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Revascularization of extracranial carotid artery stenosis (ECAS) continues to be the subject of spirited academic debate. Conflicting studies in the literature have fostered uncertainty among patients choosing between CEA and CAS. We obtained preference-based utilities from prospective patients being evaluated for ECAS and incorporated them into a decision analytic model. Patients being evaluated for ECAS in an outpatient setting were interviewed prior to their initial visit with a vascular surgeon. Patient preference data were elicited using probability trade-off (PTO) assessment and time trade-off (TTO) method. Decision analysis was performed to compare CEA with CAS. Morbidity and mortality rates were obtained from recent literature reports from the same institution. Our results showed that when patients are informed, they prefer and will more often choose CEA over CAS for revascularization of ECAS. Among patients preferring CAS, they expect no more than a 46% increase in the rate of stroke and/or death. Future clinical studies on true stroke rates for CAS will be required to further refine this analysis.

Background: Carotid angioplasty and stenting is under investigation in clinical trials as an alternative to endarterectomy. Some clinicians have hypothesized that stenting would be applicable for patients at high risk who need carotid revascularization. To further test this hypothesis, we stratified our carotid endarterectomy procedures according to current carotid stent protocols., Methods: We reviewed our computerized registry and the clinical charts of patients who underwent carotid endarterectomy. Each procedure was categorized as high risk or low risk, according to the following six separate high-risk factors: 1, severe cardiac dysfunction; 2, the requirement for combined coronary and carotid vascularization; 3, severe pulmonary dysfunction; 4, contralateral internal carotid artery occlusion; 5, previous ipsilateral carotid endarterectomy; and 6, anatomically limited access for carotid endarterectomy. Rates of stroke at 30 days, cardiac complications, and death were tabulated., Results: Between January 1, 1998, and December 31, 2000, 415 carotid endarterectomies were performed on 389 patients. Ninety-eight procedures (23.6%) were classified as high risk on the basis of the following factors: 1, severe cardiac dysfunction (n = 30); 2, requirement for combined coronary and carotid revascularization (n = 14); 3, severe pulmonary dysfunction (n = 8); 4, contralateral carotid occlusion (n = 31); 5, previous ipsilateral carotid endarterectomy (n = 25); and 6, anatomically limited access (n = 4). Seven patients had ipsilateral postoperative strokes (1.7%), with two additional patients having contralateral hemispheric strokes. One patient died from exacerbation of congestive heart failure 9 days after undergoing a second carotid endarterectomy. The total stroke and death rate was 2.6% for all the patients. Two of the 98 procedures in the high-risk group were complicated with ipsilateral stroke (2.0%) as compared with six of the 317 low-risk procedures (1.9%; P = 1). Six procedures were complicated with cardiac dysfunction after surgery, including myocardial infarction, congestive heart failure, or the new onset of atrial fibrillation. Three cardiac complications occurred in the low-risk group (1%), and three occurred in the high-risk group (3.1%; P =.15)., Conclusion: This series shows that patients at high risk can undergo carotid endarterectomy with stroke rates equivalent to the rates of patients at low risk. The cardiac morbidity rate may be increased in the high-risk group. Carotid stenting is unlikely to offer any improvement in stroke risk as compared with carotid endarterectomy, but stenting may reduce non-stroke morbidity rates associated with some high-risk cases.

Background: Endoscopic saphenous vein harvest has been explored as a minimally invasive alternative to a long continuous leg incision for removal of the greater saphenous vein. The endoscopic technique uses limited incisions (2-4) with extended "skin bridges" and videoscopic equipment for the dissection and removal of the greater saphenous vein. This study was undertaken to evaluate the long-term durability of saphenous vein grafts harvested by an endoscopic technique and used for lower extremity arterial revascularization., Methods: All patients who underwent endoscopic saphenous vein harvesting for lower extremity arterial bypass grafting were prospectively followed for graft patency and risk factors. Grafts were surveyed with serial duplex scans at 3- to 6-month intervals over this 5-year study. Life-table methods were used to assess graft survival. A computerized registry and medical records were reviewed to determine graft patency and patient survival., Results: From September 1994 to August 2000, 164 lower extremity arterial saphenous vein grafts harvested by an endoscopic technique were used for lower extremity arterial bypass grafting in 150 patients. The patient population included 111 males (75%) and 112 smokers (75%), but also included a high-risk cohort of 65 diabetic patients (43%) and 15 patients undergoing dialysis/renal transplant (10%). Twenty-eight patients (19%) died within the study period. With life-table methods, 1-, 3-, and 5-year secondary patency rates were 85% (+/- 3.2%), 74% (+/- 5.7%), and 68% (+/- 11.6%). Of the 30 failed grafts, 7 (4%) failed in the first month related to inadequate runoff (4), cardiac instability (2), and an additional surgical procedure (1). Twenty-three grafts (14%) failed between 1 and 42 months. Twenty-two (16%) of these 134 patent grafts underwent a second procedure to maintain patency (13 as primary-assisted patency and 9 as secondary patency)., Conclusions: Endoscopic saphenous vein harvest for lower extremity arterial reconstruction provides a satisfactory conduit for lower extremity bypass grafting. Although increased manipulation from this limited access technique may incite an injury response in the vein, these vein grafts can maintain an adequate patency for lower extremity bypass grafting.

Purpose: Telemedicine coupled with digital photography could potentially improve the quality of outpatient wound care and decrease medical cost by allowing home care nurses to electronically transmit images of patients' wounds to treating surgeons. To determine the feasibility of this technology, we compared bedside wound examination by onsite surgeons with viewing digital images of wounds by remote surgeons., Methods: Over 6 weeks, 38 wounds in 24 inpatients were photographed with a Kodak DC50 digital camera (resolution 756 x 504 pixels/in2). Agreements regarding wound description (edema, erythema, cellulitis, necrosis, gangrene, ischemia, and granulation) and wound management (presence of healing problems, need for emergent evaluation, need for antibiotics, and need for hospitalization) were calculated among onsite surgeons and between onsite and remote surgeons. Sensitivity and specificity of remote wound diagnosis compared with bedside examination were calculated. Potential correlates of agreement, level of surgical training, certainty of diagnosis, and wound type were evaluated by multivariate analysis., Results: Agreement between onsite and remote surgeons (66% to 95% for wound description and 64% to 95% for wound management) matched agreement among onsite surgeons (64% to 85% for wound description and 63% to 91% for wound management). Moreover, when onsite agreement was low (i.e., 64% for erythema) agreement between onsite and remote surgeons was similarly low (i.e., 66% for erythema). Sensitivity of remote diagnosis ranged from 78% (gangrene) to 98% (presence of wound healing problem), whereas specificity ranged from 27% (erythema) to 100% (ischemia). Agreement was influenced by wound type (p < 0.01) but not by certainty of diagnosis (p > 0.01) or level of surgical training (p > 0.01)., Conclusions: Wound evaluation on the basis of viewing digital images is comparable with standard wound examination and renders similar diagnoses and treatment in the majority of cases. Digital imaging for remote wound management is feasible and holds significant promise for improving outpatient vascular wound care.