Carotid endarterectomy: general anaesthesia with remifentanyl conscious sedation vs loco-regional anaesthesia.

AIM: To retrospectively evaluate and compare the safety and efficacy of general anesthesia with remifentanyl conscious sedation (RCS) vs local-regional anesthesia (LA) for carotid endarterectomy (CEA). METHODS: From January 2004 to January 2008, 390 CEA performed in 325 patients (M/F 214/111, age 75 +/- 7) were collected in 2 groups: RCS group included 275 consecutive CEA in 230 patients carried out under remifentanyl conscious sedation with stopping of the remifentanyl infusion at the carotid clamping time to evaluate the clinical neurological status; LA group was composed of 115 consecutive CEA in 95 patients, performed under local-regional anesthesia. We evaluated complications, postoperative morbidity and mortality, need for shunt insertion and compared the results by means of Student's t-test and chi2 analysis. P value <0.05 (T=2.28) was considered significant. RESULTS: The 30 days mortality was 0.35% in the RCS group and 0% for LA group (P=NS). The 30 days stroke rates were 0.3% and 0% respectively (P=NS). TIA/RIND rates were 0.3% for RCS group and 1.7% for LA group (P=0.47); shunt usage was 20% for RCS group and 17% for LA group (P=0.26). We found higher postoperative nausea/vomiting in the RCS group (3.9% vs 0.8%, P<0.05). CONCLUSIONS: General anesthesia with remifentanyl conscious sedation seems to be a safe technique, allowing monitoring of the neurological status, cerebral protection during arterial clamping, better control of the airway and a good compliance to both the surgeon and the patient. A randomized control trial is needed to prove RCS to be effective as LA.

[Hypoglossal artery and carotid endarterectomy. Case report]. / Persistenza dell'arteria ipoglossa ed endoarteriectomia carotidea. Case report

The persistence of hypoglossal artery is a rare malformation. Association of carotid stenosis with persistent hypoglossal artery can lead to cerebral posterior symptoms due to ischemia intolerance. The Authors report a case of unexpected intraoperative detection of this anomaly in a patient with high grade stenosis of the right internal carotid artery. Right carotid endarterectomy was performed, and no shunt was used. The postoperative course was normal. The literature was reviewed.

The role of cross-over bypass graft in the treatment of acute ischaemia of the lower limb.

INTRODUCTION: The Authors reports their experience with the use of femoro-femoral cross-over bypass graft in the management of acute lower limb ischaemia. PATIENTS AND METHODS: Fourteen femoro-femoral bypass graft were performed for acute lower limb ischaemia due to unilateral thrombosis of iliac and femoral artery in 8 cases, late unilateral occlusion of a branch of previous aortobifemoral bypass in 3 cases, acute thrombosis of abdominal aorta in 2 cases and in the last one for an injury of common iliac artery during urological procedure. In all the cases the operations were carried out under local anaesthesia and a subcutaneous bypass with 'C' shape type configuration with 8 mm Dacron prosthesis were performed. The first and second year primary and secondary patency rates and limb salvage rates were evaluated. RESULTS: One and two year patency rate was 83.3 (10/12) and 70% (7/10) respectively. Secondary patency rate and limb salvage rate was 91.6% (11/12) and 80% (8/10) respectively. A tight amputation had to performed in 3 failed reconstruction (3/12, 25%). Two patient died within 30 days after surgery from acute myocardial infarct. In 1 case infection occurred and re-do femorofemoral cross-over bypass with saphenous vein was carried out (8.3%). CONCLUSIONS: Cross-over bypass is an attractive technique, especially in case of acute ischemia because of its simplicity, low morbidity and mortality, and good long term results.

An unexpected anatomical variant of the femoral artery in a patient with acute lower limb ischemia: case report.

We report a case of acute embolic ischemia of the right lower limb in a patient with unexpected intraoperative anatomic variant of femoral artery. In this anomaly, the deep femoral artery arises from the external iliac artery, 2 cm above the inguinal ligament, runs with a parallel course with the superficial femoral artery, and placed between the branches of femoral nerve. In consideration of the difficulty to achieve extensive and optimal control of the external iliac artery with the femoral approach, a retrograde embolectomy of the iliac artery by two separate arteriotomies on the deep and superficial femoral arteries were successfully performed. The literature reviewed about this anomalies. In these unexpected intraoperative cases a ductile and ingenious approach seems to be mandatory to perform a safe operation with low systemic impact.

High-risk patients for carotid endarterectomy: turned down cases are rare.

AIM: The increasing use of carotid artery stenting (CAS) is justified in patients at high-risk for carotid endarterectomy (CEA). The aim of this study was to evaluate the hypothesis that the high-risk patients can be submitted to CEA without increased risk of stroke and death. METHODS: A retrospective analysis of 625 consecutive CEA in 545 patients (M/F 386/159, age 75 ± 7) performed from January 2005 to December 2010 was carried out. Definite anatomical and pathophysiological high-risk cohort of patients (N.=173, 31.7%) was evaluated and compared to normal risk patients. Univariate, multivariate and Kaplan-Meier analysis were used as appropriate. Poisson regression (Pr) model was used to study all univariate criteria in combination. A P value <0.05 was statistically significant. RESULTS: The overall 30-day stroke and death rate was 0.96%. No difference between high-risk vs. normal patient cohort regarding physiological and anatomical risk factors was detected. Univariate and multivariate analysis did not show statistical difference for 30-day outcome in any of the variables examined. No increase of risk in cases of presence of more risk factors resulted to the Pr analysis. The 24-month survival rate was worse in high-risk patients, especially when more physiologic risk as chronic renal failure, severe pulmonary and cardiac diseases and age over eighty were present. CONCLUSION: CEA is a safe procedure in patients at high-risk carotid artery disease. A better classification of high-risk patients may be necessary because trials criteria appear ineffective to define the patients at real high surgical risk. Long-term outcome was affected by the presence of severe comorbidities.