Coronary angiography in 506 patients with extracranial cerebrovascular disease.

Coronary angiography was performed during the evaluation of a prospective series of 506 patients (mean age, 65 years) presenting with extracranial cerebrovascular disease and previous neurologic symptoms (N = 288) or asymptomatic carotid bruits (N = 218). Severe, surgically correctable coronary artery disease was documented in 37% of patients suspected to have coronary artery disease by conventional clinical criteria, compared with 16% of those who were not. Severe inoperable coronary disease was present in 9.8% and 1.5% of these respective subsets and was especially common (14%) among diabetics. As the result of this investigation, an algorithm for perioperative cardiac screening has been developed in an attempt to reduce the eventual mortality caused by myocardial infarction in patients who require extracranial reconstruction.

Angiographic correlates of cardiac death and myocardial infarction complicating major nonthoracic vascular surgery.

In a case-control study of 63 patients undergoing major nonthoracic vascular surgery with prior cardiac catheterization, we found total coronary occlusion serving viable myocardium and "nonobstructive" lesions to be the most common proximate cause of perioperative myocardial infarction or death. The extent of coronary disease by several measures was significantly correlated with adverse outcome, and prior bypass surgery appeared to be protective.

Combined myocardial revascularization and carotid endarterectomy. Operative and late results in 331 patients.

Simultaneous coronary artery bypass and carotid endarterectomy were performed in 331 patients (mean age 61 years) at the Cleveland Clinic from 1973 through 1981. Of these, 195 (59%) had Functional Class III-IV angina pectoris, 308 (93%) had multiple-vessel coronary artery disease (CAD), 68 (21%) had over 50% stenosis of the left main coronary artery, and 185 (56%) had either segmental or diffuse impairment of left ventricular function. Asymptomatic carotid stenosis was documented in 173 patients (52%), and the remaining 158 had experienced either previous transient cerebral ischemia (38%) or completed strokes (10%). Single aorta-coronary grafts were placed in 59 patients (18%), double grafts in 131 (40%), and three or more grafts in 141 (42%). Nineteen patients (5.7%) died postoperatively in the hospital. Neurologic deficits occurred in 30 patients (9.0%) and produced permanent functional impairment in 15 (4.5%). Late results have been obtained for 312 operative survivors at a mean postoperative interval of 38 months. Thirty-eight patients (12%) have died, but the 5 year life-table survival rate of the study group was identical to that of the normal population aged 61 years. Significant differences in cumulative 5 year survival rates were identified among diabetic patients (p less than 0.025) and among those receiving single rather than double (p less than .005) or multiple (p less than .01) coronary grafts. Although 18 patients (5.8%) have had late strokes, only five (1.6%) of these strokes have involved the cerebral hemisphere on the same side as combined carotid endarterectomy.

Peripheral atheromatous embolization following blunt abdominal trauma.

A 65-year-old man sustained blunt abdominal trauma in an automobile accident which resulted in severe acute ischemia of the right lower leg and foot. Complete arteriography showed extensive aortoiliac arteriosclerosis and embolic occlusion of the distal right popliteal artery. Prompt embolectomy accomplished limb salvage and confirmed the diagnosis of traumatic artheromatous embolization.

Influence of distal arterial occlusive disease on prognosis following aortobifemoral bypass.

Arteriographic criteria were used to classify 376 consecutive patients who underwent aortobifemoral bypass for aortoiliac occlusive arterial disease between 1967 and 1977. Group A (126 patients, 34%) had isolated aortoiliofemoral disease, group B (156 patients, 41%) had associated femoropopliteal disease, and group C (94 patients, 25%) had associated femoropopliteal and tibioperoneal disease. Ischemic rest pain or tissue necrosis was the indication for operation in 13% of patients in group A, 30% of those in group B (P < 0.01), and 45% of those in group C (P < 0.001). The overall operative mortality rate was 5.6%, and differences in operative mortality among the three groups had no statistical significance. Fatal postoperative myocardial infarctions occurred in 4.5% of the entire series and accounted for 17 (81%) of 21 postoperative deaths. Late follow-up information for 3 to 13 postoperative years (mean, 6.3 years) was available for 337 (95%) of 355 operative survivors. Subsequent femoropopliteal or femorotibial bypass was necessary for 8% of patients in group A, 13% of those in group B, and 19% of those in group C (P < 0.05), but the presence of distal occlusive disease was not associated with meaningful differences in cumulative aortofemoral limb patency or major amputation. The late mortality rate was 28% for group A, 33% for group B, and 41% for group C. Myocardial infarctions were responsible for 46% of all late deaths and occurred in 11% of patients in group A, 15% of those in group B, and 20% of those in group C. The mortality rate (P < 0.01) and the incidence of fatal myocardial infarction (P < 0.02) within five postoperative years were statistically significant in group C.

Staged and combined surgical approach to simultaneous carotid and coronary vascular disease.

Between 1969 and 1976, 174 patients were treated surgically for simultaneous carotid and coronary atherosclerosis. In 59 patients, staged carotid endarterectomy was performed a few days to 6 months prior to myocardial revascularization. Severe (more than 60% stenosis) coronary atherosclerosis affected a single vessel in 11 patients (19%), two vessels in 20 patients (34%), and three vessels in 28 patients (47%). Left ventricular contraction was impaired in 30 patients (51%). Nine patients (15%) had previous neurological symptoms, and 50 patients (85%) had asymptomatic carotid stenosis. One patient (1.5%) had a permanent stroke after carotid endarterectomy. There were no permanent strokes after staged myocardial revascularization, and the early mortality rate was 1.7%. Combined carotid endarterectomy and myocardial revascularization were performed in 115 patients with severe cardiac disease. Coronary atherosclerosis affected a single vessel in 10 patients (9%), two vessels in 39 patients (34%), and three vessels in 66 patients (57%). Left ventricular impairment was present in 72 patients (63%). Thirty-five patients (30%) had previous neurological symptoms, and 80 patients (70%) had asymptomatic carotid stenosis. Five patients (4.3%) had permanent strokes after combined revascularization, and four of these patients had occlusion or severe stenosis of the contralateral internal carotid artery. The early mortality rate was 4.3%, but no deaths could be attributed to carotid repair. The results suggest that significant simultaneous carotid and coronary atherosclerosis should be corrected in selected patients by staged operations when feasible. In the presence of severe cardiac disease, a combined precedure may be performed in face of higher risk of intraoperative stroke.

Revascularization of the kidney after occlusion of the aorta and both renal arteries.

A patient who developed acute renal artery thrombosis as a complication of distal abdominal aortic occlusion is described. Because of the presence of an extensive collateral arterial supply, the right kidney survived and revascularization was accomplished successfully with a saphenous vein graft interposed between the superior mesenteric and the right renal arteries. Criteria for revascularization of renal artery occlusion are presented, with emphasis on the importance of collateral circulation and the elective correction of distal aortic thrombosis.

Reduction in the homologous blood requirement for abdominal aortic aneurysm repair by the use of preadmission autologous blood donation.

BACKGROUND: To evaluate the effectiveness of preadmission autologous blood donation (PABD) in reducing the homologous transfusion requirement of abdominal aortic aneurysm resection, the blood product requirements of 145 patients who underwent operation at Cleveland Clinic from September 1987 through May 1991 were reviewed. METHODS: A study group of 73 patients underwent aortic grafting for aneurysm after PABD. Intraoperative autotransfusion (IAT) was used routinely. Homologous blood requirements were compared to those of 72 patients at the same center who underwent similar operations using IAT alone. No significant differences were noted in age, gender, cardiovascular risk factors, operation complexity, intraoperative blood loss, or IAT volumes between the two groups. Mean aneurysm size of the study patients (5.4 cm) was slightly less than that of the comparison patients (6.0 cm) (p < or = 0.001). Patients in the study group received a mean of 1.9 units predeposited autologous blood. RESULTS: The mean discharge hematocrit (33.4%) and hemoglobin (11.0 gm/dl) levels of the study group were indistinguishable from those of the comparison group (33.3% and 11.1 gm/dl, respectively). The homologous blood requirement of the study group was significantly less (median, 0; mean, 1.3 units/patient) than that of the comparison group (median, 1.5; mean, 1.9 units/patient) (p = 0.001). Furthermore, 67% (49 of 73 patients) of the study group required no homologous blood although only 36% (26 of 72 patients) of the comparison patients avoided banked blood transfusions (p = 0.0004). No significant differences were found in platelet, fresh frozen plasma, or cryoprecipitate requirements between the study and comparison groups. CONCLUSIONS: PABD significantly reduces the homologous blood requirements for elective aortic aneurysm resection and, when used in combination with IAT, eliminates the need for homologous blood in at least two thirds of properly selected patients.

Incidental asymptomatic carotid bruits in patients scheduled for peripheral vascular reconstruction: results of cerebral and coronary angiography.

From 1978 to 1982 routine preoperative coronary angiography was performed in a series of 1000 patients under consideration for elective peripheral vascular reconstruction, including 295 who were selected primarily because of recognized extracranial cerebrovascular disease. Incidental asymptomatic carotid bruits were discovered in 144 (20%) of the remaining 705 patients who primarily were scheduled for such procedures as aortic replacement, lower extremity revascularization, or visceral artery bypass, and 139 of these 144 patients underwent cerebral angiography as well as cardiac catheterization. Carotid stenosis exceeding 50% of lumen diameter was documented by biplanar angiography in 39 (58%) of 67 patients with unilateral bruits and in 54 (75%) of 72 patients with bilateral bruits (p = 0.0471), and greater than 75% stenosis was present in 42% and 46% of these subsets, respectively. Cardiac catheterization revealed severe, surgically correctable coronary artery disease (CAD) in 29% of patients with incidental carotid bruits and in 24% of those without bruits, as well as in 32% of patients who had documented carotid stenosis and in 22% of those who did not. Although these differences were not statistically valid, the incidence of severe, correctable CAD was significantly higher among patients suspected to have CAD by standard clinical criteria (33% to 38%) than among those who were not (13%), irrespective of whether carotid bruits were present (p = 0.0021) or absent (p = 3.48 X 10(-9). Prophylactic carotid endarterectomy was performed in 54 patients (bilateral in nine), with one death (1.6%) and one postoperative stroke. In addition, 153 patients underwent elective myocardial revascularization in an attempt to reduce subsequent surgical risk and enhance late survival, with an early mortality rate of 5.2%. Only three strokes (0.4%) occurred after a total of 714 other peripheral vascular procedures in this series, and the overall operative mortality rate was 2.7%. While this study does not resolve the controversy concerning the management of incidental asymptomatic carotid bruits in patients scheduled for other operations, it provides new perspective regarding synchronous carotid and coronary disease and confirms the low risk for subsequent stroke and death after appropriate carotid and coronary reconstruction.

Early patency of the carotid artery after endarterectomy: digital subtraction angiography after two hundred sixty-two operations.

During a 12-month period of study, 265 patients (mean age 65 years) underwent a total of 314 carotid endarterectomies for the management of previous transient cerebral ischemia (39%), prior stroke (10%), or severe asymptomatic carotid stenosis (51%). Five patients (1.6%) died within 30 days of operation, but only three deaths (1%) were related to carotid reconstruction. Six patients (1.9%) experienced postoperative strokes, including 1.6% of those with previous transient ischemia, 9.7% of those with prior strokes (P less than 0.02), and 0.6% of those with asymptomatic carotid stenosis before operation. Digital subtraction angiography (DSA) was performed during the same hospital admission following 262 procedures in a group of 214 patients, including all patients who had postoperative neurologic complications. Seven of these operations were limited to external carotid endarterectomy. The internal carotid artery was entirely normal in 239 (94%) of the remaining 255 DSA studies. The external carotid artery was normal on 238 (93%) of 255 DSA examinations, but was occluded on 12 (4.7%). A focal intimal defect corresponding to the apical arteriotomy suture was found in nine internal carotid arteries (3.6%), but these lesions did not appear to be hemodynamically significant. The internal carotid artery contained over 30% stenosis in two patients (0.8%) and was occluded in five (1.9%). Two of these five patients had neurologic complications, but four others with operative strokes had normal angiograms. Asymptomatic postoperative thrombosis of the internal carotid artery was documented in only three patients (1.2%).

Postoperative stroke and late neurologic complications after carotid endarterectomy.

From 1969 through 1973, 335 consecutive patients (mean age, 60 years) underwent 390 carotid endarterectomies using hypercarbic general anesthesia and no carotid shunting. Early neurologic complications were most common among patients with previous neurologic symptoms and among those with subtotal stenosis or occlusion of the contralateral internal carotid artery. The introduction of routine carotid shunting without hypercarbia during a subsequent series of 626 procedures from 1974 through 1978 has been associated with significantly fewer operative strokes in comparable groups of patients. Complete follow-up information during a mean interval of 8.6 years is available for 95% of 325 operative survivors. Late completed strokes have occurred in 17% of patients but have involved the cerebral hemisphere on the side of previous carotid endarterectomy in only 7%. Of 93 operative survivors who had subtotal stenosis of the contralateral internal carotid artery, 45 underwent contralateral endarterectomy as an elective procedure and 48 did not. The late contralateral stroke rates for these two groups of patients were 4% and 16%, respectively, although these differences did not attain statistical significance. Forty-nine (78%) of 63 patients with contralateral internal carotid occlusion have had no late neurologic symptoms following unilateral carotid endarterectomy.

Venous access using the bovine carotid heterograft: techniques, results, and complications in 75 patients.

Between January 1974 and March 1977, arm bovine carotid heterograft arteriovenous fistulas were constructed in 75 patients. Twenty-six fistulas were established between the distal radial artery and an antecubital vein, and 49 fistulas used the brachial artery and the axillary vein. Thirty-eight heterografts have functioned without complication over a maximun interval of 29 months, including 15 of 26 radiobasilic fistulas and 23 of 49 brachioaxillary fistulas. Of the 37 heterograft failures, 28 were caused by thrombosis, six by infection, two by false aneurysm formation, and one by distal arm ischemia. Early postoperative thrombosis was associated with a higher subsequent failure rate after thrombectomy than was late thrombosis and it often required insertion of a new heterograft. Infected heterografts must be ligated and eventually replaced with another fistula at a distant site to avoid the potentially lethal complications of systemic sepsis and local hemorrhage.

Routine surgical management of brachial artery occlusion after cardiac catheterization.

From 1965 through 1980, 1,108 patients (1.5%) underwent thrombectomy and local arterial reconstruction because of brachial artery occlusion after a total of 73,750 cardiac catheterization procedures performed at the Cleveland Clinic. In a study group of 100 consecutive patients, 91 had simple arteriotomy revision and nine had segmental arterial resection with either axial reanastomosis or a saphenous vein interposition graft. Thirteen patients sustained early recurrent thrombosis after limited arteriotomy revisions, and 11 of these had successful reoperations. Ninety-eight patients were discharged from the hospital with normal distal pulses and no ischemic symptoms. Statistical analysis indicated that women were more likely than men to experience early recurrent thrombosis, and that late ischemic symptoms were most common among women and among those who required reoperations at the time of initial treatment.

Ultramicroscopic ulcerations and thrombi of the carotid bifurcation.

It is widely accepted that transient cerebral ischemia and permanent stroke frequently are caused by platelet and thrombotic cerebral emboli that originate from lesions at the carotid bifurcation. Microembolization from ulcerated atheroma during carotid dissection also offers a logical explanation for the incidence of intraoperative neurologic deficits during carotid endarterectomy. The risk of intraoperative embolization is obvious when ulcers are macroscopic; but focal cerebral ischemia associated with atheroma that appear smooth and nonulcerated usually has been attributed to decreased regional cerebral blood flow. Several endarterectomy specimens were submitted for scanning electron microscopic evaluation using X20 through X4,000 malignification. Results indicate that carotid atheroma may contain superficial ulcerations and thrombi that are not appreciated by direct inspection or conventional microscopic techniques. Electron microscopic ulcerations and intraluminal thrombi may be responsible for embolic transient ischemic attacks, spontaneous strokes, and intraoperative neurologic deficits in patients in whom gross ulcerations are absent.

Routine coronary angiography prior to elective aortic reconstruction: results of selective myocardial revascularization in patients with peripheral vascular disease.

Routine coronary angiography to determine the prevalence of severe coronary artery disease (CAD) has been recommended to all patients under consideration for elective peripheral vascular reconstruction at the Cleveland (Ohio) Clinic since April 1978. Those found to have severe, correctable CAD have been advised to undergo myocardial revascularization prior to performance of elective peripheral vascular operations. Forty-one of the 68 patients with abdominal aortic aneurysms (AAA) and 26 of the 71 patients with aortoiliac occlusive arterial disease (AI) had clinical evidence of CAD; coronary angiography demonstrated severe, correctable CAD in 23 patients with AAA and in 14 patients with AI. Twenty-seven patients with AAA and 45 patients with AI had no clinical evidence of CAD; severe, correctable CAD was found in six patients with AAA and in six patients with AI. Ninety-six patients, including 26 who had staged cardiac procedures performed, have had elective aortic reconstruction, with one operative death.

Vascular problems in urologic patients.

Intraoperative vascular surgical consultation may be necessary if venous or arterial injury occurs during transabdominal urologic operations. Loss of blood usually can be controlled by simple digital compression until the consultant arrives, but urologists should be familiar with the principles of vascular reconstruction. Adequate exposure of the injured segment is essential, and the repair of major vessels must preserve patency as well as provide hemostasis. In this regard, patch angioplasty is sometimes necessary, and formal replacement with autogenous or prosthetic grafts may rarely be required. Blunt arterial trauma can precipitate distal arterial embolization, a complication that usually is not suspected until the immediate postoperative period. Although salvage should be managed by a vascular surgeon, urologists must be alert for the early signs of acute extremity ischemia after extensive retraction has been used deep in the pelvis, particularly in elderly or atherosclerotic patients. Considering the established diagnostic accuracy of roentgenographic studies presently employed in the fields of urology and vascular surgery, preoperative planning should limit the number of urgent intraoperative consultations between members of these two specialties. Each may have valuable advice to offer the other concerning the treatment of unusual problems involving obstructive uropathy, aortic aneurysms, and occlusive arterial disease, and their cooperative effort is especially important in the management of renal revascularization.

Intraoperative autotransfusion during abdominal aortic reconstruction.

Intraoperative autotransfusion by a continuous-flow centrifuge system was used during more than 300 abdominal aortic reconstructions at the Cleveland Clinic since May 1979. Fifty consecutive patients undergoing such operations were studied prospectively. Volumes of blood lost, salvaged, and transfused during each operation were tabulated. Autologous autotransfused blood was compared with homologous bank blood with respect to oxygen-carrying capacity, coagulation factors, microaggregate levels, red cell mass, pH, and free hemoglobin concentration. Chromium-51 red cell survival studies were performed in autotransfused blood in random patients and in control subjects. Renal, hepatic, and coagulation functions were determined during the first postoperative week. Each patient received a mean volume of 1,203 ml of autotransfused blood and 1,682 ml of bank blood to replace a mean operative blood loss of 2,386 ml. Red blood cell survival of both salvaged autologous and unshed autologous blood in the control group was nearly identical. Salvaged blood had superior oxygen-carrying capacity, a lower microaggregate level, and better buffering capacity than bank blood. Although transient elevations in liver function values and free hemoglobin levels were noted, no clinically important aberration of coagulation, hepatic, or renal function was demonstrated.

Construction of arteriovenous fistulas for hemodialysis.

Establishment of a dependable means of venous access is vitally important to patients who require hemodialysis. Physical examination and phlebography are used to assess the most appropriate site for arteriovenous fistula construction. The radial artery and cephalic vein near the wrist should be used whenever possible, but several alternative procedures are available, including the brachiocephalic fistula, and saphenous vein and bovine heterograft interposition. Each operation contributes immeasurably to the comfort and survival of patients with terminal renal failure, and each must be performed with careful attention to detail.

Results of carotid endarterectomy: the gold standard for carotid repair.

Carotid endarterectomy (CEA) generated substantial controversy during the mid-1980s because of the large number of operations that were being performed in the United States compared with other industrialized nations, the emergence of antiplatelet therapy as a possible alternative to surgical treatment for carotid disease, and the lingering question about whether the safety of CEA in published reports actually is attained at the thousands of hospitals in which it is performed. Several influential randomized trials now have validated the efficacy of CEA for stroke prevention in symptomatic patients having at least 50% carotid stenosis, as well as in asymptomatic patients with higher-grade lesions and no surgical contraindications. It must be remembered, however, that the surgeons who participated in these trials were vetted on the basis of acceptable stroke and mortality rates that were documented for their previous experience with CEA. A number of statewide and Medicare audits have shown that, although the complication rates of CEA appear to have declined to some extent during the past decade, they still exceed the standards established by the randomized trials in many geographic areas and often assume an inverse relationship to the annual volume of CEAs performed at hospitals and by individual surgeons. Although the indications for CEA never have been more clearly known or widely accepted than they are today, its designation as the gold standard for the management of patients meeting these criteria continues to depend on outcome assessment and quality control at the local level. Furthermore, these measures will be just as necessary for carotid balloon angioplasty and intraluminal stenting, because any competitive form of treatment legitimately should receive the same scrutiny as CEA.

Acute intestinal ischemia.

The present mortality rate of more than 80% for patients with superior mesenteric arterial thrombosis or embolism will remain unacceptable until earlier diagnosis is achieved. Although leukocytosis is often an early feature and may seem elevated out of proportion to the severity of the illness, the later developments of abdominal rigidity, intestinal paralysis, and vascular collapse indicate transmural gangrene and peritonitis. At this stage, the eventual high mortality of acute ischemia is established whatever the urgency of the operation or the skill with which it is performed. The syndrome must be suspected immediately when a patient in an older age group complains of sudden abdominal pain in the presence of associated cardiac arrhythmia, valvular disease or congestive heart failure, particularly if other sites of peripheral embolization are identified.