Carotid endarterectomy in awake patients: safety, tolerability and results / Endarterectomia de carótida em pacientes acordados: segurança, tolerabilidade e resultados

Objective: To analyze the results of 125 carotid endarterectomies under loco-regional anesthesia, with selective use of shunt and bovine pericardium patch. Methods: One hundred and seventeen patients with stenosis ≥ 70% in the internal carotid artery on duplex-scan + arteriography or magnetic resonance angiography underwent 125 carotid endarterectomies. Intraoperative pharmacological cerebral protection included intravenous administration of alfentanil and dexametasone. Clopidogrel, aspirin and statins were used in all cases. Seventy-seven patients were males (65.8%). Mean age was 70.8 years, ranging from 48 to 88 years. Surgery was performed to treat symptomatic stenosis in 69 arteries (55.2%) and asymptomatic stenosis in 56 arteries (44.8%). Results: A carotid shunt was used in 3 cases (2.4%) due to signs and symptoms of cerebral ischemia after carotid artery clamping during the operation, and all 3 patients had a good outcome. Bovine pericardium patch was used in 71 arteries ≤ 6 mm in diameter (56.8%). Perioperative mortality was 0.8%: one patient died from a myocardial infarction. Two patients (1.6%) had minor ipsilateral strokes with good recovery, and 2 patients (1.6%) had non-fatal myocardial infarctions with good recovery. The mean follow-up period was 32 months. In the late postoperative period, there was restenosis in only three arteries (2.4%). Conclusion: Carotid artery endarterectomy can be safely performed in the awake patient, with low morbidity and mortality rates. .

Objetivo: Analisar os resultados de 125 endarterectomias carotídeas, realizadas sob anestesia loco-regional com uso seletivo de shunt e remendo de pericárdio bovino. Métodos: Cento e dezessete pacientes com estenose na artéria carótida interna ≥ 70% ao ecoDoppler colorido + arteriografia ou angiorressonância magnética foram submetidos a 125 endarterectomias carotídeas. As medidas de proteção farmacológica intraoperatória incluíam a administração endovenosa de alfentanil e dexametazona. Clopidogrel, aspirina e estatinas eram utilizadas em todos os casos. Setenta e sete pacientes eram do sexo masculino (65,8%). A idade média foi de 70,8 anos, variando de 48 a 88 anos. A operação foi indicada por estenose sintomática em 69 artérias (55,2%), e por estenose assintomática em 56 artérias (44,8%). Resultados: O shunt de carótida foi necessário em 3 casos (2,4%) devido a sintomas de isquemia cerebral após a colocação do clampe carotídeo durante o ato cirúrgico, e os três pacientes tiveram boa evolução. Remendo de pericárdio bovino foi utilizado em 71 artérias ≤ 6 mm de diâmetro (56,8%). A mortalidade perioperatória foi de 0,8%: um paciente faleceu devido a infarto agudo do miocárdio. Dois pacientes (1,6%) tiveram infartos cerebrais isquêmicos ipsilaterais menores com boa recuperação, e 2 pacientes (1,6%) tiveram infartos do miocárdio não-fatais com boa recuperação. O tempo médio de seguimento foi de 32 meses. No pós-operatório tardio, houve reestenose significativa em apenas três artérias (2,4%). Conclusão: A endarterectomia carotídea no paciente acordado é uma técnica segura, sendo realizada com baixas taxas de morbimortalidade. .

Carotid endarterectomy in awake patients: safety, tolerability and results.

OBJECTIVE: To analyze the results of 125 carotid endarterectomies under loco-regional anesthesia, with selective use of shunt and bovine pericardium patch. METHODS: One hundred and seventeen patients with stenosis ≥ 70% in the internal carotid artery on duplex-scan + arteriography or magnetic resonance angiography underwent 125 carotid endarterectomies. Intraoperative pharmacological cerebral protection included intravenous administration of alfentanil and dexametasone. Clopidogrel, aspirin and statins were used in all cases. Seventy-seven patients were males (65.8%). Mean age was 70.8 years, ranging from 48 to 88 years. Surgery was performed to treat symptomatic stenosis in 69 arteries (55.2%) and asymptomatic stenosis in 56 arteries (44.8%). RESULTS: A carotid shunt was used in 3 cases (2.4%) due to signs and symptoms of cerebral ischemia after carotid artery clamping during the operation, and all 3 patients had a good outcome. Bovine pericardium patch was used in 71 arteries ≤ 6 mm in diameter (56.8%). Perioperative mortality was 0.8%: one patient died from a myocardial infarction. Two patients (1.6%) had minor ipsilateral strokes with good recovery, and 2 patients (1.6%) had non-fatal myocardial infarctions with good recovery. The mean follow-up period was 32 months. In the late postoperative period, there was restenosis in only three arteries (2.4%). CONCLUSION: Carotid artery endarterectomy can be safely performed in the awake patient, with low morbidity and mortality rates.

Endovascular treatment of abdominal aortic aneurysms in high-surgical-risk patients using commercially available stent-grafts.

PURPOSE: To analyze the initial and long-term results of endovascular aneurysm repair (EVAR) in high-surgical-risk patients (i.e., age > or =80 years, serum creatinine level > or =3 mg/dL, severe pulmonary dysfunction, severe cardiac dysfunction). METHODS: From April 2002 to June 2009, 50 consecutive high-surgical-risk patients (42 men; mean age 74.0+/-8.7, range 54-91) with an abdominal aortic aneurysm (AAA; mean diameter 64.8 mm) who were treated electively using a bifurcated aortic endograft (32 Excluder, 18 Zenith) were entered in a prospective registry. Thirty-five (70%) patients were classified ASA III and 15 (30%) were ASA IV. High-risk status was corroborated using the Customized Probability Index (CPI). Primary endpoints were operative mortality and long-term survival; secondary endpoints were the frequency of reintervention, evolution of the aneurysm sac, and rates of primary and secondary patency and rupture. RESULTS: The mean CPI score was 11.04+/-6.3. Operative mortality was 2% (1/50). There were 4 endoleaks, 1 case of endotension, and 1 endograft limb occlusion. Two patients required reintervention during the mean follow-up of 35.6 months. Survival at 3 years was 94%. Primary and secondary patency rates at 3 years were 98% and 100%, respectively. There were no ruptures. CONCLUSION: Initial and long-term results with endovascular treatment of AAA in high-surgical-risk patients were satisfactory and appear to justify this approach in this patient population.

Endovascular treatment of contained rupture of a superior mesenteric artery aneurysm resulting from neurofibromatosis type I.

A 31-year-old woman with neurofibromatosis type I (NF-I) came to our hospital with hypotension and abdominal pain. A computed tomography (CT) scan showed blood in the retroperitoneum and two saccular aneurysms in the superior mesenteric artery (SMA). The largest measured 2.5 cm in diameter. She was treated with placement of a covered stent in the SMA, and both aneurysms were excluded from the systemic circulation. Arterial aneurysms are rare in this disease, and rupture of an SMA aneurysm in this context had been reported only once. We report an unusual case of a contained rupture of an SMA aneurysm associated with NF-I, successfully treated with a covered stent.

Endovascular treatment of abdominal aortic aneurysms in high-surgical-risk patients / Tratamento endovascular de aneurismas da aorta abdominal em pacientes de alto risco cirúrgico

Background: Following the publication of a prospective randomized trial (Endovascular Aneurysm Repair Trial 2 - EVAR2) that questioned the benefits of endovascular repair of abdominal aortic aneurysms (AAA) in high-surgical-risk patients, we decided to analyze our initial and long-term results with endovascular AAA repair in this patient population. Objective: To evaluate the operative mortality, long-term survival, frequency of secondary operations, outcome of the aneurysm sac, primary and secondary patency rates, and rupture rate after aortic stent-graft placement in high-surgical-risk patients. Methods: From April 2002 to February 2008, 40 high-surgical and anesthetic risk patients with an AAA managed by a bifurcated aortic endograft were entered in a prospective registry. Data concerning diagnosis, operative risk, treatment and follow-up were analyzed in all patients Results: Twenty-four Excluder® and 16 Zenith® stent-grafts were successfully implanted. Thirty patients (75 percent) were classed ASA III and 10 (25 percent) were ASA IV. Mean aneurysm diameter was 64 mm. Operative mortality was 2.5 percent. Two patients required reintervention during the mean follow-up of 28.5 months. Survival rate at 3 years was 95 percent. There were four endoleaks, one case of endotension, and one endograft limb occlusion. Primary and secondary patency rates at 3 years were 97.5 and 100 percent, respectively. There were no ruptures. Conclusions: Initial and long-term results with endovascular treatment of AAA in high-surgical-risk patients were satisfactory, and appear to justify such approach for this patient population.

Contexto: Após a publicação de um estudo prospectivo e randomizado (Endovascular Aneurysm Repair Trial 2 - EVAR2) que questionou o benefício do tratamento endovascular de aneurismas da aorta abdominal (AAA) em pacientes de alto risco cirúrgico, decidimos avaliar nossos resultados iniciais e tardios neste grupo de pacientes. Objetivo: Avaliar a mortalidade perioperatória, a sobrevivência tardia, a freqüência das reintervenções, o comportamento dos sacos aneurismáticos, as patências primária e secundária e a incidência de rotura após o tratamento endovascular de AAA em pacientes de alto risco cirúrgico. Métodos: Entre abril de 2002 e fevereiro de 2008, 40 pacientes de alto risco anestésico-cirúrgico portadores de AAA foram submetidos ao implante de endopróteses bifurcadas de aorta e incluídos num registro prospectivo. Os dados a respeito do diagnóstico, risco operatório, tratamento e seguimento foram analisados em todos os pacientes. Resultados: 24 endopróteses Excluder® e 16 Zenith® foram implantadas com sucesso. Trinta pacientes (75 por cento) foram classificados como ASA III e 10 (25 por cento) como ASA IV. O diâmetro médio dos AAA era de 64 mm. A mortalidade perioperatória foi de 2,5 por cento. Dois pacientes necessitaram de reintervenção durante o seguimento médio de 28,5 meses. A taxa de sobrevivência aos 3 anos foi de 95 por cento. Houve quatro endoleaks, um caso de endotensão, e uma oclusão de ramo em uma endoprótese. As patências primária e secundária aos 3 anos foram de 97,5 e 100 por cento, respectivamente. Não houve nenhuma rotura. Conclusões: Nossos resultados iniciais e tardios do tratamento endovascular de AAA em pacientes de alto risco são satisfatórios e parecem justificar a indicação deste tratamento neste grupo de pacientes.

Effects of aging on abdominal wall healing in rats.

PURPOSE: The aim of this study was to assess abdominal wall healing in old and young adult rats. METHODS: On average, young animals were 110 days old and old animals were 762 days old. A 4.0 cm median laparotomy was performed under anesthesia, followed by laparorrhaphy on two synthesis planes, i.e. peritoneum-muscle-aponeurosis and skin, using continuous 5.0 nylon sutures. The animals were evaluated on the 3rd, 7th, 14th and 21st postoperative days. The resistance of the two planes was studied separately and a histopathologic analysis was performed on sections stained with hematoxylineosin and Sirius Red. Immunohistochemical analysis was also carried out using PCNA, LCA and CD34. RESULTS: The skin scars gained resistance in a similar manner at the initial time points, but those of young rats were more resistant on the 21st day (p=0.0029). Total and type III collagen content was similar in the two groups and type I collagen content was higher in young animals on the 14th day. Inflammatory cell infiltration was more marked in the skin wounds of young animals on the 3rd day (p=0.0190). Reepithelialization was similar and angiogenesis was more intense in the skin wounds of young animals on the 14th day (p=0.0062). The peritoneum-muscle-aponeurosis wounds gained similar resistance during the early phases, but were more resistant on the 14th day (p=0.0005) and on the 21st day (p=0.0023) in old rats Collagen concentration was higher in the wounds of old animals on the 3rd day (p=0.0112) and in the wounds of young animals on the 21st day (p=0.0348). The inflammatory reaction was more intense in the wounds of old animals on the 3rd day (p=0.0060) and angiogenesis was more intense on the 14th day (0.0432). CONCLUSION: Although there are some differences in the healing course between young and old animals, age, of itself, does not impair the healing of abdominal wall wounds in rats.