The guidelines may also be perceived to be too complicated or dif®cult to apply in a routine manner. In addition, a lack of facilities or resources may also present a barrier to implementation of the guidelines. A number of strategies are being investigated in an attempt to improve compliance with guidelines for VTE prophylaxis. For example, the Investigators Against Thromboembolism (INATE) initiative has developed a simpli®ed pocket guideline on VTE prophylaxis in orthopedic and trauma surgery in order to raise awareness of the current guideline recommendations.

This prospective, uncontrolled trial explored the relationship between varying dosages of a low molecular weight heparin (LMWH) preparation, ardeparin sodium (Normiflo, Wyeth-Ayerst, Philadelphia, PA), and anticoagulant effects, monitored by an amidolytic anticoagulation factor Xa (aXa) assay and by global coagulometric methods, including the activated partial thromboplastin time (APTT) and the Heptest (Haemachem, St. Louis, MO). Thirty-three patients undergoing elective unilateral total hip or knee replacement received subcutaneous ardeparin prophylaxis initiated 12 to 18 hours following surgery, administered at a fixed 40-mg dose twice daily, 50 aXa U/kg twice daily or 90 aXa U/kg once daily for up to 14 days. The target antithrombotic aXa levels, determined by amidolytic assay in plasma 6 hours after each ardeparin injection, were most optimally attained and maintained by twice-daily dosing based on body weight and correlated well with incremental increases in Heptest values measured chronometrically. The Heptest results at 12 hours after ardeparin administration indicated that the global anticoagulant effects produced by LMWH are sustained for many hours after subcutaneous dosing.