C.M. Talkington

Asymptomatic carotid bruit: long term outcome of patients having endarterectomy compared with unoperated controls.

During 20 years (1957–1977), 1286 carotid endarterectomies were performed on 1022 private patients with cerebrovascular insufficiency. Included were 132 patients undergoing 167 endarterectomies for asymptomatic cervical carotid bruits. Ages ranged from 42 to 82 years (mean: 64.7). Operative mortality was zero. There were two transient and two permanent operation-related neurologic deficits. Complete follow-up was achieved, extending to 184 months. During postoperative follow-up, six patients (4.5%) developed TIAs appropriate to the unoperated artery, three patients had strokes (2.3%), and three patients died of strokes (2.3%). To characterize the natural history of asymptomatic bruit and determine proper indications for prophylactic endarterectomy, a control series of 138 additional patients with asymptomatic bruits not operated upon when the bruit was discovered was studied. Ages ranged from 39 to 86 years (mean: 65.7). During follow-up extending to 180 months, 77 patients (55.8%) remained neu-rologically asymptomatic, 37 patients (26.8%) developed TIAs one month to 99 months after detection of bruit, and 24 patients (17.4%) sustained mild to profound frank strokes one week to 124 months postdetection. Three of these 24 (2.2%) died of stroke. Asymptomatic carotid bruits may be potential stroke hazards, the risk of which can be significantly reduced by appropriately applied endarterectomy. A protocol for management is presented.

Mesenteric angioplasty in the treatment of chronic intestinal ischemia

PURPOSE This study was undertaken to determine the safety and efficacy of percutaneous transluminal angioplasty (PTA) in the treatment of chronic mesenteric ischemia (CMI) in very high-risk surgical patients. METHODS Twenty-four focal mesenteric stenoses treated from 1984 to 1994 by PTA in 19 patients with CMI were reviewed. All 19 patients were considered poor surgical candidates. Seventeen patients had classic symptoms of CMI, and two patients had atypical abdominal complaints. Vessels dilated included the superior mesenteric artery (18), celiac artery (3), inferior mesenteric artery (1), aorta-superior mesenteric artery vein graft (1), and aorta-splenic artery vein graft (1). Complete follow-up was possible in all patients, with the exception of one patient who had no symptoms when last seen 17 months after the procedure. RESULTS PTA was technically successful in 18 of 19 patients (95%) and 23 of 24 stenoses (96%). The lone technical failure resulted in superior mesenteric artery dissection with thrombosis and bowel infarction; the patient died despite emergent laparotomy and revascularization (mortality rate, 5%). Complete symptomatic relief was attained in 15 patients (79%), with follow-up showing continued relief of symptoms for a mean of 39 months (range, 4 to 101 months). Partial symptomatic relief was attained in three patients. Recurrent symptoms developed in three patients (20%) at a mean interval of 28 months (range, 9 to 43 months). Repeat PTA performed in two patients provided good technical results and relief from clinical symptoms. One patient had a symptomatic axillary sheath hematoma that required surgical decompression. CONCLUSIONS Mesenteric PTA is a valuable treatment option in patients who have CMI and are considered very high operative risks. The initial technical success rate is excellent, with the majority of patients having complete symptomatic improvement and continued relief of symptoms at short-term follow-up.

Mesenteric vascular problems. A 26-year experience.

Mesenteric vascular problems are infrequent, but may be catastrophic. During a 26-year period, 55 private patients were treated for the following disorders: (1) 12 patients with visceral artery aneurysms, (2) 8 with celiac compression syndrome, (3) 13 with chronic mesenteric ischemia, (4) 12 with acute mesenteric ischemia, and (5) 10 with mesenteric ischemia associated with aortic reconstructions. Splenic artery aneurysms were managed by excision and splenectomy, while celiac and hepatic had excision with graft replacement. Patients with celiac compression syndrome underwent lysis of the celiac artery. Two patients had compression of both celiac and superior mesenteric artery (SMA). One patient required vascular reconstruction of both arteries for residual stenoses. Patients having chronic mesenteric ischemia were treated with bypass grafts, with one death (7.7% mortality) and good long-term results. Those with acute mesenteric ischemia were treated by SMA embolectomy, bowel resection, or both, with a mortality of 67%. When associated with aortic reconstructions, mesenteric ischemia carried a mortality of 100% if bowel infarction occurred after operation, but when prophylactic mesenteric revascularization was performed at the time of aortic surgery, prognosis was greatly improved, with only one death among six patients. An aggressive approach including prompt arteriography with early diagnosis and surgical therapy is advocated for these catastrophic acute mesenteric problems.

Arterial Embolectomy: A 34-Year Experience with 400 Cases

A series of 400 peripheral arterial embolectomies performed in 326 patients over a 34-year period is presented. Operative mortality was 11.0 per cent overall and 10.0 per cent in patients after the introduction and use of Fogarty catheters. The plateau in mortality is related to the association with serious underlying cardiac disease. The amputation rate was 9.5 per cent, with a corresponding 90.5 per cent limb salvage rate. Cardiac disease was the most common cause of emboli and was responsible for the majority of deaths. Mortality was considerably higher in patients with aortic and iliac emboli and in patients with recent myocardial infarcts. Amputation rates were higher with femoral and popliteal emboli and correlated directly with the time delay from onset of symptoms to performance of embolectomy. Higher amputation rates in the second half of the series are related to liberalization of the indications for embolectomy. Prompt operative management of patients with peripheral arterial emboli remains the treatment of choice. Low mortality and amputation rates can be achieved with early embolectomy and routine use of heparin.

Carotid surgery for cerebral ischemia.

Changing concepts of the causes, diagnosis, and treatment of strokes have led to the use of endarterectomy as a preventive measure, particularly in patients with transient ischemic attacks. Selection of patients, and diagnostic and surgical techniques are discussed.

Persistent sciatic artery and vein: An unusual case

Persistent sciatic artery is a rare anomaly that has been reported in 48 patients in the North American literature. No report has contained more than two cases. This article discusses the first reported case of bilateral persistent sciatic arteries in a patient who also has normally developed superficial femoral arteries. This unique situation allowed removal of the superficial femoral artery for a malignant femoral nerve schwannoma without a concomitant reconstructive arterial procedure. A similar anomaly of the venous system permitted the operation to be done without compromising venous outflow.

Carotid endarterectomy in patients less than 50 years old

PURPOSE The purpose of this study was to compare the results of carotid endarterectomy (CEA) in a young population with premature atherosclerosis with the results of an older control group, examining perioperative morbidity and mortality data, recurrent stenosis and symptoms, late stroke, and survival data. METHODS We retrospectively studied 26 patients less than 50 years old (mean, 43.2 +/- 3.8 years) and 30 patients greater than 55 years old (mean, 69.1 +/- 7.4 years) who underwent CEA during the same time period. Data were obtained regarding demographics, atherosclerotic risk factors, indication for CEA, perioperative complications, recurrent stenosis and symptoms, late stroke, and survival. RESULTS Smoking was more prevalent among young patients who underwent CEA (92% vs 70%; p = 0.036). Young patients were also more likely to be symptomatic at presentation (92% vs 57%; p = 0.003). The perioperative mortality rate (0% vs 0%) and neurologic morbidity rate (0% vs 3%; p = 1.000) were low for the study patients. During a mean follow-up of 67 +/- 42.7 months, there was no significant difference in survival rate (5-year survival rate, 93% vs 81%; p = 0.373), rate of late ipsilateral (4% vs 3%) and contralateral (4% vs 3%) stroke, restenosis and occlusion (26.9% vs 14.3%), recurrent symptoms (22% vs 17%), reoperation (11.5% vs 5.7%), or contralateral disease (17% vs 23%) development that required surgery for the study or the control cohorts. CONCLUSIONS Our data show that there is a high incidence of smoking and symptomatic presentation among young patients in whom carotid occlusive disease develops. CEA may be performed in young patients with low perioperative morbidity and mortality rates. Recurrent disease, late stroke, and survival rates are not significantly different than for older patients. Follow-up with serial duplex ultrasound and reoperation for symptomatic and high-grade asymptomatic restenosis may decrease the risk of late stroke.

Endovascular “Repair” of Abdominal Aortic Aneurysm and Iliac Artery Aneurysm

Endovascular aneurysm repair is currently being developed as an alternative to traditional surgical repair for patients with abdominal aneurysms. The divisions of vascular surgery and interventiona...

Vasculo-Behçet's Syndrome

The 3 cases presented here exemplify the variety of vascular pathology seen with vasculo-Behcets syndrome and the difficulties encountered during treatment. Although this syndrome is uncommon in t...