Intraoperative cerebral monitoring in carotid surgery.

We have used and studied intraoperative cerebral monitoring in order to prevent intraoperative and early postoperative cerebral ischaemia. The techniques examined have included stump pressure measurement, the evaluation of somatosensory evoked potentials (SEPs) and completion intraoperative angiography. Stump pressure was measured in 920 patients and a safety level of 50 mmHg confirmed. Below this value, non-shunted patients were three times more likely to have cerebrovascular accident (CVA). SEPs were prospectively monitored in 72 patients and a mean decrease of N20-P25 in complex amplitude was seen in patients with a positive CT scan. In particular, pathological SEPs were found in 53% of patients with a positive CT scan, and in 54% of those with a contralateral carotid occlusion. In these patients, the N20-P25 amplitude fell progressively in the first 4 min. Using SEPs, the indication for shunting was 42% lower than with the measurement of back pressure and no patient with normal SEPs had a postoperative neurological deficit. The data obtained under local anaesthesia in 25 patients monitored by stump pressure and SEPs did not give better results. Intraoperative completion angiography performed routinely since 1978 has made it possible to reduce the need for immediate reoperation from 10-2%.

Cerebral SPECT with 99mTc-HMPAO in extracranial carotid pathology: evaluation of changes in the ischemic area after carotid endarterectomy.

The authors report their experience in studying patients undergoing carotid endarterectomy with simple photon emission computed tomography (SPECT). This technique made it possible to identify areas of preoperative cerebral hypoperfusion in 54.8% of the patients which had a good correlation with neurological symptoms. To distinguish gradual changes in the ischemic lesions, a method of assessing the surface of the hypoperfused areas was adopted. In addition, SPECT made it possible to detect a greater number of hypoperfused areas even in sites other than those revealed by CT. Moreover, there was good correlations between the SPECT data and the grade and site of the carotid lesion and the data provided by some intraoperative monitoring procedures. The Authors therefore propose the use of SPECT in the evaluation of patients with cerebrovascular insufficiency following a carotid disease.

Traumatic amputation of the upper limb: replantation of the arm.

From 1970 to 1985, 13 patients were treated as a result of an upper limb traumatic sub-amputation. Three of them were younger than 15 years and another one was only 3 years old at the time of the trauma. All the elements involved in the treatment of the lesions are described. When it was possible, an end-to-end anastomosis was used for the repair of arteries and veins. Otherwise, when the loss of tissue was marked, a saphenous vein graft was used. The fracture was treated, when possible, with an intramedullary fixation, surely less traumatizing for soft tissues than a plate. The repair of the nerve was at times simultaneous at other times delayed. The followup has shown a good functional restoration of the limb and of the joints affected by the trauma and a normal development of the patients in terms of age.

Late urologic complications in aorto-iliac reconstructions.

Aortoiliac reconstructive hydroureteronephrosis after surgery may be due to an incorrect position of the .0.prosthesis, anteriorly to the ureter, to a reactive retroperitoneal fibrosis or to a sclerotic outcome caused by vessel and ureter dissection. It is important to consider the possible correlation of hydronephrosis with recurrent prosthetic infections, both as a consequence and as a pre-existing cause of the infective process itself. In the present study, 100 patients were examined, all affected with chronic peripheral obstructive arterial disease and operated on for aortoiliac reconstruction by the same surgeon. A clinical, laboratory and echographic study was performed, after a follow-up period from surgery ranging between 23 and 146 months (72 months on average). Four of them (4%) showed unilateral hydronephrosis, always asymptomatic and resulting from a retroperitoneal fibrosis. When hydronephrosis was moderate or severe, an intravenous pyelography was performed. Only one patient required ureterolysis and "wrapping" of the ureter with adipose tissue, and insertion of an indwelling ureteral catheter, due to marked hydronephrosis and a reduction in the diameter of contralateral kidney. From this retrospective study, the opportunity and the prognostic importance of a perspective study of the patients undergoing aorto-iliaco-femoral reconstruction for an obstructive or aneurysmal disease is evidenced.

Long-term prognosis after carotid endarterectomy.

This study analyzed 76 consecutive patients with carotid transient ischemic attacks (TIA) and carotid lesions appropriate to symptoms who underwent endarterectomy during the period 1975-1981. The mean age of the patients was 51.9 +/- 8 years at the time of surgery. Hypertension was present in 32.9%, diabetes mellitus in 13%, ischemic cardiopathy in 8.2% and peripheral vascular disease in 6.6%. Operative mortality was 1.3% and harder morbidity 4%. The average follow-up was 2.6 years (range 1-7 years). The observed 5-year survival rate was 85.2% compared to the expected rate of 92.4% in a normal population. During the follow-up 5 patients had a stroke: the cumulative stroke rate was 4.6% at 1 year and 7.9% at 3 years. 18 patients had further TIAs (13 carotid TIAs and 5 vertebro-basilar TIAs). 6 patients suffered myocardial infarction. The prognosis of TIA patients treated with endarterectomy is difficult to evaluate because the natural history of TIAs is still undefined.