Endovascular treatment of a symptomatic carotid artery aneurysm with a stent graft.

Endovascular methods have become more widespread and offer an alternative to surgery, which is often difficult in case of a hostile neck resulting from radiotherapy. Carotid pseudoaneurysm after laryngectomy is a very uncommon complication. We report a case of symptomatic carotid artery pseudoaneurysm treated using a stent graft.

Home therapy with LMWH in deep vein thrombosis: randomized study comparing single and double daily administrations.

The aim of this study was to assess the effectiveness of low-molecular-weight heparin (LMWH) treatment of deep vein thrombosis (DVT) in terms of the evolution of thrombosis, the incidence of adverse events, and compliance with heparin treatment using 2 types of LMWH available on the market administered in therapeutic doses throughout the period of treatment (Nadroparin) or at therapeutic doses only during the first month of treatment followed by a prophylactic phase at half dose (Parnaparin). A randomized prospective study was carried out on patients under observation with a recent diagnosis of DVT. The objectives of the study were to confirm the effectiveness of therapy with LMWH in terms of prevention of the risk of thromboembolism, of relapse of DVT, and of hemorrhagic complications, and to complete an evaluation of venous recanalization and residual valve competence in the 2 groups of patients. From December 2002 to June 2005, we randomized a total of 91 patients (51 in the Parnaparin group and 40 in the Nadroparin group). Overall, there was 1 case of nonfatal pulmonary embolism (1.1%) at 7 days into therapy with LMWH. There were 3 cases (3.3%) of progression of thrombosis despite therapy with LMWH, 2 cases (5%) in the Nadroparin group, and 1 case (2%) in the Parnaparin group (P = NS), and after suspension of the therapy, there was 1 case of relapse of thrombosis. Three of the 4 thrombotic events occurred in patients with active neoplasia. Moreover, only 1 major hemorrhagic event (1.1%) required blood transfusion. The Doppler ultrasound in the follow-up showed a complete resolution of 56% of the vein thromboses at an average of 6.1 +/- 4.6 (mean +/- SD) months. Valve competence recovered in 65.9% of cases with no significant difference between the 2 heparin groups. Home treatment of sural and femoral-popliteal DVT using LMWH represents a safe and effective method in the prevention of pulmonary embolism and encourages the process of recanalization of the thrombosed vessel, especially in cases of sural and/or popliteal DVT. Administration can be carried out with the same degree of safety at the therapeutic dose throughout the period of treatment or can be halved after the first month of treatment. In patients with active neoplasia, treatment with oral anticoagulant therapy must be considered.

Routine shunting is a safe and reliable method of cerebral protection during carotid endarterectomy.

The purpose of this report is to describe the perioperative and long-term outcomes of standard carotid endarterectomy (CEA) with general anesthesia, routine shunting, and patching and to show that routine shunting is a safe and reliable method of cerebral protection. Between January 1998 and December 2004, 700 patients attending our Department of Vascular Surgery underwent 786 CEAs performed using a standardized technique. Forty-four patients were excluded from the analysis because they underwent combined CEA and coronary artery bypass grafting, so the analysis is based on the results of 742 CEAs in 656 patients (86 bilateral CEAs). The strict surgical protocol included general anesthesia and standard carotid bifurcation endarterectomy with routine shunting (Javid's shunt) and Dacron patching. The Javid shunts were easily inserted in 738 cases (99.4%) but could not be used in four cases (0.5%) because of the presence of a very small internal carotid artery. The mean ischemic time required to insert the shunt and complete the suture was 4.7 min (+/-1.15), and the mean time to perform the endarterectomy was 34.3 min (+/-6.7). The mean follow-up was 24.4 months (+/-17.3). Overall 30-day mortality was 0.1% (one patient) due to a contralateral major stroke. The 1-month perioperative neurological complication rate was 0.7%, with three major and two minor strokes. The cumulative stroke and death rate was 0.8%. Preoperative symptoms such as hypertension, contralateral occlusion, or an age of more than 80 years were not independent risk factors for perioperative stroke. In the long-term follow-up, Kaplan-Meier analysis indicated an estimated 5-year stroke-free rate of 98.0%. There were eight cases (1%) of >70% restenosis (four cases) or thrombosis (four cases) of the operated internal carotid artery during the follow-up in asymptomatic patients: in four cases, carotid stenting due to >70% restenosis led to good results. The Kaplan-Meier estimate of the restenosis-free rate was 97.8%. The combined stroke and mortality rate of 0.8%, and the restenosis rate of 1% support the argument that standard CEA performed with routine shunting as brain protection leads to excellent early and long-term results.