What is the role of dual antiplatelet therapy after high risk transient ischaemic attack or minor stroke? Specifically, does dual antiplatelet therapy with a combination of aspirin and clopidogrel lead to a greater reduction in recurrent stroke and death over the use of aspirin alone when given in the first 24 hours after a high risk transient ischaemic attack or minor ischaemic stroke? An expert panel produced a strong recommendation for initiating dual antiplatelet therapy within 24 hours of the onset of symptoms, and for continuing it for 10-21 days. Current practice is typically to use a single drug

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Objectives: Thoracic outlet syndrome (TOS) results from compression of the neurovascular structures supplying the upper extremity as they exit through the thoracic outlet. Depending on the clinical presentation, surgical decompression may be required. The transaxillary (TA) approach has been the preferred approach, although the supraclavicular (SC) approach has become more widely used, especially when adjunct procedures are required. Our objective was to review the results with both approaches in our institution.Methods: A retrospective review of patients who underwent thoracic outlet decompression between 2009 and 2014 at the University of Iowa Hospitals and Clinics was conducted. Data on demographics, comorbidities, presenting symptoms, and type of TOS (neurogenic, venous, or arterial) were collected preoperatively. Operative times, hospital length of stay, perioperative complications, and outcomes were also studied.Results: During the study period, 82 thoracic outlet decompression procedures were performed: 48% were for neurogenic TOS, 46% for venous TOS, and 6% for arterial TOS. Thirty-nine patients (47.5%) underwent the TA approach, and 43 (52.5%) underwent the SC approach. Adjunct procedures were performed in 16% of patients in addition to decompression, 85% of which were in the SC group. There was a significant difference in average operative time between TA and SC (124.5 vs 157 minutes; P < .05) but no differences in hospital length of stay. Minor complications were seen in 20% of patients, with no significant difference between the TA and SC groups. Major complications occurred in 6%, with four patients (3 TA and 1 SC) requiring re-exploration. There were no perioperative or 30-day deaths. On follow-up, 37% of patients with neurogenic TOS had complete resolution of symptoms, 54% had partial improvement, and 9% had no improvement. In both the venous and arterial TOS groups, 66% had complete symptom resolution and 34% had partial resolution. There was no difference in symptom resolution between the TA and SC groups.Conclusions: There is no significant difference between TA and SC approaches for TOS in perioperative complications, length of stay, and improvement of symptoms. Although operative time appears to be longer in the SC group, this can be attributed to adjunct procedures, including vascular reconstructions performed using this approach.

The aim of our study is to report the early results of the use of a new tri-layer expanded polytetrafluoroethylene (ePTFE) graft for prosthetic vascular access (pVA) in patients with end-stage renal disease on hemodialysis.Methods: Between October 2011 and October 2013, 40 patients with end-stage renal disease underwent implantation of a new ePTFE tri-layer grafts. Primary and secondary patency, complications, and survival were recorded.Results: We treated 40 patients; 24 (60%) were males, and mean age was 60 6 12 years (range, 34-85 years). PVAs loop were as follows: radial-basilic, 18 (45%); brachial-basilic, 13 (32.5%), radial-cephalic, 2 (5%); radial-antecubital forearm, 2 (5%); brachial-axillary, 2 (5%); and femoral-femoral in 3 (7.5%). The mean follow-up time was 6.3 6 5.9 months (range, 1-24; median, 5 months). Mean latency between pVA implantation and cannulation was 2.4 6 1.2 days (range, 1-15 days). Two patients (5%) died during the follow-up. Permanent graft failure was 0% at 24 months. Local complications included access thrombosis (n ¼ 8 [20%]) and skin erosion (n ¼ 1 [2.5%]): early (<30 days) thrombosis occurred in one patient (2.5%), and late (>30 days) thrombosis occurred in four patients (10 %). Cause of late thrombosis were intimal hyperplasia at the venous outflow (n ¼ 4 [10%]), stenosis of the arterial anastomosis (n ¼ 1 [2.5%]), and graft thrombosis with no anastomotic defects (n ¼ 3 [7.5%]). All complications were treated at our hospital and included clot removal (n ¼ 5) and clot removal plus revision of the anastomosis with patch interposition (n ¼ 3). Primary patency was 92% 6 5 and 61% 6 13 at 1 and 12 months, respectively; secondary patency was 100% and 92% 6 8% at 1 and 12 months.Conclusions: In our experience the new tri-layer graft Acuseal (W.L Gore, Flagstaff; Ariz) proved to be safe and effective. Cannulation-related complications were absent, and patency rates are superior if compared with the standard grafts used for vascular accesses.