Asymptomatic carotid stenosis and unrelated operations: should we be more aggressive?

BACKGROUND: Carotid lesions will often remain asymptomatic during the perioperative period, so prophylactic carotid endarterectomy (CEA) has not been advocated before other operations. The purpose of this study was to characterize the clinical manifestations of new neurologic symptoms occurring in patients with previously asymptomatic carotid occlusive disease who have undergone recent operations. STUDY DESIGN: We performed a retrospective review of patients developing neurologic symptoms attributable to carotid occlusive disease after unrelated operations. RESULTS: Eleven patients (mean age 68+/-6.4 years, 8 men, 3 women) developed new neurologic symptoms from previously asymptomatic extracranial carotid stenoses after 11 unrelated procedures. Neurologic events included hemispheric stroke (n = 10) and amaurosis fugax (n = 1). Two intraoperative strokes occurred (one mastectomy, one prostatectomy). Other events occurred a mean of 5.8+/-5 (range 1 to 16) days after aortic surgery (n = 2), infrainguinal bypass (n = 3), contralateral CEA for symptomatic disease (n = 2), incisional herniorrhaphy (n = 1), and prostate surgery (n = 1). Responsible internal carotid artery lesions were all stenoses greater than 80%; seven were clearly greater than 90%. Those suffering intraoperative stroke or stroke within 24 hours of operation (n = 3) were not receiving antithrombotic therapy. All other events (n = 8) occurred despite the use ofantiplatelet or anticoagulant agents. Four underwent emergent CEA. Four had elective CEA performed after reaching a neurological recovery plateau. CONCLUSIONS: Critical, asymptomatic internal carotid artery stenoses may cause neurologic symptoms after unrelated surgical procedures.

Intraoral tumor of Chievitz in a child.

Juxtaoral organs known as organs of Chievitz are intramuscular embryonic structures found close to the angle of the mandible near the insertion of the pterygomandibular raphae. They are considered of neuroepithelial origin with no known function. We describe the first tumor of the organ of Chievitz which presented intraorally in a child. Immunohistochemically, the Chievitz nests showed positive reaction for vimentin, cytokeratins, and epithelial membrane antigen and ultrastructurally demonstrated cytoplasmic processes and intermediate filament bundles. These observations, together with light microscopic features, suggest that the epithelial nests of the organ of Chievitz are meningothelial rather than neuroepithelial.

Creation of a neo-aortoiliac system from lower extremity deep and superficial veins.

OBJECTIVE: This study evaluated the morbidity, mortality, and intermediate term follow-up of patients undergoing replacement of their aortoiliac-femoral systems with lower extremity deep and superficial veins. SUMMARY BACKGROUND DATA: The most commonly used treatment for aortic prosthetic infection is ectopic bypass and removal of the prosthesis. The overall mortality rate with this approach is approximately 20%, with an amputation rate of 10% to 14%. Other limitations include thrombosis of the ectopic bypass leading to limb loss, reinfection of the ectopic bypass, and aortic stump blowout. Dissatisfaction with this approach has led the authors to develop the following. METHODS: A neo-aortoiliac system (NAIS) was fashioned from lower extremity deep veins (DV), greater saphenous veins (GSV), or both in patients with infected aortobifemoral prosthesis (n = 17) and other complex aortic problems (n = 3). Removal of infected prosthetic material, harvest of vein, and creation of NAIS was performed as a single-staged procedure. RESULTS: The in-hospital mortality and amputation rates were 10% each. The mean (+/- standard deviation [SD]) operative time was 6.5 +/- 1.8 hours and the blood transfusion requirement was 4 +/- 3 units. Four patients experienced postoperative gastrointestinal complications with peritonitis and sepsis; NAIS vein graft resisted infection and remained intact. The mean follow-up time was 22.5 +/- 16 months. NAISs constructed from GSVs were prone to the development of focal stenoses requiring intervention or diffuse neointimal hyperplasia leading to occlusion. In contrast, all NAISs from larger caliber DVs have remained widely patent. The failure rate of GSV NAISs was 64%, compared to 0% for DV NAISs (p = 0.006). Despite the high failure rate in patients with GSV NAISs, none has required amputation. In patients who had DVs harvested for NAIS reconstruction, limb edema and other signs of venous hypertension have been minimal. CONCLUSION: NAIS reconstruction from lower extremity veins is a successful option in patients with extensive aortic prosthetic infection and other complex aortic problems.

Splenic infarction after splenorenal arterial bypass.

Because of the spleen's extensive collateral circulation, the risk of splenic infarction after splenorenal arterial bypass (SRB) has been considered negligible. We report four patients in whom splenic infarctions developed after SRB. Splenic infarction developed in one patient at the time of SRB, and symptoms of splenic abscess (fever, abdominal pain, and leukocytosis) that proved to be splenic infarctions at laparotomy developed in three patients 2 to 16 days after the operation. Factors possibly contributing to splenic infarction could be determined for three patients. These included interruption of collateral vessels, intraoperative hypotension and disseminated intravascular coagulation, and distal splenic artery ligation. Normal Doppler flow was detected in the splenic parenchyma during test occlusions of the splenic artery before SRB in three patients. Our experience suggests that existing collateral circulation may not always sustain splenic viability after SRB, and some patients may not be suitable candidates for this operation. Factors such as adequacy of inflow, splenic artery length, and risk of perioperative hypotension should be considered.

Is routine CT scanning necessary in the preoperative evaluation of patients undergoing carotid endarterectomy?

To evaluate the usefulness of CT scanning before carotid endarterectomy, a prospective study was performed on 469 consecutive patients considered for carotid endarterectomy during a 5-year period. All patients underwent carotid duplex scanning and CT scanning before carotid arteriography. Two hundred thirty-seven patients (51%) had transient ischemic attacks, 109 (23%) had a prior stroke, and 122 (26%) were asymptomatic. Results of the CT scan were abnormal in 68 (62%) of the 109 patients with stroke. Fifty-one of the 360 patients (14%) without a clinical history of stroke had an abnormal CT scan outcome. Of patients with a stroke documented by CT scanning, 27 had lacunar infarcts, and 92 had cortical infarcts; these findings did not change surgical management in any patient. CT scanning did not reveal any unsuspected infarcts or tumors. Two hundred thirty carotid endarterectomies were performed on 206 patients. Forty-seven patients (23%) in the operative group had abnormal CT scan findings, but the scan did not influence operative decisions or timing in any case. Seventy-two patients (27%) in the nonoperative group had abnormal CT scan results, but CT scan findings did not exclude any patient from arteriography or surgery. Three perioperative strokes (1.3%) occurred. CT scan findings did not correlate with postoperative neurologic complications. Cost of CT scanning was one-half million dollars in our study alone. Routine CT scanning is unnecessary before carotid endarterectomy and is not cost-effective.

Asymptomatic celiac and superior mesenteric artery stenoses are more prevalent among patients with unsuspected renal artery stenoses.

The prevalence of unsuspected renal artery stenosis among patients with peripheral vascular disease has been reported to be as high as 40%, but the prevalence of asymptomatic celiac and superior mesenteric artery stenoses in these patients is not known. The biplane aortograms of 205 male patients who were military veterans and had aneurysms or occlusive disease were independently reviewed, and medical records were studied to determine associated coronary disease, risk factors, and patient outcome. Fifty-six patients (27%) had a 50% or greater stenosis in the celiac or superior mesenteric artery, and seven patients (3.4%) had significant stenoses in both mesenteric arteries. Patients with celiac or superior mesenteric artery stenoses were older (p = 0.002) and had a higher prevalence of hypertension (p = 0.029) than those without significant mesenteric stenoses. Fifty of the 205 patients had significant renal artery stenoses, and 20 had advanced (greater than 75% diameter loss) renal stenoses. Ten of the 20 patients (50%) with advanced renal stenoses had a concomitant celiac artery stenosis, compared to 40 of the 185 patients (22%) who did not have advanced renal stenoses (p = 0.011). In the present study asymptomatic celiac or superior mesenteric artery stenoses were common among male veterans evaluated for peripheral vascular disease, but the prevalence of significant stenoses in both the celiac and superior mesenteric arteries was low. The prevalence of significant celiac stenosis was higher in patients with advanced (greater than 75%) renal artery stenoses who might be considered for prophylactic renal revascularization. Lateral aortography with evaluation of the celiac artery is always appropriate in these patients.

Alternate Wenckebach conduction through the right bundle branch.

This case report describes a patient with chronic chagasic myocarditis who presented with a unique tachycardia-dependent or phase 3 aberrant ventricular conduction. The electrocardiogram showed sinus tachycardia with sequences of alternate and progressive right bundle branch block, that is, Wenckebach periods of alternate beats. We postulated the existence of functional longitudinal dissociation in atrioventricular conduction axis, responsible for the alternant normal and Wenckebach beats.

[Dysplastic pulmonary valve and pulmonary valvuloplasty. A case report]. / Valva pulmonar displásica e valvuloplastia pulmonar. Relato de caso.

The authors report a case of dysplastic pulmonary valve which undergone unsuccessfully balloon dilation. Clinical, non-invasive and angiographic diagnostic criteria are discussed.

Intermediate to late term results of Mustard's procedure for complete transposition of the great arteries with an intact ventricular septum.

Overall survival after Mustard's operation was assessed in 130 patients with complete transposition of the great arteries and an intact ventricular septum who were operated on at the Brompton Hospital in the 12 year period from January 1974 to December 1985. Actuarial analysis showed a survival at five years of 79.1% (25 deaths in 130 patients). Half the deaths occurred within a month of operation and half up to five years later. Operation under the age of three months carried a greater mortality (six deaths in 11 patients). Statistical analysis showed that these survival figures were consistent throughout the series and did not alter with the year of operation. In the light of recent trends in treatment of this lesion, it is concluded that for neonates an arterial switch procedure is now likely to carry the best chance of long term success. For the patient who presents after the age of three months, however, there may still be a place for the Mustard procedure.

Conjoined twins, right atrial isomerism, and sequential segmental analysis.

Three cases of twins conjoined across the chest were examined. In one set, one twin showed right atrial isomerism and the other showed the usual atrial arrangement. The other two sets showed the usual atrial arrangement in both twins. The associated cardiac anomalies were diverse, ranging from atrioventricular septal defects to absent atrioventricular connections. Sequential segmental analysis was used successfully in each case to classify the complex cardiac anomalies. The first step was the recognition of the atrial arrangement. This was easily achieved despite the complexity of the intracardiac morphology.

Coronary arteries in complete transposition: the significance of the sinus node artery.

Hearts from 29 children with complete transposition were examined postmortem to analyze the pattern of the coronary arteries and the origin of the sinus node artery. Four patterns of origin and distribution of the coronary arteries were found. In all, the coronary arteries arose from one or both of the facing sinuses, which were termed sinus 1 and sinus 2. The patterns were left coronary artery from sinus 1 and right coronary artery from sinus 2; anterior descending artery from sinus 1 and right coronary artery and circumflex artery from sinus 2; left coronary and right coronary from sinus 2; and circumflex artery from sinus 2 and right coronary artery from sinus 1. This study highlights the patterns of the coronary arteries in complete transposition and categorizes the variability using a simple classification. It also emphasizes the surgical significance of variations in distribution of the sinus node artery.

Absent aortic valve leaflets.

A newborn with difficulty in feeding and with tachypnoea was admitted to the hospital. During the following days his condition deteriorated and he died at the age of 8 days. At autopsy we found an unusual association of hypoplastic left heart syndrome and absence of the aortic leaflets.

Heart block and atrioventricular septal defect.

The cardiac conduction system was examined in 2 hearts which had repair of atrioventricular septal defect. The first was from a child known to have had a prolonged P-R interval and the second was from a girl who developed complete heart block before submission to surgery. The atrioventricular conduction axis was histologically discontinuous in the first case, but preserved and surrounded by hemorrhage in the second case. This study draws attention to the inherent vulnerability of the cardiac conduction axis which must also be recognized before surgical intervention.

Morphological observations following "anatomical correction" for abnormal ventriculo-arterial connection.

Seven postmortem hearts from children who underwent anatomical correction for complete transposition (6 cases) and double outlet right ventricle (1 case) were examined in order to gain a better understanding of the pathological morphology in relation to the surgical procedure. Associated malformations were ventricular septal defect in all, patient arterial duct in 4 and aortic coarctation in 3. In all hearts the coronary arteries arose from the facing aortic sinuses and were relocated into the facing sinuses of the pulmonary trunk with minimal displacement. The orifices of the coronary arteries were reduced in caliber in one case. The sinus node artery arising from a lateral atrial artery was transected in one case. The Lecompte maneuver was performed in 4 cases and tension on the pulmonary trunk was observed in 2 cases. Potential right ventricular outflow tract obstruction was evident in all (including one in which it had been resected during surgery). The substrates of obstruction were anomalous parietal insertion of the outlet septum (2 cases), anomalous muscular trabeculation (1 case), rightward displacement of the outlet septum (1 case), parietal insertion of the outlet septum (1 case) and restrictive muscular infundibulum (1 case--DORV). In addition, all the complete transposition cases had hypertrophy of the parietal right ventricular wall. This study highlighted the anatomical features which could lead to poor results in the anatomical correction procedure. Some of the potential problems could be avoided by minor modifications to the technique.

Meltzer-Lyon test simultaneous with fiberoptic gastroduodenoscopy.

We have found that performing a Meltzer-Lyon test simultaneously with upper gastrointestinal endoscopy is an efficient as well as accurate technique for diagnosing acalculous cholecystitis. For the patient with upper abdominal pain and normal contrast and sonographic studies, endoscopy is often the next logical step in diagnosis. When the results of endoscopy do not reveal a source of upper abdominal pain, one can proceed directly to a Meltzer-Lyon test. Early diagnosis and cost containment are the obvious advantages of this procedure. The reliability of the Meltzer-Lyon test justifies the additional five to ten minutes of endoscopic time in these diagnostically challenging patients.