Carotid endarterectomy: despite the NASCET report, the controversy is not over.
Explore the source record for details and available documents.
Carotid Stenosis↗
Biomedical subjects
H H Trout
Publications and source records attributed to H H Trout.
Arteriovenous fistula simulating arteriovenous malformation.
A 36-year-old man was thought (for 20 years) to have an arteriovenous malformation that could not be excised. Repeated ligations of proximal arterial supply to the vascular lesion were only transiently beneficial and may have caused a delay in correct diagnosis because of impaired angioaccess. Once it was discovered that he had an arteriovenous fistula--probably caused by a tonsillectomy at age 6--it was possible to occlude the fistula with detachable balloons. The mass and his headaches subsequently resolved. AV fistulas are caused by trauma. Growth of AVMs is often stimulated by trauma. Both lesions have pulsatile masses associated with overlying bruits. The differential diagnosis can usually be made by arteriography, since AV fistulas are acquired lesions with a single communication between an artery and a vein, whereas AVMs are congenital lesions with multiple, large arterial feeding vessels and numerous arteriovenous communications. Proper diagnosis is important, since AVMs are aggressive lesions that tend to regrow if not completely excised. AV fistulas will be cured if the single arteriovenous communication can be obliterated. Proper treatment for AV fistula is obliteration of the single arteriovenous communication, operatively or with occlusive balloons; treatment of AVMs--when possible--is excision of the entire mass, combined (on occasion) with preoperative embolization of the tumor mass. This case report emphasizes the importance of accuracy in the differential diagnosis between arteriovenous malformations and arteriovenous fistulas; moreover, it demonstrates both the ineffectiveness and deleterious consequences of proximal arterial ligation, since collateral development is enhanced and angiographic access is compromised.
Adolescent↗
Management of patients with hemangiomas and arteriovenous malformations.
Hemangiomas and AVMs are distinct congenital, benign, vascular lesions. Differentiation between the two is important because AVMs are amenable to embolization techniques and because patients with hemangiomas can be told they have a better prognosis than those with AVMs. A major error of management is to ligate the arterial blood supply to an AVM proximally, as the lesion will continue to grow, more collateral vessels will develop, and future angioaccess for purposes of evaluation or embolization will be denied. With care and prudence, many of these lesions can be successfully excised, or at least managed, so that the effect of these sometimes devastating lesions can be ameliorated.
Adult↗
Anomalies of the inferior vena cava.
The inferior vena cava is formed by a complex process of embryogenesis during the sixth to tenth week of gestation. Improper completion of the process may result in four anatomic anomalies: duplication of the inferior vena cava, transposition or left-sided inferior vena cava, retroaortic left renal vein, and circumaortic left renal vein. The first two anomalies can be diagnosed by sonography and all four anomalies can be seen on CT scan of the abdomen. Duplication and transposition of the inferior vena cava should be further delineated by preoperative phlebography. Preoperative diagnosis of the anomalies should reduce the complication rate of abdominal aortic operations.
Aged↗
Regional nerve block for femoropopliteal and tibial arterial reconstructions.
Thirteen high-risk patients underwent lower extremity revascularization anesthetized with a regional nerve block technique. The sciatic, femoral, and obturator nerves were infiltrated with 1% lidocaine and 0.25% bupivacaine. Eight femoropopliteal and five femorotibial bypasses were performed for limb salvage (11 patients), disabling claudication (one patient), and popliteal artery aneurysm (one patient). Analgesia was adequate with only one patient who needed supplemental nitrous oxide. One patient died on the sixth postoperative day of a myocardial infarction. Regional nerve block is an effective anesthetic technique that should be considered if general or spinal anesthesia is inappropriate.
Adult↗
Transperitoneal approach and right retroperitoneal dissection for abdominal aortic aneurysm.
Most abdominal aortic aneurysms can be resected through a standard transperitoneal approach. In patients with large aneurysms, supra-renal extension of the aneurysm, those requiring renal reconstructive procedures and in patients who have had previous extensive intra-abdominal operations, alternative approaches have been recommended. We exposed the abdominal aorta in ten of these difficult patients using a midline transperitoneal incision and right retroperitoneal dissection that provided excellent exposure of the suprarenal aorta. We recommend this technique for performance of complicated abdominal aortic aneurysm resections.
Aorta, Abdominal↗
Stimulation of gastric acid secretion in the rhesus monkey.
Similar maximal rates of gastric acid secretion are achieved with histamine and gastrin stimulation in human, dog, or cat, but gastrin produces higher rates than histamine in the rat. Gastric acid secretion was measured in seven nonsedated, alert, chaired rhesus monkeys (Macaca mulatta). Dose-response studies were performed using intravenous histamine or tetragastrin. These studies showed histamine to be a much more efficacious and more potent stimulant of gastric acid secretion than tetragastrin in the monkey. Both histamine and tetragastrin had similar potency and efficacy in the dog, while tetragastrin, pentagastrin, and hog heptadecapeptide were similarly less active than histamine in the monkey. Background carbachol (4 micrograms/kg/hr) did not affect the histamine or tetragastrin dose-response curves. Histamine stimulation with background tetragastrin (64 micrograms/kg/hr) did not produce a dose-response curve statistically different from histamine alone. Tetragastrin stimulation with background histamine (60 micrograms/kg/hr) increased the tetragastrin dose-response curve, with a probable additive effect. We conclude that the rhesus monkey differs from cat, dog, and man in that gastrin and its analogs are not able to stimulate maximal acid secretion to the level achieved by histamine.
Animals↗
Treatment of carotid sinus hypersensitivity.
Explore the source record for details and available documents.
Carotid Artery Diseases↗
Vascular malformations.
Fourteen patients with hemangiomas or arteriovenous malformations treated with operative management are described. Particular emphasis is placed on the definition of terms and the methods of differentiating arteriovenous fistulas, hemangiomas, and arteriovenous malformations. Arteriovenous fistulas are acquired lesions consisting of a single communication. Hemangiomas are congential lesions that rarely pulsate or have an associated bruit; moreover by angiography they have multiple small feeding arterial vessels and histologically are composed of numerous thin-walled, but normal-appearing, blood vessels. Arteriovenous malformations are also congenital but they pulsate and have associated bruits; furthermore on angiography they have a number of larger arterial feeding vessels and histologically are composed of abnormal dysplastic vessels. Operative management of all lesions should be carefully planned and executed. Arteriovenous malformations and skeletal muscle hemangiomas will have a tendency to recur if not completely excised.
Adolescent↗
Timing of carotid artery endarterectomy after stroke.
Carotid endarterectomy has been advocated to prevent further neurologic deterioration in patients who have had a stroke. Previous reports have shown that endarterectomy within 2 weeks of a stroke is associated with high morbidity and mortality rates presumably from hemorrhagic complications in the brain. Some recommend a 2- to 6-week waiting period after a stroke, but the safety of operation in the interval of time beyond 2 weeks has not been documented in the literature. The present study investigated the morbidity and mortality rates of 352 consecutive carotid endarterectomies. Three hundred three endarterectomies were performed on patients with symptoms other than stroke. Forty-nine endarterectomies were performed on patients with a deficit lasting more than 24 hours. Of these, 27 carotid endarterectomies were performed in an interval less than 5 weeks after initial stroke (early interval) and 22 operations were performed in a 5- to 20-week interval after stroke (late interval). Five strokes occurred in the 27 patients operated on within 5 weeks, an incidence of 18.5%; none of the patients operated on after 5 weeks exhibited worsening of their preoperative neurologic status. With the use of Fisher's exact test to compare these two intervals, the results were found to be significant (p less than 0.05). The cause of stroke in those operated on in the early interval was investigated by postoperative CT scans; in only one instance was there a hemorrhagic infarct of the ipsilateral hemisphere. The literature suggests that a variety of intracerebral vascular changes render the brain more susceptible to reinfarction soon after stroke. This study suggests an unstable situation in the 5-week interval following stroke that contraindicates carotid endarterectomy.
Adult↗
Lytic therapy in the treatment of axillary and subclavian vein thrombosis.
The importance of individualized treatment of patients with primary and secondary axillary-subclavian vein thrombosis is described with special emphasis on the use of thrombolytic therapy. Nine patients were treated with streptokinase or urokinase. Balloon dilation of the axillary or subclavian vein and first rib resection were also selectively used. Of the five patients with primary axillary-subclavian thrombosis, three did not have symptoms after the thrombus was lysed. Two had successful lysis of the thrombus but later suffered a rethrombosis, one of which most likely resulted from an untreated stenosis. All four of the patients with secondary thrombosis had successful thrombolysis. Patients with primary axillary-subclavian thrombosis are usually young and as many as 40% continue to have intermittent upper extremity edema or pain. For this reason we believe aggressive attempts to reestablish normal venous return through the axillary and subclavian veins are warranted. Patients with secondary axillary-subclavian thrombosis usually require prolonged venous catheterization for chemotherapy or total parenteral nutrition. Since patency of major upper extremity veins is extremely important in these patients with secondary thrombosis, we believe that vigorous attempts to restore these venous access routes are indicated and appropriate.
Adult↗
Priority of revascularization in patients with graft enteric fistulas, infected arteries, or infected arterial prostheses.
Patients with arterial infections, infected arterial prostheses, or graft enteric erosions or fistulas have high amputation and mortality rates after treatment. An unresolved therapeutic question is whether remote ("extra-anatomic") bypass should precede or follow removal of the infected artery or prosthesis. None of the ten patients reported here who had a remote bypass inserted first developed distal limb ischemia or infection of the remote bypass. Literature review of patients with aortic prosthetic infections revealed a mortality of 71% (10/14) if infected graft removal preceded remote bypass and 26% (6/23) if remote bypass was first. Patients with graft enteric erosions or fistulas had a mortality of 53% (40/75) if graft removal was first and 17% (5/29) if remote bypass was first. Subsequent infection of the remote bypass was rare. Therefore, when possible, remote bypass with a prosthetic graft should precede removal of an infected artery, an infected arterial prosthesis, a graft enteric erosion, or a graft enteric fistula.
Aged↗
The use of fluoroscopy with the C arm for femoral arterial embolectomy and cannulation of the popliteal trifurcation vessels.
Fluoroscopy with the C arm allows for the immediate assessment of distal arterial circulation following embolectomy. With the use of two embolectomy catheters, each one of the trifurcation vessels can be separately cannulated to remove additional thrombus. The technique described is not difficult and adds little time to the operative procedure.
Catheterization↗
Ulcer recurrence, morbidity, and mortality after operations for duodenal ulcer.
Due to fear of duodenal ulcer recurrence, PGV is not yet accepted by most surgeons in the United States as a satisfactory operation for treatment of intractable duodenal ulcer. Currently PGV has a 30 day operative mortality of 0.3 percent, a severe morbidity of 1 percent, and a long-term ulcer recurrence rate of about 11 percent. Truncal vagotomy and pyloroplasty has a mortality of 0.7 percent, a morbidity of 5 percent, and a recurrence rate of about 10 percent. Truncal vagotomy and antrectomy has a mortality of 1 percent, a morbidity of 5 percent, and a recurrence rate of about 2 percent. Thus, PGV is preferable to vagotomy and pyloroplasty since vagotomy and pyloroplasty has higher mortality and morbidity rates. The recurrence rate is similar. Furthermore, since postoperative morbidity is more difficult to manage than ulcer recurrence, a cogent argument can be made that PGV is superior to vagotomy and antrectomy as an operation for intractable duodenal ulcer.
Duodenal Ulcer↗
Lateral iliopopliteal arterial bypass as an alternative to obturator bypass.
Explore the source record for details and available documents.
Blood Vessel Prosthesis↗
Cervical arterial bruits.
Explore the source record for details and available documents.
Auscultation↗
Carotid sinus syndrome: treatment by carotid sinus denervation.
Hypersensitive carotid sinus is a rare cause of spontaneous syncopal attacks. It must be differentiated from the other more common causes, such as intrinsic cardiac disease, vasovagal responses, postural hypotension and cerebrovascular insufficiency, although it may accompany these conditions. The definition of carotid sinus syncope is syncope elicited by stimulation of a hypersensitive carotid sinus. Nineteen patients with carotid sinus syncope were treated by carotid sinus denervation. Ages ranged from 48 to 83 with a mean of 65.5 years. Symptoms of marked dizziness or syncope were reproduced by gentle compression over the carotid bifurcation, while ECG monitoring revealed bradycardia or transient asystole. Seventeen patients had carotid arteriograms, eleven of which were normal. One patient had stenosis of the external carotid artery, while five had stenosis of the internal carotid. The right carotid sinus was involved in ten patients, the left in three and both sides in six. All patients underwent unilateral or bilateral carotid sinus denervation. Five patients with internal carotid stenosis had concomitant carotid endarterectomy. Complete relief of symptoms or marked improvement was noted in all but one patient. Postoperative follow-up ranged up to 15 years. Carotid sinus denervation is a simple, effective method of treating this disorder.
Aged↗