John B. Chang

Ten-year outcome after saphenous vein patch angioplasty in males and females after carotid endarterectomy.

Many surgeons use a vein-patch angioplasty after endarterectomy of small (< 4 mm) diameter carotid arteries in males and females. Because evidence suggests that females may have a poorer outcome than males after revascularization, the long-term success of carotid endarterectomy may be different among the genders. The 10-year outcome after a saphenous vein-patch angioplasty in females was studied. Endarterectomies were performed on 708 carotid arteries of 615 patients, who had evidence of symptomatic disease or had asymptomatic greater than 80% stenosis. A segment of proximal greater saphenous vein was harvested for the patch. The 247 females had a mean age of 69.1 ±9.8 (SD) years and a follow-up time of 4.0 ±4.0 (SD) years. The 368 males had a mean age of 69.2 ±8.8 (SD) years and a follow-up time of 4.4 ±4.0 (SD) years. After endarterectomy, survival, the ipsilateral stroke-free rates and the restenosis-free rates were determined by life table analyses with 73 endarterectomies in 66 patients being at risk at 10 years. The 5- and 10-year survival rates in males were 81.9% and 62.2%, respectively. The 5- and 10-year survival rates in females were 82.6% and 73.0%, respectively. The 5- and 10-year ipsilateral stroke-free rates after carotid endarterectomy were 98.3% and 93.9% in males and 96.7% and 95.6% in females. The respective 5- and 1 0-year restenosis-free rates were 96.7% and 93.3% in males and 88.6% and 82.8% in females; p <0.0002, by the Mantel-Cox test. Although survival and the incidence of an ipsilateral stroke were similar in females and males, the hemodynamic restenosis rate was higher in females. It is especially important to use routine duplex scanning to follow the postendarterectomy health of the carotid artery in females.

Long-Term Success of Vein-Patch and Carotid Endarterectomy

Most patients with severe symptomatic carotid artery disease will benefit from a carotid endarterectomy to reduce the risk of a stroke. The long-term success of vein-patch angioplasty has been determined in this study. From 1974 to 1997, 507 patients had 587 carotid endarterectomies with a greater saphenous vein graft and 97 patients had 116 carotid endarterectomies with primary closure. Mean follow-up times were 3.6 and 3.7 years, respectively. Ten percent of the patients were followed for more than 10 years. Carotid duplex ultrasonography and/or angiography were used to determine patency. Graft occlusion or significant restenosis (>69%) of the carotid artery, and the occurrence of a stroke were determined. Life-table analyses of graft patency, stroke survival were done. Perioperative ipsilateral stroke rates were 0.5% and 2.6% with the vein patch graft and primary closure, respectively (p<0.01). At 14 years, ipsilateral stroke-free rates were 97% for patients with a patch graft and 94% with primary closure (p<0.001). The rates of freedom from restenosis were 94% with the patch graft and 70% with primary closure (p<0.001), and primary patency rates were 96% and 81%, respectively (p<0.002). Ipsilateral stroke-free survival rates were 52% and 37%, respectively for patients with a patch graft and primary closure (p<0.02). Carotid endarterectomy with the vein-patch angioplasty gave an excellent result. The long-term patency of the graft and artery, freedom from an ipsilateral stroke, and survival were good. The results with a primary closure were inferior.

Nonresective Repair for Abdominal Aortic Aneurysm

BACKGROUND In this report, we present our experience with nonresective repair of abdominal aortic aneurysm in selected patients who were unsuited for other surgical approaches and would benefit from repair. METHODS Seven patients with abdominal aortic aneurysm underwent nonresective repair comprising aneurysm embolization followed by the creation of an axillary-femoral, femoral-femoral bypass with a polytetrafluoroethylene (PTFE) graft. RESULTS Between April 2006 and March 2009, seven patients (mean age: 85 years) underwent surgery. Of these, four (57%) are currently alive and healthy, with a mean follow-up of 15.7 months, the remaining three died. CONCLUSION Nonresection may be used as an alternative surgical treatment in certain high-risk patients.

Management of Varicose Veins by High Ligation, Sclerotherapy and Duplex Scanning

Background Venous duplex scanning helps in the management of patients after high ligation of the greater saphenous vein and spares it for future vascular reconstructions. Methods Duplex scanning was used to locate incompetent veins in these patients. The clinical, etiologic, anatomic, and pathophysiologic (i.e., CEAP) criteria classified the clinical severity of disease. High ligations of the greater saphenous vein at the saphenofemoral junction were performed in 1,021 limbs of 608 patients who only had chronic superficial venous insufficiency. Unless contraindicated, the use of 30–40 mmHg compression hose was prescribed. The progression of venous disease was determined by examination, history, and duplex scanning at 1- to 3-month and 6- to 12-month intervals. Ulceration, ankle edema, night cramps, stasis changes, cellulitis, varicose veins, and reflux were recorded. If there was a nonhealing ulcer, no significant improvement, or a recurrence of symptoms, then residual varicose veins were injected with a sodium tetradecyl sulfate solution to sclerose incompetent veins. At follow-up times, limbs were classified as improved, stable, or worse. Results After the high ligation, symptoms were improved in 449 limbs (44%), stable in 398 limbs (39%), and worse in 174 limbs (17%). After sclerotherapy of 572 limbs, 517 limbs (90%) improved. Ulcers occurred in 14 limbs. Edema occurred in 33 limbs, cellulitis developed in 15 limbs, and night cramps occurred in 12 limbs. If varicose veins persisted, they were managed by sclerotherapy, and 60% of the sclerotherapy-treated limbs were free of symptoms or varicosities at 8 years. Conclusion High ligation at the saphenofemoral junction is a valuable procedure in select patients to preserve the greater saphenous vein. Periodic venous duplex scanning is needed to properly manage these patients.

Comparative Review of the Treatment Methodologies of Carotid Stenosis

The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.

Sex Differences in Carotid Endarterectomy Outcomes

Background and Purpose— The existing literature provides conflicting evidence on surgical risks of carotid endarterectomy in women compared with men. We used data from a large population-based carotid surgery registry to determine whether sex differences exist in the risk of perioperative complications from carotid endarterectomy. Methods— We analyzed data from the Ontario Carotid Endarterectomy Registry, which contains data on all patients who underwent carotid endarterectomy in the province of Ontario between 1994 and 1997. We compared the risk of death or stroke at 30 days in women and men and used multivariate analyses to adjust for age, comorbid conditions, and surgical factors. Secondary analyses compared the risks of death and/or stroke in women and men at 2 years after surgery. Results— The study sample consisted of 6038 patients (35% women). The risks of perioperative stroke or death were not significantly different in women compared with men (adjusted hazard ratio, 1.10; 95% CI, 0.90 to 1.35). T...

Early Amiodarone-Induced Pulmonary Toxicity after Endovascular Aneurysm Repair: A Case Report

Amiodarone is an antiarrhythmic drug that has been commonly used to treat supraventricular and ventricular arrhythmias. This drug is an iodine-containing compound that tends to accumulate in several organs, including the lungs. Especially, its main metabolically active metabolite desethylamiodarone can adversely affect many organs. A very well-known severe complication of amiodarone therapy is the amiodarone-induced pulmonary toxicity. This article presents the case study of an 82-year-old male patient with acute amiodarone-induced pulmonary toxicity. The patient underwent endovascular aneurysm repair for rapidly increasing abdominal aortic aneurysm. During the postoperative period the patient developed rapid atrial fibrillation and amiodarone therapy was initiated. Subsequently, the patient went into acute respiratory failure and was requiring high supplemental oxygen support and a chest X-ray revealed bilateral pulmonary infiltrates. During the hospital course the patient required mechanical ventilator support. With discontinuation of amiodarone, supportive therapy and steroid treatment patient symptoms significantly improved. Amiodarone-induced pulmonary toxicity must be considered in the differential diagnosis of all patients on the medication with progressive or acute respiratory symptoms. Early discontinuation of amiodarone and aggressive corticosteroid therapy should be considered as a viable treatment strategy.

Management of carotid artery stenosis: A review

Carotid endarterectomy clearly benefits high stroke-risk patients, but its value for asymptomatic patients is still being debated. If a high exposure is necessary for redo procedures or distal aneurysms, mandibular subluxation and styloidectomy may be required. Perioperative mortality and morbidity are acceptably low. Restenosis occurs in few patients.

Indications, Management, and Long-term Outcome of Abdominal Aortic Aneurysms

Without intervention, abdominal aortic aneurysms (AAAs) continue to grow and eventually rupture. When rupture occurs, nearly one half of patients die before reaching the operating room, and of those who have an aneurysmal repair, the 1-month survival rate is only 53%.1 In the United States, approximately 15,000 deaths per year are caused by AAAs.2 Ruptured and symptomatic aneurysms must be treated as soon as possible, and even asymptomatic aneurysms larger than 5 cm in diameter should be attended to, because 25% to 41% of these aneurysms will rupture within 5 years.2-7 Surgical reconstruction has been an effective treatment for AAAs but has a mortality risk of approximately 5%.8,9 In some patients, endovascular stented grafts have been used to exclude the infrarenal AAAs, but the long-term benefit is still unclear. Although smaller aneurysms (less than 4 cm in diameter) can rupture,10,11 it is less clear when to reconstruct these aneurysms. Some vascular surgeons advocate watchful waiting until the aneurysm reaches a critical size or the rate of expansion increases.12,15

Composite Grafts for Limb Salvage

Progressive peripheral arterial occlusive disease of the lower extremity leads to inadequate blood flow for the delivery of nutrients to the distal leg. If left untreated, ulceration and gangrene can occur. Limbs are amputated to prevent sepsis and the loss of life. Revascularization of the occluded arterial system can provide sufficient blood flow to salvage limbs destined for failure. After arterial reconstruction, nearly one half of these patients feel better and return to a near normal level of activity.1 Preservation of the lower extremity requires identifying the sites of occlusion, determining the adequacy of distal perfusion, and planning arterial reconstruction. To bypass the occluded segment, various materials have been used for grafts to increase blood flow to patent vessels. Autogenous veins, synthetic materials such as poly-tetrafluoroethylene (PTFE), and composites of vein and PTFE have been used for femoropopliteal and femorotibial bypass grafts.2-5