Journal of vascular surgery
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Comparative Study
The impact of intraoperative shunting on early neurologic outcomes after carotid endarterectomy.
Although the need for intraoperative shunting during carotid endarterectomy (CEA) is intensely debated, relatively few studies have compared the neurologic outcomes of patients undergoing CEA with or without shunts. The objective of our analysis was to determine the impact of intraoperative shunting during CEA on the incidence of postoperative stroke. ⋯ There is no clinical benefit to intraoperative shunting during CEA, even in patients who may be at high risk for intraoperative cerebral hypoperfusion due to severe stenosis or occlusion of the contralateral carotid artery.
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Thoracic endovascular aortic repair (TEVAR) is widely used for treatment of traumatic aortic injury (TAI). Stent graft coverage of the left subclavian artery (LSA) may be required in up to 40% of patients. We evaluated the long-term effects of intentional LSA coverage (LSAC) on symptoms and return to normal activity in TAI patients compared with a similarly treated group whose LSA was uncovered (LSAU). ⋯ Intentional LSAC during TEVAR for TAI appears safe, without compromising mental or physical health outcomes. Furthermore, LSAC does not increase the long-term risk of upper extremity symptoms or impairment of normal activities.
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Despite increased awareness of the value of discussing patients' goals of care, advance directives, and code status as part of the surgical informed consent process, the actual outcomes and risks of cardiopulmonary resuscitation (CPR) remain poorly defined among some subsets of surgical patients. Thus, in an effort to generate an evidence base for communication about shared decision making and informed consent for vascular surgery patients and their surrogates, we defined the incidence, risks, and outcomes of postoperative cardiac arrest after primary vascular surgery procedures. ⋯ Patients undergoing vascular surgery who suffer a postoperative cardiac arrest frequently die in spite of receiving CPR; for those who survive, there is likely to be prolonged hospitalization and significant morbidity. These data provide an evidence base for discussing goals of care, advance directives, and code status with vascular surgery patients and their surrogates. Further research into how to best communicate risk, to elicit patient preferences, and to engage in shared decision making is needed.
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Case Reports
Successful laparoscopic repair of refractory type Ia endoleak after endovascular abdominal aortic aneurysm repair.
Type I endoleaks associated with sac enlargement after endovascular abdominal aortic aneurysm repair mandate urgent intervention. Endoluminal treatments are generally considered first, but when these fail, open surgery has been advocated as a last resort. Open surgery is associated with significant mortality and morbidity, and thus, approaches that reduce this risk would be of interest. We report a successful case of laparoscopic treatment of a refractory type Ia endoleak after endovascular abdominal aortic aneurysm repair in an 83-year-old man.
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This study used a recently released procedure-targeted multicenter data source to determine independent predictors of postoperative stroke or death in patients undergoing carotid endarterectomy (CEA) for carotid artery stenosis. ⋯ After adjustment for a comprehensive array of patient-related and procedure-related variables of particular import to patients with carotid artery stenosis, we have identified several factors that are independently associated with early stroke or death after CEA. These factors are generally related to the comorbid condition of CEA patients and to specific characteristics of their carotid disease, and not to technical features of the CEA procedure. Knowledge of these factors will assist surgeons in selecting appropriate patients for this procedure.