Journal of vascular surgery
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Randomized Controlled Trial Multicenter Study Comparative Study
Differential outcomes of carotid stenting and endarterectomy performed exclusively by vascular surgeons in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).
Outcomes in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) did not differ between carotid artery stenting (CAS) and carotid endarterectomy (CEA) for the composite primary end point of stroke, myocardial infarction (MI), or death during the periprocedural period or ipsilateral stroke within 4 years. Rigorous credentialing and training of interventionists, including vascular surgeons, were required for the randomization phase of CREST. Because the lead-in phase of CREST had suggested higher perioperative risks after CAS performed by vascular surgeons, the purpose of this analysis was to examine differences in outcomes after randomization between CAS and CEA performed by vascular surgeons. ⋯ When performed by surgeons, CAS and CEA have similar net outcomes, although the periprocedural risks vary (lower stroke with CEA and lower MI with CAS). These data suggest that appropriately trained vascular surgeons may safely offer both CEA and CAS for the prevention of stroke. The remarkably low stroke and death rates after CEA performed by vascular surgeons in CREST, particularly among symptomatic patients, represent the best outcomes ever reported after carotid interventions from a randomized controlled trial. ClinicalTrials.gov identifier: NCT0000473.
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Multicenter Study Comparative Study
Derivation and validation of a practical risk score for prediction of mortality after open repair of ruptured abdominal aortic aneurysms in a US regional cohort and comparison to existing scoring systems.
Scoring systems for predicting mortality after repair of ruptured abdominal aortic aneurysms (RAAAs) have not been developed or tested in a United States population and may not be accurate in the endovascular era. Using prospectively collected data from the Vascular Study Group of New England (VSGNE), we developed a practical risk score for in-hospital mortality after open repair of RAAAs and compared its performance to that of the Glasgow aneurysm score, Hardman index, Vancouver score, and Edinburg ruptured aneurysm score. ⋯ Existing scoring systems predict mortality after RAAA repair in this cohort but do not identify patients at highest risk. This parsimonious VSGNE RAAA risk score based on four variables readily assessed at the time of presentation allows accurate prediction of in-hospital mortality after open repair of RAAAs, including identification of those patients at highest risk for postoperative mortality.
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Transfused blood can disrupt the coagulation cascade. We postulated that packed red blood cell (PRBC) transfusion may be associated with thromboembolic phenomena. We used propensity matching to examine the relationship between intraoperative PRBC transfusion and stroke during carotid endarterectomy (CEA). ⋯ Intraoperative transfusion of one to two units of PRBCs is associated with a fivefold increase in stroke risk. This holds true after consideration of stroke risk variables and operative duration as a surrogate for technical difficulty. The increased risk may be related to several effects of transfused blood on the coagulation inflammation cascade.
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Case Reports
Late neurological recovery of paraplegia after endovascular repair of an infected thoracic aortic aneurysm.
Spinal cord ischemia is a potentially devastating complication after thoracic endovascular aorta repair (TEVAR). Patients with spinal cord ischemia after TEVAR often develop paraplegia, which is considered irreversible, and have significant increased postoperative morbidity and mortality. We report the case of a patient with unusual late complete neurologic recovery of acute-onset paraplegia after TEVAR for an infected thoracic aortic aneurysm.