Dual antiplatelet therapy prior to carotid endarterectomy reduces post-operative embolisation and thromboembolic events: post-operative transcranial Doppler monitoring is now unnecessary.

BACKGROUND: Thrombotic stroke following carotid endarterectomy (CEA) is preceded by high-grade embolisation (detected using transcranial Doppler (TCD)) and can be prevented by incremental doses of Dextran. However, this strategy is labour intensive and Dextran manufacture has now ceased. A randomised trial has suggested that a single 75 mg dose of Clopidogrel (administered the night before surgery in addition to daily 75 mg Aspirin) significantly reduces post-CEA embolisation. We hypothesized that this model of dual antiplatelet therapy might significantly reduce the need for adjuvant Dextran therapy. METHODS: Retrospective audit of prospectively acquired data in 297 patients undergoing CEA between 01.08.2006 and 30.07.2009. All received routine Aspirin (75 mg daily) in addition to a single 75 mg dose of Clopidogrel the night before surgery. All underwent completion angioscopy and those with a temporal window (n = 270) underwent intra- and post-operative TCD monitoring. RESULTS: High rate embolisation requiring Dextran (>25 emboli in any 10 min period) occurred in only 1/270 patients (0.4%), significantly less than the 3.2% rate in historical controls where Clopidogrel was not administered. There were no peri-operative deaths, but 3/297 patients suffered non-disabling strokes (intra-operative extension of a pre-existing deficit, haemorrhage into lentiform nucleus after hypertensive crisis, contralateral embolic stroke). The overall 30-day death/stroke rate (1.0%) was not-significantly lower than the 2.6% rate observed in the preceding 821 patients. CONCLUSIONS: 75 mg Clopidogrel administered the night before surgery (in addition to daily 75 mg Aspirin) was associated with a significant reduction in post-operative embolisation and Dextran utilisation. No ipsilateral thromboembolic ischaemic events occurred in this series. As a consequence of this audit, one dose of 75 mg Clopidogrel will continue to be given pre-operatively (in addition to daily 75 mg Aspirin) and routine post-operative TCD monitoring has now ceased.

An aggressive policy of bilateral saphenous vein harvest for infragenicular revascularisation in the era of multidrug resistant bacteria.

BACKGROUND: The success of infragenicular revascularisation for lower limb ischaemia is limited by the high proportion of patients without ipsilateral long saphenous vein (LSV) of adequate length or quality. The aim of this study was to report the results of an autogenous vein only policy for infragenicular revascularisation utilising contralateral LSV when ipsilateral LSV is inadequate. The treatment and outcome of infection of autogenous grafts with methicillin resistant Staphylococcus aureus (MRSA) is also reported. PATIENTS AND METHODS: The vascular audit database and patient case notes were reviewed retrospectively for patients with arterial occlusive disease requiring infragenicular reconstruction. There were 68 critically ischaemic legs in 65 patients of whom 48 were male: median age (range) 74 years (41-94), over a three year period. RESULTS: Thirty six patients (53%) underwent revascularisation (eight infragenicular femoropopliteal bypass, 28 femorodistal), 24 (35%) underwent primary amputation and a further eight (12%) were found to have unsuitable distal vessels for revascularisation after tibial vessel exploration and intraoperative angiography. Thirty three grafts (92%) utilised LSV and three (8%) were polytetrafluoroethylene grafts. Thirteen patients (39%) lacked adequate ipsilateral LSV of whom 12 had the contralateral leg explored providing suitable LSV in 10/12 (83%). Contralateral LSV was used as a single length conduit in two cases and as a venovenous composite graft in eight cases. Primary, primary assisted, and secondary patency rates at two years were 38%, 77%, and 81% respectively. Actuarial limb survival and patient survival rates at two years were 86% and 61% respectively. Eleven patients developed ipsilateral wound complications (30%) including seven (21%) who developed MRSA infection of the ipsilateral leg wound. MRSA wound infection was treated successfully in all cases by antibiotic therapy (intravenous vancomycin). No patient subsequently required saphenous vein harvesting for a secondary reconstruction or coronary artery bypass graft. CONCLUSION: Excellent long term results can be achieved using autogenous vein for infragenicular revascularisation and the contralateral LSV is an excellent alternative in the absence of suitable ipsilateral LSV. Autogenous vein may confer some protection against severe complications observed with MRSA infection seen in vascular patients and therefore its use is recommended.