Journal of vascular surgery
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Remote ischemic preconditioning is a physiologic mechanism in mammalian species whereby brief exposure to nonlethal ischemia in one tissue confers protection against a prolonged ischemic insult in a distant tissue. First described almost 15 years ago, it has been slow to translate into clinical practice. ⋯ In addition, a randomized trial in patients undergoing open abdominal aortic aneurysm repair reported a significant reduction in perioperative myocardial infarctions. Remote ischemic preconditioning is easily performed and likely to prove highly cost-effective. large-scale trials of the technique are warranted in patients undergoing major vascular surgery.
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Comparative Study
Analysis of motor and somatosensory evoked potentials during thoracic and thoracoabdominal aortic aneurysm repair.
Use of motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) monitoring during thoracic and thoracoabdominal aortic surgery is controversial. This study evaluated the intraoperative use of SSEP and MEP during thoracoabdominal repair and assessed their role in decreasing the risk of spinal cord ischemia and paralysis. ⋯ SSEP and MEP monitoring were highly correlated only when intraoperative changes were irreversible. Reversible changes were not significantly associated with immediate neurologic deficit. Irreversible changes were significantly associated with immediate neurologic deficit, and the findings were identical for SSEP and MEP in this variable, indicating that the more complex MEP measures do not add further information to that obtained from SSEP. Normal SSEP and MEP findings had a strong negative predictive value, indicating that patients without signal loss are unlikely to awake with neurologic deficit.
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Multicenter Study Comparative Study
Outcomes of endovascular abdominal aortic aneurysm repair compared with open surgical repair in high-risk patients: results from the Swedish Vascular Registry.
The management of infrarenal aortic aneurysms in high-risk patients remains a challenge. Endovascular aneurysm repair (EVAR) is associated with superior short-term mortality rates but unclear long-term results and has not been shown to improve survival in patients unfit for open repair (OR). The aim of this population-based study was to evaluate the outcome after elective EVAR compared with OR in a high-risk patient cohort. ⋯ Elective OR of aortic aneurysms seems to have a better outcome compared with EVAR in this specific, population-based, high-risk patient cohort after adjusting for covariates. We cannot confirm the benefit of EVAR from previous registry studies with a similar high-risk definition. In clinical practice, OR may be at least as good as EVAR in high-risk patients fit for surgery.
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Multicenter Study Comparative Study
Effect of chronic renal insufficiency on outcomes of carotid endarterectomy.
Conflicting data exist regarding the effect of chronic renal insufficiency (CRI) on carotid endarterectomy (CEA) outcomes. A large database was used to analyze the effect of CRI, defined by glomerular filtration rate (GFR), as an independent risk factor of CEA. ⋯ Although impaired renal function does not independently increase the risk of neurologic or infectious complications, CRI is a significant negative independent risk factor in predicting other outcomes after CEA. Patients with moderate CRI (GFR, 30-59 mL/min/1.73 m(2)) are at increased risk for cardiac and pulmonary morbidity, but not death, and those with severe CRI (GFR <30 mL/min/1.73 m(2)) have a much higher operative mortality. Patients with CRI should be carefully evaluated before CEA to optimize existing cardiac and pulmonary disease. Understanding this increased risk may assist the surgeon in preoperative counseling and perioperative management.
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Multicenter Study Comparative Study
Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005.
Carotid endarterectomy (CEA) remains the procedure of choice for treatment of patients with severe carotid artery stenosis. The role of carotid artery stenting (CAS) in this patient group is still being defined. Prior single and multicenter studies have demonstrated economic savings associated with CEA compared with CAS. The purpose of this study was to compare surgical outcomes and resource utilization associated with these two procedures at the national level in 2005, the first year in which a specific ICD-9 procedure code for CAS was available. ⋯ Based on a large representative sample during the year 2005, CEA was performed with significantly lower in-hospital mortality, postoperative stroke rates, and lower median total hospital charges than CAS in US hospitals. As the role for CAS becomes defined for the management of patients with carotid artery stenosis, clinical as well as economic outcomes must be continually evaluated.