Five hundred thirty-nine patients with no symptoms of cerebral ischemia undergoing coronary artery bypass were preoperatively evaluated for presence of carotid stenosis by noninvasive methods (duplex scanning and ocular pneumoplethysmography-Gee). Overall prevalence of carotid stenosis greater than 75% was higher (8.7%) than that generally reported. Age greater than 60 years was significantly related to presence of carotid stenosis greater than 75% (11.3% vs 3.8%, p = 0.003). Risk factors such as hypercholesterolemia, hypertension, diabetes mellitus, and smoking were not predictive for carotid stenosis, postoperative stroke, or death. Carotid stenosis greater than 75% (odds ratio 9.87, p less than 0.005) and coronary artery bypass redo (odds ratio 5.26, p less than 0.05) were both independent predictors of stroke risk. Patients were divided into four groups: group 1, minimal or mild degree of carotid stenosis (less than 50%), not submitted to prophylactic carotid endarterectomy (432 patients, 80.1%); group 2, moderate degree of stenosis (50% to 75%), no prophylactic carotid endarterectomy (60 patients, 11.2%); group 3, severe carotid stenosis; (greater than 75%), submitted to prophylactic carotid endarterectomy (19 patients, 3.5%), group 4, severe carotid stenosis (greater than 75%) no prophylactic carotid endarterectomy (28 patients, 5.2%). Patients in group 4 had significantly higher stroke rate (14.3%) compared to the other three groups (1.1%) (p = 0.0019). The finding of carotid stenosis greater than 75% in patients over 60 years of age was associated with occurrence of stroke in 15% of cases. Carotid screening is helpful to determine patients at increased risk of stroke and should be performed in patients greater than 60 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome of 113 operations for ruptured abdominal aortic aneurysms were reviewed to determine the contribution of perioperative events to mortality rates. Preoperative, intraoperative, and postoperative factors were examined with regard to their influence on early and late deaths. A mortality rate of 64% (72/113) was unrelated to age, gender, and preexistent medical conditions. Death within 48 hours occurred in 42 of 72 patients (58%). Preoperative status, including cardiac arrest, loss of consciousness, and acidosis influenced early deaths (less than 48 hours) but not late deaths. Early deaths were also influenced by severe operative hypotension and excessive transfusion requirements. Late deaths (greater than 48 hours) occurred in 30/72 cases (42%) at a mean of 24.6 +/- 22.9 days. Late death was related to postoperative organ system failure, specifically renal and respiratory failure, and the need for reoperation. The overall mortality rate was influenced by preoperative, intraoperative, and postoperative factors. Postoperative renal failure was the strongest predictor of overall deaths. Survival after ruptured abdominal aortic aneurysm depends on intraoperative and postoperative complications as well as preoperative conditions. Late death, the greatest strain on resources, is independent of preoperative status. The thesis that some patients with ruptured abdominal aortic aneurysm should be denied operation to conserve resources is not supported by these data. Efforts to improve survival should focus on reducing intraoperative complications and improving management of postoperative organ failure.

We conducted a retrospective review of all patients undergoing repair of abdominal aortic aneurysm at or above the proximal anastomosis of a previous infrarenal aortic graft between 1986 and 1991. Infected grafts and patients with suprarenal aneurysms present at the time of the original graft were excluded. Twenty-one patients, 19 men and two women, were included. The original indication for surgery was aneurysm in 14 patients and occlusive disease in seven; the mean interval from initial surgery to presentation was 10 years (range, 3 to 23 years). Twelve lesions were anastomotic false aneurysms, and nine were true aneurysms beginning in the proximal juxta-anastomotic aorta. Fourteen patients had an asymptomatic abdominal mass. Seven patients had symptoms of acute expansion (three), rupture (three), or thrombosis (one). True aneurysm and symptomatic presentation were correlated with aneurysm as the original indication for surgery. Repair was accomplished by an interpositional graft in 13 and graft replacement in eight. Seven patients required suprarenal anastomosis or renal and visceral reconstruction. Five operative deaths (24%) occurred, including two of three patients with rupture (67%) and two of seven patients (28%) in the suprarenal group. The mortality rate for elective repair with an infrarenal anastomosis was 11%. Two additional late deaths occurred during the follow-up period.

Aortoiliac or infrainguinal disease diagnosed in patients less than 50 years of age portends a poorer outcome than does similar disease in an older patient population.

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Absence of all three risk factors indicates a very low risk for DVT (1.1%). Screening of SICU patients is indicated because of a high prevalence of asymptomatic disease. Patients who have proximal DVT require active therapy and not prophylaxis. Costs and resources may be contained by using the above risk factors as a filter for duplex screening.

When the saphenous vein is used in the in situ position for arterial bypass surgery, it is associated with more optimal preservation of the endothelial lining and with improved graft patency compared with reversed vein grafts. However, it is not clear whether preservation of endothelial integrity persists after arterialization. The goal of this study was to establish whether preservation of the endothelium before arterialization is a critical factor in the development of late functional and morphologic abnormalities of autogenous vein grafts. Paired reversed and in situ vein grafts were created in 75 mongrel dogs. Veins to be used in the reversed position were excised and stored in either heparinized whole blood at 37 ° C or saline solution at 4 ° C. Veins were studied before and after arterialization. The veins were arterializcd by anastomosis to the carotid artery and excised at intervals of 1 day to 12 weeks for studies of the luminal production of prostacyclin and thromboxane A2 in addition to luminal morphology. Before arterialization, normothermic whole blood preserved biochemical function of the endothelium significantly better than hypothermic saline solution, but not as well as the in situ vein procedure. Soon after arterialization, all three vein grafts showed significant functional and morphologic abnormalities consistent with injury of the vein graft. Morphologic healing of the endothelial monolayer progressed slowly back to normal; however, the biochemical capacity of the vein graft never matched that of the prearterialized vein, nor that of normal host arteries. Regardless of surgical technique, all vein grafts exhibited a period of abnormal structure and fimction, which exposed them to the risk of thrombogenesis. This period of potential leukocyte or platelet interaction with the vein wall could lead to release phenomena as well as proliferative changes in the vessel wall. (J VAsc SURG 1986; 3:204-15.)The autogenous saphenous vein is the preferred conduit for vascular reconstruction in the coronary, renal, visceral, and lower extremity circulations. Despite the durability of the autogenous saphenous vein graft, thrombosis at the end of 1 year in the coronary and lower extremity circulations ranges from 20% to 50%. 1-~ Graft failure may be due to acute thrombogenesis or to progressive myointimal hyperplasia following endothelial injury. 2' 6~9 Therefore, the commonly accepted goal in vein graft surgery is the implantation of a vein graft that possesses viable endothelium and smooth muscle media with intact metFrom the

To discuss the presentation, diagnosis, and treatment of stent-related infections on the basis of 2 new cases and historical review. Case Reports: Two previously unreported cases of vascular stent infection are presented with a summary of cases from the literature. One case involved an iliac artery stent infection secondary to a remote bacteremia 6 months after stent placement. The other case was an early iliac vein stent infection, a previously unreported site of this complication. Both cases were diagnosed by use of computed tomography and were treated surgically after medical management failed. Both patients survived. Conclusions: A high index of suspicion is necessary for the diagnosis of stent infections, and an aggressive treatment is usually necessary for survival. Prophylactic antibiotics should definitely be considered in cases involving repeat interventions and prolonged catheterization, as well as before bacteremia-inducing therapies.