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Background Parenteral anticoagulants and vitamin K antagonists (VKAs) have constituted the cornerstone of venous thromboembolism (VTE) treatment. Meanwhile, direct oral anticoagulants (DOACs) provide physicians with an alternative. The Global Anticoagulant Registry in the FIELD (GARFIELD)-VTE observes real-world treatment practices. Objectives Describe initial anticoagulation (AC) treatment patterns in VTE patients who received parenteral AC, VKAs, and/or DOACs within ±30 days of diagnosis. Methods VTE patients were categorized into parenteral AC only, parenteral AC with transition to VKA, VKA only, parenteral AC with transition to DOAC, and DOAC only. Results A total of 9647 patients were initiated on AC treatment alone. 4781 (49.6%) patients received DOACs ± parenteral ACs; 3187 (33.0%), VKA ± parenteral ACs; and 1679 (17.4%) parenteral ACs alone. Rivaroxaban was the most frequently used DOAC (79.4%). DOACs were more frequently used in North America/Australia (58.1%), Europe (52.2%), and Asia (47.6%) than in Latin America (29.7%) and the Middle East/South Africa (32.5%). In patients with suspected VTE, most received parenteral AC monotherapy (67.7%). Patients with deep vein thrombosis were more likely to receive DOACs alone than those with pulmonary embolism with or without deep vein thrombosis (36.2% vs 25.9%). Active cancer patients received parenteral AC alone (58.9%), with 25.5% receiving DOAC ± parenteral AC and 12.8% parenteral AC and VKA. A total of 46.5% of pregnant patients received parenteral AC monotherapy, 34.0% were treated with VKA ± parenteral AC, and 19.5% received a DOAC (± parenteral AC). Conclusion AC treatment patterns vary by patient population, geographic region and site of VTE. Guidelines for AC therapy are not always adhered to.

Accurate evaluation of stenosis in severely calcified arteries is a major challenge in conventional CT angiography (CTA) for peripheral arterial disease (PAD). The aim of this study was to evaluate the efficacy of subtraction CTA compared with conventional CTA and conventional angiography. 175 arterial segments of 31 consecutive patients with PAD who underwent CTA and subsequent digital subtraction angiography (DSA) were evaluated. The percentage stenosis of diseased arteries was measured in iliac arteries with caliper methods on conventional CTA and subtraction CTA, and the concordance of each CTA method with DSA in the identification of >50 % stenosis was evaluated. Interpretation of CTA was always based only on maximum intensity projection (MIP). 174 (99 %) segments were interpretable on subtraction CTA and showed a good correlation with DSA (R 2 = 0.844), although 55 (31 %) segments were not evaluable on conventional CTA due to severe calcification. On subtraction CTA, the segmental accuracy, sensitivity, and specificity were 90.5, 78.9, and 80.0 %, respectively. Subtraction CTA is an accurate diagnostic tool for the evaluation of PAD. It may be easier to interpret stenosis in the presence of calcifications using subtraction CTA rather than with the conventional CTA approach. Also, subtraction CTA using only MIP presented a similar accuracy to DSA.

Objective The association between carotid atherosclerosis and the metabolic syndrome (MetS) was analyzed in the general population. The usefulness of the inclusion of the serum adiponectin concentration in the MetS criteria for the detection of atherosclerosis was also examined. Patients and Methods The 825 participants of a comprehensive health checkup who underwent carotid ultrasonography and the measurement of serum adiponectin levels were studied. Results The carotid plaque score (PLS) was significantly higher in the MetS group than in the non-MetS group in women, but not in men. In women, a significantly higher odds ratios was obtained for MetS, in terms of the current waist circumference criterion, and a high PLS (fourth quartile) (OR=2.64, p=0.040). In men, however, a waist circumference of around 85 cm did not reflect high a PLS, and even when the waist circumference criterion was varied, the odds ratio did not increase. When the waist circumference was replaced by hypoadiponectinemia in the current MetS criteria, the odds ratio was significantly increased in men (OR=1.82, p=0.032). Conclusion The current MetS criteria seem appropriate for women. In men, there was no significant evidence for the validity of the inclusion of the waist circumference criterion as an essential component. Incorporating hypoadiponectinemia into the current criteria would be useful for the early detection of atherosclerosis in men.

We report a rare case of a patient with hemolytic anemia who underwent emergency total arch replacement using the elephant trunk technique for type A acute aortic dissection 3 years earlier. The 78-year-old woman was referred to our hospital for diagnosis of the cause of the hemolytic anemia, which required twice weekly blood transfusion. Although contrast-enhanced computed tomography could not provide sufficient information, transesophageal echocardiography (TEE) revealed graft flection with high velocity. After percutaneous balloon dilatation, the hemolytic anemia improved and follow-up TEE showed no re-stenosis of the dilatation site.

Patients with chronic kidney disease (CKD) show a much higher risk of cardiovascular disease. However, the mechanisms underlying this association and the impact of CKD on behaviors of the vascular walls have not been fully clarified. Using ultrasonography, this study investigated associations of CKD (estimated glomerular filtration rate60 ml/min/1.73 m(2) and/or presence of proteinuria) with both elasticity (stiffness β index) of the carotid artery and intimal atherosclerotic changes in participants of health check-up programs (n=3406, 63% men; mean age, 58.8 years).Stiffness β was significantly higher in CKD subjects (7.49 ± 0.14) than in non-CKD subjects (6.87 ± 0.05, P0.001). This significant difference was maintained in a multiple adjusted model including conventional risk factors such as hypertension, diabetes mellitus, dyslipidemia, smoking and obesity (7.20 ± 0.14 vs. 6.91 ± 0.05, P=0.043). No significant differences in intima-media complex thickness or plaque score were seen between CKD and non-CKD subjects.In participants of health check-up programs, CKD was associated with increased carotid arterial stiffness without intimal disease, independently of conventional risk factors. These findings indicate that CKD may predispose the carotid arteries to earlier development of arteriosclerosis, characterized by increased arterial stiffness.

A higher ratio of low-density lipoprotein cholesterol (LDL-C) to high-density lipoprotein cholesterol (HDL-C) is associated with a greater risk of cardiovascular events in patients with coronary heart disease. However, the role of this lipid index during early-stage atherosclerosis has not yet been established. This study investigated relationships between LDL-C/HDL-C ratio and carotid plaque score as assessed by ultrasonography in 825 subjects from the general population (527 men, 298 women; mean age, 60.5 years). To identify factors strongly associated with plaque score, stepwise multiple regression analysis was performed using various clinical variables including conventional lipid indices. In both sexes, increased LDL-C/HDL-C ratio was associated with increased plaque score (men: beta = 0.132, P = .001; women: beta = 0.150, P = .012). This association was maintained in men with normal LDL-C level (140 mg/dL). The highest quartile of LDL-C/HDL-C ratio (2.9 in men,2.6 in women) showed significantly increased plaque score even when adjusted by factors included in the final model of stepwise analysis (P = .007 in men, P = .033 in women). No association was seen between LDL-C and plaque score in the multivariate-adjusted model. These findings indicate that increased LDL-C/HDL-C ratio may also be associated with initiation of atherosclerosis. Assessment of this lipid ratio may thus facilitate early management of atherosclerotic risks better rather than assessment of LDL-C alone.

Background Increased arterial stiffness is associated with greater risk of cardiovascular events and mortality. However, in patients with peripheral arterial disease (PAD) who have severe atherosclerotic disorder or risk clustering, the major determinants of increased stiffness have been not clarified. Methods This study investigated the associations between elastic properties of the carotid artery as measured by ultrasonography and atherosclerotic risk factors, with particular focus on diabetes mellitus (DM), in PAD patients ( n =481; mean age, 69.6 years). DM was defined as hemoglobin A1c ≥6.5%, administration of anti-diabetic agents, or DM pattern on 75-g oral glucose tolerance test. Stiffness β index was calculated from luminal diameter changes measured by the M-mode method using a linear array imaging probe. Results Stiffness parameter β was significantly increased in diabetic patients compared with non-diabetic patients (9.56±0.35 vs. 8.31±0.32; p =0.009) in an age- and gender-adjusted model. This significant difference was maintained in a multivariate-adjusted model including age, gender, hypertension, hyperlipidemia, obesity and smoking history (9.43±0.36 vs. 8.39±0.33; p =0.037). No significant differences in mean intima-media complex thickness or plaque score of the carotid artery were seen between diabetic and non-diabetic patients. Conclusion Diabetic condition impairs the elastic properties of arteries, independent of other known atherosclerotic risk factors or excessive intimal diseases in PAD patients. This may support the notion that diabetic condition can worsen prognosis for PAD patients.

Spinal cord ischemia (SCI) is a serious complication of thoracic endovascular aortic repair (TEVAR). The purpose of this study was to establish if preoperative identification of the artery of Adamkiewicz (AKA) can help prevent post-TEVAR SCI. Of 74 post-TEVAR patients, 51 had the critical segmental artery (CSA) to the AKA pre-identified to help the surgeon deploy stent grafts. None of these 51 patients suffered permanent paraplegia postoperatively, but 5 (23.8 %) of the remaining 23 patients (2 of whom had pre-existing paraplegia) did suffer permanent SCI. The CSA/AKA was preserved in 43 patients with pre-identification of the CSA/AKA; however, in 8 patients, the CSA was completely or partially occluded by a stent graft. Transient SCI developed in one patient from each group, but both of these patients recovered fully before discharge. No change in the anatomical route was identified in 29 of the patients who had postoperative evaluation of the CSA/AKA. Five of eight patients whose CSA was completely occluded had new collateral circulation to the AKA. None of the 51 patients with the CSA/AKA identified before TEVAR suffered permanent paraplegia, whereas 5 of the 23 without pre-identification did suffer permanent SCI. Thus, careful identification of the CSA/AKA may prove useful for preventing postoperative SCI. Preservation of potential collateral circulation may also reduce the risk of postoperative SCI.

Figure 1: The left anterior lateral view of a volume-rendering image with semitransparent skeletal system shows that the left seventh intercostal artery (ICA 7), which is the origin of the artery of Adamkiewicz (arrowed), is occluded proximal to the aorta. This image also shows collateral circulation from the left internal thoracic artery (ITA) and muscular branch of the left ninth intercostal artery (ICA 9) to ICA 7. Figure 2: The left anterior lateral view of a volume-rendering image after the endovascular aneurysm repair shows full continuity from the ITA to the artery of Adamkiewicz (arrowed) via axillo-axillary bypass. Because of the coverage of ICA 9 by the stent graft and the left subclavian artery, axillo-axillary bypass was intentionally performed to preserve collateral circulation. In this case, we performed an axillo-axillary bypass instead of a direct left axillary-left carotid artery bypass or direct anastomosis, owing to concerns over the risk of cerebrovascular events.

Hypertensive patients whose BP was uncontrolled despite the use of antihypertensive agents, including an ARB (candesartan 8 mg/day or valsartan 80 mg/day), were enrolled. The patients were randomly assigned to combination therapy with telmisartan 40 mg/day (changed from current ARB) and hydrochlorothiazide (HCTZ) 12.5 mg/day (T + H, n = 32) or to no change in their current drug regimen (CTL, n = 32). The observation period was 12 weeks. The office and home BPs were significantly reduced in the T + H compared to those in the CTL. A sufficient and long-acting BP lowering effect, as reflected in decreased early morning BP, was obtained with the combination of low-dose HCTZ and telmisartan without apparent metabolic deterioration.

Few studies have analyzed intraclass differences in angiotensin II receptor blockers (ARBs) with respect to antidiabetic or metabolic effects. We designed a prospective randomized study to compare a peroxisome proliferator-activated receptor-gamma (PPARgamma)-activating ARB with a nonactivating ARB to delineate the effects on metabolic factors associated with cardiovascular disease. Subjects initially comprised 153 hypertensive patients (72 men, 81 women; mean age, 67.9 +/- 7.8 years) with diagnosed glucose intolerance on the glucose loading test. Patients were randomly assigned to receive 6-month administration of telmisartan 47.0 mg/d (TEL) or candesartan 8.4 mg/d (CAN), or to have no change in drug regimen (control group, CTL). Fasting plasma glucose level was significantly reduced in TEL (n = 46) compared with CTL (n = 47) (percentage of change from baseline, -1.7% vs +2.2%; P = .045). Percentage of increase in adiponectin was significantly larger in TEL than in CTL (+10.5% vs +2.2%, P = .025), but not significantly larger in CAN (n = 44) than in CTL (+4.9% vs +2.2%; P = .13). Percentage of decrease in body weight from baseline was significantly enhanced in TEL compared with CTL (-2.2% vs -0.8%, P = .023) and CAN (-2.2% vs -0.3%, P = .007). Telmisartan decreased body weight while increasing serum adiponectin levels in hypertensive patients with glucose intolerance. Candesartan did not achieve similar improvements in these patients. Among ARBs, telmisartan may have a larger impact on obesity-related diseases that can lead to cardiovascular disorders.

Conflict of interest: none declared. Figure 1: The anterior view of volume-rendering image with semitransparent skeletal system, aorta and kidney shows that the left ICA 9, which is the origin of the artery of Adamkiewicz (arrow), is occluded proximally at the aorta. This image also shows collateral circulation to the artery of Adamkiewicz via the left inferior epigastric artery (IEA), the left 10th ICA and the muscular branch (arrowhead) between the left ICA 9 and the left ICA 10. Intentional preservation of the collateral circulation is planned by a median laparotomy with abdominal aortic graft replacement with careful wound retraction and cannulation from the left femoral artery for cardiopulmonary circulation. T9: 9th thoracic vertebra; ICA 10: 10th intercostal artery. Figure 2: A curved planar reformatted image shows full continuity from the left inferior epigastric artery (IEA) to the artery of Adamkiewicz (arrow) via the left 10th intercostal artery (ICA10).