Faculty Bibliography

In order to maximize the efficacy of carotid endarterectomy (CEA), the rate of perioperative stroke must be kept to a minimum. A recent analysis of carotid surgery at our institution found that most perioperative strokes were due to technical errors resulting in thrombosis or embolization. From 1992 through 1997 we have performed nearly 1200 additional CEAs; the purpose of this study was to examine recent trends in the causes of perioperative stroke, with specific attention to differences in symptomatic and asymptomatic patients. The records of 1041 patients undergoing 1165 CEAs were reviewed from a prospectively compiled database. Analysis of these data showed that a history of preoperative stroke appears to increase the risk of perioperative stroke after CEA. Surgical factors associated with perioperative stroke include an inability to tolerate clamping, use of an intraarterial shunt, and having surgery performed under general anesthesia; these factors are clearly interrelated and only the use of intraarterial shunting remains a risk factor by multivariate analysis. Over half of all perioperative strokes (54%) appear to be caused by intraoperative or postoperative thrombosis and embolization. The patient requiring use of intraarterial shunting and/or with a preoperative stroke most likely has a significant watershed area of brain at increased risk of infarction. However, technical errors are still the most common cause of perioperative stroke in these high-risk patients. Such high-risk patients may manifest clinical stroke from small emboli that may be tolerated by asymptomatic clamp-tolerant patients. Technical precision and appropriate cerebral protection are particularly critical for successful outcomes in high-risk patients

OBJECTIVES: Although the results of the Asymptomatic Carotid Atherosclerosis Study clearly demonstrated the benefit of surgical over medical management of severe carotid artery stenosis, the results for women in particular were less certain. This was to some extent because of the higher perioperative complication rate observed in the 281 women (3.6% vs 1.7% in men). The objective of this study was to review a large experience with carotid endarterectomy in female patients and to determine whether the perioperative results differed from those of male patients. METHODS: A review was conducted of a prospectively compiled database on all carotid endarterectomies performed between 1982 and 1997. Operations performed in 991 female patients were compared with those performed in 1485 male patients. RESULTS: Female patients had a significantly lower incidence of diabetes, coronary artery disease, and contralateral carotid artery occlusion than did male patients. Female patients had a significantly higher incidence of hypertension. There were no significant differences in the age, smoking history, anesthetic route, shunt use, or clamp tolerance between the two groups. Of 991 female patients, 659 (66.5%) had preoperative symptoms, whereas 332 (33.5%) cases were performed for asymptomatic stenosis. Among 1485 male patients, 1041 (70.1%) had symptoms, and 444 (29.9%) were symptom free before surgery. There were no significant differences noted in the perioperative stroke rates between men and women overall (2.3% vs 2.4%, P =.92), or when divided into symptomatic (2.5% vs 3.0%, P =.52) and asymptomatic (2.0% vs 1.2%, P =.55) cases. CONCLUSIONS: Carotid endarterectomy can be performed with equally low perioperative stroke rates in men and women in both symptomatic and asymptomatic cases. In this series, symptom-free female patients had the lowest overall stroke rate. The concerns of the Asymptomatic Carotid Atherosclerosis Study regarding the benefit of carotid endarterectomy in female patients should therefore not prevent clinicians from recommending and performing carotid endarterectomy in appropriately selected symptom-free female patients

OBJECTIVES: Vascular malformations of the pelvis are rare and present a difficult therapeutic challenge. Surgical treatment is notoriously difficult and carries a high likelihood of recurrence. Surgical proximal ligation of a feeding vessel may in fact be contraindicated, because it can make subsequent transcatheter therapy impossible. The purpose of this study was to review our results with transcatheter embolization therapy in symptomatic complex pelvic vascular malformations in 35 patients. METHODS: A retrospective review was conducted of a prospectively compiled database of all patients undergoing transcatheter therapy of a pelvic vascular malformation at our institution. RESULTS: The mean age of the patients was 34 years (range, 16 months-66 years), and 51% were male. The most common presenting symptoms included pain (59%), a visible or palpable lesion (62%), associated palpable pulsation or thrill (44%), hemorrhage (27%), congestive heart failure (18%), and symptoms due to mass effect (35%). A significant number of patients had undergone previous, unsuccessful attempted surgical treatment of the lesion (32%). The most common type of lesion noted on arteriography was arteriovenous shunting (89%). Patients required a mean of 2.4 embolization procedures (range, 1-11 procedures) over a mean period of 23.3 months (range, 1-144 months). The most common agents used were rapidly polymerizing acrylic adhesives. The most common vessels involved and treated were branches of the hypogastric artery (82%). More than one procedure were performed in 20 patients (53%). Seven were planned as staged embolizations, whereas 13 were due to residual or recurrent symptoms. Adjunctive surgical procedures were performed subsequent to embolization therapy in five patients (15%). Eighty-three percent of patients were asymptomatic or significantly improved at a mean follow-up of 84 months (range, 1-204 months). CONCLUSIONS: Pelvic vascular malformations are difficult to eradicate completely, and recurrences are common. Many patients require multiple therapeutic interventions. However, most of these difficult cases have good results in the long term. Transcatheter embolization plays a significant role in, and may be the treatment of choice for, symptomatic pelvic vascular malformations

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

Transesophageal echocardiography (TEE) is the procedure of choice for identifying aortic atheromas, which may result in stroke, transient ischemic attack and peripheral embolization. However, because of anatomic constraints, the innominate artery may not be visualized. We investigated gadolinium-enhanced MR angiography (MRA) as an alternative technique for evaluation of suspected atheromas of the innominate artery. From a retrospective review of 520 examinations, we identified five patients who had innominate artery atheromas diagnosed prospectively with gadolinium-enhanced MRA who also underwent TEE within 1 month. A total of 10 innominate artery atheromas were demonstrated on MRA; none of these were visualized on TEE. One patient had three atheromas, two patients had two atheromas and three patients had one atheroma. They ranged in size from 3 mm to 1.5 cm (mean 6.5 mm). One atheroma was flat, two were filiform, and seven were protruding. Gadolinium-enhanced MRA is superior to TEE for the diagnosis of atheromas of the innominate artery. In the setting of right cerebral or right arm embolization, when no source is seen in the arch on TEE, gadolinium-enhanced MRA should be considered

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

The purpose of this study was to review a single-institution experience with the Endovascular Technologies [(EVT) Menlo Park, CA] transfemoral, endovascular system of abdominal aortic aneurysm repair. This study was performed at a medical center participating in the phase 1 and phase 2 evaluations of the EVT device. We reviewed the 25 cases performed at our institution. The patient population consisted of 21 males (84%) and 4 females (16%), with a mean age of 73.4 years. A total of eight tube grafts (32%) and 17 bifurcated grafts (68%) were attempted. Twenty-two of the twenty-five grafts were successfully implanted endovascularly (88%). Implantation failures were due to tortuosity or inadequate caliber of the iliac arteries, or incorrect positioning of the graft. The results show that endovascular repair of abdominal aortic aneurysms is an appropriate treatment for selected patients. Conversions to open repair have decreased as experience has grown; careful patient selection can minimize the number of unsuccessful implantations. Patient selection and accurate technique can also minimize the number of endoleaks

OBJECTIVE: The ideal method of arterial reconstruction in operations for recurrent carotid disease after prior endarterectomy is unknown. The goal of this study was to review a series of carotid reoperations and to determine whether the surgical technique influenced the rate of perioperative stroke, late stroke, or secondary restenosis. METHODS: A retrospective review was conducted of 82 carotid reoperations performed on 74 patients at our institution. RESULTS: The patient population included 39 men (52.7%) and 35 women (47.3%), with a mean age of 67.5 years. The indications for redo surgery included transient ischemic attack or amaurosis fugax in 35.3% of the patients, stroke in 6.1%, and asymptomatic restenosis (>80%) in 58.5%. Patch angioplasty with or without redo endarterectomy was used in 47 cases (57.3%), with saphenous vein in 26 (31.7%), Dacron in 15 (18.3%), and polytetrafluoroethylene in 6 (7.3%). Interposition grafting was used in 35 cases (42.7%), with saphenous vein in 9 (11.0%), Dacron in 10 (12.2%), and polytetrafluoroethylene in 16 (19.5%). The perioperative complications included three strokes (3.7%). There was a trend toward increased perioperative neurologic complications with interposition grafting when compared with patch angioplasty (8.6% vs 2.1%), although this did not reach statistical significance. Long-term clinical follow-up was obtained in all cases with a mean duration of 35 months, with follow-up duplex scanning performed in 89.2%. The late failures of redo surgery included four significant secondary restenoses and five total occlusions. There was a trend towards improved long-term results with interposition grafting as opposed to patch angioplasty. However, the cases in which reconstruction was performed with a vein had a significantly higher rate of late failures (stroke, secondary recurrent stenosis, or occlusion) than those in which reconstruction was performed with any prosthetic material (26.7% vs 2.3%; P =.002 by Fisher exact test). CONCLUSION: The use of autologous material for redo carotid surgery in any configuration appears to significantly increase the rate of subsequent recurrent stenosis or total occlusion of the operated artery. The reason for this finding is unclear but may be related to both host and technical factors. Prosthetic material may be more durable in the long-term for redo carotid surgery. Interposition grafting for redo carotid surgery may increase the perioperative neurologic complication rate to some degree; however, this was not statistically significant in this series. Interposition grafting may be a more durable solution in long-term follow-up than redo endarterectomy and patch angioplasty. A longer follow-up period will be needed to confirm this conclusion