Review of Vascular Surgery
Recent Advances in Surgery-23, Year – 2000, Pg. 23
The Conventional open treatment of abdominal aortic aneurysm [AAA] is now well established and is an effective way of preventing death. The feasibility of repair of AAA using endovascular techniques continues to be evaluated although when, and if, this approach might replace open repair, remains uncertain.
Surgery cannot be recommended to patients with an asymptomatic small AAA.
Patients with an AAA of 6 cm or less can be managed conservatively.
The prevention of AAA rupture, that has an overall mortality of up to 90%, can only be achieved by early detection, since most AAA are asymptomatic up until the time of rupture. Early detection can be achieved by ultrasonographic screening.
Carotid Artery Angioplasty –
The role of surgery in the treatment of symptomatic carotid artery stenosis is now well established.
The concern over periprocedure stroke and cerebral ischaemia secondary to embolisation and thrombosis remains, and has restricted the wide-spread adoption of carotid angioplasty.
Venous Ulceration and Seps –
Leg ulcers present a significant problem to patients.
Ulceration is the end result of venous reflux causing chronic venous hypertension. Reflux may originate from superficial veins [about 50%], deep veins [30%] or both.
Subfascial endoscopic perforator surgery [SEPS] is an attractive approach employing the techniques of minimal access surgery.
HJM Barnett, for the North American Symptomatic Carotid Endarterectomy Trial Collaborators (John P Robarts Research Inst, London, Ont; et al )
Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis.
N Engl. J Med 339:1415-1425, 1998.
Carotid endarterectomy (CEA) in patients with symptomatic stenosis of 50% to 69%, reduces stroke risk by a modest but significant degree. However, CEA in patients with less than 50% symptomatic stenosis is of little value.
In patients with severe symptomatic carotid stenosis, the stroke risk reduction from carotid endarterectomy is very durable.
AR Naylor, A Bolia, RJ Abbot et al (Leicester Royal Infirmary, England) :
Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: A stopped trial.
J Vasc Surg 28: 326-334, 1998.
The cost effectiveness and safety of carotid endarterectomy (CEA) for symptomatic severe internal carotid artery disease has been called into question, and the use of the purportedly less expensive and safer carotid angioplasty (CA) procedure has been advocated.
Only 10 CEA patients and 7 CA patients were treated before the trial was SUSPENDED. Patients randomized to CEA experienced no short-term adverse events. In contrast, five of seven patients randomized to CA had CA-related strokes.
J May, GH White, W Yu, et al (Univ of Sydney, Australia) :
Concurrent comparison of endoluminal versus open repair in the treatment of abdominal aortic aneurysms: Analysis of 303 patients by life table method.
J Vasc Surg 27: 213-221, 1998.
The long-term outcome after endoluminal repair (ER) of abdominal aortic aneurysm (AAA) is not known, and concurrent comparison studies of ER and open repair (OR) have not been conducted. Results of a concurrent comparison of ER and OR in consecutive patients with AAA using life table analysis are presented.
ER of AAA is safe and potentially associated with less perioperative morbidity. However, OR remains the most reliable method of successfully managing AAA, and patients should be made aware of the higher failure rate associated with ER of AAA.
JS Matsumura, for the EVT investigators (North Western Univ, Chicago, et al) :
Continued expansion of aortic necks after endovascular repair of abdominal aortic aneurysms.
J Vasc Surg 28:422-431, 1998.
Aortic neck dilatation sometimes occurs after repair of an infra-renal abdominal aortic aneurysm (AAA). Continued dilatation could lead to endoleak or catastrophic device failure after endoluminal aneurysm repair.
This phenomenon and its progressions have not been well studied. The rate of neck size enlargement after AAA repair with a tube endograft system, the duration of this phenomenon and its relationship to endoleak, endograft size, device migration, change in aneurysm size, attachment system failure, and preoperative neck diameter were investigated as part of a multi-institutional study of endoluminal repair of infrarenal aortic aneurysms.
Aortic neck expansion after AAA repair continues for at least two years, raising the likelihood of later failure after endoluminal AAA repair.
Johnson D, Perrault H, Vobecky SJ, et al [ Ste-Justine Hospital, Montreal; McGill Univ, Montreal]
Influence of the Postoperative Period and Surgical Procedure on Ambulatory Blood Pressure -Determination of Hypertension Load After Successful Surgical Repair of Coarctation of the Aorta
Eur Heart J 19: 638-646, 1998
The monitoring of blood pressure after surgical correction of coarctation of the aorta is usually performed using a sphygmomanometer. Ten to 40% of patients who undergo an apparently successful repair of coarctation of aorta have hypertension 10 to 20 years later. The hypertension load was quantified using 24-hour ambulatory blood pressure monitoring in patients less than 10 years and more than 10 years after surgery. The type of surgical repair was also assessed.
Ambulatory blood pressure recordings were taken using an Accutracker II monitor every 30 minutes in the daytime and every one hour at night. Patients were grouped in two groups according to the period elapsed after surgery. Group 1 less than 10 years and Group 2 more than 10 years after surgery. A group of healthy adolescents were used as a control group. Of the twenty-one patients 12 had end-to-end anastomosis and 9 left subclavian artery angioplasty for correction of the coarctation.
Compared with the controls all operated cases showed higher day and night systolic and diastolic blood pressures. Daytime systolic hypertension occurred in 20% in Group 1 and in 49% in Group 2. There was no diastolic hypertension. There were also no differences in blood pressure recordings in the two types of operation.
Patients undergoing repair for coarctation of aorta develop hypertension with time and need constant monitoring.