Reconstructive surgery for complex aortoiliac occlusive disease in ypoung adults

Background: Although aortoiliofemoral bypass grafting is the optimal revascularization method for patients with severe aortoiliac occlusive disease (AIOD), previous studies have documented poor patency rates in young adults. This study investigated whether young patients with AIOD have worse outcomes in patency, limb salvage, and long-term survival rates after reconstructive surgery than their older counterparts. Methods: Patients aged <50 years undergoing reconstructive surgery at our institution for AIOD between 1995 and 2010 were compared with a cohort of randomly selected patients aged >60 years (two for each of the young patients, matched for year of operation), analyzing demographics, risk factors, indications for surgery, operative details, and outcomes. Results: Among 927 consecutive patients undergoing primary surgery for AIOD, 78 (8.4%) aged <50 years (mean age, 48.4 years) and 156 older control patients (mean age, 71.2 years) were identified. The younger patients were mainly men (81%) and 59% had surgery for limb salvage and 41% for disabling claudication (P .02). Compared with older patients, they were significantly more likely to be smokers (90% vs 72%; P .002) and had previously needed significantly more inflow procedures (28% vs 16%; P .03). Only one death occurred perioperatively (30-day) among the control patients, and no major amputations or graft infections occurred in either group. The need for subsequent infrainguinal reconstructions was greater in the younger patients (18% vs 7%; P .01). The primary patency rates were inferior in the younger patients at 5 years (82% and 75%) and 10 years (95% and 90%; P .01), whereas assisted secondary patency (89% and 82% vs 96% and 91%; P .08), secondary patency (93% and 86% vs 98% and 92%; P .19), limb salvage (88% and 83% vs 95% and 91%; P .13), and survival rates (87% and 76% vs 91% and 84%; P .32) were comparable in the two groups. Conclusions: This study shows that despite a higher primary graft failure rate than that in older patients, aortoiliofemoral revascularization for complex AIOD is a safe procedure for younger patients with disabling claudication or limbthreatening ischemia, providing they are willing to follow a regular protocol to complete their postoperative surveillance and to undergo graft revision as necessary

Carotid plaque gross morphology and clinical presentation: A prospective study of 457 carotid artery specimens.

Background and purpose. In carotid artery disease,the relationship between carotid plaque morphologyand the patient\u2019s neurologic symptoms is reportedly conflicting. The aim of this study was to correlate gross carotid plaque characteristics with the presenting symptoms in a relatively large series of patients who underwent carotid endarterectomy (CEA). Methods. Four hundred and five patients who underwent 461 CEAs were divided into three groups: (1) transiently symptomatic [transient ischemic attack (TIA) or amaurosis fugax]; (2) prior stroke; and (3) asymptomatic. The degree of stenosis based on the preoperative angiograms was used in association with the presenting symptoms as the primary criterion in the decision to operate. Carotid plaque characteristics, including ulcerated plaque (UP), intraplaque hemorrhage (IH), uncomplicated plaque, and degree of stenosis, were recorded prospectively for 457 CEAs, since 4 CEAs were excluded from the study. All CEA specimens were grossly evaluated at surgery. Results. There was a statistically higher incidence of UP in transiently symptomatic (P 5 0.008) or prior stroke (P 5 0.006) patients than in the asymptomatic group. When IH was onsidered independently, its incidence did not differ significantly between the three groups. Previously symptomatic patients tended to have higher-grade stenosis than asymptomatic patients, although the difference failed to reach statistical significance (P 5 0.06). Although the incidences of UP and IH were higher in the higher-grade stenosis group, the difference was again not significant. Conclusions. Carotid UP correlates closely with an initial presentation of TIA, amaurosis fugax, or prior stroke, while the association between IH and presenting symptoms is less clear. Although there is an insignificant trend toward a correlation between the higher degrees of stenosis and the onset of transient symptoms, the degree of stenosis appears unaffected by the morphology of the plaque. These findings suggest that plaque morphology may play an important role in the presentation of carotid artery disease

Carotid endarterectomy contralateral to carotid occlusion: Analysis from a randomized study.

ABSTRACT. Background and aims . Many studies have reported on the benefits of carotid endarterectomy (CEA) contralateral to an occluded internal carotid artery (ICA) with divergent results. This study analyses perioperative and late outcomes of CEA in patients with contralateral ICA occlusion emerging from a recent trial in which patients were randomised to two different surgical techniques, i.e. carotid eversion endarterectomy (CEE) or traditional CEA with patching (CEAP). Patients/Methods. In 336 primary CEAs (310 patients), that were randomised into CEE versus CEAP, 68 were contralateral to an occluded ICA (group I). The remaining 268 CEAs served as control group (group II). All patients underwent clinical follow-up and duplex ultrasonography at 1,6 and 12 months, and every year thereafter. Endpoints of the study were early and late neurologic events, and deaths. Results. Demographics, risk factors, clinical presentation, indications for surgery and mean follow-up were comparable in the two groups. Group I had a statistically higher incidence of perioperative electroencephalic changes (p< .0001) and the need for shunting (p< .0001). Although the perioperative stroke rate in group I was almost 3 times higher than in group II, the difference was not significant. Similarly, the perioperative minor neurologic event and death rates, like the cumulative stroke-free and survival rates at 1,3 and 5 years, were comparable in the two groups. Conclusions. CEA contralateral to an occluded ICA can be implemented with perioperative stroke and mortality rates and late stroke-free and survival rates comparable to CEA with no contralateral ICA occlusion

Regarding "eversion technique increases the risk for post-carotid endarterectomy hypertension".

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Elongation of the internal carotid artery and abdominal aortic aneurysm: Is there a relationship?

IF 0.

Is diabetes mellitus a risk factor for carotid endarterectomy? A prospective study.

Background. Although many randomized trials and other multicenter studies have demonstrated the benefits of carotid endarterectomy (CEA) in selected symptomatic and asymptomatic patients, several investigators have noted an increased rate of perioperative neurologic and cardiac morbidity in diabetic patients. To compare the perioperative outcome of CEA in diabetic patients (group I) versus nondiabetic patients (group II), we analyzed a consecutive series of CEAs performed by the same vascular surgeon at the same institution. Methods. Data collection was prospective for all CEA procedures performed between August 1, 1992 and March 31, 1999. Group I and group II were matched for clinical presentation, percentage of internal carotid artery stenosis and indication for surgery. Results.Of 547 CEAs performed in 474 patients, 199 (36.4%) were in group I. Group I was younger at presentation than group II (P < .005) and women were in a higher proportion in group I than in group II (43.7% vs 27.1%, P = .0001). Although the incidence of peripheral atherosclerotic disease was comparable in the 2 groups, there was a significantly higher incidence of previous vascular surgery in group I (P = .01). Perioperative neurologic and cardiac morbidity rates were comparable in the 2 groups. The overall perioperative mortality rate was 0.5%. Long-term information was obtained in all patients (mean, 44 months; range, 1 to 75 months). No differences were found in the recurrent stenosis and occlusion rates between the 2 groups. Although there was no difference in the late mortality between the 2 groups, diabetic patients had a significantly higher cardiac-related death incidence (P = .01) than nondiabetic patients. Conclusions. The findings of this analysis indicate that CEA can be performed in diabetic patients with excellent perioperative morbidity and mortality rates and late stroke-free and survival rates that are comparable with those recorded in nondiabetic patients