Impact of routine completion angiography on the results of primary carotid endarterectomy: a prospective study in a teaching hospital.

OBJECTIVE: To assess the usefulness of completion angiography in the prevention of stroke, carotid occlusion and residual stenosis after primary carotid endarterectomy (CEA) in the setting of a teaching hospital. MATERIAL AND METHODS: From January 1995 to August 2009, 1055 consecutive patients having 1179 CEAs were entered in a prospective study excluding patients with severe renal insufficiency, allergy to contrast media and patients with repeat CEA or carotid bypass. In this cohort, 552 patients (52.3%) were asymptomatic, 318 (30.2%) had a transient ischaemic attack (TIA) and 185 (17.5%) had a stroke. Routine completion angiography was obtained in all 1055 patients. The decision to perform a surgical revision was decided for any of the following defects: (1) a residual stenosis of more than 50% of the internal carotid artery (ICA) or common carotid artery (CCA) and of more than 70% of the external carotid artery (ECA), (2) any flap and (3) any intraluminal-filling defect. A postoperative duplex scan was obtained within a week after surgery and thereafter on a yearly basis. Median follow-up was 7 years. RESULTS: CEA was performed by a senior surgeon as first operator in 812 cases (69%) and by a trainee, with a scrubbed senior surgeon, in 367 cases (31%). Completion angiography revealed significant defects in 72 cases (6.1%) warranting revision for ECA flap (n = 30), thrombus in contact with the patch (n = 7), distal ICA flap or stenosis (n = 20) and CCA flap or residual plaque (n = 15). Logistic regression analysis showed that total length of the carotid plaque >6 cm (p = 0.02, Odds ratio: 2.31; 95% confidence interval (CI) (1.21-3.72)), eversion endarterectomy of the ECA (p = 0.01, Odds ratio 3.41; 95%CI (2.10-5.94)) and trainee as first operator (p = 0.02, Odds ratio 2.42; 95%CI (1.81-4.23)) were independent predictors of operative defects seen on completion angiography. No complication in relation to carotid catheterisation or injection of contrast media occurred in this series. The 30-day combined stroke and death rate was 1.5%, comparable between senior surgeons and trainees (p = 0.60). There was no significant difference in the combined stroke and death rate observed in patients with normal completion angiography (1.4%) compared with that of the patients with a defect corrected (2.8%) (p = 0.28, Odds ratio: 0.67; 95%CI (0.22-2.09)). But there was an increased incidence of postoperative TIA in the group with revision (p = 0.001, odds ratio: 5.8, 95%CI: 1.8-18.9). At 7 years, the freedom rate from >50% carotid restenosis or occlusion was 87.5 ± 6.7% in patients with normal completion angiography and 92 ± 5.4% in patients, who undergo a surgical revision. CONCLUSION: In a single centre, CEA with routine completion angiography resulted in good perioperative outcome. Plaque length, technique for external carotid artery (ECA) endarterectomy and trainee as first operator were independent predictors of operative defects seen on completion angiography.

Open surgery for chronic limb ischemia: a review.

This review considers the role of the different revascularization strategies in patients with chronic limb ischemia (CLI) and reveals that clinical evidence guiding therapeutic decision-making in CLI is poor and only careful basic recommendations can be made. For diffuse aortoiliac disease with occlusion of the aorta, aortobifemoral bypass remains the best option if the patient is fit for open surgery. Unilateral iliac occlusion should be treated by primary stenting, but an iliofemoral bypass may be the best option when the disease extends down to the common and deep femoral arteries. For infrainguinal revascularisation, bypass using the saphenous vein remains the best option for patients with occlusion of the superficial femoral artery >25 cm and for patients with multiple occlusions of the infrapopliteal arteries. In the absence of leg veins, arm veins should be used. Prosthetic grafts are the last option. Endovascular techniques are recommended in patients with short arterial lesions and limited life expectancy <2 years. Finally some patients with CLI are best treated by primary amputation. In conclusion, this review demonstrates that neither an endo- first nor a bypass-first attitude is appropriate in patients with CLI and suggests that these patients should be cared for by specialists in a multidisciplinary center in order to preserve their life and limbs, to conduct clinical trials and to control costs.

The diabetic foot: a review.

Diabetic foot ulceration (DFU) is among the most frequent complications of diabetes. Neuropathy and ischaemia are the initiating factors and infection is mostly a consequence. We have shown in this review that any DFU should be considered to have vascular impairment. DFU will generally heal if the toe pressure is >55 mmHg and a transcutaneous oxygen pressure (TcPO2) <30 mmHg has been considered to predict that a diabetic ulcer may not heal. The decision to intervene is complex and made according to the symptoms and clinical findings. If both an endovascular and a bypass procedure are possible with an equal outcome to be expected, endovascular treatments should be preferred. Primary and secondary mid-term patency rates are better after bypass, but there is no difference in limb salvage. Bedridden patients with poor life expectancy and a non-revascularisable leg are indications for performing a major amputation. A deep infection is the immediate cause of amputation in 25% to 50% of diabetic patients. Patients with uncontrolled abscess, bone or joint involvement, gangrene, or necrotising fasciitis have a "foot-at risk" and need prompt surgical intervention with debridement and revascularisation. As demonstrated in this review, foot ulcer in diabetic is associated with high mortality and morbidity. Early referral, non-invasive vascular testing, imaging and intervention are crucial to improve DFU healing and to prevent amputation. Diabetics are eight to twenty-four times more likely than non-diabetics to have a lower limb amputation and it has been suggested that a large part of those amputations could be avoided by an early diagnosis and a multidisciplinary approach.