Long-term results of a randomized controlled trial analyzing the role of systematic pre-operative coronary angiography before elective carotid endarterectomy in patients with asymptomatic coronary artery disease.

OBJECTIVES: To evaluate the potential benefit of systematic preoperative coronary-artery angiography followed by selective coronary-artery revascularization on the incidence of myocardial infarction (MI) in patients undergoing carotid endarterectomy (CEA) without a previous history of coronary artery disease (CAD). METHODS: We randomised 426 patients who were candidates for CEA, with no history of CAD, a normal electrocardiogram (ECG), and a normal cardiac ultrasound. In group A (n = 216) all patients underwent coronary angiography before CEA. In group B (n = 210) CEA was performed without coronary angiography. Patients were not blinded for relevant assessments during follow-up. Primary end-point was the occurrence of MI at 3.5 years. The secondary end-point was the overall survival rate. Median length of follow-up was 6.2 years. RESULTS: In group A, coronary angiography revealed significant coronary artery stenosis in 68 patients (31.5%). Among them, 66 underwent percutaneous Intervention (PCI) prior to CEA and 2 received combined CEA and coronary-artery bypass grafting (CABG). Postoperatively, no MI was observed in group A, whereas 6 MI occurred in group B, one of which was fatal (p = .01). During the study period, 3 MI occurred in group A (1.4%) and 33 were observed in group B (15.7%), 6 of which were fatal. The Cox model demonstrated a reduced risk of MI for patients in group A receiving coronary angiography (HR,.078; 95% CI, 0.024-0.256; p < .001). In addition, patients with diabetes and patients <70 years presented with an increased risk of MI. Survival analysis at 6 years by Kaplan-Meier estimates was 95.6 ± 3.2% in Group A and 89.7 ± 3.7% in group B (Log Rank = 6.54, p = .01). CONCLUSIONS: In asymptomatic coronary-artery patients, systematic coronary angiography prior to CEA followed by selective PCI or CABG significantly reduces the incidence of late MI and increases long-term survival. (ClinicalTrials.gov number, NCT02260453).

Systematic preoperative coronary angiography and stenting improves postoperative results of carotid endarterectomy in patients with asymptomatic coronary artery disease: a randomised controlled trial.

OBJECTIVE: To evaluate the usefulness of systematic coronary angiography followed, if needed, by coronary artery angioplasty (percutaneous coronary intervention (PCI)) on the incidence of cardiac ischaemic events after carotid endarterectomy (CEA) in patients without evidence of coronary artery disease (CAD). MATERIALS AND METHODS: From January 2005 to December 2008, 426 patients, candidates for CEA, with no history of CAD and with normal cardiac ultrasound and electrocardiography (ECG), were randomised into two groups. In group A (n=216) all the patients had coronary angiography performed before CEA. In group B, all the patients had CEA without previous coronary angiography. In group A, 66 patients presenting significant coronary artery lesions at angiography received PCI before CEA. They subsequently underwent surgery under aspirin (100 mg day(-1)) and clopidogrel (75 mg day(-1)). CEA was performed within a median delay of 4 days after PCI (range: 1-8 days). Risk factors, indications for CEA and surgical techniques were comparable in both groups (p>0.05). The primary combined endpoint of the study was the incidence of postoperative myocardial ischaemic events combined with the incidence of complications of coronary angiography. Secondary endpoints were death and stroke rates after CEA and incidence of cervical haematoma. RESULTS: Postoperative mortality was 0% in group A and 0.9% in group B (p=0.24). One postoperative stroke (0.5%) occurred in group A, and two (0.9%) in group B (p=0.62). No postoperative myocardial event was observed in group A, whereas nine ischaemic events were observed in group B, including one fatal myocardial infarction (p=0.01). Binary logistic regression analysis demonstrated that preoperative coronary angiography was the only independent variable that predicted the occurrence of postoperative coronary ischaemia after CEA. The odds ratio for coronary angiography (group A) indicated that when holding all other variables constant, a patient having preoperative coronary angiography before carotid surgery was 4 times less likely to have a cardiac ischaemic event after carotid surgery. No complications related to coronary angiography were observed and no cervical haematomas occurred in patients undergoing surgery under aspirin and clopidogrel in this study. CONCLUSIONS: Systematic preoperative coronary angiography, possibly followed by PCI, significantly reduces the incidence of postoperative myocardial events after CEA in patients without clinical evidence of CAD.

Surgical treatment of pararenal aortic aneurysms in the elderly.

AIM: Until fenestrated endografts will become the standard treatment of pararenal aortic aneurysms, open surgical repair will currently be employed for the repair of this condition. Suprarenal aortic control and larger surgical dissection represent additional technical requirements for the treatment of pararenal aneurysms compared to those of open infrarenal aortic aneurysms, which may be followed by an increased operative mortality and morbidity rate. As this may be especially true when dealing with pararenal aneurysms in an elderly patients' population, we decided to retrospectively review our results of open pararenal aortic aneurysm repair in elderly patients, in order to compare them with those reported in the literature. METHODS: Twenty-one patients over 75 years of age were operated on for pararenal aortic aneurysms in a ten-year period. Exposure of the aorta was obtained by means of a retroperitoneal access, through a left flank incision on the eleventh rib. When dealing with interrenal aortic aneurysm the left renal artery was revascularized with a retrograde bypass arising from the aortic graft, proximally bevelled on the ostium of the right renal artery. RESULTS: Two patients died of acute intestinal ischemia, yielding a postoperative mortality of 9.5%. Nonfatal complications included 2 pleural effusions, a transitory rise in postoperative serum creatinine levels in 3 cases, and one retroperitoneal hematoma. Mean renal ischemia time was 23 min, whereas mean visceral ischemia time was 19 min. Mean inhospital stay was 11 days. CONCLUSION: Pararenal aortic aneurysms in the elderly can be surgically repaired with results that are similar to those obtained in younger patients.

Distal polytetrafluoroethylene bypasses in patients older than 75 years.

HYPOTHESIS: Polytetrafluoroethylene (PTFE) alone is justified for infrapopliteal arterial grafting in elderly patients with critical ischemia of the lower limbs who lack a suitable, autogenous saphenous vein. DESIGN: A consecutive sample clinical study with a mean follow-up of 16 months. SETTING: The surgical department of an academic tertiary care center and an affiliated secondary care center. PATIENTS: Thirty-one patients older than 75 years with critical ischemia of the lower limbs received 34 PTFE bypass grafts to the infrapopliteal arteries: 12 patients to the anterior tibial, 8 to the peroneal, 8 to the posterior tibial, and 2 to the dorsalis pedis artery. MAIN OUTCOME MEASURES: Cumulative survival, primary graft patency, and limb salvage rates expressed by standard life-table analysis. RESULTS: Operative mortality rate was 3%. Cumulative survival rate was 80% at 2 years (SE, 9.2%) and 43% at 3 years (SE, 11.4%). Cumulative primary patency rate was 67% at 2 years (SE 9.1%), and 61% at 3 years (SE, 12.7%). Cumulative limb salvage rate was 77% at 2 years (SE, 8.7%) and 70% at 3 years (SE, 12.8%). CONCLUSION: Polytetrafluoroethylene alone is justified as graft material for infrapopliteal bypass grafts in elderly patients with critical ischemia of the lower limbs and without a suitable autogenous saphenous vein.

Endocaval suture of aortocaval fistula.

A case of aortocaval fistula complicating a ruptured infrarenal aortic aneurysm is reported. As the length of the defect and the thickness of the aortic wall made repair from within the aorta unsafe, the defect was repaired from within the vena cava. The details of the technique are reported. It can be a useful alternative to inferior vena cava ligation, when standard repair of aortocaval fistulae from within the aorta is risky or difficult to attempt.

Seat-belt injuries to the supra-aortic trunks.

Five seat-belt related injuries to the supra-aortic and cervical vessels occurring in four patients are reported. All patients but one were symptomatic, none presented with stroke, and in one case arterial lesion was revealed by delayed onset of symptoms. Outcome of surgical treatment was overall good. Systematic search of such injuries and surgical repair of those without major neurological signs might be advisable.

Surgical treatment of digestive arteries aneurysms.

Eight patients of a mean age of 56.4 years, have been operated on for 9 digestive arteries aneurysms in a 7-years-period. Sites of aneurysmal disease included 3 splenic, 3 superior mesenteric, 2 hepatic, and 1 left gastric arteries. Five patients (62.5%) were asymptomatic, while 3 (37.5%) presented with symptoms. Three patients (37.5%) presented associated aortic lesions consisting in 2 infrarenal aneurysms and 1 aorto-iliac stenosis. Of the 9 arteries treated, 5 were revascularized. Restaurative operations included 1 reconstructive endoaneurysmorraphy, 3 retrograde by-pass grafts (2 Dacron and 1 PTFE), and 1 antegrade by-pass graft (Dacron) from the coeliac aorta. There were no post-operative deaths. Mean length of follow-up was 47.8 months. No patient presented with late intestinal or operation related problems.

Infectious aneurysm of the interosseous artery at the forearm. Case report.

The case of an infectious aneurysm of the interosseous artery at the right forearm is reported, with presenting symptoms consisting in pain, loss of motor functions and paresthesias. The association of occupational trauma and hematogenous bacterial grafting were the possible etiologic agents. Diagnostic evaluation included ultrasound, Doppler study, CT-scan and arteriography, but the exact origin of the mass from the interosseous artery could be detected only at operation. As good collaterals were present at preoperative evaluation, simple excision followed by debridment and ligation was performed with a good result. The isolated infecting agent belonged to the salmonella species.

The surgical treatment of chronic intestinal ischemia: results of a recent series.

Due to the rarity of the condition, large and prospective series defining the optimal method of digestive arteries revascularization, for the treatment of chronic intestinal ischemia, are lacking. The aim of this consecutive sample clinical study was to test the hypothesis that flexible application of different revascularization methods, according to individual cases, will yield the best results in the management of chronic intestinal ischemia. Eleven patients, of a mean age of 56 years, underwent revascularization of 11 digestive arteries for symptomatic chronic mesenteric occlusive disease. Eleven superior mesenteric arteries and one celiac axis were revascularized. The revascularization techniques included retrograde bypass grafting in 7 cases, antegrade bypass grafting in 2, percutaneous arterial angioplasty in 1, and arterial reimplantation in one case. The donor axis for either reimplantation or bypass grafting was the infrarenal aorta in 4 cases, an infrarenal Dacron graft in 4, and the celiac aorta in one case. Grafting materials included 5 polytetrafluoroethylene (PTFE) and 3 Dacron grafts. Concomitant procedures included 3 aorto-ilio-femoral grafts and one renal artery revascularization. Mean follow-up duration was 31 months. There was no operative mortality. Cumulative survival rate was 88.9% at 36 months (SE 12.1%). Primary patency rate was 90% at 36 months (SE 11.6%). The symptom free rate was 90% at 36 months (SE 11.6%). Direct reimplantation, antegrade and retrograde bypass grafting, all allow good mid-term results: the choice of the optimal method depends on the anatomic and general patient's status. Associated infrarenal and renal arterial lesions can be safely treated in the same time of digestive revascularization. Angioplasty alone yields poor results and should be limited to patients at poor risk for surgery.

Results of distal revascularization in elderly patients for critical ischemia of the lower limbs.

Thirty eight patients over 75 years of age were operated upon of 40 distal arterial revascularizations for critical ischaemia of the lower limbs. Arterial reconstruction was proposed to ambulatory, self sufficient patients, with a patent artery of the leg or the foot in continuity with pedal arch, at arteriography. The revascularized artery was the peroneal in 14 cases, the anterior tibial in 11, the posterior tibial in 9, the dorsalis pedis in 5, and the external plantar artery in 1 case. Postoperative mortality was 2.6%. No postoperative arterial occlusion occurred and no postoperative amputation needed to be performed. The mean follow-up of 37 patients surviving operation was 21 months (ext. 2-52 months). At 36 months interval, patients' survival was 43%, primary patency rate was 57%, and limb salvage rate was 76%, at life-table analysis. Distal revascularization enables a good number of elderly patients in critical ischaemia of the lower limb, to enjoy an active, independent life, with a viable limb.

[Bifurcated prosthesis in infrarenal aortic position in stenosing lesions. Functional results]. / Le protesi biforcate in posizione aortica sottorenale per lesioni stenosanti. Risultati funzionali.

Fifty-eight patients operated upon of infrarenal aortic bifurcated grafts for occlusive disease, in a 6-year period, have been followed-up with a minimum interval of 2 years. The patients were in claudication stage in 63% of the cases and in critical limb threat ischemia in 37% Bypass consisted always in a bifurcated knitted dacron graft either pre-coagulated or sealed. Infrarenal aorta has always been the donor axis, whereas distal anastomosis has been performed on both common femoral in 80% of the cases, on at least one external iliac in 20%. In 5% of the cases a femoro-popliteal bypass has been associated to the main procedure. Postoperative mortality was 3.5%. The occlusion of a prosthetic branch in the postoperative period occurred in one case, requiring a major amputation. Seven patients (12%) presented 11 late thrombosis of one prosthetic branch or both on an interval varying from 4 to 62 months. Eight occlusions required reintervention. Only one, lethal, late prosthetic sepsis was recorded. In a mean interval of 54 months, a good or fair functional result was achieved in 93% of the patients. Out of 22 patients specifically questioned upon, 82% returned to their normal work activity, whereas 18% retired but had a fully normal everyday's life. Sexual function was ameliorated or unchanged in 67% of the cases, while it was impaired in 33%. Eighty-seven percent of the followed-up patients did not require any further hospitalisation for atherosclerotic disease, while 13% of them experienced subsequent hospitalisation or reintervention for progression of the disease either at the same or at different arterial sites. Overall good results support an aggressive attitude towards aorto-iliac-femoral grafting for occlusive disease.

[Simultaneous carotid and vertebral revascularization in the aged]. / Rivascolarizzazione simultanea carotidea e vertebrale nell'anziano.

Five patients of a mean age of 76, have been submitted to combined vertebral and carotid artery revascularization for a severe vertebro-basilar insufficiency. Vertebral artery revascularization consisted of a transposition to the common carotid artery in one case and of a carotid-distal vertebral artery saphenous bypass graft. The associated carotid artery revascularization consisted of a carotid endarterectomy with patch in 4 cases and without patch in one case. There were no postoperative mortality and no postoperative stroke. Postoperative morbidity included a transitory revascularization syndrome, a myocardial ischemia and a Horner's syndrome. Complete relief of vertebrobasilar symptoms was obtained in 4 patients whereas in one patient only a mild positional vertigo persisted. All vascular reconstructions have been assessed with postoperative arteriography and duplex-scan every six months. At 11 months mean follow-up, all revascularizations are patent. Combined carotid and vertebral artery surgery is effective in well selected cases, and it does not enhance the risk of the two operations performed separately. It also eliminate the possibility of failure of isolated carotid revascularization for vertebrobasilar symptoms.

The treatment of chronic intestinal ischemia.

BACKGROUND AND AIMS: Due to the rarity of the condition, large and prospective series defining the optimal method of digestive arteries revascularization, for the treatment of chronic intestinal ischemia, are lacking. The aim of this consecutive sample clinical study was to test the hypothesis that flexible application of different revascularization methods, according to individual cases, will yield the best results in the management of chronic intestinal ischemia. PATIENTS AND METHODS: Eleven patients, of a mean age of 57 years, underwent revascularization of 11 digestive arteries for symptomatic chronic mesenteric occlusive disease. Eleven superior mesenteric arteries and one celiac axis were revascularized. The revascularization techniques included retrograde bypass grafting in 7 cases, antegrade bypass grafting in 2, percutaneous arterial angioplasty in 1, and arterial reimplantation in one case. The donor axis for either reimplantation or bypass grafting was the infrarenal aorta in 4 cases, an infrarenal Dacron graft in 4, and the celiac aorta in one case. Grafting materials included 5 polytetrafluoroethylene (PTFE) and 3 Dacron grafts. Concomitant procedures included 3 aorto-ilio-femoral grafts and one renal artery revascularization. Mean follow-up length was 31 months. RESULTS: There was no operative mortality. Cumulative survival rate was 88.9% at 36 months (SE 12.1%). Primary patency rate was 90% at 36 months (SE 11.6%). The symptom free rate was 90% at 36 months (SE 11.6%). CONCLUSIONS: Direct reimplantation, antegrade and retrograde bypass grafting, all allow good mid-term results: the choice of the optimal method depends on the anatomic and general patients status. Associated infrarenal and renal arterial lesions can be safely treated in the same time of digestive revascularization. Angioplasty alone yields poor results and should be limited to patients at poor risk for surgery.

The surgical treatment of ilio-femoral venous obstruction.

METHODS: A series of 9 patients of a mean age of 48 years, operated on for compression of the ilio-femoral venous axis is reported. The cause of obstruction was external compression in 3 cases, a retroperitoneal sarcoma in 1 case, and an infrarenal aortic aneurysm in 2. Two patients presented with a Cockett's syndrome, 3 with a chronic ilio-femoral thrombosis, and one with a post-traumatic segmentary stenosis. Treatment consisted in a resection/Dacron grafting of 2 infrarenal aortic aneurysms, one femoro-caval bypass graft, 2 transpositions of the right common iliac artery in the left hypogastric artery for Cockett's syndrome, 3 Palma's operations for chronic thrombosis, and one internal jugular vein interposition for segmentary stenosis. RESULTS: There were no postoperative deaths and no early thromboses of venous reconstructions performed. All the patients were relieved of symptoms during the follow-up period, whose mean length was 38 months. CONCLUSION: The cause of venous obstruction and the presence of symptoms which are resistant to medical treatment are the main indications to ilio-femoral venous revascularization. The choice of the optimal treatment in each single case yields satisfactory results.

Results of bypasses to the anterior tibial artery through the interosseous membrane.

The purpose of the present study was to retrospectively evaluate the results of anatomically tunneled grafts to the anterior tibial artery for distal revascularization in terms of patency and limb salvage rates as well as local morbidity, which can lengthen the postoperative hospital stay. Twenty-three patients received 24 bypasses to the anterior tibial artery, with grafts tunneled through the interosseous membrane. The mean age was 67 years; 10 patients were diabetic, 12 were smokers, 9 presented with significant coronary artery disease, and 2 with chronic renal insufficiency. The donor vessel was the common femoral artery in 17 cases, the superficial femoral artery in 4, and the infra-articular popliteal artery in 3. The graft material consisted in the reversed saphenous vein in 4 cases, the non-reversed devalvulated ex situ saphenous vein in 11, composite polytetrafluoroethylene (PTFE) + inversed saphenous vein in 6, and PTFE alone in 3 cases. No postoperative mortality was observed, nor was there postoperative graft occlusion or need for major amputation. The average postoperative length of stay in the hospital was 9.7 days. Two local surgical wound complications were observed, which did not necessitate a postoperative hospital stay exceeding 15 days. Cumulative primary patency and limb salvage rates at 3 years were 50% and 70%, respectively. Anatomic tunneling of grafts to the anterior tibial artery yields patency and limb salvage rates comparable to those reported in the literature for distal bypasses and, considered overall, an acceptably low local morbidity and short hospital stay. Definitive superiority over externally tunneled grafts, however, is not definitely demonstrated by this study and should be prospectively tested.

Results of axillofemoral by-passes for aorto-iliac occlusive disease.

The purpose of this study was to review our results with axillofemoral by-passes performed for aorto-iliac occlusive disease. Fifty patients receiving 51 axillofemoral by-passes from January 1989 to December 1994 were retrospectively reviewed. The 30-day post-operative mortality was 4%. Seven patients (14%) presented graft-related local complications and all but one required reoperation. Five patients were lost to follow-up, the mean length of which was 36 months (16-74 months). Forty-nine per cent of the patients died during the follow-up period. At 36 months, the primary patency rate was 51%, the secondary patency rate was 69%, and limb valvage rate was 87%. A statistical difference was seen in the secondary patency rate between axillobifemoral by-pass (87%) and axillo-unifemoral by-pass (56%) at 36 months (P < 0.01), but no difference was seen in the limb salvage rate at 36 months between the two configurations of the by-pass (94% vs 81%) (P = NS). Twenty patients (40%) operated upon for acute ischemia had a significantly higher post-operative mortality rate (10% vs 0), a significantly higher amputation rate (20% vs 6.6%) and a significantly lower patency rate of by-pass (26% vs 63%) (P < 0.01), than the 30 patients (60%) operated on for claudication, rest pain or trophic ulcers. Our findings indicate that the results of axillofemoral by-pass are significantly influenced by the selection of patients for operation, namely the clinical status of ischaemic symptoms, and that since the overall results of axillofemoral by-pass are inferior to those of aortofemoral by-pass, this treatment should be restricted to patients at high risk of aortic clamping.

Seat-belt-related injuries to the supra-aortic arteries.

Five seat-belt-related injuries occurring in four adults are reported. One injury involved the common carotid artery, two the internal carotid and two the subclavian arteries. Three of the four injured persons were asymptomatic and one had delayed-onset symptoms; none suffered stroke. There was no operative mortality or morbidity. Overall, the functional results of arterial reconstruction were good, with satisfactory patency at follow-up averaging 15 months.

Infectious arterial aneurysms: patterns and treatment.

PURPOSE: To evaluate patterns and evolution of treatment of infectious arterial aneurysms in a 15 year period. MATERIAL AND METHOD: Eight patients bearing 8 arterial aneurysms: 4 aorto-iliac, 1 of the internal carotid, 1 of the posterior tibial, 1 of the cubital, 1 of the internal carotid artery. For the aorto-iliac aneurysms treatment consisted in resection extra-anatomic by-pass in 2, "in situ" prosthetic grafting in the other 2. Extra-abdominal aneurysms were treated by excision/"in situ" vein grafting in two cases and simple resection in other two cases. RESULTS: One post-operative death occurred, due to rupture of a ligated aortic stump. No death or major complication occurred after "in situ" treatment of aorto-iliac aneurysms and, overall, in extra-aortic aneurysms. CONCLUSIONS: Staphylococcus and miceti have become the most frequently encountered causative agents. "In situ" grafting together with aggressive antibiotic therapy became the preferred method in the recent years and yielded good results.

Transcranial Doppler validation of hemodynamic vertebrobasilar insufficiency diagnosis.

Transcranial Doppler (TCD) can be useful in the diagnosis and validation of surgical treatment of vertebrobasilar insufficiency (VBI). A case is reported in which TCD confirmed the diagnosis of vertebrobasilar insufficiency and validated the indication of surgery by detecting a bidirectional flow in a stenotic and compressed vertebral artery. In the postoperative period and at late follow-up TCD demonstrated a restored antegrade flow, as a consequence of a well functioning revascularization. Surgical indication of VBI is rare and TCD can be proposed as part of routine patients' study before a surgical decision is taken.

Trypanosoma lewisi in liquid culture: findings and comparisons with different types of media. Culture medium for Trypanosoma lewisi.

The culture technique used proved to be more simple and economical than the different culture methods described in literature. This process permits the in vitro growth of parasites for a period long enough (10 days) to determine the possible activity of drugs. On the 10th day the cultures are infectious.