Lorenza Franceschi

Outcome from Carotid Endarterectomy. Neuropsychological Performances, Depressive Symptoms and Quality of Life: 8-Month Follow-up

A preliminary study was carried out on a population of twenty-five consecutive and unselected patients undergoing carotid endarterectomy. A matched control group of subjects suffering from same pathology, but unoperated, was compared to experimental sample. A battery of neuropsychological tests, the Zung Self-Rating Depression Scale and the Jachucks Quality of Life Impairment Scale were administered one week before surgery, two weeks after (surgical sample only) and then eight months later. The research shows that carotid endarterectomy does not impair neuropsychological performances, but produces some improvement, reaching significant level in the case of Word Fluency 1 and Similarities tests; depressive scores remained substantially unchanged, while quality of life improved slightly.

Carotid artery endarterectomy in patients with contralateral carotid artery occlusion: Perioperative hazards and late results

The aim of this study was to analyze and compare the perioperative hazards and late results of internal carotid endarterectomy (CEA) in patients with and without contralateral internal carotid artery occlusion. From March 1980 to April 1990, 375 consecutive patients underwent 439 CEAs at the First Department of Vascular Surgery of Padova Medical School. Patients were divided into two groups; group 1 (61 patients) had contralateral internal carotid artery occlusion and group 2 (314 patients) did not (378 CEAs, 64 bilateral). Indications for CEA were similar in both groups. The only significant difference in patient characteristics was a higher rate of previous stroke in group 1 (11% vs. 3%,p< 0.001). General anesthesia, continuous EEG monitoring, selective intraluminal shunt, and arteriotomy closure with a polytetrafluoroethylene patch (PTFE) were used routinely in both groups. An intraluminal shunt was inserted more frequently in group 1 than in group 2 (69% vs. 17%,p<0.001). Major perioperativestroke occurred in one patient in each group (1.7% vs. 0.31%, respectively; NS). Early fatal stroke rates were 0% and 0.95% in groups 1 and 2, respectively (NS). All patients had neurologic examinations and duplex scans every 6 months (range 6 to 118 months; mean 42 months). Kaplan-Meier survival curves were virtually identical in the two groups; the majority of deaths were caused by myocardial infarction and cancer. There were no stroke-related deaths in group 1 as compared with 8.2% in group 2 (NS). New neurologic symptoms appeared in 4.7% of patients in group 1 and 6% in group 2 (NS) whereas the late stroke rates were 0% and 3.1%, respectively (NS). Restenosis was observed in two and three patients in groups 1 and 2, respectively (NS). In conclusion, CEA for ulcerated or stenotic lesions of the internal carotid artery in patients with contralateral carotid occlusion is associated with very low early and long-term neurologic morbidity and mortality, similar to findings in patients who undergo CEA with a patent contralateral carotid artery.

Great saphenous vein protection in arterial reconstructive surgery

An original method of great saphenous vein bypass protection during reconstructive arterial surgery is described. The use of a reinforced prosthetic support (Ringed PTFE), surrounding the vein, avoids possible compression by anatomical structures and strangulation by scar tissue after reoperation. This technique can also prevent eventual dilatation of the vein graft. Since 1981, this technique has been successfully applied to 30 selected patients. On the basis of clinical experience, the authors conclude that this method is safe and effective, and may increase the long-term patency rate of saphenous vein grafts.

Stroke risk reduction in asymptomatic and symptomatic patients treated surgically: The effectiveness of carotid endarterectomy with patch graft angioplasty

From March 1980 to March 1987, 217 consecutive patients underwent 252 carotid revascularisations with routine use of continuous EEG monitoring and selective use of an intraluminal shunt for symptomatic (70%) or asymptomatic (30%) internal carotid artery (ICA) atherosclerotic stenosis. All carotid endarterectomies were routinely performed with a patch graft angioplasty. None of the patients suffered permanent or transient neurological deficits in the immediate postoperative period and none of them died. There was an 0.8% stroke rate and 0.4% mortality rate in the early postoperative course. Neurological assessment, Doppler and Echo doppler sonography of both the operated and the contralateral ICA was performed every 6 months. One-hundred and twenty-one patients (142 carotid revascularisations) operated on up to December 31st 1985 were reassessed in July 1986. The mean follow-up time was 35 months (range: 6 months to 6 years). New neurological symptoms were present in 7.4% of the patients; 2.5% of patients developed a stroke and 8.9% showed progression of stenosis in the contralateral ICA. One patient had a common carotid artery stenosis 2 years after surgery. Re-stenosis of the ICA was found in two patients who underwent re-operation without difficulty. The late mortality was 21.4% (11.9% of the overall series). In only two patients (7.6%) was stroke the cause of death.

An Effective Surgical Technique for Limb Salvage in Femorodistal Bypass

Usually, the extension of revascularization of lower extremities to the distal arteries is performed to avoid limb amputation. Technical errors in the performance of the distal anastomosis or poor runoff cause early failure of the bypass; myointimal fibroplasia or new atherosclerosis at the distal suture edges cause long-term failure. A new modified technique was used in 20 patients to facilitate the perform ance of the distal anastomosis. A vein patch is employed to widen the distal arteriotomy, and then, the graft is sutured into the vein patch so that the caliber of the distal artery is increased; potential technical defects and the risk of an early thrombosis are thus avoided. Care is always taken to guarantee a backflow in the vessel, which will permit limb salvage even if the distal runoff is not maintained in long-term follow-up because of occlusion of the outflow. From 1979 to 1985, 20 patients underwent 21 distal arterial reconstructive procedures with this new technique. All patients presented an absolute indica tion for surgery: rest pain (6), gangrene or ulcer (12), and severe ischemia (2). For the bypass procedure, the great saphenous vein was employed in 13 cases and PTFE in 8. Three major amputations were necessary within eight days of the operation. There was no operative mortality. Long-term patency rate was very high (85%).

A new method for renal protection during renal artery revascularization

An original method for renal protection during renal artery revasculariza tion is described. Temporary reperfusion of the renal artery (three to five min utes) after critical periods of cross-clamping (thirty minutes), using a balloon T-shunt, permits prolongation of the total time of renal ischemia. A more care ful operative technique is permitted; if necessary, technical errors can be cor rected during the surgical procedure. Accordingly, this method is useful for providing renal protection during resection of thoracoabdominal aneurysms. On the basis of their experimental and clinical results, the authors conclude that this method is safe and suitable for clinical application.

The P.T.F.E. Graft Angioplasty After Endarterectomy. Personal Experience and Longterm Follow-up

Autogenous or synthetic prosthetic material can be used for angioplasty grafts after endarterectomy, although the former, especially the great saphenous vein (g.s.v.) are preferred due to their greater patency longterm and the avoidance of problems connected with the introduction of foreign bodies into the organism. When, for some reason, the g.s.v. cannot be used (too narrow, varicose, inflammed etc.) has already been used or its preservation is required for some future peripheral reconstruction, or in order to reduce the operative time, expanded polytetrafluoroethylene (P.T.F.E.*) can be used to patch the carotid or subclavian arteries or the aortoiliac and iliofemoral axes after endarterectomy (EA). The reasons for which angioplasty is preferable to direct suture of the arteriotomy, outlined below for carotid EA, are valid for all distrects.

Trends and Criteria of Indications for Carotid Revascularization

From the Department of Vascular Surgery, Padua University Medical School, Padova, Italy The role of surgical revascularization of the extracranial carotid artery is largely accepted in cases of symptomatic carotid lesions but it might seem less convincing in asymptomatic cases. 1-:3 From 1970 to 1979, the personal experience of carotid revascularization in patients operated either without neurologic symptoms but with cervical bruits arising from stenosing or from angiographically demonstrated carotid plaques, or with manifestations of cerebrovascular insufficiency (C.V.I.), reports about 2,6 percent permanent neurologic complications and 1,6 percent mortality due to cerebral infarction following carotid clamping. Paradoxically, the routinely or temporarily used indwelling shunt involves a risk of neurologic disorders in a similar and sometimes even superior percentage of cases (3%), due to the possibility of intimal dissection, poor flow, etc. These personal data are superimposable to percentage referred by major authors.:’-’ Since 1980, according to our criteria of indication for carotid revascularization, summarized in Table I, 69 patients underwent 83 revascularizations. In these cases, trying to obtain a theoretical risk = 0 of cerebral ischemia during carotid clamping, we have employed continuous operative EEG monitoring associated with &dquo;stump pressure&dquo; measurement for the selective use of intraluminal shunt in cases where EEG ischemic abnormalities appear. 6,7 Continuous EEG monitoring and stump

Abdominal Aortic Aneurysms and Associated Peripheral Occlusive Disease

During the past 12 years (1970-1982), one hundred and twenty patients were electively operated by the senior author for abdominal aortic aneurysm (AAA) at the Vascular Surgery Department of the University of Padua. Only in about 50% of cases, the lesion was revealed by the presence of a palpable pulsating mass or a calcium line on the X-ray film, especially in the lateral projection. In the remain ing cases, the diagnosis of AAA was made in patients observed for concomitant occlusive disease of the legs or the mass was casually found during laparotomy for other reasons. In 66 patients, the translumbar aortography revealed occlusive disease of the legs with lesions of the iliac axis in 43 cases (bilaterally in 26) and of the femoropopliteal axis in 33 (bilaterally in 19). The tibioperoneal axis was involved in 2 cases. Associate carotid or coronary lesions were surgically treated in separate operative sessions. For technical reasons, the proximal control of the abdominal aorta required section of the left renal vein in 4 cases, section of the inferior mesenteric vein in 10 cases and bilateral revascularization of the renal arteries in 2 cases. In addition, the patients were subdivided 1) according to the means by which intestinal blood flow was guaranteed: adequate blood flow was always guaranteed at least in one of the hypogastric arteries by revascularization of the iliac bifurcation, backflow or reimplantation, or as a last resort reimplanta tion of the inferior mesenteric artery; 2) according to whether or not the con comitant occlusive disease of the legs is corrected: whereas lesions of the iliac axis were routinely corrected either for technical reasons or because of outflow, correction of the second complete occlusion, never routinely performed in pa tients with peripheral occlusive disease, was only necessary in 11.5% of cases; 3) according to the performance of eight aorto-renal bypasses and one transaortic renal artery endarterectomy either for concomitant renovascular hypertension or almost occlusive stenosis of the renal arteries. Early operative mortality was 4.1%. Follow-up (from 6 months to 12 years) information regarding survival was obtained in 87 patients.