Ralph B. Dilley

Recurrent carotid artery stenosis following endarterectomy

Spectral analysis was used to examine 257 carotid arteries in 227 patients who had undergone carotid endarterectomy at 1, 3, 6, and 12 months after surgery and annually thereafter. Routine intraoperative completion angiography ensured that the operations were technically satisfactory. Postoperative restenoses were identified in 38 patients (15%). In 23 arteries (9%), the restenosis exceeded a 50% diameter reduction while in 15 arteries (6%) the stenosis was less than 50% of the diameter. Restenosis developed in 24/96 women (25%) and 14/161 men (9%). Twenty-nine (70%) stenotic lesions occurred within 12 months. In three patients early lesions regressed. Reoperation with patch angioplasty was required in six patients. When the 219 carotid arteries that remained widely patent were compared to the 38 that restenosed, no differences were noted for age, diabetes mellitus, hypertension, smoking, or degree of preoperative stenosis. Early stenotic lesions appear to be due to myointimal hyperplasia, which is probably platelet mediated. The predominant female sex distribution may be explained by differences in platelet responsiveness in men and women.

Does carotid restenosis predict an increased risk of late symptoms, stroke, or death?

The identification of carotid restenosis as an unexpected late complication of carotid endarterectomy has prompted concerns regarding its importance as a source of new cerebral symptoms, stroke, and death. To investigate these concerns, we analyzed a consecutive series of 507 patients undergoing 566 carotid endarterectomies, each documented as technically satisfactory. Post-operative duplex Doppler examination data at 3 days, 1, 3, 6, 12 months, and annually thereafter in 484 arteries (85.5%) permitted classification of these arteries according to the most severe degree of postoperative stenosis: normal (n = 306); 1% to 19% (n = 89); 20% to 50% (n = 40); more than 50% (n = 49, including 8 occluded). The incidence of more than 50% restenosis was 14.5% in female and 7.7% in male patients (p = 0.003). Life table analyses to 10 years revealed a significantly greater life expectancy among those with restenosis (p = 0.05). Stroke was also less likely in patients with restenosis, although this difference did not reach statistical significance. When survival and stroke were both endpoints, the likelihood of patients with more than 50% restenosis remaining alive and stroke free was also greater than the less than 20% stenotic group (p = 0.03). Thus patients with carotid restenosis were less likely than patients with normal postoperative scans to have late symptoms, stroke, or early death.

Noninvasive physiologic tests in the diagnosis and characterization of peripheral arterial occlusive disease

A panel of noninvasive tests has been developed to quantitate the functional disability associated with peripheral arterial obstructive diseases. The tests are useful in localizing the site of significant lesions, determining their physiologic significance, identifying postoperative benefit, and detecting progression of the disease.

Life expectancy and late stroke following carotid endarterectomy.

A review of the UCSD experience with 456 consecutive carotid endarterectomy procedures confirms the acceptably low operative mortality and morbidity associated with this operation. Immediate complications were not different when routine or selective shunting was performed, but the patients with a low internal carotid artery back pressure had higher operative complication rates. The coexistence of atherosclerosis in other parts of the body severe-enough to warrant surgery for them was not associated with either higher early or late carotid surgery complication rates. Following both coronary bypass and carotid procedures, the late mortality was decreased, and the late incidence of stroke was particularly low in comparison to the remainder of the patient group. Late follow-up emphasized the high continuing attrition rate from all causes in these patients. Late strokes continued to occur, particularly in patients with prior strokes and severe preoperative bilateral carotid disease. The late course of patients with posterior circulation transient ischemic attacks treated by carotid endarterectomy was quite similar to that of patients treated for anterior circulation transient ischemia attacks (TIAs). Newer postoperative screening procedures may decrease the incidence of late postoperative stroke by identifying recurrent carotid stenosis while it is still in the asymptomatic stage.

The improving long-term outlook for patients over 70 years of age with abdominal aortic aneurysms.

During the past decade, selective criteria for elective surgery for abdominal aortic aneurysms have been refined based on natural history and aneurysm expansion information. Using these criteria, contemporary preoperative preparation and newer intraoperative technical adjuncts, 123 consecutive patients underwent elective resection with 1 death (mortality rate: 0.8%). These include all patients operated on with both elective and urgent aneurysms at this institution since 1978, with the exception of those with frank rupture. Most importantly, however, the 5-year life-table survival of all of these patients (average age: 71.3 years, range 46–96 yr) was 72%, including both hospital and late mortality rates. More than half of the patients were over 70 years old (78 cases), with no hospital deaths and a 5-year life-table survival probability of 67%. For those under 70 years of age at the time of operation, the 5-year life-table probability of survival was 79%. We believe that these accomplishments were a direct result of an aggressive policy of screening for and selectively treating coronary disease and carotid stenosis preopcratively and the utilization of such intraoperative adjuncts as routine Swan-Ganz monitoring, autologous blood transfusion, the cell saver, and the frequent use of the tube grafting (50%). Thus, with proper selection, the outlook for the patient over 70 years old with an elective abdominal aortic aneurysm resection now approaches that of the normal population (67% vs. 69%).

Infection of a ruptured aortic aneurysm and an aortic graft with bacille Calmette-Guérin after intravesical administration for bladder cancer ☆ ☆☆ ★

A case of aortic graft infection with bacille Calmette-Guérin (BCG) is described. The graft was placed during urgent repair of a ruptured abdominal aortic aneurysm 2 years after intravesical administration of BCG for grade II transitional cell carcinoma of the bladder with associated carcinoma in situ. At the time of operation, no gross evidence of infection was found and pathologic examination of the aortic wall was unremarkable. Aortic graft infection with BCG was diagnosed 1 year after placement of the graft. Retrospective examination of formalin-fixed, paraffin-embedded aortic wall and thrombus removed at the time of graft placement by the polymerase chain reaction technique demonstrated the presence of mycobacterial DNA. The patients condition improved with medical therapy during an observation period of 18 months with near total resolution on computed tomography scanning. Ultimately (20 months later), an aortoenteric fistula developed that required graft removal and axillobifemoral bypass.

Inadequacy of diagnosis related group (DRG) reimbursements for limb salvage lower extremity arterial reconstructions

Prospective cost and reimbursement data were collected from 10 centers in various parts of the United States on 566 patients undergoing lower extremity arterial reconstructions for limb salvage and nonlimb salvage indications. Information for each patient was available on indication and type of procedure, length of stay, the type of hospital insurance, and hospital costs/charges. Diagnosis related group payments from each center were used to determine net gain or loss for each patient. Patients were classified as having claudication or critical ischemia (limb salvage). Reimbursements matched costs/charges for the claudication group; overall mean loss in this group was only

Posterior communicating artery visualization in predicting results of carotid endarterectomy for vertebrobasilar insufficiency

915 per patient. However, all centers had important losses in the limb salvage group. Reimbursements averaged 60% of costs/charges, with a mean loss of

Is Carotid Endarterectomy Beneficial in Prevention of Recurrent Stroke

8158 per patient and an overall loss for all 10 centers of

Prolonged pulseless perfusion in unanesthetized calves.

3,653,918. An effort to remedy this inequity is progressing via a dialogue between representatives of the Society for Vascular Surgery, the North American Chapter of the International Society for Cardiovascular Surgery, and the federal government.