RESUMEN
OBJECTIVES: Extracranial carotid artery aneurysms (ECAA) are rare and consequentially understudied; yet multiple management strategies for ECAA have been pursued. The goal of this study was to compare rates of stroke and cardiac events following surgical or endovascular management of ECAA utilizing the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP). METHODS: The ACS-NSQIP database was queried for patients with both selected procedure codes and diagnostic codes specific for ECAA. 139 patients, 0.2% of carotid procedures, were located within ACS-NSQIP from 2013-2017. RESULTS: The endovascular group (n = 19) had a higher proportion of emergency procedures than the open surgical group (n = 120). Post-operative strokes in the endovascular group (n = 3, 15.8%) were not significantly higher than the open surgical group (n = 5, 4.2%; P = 0.078). One cardiac event (0.7%) in the cohort occurred in the surgical group. DISCUSSION: This study provides insight into trends in national management of ECAA. Post-operative stroke rates trended higher with endovascular approaches, perhaps due to traumatic presentation as this group had a higher proportion of emergency procedures. Additionally, this study suggests patients with ECAA may have less cardiac burden than their peers with carotid stenosis.
Asunto(s)
Aneurisma , Enfermedades de las Arterias Carótidas , Procedimientos Endovasculares , Accidente Cerebrovascular , Cirujanos , Aneurisma/cirugía , Arterias Carótidas/cirugía , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/cirugía , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Humanos , Complicaciones Posoperatorias/etiología , Mejoramiento de la Calidad , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Carotid stump pressure (CSP) is frequently measured to determine the need for shunt use during carotid endarterectomy (CEA). We hypothesized that the preoperative carotid duplex examination correlates with preoperative symptoms and intraoperative CSP. METHODS: Patients undergoing CEA over a 7-year period were identified from our vascular registry. CEA was performed with selective shunting on the basis of intraoperative CSP <30 mm Hg regardless of symptoms or contralateral internal carotid artery (ICA) stenosis. The preoperative duplex was categorized by ipsilateral and contralateral ICA diameter-reduction stenosis (<15%, 15-45%, 45-70%, 70-99% [severe] and occluded), and the direction of vertebral artery flow. The relationships among preoperative duplex findings, symptom status, and CSP were evaluated using unpaired t-test and Chi-square analysis. RESULTS: A total of 303 CEAs were performed. Stump pressures were documented in 284 patients, which comprised the study population. Asymptomatic severe stenosis was the indication for CEA in 179 cases (59.1%). Symptomatic patients (Sx) had significantly lower stump pressures than asymptomatic (ASx) patients (40.72 ± 16.27 vs. 45.8 ± 17.64 mm Hg, p = 0.0167). Fifty-seven patients (19%) had contralateral severe ICA stenosis or occlusion. Contralateral ICA stenosis or occlusion had significantly lower CSP than those with lesser degrees of stenosis (39.24 ± 15 vs. 44.82 ± 17.62 mm Hg, p = 0.0267). Contralateral ICA severe stenosis or occlusion correlated with lower CSP in Sx patients (32.05 ± 8.24 vs. 42.92 ± 16.95 mm Hg, p = 0.038) but not in ASx patients (43.2 ± 16 vs. 46.29 ± 17.5 mm Hg, p = 0.39). CSP was <30 mm Hg in 63% of Sx patients and 24% of ASx patients (p = 0.012). Overall shunt usage was 84/2,842 (9.5%). Perioperative stroke and death rate was 2.7%. Perioperative stroke did not correlate with the presence of contralateral occlusion, or severity of contralateral stenosis. CONCLUSIONS: Symptomatic patients undergoing CEA have lower stump pressures than ASx patients overall and also in the presence of contralateral disease. The incidence of perioperative stroke was not predicted by severity of contralateral disease. A strategy of selective shunting seems appropriate even in Sx patients with contralateral severe stenosis or occlusion. Although a high-risk cohort for perioperative neurologic events exists and may include those with symptomatic disease and contralateral severe stenosis or occlusion, further study is warranted to define the patients who will clinically benefit from shunt placement.
Asunto(s)
Presión Sanguínea , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/cirugía , Endarterectomía Carotidea , Ultrasonografía Doppler Dúplex , Enfermedades Asintomáticas , Determinación de la Presión Sanguínea , California , Estenosis Carotídea/mortalidad , Estenosis Carotídea/fisiopatología , Distribución de Chi-Cuadrado , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Femenino , Humanos , Masculino , Valor Predictivo de las Pruebas , Cuidados Preoperatorios , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/fisiopatología , Accidente Cerebrovascular/prevención & control , Resultado del TratamientoRESUMEN
A 78-year-old woman presented to our trauma center with an initial, erroneous history of a ground-level fall. Further investigation revealed that the patient had been assaulted by her husband immediately prior to presentation. The initial abdominal examination was benign, and the patient was hemodynamically stable. The patient was found to have a large subdural hematoma (SDH). Following open evacuation of the SDH, the patient developed ongoing hemodynamic instability. Further evaluation with computed tomography of the abdomen and pelvis uncovered the diagnosis of a 6 cm abdominal aortic aneurysm (AAA) with a large retroperitoneal hematoma. The patient underwent emergent repair of the ruptured AAA. There were no other significant intra-abdominal injuries, and the patient had an uneventful recovery. This case highlights the need for thorough evaluation of the trauma patient and recognition of the possibility of coexistent AAA in the elderly trauma patient. We believe that this is the first reported case of a ruptured AAA following nonaccidental blunt abdominal trauma.
Asunto(s)
Traumatismos Abdominales/complicaciones , Aneurisma de la Aorta Abdominal/complicaciones , Rotura de la Aorta/etiología , Maltrato Conyugal , Heridas no Penetrantes/complicaciones , Traumatismos Abdominales/diagnóstico por imagen , Traumatismos Abdominales/fisiopatología , Anciano , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/fisiopatología , Rotura de la Aorta/cirugía , Aortografía/métodos , Femenino , Hemodinámica , Humanos , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/fisiopatologíaRESUMEN
Chronic use of ergot alkaloids has been recognized as a rare cause of lower extremity ischemia. Most patients with ergot toxicity present with symptoms of lower extremity claudication. Herein we present a woman with bilateral lower extremity rest pain and a history of chronic ergot use for migraine headaches. Arteriography demonstrated extensive pruning of the distal arterial tree along with bilateral external iliac artery dissections - a finding that is not often associated with young, normotensive patients with chronic ergot toxicity. This patient was treated with endovascular stenting of the dissections along with cessation of ergot. Her symptoms improved markedly, and follow-up arteriography 6 weeks later demonstrated resolution of the iliac dissections along with restoration of nearly normal lower extremity runoff vessels. Discontinuation of ergot-containing products and cessation of tobacco and caffeine use is the cornerstone of therapy in chronic ergot toxicity. The association of ergot toxicity and iliac dissection has not been previously described. Endovascular or surgical interventions may be considered in patients with ergot toxicity for specific indications or those whose symptoms progress despite conservative management.