Clamping ischemia, threshold ischemia and delayed insertion of the shunt during carotid endarterectomy with patch.

BACKGROUND: Shunt insertion during carotid endarterectomy (CEA) is mandatory to avoid neurological damage due to clamping ischemia; however shunt insertion before plaque removal has many inconveniences (atheroembolism, intimal dissection, difficulty of endarterectomy). The aim of this study is to verify whether and how long shunt insertion may be safely delayed to permit plaque removal and ensure cerebral perfusion during the further time consuming manoeuvres of CEA (peeling, patch angioplasty). METHODS: From July 1990 to February 1996 383 patients underwent 411 CEAs under general anesthesia with EEG continuous monitoring and PTFE patch angioplasty. A Pruitt-Inahara shunt was routinely inserted only after atherosclerotic plaque removal. In 316 CEAs (76.9%) without EEG signs of cerebral ischemia (Group A) the mean clamping time was 10 min +/-4.8 (range 2-37 min). In 95 CEAs (23.1%) with EEG signs of cerebral ischemia (Group B) it was 7.3 min +/-3.5 (range 3-20 min). All patients had normal EEG signals after delayed shunt insertion and reperfusion (mean 21 min, range 5-45 min). RESULTS: In the short term results (within 30 days) there was a relevant neurological complication rate of 0.96% (2 major stroke and 2 lethal stroke); at awakening we observed 5 RINDs (1.21% of total) 1 in a patient of Group A (0.31%) and the other 4 in patients of Group B (4.21%). CONCLUSIONS: These data confirm the rationale of a delayed insertion of the shunt: actually the cerebral parenchyma may tolerate under general anesthesia a sufferance due to carotid clamping, EEG detectable, without neurological deficits for at least 7.3 min. This time is sufficient to perform the most difficult steps of CEA (plaque removal, distal intima checking) allowing shunt insertion in a clean operatory field, without inconveniences. Finally the shunt allows complementary time consuming steps, as patch angioplasty, with improvement of both short- and long-term results.

Surgical treatment of atherosclerotic lesions of subclavian artery: carotid-subclavian bypass versus subclavian-carotid transposition.

BACKGROUND: The aim of this retrospective study is to analyze the short and long term results of two different surgical treatments in patients with subclavian lesions: common carotid-subclavian artery bypass (CSB) versus transposition of subclavian artery on the common carotid artery (SCT). METHODS: From 1981 until 1995, 40 non randomized patients with symptomatic subclavian steal underwent 20 CSBs and 20 SCTs. Risk factor rates were equally balanced in the two groups. Surgery was carried out routinely under general anesthesia, with electroencephalic continuous monitoring. Patency of revascularization was assessed by physical examination, brachial blood pressure determinations, ultrasound sonography and angiography whenever recurrence of symptoms developed or when the function of repair was in doubt. Patients were examined every year. In Spring 1996 (range 9-189 mos, average 7 years) a general clinical-instrumental follow-up was performed. RESULTS: In the short term (<30 days) mortality was 5%: one death (5%) for pulmonary embolism in a patient with CSB and one for myocardial infarction in a patient with SCT. The early thrombosis rate was 5% (1 CSB and 1 common carotid artery distal to a patent SCT). During follow-up 10 patients (25%) died and 6 were lost. The six-year actuarial patency rate was 100% for SCT and 66% for CSB. Moreover there were 3 thromboses of the vertebral artery homolateral to patent CSBs. CONCLUSIONS: In conclusions SCT should be considered the surgical technical choice for the treatment of proximal subclavian artery lesions.

[Sarcoid febrile hepatic granulomatosis. Description of a case associated with initial liver cirrhosis]. / Granulomastosi epatica febbrile sarcoidotica. Descrizione di un caso con associata cirrosi iniziale del fegato.

A case of febrile hepatic granulomatosis was examined and the many aetiologies to be considered in the differential diagnosis of the condition evaluated. This is not a separate disease but a specific histological peculiarity of the liver. The case in question was diagnosed as hepatic granulomatosis originating in sarcoidosis. This diagnosis requires, it is though, the presence of characteristic granulomas in the liver biopsy sample but more important in the Kweim reaction or preferably in more specific tissue biopsies (spleen, lymph nodes, mesentery). In the present case the histologically revealed initial cirrhosis may be purely concomitant though certain authorities believe that sarcoidotic hepatic granulomas may develop into cirrhosis.

[Kinetic analysis of bromosulfophthalein in alcoholic liver disease]. / L'analisi della cinetica della bromosulfonftaleina (BSF) nell danno epatico da alcool.

The Authors evaluated BSF kinetics in 100 subjects affected by hepatic disorders of different degrees of progression produced by chronic alcoholic abuse in comparison with 22 healthy subjects. CBSF and Ke, model independent parameters, were found to discriminate better among groups; model dependent parameters showed, above all, a progressive reduction of fractional hepatic uptake (a) as liver damage worsens and a typical pattern of cirrhosis, especially of decompensated form, characterized by a high fractional hepatic plasma reflux (b). BSF kinetics also showed the early cholestatic effect produced by alcohol. Even if kinetic analysis proved useful, from a clinical point of view, the Authors feel that the simple 45 min BSF retention test and still better the one for Ki (uncorrected initial slope of the disappearance curve) are sufficient to detect and discriminate among the different stages of liver alcoholic diseases.