Vascular
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Virtual reality (VR) simulations have long been used for training in aviation and other professions. High-fidelity endovascular procedure simulators are now available, providing procedure simulations with real-time interactions; two-dimensional graphic displays of angiographic anatomy; mechanical interfaces with guidewires, sheaths, and catheters that provide some degree of haptic feedback; modeling of physiologic and pharmacology responses; and other features. ⋯ Early experience has shown that simulation is well accepted by trainees, performance on simulators improves with training and practice, and simulation prior to first performing endovascular procedures can improve clinical performance. Specific to CAS, the value of education programs using simulators appears to be tangible as trained but inexperienced CAS operators have clinical results comparable to those of physicians with extensive CAS experience.
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Multicenter Study
Stent-graft treatment of pseudoaneurysms and arteriovenous fistulae in the carotid artery.
The purpose of this study was to assess the safety and efficacy of stent-graft placement in the management of arteriovenous fistulae (AVF) and pseudoaneurysms (PAs) involving the carotid artery (CA). Twenty-two patients (16 men, 6 women) with a CA AVF (n = 5) or PA (n = 17) owing to a gunshot or stab wound, carotid endarterectomy, blunt trauma, a tumor, spontaneous dissection, or a central venous catheter were treated with percutaneous placement of stent grafts. The patients presented with tumor, bruit, headache, mouth and tracheostomy bleeding, transitory hemiparesis, seizure, or stroke. ⋯ Three other patients died of causes unrelated to stent-graft placement. In all other patients, the stent graft remained patent. Our results indicate that stent grafting is an acceptable alternative to surgery in the treatment of AVF and PAs in the CA.
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Randomized Controlled Trial
Pain associated with carotid artery surgery performed under carotid plexus block: preemptive analgesic effect of ketorolac.
Carotid artery surgery (CAS) performed under cervical plexus block is frequently associated with significant intra- and postoperative pain. To evaluate whether preoperative administration of ketorolac may improve analgesia in this type of surgery, 80 patients scheduled for CAS under cervical plexus block were randomly allocated to receive intravenously either 30 mg of ketorolac or placebo 30 minutes before surgery. Verbal rating scale pain scores during surgery and 3 and 6 hours after surgery, the number of patients requiring additional analgesia, and the total analgesic consumption both during and within 6 hours after surgery were significantly lower, whereas the time to first postoperative analgesia was significantly shorter in the ketorolac group than in the control group. The results of this prospective, randomized, double-blind study show that a single 30 mg dose of ketorolac administered intravenously 30 minutes before surgery reduces intraoperative pain and preempts postoperative pain in patients undergoing CAS under carotid plexus block.
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Comparative Study
Paravertebral blockade with propofol sedation versus general anesthesia for elective endovascular abdominal aortic aneurysm repair.
The objective of this study was to evaluate the applicability of paravertebral blockade (PVB) for endovascular abdominal aortic aneurysm repair compared with general anesthesia (GA). Data from patients who underwent elective infrarenal endovascular abdominal aortic aneurysm repair between August 2001 and July 2002 using PVB or GA were retrospectively reviewed and compared with respect to risk factors, intraoperative hemodynamic characteristics, operative outcome, and complications. Ten patients underwent elective infrarenal endovascular abdominal aortic aneurysm repair under PVB, whereas 15 patients were operated on under GA. ⋯ The perioperative (< 30 days) cardiovascular morbidity and overall mortality were zero in both groups. The PVB group benefited significantly with respect to the incidence of intraoperative hypotension (p < .05) and blood pressure lability (p < .01), as well as postoperative nausea (p < .01). Our preliminary results indicate that PVB is feasible and can be performed safely in a patient population with significant comorbidities.
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Owing to the overall poor medical health of patients with end-stage renal disease, we have sought alternatives to the use of general anesthesia for access procedures. Furthermore, since local anesthesia (1) does not offer the motor block that is sometimes desired and (2) can be difficult to maintain when a large amount of vein needs to be transposed, we examined whether regional blocks can be useful for the creation of new arteriovenous fistulae (AVF). From August 2002 to January 2005, 41 patients scheduled for AVF placement underwent a regional block with the use of a lidocaine and ropivacaine mixture using a nerve stimulator. ⋯ Accesses placed included 20 radiocephalic AVF, 8 brachiobasilic AVF, 8 brachiocephalic AVF, 2 arteriovenous grafts, 2 radiobasilic AVF, and 1 brachial vein AVF. Regional block is a safe and, in our opinion, preferred technique for providing anesthesia for upper extremity vascular surgery. The venodilatation observed is augmented compared with that using a tourniquet and may allow more options for access placements.