Objective: To compare the results and time and cost efficacy of eversion carotid endarterectomy (ECEA) with standard carotid endarterectomy (SCEA). Methods: A retrospective analysis of 88 carotid endarterectomies performed by the residents under the guidance of the senior author between January 1, 1991, and December 31, 1993, was done. Fifty-five patients underwent SCEA (44 vein patch, 11 primary closure) and 33 had ECEA. The two groups were compared for operative time, intraoperative evaluation, cost, immediate and delayed morbidity, and restenosis (> 50%). Results: The two groups were found to be similar for age, sex ratio, and associated diseases. The indications for surgery were transient ischemic attack (TIA) (57% ECEA, 64% SCEA), previous stroke with minimal residual deficit (9% ECEA, 17% SCEA), and asymptomatic high-grade stenosis (34% ECEA, 19% SCEA). The average operative time for ECEA was significantly less (99.2 vs 135.2 minutes, P < 0.02). The mean blood loss was also less for ECEA (86 vs 181 cc). Two SCEA patients had immediate postoperative thrombosis resulting in 1 cerebrovascular accident (CVA) (1.8%), and 3 SCEA patients had cranial nerve injuries. In follow-up, 1 patient with SCEA had restenosis and 1 had a CVA unrelated to carotid disease. Morbidity associated with ECEA included 1 unsuccessful ECEA requiring interposition vein grafting and 1 intraoperative repair of an intimal flap. There was no associated residual morbidity. There was no significant difference in stroke rate between the two groups. The operative cost (excluding surgeon fee) was 28% higher for SCEA patients. Conclusion: Eversion carotid endarterectomy is a safe procedure and can be an important addition to a surgeon's armamentarium in efforts to cut costs while maintaining quality.
Standard polytetrafluoroethylene (PTFE) grafts (30-microns internodal distance, ID) (ST grafts), high-porosity PTFE grafts (90 microns ID) (HP grafts), high-porosity PTFE grafts preclotted with autogenous blood (BHP grafts), and high-porosity PTFE grafts presealed with fibrin glue (FHP grafts) were implanted in both common carotid and femoral arteries of 18 dogs. Of the three high-porosity groups, the FHP graft showed the shortest bleeding time. Seromas and/or hematomas occurred as follows: ST grafts 1, HP grafts 7 (P < .05 vs ST), BHP grafts 5 and 2 with FHP grafts. Fibrin glue was observed in all histological sections of 1-week samples, but by 4 weeks it was almost totally absorbed. No endothelialization (ET) was measurable at 2 weeks. By 4 weeks ET extended for a short distance from each anastomosis and there were no significant differences between the four graft groups. At 18 weeks, the HP, BHP, and FHP grafts showed a significant increase in ET compared with the ST graft (P < .01) but there were no significant differences between the three types of high-porosity graft. The differences in patency rates and neointimal thicknesses did not reach statistical significance. High-porosity PTFE grafts showed superior endothelialization in dogs; however, the enlarged ID of PTFE grafts increased intraoperative bleeding and postoperative seroma formation. Fibrin glue sealant controlled bleeding through the graft wall without affecting graft healing, but its sealant effect was not enough to prevent late fluid leakage.
Angiosarcomas are rare neoplasms of the head and neck region accounting for less than 1% of malignancies. The median survival after diagnosis varies from eleven to twenty months. The authors present a case of angiosarcoma that was difficult to diagnose at initial presentation. After initial diagnosis and treatment, the patient developed regional metastasis (parotid gland/neck) at three months, femoral head metastasis at two and one-half years, and liver metastasis at five years. These occurrences were treated aggressively. The patient is now almost seven years postpresentation and apparently disease-free and working full time.
The differences in nature, etiology, and outcome of abdominal aortic aneurysms (AAA) in females have received little attention. We retrospectively analyzed 23 females undergoing elective AAA repairs in the hands of one surgeon at Guthrie Clinic and compared them with agematched males from the same population undergoing elective AAA repairs over the same time period (19 years).
The fastest growing population in the United States is greater than seventyfive years of age, and this is the population most prone to strokes. There has been some hesitation in performing carotid endarterectomy in the elderly. In this study, the authors attempted to evaluate short-and long-term effects of carotid endarterectomy in the elderly population and also compared these with those in younger patients. Results of 74 carotid endarterectomies in 68 patients more than seventy-five years of age performed by a single surgeon at Robert Packer Hospital/Guthrie Clinic in rural Pennsylvania over the past fifteen years were evaluated. These were compared with a similar number of surgeries done in younger patients by the same surgeon over the same time period. They found a 4% perioperative stroke rate and 4% perioperative mortality in the elderly patients compared with 4% perioperative stroke rate and 2.7% perioperative mortality in younger patients. Life table analysis done for elderly patients revealed a cumulative survival of 76.9% and a stroke-free survival of 70% at ten years. They found carotid endarterectomy as well tolerated in the elderly population as in the younger patients. The long-term benefits of carotid endarterectomy in the elderly in their setting have been excellent, and there is much to recommend this surgery in elderly patients with carotid artery stenosis.
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