Faculty Bibliography

OBJECTIVE: Most studies on outcomes of carotid endarterectomy (CEA) have focused on the major complications of death and stroke. Less is known about minor but more common surgical complications such as hematoma, cranial nerve palsy, and wound infection. This study used data from a large, population-based cohort study to describe the incidence of minor surgical complications after CEA and examine associations between minor and major complications. METHODS: The New York Carotid Artery Surgery (NYCAS) study examined all Medicare beneficiaries who underwent CEA from January 1998 to June 1999 in NY State. Detailed clinical information on preoperative characteristics and complications < or =30 days of surgery was abstracted from hospital charts. Associations between minor (cranial nerve palsies, hematoma, and wound infection) and major complications (death/stroke) were examined with chi(2) tests and multivariate logistic regression. RESULTS: The NYCAS study had data on 9308 CEAs performed by 482 surgeons in 167 hospitals. Overall, 10% of patients had a minor surgical complication (cranial nerve (CN) palsy, 5.5%; hematoma, 5.0%; and wound infection, 0.2%). Cardiac complications occurred in 3.9% (myocardial 1.1%, unstable angina 0.9%, pulmonary edema 2.1%, and ventricular tachycardia 0.8%). In both unadjusted and adjusted analyses, the occurrence of any minor surgical complication, CN palsy alone, or hematoma alone was associated with 3 to 4-fold greater odds of perioperative stroke or combined risk of death and nonfatal stroke (P < 0.0001). Patients with cardiac complications had 4 to 5-fold increased odds of stroke or combined risk of death and stroke. CONCLUSION: Minor surgical complications are common after CEA and are associated with much higher risk of death and stroke. Patient factors, process factors, and direct causality are involved in this relationship, but future work will be needed to better understand their relative contributions

BACKGROUND: Major changes in health care delivery and financing have negatively impacted students' experience during the surgery clerkship, particularly their exposure to physicians' decision-making processes and to the continuity of patient care. In response to these dilemmas in surgical education, we have developed the Web Initiative for Surgical Education (WISE-MD), a comprehensive surgery clerkship curriculum delivered through multimedia teaching modules and designed to enhance exposure to surgical disease and clinical reasoning. METHODS: As part of the process of creating WISE-MD, we conducted preliminary studies to assess the impact of this computer-assisted approach on students' knowledge, clinical reasoning, and satisfaction. RESULTS: Compared to students who did not view the modules, early data show a trend toward improved knowledge and an improvement in clinical reasoning for students who used the WISE-MD modules. This effect was specific to the clinical content area addressed in the module seen by the students. Most students felt the module was superior to traditional teaching methods and enhanced their understanding of surgical technique and anatomy. CONCLUSIONS: WISE-MD, a theory-driven example of a concerted technology-based approach to surgical education, has the potential to address the myriad problems of today's clinical learning environment.

Approval for this HIPAA-compliant study was obtained from the institutional review board; informed consent was not required for retrospective review of patient studies that had been performed for clinical evaluation. The purpose of this study was to retrospectively compare the accuracy of intrastent luminal diameter, as measured on transverse computed tomographic (CT) angiograms and virtual angioscopic views, with the manufacturer's specifications for phantom diameter and with digital subtraction angiographic (DSA) measurements of stent diameter obtained in patients. Intrastent diameter was measured by using standard and stent-optimized reconstruction kernels with three window settings. Endoluminal virtual angioscopic views of the stent-containing vessels were also generated. Measurements at CT angiography were compared with known specifications for the phantom and with DSA measurements in patients. Erroneous measurements of intrastent diameter occurred when a standard kernel and nonoptimized window settings were used. A set of parameters that minimized error relative to measurements obtained at DSA was also identified. Virtual angioscopy helped demonstrate morphologic aspects of stenosis that were otherwise difficult to appreciate

OBJECTIVE: The optimal timing of carotid endarterectomy (CEA) after ipsilateral hemispheric stroke is controversial. Although early studies suggested that an interval of about 6 weeks after a completed stroke was preferred, more recent data have suggested that delaying CEA for this period of time is not necessary. With these issues in mind, we reviewed our experience to examine perioperative outcome with respect to the timing of CEA in previously symptomatic patients. METHODS: A retrospective review of a prospectively maintained database of all CEAs performed at our institution from 1992 to 2003 showed that 2537 CEA were performed, of which 1,158 (45.6%) were in symptomatic patients. Patients who were operated on emergently <or=48 hours of symptoms for crescendo transient ischemic attacks (TIAs) or stroke-in-evolution were excluded from analysis (n = 25). CEA was considered 'early' if performed <or=4 weeks of symptoms, and 'delayed' if performed after a minimum of a 4-week interval following the most recent symptom. RESULTS: Of nonurgent CEAs in symptomatic patients, in 87 instances the exact time interval from symptoms to surgery could not be precisely determined secondary to the remoteness of the symptoms (>18 months), and these were excluded from further analysis. Of the remaining 1,046 cases, 62.7% had TIAs and 37.3% had completed strokes as their indication for surgery. Among the entire cohort, patients who underwent early CEA were significantly more likely to experience a perioperative stroke than patients who underwent delayed CEA (5.1% vs 1.6%, P = .002). Patients with TIAs alone were more likely to be operated on early rather than in a delayed fashion (64.3% vs 46.7%, P < .0001), likely reflecting institutional bias in selecting delayed CEA for stroke patients. However, even when examined as two separate groups, both TIA patients (n = 656) and CVA patients (n = 390) were significantly more likely to experience a perioperative stroke when operated upon early rather than in a delayed fashion (TIA patients, 3.3% vs 0.9%, P = .05; CVA patients, 9.4% vs 2.4%, P = .003). There were no significant differences in demographics or other meaningful variables between patients who underwent early CEA and those who underwent delayed CEA. CONCLUSIONS: In a large institutional experience, patients who underwent CEA <or=4 weeks of ipsilateral TIA or stroke experienced a significantly increased rate of perioperative stroke compared with patients who underwent CEA in a more delayed fashion. This was true for both TIA and stroke patients, although the results were more impressive among stroke patients. On the basis of these results, we continue to recommend that waiting period of 4 weeks be considered in stroke patients who are candidates for CEA

Systemic administration of dexmedetomidine (DEX) decreases cerebral bloodflow (CBF) via direct alpha-2-mediated constriction of cerebral blood vessels and indirectly via its effect on the intrinsic neural pathway modulating vascular smooth muscle. Reduction in CBF without a concomitant decrease in cerebral metabolic rate has raised concerns that DEX may limit adequate cerebral oxygenation of brain tissue in patients with already compromised cerebral circulation (e.g., carotid endarterectomy [CEA]). In this study, we established the incidence of intraarterial shunting used as a sign of inadequate oxygen delivery in a consecutive series of 123 awake CEA performed in our institution using DEX as a primary sedative. Data were prospectively recorded in 151 patients who underwent CEA during the study period. Eighteen patients were sedated with midazolam and fentanyl (M/F) for medical or logistical reasons. Patients thought to be at risk of an intraoperative stroke were treated with a prophylactic intraarterial shunt. These patients, as well as those who required general anesthesia, were excluded from the final analysis. Five patients (4.3%) in the DEX group required intraarterial shunts. The incidence of shunting in patient undergoing awake CEA in our institution is 10% (historical control). No patients developed a stroke or other serious complications. It appears that the use of DEX as a primary sedative drug for CEA does not increase the incidence of intraarterial shunts

BACKGROUND: Physician communication skills, linked to important patient outcomes, are rarely formally addressed after the pre-clinical years of medical school. We implemented a new communication skills curriculum during the third year Surgery Clerkship which was part of a larger curriculum revision found in a controlled trial to significantly improve students' overall communication competence. DESCRIPTION: In three 2 hour workshops students, learned to address common communication challenges in surgery: patient education, shared decision-making, and delivering bad news. Each 2 hour, surgeon facilitated session was comprised of a 30 minute introductory lecture, a 15 minute checklist driven video critique, a 15 minute group discussion, a 45 minute standardized patient (SP) exercise with feedback from the SP, peers, and faculty member, and a 15 minute closing summary. To date, over 25 surgery faculty have been trained to conduct these sessions. In an end-of-clerkship survey, students reported on skill changes and assessed the curriculum's educational effectiveness. EVALUATION: A survey was completed by 120 of the 160 (76%) third year students who participated in the curriculum. Fifty-five percent of students reported improvement in their communication skills and ability to address specific communication challenges. Students were satisfied with the amount and quality of teaching. CONCLUSIONS: Communication skills teaching can be implemented in the surgery clerkship, and surgeons are particularly well suited to teach about patient education, discussing informed consent and shared decision making, and delivering bad news. Structured case-based sessions are acceptable to, and improve the self-assessed skills of, surgery clerkship students. Faculty development geared toward such sessions has added benefits to educational activities in a clinical department overall.

INTRODUCTION: Arterial endarterectomy and reconstruction during carotid endarterectomy (CEA) can be performed in a variety of ways, including standard endarterectomy with primary closure, standard endarterectomy with patch angioplasty, and eversion endarterectomy. The optimal method of arterial reconstruction remains a matter of controversy. The objective of this study was to determine the effect of the method of arterial reconstruction during CEA on perioperative outcome. METHODS: A retrospective cohort study of consecutive CEAs performed by 81 surgeons during 1997 and 1998 in six regional hospitals was performed. Detailed clinical data regarding each case and all deaths and nonfatal strokes within 30 days of surgery were ascertained by an independent review of the inpatient chart, outpatient surgeon record, and the hospitals' administrative databases. Two physician investigators--one neurologist and one internist--confirmed each adverse event by independently reviewing patients' medical records. RESULTS: A total of 1972 CEAs were performed. The mean age of the patients was 72.3 years, and 57.2% were male. Preoperative neurologic symptoms occurred in 28.7% of cases (n = 566), and the remaining 71.3% were asymptomatic before surgery (n = 1406). The method of arterial reconstruction was chosen by the surgeon. Primary closure was performed in 11.8% (n = 233), patch angioplasty in 69.8% (n = 1377), and eversion endarterectomy in 18.4% (n = 362). There was no significant difference in the preoperative symptom status of patients who underwent primary closure compared with the other methods of reconstruction (72.5% asymptomatic vs 71.1%, p = NS). Primary closure cases were significantly more likely to experience perioperative stroke compared with the other closure techniques (5.6% vs 2.2%, P = .006). Primary closure cases also had a higher incidence of perioperative stroke or death compared with the other closure techniques (6.0% vs 2.5%, P = .006). There were no significant differences with regard to either perioperative stroke, or perioperative stroke/death noted when comparing patch angioplasty with eversion endarterectomy: stroke, 2.2% vs 2.5% (P = NS) and stroke/death, 2.5% vs 2.5% (P = NS) respectively. CONCLUSION: It appears that primary closure is associated with significantly worse perioperative outcomes compared with endarterectomy with patch angioplasty and eversion endarterectomy, even when the preoperative symptom status of the patient cohorts is equivalent. Although some of its advocates have reported that they can properly select appropriate patients for primary closure based on the size of the artery and other factors, the data demonstrate that these patients have poorer outcomes nonetheless. Primary closure during carotid endarterectomy should predominantly be abandoned in favor of either standard endarterectomy with patch angioplasty or eversion endarterectomy

Objective We compared the physiologic effect of selective atropine administration for bradycardia with routine prophylactic administration, before balloon inflation, during carotid angioplasty and stenting (CAS). We also compared the incidence of procedural bradycardia and hypotension for CAS in patients with primary stenosis vs those with prior ipsilateral carotid endarterectomy (CEA). Methods A total of 86 patients were treated with CAS at 3 institutions. Complete periprocedural information was available for 75 of these patients. The median degree of stenosis was 90% (range, 60%-99%). Indications for CAS were severe comorbidities (n = 49), prior CEA (n = 21), and prior neck radiation (n = 5). Twenty patients with primary lesions were treated selectively with atropine only if symptomatic bradycardia occurred (nonprophylactic group). Thirty-four patients with primary lesions received routine prophylactic atropine administration before balloon inflation or stent deployment (prophylactic group). The 21 patients with prior CEA received selective atropine treatment only if symptomatic bradycardia occurred (prior CEA group) and were analyzed separately. Mean age and cardiac comorbidities did not vary significantly either between the prophylactic and nonprophylactic atropine groups or between the primary and prior CEA patient groups. Outcome measures included bradycardia (decrease in heart rate >50% or absolute heart rate <40 bpm), hypotension (systolic blood pressure <90 mm Hg or mean blood pressure <50 mm Hg), requirement for vasopressors, and cardiac morbidity (myocardial infarction or congestive heart failure). Results The overall incidence of hypotension and bradycardia in patients treated with CAS was 25 (33%) of 75. A decreased incidence of intraoperative bradycardia (9% vs 50%; P < .001) and perioperative cardiac morbidity (0% vs 15%; P < .05) was observed in patients with primary stenosis who received prophylactic atropine as compared with patients who did not receive prophylactic atropine. CAS after prior CEA was associated with a significantly lower incidence of perioperative bradycardia (10% vs 33%; P < .05), hypotension (5% vs 32%; P < .05), and vasopressor requirement (5% vs 30%; P < .05), with a trend toward a lower incidence of cardiac morbidity (0% vs 6%; not significant) as compared with patients treated with CAS for primary carotid lesions. There were no significant predictive demographic factors for bradycardia and hypotension after CAS. Conclusions The administration of prophylactic atropine before balloon inflation during CAS decreases the incidence of intraoperative bradycardia and cardiac morbidity in primary CAS patients. Periprocedural bradycardia, hypotension, and the need for vasopressors occur more frequently with primary CAS than with redo CAS procedures. On the basis of our data, we recommend that prophylactic atropine administration be considered in patients with primary carotid lesions undergoing CAS

Endovascular intervention can provide an alternative method of treatment for visceral artery aneurysms. We conducted a retrospective review of all patients with visceral artery aneurysms at a single university medical center from 1990 to 2003, focusing on the outcome of endovascular therapy. Sixty-five patients with visceral artery aneurysms were identified: 39 splenic (SAA), 13 renal, seven celiac, three superior mesenteric (SMA), and three hepatic. Eleven patients (16.9%) had symptoms attributable to their aneurysms, which included a total of four ruptures (6.2%): three splenic and one hepatic. Management consisted of 18 (27.7%) endovascular interventions, nine (13.9%) open surgical repairs, and 38 (58.5%) observations. Mean aneurysm diameter for patients treated expectantly was significantly less than for those who underwent intervention (p = 0.001). Endovascular interventions included 15 (83.3%) embolizations (11 SAA, three renal, one hepatic) and three (16.7%) stent grafts (two SMA, one renal). The initial technical success rate of the endovascular procedures was 94.4% (17/18). However, there were four patients (22.2%) with major endovascular procedure-related complications: one late recurrence requiring open surgical repair, two large symptomatic splenic infarcts, and one episode of severe pancreatitis. These four patients had distal splenic artery aneurysms at or adjacent to the splenic hilum. There were no endovascular procedure-related deaths. Reasons for performing open surgical repair included three SAA ruptures diagnosed at laparotomy and complex anatomy not amenable to endovascular intervention (six patients). One surgical patient had a postoperative small bowel obstruction treated nonoperatively; and there was one perioperative death in a patient operated on emergently for rupture. Endovascular management of visceral artery aneurysms is a reasonable alternative to open surgical repair in carefully selected patients. Individual anatomic considerations play an important role in determining the best treatment strategy if intervention is warranted. However, four of 11 (36.4%) patients with distal splenic artery aneurysms treated with endovascular embolization developed major complications. Based on our experience, traditional surgical treatment of SAA with repair or ligation and concomitant splenectomy when necessary may be preferred in these cases