Carotid endarterectomy without a shunt for symptomatic lesions associated with contralateral severe stenosis or occlusion.

PURPOSE: The purpose of this study was to assess the adequacy of thiopental protection against ischemic cerebral damage in patients undergoing carotid endarterectomy for symptomatic stenosis greater than 70% in association with contralateral stenosis greater than 70% or contralateral occlusion. METHODS: All patients (n=259) with severe bilateral carotid disease who underwent carotid endarterectomy for symptomatic stenosis greater than 70% were extracted from the database of an ongoing prospective carotid surgery study. Large-dose thiopental sodium without shunting was used for cerebral protection during endarterectomy. Asymmetric electroencephalogram changes during the operation, carotid occlusion time, stroke onset, and neuropathologic outcomes were analyzed. RESULTS: Three contralateral strokes occurred in the series, producing a cerebral morbidity/mortality rate of 1.2% (major 0.4%, minor 0.8%). Transient morbidity was 1.9% made of two reversible ischemic neurologic deficits and three transient ischemic attacks. New asymmetric electroencephalography changes were seen in 49 (19% patients, one of whom had transient deficit. Average occlusion time was 35 minutes. All strokes occurred within 24 hours of the procedure. Patients with previous stroke and and systemic hypertension seemed at greatest risk, and the contralateral hemisphere was the area at greatest risk. All transient deficits were ipsilateral and related to technical complications rather failed protection. CONCLUSIONS: Thiopental cerebral protection eliminates strokes caused by complications of shunting, prevents ischemic stroke during carotid occlusion for periods up to 67 minutes (average 35 minutes), allows meticulous management of the operative site, may modify or minimize clinical neurologic deficit, and in our experience has rendered intraluminal shunting obsolete.

Primary access surgery for long-term haemodialysis.

This paper assessed the efficacy of arterio-venous fistulae, vein grafts, and synthetic grafts for long-term haemodialysis. Over a selected 10 year period, 486 primary access sites were established and 182 revisions were necessary. Access procedures were assessed for primary survival, the success or otherwise of revision surgery, and long-term efficacy for haemodialysis. Significant differences were shown for long-term survival of fistulae over vein grafts and synthetic grafts. Successful revision surgery favoured fistulae over synthetic grafts. Arterio-venous fistulae offered the best prospect for effective long-term dialysis. Revision surgery with continued dialysis using the primary-access site was largely unsuccessful, secondary access reconstruction being required in 78.2% of all failures.

Thiopental sodium cerebral protection during carotid endarterectomy: perioperative disease and death.

PURPOSE: This study reports our experience with thiopental sodium (Pentothal) cerebral protection, without intraluminal shunting, during carotid endarterectomy. Only those complications that occurred during surgery or within 30 days of operation have been addressed. METHOD: A prospective, unselected, consecutive series of 621 carotid endarterectomies was done during a 7-year period, with electroencephalography-monitored, high-dose Pentothal for cerebral protection. RESULTS: Five ischemic strokes (0.8%), completion of two strokes-in-evolution (0.3%) and four strokes caused by cerebral hemorrhage (0.6%) occurred in 11 patients in the perioperative (30-day) period, for a combined cerebral morbidity-mortality rate of 1.7%. Four reversible ischemic neurologic deficits (0.6%) and two transient ischemic attacks (0.3%) in six patients produced a transient deficit rate of 0.9%. Symptomatic coronary artery disease coexisted in 37% of the patients but resulted in only five acute myocardial infarctions (0.7%), one of which was fatal (0.1%). Other perioperative complications in 10 patients (1.5%) were associated with the operative procedure. There were no complications directly attributable to the high-dose Pentothal. Prospective data collection has allowed definition of the disease and cause of all cerebral complications. CONCLUSION: The complications in this series have been related to surgical and clinical management problems rather than failure of cerebral protection. Cerebral protection with high-dose Pentothal under electroencephalographic control has been effective and complication free.

Aortic aneurysm surgery in the presence of a horseshoe kidney.

A review of three cases of aortic aneurysm in association with a horseshoe kidney is presented. Both the transperitoneal and retroperitoneal approaches to the aneurysm are detailed and the relative advantages and disadvantages outlined. The conventional approach of transection of the renal isthmus is not recommended because of the possibility of damage to the collecting system of the horseshoe kidney. The place of specialized investigations is outlined.