Alterations of baroreflex sensitivity after carotid endarterectomy according to the preoperative carotid plaque echogenicity.

OBJECTIVE: Baroreflex sensitivity is lower in patients with echogenic carotid plaques compared with patients with echolucent ones. The purpose of our study was to compare the baroreflex function after carotid endarterectomy (CEA) between patients with different plaque echogenicity. METHOD: Spontaneous baroreflex sensitivity (sBRS), heart rate, and systolic and diastolic arterial pressure were calculated in 51 patients with a severe carotid stenosis (70%-99%) 24 hours before CEA, as well as 24 and 48 hours after CEA. Carotid plaque echogenicity was graded from 1 to 4 according to Gray-Weale classification, after duplex examination, and the patients were divided into two groups: the echolucent (grade 1 or 2) and the echogenic (grade 3 or 4). RESULTS: The postoperative mean systolic arterial pressure values in all 51 patients at 24 and 48 hours (143.2 and 135.5 mm Hg, respectively) were found to be significantly increased compared with the preoperative value (132.5 mm Hg; x2=32, P<.001). Mean sBRS value, in all patients, was significantly reduced postoperatively to 2.1 ms mm Hg(-1), from the mean preoperative value, 3.7 ms mm Hg(-1), independently of plaque echogenicity. Twenty patients (39%) were included in the echolucent group and 31 (61%) in the echogenic. The two groups had significant differences in two parameters: the rate of diabetes mellitus and the rate of symptomatic plaques. After adjusting the two groups for these differences, we found that the preoperative difference in sBRS between the two groups (F[1,51]=11, P<.003) was eliminated 24 and 48 hours after CEA (F[1,51]=.007, P<.9 and F[1,51]=.4, P<.5 for 24 and 48 hours, respectively). CONCLUSIONS: Before the removal of carotid atheroma, baroreflex sensitivity, which is a well established cardiovascular risk factor, seems to be affected by carotid plaque echogenicity. However, CEA has as a result a similar baroreflex response in all patients, regardless of plaque echogenicity, implying no association of plaque morphology and postoperative baroreflex sensitivity.

The role of carotid plaque echogenicity in baroreflex sensitivity.

OBJECTIVE: The baroreflex sensitivity is impaired in patients with carotid atherosclerosis. The purpose of our study was to assess the impact of carotid plaque echogenicity on the baroreflex function in patients with significant carotid atherosclerosis, who have not undergone carotid surgery. METHOD: Spontaneous baroreflex sensitivity (sBRS) was estimated in 45 patients with at least a severe carotid stenosis (70%-99%). sBRS calculation was performed noninvasively, with the spontaneous sequence method, based on indirectly estimated central blood pressures from radial recordings. This method failed in three patients due to poor-quality recordings, and eventually 42 patients were evaluated. After carotid duplex examination, carotid plaque echogenicity was graded from 1 to 4 according to Gray-Weale classification and the patients were divided into two groups: the echolucent group (grades 1 and 2) and the echogenic group (grades 3 and 4). RESULTS: Sixteen patients (38%) and 26 patients (62%) were included in the echolucent and echogenic group, respectively. Diabetes mellitus was observed more frequently among echolucent plaques (χ(2) = 8.0; P < .004), while those plaques were also more commonly symptomatic compared with echogenic atheromas (χ(2) = 8.5; P < .003). Systolic arterial pressure, diastolic arterial pressure, and heart rate were similar in the two groups. Nevertheless, the mean value of baroreflex sensitivity was found to be significantly lower in the echogenic group (2.96 ms/mm Hg) compared with the echolucent one (5.0 ms/mm Hg), (F [1, 42] = 10.1; P < .003). CONCLUSIONS: These findings suggest that echogenic plaques are associated with reduced baroreflex function compared with echolucent ones. Further investigation is warranted to define whether such an sBRS impairment could be responsible for cardiovascular morbidity associated with echogenic plaques.

A hybrid approach using a composite endovascular and open graft procedure for a symptomatic common femoral aneurysm extending well above the inguinal ligament.

We report the use of a unique hybrid technique to treat a patient with a painful aneurysm extending both above and below the inguinal ligament. The patient was at high surgical risk, and endovascular treatment was not possible due to the absence of an appropriate vascular access site. Under local anesthesia, this aneurysm was treated using both a stent graft and a traditional Dacron graft for the iliac and femoral portions, respectively. Simultaneously, a popliteal aneurysm was treated endovascularly through a jump graft, which was used to bypass a short occlusion at the origin of the superficial femoral artery. Hybrid techniques can be an alternative approach in high-risk patients where endovascular procedures cannot be applied.

Surgical management of extracranial internal carotid aneurysms by cervical approach.

BACKGROUND: Extracranial internal carotid artery aneurysms (EICAA) are rare vascular problems with a great potential for lethal thromboembolic episodes. METHODS: From 1994 to 2004, nine patients with EICAA, seven men and two women, were surgically treated for 10 aneurysms in our department. Aneurysm led to hemispheric symptoms in six cases (two hemispheric strokes and four hemispheric transient ischaemic attacks). The cause was fibrodysplasia in two cases, atherosclerosis in four cases, trauma in two cases and spontaneous dissection in two cases. All aneurysms were treated surgically by the cervical approach using shunting. Extended cervical approach was necessary in four patients with high-lying aneurysms. Nine aneurysms were totally resected and successful revascularization was carried out. Open aneurysmorrhaphy with vein patch angioplasty was carried out in one case of a saccular aneurysm. RESULTS: There were no perioperative deaths or transient ischaemic attacks or strokes. Four patients developed cranial nerve deficits: one had hoarsness, two had partial facial paralysis (patients with extended cervical approach) and one had tongue deviation. These neurological symptoms were observed in large aneurysms (>4.5 cm) and disappeared within 14 months. No neurological complication was observed in a follow up that ranged from 6 months to 10 years. CONCLUSIONS: Surgical repair of EICAA, especially with total resection and arterial reconstruction, is strongly recommended. Extended cervical approach has many technical difficulties but can allow treatment of high-lying aneurysms.

Minilaparotomy abdominal aortic aneurysm repair in the era of minimally invasive vascular surgery: preliminary results.

BACKGROUND: This study aimed to evaluate the early post-operative clinical impact of minimal incision aortic surgery (MIAS) for infrarenal abdominal aortic aneurysm (AAA) repair in comparison with the standard open repair. METHODS: A case-control study was conducted. Patients of groups A (19 patients) and B (18 patients) were treated with the MIAS technique and the standard open method, respectively. RESULTS: There were significant differences between the two groups in fluid resuscitation during the operation. Post-operatively, there were significant differences between groups A and B in the time until starting liquid diet (2 +/- 0.74 versus 3.55 +/- 0.85 post-operative days (PD), respectively; P < 0.05), the time until starting the solid diet (3.05 +/- 0.77 versus 5.11 +/- 0.75 PD, respectively; P < 0.05), the time of ambulation (2 +/- 0.74 versus 3.4 +/- 0.98 PD, respectively; P < 0.05) and in the hospital length of stay (4 +/- 0.81 versus 9.7 +/- 2.66 days, respectively; P < 0.05). CONCLUSIONS: The MIAS technique, for repair of infrarenal aortic aneurysms, is a safe and feasible procedure that combines the early advantages of endovascular repair with the long-term advantages of the traditional open repair.

Fungal infection of aortoiliac endograft: a case report and review of the literature.

Infection of aortoiliac endografts is, to date, a rare complication of endovascular surgery. Staphylococcus species are the most common responsible pathogens, just as in cases with infected grafts after open aortic surgery. We report a case of a 65-year-old man with a history of diabetes mellitus and bladder cancer who developed stent-graft infection 3 years after endovascular treatment for a 5.6 cm abdominal aortic aneurysm. The diagnosis of endograft infection was established radiologically by computed tomographic scans. After intravenous administration of antibiotics and fluids to improve his clinical condition, the patient underwent surgical excision of the infected prosthesis and a bifurcated rifampicin-impregnated Dacron graft was placed in situ. Cultures from the purulent fluid around the aorta and from the endograft revealed development of Candida albicans. To our knowledge, this is the first case of an infected endograft due to a fungus. The patient died from septic shock 3 days postoperatively in the intensive care unit.