Carotid Endarterectomy Under Local Anesthesia: An Alternative Treatment for Carotid Stenosis

Purpose. Carotid artery stenosis accounts for approximately 10% of all ischemic strokes, causing significant morbidity and mortality. Historically the standard of care for surgical candidates for carotid stenosis was carotid endarterectomy, traditionally done under general anesthesia. As carotid stenting becomes an established less invasive modality of treatment, we investigated carotid endarterectomy under local anesthesia as an alternative option. Methods. We conducted a retrospective review of medical charts for patients undergoing carotid endarterectomy at a large community hospital from July 2007 to June 2010. 30-day postoperative myocardial infarctions and strokes were evaluated for patients undergoing carotid endarterectomy under local anesthesia, compared to carotid endarterectomy under general anesthesia. Carotid artery shunting and preoperative stroke were also evaluated as risk factors for postoperative myocardial infarction and stroke. Fisher exact tests were calculated to compare postoperative outcomes between patient groups. Results. A total of 407 carotid endarterectomies under local anesthesia and 256 carotid endarterectomies under general anesthesia were included in the analysis. Age, sex, and occurrence of preoperative stroke were similar between study groups. General anesthesia patients were more likely to receive a shunt (82% vs 11%, P\u3c.001). General anesthesia patients had higher rates of postoperative myocardial infarction (1.2% vs 0%, P=.057) and stroke (2.3% vs 0.7%, P=.095), but these differences were not statistically significant. Patients with a shunt also had non-significantly higher rate of postoperative stroke (2.3% vs 0.7%, P=.096). Conclusions. Our evidence suggests that carotid endarterectomy under local anesthesia can be an effective alternative for carotid stenosis with a possibly better safety profile than carotid endarterectomy under general anesthesia. Larger randomized studies are needed to further evaluate these complications

Carotid Endarterectomy Under Local Anesthesia: An Alternative Treatment for Carotid Stenosis

Purpose. Carotid artery stenosis accounts for approximately 10% of all ischemic strokes, causing significant morbidity and mortality. Historically the standard of care for surgical candidates for carotid stenosis was carotid endarterectomy, traditionally done under general anesthesia. As carotid stenting becomes an established less invasive modality of treatment, we investigated carotid endarterectomy under local anesthesia as an alternative option. Methods. We conducted a retrospective review of medical charts for patients undergoing carotid endarterectomy at a large community hospital from July 2007 to June 2010. 30-day postoperative myocardial infarctions and strokes were evaluated for patients undergoing carotid endarterectomy under local anesthesia, compared to carotid endarterectomy under general anesthesia. Carotid artery shunting and preoperative stroke were also evaluated as risk factors for postoperative myocardial infarction and stroke. Fisher exact tests were calculated to compare postoperative outcomes between patient groups. Results. A total of 407 carotid endarterectomies under local anesthesia and 256 carotid endarterectomies under general anesthesia were included in the analysis. Age, sex, and occurrence of preoperative stroke were similar between study groups. General anesthesia patients were more likely to receive a shunt (82% vs 11%, P\u3c.001). General anesthesia patients had higher rates of postoperative myocardial infarction (1.2% vs 0%, P=.057) and stroke (2.3% vs 0.7%, P=.095), but these differences were not statistically significant. Patients with a shunt also had non-significantly higher rate of postoperative stroke (2.3% vs 0.7%, P=.096). Conclusions. Our evidence suggests that carotid endarterectomy under local anesthesia can be an effective alternative for carotid stenosis with a possibly better safety profile than carotid endarterectomy under general anesthesia. Larger randomized studies are needed to further evaluate these complications

Modified “Trap Door” Approach for Thoracic Outlet Syndrome Complicated by Subclavian Artery Aneurysm

Arterial thoracic syndrome is a rare condition that usually presents in young patients with upper extremity thromboembolization. The traditional surgical approaches described are supraclavicular and transaxillary. We hereby present the case of a 46-year-old male with left arterial thoracic outlet syndrome and left subclavian artery aneurysm. We describe our technique in approaching his condition with a modified “trap door” approach

“Chimney” Graft Technique for Juxtarenal AAA Using Unibody Bifurcated Stent Graft

Juxtarenal abdominal aortic aneurysms in patients who are poor candidates for open repair present a challenge for the treating surgeon. With fenestrated aortic endografts currently not readily accessible, the alternative option would be aortic endograft using a “chimney” technique. We present a case report of an 84-year-old female who is a poor surgical candidate, presenting with symptomatic juxtarenal abdominal aortic aneurysm involving the left renal artery. Satisfactory repair was performed using an Endologix Powerlink endograft with chimney technique for the left renal artery. To our knowledge this is the second report of chimney graft using the Endologix Powerlink system

An Exhaustive Survey on P4 Programmable Data Plane Switches: Taxonomy, Applications, Challenges, and Future Trends

Traditionally, the data plane has been designed with fixed functions to forward packets using a small set of protocols. This closed-design paradigm has limited the capability of the switches to proprietary implementations which are hardcoded by vendors, inducing a lengthy, costly, and inflexible process. Recently, data plane programmability has attracted significant attention from both the research community and the industry, permitting operators and programmers in general to run customized packet processing function. This open-design paradigm is paving the way for an unprecedented wave of innovation and experimentation by reducing the time of designing, testing, and adopting new protocols; enabling a customized, top-down approach to develop network applications; providing granular visibility of packet events defined by the programmer; reducing complexity and enhancing resource utilization of the programmable switches; and drastically improving the performance of applications that are offloaded to the data plane. Despite the impressive advantages of programmable data plane switches and their importance in modern networks, the literature has been missing a comprehensive survey. To this end, this paper provides a background encompassing an overview of the evolution of networks from legacy to programmable, describing the essentials of programmable switches, and summarizing their advantages over Software-defined Networking (SDN) and legacy devices. The paper then presents a unique, comprehensive taxonomy of applications developed with P4 language; surveying, classifying, and analyzing more than 150 articles; discussing challenges and considerations; and presenting future perspectives and open research issues

Posterior tibial artery aneurysm in a child with SMAD3 mutation

Peripheral arterial aneurysms in children are uncommon. We report a 6-year-old boy who developed a right posterior tibial artery aneurysm with symptoms including pain and pulsatile tenderness. His genetic testing revealed a SMAD3 mutation, a condition associated with familial aortic aneurysm, early-onset of osteoarthritis, and peripheral aneurysms. The posterior tibial artery aneurysm was treated with surgical resection and primary anastomosis. The patient remained free of symptoms or aneurysm recurrence in his tibial artery 2 years later. This represents the first reported case of pediatric tibial artery aneurysm linked to a SMAD3 mutation