High-risk patients for carotid endarterectomy: turned down cases are rare.

AIM: The increasing use of carotid artery stenting (CAS) is justified in patients at high-risk for carotid endarterectomy (CEA). The aim of this study was to evaluate the hypothesis that the high-risk patients can be submitted to CEA without increased risk of stroke and death. METHODS: A retrospective analysis of 625 consecutive CEA in 545 patients (M/F 386/159, age 75 ± 7) performed from January 2005 to December 2010 was carried out. Definite anatomical and pathophysiological high-risk cohort of patients (N.=173, 31.7%) was evaluated and compared to normal risk patients. Univariate, multivariate and Kaplan-Meier analysis were used as appropriate. Poisson regression (Pr) model was used to study all univariate criteria in combination. A P value <0.05 was statistically significant. RESULTS: The overall 30-day stroke and death rate was 0.96%. No difference between high-risk vs. normal patient cohort regarding physiological and anatomical risk factors was detected. Univariate and multivariate analysis did not show statistical difference for 30-day outcome in any of the variables examined. No increase of risk in cases of presence of more risk factors resulted to the Pr analysis. The 24-month survival rate was worse in high-risk patients, especially when more physiologic risk as chronic renal failure, severe pulmonary and cardiac diseases and age over eighty were present. CONCLUSION: CEA is a safe procedure in patients at high-risk carotid artery disease. A better classification of high-risk patients may be necessary because trials criteria appear ineffective to define the patients at real high surgical risk. Long-term outcome was affected by the presence of severe comorbidities.

[Results of open repair of infrarenal abdominal aortic aneurisms in patients unfit for endovascular treatment]. / Risultati della chirurgia tradizionale nel trattamento degli aneurismi dell'aorta addominale sottorenale con controindicazione alla terapia endovascolare.

INTRODUCTION: Purpose of the study was to assess how the introduction of endovascular treatment has affected mortality and morbidity of the traditional surgery for infrarenal abdominal aortic aneurysms (AAA). PATIENTS AND METHODS: From January 2002 to December 2009 we treated 230 patients with AAA (mean age 71.6; 121 male 70.7%); 171 (74.4%) were treated with surgery, 59 (25.6%) underwent to endovascular exclusion .We divided the patients into two groups: Group A, before the beginning of our "endovascular"; Group B, after the beginning of our endovascular experience. A total of 171 patients were treated with traditional surgical intervention, 99 in Group A and 72 in Group B. We evaluated the morbidity and mortality between the two groups by statistical analysis (by Student t test and χ ² test) considering a significant p-value <0.001. RESULTS: e 30-day mortality was 4% respectively in group A and 5.5% in group B (P = not significative, n.s.). The incidence of renal and ischemic peripheral complications was, respectively, 2% and 4% in group A, and 4.1% and 8.3% in group B showing statistical significance (P <.001). There were no documented statistically significant differences between the two groups in terms of cardiac and respiratory complications (P = n.s.). CONCLUSIONS. The results of the traditional surgery for the infrarenal AAA not suitables for endovascular repair suffer from the difficult anatomy of aorto-iliac district. Although the incidence of complications of open surgery is increased, the mortality is similar to anatomical not complicated aneurysms.

Carotid endarterectomy: general anaesthesia with remifentanyl conscious sedation vs loco-regional anaesthesia.

AIM: To retrospectively evaluate and compare the safety and efficacy of general anesthesia with remifentanyl conscious sedation (RCS) vs local-regional anesthesia (LA) for carotid endarterectomy (CEA). METHODS: From January 2004 to January 2008, 390 CEA performed in 325 patients (M/F 214/111, age 75 +/- 7) were collected in 2 groups: RCS group included 275 consecutive CEA in 230 patients carried out under remifentanyl conscious sedation with stopping of the remifentanyl infusion at the carotid clamping time to evaluate the clinical neurological status; LA group was composed of 115 consecutive CEA in 95 patients, performed under local-regional anesthesia. We evaluated complications, postoperative morbidity and mortality, need for shunt insertion and compared the results by means of Student's t-test and chi2 analysis. P value <0.05 (T=2.28) was considered significant. RESULTS: The 30 days mortality was 0.35% in the RCS group and 0% for LA group (P=NS). The 30 days stroke rates were 0.3% and 0% respectively (P=NS). TIA/RIND rates were 0.3% for RCS group and 1.7% for LA group (P=0.47); shunt usage was 20% for RCS group and 17% for LA group (P=0.26). We found higher postoperative nausea/vomiting in the RCS group (3.9% vs 0.8%, P<0.05). CONCLUSIONS: General anesthesia with remifentanyl conscious sedation seems to be a safe technique, allowing monitoring of the neurological status, cerebral protection during arterial clamping, better control of the airway and a good compliance to both the surgeon and the patient. A randomized control trial is needed to prove RCS to be effective as LA.