AIM The aim of this paper was to determine prevalence, cardiovascular risk factors and association with coronary heart disease (CHD) of isolated infrapopliteal arterial disease in old-adult men. METHODS DESIGN cross-sectional; participants: population-based sample of 699 men aged 55 to 74 years, measurements: cardiovascular history and risk factors, electrocardiogram, segmental pressures and velocity waveforms in lower limbs. RESULTS Peripheral arterial occlusive disease (PAOD) was observed in 13.4% subjects, of whom 39.4% (37 patients) had isolated infrapopliteal PAOD. Of these, 11 (29.7%) patients were symptomatic. Isolated infrapopliteal PAOD was significantly associated with increased age, smoking, diabetes and hypertriglyceridemia. Subjects with extended PAOD differed from those with isolated infrapopliteal PAOD in increased tobacco exposure, higher levels of LDL and lower levels of HDL cholesterol. Association between PAOD and CHD was almost always significant (odds ratio from 1.8 to 3.4) irrespective of PAOD topographic pattern and symptom characteristics of CHD subjects. CONCLUSION Isolated infrapopliteal PAOD is a frequent asymptomatic disorder in old-adult men, clearly associated with both symptomatic and asymptomatic CHD. In contrast to an expected risk factor profile biased by clinical practice, these subjects only differed from those with PAOD significantly extended to proximal arteries in their smoking exposition and a more atherogenic lipid profile.

Introduction: Quality of care and learning effect surveillance are two mandatory responsibilities within a changing therapeutical paradigm. We aimed to evaluate the feasibility and value of CUSUM chart method in assessing performance in consecutive endovascular procedures done by vascular surgeons of a single department on aorto-iliac, femoropopliteal and renal artery occlusive disease.Material and method: Data were collected in 405 consecutive patients, scheduled for endovascular intervention of aorto-iliac (n = 131, 32.3%), femoropopliteal (n = 142, 35%) and renal artery (n = 132, 32.7%) occlusive disease during a 6-year period. Quality indicators included inability to cross the lesion, peri and post-procedural complications and significant residual stenosis or occlusion at 1 month. CUSUM curves were generated for each territory globally and according to each quality indicator. The relevance of curve upward inflections was evaluated with Fisher's Exact Test.Results: Failure to cross the lesion occurred in 6.9% (aorto-iliac), 10.6% (femoropopliteal) and 2.3% (renal) of patients. One-hundredth twenty aorto-iliac, 127 femoropopliteal and 132 renal angioplasties were finally performed. peri and post-procedural complications appeared in 14.5% (aorto-iliac), 9.2% (femoropopliteal) and 2.3% (renal), while significant residual stenosis or occlusion was seen in 0.8%, 4.9% and 2.3% of patients, respectively. Aorto-iliac CUSUM curve showed two upward inflections at the beginning and the end of the period, both associated with peri and post-procedural complications (p = 0.002 and p = 0.0013) and the latter also with failure to cross the lesion (p = 0.009). Femoro-popliteal CUSUM curve moved progressively upward during all the period, initially related to peri and post-procedural complications (p = 0.038) and later to failure to cross the lesion (p = 0.004). Renal CUSUM curve didn't show any upward inflection during the analysed period.Conclusion: CUSUM curves are an excellent tool for measuring learning effect and quality of care within a changing paradigm, such it is the case of endovascular interventions. Curve upward inflections can be further interpreted according to the type of "failure" thus helping to evaluate their underlying causes. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Aim. To determine the natural history of patients who undergo below-knee amputation (BKA) by analysing the prognostic factors of early reamputation, prosthetics surgery, survival and walking at one year. Patients and methods. Our sample included 140 consecutive amputations in 124 patients (mean age 70.2; 64% males) who, between 1995 and 2004, underwent surgery involving BKA (57% transversal, 43% sagittal) as a result of acute ischaemia (6%), critical ischaemia (86%) or infection (exclusive 8%; concomitant 59%). Statistics: logistic regression, inverted Kaplan-Meier, Cox. Results. Survival: immediate (< 30 days/discharge) 87.6% and at one year 67%; the former dropped significantly with a history of chronic obstructive pulmonary disease (odds ratio, OR = 2.698; p = 0.087) while the latter decreased with cerebrovascular accident (CVA) (OR = 2.86; p = 0.039) or age > 80 years (OR = 2.94; p = 0.049). Progression of the residual limb: 20 early proximal reamputations (14%), which were associated with a history of CVA (OR = 3.675; p = 0.021), an age of 60-69 years (OR = 3.337; p = 0.027) and acute ischaemia (OR = 5.097; p = 0.051). The accumulated percentage of scarring in the other 120 was 44/84/91% at 30/60/90 days, respectively (mean 47 days), and was lower with a history of diabetes (OR = 1.654; p = 0.020). Prosthetics surgery: 56/140 (40%) patients (at 90/180/365 days: 19/38/55%), which was lower with a history of congestive heart failure (OR = 0.245; p = 0.002), CVA (OR = 0.217; p = 0.035) and previous limited (OR = 0.154; p = 0.002) or null walking ability (OR = 0.191; p = 0.085). Walking at one year: 41/124 patients (35%: limited = 37%, normal = 63%), which were lower with a history of an age > 70 years (OR = 0.169; p = 0.006), chronic renal failure (OR = 0.035; p = 0.001), CVA (OR = 0.000; p = 0.998), previous limited (OR = 0.154; p = 0.002) or null walking ability (OR = 0.191; p = 0.085). Conclusions. Despite our tendency to be optimistic when indicating a BKA, a relatively small number of patients reach the end of the way and the figure depends on factors that go far beyond the patient's having the clinical level required for this procedure. Knowledge of these factors can help improve the selection process and avoid what are sometimes unrealistic expectations.

Objectives: The association of peripheral arterial occlusive disease (PAD) association with major coronary events (MCE) has been well documented, nevertheless data are tacking for populations with a low incidence of coronary heart disease (CHD). We aimed to assess the association of PAD with MCE in a Mediterranean population. Design: Prospective survey of 699 55-74 year-old men representative of an urban district near Barcelona (Spain).Methods: Baseline cardiovascular risk factors, CHD and PAD (ankle/brachial index < 0.9) were recorded. MCE were evaluated during the 5-year follow-up.Results: At recruitment 94 subjects (13.4%) had PAD. During follow-up (mean 69.3 months), 35 (5%) subjects suffered a MCE, of whom 12 had PAD, 9 previous symptomatic CHD and 1 subject both conditions. Higher CHD related mortality (8.6% vs 1.4%; p < 0.001) and Lower MCE-free survival (78.67% vs 93.26%; p < 0.001) was observed for PAD subjects. On Cox regression analysis PAD (RR = 3; p = 0.003) and previous symptomatic CHD (RR = 4.1; p < 0.001) were associated independently with MCE during follow-up.Conclusions: Even in a population with a low incidence of CHD there is a strong relationship between PAD and future MCE. Screening for PAD may improve the selection of patients targeted for cardiovascular risk prevention. (C) 2008 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Resumen. Objetivo. Conocer la historia natural del paciente sometido a una amputación infracondílea (AIC), analizando los factores pronósticos de reamputación precoz, protetización, supervivencia y deambulación al año. Pacientes y métodos. 140 amputaciones consecutivas en 124 pacientes (edad media 70,2, varones 64%), intervenidos entre 1995 y 2004 por isquemia aguda (6%), crítica (86%) o infección (exclusiva 8%; concomitante 59%); practicándose una AIC (57% transversal, 43% sagital). Estadístico: regresión logística, Kaplan-Meier invertido, Cox. Resultados. Supervivencia: inmediata (< 30 días/alta) del 87,6% y al año del 67%, disminuyendo significativamente la primera con antecedente de enfermedad pulmonar obstructiva crónica (odds ratio, OR = 2,698; p = 0,087), y la segunda si accidente vascular cerebral (AVC) (OR = 2,86; p = 0,039) o edad > 80 años (OR = 2,94; p = 0,049). Evolución del muñón: 20 reamputaciones proximales (14%) precoces, asociándose a antecedentes de AVC (OR = 3,675; p = 0,021), edad 60–69 años (OR = 3,337; p = 0,027) e isquemia aguda (OR = 5,097; p = 0,051). El porcentaje acumulado de cicatrización de las restantes 120 fue a 30/60/90 días de 44/84/91%, respectivamente (mediana 47 días), siendo menor con antecedente de diabetes (OR = 1,654; p = 0,020). Protetización: 56/140 (40%)pacientes (a 90/180/365 días: 19/38/55%), siendo menor si antecedente de insuficiencia cardíaca congestiva (OR = 0,245; p = 0,002), AVC (OR = 0,217; p = 0,035) y deambulación limitada (OR = 0,154, p = 0,002) o nula (OR = 0,191, p = 0,085) previas. Deambulación al año: 41/124 pacientes (35%: limitada = 37%, normal = 63%), siendo menor si antecedente de edad > 70 años (OR = 0,169; p = 0,006), insuficiencia renal crónica (OR = 0,035; p = 0,001), AVC (OR = 0,000; p = 0,998), deambulación limitada (OR = 0,154, p = 0,002) o nula (OR = 0,191, p = 0,085) previas. Conclusiones. A pesar de nuestra tendencia optimista al indicar una AIC, el número de pacientes que llegan al final del camino es modesto y depende de factores que van mucho más allá de que el paciente tenga nivel clínico para esta intervención. El conocimiento de estos factores puede contribuir a un mejor proceso de selección, evitando expectativas, a veces, poco realistas. [ANGIOLOGÍA 2008; 60: 247–53]

Objective. To evaluate the association between compassionate attitudes and seniority in vascular surgeons facing clinical ethical dilemmas (CED).Subjects and methods. (1) Design: Cross-sectional. (2) Subjects: Vascular surgeons (residents included) from the 28 vascular teaching departments of one European country. (3) Measurements: Multidisciplinary team-designed, structured and self-administered questionnaire consisting of five clinical ethical dilemmas, of which four had conflict between compassion towards a 'small' or 'very costly' beneficial action vs. a reasonable but more 'pragmatic' allocation of health resources. Participants stated their degree of agreement with eight answers representing the two attitudes on a continuous scale. (4) Statistics: Cluster analysis and logistic regression model adjusted by confounding factors.Results. Two hundred and fifty three vascular surgeons (median age 37 years, 74% male)from the 26 participating teaching vascular departments (public hospitals) completed the questionnaire (88% surgeons/department). Cluster analysis identified two groups of surgeons according to their pattern of answers: Group I (n = 63) were mainly compassionate whereas Group Il (n = 180) were mainly pragmatic. The multivariate analysis disclosed, after adjusting for additional private practice, on call services and career status, a significant V-shaped relationship between the compassionate behaviour and seniority. Surgeons with 8-15 years experience were the least compassionate.Conclusions. The youngest and the most senior vascular surgeons were more prone to favour compassionate attitudes when facing clinical ethical dilemmas. Although both compassionate and pragmatic attitudes may be legitimate ethically, physicians not favouring compassion may be at risk of leaving the patient without an advocate within the health care system.

Objective. The aim of this study was to assess the accuracy of CT-angiography for identification and measurement of calcification of carotid atherosclerotic plaques and to characterise the content and distribution pattern Of mineral calcium (hydroxyapatite, Ca) in carotid bifurcations and investigate its relationship with neurological symptoms.Methods. Twenty-six patients with ICA stenosis > 60% (13 symptomatic, 13 asymptomatic) were selected for study. Ca zoos estimated from the weight of the ashed remnants of carotid endarterectomy (CEA) specimens in 11 patients. Calcium content (calcification volume (mm(3)),CV), and average calcium density (Hounsfield units (HU),CD), were determined by CT-angiography. The distribution pattern of calcium within the lesion (base (posterior), shoulder or luminal surface) was assessed in all cases.Results. CT-derived estimation of CV and Ca mass (modified Agatston Score, (mAS) = CV x CD) showed a good correlation with its direct measurement in CEA specimens (r = 0.911 and 0.993 respectively, p < 0,005). Asymptomatic patients with ICA stenosis > 60% showed statistically significant higher content of Ca than those who were symptomatic (mAS: 122.6 +/- 138.0 HU mm(3) vs 42.8 +/- 59.1 HU mm(3), p = 0.04). Calcification on the surface of the plaque was observed more commonly in asymptomatic patients (9/12 vs 3/15, p = 0.006). Non-calcified or plaques with posterior calcification were 12 times more likely to be symptomatic (OR: 12, 95%CI 1.5-91.1, p = 0.021).Conclusions. CT-angiography permits the reliable quantification of calcification of carotid plaques. A lower content of calcium in carotid plaques, as well as its distribution in the base of the lesion, was associated with a greater prevalence of neurological symptoms. These parameters may be useful to identify those patients at higher risk of stroke.

Objective. To evaluate the association between professional seniority and self-interest (PSI) attitudes in the resolution of vascular ethical dilemmas (VED).Design. Cross-sectional. Subjects. Vascular surgeons (residents included) from the 28 vascular teaching departments of Spain. Measurements. Multidisciplinary team-designed questionnaire of 5 VED. Each VED had 3 different answers (attitudes): 2 favouring legitimate ethical attitudes (LEA) and 1 favouring PSI. The questionnaire was self-administered and all participants stated their degree of agreement with each answer on a continuous Likert scale. PSI was evaluated by: (1) adding the magnitudes of the 5 answers favouring PSI (absPSI); and (2) by comparing in each case the magnitude of the PSI answer with that of the 2 LEA (relPSI).Statistics. Linear regression adjusted by confounding factors.Results. Two hundred and fifty-three vascular surgeons from the 26 participating teaching vascular departments of public hospitals completed the questionnaire (87.5% surgeons/department). Surgeon characteristics were: (1) median age 37 years; (2) 187 (74%) male; (3) 59 (23%) brought up with a health professional relative; (4) 94 (38%) had additional private practice; (5) 133 (65%) professed religious beliefs; and (6) 1-10 years of experience in 116 (47%), 11-20 years in 58 (24%), 21-30 years in 57 (23%), and >30 years in 15 (6%). The multivariate analysis disclosed that for every 10-years rise in professional seniority there was a 3.2% increase in absPSI (p = 0.007, adjusted by variables 3 and 4), and a 3.4% increase in relPSI (p = 0.002, adjusted by variable 5).Conclusions. Professional seniority is associated with a slight increase in pro-PSI attitudes in cases of vascular ethical dilemma. Both vascular surgeons and health institutions should promote the reversal of this worrying tendency.

Planas, A.1; Clara, A.2; Armario, P.3; Del Rey, R. Hernandez3; Vidal-Barraquer, F.2; Pou, J. M.4; Concustell, R.5; Trave, P.5 Author Information

An adequate strategy for selecting venous outflow for repeated vascular access plays a major role in determining the long term survival of patients in a haemodialysis programme. Since the first description of the method for creating an arteriovenous (AV) fistula by Brescia et al., numerous techniques and materials have been tried in order to achieve better patency rates. However, failure of vascular access continues to be the main cause of hospital admission in haemodialysis patients. Although surgery for vascular access is commonly performed by most vascular surgeons, the search for a suitable venous outflow is often hampered by the progressive exhausting of superficial veins, due to repeated punctures or failure of previously fashioned access conduits. An AV graft constructed in a loop fashion, between the brachial artery and the superficial forearm veins, is the usual technique in most centres. However, the use of deep forearm veins as an outflow for an AV, and their role as an alternative choice after a previously failed fistula, has scarcely been analysed. In this short report, a description of the procedure and preliminary results are discussed.

To establish the incidence of occult neoplasia (NEO) inpatients with primary deep vein thrombosis (DVT) during the first year and evaluate the most effective strategy for diagnosis. Setting. General hospital, period 1995-1999; 266 consecutive patients with objective diagnosis of DVT, excluding 111 cases of secondary DVT and 16 primary DVT with >1 year follow-up (8 non-neoplastic deaths and 8 lost to follow-up); variables: age, sex, site of DVT, associated pulmonary thromboembolism, haemogram, liver function tests (LF), tumour markers (TM), chestX-ray (RxTx), abdominal CATscan. In the 139 primary DVT analyzed, 17 (12.2%) patients were diagnosed as having NEO in the first year (3 haematological, 13 adenocarcinomas and 1 carcinoma of the bladder). Sixteen cases (94%) were detected from the differential diagnosis and 9 given early treatment to achieve survival. The clinical data were not related to the NEO. The positive and negative predictive values of the investigations done were: haemogram (16/89%), LF (26/88%), TM (34/90%), RxTx (100/87%) and CAT scan (69/93%). A limited strategy for diagnosis (haemogram, liver function, RxTx and prostatic antigen in men) would give a result suggestive of NEO in 69% of the primary DVT, permitting diagnosis of 13/16 (81%) of the neoplasias detected. With this algorithm other investigations would not have been necessary (CAT, other TM) in 31% of the primary DVT, which made early diagnosis slower in 3/16(19%) of the cases and early treatment delayed in 2/9 (22%) of the patients. The incidence of NEO in primary DVT makes it necessary to rule them out of the differential diagnosis. A limited strategy for diagnosis allows detection of most, but not all, treatable tumours at the expense of being more economical in the use of investigations in a limited percentage of cases. It would seem therefore preferable to make a fuller investigation of the potential differential diagnosis. Establecer la incidencia de neoplasia oculta (NEO) tras un diagnóstico de trombosis venosaprofunda (TVP) primariay evaluar la eficacia de realizar un cribado de cáncer oculto en estos pacientes. Ámbito: hospital general, período 1995-1999; sujetos: 266 pacientes consecutivos condiagnóstico objetivo de TVP, excluyéndose 111 TVP secundarias y 16 TVP primarias con seguimiento inferior a un año (8exitus no neoplásicosy 8 pérdidas de seguimiento); variables: edad, sexo, localización TVP, tromboembolismo pulmonar asociado, hemograma, función hepática (FH), marcadores tumorales (MT), radiografía de tórax (RxTx), ecografía o TAC abdominal. En las 139 TVP primarias analizadas, a 17 (12,2%) pacientes se lesdiag-nosticó NEO en elprimer año (3 hematológicas, 13 adenocarcinomasy 1 carcinoma vesical). 16 casos (94%) sedetectaron mediante cribadoy 9 se trataron precozmente para mejorar lasuper-vivencia. Los datos clínicos no guardaron relación con NEO. Los valores predictivos positivo y negativo de los exámenes efectuados fueron, respectivamente: hemograma, 16 y 89%; FH, 26 y 88%; MT, 34y 90%; RxTx, 100y 87%, y TAC, 69y 93%. Una estrategia de cribado limitada (hemograma, FH, RxTxy antígeno prostático en varones) habría resultado sugestiva de NEO en el69% de las TVP primarias, y habríapermitido diagnosticar 13 (81%) de las neoplasias detectadas. Con este algoritmo se habríanahorrado otras exploraciones (TACy otros MT) en el31% de las TVP primarias, impidiendo el diagnóstico precoz de 3casos (19%)y eltratamiento precoz de 2/9 (22%) pacientes. La incidencia de NEO en las TVP primarias requiere su cribado. Una estrategia diagnóstica limitada permite detectar granparte, pero no todos los tumores tratables, a expensas deahorrarexploraciones en unporcentaje limitado de casos. Un cribado más completoparece más conveniente. Estabelecer a incidência de neoplasia oculta (NEO) em doentes comtrom-bose venosaprofunda (TVP) primáriadentro do primeiro ano e avaliar a estratégia de despiste de neoplasia oculta mais eficaz. Ámbito: hospital geral, período 1995-1999; indivíduos: 266 doentes consecutivos com diagnóstico objectivo de TVP, sendo excluídas 111 TVP secundárias e 16 TVP primária com seguimento inferiora 1 ano (8 êxitos não neoplásicos e 8 baixas); variáveis: idade, sexo, localização TVP, tromboembolismo pulmonar associado, hemograma, função hepática (FH), marcadores tumorais (MT), radiografia tórax (RxTx) e TAC abdominal. Nas 139 TVP primárias analisadas, em 17(12,2%) doentes foi diagnosticado NEO no primeiro ano (3 hematológicas, 13 adenocarcinomas e 1 carcinoma vesicular). Dezasseis casos (94%) foram detectados por despiste e 9 tratados precocemente comfinalidade de sobrevivencia. Os dados clínicos nao tiveram relação com NEO. Os valorespremonitorespositivo e negativo dos exames efectuados foram, repectivamente: hemograma (16/89%), FH (26/88%), MT (34/90%), RxTx(100/87%), TAC(69/93%). Uma estratégia diagnostica limitada (hemograma, FH, RxTx e antigénio prostático nos homens) teve resultado sugestiva de NEO em 69% das TVP primárias, permitindo o diagnóstico de 13/16(81%) neoplasias. Com este algoritmo, ter-se-iam economizado outros exames (TACe outros MT) em 31% das TVP primárias, impedindo o diagnós-ticoprecoce de 3 (19%) dos casos e o tratamento precoce de 2/9 (22%) doentes. A incidênciade NEO nas TVP primárias torna necessária o seu despiste. Uma estratégia diagnóstica limitada permite detectar grandeparte, mas não todos os tumores tratáveis, á custa de economizar explorações numa percentagem limitada de casos. Um despiste mais completo parece, por conseguinte, mais conveniente.

The paragangliomas are uncommon neuroectodermal tumours which are neurosecretory in 5% of cases, and associated with other multiple endocrine tumours. In 10% of the cases they become malignant, with a marked familial tendency. We report a case of paragangliomas of the carotid body (chemodectoma) associated with a paraganglioma in the territory of the vagal nerve (which extended to the base of the skull) and required an unusual laterocervical approach involving subluxation of the mandible. A27 year old patient with no previous clinical history was referred with the diagnosis of apossible branchial cyst. On systematic physical examination the only unusual finding was of a nonpulsatile tumour with no bruit in the upper left laterocervical region. Complementary investigations included: carotid Doppler ultrasonography which showed a rounded echogenic image of 1.4 × 1.86 cm at the bifurcation of the carotid artery; cervical CAT scan showed a vascularized mass at the left carotid bulb which extended towards the posterior cervical triangle and was compatible with a vagal glomus tumour; andselective arteriography of the left external carotid artery which showed hypervascularization at the carotid bifurcation in association with the posterior branch of the external carotid artery. The surgical treatment was to resect both tumours (in the carotid bifurcation andposterior aspect of the distal part of the left internal carotid respectively) by means of subluxation of the mandible using a dental prosthesis. Immunohistochemical study of both specimens showed chromogranine and specific enolase in the tumour cells. The diagnosis of double paraganglioma was confirmed. Los paragangliomas son tumores neuroectodérmicospoco frecuentes, de carácter neurosecretor en el5% de los casos, que se asocian a otras tumoraciones endocrinas múltiples. Muestran tendencia a malignizar en un 10% de los casosy marcada presentación familiar. Presentamos un caso de paraganglioma localizado en el cuerpo carotídeo (quemodectoma) asociado apara-ganglioma en territorio del nervio vago (con extensión hacia la base del cráneo) que requirió un abordaje laterocervical poco frecuente por medio de subluxación mandibular. Paciente de 27 años de edad, sin antecedentes de interés, remitida con el diagnóstico de sospecha inicial de quiste branquial. En la exploración física por sistemas tan sólo destaca una tumoración no pulsátil en región latero-cervical izquierda alta sin soplo. Las exploraciones complementarias preoperatorias incluyeron: ecografía Doppler carotídea, que mostró imagen ecogénica redondeada de 1,4 × 1,86 cm en la bifurcación carotídea; TAC cervical: masa vascularizadaen bulbo carotídeo izquierdo, que se extiende hacia triángulo cervical posterior compatible con tumoraciónglómicay vagal,y arteriografía selectiva de carótida externa izquierda, que muestra imagen de hipervascula-rización en bifurcación carotídea dependiente de rama posterior de la arteria carótida externa.El tratamiento quirúrgico consistió en la resección de dos tumoraciones (en bifurcación carotídeay cara posterior de la porción distal de la carótida interna izquierda, respectivamente) mediante subluxación mandibular con prótesis dentaria. El estudio in-munohistoquímico fue positivo (en ambas piezas) para cromograninay enolasa específica en las células tumorales. Se confirmó el diagnóstico de doble paraganglioma. Os paragangliomas são tumores neuroectodérmicos poum frequentes, de carácter neurosecretor em 5% dos casos, que se associam a outras tumefacções endócrinas múltiplas. Mostram tendência para se tornarem malignos em 10% dos casos e possuem marcada apresentação familiar. Apresentamos um caso de paraganglioma localizado no corpo carotídeo (quemodectoma) associado a paraganglioma no território do nervo vago (com extensão até á base do crânio) que necessitou de abordagem laterocervical, pouco frequente, por meio de subluxação mandibular. Doente de 27 anos de idade sem antecedentes de interesse, com hipótese diagnóstica de quisto branquial. No exame físico por sistemas destaca-se apenas uma tumefacção não pulsátil na região laterocervical esquerda alta sem sopro. Os exames complementares pré-operatórios incluíram: ecografia Doppler carotídea, que mostrou imagem ecogénica arredondada de 1,4 × 1,86 cm na bifurcação carotídea; TAC cervical: massa vascularizada no bulbo carotídeo esquerdo que se estende até ao triángulo cervical posterior, compatível com tumefacção glómica e vagal, e arteriografia selectiva da carótida externa esquerda, que mostra imagem de hipervascularização na bifurcação carotídea, dependente do ramo posterior da artéria carótida externa. O tratamento cirúrgico englobou dissecçõo das duas tumefacções (na bifurcação carotídea e face posterior da porção distal da carótida interna esquerda, respectivamente) por subluxação mandibular com prótese dentária. O estudo imunohistoquímico foipositivo em ambas as peças para cromogranina e enolase, específica para as células tumorais. Foi confirmado o diagnóstico de duplo paraganglioma.

Purpose: The potential effects of age at onset of smoking on cardiovascular diseases have been studied little, in contrast to the well-established evidence supporting a causal role of cigarette smoking in these diseases. We sought to analyze the relationship between age at smoking onset and development of symptomatic peripheral arterial occlusive disease (PAOD). Methods: A population-based sample of 573 active or former male smokers aged 55 to 74 years were studied. Present or previous symptomatic PAOD was confirmed by noninvasive testing. Results: Sixty-one subjects (10.6%) had symptomatic PAOD. Prevalence of disease increased with earlier starting age (15.6% if ≤16 years versus 5.4% if >16 years) of smoking. After controlling for risk factors that meet confounding factor criteria (ie, subject age and number of pack-years), men who started smoking at age 16 or earlier had a substantially higher risk for development of PAOD (odds ratio, 2.19; 95% CI, 1.15-4.15; P =.016) than men who began to smoke at a later age. Conclusions: A starting age for smoking of 16 years or earlier more than doubles the risk of future symptomatic PAOD regardless of the amount of exposure to cigarette smoking. (J Vasc Surg 2002;35:506-9)