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Opinion Statement: Ever since the observation was made linking a higher prevalence of a patent foramen ovale (PFO) in younger individuals with cryptogenic stroke (CS), there has been a vigorous debate as to the role the PFO plays and a search for the optimal management strategy to prevent recurrent CS. Data from observational studies from the past two decades have demonstrated the superiority of percutaneous device closure over medical therapy. The recent publication of three randomized controlled trials (RCTs), which failed to demonstrate the superiority of percutaneous closure has reignited the controversy as to how best treat these patients. In this article, we will review the contemporary literature from the past three years including the results from new meta-analyses of medical therapy and device closure. In addition, we will review the three published randomized control trials to date (ie, CLOSURE I, the PC trial, and RESPECT) along with a meta-analysis of their results. While on primary intention-to-treat analysis, the three RCTs failed to demonstrate a superiority of percutaneous PFO closure vs medical therapy, a closer look at the data seems to suggest a trend toward benefit. We come to the conclusion that the issue of optimal treatment of PFO in patients with CS is far from settled and is unlikely to be a "one size fits all" approach due to the heterogeneity of this condition. In our opinion, based on the entirety of available data, both observational and randomized, there is likely a role for percutaneous device closure in select patients with CS in whom a PFO is the likely cause of their first stroke and will remain a significant risk for recurrent neurologic events. The article will go on to review current indications for atrial septal defect (ASD) closure and will highlight safety, efficacy and caveats regarding this technique.

Opinion Statement: Cerebrovascular disease remains a leading cause of morbidity, mortality, and health care expenditure in the United States. Approximately 80% of strokes are ischemic in origin, with 20% to 25% due to atherosclerotic disease of the carotid artery. It is well established that untreated, symptomatic carotid stenosis confers a 25% risk of stroke within 2 years, and that asymptomatic carotid stenosis > 60% is associated with an 11% stroke risk at 5 years. Over the past six decades, surgical revascularization with carotid endarterectomy, when performed by experienced surgeons, has been demonstrated to be effective in reducing stroke risk in patients with severe stenosis. During the same time, medical therapy has improved considerably, and endovascular therapy with carotid angioplasty and stenting has emerged as an important alternative strategy that may play a significant role in reducing the risk of stroke in patients with carotid disease. In this review, we examine the current evidence regarding optimal medical therapy, endarterectomy, and stenting for the management of patients with carotid stenosis. Armed with these data, we may tailor our approach to optimize care based on patient- and lesion-specific considerations.

Opinion Statement: Upper extremity deep venous thrombosis (UEDVT) accounts for between 4% and 10% of all deep venous thromboses, and may be due to primary or secondary causes. The incidence of UEDVT is increasing, partly due to the exponential growth in the use of central venous catheters and the increasing placement of permanent cardiac pacemaker or defibrillator devices. UEDVT not only compromises future vascular access but results in significant morbidity and mortality, with symptomatic pulmonary embolus occurring in approximately 12%, post-thrombotic syndrome in 13%, and mortality ranging from 15-50%. Treatment of UEDVT depends on the underlying cause, primary or secondary. In this review, we will evaluate the management options and present a proposed treatment algorithm for primary UEDVT, involving catheter-directed thrombolysis, selective use of mechanical thrombectomy, anticoagulation and antithrombotic therapy, expeditious early first rib resection to decompress the thoracic outlet, and the role of adjunctive endovascular balloon angioplasty and stenting in improving axillo-subclavian vein patency. With regard to secondary UEDVT, we will present a treatment algorithm for managing central venous catheter (CVC) thrombosis; review the options for antithrombotic and anticoagulant therapy; and discuss the role of endovascular therapy. Finally, we will review the data supporting the growing role of percutaneous transluminal angioplasty (PTA) or venoplasty and endovascular stenting as the modality of choice in managing SVC obstruction, whether due to benign or malignant causes, and provide a brief description of the role, benefits and potential complications of SVC filter placement.