Rebore or restore?
An RCT by the CADILLAC group (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) has found that stent implantation after acute myocardial infarction (AMI) results in lower rates of re-occlusion than percutaneous transluminal coronary angioplasty (PTCA). Patients whose symptoms of AMI had been present for 30 minutes to 12 hours, with ST-segment elevation or LBBB, and who met defined angiographic criteria, were randomised to undergo PTCA or stenting, with or without abciximab. Altogether, 2082 patients were randomised at 76 centres in Europe and America. Treatment also included aspirin, heparin, β-blockers and ACE inhibitors, with clopidogrel or ticlopidone if a stent was used. After six months, there were no differences between the groups in the rates of death, stroke, or re-infarction. However, rates of ischaemia-driven target-vessel revascularisation were significantly different (PTCA, 15.7%; PTCA with abciximab, 13.8%; stent, 8.3%; and stent with abciximab, 5.2%).
N Engl J Med 2002; 346: 957-966
Losing the spark
In a Dutch RCT, the cognitive outcome following first coronary artery bypass graft “off-pump” was not convincingly better than with cardiopulmonary bypass (CPB) surgery. A battery of 10 cognitive tests was performed before, then 3 and 12 months after, surgery by psychologists blinded to the treatment group. Cognitive decline was defined as a decrease in an individual’s performance of > 20% in at least three of 11 main variables drawn from the tests. At three months, 21% of 128 patients in the off-pump group and 29% of 120 patients in the CPB group showed cognitive decline (RR, 0.65; 95% CI, 0.36–1.17; P = 0.15). At 12 months, cognitive decline occurred in 30.8% of the off-pump group and 33.6% of the CPB group.
JAMA 2002; 287:1405-1412
Spare parts
A 25-year follow-up report from the Mayo Clinic confirms that the Charney total hip arthroplasty gave good service. Between 1969 and 1971, 2000 hips were replaced in 828 men and 861 women (1647 for osteoarthritis); 541 were placed in people who lived for at least 25 years after operation. Altogether, 296 hips were re-operated, including 151 for aseptic loosening. Being younger at the time of operation and male sex were associated with increased risk of aseptic loosening (OR for each 10-year increase in age was 0.5 [95% CI, 0.4–0.6; P < 0.001] and, for male sex, 2.7 [95% CI, 1.9–3.9; P <0.001]).
J Bone Joint Surg Am 2002; 84A: 171-177
Full service
A systematic review and meta-analysis has revealed that intensive follow-up after curative resection for colorectal cancer improves survival. Using data from five RCTs, the British group found that, after five years, 197 of 666 patients (30%) randomised to intensive follow-up had died, compared with 247 of 676 patients (37%) in the control groups. The survival benefit was pronounced in the four trials that sought recurrence beyond the colon, using regular computed tomography and/or frequent measurements of serum carcinoembryonic antigen (risk ratio, 0.73 [95% CI, 0.60–0.89; P = 0.002]). There were no differences in rates of recurrence; however, these were detected significantly earlier in the intensive follow-up group (difference in means, 8.5 months (95% CI, 7.6–9.4; P < 0.001]). This suggests that the improved survival was owing to earlier detection of recurrences.
BMJ 2002; 234: 1-8
Road testing
After the first year of an Australian audit to evaluate endoluminal graft (ELG) for abdominal aortic aneurysm, 474 ELG patients could be compared with 356 patients treated with open repair. The Australian Safety and Efficacy Register for New Interventional Procedures – Surgical (ASERNIP-S) notes that death occurred in six of the ELG group and nine of the open group within 30 days of surgery; subsequently, there were five and seven deaths, respectively. The rate of procedural complications was 15% in both groups, but the percentage of systemic complications was higher following open repair. In an attempt to reduce bias, the open group were compared with a subgroup of ELG patients (n = 252) deemed by their surgeons to be suitable for open repair. There was no statistically significant difference in mortality, nor evidence that the complication rate was higher. It remains unclear whether Australian surgeons and patients will be willing to participate in an RCT.
A N Z J Surg 2002; 72: 190-195