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In a placebo-controlled trial, 497 patients undergoing vascular surgery were randomly assigned to receive either fluvastatin or placebo, both before surgery and for 30 days after surgery. Postoperative myocardial ischemia occurred significantly less frequently in the fluvastatin group. Fluvastatin was also associated with a reduction in the rate of death from cardiovascular causes or myocardial infarction. In patients undergoing vascular surgery, postoperative myocardial ischemia occurred significantly less frequently in the fluvastatin group than in the placebo group. Fluvastatin was also associated with a reduction in the rate of death from cardiovascular causes or myocardial infarction. Patients with atherosclerotic vascular disease who undergo noncardiac vascular surgery are at high risk for postoperative cardiac events, such as myocardial infarction and death from cardiovascular causes. Cardiac events occur in up to 24% of patients in high-risk cohorts 1 and are related to the high incidence of underlying coronary artery disease. Hertzer et al., performing routine coronary angiography in 1000 patients scheduled for vascular surgery, found that only 8% had a normal coronary-artery tree. 2 Although the pathophysiology of perioperative myocardial infarction is not entirely understood, it is well accepted that rupture of coronary plaque, leading to thrombus formation and subsequent . . .

Inferior vena cava agenesis (IVCA) is a rare condition, found in almost 5% of patients under 30 years old with unprovoked deep venous thrombosis (DVT). We describe 10 consecutive patients with IVCA-associated DVT and conducted an extensive literature review to investigate the typical spectrum of IVCA-associated DVT. Among our patients (eight men and two women; mean age, 25 ± 4.5 years), DVT followed intense and unusual (major) physical activity for eight of them. DVT was bilateral in six patients and unilateral in four. Ultrasonography was unable to detect IVCA, which was visualized by computed-tomography scans for seven patients, and magnetic resonance imaging and angiography for 10. Hereditary thrombophilia screening, to detect factor V Leiden or prothrombin gene heterozygosity (G20210A mutation), was positive for only two patients. Wearing elastic stockings and taking an indefinite or long-term vitamin K antagonist were prescribed for all 10 patients and nine complied with the latter. To date, 62 patients with IVCA-associated DVT have been reported in the English literature. Analysis of them and our patients yielded a typical spectrum of IVCA-associated DVT characteristics: IVCA occurs in young adults, particularly males, and is revealed by proximal DVT following major physical exertion. All were treated with a prolonged vitamin K antagonist and advised to wear elastic stockings. No precise duration of anticoagulation has been established.

Whether clinically stable small abdominal aortic aneurysms should be surgically repaired or monitored with periodic noninvasive imaging is controversial. This study compared the two approaches in patients with aneurysms 4.0 to 5.4 cm in diameter. After a mean follow-up of nearly five years, there was no survival advantage associated with immediate surgical repair. This study compared the two approaches in patients with aneurysms of 4.0 to 5.4 cm. There was no survival advantage with immediate surgical repair. Each year in the United States, 9000 deaths result from rupture of abdominal aortic aneurysms. 1 Another 33,000 patients undergo elective repair of asymptomatic abdominal aortic aneurysms to prevent rupture, which results in 1400 to 2800 operative deaths. 2 , 3 Because most abdominal aortic aneurysms never rupture, 4 elective repair is undertaken only when the risk of rupture is considered high. The strongest known predictor of rupture is the maximal diameter of the aneurysm. 5 , 6 Elective repair has been recommended for patients with aneurysms of 4.0 cm or more in diameter who do not have medical contraindications, 7 although others have advocated the use . . .

The control of nanofiber orientation in nanofibrous tubular scaffolds can benefit the cell responses along specific directions. For small diameter tubular scaffolds, however, it becomes difficult to engineer nanofiber orientation. This paper reports a novel electrospinning technique for the fabrication of 3-D nanofibrous tubular scaffolds with controllable nanofiber orientations. Synthetic absorbable poly-ε-caprolactone (PCL) was used as the model biomaterial to demonstrate this new electrospinning technique. Electrospun 3-D PCL nanofibrous tubular scaffolds of 4.5 mm in diameter with different nanofiber orientations (viz. circumferential, axial, and combinations of circumferential and axial directions) were successfully fabricated. The degree of nanofiber alignment in the electrospun 3-D tubular scaffolds was quantified by using the fast Fourier transform (FFT) analysis. The results indicated that excellent circumferential nanofiber alignment could be achieved in the 3-D nanofibrous PCL tubular scaffolds. The nanofibrous tubular scaffolds with oriented nanofibers had not only directional mechanical property but also could facilitate the orientation of the endothelial cell attachment on the fibers. Multiple layers of aligned nanofibers in different orientations can produce 3-D nanofibrous tubular scaffolds of different macroscopic properties.

Small abdominal aortic aneurysms (no more than 5.5 cm in diameter) are believed to have a low risk of rupture. This study compared two management strategies: immediate surgery and ultrasonographic surveillance followed by surgery if needed. Because of operative mortality, there was an early survival advantage with surveillance, but after eight years, the early-surgery group had gained a survival advantage. Rupture of an abdominal aortic aneurysm is associated with a high fatality rate and is an important cause of sudden death. Low rates of rupture of small abdominal aortic aneurysm were observed among patients enrolled in the United Kingdom Small Aneurysm Trial and the Aneurysm Detection and Management Trial in the United States — 1.0 percent and 0.6 percent per year, respectively. 1 , 2 These low rates of rupture may explain in part why these trials did not demonstrate a five-year survival benefit for patients who were randomly assigned to undergo early elective surgery. Operative mortality rates of 5.8 percent in . . .

Cognitive decline has increasingly been recognized as a complication after cardiac surgery. Although important advances in techniques for perioperative anesthesia, surgery, and the protection of organs have resulted in substantial reductions in age-adjusted and risk-adjusted mortality, 1 the incidence of cognitive decline has changed little over the past 15 years. Elderly patients with multiple health problems, who are at higher risk than other groups of patients for neurologic and neurocognitive problems, are now able to undergo surgical procedures relatively late in life without serious concern about loss of life. However, they are at substantially increased risk for central nervous system dysfunction . . .

In 1954 a patient with symptoms suggesting that a stroke was imminent underwent successful removal of a stenosed segment of the carotid artery. 1 From that initial experience, carotid endarterectomy evolved. In 1985 it was performed 107,000 times in the United States. 2 Two negative randomized trials were reported. 3 , 4 On the basis of anecdotal evidence, about 1 million endarterectomies were performed worldwide between 1974 and 1985. 5 , 6 Reports of unacceptable rates of complications, reviews of health care data bases, and editorials called into question the benefit of endarterectomy. 7 – 13 The failure of cerebral bypass surgery in a randomized trial strengthened the . . .

Experiments conducted by Goldblatt and colleagues 1 on the effects of renal-artery constriction in animals led to the recognition that renal-artery stenosis may cause hypertension. Initially, surgical revascularization was the only treatment for renal-artery stenosis, 2 , 3 but percutaneous transluminal balloon angioplasty, 4 with or without stent placement, later supplanted surgery as the preferred treatment. 5 In uncontrolled, retrospective studies of balloon angioplasty, 36 to 100 percent of patients with hypertension had some reduction in blood pressure, with the highest rates of response in patients with fibromuscular dysplasia, 6 but in few patients, however, was blood pressure restored to normal levels. In two small, randomized . . .

Early elective surgery may prevent rupture of abdominal aortic aneurysms, but mortality is 5–6%. The risk of rupture seems to be low for aneurysms smaller than 5 cm. We investigated whether prophylactic open surgery decreased long-term mortality risks for small aneurysms. We randomly assigned 1090 patients aged 60–76 years, with symptomless abdominal aortic aneurysms 4·0–5·5 cm in diameter to undergo early elective open surgery (n=563) or ultrasonographic surveillance (n=527). Patients were followed up for a mean of 4·6 years. If the diameter of aneurysms in the surveillance group exceeded 5·5 cm, surgical repair was recommended. The primary endpoint was death. Mortality analyses were done by intention to treat. The two groups had similar cardiovascular risk factors at baseline. 93% of patients adhered to the assigned treatment. 309 patients died during follow-up. The overall hazard ratio for all-cause mortality in the early-surgery group compared with the surveillance group was 0·94 (95% Cl 0·75–1·17, p=0·56). The 30-day operative mortality in the early-surgery group was 5·8%, which led to a survival disadvantage for these patients early in the trial. Mortality did not differ significantly between groups at 2 years, 4 years, or 6 years. Age, sex, or initial aneurysm size did not modify the overall hazard ratio. Ultrasonographic surveillance for small abdominal aortic aneurysms is safe, and early surgery does not provide a long-term survival advantage. Our results do not support a policy of open surgical repair for abdominal aortic aneurysms of 4·0–5·5 cm in diameter.

The overall incidence of gastric adenocarcinoma is declining despite the increasingly frequent occurrence of proximal gastric tumors. Nevertheless, stomach cancer remains an important cause of death worldwide. In the Netherlands, gastric cancer ranks fourth among all causes of death from cancer, with an annual mortality rate of approximately 20 per 100,000. In Japan, it is the most frequently diagnosed cancer. Reported rates of survival after gastric resection are consistently higher in Japan than in the West. 1 Japanese and Western surgeons differ in their approach to lymph-node dissection during surgery for stomach cancer. D2 lymph-node dissection has never gained widespread popularity . . .