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As less arteriography is performed before carotid surgery, concern arises about missing occult cerebral aneurysms and possible adverse outcomes. A study was conducted by the divisions of vascular surgery and neurosurgery of Northwestern University Medical School to evaluate the frequency of incidental cerebral aneurysms and outcomes of patients with extracranial cerebrovascular disease and asymptomatic cerebral aneurysms. From October 1995, through March 1997, 200 patients underwent intracranial and extracranial cerebrovascular angiography for evaluation of extracranial disease. Demographic data, symptoms, data of vascular lesions, surgical treatment and outcomes of stroke and death were recorded prospectively. Two patients (1%) had asymptomatic cerebral aneurysms found on angiography. Six more patients were referred with a known asymptomatic cerebral aneurysm with extracranial disease during this same period. Of these eight patients, five underwent extracranial vascular reconstruction surgery and seven received treatment for their aneurysms. There were two stroke complications, both occurred after treatment of a basilar artery aneurysm. One of these patients died. No aneurysms ruptured following 203 extracranial revascularizations during this same period. On the basis of the low prevalence of diagnosing coincidental cerebral aneurysms during work-up of extracranial disease, as well as the lack of evidence that carotid surgery predisposes to aneurysm rupture in these patients in both our study and the literature review, it is concluded that coexisting extracranial disease and asymptomatic cerebral aneurysms do not pose a case against carotid surgery without routine arteriography. However, arteriography should be considered in selected groups of patients where the yield of intracranial aneurysms is high; these include patients with a familial history of cerebral aneurysms, autosomal dominant polycystic kidney disease, extracranial internal carotid artery medial fibrodysplasia, Takayasu's arteritis, alpha1-antitripsin deficiency and atypical clinical presentations, including headache.

The presentation of long-term complications after conventional aortic surgery and the treatment of patients that have had reoperative aortic operations are reviewed. Ninety-seven consecutive patients that had 102 subsequent aortic operations at a tertiary referral center were studied. Presenting symptoms, demographics, risk factors, indications for initial and second procedures, operative techniques and outcomes were recorded in a computerized database. There were 70 men and 27 women studied, with an average age of 64 years. First operations were performed primarily for aneurysm (56%) and occlusive disease (44%). The interval between procedures ranged up to 23 years, with a mean of 6 years. Indications for reoperation were subsequent aneurysm (65), graft occlusions (25) and/or infections (24). Seventy-three percent of the subsequent aneurysms were true metachronous aneurysms; the others were associated with the graft or an anastomosis. Para-anastomotic aneurysms may be more common with a primary end-to-side graft configuration. One-third of subsequent aneurysms were not palpable and asymptomatic. Graft occlusion can be treated safely with elective repeat bypass (mortality 0%). Graft infections that require total graft removal remain a challenging problem (mortality 17%). Although surgical approach for reoperations utilized more extensive exposure and proximal clamping, 59 elective aneurysm cases had a 5.1% mortality rate; eight emergent procedures for ruptured aneurysms resulted in 88% mortality. Reoperation for graft occlusion or infection showed a similar high mortality rate with emergent cases. In this referral practice, graft occlusion and infection are relatively less frequent, whereas metachronous aneurysm formation is now the most common indication for reoperation. These aneurysms often remain undetected until symptoms occur; frank rupture is usually lethal. As elective repair with modern reoperative techniques can be safely performed, routine computed tomographic examination is advisable at least every 5 years after aortic operations.