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Biomedical subjects

G Da Giau

Publications and source records attributed to G Da Giau.

15 recordsLinked to original sources
PubMed2001

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.

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PubMed2000

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 morphology and the patient's 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 = 0.008) or prior stroke (P = 0.006) patients than in the asymptomatic group. When IH was considered 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 = 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.

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PubMed2000

Carotid endarterectomy in women: early and long-term results.

BACKGROUND: Although many randomized trials and other multicenter studies have demonstrated the benefits of carotid endarterectomy (CEA) in selected symptomatic and asymptomatic patients, including women, there is a remarkable lack of reports regarding the outcome of CEA with respect to sex. To analyze and compare the outcome of CEA in men and women in a single-group experience, we reviewed a consecutive series of 619 CEAs performed in 539 patients, 371 men (423 CEAs) and 168 women (196 CEAs). METHODS: Data collection was retrospective up to August 1, 1992 and prospective for all 405 patients treated thereafter. RESULTS: Women were significantly less likely than men to have overt evidence of coronary artery disease (P < .001) and had a significantly higher incidence of diabetes (P < .001). No perioperative death occurred in the female group (P = NS), and no statistical difference was found in perioperative stroke risk incidence. Women had a significantly higher incidence of late occlusive events (P = .01), which were all asymptomatic. No late stroke occurred in the female group (P = NS). Life-table cumulative survival rates at 1, 3, 5, and 7 years were 99.3%, 90.5%, 85.9%, and 82.3%, respectively, in women, and 98.9%, 91.9%, 85.2%, and 79.6% in men (log-rang P = .8). CONCLUSIONS: These findings show that perioperative stroke risk and mortality rates, as well as late stroke-free, mortality, and recurrence rates, in patients undergoing CEA, are comparable in men and women. Further, larger comparative studies are necessary to provide more information on the benefit and durability of CEA in asymptomatic patients, but the results of this study suggest that the early and late outcomes are excellent and comparable in symptomatic and asymptomatic men and women.

Adult↗
PubMed2000

A prospective randomized study on bilateral carotid endarterectomy: patching versus eversion.

OBJECTIVE: To compare the clinical outcome and restenosis incidence of patients who underwent carotid endarterectomy with patch closure (CEAP) on one side and carotid eversion endarterectomy (CEE) on the other. SUMMARY BACKGROUND DATA: Although a few investigators have compared the results of CEAP versus CEE, no reports have compared the outcome of CEAP versus CEE in the same patient. METHODS: Eighty-six patients were randomly selected for sequential surgical treatment involving either CEAP/CEE or CEE/CEAP. All patients underwent postoperative duplex ultrasound study and clinical follow-up at 1, 6, and 12 months and every year thereafter. Various factors were analyzed to ascertain any association with restenosis, and Kaplan-Meier analysis was used to estimate the risk of restenosis. RESULTS: Demographic and clinical data were similar in the CEAP and CEE groups. The selective shunting rate was statistically higher in the CEAP group. There were no perioperative deaths. Although the incidence of perioperative ipsilateral stroke was not significant, CEAP patients had a rate of combined transient ischemic attacks and strokes that approached statistical significance. The mean follow-up was 40 months. CEAP patients had a significantly higher incidence of restenosis and combined occlusive events and restenoses. Kaplan-Meier analysis showed that CEE had a significantly better cumulative patency rate than CEAP and that freedom from restenoses at 24 and 36 months was 87% and 83% for CEAP and 98% and 98% for CEE, respectively. CONCLUSIONS: CEE is less likely to cause perioperative neurologic complications and restenoses than CEAP. The significantly higher rate of unilateral recurrence suggests that local factors play a more important role than systemic factors in the occurrence of restenosis.

Adult↗
PubMed1999

Carotid endarterectomy in symptomatic and asymptomatic patients aged 75 years or more: perioperative mortality and stroke risk rates.

The aim of this retrospective study was to determine whether age per se constitutes a contraindication to surgery in the elderly patient undergoing carotid endarterectomy (CEA) with regard to operative mortality and stroke risk morbidity. During an 8-year period, 96 patients aged 75 years or more underwent 103 CEAs. The age range was 75 to 89 years, with a median age of 79 and a mean age of 79.4 years. Fifty-nine CEAs with patch closure and 44 carotid eversion endarterectomies and reimplantation were performed for symptomatic (70.9%) and asymptomatic (29.1%) carotid lesions under general anesthesia and with continuous perioperative electroencephalographic (EEG) monitoring. In light of the efficacy and success achieved in this experience, advanced age does not seem in itself to contraindicate the performance of CEA; the surgical risk for elderly patients appears sufficiently low to justify the operation. A more aggressive approach may be warranted in elderly patients because of the morbidity and cost of the disease that it effectively prevents.

Age Factors↗
PubMed1999

Elective surgery for small abdominal aortic aneurysms.

BACKGROUND AND PURPOSE: Surgical repair for abdominal aortic aneurysm has become more frequent and the mortality associated with elective surgery has been reduced, but the overall mortality for ruptured aneurysm remains unacceptably high. The dilemma for the vascular surgeon is whether to operate early and electively on asymptomatic small aneurysms, less than 5 cm in diameter, or to delay surgery, adopting a wait-and-see attitude. The purpose of this retrospective study was to review a recent 5-year experience of elective aneurysm surgery, with special emphasis on the perioperative outcome of surgical repair of asymptomatic small aneurysms, in order to evaluate whether early mortality and morbidity justify an aggressive approach. METHODS: The report concerns a series of 141 consecutive patients who underwent aneurysm repair for small (n = 65, group I) and large aneurysms (n = 76, group II). For each group, the age, sex, risk factors and associated diseases, operative and aortic cross-clamping times, estimated blood loss, blood transfusion volume, type of operation and graft, perioperative morbidity and mortality, and causes of death were recorded and compared. RESULTS: The majority of patients were males. The mean age of the patients was lower in group I than in group II. No statistically significant difference was found from the comparison of the risk factors and associated diseases in groups I and II. The mean operating time was 82 minutes in group I, 98 minutes in group II, and the aortic cross-clamping time was also shorter in group I (37 min versus 52 min), whereas blood loss was greater, with a statistically significant difference (P < 0.05). The operative mortality rate was higher in group II than in group I (1.3% versus 0%, P = NS). CONCLUSIONS: Elective small aneurysm repair is recommended in good-risk patients for the following reasons: (i) the operative mortality and morbidity rates are lower in small than in large aneurysm patients, and (ii) the small aneurysm repair is technically easier and safer to perform. In addition, there are two other considerations that are more difficult to quantify, but may support an aggressive approach: the cost-benefit ratio is better with early diagnosis and elective surgery, before an emergency operation is required, and personal choice and psychological reasons can induce patients to prefer early elective repair to periodic monitoring by ultrasound or computed tomography scans.

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PubMed1999

Carotid endarterectomy without angiography: can clinical evaluation and duplex ultrasonographic scanning alone replace traditional arteriography for carotid surgery workup? A prospective study.

BACKGROUND: The aim of this study was to determine whether clinical evaluation and duplex ultrasonography (DUS) alone can replace contrast cerebral arteriography (CA) for the detection of patients suitable for surgery at our institution. METHODS: During an 18-month period, 100 patients underwent DUS and CA during evaluation for carotid endarterectomy (CEA). All patients were studied prospectively; in each case an initial decision for or against CEA on the basis of DUS evaluation of the internal carotid arteries (ICAs) was subsequently compared with the surgeon's final management plan after CA. Of the 200 ICAs evaluated, 113 were considered for CEA but 14 were excluded from the study because the patient could not be evaluated before and after CA. This left 99 ICAs (86 patients) available for comparative analysis. RESULTS: The outcome of the 2 diagnostic modalities was perfectly consistent in 95.3% of the ICAs (kappa = 0.969). The clinical management decision was altered by the CA findings in only 2 cases (2%). Of the 99 ICAs considered suitable, 97 underwent CEA. No arteriographic complications occurred among the 100 patients undergoing CA. The perioperative stroke risk and mortality rates were 0%. CONCLUSIONS: Ninety-eight percent of the ICAs considered for surgery would have received appropriate clinical treatment on the strength of the patients' neurologic history and the outcome of DUS alone. Our results indicate that DUS is sufficient to establish the need for surgery in symptomatic and asymptomatic patients being considered for CEA and can replace CA in most clinical circumstances.

Carotid Artery, Internal↗
PubMed1999

Carotid endarterectomy with patch closure versus carotid eversion endarterectomy and reimplantation: a prospective randomized study.

BACKGROUND: Although carotid eversion endarterectomy (CEE) has obtained consensus providing excellent early and late results, conventional carotid endarterectomy (CEA) with or without patching continues to be considered the gold standard surgical procedure. The few studies published to date comparing CEE with CEA in a small series of patients have failed to show substantial advantages of one technique over the other, and further randomized comparative studies are still required. The purpose of this study was to compare the outcome of CEA with routine patch closure (CEAP) with that of CEE and reimplantation (CEER) of the internal carotid artery in the common carotid artery. METHODS: Three hundred thirty-six primary CEAs performed in 310 patients were randomized into 2 groups, 167 CEAPs and 169 CEERs. Surviving patients underwent duplex ultrasound scan control at 30 days, 6 months, 12 months, and every postoperative year thereafter. The mean follow-up was 34 months (range, 1 to 69 months). Demographic characteristics, risk factors, associated diseases, and indications for surgery were comparable in the 2 groups. RESULTS: Although the rate of intraoperative electroencephalogram changes was comparable in the 2 groups, the incidence of shunting was statistically higher in the CEAP group (28.1% vs 1.2%, P < .00001). The carotid cross-clamping time was significantly lower in the CEER group (P = .01). Although all deaths were in the CEAP group, the overall perioperative death and stroke-related death rates were comparable in the 2 groups. The perioperative stroke rate was statistically higher in the CEAP group (2.9% vs 0%, P = .03). Although the recurrent stenosis rate was comparable in the 2 groups (1.2% vs 0%), the CEAP group had a statistically higher rate of combined recurrent stenoses and occlusions (4.9% vs 0%, P = .003). The late mortality rate was similar in both groups. CONCLUSIONS: Although the outcome of CEAP in this series is consistent with that of the main reported trials, the CEER procedure is less likely than CEAP to cause perioperative stroke and death and seems superior in reducing the incidence of recurrent stenosis and late occlusive events.

Adult↗
PubMed1999

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

BACKGROUND: This study was undertaken to analyze whether there is a relationship between the elongation of the internal carotid artery (e-ICA) and abdominal aortic aneurysm (AAA). METHODS: Forty-three patients had concomitant evidence of an asymptomatic AAA and e-ICA: all of these patients underwent surgical AAA repair, while 25 (58.1%) also underwent surgical e-ICA correction. The 43 patients were compared with a control group of 141 e-ICA subjects with no AAA as regards to age, gender, risk factors and associated diseases. An operative specimen of the aneurysmal wall was obtained in 32 instances (74.2%); an operative specimen of the carotid wall was obtained in 100% of operations. RESULTS: The overall perioperative mortality rate was 0%. Patency of the revascularized ICA was assured in 100% of cases. The perioperative stroke risk rate was 0%. The perioperative morbidity rate for abdominal surgery was 6.9% (3/43). There were three late deaths: one patient died from a major stroke due to occlusion of the unoperated e-ICA. Degenerative dysplastic changes were observed in the tunica media in all carotid specimens; non-obstructive atherosclerotic intimal lesions were superimposed in a few cases. Histological features of "classic" AAA, i.e. thinning of the tunica media underlying the atherosclerotic plaque, were discovered in all but five aortic wall specimens. CONCLUSIONS: The association between e-ICA and AAA is stronger than one would expect from atherosclerosis alone and should not be ignored. A primary arterial disorder of the tunica media seems to lie at the basis of both conditions, so patients with e-ICA should be investigated and followed up for any occurrence of AAA and, vice versa, patients with AAA should be investigated for any presence of e-ICA. On the basis of the results obtained, surgical repair of both conditions is recommended in selected patients.

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PubMed1999

Early and late outcomes of young patients after carotid endarterectomy.

BACKGROUND AND PURPOSE: Carotid atherosclerotic disease in young adults is uncommon but may be more virulent and diffuse than in older patients. Although few studies have well established that carotid endarterectomy (CEA) is of benefit for high-grade asymptomatic lesions and for moderate- and high-grade symptomatic lesions, the safety and durability of CEA in the young remain controversial. The aim of this study was to compare CEA outcome in young people with outcome in an older control group. METHODS: Thirty-five patients up to 50 years old (mean 46.5 +/- 0.5 years) and undergoing 42 CEAs were compared with a randomly selected group of 50 patients more than 60 years old (mean 68.7 +/- 0.4 years) and undergoing 55 CEAs during the same period. Data were obtained on demographics, atherosclerotic risk factors, indications for surgery, perioperative outcome, recurrent stenosis and symptoms, late stroke, and survival. RESULTS: Smoking (P < .001), alcohol consumption (P < .001), and lower levels of high-density lipoprotein cholesterol (P = .02) were more prevalent in the young patients, who were also more likely to be symptomatic at presentation (P < .001) with a higher incidence of stroke (P = .01) and contralateral carotid occlusion (P = .04). The perioperative stroke risk and mortality rates were nil for the young group. During a mean follow-up of 47 +/- 40 months, there were no significant differences between the 2 groups in survival, symptom recurrence, stenosis recurrence, and reoperation rates. Young patients had a higher incidence of contralateral disease requiring surgery (P = .04). CONCLUSIONS: These findings show that CEA may be performed in young adults with an excellent perioperative outcome; recurrence, late stroke, and survival rates do not differ significantly from those observed among their older counterparts.

Age Factors↗
PubMed1999

Cranial and cervical nerve injuries after carotid endarterectomy: a prospective study.

BACKGROUND: The purpose of this study was to review the outcome of patients who had cranial and cervical nerve injuries after carotid endarterectomy (CEA). METHODS: This prospective study reviewed 200 consecutive CEAs. Preoperative and postoperative cranial nerve assessment was completed on all patients. Neurologic evaluation included routine direct fiberoptic laryngoscopy. Patients found to have no neurologic injury had no further follow-up. Patients with postoperative peripheral neurologic dysfunction were enrolled for regular long-term follow-up to assess delayed recovery. RESULTS: Overall, 25 (12.5%) nerve injuries were identified in 24 patients. There were 11 (5.5%) hypoglossal, 8 (4%) recurrent laryngeal, 2 (1%) superior laryngeal, 2 (1%) marginal mandibular, and 2 (1%) greater auricular nerve injuries. None of the patients were lost to follow-up. All nerve dysfunctions were transient, with all but 4 nerves recovering completely within 6 months. The recovery took from 1 week to 37 months, with a mean recovery time of 5.8 months. Two patients with recurrent laryngeal nerve dysfunction were found to have prolonged full recovery time (i.e., 31 and 37 months, respectively). Two patients successfully underwent contralateral CEA, although movement of the opposite vocal cord was not fully restored. CONCLUSIONS: Cranial nerve injury after CEA is a common occurrence and can be classified as a "major" or "minor" complication, depending on the severity of the clinical consequences. Extended follow-up will identify the specific subset of patients with a late complete nerve recovery.

Adult↗
PubMed1998

Carotid endarterectomy and contralateral internal carotid artery occlusion: perioperative risks and long-term stroke and survival rates.

BACKGROUND: The aim of this article was to analyze the perioperative mortality and stroke risk rates and late benefits of carotid endarterectomy (CE) contralateral to an occluded internal carotid artery (ICA), on the basis of our surgical experience from July 1990 to June 1996. METHODS: In 57 (14.7%) of 336 patients undergoing 388 CEs, the contralateral ICA was occluded (group I). All operations were performed under general anesthesia with selective shunting based on electroencephalographic criteria. Shunting was used in 36 (63.1%) of 57 revascularizations in group I and 47 (14.2%) of 331 operations performed on the remaining 279 patients with patent contralateral ICAs (group II) (p < 0.001). RESULTS: Perioperative strokes occurred in two patients (3.5%) in group I and three patients (1%) in group II (difference not significant). The only perioperative death, which occurred in one patient (1.7%) in group I, was the result of a perioperative stroke; two patients (0.7%) in group II died within 30 days of operation (difference not significant). Life-table cumulative stroke-free rates at 1, 3, and 5 years were 95%, 95%, 95% in group I and 98.8%, 98.2%, and 98.2% in group II, respectively (p = 0.272). Life-table cumulative survival rates at 1, 3, and 5 years were 97.5%, 94.2%, and 78.1% in group I and 99.2%, 94.8%, and 71.7% in group II, respectively (p = 0.306). CONCLUSIONS: The results of this analysis indicate that CE contralateral to an occluded ICA can be performed with acceptable perioperative mortality and stroke risk rates and late stroke-free and survival rates comparable to those seen in patients without contralateral ICA occlusion who have undergone operation. Nevertheless, we think it is misleading to imply that the risks of operating on the two groups are the same. Moreover, because no late stroke-related death occurred in patients with contralateral ICA occlusion, it would appear that superior late stroke-free rates did not translate into a prolonged survival advantage.

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PubMed1997

Carotid eversion endarterectomy and reimplantation: a safe and simple technique to prevent acute thrombosis-occlusion and/or early and late restenosis.

The purpose of this report is to consider the technical aspects of carotid eversion endarterectomy and reimplantation into the common carotid artery for surgical treatment of atherosclerotic occlusive disease, in light of previous early and late results. In the past 2 years, the authors have more frequently used carotid eversion endarterectomy and reimplantation to minimize the risk of perioperative stroke due to acute occlusion-thrombosis, and the incidence of early and late restenosis. Some 88 patients underwent 95 carotid eversion endarterectomies and reimplantation (seven bilateral): 59 internal carotid arteries were surgically corrected for ischaemic symptoms while 36 patients were symptomless but presented with a haemodynamically significant stenosis at the internal carotid artery bifurcation. The ischaemic preoperative symptoms consisted of one or more transient ischaemic attack's in 39 patients (66%), amaurosis fugax in 15 (25%) and mild stroke in five (8%). Associated elongation of the internal carotid artery beyond the end of the plaque was present in 81 cases (85%). After freeing the internal carotid artery sufficiently beyond the distal limit of the lesion, the vessel was transected obliquely to its origin, the extramedial cleavage plane opened and the endarterectomized arterial wall everted beyond the natural end of the plaque, which was gently removed. The artery was dilated distally and finally reimplanted end-to-side into the common carotid artery, 1-2 cm or more above the original site. This technique has provided excellent early and late results: no deaths, no acute thrombosis-occlusion, no minor or major stroke occurred perioperatively. No restenosis, no symptomless or symptomatic late occlusion was found during late follow-up (mean 28 (range 6-44) months). The performance of this vascular technique must be encouraged and recommended because of its speed, effectiveness and success. Carotid eversion endarterectomy and reimplantation should be performed routinely when the internal carotid artery is elongated.

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