Neodymium:yttrium-aluminum-garnet laser fusion of endarterectomy flaps.

PURPOSE: This study evaluated the efficacy of neodymium:yttrium-aluminum-garnet laser welding of flaps in canine arteries and in securing the distal flap during human carotid endarterectomy. METHODS: Endarterectomy flaps were created in both common carotid and both common femoral arteries in 12 dogs. The flaps were repaired with either the neodymium:yttrium-aluminum-garnet laser or with 6-0 polypropylene sutures. The arteries were removed after duplex scanning at either 7 or 28 days. Eighteen high carotid endarterectomy flaps in 16 patients have been subsequently secured with the laser welding technique. RESULTS: Laser repairs (125 +/- 19 joule) of the canine arteries were completed more quickly than suture repairs (mean 25 seconds vs 135 seconds, respectively; p < 0.04). Duplex ultrasonography revealed no discernable differences between the two groups of arteries. Arteries studied at 7 days revealed three microscopic flaps (two suture, one laser), more subintimal fibroblastic proliferation in suture than laser-repaired carotid arteries (3: 1, p = 0.0530), and similar amounts of inflammation in suture- and laser-repaired arteries. Arteries studied at 28 days revealed one microscopic intimal flap (suture-repaired); equal fibroblastic and inflammatory responses in suture- and laser-repaired vessels; and no evidence of laser thermal injury. Eighteen carotid endarterectomy flaps have been successfully fused with no immediate or long-term complications in 16 patients (follow-up of 0 to 24 months). CONCLUSION: Laser fusion appears to be a safe and effective method for securing distal carotid endarterectomy flaps.

Rural vascular trauma: a twenty-year review.

A 20-year review documented 248 vascular injuries in 210 patients from principally rural areas. The average time between injury and treatment from 1970 to 1983 was 6 hours. Between 1983 to 1990, when 46% of patients were transported by helicopter, the average delay was 4 hours. Blunt trauma (41%, with 29% motor vehicle accidents and 12% farm/industrial accidents) caused the most severe injuries and accounted for most amputations (89%) and deaths (80%). All of the blunt trauma patients had associated injuries. Penetrating injuries occurred in 59% of the patients and accounted for 11% of the amputations and 20% of the deaths. Extremity vessels were injured 73% of the time (upper extremity, 47%; lower extremity, 26%). Eighty-seven percent of the vessels injured were arteries and 13% were major venous injuries. Preoperative arteriograms were obtained in 30% of our patients. Vascular injury was determined in the others at the time of operative exploration. Vascular repair included direct anastomosis or lateral suture repair (51%), autogenous vein graft (16%), synthetic graft (6%), and ligation (19%). Primary amputation and thrombectomy were other (8%) initial treatments. In the past 10 years concomitant major peripheral venous injuries were repaired in six patients (one amputation) and ligated in one patient (no amputation). The mortality rates (4.8% total) for patients with blunt and penetrating trauma were 9.3% and 1.6%, respectively. Survival rates have not improved since the implementation of a helicopter transport system in 1983, but the amputation rate declined from 18% to 7%.

Can low molecular weight heparins and heparinoids be safely given to patients with heparin-induced thrombocytopenia syndrome?

BACKGROUND: Low molecular weight heparin (LMWH) and heparinoids have been offered as alternatives to unfractionated heparin (UH) to patients with heparin-associated antiplatelet antibodies (HAAb) and heparin-induced thrombocytopenia syndrome (HIT). Some of these patients have had continued HIT in the presence of the UH substitutes. It would seem important to know whether the heparin substitute is likely to cause patients' platelets to aggregate before administering the substitute to patients with HAAb. METHODS: Patients with HIT were identified as having HAAb by positive platelet aggregometry testing with commercial UH. Plasmas from 51 patients with HAAb were tested for the ability to aggregate platelets in the presence of two LMWHs (Mono-Embolex NM and Fragmin) and one heparinoid (Org 10172). RESULTS: The proportions of plasmas reacting to each UH substitute are Mono-Embolex NM, 60.8%; Fragmin, 25.5%; and Org 10172, 19.6%. Although Fragmin and Org 10172 aggregated platelets in the presence of HAAb significantly less often than Mono-Embolex NM (p < 0.001), a patient with HAAb has a substantial chance of reacting to one of these UH substitutes. CONCLUSIONS: Before giving a LMWH or heparinoid to a patient with HAAb, one should determine with in vitro testing that the patient's HAAb will not cause platelet aggregation in the presence of the heparin substitute.

Spontaneous common carotid artery dissection.

A case of a symptomatic spontaneous common carotid artery dissection that occurred several months after an ipsilateral carotid endarterectomy is presented. The case was successfully managed with resection of the dissected common carotid artery and placement of an interposition saphenous vein graft. Examination of the specimen demonstrated cystic medial degeneration. Postoperative duplex scans of the carotid artery and graft have been normal. The data obtained from this case and a review of the seven previously reported cases suggest that surgical management of symptomatic spontaneous common carotid artery dissections can be accomplished safely. Surgical management of these dissections is recommended for patients with symptoms and for those without symptoms who have aneurysmal changes in the dissected segment.