Does contralateral carotid occlusion influence neurologic fate of carotid endarterectomy?

Divergent opinions regarding operative risks and late prognosis of patients undergoing endarterectomy for carotid stenosis with contralateral carotid occlusion have prompted a review of the experience at Emory University Hospital from Jan. 1, 1978, through Dec. 31, 1982. Fifty-four patients (37 men, 17 women; mean age 63 years) who underwent carotid endarterectomy (CEA) with contralateral carotid occlusion (group I) were compared with 410 demographically similar patients without contralateral carotid occlusion (group II) who underwent 503 CEAs during the same interval. CEA indications in group I were the following and were proportionately similar to those of group II: hemispheric transient ischemic attacks, 22 patients; asymptomatic stenosis, 12 patients; nonhemispheric symptoms, 11 patients; previous cerebral infarction, eight patients; and vascular tinnitus, one patient. General anesthesia, routine intraluminal shunting, systemic heparinization, and arteriotomy closure without patch were routinely employed in both groups. Three patients in group I suffered permanent neurologic deficits after operation (5.6%) and two had transient postoperative deficits with complete recovery. Ten patients (2.0%) in group II suffered permanent neurologic deficits and 10 patients experienced transient neurologic events after operation. Neither the transient nor the permanent neurologic deficit rates were statistically different (p greater than 0.05; Fisher exact test) in the two groups. Operative mortality rates for group I and group II were 0% and 0.8%, respectively, and were not significantly different (p greater than 0.10; Fisher exact test). Late postoperative ischemic brain infarctions occurred in two patients in group I (3.8%) and in 13 patients (3.6%) in group II (p greater than 0.10; Fisher exact test). Kaplan-Meier survival analyses were virtually identical in both groups, with the majority of deaths caused by cardiac occlusion may undergo CEA with morbidity and mortality rates similar to those without contralateral occlusions. Contralateral carotid occlusion does not necessarily portend an unfavorable early or late prognosis after CEA.

Acute mesenteric ischemia.

Forty-nine patients with acute mesenteric ischemia have been treated during the past 15 years. The overall mortality rate was 65%; the prognosis varied with the cause of disease. None of the 12 patients with primary thrombosis of the mesenteric arteries, 5 of 14 with spontaneous embolization, and 2 of 4 with arterial occlusion subsequent to diagnostic angiography survived. Seven of 11 patients with primary mesenteric venous thrombosis and 2 of 7 patients in whom mesenteric ischemia was related to low flow unassociated with occlusion of either the major arteries or veins survived. The only patient with occlusive arterial vasculitis survived. Thirty-one of these 49 patients presented with peritoneal signs. The serum glutamic oxaloacetic transaminase, lactic dehydrogenase, and creatine phosphokinase levels were significantly elevated in patients with nonocclusive ischemia and less elevated in patients with arterial or venous thrombosis. By contrast, the enzyme levels were frequently normal in patients with arterial embolization. Angiography was diagnostic in all four patients who were evaluated with this procedure--three patients with arterial embolization and one patient with nonocclusive ischemia. This procedure should be used more frequently, especially when embolization is suspected. The value of reexploration was assessed. There were 17 reexplorations, with only three contributing to survival (17.7%). Two patients with mesenteric venous thrombosis and one patient with arterial embolization benefited from resectional therapy during reexploration. The study emphasizes that diagnostic criteria, therapy, and prognosis can be correlated with the etiologic factor.

Segmental thrombotic occlusion of infrarenal abdominal aorta.

Five patients had segmental atherosclerotic occlusive disease confined to the midportion of the infrarenal abdominal aorta. Four of five patients had claudication, and in addition, four had evidence of peripheral microembolization and ischemic toes. Local endarterectomy or thrombectomy resulted in satisfactory restoration of distal blood flow in three patients. Two patients required replacement with a prosthetic tube graft. four of five patients have maintained good pedal pulses and have been asymptomatic for up to 14 years. These five cases were compared and contrasted with other series with similar lesions. Several causal factors are involved in segmental aortic occlusions.