Carotid angioplasty and stenting: is endovascular treatment for cerebrovascular disease justified.
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Angioplasty, Balloon↗
Biomedical subjects
P Bergeron
Publications and source records attributed to P Bergeron.
Local anesthesia in carotid angioplasty.
PURPOSE: To determine the safety and efficacy of local anesthesia for percutaneous carotid angioplasty and stenting performed via a direct common carotid access. METHODS: Deep cervical plexus blockade was used for anesthesia in 22 of 32 patients (26 males; mean age 66 years) undergoing percutaneous carotid balloon angioplasty and/or stenting via direct carotid puncture. Local anesthesia was selected according to patient preference (n = 9); advanced age (n = 4); ischemic heart disease (n = 4); intended extracorporeal circulation for unstable angina (n = 3); and an incompetent circle of Willis (n = 2). The technique involved injection of bupivacaine hydrochloride along the C2, C3, and C4 transverse processes. No superficial cervical plexus blockade was used. RESULTS: No complications of anesthesia were observed, though there were cases in which surgery became necessary under local anesthesia for angioplasty-related complications. These conversions were accomplished without difficulty. CONCLUSIONS: Cervical nerve blockade appears to be a safe and effective anesthetic method for endovascular carotid interventions performed percutaneously through direct carotid puncture.
Age Factors↗
Recurrent carotid disease: will stents be an alternative to surgery?
PURPOSE: To report the results of balloon angioplasty in recurrent carotid occlusive disease and evaluate the potential for stent implantation. METHODS AND RESULTS: Between April 1991 and September 1995, 15 patients with carotid restenosis underwent 17 endoluminal procedures in 3 common carotid and 14 internal carotid arteries. Two postdilation complications (dissection and acute occlusion) required prompt stenting; one common carotid artery was stented for postdilation residual stenosis. One recurrent lesion was also stented 6 months after initial angioplasty. One stroke, 1 silent cerebral infarction, and 3 transient ischemic attacks occurred in the balloon angioplasty patients (33% neurological complication rate). The common carotid stent patient died 3 days postoperatively due to hyperperfusion syndrome. Long-term follow-up in two stent patients showed no restenosis at 18 and 48 months, respectively. The 11 balloon angioplasty patients likewise have not demonstrated restenosis. CONCLUSIONS: Balloon angioplasty alone appears too risky for treating recurrent carotid disease. Stents may offer a safer alternative, particularly when implanted primarily.
Aortic Dissection↗
Carotid angioplasty and stenting: will periprocedural transcranial Doppler monitoring be important?
PURPOSE: To explore the value of transcranial Doppler (TCD) ultrasonography in the periprocedural monitoring of patients undergoing angioplasty procedures for stenosis of the internal carotid artery. METHODS: Thirty-two patients were included in the study between April 1991 and September 1995 (6 females, 26 males; average age 66 years). All patients were interrogated before and after angioplasty by a standard TCD examination protocol. Intraprocedurally, TCD was used continuously to monitor cerebral blood flow and supply evidence of embolic particulates. Nineteen patients were treated by percutaneous transluminal angioplasty (PTA) alone; the other 13 underwent primary stent (PS) implantation. RESULTS: High-intensity transient signals indicative of emboli appeared to be more frequent in the PTA group than in the PS cohort. Preoperative TCD identified 3 (9%) high-risk patients with incompetent collateral pathways through the circle of Willis. Intraoperatively, TCD detected two postdilation carotid occlusions, a sylvian embolism, and one case of arterial spasm. The preprocedural TCD in a patient with contralateral carotid occlusion showed good collateral circulation, providing reassurance during conversion to endarterectomy when an undeployed stent obstructed blood flow. Postoperatively, TCD confirmed restored intracerebral circulation and identified one hyperperfusion syndrome. CONCLUSIONS: TCD is a simple, relatively inexpensive examination that can preprocedurally identify carotid stenosis patients at high risk for intraoperative cerebral ischemia in whom PTA might be preferable to surgery. During the procedure, TCD can document the benefits of endovascular treatment and offer early detection of ischemic complications.
Aged↗
Cervical carotid artery stenosis: which technique, balloon angioplasty or surgery?
METHODS: Between April 1991 and November 1995, 38 patients mean age 65 (6 females, 32 males) were treated by cervical puncture for isolated cervical carotid stenosis (33 internal, 1 external, and 6 common carotid). All patients but 5 were symtomatic (19 TIA, 7 amarosis, 2 strokes and 4 VB symptoms). Complex lesions involving the carotid bifurcation and heavy calcifications were treated by conventional surgery. Two different groups of patients were considered. A first group of 19 patients (17 restenosis, 1 primary, 1 FM dysplasia) was treated by simple balloon angioplasty (BA). A second group of 19 patients was treated by primary stenting (16 DF NOVO, 2 radio-induced, and 2 recurrent stenosis). RESULTS: No hematoma required surgery. In the first group one patient died from an intracerebral hemorrhage, one presented a reversible stroke and 3 others a TIA. In the second group there was no complication or silent infarction on the CT SCAN: CONCLUSIONS: Balloon angioplasty appears to be associated with a high neurologic risk. While primary stenting seems much more reliable. A longer follow-up to deal with restenosis. Conventional surgery remains the gold standard.
Aged↗
[Endovascular treatment of arteries with cerebral destination: failures and limits].
OBJECTIVE: Evaluate endovascular treatment of vessels irrigating the brain. Assess risks and indications of balloon angioplasty and stents. METHODS: Retrospective study in 38 patients (6 females, 32 males) who underwent revascularization from December 1990 to July 1995: 47 balloon angioplasties and 17 stents (36%). Three patients were asymtomatic, 17 had a past history of transient ischaemia, 5 had amauraosis, 9 signs of vertebrobasilar insufficiency and 2 had an ischaemia of the upper limbs. Endoluminal treatment was performed in 4 brachiocephalic trunks with implantation of 1 stent, in 7 common carotid arteries with 4 stents, in 24 internal carotid arteries with 9 stents, 2 osteal stenosis of the vertebral artery and one external carotid. RESULTS: There were no complications in patients treated for lesions of the brachiocephalic trunk, the subclavian artery and the vertebral arteries. Among the 7 patients with a stenosis of the common carotid artery, there was one death after reperfusion due to cerebral oedema. For the carotid internal, two groups of patients could be distinguished. In one group of 13 patients with restenosis of the internal carotid artery who were treated by balloon angioplasty, there were 3 transient episodes of ischaemia, one reversible hemiplegia and one silent infarction. A second group of 8 patients had atheromatous stenosis. One was treated by balloon angioplasty with one transient episode of ischaemia and the 7 others were treated with a stent without complications. The rate of neurological complications was 15.7% (6 deficits in 38 patients). The permeability after revascularization was verified at mid-term with repeated echo-Doppler examinations and by angiography one year after operation. Restenosis occurred early after one subclavian stent covered with a patch. Among the 16 Palmaz stents, one implanted in a post-irradiation common carotid occluded after 2 months. The other 15 stents were patent at a mean follow-up of 18 months (2-56), i.e. 93%. There were 2 restenoses after balloon angioplasty in the group of carotid restenosis, i.e. 15%. CONCLUSIONS: Risk in balloon angioplasty of arteries irrigating the brain is a serious problem. Stenosis of the subclavian artery and the vertebral arteries appears to be a good indication. Lesions of the carotid bifurcation should not be treated with balloon angioplasty due to the risk of neurological complications. Among the restenosis after endarterectomy, only those lesions situated in the distal internal carotid are good indications. Stents have greatly improved treatment possibilities. They should be implanted whenever there is a risk of supra-aortic lesions and in certain lesions of the carotid bifurcation in high-risk, patients. Their application in all situations cannot be proposed yet before long-term outcome is established.
Angioplasty, Balloon↗
Long-term results with the Palmaz stent in the superficial femoral artery.
PURPOSE: Femoral stenting has demonstrated inconsistent and often disappointing long-term results. To compare out experience, we retrospectively analyzed a series of patients who had Palmaz balloon-expandable stents placed exclusively for superficial femoral artery (SFA) lesions. METHODS: From January 1990 to November 1993, 39 patients were evaluated for claudication (79%) or critical ischemia in 42 limbs. The culprit lesions were confined to the SFA: 24 (57%) occlusions and 18 (43%) stenoses, including 3 restenotic lesions. Stenting was elective in 12 (29%) cases: the 3 restenoses and 9 chronic, calcified occlusions. The remaining stents were applied for postangioplasty residual stenosis or angioscopic findings of thrombogenic luminal irregularities. A total of 55 prostheses were successfully implanted. All patients were maintained on ticlopidine and followed by routine duplex scanning. Follow-up angiography was performed in 28 (72%) patients between 4 and 45 months. RESULTS: In the postprocedural period, two acute thromboses (4.8%) occurred within 48 hours in patients who had long occlusions and poor runoff; no other major complications were encountered, for a clinical success rate of 95%. Follow-up evaluation ranged from 4 months to 4 years with a mean of 25 months. The restenosis rate was 19% (34% in occlusions; 10% in stenotic lesions, p = NS). At 24 months, cumulative primary patency was 77% and secondary patency 89%. CONCLUSIONS: Palmaz stents performed will in the SFA, demonstrating a low acute thrombosis rate and good long-term patency. The incidence of restenosis is likely to be greater in occlusions than in stenoses.
Aged↗
Effects of routine premedication for cardiac catheterization on sedation, level of anxiety and arterial oxygen saturation.
OBJECTIVE: To assess the efficacy and side effects of routine premedication in patients undergoing cardiac catheterization procedures in a tertiary cardiac care institute. The criteria used included: arterial hemoglobin oxygen saturation (%SaO2), level of sedation and level of anxiety before and after the procedure. Overall patient satisfaction was also quantified. DESIGN: Sixty-two adult patients scheduled for cardiac catheterization procedures were recruited for the study. They were premedicated with one of several premedication regimens: oral diazepam 5 to 10 mg; oral lorazepam 1 mg; oral diazepam 10 mg+oral promethazine 25 mg; or oral diazepam 10 mg+oral diphenhydramine 25 mg. No attempt was made to control the premedication the patients received; it was ordered by each patient's cardiologist according to personal preference. Patients underwent pulse oximetry and evaluation of sedation, anxiety and level of satisfaction before and after cardiac catheterization. RESULTS: All patients tested had values for mean precatheterization %SaO2 above 92%. No patient had postcatheterization %SaO2 readings below that defined as indicating clinically significant hypoxemia (%SaO2 less than 90%). Patients were awake or lightly sedated before and after cardiac catheterization. Thirteen per cent of patients suffered from high levels of anxiety before, and 16% during, cardiac catheterization. Twenty-three per cent of patients reported being dissatisfied with the premedication before, and 10% of patients reported being dissatisfied during, cardiac catheterization. CONCLUSIONS: Clinically significant hypoxemia and oversedation are not problems for most patients given the types and doses of precatheterization medication used in the study population. The premedication schedules followed in the study failed to provide satisfaction and anxiolysis in a significant number of those studied.
Aged↗
[Video-assisted thoracic surgery with mini-thoracotomy: limits and indications].
Video-assisted thoracic surgery (VATS) combines a 5 cm mini-thoracotomy and videoscopic control using a camera. This technique is designed to reduce surgical invasiveness. From January 1993 to March 1994, we operated on 60 patients by 61 VATS. The conversion rate to classical thoracotomy was 8%. The cases treated included 18 lung cancers, 20 cases of pulmonary emphysema, 6 cases of non-malignant pulmonary nodules, 2 cases of bronchectasies and 10 operations on the pleura, pericardium or thoracic sympathetic nerves. We performed 12 lobectomies, 24 atypical segmentectomies and 10 other operations. The hospital mortality rate was 2/60 (3.5%), the mean thoracic drainage duration was 3.2 days, and the mean hospital stay was 9.2 days. VATS provides certain analgesic and esthetic benefits but the functional benefit must be studied in more detail. VATS can be applied to segmentectomies and lobectomies for T1 or T2 lung cancers; but the benefits relating to malignancy must be precisely identified by long-term studies.
Humans↗
Hypomethylation and hypoexpression of human CYP2E1 gene in lung tumors.
We have demonstrated the presence of CYP2E1 protein in a catalytically active form in lung tumors, differences being observed between the tumors and normal tissues from the same patients. Indeed, a higher microsomal CYP2E1 N-nitrosodimethylamine (NDMA) demethylase activity was present in normal tissues compared to tumors and was accompanied by corresponding change in CYP2E1 protein concentration, as shown by Western blot analysis. The catalytic activity among tumors differed from that among normal tissues with statistical significance of p < 0.01. CYP2E1 mRNA was present in lung tumors and less expressed compared to normal tissues from the same individuals. In order to understand the regulation of CYP2E1 gene expression, we studied the methylation status of the CYP2E1 gene in human lung tumors and normal tissues from the same patients and observed that a hypomethylation was associated with a hypoexpression of the CYP2E1 gene in lung tumors.
Base Sequence↗
Case report 831: Juxta-articular osteoid osteoma.
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Bone Neoplasms↗
Radiation doses to patients in neurointerventional procedures.
PURPOSE: To evaluate stochastic and deterministic risks associated with neurointerventional procedures for the patient. METHODS: Eight neurovascular interventional procedures were evaluated to determine the entrance skin dose and effective dose for the patient. Dosimetry was done with thermoluminescence dosimeters. The highest dose on the patient's head was recorded as the maximum entrance skin dose. The equivalent dose was obtained by conversion of the dose-area product using published conversion tables. RESULTS: The maximum entrance skin dose varied from 129 to 1335 mGy. The mean effective dose was 1.67 mSv with a range of 0.44 to 3.44 mSv. No deterministic effect has been encountered. Stochastic risk linked to the highest effective dose value was approximately one death by fatal cancer for every 6000 procedures, according to the new International Commission on Radiological Protection coefficient. CONCLUSIONS: Because no deterministic effect has been detected, and stochastic risks were very low, radiation hazard to the patient is a minor consideration in deciding whether to undertake a neurointerventional procedure.
Adult↗
[Multiple pancreatic metastases of small-cell bronchogenic carcinoma].
Multiple pancreatic metastasis of small cell lung cancer. Pancreatic metastasis of small cell lung cancer are unusual, in spite of their fast evolution. The authors describe a case of small cell lung cancer with multiple pancreatic metastasis showed by echography and confirmed by ultrasonic guided biopsy.
Carcinoma, Bronchogenic↗
[Hemangioendothelioma of the aortic valve revealed by transient ischemic episodes].
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Aortic Valve↗
[Primary surgical resection of tumors of the anterior mediastinum].
Seventy-two anterior mediastinal tumors were operated upon between 1981 and 1991. This accounted for 2% of the 3579 thoracotomies performed during the same period (excluding cardiac surgery). With the exception of Hodgkin's disease, lymphomas and metastases diagnosed either by anterior mediastinoscopy or at thoracotomy, other tumors were treated by the widest possible excision followed by adjuvant treatment in case of incomplete excision. These tumors included 16 metastatic carcinomas and 55 affecting the thymus-including 27 malignant thymomas and 15 benign tumors of the thymus including 2 carcinoids, 6 cases of Hodgkin's disease involving the thymus, 5 non-seminomatous germinal tumors, one differentiated neuro-endocrine carcinoma, 1 thymus lymphoma and 1 seminoma. The approach was via sternotomy in 32 cases and thoracotomy in the other 40. Excision was deemed complete in 45 cases, incomplete in 25 cases and impossible in 2 cases. Extension of surgical excision involved various adjacent organs: the lung in 10 cases and the pericardium in 5. Involvement of the phrenic nerves was found in 25 cases, the aorta in 1, the pulmonary artery in 1 and the vena cava or its afferent vessels in 33 cases. Seven PTFE venous bypasses were performed. Operative mortality was nil. One patient died on the 8th day of undefined causes. Mean tumour survival in metastatic thymomas was nevertheless 19 months. Survival in malignant thymomas was related to the stage of progression of the tumour. When complete excision was possible, survival was 89% with a mean follow-up of 57 months.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
False aneurysm of the abdominal aorta due to Brucella suis.
A 48-year-old man presented with a fissured false aneurysms of the abdominal aorta due to Brucella suis. Clinical findings were lumbosciatic pain, fever, and sudation. Diagnosis was reached through abdominal computed tomographic (CT) scan and arteriograms. An extremely large false aneurysm, thrombosed and perforated posteriorly, was found in the infrarenal aorta. Semiurgent therapy consisted of resection of the aneurysm and prosthetic Dacron graft replacement associated with a transposed omental wrap. Antibiotic therapy was administered for three months. Although bacteriologic specimens were negative, brucellosis was diagnosed because of a positive Wright test and high Brucella antibodies in this patient originating from an endemic area. Six months after surgery he is apparently in good health.
Aneurysm, False↗
[Place of the right gastro-epiploic artery in coronary revascularization by exclusive arterial grafts].
From March 1990 to July 1991, 35 patients underwent coronary artery bypass grafts using the right gastro-epiploic artery (GEA). Twenty-nine patients had exclusively arterial grafts using a combination of GEA and internal mammary artery (IMA) in situ. The selection criteria for this group of 29 patients included a life expectancy exceeding ten years to avoid the need for reoperation due to deterioration of the grafts. This group consisted of 27 men and two women under the age of 70 years (mean age: 58 years, range: 36 to 70), 11 patients (38%) were under the age of 50 years and 15 (52%) were under the age of 60 years. Cardiac status was relatively well preserved. The mean ejection fraction was 58% (range: 25-70%). Fourteen patients (48%) had had a preoperative myocardial infarction. Fifty-five p. cent were smokers, 41% suffered from HT and 31% had a dyslipidaemia. Six patients (20%) had respiratory failure, 6 others (20%) were severely overweight and 2 patients were diabetic. According to the NYHA classification, 14 patients (48%) were stage IV, 9 patients (31%) were stage III and 6 patients (20%) were stage II. The mean number of bypass grafts per patient was 2.8 and 8 sequential bypass grafts (27%) were performed. The GEA was used in 29 cases, the left IMA was used in 28 cases, the right IMA was used in 13 cases and the epigastric artery was used as a free graft in 3 cases. Associated lesions included a resected left ventricular aneurysm. No associated valve procedures were performed.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Secondary aortoduodenal fistulas: value of initial axillofemoral bypass.
Between January 1970 and April 1989, 20 patients underwent operation for secondary aortoduodenal fistulas. When the preoperative diagnosis was certain and emergency control of bleeding not required, initial axillofemoral bypass was performed before ablation of the infected aortic prosthetic graft during the same operation. When diagnosis was uncertain or severity of bleeding required emergency laparotomy, the therapeutic plan varied over time. Until 1980, we performed either a direct repair (three cases) or the ablation of the aortic graft followed by secondary axillofemoral bypass (four cases). After 1980, the order of procedures was 1) control of bleeding whenever necessary, 2) axillofemoral bypass, and 3) ablation of the aortic graft. Postoperative mortality was two of 13 in patients undergoing initial axillofemoral bypass, compared with six of seven patients undergoing direct surgery or initial ablation of the aortic graft. Of the 12 patients surviving the postoperative period, three died of aortic stump hemorrhage, four, 12, and 14 months after operation. Two patients had a new aortic graft inserted. Repeat replacement of the abdominal aorta graft was performed in one case and ascending thoracic aortobifemoral bypass in the other because of secondary thrombosis of the axillofemoral bypass. We conclude that initial axillofemoral bypass before dealing with the aortic graft improves the immediate prognosis in operations for secondary aortoduodenal fistulas. This procedure does not, however, preclude the possibility of aortic stump infection which can lead to recurrent aortoduodenal fistula. The risk of infection or secondary occlusion of axillofemoral bypass is minimal. Secondary prosthetic replacement is not systematically necessary.
Aged↗