Preoperative magnetic resonance angiography as a predictive test for cerebral ischemia during carotid endarterectomy.

BACKGROUND: To evaluate whether the preoperative magnetic resonance angiography (MRA) can predict the risk of cerebral ischemia associated with the carotid endarterectomy (CEA). METHODS: Between January 2004 and December 2010, 382 consecutive patients (mean age: 56.6 years; range: 45-78 years) were identified to have undergone preoperative MRA and the CEA under regional anesthesia. It was determined that the patient needs shunting during the CEA by intraoperative monitoring of patient's neurology. All patients were divided into two subgroups: shunt group or no-shunt group. Imaging findings on preoperative MRA were correlated to shunting using univariate and multivariate logistic regression analyses combined with patient's demographic and clinical features to identify predictors of cerebral ischemia during the CEA. RESULTS: In 37 of 382 CEA cases (9.7%), shunting had been performed intraoperatively because the patient had a neurologic deficit. At multivariate analysis, preoperative MRA findings such as the absence of patent communicating arteries (odds ratio [OR], 5.56; 95% confidence interval [CI], 3.05-9.69; p = 0.013) and the increase of intracranial arteries which were not patent in the contralateral hemisphere (OR, 4.277; 95% CI, 2.575 to 7.104; p < 0.0001) were significantly associated with shunting. CONCLUSIONS: Preoperative MRA is valuable when predicting cerebral ischemia leading to an inevitable shunting during CEA. Therefore, if there are preoperative MRA findings such as multiple occlusive intracranial arteries in the contralateral hemisphere or the absence of patent communicating arteries, it is recommended that CEA be performed under general anesthesia with routine shunting to avoid a serious shunt-related complication.

Ten-year comparative analysis of bovine pericardium and autogenous vein for patch angioplasty in patients undergoing carotid endarterectomy.

BACKGROUND: To evaluate early and late clinical outcomes of carotid endarterectomy (CEA) with bovine pericardium patch in comparison with autogenous vein. METHODS: During a 10-year period, 456 CEAs were performed using patch closure of the arteriotomy with bovine pericardium (252 cases) and autogenous vein (204 cases). Retrospectively, surgical outcomes were evaluated and compared regarding CEA-related parameters, early and late mortality and morbidity rates, and the incidence of restenosis and aneurysmal dilatation between patients with bovine pericardium patch closure and those with autogenous vein closure. RESULTS: The two groups were comparable regarding basic demographics, clinical data, and anatomic data, except the incidence of coronary or peripheral arterial diseases. In patients with bovine pericardium patch closure, the total operating time and carotid clamping duration were statistically significantly shorter than in those with autogenous vein closure (P < 0.01). During the early postoperative period, 10 major (stroke and death) complications (2.2%) occurred without statistically significant difference between the two groups. The incidence of early minor postoperative complications was less with bovine pericardium patch closure (5.6% vs. 10.8%; P < 0.05). With a mean follow-up of 62 months for bovine pericardium patch closure and 67 months for autogenous vein closure, the incidence of restenosis was similar, but aneurysmal dilatation was higher in patients with autogenous vein closure with a statistically significant difference (0% vs. 2.0%; P < 0.05). CONCLUSION: CEA with bovine pericardium patch angioplasty showed excellent early and late clinical outcomes. Our results demonstrated bovine pericardium to be a suitable patch material for routine use in CEA.

Carotid endarterectomy for symptomatic complete occlusion of the internal carotid artery.

We described 9 consecutive patients who underwent operative carotid artery exploration with attempted carotid endarterectomy (CEA) for symptomatic internal carotid artery (ICA) occlusion. Indications for this surgery based on vascular imaging included segmental occlusion of the proximal ICA and also extensive occlusion of the distal ICA in selected patients in whom color-flow duplex ultrasound showed a poorly echogenic or anechoic thrombus with a flow void, suggestive of an acute thrombus. CEA was performed successfully to restore blood flow in all 9 patients:CEA in 5 and CEA with Fogarty thrombectomy in 4. Postoperative magnetic resonance (MR) angiography confirmed that revascularization had been successful in all 9 patients, and MR imaging displayed improved perfusion in 4 patients. Despite the lack of a generalized efficacy of surgical revascularization for symptomatic ICA occlusion, our study demonstrated that preoperative vascular imaging allows the selection of patients who may benefit from CEA.

Sarcoma of the abdominal aorta involving marginal arteries of the small intestine: a case report.

Primary sarcoma of the aorta is extremely rare. In the past, the disease was commonly diagnosed on autopsy. However, now it is possible to make a diagnosis preoperatively using various imaging studies such as computed tomographic scanning and magnetic resonance imaging. The authors have experienced one case of abdominal aortic sarcoma in a patient who complained of the symptoms of typical intestinal angina. We diagnosed an aortic sarcoma preoperatively but failed to resect the tumor on thoracolaparotomy because of the tumor extension to marginal arteries of the whole small intestine. We recommend preoperative laparoscopy for evaluation of tumor extension to marginal arteries of the small intestine in a patient having aortic sarcoma and intestinal angina if the patient is considered to be a surgical candidate.

Experience of an abdominal aortic aneurysm in a patient having crossed ectopia with fusion anomaly of the kidney.

We report a case of surgically treated abdominal aortic aneurysm (AAA) in a patient having crossed ectopia with fusion anomaly of the kidney. One artery from the abdominal aorta above the aneurysm supplies the right kidney while three renal arteries (two from the aneurysm itself and one from the left common iliac artery) supply the crossed ectopic kidney. Preoperative imaging to define the arterial and collecting systems along with a detailed planning of the operation is essential to prevent ischemic renal injury as well as ureteral injury during AAA repair.

Large vessel injury following operation for a herniated lumbar disc.

Major vascular injury can occur during an operation for a herniated lumbar disc due to the intimate anatomical relation between the lumbar vertebrae and major vessels. Although occurrence is infrequent, it is associated with high morbidity and mortality. Diagnosis is suspected when early signs of retroperitoneal hemorrhage appear, but may often be delayed for weeks or years. Formation of a pseudoaneurysm or an arteriovenous (A-V) fistula may be of gradual onset and produce initially only a few symptoms. We report here six cases of large vessel injury, which consisted of active bleeding from an injured common iliac artery, or a pseudoaneurysm of the common iliac artery with or without an A-V fistula that occurred following an operation for a herniated lumbar disc and was successfully treated by radiologic intervention and/or surgery. Angiography with the intention of intervention is considered the first step of treatment for a large vessel injury following an operation for a herniated lumbar disc at the level between fourth and fifth lumbar or between fifth lumbar and first sacral intervertebral space.

Ruptured abdominal aortic aneurysms due to Salmonella, not of typhi species.

Ruptured aortic aneurysms due to Salmonella not of typhi species are rare and associated with high morbidity and mortality. We present three patients with Salmonella-infected ruptured aortic aneurysms successfully treated with an in situ prosthetic bypass graft. One patient had a saccular aneurysm at the infrarenal aorta and two patients had fusiform aneurysms at the aortic bifurcation. All the patients were treated with wide debridement of the infected aortic tissue followed by in situ graft replacement and long-term systemic antibiotic therapy. The method of revascularization, in situ bypass or extraanatomic bypass, remains controversial. On the basis of our clinical experience and recent literature focusing on more than 10 cases, in situ bypass reconstruction may be a feasible surgical technique for Salmonella-infected ruptured aortic aneurysm.

Pararenal leiomyosarcoma of the inferior vena cava.

A complete surgical resection is the only proven therapeutic modality that prolongs the survival in patients with leiomyosarcoma of the inferior vena cava (IVC). Reconstruction of the IVC is not always necessary but is often required to facilitate venous drainage of the kidney for the tumors at the pararenal area of the IVC. Controversy exists in postoperative adjuvant therapy. Recently, we experienced four cases of pararenal leiomyosarcoma of the IVC, of which treatment consisted of a complete resection of the tumor, ringed polytetrafluoroethylene (PTFE) graft interposition, and bilateral renal vein reconstructions in all patients. Postoperative radiation therapy was instituted in 3 of 4 patients. One patient who did not receive the postoperative radiation therapy was treated with adjuvant chemotherapy. The kidneys were preserved in all patients and no deep vein thrombosis (DVT) or venous insufficiency of the lower extremity veins developed. Distant metastasis to the lung was noted in one patient at 18 months after surgery, who was not received the postoperative radiation therapy but chemotherapy. In conclusion, a complete resection of the tumor, IVC reconstruction, and bilateral renal vein reconstruction followed by adjuvant radiation therapy is recommended for the treatment of pararenal leiomyosarcoma of the IVC.

Inflammatory pseudotumor of the carotid artery: radiologic findings.

The radiologic appearance of inflammatory pseudotumor in the two cases presented was a fusiform mass surrounding the carotid bifurcation. The masses showed an avascular mass with focal narrowing of the carotid bifurcation on carotid arteriography, a homogeneous hypoechoic mass on ultrasound, less enhancement on contrast-enhanced computed tomography, and relatively intense enhancement on magnetic resonance imaging.

Mesenteric Buerger's disease.

A young male patient with a history of heavy smoking and low-extremity Buerger's disease was operated on because of small bowel infarction. The postoperative histopathological diagnosis was mesenteric involvement of Buerger's disease. Mesenteric Buerger's disease is extremely rare, the early diagnosis is difficult, and the prognosis is poor. Considering the difficulty in diagnosis and the poor prognosis, patients with Buerger's disease presenting with gastrointestinal manifestations should be carefully evaluated, and early surgical intervention is recommended.

Mesenchymal chondrosarcoma originating from the femoral vein.

Mesenchymal chondrosarcoma is a rare variant of chondrosarcomas characterized by a bimorphic pattern with areas of the undifferentiated malignant small cells and well differentiated cartilaginous islands.(1) It occurs most commonly in the bone but can also occur in the extraskeletal soft tissues, the brain, and the meninges. This type of tumor has also been described in the eyelids, parapharyngeal space, mediastinum, and the kidney.(1-5) An origin from the large vessels has not been reported in the medical literature. The authors report a case of mesenchymal chondrosarcoma originating from the femoral vein in a 28-year-old female patient, treated by the wide-margin resection.

Can carotid endarterectomy improve metabolic status in patients with asymptomatic internal carotid artery flow lesion? Studies with localized in vivo proton magnetic resonance spectroscopy.

PURPOSE: Carotid endarterectomy (CEA) has proven to be effective in the prevention of stroke in patients with significant internal carotid artery (ICA) stenosis. However, whether increased cerebral blood flow after CEA improves the cerebral metabolism in patients with asymptomatic ICA flow lesions is unknown. Localized in vivo proton magnetic resonance spectroscopy ((1)H-MRS) has been used to measure the metabolic status of the human brain in a totally noninvasive manner. The aim of this study was to investigate the cerebral metabolism after CEA in patients with asymptomatic ICA flow lesions and no visible infarction on magnetic resonance imaging (MRI). MATERIALS AND METHODS: We designed a prospective study to investigate the metabolic changes in the middle cerebral artery (MCA) territory with (1)H-MRS for 18 consecutive patients with asymptomatic severe stenosis of the ICA (>70% reduction in diameter) and for 16 healthy control subjects. The 18 patients with ICA flow lesion and no visible infarction on MRI who underwent CEA were evaluated before and 7 days after surgery (CEA group). The 16 control subjects had never had a cerebral event, and brain MRI and carotid duplex scan study results were normal in all (control group). RESULTS: Preoperative ICA volume flow was severely decreased to less than 150 mL/min in all 18 patients, in comparison with our laboratory normal value of matched age group of 250 to 300 mL/min. After CEA, ICA volume flow was increased to greater than 300 mL/min in all patients (P =.00). For patients in the CEA group, preoperative N-acetylaspartate/creatine and choline/creatine ratios in the MCA territory were slightly decreased compared with the healthy subjects in the control group but were within normal limits. However, the postoperative values of N-acetylaspartate/creatine and choline/creatine ratios in the ipsilateral MCA territory were significantly increased as compared with the preoperative values (P <.05). In the contralateral side, the postoperative increase of choline/creatine ratio and the decrease of myo-inositol/creatine ratio were statistically significant as compared with the preoperative values (P <.05). CONCLUSION: CEA seems to improve the cerebral metabolic status in patients with asymptomatic ICA flow lesions and no visible infarction on MRI.

Sonographic appearance of a free-floating atheromatous plaque in a patient with acute stroke.

We report the case of a neurologically unstable acute stroke patient in whom carotid sonography identified the need for emergency carotid surgery because of an increased risk of distal embolization from a free-floating atheromatous plaque. Longitudinal and transverse sonograms revealed a 6-mm free-floating thrombus loosely attached to the wall of the left common carotid artery. During emergency surgery, a free-floating atheromatous plaque was seen at this location, along with extensive atheromatous lesions. The diseased segment of the common carotid artery was resected and repaired with an interposition graft, and the patient recovered uneventfully, with no recurrence of stroke.