Reducing the Risk of Intraoperative Neurological Complications during Carotid Endarterectomy with Early Distal Control of the Internal Carotid Artery

n/

A Poverty and Income Inequality in Indonesia

This study aims to describe and evaluate government policies and strategies in overcoming the problem of poverty. The research method used in this study is the research approach used is descriptive qualitative. The results of this study indicate that many poverty alleviation programs carried out by the government have not yet brought significant change. The strategies that have been taken to overcome poverty not only prioritize economic aspects but pay attention to other dimensions to increase capacity and encourage productivity. The strategy chosen was to improve the basic ability of the poor to increase income, involving the poor in the whole process of poverty reduction; empowerment strategy. To support the success of this strategy, it should be done thoroughly, integratedly, across sectors, and adapted to the conditions of Indonesian social diversity

Surgical management of popliteal artery aneurysms: Which factors affect outcomes?

Objective: Popliteal artery aneurysm (PAA) is uncommon. The clinical presentation of PAA includes rupture, embolism, and thrombosis. In this article, we evaluate the results of our 20-year experience with surgical management of PAAs, analyzing the role of anatomic, clinical, and surgical factors that potentially affect early and long-term results. Methods: From January 1984 to December 2004, 159 PAAs in 137 patients were operated on at our department. Data from all the patients were retrospectively collected in a database. PAAs were asymptomatic in 67 cases (42%); 5 (3%) PAAs were ruptured. In 51 cases (32%), PAA caused intermittent claudication. The remaining 36 limbs (23%) had threatening ischemia due in 30 cases to acute PAA thrombosis, in 4 cases to chronic PAA thrombosis, and in 2 cases to distal embolization. In selected patients with acute ischemia, preoperative intra-arterial thrombolysis with urokinase was performed. Early results in terms of mortality, graft thrombosis, and limb salvage were assessed. Follow-up consisted of clinical and ultrasonographic examinations at 1, 6, and 12 months and yearly thereafter. Long-term survival, patency, and limb salvage rates were analyzed. Results: Forty cases were treated with aneurysmectomy and prosthetic graft interposition; in 39 cases, the aneurysm was opened, and a graft was placed inside the aneurysm. Four patients had aneurysmectomy with end-to-end anastomosis. In 73 cases, ligation of the aneurysm with bypass grafting (39 with a prosthetic graft and 34 with an autologous vein) was performed. The remaining three patients underwent endovascular exclusion of their PAAs. A medial approach was used in 97 patients (61%), and a posterior approach was used in 59 patients (37.1%). The outflow vessel was in most cases (93.7%) the below-knee popliteal artery. Thirty-day amputation and death rates were 4.4% (7/159 limbs) and 2.1% (3/137 patients), respectively. The amputation rate was significantly higher in symptomatic limbs than in asymptomatic ones (6.5% and 1.4%, respectively; P = .05). Eight limbs (5%) had an early graft thrombosis that required a reintervention. Follow-up was available in 116 patients (84.7%) and 138 limbs (86%) with a mean follow-up time of 40 months (range, 1-205 months). The cumulative estimated 60-month survival, limb salvage, and primary and secondary patency rates were 84.2%, 86.7%, 66.3%, and 83.6%, respectively. Asymptomatic limbs had significantly better results than symptomatic ones in terms of limb salvage (93.4% and 80.4%, respectively; P = .03; log-rank, 4.2) and primary patency (86.5% and 51.6%, respectively; P = .001; log-rank, 10.3). Among symptomatic patients, results were better in claudicant limbs than in acutely ischemic ones in terms of limb salvage (90.5% and 58.7%, respectively; P = .001; log-rank, 17.5). Univariate analysis showed the absence of symptoms, the presence of two or three tibial vessels, the use of a posterior approach, the kind of intervention, and the site of distal anastomosis to significantly affect long-term patency. Cox regression for factors affecting 60-month primary patency showed that clinical presentation, runoff status, and the site of distal anastomosis significantly influenced long-term results. Conclusions: Results of surgery on asymptomatic PAAs are good - significantly better than those for symptomatic ones. Elective surgical intervention should be performed in patients with a low surgical risk and a long life expectancy when the correct indication exists. In thrombosed aneurysms, intra-arterial thrombolysis may represent an alternative to emergent surgical management. Our data demonstrated that results are similarly good in claudicants, and this fact confirms that only acute ischemia due to PAA thrombosis represents a real surgical challenge. In selected patients with focal lesions, a posterior approach seems to offer better long-term results. The runoff status and the site of distal anastomosis affect long-term patency as well. Copyright © 2006 by The Society for Vascular Surgery

Carotid artery dissection

Carotid dissection may be spontaneous, traumatic or iatrogenic. The incidence of this disease is very low. Carotid dissection is a rare cause of ischemic stroke and the instrumental diagnosis includes conventional angiography, magnetic resonance imaging, ultrasound techniques and helical computed tomography angiography. Anticoagulant therapies are recommended for all the patients regardless by dissection's aetiology in order to prevent thromboembolic complications. Options for open surgical repair include resection of the involved segment with interposition of vein graft, thromboendarterectomy and patch closure, extracranial to intracranial carotid artery bypass, gradual dilation of the carotid artery and ligation of the cervical carotid artery. More recently endovascular techniques have been used to treat high-grade stenosis and aneurysmal dilatation as a consequence of a carotid dissection. No evidence exists about the benefits of one technique than the others. In any case, surgical or endovascular treatment should be reserved for patients who have persistent symptoms of ischemia despite adequate anticoagulation. In this report we review recent new knowledges in epidemiology and pathogenesis of carotid artery dissection, paying particular attention to clinical manifestations, methods of diagnosis and kinds of treatment

The Treatment of Isolated Iliac Artery Aneurysm in Patients with Non-aneurysmal Aorta

Objectives: The aim of the study was to evaluate early and mid-term results of surgical repair of isolated iliac artery aneurysm (IAA) in patients with non aneurysmal abdominal aorta. Methods: From January 1996 to December 2006, 34 patients with IAA had elective surgery. In 32 cases open repair was performed. Two patients had endovascular repair using a tube endoprosthesis and internal iliac artery coil embolization. The diameters of the abdominal aorta and iliac arteries were measured preoperatively and during follow-up. Early and late results in terms of mortality, major morbidity, reinterventions and graft-related complications were recorded. Mean pre and postoperative diameters of abdominal aorta were compared. Results: The site of the IAA was the common iliac artery in 29 cases (10 bilateral), internal iliac artery in 4 cases and external iliac artery in 1 case. Preoperative mean abdominal aortic diameter was 22.2 mm (SD 7.6). There were no perioperative deaths and two major complications (retroperitoneal bleeding and limb ischemia) occurred. At the median follow-up time of 24 months survival was estimated as 91%. No reinterventions, graft thrombosis and graft related complications occurred. There were no cases of abdominal aorta aneurysm development. Mean aortic diameter at the most recent imaging was 23.1 mm, which was not significantly different from preoperative values (p = 0.2). Conclusions: Surgical treatment of IAAs provides good early and mid-term results. During mid-term follow-up the diameter of abdominal aorta remains stable, suggesting IAA may be a localized aneurysmal disease. © 2007 European Society for Vascular Surgery

Carotid endarterectomy in patients with acute neurological symptoms: A case-control study

Objective: The aim of this study was to retrospectively evaluate our experience in urgent carotid endarterectomy (CEA) in patients with acute neurological symptoms comparing them with results obtained in stable symptomatic patients in a case-control study. Materials and methods: From January 1996 to December 2005, 3336 consecutive CEAs were performed at our department. In 70 cases CEA was carried out in patients with acute neurological deficit; in all these patients, clinical presentations were recent (<24 h) or crescendo (defined as two or more episodes in 24 h, with complete recovery after each episode) TIAs (group 1). The control group was randomly obtained from our historical database and consisted of 352 stable symptomatic patients operated on in the same period (group 2). Early (30-day) results in the two groups were compared by x2 and Fisher exact tests; follow-up data were analysed by life-table analysis (Kaplan-Meier test) and results in subgroups were compared by means of log-rank test. Results: Considering mortality and any neurological morbidity, the patients of group 1 showed a cumulative rate of death and neurological complication significantly higher than those in group 2 (5.4% and 0.3%, respectively; P=005); however, when analysing 30-day disabling strokes and deaths, the patients of group 1 had a cumulative complication rate of 1.4%, whereas in group 2 the corresponding figure was 0.3% (P=n.s.). In patients of group 1, univariate analysis and logistic regression for multivariate analysis for 30-day risk of stroke and death did not show any influence of comorbidities, clinical status, anatomical and surgical features. Estimated cumulative 36-month survival was significantly better in group 2 than in group 1. Considering the absence of ipsilateral stroke at 36 months, there were no differences between the two groups; however, analysing the estimated absence of any neurological events, both ipsilateral and contralateral, at 36 months, patients of group 1 had a higher risk than those of group 2. Conclusions: Urgent CEA in patients with recentycrescendo TIA and appropriate carotid artery lesion, carries good early and longterm results, which, however, remain slightly poorer than those obtained in symptomatic patients with a stable neurological status

Early and Intermediate Results of Elective Endovascular Treatment of True Visceral Artery Aneurysms

Background To retrospectively analyze early and follow-up results of endovascular management of visceral artery aneurysms (VAAs) in a single-center experience. Methods From 2007 to June 2013, 26 consecutive elective endovascular interventions for VAAs were performed in 26 patients; preoperative, intraoperative, and postoperative data were prospectively collected in a dedicated database. Early (<30 days) and follow-up results were evaluated. Results The site of aneurysm was splenic artery in 17 patients, common hepatic artery in 3 patients, renal artery and pancreaticoduodenal artery in 2 cases each, and gastroduodenal artery and celiac trunk in one case each. All the lesions were asymptomatic, and the mean diameter was 22.8 mm. Interventions consisted in coiling in 19 cases; in 4 patients a covered stent was placed, whereas the remaining 3 patients had a multilayer stent. Technical success was 89%. There were no perioperative deaths; 1 patient with splenic artery aneurysm had coils migration with symptomatic splenic infarction and underwent successful redo coils packing. Median duration of follow-up was 18 months. During follow-up, 1 aneurysm-unrelated death occurred. One asymptomatic thrombosis of a treated vessel was recorded, with a 2-year estimated patency rate of 91%. Mean aneurysmal diameter at the latest follow-up was 20.2 mm (P = 0.001 in comparison with preoperative values; 95% confidence interval 1.9-5.2). Complete exclusion of the aneurysm occurred in all but 1 patient, who had a limited increasing in the diameter of its splenic aneurysmal sac after coiling. Another patient developed a more distal aneurysm of the splenic artery after 24 months. No reinterventions were required. Freedom from aneurysm-related complications at 2 years was 72.9% (Standard Error, 0.09). Conclusions In our experience, endovascular treatment of VAA, when feasible, provided excellent perioperative results with low rates of complications and reinterventions. Even if the risk of developing aneurysm-related complications during follow-up is substantial, most of them can be watched without the need for repeated interventions

Early and mid-term results of kissing stent technique in the management of aorto-iliac obstructive disease

To retrospectively analyze early and mid-term results of endovascular management of aorto-iliac obstructive disease with the kissing stent technique