The impact of the multidisciplinary tumor board (MDTB) on the management of pancreatic diseases in a tertiary referral center.

BACKGROUND: The implementation of multidisciplinary tumor board (MDTB) meetings significantly ameliorated the management of oncological diseases. However, few evidences are currently present on their impact on pancreatic cancer (PC) management. The aim of this study was to evaluate the impact of the MDTB on PC diagnosis, resectability and tumor response to oncological treatment compared with indications before discussion. PATIENTS AND METHODS: All patients with a suspected or proven diagnosis of PC presented at the MDTB from 2017 to 2019 were included in the study. Changes of diagnosis, resectability and tumor response to oncological/radiation treatment between pre- and post-MDTB discussion were analyzed. RESULTS: A total of 438 cases were included in the study: 249 (56.8%) were presented as new diagnoses, 148 (33.8%) for resectability assessment and 41 (9.4%) for tumor response evaluation to oncological treatment. MDTB discussion led to a change in diagnosis in 54/249 cases (21.7%), with a consequent treatment strategy variation in 36 cases (14.5%). Change in resectability was documented in 44/148 cases (29.7%), with the highest discrepancy for borderline lesions. The treatment strategy was thus modified in 27 patients (18.2%). The MDTB brought a modification in the tumor response assessment in 6/41 cases (14.6%), with a consequent protocol modification in four (9.8%) cases. CONCLUSIONS: MDTB discussion significantly impacts on PC management, especially in high-volume centers, with consistent variations in terms of diagnosis, resectability and tumor response assessment compared with indications before discussion.

Atypical presentation of acute pancreatitis: a single center case-match analysis of clinical outcomes.

OBJECTIVE: Acute pancreatitis (AP) may present an aspecific clinical picture without abdominal symptoms (atypical AP). We compared clinical outcomes between typical and atypical AP. PATIENTS AND METHODS: Thirty out of 1163 patients (2.6%) presented an atypical AP. Demographic, clinical data, laboratory and radiological findings, management type, length of hospital stay (LOS) and mortality rate were retrospectively reviewed. A case match analysis 2:1 was performed. The final groups comprised 50 typical APs (TAP group) and 25 atypical APs (AAP group). RESULTS: The AAP patients presented fever (36%), syncope (32%) and dyspnea (16%) as the most frequent symptoms. Laboratory values showed similarity between the two groups. We noted a comparable edematous AP rate in both groups (p=0.36). Ten (20%) TAP and 3 (12%) AAP patients needed ERCP, respectively (p=0.38). Cholecystectomy was similarly performed in both cohorts (p=0.81). One TAP patient underwent a percutaneous drainage and subsequent surgical necrosectomy compared to none in the AAP cohort (p=0.47). LOS and mortality rate were comparable (p=0.76 and 0.3, respectively). CONCLUSIONS: Similar outcomes have been reached in the two groups. Routine evaluation of the serum amylase values fundamentally contributed to early diagnosis and appropriate treatment.

Colonoscopy quality assessment and accuracy: analysis of the influencing factors and surgical sequelae on 216 colonoscopies.

OBJECTIVE: Colonoscopy is recognized as the primary screening test for colorectal cancer. However, its inaccuracy in identifying the exact tumor localization is still high. As a consequence, repeated colonoscopies and changes in the surgical management have been reported. This study aims to evaluate the quality of 216 colonoscopies, to define colonoscopy accuracy and to investigate the surgical sequelae of an incorrect localization. PATIENTS AND METHODS: A retrospective analysis of 216 colonoscopies has been conducted. Colonoscopy quality was assessed on: quality of bowel preparation, completeness of the examination, video and/or photographic documentation, and reported the distance of the lesion from the anal verge. Colonoscopy accuracy was evaluated in terms of correspondence between the endoscopic and intra-operative tumor localization. RESULTS: Bowel preparation adequateness was reported in 121 out of 216 (56%) colonoscopies, with an adequate grade in 68.6% of cases. A complete colonoscopy was accomplished in 86.9% of cases with photo documentation in only 59 colonoscopies (27.3%). The lesion distance from the anal verge was documented only in 93 out of 216 colonoscopies. Of the 157 lesions described at the colonoscopy, 117 matched with the intra-operative localization (accuracy 74.5%). Fifteen of the 40 incorrectly localized lesions (37.5%) required changes in the surgical management. At multivariate analysis, the colonoscopy completeness was the only influencing factor on the concordance between endoscopic and intra-operative localization. CONCLUSIONS: Colonoscopy demonstrated adequate accuracy in localizing lesions. However, the incorrect tumor localization leads to a high rate of changes in surgical management. Increase in.

The hyperthermic intraoperative intraperitoneal chemotherapy in the treatment of advanced abdominopelvic cancer. Personal experience on 103 procedures during a seventeen year period in a single Italian center.

OBJECTIVE: Integration of different therapeutic strategies in cancer surgery in the last years has led from treating primary lesions to the surgical treatment of metastases. The purpose of this paper is to report a single Italian center experience of treatment of peritoneal carcinosis of the abdominopelvic malignancies. PATIENTS AND METHODS: 103 HIPEC procedures were performed in 17 years on 94 selected patients affected by abdominopelvic cancer. The PCI score was calculated at laparotomy. The CC score was calculated before doing HIPEC. HIPEC was carried out according to the Coliseum technique. RESULTS: The surgical cytoreduction allowed 89 patients to be subjected to HIPEC treatment with a CC score 0; 9 patients with a CC 1; 3 patients with a CC 2 and 2 patients with a CC 3. In 22 patients postoperative complications were recorded. No operative mortality occurred. The median follow-up of 53 months shows a rate of survival equivalent to 49 %, with a relapse in 46 patients, 29 of them reached exitus. CONCLUSIONS: The surgical resection alone for patients affected by advanced cancer with peritoneal carcinomatosis cannot be considered a sufficient treatment any longer and HIPEC would help to prolong survival in these patients.

Complications related to hyperthermia during hypertermic intraoperative intraperitoneal chemiotherapy (HIPEC) treatment. Do they exist?

BACKGROUND AND OBJECTIVES: Hyperthermia, either alone or in combination with anticancer drugs, is becoming more and more a clinical reality for the treatment of far advanced gastrointestinal cancers, acting as a cytotoxic agent at a temperature between 40-42.5 degrees C. Although hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) is demonstrated to have some benefit in selected patients with peritoneal seeding, there are not enough data on the risk of damage of normal tissue that increases as the temperature rises, with possible serious and, sometimes, lethal complications. MATERIALS AND METHODS: We searched on medline words like "intraoperative intraperitoneal chemohyperthermia and morbidity", focusing our attention on studies (published since 1990) which reported morbidity as bowel obstruction, bowel perforation or anastomic leak, during intraoperative intraoperitoneal chemotherapy in hyperthermia (HIPEC). RESULTS: Heat acts increasing cancer cell killing after exposure to ionizing radiation, inhibiting repairing processes of radiation-induced DNA lesions (radiosensitization), and also sensitizing cancer cells to chemotherapeutic drugs, particularly to alkylating agents (chemosensitization). The peritoneal carcinomatosis (a frequent evolution of advanced digestive cancer) represents one of the main indication to hypertermic treatment. In the last fifteen years, in fact, different methods were developed for the surgery treatment (peritonectomy) and for loco-regional chemotherapic treatment of the carcinomatosis (intraperitoneal intra/post-operative iper/normothermic chemotherapy) to act directly on neoplastic seeding. We found, as result of different studies, 9 articles, written about perforation after HIPEC. CONCLUSION: The aim of the present study is to present the review of the literature in terms of peri-operative complications related to the hyperthermia during intraoperative chemohyperthermia procedure.

Cannulation of the right axillary artery for extracorporeal circulation in aortic surgery through a left thoracotomy: a novel technique.

Extensive aortic disease, such as atherosclerosis with aneurysms or dissections that involve the ascending aorta, can complicate the choice of a cannulation site for cardiopulmonary bypass. Antegrade selective cerebral perfusion through the right axillary artery has proved to be a reliable and valuable method for cerebral protection in aortic surgery. In the supine position it is an artery straightforward to access, it is more complicated in the right thoracoabdominal position. We present an innovative method of axillary artery cannulation for patients requiring surgery through a left thoracotomy.

Role of oxidized regenerated cellulose in preventing infections at the surgical site: prospective, randomized study in 98 patients affected by a dirty wound.

AIM: The aim of this study was to evaluate whether oxidized regenerated cellulose (ORC), applied to "dirty" surgical wounds, is able to reduce the microbial load and, consequently, the infection rate as compared to conventional local wound treatment. METHODS: The study included 98 patients who underwent intestinal recanalization procedures between December 2003 and December 2008, with the stoma as the surgical site. Authors considered several risk factors for SSI. The patients were divided into two groups. In group A (50 patients), the surgical wound, previous site of the stoma, was packed with ORC, whereas in group B (48 patients) gauze soaked in iodine was used. Microbial contamination was evaluated with three swabs (in subcutaneous tissue and the dermis), in the operating room before wound packing and on the 2nd and 3rd postoperative day (before suturing the skin). RESULTS: There were no cases of wound dehiscence and no clinically evident superficial or deep surgical site infections in either group. Analysis of all data revealed that there was no or reduced bacterial contamination in the second and third swab in 33 patients (66%) of Group A versus 12 patients (25%) of Group B. CONCLUSION: Although it is necessary to consider all factors which can have an influence on SSI and use all the means shown to be effective to reduce the risk of SSI, there is a rationale for using ORC to prevent this kind of infection, especially in patients who undergo "dirty" surgery.

Spatial patterns of fishing effort off San Diego: implications for zonal management and ecosystem function.

The essence of ecosystem-based management is managing human practices to conserve the ecosystem. Ecologists focus on understanding the ecosystem, but there are fundamental information gaps including patterns of human exploitation. In particular, the spatial distribution of fishing effort must be known at the scales needed for ecologically relevant management. Fishing is a primary impact on coastal ecosystems, yet catch distribution at scales relevant to habitats and processes are not well known for many fisheries. Here we utilized photographic time series, logbook records, and angler surveys to estimate the intensity and spatial pattern of commercial and recreational fishing. Effort was clearly aggregated for most types of fishing, the motivating factors for effort distribution varied among areas, and effort was coupled or uncoupled to habitat depending on the area and type of fishing. We estimated that approximately 60% and approximately 74% of private recreational and recreational charter vessel fishing effort, respectively, were concentrated into two small areas that also included approximately 78% of commercial sea urchin effort. Exploitation and effort were considerably greater in one kelp forest, which has important implications for patterns of kelp persistence, productivity, and ecosystem function. Areas subject to the greatest recreational fishing pressure appeared to have lower diversity. Our results indicate that fine-scale patterns of fishing effort and exploitation have profound consequences for ecosystem functioning and biodiversity. 'Ecosystem-based management of nearshore ecosystems depends on an understanding of the fine-scale patterns of exploitation.

A study of pullout forces of the components of modular multi-manufacturer hybrid endografts used for aortic aneurysm repair.

OBJECTIVES: Aorto-iliac angulations may be challenging for modular stent-graft systems (SGSs) from a single manufacturer. This study aims to define the pullout forces (POFs) of SGSs derived from the same (non-hybrid) or different manufacturers (hybrid). METHODS: The POFs were tested in a vertical position in air and 5% albumin. We studied the POFs between legs from Anaconda (Vascutek), Excluder (Gore), Talent (Medtronic) and Zenith (Cook) with the contralateral limb of bifurcated aortic bodies from Zenith (12 mm), Anaconda and Excluder. RESULTS: For non-hybrid SGSs, the POFs decreased in the following order: Anaconda (11.2+/-0.6N), Talent (6.25+/-0.6N), Zenith (3.5+/-0.01 N) and Excluder (2.5+/-0.5 N). The Zenith body with the Anaconda limb (15 mm) registered the greatest POF (13.083+/-0.821 N); the Zenith and Excluder bodies combined with the Excluder limb (16 mm) registered the weakest POFs (2.397+/-0.22 N and 2.500+/-0.479 N, respectively). The Zenith body combined with the Excluder limb (16 mm) had a POF similar to the Zenith non-hybrid; combined with Talent 14 mm and Anaconda limb exhibited POFs greater than the Zenith non-hybrid system. For the limb-to-limb POFs, the greatest was registered for the Anaconda limb, 13 mm within a 12-mm extension for 40-mm overlaps (23.06+/-0.480 N); the weakest POFs were recorded for the Excluder limbs at 30-mm overlaps (1.09+/-0.167 N and 1.11+/-0.250 N). CONCLUSIONS: The hybrid SGSs performed as well as or better than the non-hybrid systems, and should be considered for clinical testing in patients whose unique anatomy warrants the flexibility that the use of hybrids provides.

Endovascular repair of popliteal artery aneurysms with Anaconda limbs: technique and early results.

OBJECTIVES: The objective is to report the feasibility and technique of treating popliteal artery aneurysms (PAA) with a stent made of nitinol rings externally supported by thin polyester (Anaconda limbs). BACKGROUND: PAA are the most common peripheral aneurysms. The main limitations of stents used in these settings are: short lengths, longitudinal and horizontal compliance mismatch; graft failure from angulation and movement at the joint level; and dislodgment. METHODS: This is a prospective multicenter cohort study of consecutive symptomatic and asymptomatic PAA treated in tertiary vascular centers. Outcomes included patency of the stent and postoperative time-to-independent-ambulation and to-climb-a-flight-of-stairs. RESULTS: Fourteen PAA were treated in 12 men, age 72 +/- 3 years. The median ASA classification was 2.5. The length of artery covered was 147 +/- 41 mm. The PAA diameter was 31 +/- 5 mm, 6 were symptomatic. One stent was used in 6 aneurysms, two in 7, and three in 1. The average stent diameter was 10 +/- 1 mm. The length of the proximal neck was 24 +/- 6 mm with a diameter of 9.8 +/- 1.9, and length of the distal neck 23 +/- 3 mm with a diameter of 8.7 +/- 1.2 mm. In 6 aneurysms, the stent crossed the knee joint. There was no mortality, and one stent occluded (primary patency 93% at 6 +/- 3 months). The median hospital stay was 1.7 days, time to independent ambulation was 3 hr and the time to climbing a flight of stairs was 1 day. CONCLUSIONS: The use of Anaconda limbs for endovascular repair of PAA is feasible and safe.

Anaesthesia for surgical repair of thoracoabdominal aortic aneurysms.

Thoracoabdominal aortic aneurysms are one of the most challenging surgeries for the anaesthetists. They account for 10% of aneurysms of the aorta. A thorough understanding of pathophysiology, anatomy, and surgical interventions including extracorporeal circulation are essential to achieve a good outcome. Crawford classified them accorting to their their extent and location in 4 types. Patients with Crawford type II aneurysms are at greatest risk for paraplegia and renal failure from ischemia to the spinal cord and kidneys during cross-clamp. Neurologic and renal complications are significant for the most extensive forms of aneurysms. Mortality has improved over time as a consequence of either increased surgical experience, the adoption of a protocolized strategy for repair, or secular improvements in anaesthetic and intensive care treatment. Long-term survival after elective TAAA repair is excellent.

Endoscopic thoracic sympathectomy for hyperhidrosis: Technique and results.

OUTLINE: We review the clinical features of hyperhidrosis and the range of treatments used for this condition. We describe in detail the technique of endoscopic sympathectomy. We summarize studies that have reported results of endoscopic sympathectomy. We present new data highlighting the difference in quality of life between patients with hyperhidrosis and controls.

Effect of endoscopic sympathectomy for hyperhidrosis on quality of life using the illness intrusiveness rating scale.

AIM: The objective of this study was to assess the impact of bilateral endoscopic thoracic sympathectomy (ETS) on the quality of life of patients with hyperhidrosis of the upper limbs. METHODS: This is a prospective, multicentre cohort study. Patients were studied before surgery and early (within 2 months) and late (4 months or more) after surgery. The primary outcome was the total score of the illness intrusiveness rating scale (IIRS), which on a sevenpoint Likert scale assesses the impact of their disease on each of 13 domains of quality of life. At each visit participants completed the IIRS, 10 additional questions to assess severity of disease, a global severity item, questions about employment, companionship and smoking, and a single item question reflecting the results of surgery. RESULTS: From 1994 to 2003, 22 patients underwent surgery. Early postoperative data were available in 12, and late postoperative data in 19 patients. Preoperative IIRS score was high 57 +/- 14. After surgery a statistically significant improvement was noted for the IIRS score, the severity questions, and the global severity score at both early and late postoperative time points. Preoperatively, 47% of patients were in a stable relationship, 30% were currently smoking, and 73% were employed; postoperatively, the responses were 58%, 16%, and 90%, respectively (P = NS). One patient (5%) developed a postoperative pneumothorax and one (5%) compensatory hyperhidrosis. There were no other local complications and none developed Horner's syndrome. CONCLUSIONS: Using a reliable and valid quality of life instrument we have shown that surgery is effective for the treatment of hyperhidrosis. Given the possibility of complications, we believe that surgery should be reserved for patients with the most severe form of this condition. The severity can be defined by the use of the IIRS and the 10 severity questions, which we have designed.

Local anesthesia for endovascular abdominal aortic aneurysm repair.

OBJECTIVES: This study reports the results of a prospective continuous cohort of patients treated for endovascular aneurysm repair (EVAR) with a unified anesthetic strategy based on the use of local anesthesia (LA) in all patients, while reserving regional (RA) or general anesthesia (GA) only for those with predefined individually or surgically specific indications. METHODS: All patients treated by EVAR for an elective aortic abdominal aneurysm (AAA) between April 1998 and December 2003 were included. The strategy of treatment generated three cohorts of patients (LA, RA, or GA). Primary outcome included all-cause mortality, nonfatal cardiac morbidity, respiratory complications, and renal failure. Secondary outcome measures included conversion to general anesthesia, use of analgesics, and time-related outcomes (operating time, length of stay in intensive care unit and hospital, time required to resume oral intake, and time to ambulation). RESULTS: A total of 239 patients underwent EVAR: 170 LA, 31 RA, and 38 GA. Overall mortality was one patient (0.4%). LA was associated with a lower incidence of complications compared with GA (P < .001). In the LA group, two patients had to be converted to GA, one because of a dissection and one because of anxiety. In 13% of the patients in the LA group, additional intravenous sedation or analgesia was required. Operating time and length of stay in intensive care was shorter in the LA and RA groups than in the GA group (P < .001). Length of stay in hospital and time to ambulation and regular diet was shorter in the LA group compared with the RA and GA groups (P < .001). CONCLUSIONS: A strategy based on the preferential use of LA for EVAR restricting RA or GA only to those with predefined contraindications is feasible and appears to be well tolerated.

Frequency and outcome of re-interventions after endovascular repair for abdominal aortic aneurysm: a prospective cohort study.

PURPOSE: To describe frequency, type, and outcome of re-intervention after endovascular aortic aneurysm repair (EVAR). METHODS: Between September 1996 and December 2003, 308 patients were treated, with data collected prospectively. No patient was lost to follow up, but two were excluded (one primary conversion, and one post-operative death). Vanguard, Talent, Excluder, Zenith, and Quantum devices were used. Follow up required a CT scan before discharge. Initially, a CT scan was done at each follow up. Subsequently, we used duplex ultrasound and abdominal X-ray, with CT scan used selectively. RESULTS: Mean follow-up was 36+/-22 months. Re-interventions were required in 47 (15%) patients, 31 (66%) elective and 16 (34%) emergency cases. In 32 patients, the primary re-intervention was successful; in 15 patients an additional 13 secondary and four tertiary re-interventions were required. A total of 72 adjunctive manoeuvres were performed: 49 endovascular (68%) and 23 open (32%). The success of endovascular re-interventions was 80%. The success of open re-interventions was 96%. Open conversions were required in nine patients (3%). There was no mortality. CONCLUSION: EVAR was associated with a low burden of re-interventions, with only 15% patients requiring re-intervention. Our long-term follow up, without regular CT, was simple and effective.

Kommerell's diverticulum and right-sided aortic arch: a cohort study and review of the literature.

We report four consecutive cases of Kommerell's aneurysm of an aberrant left subclavian artery in patients with a right-sided aortic arch and the results of a systematic review of the literature. In our cohort of patients, three had an aneurysm limited to the origin of the aberrant subclavian artery, causing dysphagia and cough, and one had an aneurysm involving also the distal arch and the entire descending thoracic aorta, causing compression of the right main-stem bronchus. A left subclavian-to-carotid transposition was performed in association with the intrathoracic procedure, and a right thoracotomy was used in all patients. One of the patients underwent surgery with deep hypothermia and circulatory arrest, and the others with the adjunct of a left-heart bypass. The repair was accomplished with an interposition graft in two patients and with endoaneurysmorrhaphy in the others. The postoperative course was complicated by respiratory failure and prolonged ventilation in one patient, and one patient died because of severe pulmonary emboli. The survivors are alive and well at a follow-up of 1 to 3 years. Only 32 cases of right-sided aortic arch with an aneurysm of the aberrant subclavian artery have been reported: 12 were associated with aortic dissection, and 2 presented with rupture. Surgical repair was accomplished in 29 patients. A number of operative strategies were described: right thoracotomy, bilateral thoracotomy, left thoracotomy with sternotomy, sternotomy with right thoracotomy, and left thoracotomy. In only 12 cases was the subclavian artery reconstructed. We believe that a right thoracotomy provides good exposure and avoids the morbidity associated with bilateral thoracotomy or sternotomy and thoracotomy. We feel that a left subclavian-to-carotid transposition completed before the thoracic approach revascularizes the subclavian distribution without increasing the complexity of the intrathoracic procedure.

Medical management versus investigate-and-operate strategy in asymptomatic carotid stenosis: a decision analysis.

OBJECTIVE: The objective of this study was to determine whether asymptomatic patients at high risk for carotid stenosis should undergo screening Duplex ultrasound (DUS), with a view to offering carotid endarterectomy (CE) to those patients with significant stenosis. METHOD: We constructed a decision analysis model to evaluate the impact of an investigate-and-operate strategy, compared with medical management alone, on the risk of stroke in patients at high risk for carotid stenosis. We studied five investigate-and-operate models addressing different thresholds for intervention (in terms of degree of stenosis) and the effects of using or not using preoperative angiography. RESULTS: For each of the strategies, under the base case conditions (30% prevalence of >50% carotid stenosis), the number needed to screen (NNS) and the number needed to treat (NNT) are high (213 to 769 and 13 to 144, respectively). The strategy of angiography for >50% stenosis and CE for >70% stenosis was harmful. Other strategies were unattractive because of unacceptably high NNT (no angiography, CE >50% stenosis), or because of unacceptably high NNS (angiography >70%, CE >70% stenosis), or both (angiography >50% stenosis, CE >50% stenosis; no angiography, CE > 70% stenosis). At 50% prevalence of >50% stenosis, two models produced more reasonable combinations of NNT and NNS: 11 and 370, respectively, for angiography >70%, CE >70% stenosis; and 27 and 286, respectively, for no angiography, CE >70% stenosis. Within the range of clinically plausible values for sensitivity and specificity of DUS, results were not greatly influenced by the measurement properties of DUS. However, angiographic or surgical rates of stroke or death were critical to the outcomes with any strategy. Only 3% to 12% of strokes in the studied population were prevented. CONCLUSIONS: Screening is acceptable only in populations at >40% to 50% risk for >50% carotid stenosis, who are surgical candidates, and who would undergo surgery if recommended. Acceptable investigate-and-operate strategies include angiography for DUS stenosis >70%, with CE if this level of stenosis is confirmed, and CE for DUS-measured stenosis >70% without angiographic confirmation. Surgery for asymptomatic carotid stenosis is unlikely to have a large impact upon the burden of stroke in society.

Prevalence and progression of internal carotid artery stenosis in patients with peripheral arterial occlusive disease.

OBJECTIVE: The purpose of this study was to determine the prevalence of significant carotid stenosis, to identify risk factors increasing this prevalence, and to determine the risk of progression of stenosis, in patients with peripheral arterial occlusive disease who are neurologically asymptomatic. STUDY DESIGN: Consecutive patients who underwent evaluation in a vascular laboratory for peripheral arterial occlusive disease, who had no recent neurologic symptoms, were investigated. RESULTS: From July 1999 to December 2000, 620 patients underwent duplex scanning on one occasion, and 417 on two occasions. The average age was 72 +/- 10 years, and 61% were men. An occluded internal carotid artery was found in 4.8% of patients. The prevalence of a carotid stenosis >50% was 33% on the initial evaluation. Age of more than 70 years (P =.007), diabetes mellitus (P =.042), history of stroke (P =.011), and ankle/brachial index of less than 0.8 (P =.0006), were independently associated with carotid stenosis >50%. The odds ratio associated with each of these risk factors was similar. The prevalence of carotid stenosis >50% was 16%, 21%, 38%, 47%, and 44% for patients with no, one, two, three, and four risk factors, respectively. The highest prevalence of carotid stenosis >50% was identified in patients with ankle/brachial indices of less than 0.4 (59%). During the follow-up period, no patient had a cerebrovascular event. In 15% of carotid arteries, progression from one class of stenosis to a more severe class was observed, and 6.5% of patients progressed from a lower degree to 50% to 99% stenosis. No differences in progression of disease were identified when the variables of age, diabetes, previous stroke, and ankle/brachial index of less than 0.8 were studied or when patients with zero to two of these putative risk factors were compared with patients with three or four. CONCLUSION: Screening for carotid stenosis in asymptomatic patients with peripheral vascular disease is justifiable, but not mandatory, when two or more risk factors are present or when the ankle/brachial index is less than 0.4. Rates of progression to clinically significant stenosis are low and do not justify reevaluation every 6 months. Further research to identify the optimal interval for reevaluation is needed.

Retrojugular approach for carotid endarterectomy: a prospective cohort study.

The purpose of this study was the examination of the feasibility of the retrojugular approach for carotid endarterectomy and the investigation of its safety and effectiveness. A consecutive prospective cohort of 43 patients who underwent carotid endarterectomy with the retrojugular approach was compared with a retrospective cohort of 43 patients who underwent surgery with the standard antejugular technique. Age, sex, comorbidity, diagnostic investigations, and indications for surgery were comparable in both groups. In the retrojugular group, a carotid shunt was used in 18 patients (42%) and a patch closure in 15 patients (35%), and in the antejugular group, a carotid shunt was used in 43 patients (100%) and a patch closure in 20 patients (47%). There were no perioperative deaths, strokes, nerve injuries, or 30-day postoperative neurologic events. Wound hematomas were equally distributed in both groups (5%). Transient hoarseness was present in two patients in the antejugular group. The mean operative time was 72 +/- 15 minutes for the retrojugular technique and 100 +/- 27 for the antejugular technique (P <.0001). The hospital stay was 2 +/- 1 days in both groups. In conclusion, the retrojugular approach appears to be safe and the operative time may be shorter than with the antejugular approach.