Alex D. Ammar

Intraplaque hemorrhage: Its significance in cerebrovascular disease

Recently, carotid plaque factors, specifically intraplaque hemorrhage, have been studied with respect to the production of cerebrovascular symptoms. Ninety-five carotid endarterectomies were performed and the plaques that were removed were examined for intraplaque hemorrhage. Patients were separated into three groups: those with specific neurologic symptoms, those with nonlateralizing symptoms, and those who were asymptomatic. In the group of patients who presented with specific neurologic symptoms, correlation was made between the age of the intraplaque hemorrhage and the timing of symptoms. The vast majority of patients with specific neurologic symptoms exhibited carotid plaque hemorrhage, but patients with nonlateralizing symptoms and those who were asymptomatic also demonstrated an unexpectedly high percentage of intraplaque hemorrhage. Moreover, our results show a poor relationship between the timing of symptoms and the age of the intraplaque hemorrhage. These data do not refute the concept that intraplaque hemorrhage may play a role in the production of cerebrovascular symptoms, but they do refute the notion that the mere presence of hemorrhage causes specific neurologic symptoms and they also refute the previous report that demonstrates a good correlation between the timing of symptoms and the age of the intraplaque hemorrhage.

Should the Cell Saver Autotransfusion Device be used routinely in all infrarenal abdominal aortic bypass operations

PURPOSE The purpose of this study was to attempt to identify a group of patients undergoing infrarenal aortic bypass in whom blood loss is consistently less than 2 units, making the routine use of autotransfusion devices unnecessary. METHODS Four groups of patients were prospectively studied as follows: abdominal aortic aneurysm (AAA) repair with tube graft (n = 21), AAA repair with bifemoral or biiliac bypass (n = 19), and aortobifemoral bypass (AFB) or biiliac bypass for occlusive disease either with Cell Saver Autotransfusion Device (Haemonetics Corp., Braintree, Mass.) (n = 18) or without Cell Saver (n = 18). The latter two groups were randomized on an alternating basis. RESULTS The following parameters were obtained on all patients: preoperative hemoglobin values, estimated blood loss, Cell Saver return volumes, intraoperative and postoperative homologous blood transfused, postoperative hemoglobin values on the day of surgery and on postoperative days 1 and 4, complications, and length of hospital stay. In comparing the groups undergoing AFB with Cell Saver and AFB without Cell Saver by the above parameters, we found no statistically significant differences, except for a higher hemoglobin level on postoperative day 1 in the group undergoing AFB with Cell Saver (mean 11.86 vs 10.74, p = 0.02). The estimated blood loss and Cell Saver return volumes were less for those patients undergoing AFB for occlusive disease compared with those undergoing AFB for aneurysmal disease. Interestingly, estimated blood loss and Cell Saver return volumes for patients with AAA with tube graft and patients undergoing AFB with Cell Saver were similar. CONCLUSIONS We conclude that routine setup and use of rapid autotransfusion devices may not be necessary in every patient undergoing routine aortofemoral bypass for occlusive disease. Furthermore, the possibility that some patients may undergo AAA repair with tube grafts without use of the Cell Saver may be deserving of further investigation.

Operative Volume in the New Era: A Comparison of Resident Operative Volume Before and After Implementation of 80-Hour Work Week Restrictions

OBJECTIVE To determine the effect of the 80-hour work week restrictions on general surgery resident operative volume in a large, community-based, university-affiliated, general surgery residency program. METHODS We performed a retrospective review of Accreditation Council for Graduate Medical Education (ACGME) operative logs of general surgery residents graduating from a single residency. The control group consisted of the residents graduating in the 3 years prior to the work-hour restriction implementation (2001, 2002, and 2003). Our comparison group consisted of those residents graduating in the first 2 classes whose entire residency was conducted after the implementation of the 80-hour work week (2008 and 2009). Comparisons were made between the control and the comparison groups in the 19 ACGME defined categories, total number of major cases, total number of chief cases, and total number of teaching assist cases. RESULTS Operative volumes in 13 categories (skin/soft tissue/breast, alimentary tract, abdominal, liver, pancreas, vascular, endocrine, pediatrics, endoscopy, laparoscopic-complex, total chief cases, total major cases, and teaching cases) were not significantly affected by the implementation of the 80-hour work week. One of the 19 categories (laparoscopic-basic) showed a significant increase in operative volume (p < 0.0001). In 4 of the 19 categories (head/neck, operative-trauma, thoracic, and plastics), operative volume was significantly decreased in the post-80-hour work week era (p < 0.05). Nonoperative trauma could not be assessed, as the category did not exist before the work-hour restrictions. CONCLUSIONS Resident operative volume at our institutions general surgery residency program largely has been unaffected by implementation of the 80-hour work week. Residencies in general surgery can be structured in a manner to allow for compliance with duty-hour regulations while maintaining the required operative volume outlined by the ACGME defined categories.

Cost-efficient carotid surgery: A comprehensive evaluation

PURPOSE This study was performed to determine whether comprehensive cost-cutting strategies adversely affect the outcome in patients undergoing carotid endarterectomy. METHODS From December 1994 to December 1995, 237 consecutive patients undergoing 260 carotid endarterectomies were prospectively studied. The following variables were assessed: carotid arteriography, preoperative laboratory tests, electrocardiograms and chest x-ray films, use of carotid shunts during operation, use of pathology department, intensive care, oxygen therapy, telemetry, and hospital stay. In addition, complications were tabulated. RESULTS Previously, all variables evaluated were routinely ordered. Subsequent to initiating the cost-containment strategies, the following results were achieved: arteriography in 52 (22%) of 237 patients, preoperative complete blood cell count and SMA-7 in 161 (62%) of 260 cases, preoperative electrocardiograms in 185 (71%) of 260 cases, preoperative chest x-ray films in 190 (73%) of 260 cases, carotid shunts in 83 (32%) of 260 cases, disease in no cases (0%), intensive care in 29 (11%) of 260 cases, oxygen therapy in 34 (13%) of 260 cases, telemetry in 17 (7%) of 260 cases, and hospital stay was decreased from an average of 2.6 to 1.3 days. Total savings based on average hospital and physician charges was

The influence of repeated carotid plaque hemorrhages on the production of cerebrovascular symptoms

2.3 million. Complications included four strokes, one myocardial infarction, and no deaths. No patient required readmission. No recurrent or new neurologic or cardiac findings were identified clinically in follow-up at 1 and 4 weeks after surgery. CONCLUSIONS The results clearly demonstrate that comprehensive cost-cutting strategies can reduce charges significantly while maintaining patient safety.

Seizures following subclavian-carotid bypass *

Single carotid intraplaque hemorrhage has been related to the occurrence of cerebrovascular ischemic symptoms. We were unable to reproduce these findings; therefore, our patient population was reinvestigated to ascertain the importance of repeated plaque hemorrhages and their possible relationship to the production of neurologic symptoms. Eighty-five consecutive patients underwent 95 carotid endarterectomies. Plaques were separated into three groups: those from patients with lateralizing symptoms, nonlateralizing symptoms, and no symptoms. All the plaques were inspected microscopically for evidence of hemorrhage, specifically, repeated hemorrhages. Repeated hemorrhages were found in 29 of 44 plaques (66%) in the lateralizing symptom group, 6 of 19 (32%) in the nonlateralizing symptom group, and 12 of 32 (37%) in the no symptom group. We conclude that repeated rather than single intraplaque hemorrhage is the critical factor related to the production of specific cerebrovascular ischemic symptoms.

Exposed synthetic vascular grafts of the groin: Graft preservation by means of a tensor fasciae latae flap

Seizures are uncommon after carotid endarterectomy. Patients at greatest risk for having this complication are those with high-grade carotid stenosis and possibly those with recent stroke or severe hypertension. The most favored theory regarding the pathophysiology is hyperperfusion caused by failure of cerebral autoregulation. This article describes our experience with the management of a patient suffering focal motor seizures after subclavian-carotid bypass performed to treat common carotid occlusion.

Tongue necrosis as an unusual presentation of carotid artery stenosis

Presentation de 3 cas de rupture non purulente de la plaie inguinale lors de la periode postoperatoire precoce avec exposition de la prothese

The effect of antiplatelet therapy on the incidence of carotid plaque hemorrhage.

A 57-year-old man with premature coronary artery disease presented to the emergency department with left facial pain, numbness, and tongue swelling. The patient was found to have significant tongue necrosis, and subsequent arteriography demonstrated carotid bifurcation stenosis with embolization to the left lingual artery. The patient was successfully treated with debridement of his tongue and left carotid endarterectomy.

Carotid stenosis: change of treatment plan based on repeat duplex ultrasonography.

Hemorrhage into the carotid atheroma has recently been gaining attention with respect to the pathophysiology of cerebrovascular disease. Many patients are currently receiving platelet agents for various vascular diseases. Some researchers have postulated that antiplatelet therapy may be detrimental by possibly inducing intraplaque hemorrhage or by increasing preexisting hemorrhage. This retrospective study was undertaken to determine if the use of antiplatelet therapy increases the incidence of carotid plaque hemorrhage. Ninety-five consecutive carotid endarterectomies were performed and the atheromas examined microscopically for intraplaque hemorrhage. The atheromas were divided into two groups; those from patients receiving preoperative antiplatelet therapy and those who were not. Forty-five atheromas were removed from patients receiving preoperative antiplatelet therapy; 39 (87%) of these demonstrated intraplaque hemorrhage. Of the 50 atheromas which were removed from patients not receiving preoperative therapy, 45 (90%) showed intraplaque hemorrhage. We conclude that antiplatelet therapy does not increase the incidence of carotid plaque hemorrhage.