The Longitudinal Course of Prospectively Recorded Patient-reported Outcomes in Prostate Cancer Patients Treated with Surgery and Salvage Radiotherapy.

Background: Patient-reported outcome measures (PROMs) after prostate cancer (PC) treatment, including both radical prostatectomy (RP) and salvage radiation therapy (SRT), are under-reported. Objective: To investigate PROMs longitudinally from before SRT until 18 mo after SRT for men treated with contemporary treatment modalities. Design setting and participants: This prospective, longitudinal cohort study included 120 men (whole cohort) treated with SRT administered with volumetric modulated arc radiotherapy from 2016 to 2021 at the University Hospital of North Norway. The whole cohort was followed from before SRT until 18 mo after SRT. A subcohort of 48 men was followed from before RP until 18 mo after SRT. Outcome measurements and statistical analysis: PROMs were collected with the Expanded Prostate Cancer Index-26 (EPIC-26), covering symptoms of urinary incontinence, urinary irritative, bowel, sexual, and hormonal domains. The domain scores were inquired before RP, 3 mo after RP, before SRT, at SRT termination, and 3 and 18 mo after SRT. We used linear mixed models with repeated measurements design to assess changes in PROMs throughout the treatment period. Results and limitations: The median age before SRT was 63 yr. For the whole cohort, all five domains worsened at 3 and 18 mo after SRT compared with those before SRT. The estimated mean changes from before SRT to 18 mo after SRT are as follows: urinary incontinence -13.1, urinary irritative function -10.4, bowel -16.8, sexual function -9.1, and hormonal function -20.2 (at clinically important levels for all domains but sexual). For the subcohort, the mean urinary incontinence, bowel, sexual, and hormonal functions were significantly worsened 3 and 18 mo after SRT compared with those before RP at clinically important levels. Conclusions: Men treated for PC report particular increased severity of urinary, bowel, sexual, and hormonal symptoms after SRT compared with baseline status. Patient summary: For men with prostate cancer, the treatment combination of surgery and salvage radiotherapy worsens urinary incontinence and bowel, sexual, and hormonal functions.

Patient-reported outcomes after curative treatment for prostate cancer with prostatectomy, primary radiotherapy or salvage radiotherapy.

BACKGROUND: Trials reporting adverse health outcomes (AHOs) in terms of patient-reported outcome measures (PROMs) after contemporary curative treatment of prostate cancer (PC) are hampered by study heterogeneity and lack of new treatment techniques. Particularly, the evidence regarding toxicities after radiotherapy (RT) with the volumetric arc therapy (VMAT) technique is limited, and comparisons between men treated with surgery, primary radiotherapy (PRT) and salvage radiotherapy (SRT) are lacking. The aim of the study was to evaluate change in PROMs 3 months after treatment with robotic-assisted laparoscopic prostatectomy (RALP), PRT and SRT administered with VMAT. MATERIAL AND METHODS: A prospective cohort study of men with PC who received curative treatment at the University Hospital of North Norway between 2012 and 2017 for RALP and between 2016 and 2021 for radiotherapy was conducted. A cohort of 787 men were included; 406 men treated with RALP, 265 received PRT and 116 received SRT. Patients completed the validated PROM instrument EPIC-26 before (pre-treatment) and 3 months after treatment. EPIC-26 domain summary scores (DSSs) were analysed, and changes from pre-treatment to 3 months reported. Changes were deemed clinically relevant if exceeding validated minimally clinically important differences (MCIDs). RESULTS: Men treated with RALP reported clinically relevant declining urinary incontinence DSS (-41.7 (SD 30.7)) and sexual DSS (-46.1 (SD 30.2)). Men who received PRT reported worsened urinary irritative DSS (-5.2 (SD 19.6)), bowel DSS (-8.2 (SD 15.1)) and hormonal DSS (-9.6 (SD 18.2)). Men treated with SRT experienced worsened urinary incontinence DSS (-7.3 (SD 18.2)), urinary irritative DSS (-7.5 (SD 14.0)), bowel DSS (-12.5 (SD 16.1)), sexual DSS (-14.9 (SD 18.9)) and hormonal DSS (-23.8 (SD 20.9)). CONCLUSION: AHOs 3 months after contemporary curative treatment for PC varied according to treatment modality and worsened in all treatment groups, although most in SRT.

Isoflurane Increases Tolerance to Renal Ischemia Reperfusion Injury Compared to Propofol: An Experimental Study in Pigs.

Purpose: To compare two clinically relevant anesthetic agents, i.e., isoflurane versus propofol with respect to protection of the kidney in a porcine renal ischemia reperfusion model. Materials and Methods: 14 hybrid pigs were randomized to anesthesia with either isoflurane or propofol prior to laparoscopic surgery. Following anesthesia, the left kidney hilum was clamped for 60 min and the right kidney removed. After 48 h of reperfusion, urine was sampled for analysis of neutrophil gelatinase-associated lipocalin (NGAL), albumin, and creatinine. The left kidney was harvested for histologic scoring of injury. Results: Histologic examination of renal injury revealed a statistically significant difference in favor of isoflurane on denuded basement membrane score (isoflurane group 1.58 ± 0.38 vs. propofol 2.42 ± 0.80, p = .026). Median (25-75 percentile) urinary albumin 3.4 g/L (2.25-7.48) vs. 8.9 g/L (3.73-13.8), (p = .041) and urinary albumin/creatinine ratio 1.17 (0.76-1.82) vs. 1.76 (1.63-5.99), (p = .026) were both significantly lower in the isoflurane group. Median (25-75 percentile) urinary NGAL was 167 (51-215) pg/ml in the isoflurane group compared with 362 (149-508) pg/ml in the propofol group (p = .093). Conclusion: Isoflurane increases tolerance to renal ischemia reperfusion injury compared to propofol in this model.

Improvement in early continence after introduction of periurethral suspension stitch in robotic prostatectomy.

Early urinary incontinence remains a major source of morbidity for patients undergoing robotic prostatectomy. The purpose of the study was to determine whether the introduction of a suspension stitch would improve early urinary continence rates in patients undergoing robotic prostatectomy for localized prostate cancer at our department. We retrospectively reviewed patients undergoing robotic prostatectomy with either suspension (n = 119) or figure-of-eight (n = 48) stitching of the dorsal venous complex. The patients submitted EPIC-26 questionnaires before surgery and after 3 and 18 months, respectively. Logistic regression analysis was run to determine the effect of the suspension stitch, nerve-sparing, posterior reconstruction, prostate volume, age and body mass index on early continence rate. The odds ratio of experiencing urinary leaks was 2.1 times higher (95% CI 1.0-4.3) in the figure-of-eight stitch group compared to the suspension stitch group 3 months after surgery (p < 0.05). The early urinary continence rate was 61.3% in the suspension stitch group compared to 35.4% in the figure-of-eight stitch group (p < 0.005). There were no differences between the groups 18 months post-prostatectomy (90.7% in the suspension stitch group versus 81.4% in the non-suspension stitch group, p = 0.1). Ordinal regression analysis identified the suspension stitch, bilateral nerve-sparing and body mass index as independent predictors of urinary continence at 3 months. The association between urinary continence and either unilateral nerve-sparing, posterior reconstruction, prostate volume or age did not reach statistical significance. Our results suggest that the suspension stitch improved early urinary continence following robotic prostatectomy.

Hoffmann's syndrome necessitating forearm fasciotomy: a case report.

BACKGROUND: Hoffmann's syndrome is a rare form of hypothyroid myopathy. Only a few cases of fasciotomy in this setting have previously been reported. CASE PRESENTATION: A 41-year-old Caucasian man under treatment for hypothyroidism presented with acute-onset severe pain in his forearm for no obvious reason and was admitted to our emergency room. He eventually developed compartment syndrome which necessitated surgical decompression. Soon after surgery he complained of similar symptoms in his calves. By the time his hypothyroid status was confirmed, conservative treatment and orally administered levothyroxine gradually made the pain from his calves disappear, without further surgical treatment. CONCLUSION: Hoffmann's syndrome may precipitate a compartment syndrome in the absence of trauma.

The influence of frame rate on two-dimensional speckle-tracking strain measurements: a study on silico-simulated models and images recorded in patients.

AIMS: Ultrasound-derived myocardial strain can render valuable diagnostic and prognostic information. However, acquisition settings can have an important impact on the measurements. Frame rate (i.e. temporal resolution) seems to be of particular importance. The aim of this study was to find the optimal range of frame rates needed for most accurate and reproducible 2D strain measurements using a 2D speckle-tracking software package. METHODS AND RESULTS: Synthetic two dimensional (2D) ultrasound grey-scale images of the left ventricle (LV) were generated in which the strain in longitudinal, circumferential, and radial direction were precisely known from the underlying kinematic LV model. Four different models were generated at frame rates between 20 and 110 Hz. The resulting images were repeatedly analysed. Results of the synthetic data were validated in 66 patients, where long- and short-axis recordings at different frame rates were analysed. In simulated data, accurate strain estimates could be achieved at >30 frames per cycle (FpC) for longitudinal and circumferential strains. Lower FpC underestimated strain systematically. Radial strain estimates were less accurate and less reproducible. Patient strain displayed the same plateaus as in the synthetic models. Higher noise and the presence of artefacts in patient data were followed by higher measurement variability. CONCLUSION: Standard machine settings with a FR of 50-60 Hz allow correct assessment of peak global longitudinal and circumferential strain. Correct definition of the region of interest within the myocardium as well as the reduction of noise and artefacts seem to be of highest importance for accurate 2D strain estimation.

Strategies to improve quality of life in bladder cancer patients.

Bladder cancer is a heterogeneous disease that includes both tumors with low risk of dissemination as well as highly malignant tumors with a considerable potential to metastasize. The patient's quality of life is closely related to the management of the disease. The challenge for the urologist is to acknowledge the malignant potential of the cancer and to adjust the approach to the patient accordingly. Patients with low-risk bladder cancer should avoid an exaggerated follow-up, but on the other hand high-risk patients must be sufficiently surveyed to secure that definitive surgical treatment is performed before it's too late. When the decision to perform a cystectomy has been made, it is crucial that the patient understands the consequences of the surgery as well as the possible options for urinary reconstruction. This review focuses on aspects of bladder cancer management that we believe are vital for the quality of life of these patients.

Enhanced recovery after surgery: are we ready, and can we afford not to implement these pathways for patients undergoing radical cystectomy?

Enhanced recovery after surgery (ERAS) for radical cystectomy seems logical, but our study has shown a paucity in the level of clinical evidence. As part of the ERAS Society, we welcome global collaboration to collect evidence that will improve patient outcomes.

Telemedical technologies in urological cancer care: past, present and future applications.

Since the initial development of telegraphy by Sir Charles Wheatstone in 1837 and the telephone by Alexander Graham Bell in 1875, doctors have been able to convey medical information across great distances. The exchange and sharing of medical information has evolved and adapted to suit the vast array of today's medicine. Early adopters of telemedicine within clinical practice have gained significant health economic benefits. The arrival of wireless connections has further enhanced the possibilities for all clinical work with focus on diagnosis, treatment and management of urological cancers, as highlighted in this article.

Peak longitudinal strain most accurately reflects myocardial segmental viability following acute myocardial infarction - an experimental study in open-chest pigs.

BACKGROUND: The extension and the transmurality of the myocardial infarction are of high predictive value for clinical outcome. The aim of the study was to characterize the ability of longitudinal, circumferential and radial strain measured by 2-dimensional speckle tracking echocardiography (2D-STE) to predict the extent of necrosis in myocardial segments following acute myocardial infarction and to separate transmural necrotic segments from non-transmural necrotic segments in a full 18-segment porcine model. METHODS: 2D-STE strain was assessed in long- and short-axis following myocardial infarction in ten open-chest anesthetized pigs. Strain was defined according to systolic peak values. In segments displaying both negative and positive peaks, only the peak with the highest absolute value was utilized. Necrosis was measured by 2,3,5-triphenyltetrazolium chloride (TTC) staining and expressed as percent of each myocardial segment. RESULTS: Significant correlations were found between the extension of necrosis and all measured parameters of myocardial deformation (p < 0.001), but was stronger for longitudinal strain (r(2) = 0.52) than circumferential strain (r(2) = 0.38) and radial strain (r(2) = 0.23). The area under the receiver operator characteristic curve (AUC) for separating transmural necrotic segments (>50% necrosis) from predominantly viable segments (0-50% necrosis) was significantly larger for longitudinal strain (AUC = 0.98, CI = 0.97-1.00) when compared with circumferential strain (AUC = 0.91, CI = 0.84-0.97, p < 0.05) and radial strain (AUC = 0.90, CI = 0.83 - 0.96, p < 0.01), indicating a stronger ability of longitudinal strain to identify segments with transmural necrosis. CONCLUSION: Peak strain values derived from 2D-STE correlate well with the extent of necrosis in myocardial segments following acute myocardial infarction. Longitudinal strain most accurately reflects myocardial segmental viability in this setting.

Oral ß-glucan reduces infarction size and improves regional contractile function in a porcine ischaemia/reperfusion model.

OBJECTIVES: We previously reported a cardioprotective effect of oral ß-glucan in patients who underwent coronary artery bypass grafting. The present study was conducted to determine whether oral ß-glucan could reduce myocardial infarction size and whether these changes would be reflected by better preservation of contractile indices measured by speckle tracking echocardiography (STE). METHODS: Fourteen pigs were randomized to receive oral ß-glucan 50 mg/kg (n = 7) or placebo (control, n = 7) 10 days before they were anaesthetized and subjected to 1 h clamping of the left anterior descending coronary artery followed by reperfusion for 3 h. Longitudinal strain, circumferential strain and radial strain were assessed by STE after 3 h of reperfusion. Infarction size and area at risk were determined by Evans blue and 2,3,5-triphenyltetrazolium chloride staining. RESULTS: Pretreatment with ß-glucan reduced the infarct area/area at risk ratio by 36% (P < 0.05) and the total necrotic area of the left ventricle by 37% (P < 0.05) compared with controls. Viable myocardium at risk was 30% higher in the ß-glucan vs. control group (P < 0.05). Anterior apical strain values for ß-glucan vs. control were -4.7 ± 9.4 vs. 5.9 ± 6.1% (P < 0.05) for longitudinal strain, -14.7 ± 6.6 vs. -7.7 ± 4.3 (P < 0.05) for circumferential strain, 15.1 ± 7.7 vs. 7.1 ± 11.8 (ns) for radial strain. CONCLUSIONS: Oral ß-glucan pretreatment reduces infarction size and improves regional contractile function in a porcine ischaemia/reperfusion model.

Inhibition of NF-κB activation by ß-glucan is not associated with protection from global ischemia-reperfusion injury in pigs.

BACKGROUND: Pretreatment with ß-glucan has been shown to protect against regional ischemia-reperfusion injury, through inhibition of myocardial NF-κB activation. The aim was to examine whether ß-glucan pretreatment could protect against the global ischemia-reperfusion injury, which is encountered in the clinical setting during open heart surgery. MATERIALS AND METHODS: Twenty-one pigs were randomized to pretreatment with oral ß-glucan (SBGo, n = 7), pretreatment with i.p. ß-glucan (SBGip, n = 7), and untreated controls (n = 7). The pigs were subjected to cardiopulmonary bypass (CPB) with 1 h of global cardioplegic ischemia followed by wean from CPB and reperfusion for 4 h. Cardiac function was determined by a conductance catheter, and troponin T was sampled from the coronary sinus. Atrial biopsies obtained at baseline, following 30 min, and 3 h of reperfusion were analyzed for phosphorylated NF-κB by Western blot. RESULTS: Following reperfusion, phosphorylated NF-κB increased by 210% in the control group, 197% in the SBGo group, but was reduced by 5% in the SBGip group (P < 0.01 versus control). After 4 h of reperfusion, preload recruitable stroke work dropped by 19% in the control group and 25% in the SBGo group compared with 60% in the SBGip group (P < 0.01 versus control). The area under the curve for troponin T was larger in the SBGip group compared with the control group (P < 0.05) and the SBGo group (P < 0.01). CONCLUSION: Inhibition of NF-κB activation by i.p. ß-glucan does not protect against ischemia-reperfusion injury in pigs subjected to global ischemia and reperfusion, and may be associated with aggravation of ischemia-reperfusion injury.

High resolution speckle tracking dobutamine stress echocardiography reveals heterogeneous responses in different myocardial layers: implication for viability assessments.

BACKGROUND: Speckle-tracking echocardiography (STE) can be used to quantify wall strain in 3 dimensions and thus has the potential to improve the identification of hypokinetic but viable myocardium on dobutamine stress echocardiography (DSE). However, if different myocardial layers respond heterogeneously, STE-DSE will have to be standardized according to strain dimension and the positioning of the region of interest. Therefore, the aim of this study was to create a high-resolution model for ejection time (ET) strain and tissue flow in 4 myocardial layers at rest, during hypoperfusion, and during dobutamine challenge to assess the ability of STE-DSE to detect deformation and functional improvement in various layers of the myocardium. METHODS: In 10 open chest pigs, the left anterior descending coronary artery was constricted to a constant stenosis, resulting in 35% initial flow reduction. Fluorescent microspheres were used to measure tissue flow. High-resolution echocardiography was performed epicardially to calculate ET strain in 4 myocardial layers in the radial, longitudinal, and circumferential directions using speckle-tracking software. Images were obtained at rest, during left anterior descending coronary artery constriction (hypoperfusion), and during a subsequent dobutamine stress period. RESULTS: Dobutamine stress at constant coronary stenosis increased flow in all layers. ET strain increased predominantly in the midmyocardial layers in the longitudinal and circumferential directions, whereas subendocardial strain did not improve in either direction. CONCLUSION: Dobutamine stress influences ET strain differently in the various axes and layers of the myocardium and only partially in correspondence to tissue flow. Longitudinal and circumferential functional reserve opens the potential for the specific detection of midsubendocardial viable tissue by high-resolution STE.

Mechanoenergetic function and troponin T release following cardioplegic arrest induced by St Thomas' and histidine-tryptophan-ketoglutarate cardioplegia--an experimental comparative study in pigs.

The study compares the single dose histidine-tryptophan-ketoglutarate (HTK) cardioplegia to the repeatedly delivered St Thomas' Hospital Solution (STHS) with respect to preservation of left ventricular mechanoenergetics and leakage of troponin T in a porcine experimental model. Fourteen pigs were randomized to a single infusion of 30 ml/kg HTK cardioplegia (n=7) or 500 ml STHS (n=7) followed by 200 ml after 20 and 40 min. After 1 h of aortic cross-clamping on cardiopulmonary bypass (CPB), the pigs were weaned and the hearts reperfused for 4 h. Stroke work (SW) was determined by a conductance catheter in the left ventricle. Myocardial oxygen consumption (MvO(2)) was measured as a function of coronary blood flow and arterial-to-coronary sinus oxygen saturation difference. Troponin T was sampled from the coronary sinus. The slope of the SW-MvO(2) relationship increased by 1.09 (+/-0.53) in the HTK group compared with 0.33 (+/-0.70) in the STHS group following ischemia and 4 h of reperfusion (P=0.04). Troponin T was significantly higher in the HTK group compared with the STHS group (P=0.04). Repeatedly delivered STHS gives better preservation of postischemic mechanoenergetic function and lower troponin T release compared with single dose HTK cardioplegia, indicating improved cardioprotection with STHS.

Left ventricular size determines tissue Doppler-derived longitudinal strain and strain rate.

AIMS: Tissue Doppler-derived indices of strain (epsilon) and strain rate (SR) have been developed to assess regional cardiac function. However, the effect of left ventricular (LV) size on epsilon and SR has not been studied in depth. The aim of this study was to assess to what extent heart size influence epsilon or SR. METHODS AND RESULTS: In 21 anaesthetized pigs ranging from 12.5 to 70.0 kg, tissue Doppler-derived epsilon and SR, and haemodynamic parameters, were assessed during controlled heart rates and different loading conditions. dP/dt did not correlate to pig weight, suggesting constant contractility during growth. Longitudinal epsilon and SR were significantly higher in smaller compared with larger hearts. The hyperbolic correlation between pigs weight and epsilon and SR was r(2)=0.621 and 0.372, respectively, both P<0.0001. Afterload elevation induced a reduction in longitudinal epsilon (from -24.2+/-3.2 to -12.1+/-5.5%, P=0.001) and SR (from -2.3+/-0.8 to -1.3+/-2.4 s(-1), P=0.034), whereas increasing preload increased epsilon (from -26.4+/-10.3 to -38.1+/-14.3%, P=0.006) and SR (from -2.3+/-0.9 to -4.22+/-1.8 s(-1), P=0.002). CONCLUSION: Longitudinal epsilon and SR decrease with increasing LV dimensions in spite of an unaltered contractility. These results show and confirm that heart size influences epsilon and SR, which are highly load-dependent parameters.

Adenosine instead of supranormal potassium in cardioplegic solution improves cardioprotection.

OBJECTIVE: To determine whether adenosine instead of supranormal potassium in cold crystalloid cardioplegia gives satisfactory cardiac arrest and improved cardioprotection. Cold crystalloid cardioplegia with adenosine, procaine and magnesium (A) was compared with standard cold crystalloid hyperkalemic cardioplegia (K). METHODS: Sixteen pigs were randomized to receive either cold K (n=8) or A (n=8), where hyperkalemia was substituted with 1.2 mM adenosine. The cold (6 degrees C) cardioplegia was given intermittently and antegradely, with an aortic cross-clamp time of 1 h. Hemodynamic data was continuously measured and pressure-volume conductance catheters were used to determine global left ventricular systolic and diastolic function. Coronary flow and O2 content differences allowed determination of left ventricular energetics. Blood samples, and left ventricular microdialysis were used to measure parameters of ischemia. Measurements were done at 1 and 2 h after cross-clamp release. RESULTS: Mean arterial pressure was reduced with 55 mmHg (standard deviation, SD: 19) in the K group versus 30 mmHg (SD: 14) in the A group 2 h after cross-clamp release (p=0.030). Left ventricular contractility expressed as slope of the preload recruitable stroke work index (Mw) was reduced to 53% (SD: 14) in the K group versus 78% (SD: 23) in the A group 2h after cross-clamp release (p=0.046). Reduction of maximum of first derivate of pressure with respect to time (dP/dtmax) was 804 mmHg/s (SD: 189) in the K group versus 538 mmHg/s (SD: 184) in the A group (p=0.033). The slope of the myocardial oxygen consumption-pressure volume area was at 2 h reperfusion increased from 1.37 (SD: 0.64) to 2.86 (SD: 1.27) in the K group, whereas no shift was detected in the A group (p=0.019). Cardiac troponin T measured in the coronary sinus 1 h after cross-clamp release was 1.25 microg/l (SD: 0.64) in the K group versus 0.73 microg/l (SD: 0.31) in the A group (p=0.046). CONCLUSION: Adenosine instead of supranormal potassium in cold crystalloid cardioplegia gives satisfactory cardiac arrest, improves post cardioplegic left ventricular systolic function and efficiency, and attenuates myocardial cell damage.

Cardioprotective effect of pretreatment with beta-glucan in coronary artery bypass grafting.

BACKGROUND: Beta-glucan pretreatment has been shown to attenuate inflammatory response and to protect against ischemia-reperfusion injury in animal studies. The aims of the present study were to examine the safety of pretreatment with beta-1,3/1,6-glucan in patients scheduled for coronary artery bypass grafting (CABG), and to investigate whether beta-1,3/1,6-glucan pretreatment could suppress inflammatory response and protect against ischemia-reperfusion injury following CABG. METHODS: Twenty one patients scheduled for CABG were assigned to oral beta-1,3/1,6-glucan 700 mg (Group 1) or 1 400 mg (Group 2) five consecutive days before surgery and were compared with a control group (Group 3). Blood samples were drawn preoperatively and on the first, third and fifth postoperative day for analysis of acute-phase reactants, hematology, cytokines and myocardial enzymes. RESULTS: The study drug was well tolerated. Creatine kinase isoenzyme MB was significantly lower in Group 2 compared with controls on the first postoperative day (p = 0.028). Mean change in cardiac troponin T was lower in Group 2 compared with controls (p = 0.028). CONCLUSIONS: Beta-1,3/1,6-glucan pretreatment is safe in patients undergoing CABG and may protect against ischemia reperfusion injury following CABG.

[Carotid endarterectomy in patients with coronary heart disease]. / Carotisendarterektomi hos pasienter med koronarsykdom.

BACKGROUND: Patients with coexistent coronary and carotid artery disease are at high risk of developing stroke following coronary artery bypass grafting (CABG) and at the same time at increased risk of myocardial infarction when subjected to carotid endarterectomy (CEA). In patients with pronounced symptoms from both vascular territories, some institutions advocate a combined approach, with both CABG and CEA performed during the same period of anaesthesia. MATERIAL AND METHODS: We reviewed the medical records of patients who underwent the combined procedure between 1986 and 2004 (n = 37; group 1) and compared them to patients with coronary artery disease who underwent isolated CEA over the same period of time (n = 118; group 2). RESULTS: The ASA score, NYHA class, prevalence of peripheral artery disease, atrial fibrillation and contralateral carotid occlusion were significantly higher in group 1. Two patients (5.4%) in group 1 and five patients (4.2%) in group 2 suffered a stroke. Five of these were ipsilateral to the CEA. Six patients had a perioperative myocardial infarction, one in group 1 (2.7%) and five (4.2%) in group 2 (ns). There were no deaths in group 1 and three deaths (2.5%) in group 2 during the first 30 days after surgery. The cumulative risk of death, stroke and myocardial infarction within 30 days was 8.1% in group 1 and 11.0% in group 2. INTERPRETATION: Patients with coexistent atherosclerosis of the coronary and carotid arteries who underwent the combined procedure seem to have the same perioperative risk as patients with coronary artery disease who underwent isolated CEA, in spite of the fact that the former had a more generalised atherosclerotic disease.