Faculty Bibliography

In this case report, we present a 45-year-old man who experienced abdominal pain while bench-pressing heavy weights. A computed tomography angiogram showed a dissection of the celiac artery extending into the hepatic and splenic arteries, with thrombus in the false lumen into the common hepatic artery. With resolution of his symptoms, he was discharged after several days of warfarin and metoprolol therapy. To our knowledge, this is the first reported case of a dissection of the celiac artery and its branches caused by weight lifting

BACKGROUND: Abdominal aortic aneurysm (AAA) disease is an insidious condition with an 85% chance of death after rupture. Ultrasound screening can reduce mortality, but its use is advocated only for a limited subset of the population at risk. METHODS: We used data from a retrospective cohort of 3.1 million patients who completed a medical and lifestyle questionnaire and were evaluated by ultrasound imaging for the presence of AAA by Life Line Screening in 2003 to 2008. Risk factors associated with AAA were identified using multivariable logistic regression analysis. RESULTS: We observed a positive association with increasing years of smoking and cigarettes smoked and a negative association with smoking cessation. Excess weight was associated with increased risk, whereas exercise and consumption of nuts, vegetables, and fruits were associated with reduced risk. Blacks, Hispanics, and Asians had lower risk of AAA than whites and Native Americans. Well-known risk factors were reaffirmed, including male gender, age, family history, and cardiovascular disease. A predictive scoring system was created that identifies aneurysms more efficiently than current criteria and includes women, nonsmokers, and individuals aged <65 years. Using this model on national statistics of risk factors prevalence, we estimated 1.1 million AAAs in the United States, of which 569,000 are among women, nonsmokers, and individuals aged <65 years. CONCLUSIONS: Smoking cessation and a healthy lifestyle are associated with lower risk of AAA. We estimated that about half of the patients with AAA disease are not eligible for screening under current guidelines. We have created a high-yield screening algorithm that expands the target population for screening by including at-risk individuals not identified with existing screening criteria.

Despite randomized controlled trials demonstrating the superiority of carotid endarterectomy over medical management in the prevention of stroke in asymptomatic patients with severe carotid artery stenosis, considerable controversy remains with regard to selecting the appropriate asymptomatic patient for carotid intervention. Adding to the complexity of this issue is the fact that the extensive existing literature on this topic is heterogeneous, with trials having used varying definitions of high-grade stenosis, inclusion criteria for patients, and outcome measurements. The current article will review the existing randomized controlled trials on this topic, data regarding the risk of stroke in asymptomatic patients with severe stenosis, data regarding subsets of asymptomatic patients that may be at a higher-than-average risk of future stroke, and data regarding the efficacy of current medical therapy on the risk of stroke in asymptomatic patients with high-grade stenosis. Ultimately, the challenge for clinicians is to ensure that asymptomatic patients with the highest risk of future stroke are offered carotid revascularization and that the intervention is performed with the lowest possible complication rate, in order to maintain the benefit of prophylactic treatment

OBJECTIVE: Prophylactic atropine traditionally has been used to prevent CAS-associated hemodynamic depression. Glycopyrrolate may serve as an alternative with decreased cardiac effects. This study aims to compare the efficacy of prophylactic glycopyrrolate to atropine in preventing CAS-induced hemodynamic instability and cardiac complications. METHODS: 115 consecutive CAS patients from 2004-2010 were evaluated. Primary endpoints were stroke, MI, bradycardia (HR<60 beats/min), and hypotension (systolic BP <90 mm Hg). Additional outcomes included tachycardia (HR >100 beats/min), hypertension (systolic BP >160 mm Hg), pre- and postoperative systolic BP difference, vasopressor use, arrhythmias, cardiac enzyme elevations, and access site complications. RESULTS: Of 115 patients, 65 (56.5%) patients who received atropine or glycopyrrolate prior to CAS were analyzed [40 (61.5%) patients received glycopyrrolate, 25 (38.5%) received atropine]. Mean age was 70.0 +/- 8.5 years (range, 48-86 years). Mean stenosis was 86.2 +/- 7.4% (range, 70-99%). No MI, major stroke, or death was observed in the 30-day postoperative period. Baseline systolic BP and HR were equivalent between groups. Postoperative bradycardia and hypotension were significantly lower in glycopyrrolate patients compared with atropine patients (30% vs 72%, P = .002; 2.5% vs 36%, P < .001, respectively). Postoperative hypertension was also significantly lower in the glycopyrrolate cohort (2.5% vs 16%, P = .047), whereas tachycardia, pressure changes, vasopressor use, and cardiac complications did not differ significantly. No significant differences in neurologic and access site complications were observed. CONCLUSIONS: Prophylactic glycopyrrolate, compared with atropine, reduces hemodynamic instability during CAS. The authors recommend glycopyrrolate use to prevent CAS-induced bradycardia and hypotension

OBJECTIVE: With the decline of diagnostic angiography, clinicians increasingly rely upon duplex scan criteria to select appropriate asymptomatic candidates for carotid intervention. Some recent trials have enrolled patients for intervention based upon end diastolic velocities (EDVs) as low as 100 cm/second, and peak systolic velocities (PSVs) as low as 230 cm/second. In as much as we have used more selective duplex scan criteria, we reviewed the course of asymptomatic patients who had EDVs from 100 to 124 cm/second. METHODS: Of the patients evaluated in our Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) accredited laboratory from 2002 to 2007, 144 patients had an EDV 100 to 124 cm/second. Of these, 47 patients underwent initial carotid intervention for concomitant symptoms (10), contralateral occlusion (3), or other imaging findings felt to warrant intervention. The remaining 97 asymptomatic patients were followed. One patient had both arteries fall within this EDV range. The mean follow-up for the 98 arteries was 29.1 months (range, 2-116 months). RESULTS: Five patients (5.2%) developed ipsilateral symptoms consisting of one stroke and four transient ischemic attacks (TIAs), at a mean time of 35.3 months (range, 12-58 months). Twenty-six patients (26.8%), including 3 who also developed ipsilateral symptoms, progressed to having an EDV of >/= 125 cm/second at a mean time of 24 months (range, 2-58). Two of these (2.1%) progressed directly to occlusion without symptoms and with no documented interim worsening of stenosis. CONCLUSION: For asymptomatic individuals with an initial EDV of 100 to 124 cm/second, the risk of ipsilateral stroke is small and, therefore, medical management is appropriate in most cases. However, the risk of progression to a more severe degree of stenosis, often warranting carotid intervention, is clinically meaningful. Yearly duplex scan follow-up is necessary to assess disease progression in this patient cohort