Journal of vascular surgery
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Multicenter Study
Factors associated with a provider's recommendation of carotid endarterectomy: implications for understanding disparities in the use of invasive procedures.
This study assessed the relative importance of clinical and nonclinical factors in a provider's decision to recommend carotid endarterectomy (CEA) for a patient, with emphasis on the role of the patient's race in the provider's assessment of the risks and benefits of the procedure. ⋯ A major determinant of a provider's recommendation for a patient to receive CEA endarterectomy is the assessment of the patient's likely future risk of stroke, regardless of the patient's race.
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Preoperative knowledge of the blood-supplying trajectory to the spinal cord is of interest, because spinal cord ischemia may occur during thoracic aortic aneurysm (TAA) and thoracoabdominal aortic aneurysm (TAAA) repair and possibly leads to paraplegia. The Adamkiewicz artery (AKA) is considered to be the most important blood supplier of the thoracolumbar spinal cord and has therefore been the focus in preoperative diagnostic imaging. However, in TAA(A) patients, the blood supply to the spinal cord may strongly depend on (intersegmental) collateral circulation, because many segmental arteries are occluded as a result of atherosclerosis. Therefore, the importance of preserving the segmental artery supplying the AKA (SA-AKA) is debated. Here it was investigated whether (1) the AKA and its segmental supplier can be imaged by using magnetic resonance (MR) angiography and (2) aortic cross-clamping of the SA-AKA influences intraoperative spinal cord function, monitored by motor evoked potentials (MEPs). ⋯ The AKA can be localized before surgery in 100% of TAA(A) patients by using MR angiography. Location of the SA-AKA outside the cross-clamped aortic area is attended with stable MEPs. Interestingly, it was found that in most patients in whom the SA-AKA was cross-clamped, MEPs were not affected, thus indicating sufficient collateral blood supply to maintain spinal cord integrity. Nevertheless, preoperative knowledge of SA-AKA location is of importance, because in 32% of patients, spinal cord function was dependent on this supplier. Revascularization of the SA-AKA can thereby reverse spinal cord dysfunction.
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Blunt popliteal arterial injury is uncommon and is usually associated with surrounding soft tissue and orthopedic injuries, which may complicate traditional open operative repair. We present the successful management of a blunt popliteal artery injury through an endovascular approach, where we imaged the lesion, extracted the thrombus, protected against distal embolization, and performed a balloon angioplasty to the intimal lesion. Our approach is the first documented in the literature in which endovascular repair of a blunt popliteal artery injury was performed successfully in an acutely ischemic extremity. Using a filter wire is a novel way to prevent distal embolization during manipulation.