Faculty Bibliography

According to the 2011, as well as the 2014 updated American Heart Association/American Stroke Association Guidelines, carotid artery stenting (CAS) is indicated as an alternative to carotid endarterectomy (CEA) for the management of symptomatic carotid patients. According to these recommendations, CAS is preferred over CEA in symptomatic patients with specific technical, anatomic or physiologic characteristics that render these individuals at "high risk" for surgery (e.g. contralateral carotid occlusion, previous neck irradiation, recurrent carotid stenosis, etc.). This article will present emerging data suggesting that most of these criteria do not comprise contraindications for CEA. In fact, CEA is associated with similar (or even better) outcomes compared with CAS in many such "high-risk" patients. Based on these results, the indications of CAS in symptomatic patients may need to be reconsidered.

We report the case of a 78-year-old man with coronary artery disease, chronic obstructive pulmonary disease, and chronic renal insufficiency with an enlarging 6.7-cm infrarenal abdominal aortic aneurysm. He also had a 4-cm right common iliac artery aneurysm, and right external iliac artery occlusion. The patient had a history of an axillobifemoral bypass graft placed 10 years prior for aortoiliac occlusive disease. We describe the use of an infrarenal aorto-uni-iliac graft and subsequent intentional graft occlusion as an endovascular solution to treat aneurysmal disease in this sick patient. He remains asymptomatic after surgery, with demonstrated occlusion of his aneurysms.

A 45-year old female referred for a large carotid body tumor resection. The tumor was encasing the internal (ICA) and external carotid arteries (ECA). She underwent angiogram and embolization of the ascending pharyngeal artery and a distal branch of the ECA using ethylene vinyl-alcohol copolymer (EVOH). Two days later, surgical resection of the tumor with regional lymph node dissection was performed along with an interposition reversed vein graft anastomosis between the mid common carotid and distal ICA. Devascularization of carotid body tumor can be performed using EVOH delivered through trans-arterial and percutaneous routes. Embolization may facilitate surgical resection and decrease blood loss but does not decrease the rate of neurological complications. Embolization can be performed by the vascular surgeon before a large carotid body tumor resection with minimal migration and or stroke risk.

PURPOSE OF REVIEW: The most common and significant morbidity and mortality of vascular surgical procedures remain coronary artery disease, arrhythmia, and heart failure. Cardiac evaluation and medical optimization provide the groundwork for best medical practice in an otherwise high-risk surgical population. The goal of this study is to review the most current literature and guidelines for evaluating patients prior to vascular surgical interventions. From this, we have made our own recommendations regarding both the preoperative and perioperative management of vascular surgical patients. RECENT FINDINGS: Risk stratification using a modified Lee index may be best to assess perioperative cardiac risk. Coronary revascularization should be reserved for those patients with significant coronary disease irrespective of symptoms. beta-blockers, statins, and antiplatelet agents should be considered for all patients with peripheral vascular disease. SUMMARY: The preoperative management of vascular surgical patients requires a complete understanding of the patient's medical history as it relates to their perioperative cardiac risk. Overwhelming data support the use of medical therapy as adjunct to minimize or prevent the risk of future cardiovascular events. As vascular surgery transitions to the outpatient setting, further studies will be required to better elucidate cardiac evaluation in this patient population.