Are both color-flow duplex scanning and cerebral arteriography required prior to carotid endarterectomy?

In an attempt to eliminate the morbidity, mortality, and cost associated with arteriography, surgeons are relying increasingly on duplex scanning of the extracranial arteries as the primary preoperative evaluation prior to carotid endarterectomy (CEA). This study was initiated to evaluate the need for cerebral arteriography in the preoperative evaluation of patients for CEA. One hundred five patients undergoing 114 CEA procedures are included in a retrospective review to determine whether the addition of cerebral arteriography changed the operative management of these patients. In 58 of 105 patients (55%), color-flow duplex scanning and cerebral arteriography were performed in the workup prior to CEA. In four patients a discrepancy was found between the duplex results and the arteriogram, leading to a change in the operative approach in two. The remaining 47 patients (45%) underwent color-flow duplex scanning as the definitive preoperative study; the surgical management was altered because of the operative findings in one patient. Although color-flow duplex scanning does not provide absolute concordance with cerebral arteriography, in most instances it can be used as the definitive preoperative study prior to CEA. We define the indications for cerebral arteriography in patients undergoing CEA.

Carotid endarterectomy in patients with contralateral carotid occlusion: is the risk increased?

Many vascular surgeons believe the risk of carotid endarterectomy is greater if the patient has a contralateral carotid occlusion, and thus believe intraoperative shunting is mandatory. Five hundred and eleven carotid endarterectomies were performed over the last 11 years by two of us (JEM and RAL). Of these, 370 had charts available for detailed analysis. Twenty-seven of these patients had complete occlusion of the contralateral carotid artery. Eight of these 27 patients were asymptomatic and 16 patients had transient ischemic attacks prior to surgery. Two patients had strokes which were stable at the time of surgery. One patient with a previous stroke was operated upon emergently with a new stroke in evolution. All were operated upon under general anesthesia and only three had intraoperative shunting. Occlusion time averaged 17.1 minutes varying from 11 to 34 minutes. There were two deaths, one cardiac and one pulmonary, and no postoperative strokes either temporary or permanent. Of the 343 patients without contralateral occlusion, three patients (.87%) died, and there were 19 (5.5%) neurologic complications of which seven (2%) were present at the time of hospital discharge. It appears that contralateral carotid occlusion does not increase the risk of stroke after carotid endarterectomy even when intraoperative shunting is not used.

Surgical approach to the treatment of popliteal aneurysm.

Seventeen popliteal artery aneurysms were repaired at the Santa Barbara Cottage Hospital from 1975 to 1987. Fourteen patients were involved, with three having bilateral lesions. All but one were men with an average age of 67 years. Four of the aneurysms (three patients) presented with asymptomatic masses while the others were associated with arterial or venous obstructive symptoms. The aneurysms were repaired and there was no mortality. One patient developed a transient foot-drop. All patients with symptoms caused by their aneurysm were improved or became asymptomatic, postoperatively. We are impressed that the posterior approach to an uncomplicated popliteal artery aneurysm has several advantages over the bypass technique. The distal anastomosis can frequently be kept proximal to the knee joint, and since exposure of the aneurysm is excellent, aneurysmectomy is often possible thus eliminating pressure symptoms as well as the possibility of late rupture.

Surgical management of the radiologically identified but nonpalpable pulmonary lesion.

A solitary intrapulmonary nodule may, on rare occasions, be of the same consistency as the pulmonary tissue and therefore not be palpable by the surgeon at operation nor by the pathologist in the removed specimen. The importance of routine preoperative anatomic localization of such lesions is obvious. In a series of four patients, resection of the lobe containing the nodule was possible and the lesions were identified after meticulous serial sectioning of the excised lung parenchyma. Two of the lesions proved to be carcinoid bronchial tumors and two others were alveolar cell carcinoma.

Nitroglycerin and the neuromuscular blockade produced by gallamine, succinylcholine, d-tubocurarine, and pancuronium.

The finding in cats of prolonged pancuronium neuromuscular blockade in conjunction with intravenous infusion of nitroglycerin was previously reported by this laboratory. To expand on this finding the present study compared the effects of nitroglycerin on neuromuscular blockade produced by gallamine, d-tubocurarine, succinylcholine, and pancuronium, and further characterized the nitroglycerin-pancuronium interaction. The results indicate that of the relaxants studied only pancuronium neuromuscular blockade is prolonged, and that the prolongation is not due to altered plasma elimination of pancuronium. In vitro pancuronium blockade was not affected by nitroglycerin, suggesting the involvement of a metabolite in the block prolongation response. Reversibility of the prolonged pancuronium block by neostigmine is not influenced by nitroglycerin.