Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation?

Thoracic endovascular aortic repair (TEVAR) has emerged as a promising therapeutic alternative to conventional open aortic replacement but it requires suitable proximal and distal landing zones for stent-graft anchoring. Many aortic pathologies affect in the immediate proximity of the left subclavian artery (LSA) limiting the proximal landing zone site without proximal vessel coverage. In patients in whom the distance between the LSA and aortic lesion is too short, extension of the landing zone can be obtained by covering the LSA's origin with the endovascular stent graft (ESG). This manoeuvre has the potential for immediate and delayed neurological and vascular symptoms. Some authors, therefore, propose prophylactic revascularisation of the LSA by transposition or bypass, while others suggest prophylactic revascularisation only under certain conditions, and still others see no requirement for prophylactic revascularisation in anticipation of LSA ostium coverage. In this review about LSA revascularisation in TEVAR patients with coverage of the LSA, we searched the electronic databases MEDLINE and EMBASE historically until the end date of May 2010 with the search terms left subclavian artery, covering, endovascular, revascularisation and thoracic aorta. We have gathered the most complete scientific evidence available used to support the various concepts to deal with this issue. After a review of the current available literature, 23 relevant articles were found, where we have identified and analysed three basic treatment concepts for LSA revascularisation in TEVAR patients (prophylactic, conditional prophylactic and no prophylactic LSA revascularisation). The available evidence supports prophylactic revascularisation of the LSA before ESG LSA coverage when preoperative imaging reveals abnormal supra-aortic vascular anatomy or pathology. We further conclude that elective patients undergoing planned coverage of the LSA during TEVAR should receive prophylactic LSA transposition or LSA-to-left-common-carotid-artery (LCCA) bypass surgery to prevent severe neurological complications, such as paraplegia or brain stem infarction.

The quality of primary care in a country with universal health care coverage

Standard indicators of quality of care have been developed in the United States. Limited information exists about quality of care in countries with universal health care coverage.

Long-term tissue coverage of a biodegradable polylactide polymer-coated biolimus-eluting stent: comparative sequential assessment with optical coherence tomography until complete resorption of the polymer

Biolimus-eluting stents (BESs) with a biodegradable polymer in abluminal coating achieve more complete coverage at 9 months compared with sirolimus-eluting stents (SESs) with a durable polymer, as assessed by optical coherence tomography (OCT). Whether this advantage persists or augments after complete resorption of the polymer (>12 months) is unknown.

Delayed coverage in malapposed and side-branch struts with respect to well-apposed struts in drug-eluting stents: in vivo assessment with optical coherence tomography

Background—Pathology studies on fatal cases of very late stent thrombosis have described incomplete neointimal coverage as common substrate, in some cases appearing at side-branch struts. Intravascular ultrasound studies have described the association between incomplete stent apposition (ISA) and stent thrombosis, but the mechanism explaining this association remains unclear. Whether the neointimal coverage of nonapposed side-branch and ISA struts is delayed with respect to well-apposed struts is unknown. Methods and Results—Optical coherence tomography studies from 178 stents implanted in 99 patients from 2 randomized trials were analyzed at 9 to 13 months of follow-up. The sample included 38 sirolimus-eluting, 33 biolimus-eluting, 57 everolimus-eluting, and 50 zotarolimus-eluting stents. Optical coherence tomography coverage of nonapposed side-branch and ISA struts was compared with well-apposed struts of the same stent by statistical pooled analysis with a random-effects model. A total of 34 120 struts were analyzed. The risk ratio of delayed coverage was 9.00 (95% confidence interval, 6.58 to 12.32) for nonapposed side-branch versus well-apposed struts, 9.10 (95% confidence interval, 7.34 to 11.28) for ISA versus well-apposed struts, and 1.73 (95% confidence interval, 1.34 to 2.23) for ISA versus nonapposed side-branch struts. Heterogeneity of the effect was observed in the comparison of ISA versus well-apposed struts (H=1.27; I2=38.40) but not in the other comparisons. Conclusions—Coverage of ISA and nonapposed side-branch struts is delayed with respect to well-apposed struts in drug-eluting stents, as assessed by optical coherence tomography.

Tissue coverage of a hydrophilic polymer-coated zotarolimus-eluting stent vs. a fluoropolymer-coated everolimus-eluting stent at 13-month follow-up: an optical coherence tomography substudy from the RESOLUTE All Comers trial

Aims To compare the tissue coverage of a hydrophilic polymer-coated zotarolimus-eluting stent (ZES) vs. a fluoropolymer-coated everolimus-eluting stent (EES) at 13 months, using optical coherence tomography (OCT) in an ‘all-comers' population of patients, in order to clarify the mechanism of eventual differences in the biocompatibility and thrombogenicity of the devices. Methods and results Patients randomized to angiographic follow-up in the RESOLUTE All Comers trial (NCT00617084) at pre-specified OCT sites underwent OCT follow-up at 13 months. Tissue coverage and apposition were assessed strut by strut, and the results in both treatment groups were compared using multilevel logistic or linear regression, as appropriate, with clustering at three different levels: patient, lesion, and stent. Fifty-eight patients (30 ZES and 28 EES), 72 lesions, 107 stents, and 23 197 struts were analysed. Eight hundred and eighty-seven and 654 uncovered struts (7.4 and 5.8%, P= 0.378), and 216 and 161 malapposed struts (1.8 and 1.4%, P= 0.569) were found in the ZES and EES groups, respectively. The mean thickness of coverage was 116 ± 99 µm in ZES and 142 ± 113 µm in EES (P= 0.466). No differences in per cent neointimal volume obstruction (12.5 ± 7.9 vs. 15.0 ± 10.7%) or other areas–volumetric parameters were found between ZES and EES, respectively. Conclusion No significant differences in tissue coverage, malapposition, or lumen/stent areas and volumes were detected by OCT between the hydrophilic polymer-coated ZES and the fluoropolymer-coated EES at 13-month follow-up.

A VEGETATION RECONSTRUCTION OF UNION COUNTY, PENNSYLVANIA DURING THE EARLY HISTORICAL PERIOD (1755-1855)

This thesis assesses relationships between vegetation and topography and the impact of human tree-cutting on the vegetation of Union County during the early historical era (1755-1855). I use early warrant maps and forestry maps from the Pennsylvania historical archives and a warrantee map from the Union County courthouse depicting the distribution of witness trees and non-tree surveyed markers (posts and stones) in early European settlement land surveys to reconstruct the vegetation and compare vegetation by broad scale (mountains and valleys) and local scale (topographic classes with mountains and valleys) topography. I calculated marker density based on 2 km x 2 km grid cells to assess tree-cutting impacts. Valleys were mostly forests dominated by white oak (Quercus alba) with abundant hickory (Carya spp.), pine (Pinus spp.), and black oak (Quercus velutina), while pine dominated what were mostly pine-oak forests in the mountains. Within the valleys, pine was strongly associated with hilltops, eastern hemlock (Tsuga canadensis) was abundant on north slopes, hickory was associated with south slopes, and riparian zones had high frequencies of ash (Fraxinus spp.) and hickory. In the mountains, white oak was infrequent on south slopes, chestnut (Castanea dentata) was more abundant on south slopes and ridgetops than north slopes and mountain coves, and white oak and maple (Acer spp.) were common in riparian zones. Marker density analysis suggests that trees were still common over most of the landscape by 1855. The findings suggest there were large differences in vegetation between valleys and mountains due in part to differences in elevation, and vegetation differed more by topographic classes in the valleys than in the mountains. Possible areas of tree-cutting were evenly distributed by topographic classes, suggesting Europeans settlers were clearing land and harvesting timber in most areas of Union County.

Spatial assessment of carbon stocks of living vegetation at the national level in Lao PDR

The international mechanism for Reducing Greenhouse Gas Emissions from Deforestation and Forest Degradation (REDD) supposedly offers new opportunities for combining climate mitigation, conservation of the environment, and socio-economic development for development countries. In Laos REDD is abundantly promoted by the government and development agencies as a potential option for rural development. Yet, basic information for carbon management is missing: to date no knowledge is available at the national level on the quantities of carbon stored in the Lao landscapes. In this study we present an approach for spatial assessment of vegetation-based carbon stocks. We used Google Earth, Landsat and MODIS satellite imagery and refined the official national land cover data to assess carbon stocks. Our study showed that more than half (52%) of carbon stock of Laos is stored in natural forests, but that 70% of this stock is located outside of national protected areas. On the basis of two carbon-centered land use scenarios we calculated that between 30 and 40 million tons of carbon could be accumulated in shifting cultivation areas; this is less than 3% of the existing total stock. Our study suggests that the main focus of REDD in Laos should be on the conservation of existing carbon stocks, giving highest priority to the prevention of deforestation outside of national protected areas.