These data suggest that perioperative statin use may reduce the incidence of cerebrovascular events and mortality among patients undergoing CEA.

Laparoscopic decompression of the CA may be a useful therapy for CACS, but there is potential for vascular injury, and adjunctive CA intervention is often required. Surgeons should consider laparoscopic CA decompression as a therapeutic alternative for CACS and should participate in the care of patients with this diagnosis.

Although Crawford's inclusion method of visceral patch construction is generally durable, patients undergoing thoracoabdominal aortic replacement require yearly surveillance for the detection of aneurysmal expansion of the visceral patch. We recommend limiting visceral patch size at the original operation by routinely excluding the orifice of the left renal artery. Patients at high risk for recurrent aneurysmal expansion, such as those with connective tissue disorders, will benefit from creating small visceral patches and possibly implanting both renal arteries separately during the original operation.

Subdural hematoma is an unusual and potentially catastrophic complication after TAAA repair. Prompt recognition and neurosurgical intervention is necessary for survival and recovery after acute presentation. Epidural placement of a blood patch is recommended if a chronic subdural hematoma is detected. Care should be taken to ensure that excessive CSF is not drained perioperatively, and higher (10 cm H(2)O) lumbar drain popoff pressures may be necessary together with meticulous monitoring of patient position and neurologic status.

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The approach with selective intercostal angiography did not improve overall results. One third of our patients were not studied, and they fared as well as patients who were studied and the GRA was localized (not studied, 4 of 49, 8% with SCD; GRA localized, 3 of 65, 5% with SCD; P =.8). However, when the GRA was found, SCD occurred only in patients with aortic dissection. The studies confirmed the concept that the existence of mural thrombus in degenerative aneurysms results in the occlusion of many intercostal arteries, leaving those remaining patent to supply rich vascular watersheds through acquired collateral channels. As a result, in the group of patients with degenerative aneurysms, the identification of the critical intercostal artery allows focused reimplantation with uniform success. This is not the case in patients with aortic dissection. In those patients, most intercostal vessels remain patent, such that the insertion of one pair is insufficient to supply the paravertebral plexus and the spinal cord. Finally, failure to identify the GRA angiographically with our methods does not provide assurance that the GRA does not exist. Therefore negative findings did not provide license to ligate all intercostal arteries.

A dramatic decrease in the in-hospital stroke rates in Maryland occurred around 1995. The stroke rates in Maryland in the past 5 years are similar to those in California during the same period. An analysis of data from the two states shows that the in-hospital stroke rate now for carotid endarterectomy is approximately 0.54%.

No abstract