Carotid thromboendarterectomy for recent total occlusion of the internal carotid artery.

BACKGROUND: The efficacy of emergency carotid thromboendarterectomy (CTEA) for acute internal carotid artery (ICA) thrombosis has been questioned. We evaluated the use of CTEA in patients with recent ICA occlusion. METHODS: From August 1989 to December 1999 patients who underwent urgent CTEA for recent ICA thrombosis were retrospectively evaluated. Patient data analyzed included age, sex, comorbid risk factors, diagnostic evaluation, operative procedure, and long-term follow-up with clinical assessment and carotid duplex scan. Neurologic status was evaluated with the Modified Rankin Scale (MRS) before the operation, immediately after the operation, and at 3- to 6-months' follow-up. RESULTS: Twenty-nine patients underwent emergency ipsilateral CTEA for acute ICA thrombosis over the last 10 years. The average age of the patients was 69.9 +/- 1.7 years, and 66% were men. Patient risk factors included diabetes (7 [24%]), hypertension (21 [72%]), coronary artery disease (8 [29%]), and history of tobacco abuse (20 [69%]). Presenting symptoms included cerebrovascular accident (7 [24%]), transient ischemic attack (nonamaurosis) (10 [34%]), crescendo transient ischemic attack (7 [24%]), stroke in evolution (2 [7%]), and amaurosis fugax (3 [10%]). Diagnostic evaluation included computed tomographic scan (29 [100%]), magnetic resonance imaging/magnetic resonance angiography (4 [14%]), duplex scan evaluation of the carotid arteries (23 [79%]), and cerebral angiography (18 [64%]). Antegrade flow in the ICA was successfully established in 24 (83%) of 29 patients and confirmed with intraoperative angiography or duplex sonography. Postoperative morbidity included 2 hematomas (7%), 4 transient cranial nerve deficits (14%), and 1 conversion to hemorrhagic stroke (3.6%), which resulted in the only death (3.6%). MRS scores averaged 3.4 +/- 0.2 preoperatively. Follow-up averaging 74.1 +/- 21 months (range, 3-140 months) was obtained in 27 (93%) patients. Improvement or deterioration was defined as a change in MRS +/- 1. Immediately postoperatively, 14 (48%) patients were improved, 2 (7%) deteriorated, and 13 (45%) had no change. At 3 to 6 months, 20 (74%) of 27 patients were improved, seven (26%) had no change, and none deteriorated. Of patients with successful CTEA, 23 (96%) of 24 had a patent ICA on follow-up duplex scan evaluation, and there was no evidence of recurrent ipsilateral neurologic events at an average of 49 months. CONCLUSION: These data support an aggressive early surgical intervention for acute ICA thrombosis in carefully selected patients. In the previous decade we reported a 46% success rate for establishing antegrade flow in the ICA long term. Data from this decade show a 79% (P =.0114) success rate for establishing antegrade flow long term in all patients undergoing emergency CTEA. New and improved imaging modalities have allowed better patient selection, resulting in improved outcomes.

Improving longevity of prosthetic dialysis grafts in patients with disadvantaged venous outflow.

OBJECTIVE: Angioaccess for hemodialysis in an extremity with disadvantaged venous outflow has reduced long-term patency. We hypothesized that arteriovenous bridge graft patency could be improved in patients with disadvantaged venous outflow by preoperative venous duplex mapping. METHODS: The charts of 114 patients who underwent 115 prosthetic arteriovenous bridge grafts were reviewed. Disadvantaged venous outflow was defined on the basis of any combination of prior arteriovenous bridge graft, multiple venipunctures, and clinical examination. Patients were grouped according to the presence or absence of disadvantaged venous outflow. Three groups were analyzed: those with normal venous outflow who had an initial arteriovenous bridge graft (NML), those with disadvantaged venous outflow who had only a clinical examination before redo arteriovenous bridge graft (REDO/DVO), and those with disadvantaged venous outflow who underwent preoperative duplex scanning venous evaluation (MAP/DVO). Life table primary and secondary 12-month patency rates were compared by means of log-rank analysis. RESULTS: Life table analysis yielded 6-month primary patency rates of 65.9% +/- 5.7%, 66.4% +/- 7.3%, and 43.8% +/- 10.9% for NML, MAP/DVO, and REDO/DVO, respectively. The secondary patency rates at 6 months for NML (91.9% +/- 3.4%) and MAP/DVO (91.1% +/- 4. 9%) were statistically equivalent, and both were significantly better than the patency for REDO/DVO (75.0% +/- 10.0%; P =.004 and P =.04, respectively). This trend persisted beyond 12 months. CONCLUSION: Preoperative evaluation of venous anatomy in patients with disadvantaged venous outflow results in an arteriovenous bridge graft patency comparable to that seen in patients undergoing initial arteriovenous bridge grafts. Vein mapping improves arteriovenous bridge graft durability in the patient with disadvantaged venous outflow by allowing the surgeon to select venous return that is in direct continuity with the central venous system.

Upper extremity hemodynamic changes after radial artery harvest for coronary artery bypass grafting.

Twenty-seven patients were studied with arterial duplex, photoplethysmography, segmental pressures, and pulse volume recordings both preoperatively and following radial artery harvesting. The average number of days to the follow-up visit was 66. Preoperative and postoperative data were compared using the matched Student's t-test. There were no significant changes between preoperative and postoperative pressures in the brachial, radial, and ulnar arteries, and thumb, index, long, ring, or little fingers. Pressure changes in the thumb and index finger approached but did not achieve a statistical difference. Peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI) in the distal ulnar artery changed significantly between preoperative and postoperative measurements. PSV changed from 0.50 +/- 0.05 m/sec to 0.67 +/- 0.04 m/sec (p = 0.02); EDV changed from 0.03 +/- 0.03 m/sec to -0.10 +/- 0.05 m/sec (p = 0.05); and RI changed from 0.97 +/- 0. 05 to 1.13 +/- 0.05 (p = 0.02). Palmar arch evaluations revealed significant changes at rest and with ulnar compression between preoperative and postoperative measurements: (1) at rest EDV changed from 0.03 +/- 0.02 m/sec to -0.05 +/- 0.02 m/sec (p < 0.01); (2) at rest RI changed from 0.96 +/- 0.05 to 1.12 +/- 0.05 (p = 0.01); (3) with ulnar compression the PSV changed from 0.23 +/- 0.05 m/sec to 0. 005 +/- 0.01 m/sec (p < 0.01); and (4) with ulnar compression the RI changed from 0.82 +/- 0.11 to 0.27 +/- 0.12 (p < 0.01). Eight patients had a variety of complaints at the follow-up visit, the majority being numbness and tingling. No patients reported symptoms of claudication or rest pain at the follow-up visit. The data suggest that while statistically significant changes in velocity and arterial resistance do occur, patients seem to tolerate radial artery harvesting without clinical consequences. The ideal method of preoperative evaluation remains to be determined.