Carotid intervention: stent or surgery? A prospective audit.

This study represents a prospective audit comparing carotid artery stenting (CAS) with carotid endarterectomy (CEA), performed by a single surgical team. Between January 2005 and December 2008, 440 patients were referred; 177 had CAS and 263 CEA. Selection of procedure was individualised and contra-indications for CAS included internal carotid artery (ICA) stenosis > 85-90%, intraluminal thrombus, ICA tortuosity, gross surface ulceration of plaque and excessive calcification. Type III aortic arch and arch calcification also precluded CAS. Standard techniques were used for both procedures with a protection device routinely used for CAS. Most CEAs were performed under general anaesthesia, with selective intraluminal shunting. One hundred and eighty-six patients were selected for CAS; nine (48% ) were converted to CEA for technical reasons. The operative risk profile was similar, but significantly more in the CAS group were hypertensive. Almost half (49% ) in the CAS group were asymptomatic vs 26% in the CEA group. All asymptomatics had 70+ % stenosis on Duplex Doppler. Results were reported within one month of the procedure. The stroke rate was 2.3% for CAS vs 1.9% for CEA (p > 0.05). Stroke and death plus one M1 was 4.5% after CAS vs 3.4% after CEA (p > 0.05). Disabling stroke occurred in 1.1% of CAS patients vs 0.4% of CEA patients. These results are satisfactory and compare favourably with other similar series.

Carotid artery stump pressure and associated neurological changes in predominantly symptomatic carotid artery disease patients undergoing awake carotid endarterectomy.

AIM: To determine the mean carotid artery stump pressure (SP) at which patients develop neurological changes while undergoing awake carotid artery endarterectomy (CEA) under cervical block anaesthesia (CBA). METHODS: A prospective analysis was carried out of patients undergoing awake CEA under CBA between February 2004 and April 2007. All patients had mean SP measured, with selective shunting on those who developed neurological symptoms on carotid artery clamping regardless of stump pressure. A ball connected to a pressure sensor was put in the patient inverted exclamation mark s contra-lateral hand. RESULTS: Fifty-nine patients had awake CEA, 40 were males with a mean age of 64 years. Indications for CEA were asymptomatic high-grade stenosis in 12 (20%) patients and symptomatic stenosis in 47 (80%). Seven (12%) patients required shunting, one for transient ischaemic attack (TIA) and six for loss of consciousness. Six of these patients had presented with symptomatic disease. Taking the threshold of mean carotid SP of 50 mmHg as an indication for shunting, 22% (6/27) of patients with a mean SP of < 50 mmHg required shunting and only 3% (1/32) with a mean carotid SP of > 50 mmHg needed a shunt. This was not statistically significant. Using a mean carotid SP of < or = 40 mmHg as the threshold for shunting, 40% (4/10) of patients required shunting and 3% (1/31) with a mean carotid SP of > 40 mmHg required shunting. This was statistically significant. Thirteen (22%) patients were complicated by transient hoarseness of voice. One (2%) had a haematoma that required re-exploration. None of these patients had any major postoperative neurological or cardiological complications. CONCLUSION: Even though the sample in this study was small, awake CEA under local anaesthesia was seen as a safe procedure. It would appear to be safe to use the mean SP of 40 mmHg as a threshold for selective shunting in CEA under general anaesthesia.

Carotid Artery Stump Pressure and Associated Neurological Changes in Predominantly Symptomatic Carotid Artery Disease Patients Undergoing Awake Carotid Endarterectomy : Cardiovascular Topics

Aim : To determine the mean carotid artery stump pressure (SP) at which patients develop neurological changes while undergoing awake carotid artery endarterectomy (CEA) under cervical block anaesthesia (CBA). Methods : A prospective analysis was carried out of patients undergoing awake CEA under CBA between February 2004 and April 2007. All patients had mean SP measured; with selective shunting on those who developed neurological symptoms on carotid artery clamping regardless of stump pressure. A ball connected to a pressure sensor was put in the patient's contra-lateral hand. Results : Fifty-nine patients had awake CEA; 40 were males with a mean age of 64 years. Indications for CEA were asymptomatic high-grade stenosis in 12 (20) patients and symptomatic stenosis in 47 (80). Seven (12) patients required shunting; one for transient ischaemic attack (TIA) and six for loss of consciousness. Six of these patients had presented with symptomatic disease. Taking the threshold of mean carotid SP of 50 mmHg as an indication for shunting; 22(6 / 27) of patients with a mean SP of 50 mmHg required shunting and only 3(1 / 32) with a mean carotid SP of 50 mmHg needed a shunt. This was not statistically significant. Using a mean carotid SP of ? 40 mmHg as the threshold for shunting; 40(4 / 10) of patients required shunting and 3(1 / 31) with a mean carotid SP of 40 mmHg required shunting. This was statistically significant. Thirteen (22) patients were complicated by transient hoarseness of voice. One (2) had a haematoma that required re-exploration. None of these patients had any major postoperative neurological or cardiological complications. Conclusion : Even though the sample in this study was small; awake CEA under local anaesthesia was seen as a safe procedure. It would appear to be safe to use the mean SP of 40 mmHg as a threshold for selective shunting in CEA under general anaesthesia

Carotid Intervention : Stent or Surgery? A Prospective Audit : Cardiovascular Topic

This study represents a prospective audit comparing carotid artery stenting (CAS) with carotid endarterectomy (CEA); performed by a single surgical team. Between January 2005 and December 2008; 440 patients were referred; 177 had CAS and 263 CEA. Selection of procedure was individualised and contra-indications for CAS included internal carotid artery (ICA) stenosis 85-90; intraluminal thrombus; ICA tortuosity; gross surface ulceration of plaque and excessive calcification. Type III aortic arch and arch calcification also precluded CAS. Standard techniques were used for both procedures with a protection device routinely used for CAS. Most CEAs were performed under general anaesthesia; with selective intraluminal shunting. One hundred and eighty-six patients were selected for CAS; nine (48) were converted to CEA for technical reasons. The operative risk profile was similar; but significantly more in the CAS group were hypertensive. Almost half (49) in the CAS group were asymptomatic vs 26in the CEA group. All asymptomatics had 70+stenosis on Duplex Doppler. Results were reported within one month of the procedure. The stroke rate was 2.3for CAS vs 1.9for CEA (p 0.05). Stroke and death plus one M1 was 4.5after CAS vs 3.4after CEA (p 0.05). Disabling stroke occurred in 1.1of CAS patients vs 0.4of CEA patients. These results are satisfactory and compare favourably with other similar series

Limited thoracoscopic ganglionectomy for primary hyperhidrosis.

Sympathetic ganglionectomy is universally accepted as an effective and enduring treatment for primary hyperhidrosis. However, the variable extent of the ganglionectomy to treat this condition has been reported to be associated with a troublesome compensatory hyperhidrosis in between 22% and 81% of patients. In this prospective evaluation of a limited second thoracic ganglionectomy this approach, in addition to always being effective for pallmar hyperhidrosis, proved useful in up to 90% of patients with associated axillary and plantar hyperhidrosis. A compensatory hyperhidrosis rate of 13% was noted, confirming that a limited ganglionectomy should be standard practice in the management of primary hyperhidrosis.

Right aortic arch with isolated left brachiocephalic artery.

Right aortic arch with complete isolation of the left brachiocephalic artery is an extremely uncommon anomaly of the aortic arch. This case reports the hitherto unreported association of the right aortic arch with isolated left brachiocephalic artery presenting with a subclavian steal syndrome detected in a 36-year-old female patient being investigated for increasing attacks of episodic dizziness, vertigo, and left upper limb claudication spanning 1 year. A review of the literature relevant to this condition is presented. It is likely that with advances in imaging techniques and a wider clinical usage of these investigative modalities there will be further recognition of these uncommon conditions.

Resympathectomy for sympathetic regeneration.

Explanations for recurrent sympathetic activity after an apparently successful sympathectomy are varied and often tenuous. Among the theories given for recurrent sympathetic activity are the development of alternate neuroanatomic pathways, the possibility of an incomplete operation (failure to appreciate an alternative anatomic pathway at the time of surgery, i.e., nerve of Kuntz), and sympathetic regeneration. The latter, although long suspected, has never been conclusively demonstrated in humans. In this report, a case of recurrent sympathetic activity with conclusive evidence of sympathetic regeneration is described.

Laparoscopic diagnosis of gallbladder agenesis.

We describe the case of a 32-year-old patient with gallbladder agenesis encountered at laparoscopy. Diagnostic confirmation was made by endoscopic retrograde cholangiopancreatography and computerized scanning. Formal laparotomy was avoided. A review of the literature is presented.

Endoscopic transthoracoscopic sympathectomy--the Durban experience.

Advances in optics, illumination and video-technology together with refinements in operative technique have made endoscopic transthoracoscopic sympathectomy (ETS) the method of choice for upper thoracic sympathectomy. Palmar hyperhidrosis is by far the main indication for ETS. The procedure is technically easy and well tolerated by patients, and complications are few and minor.

Extracranial arterial reconstruction for chronic cerebral ischaemia. An audit of experience in the Durban Teaching Hospitals.

Experience with 147 operations for extracranial cerebral arterial reconstruction in 122 patients over a 36-month period is presented. The commonest condition in white, black and indian patients was atherosclerosis, although 8 of the 23 black patients had nonspecific aorto-arteritis (Takayasu's disease). Operations within the mediastinum included bypass from the ascending aorta to major arterial branches (14), brachiocephalic endarterectomy (1), and replacement grafts of carotid (1) and subclavian (1) arteries. Cervical procedures included carotid endarterectomy or reconstruction (115), carotid-subclavian artery bypass (13) and axillary-to-axillary artery crossover (2). Both early and longer-term results are comparable with those reported in the surgical literature.

Operative treatment of nonspecific aortoarteritis (Takayasu's arteritis).

Operative treatment of nonspecific aortoarteritis remains controversial and little information is available on the results of reconstruction of extracranial cerebral vasculature in this disease. Our experience with 25 patients with histologically proven symptomatic disease treated during a 4-year period is presented. The aortic arch and its branches were involved in 12 patients and 13 had disease affecting the descending aorta and its tributaries. Patients with cerebrovascular disease had aneurysms, minor stroke, or intermittent neurologic dysfunction. Descending aortic involvement resulted either in symptomatic or ruptured aneurysm and renovascular hypertension. Operative treatment of cerebrovascular disease comprised aortic arch (three patients), carotid (three patients), or subclavian artery reconstruction (six patients). Descending aortic reconstruction comprised thoracoabdominal (four patients) or infrarenal (five patients) aneurysmorrhaphy, abdominal aortic replacement with bilateral renal artery reconstruction (two patients), and nephrectomy (two patients). One early postoperative death occurred because of stroke. Twenty-four survivors have been observed between 3 and 42 months. No deaths or further neurologic episodes have occurred during this period and three of five hypertensive patients were cured. We conclude that symptomatic aortoarteritis, including cerebrovascular disease, may be treated by standard operative techniques with rewarding results.

Bypass versus primary major amputation in patients with femoropopliteal distal disease and a threatened limb.

Over a 36-month period 201 patients came to the Vascular Service, King Edward VIII Hospital, with atherosclerotic occlusive disease involving the femoropopliteal or femoro-infrapopliteal segments. On the basis of angiographic and clinical assessment 113 patients underwent bypass procedures and in 88 amputation was performed. The two groups were well matched as regards age and clinical condition. In-hospital mortality was 3,5% and 2,3% in the bypass and amputation groups respectively and the time spent in hospital was 5-6 weeks. In the longer term the desired achievement was limb salvage or ambulation on a prosthesis. Cumulative life-table analysis showed that more patients in the limb-salvage group than amputees were ambulant over any given time interval, although at 36 months after operation there was only an 8-10% difference. The results suggest that it is worth while attempting limb salvage in these cases, certainly as far as the first 3 years after operation are concerned.

Neurological deficit and injuries involving the neck arteries.

The management of 85 patients with penetrating injuries involving the external (n = 19), internal (n = 6) and common carotid (n = 46), vertebral (n = 10) and brachiocephalic (n = 4) arteries over a 5-year period in one hospital is reviewed. Sixty-three patients had no peroperative neurological deficit; 22 presented with localizing neurological signs. Where there was no deficit, the external carotid (n = 19) and vertebral (n = 10) arteries were ligated without adverse sequelae. Arterial reconstruction was performed of the internal carotid (n = 2) which resulted in a temporary neurological deficit in 7 patients and death in 3. Among the 22 patients with a preoperative neurological deficit, arterial reconstruction was performed in 18, which involved the common carotid in 17 patients and the internal, carotid in 1 patient. There was complete neurological recovery in 11 patients and 2 patients died. Four comatose patients had cerebral revascularization performed without fatality and with complete recovery in 3 of them. CT head scanning was not routinely employed for logistic reasons but has proved of limited value. No intraluminal arterial shunts were used in this series. It would seem that arterial reconstruction is not harmful and may well be beneficial to the young patient with extracranial cerebral arterial injury associated with a neurological deficit. Shunts are probably unnecessary for routine use.

Cervicomediastinal arterial injuries. A surgical challenge.

The initial clinical observations and methods and results of treatment in 104 patients with subclavian (48), vertebral (four), and carotid (52) artery injuries are reported. Delayed hemorrhage ten days after misdiagnosed subclavian artery injuries resulted in false aneurysms causing compressive brachial plexus palsies. A conservative approach to penetrating cervicomediastinal wounds was adopted with selective use of arch aortography when arterial injury was suspected by defined criteria. This proved safe, accurate, and invaluable for planning operative approach. Partial median sternotomy without entering the pleura proved optimal for superior mediastinal access; simple clavicle transection provided adequate distal subclavian exposure. External carotid and vertebral arteries were ligated. No shunts were employed for common and internal carotid repair. None of the 14 patients revascularized in the presence of a neurologic deficit died and none was made worse by carotid reconstruction.