Does carotid stenting measure up to endarterectomy? A vascular surgeon's experience.

HYPOTHESIS: Carotid angioplasty and stenting seems to have equal or better outcomes in high-risk patients than carotid endarterectomy. DESIGN: Single-center case-control study. SETTING: University hospital tertiary referral center. PATIENTS: Individuals (n = 53) undergoing elective carotid angioplasty and stenting for cervical carotid stenosis (n = 57) between April 2001 and October 2003. All patients were referred to and treated by the primary author (M.K.E.). RESULTS: Mean +/- SD age was 68.8 +/- 1.2 years (64% men [34] and 36% women [19]), and overall mean +/- SD rate of stenosis was 79% +/- 10%. Preprocedural neurologic symptoms were present in 42% of the group. Indications for treatment included prior neck surgery with irradiation (4), recurrent stenosis (19), and severe comorbidities (34). Duplex scanning 24 hours after stenting showed immediate mean percentage reductions in peaksystolic velocity and end diastolic velocity of 74% and 76%, respectively. After a 30-day follow-up period, there were no deaths and no major or minor strokes. One patient (1.7%) developed transient amaurosis fugax 12 hours after the procedure. Four patients (7.0%) experienced access-related complications. Intraoperative complications included 1 seizure (1.7%) and 1 asystolic arrest (1.7%), both treated successfully. During follow-up, 3 cases of re-stenosis (5.0%) occurred. One asymptomatic occlusion (1.7%) was detected at the 6-month follow-up visit. There have been no late carotid-related complications or deaths. CONCLUSIONS: Vascular surgeons possessing advanced catheter-based skills can safely perform carotid angioplasty and stenting and can achieve perioperative results comparable with carotid endarterectomy. Determination of the true efficacy and durability of carotid angioplasty and stenting as compared with endarterectomy awaits ongoing randomized national trials.

Greater local recurrence occurs with "berry picking" than neck dissection in thyroid cancer.

Managing cervical lymph node metastases in well-differentiated thyroid cancer with either "berry picking" (BP) or anatomic neck dissection (AND) has not been shown to alter survival. Nevertheless local control of thyroid cancer is important. The purpose of this study is to determine whether the local recurrence rate of well-differentiated thyroid cancer is equivalent with BP versus AND. A retrospective analysis revealed 41 patients with well-differentiated thyroid cancer and cervical node metastases seen by a single surgeon from 1985 to 2002. A total of 83 initial and repeat neck operations were performed (nine BPs, 30 central neck dissections, and 44 modified radical neck dissections). Recurrence of cancer, intervention for recurrence, and complications of the BP and AND groups were evaluated. All nine (100%) patients undergoing a limited BP operation had local recurrence of cancer. Only three of the 32 (9%) patients undergoing an initial formal neck operation had local recurrence of tumor. The recurrences after BP (100%) were significantly greater than the recurrences after AND (9%) (P < 0.001). The incidence of surgical complications with BP and AND was not different. Six of 32 (19%) initial formal neck dissection patients and four of nine (44%) BP patients had surgical complications. We conclude that BP is associated with greater local recurrence of thyroid cancer. Patients with nodal metastases should be managed with ANDs.

Carotid artery revascularization.

Stroke is the third leading cause of death in the United States, and up to one third of patients have a stroke secondary to carotid occlusive disease. Surgical management has firmly established itself as an important modality in treating this disease. Several prospective randomized trials have defined the patients that would have the most benefit from carotid endarterectomy (CEA). These patient populations include asymptomatic patients with a >or= 60% stenosis and symptomatic patients with a >or= 50% stenosis. The timing of CEA after stroke remains controversial, but recent studies advocate early CEA in a select group of patients. During the CEA, the method of closing of the arteriotomy has an overall effect on the safety of the procedure as well as long-term outcome. As compared with primary repair of the arteriotomy, patch closure has been shown to decrease the frequency of restenosis. In addition, carotid eversion endarterectomy (CEE) is an alternative method to remove the plaque that has a similar efficacy to standard CEA. The role of carotid angioplasty and stenting (CAS) continues to evolve and offers the patient a less invasive method of treating the carotid plaque.

Enhanced abdominal aortic aneurysm in TIMP-1-deficient mice.

BACKGROUND: Matrix metalloproteinases (MMPs) are known elastolytic mediators of abdominal aortic aneurysm (AAA) degeneration, and their activity is tightly regulated by the presence of tissue inhibitors of MMPs (TIMPs). Imbalances in this system may be instrumental in compromising arterial wall integrity. The aim of this study was to show that, in an elastase-induced murine model of aneurysm formation, TIMP-1 has a protective effect. MATERIALS AND METHODS: Twenty-four wild-type (TIMP-1+/+) and 22 knockout (TIMP-1-/-) mice underwent laparotomy and isolation of the infrarenal aorta. A polyethylene catheter was inserted into the aorta and dilute pancreatic elastase (0.39 Units/ml) was infused over 5 min using a perfusion pump. Pre- and postinfusion maximal aortic diameters were obtained in triplicate for each animal using NIH Image. Final aortic measurements were obtained 14 days later, prior to perfusion fixation with 10% buffered Formalin. Aortic specimens were sectioned and stained. Statistical analysis was performed using the Student's t test. RESULTS: TIMP-1-/- mice demonstrated a significant postinfusion diameter increase compared to wild-types after elastase, which was not seen after saline infusion. At sacrifice, TIMP-1-/- mice, following both saline and elastase infusion, showed a significant increase in maximal aortic diameter relative to postinfusion measurements compared to TIMP-1+/+ mice. CONCLUSIONS: TIMP-1-/- mice develop larger aneurysms than TIMP-1+/+ mice. This study illustrates the protective effects of TIMP-1 in an experimental AAA model and may provide a means for pharmacologically controlling aneurysm growth.

Management of biliary and duodenal complications of chronic pancreatitis.

Biliary stricture and duodenal obstruction have been increasingly recognized as complications of chronic pancreatitis. The anatomical relationship of the distal common bile duct and the duodenum with the head of the pancreas is the main factor for their involvement in chronic pancreatitis. In hospitalized patients with pancreatitis, the incidence of biliary stricture and duodenal obstruction is reported to be about 6% and 1.2%, respectively. For patients requiring an operation for chronic pancreatitis the incidence increases to 35% for biliary stricture and 12% for duodenal obstruction. Fibrosis around the distal common bile duct can cause stenosis with obstruction of bile flow. Clinically, the presentation of these patients ranges from being asymptomatic with elevated alkaline phosphatase or bilirubin, or both, to being septic with cholangitis. Jaundice, cholangitis, hyperbilirubinemia, and persistent elevation of serum alkaline phosphatase occur more frequently in patients with pancreatitis with a biliary stricture. A twofold elevation of alkaline phosphatase is a marker of possible common duct stenosis in patients with chronic pancreatitis. The incidence of both biliary cirrhosis and cholangitis in these patients is about 10%. ERCP reveals a characteristic long, smoothly tapered stricture of the intrapancreatic common bile duct. In duodenal obstruction, the factors that convert self-limiting edema to chronic fibrosis and stricture formation are unknown, but ischemia superimposed on inflammation may be the major cause. These patients present with a prolonged history of nausea and vomiting. Barium studies typically show a long constricting lesion of the duodenum, and endoscopy reveals reactive inflammatory changes in a narrowed duodenum. Operation is indicated in patients with common bile duct strictures secondary to chronic pancreatitis when there is evidence of cholangitis, biliary cirrhosis, common duct stones, progression of stricture, elevation of alkaline phophatase and/or bilirubin for over a month, and an inability to rule out cancer. The operation of choice is either choledochoduodenostomy or choledochojejunostomy. A cholecystoenterostomy is less favored because of its higher failure rate (23%). Endoscopic stenting plays a role in patients who are unfit for surgery, but it is not recommended as definitive therapy. For duodenal obstruction, failure to resolve the obstruction with 1-2 weeks of conservative therapy is an indication for bypass. The operation of choice is a gastrojejunostomy. Not uncommonly, combined obstruction of the pancreatic duct, common bile duct, and duodenum will develop. Combined drainage procedures or resection are used to manage these problems.