Prospective randomized trial of bilateral carotid endarterectomies: primary closure versus patching.

BACKGROUND AND PURPOSE: Although several studies have compared the results of carotid endarterectomy (CEA) with primary closure (PC) versus patch closure, none have compared the outcome of bilateral CEAs with patch versus PC performed on the same patient. This prospective randomized study compares the clinical outcome and incidence of recurrent stenosis (>/=80%) for CEA with PC versus patch closure in patients with bilateral CEAs. METHODS: This study includes 74 patients with bilateral CEAs with PC on one side and patching on the other. Patients were randomized to sequential operative treatment of either patching/PC or PC/patching. Postoperative duplex ultrasounds and clinical follow-up were done at 1, 6, and 12 months and every year thereafter. A Kaplan-Meier analysis was used to estimate the risk of significant restenosis (>/=80%). RESULTS: Demographic characteristics and the mean operative diameter of the internal carotid artery were similar for both PC and patching. The mean follow-up was 29 months (range, 6 to 65 months). The incidence of ipsilateral stroke was 4% for PC versus 0% for patching. PC had a significantly higher incidence of neurological complications (transient ischemic attacks and stroke combined) than patching (12% versus 1%; P=0.02). Operative mortality was 0%. PC had a higher incidence of recurrent stenosis (22% versus 1%; P<0.003) and total internal carotid artery occlusion (8% versus 0%; P=0.04) than patching. Restenoses necessitating a repeated CEA were also higher for PC (14%) than for patching (1%; P=0.01). The Kaplan-Meier analysis showed that patching had a significantly better cumulative patency rate than PC (P<0.01). This analysis also showed that freedom from recurrent stenosis at 24 months was 75% for PC and 98% for patching. CONCLUSIONS: Patch closure is less likely than PC to cause ipsilateral stroke, transient ischemic attacks, and recurrent carotid stenosis. The higher rate of unilateral recurrent stenosis may suggest that local factors play a more significant role than systemic factors in the etiology of recurrent carotid stenosis.

Etiology of peripheral arterial thromboembolism in young patients.

BACKGROUND: No prior studies have explored the etiology of peripheral arterial thromboembolic events (PATE) in younger patients. Therefore, we analyzed the sources of these events in patients <50 years of age over a recent 10-year period. Diagnostic and work-up strategies will be proposed based on the presence of cardiac or atherosclerotic risk factors. PATIENTS AND METHODS: The sources of emboli were classified as (1) conventional (cardiac or arterioarterial), (2) unconventional, or (3) unknown. A statistical analysis of risk factors that, if absent, would suggest an unconventional cause was performed. Risk factors included those for cardiac and atherosclerotic disease: coronary artery disease (CAD), valvular disease, smoking, arrhythmia, hypertension, or diabetes mellitus. RESULTS: Overall, 51 patients were identified. Twenty-nine patients (57%) had unconventional causes (8 paradoxical emboli, 4 possible paradoxical emboli, 12 hypercoagulable states, 3 white clot syndromes, and 2 cervical ribs), 17 (33%) had conventional causes, and 5 (10%) were unknown. When the number of cardiac risk factors was < or =1, excluding smoking, the probability of a conventional source was zero, in contrast to 100% if the number of risk factors was >1. When the following risk factors were absent, there were significantly more unconventional than conventional sources of emboli (P < 0.001): smoking (100% versus 0%), CAD (93% versus 7%), arrhythmias (83% versus 17%), hypertension (93% versus 7%), and diabetes mellitus (81% versus 19%). Patients with a conventional source were significantly older (44 versus 38 years). CONCLUSIONS: The "unconventional" causes of PATE were responsible for a higher percentage of cases in young patients. An analysis of the number of risk factors was useful in predicting which patients suffered embolic events from conventional sources, with the critical number being >1 (excluding smoking). Therefore, when younger patients present with PATE, and are found to have < or =1 identifiable cardiac risk factor, their work-up should be directed toward the unconventional sources first.

Laparoscopy-associated mesenteric vascular events: description of an evolving clinical syndrome.

Over the past few years, several cases of acute mesenteric ischemic events following laparoscopy have appeared in the literature. To date, no formal description of this phenomenon has been provided. In this article, we summarize and analyze the features of the five reported cases to date as well as a sixth case encountered at our institution. The probable cause of this complication involves changes in splanchnic hemodynamics related to elevated intra-abdominal pressure. A review of the relevant literature is provided.

Effect of contralateral severe stenosis or carotid occlusion on duplex criteria of ipsilateral stenoses: comparative study of various duplex parameters.

PURPOSE: This study compares the accuracy of various duplex parameters in grading ipsilateral carotid stenoses in patients with contralateral severe stenoses or occlusion. METHODS: Four duplex criteria were correlated to arteriography in 356 carotid arteries in blind fashion: (1) standard criteria: a peak systolic frequency (PSF) of the internal carotid artery (ICA) of > or = 4 kHz was used to diagnose > or = 50% stenosis; (2) new criteria: a PSF of the ICA of > or = 4.5 kHz was used; (3) Fujitani criteria: a PSF of the ICA of > 4.5 kHz and an end-diastolic frequency of < 5.0 kHz was used; (4) internal carotid/common carotid artery (ICA/CCA) PSF ratio of > or = 1.5 was used. RESULTS: The standard method overestimated 56 (16%) of 356 stenoses in contrast to 3% for the new method (p < 0.001), and this effect was most evident in the 50% to < 80% stenosis category (30%). The Fujitani method underestimated 97 (27%) of 356 stenoses, and the ICA/CCA ratio overestimated stenoses in 77 (22%) of 356. The overall exact correlation was 94%, 82%, 70%, and 75% for the new, standard, Fujitani, and ICA/CCA ratio, respectively. The kappa statistic and corresponding confidence intervals for the new method (kappa = 0.923, +/- 0.016) are significantly higher (p < 0.001) than those for the standard method (kappa = 0.760, +/- 0.027), the Fujitani method (kappa = 0.608, +/- 0.031), and the ICA/CCA ratio method (kappa = 0.642, +/- 0.051). The overall accuracy in diagnosing > or = 50% ipsilateral stenosis in the whole series was 85% for the standard method, 97% for the new method, 95% for the Fujitani method, and 81% for the ICA/CCA ratio. The new method was superior to the standard and ICA/CCA ratio methods (p < 0.001) and the Fujitani method (p = 0.024). CONCLUSIONS: The presence of significant contralateral stenosis (> or = 50%) can lead to overestimation of ipsilateral stenosis if the standard criteria are used; however, this problem can be avoided by using a PSF of the ICA of > or = 4.5 kHz for the diagnosis of > or = 50% stenosis.

Congenital cystic supratentorial hemangioblastoma. Case report.

The first documented case of congenital supratentorial hemangioblastoma is presented, occurring in a 3-week-old infant. Extensive review of the literature revealed approximately 83 cases of supratentorial hemangioblastoma; however, only one of these occurred in the first year of life, and that case was not presented in detail.

Seventeen level laminectomy for extensive spinal epidural abscess: case report and review.

Several studies have suggested that non-operative treatment be employed for spinal epidural abscesses involving a considerable length of the vertebral column. The reasons for this have not been clearly stated in the literature, however, nor has the critical number of vertebral levels been specified. Presumably, this is related to the morbidity of extensive laminectomy, but we began to question this assumption because of advances in surgical instrumentation combined with frequent reports of irreversible disease progression while on appropriate antibiotics. In this article, we present a case of an extensive spinal epidural abscess managed surgically with no associated morbidity. In addition, we present a review of the literature concerning spinal epidural abscess.

Giant posterior inferior cerebellar artery aneurysm associated with foramen magnum syndrome.

The case of a giant distal posterior inferior cerebellar artery (PICA) aneurysm which caused foramen magnum syndrome is presented. A 67-year-old male was referred for evaluation of a posterior fossa mass lesion on MRI scan. Craniotomy was performed which revealed a giant and completely thrombosed aneurysm of the distal PICA, which was subsequently excised intact. This report adds giant aneurysm of the PICA to the list of posterior fossa lesions reported which cause foramen magnum syndrome.

Effect of naloxone on hypertension in Dahl salt-sensitive rats.

Experiments were conducted to test the hypothesis that chronic administration of an opioid receptor antagonist, naloxone, would affect the outcome of the developmental phase of hypertension in Dahl salt-sensitive (S/JR strain) rats. Accordingly, S/JR rats were maintained on either a low-salt (0.45% NaCl) or a high-salt (7% NaCl) diet for 4 wk. Half of the animals of each dietary group were treated with naloxone (100-130 micrograms/h) by osmotic minipump. Food and water intakes of the high-salt animals were measured for the first 25 days, and blood pressure was measured at the end of the 4 wk via an indwelling femoral arterial catheter. Naloxone treatment slightly but significantly reduced the level of hypertension attained in the high-salt animals (158 +/- 2 mmHg in naloxone-treated animals vs. 168 +/- 3 mmHg in control animals; P less than 0.05) and also attenuated food (and hence salt) and water intakes. Naloxone did not affect the blood pressure of the low-salt animals. To determine whether the slight attenuation of hypertension might be secondary to a reduction of salt intake, a group of control S/JR animals were fed a moderately high-salt diet (2% NaCl), and naloxone-treated S/JR animals were salt-intake matched to this group by daily adjustment of the dietary salt content. Blood pressures after 4 wk of treatment were not different between these two groups. Finally, acute administration of 1 and 30 mg/kg of naloxone failed to lower blood pressure of animals with established hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)