Carotid endarterectomy in the very elderly: is it worthwhile?

BACKGROUND: Stroke continues to be the third leading cause of death in this country, its incidence and corresponding mortality rate increase with age, and in the majority of cases it results from arteriosclerosis of the carotid artery. Although recent studies have clearly shown the benefit of carotid endarterectomy in reducing the incidence of stroke, performance of this procedure in very elderly patients, the patient population for whom it should be most beneficial, has been challenged by some investigators on the basis of perceived increased operative risk. METHODS: The records of all carotid endarterectomies (n = 63) performed during the last 12 years for all patients (n = 59) with a minimum age of 75 years were reviewed to define the short-term risk of operative mortality, stroke and other major complications, and the long-term outcome. RESULTS: No (0%) operative deaths and three (4.8%) perioperative strokes occurred. Major cardiac complications occurred in five cases (7.9%). Follow-up, ranging from 1 to 122 months (mean, 27.4 months), was available for 54 patients (91.5%). Cumulative freedom from stroke was 92% at 2 years and 80% at 5 and 10 years of follow-up. Long-term survival rate was 80% at 5 years and 52% at 10 years, and stroke-free survival rate was 68% at 5 years and 42% at 10 years of follow-up. CONCLUSIONS: Carotid endarterectomy can be performed in very elderly patients with low operative risk and excellent long-term results.

The influence of female gender on the outcome of carotid endarterectomy: a challenge to the ACAS findings.

BACKGROUND: In the Asymptomatic Carotid Endarterectomy Study (ACAS) the perioperative stroke and mortality rate was more than twice as high in women as in men, markedly reducing the long-term benefit of the operation; therefore the role of carotid endarterectomy (CEA) among women with asymptomatic carotid stenoses remains unclear. The current study was undertaken to further examine the influence of gender on the outcome of the operation. METHODS: To control for all variables except gender, the records of all patients in an academic medical center who underwent elective CEA for asymptomatic disease, performed by one surgeon employing a uniform technique, over a 7-year interval were reviewed. RESULTS: From January 1992 through September 1998, 156 CEA procedures for asymptomatic carotid stenoses were performed on 66 (44%) women (n = 68) and 83 (56%) men (n = 88). There were no differences in the prevalence of hypertension (69% vs 69%), diabetes mellitus (24% vs 19%), hyperlipidemia (47% vs 47%), or smoking (46% vs 60%) between women and men, respectively, although a history of angina (28% vs 13%, P < .05) and myocardial infarction (23% vs 6%, P < .01) was more common among men. The mean stenosis was 86% for men and 83% for women. The incidence of perioperative mortality, stroke, and transient ischemic events was 0%, 0.6%, and 0%, with no differences between women and men: 0% vs 0%, 0% vs 1.3%, and 0% vs 0%, respectively. CONCLUSIONS: These findings indicate that female gender does not adversely influence the outcome of CEA when performed for treatment of asymptomatic disease. Gender should not be a consideration in the decision to perform CEA because of asymptomatic disease.

Aortic mural thrombus in young women: premature arteriosclerosis or separate clinical entity?

Two young women were admitted with peripheral arterial emboli secondary to aortic mural thrombi, and each underwent successful aortic thromboendarterectomy procedures. Both patients were taking oral steroidal medications, and both patients were heavy cigarette smokers. These cases and a careful review of the previous literature suggest that the development of aortic mural thrombi in young women may not always represent premature arteriosclerosis, as has been previously presumed, but may represent a separate and distinct clinical entity, at least in some patients.

Inhibition of the compartment syndrome by the ablation of free radical-mediated reperfusion injury.

Skeletal muscle edema secondary to an increase in capillary permeability after reflow is an important cause of the compartment syndrome after acute arterial revascularization. The purpose of this study was to investigate the possible role of oxygen free radicals, generated at reperfusion, in the pathogenesis of the compartment syndrome secondary to acute arterial ischemia/reperfusion. A reproducible model of this syndrome was produced in anesthetized rabbits by femoral artery occlusion after surgical devascularization of collateral branches from the aorta to the popliteal artery. Increasing periods of ischemia from 6 to 12 hours, followed by 2 hours of reperfusion, were associated with corresponding increases in the anterior muscle compartment hydrostatic pressure and inversely proportional decreases in tibialis anterior muscle blood flow within that compartment as assessed by xenon 133 washout (n = 46) (r = -0.62, p less than 0.001). Anterior compartment pressure increased from 5 +/- 1 to 48 +/- 5 mm Hg (n = 46) (p less than 0.001) after 7 hours of total arterial ischemia and 2 hours of reperfusion. Ablation of free radicals generated from xanthine oxidase with either allopurinol (n = 8) or oxypurinol (n = 8), by scavenging the superoxide radical at reperfusion with superoxide dismutase (n = 8), or by blocking secondary hydroxyl radical formation with deferoxamine (n = 8) significantly ameliorated the rise in compartment pressure (p less than 0.05) in each case; it also significantly improved muscle perfusion in the superoxide dismutase-, allopurinol-, and deferoxamine-treated animals (p less than 0.05). These findings indicate that development of the compartment syndrome after acute arterial revascularization may be due, at least in part, to microvascular injury mediated by oxygen-derived free radicals generated from xanthine oxidase at reperfusion.

Can infected prosthetic grafts be salvaged with rotational muscle flaps?

The conventional approach to prosthetic graft infection, including graft removal and extraanatomic reconstruction, conveys a substantial risk of limb loss and death and mandates more innovative solutions. From January 1985 to January 1989 eight rotational muscle flaps were performed on four men and three women with prosthetic graft infection who ranged in age from 42 to 79 years (mean, 67 years). The grafts involved included aortofemoral (three patients), femoropopliteal (two patients), femorofemoral (one patient), and subclavian-carotid-carotid (one patient) and were composed of Dacron (five grafts) or polytetrafluorethylene (two grafts). Infections were in the groin in six patients and in the neck in the other patient; all patients had anastomotic exposure. Clinical presentations included abscess/purulent drainage (four patients), anastomotic hemorrhage (two patients), and anastomotic false aneurysm (one patient) and was associated with fever and/or leukocytosis in all patients. Positive bacterial cultures were obtained from all patients. Rotational muscle flaps performed included rectus abdominis (five grafts), pectoralis major (one graft), gracilis (one graft), tensor fascia lata (one graft); in two patients, rotational muscle flaps were performed after failed local sartorius muscle transfer. No major complications of the RMF procedures were encountered. One patient died 4 months after the operation of complications of ischemic colitis/perforation. The other six patients were discharged with completely healed wounds. One patient developed recurrent infection 12 months after the rotational muscle flap procedure; five (83%) patients have been followed for 12 to 51 months (mean, 27 months) without evidence of recurrent infection. These preliminary results suggest that rotational muscle flaps are a safe and effective treatment for prosthetic graft infection, even when local sartorius muscle coverage has failed.

Superior mesenteric vein inflow for liver transplantation when the portal vein is occluded.

An alternative solution to the problem of liver transplantation in the patient with an occluded portal vein is described. It uses a bridge graft of donor iliac vein from the superior mesenteric vein at the base of the colonic mesentery. The graft is tunnelled over the pancreas and under the stomach to the region of the liver hilum to provide portal inflow. This procedure was employed successfully in four patients, with patency for more than 2 years in the patient with the longest follow-up. By this approach it is routinely possible to perform a transplant procedure in a recipient with an occluded portal vein.

Venous aneurysm. An unusual upper-extremity mass.

A venous aneurysm was diagnosed in an otherwise healthy 39-year-old woman who presented with an arm mass. The clinical features of these exceedingly uncommon lesions are discussed.

Aortofemoral graft for multilevel occlusive disease. Predictors of success and need for distal bypass.

Results of aortofemoral reconstruction of 181 consecutive patients with multilevel occlusive disease were reviewed and correlated with possible predictors of outcome. Overall, 74% of patients attained satisfactory relief of ischemic symptoms with proximal operation alone. Forty-six patients (26%) had an unsatisfactory result, 31 (17%) of whom underwent distal bypass grafts. Of 42 variables studied, 12 achieved statistical significance as predictors of outcome, and multivariate analysis identified five factors an independent indicators. Factors documenting hemodynamically significant inflow disease were associated most strongly with a good result. Several noninvasive laboratory variables were found helpful, particularly in assessing the hemodynamic compensation of distal disease. While no single variable reliably indicated the definite need for distal grafting, careful consideration of important factors together with the clinical situation will aid the surgeon in selection of the small group of patients best treated by synchronous aortofemoral and femoropopliteal grafts.

Vascular complications of intra-aortic balloon counterpulsation.

Although the intra-aortic balloon pump (IABP) saves many lives, complication rates as high as 36% have been reported. Many of the complications require surgical attention. In 794 patients of the Massachusetts General Hospital in Boston, an IABP was inserted into either the femoral or iliac artery between Nov 1, 1968, and June 30, 1981. Eighty-seven major vascular complications occurred in 70 (8.8%) of them. Of those 70 patients, 95% denied previous symptoms of vascular disease, and 78% had had normal pulses before insertion. The two most common complications were limb ischemia (n = 36) and arterial trauma (n = 20). Other complications included sepsis (n = 14), wound problems (n = 10), and hemorrhage (n = 7). No limbs were lost. Analysis of each group of complications allowed specific conclusions to be drawn concerning prevention, early diagnosis, and the most appropriate treatment.

The impact of advanced age on the results of carotid endarterectomy: an outcome analysis.

BACKGROUND: This study examined whether advanced age adversely influences the outcome of carotid endarterectomy. STUDY DESIGN: The records of 173 patients who underwent 187 carotid endarterectomies performed by the author from January 1990 through December 1995 were retrospectively reviewed. Group 1 included 58 patients, ranging in age from 75 to 92 years (mean, 79.4 years), who underwent 63 procedures, and group 2 included 115 patients, ranging in age from 41 to 74 years (mean, 66.3 years), who underwent 124 procedures. The operation was performed for symptomatic disease in 67 percent of the cases in each group. The operated lesion was more than 80 percent stenotic in 85 percent of the group 1 and 79 percent of the group 2 cases. RESULTS: No significant differences were found in the operative mortality (1.6 percent compared with 1.6 percent), incidence of perioperative stroke (4.8 percent compared with 1.6 percent), or rate of major cardiac complications (7.9 percent compared with 7.3 percent) between groups 1 and 2. No significant difference was found in the mean postoperative length of hospital stay between the group 1 and group 2 patients (4.13 +/- 2.58 days compared with 3.68 +/- 1.40 days). However, during the last 2 years of the study, the mean postoperative length of stay among the group 2 patients (3.06 +/- 1.44 days) was significantly shorter than among the group 1 patients (4.15 +/- 1.45 days) (p < .05). CONCLUSIONS: Advanced age does not adversely affect the results of carotid endarterectomy. However, the very elderly may be expected to experience a longer postoperative length of stay because of associated comorbid conditions.

Femoro-femoral or ilio-femoral bypass for unilateral inflow reconstruction?

Femoro-femoral and ilio-femoral bypass are two popular options for unilateral inflow reconstruction. In order to evaluate these alternative approaches, the records of 70 consecutive patients who underwent either femoro-femoral (n = 50) or ilio-femoral (n = 22) grafts were retrospectively reviewed. There were 46 men and 24 women, ranging in age from 27 to 84 years (mean: 66 years). Operative mortality was 10% for all femoro-femoral procedures, including 50% for emergent, 14% for synchronous, and 0% for solitary procedures; mortality was 9% for all ilio-femoral grafts including 20% for synchronous and 6% for solitary procedures. Among the elective solitary procedures, there was no significant difference with respect to operative time, blood loss, fluid requirement, time until resuming an oral diet, or duration of postoperative course for the two procedures. Five-year patency was 93% for all ilio-femoral and 57% for all femoro-femoral grafts. Although femoro-femoral bypass has been the more popular option for unilateral inflow reconstruction in this and other institutions, these findings justify the more widespread use of ilio-femoral bypass.

Vascular disease in the elderly patient.

At a time of potentially dramatic changes in health care policy in this country, and in view of the necessity for health care cost containment, physicians are expected to exercise serious introspection in the selection of treatment for the elderly patient with peripheral arterial disease. These decisions should be made while acknowledging that it is the goal of the health-care provider "to postpone chronic illness, to maintain vigor, and to slow social and psychological involution." For the elderly patient with an abdominal aortic aneurysm, with significant carotid disease, or with limb-threatening peripheral ischemia, the evidence is compelling that timely surgical intervention in properly selected patients is well tolerated and will satisfy this goal.

Emergency gastroduodenal-renal artery bypass. An extra-anatomic approach for salvage of the solitary kidney.

A 68-year-old woman had acute anuric renal failure and congestive heart failure. Angiography demonstrated occlusion of the renal artery to the known solitary right kidney and severely ulcerative aortic arteriosclerosis. She underwent an emergency gastroduodenal-renal artery saphenous vein bypass graft with almost immediate restoration of urine output and eventual dramatic improvement in renal function. She remains well two years postoperatively. This is the first report of gastroduodenal-renal bypass performed in the emergency setting for salvage of a solitary kidney.

Percutaneous transluminal angioplasty and transaxillary first rib resection. A multidisciplinary approach to the thoracic outlet syndrome.

A 33-year-old man with the thoracic outlet syndrome complicated by recurrent upper extremity deep venous thrombosis underwent venographic and dynamic venous pressure studies that suggested both extrinsic and intrinsic venous obstruction. The patient was treated with transaxillary first rib resection and percutaneous transluminal angioplasty of the involved subclavian vein stenosis and is symptom-free at 16 months follow-up. To our knowledge this is the first case in which such a multidisciplinary approach to the thoracic outlet syndrome has been performed.

Massive small bowel infarction. An unusual complication of abdominal aortic surgery.

Only 16 cases of small bowel infarction as a complication of abdominal aortic surgery have previously been reported, with 100 per cent mortality among adults. This case represents the first adult survivor of this unusual complication reported to date. The possible etiologies of this problem including "aorto-iliac steal" phenomena, thromboembolic events, low cardiac output states, operative interruption of important collateral pathways, and mesenteric vasoconstriction secondary to pharmacologic agents are elaborated. The diverse clinical presentations of this devastating complication are likewise reviewed.

Oculoplethysmography and supraorbital Doppler evaluation of carotid disease. A reappraisal.

A variety of noninvasive tests are available for the evaluation of patients with suspected extracranial cerebrovascular disease. Recent emphasis on more sophisticated techniques has raised questions concerning the current utility of older methods, e.g., pulse delay oculoplethysmography (OPG) and supraorbital Doppler (SOD) examination. The results of OPG and SOD examination were compared with the findings of carotid arteriography in 75 consecutive patients. This analysis revealed a sensitivity of 78 per cent, specificity of 92 per cent, false-positive rate of 12.5 per cent, false-negative rate of 15.8 per cent, and overall diagnostic accuracy of 85 per cent for OPG. Although the specificity of SOD was superior (94.3%), the sensitivity (41%) false-positive rate (16.6%), false-negative rate (30.5%), and overall diagnostic accuracy of 71.6 per cent of SOD revealed it to be an inferior test of significant carotid stenosis. Based on its ease of performance, minimum of time required, and high level of diagnostic accuracy, OPG currently remains a valuable screening procedure for carotid disease, particularly in the asymptomatic bruit population.

The influence of anesthetic method on infrainguinal bypass graft patency: a closer look.

Although several studies have demonstrated a reduced incidence of postoperative deep venous thrombosis among patients who receive regional anesthesia, the influence of anesthetic method on early arterial bypass graft patency has not been well studied. The records of 78 consecutive patients undergoing elective femoro-popliteal (FP) or femoro-tibial (FT) bypass grafts, and who were randomized to receive general anesthesia and postoperative patient-controlled intravenous narcotic analgesia (GEN, n = 41), or epidural anesthesia and postoperative continuous epidural analgesia (EPI, n = 37), were retrospectively reviewed. The two groups were evenly matched with respect to demographic characteristics, risk factors, and vascular variables. There was one death in each group, yielding an operative mortality of 2.6 per cent, and leaving 76 patients available for further analysis. Graft occlusion occurred in 11 (14.5%) cases within the first 7 postoperative days, including 9 (22.5%) GEN and 2 (5.6%) EPI patients (P < 0.05). There were two (4.4%) FP occlusions, including two (8.7%) GEN and 0(0%) EPI cases; there were nine FT occlusions, including seven (41.2%) GEN and two (14.3%) EPI cases. Graft occlusion occurred in 11 (17.1%) of the 64 limb salvage cases, including nine (27.3%) GEN and two (6.5%) EPI cases (P < 0.05), and in seven (12.7%) of 55 greater saphenous vein grafts, including six (22.2%) GEN and 1 (3.6%) EPI cases (P < 0.05). By multivariate analysis, FT grafts, preoperative plasminogen activator inhibitor-1 (PAI-1) levels, and GEN were predictive of early graft occlusion (P < 0.05). Furthermore, the levels of circulating PAI-1 were higher 24 hours postoperatively among patients in the GEN group (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal aortic replacement with a left-sided inferior vena cava: transperitoneal and left retroperitoneal approaches.

An unsuspected left-sided inferior vena cava (IVC) can present a formidable challenge for the surgeon attempting aortic reconstructive surgery. A 73-year-old man with aorto-iliac occlusive disease and a 64-year-old man with a seven centimeter (cm) abdominal aortic aneurysm (AAA) each underwent an aorto-femoral bypass graft in the setting of a left-sided cava. In the former case the conventional transperitoneal approach was utilized and in the latter case the extended left retroperitoneal incision was employed. The technical details required in performing these procedures and the developmental anatomy of this and other major venous anomalies are discussed.

Immediate post-operative urokinase infusion: extending the limits of limb salvage surgery.

We report the case of a 74-year-old woman with multi-level arterial occlusive disease and severe ischemia of the right lower extremity who underwent a re-operative femoro-femoral and a right femoro-popliteal bypass graft. Her right foot remained non-viable post-operatively despite patent grafts. She then underwent a 12-hour infusion of urokinase through a percutaneously placed popliteal artery catheter during that first post-operative day, with salvage of the right leg.

Balloon dilatation versus surgical revision of infra-inguinal autogenous vein graft stenoses: long-term follow-up.

Although infra-inguinal autogenous vein graft stenoses may be treated by balloon dilatation (PTA) or surgical revision, the optimal approach is undefined. Over the last 7 years 24 PTA procedures were performed on 37 vein graft stenoses in 19 grafts. Graft stenoses were diagnosed from 2 to 72 (mean = 17.3) months after implantation. PTA was successfully completed in 23 (96%) of the 24 procedures including 18 (95%) of the primary, and 5 (100%) of the secondary procedures. Recurrent vein graft stenosis or graft thrombosis developed in 12 (67%) grafts from 3 to 47 (mean = 12.5) months after primary PTA. Long-term patency after primary PTA was 69% at 6, 29% at 12, and 22% at 36 months; secondary patency was 81% at 6, 45% at 12, and 27% at 36 months. During the same period vein graft stenosis in 7 fem-pop and 2 fem-tib grafts were surgically revised with an initial success rate of 100%, and 2 (22%) complications. Four (44%) of these grafts occluded from 1-17 (mean 6.2) months after repair, yielding a primary 5-year patency of 62%. Although vein graft stenosis may be safely, effectively, and repeatedly treated with PTA, long-term durability appears to be superior after surgical revision.