BACKGROUND:With the risk of recurrent ischemic stroke being highest in the first week following transient ischemic attack or stroke, the current guidelines of "early" endarterectomy within 2 weeks still leave potential vulnerability for patients with a significant bifurcation lesion and a new stroke. The intent of this analysis is to determine the safety of carotid endarterectomy even earlier than the current guidelines, based on a single surgeon experience of more than 12 years. SUMMARY BACKGROUND DATA:Although there has been a progressive movement toward earlier intervention following acute ischemic stroke in the presence of a culprit bifurcation lesion, most of the recommendations still are for performance of endarterectomy within two weeks following the event. This compression is welcome but given that the risk of recurrent stroke is highest within the first week following stroke, there is a reason to evaluate an earlier time frame for carotid endarterectomy (CEA). METHODS:A retrospective review of all CEA performed by a single surgeon over a 12-year period was performed. Patient demographics, Modified Rankin score (mRS) whenever documented, degree of internal carotid artery (ICA) stenosis, and preoperative neurologic symptoms were recorded. The 30-day outcomes including stroke, transient ischemic attack, death, and other major complications were tabulated. RESULTS:A total of 444 patients (mean age 74 ± 10.1) underwent a total of 465 CEAs. Two hundred and twenty-eight (49%) CEAs were for a symptomatic disease: of these, 194 had a documented stroke. One hundred and eighty-one stroke patients (93%) underwent CEA within 72 hr and the remaining 13 patients within 5 days. Of the stroke cohort, for whom the mRS was available, the mean preCEA mRS was 3.4. One patient in the stroke cohort had a postoperative stroke (0.5%, 1/194). In the total CEA cohort, there were 3 total postoperative strokes (0.6%, 3/465). There was one death in the total cohort (0.2%). The mean operative time was 45 min ± 4 min. CONCLUSIONS:Early CEA for recurrent stroke prevention can be performed safely, at an earlier time frame than current recommendations. Given the safety of early CEA and the risk of recurrent stroke, CEA for stroke is best done early with no additional increase in morbidity or mortality.

The Society for Vascular Surgery clinical practice guidelines on popliteal artery aneurysms (PAAs) leverage the work of a panel of experts chosen by the Society for Vascular Surgery to review the current world literature as it applies to PAAs to extract the most salient, evidence-based recommendations for the treatment of these patients. These guidelines focus on PAA screening, indications for intervention, choice of repair strategy, management of asymptomatic and symptomatic PAAs (including those presenting with acute limb ischemia), and follow-up of both untreated and treated PAAs. They offer long-awaited evidence-based recommendations for physicians taking care of these patients.

There has been an evolution toward early carotid endarterectomy (CEA) after stroke, but there remains a reluctance to perform CEA earlier than 2 weeks. There has also historically been a bias toward shunting for previous stroke. This study analyzed the results of early CEA (<2 weeks) for stroke patients without shunting over a 12-year period to determine whether CEA earlier than 2 weeks after stroke was safe and whether a strategy of no shunting absent neuromonitoring changes was justified. A retrospective review of all CEA performed by a single surgeon over a 12-year period was performed. All patients with stroke were included except modified Rankin scale 6. The decision to shunt was based only on defined changes in continuous electroencephalography/somatosensory evoked potentials dynamics reflecting ischemia intraoperatively. Patient demographics, including age, degree of internal carotid artery (ICA) stenosis, preoperative neurologic symptoms, and medications were reviewed. Thirty-day outcomes were tabulated, including stroke, transient ischemic attack, death, and other major complications. A total of 432 patients (100 men [62.5%]) with a mean age of 69.4 years (range, 44-91 years) underwent 451 CEAs. There were 220 CEAs (49%) for symptomatic disease; of these, 183 had a documented stroke. CEA was performed within 72 hours in 162 stroke patients (88%) and within 5 days in the remaining 21 patients. Of the stroke cohort, mean pre-CEA modified Rankin scale was 3.8. One patient of this cohort had a new stroke (contralateral). The 72-hour perioperative stroke rate for the whole CEA group was 0.66% (3 of 451). The 30-day stroke, transient ischemic attack, and death rates were 5 (1.1%), 0 (0%), and 5 (1.1%), respectively. There was one intraoperative stroke, and the remainder of the four strokes occurred within 30 days. Early CEA for stroke (ie, <72 hours) can be performed safely without the need for shunting and does not increase postoperative stroke, morbidity, or mortality. Electroencephalography and somatosensory evoked potentials monitoring dramatically reduces the need to place a shunt during CEA. Recent stroke, contralateral ICA occlusion, or contralateral high-grade ICA stenosis are not an indication for intraoperative shunting. CEA for stroke is best done early, with no additional increase in perioperative stroke, thus shielding the patient from the early risk of recurrent stroke.

Carotid plaque calcification normally appears as a signal void with clinical MR sequences. Here, we describe the use of an adiabatic inversion recovery prepared two-dimensional ultrashort echo time sequence to image and characterize carotid plaque calcification using a clinical 3-T scanner. T-1, T-2(star), and free water content were measured for seven carotid samples, and the results were compared with micro-CT imaging. Conventional gradient echo and fast spin echo images were also acquired for comparison. Correlations between T-1, T-2(star), free water concentration, and mineral density were performed. There was a close correspondence between inversion recovery prepared two-dimensional ultrashort echo time morphologic and micro-CT appearances. Carotid plaque calcification varied significantly from sample to sample, with T(1)s ranging from 94 +/- 19 to 328 +/- 21 msec, T(2)(star)s ranging from 0.31 +/- 0.12 to 2.15 +/- 0.25 msec, and free water concentration ranging from 5.7 +/- 2.3% to 16.8 +/- 3.4%. There was a significant positive correlation between T-1 (R = 0.709; P < 0.074), T-2(star) (R = 0.816; P < 0.025), and free water concentration, a negative correlation between T-1 (R = 0.773; P < 0.042), T-2(star) (R = 0.948; P < 0.001) and CT measured mineral density, and a negative correlation between free water concentration (R = 0.936; P < 0.002) and mineral density. Magn Reson Med 65:1013-1020, 2011. (C) 2010 Wiley-Liss, Inc.

To provide an overview of molecular and cellular processes involved in erectile dysfunction (ED) with emphasis on circulating endothelial progenitor cells (EPC) and discuss possible nutraceutical means of intervention. A review of literature on Pubmed related to EPC and ED was conducted. Patients with ED appear to possess a reduced number of circulating EPC, which is associated with poor endothelial function possibly as a result of underlying low-grade inflammation. Several studies support the possibility of improving erectile function by inhibition of inflammation as well as administration of various stem cell types. One particularly interesting approach is nutraceutical supplementation to increase circulating EPC, as demonstrated in the product Stem-Kine. Interventions aimed at increasing circulating EPC may have potential in treatment of vascular ED.

Objective: The utilization of selective cerebral shunting during carotid endarterectomy (CEA) has been predicated on surrogate measures such as contralateral carotid occlusion, back-pressure measurements, and the patient's motor and cognitive function with regional anesthesia or recent stroke. This study analyzed the need for shunting in CEA where comprehensive electroencephalography (EEG) monitoring with somatosensory evoked potentials (SSEP) was the sole determinant of the necessity of a shunt. Design: A retrospective review was performed in a single institution of all consecutive CEAs performed between September 2002 and March 2010. The decision for carotid shunting was based only on changes in continuous EEG dynamics reflecting ischemia as assessed intraoperatively by a neurologist. SSEP were used in a portion of cases as a functional confirmation of EEG findings. No other factor influenced the need for a shunt. Patient demographics, including age, degree of internal carotid artery (ICA) stenosis, preoperative neurologic symptoms, and medications were reviewed. Thirty-day outcomes, including stroke, TIA, death, and other major complications were tabulated. Results: A total of 163 patients (100 [62.5%] men; mean age 69.4 years, [range, 44-91]) underwent 169 carotid endarterectomies. Of the total arteries treated, 76 (45%) were symptomatic, of which 66 (39%) had a documented stroke. A total of 20 patients (11.8%) had high-grade contralateral (80%-99%) ICA stenosis and 12 (7%) had contralateral ICA occlusion. Only two shunts (1.2%) were used. The 30-day stroke, TIA, death rates were four (2.3%), zero (0%), and two (1.2%), respectively. There was one intraoperative stroke and the other three strokes occurred ≤30 days. None of the patients with contralateral occlusion or contralateral high-grade ICA stenosis had EEG changes necessitating a shunt. Conclusion: Continuous EEG monitoring with SSEP dramatically reduces the need to place a shunt during CEA. Recent stroke, contralateral ICA occlusion, or contralateral high-grade ICA stenosis are not an indication for intraoperative shunting. Shunting for CEA should be vanishingly rare. EEG with SSEP should be considered the gold standard for monitoring of cerebral perfusion during CEA.

High-voltage electrical burns are rare but cause devastating injuries, resulting in potential limb loss and major morbidity and mortality. These injuries are more insidious than flame burns in that the extent of the injury is not obvious at first glance. Damage to underlying muscle, nerve, and vessels may occur, resulting in limb-threatening ischemia and delayed hemorrhage. The management of such injuries remains controversial and can be challenging for the vascular and reconstructive surgeon. We present a case of high-voltage electrical injury to bilateral upper extremities resulting in limb-threatening ischemia, review the literature on the management of such injuries, and propose an algorithm to guide the management of these devastating injuries.

Les brûlures électriques à haute tension sont rares mais causent des lésions dévastatrices, ayant pour résultat la perte potentielle du membre et une morbi-mortalité grave. Ces lésions sont plus insidieuses que des brûlures par flamme parce que l’importance du préjudice n’est pas évidente au premier regard. Des lésions des muscles sous-jacents, des nerfs, et des vaisseaux peuvent se produire, ayant pour résultat une ischémie menaçant le membre et une hémorragie retardée. La gestion de tels dommages demeure controversée et peut être difficile pour le chirurgien vasculaire et le chirurgien plastique. Nous présentons un cas de lésions électriques à haute tension bilatérales des membres supérieurs ayant pour résultat une ischémie menaçante de membre, passons en revue la littérature sur le traitement de ces lésions, et proposons un algorithme pour guider la gestion de ces lésions dévastatrices.

Las lesiones vasculares contusas de la extremidad inferior son mucho menos frecuentes que las penetrantes, en particular en ausencia de un traumatismo musculoesquelético sustancial. Presentamos un caso insólito de avulsión completa de la arteria y vena femoral que fue consecuencia de una hiperextensión forzada de la cadera y abducción del muslo por caída accidental en una escalera. Se presentó a las 8 h del traumatismo con isquemia aguda de la extremidad inferior derecha, que requirió una exploración quirúrgica inmediata, un shunt intravascular temporal, un injerto de interposición y una fasciotomía profiláctica. Hasta lo que conocen los autores, el caso de este paciente es el primero en el que se describe este mecanismo que dio lugar a la transección completa tanto de la arteria como de la vena femoral. Revisamos el mecanismo de la lesión y su tratamiento.

Nature 456, 809–813 (2008) In Fig. 2b of this Letter, the labelling of the x axis of the graph was incorrect. The corrected figure is printed below.

BACKGROUND:The Surgical Care Improvement Project (SCIP) was designed to reduce perioperative complications. We describe our institutional experience in 6 major areas: surgical site infection, venous thromboembolism prevention, use of perioperative beta-blockade, serum glucose level greater than 200 mg/dL, normothermia, and the use of electric razors for hair removal.METHODS:This was a retrospective review of surgical cases. Evidence-based training and standardization of system and process were undertaken. Compliance with SCIP guidelines was determined.RESULTS:Overall SCIP compliance improved from 80% to 94% over a 2-year period. Standardized antibiotic dosing times improved compliance to more than 90%. Appropriate preoperative antibiotic choice improved to 100%. Cessation of antibiotics postoperatively within 24 hours remains a difficult task. Venous thromboembolism prophylaxis has been difficult to achieve because of postoperative bleeding concerns. Administration of beta-blockers has remained one of the most difficult problems to correct because of the multiplicity of avenues by which a patient may arrive to the operating suite.CONCLUSIONS:Achievement of the SCIP goals is a formidable, but achievable, process requiring individual, cultural, systems, and institutional changes to achieve success.

Les traumatismes vasculaires fermés des membres sont beaucoup moins fréquents que les lésions traumatiques pénétrantes, en particulier en l'absence de traumatisme musculo-squelettique important. Nous présentons un cas inhabituel d'arrachement complet de l'artère et de la veine fémorales causé par une extension de hanche et une abduction de cuisse forcées au cours d'une chute d'échelle avec blocage du pied. A l'admission 8 heures après le traumatisme, il existait un tableau d'ischémie aiguë du membre inférieur droit, qui nécessitait une exploration chirurgicale immédiate, la mise en place d'un shunt temporaire, une revascularisation par pontage ainsi que des aponévrotomies. A notre connaissance, il s'agit de la première publication de ce type de mécanisme entraînant une section complète de l'artère et de la veine fémorales. Nous analysons le mécanisme du traumatisme ainsi que la prise en charge thérapeutique.

Blunt peripheral extremity vascular injuries are much less frequent than those of penetrating injuries, especially in the absence of significant musculoskeletal trauma. We present an unusual case of complete femoral artery and vein avulsion that resulted from a forced hip hyperextension and thigh abduction after slipping when a patient's foot became entrapped in a ladder. The patient presented with an acutely ischemic right lower extremity 8 hr postinjury, which necessitated immediate surgical exploration, temporary intravascular shunting, interposition grafting, and prophylactic fasciotomy. To our knowledge, this is the first such mechanism to be reported resulting in complete transection of both femoral artery and vein. We review the mechanism of injury and management.

Angiogenesis does not only depend on endothelial cell invasion and proliferation: it also requires pericyte coverage of vascular sprouts for vessel stabilization. These processes are coordinated by vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF) through their cognate receptors on endothelial cells and vascular smooth muscle cells (VSMCs), respectively. PDGF induces neovascularization by priming VSMCs/pericytes to release pro-angiogenic mediators. Although VEGF directly stimulates endothelial cell proliferation and migration, its role in pericyte biology is less clear. Here we define a role for VEGF as an inhibitor of neovascularization on the basis of its capacity to disrupt VSMC function. Specifically, under conditions of PDGF-mediated angiogenesis, VEGF ablates pericyte coverage of nascent vascular sprouts, leading to vessel destabilization. At the molecular level, VEGF-mediated activation of VEGF-R2 suppresses PDGF-Rbeta signalling in VSMCs through the assembly of a previously undescribed receptor complex consisting of PDGF-Rbeta and VEGF-R2. Inhibition of VEGF-R2 not only prevents assembly of this receptor complex but also restores angiogenesis in tissues exposed to both VEGF and PDGF. Finally, genetic deletion of tumour cell VEGF disrupts PDGF-Rbeta/VEGF-R2 complex formation and increases tumour vessel maturation. These findings underscore the importance of VSMCs/pericytes in neovascularization and reveal a dichotomous role for VEGF and VEGF-R2 signalling as both a promoter of endothelial cell function and a negative regulator of VSMCs and vessel maturation.

La National Kidney Foundation Dialysis Outcomes and Quality Initiative (DOQI) recommande les fistules autogènes comme accès de choix pour les nouvelles créations d'accès pour hémodialyse. Malheureusement, malgré des taux supérieurs de perméabilité par rapport aux pontages prothétiques, la durabilité des accès autologues est souvent remise en cause par les sténoses veineuses dues à l'hyperplasie intimale à la sortie de la veine ou par les sténoses veineuses centrales due aux cathéters veineux centraux longtemps laissés en place. Les interventions de sauvetage, sous forme de gestes endovasculaires tels que l'angioplastie transluminale percutanée (ATL) et/ou le stenting, sont de plus en plus utilisés pour le sauvetage et l'entretien des accès. L'objectif de cette étude était d'évaluer l'efficacité des gestes endovasculaires de dialyse à l'ère de la DOQI. Une évaluation rétrospective d'une base de données gestes endovasculaires sur accès de dialyse réalisés pendant 36 mois dans un centre universitaire a été menée. Les lésions veineuses centrales et celles d'aval ont été incluses dans l'analyse. Les courbes de Kaplan-Meier et l'analyse log-rank ont été employées pour évaluer et comparer les variables dépendant du temps. Quarante-cinq patients ayant un accès pour dialyse ont eu 72 interventions endovasculaires pour entretien de l'accès. Il y avait 27 interventions endovasculaires veineuses centrales et 32 sur l'aval avec un suivi de 98%. Les taux primaires et primaires assistés de perméabilité des ATL d'aval étaient respectivement de 50% et 72% à 12 mois. Il y eut 1,1 réinterventions par procédure d'ATL sur l'aval. Les taux primaires de perméabilité post-intervention des ATL veineuses centrales étaient respectivement de 30% et 9% à 6 et 12 mois. La perméabilité assistée post-intervention des ATL veineuses centrales était de 100% à 12 mois, avec 1,8 réinterventions par ATL. Les interventions veineuses centrales et sur le lit d'aval ont respectivement prolongé la perméabilité globale des accès de 38,5 et 33 mois (p < 0,0001). Les interventions endovasculaires sont la base du traitement des dysfonctionnements des accès pour dialyse. En dépit du besoin de réinterventions multiples et d'une surveillance étroite, les interventions par cathétérisme contribuent franchement à la durabilité des accès pour dialyse selon les recommandations de la DOQI.

The purposes of this study were to (1) investigate compression levels beneath an inelastic legging equipped with a new pressure-adjustment system, (2) compare the inelastic compression levels with those provided by a well-known elastic stocking, and (3) evaluate each support's gradient compression production. Eighteen subjects without venous reflux and 12 patients with previously documented venous reflux received elastic and inelastic compression supports sized for the individual. Skin surface pressures under the elastic (Sigvaris 500, 30-40 mm Hg range, Sigvaris, Inc., Peachtree City, GA) and inelastic (CircAid C3 with Built-in-Pressure System [BPS], CircAid Medical Products, San Diego, CA) supports were measured using a calibrated Tekscan I-Scan device (Tekscan, Inc., Boston, MA). The elastic stocking produced significantly lower skin surface pressures than the inelastic legging. Mean pressures (+/- standard error) beneath the elastic stocking were 26 +/- 2 and 23 +/- 1 mm Hg at the ankle and below-knee regions, respectively. Mean pressures (+/- standard error) beneath the inelastic legging with the BPS were 50 +/- 3 and 38 +/- 2 mm Hg at the ankle and below-knee regions, respectively. Importantly, our study indicates that only the inelastic legging with the BPS produces significant ankle to knee gradient compression (p = .001).