Faculty Bibliography

To determine whether choice of material used for patch closure following carotid artery endarterectomy (CAE) influences rates of early or late restenosis, stroke, and death, 274 consecutive CAEs were retrospectively reviewed. Saphenous vein (SV) was used in 159 (58.0%) procedures; everted, double-thickness jugular vein (JV) was used in 25 (9.1%); and knitted Dacron (KD) was used in 90 (32.9%). Primary closure was not used in this series. There were four perioperative strokes: two (1.3%) in SV, one (4%) in JV, and one (1.1%) in KD (NS). Follow-up was obtained on 263 (96%) operated arteries (mean 41.5 months). Duplex scan results were available for 236 (89.7%) of these arteries (mean follow-up time 33.7 months). There were three (2%) late strokes in SV and two (2.2%) in KD (NS). In long-term follow-up, one patient (0.7%) in SV and two (2.4%) in KD developed > 80% stenosis (NS). One patient (0.7%) in SV, one (5.3%) in JV, and one (1.2%) in KD had total occlusion of the operated vessel (NS). Three procedures (2.2%) in SV, 1 (5.3%) in JV, and 7 (8.5%) in KD demonstrated moderate stenosis (50-79%) (NS). Three-year follow-up shows that choice of patch material does not affect early or late stroke rate, stroke-related death rate, rate of high-grade (> 80%) restenosis, or rate of total occlusion. There is a higher incidence of moderate stenosis in KD. Although our results and a review of the literature do not indicate that these patients are at increased risk for symptoms or progression of stenosis, they should be followed by duplex scanning to ensure that this is the case

Prior studies have suggested that young patients may be more prone to recurrent disease after carotid endarterectomy (CEA). The goal of this study was to review a series of CEAs performed on younger patients (< or = 55 years) and to determine if these patients are more likely to develop recurrent stenosis. A review was conducted of CEAs performed from 1985 through 1994. Analysis was performed on a study group of 94 young patients who underwent 109 CEAs during this time. A control group of 222 patients older than 55 years who underwent 256 CEAs during the years 1991 through 1993 was selected for comparison. During a mean of nearly 4 years of follow-up, younger patients were significantly more likely to experience a late failure of CEA, including total occlusion of the operated artery, or recurrent stenosis requiring redo surgery. Careful patient evaluation is important in choosing younger patients who require CEA. Implications of these data include mandating careful noninvasive follow-up examinations for younger patients undergoing CEA

Lower extremity paraplegia or paraparesis is an extremely rare event after operative repair of infrarenal abdominal aortic aneurysms (AAAS). We report two such cases that occurred after endovascular repair or attempted endovascular repair of routine AAAS. To our knowledge, these are the first two cases reported specifically in the literature. These cases may have significant implications with regard to the endovascular management of AAAS, because atheroembolization to the spinal cord appears to be the underlying cause

In selected patients with descending aortic dissection, percutaneous intimal flap fenestration is a less-invasive alternative to surgery. We describe a patient with decreased renal and mesenteric blood flow as a result of descending aortic dissection. Percutaneous balloon intimal fenestration was performed under guidance of transesophageal echocardiography. Transesophageal echocardiography provided crucial information about the intimal flap puncture site and true- and false-lumen blood flow. After the flap fenestration, false-lumen blood flow increased, and the patient improved clinically

Thrombosis of the internal jugular vein is a rare entity with the potential for serious consequences. Most of the reported cases of jugular venous thrombosis have occurred in the presence of an indwelling venous catheter, an established hypercoagulable state, or in association with head and neck sepsis. This report presents a case of a patient in whom jugular venous thrombosis developed during the first trimester of pregnancy after in vitro fertilization. Thromboembolism in these circumstances can be related to a condition known as the ovarian hyperstimulation syndrome. The presentation of severe neck pain in pregnant women, especially in those who have undergone assisted reproduction procedures, should prompt evaluation by duplex scan to evaluate the jugular veins for thrombosis. Anticoagulation is the treatment of choice

PURPOSE: When managing a new neurologic deficit after carotid endarterectomy (CEA), the surgeon is often preoccupied with determining the cause of the problem, requesting diagnostics tests, and deciding whether the patient should be surgically reexplored. The goal of this study was to analyze a series of perioperative neurologic events and to determine if careful analysis of their timing and mechanisms can predict which cases are likely to improve with reoperation. METHODS: A review of 2024 CEAs performed from 1985 to 1997 revealed 38 patients who manifested a neurologic deficit in the perioperative period (1.9%). These cases form the focus of this analysis. RESULTS: The causes of the events included intraoperative clamping ischemia in 5 patients (13.2%); thromboembolic events in 24 (63.2%); intracerebral hemorrhage in 5 (13.2%); and deficits unrelated to the operated artery in 4 (10.5%). Neurologic events manifesting in the first 24 hours after surgery were significantly more likely to be caused by thromboembolic events than by other causes of stroke (88.0% vs. 12.0%, P<.002); deficits manifesting after the first 24 hours were significantly more likely to be related to other causes. Of 25 deficits manifesting in the first 24 hours after surgery, 18 underwent immediate surgical reexploration. Intraluminal thrombus was noted in 15 of the 18 reexplorations (83. 3%); any technical defects were corrected. After the 18 reexplorations, in 12 cases there was either complete resolution of or significant improvement in the neurologic deficit that had been present (66.7%). CONCLUSIONS: Careful analysis of the timing and presentation of perioperative neurologic events after CEA can predict which cases are likely to improve with reoperation. Neurologic deficits that present during the first 24 hours after CEA are likely to be related to intraluminal thrombus formation and embolization. Unless another etiology for stroke has clearly been established, we think immediate reexploration of the artery without other confirmatory tests is mandatory to remove the embolic source and correct any technical problems. This will likely improve the neurologic outcome in these patients, because an uncorrected situation would lead to continued embolization and compromise

Endoleak is the persistence of blood flow outside the lumen of an endograft, but within an aneurysm sac or adjacent vessel being treated by the graft. Diagnosis may be difficult, and treatment remains somewhat controversial. The purpose of this article is to discuss the clinical significance and appropriate management of endoleaks within the context of our current understanding of this phenomenon. The diagnosis of an endoleak can be made by conventional angiography, duplex ultrasound, intravascular ultrasound (IVUS), and computed tomography (CT) angiography. All of these modalities are effective, although CT angiography may be the most sensitive. Endoleaks can be categorized into 5 classes: (1) perigraft flow around the proximal end of the endograft; (2) perigraft flow around the distal end of the endograft; (3) flow through a defect in the body of the endograft; (4) flow between segments of a multicomponent endovascular graft; and (5) flow between arterial branches within an aneurysm sac. The first 4 classes have been shown to represent a clinical situation in which systemic arterial pressure is transmitted to an inadequately excluded aneurysm sac, placing the sac at risk of rupture. In contrast, branch-flow leaks do not appear to carry an increased risk of rupture, provided there is no increase in aneurysm sac diameter. However, an increase in the diameter of an aneurysm sac after endograft implantation may be a sign of occult endoleak, even if not visualized by current imaging techniques. Thus, we believe that collateral branch leaks with no associated aneurysm sac expansion may be observed with regular follow-up by CT angiography. All other endoleaks should be treated with adjunctive endovascular maneuvers or explanation of the endograft with standard open repair-in short, routine follow-up imaging on endografts to detect the presence of late endoleaks or aneurysm sac expansion

PURPOSE: The morbidity and clinical outcome of the failure to successfully repair an abdominal aortic aneurysm with Endovascular Technologies (EVT) grafts, resulting in explantation of the device, was assessed. METHODS: The records of all patients worldwide undergoing attempted endovascular repair with EVT devices from February 1993 to October 1997 were retrospectively reviewed. Of 669 patients, 19 (3%) were converted to open procedure with immediate explantation during the initial attempt at endovascular repair, and 27 patients (4%) required explantation at a later date, ranging from 1 day to 40 months. The incidence, morbidity, mortality, and effect on clinical outcome were evaluated. RESULTS: Causes of immediate conversion with explantation were: inaccurate deployment of the proximal or distal attachment systems (11 of 19; 58%); twists in the system (3 of 19; 16%); mechanism malfunction during deployment (4 of 19; 21%); and an aortic tear (1 of 19; 5%). Among the 27 patients undergoing late explantation, 20 (74%) did so because of persistent endoleaks. Three cases (11%) were performed because of aneurysm rupture, three (11%) because of graft occlusion, one because of aortic dissection (4%), and one (4%) because of graft migration into the aneurysm sac. The overall perioperative mortality rate was 11% (2 of 19) for immediate explantation and 7% (2 of 27) for late explantation. The average length-of-stay was 11 days for immediate explantation and 14 days for late explantation (NS). Complications included myocardial infarction (4%), pulmonary insufficiency (13%), wound infection (4%), and permanent renal failure (2%). There were no significant differences in the incidence rates of these complications between immediate and late explants. No cases of limb loss occurred. Median American Society of Anesthetists (ASA) classification was 3, and there was no correlation between ASA classification and mortality rate. Average operating time was 374 minutes for immediate explantation (including the time for the failed endovascular procedure) and 185 minutes for late explantation. CONCLUSION: Immediate and late explantation are infrequent events, occurring in 3% and 4%, respectively, of attempted EVT endovascular aortic stent placements. The mortality rate was higher for both immediate (11%; P <.05) and late (7%; NS) explantation when compared with the mortality rate of all patients undergoing EVT aortic endograft placement (1.5%). There does not appear to be increased long-term morbidity among patients undergoing successful explantation. Early recognition of the need to convert to open procedure, device improvement, and increased operator experience should continue to minimize the incidence of immediate and late explantation and their associated complications