Background Carotid artery stenting (CAS) has grown as a possible alternative for the treatment of extracranial cerebrovascular disease in the past decade. A pre-existing contralateral carotid artery occlusion has been described as a risk factor for inferior outcomes following carotid endarterectomy (CEA), yet its impact on CAS outcomes is less understood. Methods Retrospective review of 417 CAS procedures from May 2001 through July 2010 at a single center using self-expanding nitinol stents and mechanical embolic protection devices. Patients were divided into those with a pre-existing contralateral carotid occlusion (Group A, n=39) versus those without a contralateral occlusion (Group B, n=378). Patient demographics and co-morbidities as well as 30-day and late death, stroke, and myocardial infarction (MI) rates were analyzed. Mean follow-up was 4.0 years (range 0–9.4 years). Results Overall mean age of the 314 men and 103 women was 70.5 years. In Group A there were 2 (5.1%) octogenarians and 9 patients (23.1%) with symptomatic disease as compared to Group B with 53 (14.0%) octogenarians and 121 (32.0%) patients with symptomatic disease. The overall 30-day death, stroke, and MI rates were 0.5%, 1.9%, and 0.7%. When comparing Group A to Group B these results were not significantly different: death (0% vs 0.5%), stroke (2.6% vs 1.9%), and MI (0% vs 0.8%). Long-term outcomes for Groups A and B were not significantly different: death (25.6% vs 22.2%), stroke (5.3% vs 3.4%), and MI (15.4% vs 14.0%) (p=NS). Conclusion A pre-existing contralateral carotid artery occlusion does not appear to adversely impact CAS outcomes.
Background Delayed carotid endarterectomy (CEA) after a stroke or transient ischemic attack (TIA) is associated with risks of recurrent neurologic symptoms. In an effort to preserve cerebral function, urgent early CEA has been recommended in many circumstances. We analyzed outcomes of different time intervals in early CEA in comparison with delayed treatment. Study Design Retrospective chart review from a single university hospital tertiary care center between April 1999 and November 2010 revealed 312 patients who underwent CEA following stroke or TIA. Of these 312 patients, 69 received their CEA within 30 days of symptom onset and 243 received their CEA after 30 days from symptom onset. The early CEA cohort was further stratified according to the timing of surgery: Group A (27 patients), within 7 days; Group B (17), between 8 and 14 days; Group C (12), between 15 and 21 days; and Group D (12), between 22 and 30 days. Demographic data as well as 30-day (mortality, stroke, TIA, and myocardial infarction) and long-term (all-cause mortality and stroke) adverse outcome rates were analyzed for each group. These were also analyzed for the entire early CEA cohort and compared against the delayed CEA group. Results Demographics and co-morbid conditions were similar between groups. For 30-day outcomes, there were no deaths, 1 stroke (1.4%), 0 TIAs, and 0 myocardial infarctions in the early CEA cohort; in the delayed CEA cohort, there were 4 (1.6%), 4 (1.6%), 2 (0.8%), and 2 (0.8%) patients with these outcomes, respectively (p > 0.05 for all comparisons). Over the long-term, the early group had 1 ipsilateral stroke at 17 months and the delayed group had 2 ipsilateral strokes at 3 and 12 months. For long-term outcomes, there were 16 deaths in the early CEA cohort (21%) and 74 deaths in the delayed CEA cohort (30%, p > 0.05). Mean follow-up times were 4.5 years in the early CEA cohort and 5.8 years in the delayed CEA cohort. Conclusion There were no differences in 30-day and long-term adverse outcome rates between the early and delayed CEA cohorts. In symptomatic carotid stenosis patients without evidence of intracerebral hemorrhage, carotid occlusion, or permanent neurologic deficits early carotid endarterectomy can be safely performed and is preferred over delaying operative treatment.
Bullet embolism to the peripheral arterial system is a rare phenomenon which frequently results in misdiagnosis due to lack of early symptoms. Embolisms can go to either arterial or venous systems with common sites of injury including the left ventricle, pulmonary vein, thoracic and abdominal aorta and peripheral arteries. Herein we present a case of a 19 year old patient with multiple gunshot wounds to the torso with a bullet embolism to the left popliteal artery necessitating embolectomy. This subsequently led to diagnosis and repair of an abdominal aortic psuedoaneurysm not clearly evident on initial imaging.
Carotid endarterectomy (CEA) has been proven to reduce the risk of stroke and death in both asymptomatic and symptomatic patients with carotid occlusive disease. Stroke is the third leading cause of death in the USA. Since up to one-third of stroke patients have a stroke secondary to carotid occlusive disease, it is important to offer CEA to this subgroup of patients that meet indications for surgery. Historically, literature has suggested that the optimal timing to perform CEA is approximately 6 weeks after an acute stroke. This was concluded owing to high perioperative morbidity and mortality if CEA was performed too early. However, data are increasingly showing that some patients do benefit from CEA earlier than 6 weeks after an acute stroke. This article discusses mid-20th Century literature and focuses on more recent 21st Century literature discussing the timing of CEA after acute stroke. Although there are data to support delayed CEA, it is reasonable to perform early CEA in select stroke patient populations. Candidates for early CEA should have complete or near resolution of symptoms, small infarcts on imaging and ipsilateral carotid stenosis.
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