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ObjectiveCarotid endarterectomy (CEA) is proven to be the most effective treatment for symptomatic carotid artery stenosis of 50% or greater and asymptomatic carotid stenosis of 60% or greater. Although the prevalence of carotid artery disease increases with age, most prospective and randomized trials have excluded patients older than 80 years, implying that they are either at higher procedural risk or have decreased life expectancy. Since advanced age (≥80 years) has been viewed as a “high-risk” indicator for CEA, age ≥80 years has been used as an indication for alternative treatment. The study was conducted to determine if age ≥80 years is related to increased morbidity, mortality, and length of stay in patients undergoing CEA.MethodsIn the 12-year period from 1993 to 2004, 2217 CEAs were performed in 1961 patients. Three hundred sixty procedures were performed in 334 patients ≥80 years. Demographics, presentation, risk factors, operative outcome, and survival were analyzed. Contemporary literature was reviewed and the results summarized.ResultsIn patients aged ≥80 years, compared with their younger cohort, there was no difference in stroke (1.1% vs 0.8%, P = .333) but there was a higher operative mortality (1.9% vs 0.8%, P = .053). The combined stroke/death rate was higher in octogenarians (3.1% vs 1.5%, P = .041). This difference was due to the greater stroke/death rate in symptomatic octogenarians vs asymptomatic octogenarians (6.0% vs 0.9%, P = .007). The average postoperative length of stay was 3.2 ± 4.8 days for octogenarians compared with 2.4 ± 3.5 days for their younger counterparts (P < .001). Thirty-seven percent of the octogenarians were discharged on the first postoperative day vs 51% (P < .001), whereas 13% remained hospitalized beyond 5 days vs 8% (P = .003). Although Kaplan-Meier survival curves show a higher mortality in octogenarians, survival after CEA approaches that of the overall population. A summary of the contemporary literature of CEA in 2204 patients ≥80 shows an operative stroke rate of 2.23% and death rate of 1.28%, with a combined stroke/death rate of 3.51%.ConclusionCEA is a safe and effective procedure in the octogenarian. The combined stroke/death rate is increased in patients aged ≥80, indicating increased risk, predominantly in symptomatic patients. Although CEA risk in octogenarians is higher compared with a younger cohort, outcomes remain within acceptable national guidelines and within outcome measures known to confer benefit compared with best medical care. Therefore, the term “high risk” should not be arbitrarily applied to patients reaching the 80-year threshold. This is confirmed by the contemporary literature.

Objective: Cervical hematoma (CH) following carotid endarterectomy (CEA) is a serious complication. We reviewed 12 years of CEA for CH requiring operative evacuation to determine its impact on the patient outcome and relationship to perioperative pharmacotherapy. Methods: A total of 2643 CEAs were reviewed. In all, 57 CHs requiring operative evacuation were compared to all the patients for general characteristics and with a case-controlled cohort group for pharmacologic details. Results: The occurrence of CH was stable from 1994 to 1998 and then increased from 1999 to 2003. The CH increased operative mortality, neurologic complications, adverse cardiac events, and cranial nerve injury. Combined platelet inhibition and dextran alone increased the risk of CH. The CH rate dropped by 65% after the observations were reported to the vascular surgeons. Conclusion: The CH following CEA requiring operative evacuation is associated with increased postoperative mortality and cardiac and neurologic morbidity. Combined platelet inhibition, use of dextran, and elevated creatinine are causally related to CH. Physician awareness and modified pharmacotherapy have decreased the problem.

Branchial cleft sinuses are congenital anomalies that usually present in childhood or early adulthood. It is uncommon that such a sinus will remain asymptomatic to the sixth decade of life. This case describes the presence of a second branchial cleft sinus in the setting of carotid artery disease, where both were treated surgically simultaneously without complication.

There is increasing interest in using endovascular methods instead of surgical reconstruction to treat popliteal artery aneurysms. Exclusive use of the Viabahn stentgraft, a nitinol stent covered with expanded polytetrafluoroethylene, was assessed in the treatment of patients who presented with popliteal artery aneurysms in the absence of acute limb ischemia. Technical success, endoleaks, graft patency, freedom from amputation, and aneurysm sac flow and size changes were assessed by duplex ultrasound. From June 2004 to March 2006, 16 men (mean age, 76 years; range, 65-83) underwent endovascular exclusion of 23 popliteal artery aneurysms (mean diameter, 2.5 cm; range, 1.3-6.7 cm). Nine lesions had partial thrombus on preprocedural duplex imaging. Nineteen of the 23 limbs treated had at least 2-vessel tibial artery runoff. Procedures were performed under local anesthesia using ipsilateral percutaneous antegrade arterial access. All patients received 75 mg/day of clopidogrel afterward. Follow-up assessments included direct clinical examinations and duplex ultrasonography performed 1, 3, 6, and 12 months after the procedure. Primary patency and amputation-free survival were calculated using Kaplan-Meier analysis. Complete aneurysm exclusion (technical success) was achieved in all cases. During the mean follow-up of 7 months (range, 1-21 months), 22 of 23 treated limbs remained asymptomatic. One stent-graft thrombosis occurred 6 months after the procedure and was successfully treated with percutaneous mechanical thrombectomy, balloon angioplasty of a stent-graft stenosis, and insertion of an uncovered nitinol stent. No popliteal artery aneurysm sac size enlargements or endoleaks were detected. At 12 months, the treated limb mean anklebrachial index was 1.0 (range, 0.82-1.31) and the primary and secondary patency rates were 93% and 100%, respectively. Early results with Viabahn endovascular stent-graft exclusion of asymptomatic popliteal artery aneurysms are promising. Patient selection for endovascular repair depends on suitable popliteal artery anatomy, extent of aneurysmal degeneration, and quality of tibial arterial runoff.

Chronic venous insufficiency (CVI) with the resultant clinical sequelae significantly reduces quality of life. Most elderly patients with CVI are treated nonoperatively owing to concerns of increased operative risk and therefore suffer more advanced disease. Radiofrequency ablation (RFA) has emerged as a minimally invasive procedure to treat patients with superficial venous insufficiency (SVI) due to great saphenous vein (GSV) incompetence. The purpose of this study was to review our experience using RFA of the GSV to treat CVI due to superficial disease in elderly patients compared to younger patients in terms of procedure-related morbidity and severity of disease at time of treatment. RFA treatment of the GSV was performed in 490 extremities of 421 patients with SVI between March 2001 and December 2002. Indications, medical history, and outcome (operative complications and hospital stay) were compared between 2 groups: Group I: 41 extremities of 35 patients, 70 years if age or older (mean 75 ±4); and Group II: 449 limbs of 386 patients younger than 70 years (mean 47 ±11). The incidence of skin pigmentation and healed/nonhealed ulcers (CEAP 4–6) was significantly higher in the elderly than in the younger group (41% vs 16%, p

The transverse rectus abdominis musculocutaneous (TRAM) flap is a commonly used method for autologous tissue postmastectomy breast reconstruction. It is a major operative procedure, and some have argued that it needlessly exposes patients to increased risk of complications and blood transfusions. In this series the authors review their experience with 105 consecutive complex postmastectomy breast reconstructions, limited to double-pedicle flaps, identifying complications rates and blood transfusion requirements. Blood transfusions were required in 2.8% of patients undergoing bipedicle or bilateral TRAM flap breast reconstruction. Blood transfusions were only required in patients who experienced a complication. Obesity was associated with an increased rate of complications and blood transfusion. Routine typing and cross-matching of blood and self-donation of blood may not be required for TRAM flap breast reconstruction in low-risk patients.

Purpose Colonic lipomas are benign tumors usually asymptomatic. Occasionally, they may cause symptoms such as bleeding, intussusception, obstruction, or rectal prolapse. Methods We present a 44-year-old African-American female that presented with an 8 cm colonic lipoma protruding through the anal verge. We also reviewed all the reported cases in the English literature. Results The patient was treated successfully with transanal resection, which has rarely been done before for this large a tumor. Conclusions Transanal resection of large benign tumors of the rectosigmoid is possible.

PURPOSE: Malignant rhabdoid tumor (MRT) of the vulva is a rare and very aggressive neoplasm. Only 7 cases have been reported thus far in the English literature. This case reports the oldest patient to date with MRT. This 63 year old was successfully treated with surgery and radiation therapy. The current literature is reviewed, and different treatment modalities are considered and evaluated.

Purpose Torsion of the appendix is a rare cause of acute abdomen with presentation, treatment, and prognosis virtually identical to that of acute appendicitis. Methods We present a case of appendiceal torsion in a 44-year-old male, which is to our knowledge the first in an African-American man, and we review all of the reported adult cases in the English language literature. Conclusion This condition may have occurred when a normal appendix is encountered and no other pathologic findings exist.

Objective As an emerging endovascular alternative to ligation and stripping of the incompetent greater saphenous vein (GSV), radiofrequency ablation was monitored with ultrasound scaning to evaluate anatomic results. Neovascularization and inflammation are potential consequences that lead to the appearance of small vessels. The natural history of the below-knee untreated GSV segment may be important in our understanding of ongoing chronic venous disease. An ultrasound follow-up study was conducted to determine the prevalence of small vessel networks, defined as veins and arteries less than 2 mm in diameter, adjacent to the saphenofemoral junction (SFJ); prevalence of small vessel networks adjacent to the treated GSV in the thigh; and fate of the below-knee untreated GSV distal to the ablated segment. Methods One hundred six extremities with radiofrequency ablation of the GSV for treatment of superficial venous insufficiency were followed up with high-resolution ultrasound imaging 4 to 25 months (median, 9 months) after the procedure. Ninety-three limbs had concomitant ligation and division of the SFJ and its tributaries, and 13 limbs underwent radiofrequency ablation without SFJ ligation. Ultrasound was used to evaluate patients for small vessel networks, and concomitant findings of small vessel networks and recanalization at the SFJ and adjacent to the treated GSV. The status of the below-knee segment of untreated GSV was evaluated for patency and reflux. Data analysis compared the findings in the ligation group with those in the no-ligation group, with the χ 2 test and Fisher exact test. Results We found small vessel networks in 65% (n = 69) of extremities: 15% (n = 16) at the SFJ only, 26% (n = 28) in the thigh only, and 24% (n = 25) at both the SFJ and thigh, resulting in a small vessel network prevalence of 39% (n = 41) at the SJF and 50% (n = 53) in the thigh. The prevalence of small vessel networks at the SFJ was significantly less after radiofrequency ablation with SFJ ligation (34%, 32 of 93) than after radiofrequency ablation without ligation (69%, 9 of 13; P = .035). Small vessel networks and GSV recanalization at the SFJ was more common in patients undergoing radiofrequency ablation without ligation (46%, 6 of 13) than after radiofrequency ablation with ligation (14%, 13 of 93; P = .014). The prevalence of small vessel networks in the thigh was not affected by SFJ ligation. The below-knee GSV was patent in 79% (84 of 106), and 58% (61 of 106) demonstrated reflux, a decrease from the pre–radiofrequency ablation rate of 71% (75 of 106), possibly because thrombosis extended distally beyond the ablated segment in 16% (17 of 106) of the legs. Conclusions Small vessel networks were detected adjacent to or in connection with most of the radiofrequency ablation–treated GSVs. SFJ ligation was associated with fewer small vessel networks and proximal GSV recanalization. Most below-knee untreated GSV segments remained patent, and most exhibited reflux.