Manuel Garcia-Toca

Predictors of shunt during carotid endarterectomy with routine electroencephalography monitoring

BACKGROUND The routine use of intraoperative electroencephalography (EEG) monitoring with selective shunt placement during carotid endarterectomy (CEA) has been shown to be safe and effective. We attempt to identify the anatomic and clinical factors associated with significant EEG changes requiring shunt placement during CEA. METHODS Between January 2005 and June 2007, 242 CEAs were performed with selective shunt placement for significant EEG changes. Risk factors assessed include severity of both ipsilateral and contralateral disease, presence of ipsilateral preoperative symptoms, hypertension, coronary artery disease, diabetes, age, gender, and preemptive intraoperative blood pressure manipulation to >or=20% above baseline before cross-clamping. Data were analyzed with the chi(2) test (P < .05 was significant). RESULTS CEA was performed for asymptomatic disease in 177 of 242 patients (73.1%). The perioperative stroke rate was 0.8% (2 of 242), and the overall morbidity rate was 4.5%. No patients died. Significant EEG changes requiring shunt occurred in 35 patients (14.46%). Factors associated with carotid shunt placement were moderate ipsilateral carotid artery stenosis (50% to 79%) compared with severe (>or=80%) disease (30.6% vs 11.7%, P = .003) and degree of contralateral carotid stenosis (0% to 49%, 10.8%; 50% to 79%, 10.9%; 80% to 99%, 23.2%; occlusion, 50%; P = .0003). Presence of symptoms, gender, age, hypertension, diabetes, or coronary artery disease, and preemptive intraoperative manipulation of blood pressure were not significant predictors of shunt placement. CONCLUSION CEA performed with routine EEG monitoring and selective shunt placement is associated with a low risk of perioperative stroke. Identified predictors of significant EEG changes were anatomic factors including degree of contralateral carotid artery disease and moderate ipsilateral carotid artery stenosis (50% to 79%). Although contralateral carotid occlusion has been accepted as indication for shunt placement in the absence of cerebral monitoring, this study suggests that high-grade contralateral disease and moderate ipsilateral carotid stenosis are associated with cerebral ischemia resulting in EEG changes and should prompt consideration for nonselective shunting.

Endovascular Repair of Blunt Traumatic Thoracic Aortic Injuries Seven-Year Single-Center Experience

HYPOTHESIS Thoracic endovascular aortic repair (TEVAR) for acute blunt thoracic aortic injury has good early and mid-term results. DESIGN Single-center retrospective 7-year review from January 2001 to December 2008. SETTING Urban tertiary care hospital. PATIENTS Twenty-four consecutive patients with acute blunt thoracic aortic injury treated with TEVAR. MAIN OUTCOME MEASURES Procedure-related mortality, stroke, or paraplegia; injury severity score; and complications. RESULTS Among the 24 treated patients (mean age, 41 years; range, 20-71 years), the mean injury severity score was 43 (range, 25-66). Thoracic endovascular aortic repair was successful in treating the aortic injury in all patients and there were no instances of procedure-related death, stroke, or paraplegia. Access to the aorta was obtained through an open femoral/iliac approach (n = 7) or an entirely percutaneous groin approach (n = 17). Systemic heparin was not used in 84% of cases. Two access complications (8%) occurred, requiring an iliofemoral bypass in one patient and a thrombectomy in another. One patient required secondary intervention for device collapse, which was treated successfully with repeat endografting. There have been no delayed device failures or complications among the entire cohort at mid-term follow-up. CONCLUSION Thoracic endovascular aortic repair, via a percutaneous groin approach and without systemic anticoagulation, for blunt thoracic aortic injury can be performed safely with low periprocedural mortality and morbidity.

Intimal angiosarcoma causing abdominal aortic rupture

Intimal angiosarcomas are rare and difficult to diagnose preoperatively. Complete surgical resection is essential, but long-term survival is unlikely. We report a patient who presented with a contained ruptured infrarenal aorta with clinical and radiologic findings suggestive of infectious aortitis. Surgical resection, regional debridement, and reconstruction were completed using a cadaveric arterial homograft. However, pathologic evaluation revealed a high-grade intimal sarcoma.

Primary Extracranial Vertebral Artery Aneurysms

BACKGROUND Extracranial vertebral artery aneurysms are uncommon and are usually associated with trauma or dissection. Primary cervical vertebral aneurysms are even rarer and are not well described. The presentation and natural history are unknown and operative management can be difficult. Accessing aneurysms at the skull base can be difficult and, because the frail arteries are often afflicted with connective tissue abnormalities, direct repair can be particularly challenging. We describe the presentation and surgical management of patients with primary extracranial vertebral artery aneurysms. METHODS In this study we performed a retrospective, multi-institutional review of patients with primary aneurysms within the extracranial vertebral artery. RESULTS Between January 2000 and January 2011, 7 patients, aged 12-56 years, were noted to have 9 primary extracranial vertebral artery aneurysms. All had underlying connective tissue or another hereditary disorder, including Ehler-Danlos syndrome (n=3), Marfans disease (n=2), neurofibromatosis (n=1), and an unspecified connective tissue abnormality (n=1). Eight of 9 aneurysms were managed operatively, including an attempted bypass that ultimately required vertebral ligation; the contralateral aneurysm on this patient has not been treated. Open interventions included vertebral bypass with vein, external carotid autograft, and vertebral transposition to the internal carotid artery. Special techniques were used for handling the anastomoses in patients with Ehler-Danlos syndrome. Although endovascular exclusion was not performed in isolation, 2 hybrid procedures were performed. There were no instances of perioperative stroke or death. CONCLUSIONS Primary extracranial vertebral artery aneurysms are rare and occur in patients with hereditary disorders. Operative intervention is warranted in symptomatic patients. Exclusion and reconstruction may be performed with open and hybrid techniques with low morbidity and mortality.

Eight-year institutional review of carotid artery stenting

OBJECTIVES Vascular surgeons have increasingly become proficient in carotid artery stenting (CAS) as an alternative treatment modality for cervical carotid artery occlusive disease. We analyzed our early and late outcomes of CAS over the last 8 years. METHODS We report a single-center retrospective review of 388 carotid bifurcation lesions treated with CAS using cerebral embolic protection from May 2001 to July 2009. Data analysis includes demographics, procedural records, duplex exams, arteriograms, and two-view plain radiographs over a mean follow-up time of 23.0 months (interquartile range, 10.9-35.4). RESULTS At the time of treatment, the mean age of the entire cohort (76% men and 24% women) is 71 years; 13% were >/=80 years of age, and 31% had a prior history of either carotid endarterectomy (CEA) and/or external beam neck irradiation (XRT). The mean carotid stenosis is 80%, and asymptomatic lesions represent 69% of the group. Overall 30-day rates of death, stroke, and myocardial infarction are 0.5%, 1.8%, and 0.8%, respectively. The combined death/stroke rate at 30 days is 2.3%. The 30-day major/minor stroke rates for analyzed subgroups are statistically significant only for XRT/recurrent stenosis vs de novo lesions, 0% and 2.6% (P = .03), but not for asymptomatic vs symptomatic patients, 1.9% and 1.7% (P = .91) and age <80 vs >/=80, 2.0% and 1.8% (P = .52), respectively. At long-term, the freedom from all strokes at 12, 24, 36, and 48 months was 99.2%, 97.6%, 96.7%, and 96.7%, respectively. At late follow-up, the restenosis rate is 3.5%. Restenosis rates for recurrent stenosis/XRT vs de novo lesions are 2.7% and 3.4% (P = .39). Among the restenotic lesions were two associated type III stent fractures in de novo lesions, both of which were closed-cell stents. An additional two other type I fractures have been identified, yielding a stent fracture rate of 5.5%. The late death rate for the entire group is 16.8%, with one stent-related death secondary to ipsilateral stroke at 20 months (0.3% death rate). CONCLUSIONS Vascular surgeons performing CAS with embolic protection can achieve good early and late outcomes that are comparable to CEA benchmarks. Late stent failures (stroke, restenosis, and/or stent fatigue), while uncommon, are a recognized delayed problem.

Carotid Artery Reconstruction for Infected Carotid Patches

OBJECTIVES Infected carotid prosthetic patches (ICPP) are a rare but catastrophic complication of carotid endarterectomy (CEA). Prevention and appropriate surgical management is essential. We report our experience of carotid artery reconstruction for ICPP. DESIGN Single-center retrospective study. METHODS 10-year review of the surgical treatment of ICPP. RESULTS Twelve patients presented with patch infection following CEA. Three patients presented acutely with an expanding hematoma, eight with chronic complications (abscess/discharging sinus n = 5, carotid pseudoaneurysm n = 3). Mean age was 75 years. Replacement conduits included superficial femoral artery (n = 6), cadaveric homograft (n = 3), long saphenous vein (n = 2) and one patient had primary closure. Five patients had muscle flaps fashioned for carotid artery protection. Operative complications included hypoglossal nerve injury (1 patient), superficial skin infection (2 patients) and one patient was returned to the operating room for a neck haematoma. Five surgical specimens were culture positive for: Staphylococcus aureus (n = 3), Corynebacterium propionibacterium (n = 1) and Streptococcus anginous (n = 1). There were no 30-day mortalities. Mean hospital stay was 6 days. Median follow-up was 16 months (range 3-108 months). CONCLUSION Carotid artery reconstruction in a contaminated wound represents a significant surgical challenge. Unlike previous reports that used venous conduits, this is the first series where cadaveric or autologous arterial conduits were preferred. Arterial conduits achieved durable short term follow-up.

Does a contralateral carotid occlusion adversely impact carotid artery stenting outcomes

BACKGROUND Carotid artery stenting (CAS) has grown as a possible alternative for the treatment of extracranial cerebrovascular disease in the past decade. A preexisting contralateral carotid artery occlusion has been described as a risk factor for inferior outcomes after carotid endarterectomy, but its impact on CAS outcomes is less understood. METHODS A retrospective review of 417 CAS procedures performed between May 2001 and July 2010 at a single center using self-expanding nitinol stents and mechanical embolic protection devices was conducted. Patients were divided into two groups, those with a preexisting contralateral carotid occlusion (group A, n = 39) versus those without a contralateral occlusion (group B, n = 378). Patient demographics and comorbidities as well as 30-day and late death, stroke, and myocardial infarction (MI) rates were analyzed. Mean follow-up was 4 years (range: 0-9.4 years). RESULTS Overall, mean age of the 314 men and 103 women was 70.5 years. In group A, there were two (5.1%) octogenarians and nine patients (23.1%) with symptomatic disease as compared with group B with 53 (14%) octogenarians and 121 (32%) patients with symptomatic disease. The overall 30-day death, stroke, and MI rates were 0.5%, 1.9%, and 0.7%, respectively. When comparing group A with group B, these results were not significantly different: death (0% vs. 0.5%), stroke (2.6% vs. 1.9%), and MI (0% vs. 0.8%). Long-term outcomes for groups A and B were also not significantly different: death (25.6% vs. 22.2%), stroke (5.3% vs. 3.4%), and MI (15.4% vs. 14%) (p = nonsignificant). CONCLUSION A preexisting contralateral carotid artery occlusion does not seem to adversely impact CAS outcomes.

Open Revascularization Procedures Are More Likely to Influence Smoking Reduction Than Percutaneous Procedures

BACKGROUND Among patients with peripheral arterial disease (PAD), smokers have a higher incidence of life- and limb-threatening complications, including lower extremity ischemic rest pain, myocardial infarction, and cardiac death, highlighting the need for smoking reduction. Several studies have previously investigated the perioperative period as a teachable moment for smoking cessation. The purpose of this study is to determine whether the type of revascularization for PAD (percutaneous versus open) is associated with smoking reduction. METHODS Study participants included patients seen at a tertiary academic medical center in Providence, RI, between 2005 and 2010 and assigned International Classification of Diseases, Ninth Revision code diagnoses indicative of PAD. This study uses patient-answered surveys and retrospective chart review to assess changes in smoking habits after medical, percutaneous, or open revascularization. Surveys also assessed patient perceptions regarding the influence of intervention on smoking reduction and how strongly patients associate PAD with their smoking habits. RESULTS Of 54 patients who were active smokers at the time of intervention, 8 (67%) in the medical management group, 12 (50%) in the percutaneous group, and 15 (83%) in the open intervention group reduced smoking by 50% after intervention. After controlling for several confounders, open revascularization was independently associated with smoking reduction when compared with percutaneous intervention (odds ratio, 8.26; 95% confidence interval, 1.18, 76.7; P = 0.043). Surveys revealed that 94% of the patients believed that smoking was a significant contributor to their PAD. CONCLUSIONS Patients with PAD who undergo open revascularization are more likely to reduce smoking than those who undergo percutaneous revascularization. The perioperative period provides an opportunity to improve rates of smoking reduction.

Techniques in Endovascular Aneurysm Repair

Endovascular repair of infrarenal abdominal aortic aneurysms (EVARs) has revolutionized the treatment of aortic aneurysms, with over half of elective abdominal aortic aneurysm repairs performed endoluminally each year. Since the first endografts were placed two decades ago, many changes have been made in graft design, operative technique, and management of complications. This paper summarizes modern endovascular grafts, considerations in preoperative planning, and EVAR techniques. Specific areas that are addressed include endograft selection, arterial access, sheath delivery, aortic branch management, graft deployment, intravascular ultrasonography, pressure sensors, management of endoleaks and compressed limbs, and exit strategies.

Regulatory TEVAR clinical trials

It has been almost two decades since the first report of a thoracic endovascular aneurysm repair (TEVAR) by Dake et al. The early devices were custom-made by the operators themselves, using woven Dacron grafts hand-sewn to Gianturco Z-stents (Cook Group Europe, Bjaeverskov, Denmark). A few years after the first published reports using custom-made devices, a handful of companies started to produce factory-made endografts. These first generation commercial devices were superior, particularly in regards to deployment, and facilitated the increased use of endografts to treat thoracic aortic pathology. European collaborators and registries preceded administrative approval in the United States and contributed valuable clinical data. In 2005, after 7 years of clinical trials, the US Food and Drug Administration (FDA) approved commercial use of the Gore Thoracic Aortic Graft (TAG; W.L. Gore and Associates, Flagstaff, Ariz). The regulatory multicenter trials involving these current commercial thoracic endografts have provided an enormous amount of data. Three commercial devices have completed regulatory trials and are currently approved for use in the United States by the FDA: Gore TAG, TALENT (Medtronic, Santa Rosa, Calif), and Zenith TX 2 (William Cook Europe, ApS, Bjaeverskov, Denmark). One other device, Relay (Bolton Medical, Inc, Sunrise, Fla) is currently undergoing a phase II trial in the US. These studies provide the best insight on the safety and efficacy of TEVAR because they include a rigid follow-up of a uniform well-defined population. Additionally, reporting standards have been defined by the Ad Hoc Committee of the Society for Vascular Surgery (SVS)/American Association for Vascular Surgery (AAVS) in 2002. Technical success is defined as delivery of the device to the intended location with satisfactory exclusion of the aneurysm and no type I or II endoleaks. Clinical success includes the outcomes of aneurysm-related deaths, rupture, endoleaks, and re-intervention.