Biomedical subjects

Edward J Mascha

Publications and source records attributed to Edward J Mascha.

16 recordsLinked to original sources

PubMed2006

A personal experience with coronary artery bypass grafting, carotid patching, and other factors influencing the outcome of carotid endarterectomy.

OBJECTIVE: This study was conducted to investigate the influence of coronary artery bypass grafting (CABG), carotid patching, and other factors on the outcome of all carotid endarterectomies (CEAs) performed by a single surgeon at a tertiary referral center. METHODS: The series includes 2262 CEAs (335 bilateral) in 1521 men and 741 women (33%) with median ages of 66 and 68 years, respectively. Surgical indications were asymptomatic stenosis for 1503 procedures (66%), retinal ischemia or cerebral transient ischemic attacks each for 271 (12%), and prior stroke for 217 (9.6%). CEA was done as an isolated operation in 1959 patients and was performed in conjunction with simultaneous CABG in 303 (13%). Primary arteriotomy closure was used for 783 CEAs (35%), vein patching for 1232 (54%), and synthetic patching for 247 (11%). Outcome event rates were assessed by logistic regression analysis, proportional hazards models, and Kaplan-Meier estimations. RESULTS: Postoperative mortality (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.7 to 7.5; P = .001), stroke (OR, 3.2; 95% CI, 1.6 to 6.4; P = .001), and combined stroke and mortality rates (OR, 3.4; 95% CI, 2.0 to 5.8; P < .001) were significantly higher for simultaneous CEA/CABG than for isolated CEA. Ipsilateral postoperative stroke rates were similar (2.6% vs 1.7%, P = .41) in both settings. Vein patching had a lower risk for ipsilateral stroke (OR, 0.42; 95% CI, 0.21 to 0.86; P = .015) than primary closure, but was not significantly different from synthetic patching (P = .10). The documented incidence of postoperative carotid thrombosis was 1.5% with primary closure, 0.6% with vein patching, and 2.0% with synthetic patching (P = .088). Overall Kaplan-Meier survival was 92% at 1 year, 71% at 5 years, 41% at 10 years, and 20% at 15 years, but long-term mortality rates were higher after simultaneous CEA/CABG (hazard ratio, 1.3; 95% CI, 1.1 to 1.5; P = .002) than after CEA alone. Late strokes or retinal infarctions have been reported after 97 (5.0%) of the 1923 operations for which follow-up was available, 51 (2.3%) of which were ipsilateral to CEA. The incidence of > or = 60% recurrent stenosis was independently influenced by carotid patching (OR, 0.61; 95% CI, 0.40 to 0.92; P = .019) but not by the choice of patch material (P = .11). CONCLUSIONS: These results substantiate the common observation that patients who require simultaneous CEA/CABG have a higher risk for adverse outcomes than patients who undergo isolated CEA. Carotid patching provided significant benefit with respect to the risks for ipsilateral postoperative stroke and > or = 60% recurrent stenosis.

Aged↗

PubMed2006

Genetic polymorphism in the fibrinolytic system and endometriosis.

OBJECTIVE: Although most women experience retrograde menses during their reproductive life, endometriosis develops only in a small percentage. We hypothesized that persistence of a fibrin matrix in peritoneal pockets, as a result of hypofibrinolysis, could allow menstrually deposited endometrial fragments to initiate endometriosis. Fibrinolysis is modulated by several factors, and polymorphisms in the plasminogen activator inhibitor-1 (PAI-1) gene are considered to be one of the important determinants. The objective of this study was to evaluate PAI-1 genotypes in a group of women with or without endometriosis. METHODS: In 118 women (75 with laparoscopically confirmed endometriosis and 43 controls), genomic DNA was extracted from blood and the PAI-1 promoter genotype was determined by polymerase chain reaction amplification of DNA using specific primers for the 4G or 5G allele followed by gel electrophoresis. A portion of the polymerase chain reaction product was purified and sequenced to confirm the gel electrophoresis results. RESULTS: Endometriosis was more likely in patients with 4G/5G (odds ratio 38; 95% confidence interval [CI] 6-229) or 4G/4G (odds ratio 441; 95% CI 53-3,694) compared with 5G/5G PAI-1 genotype. Fifty-two of 75 women with endometriosis (69 %, 95% CI 58-79%) had the 4G/4G genotype compared with only 5 of 43 (12%; 95% CI 4-25%) controls. In contrast, the 5G/5G genotype associated with normal fibrinolysis was found in 2 of 75 (3%; 95% CI 0-9%) women with endometriosis compared with 24 of 43 (56%; 95% CI 40-71%) controls. CONCLUSION: Hypofibrinolysis, associated with the 4G allele of the PAI-1 gene, was found significantly more often in women with endometriosis compared with controls. Persistence of fibrin matrix could support the initiation of endometriotic lesions in the peritoneal cavity, explaining why some women with retrograde menstruation develop endometriosis while others do not. LEVEL OF EVIDENCE: II-2.

Adult↗

PubMed2006

Is depth of anesthesia, as assessed by the Bispectral Index, related to postoperative cognitive dysfunction and recovery?

We randomized 74 patients to either a lower Bispectral Index (BIS) regimen (median BIS, 38.9) or a higher BIS regimen (mean BIS, 50.7) during the surgical procedure. Preoperatively and 4-6 wk after surgery, the patients' cognitive status was assessed with a cognitive test battery consisting of processing speed index, working memory index, and verbal memory index. Processing speed index was 113.7 +/- 1.5 (mean +/- se) in the lower BIS group versus 107.9 +/- 1.4 in the higher BIS group (P = 0.006). No difference was observed in the other two test battery components. Somewhat deeper levels of anesthesia were therefore associated with better cognitive function 4-6 wk postoperatively, particularly with respect to the ability to process information.

Adjuvants, Anesthesia↗

PubMed2006

Increased expression of 5-lipoxygenase in high-grade astrocytomas.

OBJECTIVE: 5-Lipoxygenase (5-LO) oxidizes arachidonic acid into proinflammatory eicosanoids that may promote tumorigenesis. In this study, we investigated whether 5-LO is expressed in human astrocytomas and what effect its expression may have on patient outcome. METHODS: Increased 5-LO messenger ribonucleic acid and protein expression was detected by the polymerase chain reaction and antibody-based approaches, respectively, in surgical astrocytoma specimens and established glioblastoma multiforme cell lines compared with primary cell culture from the human white matter. RESULTS: Immunohistochemical analysis revealed predominantly nuclear 5-LO staining in 44 of 49 glioblastoma multiforme samples (90%), 8 of 10 (80%) anaplastic astrocytomas samples, and 3 of 13 (23%) low-grade astrocytoma samples analyzed. Double-staining experiments with anti-CD-68 (macrophage/microglial marker) and anti-5-LO antibodies suggest that both CD-68-positive and CD-68-negative tumor cells express 5-LO protein. Staining of 5-LO was significantly more frequent in high-grade than in low-grade tumors (P = 0.001). Patients whose tumors expressed 5-LO were significantly older, had lower preoperative Karnofsky performance scores and shorter survival than patients whose tumors did not express 5-LO. After adjusting for pathological diagnosis and age, respectively, neither Karnofsky performance score nor survival were significantly associated with 5-LO staining. CONCLUSION: These data indicate that 5-LO is overexpressed in high-grade astrocytomas and supports the idea that eicosanoids may play a role in tumorigenesis of these brain tumors.

Adult↗

PubMed2005

Assessing treatment effect heterogeneity in clinical trials with blocked binary outcomes.

This paper addresses treatment effect heterogeneity (also referred to, more compactly, as 'treatment heterogeneity') in the context of a controlled clinical trial with binary endpoints. Treatment heterogeneity, variation in the true (causal) individual treatment effects, is explored using the concept of the potential outcome. This framework supposes the existance of latent responses for each subject corresponding to each possible treatment. In the context of a binary endpoint, treatment heterogeniety may be represented by the parameter, pi2, the probability that an individual would have a failure on the experimental treatment, if received, and would have a success on control, if received. Previous research derived bounds for pi2 based on matched pairs data. The present research extends this method to the blocked data context. Estimates (and their variances) and confidence intervals for the bounds are derived. We apply the new method to data from a renal disease clinical trial. In this example, bounds based on the blocked data are narrower than the corresponding bounds based only on the marginal success proportions. Some remaining challenges (including the possibility of further reducing bound widths) are discussed.

Analysis of Variance↗

PubMed2005

A personal experience with factors influencing survival after elective open repair of infrarenal aortic aneurysms.

OBJECTIVE: To investigate risk factors that influence survival after open abdominal aortic aneurysm (AAA) repair in all elective patients treated by a single surgeon at a tertiary referral center. METHODS: The series includes 855 asymptomatic infrarenal AAAs in 732 men (86%) and 123 women with median ages of 69 and 71 years, respectively. Noninvasive myocardial imaging (n = 325), coronary arteriography (n = 418), or both were performed before surgery in 687 patients (80%), and 100 patients (15%) underwent preliminary coronary artery bypass grafting (n = 78) or percutaneous transluminal coronary angioplasty (n = 22) before their AAA procedures. Survival was assessed by using logistic regression analysis, proportional hazards models, and Kaplan-Meier estimations. RESULTS: The operative mortality rate was 2.5%, ranging only from 1.8% to 2.8% since 1980. Late survival rates (70% at 5 years, 36% at 10 years, and 16% at 15 years) also remained remarkably similar during five arbitrary intervals comprising the entire study period. On multivariable analysis, overall mortality rates were adversely affected by older age (P < .001), increased creatinine levels (P < .001), straight aortic replacement grafting (P < .001), larger aneurysm diameter (P = .036), and chronic obstructive pulmonary disease (P = .012). The risk for any early or late death was favorably influenced by preliminary coronary artery bypass grafting or percutaneous transluminal coronary angioplasty (hazard ratio, 0.76; 95% confidence interval, 0.59-0.98; P = .035) even when a separate multivariable model was fit to accommodate nine other patients who also had preliminary coronary intervention but developed symptomatic AAAs before elective repair could be performed (hazard ratio, 0.78; 95% confidence interval, 0.61-0.99; P = .044). CONCLUSIONS: Patient age and medical risk factors determine survival after open AAA repair to a very similar degree irrespective of the era when the operation is performed. In this particular series, preliminary coronary intervention seemed to benefit patients with severe coronary artery disease.

Aged↗

PubMed2004

Cryopreservation and thawing is associated with varying extent of activation of apoptotic machinery in subsets of ejaculated human spermatozoa.

We investigated the impact of cryopreservation and thawing on levels of caspases-3, -8, and -9 activity, intact mitochondrial membrane potential (Deltapsim), and DNA fragmentation in human spermatozoa. Eleven pools of cryopreserved and eight pools of fresh semen samples were examined. Mature and immature fractions were separated on a two-layer density gradient (47% and 90%) and further subdivided based on the externalization of phosphatidylserine and its binding to annexin V-labeled superparamagnetic microbeads (ANMB). Levels of activated caspases were assessed using fluorescein-labeled inhibitors of caspases (FLICA), Deltapsim using a lipophilic cationic dye, and DNA fragmentation by the terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) assay. Cryopreservation was significantly associated with activation of caspases-3, -8, and -9, as well as disruption of the mitochondrial membrane potential but no significant changes were observed in DNA fragmentation. In mature sperm, caspase activation was only detected in the ANMB+ fraction, whereas in immature sperm, both ANMB+ and ANMB- fractions showed activated caspase levels. In ANMB+ immature sperm, apoptosis seemed to be triggered by a surface ligand-receptor mechanism as well as by disruption of mitochondria, whereas in ANMB- immature sperm, apoptosis was induced by activation of caspase-9 following loss of intact Deltapsim. These results demonstrate that selection of annexin V-negative mature spermatozoa might be of clinical relevance for fertility preservation, as this sperm fraction shows no activated apoptosis during the cryopreservation process.

Annexin A5↗

PubMed2004

Determinants of in-hospital mortality and length of stay for acute intestinal gangrene.

BACKGROUND: Intestinal gangrene carries high operative mortality and morbidity rates. This study was undertaken to identify predictors of in-hospital death and length of stay. METHODS: Retrospective review of hospital data over a 6-year period identified 107 patients diagnosed with acute bowel gangrene. RESULTS: Among the baseline factors that had a significant univariable association with mortality (51%) were age (P = 0.04), symptom duration (P = 0.01), preoperative and postoperative pH and lactic acid (P < or = 0.02), history of hypertension (P = 0.001), and renal failure (P = 0.008). Symptom duration and history of hypertension were independent risk factors for mortality. Longer length of stay was univariably associated with symptom duration (P = 0.006), systemic acidosis (P < or =0.005), vascular etiology (P = 0.04), amount of resected bowel (P = 0.001), and need for second-look procedures (P <0.001). CONCLUSIONS: The presence of multiple risk factors predictive of a high mortality rate may aid more realistic decision making for physicians, patients, and family members.

Acute Disease↗

PubMed2003

The effect of craniotomy location on postoperative pain and nausea.

PURPOSE: At least one retrospective study has suggested that the need for postoperative control of pain and nausea depends on the location of the cranial surgery. This prospective study was performed to examine the hypothesis that patients who have had infratentorial craniotomy experience more severe pain and more frequent nausea than those with supratentorial procedures. METHODS: We compared postoperative outcomes in 28 patients with infratentorial craniotomy, 53 with supratentorial craniotomy, and 47 with complex spinal cord surgery (the control group). Anesthesia was standardized for all three groups and the concentration of isoflurane was titrated to keep mean arterial pressure within 30% of preoperative values. Severity of pain and frequency of nausea and vomiting were recorded for 24 h after surgery. Pain was assessed with a verbal pain score scale of 0-10, with 10 being the worst pain imaginable. Data were collected for 24 h postoperatively. RESULTS: Because nausea and pain diminish drastically 2 h after surgery, pairwise differences were assessed at each point within the first 2 h. Within 30 min of extubation, median pain scores in the supratentorial and spine groups rose to 2 and in the infratentorial group to 5. The statistical differences between groups were not significant ( P > 0.06) by logistic regression. Also, the incidence of nausea was not significantly different (57% supratentorial, 57% spine, 67% infratentorial; P = 0.62) by Dunn's procedure. CONCLUSION: There were no significant differences in the severity of pain or the frequency of nausea based on the craniotomy site.

Craniotomy↗

PubMed2003

Intracapsular tonsillar reduction (partial tonsillectomy): reviving a historical procedure for obstructive sleep disordered breathing in children.

OBJECTIVE: We sought to reintroduce a historical procedure-intracapsular tonsillar reduction (partial tonsillectomy or tonsillotomy)-for tonsillar hypertrophy causing obstructive sleep disordered breathing (OSDB) in children, as well as to determine whether partial tonsillectomy, compared with conventional (total) tonsillectomy when performed by more than one surgeon, is equally effective for the relief of OSDB while resulting in less pain and more rapid recovery. STUDY DESIGN: We conducted a retrospective case series at a tertiary children's hospital. The charts of children who underwent partial tonsillectomy and total tonsillectomy (1998 through 2002) for postoperative complications were reviewed. The caregivers were surveyed to assess postoperative pain, rapidity of recovery, and effectiveness of surgery for relieving symptoms of OSDB. RESULTS: Two hundred forty-three children underwent partial tonsillectomy and 107 children underwent total tonsillectomy. There were no significant differences in immediate and delayed complications between the groups. Both operations were equally effective in relieving OSDB. Children who had partial tonsillectomy had significantly less postoperative pain and significantly more rapid recovery. CONCLUSION: Intracapsular tonsillar reduction with an endoscopic microdebrider relieves OSDB as effectively as conventional tonsillectomy, but results in less postoperative pain and a more rapid recovery.

Child↗

PubMed2003

Association between hyperhomocysteinemia and primary pulmonary hypertension.

STUDY OBJECTIVE: This case-control study was conducted to test the hypothesis that fasting homocysteine levels are higher in PPH patients than in healthy controls. DESIGN: Levels of plasma total homocysteine, serum folate, vitamin B-12, and serum creatinine in 18 consecutive patients with PPH were compared with data from 36 age- and sex-matched controls. RESULTS: Eight of the 18 patients (44.4%) and three of the 36 controls (8.3%) had elevated plasma total homocysteine (tHcy) levels (> or = 15 mol/l, odds ratio 8.8; 95% CI: 2.0-39.6; P = 0.005). There was an inverse correlation between tHcy levels and creatinine clearance in patients with PPH (P = 0.036). CONCLUSION: PPH patients are significantly more likely to have hyperhomocysteinemia, and higher mean plasma total homocysteine levels than in controls. Plasma total homocysteine may be an important factor in the pathogenesis of PPH.

Adolescent↗

PubMed2003

Nature, frequency, and predictors of secondary procedures after endovascular repair of abdominal aortic aneurysm.

OBJECTIVES: Endovascular stent grafting offers a potentially less invasive option for treatment of abdominal aortic aneurysm. Clinical benefit has been demonstrated with respect to early parameters such as blood transfusion, return of gastrointestinal function, and length of hospital stay. Endovascular repair, however, has been criticized on the basis of inferior long-term outcome. Secondary procedures may be necessary to address durability issues such as migration, high-pressure endoleak, graft limb thrombosis, and degeneration of the stent-fabric structure itself, issues that may compromise the primary goal of aneurysm repair, protection from rupture. METHODS: Between 1996 and 2002, 703 patients underwent endovascular treatment of infrarenal abdominal aortic aneurysm at The Cleveland Clinic Foundation. During this time, five devices were used: Ancure, AneuRx, Excluder, Talent, and Zenith. Outcome was assessed with physical examination, lower extremity arterial studies, plain abdominal radiography, and computed tomography at discharge, at 1, 6, and 12 months postoperatively, and annually thereafter. Secondary procedures were defined as any procedure, exclusive of diagnostic angiography, performed after stent graft implantation, directed at treatment of aneurysm-related events. Multivariable statistical techniques for censored data (Cox proportional hazards modeling) were used to determine baseline parameters associated with need for secondary procedures over follow-up, with calculation of hazards ratio (HR) and 95% confidence interval (CI). RESULTS: Patient follow-up averaged 12.2 +/- 11.7 months. Patient survival was 90% +/- 1.4% at 1 year, 78% +/- 2.6% at 2 years, and 70% +/- 3.8% at 3 years. Aneurysm rupture occurred in 3 patients (0.4%), accounting for rupture risk of 1.4% over the first 2 years of follow-up (Kaplan-Meier method). Overall, 128 secondary procedures were required in 104 patients (15%), with a cumulative risk of 12% +/- 1.5% at 1 year, 24% +/- 2.8% at 2 years, and 35% +/- 4.4% at 3 years after stent graft implantation. Among the secondary procedures, new stent grafts and extensions were placed in 34 patients (27%), embolization of endoleak was performed in 33 patients (26%), and open surgical conversion was undertaken in 11 patients (9%). Periprocedural mortality of secondary procedures was 8% overall, but was 18% for patients undergoing open surgical conversion. Multivariable modeling identified the date the procedure was performed (HR, 1.53 per 3-month period of study; CI, 1.22-1.92; P <.001) and aneurysm size (HR, 1.35 per centimeter of minor axis; CI, 1.13-1.60; P <.001) as independent predictors of need for secondary procedures. CONCLUSIONS: Current endovascular devices are associated with a relatively high rate of complications over mid-term follow-up, culminating in frequent need for secondary remedial procedures. With strict follow-up imaging compliance, however, risk for rupture and aneurysm-related death remain exceedingly low. Newer technology may achieve improved durability and a lower requirement for secondary procedures, while maintaining the minimally invasive nature of presently available devices.

Aged↗

PubMed2002

Intracapsular partial tonsillectomy for tonsillar hypertrophy in children.

OBJECTIVE: To review our experience with intracapsular tonsillectomy using powered instrumentation in the management of tonsillar hypertrophy causing obstructive sleep-disordered breathing in children. STUDY DESIGN: Retrospective case series. METHODS: Intracapsular tonsillectomy, a form of partial tonsillectomy performed with an endoscopic microdebrider, preserves the tonsillar capsule as a barrier to exposure of the pharyngeal muscles. Results in 150 children who underwent this procedure were compared with those in 162 children who had standard tonsillectomy. RESULTS: Children who underwent intracapsular tonsillectomy had significantly less pain throughout the recovery period than those who had standard tonsillectomy. There was no significant difference between the two groups in intraoperative blood loss, and no episodes of immediate postoperative bleeding occurred in either group. Six patients who had the standard operation and one patient who had the intracapsular procedure had delayed hemorrhage requiring hospital readmission. Five children in the standard group and one in the intracapsular group were readmitted because of dehydration. Thus, in all, 11 readmissions were necessary among children who underwent standard tonsillectomy, whereas 2 were required among those who had intracapsular tonsillectomy. CONCLUSION: Intracapsular tonsillectomy is as effective as standard tonsillectomy in relieving obstructive sleep-disordered breathing but produces less postoperative pain and fewer episodes of delayed hemorrhage and dehydration.

Case-Control Studies↗

PubMed2002

A prospective, randomized study of saphenous vein patching versus synthetic patching during carotid endarterectomy.

OBJECTIVE: The objective of this study was the determination of whether the choice of either autogenous saphenous vein (ASV) or synthetic material for patch angioplasty significantly influences the results after carotid endarterectomy (CEA). METHODS: With Institutional Review Board approval, 195 patients (145 men and 50 women; mean age, 69 years) who underwent 207 CEAs were prospectively randomized to arteriotomy closure with ASV or synthetic patches from July 1996 to January 2000. One hundred and one patients (52%) were randomized to the ASV cohort, and 94 (48%) were randomized to the synthetic cohort. Aside from a slight gender imbalance (70% versus 79% male in the ASV versus the synthetic group), there were no clinically important differences in baseline demographic variables, risk factors, or surgical indications between the ASV and synthetic groups. RESULTS: With all 207 randomized procedures on an intent-to-treat basis, there were two early (<30 days) postoperative deaths (1%). There were three perioperative strokes in the ASV cohort (3.0%) and two in the synthetic cohort (2.1%; P =.99). Two of these early strokes occurred in a subset of nine patients who received neither patch material, all after randomization but before CEA. Two patients in each group had late strokes. The cumulative freedom from stroke rate at 1 year (ASV, 94%; synthetic, 95%) was virtually identical for both cohorts. With the 125 patients who had at least one postoperative duplex scan, the incidence rate of recurrent (>or=60%) carotid stenosis was 4.8% (three of 62) for the ASV group and 6.3% (four of 63) for the synthetic group (P =.99). CONCLUSION: No significant differences in the stroke, mortality, or restenosis rates were shown between the ASV and the synthetic cohorts. While conceding the power limitations inherent in this study, we conclude that CEA may be safely performed with similar early results with ASV or synthetic patches.

Aged↗

PubMed2002

Gender as a primary predictor of outcome after carotid endarterectomy.

OBJECTIVE: Post hoc analysis results of the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study suggest that carotid endarterectomy (CEA) may not be as efficacious in women as it is in men. This study was undertaken for the evaluation of whether there is a difference between men and women in early postoperative outcome after CEA and whether such a difference is consistent across other predictors. METHODS: We conducted a retrospective review of all CEAs entered into our departmental registry between January 1, 1989, and November 30, 2000. A total of 3422 CEAs was performed in 3077 consecutive patients. The ratio of men to women was 2:1, and the ratio of patients who were asymptomatic to patients who were symptomatic was 2.3:1. The following in-hospital outcome data were analyzed: transient ischemic attack (TIA), stroke, mortality, combined TIA or stroke, and combined stroke or mortality. Univariate and multivariate analysis results of selected risk factors for an adverse perioperative event were assessed with generalized estimating equation analysis with backwards selection. The following risk factors were considered: gender, preoperative neurologic status, urgency of operation, type of arteriotomy repair, reoperative CEA for recurrent stenosis, history of cardiopulmonary disease, previous coronary artery intervention, simultaneous CEA and coronary bypass grafting surgery, renal failure, and diabetes. RESULTS: Univariate analysis results of gender differences revealed that women were at higher risk for a postoperative TIA or stroke (3.3% for women versus 2.1% for men; odds ratio [OR], 1.6; confidence interval [CI], 1.04 to 2.5; P =.03) and for postoperative stroke or mortality (3.1% for women versus 2.1% for men; OR, 1.6; CI, 1.04 to 2.5; P =.03). Multivariate analysis results showed that female gender was an independent predictor for a postoperative TIA or stroke (OR, 1.7; CI, 1.1 to 2.6; P =.03). Further analysis disclosed that women who were asymptomatic were at greater risk than were men for postoperative stroke or mortality (OR, 2.3; CI, 1.3 to 3.9; P =.003). Conversely, there was no gender association for postoperative stroke or mortality in the consideration of only patients who were symptomatic (OR, 1.0; CI, 0.45 to 2.1; P =.95). The interaction between women and preoperative symptoms approached significance (P =.07) with respect to postoperative stroke and mortality rate, which suggests that the gender effect could be influenced by the clinical presentation. CONCLUSION: The combined TIA or stroke and stroke or mortality rates are higher in women as compared with men in the postoperative period, but these risks remain acceptable when CEA is performed for appropriate indications. The interaction between symptoms and gender suggests that, in patients who are asymptomatic, women are more likely than are men to have early complications. However, there is no gender difference in patients who are symptomatic. Therefore, despite a low postoperative complication rate, CEA is appropriate in both women who are asymptomatic and women who are symptomatic only if the postoperative TIA, stroke, and mortality rates are appreciably lower than in the natural history of medical management of these patients.

Aged↗

PubMed2002

Open infrarenal abdominal aortic aneurysm repair: the Cleveland Clinic experience from 1989 to 1998.

PURPOSE: The purpose of this study was to determine the safety and durability of traditional surgical treatment for asymptomatic infrarenal abdominal aortic aneurysms (AAAs) in a large series of patients who underwent open operations during the decade preceding the commercial availability of stent graft devices for endovascular AAA repair. METHODS: From 1989 to 1998, 1135 consecutive patients (985 men [87%], 150 women; mean age, 70 +/- 7 years) underwent elective graft replacement of infrarenal AAA. Computerized perioperative data have been supplemented with a retrospective review of hospital charts/outpatient records and a telephone canvass to calculate survival rates and the incidence rate of subsequent graft-related complications. Seventy-four patients (6.5%) were lost during a median follow-up period of 57 months for the entire series. RESULTS: The 30-day mortality rate was 1.2%. The hospital course was completely uneventful for 939 patients (83%), and the median length of stay for all patients was 8 days. A total of 196 patients had single (n = 150; 13%) or multiple (n = 46; 4%) postoperative complications, which were more likely to occur in men (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.1 to 5.2) and in patients with a history of congestive heart failure (OR, 3.7; 95% CI, 1.7 to 7.8), chronic pulmonary disease (OR, 1.9; 95% CI, 1.2 to 2.9), or renal insufficiency (OR, 2.5; 95% CI, 1.3 to 4.7). Kaplan-Meier method survival rate estimates were 75% at 5 years and 49% at 10 years. As was the case with early complications, the long-term mortality rate primarily was influenced by age of more than 75 years (risk ratio [RR], 2.2; 95% CI, 1.7 to 2.8) or previous history of congestive heart failure (RR, 2.1; 95% CI, 1.3 to 3.4), chronic pulmonary disease (RR, 1.5; 95% CI, 1.2 to 2.0), or renal insufficiency (RR, 3.2; 95% CI, 2.2 to 4.6). Of the 1047 patients who survived their operations and remained available for follow-up study, only four (0.4%) have had late complications that were related to their aortic replacement grafts. CONCLUSION: These results reconfirm the exemplary success of open infrarenal AAA repair. The future of endovascular AAA repair is exceedingly bright, but until the long-term outcome of the current generation of stent grafts is adequately documented, their use should be justified by the presence of serious surgical risk factors.

Aged↗