Delay between symptoms and surgery for carotid artery stenosis: modification of our practice.

BACKGROUND: Recent data from the literature concerning symptomatic carotid stenosis show that the long-term benefits of surgery are greater when the surgery is performed soon after the neurologic event, ideally within 2 weeks. Since 2009, following recommendations, we decided to perform surgery as quick as possible. The aim of the study was to determine whether this approach increased postoperative morbimortality and the way it could change our practice. METHODS: Using a prospective database containing a consecutive and continuous series of 1,500 carotid endarterectomies performed between 2003 and 2012, we extracted the records concerning the 417 symptomatic carotid stenoses (27.8%). We compared the 30-day and long-term outcome in 3 groups of patients: those operated within 2 weeks of the neurologic event (early surgery group [ESG], n = 158, 37.9%), those operated between 16 days and 6 weeks after the event (deferred surgery group [DSG], n = 79, 18.9%), and those operated more than 6 weeks after the event (late surgery group [LSG], n = 180, 43.2%). In the second part, to assess the new management beginning 2009, patients were divided in 2 periods 2003-2008 (period A) and 2009-2012 (period B) and we compared the 2 period's descriptive data and outcome. The primary outcome was the 30-day combined stroke and death rate. Secondary end points were follow-up freedoms from mortality and stroke. RESULTS: The mean time between symptom onset and surgery was 7.7 ± 3.8 days for the ESG, 28.3 ± 8.6 days for the DSG, and 89.4 ± 36.7 days for the LSG. In the 3 groups, the types of symptoms leading to the indication for carotid surgery were comparable, with a stroke in 221 cases (53.0%), a transient ischemic attack in 146 cases (35.40%), and amaurosis fugax in 50 cases (12.0%). The groups were comparable in terms of comorbidities. The overall 30-day stroke rate was 1.4% (6 cases), the 30-day death rate was 1.7% (7 cases), and the combined stroke and death rate was 3.4% (3.2% in the ESG, 5.1% in the DSG, and 2.8% in the LSG [P = 0.808]). Survival rates at 24, 48, and 60 months were, respectively, 95%, 78%, and 78% in ESG, 86%, 81%, and 81% in DSG, and 91%, 83%, and 74% in LSG (P = 0.78). Freedom from stroke at 60 months showed to be, respectively, 97% in ESG, 96% in DSG, and 91% in LSG (P = 0.32). During the period A (2003-2008), we had taken care of 217 symptomatic carotid artery stenosis patients (22.3% of stenosis) and during the period B (2009-2012), 200 symptomatic stenosis (37.9% of stenosis). During the period A, an early surgery (<15 days) had place in 31 cases (14.3%), and during the period B, in 127 cases (63.5%). The 30-day stroke and death rate was of 3.7% during the period A and of 3.0% during the period B (P = 0.455). The 24-month survival and stroke-free survival rates were comparable between the 2 periods. CONCLUSIONS: In our experience, surgery for symptomatic carotid stenosis can be performed early without increasing the rate of postoperative and long-term outcome. We have modified our practice, performing more and more early surgery for symptomatic stenosis without any impact on the outcome.

Risk index for predicting shunt in carotid endarterectomy.

BACKGROUND: To prevent ischemia during carotid endarterectomy, a routine or selective shunt can be set up in cases of insufficient cerebral perfusion during the carotid clamping. The aim of this study was to analyze predictive factors for shunting under locoregional anesthesia and to validate a risk index to predict shunt. METHODS: Using a prospective database, we studied carotid endarterectomy performed under locoregional anesthesia between January 1, 2003, and December 31, 2010 (n=1,223). A shunt was used because of clinical intolerance of clamping in 88 cases (group S, 7.2%). Clinical, comorbidities, demographics, and duplex scan data were used to compare group S to a control group (group C, n=1,135, 92.8%). A multivariable logistic regression was performed to identify predictors of shunt. Coefficients were assigned to each predictor to propose a predictive score. RESULTS: Patients in group S were significantly older than those in group C (75.6±7.8 years vs. 72.6±9.4 years, P<0.001). Other factors associated with a carotid shunt were female sex (odds ratio [OR]=2.41, 95% confidence interval [CI]: 1.54-3.78, P<0.001), systemic arterial hypertension (OR=2.478, 95% CI: 1.16-4.46, P=0.016), occlusion of the contralateral carotid artery (OR=6.03, 95% CI: 2.91-12.48, P<0.001), and 1 factor against the likelihood of a carotid shunt, a history of contralateral carotid surgery (OR=0.34, 95% CI: 0.12-0.93, P=0.037). The mean flow in the contralateral common carotid artery was 696.5±298.0 mL/sec in group S and 814.7±285.5 mL/sec in group C (P<0.001). Using those 6 items, we propose a prognostic score validated in our series and allowing to divided risk of intolerance of clamping into low-risk (≤6%), intermediate-risk (6.1%-15%), and high-risk (>15%) groups. CONCLUSIONS: We have established the first version of a score that predicts the need for a shunt by studying factors associated with intolerance to clamping. The relevance of this score, validated in our series, must be confirmed and adjusted by studies based on a larger sample size.

Influence of the contralateral carotid artery on carotid surgery outcome.

BACKGROUND: Any obstacle in the contralateral artery has long been considered a high risk for carotid surgery. Here, we report the results of a monocentric, continuous, consecutive, prospective series and present a review of the literature. METHODS: All carotid endarterectomies performed under locoregional anesthesia in our department between 2003 and 2010 were recorded in a prospective database (n = 1,212). Different statuses of the contralateral carotid artery--occlusion (group O, n = 81) and stenosis of >60% (group S, n = 173)--were compared with a control group (group C, n = 958). A shunt was used in cases of clinical intolerance to clamping. The assessment criteria concerned the need for a shunt and the combined 30-day nonfatal stroke and death rate. A stepwise logistic regression was performed. RESULTS: Overall, a shunt was necessary in 7.3% of cases. The proportion was greater in group O (25.9%, P < 0.001). Severe renal insufficiency (odds ratio [OR] = 1.94) and contralateral carotid occlusion (OR = 5.53) were the sole factors predicting the need for shunting. The overall 30-day nonfatal stroke and death rate was 2.5%, with no difference between groups (P = 0.738), and severe renal insufficiency was the single predictor of a poor outcome (OR = 3.11; 95% confidence interval: 1.21-7.97; P = 0.18). CONCLUSION: In this series, and in a large review of literature, occlusion of the contralateral internal carotid artery increased the incidence of intolerance to clamping and thus the use of shunts but did not worsen postoperative morbidity and mortality. The presence of a stenosed contralateral carotid was not predictive of postoperative events. In our experience, the status of the contralateral carotid artery cannot be considered a high risk for carotid surgery.

First results of clampless distal anastomosis in peripheral vascular bypass with LeGoo, a thermoreversible polymer.

BACKGROUND: We report our initial experience with LeGoo (Pluromed Inc, Woburn, Mass), a temporary thermoreversible occlusive gel, in peripheral vascular revascularization. METHODS: Between 2007 and 2010, LeGoo was used to occlude target vessels during bypass surgery in 14 patients who required infrainguinal revascularization. RESULTS: Proximal occlusion of the target vessel was obtained with a mean quantity of 0.25 mL of LeGoo. Distal occlusion of the vessel was obtained with a mean quantity of 0.28 mL. One injection of LeGoo was sufficient to prevent backbleeding in 11 of 14 patients. The mean occlusion time was 13.4 ± 3.3 minutes. An injection of saline through the graft or better directly into the arteries was used to dissolve the gel. For our first case, a Fogarty catheter was used to remove residual gel from the anterior tibial artery. CONCLUSIONS: LeGoo gel can be used to stop blood flow in small-bore arteries in the lower limbs to allow anastomoses to be performed.

Atrial and vascular oxidative stress in patients with heart failure.

Heart failure is characterized by a great number of metabolic and histological defects, however, previous studies did not provide strong evidence of a correlation between the antioxidant status of myocardial tissue itself and cardiac function. The goal of our study was to assess, in patients with heart failure consecutive to dilated cardiomyopathy (DCM), alterations in norepinephrine (NE), lipid peroxidation (malonedialdehyde: MDA) and iron levels in different parts of the myocardium and aorta, in relation to functional parameters. Biopsied heart samples were obtained from 12 DCM patients and from 4 brain-dead organ donors (Controls). The left ventricular ejection fraction (LVEF) was reduced to 19.1±2.6% in DCM. For all patients, the distribution of NE in the atria, ventricles and vessels was different, but NE content in control hearts was systematically higher than in cardiomyopathy patients. MDA levels tended to be higher in the different samples from the DCM group in comparison with the values obtained in the C group; the values were significantly decreased (p<0.05) in endocardium and the aortic samples. In the right atrium there was a significant correlation between NE content and LVEF and between MDA and iron concentrations. These findings could give further insights into the relationship between iron metabolism disturbances and the severity of cardiovascular diseases.

Clinical experience with a novel thermosensitive temporary coronary artery occluder (LeGoo).

BACKGROUND: A bloodless field is important for visualizing relevant anatomical structures and facilitating construction of high-quality coronary anastomoses during off-pump coronary artery bypass graft surgery (OPCABG). Currently employed devices can damage target arteries as well as myocardium and are not uniformly effective, especially with diseased arteries. METHODS: LeGoo (Pluromed, Woburn, MA) is a thermosensitive polymer that is a viscous liquid at room temperatures and changes into a firm occlusive plug instantaneously when exposed to body temperatures. The polymer is nontoxic and neither metabolized nor absorbed. It dissolves spontaneously or can be dissolved at will by cooling. LeGoo was instilled through the arteriotomy of 99 coronaries in 50 patients during construction of OPCABG anastomoses. RESULTS: LeGoo formed an occlusive endoluminal plug instantaneously and blocked blood flow into the surgical field. In 89 vessels with available information, the quality of bloodless field was satisfactory, without need for substantial use of blood removal systems or application of another device in 81 vessels (91%). Resort to other means was prompted by serious arrhythmia (1 case) epicardial bleeding (1 vessel), bleeding from collateral branches (3 vessels), and shortcomings in design of the injecting catheter (3 vessels) that has been corrected. Intraoperative and perioperative profiles of these patients were similar to those reported from other OPCABG series. Abnormal bleeding, coagulopathy, metabolic derangements, and evidence of LeGoo embolization were not observed. CONCLUSIONS: In this first large-scale human experience, LeGoo had been an atraumatic, safe, and effective temporary coronary artery occluder. It produced a bloodless field during OPCABG in 91% of target vessels. Improvements on these results with further experience is anticipated.

The impact of renal insufficiency on the outcome of carotid surgery is influenced by the definition used.

BACKGROUND: Renal insufficiency (RI) seems to be a source of complications after carotid endarterectomy (CEA). However, published studies do not use a common definition of RI. Our objective was to analyze the effects of RI on carotid surgery using three classifications of renal function. METHODS: Using a prospective database, we studied renal function and postoperative complications in patients operated on between January 1, 2003 and December 31, 2008. Renal function was studied using the level of plasma creatinine, creatinine clearance calculated according to the Cockcroft formula, and to the Modification of Diet in Renal Disease (MDRD) equation. For each method, the patients were divided into three groups: normal renal function, moderate RI, and severe RI. The principal judgment criterion was the 30-day non-fatal stroke and death rate. RESULTS: The analysis concerned 961 CEAs carried out in 901 patients. The 30-day non-fatal stroke and death rate was 2%. In the analysis of renal function using the level of creatinine, there was no statistical difference between the groups in the 30-day stroke and death rate (normal renal function: 1.8%, moderate: 2.7%, severe: 8.3%, P = .21). The analysis of renal function according to creatinine clearance calculated using the Cockcroft formula showed that in the severe RI group, the stroke and death rate was higher than in the other two groups (normal renal function: 1.7%, moderate RI: 1.4%, severe RI: 7.5%, P = .004). Analysis using the MDRD formula showed similar differences between the severe RI group and the other two with a higher rate of 30-day stroke and death (normal renal function: 1.4%, moderate RI: 1.7%, severe RI: 12.5%, P < .001). Subgroup analysis showed that among patients with severe RI according to the creatinine clearance, those with symptomatic carotid stenosis had the highest incidences of non-fatal stroke and death (Cockcroft, n = 19: 21.1%, MDRD, n = 10: 40%). CONCLUSION: Severe RI is a risk factor for complications after carotid surgery. Creatinine clearance calculated according to the MDRD formula correlates most closely with these complications. Symptomatic patients with severe RI, according to the creatinine clearance, are at high risk with a very high level of postoperative complications.

Prehospital treatment of infrarenal ruptured abdominal aortic aneurysms: a multicentric analysis.

BACKGROUND: The aim of this study was to evaluate the quality of the current treatment of patients presenting with ruptured abdominal aortic aneurysms (RAAAs), from the first symptoms to the operating room with an analysis of preoperative mortality risk factors. METHODS: For 3 years, in four vascular surgery departments, we have collected all the consecutive cases of patients operated on for RAAA. We analyzed the initial clinical situation, the means of transportation, the time elapsed before treatment, and the mortality rate at 3 days. Sixty-six RAAAs were operated on. Mean patient age was 76 years (range, 52-93 years). RESULTS: The initial symptoms were a precisely located pain either abdominal (45.3%), lumbar (17.2%), or both (14.1%) or feeling faint (10.9%). In 22.7% of the cases, an initial hemodynamic instability was observed. In 46.8% of the cases, patients first went to a peripheral hospital before being admitted into a referral centre. In 84.5% of the cases, medical mean of transportation was used. The mean distance covered was 59.8 kilometers (range, <5 km to 213 km). The initial diagnosis was accurate in 67.3% of the cases. The mean intrahospital waiting period between the arrival at a reference center and the admission into an operating room was 127 minutes. Global mortality rate was 44.2%. The main preoperative mortality factor to be noticed was the initial hemodynamic instability (p=0.0031). Among stable patients, only two of them (5.4%) worsened during the preoperative treatment. CONCLUSION: In our study, hemodynamic instability corresponds to the main prognosis factor of mortality. In most cases, the initial stability persisted and allowed additional evaluation. However, the intrahospital waiting periods appeared to be too long. To be optimal, the adequate treatment should be specifically designed as soon as a diagnosis has been established.

Congenital complete absence of the left pericardium: a rare cause of chest pain or pseudo-right heart overload.

BACKGROUND: Congenital defects of the pericardium are rare and poorly known cardiac malformations. Most of them are left-sided and asymptomatic and are usually incidentally diagnosed. AIMS: To describe the clinical, electrocardiographic, and imaging features of total absence of the left pericardium. METHODS AND RESULTS: We report the cases of 3 patients who have been seen in our institution with a diagnosis of total congenital absence of the pericardium. All of them complained of precordial pain; one of them experienced disabling symptoms that justified surgical intervention. All of them had previously been suspected to have an atrial septal defect because of the echocardiographic appearance of right ventricular volume overload. Electrocardiogram, chest x-ray, echocardiography, and magnetic resonance imaging of the heart consistently showed remarkably similar features including leftward displacement, increased mobility, and interposition of lung tissue between the heart and other intrathoracic structures. CONCLUSION: Congenital absence of the left pericardium should be known by clinicians as a possible differential diagnosis of chest pain or pseudo-right heart overload.

Role for endovascular therapy in chronic mesenteric ischemia.

Chronic mesenteric ischemia is a rare condition that is caused by stenosis or occlusion of the mesenteric arteries and usually manifests as abdominal pain. While surgical revascularization has been the standard treatment for symptomatic patients, recent advances in interventional devices and techniques have made endovascular treatment feasible and effective. Percutaneous transluminal angioplasty with stent placement is now recognized as a minimally invasive means of obtaining good long-term results with an acceptable recurrence rate; consequently, the technique is suggested for the primary treatment of chronic mesenteric ischemia. The present article discusses the indications and principles of endovascular treatment, and reviews the literature, with emphasis on short- and long-term outcomes, particularly morbidity and mortality rates.

Regional heterogeneity of decreased myocardial norepinephrine and increased lipid peroxidation levels in patients with end-stage failing heart secondary to dilated or ischemic cardiomyopathy.

BACKGROUND: Regional alterations in norepinephrine (NE) and lipid peroxidation in the myocardium of patients with heart failure is not well known. This study was designed to investigate regional myocardial NE levels and lipid peroxidation index and their relationships with the functional parameters in two pathologic conditions: dilated cardiomyopathy (DCM) and ischemic cardiomyopathy (ICM). METHODS: Biopsied heart samples were obtained from 13 DCM and 10 ICM patients (orthotopic cardiac transplantation). Tissue NE was assayed by high-pressure liquid chromatography with electrochemical detection. Tissue lipid peroxidation (malondialdehyde, MDA) was evaluated by the thiobarbituric acid (TBA) reaction. RESULTS: Non-failing hearts (controls, n = 4) were included in this study for comparison. Left ventricular dysfunction was present at rest with a mean left ventricular ejection fraction (LVEF) of 19.1 +/- 2.6% for DCM patients and 17.4 +/- 2.0% for ICM patients. The amount of NE in control hearts was significantly lower (p < 0.05) than in DCM or ICM hearts. For all patients, there were several differences in distribution of NE among the sub-divisions of the atria and ventricles studied. NE content was significantly higher in the right atria than in the left atria or ventricles. A significant correlation between LVEF and NE concentrations was observed in the left septum of ICM and DCM patients and in the left ventricle of the ICM group. In DCM and ICM patients, some parts of the left ventricle showed higher levels of lipid peroxides compared with controls. MDA levels in patients with DCM varied little from one region to another, whereas in ICM patients there was considerable variation. CONCLUSIONS: This study is the first demonstration of a correlation between the values of pre-operative LVEF and cardiac NE concentrations in specific parts of the myocardium. This effect could not be generalized to the entire heart. The pattern of myocardial MDA distribution did not follow that of the NE distribution.

Multiplexed flow cytometric analyses of pro- and anti-inflammatory cytokines in the culture media of oxysterol-treated human monocytic cells and in the sera of atherosclerotic patients.

BACKGROUND: Some oxysterols are identified in atheromatous plaques and in plasma of atherosclerotic patients. We asked whether they might modulate cytokine secretion on human monocytic cells. In healthy and atherosclerotic subjects, we also investigated the relationships between circulating levels of C-reactive protein (CRP), conventional markers of hyperlipidemia, some oxysterols (7beta-hydroxycholesterol, 7-ketocholesterol, and 25-hydroxycholesterol), and various cytokines. METHODS: Different flow cytometric bead-based assays were used to quantify some cytokines (IL-1beta, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17, G-CSF, GM-CSF, IFN-gamma, MCP-1, MIP-1beta, or TNF-alpha) in the culture media of oxysterol-treated U937 and THP-1 cells, and in the sera of healthy and atherosclerotic subjects. CRP and markers of hyperlipidemia were determined with routine analytical methods. Oxysterols were quantified by gas chromatography/mass spectrometry. Flow cytometric and biochemical methods were used to measure IL-8 mRNA levels, intracellular IL-8 content, and protein phosphorylation in the mitogenic extracellular kinase/extracellular signal-regulated kinase1/2 (MEK/ERK1/2) signaling pathway. RESULTS: All oxysterols investigated are potent in vitro inducers of MCP-1, MIP-1beta, TNF-alpha, and/or IL-8 secretion, the latter involving the MEK/ERK1/2 cell signaling pathway. In healthy and atherosclerotic subjects, no relationships were found between cytokines (IL-8, IL-1beta, IL-6, IL-10, TNF-alpha, IL-12, and MCP-1), CRP, conventional markers of hyperlipidemia, and oxysterols. However, in patients with arterial disorders of the lower limbs, small but statistically significant differences in the circulating levels of CRP, TNF-alpha, and IL-10 were observed comparatively to healthy subjects and according to the atherosclerotic stage considered. CONCLUSIONS: Flow cytometric bead-based assays are well adapted to measure variations of cytokine secretion in the culture media of oxysterol-treated cells and in the sera of healthy and atherosclerotic subjects. They underline the in vitro proinflammatory properties of oxysterols and may permit to distinguish healthy and atherosclerotic subjects, as well as various atherosclerotic stages.

Clinical experience and Doppler echocardiographic assessment of the first one hundred ATS AP (advanced performance) prosthetic valve in the aortic position.

BACKGROUND AND AIM OF THE STUDY: The ATS Medical mechanical bileaflet valve is composed of pyrolitic carbon and is available in two forms: Standard and Advanced Performance. The study aim was to evaluate the clinical results and define, in blinded manner, the Doppler echocardiographic characteristics of normally functioning ATS AP prostheses with respect to their size. METHODS: One hundred patients (63 men, 37 women; mean age 63.6 +/- 10.6 years) were studied between January 1996 and February 1999. Doppler echocardiography was performed at least three months after valve replacement (mean 1.68 +/- 0.86 months; range: 3 months to 3 years). RESULTS: The in-hospital mortality was 3%, and there were four late deaths. None of the deaths was valve-related. Thromboembolic and anticoagulant-related hemorrhagic rates were 0.55% per patient-year (pt-yr) and 1.1% per pt-yr, respectively. Maximum and mean gradients were calculated using the simplified Bernoulli equation. Functional valve surface area was assessed using the continuity equation and time-velocity integrals using echographic measurements to calculate the subaortic surface. The Doppler velocity index was obtained from the ratio of subaortic and transaortic velocities. For the most frequently used aortic valve (22 mm), the maximum pressure gradient was 18.67 +/- 8.31 mmHg, the mean gradient 9.97 +/- 3.84 mmHg, functional surface area 1.50 +/- 0.35 cm2, and Doppler velocity index 0.41 +/- 0.08. CONCLUSION: Based on Doppler echocardiographic characteristics, the new ATS Medical AP prosthesis, when implanted in the aortic position, has an excellent hemodynamic profile which compares favorably with that of similarly designed prostheses. The clinical results show a very low rate of thromboembolic and anticoagulant-related hemorrhagic events, perhaps due to the new design of the pivoting area.

Combined treatment of aortic type A dissection: ascending aorta repair and placement of a stent in the descending aorta.

BACKGROUND: The established treatment modality of acute Stanford type A dissection includes repairing the ascending aorta and a variable part of the aortic arch and leaving the descending aorta untreated. We report a simultaneous approach of open repair of the ascending aorta with the transluminal placement of a stent in the descending aorta to minimize the consequences of an untreated descending aorta. METHODS: Two cases of type A aortic dissection are described, one case with the entry port in the descending aorta and the second case with the entry port in the aortic arch. Both patients were treated by the replacement of the ascending aorta (and the aortic arch in the second case) and the placement of a stent in the descending aorta with a new device as the patients were under circulatory arrest and deep hypothermia. The device consists of a Djumbodis stent mounted on a compliant balloon. This stent is made of 316L stainless steel and can be adapted to the shape of the aortic arch or descending aorta. Three different lengths are available: 4 cm, 9 cm, and 14 cm. The device used in these patients has a diameter of 9 mm. RESULTS: The early results were satisfactory with a completely thrombosed false lumen in one case and a partially thrombosed false lumen in the other, according to immediate postoperative transesophageal echocardiography control. A follow-up computed tomographic chest scan was done at 12 months in the first case and at 7 months in the second case and confirmed the good surgical results. CONCLUSIONS: This preliminary study shows that combined surgical and endovascular treatment of acute type A dissection is feasible and that at least partial thrombosis of the false lumen can be achieved, potentially minimizing the risk of further dilatation or rupture. The early results are encouraging, but more cases and long-term results are required to demonstrate the effectiveness of this new combined treatment modality.

A spontaneous rupture of the external iliac vein revealed as a phlegmasia cerulea dolens with acute lower limb ischemia: Case report and review of the literature.

We reported a case in a previously healthy 45-year-old woman of spontaneous rupture of the left external iliac vein, which was revealed as a phlegmasia cerulea dolens with acute lower limb ischemia. A tear on the anterior surface of the vein was discovered during an emergency laparotomy, and the rent was repaired successfully. Twenty-four hours later, the leg swelling increased, and at the reexploration, the common iliac vein was found to be occluded by an organized thrombus as the result of a well-endothelialized membranous band (Cockett or May-Turner syndrome). A Palma-Dale operation (crossover saphenous bypass grafting) was performed secondarily. The swelling in the leg diminished slowly, and the patient was discharged 10 days later with an oral anticoagulant therapy and elastic stockings.