Concomitant unruptured intracranial aneurysms and carotid artery stenosis: an institutional review of patients undergoing carotid revascularization.

BACKGROUND: The incidence of concomitant carotid artery stenosis and unruptured intracranial aneurysms (UIAs) has been reported at between 0.5% and 5%. In these patients, treatment strategies must balance the risk of ischemic stroke with the risk of aneurysmal rupture. Several studies have addressed the natural course of UIAs in the setting of carotid revascularization; however, the final recommendations are not uniform. The purpose of this study was to review our institutional experience with concomitant UIAs and carotid artery stenosis. METHODS: We performed a retrospective review of all patients with carotid artery stenosis who underwent carotid artery endarterectomy (CEA) or carotid artery stenting (CAS) at our institution between 2003 and 2010. Only patients with preoperative imaging demonstrating intracranial circulation were included. Charts were reviewed for patients' demographic and clinical data, duration of follow-up, and aneurysm size and location. Patients were stratified into 2 groups: carotid artery stenosis with unruptured intracranial aneurysm (CS/UIA) and carotid artery stenosis without intracranial aneurysm (CS). RESULTS: Three hundred five patients met the inclusion criteria and had a total of 316 carotid procedures (CAS or CEA) performed. Eleven patients were found to have UIAs (3.61%) prior to carotid revascularization. Male and female prevalence was 2.59% and 5.26% (P = 0.22), respectively. Patients' demographics did not differ significantly between the 2 groups. The average aneurysm size was 3.25 ± 2.13 mm, and the most common location was the cavernous segment of the internal carotid artery. No patient in the study had aneurysm rupture, and the mean follow-up time was 26.5 months for the CS/UIA group. CONCLUSIONS: Concomitant carotid artery stenosis and UIAs is a rare entity. Carotid revascularization does not appear to increase the risk of rupture for small aneurysms (<10 mm) in the midterm. Although not statistically significant, there was a higher incidence of aneurysms found in females in our patient population.

Endovascular repair of contained abdominal aortic aneurysm rupture with aortocaval fistula presenting with high-output heart failure.

Aortocava fistula is a rare condition ranging from 0.22% to 6% of all ruptured aortic aneurysms. Recognition and diagnosis of this entity can often be difficult and requires heightened clinical suspicion to ensure that prompt surgical management leads to a favorable outcome. We herein describe the diagnosis and the technical points of successful endovascular management of aortocaval fistula in the setting of a ruptured abdominal aortic aneurysm.

Operative intervention for complete pancreatic transection in children sustaining blunt abdominal trauma: revisiting an organ salvage technique.

Complete pancreatic transection (CPT) in children is managed commonly with distal pancreatectomy (DP). Alternatively, Roux-en-Y distal pancreaticojejunostomy (RYPJ) may be performed to preserve pancreatic tissue. The purpose of this study was to review our experience using either procedure in the management of children sustaining CPT after blunt abdominal trauma. We retrospectively reviewed the records of all children admitted to our institution during the last 15 years who were confirmed at operation to have CPT after blunt mechanisms. Summary statistics of demographic data were performed to describe children receiving either RYPJ or DP. CPT occurred in 28 children: 15 had DP, 10 had RYPJ, and three had cystogastrostomy. RYPJ children, compared with DP, were younger (7.5 vs. 12.3 years, P = 0.039) and sustained more grade IV pancreatic injuries (70% vs. 14%, P = 0.01). DP patients were 5.63 times more likely to tolerate full enteral feeds (P = 0.009). Nevertheless, when controlling for age, injury severity score, and pancreatic injury grade, procedure type did not statistically affect total and postoperative lengths of stay and postoperative complications. In the operative management algorithm of children sustaining CPT, DP may afford an earlier return to full enteral feeds. RYPJ seems otherwise equivalent to DP and preserves significant pancreatic glandular tissue and the spleen.

Retroperitoneal repair of abdominal aortic aneurysms offers postoperative benefits to male patients in the Veterans Affairs Health System.

BACKGROUND: Transperitoneal (TP) and retroperitoneal (RP) approaches have equal efficacy in elective open abdominal aortic aneurysm (AAA) repair. The effect of open operative approach on patient-specific outcomes after AAA repair was tested. METHODS: Consecutive patients undergoing open AAA repair at the Veterans Affairs Tennessee Valley Healthcare System between January 2000 and August 2008 were retrospectively reviewed. Analysis was performed to examine the effects of demographic and clinical covariates on postoperative outcomes. RESULTS: A total of 106 patients were identified: 54 with TP approach and 52 with RP approach. Demographics and preoperative comorbidities were equivalent (p > or = 0.10), with the exception of chronic obstructive pulmonary disease which was more prevalent in the TP group (61 vs. 40%). Operative times were longer in the TP group (4.6 vs. 3.5 hours; p < 0.01); however, significantly more TP patients had reconstruction with a bifurcated graft (72 vs. 2%; p < 0.01). Postoperative nasogastric tube decompression times were shorter in the RP group (1 vs. 3 days; p < 0.01), and RP approach led to a quicker return to preoperative diet (4 vs. 6 days; p = 0.05). Patients undergoing RP repair developed fewer incisional hernias (2 vs. 15%; p = 0.03). CONCLUSION: RP approach to AAA repair offers patients faster return of bowel function and is associated with fewer incisional hernias.