Randomized Controlled Trial of Dual Antiplatelet Therapy in Patients Undergoing Surgery for Critical Limb Ischemia

Abstract

et al. Br J Surg 2010;97:650-6.Conclusion: There are no differences between sclerotherapy results in patients treated for truncal varices with foam sclerotherapy regardless of whether compression therapy after the procedure is used for 1 or 5 days.Summary: There are no data on the optimal bandaging regimen after foam sclerotherapy for truncal varices. In Great Britain, 80% of the members of the Vascular Society of Great Britain and Ireland responding to a questionnaire, and who treated patients with sclerotherapy, indicated they used compression bandages, and 90% subsequently used compression stockings after compression bandaging. Duration of treatment ranged from 1 to 7 days for initial bandages, with compression stockings used for 7 to 14 days, with some surgeons recommending compression stockings for up to 3 months. The authors sought to determine whether duration of bandaging could be reduced after foam sclerotherapy for truncal varices.Patients with primary uncomplicated varicose veins were randomized after foam sclerotherapy treatment to wearing compression bandaging for 24 hours or 5 days. In each case after compression bandages were removed, thromboembolism deterrent (TED) stockings then used for a total of 14 days of compression after foam sclerotherapy. The primary end point of the study was the 6-week Aberdeen Varicose Vein Severity Score (AVVSS) and Buford pain score. The study randomized 124 legs, of which 61 were randomized to 24 hours of compression bandaging and 63 to 5 days of compression bandaging. Venous occlusion rates at 6 weeks were 90% and 89%, respectfully (P ϭ .842). There were no differences in phlebitis after 2 weeks (P ϭ .445), skin discoloration after 6 weeks (46% vs 40%; P ϭ .546). There were no differences between groups in the AVVSS from baseline to 2 weeks (-0.29 vs -0.80; P ϭ .717) or to 6 weeks (-5.89 vs -5.14; 95% confidence interval [CI] for the difference, -3.29 to 1.8; P ϭ .563). There were also no differences between groups in changes in the Buford pain score from baseline to 2 weeks (-9.04 vs -2.80, P ϭ .248) or to 6 weeks (-17.32 vs -8.46; 95% CI for the difference, -19.06 to 1.33; P ϭ .088). Finally, the two groups also did not demonstrate any differences in changes in the Short Form-36 score from baseline to 6 weeks (2.02 vs. 1.74; P ϭ .903).Comment: Foam sclerotherapy is replacing liquid sclerotherapy as the preferred method of sclerotherapy for patients with truncal varicosities. Compression after treatment is essential to optimal results. However, as the authors point out with respect to foam sclerotherapy, the optimal duration of compression after treatment has not been adequately studied. This study is good news for patients. Compression bandages are not comfortable, and the results indicate that 24 hours of compressive bandaging, followed by a TED stocking for a total of 2 weeks, is just as efficacious as 5 days of compressive bandaging, followed by a TED stocking for a total of 2 weeks. The study provides practical guidance for post-therapy bandaging of patients...

Patient Blood Management: A Patient-Orientated Approach to Blood Replacement with the Goal of Reducing Anemia, Blood Loss and the Need for Blood Transfusion in Elective Surgery

“…Quite interestingly, it was observed that, while reducing the transfusion probability, simply increasing the Hb value had a negative impact on the Gombotz prises a comprehensive assessment of the hemostasis, treatment stop with a hemostatically active substance well ahead of the surgery, normothermia, a well-balanced acid-base balance, and a stable circulation. The widely used dual-mode antiplatelet therapy has been shown to be associated with an increased risk of spontaneous or perioperative bleedings [38]. This, however, must be carefully weighed against the then increased thrombotic risk of, e.g., implanted stents [39].…”

Non-cardiac surgery following drug-eluting coronary stent implantation—a question of timing?

“…Robust data on the bleeding risk associated with dual antiplatelet therapy during major non-cardiac surgery are lacking. In one randomised trial of 108 patients undergoing major vascular surgery, there was no increase in major or minor bleeding but a greater need for blood transfusion, with aspirin and clopidogrel compared to aspirin alone (16). Bridging with low molecular weight heparin appears to be associated with increased bleeding and worse ischaemic outcomes and is not recommended (17).…”

The role of antiplatelet therapy in patients with peripheral artery disease and lower extremity peripheral artery revascularization

“…In the overall population, DAPT showed no significant benefit over aspirin in preventing index graft occlusion, revascularization, above-ankle amputation of target limb, or death (HR: 0.98; 95% CI: 0.78-1.23), although subset analysis showed significant benefit in patients receiving prosthetic grafts (HR: 0.65; 95% CI: 0.45-0.95). Burdess et al [41] studied DAPT in CLI patients receiving bypass surgery or amputation, and randomized 108 patients to receive aspirin þ clopidogrel or aspirin þ placebo. The study was designed to examine platelet activation rates and bleeding risk of DAPT use in these high-risk surgical candidates.…”