Single center experience with modified eversion carotid endarterectomy.

BACKGROUND: Transaortic endarterectomy is a well-described technique for surgical revascularization of orificial atherosclerotic renovascular disease. Adopting this technique to carotid endarterectomy (CEA), modified eversion carotid endarterectomy (MECE), uses a traditional longitudinal arteriotomy that is confined to the bulb. This obviates the need for patch closure, simplifies the procedure, and permits easy conversion to traditional patch closure carotid endarterectomy (PCEA) for technical defects. We compared the safety and efficacy of this technique with PCEA. METHODS: Three vascular surgeons performed 223 CEAs between July 2004 and December 2008 at a tertiary teaching hospital. Outcomes measured included perioperative stroke rate, morbidity rate, mortality rate, and late restenosis. The incidence of moderate (60-79%) and severe (≥80%) restenosis was examined at <6 weeks, 1 year, and ≥2 years after operation. All patients included in this study underwent follow-up for >12 months. Data were analyzed with Student's t-test (p < 0.05 = significant). RESULTS: CEA was performed for symptomatic disease in 40.4% (90/223) of patients. One surgeon performed MECE in 73.3% (99/135) of his patients during this period; the remaining patients (n = 124) underwent traditional PCEA. Intraoperative completion duplex ultrasound was performed for all patients. In 5.1% (5/99) of the patients, MECE was converted to PCEA for residual flaps. Intraoperative carotid cross-clamping time was significantly shorter in the MECE group (29.2 minutes vs. 52.2 minutes, p < 0.05). For patients in the PCEA group, the overall mortality rate was 1.8% (4/223), and perioperative stroke rate was 1.4% (3/223). Overall morbidity was 7.2%, which was similar between the two groups. Late restenosis rate on duplex scan was 7.1% (1.0% severe stenosis), early occlusion occurred in one patient with PCEA, and the reintervention rate was 1.0% (2/196). The incidence of late restenosis was similar between the MECE and PCEA group (8.4% vs. 6.2%, p = 0.55). Mean follow-up was 26.3 months for the MECE group and 29.4 months for the PCEA group. CONCLUSIONS: MECE is a safer alternative to conventional endarterectomy with a restenosis rate comparable with PCEA, offers the potential advantage of shorter clamping time, and obviates the need for patch closure.

First rib resection in thoracic outlet syndrome.

Most patients with thoracic outlet syndrome (TOS) present with exercise-induced upper extremity paresthesia. Neurogenic TOS is the most common type where the brachial nerve plexus is compressed against a tight thoracic outlet. Vascular compromise although rare can result from thoracic outlet pressure against the subclavian artery or more commonly the subclavian vein. This article reviews the pathophysiology of TOS and describes several effective surgical interventions. Complete first rib resection with surgical decompression is an essential part of the treatment for TOS. First rib resection via supraclavicular or a preferred transaxillary route should be considered when conservative modalities provide no symptom improvement.

Stent graft repair of traumatic vertebral pseudoaneurysm with arteriovenous fistula.

Traumatic vertebral pseudoaneurysm is a rare occurrence. Such case with an enlarging symptomatic vertebral arteriovenous (AV) fistula was successfully treated with a covered endostent. Presentation, diagnosis and different acceptable treatment plans to this condition are further discussed. Stentgrafts can play an important and effective role in therapy of traumatic vertebral pseudoaneurysm with a concomitant AV fistula.

Efficacy of dextran solutions in vascular surgery.

The purpose of this paper is to discuss the role and efficacy of dextran in vascular procedures using evidence-based data from the review of surgical literature. A medline search using "dextran,'' "vascular surgery,'' and "antiplatelet therapy'' as keywords was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work. Dextran is commonly used in carotid endarterectomy (CEA) patients where the embolic rate is reduced by 46%, resulting in fewer procedure-related strokes. As a prophylactic agent against thrombosis, multiple randomized studies have reported its benefit over other antithrombotic medications. Dextran is also particularly useful in "difficult'' infragenicular lower extremity bypasses where artificial grafts (such as polytetrafluoroethylene [PTFE] or umbilical vein) are used in the setting of poor outflow vessels, or those with composite grafts and small-caliber venous conduits. Distal bypasses with adjunctive procedures (eg, arteriovenous fistula or anastomotic cuffs) also have a better outcome with the addition of dextran. Dextran has numerous important implications in vascular surgery, in particular with CEA patients or "difficult'' infragenicular bypasses. Its effectiveness with endovascular stents remains unknown.

Preoperative assessment and management to prevent complications during high-risk vascular surgery.

OBJECTIVE: Most patients requiring vascular surgical reconstruction are at high risk for major morbidity and mortality, with certain vascular procedures at particularly high risk for complications. Although numerous comorbid conditions are precisely the risk factors that determine outcome, we review particular factors for each surgery that may be optimized to alter outcome and minimize postoperative complications. DESIGN: Literature review. RESULTS: Certain aspects of care are common to all vascular surgery procedures, including thoracoabdominal aortic aneurysm repair, pararenal and ruptured abdominal aortic aneurysm repair, mesenteric and renal revascularization, and carotid endarterectomy. Some factors that are important include careful preoperative assessment and optimization of cardiac, pulmonary, and renal function and volume status. In addition, the use of experienced teams during and after the procedure, as well as clear and continuous communication between all surgical team members, may improve outcome. Particular attention to procedural details is also crucial to achieving excellent results. CONCLUSIONS: Patients needing vascular surgery often possess management challenges that increase the risk of perioperative complications. Meticulous attention to details during all phases of care, including preoperative optimization as well as intraoperative procedural conduct and communication, helps achieve optimal results and thus minimize the risk of complications.

Abdominal aortic aneurysm in association with a congenital pelvic horseshoe kidney: sentinel report and technical consideration.

A case of an abdominal aortic aneurysm in the presence of a congenital pelvic horseshoe kidney is described and the technical approach discussed. Renal function was preserved by 'double clamping' during the proximal anastomosis and infusing cold crystalloid into cannulated renal arteries originating from the aneurysm sac.