Sapheno-femoral junction reflux in patients with a normal saphenous trunk.

OBJECTIVE: To determine the patterns and clinical importance of saphenofemoral junction (SFJ) reflux in patients with chronic venous disease (CVD) and a normal great saphenous vein (GSV) trunk. METHODS: Fifteen hundred consecutive patients were examined using duplex ultrasound (DU) in three centres. Patients with reflux involving the SFJ and/or its tributaries only were included and its prevalence and patterns were studied. Patients with GSV trunk reflux or in any other veins were excluded. The SFJ diameter was categorised as normal, dilated or varicose. The results of surgery were evaluated by DU in 42 patients 1 year after the procedure. RESULTS: SFJ area incompetence with a competent GSV trunk occurred in 8.8% of limbs. It was significantly more common in CEAP class 2, 13.6% compared to class 3, 8.2% (p=0.03), class 1, 2.7%, class 4, 4.4% and classes 5 and 6 together, 1.5% (p<0.001 for all). The SFJ had a normal diameter in 21%, dilated in 62% and varicose in 17%. Reflux was seen in 39% of limbs with a normal SFJ diameter, in 85% of those with a dilated SFJ and in all varicose SFJs. Of the 42 operated limbs, 27 had ligation and division of the SFJ and tributary phlebectomies. Fifteen had tributary phlebectomies only, leaving the SFJ intact. At one-year follow-up, SFJ area reflux was found in six limbs (14.3%), involving the SFJ alone in 1, a main tributary in 1 and 4 small tributaries. No reflux was found in the GSV trunk. All but two of the 42 patients were satisfied with the results. CONCLUSIONS: SFJ reflux with tributary involvement and sparing of the GSV trunk occurs in 8.8% of CVD patients. Such reflux is found in the entire spectrum of CVD, but it is more common in class 2. Local surgery with or without SFJ ligation has very good results at 1 year. DU scanning prior to treatment is important in all patients so that the intact GSV can be spared.

Ureteral injury during aortic aneurysm repair by the retroperitoneal approach.

Three ureteral injuries (two proximal, one middle) associated with retroperitoneal repair of aortic abdominal aneurysms are reported. The authors believe these represent traction injuries that are related to the use of stationary retractors and suggest that complete anterior mobilization of the left kidney from its posterior fossa will decrease the odds of such an injury.

Timing of postcarotid complications: a guide to safe discharge planning.

OBJECTIVES: Currently, our standard of practice is that patients undergoing carotid endarterectomy (CEA) may be safely discharged on the first postoperative day. Because many patients do not appear to require overnight observation, we wanted to determine the safety and feasibility of same-evening discharge by establishing the timing of postoperative complications, which may potentially require operative intervention. METHODS: A total of 835 consecutive patients undergoing CEA were retrospectively reviewed. Sixty-two patients had a postoperative wound hematoma or neurologic deficit (ND) (transient ischemic attack or stroke) within 24 hours of their operation, complications potentially requiring a second operation. Excluded were 64 patients not eligible for same-day discharge because of other reasons (eg, heparinization, CEA with coronary artery bypass grafting). RESULTS: Sixty-two patients (8.0%) had ND (26 [3.4%]) or neck hematoma (NH) (36 [4.7%]) within 24 hours of their CEA. Nineteen (73%) of the NDs were diagnosed in the operating room or recovery room, 5 (19%) within 8 hours of the operation, and 2 (7.7%) after 8 hours but in less than 24 hours. Of the NHs, 23 (66%) were diagnosed in the recovery room, 11 (31%) within 8 hours, and 1 (2.7%) after 8 hours. Of the outliers, one patient experienced a blowout of the vein graft occurring on postoperative day 1, one patient had a delayed ipsilateral stroke, and one had a vertebrobasilar stroke. Overall, only three of 773 (0.4%) patients undergoing CEA had a complication occurring more than 8 hours after operation. CONCLUSION: NDs and NHs in post-CEA patients occurred within 8 hours of operation in 95% of those patients experiencing these complications or 99.6% of all CEA patients. These data indicate that same-evening discharge may be safely performed without increasing the adverse effects of stroke or hematoma. This plan has cautiously been initiated at this institution.

Decreased recurrent carotid stenosis by routine patching and intraoperative scanning.

Our objective was to review the results of carotid endarterectomies (CEAs) with Dacron patch angioplasty and intraoperative color-flow duplex scanning (CFS). In a 3-year period, patients who underwent CEA with Dacron patch angioplasty and intraoperative CFS were studied. We excluded patients who had primary closure, vein patch, and redo endarterectomy. Serial CFS was obtained first in the early postoperative period (one day to 3 weeks), then at 6 months, and then yearly. Intraoperative CFS abnormalities were classified as major, requiring immediate revision, or minor, which were observed. The diagnosis of recurrent stenosis by US was based on the detection of an increased peak systolic frequency (>8000 MHz) or velocity (>250 cm/second) in the internal carotid artery. There were 212 CEAs performed in 200 patients (128 men and 84 women) included in this study. Three patients (1.4%) awoke with a stroke, two (0.94%) had transient ischemic attacks, and three (1.4%) developed transient hypoglossal nerve paresis. Intraoperative CFS showed a major defect that required an immediate revision in six patients (2.8%). Minor abnormalities were detected in another 41 patients (19.3%), but no revision was necessary. In follow-up three patients were identified with a severe recurrent carotid stenosis (>80%) and they underwent redo CEA. This rate of recurrence (1.4%) is significantly lower than the rate we had previously reported in a larger study (82 of 1209, 6.8%; P = 0.003). We conclude that the combined use of Dacron patch angioplasty and intraoperative CFS after CEA is associated with a low perioperative morbidity and a low incidence of recurrent stenosis in the first 2 years after operation.

Short stay carotid surgery for veterans: an emerging standard.

We have taken the short stay approach to carotid artery surgery to our VA setting over the past 5 to 6 years. Retrospectively, we reviewed the efficacy and safety of that approach in 201 consecutive carotid operations over the recent 4-year period (January 1, 1996-December 31, 1999). In 1996 we had already begun the transition to an algorithm to (1) utilize carotid color flow Doppler duplex exams for diagnosis, (2) same-day admission (SDA), (3) intensive care unit (ICU) only when deemed medically necessary, and (4) next-day discharge. Results of this approach have been a decrease in the utilization of diagnostic arteriograms and utilization of the ICU from 100% previous to the onset of this approach to 17 and 22%, respectively. SDA increased from 24 to 89%. Mean LOS decreased from 5.13+/-0.9 to 1.97+/-0.4 days. The percentage of patients completing the algorithm went from 15 to 72%. Stroke and/or death varied from 0 to 3.7% each year and was only 2.4% over the 4-year period. In conclusion, this approach to short stay carotid surgery in the veteran population has proven both efficacious and safe with results similar to those in university and community practices.

The impact of isolated lesser saphenous vein system incompetence on clinical signs and symptoms of chronic venous disease.

PURPOSE: The purpose of this study was to determine the patterns of isolated lesser saphenous vein (LSV) system incompetence and correlate the distribution and extent of such reflux with symptoms and signs of chronic venous disease (CVD). METHODS: During a 3-year period, 2254 limbs in 1682 patients with signs and symptoms of CVD were evaluated with color flow duplex scanning. Extremities with isolated reflux in the LSV system were selected for this study. Limbs with perforating venous reflux connected to this system only were also included. Limbs that had marked reflux in the greater saphenous or deep vein, that had a documented history of deep venous thrombosis, and that previously underwent surgery or sclerotherapy were excluded. The clinical severity of the limbs was graded with the CEAP classification system. RESULTS: There were 226 limbs in 200 patients with reflux in the LSV system; 61% were female patients with a mean age of 49 years (range, 18-82 years). There were 174 patients (87%) with unilateral and 26 with bilateral disease, and 41% of the limbs belonged in CVD class 2, 26% in class 3, 12% in class 4, 3.5% in class 5, and 3% in class 6. Classes 0 and 1 were present in 14.5% of the limbs. Symptoms were present in 139 limbs (61.5%). Some degree of ache or burning sensation was the most frequent symptom (41%), followed by itching (32%), heaviness (29%), cramps (24%), and restless limbs (18%). Reflux in the main trunk of the LSV was the most prevalent (177 limbs [78%]), followed by the saphenopopliteal junction (146 limbs [64.6%]), the vein of Giacomini (39 limbs [17%]) and the gastrocnemial vein (23 limbs [10%]). Reflux involving both the saphenopopliteal junction and the LSV was seen in 50% of limbs, but almost any other combination of reflux was present, which indicated the complexity of this system. Perforator vein incompetence was detected in 56 limbs (25%). We found 83 perforator veins, resulting in a mean of 1.5 veins per limb. Both the number of incompetent perforator veins and the extent of superficial reflux correlated with clinical severity. Four main types of termination of the LSV were identified with at least nine variations. The LSV was duplicated for at least half of its length in five limbs (2.2%). Nonsaphenous reflux was detected in seven limbs (3.1%). Superficial vein thrombosis in the LSV system was found in eight limbs (3.5%), and in the gastrocnemial vein it was found in four (1.8%). CONCLUSIONS: Isolated LSV system incompetence can cause the entire range of signs and symptoms of CVD. Clinical deterioration is associated with a longer extent of reflux and perforator incompetence. Classes 2 to 4 are the most frequent clinical presentations, whereas classes 5 and 6 are uncommon. The complex anatomy of this system and the great variation in the patterns of reflux warrant the use of color flow duplex scanning before planning treatment.

Prevalence of deep venous reflux in patients with primary superficial vein incompetence.

PURPOSE: This prospective study was designed to determine the prevalence of deep reflux and the conditions under which it may occur in patients with primary superficial venous reflux and absence of deep venous thrombosis (DVT). METHODS: We studied 152 limbs in 120 consecutive patients in the standing position who had superficial venous reflux with color flow duplex scanning. Limbs with documented evidence of DVT or post-thrombotic vein wall changes during the examination were studied but not included in the analysis. Limbs were divided into those that had at least reflux in the saphenofemoral, the saphenopopliteal, or the gastropopliteal junction and into those with nonjunctional reflux in the superficial and gastrocnemial veins. Peak velocity and duration of reflux were measured. To examine the recirculation theory, we tested the deep veins by occluding and refluxing saphenous veins 10 cm below the sampling site. RESULTS: Thirteen limbs in 11 patients (9%) were excluded because of previous DVT. Of the remaining 139 limbs, 106 (76%) had junctional reflux. Saphenofemoral junction was involved in 89 limbs (84%), saphenopopliteal junction in 18 (17%), and gastropopliteal junction in 7 (4%). In 33 limbs (24%), reflux was detected in the main trunk or tributaries of the saphenous veins alone with no junctional incompetence. Femoral or popliteal reflux was present in 31 limbs (22%). This reflux was segmental in 27 limbs, and it was limited in the junction in 24 limbs. The mean duration of deep venous reflux was 0.9 seconds, it ranged from 0.6 to 3.7 seconds, and it was significantly shorter than that in the superficial veins (2.6 seconds; P <.0001). In the absence of junctional reflux, the prevalence of deep venous insufficiency (DVI) was significantly lower compared with that in limbs with junctional involvement (2 of 33 vs 29 of 106; P =.038). The mean duration of deep venous reflux in these groups was comparable (0.85 seconds vs 0. 91 seconds; P =.44). Occlusion of the incompetent superficial veins reduced somewhat the duration of the deep venous reflux but did not abolish it (0.88 seconds vs 0.82 seconds; P =.072). The presence of DVI was associated with junctional reflux of high peak velocity and long duration. CONCLUSIONS: The prevalence of DVI in patients with primary superficial venous reflux and without history of DVT is 22%. However, this reflux is segmental, mainly in the common femoral vein, and is of short duration. It is associated with the presence of junctional incompetence that has a high peak velocity and long duration. These findings may explain why surgical correction of superficial reflux abolishes DVI.

Yield of repeated screening for abdominal aortic aneurysm after a 4-year interval. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.

BACKGROUND: Little is known about the rate at which new abdominal aortic aneurysms (AAAs) develop or whether screening older men for AAA, if undertaken, should be limited to once in a lifetime or repeated at intervals. METHODS: A large population of veterans, aged 50 through 79 years, completed a questionnaire and underwent ultrasound screening for AAA. Of these, 5151 without AAA on the initial ultrasound (defined as infrarenal aortic diameter of 3.0 cm or larger) were selected randomly to be invited for a second ultrasound screening after an interval of 4 years. Local records and national databases were searched to identify deaths and AAA diagnoses made during the study interval in subjects who did not attend the rescreening. RESULTS: Of the 5151 subjects selected for a second screening, 598 (11.6%) had died (none due to AAA), and 20 (0.4%) had an interim diagnosis of AAA. A second screening was performed on 2622 (50.9%), of whom 58 (2.2%; 95% confidence interval, 1.6%-2.8%) had new AAA. Three new AAAs were 4.0 to 4.9 cm, 10 were 3.5 to 3.9 cm, and 45 were 3.0 to 3.4 cm. Independent predictors of new AAA at the second screening included current smoker (odds ratio, 3.09; 95% confidence, 1.74-5.50), coronary artery disease (odds ratio, 1.81; 95% confidence interval, 1.07-3.07), and, in a separate model using a composite variable, any atherosclerosis (odds ratio, 1.97; 95% confidence interval, 1.16-3.35). Adding the interim and rescreening diagnosis rates suggests a 4-year incidence rate of 2.6%. Rescreening only in subjects with infrarenal aortic diameter of 2.5 cm or greater on the initial ultrasound would have missed more than two thirds of the new AAAs. CONCLUSIONS: A second screening is of little practical value after 4 years, mainly because the AAAs detected are small. However, the incidence that we observed suggests that a second screening after longer intervals (ie, more than 8 years) may provide yields similar to those seen in initial screening and therefore warrants further study.

Superficial femoral artery branch avulsion after severe muscle cramping.

Avulsion of a muscular branch of a major artery without a history of major trauma has not been reported to our knowledge. Occasionally, blunt and even minor trauma can result in injuries that seem out of proportion to the level of injury. We report a case of an avulsed muscular branch of the superficial femoral artery in a patient with recent thigh cramping. This injury is likely related to the intense tetany the patient described having before he came to the hospital.

Higher prevalence of abdominal aortic aneurysms in patients with carotid stenosis but without diabetes.

BACKGROUND: We compared abdominal aortic aneurysm (AAA) prevalence in 3 groups of patients at the Hines Veterans Affairs Medical Center: (1) patients with 50% or more carotid stenosis, (2) patients with less than 50% stenosis, and (3) patients screened for the Aneurysm Detection and Management (ADAM) study. METHODS: Of all the patients referred to the vascular laboratory for carotid duplex examination during a 12-month period, patients with 50% or more carotid stenosis underwent ultrasonography of the abdominal aorta unless they had a previous scan or previous aortic surgery (group 1, n = 374). Patients with less than 50% carotid stenosis who had been screened for ADAM comprised group 2 (n = 139). They were compared with all patients screened for ADAM at our center during the same time period (group 3, n = 2477). RESULTS: AAA of 3.0 cm or more were present in 18.2%, 12.2%, and 7.2% of groups 1, 2, and 3, respectively; AAA of 4.0 cm or more were present in 8.3%, 5.8%, and 2.1% of groups 1, 2, and 3, respectively. Among patients with carotid stenosis, those patients without diabetes accounted for the observed increase in prevalence (21.9 % > or = 3.0 cm and 10.2% > or = 4.0 cm vs 9.2% and 2.8% in patients with diabetes). CONCLUSIONS: The relative risk of AAA is 2 to 3 times greater in patients with carotid stenosis compared with patients undergoing routine screening. However, only patients without diabetes account for the increased prevalence. Selective AAA screening of patients who are not diabetic with carotid stenosis is recommended.

Timing and frequency of perioperative carotid color-flow duplex scanning: A preliminary report.

PURPOSE: The results of intraoperative and early postoperative carotid color-flow duplex scanning (CFS) after endarterectomy were reviewed to determine whether any perioperative studies could be eliminated. METHODS: Patients undergoing carotid endarterectomy with intraoperative CFS between 1986 and 1997 were identified. Early postoperative CFS was performed between 1 day and 3 weeks postoperatively, then it was performed again at 6 months postoperatively. RESULTS: During the study period, 560 patients, 325 men and 235 women, underwent 621 carotid endarterectomies. A satisfactory intraoperative carotid CFS was completed in 611 (98.4%) patients. There were 20 (3.2%) vessels with a major defect that required revision for fronds or flaps (n = 11), retained atheroma (n = 5), low flow (n = 2), high velocity or turbulence (n = 1), or dissection (n = 1). Another 146 vessels (23.5%) had minor defects, such as retained proximal atheromas or small (less than 3 mm) fronds, but were not revised. The remaining 445 vessels were normal. The first postoperative CFS was normal in all the revised carotids and in 138 (94.5%) vessels with minor intraoperative defects. At 6 months, recurrent stenosis (more than 75% area reduction) was identified in 1 of 18 revised carotids (5.5%), 4 of 138 vessels (2. 9%) with minor defects, and 17 of 406 vessels (4.2%) that were normal intraoperatively. The incidence of recurrent stenosis was not significantly different in the three groups (P =.7). CONCLUSION: Intraoperative CFS is useful because major unsuspected defects can be corrected immediately, thus avoiding potential neurologic morbidity. However, the postoperative day 1 CFS can be eliminated in most cases, because it does not provide any relevant clinical information.

Outcome of moderate carotid artery stenosis in patients who are asymptomatic.

PURPOSE: The incidence rate of disease progression and stroke after the diagnosis of a moderate (50% to 79%) carotid stenosis was determined by means of color-flow duplex scanning. METHODS: During a 4-year period, 344 male veterans with moderate internal carotid artery stenoses, on one or both sides, were examined at regular intervals for a mean period of 25 months. Carotid color-flow scans were obtained semiannually. Clinical follow-up was performed to determine the incidence rate of amaurosis fugax, transient ischemic attacks, nonhemispheric symptoms, and strokes. RESULTS: New neurologic symptoms developed in 75 patients (21.8%). Fifty-one (14.8%) had ipsilateral symptoms during follow-up: 18 amaurosis fugax (5.2%), 14 transient ischemic attacks (4%), 5 nonhemispheric symptoms (1.4%), and 14 strokes (4%). Twenty-four patients (6.9%) had contralateral symptoms: 20 strokes (5.8%) and 4 transient ischemic attacks (1.2%). Life-table analysis showed that the annual rate of ipsilateral neurologic events was 8.1%, and the annual rate of stroke was 2.1%. Seventy-five patients (22%) died in the follow-up period. Disease progression to 80% to 99% stenosis or occlusion occurred in 71 of 458 vessels (15.5%). The internal carotid arteries that showed evidence of disease progression had a significantly higher initial peak systolic velocity (251 vs 190 cm/s; P <.0001) and end diastolic velocity (74 vs 52 cm/s; P < 0.0001). Black patients and patients with ischemic heart disease were at a higher risk for disease progression. We could not identify any atherosclerotic risk factors that reliably predicted patients in whom future ipsilateral neurologic symptoms were more likely to develop. However, there was an increased risk of stroke associated with progression of disease. CONCLUSION: Patients who are asymptomatic and who have moderate carotid stenoses are at significant risk for neurologic symptoms and death, but have a relatively low incidence rate of ipsilateral events. The initial flow characteristics in the stenotic vessel are predictive of future disease progression, but they are not helpful in identifying patients in whom symptoms will develop.

Acute effects of intermittent pneumatic compression on popliteal artery blood flow.

OBJECTIVES: To investigate the immediate effects of intermittent pneumatic foot and calf compression (IPFCC) on popliteal artery blood flow in symptom-free volunteers and to determine the reproducibility of color flow duplex imaging in the popliteal artery. DESIGN: Cohort study. SETTING: A university associated tertiary care hospital. PATIENTS: Forty lower limbs of 30 volunteers without symptoms or noteworthy risk factors of peripheral vascular disease. INTERVENTIONS: Popliteal artery blood flow was measured in the sitting position before, during, and after the application of IPFCC using color flow duplex imaging. The interobserver, intraobserver, and between occasion within-subject variability of the popliteal artery blood flow were evaluated in 5 symptom-free volunteers who had at least 5 color flow duplex imaging measurements taken at each of the above time points on 3 different days. MAIN OUTCOME MEASURES: The arterial diameter, peak systolic, end diastolic, and reverse-flow velocities were measured, as well as the duration of forward flow during diastole before, during, and after IPFCC. The same variables were measured in 5 separate volunteers by 3 different observers, on 3 separate days, at 3 separate times to determine reproducibility. RESULTS: Including all types of variability, the popliteal artery blood flow varied from 8% to 39% with a mean value of 19%. Since the diameter of the artery was obtained with less than 5% variability, the time average mean velocity was responsible for the high variation in flow. During application of the IPFCC, the popliteal artery blood flow increased significantly in all subjects (P<.001). The mean increase in the flow was 2.4 times the baseline values. The diameter of the arteries remained unchanged while the time average velocity increased significantly (P<.001). This velocity increase was due to marked elevation in the peak systolic and end diastolic velocities and diminution of the reverse-flow component, as well as a prolongation of the forward flow during diastole. After cessation of the pump, flow returned to baseline levels (P=.41) CONCLUSIONS: Ultrasound-derived popliteal artery blood flow measurements show moderate variability. The application of IPFCC greatly enhances popliteal artery blood flow. The flow increase is due to a dramatic drop in the peripheral vascular resistance as the peak systolic and end diastolic flow velocities increase and the reverse-flow component diminishes. Its role in the treatment of lower extremity occlusive arterial disease needs to be determined.

Relationship of age, gender, race, and body size to infrarenal aortic diameter. The Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Investigators.

PURPOSE: To assess the effects of age, gender, race, and body size on infrarenal aortic diameter (IAD) and to determine expected values for IAD on the basis of these factors. METHODS: Veterans aged 50 to 79 years at 15 Department of Veterans Affairs medical centers were invited to undergo ultrasound measurement of IAD and complete a pre-screening questionnaire. We report here on 69,905 subjects who had no previous history of abdominal aortic aneurysm (AAA) and no ultrasound evidence of AAA (defined as IAD > or = 3.0 cm). RESULTS: Although age, gender, black race, height, weight, body mass index, and body surface area were associated with IAD by multivariate linear regression (all p < 0.001), the effects were small. Female sex was associated with a 0.14 cm reduction in IAD and black race with a 0.01 cm increase in IAD. A 0.1 cm change in IAD was associated with large changes in the independent variables: 29 years in age, 19 cm or 40 cm in height, 35 kg in weight, 11 kg/m2 in body mass index, and 0.35 m2 in body surface area. Nearly all height-weight groups were within 0.1 cm of the gender means, and the unadjusted gender means differed by only 0.23 cm. The variation among medical centers had more influence on IAD than did the combination of age, gender, race, and body size. CONCLUSIONS: Age, gender, race, and body size have statistically significant but small effects on IAD. Use of these parameters to define AAA may not offer sufficient advantage over simpler definitions (such as an IAD > or = 3.0 cm) to be warranted.

Perioperative strategies in the management of carotid body tumors.

Despite the availability of noninvasive neuroradiographic techniques for the evaluation of head and neck neoplasms, paragangliomas of the carotid body often achieve substantial size before definitive diagnosis. Surgical "exploration" for the attempted resection of these lesions often results in significant blood loss, inadvertent cranial nerve injury, and procedure abandonment with partial tumor removal. Sixteen carotid body tumors were surgically resected at our institution between July 1988 and January 1995. Four of these patients had undergone cytologic examination by fine-needle aspiration (FNA) and another 6 patients underwent failed attempted resection of their lesions as the result of intraoperative hemorrhage. Of the remaining 6 patients referred for the first time evaluation of a "neck mass," the diagnosis was made by patient history, physical examination, magnetic resonance imaging, or magnetic resonance angiography. Complete tumor removal was accomplished in all 16 patients using a variety of lateral transcervical and skull base approaches. This article focuses on the clinicoradiographic diagnosis of carotid body tumors that do not need preoperative histologic confirmation. Specific intraoperative techniques for tumor removal, carotid artery management, and cranial nerve preservation are demonstrated through case presentations. Perioperative morbidity and overall results are detailed for this series of patients.

Carotid endarterectomy for recurrent stenosis.

PURPOSE: The purpose of this study was to report our results in the surgical management of recurrent carotid stenosis (RCS) after carotid endarterectomy (CEA). METHODS: In a 20-year period, we performed 1209 CEAs; 82 operations (6.8%) were for RCS. There were 33 men and 36 women, with an average age of 66.3 years. Nine patients underwent two redo CEAs and two patients underwent three redo CEAs for either bilateral recurrence or a second recurrence on the same side. Overall, 10 patients were identified with a second recurrence. RESULTS: The average time to presentation with RCS was 65 months (range, 3 to 361 months). The majority of patients (66%) were symptomatic, 34% had transient ischemic attacks, 17% had amaurosis fugax, 9% had strokes, and 6% had nonhemispheric symptoms. Before repair, angiograms were obtained. Patch repair was performed in 61 procedures (74%), 41 with vein, 11 with Dacron, and nine with polytetrafluoroethylene. Autogenous or synthetic bypass grafts were used in 20 procedures (24%), vein in eight, Dacron in two, and polytetrafluoroethylene in 10. In one patient, an occluded internal carotid artery was ligated and an endarterectomy of the external carotid artery was performed without a patch. The operative stroke rate was 4.8%. Minor complications included transient or permanent cranial nerve deficits in 7.3% and wound hematomas in 2.4%. CONCLUSION: Although repeat endarterectomy to treat RCS is technically more demanding, it can be performed safely. Long-term follow-up examination shows that a second recurrence may develop, and we recommend serial noninvasive testing.

Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group.

BACKGROUND: Independent risk factors for abdominal aortic aneurysm (AAA) have not been clearly defined in multivariable analyses of large patient populations. OBJECTIVE: To identify factors that are independently associated with AAA and to determine the prevalence of previously unrecognized AAA in defined demographic and risk groups. DESIGN: Cross-sectional screening study. SETTING: 15 Department of Veterans Affairs medical centers. PARTICIPANTS: 73451 veterans who were 50 to 79 years of age and had no history of AAA. MEASUREMENTS: The results of ultrasonographic screening for AAA and a prescreening questionnaire were analyzed using multiple logistic regression. RESULTS: An AAA of 4.0 cm or larger was detected in 1031 participants (1.4%). Smoking was the risk factor most strongly associated with AAA; the odds ratio (OR) for AAAs of 4.0 cm or larger compared with normal aortas (infrarenal aortic diameter < 3.0 cm) was 5.57 (95% CI, 4.24 to 7.31). The association between smoking and AAA increased significantly with the number of years of smoking and decreased significantly with the number of years after quitting smoking. The excess prevalence associated with smoking accounted for 78% of all AAAs that were 4.0 cm or larger in the study sample. Female sex (OR, 0.22 [CI, 0.07 to 0.68]), black race (OR, 0.49 [CI, 0.35 to 0.69]), and presence of diabetes (OR, 0.54 [CI, 0.44 to 0.65]) were negatively associated with AAA. A family history of AAA was positively associated with AAA (OR, 1.95 [CI, 1.56 to 2.43]) but was reported by only 5.1% of participants. Other independently associated factors included age, height, coronary artery disease, any atherosclerosis, high cholesterol levels, and hypertension. CONCLUSIONS: Abdominal aortic aneurysm is associated with multiple factors. Smoking was the risk factor most strongly associated with AAA and may be responsible for most clinically important cases of previously undiagnosed AAA.

Intensive care after carotid endarterectomy: a prospective evaluation.

BACKGROUND: Through prior investigation we established that only a small minority of patients who undergo carotid endarterectomy (CEA) have a complicated postoperative course requiring an intensive care unit (ICU) stay. An appropriate policy for patient management was established. This study prospectively analyzes the safety and efficacy of this policy. STUDY DESIGN: Patients were transferred directly to a nonmonitored surgical ward, regardless of preoperative comorbidity, if they remained stable from a neurologic and a hemodynamic standpoint during a short (less than three hour) stay in the recovery room. Patients whose status was questionable remained in recovery longer or were transferred to an ICU. RESULTS: One hundred forty-six (79 percent) of 185 patients were transferred safely to a ward. Average length of stay in recovery was one hour 59 minutes. No complications occurred that required a return to the operating suite or a move to an ICU. Most of these patients (88 percent) were discharged within 24 hours of surgery. Thirty-nine (21 percent) patients, each identified in recovery, required intervention or monitoring in an intensive care setting. Fourteen required prolonged, aggressive intravenous treatment of hypertension; 14 had sustained hypotension; three were observed to rule out myocardial infarction, and three had neurologic deficits. Two patients had ventricular arrhythmias, two had wound hematomas, and one patient required reintubation. This group (n = 39) remained in the recovery room two hours 40 minutes on average, spent 20 hours in the ICU, and remained in the hospital 32 hours after CEA. CONCLUSIONS: Most patients who undergo CEA follow a predictably benign postoperative course. Patients are easily identified by a recovery room protocol and approximately 80 percent can avoid ICU costs.

The changing face of carotid endarterectomy.

PURPOSE: The economic milieu and improvements in care have altered the diagnostic and therapeutic algorithm of the patient with carotid stenosis. This study analyzes the efficacy and safety of these changes. METHODS: The records of patients who underwent 320 consecutive carotid endarterectomies performed by three surgeons at our institution from 1990 to 1994 were reviewed retrospectively. Use of diagnostic angiography, use of carotid duplex ultrasound, length of hospital stay, postanesthesia recovery observation, intensive care unit (ICU) observation, complications, and hospital charges were analyzed. RESULTS: The average length of hospital stay decreased from 6.18 days to 2.00 days (p < or = 0.001). The day of discharge decreased from 3.10 days to 1.24 days after surgery (p < or = 0.01). By 1993, 68% were discharged by the first day after surgery, increasing to 73% by 1994. From 1990 to 1992, average postoperative ICU observation time fluctuated between 18 and 25 hours; this time decreased to 12.2 hours by 1994. In 1993, only 12.5% of patients were admitted to the ICU, down from 94.8% in 1990; by 1994, only 7.3% were admitted to the ICU (p < or = 0.001). Postanesthesia recovery observation time decreased from 3.77 hours to 1.63 hours during this time (p < or = 0.04). With regard to preoperative diagnosis, angiography was performed in 93.1% of patients in 1990; by 1994, only 32.8% underwent this procedure (p < or = 0.0001). Average hospital charges decreased significantly (1990, $14,378; 1994, $10,436) with these modifications in patient care (p < or = 0.001). The complication rate reflected no significant changes over the course of the study. There were six incidences of cerebrovascular accident (6/320, 1.9%), including one death. There were four incidences of transient ischemic attack (4/320, 1.3%), with no significant differences noted from year to year. CONCLUSIONS: This study confirms the changing nature of carotid endarterectomy and documents that these changes have not adversely affected the safety of the operation.

Variability in measurement of abdominal aortic aneurysms. Abdominal Aortic Aneurysm Detection and Management Veterans Administration Cooperative Study Group.

PURPOSE: The purpose of this study was to report interobserver and intraobserver variability of computed tomography (CT) measurements of abdominal aortic aneurysm (AAA) diameter and agreement between CT and ultrasonography observed in the course of a large, multicenter, randomized trial on the management of small AAAs. METHODS: CT measurements of AAA diameter from participating centers were compared with measurements made from the same scan by a central laboratory. Blinded central remeasurement of a randomly selected subset of these CT scans was used to assess intraobserver variability. Agreement between AAA measurements by CT and ultrasonography done within 30 days of each other was also assessed. RESULTS: For interobserver pairs of local and central CT measurements of AAA diameter (n = 806), the difference was 0.2 cm or less in 65% of pairs, but 17% differed by at least 0.5 cm. For intraobserver pairs of central CT remeasurements (n = 70), 90% differed by 0.2 cm or less, 70% were within 0.1 cm, and only one differed by 0.5 cm. Of 258 ultrasound-measured and central CT pairs, the difference was 0.2 cm or less in 44% and at least 0.5 cm in 33%. Ultrasound measurements were smaller than central CT measurements by an average of 0.27 cm (p < 0.0001). Local CT and ultrasound measurements showed a marked preference for recording by half centimeter. CONCLUSIONS: A high degree of precision is possible in CT measurement of AAA diameter, but this precision may not be obtained in practice because of differences in measurement techniques. Differences between imaging modalities increase variability further. Variations in AAA measurement of 0.5 cm or more are not uncommon, and this should be taken into account in management decisions. Efforts to reduce variation in measurement are warranted and might include (1) seeking agreement between surgeons and radiologists on a precise definition of AAA diameter, (2) limiting the number of radiologists who measure AAAs, and (3) use of calipers and magnifying glass for CT measurements.