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Neurofibromatosis is characterized by its cutaneous manifestations. It also is manifested by arterial lesions commonly found in arterioles and small arteries but rarely in large arteries. We present a patient with type I neurofibromatosis with spontaneous rupture of his abdominal aorta. He was found at the time of emergency laparotomy to have direct compression of his aorta by retroperitoneal neurofibromas and abnormal aortic structural wall integrity.

BACKGROUND:A coil in the internal carotid artery (ICA), defined as a circular configuration or exaggerated S shape of the ICA, is occasionally encountered during endarterectomy for carotid bifurcation lesions. The significance of coils as an etiology for symptoms is difficult to determine. It is thought, however, that the failure to correct coils and kinks during routine carotid endarterectomy (CE) may lead to turbulence and failure of the CE. Various techniques have been discussed to repair coils. METHODS:Our technique consisted of complete dissection of the coil, routine use of a Javid shunt, standard endarterectomy, resection of the redundant ICA, re-approximation of the posterior wall of the ICA and patch angioplasty of the anterior wall. Three hundred and fifteen patients underwent CE between August, 1998 and February, 2000. Fifteen patients (4.7%) had a carotid coil that was repaired. There were ten men and five women. Mean age was 72.6+/-6.1 years. Ten patients had an asymptomatic stenosis. Four patients had lateralizing symptoms and one patient had dizziness. Fifteen patients underwent preoperative duplex scanning and 14 of these patients had MRA scans performed. All patients had a preoperative stenosis of 80-99% by duplex on the operated side. The right carotid artery was repaired in 12 patients. The left in three patients. The length of resected artery varied from 1.2-2.8 cm (1.93+/-0.49 cm). RESULTS:All patients survived surgery. One patient developed a cerebellar stroke on the third postoperative day. A postoperative carotid duplex scan demonstrated a widely patent repair. There were no cranial nerve injuries in this series. One patient died seven months after surgery from cardiac events with no follow-up duplex exam. There have been no long term strokes or anastomotic complications. Follow-up duplex scans demonstrated widely patent repairs (1-15% stenosis) in seven patients and low end 15-49% stenosis in five patients. CONCLUSIONS:Resection of redundant ICA with re-anastomosis of the posterior wall and patch reconstruction of the anterior wall gives acceptable perioperative and long term results.

Renal artery stenosis has long been recognized as a cause of systemic hypertension, and has more recently been identified as a cause of progressive renal insufficiency. The diagnosis of renal artery stenosis often has been overlooked because of the difficulty in establishing the diagnosis. Until recently, surgical intervention has been the only therapeutic modality available. This article will review some recent advances in imaging modalities, particularly duplex ultrasound and magnetic resonance angiography, which have allowed easier visibility of the renal vessels. Second, the introduction of renal percutaneous transluminal angioplasty, with and without stent placement, has made operative intervention more attractive. The early and short-term results of this procedure are discussed and compared with surgical experience. Finally, the implications for using these newer interventional techniques for minimally symptomatic renal artery stenosis are reviewed.

BACKGROUND:The value of carotid patching in carotid endarterectomy in achieving low perioperative morbidity and long-term freedom from restenosis is controversial. We hypothesized that if large internal carotid arteries were closed primarily and smaller arteries selectively patched, there would be no difference in early or long-term results between the two groups. METHODS:A retrospective analysis of 133 carotid endarterectomies performed by one surgeon in a community teaching hospital was performed to evaluate a selective approach to patching vs primary closure. Primary closure was performed if the arteriotomy could be closed without tension over a Javid shunt. Seventy-seven arteries underwent primary closure and 56 underwent patching (Vein-14, PTFE-17, Dacron-25). Postoperative (>6 month) duplex scans were available on 46/77 (60%) patients undergoing primary closure, and 33/56 (59%) of patients with patch repair. RESULTS:There were 2 perioperative neurologic deficits, both in the patch group. Restenosis of equal or greater than 50% at 11 months occurred in 5/46 (10.8%) of patients with primary closure and 2/34 patients (5.9%) with patch closure (p=ns). No patient in either group had a late neurologic event or required a redo operation. CONCLUSIONS:Selective primary closure is not associated with increased risk of perioperative neurologic events or statistically significant evidence of late postoperative stenosis if primary closure is performed in large internal carotid arteries.

Splenic vein aneurysms are rare and are usually caused by portal hypertension. Symptoms are unusual, but may include rupture or abdominal pain. Diagnosis can usually be made either by means of duplex ultrasonography or computed tomography scanning. Treatment varies from noninvasive follow-up to aneurysm excision. We report an expanding splenic vein aneurysm in a young woman with abdominal and back pain and no history of portal hypertension. She was treated with aneurysm excision and splenectomy.

Twenty-four patients who underwent surgery for pararenal aortic aneurysms between January 1992 and April 1997 are reviewed. Eighteen patients had primary atherosclerotic aneurysms, three patients had symptomatic infected aneurysms, two patients had an aneurysm proximal to a prior aortic repair, and one patient had a pseudoaneurysm of a proximal aortic graft anastomosis. Thirteen patients underwent elective operation, five had an urgent operation, and six patients underwent an emergency procedure. Five patients had the proximal aortic clamp placed between the renal arteries (Group I), three patients had it placed between the superior mesenteric and the renal arteries (Group II), and 16 patients had it placed in a supraceliac location (Group III). Aneurysm size, age, sex, preoperative blood chemistries (including hemoglobin, hematocrit, liver function studies, and coagulation studies) were similar in all groups. Two patients in Group III were on hemodialysis preoperatively. Preoperative renal function (blood urea nitrogen and creatinine) was the same in all groups. Visceral ischemic time was 43.4 +/- 9.37 min to the distal kidney in Group I, 26.6 +/- 7.63 min in Group II, and 24.5 +/- 6.22 min in Group III. Mean transfusion requirements were similar in all groups. Two patients in Group I required postoperative hemodialysis. No patient in either Group II or III developed renal insufficiency. Mortality was the same in each group but was related to the urgency of operation (elective 7.6%, urgent 40%, emergent 50%). Intrarenal clamping (Group I) was associated with more renal and gastrointestinal complications than either suprarenal or supraceliac clamping. Although suprarenal and supraceliac clamping had similar results, our preference is supraceliac clamping because it is technically easy to achieve and is associated with few end-organ complications.

The etiology of perioperative stroke in patients undergoing isolated coronary artery bypass grafting (CABG) is multifactorial. One significant cause is thought to be high-grade internal carotid artery stenosis. Between April 1992 and June 1995, 1686 patients undergoing isolated CABG underwent preoperative carotid duplex scanning. This represented 77% of patients who underwent CABG during that time period (2188 patients). Sixty-eight patients (4.0%) had 80%-99% stenosis of at least one carotid artery. Fifteen patients underwent CABG without carotid intervention (Group I) and 53 patients underwent either carotid endarterectomy prior to CABG or simultaneous with CABG (Group II). Age, sex, history of prior neurologic events, ejection fraction, number of distal bypasses performed, total pump time, and aortic cross clamp times were similar between the two groups. Three patients in Group I developed a permanent postoperative neurologic deficit (20%) and one patient developed a transient deficit. The defect was focal and ipsilateral to high-grade stenosis in three patients and global in one. No patient in Group II developed either a transient or permanent neurologic deficit. There was one death in Group I in the patient who developed a global neurologic deficit and one death in Group II 2 weeks after CABG in a patient who had undergone prophylactic preCABG-carotid endarterectomy. Statistical analysis (Fisher's exact test, 2-tail) demonstrated a significant decrease both in total neurologic events (p = 0.001) and permanent neurologic defects (p = 0.005) in those patient undergoing prophylactic CE (Group II). Patients with 80%-99% carotid stenosis undergoing CEA prior to or in conjunction with isolated CABG have a decreased incidence of neurologic events postoperatively.