Iliofemoral venous thrombosis caused by compression of an internal iliac artery aneurysm: a minimally invasive treatment

PURPOSE

To report the success of a minimally invasive treatment for phlegmasia cerulea dolens without gangrene caused by compression from an internal iliac artery aneurysm.

METHODS AND RESULTS

An 81-year-old male with a 1-month history of paralysis owing to a hemorrhagic stroke presented with massive edema and skin mottling of the right lower extremity. Imaging confirmed right iliofemoral deep vein thrombosis caused by compression from a 4-cm internal iliac artery aneurysm. With thrombolysis ruled out, a minimally invasive treatment plan was undertaken, featuring percutaneous coil embolization of the aneurysm and surgical venous thrombectomy with proximal arteriovenous fistula creation and iliac vein stent placement. Failure of the coils to embolize the iliac aneurysm prompted the use of an endovascular graft to exclude the aneurysm. The patient's symptoms subsided, and he has a patent right iliofemoral venous system and internal iliac artery at his latest (16-month) follow-up.

CONCLUSIONS

This case demonstrates that minimally invasive endovascular and open techniques can be combined to achieve an optimum outcome in patients at high risk for standard surgical approaches.

The valvular apparatus in venous insufficiency: a problem of quantity?

Abnormal venous valvular function may produce venous reflux and venous insufficiency. While valvular agenesis is a known, but rare cause of venous insufficiency. While valvular agenesis is a known, but rare cause of venous insufficiency, little work has been done on the relative number of greater saphenous vein (GSV) valves in patients with venous insufficiency. This study investigates whether the GSV in patients with symptomatic venous insufficiency has fewer valves than the GSV of patients without venous insufficiency. The number of GSV valves in patients (n = 51) with symptomatic venous insufficiency undergoing saphenectomy (VI) were compared with the number of GSV valves in patients (n = 26) without venous insufficiency undergoing in situ GSV bypass under angioscopic surveillance who served as a control group. The two groups differed, as expected, in age and sex distribution. The VI group had a mean of 25.7 +/- 11.0 centimeters of GSV between valves, while the control group had 19.0 +/- 9.7 centimeters of GSV between valves (F = 6.99; p = 0.01). The mean number of valves in the saphenous veins of the two groups also differed significantly: VI = 2.3 +/- 0.83 versus control (CTRL) = 4.8 +/- 2.01 (F = 61.86; p < 0.0001). That properly functioning valve leaflets help maintain physiologic antegrade venous flow is indisputable. This study, however, suggests that the relative lack of valves may be related to the development of venous insufficiency. This report documents that patients with symptomatic reflux in the GSV have significantly fewer valves than patients with apparently normal functioning saphenous veins.

Popliteal artery aneurysm treated with a minimally invasive endovascular approach: an initial report

PURPOSE

To report a minimally invasive approach to popliteal artery aneurysm (PAA) treatment.

METHODS AND RESULTS

A 48-year-old male with a 3-cm PAA was treated electively with an endovascular in situ saphenous vein bypass and transluminal antegrade coil embolization of the PAA prior to completion of the proximal anastomosis. Two short incisions at the anastomosis sites resulted in no wound complications, and the patient was discharged after 2 days. After 14 months of follow-up, the patient is asymptomatic with continued patency of the in situ bypass and occlusion of the PAA.

CONCLUSIONS

This endovascular approach for minimally invasive femoropopliteal in situ saphenous vein bypass grafting appears feasible for treatment of PAAs. This method may reduce the rate of wound complications attending classic open in situ bypass grafts.

Diagnosis of aortocaval fistula by computed tomography

A case of an aortocaval fistula documented by contrast-enhancement computed tomography is reported. In the presence of a large abdominal aortic aneurysm, the computed tomography (CT) triad findings of: (1) vena caval effacement, (2) loss of the fat plane between the aorta and vena cava, and (3) rapid flow of contrast from the aorta into a dilated inferior vena cava is characteristic of an aortocaval fistula.

Traumatic carotid artery dissection and pseudoaneurysm treated with endovascular coils and stent

PURPOSE

To report a case of post-traumatic internal carotid artery dissection and pseudoaneurysm formation at the C-1 level successfully treated by a percutaneous endovascular technique.

METHODS AND RESULTS

A 20-year-old female presented 72 hours after a motor vehicle accident with incomplete occulosympathetic paresis (Horner's syndrome), carotidynia, and leftsided 1.5-cm x 2.5-cm pseudoaneurysm at the C-1 level. Neuroradiologists embolized the pseudoaneurysm with Guglielmi detachable coils and controlled the dissection with placement of a Wallstent.

CONCLUSIONS

This report illustrates successful percutaneous endovascular treatment of a carotid dissection and pseudoaneurysm near the base of the skull.

Parenting classes as a part of a hospice bereavement program

The impact of a loss is felt throughout the family system with the parent-child relationship being particularly vulnerable. The experience of The Mount Carmel Hospice Evergreen Center with a parenting program is presented. Responding to the expressed concerns of grieving parents, a time-limited parenting group was held. The quantitative and qualitative results of that experience are presented. In addition to normalizing the experience of parenting grieving children, the group provided the opportunity for parents to enhance skills and learn about the need to respect the individuality and uniqueness of the grief work of the child.

Teacher response to learning disability: a test of attributional principles

Attribution research has identified student ability and effort expended as causes of achievement outcomes that result in differing teacher affect, evaluative feedback, and expectation of future performance. Ninety-seven elementary-school general education teachers (84 women and 13 men) rated their responses to the test failures of hypothetical boys with and without learning disabilities. In most cases, greater reward and less punishment, less anger and more pity, and higher expectations of future failure followed the negative outcomes of the boys with learning disabilities, when compared with their nondisabled ability and effort matches, indicating that learning disability acts as a cause of achievement outcomes in the same way as ability and effort. This pattern of teacher affect and response can send negative messages that are often interpreted as low-ability cues, thus affecting students' self-esteem, sense of competence as learners, and motivation to achieve.

Extraluminal endoscopic-assisted ligation of venous tributaries for infrainguinal in situ saphenous vein bypass: a preliminary report

In an attempt to obviate the need for an incision the length of the leg during in situ saphenous vein bypass, a minimally invasive operation using 'laparoscopic techniques' was developed. At operation, standard incisions were made over the proximal femoral artery/vein and the saphenous vein at the distal popliteal artery level. An angioscopic valvulotome was used to perform valvulotomy under direct vision. After valvulotomy, a distention balloon system was used to form a 'pocket' into which a laparoscope was inserted. Trocars were then inserted under direct vision and the saphenous vein dissected and side branches individually clipped. After occlusion of the venous side branches, proximal and distal arterial anastomoses were performed in the standard fashion. This minimally invasive operation using laparoscopic techniques precludes the need for a long leg incision and saphenous vein dissection, except at the proximal and distal arterial anastomoses.

Preoperative control of a ruptured anastomotic femoral "pseudoaneurysm" by balloon catheter: a combined radiologic and surgical approach

Inflow control of a rapidly expanding or ruptured femoral anastomotic "pseudoaneurysm" can be fraught with hazard. Occlusion of an anastomotic femoral aneurysm with a balloon catheter offers the surgeon a simple method of gaining inflow control prior to surgery. After achieving inflow control with the balloon catheter, the surgeon can incise the anastomotic aneurysm without significant blood loss, control back bleeding with balloon occlusion catheters, and with relative ease and safety repair or replace the anastomotic aneurysm as indicated. An illustrative case is presented.

Infrainguinal endovascular in situ saphenous vein bypass: ongoing results

PURPOSE

With 70 cm "cutter" valvulotomes for valvulotomy and an electronically steerable nitinol catheter to occlude venous tributaries with platinum coils, endovascular in situ saphenous vein (EISV) bypass can be safely performed from within the saphenous vein. To determine whether EISV bypass could reduce hospital length of stay (LOS) and perioperative morbidity without compromising patency, another 53 EISV bypasses for limb salvage were performed.

METHODS

Tributary occlusion was accomplished with only fluoroscopic surveillance with a new, smaller, and more steerable silicone-tipped nitinol catheter.

RESULTS

Two (3.7%) wound complications occurred. The mean hospital LOS after operation was 4.2 days (range 2 to 29 days). All tributaries initially embolized remained occluded, and three "missed" arteriovenous fistulas were identified during follow-up extending to 15 month (mean 8.4 months). Eighty-eight percent (49 of 54) of phase II bypasses remained patent, whereas life-table analysis of all bypasses (phase I and II) was 77% (69/99) at 24 months follow-up (mean 13.6 months). By comparison, 41 infrainguinal saphenous vein in situ bypasses with "classic" open techniques were performed concurrently. The mean postoperative LOS was 11.6 days (range 4 to 42 days), wound complications occurred in 24% (10) of patients, and two "missed" arteriovenous fistulas were identified during follow-up. Eighty-three percent (34 of 41) of bypasses remain patent at 24 months follow-up (mean 16.2 months).

CONCLUSIONS

If EISV bypass long-term patency rates remain similar to classic in situ bypass patency results, the additional benefits of decreased hospital LOS, reduced wound-related complications, shortened recuperation, and therefore increased health care savings gives this endovascular technique strong consideration as the possible future operation for infrainguinal saphenous veins in situ bypass.

Use of the Greenfield filter in patients with major trauma

Patients with major trauma often cannot be given the benefit of preventive measures such as pneumatic compression boots and low-dose heparin against pulmonary embolism. The Greenfield filter is accepted as a safe and effective method of prophylaxis of this complication. The aim of this study was to evaluate the efficacy of placement of the Greenfield filter in 161 patients with major trauma. Between January 1984 and July 1988, 94 patients with an injury severity score (ISS) of > 16 were treated. This score is predictive of a mortality rate of at least 10% and defines major trauma based on anatomic injury. Some 20% (19 of 94) of these patients developed deep vein thrombosis despite standard prophylactic measures and 8% (eight of 94) suffered pulmonary embolism, two of which were fatal. Pulmonary embolism occurred without antecedent evidence of deep vein thrombosis in another 15% of patients (14 of 94), three of which caused death. From August 1988 until July 1992, of 67 other patients with an ISS > 16, 13% (nine of 67) developed deep vein thrombosis and 1% (one of 67) had a pulmonary embolism; this was not statistically significant (P > 0.25). Of these 67 patients who were considered to be at high risk of pulmonary embolism, because of a contraindication to anticoagulation or physical impediment to sequential compression boots, 29 had prophylactic placement of a Greenfield filter. No pulmonary emboli occurred in these patients. During long-term follow-up (mean 32.8 (range 4-58) months), 84% of the surviving patients (21 of 25) underwent duplex ultrasonography of the inferior vena cava; patency of the vessel was confirmed in all patients.

NMR measurements of Na+ and cellular energy in ischemic rat heart: role of Na(+)-H+ exchange

Interleaved 23Na- and 31P-nuclear magnetic resonance (NMR) spectra were continuously collected on perfused rat hearts subjected to low-flow ischemia (30 min, 10% flow) or zero-flow ischemia (21 min) followed by reperfusion. During untreated low-flow and zero-flow ischemia, intracellular Na+ (Nai+) increased by 53 +/- 11 (+/- SE) and 78 +/- 8%, respectively, and remained elevated for zero-flow hearts. However, during both low- and zero-flow ischemia, Nai+ did not increase in hearts treated with the Na(+)-H+ exchange inhibitor, 5-(N-ethyl-N-isopropyl)amiloride (EIPA). The pH decreases during ischemia were unchanged. EIPA treatment reduced ATP depletion during ischemia. During reperfusion from zero-flow ischemia, EIPA-treated hearts displayed more rapid and extensive recoveries of phosphocreatine and ATP. Recovery of left ventricular developed pressure was improved for zero-flow hearts treated with EIPA during the ischemic period exclusively (104 +/- 13%) compared with untreated hearts (36 +/- 21%). These data indicate that Na(+)-H+ exchange is an important mechanism for Nai+ accumulation, but not for pH regulation, during myocardial ischemia. Additionally, Nai+ homeostasis plays an important role in the postischemic recovery of cellular energy and ventricular function.

Amaurosis fugax: is it innocuous?

A 10 year retrospective study of 103 patients with amaurosis fugax was done. Sixty-two patients with symptoms of amaurosis fugax underwent arteriography, which demonstrated ulcerated carotid plaque in 36 and hemodynamically significant stenoses (greater than 75% diameter reduction) in 26. These 62 patients underwent carotid endarterectomy. The other 41 patients who had proven ulcerated plaque (33 patients) or hemodynamic stenoses (eight patients) were not treated surgically and served as a control series. No strokes or deaths occurred in the immediate postoperative period. Follow-up of the 62 operated patients extending to 10 years (mean 4.2 years), revealed one (1.6%) patient with recurrent amaurosis fugax symptoms, two (3.2%) with transient ischemic attacks, and one (1.6%) with a stroke in the operated hemisphere. In the nonoperated group, despite aspirin or warfarin treatment, four (9.7%) patients had ongoing amaurosis fugax symptoms, and two (4.8%) developed transient ischemic attacks that led to carotid endarterectomy. One (2.4%) other patient developed sudden, permanent monocular blindness, and two (4.8%) suffered hemispheric strokes, one of which was fatal. The cumulative morbidity (ongoing ocular or transient ischemic attack symptoms, perioperative and late stroke) in the operated group was 6.4% (four patients), while the cumulative morbidity in the nonoperated group was significantly higher at 21.9% (nine patients) (p = 0.02). When patients present with symptoms of amaurosis fugax and have demonstrable carotid bifurcation disease, carotid endarterectomy is recommended. Amaurosis fugax should be regarded as a harbinger of monocular blindness and stroke.

Nd:YAG iliac and femoropopliteal laser angioplasty: results with large probes as "sole therapy"

Laser assisted balloon angioplasty with a laser heated metallic capped fiberoptic catheter may be effective in the treatment of femoral and iliac artery occlusive disease. In order to avoid the inherent trauma of balloon angioplasty, yet at the same time "debulk" atheroma, 75 patients underwent laser angioplasty of the superficial femoral and iliac arteries as "sole therapy". Laser angioplasty was performed using an Nd:YAG laser coupled to a 600 micron fiber and a 3.5 mm probe (22-28 watts), 4.2 mm or 5.0 probe (32-40 watts). Fifty-nine patients had laser angioplasty for claudication and 16 for limb salvage. The initial angiographic success rate was 84% (41/49) (lesion length 2-14 cm) for the superficial femoral and 69% (18/26) (lesion length 2-14 cm) for the iliac arteries. In follow-up extending to 21 months (mean 14.4 months) 73% (30/41) of the superficial femoral artery and 76% (14/18) of the initially recanalized iliac arteries remain patent. When initial failures are included, this represents an overall intermediate-term patency rate of 52% (32/49) for superficial femoral and 49% (14/26) for iliac arteries respectively. By avoiding the disruptive effect on the arterial wall architecture caused by balloon angioplasty, while at the same time ablating and vaporizing more atheromatous material with larger laser probes, the long-term patency rates of laser angioplasty as "sole therapy" may prove to be superior to those of laser assisted balloon angioplasty.

Carotid patch angioplasty: immediate and long-term results

To determine the benefit of carotid patch angioplasty, a retrospective study of 1000 consecutive carotid endarterectomies was done. Based on the type of carotid endarterectomy closure, patients were divided into four groups: 250 had primary closure, 250 had expanded polytetrafluoroethylene patch, 250 had Dacron patch, and 250 had saphenous vein patch. On the basis of operative technique or type of carotid artery closure, no statistical difference was found in the incidence of postoperative stroke (p greater than 0.25): primary closure 1.6% (4), expanded polytetrafluoroethylene 2.0% (5), Dacron patch 1.6% (4), and saphenous vein patch (0). Postoperative carotid patency was determined by B-mode ultrasonography, and 717 patients were evaluated in follow-up extending to 6 years (mean 37.8 months). Based on the method of carotid endarterectomy closure, no significant difference (p greater than 0.25) was found in the incidence of significant restenosis (greater than 50% diameter reduction): primary closure 4.0% (7), expanded polytetrafluoroethylene 4.0% (6), Dacron 5.4% (9), and saphenous vein 1.0% (2). Significant restenosis was most frequent in habitual smokers (93%, 25/28) and females (78%, 22/28) despite the method of carotid endarterectomy closure. No statistical difference was found in the incidence of late ipsilateral stroke either (p greater than 0.25): primary closure 2.9% (5), expanded polytetrafluoroethylene 2% (3), Dacron 5% (3), and saphenous vein 0%. These results indicate that the incidence of postoperative stroke, regardless of method of arterial closure, was not statistically different. The method of carotid closure did not appear to affect the occurrence of late ipsilateral stroke or restenosis; however, patch angioplasty with saphenous vein appears appropriate in habitual smokers, and likely in patients with small internal carotid arteries.

Prosthetic above-knee femoropopliteal bypass for intermittent claudication

There is no consensus about the most appropriate management of the patient with intermittent claudication due to a superficial femoral artery occlusion. To evaluate the natural history of prosthetic above-knee femoropopliteal (AKFP) bypass, 200 operations for intermittent claudication were reviewed. One hundred AKFP bypasses were done with PTFE and 100 with dacron. In the 30 day postoperative period, four PTFE and three dacron grafts occluded without consequence and only one patient died. Analysis of results by the life-table method demonstrated statistically similar primary graft patency rates at five years (PTFE 65% SE +/- 6.5, dacron 57% +/- 6.2) and ten years (PTFE 31% +/- 18/9, dacron 32% +/- 13.2) (p greater than 0.10). Redo procedures (e.g., thrombectomy, angioplasty) were necessary on 21 grafts (12 PTFE, 9 dacron) and "secondary" patency rates at five years were 76% PTFE and 62% dacron; no grafts which required a redo procedure were patent at ten year follow-up. Major amputations during ten year follow-up were necessary in 16 (8%) patients; all amputations were in diabetic patients. Survival rates were 79% at five and 42% at ten years. An anticipated, the leading cause of death was cardiac related (25 patients); 28 (14%) patients underwent aortocoronary bypass during follow-up. A prosthetic AKFP bypass graft is a safe and durable operation which provides relief from the symptoms of intermittent claudication while allowing for the preservation of the saphenous vein for use later in the coronary or infrapopliteal circulations, should the need arise. These results indicate that the risk of amputation after AKFP is no greater than the natural history of untreated claudication; however, AKFP offers a significant improvement in life-style.

Case report 589: Use of Ostamer in fusion of lumbar spine, postoperative appearance

In the late 1950s and early 1960s there was intense orthopedic interest in a plastic polyurethane foam (Ostamer) that could be used in the fixation of fractures, performance of arthrodesis, and in spinal fusions. It saw limited success at that time but eventually fell from favor. A patient presenting with a draining sinus in the buttock, back pain, and a history of lumbar spinal fusion with Ostamer was recently scanned in our department. The CT appearance of Ostamer and a brief review of the literature are reported.

Massive pulmonary embolism: triple-armed therapy

Many patients who suffer a massive pulmonary embolus die despite emergent therapy. In these desperately ill patients an aggressive, combined method of management was initiated to improve their chances and quality of survival. During a 5-year period 10 patients were treated with (1) low-dose topical, intrapulmonary thrombolytic therapy to dissolve thrombus, (streptokinase or urokinase); (2) anticoagulation to prevent thrombus propagation (heparin); and (3) the simultaneous insertion of a Greenfield filter to prevent the early, recurrent, and therefore potentially fatal pulmonary embolus--"triple-armed therapy." Thrombolytic therapy was administered through a Swan-Ganz catheter wedged against the pulmonary embolus. During the same interval 10 other patients also sustained massive pulmonary emboli but were treated only with systemic heparin. Serial pulmonary arteriography was performed daily. The patients treated by triple-armed therapy responded favorably with a rapid (less than 6 hours), significant improvement in PaO2, pulmonary artery pressure, cardiac output, pulmonary vascular resistance, and blood pressure, compared with patients treated with continuous heparin alone. Nine patients in the triple-armed therapy group survived whereas only six in the heparin group survived. Two additional patients were treated by triple-armed therapy and had thrombolysis with triple-armed therapy with tissue plasminogen activator; these patients demonstrated the most rapid improvement in cardiorespiratory dynamics and arteriographic clearance of emboli. This management protocol shows promise for patients who sustain a massive pulmonary embolus, because it reduces the morbidity associated with pulmonary embolectomy while avoiding the hazards associated with systemic thrombolytic therapy.

Preventing drug dependency: Part 2, Educating and supporting staff

Nurse administrators can respond to the chemical abuse problem in one of two ways. They can deny it, ignore it, avoid confrontation, and terminate the employee. Such action jeopardizes both the nurse and patients. Alternatively, nurse administrators can deal with the problem by recognizing its prevalence in society, educating their personnel, providing support systems for staff, and establishing controls. By choosing this latter course of action, nurse managers evidence humanity and concern for patients, the profession, and individual practitioners.

Preventing drug dependency: Part I, Recognizing risk factors

Nurse administrators are in a key position to develop strategies to deter drug abuse by their staff. This two-part series of articles discusses the development of a prevention program. This first article describes risk factors associated with initial and continuing drug use by nurses. The second article (January 1989) will present an educational program based on these risk factors and suggest ways to provide staff with support.

Carotid endarterectomy after reversible ischemic neurologic deficit or stroke: is it of value?

The benefit of carotid endarterectomy (CE) in preventing recurrent stroke and improving survival in the patient who has sustained a reversible ischemic neurologic deficit (RIND) or stroke is still controversial. To determine the long-term benefits and value of CE in these patients, a 10-year review of 253 patients who suffered a RIND or stroke was conducted. All patients had CT brain scans, as well as arch, extracranial, and intracranial arteriography; any patients without demonstrated carotid bifurcation disease were excluded from the study. On the basis of clinical symptoms and CT scan findings, 66 patients were categorized as having sustained a RIND and 187 a stroke. One hundred fifty-one patients who suffered a RIND or stroke had CE, whereas 102 patients with RIND or stroke did not have CE and served as a control group. All endarterectomies were performed with a temporary indwelling shunt. Postoperative complications included two deaths (1%), six strokes (4%), and 10 transient neurologic deficits (7%). In follow-up extending to 10 years the cumulative incidence of recurrent stroke was only 7% (11 patients) in the operated group, whereas 18% of patients in the nonoperated control group (18) sustained a recurrent stroke (p less than 0.05). As anticipated, the leading cause of death during follow-up was cardiac related; although CE did not significantly improve long-term survival, there was more than a twofold decrease in the incidence of recurrent stroke as a cause of death in the group having CE.(ABSTRACT TRUNCATED AT 250 WORDS)

Axilloaxillary bypass: is it worthwhile?

To evaluate the efficacy and long-term patency results of axilloaxillary bypass, a review of 32 patients with follow-up extending to 11 years was done. Twenty-two bypasses were performed for vertebrobasilar symptoms or subclavian steal and 10 for upper extremity claudication and/or ischemia. The mean age of the operative group was 66 years, 94% of patients had more than one atherosclerotic risk factor (hypertension, diabetes, coronary artery disease, smoking), and 75% had undergone a previous arterial reconstruction operation. There were no operative deaths, and the only postoperative complication was a sterile seroma which responded to aspiration. At late follow-up extending to 11 years, three grafts had thrombosed while another became infected and had to be removed; no limb loss resulted from these graft failures and the actual late patency rate was 87%. Carotid-subclavian bypass, intrathoracic bypasses, and endarterectomy at the site of occlusion have all been suggested for the treatment of symptomatic proximal subclavian artery disease. With axilloaxillary bypass, however, the hazards associated with carotid artery manipulation, operation on the notoriously treacherous subclavian artery, and the morbidity related to thoracotomy in this older, high-risk patient population can be avoided. The axilloaxillary bypass is safe and simple, and the excellent long-term patency rates make it the procedure of choice for symptomatic subclavian artery disease.

Carotid endarterectomy to correct asymptomatic carotid stenosis: ten years later

The ideal management of the patient with an asymptomatic stenosis of the extracranial internal carotid artery remains controversial. The purpose of this article was to evaluate the effects of prophylactic carotid endarterectomy (CE) done to treat asymptomatic carotid stenosis (greater than 50% diameter reduction by angiography) 10 years later. In 1976, 42 prophylactic CEs were performed. There were no postoperative deaths or strokes. During 10-year follow-up two strokes occurred in the operated hemisphere; one stroke was fatal and was due to an intracranial hemorrhage, whereas the other stroke was thromboembolic in origin. Two other patients suffered strokes in the contralateral hemisphere and seven patients had transient ischemic attacks in the contralateral hemisphere, which necessitated CE. The survival rate at the end of the study period by life-table analysis was 57% (mean 8.7 years). Sixteen late deaths occurred, with coronary artery-related disease the most common cause of death. This review with actual 10-year follow-up demonstrated that prophylactic CE may be performed with minimal risk, that late stroke in the operated hemisphere was negligible, and that long-term survival was similar to that of a comparable age-matched population, possibly because late deaths attributed to stroke were reduced. On the basis of long-term follow-up, CE to treat asymptomatic high-grade carotid stenoses appears to be indicated in appropriate patients.

Prevention of postoperative neurologic deficits after carotid endarterectomy. Is platelet inhibition beneficial?

Aspirin (ASA) and dipyridamole (DIP) have been shown to reduce the incidence of transient ischemic attacks (TIAs), but aspirin's ability to reduce the incidence of postoperative neurologic deficits in patients who require carotid endarterectomy (CE) is controversial. To evaluate the role of adjunctive ASA/DIP in conjunction with CE, 908 CE cases were reviewed. Four hundred sixty-seven patients took ASA (650 mg/day) and DIP (150 mg/day) preoperatively, while 381 received no ASA/DIP. There was no statistical difference in the distribution of postoperative neurologic deficits. Twenty-six transient deficits occurred: 14 (53%) patients were taking ASA/DIP, whereas 12 (47%) were not. Seventeen permanent deficits occurred: ten (58%) patients were taking ASA/DIP and seven (42%) were not. ASA/DIP are useful medications in combating ischemic cerebrovascular disease, but ASA/DIP cannot replace precise operative technique which affords unequaled protection against a postendarterectomy neurologic deficit.

Traumatic superior mesenteric arteriovenous fistula: report of a case and review of the literature

Penetrating arterial injuries can result in the formation of a traumatic false aneurysm or an arteriovenous fistula. Traumatic arteriovenous fistulas of the mesenteric circulation are extremely rare, with only 15 operated cases reported in the English language literature that involved the superior mesenteric artery and vein. Although surgical intervention has been considered the most successful method to treat traumatic mesenteric arteriovenous fistulas, percutaneous transcatheter embolization has been occasionally advocated in the management of small iatrogenic fistulas. We report a case of a gunshot wound patient who had an 8 cm abdominal aortic false aneurysm, as well as a high-flow arteriovenous communication between the superior mesenteric artery and vein, which were successfully treated by a combination of aorto-superior mesenteric bypass and postoperative percutaneous transcatheter embolization. A review of the literature is also included.

"Chronic-contained" ruptured abdominal aortic aneurysm: is it real?

Rupture of an abdominal aortic aneurysm is readily diagnosed when the triad of abdominal or back pain, shock and a pulsatile abdominal mass are present. Clinical diagnosis can be difficult, however, when patients present with chronic pain and an aneurysm which is not readily palpable. In these patients with confusing abdominal symptoms, CT scan provides a rapid, noninvasive diagnosis. The acute leaking AAA has been documented, but only rarely. This report identifies two patients who ruptured an aortic aneurysm several "months" prior to operation--a "contained chronic" rupture.

Carotid endarterectomy in the octogenarian: is it appropriate?

To evaluate the role of carotid endarterectomy (CE) in patients 80 years and older an 8-year study of 172 nonrandomized cases of octogenarians with cerebrovascular disease was done. Ninety octogenarians underwent CE whereas 82 octogenarians, with arteriographically established carotid artery disease, were not operated on and served as a control series. The stroke rate after CE was 6%. In follow-up extending to 8 years the late stroke rate was only 2%, whereas the cumulative long-term stroke rate in the nonoperated group was 16%. These late strokes were appropriate to the side of the arteriographically demonstrated disease. In 1008 nonoctogenarians who underwent CE during this same time interval, the stroke rate after CE was 2% and the mortality rate was 0.6%. In the octogenarian population, however, the mortality rate after stroke was an alarming 40% in the operated group and 62% in the nonoperated control group. Arteriographic flow-limiting (greater than 75% stenosis) intracranial occlusive disease was identified in 53% of the octogenarians undergoing operation and in all patients who suffered a postoperative neurologic deficit. This incidence of severe intracranial disease was nearly five times that of the nonoctogenarian patients undergoing CE. Although the stroke rate after CE in the octogenarian patient was 6%, the late stroke rate was only 2% compared with the cumulative stroke rate of 16% in the nonoperated octogenarian patients. Severe intracranial occlusive disease and, therefore, flow deprivation may play a more significant role as a cause of postoperative deficits than in younger patients, but CE is appropriate for selected octogenarians on the basis of physiologic rather than chronologic age.