The role of polyester patch angioplasty in carotid endarterectomy: a multicenter study.

The objectives of this study were to examine the morphology, restenosis, dilatation, and possible complications of polyester collagen impregnated carotid patches. Between March 1994 and January 1995, 207 patients (56 females and 151 males) undergoing 221 carotid endarterectomies (CE) with a collagen-impregnated knitted polyester patch were enrolled in a European prospective multicenter study. Patches were used for arteries deemed to be smaller than usual by visual inspection. General anesthesia was used in 201 procedures (91%), and a shunt was used in 76 procedures (34.4%). One hundred fourteen CE (51.6%) were checked by a perioperative arteriography or angioscopy. The diameter of the internal carotid artery (ICA) and carotid bulb (CB) were measured by duplex scan both preoperatively and every 6 months during follow-up. The main end point was carotid occlusion or restenosis, defined as a stenosis of 50% or more according to NASCET criteria. Carotid polyester-impregnated patches appear to be reliable. The patch was easy to cut and suture, and hemostasis was obtained immediately. No rupture occurred. However, the higher restenosis rate in women may restrict the use of polyester patch to men.

Risk of early controlateral carotid endarterectomy.

Between January 1984 and January 1994, we performed early endarterectomy of the controlateral carotid on 94 patients within a delay of 1 to 8 days after the first endarterectomy. Lesions were symptomatic in 58 patients (62%) and asymptomatic in 36 patients (38%). Eighty-four operations were performed under cervical block anesthesia (89%), eight under general anesthesia, and two under local anesthesia (2%). Severe intraoperative hypertension occurred in seven patients (7%) including five under cervical block anesthesia (6%) and two under general anesthesia (25%). Two patients (2.1%) died of stroke secondary to carotid thrombosis in one case and hyperperfusion syndrome in one case. Morbidity included one transient ischemic attack (1%) and one myocardial infarction (1%). Postoperative control of patency revealed asymptomatic occlusion of the internal carotid artery in two patients, accounting for one of the two deaths. Our findings demonstrate that neurologic mortality/morbidity is not higher after early controlateral carotid endarterectomy than unilateral endarterectomy.

Infective aneurysm of the popliteal artery due to Salmonella enteritidis.

Infected aneurysms of the popliteal artery are rare and Salmonella enteritidis infection in this site has not been previously reported. In the case reported herein, septic thrombophlebitis was found to be in contact with the aneurysm. Preoperative diagnosis was made through arteriography, computed tomographic (CT) scan, and positive blood cultures. The infected aneurysm was treated by resection without any reconstruction while phlebitis was treated by thrombectomy. Appropriate antibiotic therapy was administered. The patient made an uneventful recovery.

Vertebral artery reconstruction: results in 106 patients.

Between January 1982 and December 1989, we performed 109 revascularizations of the vertebral artery in 106 patients. Eighty-six patients (81%) had isolated vertebrobasilar insufficiency, 18 (17%) had associated carotid and vertebrobasilar pathology while two (2%) had isolated carotid symptoms. The procedures performed included 98 revascularizations of the proximal vertebral artery and 11 reconstructions of the distal vertebral artery. One distal revascularization was required after early failure of proximal revascularization. In 36 cases (34%), a concomitant ipsilateral carotid artery revascularization procedure was performed, and in one case, an ipsilateral subclavian artery aneurysm was excised. Two patients (1.9%) died postoperatively and five patients (4.7%) had nonfatal neurologic complications. Four of these seven complications occurred after combined vertebral and carotid surgery. One hundred early follow-up arteriograms were obtained (92% of reconstructions). There were four occlusions, two of which were associated with neurologic deficits. Three patients were lost to follow-up. Mean follow-up was 48 months (4-100 months). Seven patients died in the late follow-up period (after one month). Actuarial five year survival was 91%. Overall patency at five years was 96%. The study of late neurologic events showed that 63% of patients had complete recovery, 30% improvement, and 7%, failure or aggravation of symptoms.

Spontaneous aneurysm of the extracranial vertebral artery associated with spinal osseous anomaly.

Spontaneous aneurysms of the extracranial vertebral artery are uncommon. We report the case of an aneurysm located at the second cervical vertebra, associated with a congenital spinal malformation. Computed tomographic scan and arteriography were diagnostic. After proximal ligation of the vertebral artery, the aneurysm was incised and the distal vertebral artery was revascularized by an infraoccipital carotid-to-vertebral artery vein bypass.

The silent brain infarct before and after carotid surgery.

Routine computed tomography was prospectively performed pre- and postoperatively in 114 consecutive patients undergoing a total of 131 procedures on the carotid artery. Hemispheric cerebral infarction was found preoperatively in three of the 16 hemispheres corresponding to symptomatic lesions (19%), in 18 of 109 hemispheres corresponding to transient ischemic attacks (16.5%), and in one of four hemispheres corresponding to lesions responsible for a fixed cerebral vascular accident (25%). Two surgical procedures (1.5%) were complicated by early cerebral infarctions as detected on postoperative computed tomographic scan. These complications resulted in death in one case, and left the patient with major sequelae in the other. Five procedures (3.8%) were complicated by transient ischemic attacks, three of which were associated with minimal cerebral infarctions visible on computed tomographic scan. Neurologic status was unchanged after 124 (94.6%) procedures, whereas four of these procedures were complicated by silent brain infarctions as visualized on postoperative computed tomographic scans (3.1%). This study confirms that existing pre- and postoperative neurologic classifications are far from perfect and that surgery is rarely responsible for cerebral infarction. Carotid surgery should no longer be performed without obtaining pre- and postoperative computed tomographic scans.

[Cervical epidural anesthesia in carotid artery surgery]. / Anesthésie péridurale cervicale dans la chirurgie carotidienne.

A series of 394 patients who underwent surgery of the carotid artery under cervical extradural anaesthesia is presented. With this technique the patient remains conscious throughout the operation, which facilitates neurological monitoring. Due to failure or complication, extradural anaesthesia was abandoned and replaced by general anaesthesia in 1.5 per cent of the cases. The mortality rate in this series was 2.3 per cent; in 2 out of 3 cases death was of neurological origin; 21 per cent of the patients had peroperative neurological accidents which, in 9 out of 10 cases, were due to a low cerebral blood flow rate during clamping. Thirty-five intra-arterial shunts (8.9 per cent) were installed, and none of these accidents was permanent. Twenty-five patients (6.3 per cent) had postoperative deficit which did not regress in 12 cases (3 per cent). The risk of peroperative neurological accident was significantly increased in patients with bilateral lesions of the vertebral arteries (x 3.5) or with occlusion of the contralateral carotid artery (x 4.5). Surgery of the carotid artery in conscious patients reveals a high incidence of ischaemic neurological events the reversibility of which is ensured by appropriate therapeutic procedures (arterial shunt, increase of brain perfusion pressure). Patients at risk of neurological accidents may benefit from cervical extradural anaesthesia.

[Technique and interpretation of cystomanometry in the neurological bladder of the child (author's transl)]. / Technique et interprétation de la cystomanométrie dans la vessie neurologique de l'enfant

One hundred and twelve cystomanometric investigations were carried out in 86 children, 67 of them were suffering from a neurological bladder. Measurement of the vesical pressure was carried out by the suprapubic route, furthermore the rectal pressure and pneumogram were recorded. This technique enables the study of vesical tonus and activity, and also permits estimation of peripheral resistance.