Endothelial function is impaired in children with diabetes mellitus within the first decade of its onset and precedes an increase in carotid IMT. The relative timing of these events is important in the evaluation of strategies to prevent progression of atherosclerosis and other vascular complications in this patient population.

Diabetic autonomic neuropathy is associated with an impaired vasodilator response of coronary resistance vessels to increased sympathetic stimulation, which is related to the degree of SND.

This study from a representative national database documents that HVHs have a significantly lower death rate than LVHs for repair of both intact and ruptured AAA. These data support the regionalization of patients to HVHs for AAA repair.

Mortality rates after AAA repair in VA hospitals were comparable with those previously reported in other large series. Outcomes for veterans with AAA may improve by referring patients eligible for elective repair to VA medical centers with a greater operative volume or to lower-volume centers that have had excellent results.

During the last decade (1980 to 1989) 186 patients with ruptured abdominal aortic aneurysm were admitted to a single urban hospital. Ninety-six percent of these patients had a prehospital systolic blood pressure less than 90 mm Hg. Management included paramedic field resuscitation and transport, an emergency department diagnostic protocol completed in an average of 12 minutes, rapid transport to a dedicated emergency operating room, aneurysmorrhaphy by general surgery chief residents under the supervision of specialist vascular surgeons, and skilled postoperative intensive care unit care. Nevertheless, 130 (70%) patients died in the first 30 postoperative days--3% in the emergency department, 13% in the operating room, 51% in the intensive care unit, and 3% on the ward or at home. Certain features--age greater than 80 years, female gender, persistent preoperative hypotension despite aggressive crystalloid and blood replacement, admission hematocrit less than 25, transfusion requirements exceeding 15 units--were associated with a greater than 90% likelihood of death. No patient with preoperative cardiac arrest survived more than 24 hours. From this experience we conclude that, although "optimal" prehospital, emergency department, operating room, and postoperative care can improve the outcome of patients with ruptured abdominal aortic aneurysms in shock, most such patients will die. Certain clinical features predict such excessive mortality rates after ruptured abdominal aortic aneurysms that withholding operation may be reasonable. Screening of patients at high risk for abdominal aortic aneurysm, followed by elective aneurysmorrhaphy, is clearly indicated.

During fiscal years 91-95, 6260 patients underwent 6269 abdominal aortic aneurysm (AAA) repairs in Veterans Affairs Medical Centers. Those > or =80 years old comprised 3.7% (n = 231) of the patients. A total of 5833 patients underwent repair of nonruptured AAA: mortality was 4.1% (228/5627) in those <80 and 8.25% (17/206) in those > or =80 years old (p < 0.009). Logistic regression analysis indicated age > or =80 was independently associated with higher mortality (odds ratio 1.834:1, 95% bounds 1.117-3.012). Octogenarian status (defined as > or =80 years of age), however, had a less important association with in-hospital death than did surgical complications of the heart or genitourinary tract, postoperative hemorrhage, septicemia, respiratory insufficiency, myocardial infarction (MI), acute renal failure, surgical complications of the central nervous system (CNS), aneurysm rupture, postoperative shock, or disseminated intravascular coagulation (DIC), in ascending order of importance. Only 5.9% (n = 25) of the 427 patients undergoing repair of ruptured AAA were > or =80 years old. In those > or =80 undergoing repair of ruptured aneurysms, mortality was 48% which did not differ from the 45% mortality in those <80 (NS). The likelihood that one would be operated for rupture was statistically greater (1.66:1) for those > or =80 years (p < 0.025). Length of stay (LOS) for those > or =80 undergoing AAA repair was longer being 22.3 +/- 14.8 days versus 18.3 +/- 13.2 days for younger patients (p < 0.001). Mortality and LOS after AAA repair were statistically greater for those > or =80 years of age. Severity of illness, however, was also greater for octogenarians. Patient Management Category (PMC) software defined illness severity was 4.06 +/- 1.22 in octogenarians versus 3.84 +/- 1.13 for those younger (p < 0.005). Though age > or =80 was independently associated with increased mortality, selected elderly patients could benefit from AAA repair.

Twenty-four atherosclerotic extracranial carotid artery aneurysms were encountered in 21 patients during a 25-year period. These represented 46% of all extracranial carotid artery aneurysms diagnosed at the University of Michigan during this period. Neurologic symptoms including amaurosis fugax, transient ischemic attacks, and stroke were present in 50% of the patients. An asymptomatic pulsatile neck mass occurred in 33%. Surgical therapy was undertaken for 18 aneurysms, and nonoperative treatment was pursued in the remaining six aneurysms. Operative therapy included 14 aneurysmectomies and four aneurysmorraphies. There were no surgical deaths. Transient perioperative neurologic deficits affected three of these patients (17%), and one individual (5%) experienced a permanent deficit. Transient cranial nerve deficits occurred in three patients (17%), and a permanent deficit was noted in one patient (5%). During a 7.6-year follow-up period no late strokes occurred among patients who were operated on. Nonoperative therapy was associated with three ipsilateral strokes during a mean follow-up period of 6.3 years. Atherosclerotic extracranial carotid artery aneurysms were associated with an exceptionally high stroke rate (50%) if treated nonoperatively. Prevention of late stroke justifies surgery, although perioperative neurologic deficits may accompany this therapy more often than with nonatherosclerotic carotid artery aneurysms.

Since ultrasonic energy can be used to interrogate vessels at great depth, it is only natural that it should be applied to deeply placed arteries in the abdomen. Early studies suggested that high-grade stenoses of the renal artery could be detected by this approach as long as the peak systolic velocity in the renal artery was normalized by that measured in the abdominal aorta. A retrospective study comparing the peak velocity in the renal artery to that from the adjacent abdominal aorta (the renal aortic ratio) showed that if this value exceeded 3.5, it is likely to be associated with a greater than 60% diameter-reducing stenosis. To test this hypothesis, we used duplex scanning to prospectively evaluate 58 renal arteries in 29 patients in whom arteriograms were available. There were 39 renal arteries with 0% to 59% stenosis, 14 with 60% to 99% stenosis, and five occlusions by angiography. Renal duplex scanning accurately diagnosed 38 of 39, 11 of 14, and four of five of these, respectively, giving a sensitivity of 84%, a specificity of 97%, and a positive predictive value of 94% for the detection of a greater than 60% diameter-reducing stenosis. The overall agreement with angiography was 93%. These data show that renal duplex scanning can be used to diagnose renal artery stenosis in patients with hypertension or renal dysfunction, thus providing a rational basis for the selection of patients for angiography.