Richard E. Welling

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.

Management of Blunt Injury to the Internal Carotid Artery

The management of vascular injury to the internal carotid artery (ICA) is controversial. We undertook a retrospective review of 14 patients with blunt injuries to the ICA and found three types of ICA injury, often presenting with delayed symptomatology. Six patients had intraluminal arterial stenosis or obstruction and were treated with anticoagulants. Five patients had pseudoaneurysms. Three of these were treated with balloon occlusion of the ICA above and below the orifice of the aneurysm, one with aneurysmorrhaphy, and one with resection and interposition vein graft. Three patients sustained a carotid cavernous fistula and were treated by balloon occlusion of the fistula while patency of the ICA was maintained. Treatment rendered all patients either asymptomatic or with residual deficits only. Angiography is essential to anatomically delineate the injury. The vascular surgeon, the neurosurgeon, and the interventional radiologist all make important contributions to the successful treatment of patients with blunt ICA injuries.

Selective use of pelvic roentgenograms in blunt trauma patients

This study was initiated to investigate the need for routine pelvic roentgenograms for all blunt trauma victims. Over a 2-year period, we prospectively studied patients referred to the trauma service in the level I trauma center at our institution who met the inclusion criteria. The patients were evaluated by physical examination and, if mentally alert and reliable, were included in the study. After inclusion into the study, a routine pelvic roentgenogram was performed to substantiate the results of our physical examination. All 125 patients included in the study were found to have normal results on pelvic roentgenograms. We conclude that alert, oriented and reliable patients involved in blunt trauma do not need a routine pelvic roentgenogram if the findings on physical examination are negative.

Bilateral Renal Artery Stent Infection and Pseudoaneurysm Formation

JVIR 2000; 11:337–341 ENDOVASCULAR stents have become a commonly employed tool in the treatment of vascular disease. Possible complications associated with the use of stents include hemorrhage and/or hematoma, acute or chronic reocclusion, vessel dissection or rupture, and embolic phenomenon. Endovascular stents have been shown in animal models to have the potential for infection (1,2), and in recent years there have been increasing numbers of single case reports in the literature of stent infections in humans. These infections can have the potential to become life threatening (3,4). This article describes a report of death secondary to bilateral infected renal artery pseudoaneurysms after placement of bilateral renal artery stents.

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.

Blunt Arterial Injuries Associated with Multiple Trauma

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.

Mortality of Gastrointestinal Complication After Cardiac Surgery-Reply

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.

Extracranial carotid artery aneurysms.

In this retrospective study, we reviewed the records of 62 patients who were treated at a tertiary care community teaching hospital between 1977 and 1987 for major arterial injury caused by blunt trauma. Nearly half (45%, 28/62) of the injuries were to the thoracic aorta, 24% (15/62) were to arteries of the head and neck, 21% (13/62) were to the arteries of the extremities, and 10% (6/62) were to abdominal arteries. Twenty-eight thoracic aortic transections were repaired, 25 with Dacron grafts and three by primary repair. One patient developed an adventitial hematoma in the thoracic aorta, which was evacuated. Two patients required nephrectomies secondary to renal artery injury. Ten patients with internal carotid artery dissection were successfully treated with anticoagulation therapy. Eight (13%) of the 62 patients died: four from exsanguination, one from cardiac tamponade, one from renal failure, one from pulmonary emboli, and one from cerebral infarction secondary to intracerebral edema. Such injuries are amenable to treatment, with patient and end-organ viability, if recognized and treated promptly by the trauma surgeon.