Biomedical subjects

A B Lumsden

Publications and source records attributed to A B Lumsden.

At least 73 records · Page 4Linked to original sources

PubMed1996

Local infusion of FGF-saporin reduces intimal hyperplasia.

The recent conjugation of the potent ribosome-inactivating protein saporin (SAP) with basic fibroblast growth factor (FGF2) to form recombinant (r)FGF2-SAP permits increased selectivity of this mitoxin for cells exhibiting upregulated FGF receptors. Systemic administration of rFGF-SAP in therapeutic doses, however, may be associated with significant liver toxicity. In this blinded study, we used a local boundary layer infusion approach to increase local drug concentration while minimizing the risk of side effects. Six dogs underwent bilateral carotid endarterectomies. Expanded polytetrafluoroethylene infusion devices, blindly primed with rFGF2-SAP to one artery or vehicle to the contralateral vessel, were anastomosed proximal to the injured segments so that each animal served as its own control. rFGF2-SAP (2 microgram/kg/day) or vehicle (5 microl/hr) was continuously delivered for 14 days from an osmotic reservoir, through the wall of the graft infusion device. Euthanasia was carried out at 14 days and the processed arteries were blindly analyzed for intimal thickening and cellular proliferation. All dogs survived until sacrifice with no clinical side effects. Liver function tests at euthanasia were not significantly altered when compared to baseline values. Intimal area in rFGF2-SAP-treated vessels averaged 0.31 +/- 0.10 mm2 versus 0.57 +/- 0.24 mm2 in the control segments (P = 0.02), a relative reduction of 46%. Cell proliferation, however, was not significantly different at 14 days postendarterectomy (2.40 +/- 1.31% vs 2.39 +/- 0.45%). From this study it can be concluded that locally delivered rFGF2-SAP reduces intimal hyperplasia and that the boundary layer infusion strategy is an effective means for delivering high local drug concentration while minimizing systemic drug effects.

Amino Acid Sequence↗

PubMed1996

Hepatic artery aneurysms: the management of 22 patients.

Hepatic artery aneurysms (HAAs) are being encountered with increasing frequency. A retrospective study of the management of HAAs at a single institution over an 18-year period is presented. The medical records of all patients diagnosed with HAA were reviewed. There were 22 patients who collectively had 23 HAAs. They were of equal gender distribution with a mean age of 53 +/- 16 years. Sixteen patients were symptomatic. Angiography was definitive in all cases and was necessary for determining therapy. There were 16 true aneurysms and 7 pseudoaneurysms. The method of treatment depended on the anatomic location of the aneurysm and the status of the patient. Treatment was by surgery (n = 10 patients), embolization (n = 8 patients), or by observation (n = 3 patients). There were two acute deaths; one patient died on admission without therapy, and one patient died following surgery. Two patients had surgical complications. Three of seven patients required repeat embolization, and one had open surgery after failed embolization. Three patients died of unrelated causes. The follow-up period was 2 months to 8 years. Thus, early HAA mortality and morbidity rates were 9.1 and 22.7%, respectively. Unless precluded by significant comorbidities, active treatment is advocated in the management of patients with HAAs. Surgery is the preferred treatment for extrahepatic lesions, while embolization is appropriate for intrahepatic aneurysms, the majority of which are pseudoaneurysms. Increased clinical awareness and aggressive, definitive management are necessary in obtaining optimal outcomes.

Adolescent↗

PubMed1996

Tenascin: a potential role in human arteriovenous PTFE graft failure.

To investigate the involvement of tenascin (TN) in human neointimal hyperplastic lesion formation, we studied 12 human arteriovenous (AV) polytetrafluoroethylene (PTFE) loop grafts removed at the time of graft revision. Immunoperoxidase technique was used to determine TN and proliferating cell nuclear antigen (PCNA) as an index of cell proliferation. The venous anastomotic neointimal hyperplastic lesion was analyzed as three layers, each one-third of the thickness. TN was distributed in the neointima as follows: (1) in the luminal layer, all lesions were intensely stained; (2) in the middle layer, 9 of 12 (75%) lesions had moderate reactivity; (3) in the deep layer near the PTFE grafts, 3 of 12 (25%) lesions were strongly stained and 5 of 12 (42%) had moderate reactivity; and (4) 90 +/- 6% of microvessels within the neointima showed intense periendothelial staining. PCNA indices were as follows: luminal layer, 29 +/- 11%; middle layer, 9 +/- 5%; deep layer near the graft, 9 +/- 7%; and microvessel containing intimal fields, 67 +/- 4%. The cell proliferation rate was significantly higher in the luminal layer than in the middle or deep layers of neointima (P < 0.05). The PCNA index in microvessel-containing intimal fields was three to eight times that of avascular fields (P < 0.001). These data demonstrate that TN is distributed in a pattern similar to that of cell proliferation in human neointimal hyperplastic lesions. The results suggest that TN expression may have a potential role in neovascularization and neointimal growth in human AV PTFE graft failure.

Adult↗

PubMed1996

Normothermic renal artery perfusion: a comparison of perfusates.

Hypothermia and preservative perfusates have been used to decrease ischemic renal injury. This study was performed to identify the preservative function of perfusates independent of the effects of hypothermia. Rats underwent 45 minutes of renal ischemia. Rectal and renal parenchyma temperatures were monitored and maintained within 1 degree C of normal. Perfusates were University of Wisconsin solution (UW), Euro-Collins solution, normal saline solution, and Ringer's lactate solution. A nonperfused ischemic control and a nonischemic control group were also evaluated. Parameters evaluated included serum creatinine and blood urea nitrogen levels, renal ischemic injury grade, renal weight, and gross appearance of the injured kidney. Rats treated with UW solution were found to have a significantly lower creatinine, blood urea nitrogen, and injury grade than the other three perfused groups. The external gross appearance of the UW-treated kidneys was normal, whereas that of the other groups demonstrated moderate to severe injury. Although the mean right/left renal weight difference of the UW-treated group was lower than that of the other three groups, this was not statistically significant. Under normothermic conditions in rats, UW solution affords significant renal protection from ischemia. Euro-Collins, normal saline, and Ringer's lactate solutions display no significant protective effect.

Adenosine↗

PubMed1996

Transgraft infusion of heparin to prevent early thrombosis of expanded PTFE grafts in canine femoral veins.

Recently we designed an expanded polytetrafluoroethylene (ePTFE)-based local infusion device that delivers therapeutic agents directly through the graft wall in the region adjacent to the upstream anastomosis, thereby achieving a high drug concentration downstream along the graft-blood interface. In this study we evaluated the effects of infusing heparin by this method on graft patency and neointimal hyperplasia in a canine model of femoral vein replacement. Five dogs underwent bilateral femoral vein replacement with the device. In each case one graft was infused with continuous heparin (48 U/kg/day) while the contralateral control graft received phosphate-buffered saline solution for 14 days. All heparin-treated grafts were patent and all control grafts were thrombosed at 14 days. There was no significant difference in systemic activated partial thromboplastin time among samples taken preoperatively, at 48 hours, and at 14 days of implantation (p > 0.5). There was no significant difference in neointimal hyperplasia between the upstream and downstream anastomoses in heparin-treated grafts. These data demonstrate that the transgraft infusion of heparin preserved venous ePTFE graft patency without measurable systemic anticoagulation. Thus this approach may represent an attractive strategy for maintaining patency of synthetic venous grafts.

Anastomosis, Surgical↗

PubMed1996

Renal artery aneurysm: a report of 28 cases.

Renal artery aneurysms are being increasingly encountered due to the wider use of angiography. From 1972 to 1992, 28 patients with renal artery aneurysm were identified in the present study, including 18 women and 10 men, with a mean age of 58 years. The aneurysms were discovered incidentally in 39% of patients during evaluation for hypertension in 39%, and during investigation of abdominal pain in 22%. Only 7% of patients had symptoms directly attributable to the aneurysm. Aneurysm size varied from 0.5cm to 8cm in diameter, with a mean of 2.1 cm. The main renal artery was involved in 52% of cases, and primary branches in 44%; the remainder were intraparenchymal. There was a slight right-sided predominance in this series. The etiology of the aneurysms included atherosclerosis (75%), fibromuscular disease (21%), and Ehlers-Danlos syndrome (4%). Surgical therapy was undertaken in 10 patients (36%). Procedures performed included aortorenal bypass in four patients, aneurysm excision and renal artery repair in three, partial nephrectomy in one, and total nephrectomy in two. Although the natural history of renal artery macroaneurysms is not known with certainty, potential complications include embolization and rupture. The authors' indications for surgery include: (a) symptomatic or enlarging aneurysms; (b) renal embolization; (c) aneurysms in pregnant females or those considering pregnancy; (d) renovascular hypertension; (e) aneurysms> 2.5cm. Most symptom-free aneurysm s<2.5 cm in diameter can be safely treated expectantly.

Adult↗

PubMed1996

Carotid endarterectomy in patients with contralateral carotid occlusion: review of a 10-year experience.

A total of 116 carotid endarterectomies were performed in patients with a totally occluded opposite internal carotid artery over a 10-year period from 1983 until 1992. The average age of patients was 66.4 years; 75% were men and 25% were women. The average degree of stenosis on the operated side was 76.7%. Twenty-one patients (18.1%) had had a documented previous stroke referrable to the side of the occlusion; 22 had a neurologic deficit attributable to the occluded vessel at the time of preoperative evaluation. Indications for surgery included transient ischemic attacks in 35 (30.2%), ipsilateral stroke in 10 (8.6%), amaurosis fugax in 11 (9.5%), and high-grade asymptomatic stenosis in 60 (51.7%). Forty-eight percent of the procedures were performed using local anesthesia, with intraluminal shunts inserted in all except one patient. The combined 30-day mortality and stroke morbidity in this population was 4.3%, which is comparable with a combined stroke and death rate of 4.0% among 956 patients without contralateral carotid occlusion undergoing endarterectomy during this period. This experience suggests that endarterectomy can be performed safely in the patient with internal carotid occlusion and is an important mechanism for the prevention of stroke.

Adult↗

PubMed1996

Nonporous silicone polymer coating of expanded polytetrafluoroethylene grafts reduces graft neointimal hyperplasia in dog and baboon models.

PURPOSE: Neointimal hyperplasia frequently develops after placement of prosthetic vascular grafts and is a major cause of graft failure. This study was an attempt to prevent vascular lesion formation by coating the graft luminal surface with a thin layer of nonporous silicone polymer, and subsequently with an ultrathin layer of vapor phase (plasma gas)-deposited fluoropolymer, thereby providing a smooth and chemically uniform surface that was postulated to limit pannus tissue ingrowth across the graft anastomoses. METHODS: Bilateral femoral arteriovenous (AV) conduits were constructed in four dogs using expanded polytetrafluoroethylene graft materials (ePTFE; 6-mm inside diameter, 2.5-cm long). In each animal, one femoral AV shunt was constructed from a graft whose luminal surface was entirely coated with polymer. On the contralateral side, an uncoated graft served as a control. Bilateral aortoiliac grafts were placed in three baboons using 5-cm segments of ePTFE (4-mm inside diameter). One end (1 cm) of each graft had been coated with polymer. In each animal, the coated end of one graft was placed proximally and the coated end of the second graft was placed distally in the contralateral vessels. RESULTS: All grafts were patent at 30 days. In the dog model, there was a significant reduction in graft neointimal area at the venous anastomoses for the coated grafts compared with the uncoated grafts (0.03 +/- 0.02 mm2 and 1.11 +/- 0.54 mm2, respectively; p < 0.05). In the baboon model, the silicone coating significantly reduced the graft neointimal thickness (0.003 +/- 0.003 mm vs 0.21 +/- 0.05 mm; p < 0.05) and neointimal area (0.05 +/- 0.08 mm2 vs 0.82 +/- 0.58 mm2; p < 0.05). CONCLUSIONS: These data demonstrate that healing of ePTFE grafts can be effectively modified by altering the physical properties of the graft surface. Neointimal hyperplasia within ePTFE grafts is significantly reduced by the local application of a fluorocarbon-coated, silicone-based polymer. The resulting graft flow surface effectively prevents tissue ingrowth from the adjacent native vessel, thereby preserving the anastomosis luminal area. This approach could represent a new strategy for limiting graft surface anastomotic neointimal hyperplasia.

Animals↗

PubMed1996

Empirical reconstruction of the renal artery: long-term outcome.

PURPOSE: Unequivocal indications for renal artery reconstruction remain the presence of significant underlying renal insufficiency or severe hypertension. Thus surgical intervention for renal artery stenosis in the absence of this clinical picture may well be considered empirical and, as a consequence, treatment recommendations are ill-defined. Our experience with reconstruction of the minimally symptomatic or asymptomatic renal artery lesion in association with primary aortic repair over a 10-year period was reviewed. METHODS: Thirty-two patients who had atherosclerotic renal artery stenosis > or = 70% underwent prophylactic renal revascularization between 1982 and 1992. The patients' median age was 63 years (range, 44 to 79 years); 23 (72%) were men and nine (28%) were women. All had preoperative serum creatinine levels < or = 1.7 mg/dl (1.29 +/- 0.24 mg/dl) and were receiving either no antihypertensive medication (22%) or only a single agent (78%). Aortoiliac occlusive disease was present in 38% of this population, and aortic aneurysmal disease either alone or in combination with occlusive disease was found in 62%. RESULTS: Operative management included unilateral renal artery repair in 21 patients (66%) and bilateral renal revascularization in the remaining 11 (34%). The median decrease in postoperative serum creatinine level (> or = 7 days after operation) was 0.81 +/- 0.05% (mean postoperative serum creatinine level 1.27 +/- 0.07 mg/dl). The 30-day operative mortality rate was 3.1% (1 of 32). Late follow-up was available for 96% of patients (30 of 31; median, 64 months). Kaplan-Meier life table analysis revealed a 5-year probability of survival of 90.2% (95% confidence interval, 0.802 to 1.00). Stability of renal function was assessed by modeling the change in serum creatinine level over time with the intraclass correlation model. A serum creatinine level (mg/dl) = 1.3348 + 0.0011 x time (months) demonstrated minimal deterioration of excretory function during the observation period. Furthermore, the blood pressure of the majority of patients (75%) remained normal either with a single agent or without medication. Recurrent stenosis in one patient required treatment by percutaneous transluminal angioplasty. CONCLUSIONS: Adjunctive repair of the renal artery may be an appropriate option in selected patients who undergo simultaneous aortic surgery, even in the absence of severe hypertension or renal insufficiency. Surgical intervention can be accomplished with acceptable perioperative morbidity rates, and stability of renal function is sustainable in the majority of patients.

Adult↗

PubMed1996

Subcutaneous, video-assisted saphenous vein harvest: report of the first 30 cases.

Harvest of the saphenous vein is a commonly performed procedure in cardiovascular surgery. The incision required for its removal is the longest used anywhere. In this report, the authors describe a minimally invasive technique for removal of the vein. This has been used in 30 patients undergoing peripheral arterial bypass (n = 27), venovenous bypass (n = 2), and a saphenopopliteal fistula (n = 1). There were three perioperative complications: skin necrosis over tunnel (one), bulla (one), and saphenous vein injury (one). Harvest time averaged 1.25 h. There was minimal postoperative discomfort in the harvest site and minimal scarring. Endoscopic harvest of the saphenous vein differs from most laparoscopic procedures because of its linear course. Consequently, visualization and dissection is coaxial rather than triangulation. This study demonstrates the technical feasibility of vein harvest. Development of appropriate instrumentation for opening the optical cavity and vein manipulation will reduce operative times.

Dermatologic Surgical Procedures↗

PubMed1995

Morbidity and mortality associated with carotid endarterectomy: effect of adjunctive coronary revascularization.

The occurrence of significant carotid disease in patients requiring coronary revascularization results in the dilemma of whether simultaneous or staged operations should be performed. To determine appropriate therapy we reviewed this experience at Emory University Hospital. During a 10-year period from 1983 to 1992, 110 patients underwent carotid endarterectomy during the same hospitalization or simultaneously with coronary artery bypass; 907 patients underwent carotid endarterectomy alone during the same period. The combined 30-day postoperative stroke and death rate was 18.2% for the 110 patients undergoing concomitant procedures. When comparing morbidity and mortality rates for those having simultaneous carotid endarterectomy and coronary artery bypass with those having delayed coronary artery bypass, the latter group was found to have a 6.6% combined risk of postoperative stroke or death within 30 days, whereas those undergoing simultaneous procedures had a 26.2% rate. In the control group of 907 patients undergoing carotid endarterectomy alone during the same period, the combined 30-day mortality and stroke morbidity rate was 2.1%. Although the patient population undergoing simultaneous carotid and coronary revascularization may have more severe disease, we believe that combining the procedures during the same operative setting results in an increased perioperative stroke and death rate. Consequently only extremely high-risk patients are selected for simultaneous procedures; otherwise our experience suggests that delaying coronary artery bypass by several days will reduce overall postoperative mortality and stroke morbidity.

Cerebrovascular Disorders↗

PubMed1995

Coronary-subclavian steal syndrome: report of five cases.

The internal mammary artery (IMA) is the conduit of choice for cardiac revascularization. The phenomenon of retrograde flow in this graft secondary to proximal subclavian artery stenosis is an infrequent but increasingly recognized clinical entity and has been termed the "coronary-subclavian steal syndrome." We report on five patients with this syndrome. All were men. The average age was 65 years (range 56 to 68 years). The mean interval from coronary bypass to presentation was 7.8 years (range 1 month to 18 years). Three patients presented with unstable angina and one with congestive heart failure. One patient was asymptomatic from a cardiac standpoint. The mean arm systolic blood pressure differential was 45 mm Hg (range 30 to 60 mm Hg). Each patient underwent cardiac catheterization, and retrograde IMA flow was demonstrated in 100%. Arteriography confirmed the presence of a proximal high-grade (> 75%) subclavian stenosis in all patients. Stress thallium scanning was performed in two patients and demonstrated anterolateral ischemia in both. Operative intervention in four patients consisted of a left carotid-subclavian bypass using an 8 mm synthetic graft. There was no perioperative morbidity or mortality. Postoperative thallium scanning revealed resolution of the ischemic process. The average length of follow-up was 20 months (range 12 to 25 months) with all patients remaining asymptomatic. The one patient who refused surgery died at 12 months. When IMA grafting is contemplated, proximal subclavian stenosis should be suspected if there is > 20 mm Hg systolic pressure differential between the arms.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed1995

The occluded renal artery: an ongoing surgical challenge.

Nephrectomy and revascularization are currently the preferred options in the management of the chronically occluded renal artery in patients with renovascular hypertension or renal insufficiency. We review our experience with these two options including early and late functional outcome. Between December 1982 and August 1993, chronic occlusion of the main renal artery was documented in 30 patients. Patients were categorized with respect to surgical intervention: group I underwent nephrectomy (on the occluded side) plus contralateral revascularization and group II underwent revascularization of the occluded renal artery. The median age at the time of operative intervention was 63 years; 53% of the patients were women and 47% were men. Hypertension was poorly controlled (> or = 3 medications) in 19 patients, and the preoperative serum creatinine level was > 1.8 mg/dl in 24 patients (mean 2.6 +/- 1.4 mg/dl). There were 16 patients in group I and 14 patients in group II, and there were no perioperative deaths. Estimated glomerular filtration rate (> or = 7 days after operation) was either unchanged or improved in 15 of 16 patients in group I and in 13 of 14 in group II, one of whom became dialysis dependent. Follow-up data were available for 25 of 30 (83%) patients (mean 45 months; range 1 to 108 months). Excluding one early failure, 10 of 13 patients in group I and 7 of 11 in group II did not have end-stage renal disease at last follow-up. Overall, hypertension was cured or improved in 16 of 21 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1995

The management of splenic artery aneurysms: experience with 23 cases.

BACKGROUND: Splenic artery aneurysms (SAA) are rare clinical entities that carry the risk of rupture and fatal hemorrhage. They are being detected with increased frequency and often cause a clinical dilemma, particularly when small lesions occur in compromised patients. This paper relates our experience in the management of SAA over a 14-year period. PATIENTS AND METHODS: We analyzed data from the medical charts and radiological images of all patients diagnosed with SAA at Emory University Hospital from December 1979 to January 1993. RESULTS: A search of medical records discovered 23 patients who experienced 44 SAAs during the time period under study. Twelve patients had multiple SAAs, most of them in the distal third of the artery. Seven had SAAs > 2 cm in diameter. Modalities used to diagnose SAA included Doppler ultrasound in 9 patients, computerized tomography in 10, and arteriography in 21. Sixteen patients had portal hypertension. Splenomegaly was present in 13 of those with portal hypertension. Aneurysm excision and splenectomy were carried out emergently on 2 patients and electively on 1. Aneurysm ligation was performed on 3 patients. One patient underwent embolization of the lesion. Sixteen asymptomatic patients whose aneurysms were < 2 cm in diameter were treated expectantly for a mean period of 3 years. One patient who received active treatment died. There were no documented deaths attributable to SAA among patients treated by observation. Six patients in this group died of unrelated causes. The longest follow-up was 7 years. CONCLUSIONS: We support current criteria that call for active treatment of symptomatic or enlarging SAAs, with particular emphasis on treating women anticipating pregnancy and patients undergoing orthotopic liver transplantations. For most other cases, expectant treatment is acceptable.

Adolescent↗

PubMed1995

Delayed rupture of aortic aneurysms following endovascular stent grafting.

BACKGROUND: Deployment of transfemoral, endovascular stent grafts for treatment of abdominal aortic aneurysms is appealing for several reasons: avoidance of abdominal incision, lack of aortic cross-clamping, potential for regional anesthesia, and shortened hospital stay. Concerns remain, however, regarding the ability of these devices to completely exclude the aneurysm and prevent aneurysm rupture and the long-term integrity of the device. The availability of endografts and the likely development of percutaneous devices have also raised the delicate issue of personnel training for patient selection, endograft implantation, and postoperative follow-up. PATIENTS AND METHODS: The cases of 2 patients are reported in which Dacron endovascular grafts, anchored proximally and distally by Palmaz stents, were deployed for treatment of infrarenal abdominal aortic aneurysms. RESULTS: In a patient with and absent distal cuff, choosing this procedure represented a clear error in patient selection. The endograft failed to reach the aortic bifurcation and the aneurysm ruptured, with the death of the patient 4 months postimplantation. In a patient with anatomy suitable for endograft placement, a perigraft leak persisted at the distal anastomosis following device placement. The aneurysm ruptured 14 days postprocedure. Although the patient survived emergent aneurysm repair, he developed acute renal failure. CONCLUSION: Careful preoperative assessment of aortic anatomy is crucial in selection of patients for transfemoral endovascular graft placement. Lack of a distal cuff of at least 1 cm precludes tube graft implantation. Patients with a perigraft leak are not protected by the endograft from aneurysm rupture. Vascular surgeons must be involved in the preoperative evaluation of these patients and are the only specialty group who can provide the prerequisite care in evaluation and management of postoperative complications.

Aged↗

PubMed1995

Boundary layer infusion of heparin prevents thrombosis and reduces neointimal hyperplasia in venous polytetrafluoroethylene grafts without systemic anticoagulation.

PURPOSE: Recently, we designed and characterized a novel polytetrafluoroethylene-based local drug delivery device that selectively concentrates infused pharmacologic agents specifically within those blood layers adjacent to the graft wall and at downstream anastomotic sites. In this study we locally administered heparin with this approach and evaluated its effect on graft patency and neointimal hyperplasia formation in a rabbit model of inferior vena cava replacement. METHODS: Twelve animals were evenly assigned either to a control group infused with saline solution or to a treatment group infused with heparin for 14 days. Bromodeoxyuridine labeling was used to assess vascular cell proliferation. RESULTS: All grafts in the control group were occluded at 14 days. All grafts in the heparin-treated group remained patent, although there was no significant difference in systemic activated partial thromboplastin time measurements taken before and during the infusion of heparin (p > 0.5). In the treatment group, heparin reduced neointimal thickness, neointimal area, and the bromodeoxyuridine labeling index by 88%, 95%, and 72%, respectively (p < 0.01), at the locally treated downstream anastomosis as compared with the untreated upstream anastomosis. CONCLUSION: These data demonstrate that the local boundary layer infusion of heparin significantly increases overall inferior vena cava graft patency (p = 0.014) and markedly reduces downstream anastomotic neointimal hyperplasia and cell proliferation. This approach may represent an attractive strategy for antithrombotic therapy in venous replacement with synthetic graft materials.

Animals↗

PubMed1995

Carotid artery shortening: a safe adjunct to carotid endarterectomy.

PURPOSE: Kinks and coils of the extracranial carotid artery system have been described in conjunction with atherosclerotic disease of the internal carotid artery. The purpose of this study was to determine whether adding a carotid artery shortening procedure to carotid endarterectomy affected perioperative mortality and stroke-morbidity rates or late restenosis. METHODS: A retrospective chart review of all patients who concurrently underwent carotid endarterectomy and ipsilateral carotid artery shortening between 1983 and 1992 was performed. Long-term follow-up was obtained by contacting the primary physician or patient, and carotid artery duplex scans were obtained. RESULTS: One hundred seven patients were found to have undergone concurrent carotid endarterectomy and carotid artery shortening. The age range was 47 to 89 years, with 53 female and 54 male patients. Indications for surgery in this group were transient ischemic attacks in 28%, stroke in 18%, amaurosis fugax in 7%, and high-grade asymptomatic stenosis in 47%. Shortening procedures were performed by use of a variety of techniques at the completion of endarterectomy. The combined 30-day mortality and stroke morbidity rate was 2.7%, with two postoperative deaths and one stroke. In this same period, a total of 1072 carotid endarterectomies were performed, and the combined 30-day mortality and stroke morbidity rate was 4.0%. During late follow-up there were no ipsilateral strokes, recurrent symptoms, or significant restenoses. CONCLUSIONS: This experience suggests that the addition of a shortening procedure to carotid endarterectomy can be performed without increased morbidity and mortality rates and, when deemed appropriate, is a procedure with which the vascular surgeon should be familiar.

Aged↗

PubMed1995

Treatment of recurrent cerebrovascular disease. Review of a 10-year experience.

OBJECTIVE: The authors determined whether carotid endarterectomy in patients with recurrent cerebrovascular disease poses a greater perioperative risk than for those individuals undergoing first-time carotid endarterectomy. SUMMARY BACKGROUND DATA: A percentage of patients undergoing carotid endarterectomy for atherosclerosis experience recurrent cerebrovascular disease. Reoperation may be difficult because of postoperative scarring of the soft tissues of the neck and the carotid artery itself. Such patients were believed to be at greater risk for perioperative morbidity than those undergoing first-time carotid endarterectomy. METHODS: To address this concern, the authors retrospectively reviewed their experience with 69 patients who underwent repeat carotid endarterectomies over a recent 10-year period of time. This subgroup represented 6.4% of 1072 total carotid endarterectomies performed during the same time period. The average extent of stenosis on the operated side was 81% and the time elapsed after previous endarterectomy averaged 83 months. Twelve patients (17.4%) had contralateral internal carotid occlusion, and 30 patients (43.5%) had undergone previous endarterectomies on the contralateral side. RESULTS: Complications within 30 days of operation included two deaths (2.9%) and one stroke (1.4%), for a combined stroke and death rate of 4.3%. Six patients developed cervical hematomas requiring drainage; one of these had rupture of a saphenous vein patch. No patient had a significant cranial nerve injury in the reoperative group, whereas 2.0% of patients undergoing first-time carotid endarterectomy had cranial nerve injuries. Overall, these results compared favorably with a combined stroke and death rate of 4.0% among 1003 patients who underwent first-time carotid endarterectomy during the same period. CONCLUSIONS: This review suggests that repeat carotid endarterectomy can be performed safely in individuals with severe recurrent carotid stenosis, with morbidity and mortality rates similar to those for patients undergoing first-time carotid endarterectomies. For this population, reoperative carotid endarterectomy represents a safe and important mechanism for the prevention of stroke.

Aged↗