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Leila Mureebe

Publications and source records attributed to Leila Mureebe.

14 recordsLinked to original sources
PubMed2006

Analysis of outcomes following failed endovascular treatment of chronic limb ischemia.

Despite recent studies highlighting the advantages of endoluminal intervention in the management of chronic limb ischemia (CLI), outcomes following failed peripheral angioplasty remain less well described. We present a retrospective analysis of failed transluminal infrainguinal percutaneous arterial angioplasty with or without stenting (PTA/S) in patients with CLI. A database of patients undergoing infrainguinal PTA/S between 2002 and 2005 was maintained. Patients underwent duplex scanning follow-up at 2 weeks, 3 months, and every 6 months after the intervention. Angiograms were reviewed in all cases to assess lesion characteristics. Results were standardized to current Transatlantic Inter-Society Consensus (TASC) criteria. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. In total, our analysis involved 246 patients who underwent treatment for CLI using PTA/S. Eighteen percent of procedures (n = 46) were considered an intervention failure secondary to restenosis by duplex ultrasound, returning clinical symptoms, a nonhealing foot lesion, or the absence of a prior palpable pulse. Indications for the original procedure in patients whose PTA/S failed were tissue loss in 44%, claudication in 44%, and rest pain in 12%, while TASC lesion grades were A (0%), B (18%), C (18%), and D (64%). Of patients failing PTA/S, 4% failed in the first 30 days, 78% failed between 1 and 18 months, while 18% failed following 18 months, with a mean time to failure of 8.7 months. Also, 82% of PTA/S failures were candidates for a second endovascular procedure, 11% were suitable for only traditional open bypass, and 4% demonstrated progression of disease necessitating amputation. Of patients undergoing a second endovascular procedure, limb salvage rates were 86% at 12-month follow-up and there was a single periprocedural mortality and complication rate of 6.6%. Of patients requiring open surgical bypass after failed PTA/S, 20% (n = 1) required a major amputation and there were no mortalities. Failure of endoluminal therapy for treatment of lower extremity arterial occlusive disease is amenable to subsequent endovascular intervention for limb salvage with limited morbidity and mortality.

Adult↗
PubMed2005

Analysis of anatomic factors and age in patients undergoing carotid angioplasty and stenting.

Recent data suggest that patient age >80 years may be associated with increased risk of periprocedural complications from carotid angioplasty and stenting (CAS). In this study, we analyzed anatomic risk factors in patients undergoing CAS based on age >80 or <80 years. Our hypothesis was that patients >80 would have more challenging anatomy. Between February 2003 and August 2004, 82 patients underwent CAS. Images for 57 lesions were available for review. Eighteen patients were > or =80 years old and 39 were <80. Cerebral protection devices, including EPI Filterwire, Percusurge, Accunet, and Angioguard, were used in all but two cases; and self-expanding stents (Wallstent, NexStent, Acculink, Precise) were placed in all. Arterial anatomic characteristics were assigned a score based on complexity and associated procedural risk. Characteristics evaluated using angiographic images were aortic arch elongation classification, arch calcification, common carotid/innominate stenosis, common carotid tortuosity, internal carotid tortuosity, index lesion length, index lesion calcification, and index lesion stenosis. Statistical analysis was performed using Fisher's exact test. CAS was successfully completed in 98% of cases. The two patients in whom we could not perform CAS were 79 and 83 years old. The anatomic characteristics that were statistically significantly more complex/severe in patients > or =80 were arch calcification (p = 0.045), common carotid/innominate stenosis (p = 0.023), common carotid tortuosity (p = 0.049), and internal carotid tortuosity (p = 0.032). There was no statistically significant difference in arch elongation classification, lesion length, lesion calcification, or stenosis severity (p = nonsignificant). Overall, patients > or =80 years had an increased incidence of complex anatomic risk factors compared to younger patients (p < 0.001). Cerebrovascular accident without residual deficits occurred in two patients; both were >80 years old. Complex arterial anatomy is more often present in patients >80 years and may explain the increased complication rates associated with CAS. Pre- or intraoperative consideration of these characteristics may help provide better risk assessment in candidates for CAS.

Age Factors↗
PubMed2005

Heparin-induced thrombocytopenia in the pediatric intensive care unit population.

OBJECTIVES: To report the occurrence of heparin-induced thrombocytopenia (HIT), discuss its pathophysiology, and outline an approach to management in the pediatric intensive care unit (ICU) patient. DESIGN: Retrospective case reports. SETTING: Pediatric ICU in a tertiary-care center. PATIENTS AND RESULTS: Two pediatric ICU patients (2 and 6 mos of age) who developed HIT in the pediatric ICU. One was receiving heparin as a flush solution through a central line and the other had full heparinization during cardiopulmonary bypass. Both had received heparin during their neonatal course and developed thrombocytopenia; however, HIT was not considered as a possible diagnosis. HIT was diagnosed using a heparin-induced platelet aggregation study. The thrombocytopenia resolved with the cessation of heparin administration. One of the patients developed a deep vein thrombosis around a femoral venous catheter. CONCLUSION: Although well described in the adult literature, there have been a limited number of reports of HIT in pediatric-aged patients. Given its potential for morbidity, HIT should be considered in the differential diagnosis of thrombocytopenia in the pediatric ICU patient.

Fibrinolytic Agents↗
PubMed2005

Argatroban for anticoagulation during cardiopulmonary bypass in an infant.

Heparin induced thrombocytopenia (HIT) is a rare, but potentially life-threatening complication of heparin therapy. In patients with HIT, alternative means of anticoagulation are necessary. The authors present an infant with HIT who required anticoagulation during cardiopulmonary bypass for tricuspid valve excision in the treatment of bacterial endocarditis. The direct thrombin inhibitor, argatroban, was successfully used. Previous reports regarding the use of argatroban and other nonheparin anticoagulants for anticoagulation are reviewed and suggestions regarding argatroban dosing in infants are presented.

Anti-Bacterial Agents↗
PubMed2004

Inhibition of intimal hyperplasia by direct thrombin inhibitors in an animal vein bypass model.

Many functions of the coagulation system have nonthrombotic effects. The indirect thrombin inhibitor heparin has been previously shown to be effective in limiting intimal hyperplasia (IH). We sought to study the effect of thrombin on IH by using two direct thrombin inhibitors (DTIs), argatroban and lepirudin. Sprague-Dawley rats underwent interposition vein grafting to the carotid artery. Vein grafts were treated with either saline (n = 6) or one of the two DTIs (n = 6 for both). At 30 days, the rats were sacrificed and vessels were perfusion fixed. Sections of the proximal carotid artery, graft, and both anastomoses were stained with both hematoxlyin/eosin and von Gieson's elastin stain. Sections were examined and compared for luminal area and intima-to-media (IM) ratio. The vessels treated with DTIs had less (p < 0.05) IH (IM ratio for proximal anastomosis: control 1.036 +/- 0.857, lepirudin 0.373 +/- 0.21, argatroban 0.182 +/- 0.118) and better lumen preservation than the control vessels (lumen area of proximal anastomosis: control 1.69 +/- 0.9, lepirudin 2.45 +/- 0.74, argatroban 2.81 +/- 0.78). There were no thromboses in the DTI-treated vessels. Dilatation of the graft segment was noted in the argatroban group. Thus, DTIs are effective at reducing IH in a small-animal model, suggesting that inhibition of thrombin has a protective role in IH. In addition, a difference of action between DTIs is suggested by the dilatation seen only in the argatroban-treated graft sections.

Anastomosis, Surgical↗
PubMed2004

Pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis: safety and feasibility study.

PURPOSE: The current standard of care for deep venous thromboembolism (DVT) is anticoagulation; however, this treatment method does not rapidly relieve clot burden or clinical symptoms. We describe a rapid and effective method of thrombus removal, with simultaneous percutaneous mechanical thrombectomy (PMT) and thrombolysis. METHODS: Over 26 months 20 patients (22 men, 2 women; mean age, 52 +/- 6 years [range, 38-79 years]) with extensive lower extremity DVT were treated with PMT with the AngioJet thrombectomy device in combination with lytic agent (urokinase, tissue plasminogen activator, or reteplase) added to the infusion. Three patients underwent treatment twice, because of recurrent DVT. The primary end point was angiographic evidence of restoration of venous patency at completion of the procedure. Complications, recurrent ipsilateral DVT, and improvement in clinical symptoms were evaluated. RESULTS: Complete thrombus removal was obtained in 15 procedures (65%), and partial resolution in the remaining 8 procedures (35%). Inciting occlusive lesions responsible for acute DVT were revealed in 14 patients (61%), and angioplasty with or without stenting was performed when necessary. In the 8 procedures with partial resolution additional catheter-directed thrombolysis was carried out on average for 5.7 hours, with further thrombus reduction. Overall, immediate (<24 hours) improvement in clinical symptoms was noted in 17 patients (74%). There were no complications related to either PMT or the short duration of lytic agent infusion. At average follow-up of 10.2 +/- 0.3 months (range, 3-26 months), 3 patients had recurrent ipsilateral DVT, and underwent repeat treatment. CONCLUSIONS: Addition of lytic agent to PMT facilitates thrombus extraction, decreases overall interventional treatment time, and improves patient outcomes. In addition, definitive management of underlying anatomic lesions can be performed in the same setting. Further outcome measures are necessary to study the long-term efficacy of this treatment method on preservation of valve function, reduction of chronic venous insufficiency, and improved quality of life.

Adult↗
PubMed2004

Heparin-associated antiplatelet antibodies increase morbidity and mortality in hemodialysis patients.

BACKGROUND: Patients are frequently exposed to heparin during hemodialysis (HD) to prevent thrombosis of the extracorporeal circuit. Other groups with frequent heparin exposures have a high rate of development of heparin-associated antiplatelet antibodies (HAAb). We sought to define the prevalence of HAAb in HD patients and evaluate their effects. METHODS: A chart listing of all patients undergoing HD at our tertiary care institution during a six-year period was obtained. Charts of patients who tested positive for HAAb were reviewed. A cohort of randomly selected HD patients who tested negative for HAAb was analyzed as a control group. RESULTS: In our sample, 3.7% of HD patients were positive for HAAb. Morbidity, as defined by thromboembolic (TEC) or hemorrhagic complications, was higher in the HAAb-positive group compared with the control patients (60% vs 8.7%, P < .05), and the mortality rate (mortality directly related to TECs) was also higher in the HAAb-positive patients (28.6% vs 4.35%, P < .05). CONCLUSIONS: Contrary to reports of HAAb in patients undergoing HD without increased morbidity and mortality, we found significant increases in both morbidity and mortality. The elevated morbidity and mortality may represent ongoing endothelial and platelet activation from repeated heparin exposures. Reduced morbidity and mortality will likely require early recognition of HAAb and alteration of anticoagulation in HD patients.

Adult↗
PubMed2004

Role of race and sex in diagnosis and one-year follow up of deep venous thrombosis.

This study examines the role of sex and race in the diagnosis and outcome of deep vein thrombosis (DVT). A retrospective study was performed of 632 patients who underwent venous duplex ultrasound from August 1998 to July 1999. Comparisons were made by Chi-square analysis. Seventy-four percent of the patients were women and 79% of the total group was African American. Twenty-two percent (140) of the examinations were positive for DVT. Of all studies performed in men, 37% were positive for DVT, and of all studies performed in women, 18% were positive for DVT (P<0.05). Additionally, African-American women were more likely to be positive for DVT than Caucasian women. One-year follow up showed that 42% had residual thrombus and, regardless of sex, African-Americans were more likely to have persistent thrombus than Caucasians (60% vs. 19%). Findings in this study suggest, in our cohort, African American women were diagnosed with DVT twice as often as Caucasian women and African Americans were more likely to have a persistent DVT as compared to Caucasians.

Adolescent↗
PubMed2003

Heparin-induced thrombocytopenia: twenty-nine years later.

OBJECTIVE: To determine the current frequency, types of patients, indications for testing, morbidity and mortality, and management of heparin-induced thrombocytopenia (HIT). METHODS: Between December 1998 and July 2001, the charts of 102 inpatients that tested positive for heparin-associated antiplatelet antibodies (HAAb) were reviewed. There were 33,941 inpatients, 10,348 of them having received unfractionated or low molecular weight heparins. HAAb were determined by platelet aggregometry. RESULTS: There were 58 males and 44 females with a mean age of 56 years. The majority (72%) of patients were admitted to a surgical service (23% were admitted to medicine, and 5% were admitted to obstetrics/pediatrics). Indications for testing included one or more low platelet counts (n = 51), unexplained arterial (n = 33) or venous (n = 6) thromboses, resistance to anticoagulation (n = 1), prior history of HAAb (n = 3), organ transplant (n = 17), or other indication (n = 4). The HAAb "patterns" were variable, with patients having antibodies only to bovine (n = 7) or porcine heparin (n = 5), bovine and porcine heparins (n = 17), enoxaparin (n = 3), fragmin (n = 7), or all 4 heparins (n = 43). The HIT-related mortality was 6.9%, and the morbidity was 30% with 19 arterial and 7 venous thromboses and 5 bleeding events. Management consisted of discontinuation of heparin in 95 patients. Twenty-five patients did not require continued anticoagulation. When needed, anticoagulation was continued with a direct thrombin inhibitor (n = 32), enoxaparin (n = 16), warfarin (n = 15), or aspirin (n = 7). Seven patients continued to receive unfractionated heparin (n = 4) or low molecular weight heparin (n = 3). CONCLUSIONS: HIT occurs in 0.99% of inpatients receiving heparin and remains an important nondiscriminatory contributor to their morbidity and mortality. Patients receiving any form of heparin who develop a decreasing platelet count, unexplained thrombosis, or resistance to heparin anticoagulation should be tested for HAAb. If HAAb are detected, patients must not receive the sensitizing heparin(s).

Adolescent↗
PubMedDate not supplied

Heparin-induced thrombocytopenia: pathophysiology and management.

Immune-mediated heparin-induced thrombocytopenia (HIT) is a well-defined syndrome. Clinical criteria (thrombocytopenia, resistance to heparin anticoagulation, or thromboses during heparin therapy) are defined, and serologic diagnostic tests are available. Earlier recognition of HIT syndrome has allowed for significant advances in therapy, leading to marked reductions in morbidity and mortality from HIT syndrome. This review addresses the epidemiology, pathobiology, and management of HIT syndrome

Anticoagulants↗
PubMedDate not supplied

Hypercoagulable states: a review.

Vascular surgeons are often asked to evaluate patients with recurrent thromboses or thromboses in unusual locations either arterial or venous. There may be obvious inciting factors, but in many of these patients the possibility of a previously undiagnosed hypercoagulable state must be considered. Hypercoagulable states can be acquired (smoking, medication, change in physiologic status as occurs with pregnancy) or congenital. Congenital hypercoagulable disorders are more prevalent in families or patients with a history of thromboembolic events early in life or multiple miscarriages and include conditions such as protein C or S deficiencies, factor V Leiden mutation, and prothrombin gene variant. This article reviews the hypercoagulable states that are encountered in clinical practice as well as guidelines for testing and goals of therapy.

Anticoagulants↗
PubMedDate not supplied

Platelet function and pharmacologic inhibition.

Platelets have traditionally been understood within the context of hemostasis and hemorrhagic disorders. However, with increasing procedures being performed in smaller vessels and with an increasing incidence of atherosclerosis, the often critical role platelets play is more evident. Platelets are no longer viewed as "scaffolding" for the events of the coagulation cascade but rather as important catalysts in hemostasis, thrombosis, and fibrinolysis. Improved understanding of platelet physiology has led to developments of pharmacologic adjuncts resulting in improved patency rates and improved patient outcomes. This review addresses the physiology of platelet function and the impact of new pharmacologic agents in percutaneous intervention.

Abciximab↗
PubMedDate not supplied

Infrainguinal arterial intervention: is there a role for an atherectomy device?

Excision of atheromatous plaque is an attractive option for the minimally invasive treatment of peripheral arterial disease. Approved for use in 2003, the SilverHawk Plaque Exicison System (FoxHollow Technologies, Redwood City, CA) is a catheter-based plaque excision device allowing percutaneous removal of atheromatous material. This device represents the most recent generation of atherectomy tools. Overall experience with plaque debulking in the peripheral arteries spans almost two decades, and understanding of the technique continues to evolve. This article reviews the technology, current practices, and data on plaque excision.

Atherectomy↗