[Elevated incidence of cognitive impairment in patients with asymptomatic carotid stenosis]. / Elevada incidencia de deterioro cognitivo en pacientes con estenosis carotidea asintomatica.

INTRODUCTION: Stroke is one of the main causes of mortality and functional disability in developed countries. Carotid stenosis (CS) is considered the reason for 20-30% of strokes. However, the studies that have gone into depth on the cognitive status of these patients are limited. AIM: To investigate the cognitive performance of CS patients and its relationship with clinical variables (carotid obstruction, lifestyle). PATIENTS AND METHODS: 33 CS patients were evaluated using a broad neuropsychological protocol, and were divided into two groups: symptomatic CS and asymptomatic CS. RESULTS: 50-57% of CS patients showed deficits in processing speed and visual memory (immediate recall). 41.9% showed altered performance in semantic fluency, whereas the percentage was 30% in digits subtest. The percentage of altered performance was 20-27% in verbal memory (learning curve, delayed recall) and visual memory (delayed recall). No significant differences were found between the symptomatic CS and asymptomatic CS groups. Cognitive performance correlated significantly with lifestyle scale factors, but not with the percentage of carotid obstruction. CONCLUSION: A high percentage of CS patients showed a clinically altered performance in different cognitive domains, regardless of suffering vascular neurological symptoms (symptomatic vs asymptomatic CS). A close relationship was found between lifestyle and cognitive status of CS patients.

TITLE: Elevada incidencia de deterioro cognitivo en pacientes con estenosis carotidea asintomatica.Introduccion. Los ictus se situan como una de las principales causas de mortalidad e incapacidad funcional en los paises desarrollados. La estenosis carotidea (EC) se considera la causa del 20-30% de los ictus. No obstante, los estudios que han profundizado en el estado cognitivo de estos pacientes son escasos. Objetivo. Estudiar el rendimiento cognitivo de pacientes con EC y su relacion con variables clinicas (obstruccion de la carotida, estilo de vida). Pacientes y metodos. Se evaluo a 33 pacientes con EC mediante un protocolo neuropsicologico amplio, distribuidos en dos grupos: EC sintomatica y EC asintomatica. Resultados. Un 50-57% de los pacientes con EC presento una ejecucion alterada en velocidad de procesamiento y memoria visual (recuerdo inmediato). Un 41,9% rindio de forma alterada en fluidez semantica, mientras que en el subtest de digitos el porcentaje fue del 30%. En la memoria verbal (curva de aprendizaje, recuerdo demorado) y la memoria visual (recuerdo demorado), el porcentaje de alterados fue del 20-27%. No se encontraron diferencias significativas entre los grupos de EC asintomatica y EC sintomatica. El rendimiento cognitivo correlaciono significativamente con los factores de la escala de estilo de vida, pero no con el porcentaje de obstruccion de la carotida. Conclusion. Un elevado porcentaje de los pacientes con EC presento un rendimiento clinicamente alterado en diferentes dominios cognitivos, con independencia de que hubieran experimentado o no sintomatologia neurologica vascular (EC asintomatica frente a sintomatica). Se encontro una estrecha relacion entre el estilo de vida y el estado cognitivo de los pacientes con EC.

Lumbar sympathectomy as isolated technique for the treatment of lower limbs chronic ischemia.

BACKGROUND: Lumbar sympathectomy (LS) is often the only alternative treatment that can be considered as a means of improving the distal circulation to such extent that major amputation is prevented. To make a retrospective study in order to know the current value of LS as isolated technique for the treatment of severe ischemia of lower limbs in the absence of the possibility for vascular reconstruction. METHODS: Between 1987 and 1992, 100 LS were performed in 93 patients (82 males and 11 females) aged 64.5+/-11.1 yrs. 63% were older than 70 years. Indication was invalidant claudication/rest pain (grade II, 57%) or trophic lesion (grade III, 43%) in patients where previous reconstructive surgery failed (18%), was not possible to do (23%) or refused revascularization (20%), or with poor surgical risk (39%). Preoperative evaluation included Doppler measures, ankle/brachial index (ABI) and arteriography in every case. Surgical sympathectomy was performed in all patients. Success was considered if rest pain was absent or trophic lesions have healed at six months, comparing results in patients diabetics and non-diabetics with ABI higher or lower 0.3. RESULTS: Postoperative stage was 6.4+/-2.3 days. Morbidity was 4% and mortality was 7% in the 30-day postoperative period, related with patients older than 70 years. Long-term mortality was 9%, for a global nortality of 16%. 12 patients needed inflow surgery after LS. There was success in 58.5% of grade II and 61.7% of grade III patients at six months, with significative difference (p=0.049) if ABI was >0.3. In diabetics with ABI >0.3, trophic lesions have worse prognostic than ABI <0.3. Pre- and postoperative ABI were correlated (R2=0.65), and the increasing of 0.1 in preoperative ABI had a positive prognostic value over lesion healing. Patency of superficial femoral artery (SFA) has correlated significantly (p=0.000021) with successful outcome after LS. CONCLUSIONS: LS could be a technique that moderately improves the ischemic limb in patients who refuse major surgery or where arterial reconstruction is not indicated. Preoperative ABI has prognostic value in postoperative outcome, with clinical improvement if it is >0.3. Diabetes has not been a negative predictive factor in our series. Patency of superficial femoral artery is related to successful outcome of the patients.

[Right coronary artery originating from the left sinus of Valsalva. Surgical repair]. / Nacimiento de la arteria coronaria derecha en seno de Valsalva izquierdo. Corrección quirúrgica.

Anomalous origin of right coronary artery from left coronary sinus has been considered a minor disease without relevance. Currently it is associated with all symptoms derived from myocardial ischemia because of its lower coronary reserve. We present one patient with anomalous origin of right coronary artery from left coronary sinus surgically treated with saphenous vein aorto-coronary bypass. Doppler velocimetry shows the improvement of myocardial reserve after surgery.

Epidural regional hypothermia for prevention of paraplegia after aortic occlusion: experimental evaluation in a rabbit model.

PURPOSE: The efficacy of epidural regional hypothermia in the prevention of acute and delayed-onset paraplegia, as well as possible complications and limitations of this technique to a clinically acceptable form, were evaluated in 49 New Zealand white rabbits. METHODS: A modified rabbit spinal cord ischemia model of infrarenal aortic occlusion for 30 minutes was employed. The study was performed in two phases. In phase I (n=20), regional hypothermia induced by epidural perfusion of iced normal saline solution (4 degrees C) was tested versus control in 10 rabbits each (groups A and B). In phase II (n=29) the animals were subdivided into three groups to study the kinetics of absorbtion and distribution of methylene blue (group C; n=10), radiographic contrast material (group D; n=9), and measurement of cerebrospinal pressure while an epidural iced solution was or was not infused (group E; n=10). RESULTS: At 24 and 48 hours, all of the normothermic animals showed irreversible paraplegia (Tarlov score 0). In contrast, at 24 hours none of the rabbits undergoing epidural cold infusion were paraplegic, although at 48 hours one animal had weakness of a hindlimb (Tarlov score 3). Plasma concentration-time profiles of a continuous epidural perfusion with methylene blue showed that the spinal canal is a highly compliant space. Epidurographs showed that epidural perfusion tends to spread more in a cephalic than caudal direction and the main uptake is by the vascular compartment. Despite the large volumes infused (78.75 ml/hr; range, 50 to 100 ml), we observed only a modest transient increase in cerebrospinal fluid pressure (from 2.5 +/- 0.3 mm Hg to 5.4 +/- 0.1 mm Hg), although some animals had intracranial hypertension. CONCLUSIONS: Regional hypothermia induced by epidural cold perfusion has a highly protective effect against the ischemic spinal cord damage. However, this method probably does not avoid the risk of delayed-onset paraplegia. An important limitation of this technique is the difficulty of controlling the intrathecal pressures.

Sartorius myoplasty for the treatment of infected groins with vascular grafts.

INTRODUCTION: Vascular graft infection is a rare (0.8-2.6%) but serious complication of reconstructive vascular surgery, that comprises limb-threatening when located in the groin. PURPOSE: Review our experience in the treatment of infected groin wounds after femoral surgery by using sartorius myoplasty. MATERIALS AND METHODS: Between January 1989 and October 1993, 13 patients with infected groin wounds involving vascular graft (Grade III of Szilagyi) were treated with local gently debridement, 10% povidone iodide lavage for 5 days, local and systemic antibodies for 14 days and in situ change of the infected graft followed by sartorius myoplasty, detaching its origin from superior anterior iliac spine and fixing it to inguinal ligament, except in one case where tissue cultures were negative and the graft was not changed. Follow-up was done using clinical and echographical criteria at 3, 6, 12 months after operation, and annually. RESULTS: Hospital mean stage was 10 days (8-13). The mean follow-up was 36 months (12-65). There was only one immediate complication from hemorrhage that needed surgery. The patient whose graft was not changed developed an abscess in the prosthetic bed 12 weeks after treatment. It was necessary to change it after debridement and antibiotics. No mortality was related to this technique. CONCLUSIONS: Sartorius myoplasty, with detaching and origin transposition, after in situ change of infected graft, is an excellent therapeutic option for reconstruction and treatment for infected groins with vascular grafts because it is easy to perform and offers very good results in long-term follow-up.

Intraoperative fibrinolytic therapy for salvage of limbs with acute arterial ischemia: an adjunct to thromboembolectomy.

The purpose of this prospective study was to determine the value of intraoperative intra-arterial fibrinolytic therapy (IIFT) in patients with acute arterial ischemia as an adjunct to mechanical thromboembolectomy. Sixty-six femoropopliteal or distal acute arterial occlusions were assessed by means of arteriography and Doppler imaging pre- and postoperatively. Two groups of patients were compared: one (n = 35) in which mechanical thromboembolectomy was applied as the single technique and another (n = 31) in which 250,000 IU of urokinase diluted in 250 ml of normal saline solution was instilled at the end of mechanical thromboembolectomy over a 30-minute period with the arterial inflow occluded. Candidates for IIFT were selected according to a nonrandomized method. Intraoperative arteriography showed residual thrombus in 20 (30.3%) patients and unsuspected arterial lesions in 23 (34.8%). Thrombosis recurrence was associated with residual thrombus (p < 0.001) and amputation (p < 0.001). The ankle/brachial index increased significantly (p < 0.05) in the patients who received IIFT (0.88 +/- 0.03) in comparison with those who underwent mechanical thromboembolectomy (0.75 +/- 0.05). Although the percentages of distal revascularization and amputation did not differ significantly between the two groups, quantitatively the results were better in the IIFT group (80.65% success and 9.68% failure) compared to the mechanical thromboembolectomy group (60% success and 22.86% failure). There was no bleeding due to IIFT. Significant variables in our study were diabetes (p < 0.05), the time period of 12 to 24 hours before the surgery (p < 0.05), and the severity of the ischemia in association with rest pain (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Amaurosis fugax as a symptom of carotid artery stenosis. Its relationship with ulcerated plaque.

Amaurosis fugax has frequently been related to carotid artery disease. In order to determine the relationship between amaurosis fugax and significant carotid artery stenosis, we prospectively studied 81 consecutive patients presenting to an ophthalmologist with this symptom. Neurologic and vascular evaluation with PPG and Duplex-scan were performed. A stenosis of greater than 70% was regarded as significant. DSA was performed in patients with significant stenosis (55 of 81). The presence of risk factors such as hypertension, diabetes, coronary artery disease, tobacco and hyperlipidemia was considered. Mean age was 64.96 years. There was a high prevalence of hypertension, smoking and previous CVA/TIAs. Patients with significant carotid stenosis were endarterectomized. Carotid atheromata plaques were classified in three groups: hemorrhagic plaque (5), dystrophic calcification (8) and ulcerated plaque (42). There was a high correlation (0.87) between ulcerated plaque and amaurosis fugax. We conclude that amaurosis fugax is an important symptom to allocate patients with high risk of carotid disease, specially carotid stenosis complicated with ulcerated plaque. Carotid duplex scan must be done if this symptom is present.