Diagnosis of and treatment for symptomatic carotid stenosis: an updated review.

Carotid stenoses of ≥50% account for about 15-20% of strokes. Their degree may be moderate (50-69%) or severe (70-99%). Current diagnostic methods include ultrasound, MR- or CT-angiography. Stenosis severity, irregular plaque surface, and presence of microembolic signals detected by transcranial Doppler predict the early recurrence risk, which may be as high as 20%. Initial therapy comprises antiplatelets and statins. Benefit of revascularization is greater in men, in older patients, and in severe stenosis; patients with moderate stenoses may also profit particularly if the plaque has an irregular aspect. An intervention should be performed within <2 weeks. In large randomized studies comparing endarterectomy and stenting, endovascular therapy was associated with a higher risk of periprocedural stroke, yet in some studies, with a lower risk of myocardial infarction and of cranial neuropathy. These trials support endarterectomy as the first choice treatment. Risk factors for each of the two therapies have been indentified: coronary artery disease, neck radiation, contralateral laryngeal nerve palsy for endarterectomy, and, elderly patients (>70 years), arch vessel tortuosity and plaques with low echogenicity on ultrasound for carotid stenting. Lastly, in direct comparisons, a contralateral occlusion increases the risk of periprocedural complications in both types of treatment.

[Abdominal aortic aneurysms: diagnosis and endovascular therapy]. / Anévrismes de l'aorte abdominale: connaissances actuelles et traitement endovasculaire.

Abdominal aortic aneurysms are a common condition whose prognosis without treatment is poor because of the lethality in case of breakage. An early diagnosis is thus necessary by screening or symptoms recognition. Surgery is not the only option then, continuous monitoring and medical treatment being sometimes possible. If curative treatment is undertaken, endovascular technique is an alternative to open surgical repair but its indications are not yet fully established and endovascular grafts have not the same longevity as open surgery. A review of the indications for endovascular repair in patients operated at the Geneva University Hospital has been used to illustrate the importance of individualized care for each patient.

Stratified gray-scale median analysis and color mapping of the carotid plaque: correlation with endarterectomy specimen histology of 28 patients.

BACKGROUND AND PURPOSE: To determine whether a stratified gray-scale median (GSM) analysis of the carotid plaque combined with color mapping could predict plaque histology better than an overall GSM measurement. METHODS: Thirty-one carotid plaques derived from 28 patients undergoing carotid endarterectomy were investigated by ultrasound. GSMs of the whole plaque were used as measurement of echogenicity. A profile of the regional GSM as a function of distance from the plaque surface could be generated. Plaque pixels were further mapped into 3 different colors depending on their GSM value. RESULTS: Plaques with large calcifications presented the highest GSM values, and those with large hemorrhagic areas or with a predominant necrotic core exhibited the lowest. Fibrous plaques had intermediate GSM values. A necrotic core located in a juxtalumenal position was associated with significantly lower GSM values (P=0.009) and with a predominant red color (GSM <50) at the surface (P=0.0019). With respect to the thickness of the fibrous cap and the position of the necrotic core, the sensitivity and specificity of the predominant red color of the whole plaque was respectively 45% and 67% and 53% and 75%; considering the predominant red color of the surface, the sensitivity and specificity increased to 73% and 67% and 84% and 75%, respectively. CONCLUSIONS: The stratified GSM measurement combined with color mapping showed a good correlation with the different histopathological components and further allowed identification with good accuracy of determinants of plaque instability. This approach should be investigated in a prospective, natural history study.

Perception of the damaging effects of smoking, and brief cessation counselling by doctors.

An open prospective study was conducted among the patients visiting an urban medical policlinic for the first time without an appointment to assess whether the immigrants (who represent more than half of our patients) are aware of the health effects of smoking, whether the level of acculturation influences knowledge, and whether doctors give similar advice to Swiss and foreign smokers. 226 smokers, 105 Swiss (46.5%), and 121 foreign-born (53.5%), participated in the study. 32.2% (95% CI [24.4%; 41.1%]) of migrants and 9.6% [5.3%; 16.8%] of Swiss patients were not aware of negative effects of smoking. After adjustment for age, the multivariate model showed that the estimated odds of "ignorance of health effects of smoking" was higher for people lacking mastery of the local language compared with those mastering it (odds ratio (OR) = 7.5 [3.6; 15.8], p < 0.001), and higher for men (OR = 4.3 [1.9; 10.0], p < 0.001). Advice to stop smoking was given with similar frequency to immigrants (31.9% [24.2%; 40.8%] and Swiss patients (29.0% [21.0%; 38.5%]). Nonintegrated patients did not appear to receive less counselling than integrated patients (OR = 1.1 [0.6; 2.1], p = 0.812). We conclude that the level of knowledge among male immigrants not integrated or unable to speak the local language is lower than among integrated foreign-born and Swiss patients. Smoking cessation counselling by a doctor was only given to a minority of patients, but such counselling seemed irrespective of nationality.

Aortic valve repair by cusp extension with the use of fresh autologous pericardium in children with rheumatic aortic insufficiency.

OBJECTIVES: Our goal was to evaluate the midterm results of aortic valve repair by a more sophisticated tailoring of cusp extension-taking into account the dimensions of the native aortic cusps-with the use of fresh autologous pericardium. PATIENTS AND METHODS: Forty-one children who had severe rheumatic aortic insufficiency (mean age 11.5 +/- 2.7 years) underwent aortic valve repair by means of this cusp extension technique over a 5-year period. Twenty-four of them underwent concomitant mitral valve repair for associated rheumatic mitral valve disease. All children were then followed up by transthoracic echocardiography before discharge, at 3 and 6 months after the operation, and at yearly intervals thereafter. RESULTS: Follow-up was complete in all patients and ranged from 3 months to 5 years (median 3 years). No operative and no early postoperative deaths occurred. Only 1 patient died, 9 months after the operation, of septicemia and multiple organ failure. Actuarial survival was 97% at 1 year and has remained unchanged at 3 years. On discharge, the degree of aortic insufficiency was grade 0 for 27 children and grade I for 14. Exacerbation of aortic insufficiency from grade I to grade II was observed in only 1 patient, and none of the children required reoperation for aortic insufficiency during the follow-up period. Mean peak systolic aortic valve gradients at discharge were lower than preoperative values (P =.04), and no significant increase in the peak systolic transvalvular gradient was detected thereafter during the follow-up period. Mean left ventricular dimensions were significantly reduced at discharge when compared with preoperative values (P <.0001). CONCLUSIONS: Functional results of aortic valve repair with cusp extension using fresh pericardium have been satisfactory at medium term, particularly in children with a small aortic anulus at the time of initial repair, because the expansion potential of fresh autologous pericardium is equivalent to that of the growing sinotubular junction and aortic anulus diameters.

Conversion from routine CPB to centrifugal mechanical assist by transaortic inflow cannulation of the left ventricle.

We describe a technique of conversion from cardiopulmonary bypass to centrifugal mechanical assist that consists of using the existing aortic cannula for outflow and inserting a cannula into the left ventricle through a Dacron tube and across the aortic valve for inflow.

Leaflet's free edge suspension for correction of aortic insufficiency associated with ventricular septal defect.

Aortic valve regurgitation in association with ventricular septal defect results from the mechanical effect of the ventricular septal defect, which primarily affects the free edge. The elongated free edge can be repaired by plicating it using several techniques designed to restore a normal geometry to the prolapsing aortic leaflet. We describe 4 cases in which aortic insufficiency was treated by a technique of plication that allows suspension of the free edge along a pericardial strip applied from one commissure to the other.

Surgical management of hemorrhage from rupture of the aortic arch.

BACKGROUND: Control of hemorrhage in patients with active bleeding from rupture of the aortic arch is difficult, because of the location of the bleeding and the impossibility of cross-clamping the aorta without interfering with cerebral perfusion. A precise and swift plan of management helped us salvage some patients and prompted us to review our experience. METHODS: Six patients with active bleeding of the aortic arch in the mediastinum and pericardial cavity (5 patients) or left pleural cavity (1 patient), treated between 1992 and 1996, were reviewed. Bleeding was reduced by keeping the mediastinum under local tension (3 patients) or by applying compression on the bleeding site (2 patients), or both (1 patient) while circulatory support, retransfusion of aspirated blood, and hypothermia were established. The diseased aortic arch was replaced during deep hypothermic circulatory arrest, which ranged from 25 to 40 minutes. In 3 patients, the brain was further protected by retrograde (2 patients) or antegrade (1 patient) cerebral perfusion. RESULTS: Hemorrhage from the aortic arch was controlled in all patients. Two patients died postoperatively, one of respiratory failure and the other of abdominal sepsis. Recovery of neurologic function was assessed and complete in all patients. The 4 survivors are well 8 to 49 months after operation. CONCLUSIONS: An approach relying on local tamponade to reduce bleeding, rapid establishment of circulatory support and hypothermia, retransfusion of aspirated blood, and swift repair of the aortic arch under circulatory arrest allows salvage of patients with active bleeding from an aortic arch rupture.

Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency.

BACKGROUND: This study was designed to revise the mechanisms and repair techniques of anterior mitral leaflet prolapse observed during the correction of pure rheumatic mitral regurgitation in children. METHODS: From March 1993 to May 1998, 36 children suffering from pure rheumatic mitral regurgitation due to anterior leaflet prolapse underwent mitral valve repair. The mean age was 12.5 years (range, 6 to 16 years). Anterior leaflet prolapse was due to chordal elongation in 25 patients (group A), chordal rupture in 6 patients (group B), and retraction of anterior secondary chordae tendineae, creating a V-shaped deformity in the middle of the anterior leaflet, thus moving the free edge of the anterior leaflet away from the coaptation plane, in 5 patients (group C). Chordal shortening, transposition, and resection of anterior secondary chordae tendineae were used to correct anterior leaflet prolapse according to the predominantly responsible mechanism. RESULTS: All patients were available for clinical follow-up, which ranged from 6 months to 5 years (mean follow-up, 3 years). Echocardiographic studies were obtained until the 3rd postoperative month, and all patients showed significant improvement in their left ventricular and atrial dimensions. There was one late death related to endocarditis. Two patients in group C who had mitral valve repair underwent mitral valve replacement on the 19th and 24th postoperative months, respectively, because of failure of mitral valve repair. CONCLUSIONS: Mitral valve repair for pure mitral regurgitation due to rheumatic anterior leaflet prolapse can be performed safely for all types of mechanisms. Although the techniques we used provide stable short-term results in each of these groups, midterm results are better in groups A and B, where tissue thickening is less important, recurrences of rheumatic carditis are lower, and the interval between the first rheumatic attack and the surgical procedure is shorter than in group C.

Lung transplantation: how to perform the venous anastomosis when clamping is too distal.

During lung transplantation, the venous anastomosis is performed between the atrial cuffs of the donor and the receiver. In certain rare circumstances, however, the surgeon may find two veins and no possibility to reposition the clamp more proximally. A simple technique can be used in this case: both veins are reunited and the venous anastomosis carried out as usual between two large lumens.

Protective subpleural blanketing of intrathoracic esogastric anastomosis after esophagectomy.

Esophagectomy followed by intrathoracic anastomosis is threatened by leakage which may prove all the more serious that mediastinal contamination is extensive. In the technique presented, the esogastric anastomosis is slipped under the upper mediastinal pleura which is kept intact, after the azygos vein has been ligated and divided. This pleural 'blanket' may act as an efficient barrier against potential digestive spillage into the mediastinum.

Posterior deviation of the classical approach to the carotid artery to control hemorrhage from a carotido-cutaneous fistula.

Hemorrhage from a carotido-cutaneous fistula after tumor resection may be difficult to arrest, especially if occlusion of the carotid artery produces neurological symptoms. A posterior deviation of the classical incision allows an approach to the carotid artery while local digital compression controls external hemorrhage. The fistulous tract can then be resected and the carotid axis restored with a graft via this approach. Perfusion of the brain is maintained during repair by an indwelling shunt. The details of this approach are presented.

[Increased association of cardiac and thoracic vascular lesions after closed trauma of the thorax]. / Association accrue de lésion cardiaque et vasculaire thoracique après traumatisme fermé du thorax.

The association of a cardiac and a thoracic vascular lesion following blunt trauma seems real based on our experience and other published reports. Over the last 4 years, we have operated upon 3 patients with this association. The cardiac lesions included severe myocardial contusion (documented by electrocardiographic and enzymatic changes), a tear of the aortic valve, and occlusion of a coronary artery. The vascular lesions consisted in rupture of the aortic isthmus in 2 patients and traumatic pseudoaneurysm of the innominate artery. This association justifies a detailed cardiovascular evaluation in any case of severe cardiac or thoracic vascular lesion.

[Lesions of the supra-aortic arterial trunks by closed trauma]. / Lésions des troncs artériels supra-aortiques par traumatisme fermé.

Thirteen patients treated for 14 arterial lesions of the supra-aortic trunks from blunt trauma between 1985 and 1993 were retrospectively reviewed. In 2 cases, the lesion was on the innominate artery, in 1 case on the right common carotid artery and in 11 cases on the subclavian artery. It consisted of rupture in 8 cases, pseudoaneurysm in 5 and occlusion from an intimal flap in 1 case. Acute ischemia of the upper limb was present in 5 patients, and severe local hemorrhage in 1 patient. Four patients (5 lesions) did not have symptoms on initial hospitalization. Two later suffered embolisms from a pseudoaneurysm with a fatal outcome from massive cerebral ischemia in one case. Eleven arteries were repaired and two were ligated because of massive associated soft tissue destruction of the shoulder and the arm requiring immediate amputation. In addition to these two amputations, a brachial plexus injury remained disabling for 4 other patients. Blunt injuries of the supra-aortic arterial trunks constitute an immediate challenge in the case of active bleeding and often require combined mediastinal or thoracic and cervical exposure. They carry a heavy morbidity when the subclavian artery is involved due to associated soft tissue or brachial plexus damage. Occult lesions of the arteries supplying the brain are dangerous because of the risk of interference with cerebral blood flow. They should be actively investigated and, if the distal part of the lesion is accessible, they should be treated surgically.

[Approach to upper limb edema secondary to subclavian vein occlusion situated distal to an arteriovenous fistula]. / Approche des oedèmes du membre supérieur liés à une occlusion de la veine sous-clavière située en aval d'une fistule artério-veineuse.

AIM OF THE STUDY: To analyse the course of upper limb edema in patients with an arteriovenous fistula used for dialysis and to analyse the available therapeutic options. STUDY DESIGN: Retrospective study of patients with this type of edema, who were treated in our institution from 1992 to 1996. PATIENTS AND METHODS: Seven consecutive patients with an arterioveinous fistula treated for edema of the upper extremity, were reviewed. The fistula was created at the elbow in 6 patients and at the forearm in 1. The edema appeared immediately after operation in 4 patients and after a delay in 3 patients. Stenosis (3 patients) or occlusion (2 patients) of the subclavian vein was documented in 5 patients who were investigated by angiography. RESULTS: The edema regressed spontaneously in 4 patients because collaterals developed in 3 patients, and the fistula thrombosed in 1 patient. Surgical intervention allowed regression of the edema in the other 3 patients: excessive output of the fistula was reduced in 2 patients and an axillojugular bypass was performed in 1 patient. The fistula remained effective in 6 patients. Another fistula was performed on the contralateral arm in 1 patient. CONCLUSION: Non-operative management is recommended in patients who develop edema immediately after creation of the fistula, because spontaneous regression is likely. Measures aimed at reducing the output of the fistula or enhancing the venous capacities of the arm are required when edema appears at a later stage. The fistula can be saved in the majority of cases.

[Protection of intrathoracic anastomosis by pleural tent methods after Ivor-Lewis esophagectomy]. / Protection des anastomoses intrathoraciques par le procédé de la tente pleurale après oesophagectomies selon Ivor-Lewis.

PURPOSE OF THE STUDY: Description of a technical procedure to diminish the risk of spillage into the mediastinum in case of leakage from an intrathoracic anastomosis after partial esophagectomy. METHOD: In Ivor-Lewis procedures for cancer of the middle or lower third of the esophagus, the esogastric anastomosis is slipped under ther upper mediastinal pleura which is kept intact. From 1989 to 1997, this technique has been used in 43 consecutive patients (squamous carcinoma in 22, adenocarcinoma in 21). Three patients died postoperatively (7%) and complications (in 38%) were mostly pulmonary and cardiac. No anastomotic leak was detected on routine Gastrografin swallow performed on the 7th postoperative day. Three patients required dilation for stenosis. DISCUSSION AND CONCLUSION: Subpleural blanketing of intrathoracic anastomoses after esophagectomy is safe and easy to do, and should help diminish the consequences of possible anastomotic leakage.

Near-fatal acute dissection of the thoracic aorta involving the right coronary artery.

Aortic dissection is the most common acute disease involving the ascending aorta and carries a high mortality rate if surgical therapy is not initiated rapidly following the onset of symptoms. Therefore, timely recognition of this disease entity coupled with urgent and appropriate management is the key to a successful outcome. We describe a patient with aortic dissection extending into the right coronary artery (RCA) who was successfully resuscitated and operated on following a cardiac arrest during transfer to the operating room.