Gregory C. Kasper

A Multidisciplinary Approach to Carotid Paragangliomas

The surgical management of carotid paragangliomas can be problematic. A multidisciplinary approach was used to include vascular surgery, otolaryngology, and neuroradiology to treat these patients over 9 years. From January 1992 to July 2001, a multidisciplinary team evaluated patients with carotid paragangliomas. Analyzed patient data included age, gender, diagnostic evaluation, tumor size, preoperative tumor embolization, operative exposure, need for extracranial arterial sacrifice/reconstruction, postoperative morbidity including cranial nerve dysfunction, and long-term follow-up. Twenty-five carotid paragangliomas in 20 patients underwent multidisciplinary evaluation and management. Average age was 51 years (range, 28-83 years), and 52% were male. Diagnostic evaluation included computed tomography in 76%, magnetic resonance imaging/magnetic resonance angiography in 52%, catheter angiography in 60%, and duplex ultrasonography in 16%. An extended neck exposure was required in 11 cases (44%), mandibulotomy was used once (4%), and mandibular subluxation was never required. The external carotid artery (ECA) was sacrificed in 8 cases (32%). The carotid bifurcation was resected in 1 patient (4%) requiring interposition reconstruction of the internal carotid artery. Preoperative tumor embolization was performed for 13 tumors (52%). Operative blood loss for patients undergoing preoperative embolization (Group I) was comparable to the nonembolized group (group II): group I lost 365 +/-180 mL versus 360 +/- 101 mL for group II (P = .48). This occurred despite larger tumors (group I - 4.2 cm versus group II - 2.1 cm, P = .03) and a higher mean Shamblin class (group I - 2.5 versus group II - 1.45, P = .001) for group I. There were no perioperative mortalities. Transient cranial nerve dysfunction occurred in 13 CBTs (52%), 2 (8%) of which remained present after 4 months. Patients with carotid paragangliomas benefit from a multidisciplinary team approach. Neuroradiology has been used for selective preoperative embolization, which has decreased estimated blood loss during excision of larger complex tumors. A combined surgical team of otolaryngology and vascular surgery provides for exposure of the distal internal carotid artery as high as the skull base, limited permanent cranial nerve dysfunction, and selective early division and excision of the external carotid artery for complete tumor resection.

Clinical Benefit of Carotid Endarterectomy Based on Duplex Ultrasonography

Carotid endarterectomy has been shown to significantly reduce the risk of stroke caused by carotid artery stenosis in selected patients. Limiting the morbidity and costs of this process without increasing the risks should further improve the benefits of this procedure. Results were prospectively collected from 123 consecutive carotid endarterectomies performed at a community teaching hospital. All patients underwent duplex ultrasonography for preoperative evaluation. Catheter angiography was used on a selective basis. Preferential use of regional anesthetic and selective use of the intensive care unit were applied. The mortality, morbidity, complications, and costs were then compared for the group receiving only preoperative duplex ultrasonography with those undergoing catheter angiography preoperatively. Age, comorbid risk factors, indications for carotid endarterectomy, and incidence of stroke were similar in both patient groups. The rates of mortality, morbidity, and stroke for carotid endarterectomy were low (mortality 0%, morbidity 6.5%, stroke 0.8%). For preoperative evaluation all patients underwent duplex ultrasonography (100%) and 28 (23%) underwent preoperative catheter angiography in addition to duplex ultrasonography. The complication rate associated with catheter angiography was 6/28 (21%). Complications included groin hematoma (7%), pseudoaneurysm (3.6%), bradycardia (7%), and unstable angina (3.6%). Costs for duplex ultrasonography averaged

Operative management of an aberrant splenic artery aneurysm: Utility of the medial visceral rotation approach: a case report and review of the literature.

165 and additional costs incurred by the use of catheter angiography averaged

Diagnostic Options in Assessing Abdominal Aortic Endograft Infection A Case Report

4,200. Intraoperative assessment of the carotid endarterectomy site did not change based on the use of preoperative catheter angiography. Morbidity, mortality, and stroke rates were the same for the 2 groups. The preoperative use of duplex ultrasonography for the sole evaluation in carotid endarterectomy is well established. The use of preoperative catheter angiography is still preferred by a subset of surgeons. The use of catheter angiography is associated with significant morbidity and additional costs when compared to performing carotid endarterectomy based solely on preoperative duplex ultrasonography. The added costs and morbidity of angiography increase the societal cost of this procedure without significant clinical improvement in patient outcome.

Shear rate is a better marker of symptomatic ischemic cerebrovascular events than velocity or diameter in severe carotid artery stenosis

The authors report an unusual case of a splenic artery aneurysm arising off the superior mesenteric artery. This was an incidental finding on computed tomography scan found during evaluation for a different or a separate disease process.

SS25. The Association between Shear Rate and Symptomatic Carotid Disease Is a Better Predictor than Velocity or Diameter in Severe Carotid Stenosis

Endovascular treatment of aortic aneurysms has gained widespread popularity in recent years. Stent grafts have emerged as another option in the surgeons armamentarium in the treatment of aneurysmal disease. The infectivity of endovascular grafts and therapy for associated graft infections is unknown. Aortic graft infections have the potential for disastrous complications. This report presents a 72-year-old woman with persistent fever and an infected aortic stent graft in the early postoperative period.

Cilostazol May Improve Maturation Rates and Durability of Vascular Access for Hemodialysis

Objective This study was designed to test the hypothesis that the high shear rate of flow in the area of carotid stenosis is associated with the incidence of ischemic symptoms in patients with a high degree of carotid stenosis. Methods This is a case‐control study of patients with >70% stenosis of the internal carotid artery (ICA) identified by duplex ultrasound in an Intersocietal Accreditation Commission‐accredited laboratory during 1 year. Symptomatic patients were included in the study group, and asymptomatic patients served as controls. Shear rates were calculated from high‐resolution ultrasound images. Descriptive statistics and univariate and multivariate analysis were performed to account for confounding factors. Receiver operating characteristic curves were used to compare diagnostic values of shear rate, velocities, and diameters of the ICA. Results The study included 308 patients (55.5% male; mean age, 73 ± 10 years); 209 of them were asymptomatic and 99 were symptomatic. The mean shear rate was 7930 s−1 for asymptomatic and 9338 s−1 for symptomatic patients. Receiver operating characteristic curve identified a cutoff value of 8000 s−1 to differentiate between symptomatic and asymptomatic patients; 92% of asymptomatic patients and 8.0% of symptomatic patients had a shear rate of <8000 s−1 compared with 48.5% asymptomatic and 51.5% symptomatic who had a shear rate ≥8000 s−1. Patients who had a shear rate higher than this cutoff value were 12 times more likely to be symptomatic than those with a shear rate <8000 s−1 (odds ratio, 12.1; 95% confidence interval, 6.12‐24.09). Sensitivity and specificity were 84.8% and 61.2%, respectively. Conclusions In patients with >70% ICA stenosis, the shear rate is associated with the prevalence of symptomatic cerebrovascular ischemic events. A shear rate of 8000 s−1 and above may be used as a predictor for having symptomatic cerebrovascular ischemic events. Further validation as well as further study of the pathologic mechanism connecting the high shear rate and ischemic cerebrovascular events is needed.

Optimal Compression Therapy and Wound Care for Venous Ulcers

CI, Confidence interval; OR, odds ratio; TIA, transient ischemic attack. Multivariate analysis adjusted for gender, race, ethnicity, age, insurance status, coronary artery disease, congestive heart failure, prior coronary artery bypass grafting/percutaneous coronary intervention, diabetes, smoking, chronic kidney disease, diabetes, American Society of Anesthesiologists class, symptomatic status, restenosis, prior carotid endarterectomy/carotid stenting, prior amputation, medications (aspirin, antiplatelets, statin, anticoagulants, angiotensin-converting enzyme inhibitors), anatomic and medical high risk, and elective versus urgent or emergent procedures. Coarsened exact matching based on ethnicity, age, coronary artery disease, congestive heart failure, prior coronary artery bypass grafting/percutaneous coronary intervention, chronic kidney disease, diabetes, American Society of Anesthesiologists class, symptomatic status, restenosis, anatomic and medical high risk, and elective versus urgent or emergent procedures. Journal of Vascular Surgery Abstracts e171 Volume 67, Number 6

Carotid thromboendarterectomy for recent total occlusion of the internal carotid artery

Cilostazol is effective in controlling pathophysiological pathways similar or identical to those involved in nonmaturation and failure of the arteriovenous access. This case–control study examined whether cilostazol would improve maturation rates and durability of vascular access for hemodialysis. The treatment group included 33 patients who received cilostazol for ≥30 days prior to creation of a dialysis access and continued with cilostazol therapy for ≥60 days after surgery. The matched (gender, age, race, diabetes, and the year of surgery) control group included 116 patients who underwent the same procedure but did not receive cilostazol prior to and at least 3 months after surgery. Primary outcomes were maturation and, for those that matured, time of functioning access, defined as the time from the first use to irreparable failure of the access. Secondary outcomes were time to maturation, complications, and time to first complication. Study group patients were 3.8 times more likely to experience fistula maturation compared to the controls (88% vs 66%, RR = 3.8, 95% confidence interval: 1.3-11.6, P = .016). Fewer patients in the study group had complications (76% vs 92%, P = .025), and the time from construction of the fistula to the first complication was longer (345.6 ± 441 days vs 198.3 ± 185.0 days, P = .025). Time to maturation was similar in both groups (119.3 ± 62.9 days vs 100.2 ± 61.7 days, P = .2). However, once matured, time to failure was significantly longer in the treatment group (903.7 ± 543.6 vs 381.6 ± 317.2 days, P = .001). Multivariate analysis confirmed that the likelihood of maturation was significantly higher in the treatment group patients. These results suggest that dialysis access patients may benefit from preoperative and postoperative cilostazol therapy. If confirmed by a randomized trial, this treatment will have a major beneficial impact on patients dependent on a well-functioning access for their hemodialysis.

Blunt injury to the external iliac artery: a case report.

Venous leg ulcers remain a major public health issue with significant economic impact. Two main components of the management of patients with venous leg ulcers are compression therapy and wound care. This article addresses principles and specific aspects of compression therapy and focal wound care for patients with venous leg ulcers.