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BackgroundCarotid endarterectomy (CEA) is currently performed by various surgical specialties with varying outcomes. This study analyzes different surgical practice patterns and their effect on perioperative stroke and cost.MethodsThis is a retrospective analysis of prospectively collected data of 1000 consecutive CEAs performed at our institution by three different specialties: general surgeons (GS), cardiothoracic surgeons (CTS), and vascular surgeons (VS).ResultsVS did 474 CEAs, CTS did 404, and GS did 122. VS tended to operate more often on symptomatic patients than CTS and GS: 40% vs 23% and 31%, respectively (P < .0001). Preoperative workups were significantly different between specialties: duplex ultrasound (DUS) only in 66%, 30%, and 18%; DUS and computed tomography angiography in 27%, 35%, and 29%; and DUS and magnetic resonance angiography in 6%, 35%, and 52% for VS, CTS, and GS, respectively (P < .001). The mean preoperative carotid stenosis was not significantly different between the specialties. The mean heparin dosage was 5168, 7522, and 5331 units (P = .0001) and protamine was used in 0.2%, 19%, and 8% (P < .0001) for VS, CTS, and GS, respectively. VS more often used postoperative drains; however, no association was found between heparin dosage, protamine, and drain use and postoperative bleeding. Patching was used in 99%, 93%, and 76% (P < .0001) for VS, CTS, and GS, respectively. Bovine pericardial patches were used more often by CTS and ACUSEAL (Gore-Tex; W. L. Gore and Associates, Flagstaff, Ariz) patches were used more often by GS (P < .0001). The perioperative stroke/death rates were 1.3% for VS and 3.1% for CTS and GS combined (P = .055); and were 0.7% for VS and 3% for CTS and GS combined for asymptomatic patients (P < .034). Perioperative stroke rates for patients who had preoperative DUS only were 0.9% vs 3.3% for patients who had extra imaging (computed tomography angiography/magnetic resonance angiography; P = .009); and were 0.9% vs 3% for asymptomatic patients (P = .05). When applying hospital billing charges for preoperative imaging workups (cost of DUS only vs DUS and other imaging), the VS practice pattern would have saved $1180 per CEA over CTS and GS practice patterns; a total savings of $1,180,000 in this series.ConclusionsCEA practice patterns differ between specialties. Although the cost was higher for non-VS practices, the perioperative stroke/death rate was somewhat higher. Therefore, educating physicians who perform CEAs on cost-saving measures may be appropriate.

Background Few studies have specifically correlated the amount of thrombus in the aneurysm sac and the presence of type II endoleaks (TIIE). This study examined the correlation of preoperative thrombus load and location to the incidence of TIIE and late sac regression. Methods Prospectively collected data from 266 endovascular aneurysm repair (EVAR) patients were analyzed. Maximum thrombus thickness (MTT) and percentage of the circumference of the aortic wall lined by thrombus (thrombus-lined aneurysm circumference [TLAC]) were determined from preoperative computed tomography angiography (CTA) images at four levels: neck, maximum abdominal aortic aneurysms (AAA) diameter (zone B), zone A (between neck and zone B), and zone C (between zone B and aortic bifurcation). The number of aortic side branches (ASB) was also recorded (inferior mesenteric artery [IMA], accessory renals, lumbar, and middle sacral). Logistic regression was used to determine the association of TIIE with each variable. Results Thirty-three (12%) early and 32 (13%) late TIIE were noted at a mean follow-up of 22 months (range, 1-87 months). The mean MTT at zone B was 19.7 mm in patients without early TIIE and 18.8 mm in patients without late TIIE vs 14.4 and 17.2 mm in patients with early and late TIIE ( P = .0137 and P = .444, respectively). The mean percentage of TLAC was 76% and 75% vs 65% and 64% in patients without vs with early and late TIIE ( P = .0329 and P = .044, respectively). There was no correlation of early and late TIIE and thrombus location by zones. The IMA was patent in 7% and 7% of patients without early and late TIIE vs 16% and 15% with TIIE ( P = .0367 and P = .077, respectively). The mean number of ASB in patients without (early and late) TIIE was 5.8 and 5.6 vs 5.8 and 7 with endoleak ( P = .932 and P = .001, respectively). Univariate analysis showed the following variables decreased the incidence of early TIIE: MTT for zone B (odds ratio [OR] 0.79 for 5-mm increase; P = .014), MTT zone A (OR, 0.78; P = .028), MTT zone C (OR, 0.82; P = .043), and percentage of TLAC (OR, 0.88 for 10% increase; P = .036). For late TIIE: percentage of TLAC (OR, 0.88 for 10% increase; P = .048), and ASB (OR, 1.39 for each additional vessel; P = .001). A multiple regression model showed only ASB (OR, 1.34; P = .009) was a predictor for late TIIE. Four of five patients (80%) with late sac expansion vs 24 of 208 (12%) without expansion had late TIIE ( P = .001). Conclusions MTT, percentage of TLAC, number of ASB, and patent IMA influenced early TIIE; however, only the number of ASB influenced late TIIE.

BackgroundThe use of shunting in carotid endarterectomy (CEA) is controversial. This randomized trial compared the results of routine (RS) vs selective shunting (SS) based on stump pressure (SP).MethodsTwo-hundred CEA patients under general anesthesia were randomized into RS (98 patients) or SS (102 patients), where shunting was used only if systolic SP (SSP) was .99). The overall perioperative complication rates were 8.3% in RS (2 TIA, 3 hemorrhage, 1 myocardial infarction [MI], and 1 asymptomatic carotid thrombosis) vs 7.8% in SS (2 strokes, 1 TIA, 3 hemorrhage, 1 MI, and 1 congestive heart failure; P = .917).ConclusionsRS and SS were associated with a low stroke rate. Both methods are acceptable, and surgeons should select the method with which they are more comfortable.

Background Several authorities have proposed stenting of the superior mesenteric artery (SMA)/celiac artery (CA) as the primary treatment for patients with chronic mesenteric ischemia. However, most of these reports had small samples and short follow-up periods. Methods Eighty-three patients were treated over a 10-year period. Clinical follow-up and duplex ultrasound exams were done to evaluate long-term patency. We used our newly validated duplex criteria to detect ≥70% in-stent stenosis of the SMA and CA. A Kaplan-Meier life-table analysis was used to estimate freedom from in-stent stenosis and late symptom and survival rates. Results Fifty-four SMA and 51 CA stents were analyzed. The initial technical and clinical success rates were 97% and 96%, respectively, with 2% procedure morbidity and 2% mortality. The primary late clinical success rate was 59%, and the late ≥70% in-stent stenosis rate was 51% at a mean follow-up of 31 months (range, 1-124). Freedom from late recurrent symptoms at 1, 2, 3, 4, and 5 years was 83, 77, 70, 70, and 65%, respectively. Survival rates at the same intervals were 88%, 82%, 70%, 64%, and 51%. Primary patency rates for the whole series were 69%, 48%, 39%, 28%, and 19% at 1, 2, 3, 4, and 5 years, respectively. Assisted primary patency rates for the whole series were 80%, 61%, 54%, 43%, and 34% at 1, 2, 3, 4, and 5 years, respectively. Primary patency rates for the SMA at 1, 2, 3, 4, and 5 years were 71%, 47%, 37%, 28%, and 18%, respectively; and assisted primary rates were 82%, 64%, 57%, 45%, and 32%, respectively. Primary patency rates for the CA were 68%, 50%, 40%, 29%, and 21%; and assisted primary rates were 79%, 58%, 52%, 42%, and 36% for 1, 2, 3, 4, and 5 years, respectively. There were no significant differences in either primary or assisted primary patency between the SMA and CA ( P = .7729 and .8169). A secondary intervention was carried out in 30% of the series. Freedom from ≥70% in-stent stenosis for the SMA was 82%, 65%, 56%, 42%, and 34%, and that for the CA was 73%, 59%, 48%, 34%, and 25%, at 1, 2, 3, 4, and 5 years, respectively. Conclusions Stenting of SMA/CA stenosis has high technical/early clinical success rates with a satisfactory late clinical outcome; however, it is associated with high rates of late in-stent stenosis and intervention.

Background In the U.S. diabetes prevalence estimates for adults ≥ 65 years exceed 20%. Rural communities have higher proportions of older individuals and health disparities associated with rural residency place rural communities at risk for a higher burden from diabetes. This study examined the adequacy of care received by older rural adults for their diabetes to determine if older rural adults differed in the receipt of adequate diabetes care when compared to their non-rural counterparts. Methods Cross-sectional data from the 2009 Behavioral Risk Factor Surveillance Survey were examined using bivariate and multivariate analytical techniques. Results Logistic regression analysis revealed that older rural adults with diabetes were more likely to receive less than adequate care when compared to their non-rural counterparts (OR = 1.465, 95% CI: 1.454-1.475). Older rural adults receiving less than adequate care for their diabetes were more likely to be: male, non-Caucasian, less educated, unmarried, economically poorer, inactive, a smoker. They were also more likely to: have deferred medical care because of cost, not have a personal health care provider, and not have had a routine medical check-up within the last 12 months. Conclusion There are gaps between what is recommended for diabetes management and the management that older individuals receive. Older adults with diabetes living in rural communities are at greater risk for less than adequate care when compared to their non-rural counterparts. These results suggest the need to develop strategies to improve diabetes care for older adults with diabetes and to target those at highest risk.

BackgroundSeveral published studies have reported differing results of renal duplex ultrasound (RDU) imaging in detecting significant renal artery stenosis (RAS) using different Doppler parameters. This study is the largest to date to compare RDU imaging vs angiography and assess various published Doppler criteria.MethodsRDU imaging and angiography were both done in 313 patients (606 renal arteries). RAS was classified as normal