Carotid arterial trauma: Assessment with the Glasgow Coma Scale as a guide to surgical management

JOURNAL

3 18 Meetind

OF VASCULAR

abstracts

0.04). The other factors listed (sex, diabetes, smoking, chronic obstructive pulmonary disease, indication for surgery, length of preoperative hospital stay, endotracheal tube diameter, FI-02, blood lossand replacement, epidural analgesia, stressulcer prophylaxis) were not predictive. These factors may help to identify candidates for elective abdominal aortic surgery who are at high risk for pulmonary complications. Carotid arterial trauma: Assessment with the Glasgow Coma Scale as a guide to surgical management Edwin I?. Teehan, MD, Frank T. Padberg, Jr., MD, Robert W. Hobson II, MD, Peter N. Thompson, MD, Bing C. Lee, MD, and Vincent Milazzo, MD, Veterans AjiGs Medical Center, East Ovange, N;/Coma is considered an indication for ligation in carotid arterial injury. We reviewed 38 carotid arterial injuries to objectively assessimpairment in the state of consciousness (SCON) and outcome. Blunt injuries (two) did well and required no surgical intervention. Of 36 patients with penetrating injuries of the common (23), internal (1 l), and external (2) carotid arteries, 50% had hypotension. Treatment included repair in 68%, ligation in 24%, and observation in 8%. The SCON was normal (Glasgow Coma Scale [GCS] 15) on admission in 18 patients; 83% were repaired and remained normal. Patients (n = 14) with diminished SCON were assigned a GCS score and separated into subgroups of severe (n = 10, GCS I 8) and moderate sensorial changes (n = 4, GCS 9 to 14). GCS could not be accurately assigned in four (aphasia, tracheostomy). All patients in the subgroup with a moderately diminished SCON (GCS 9 to 14) regained a normal SCON after surgical treatment. Of 10 patients with severe reductions in SCON, five regained a normal mental state, and five remained in coma; treatment consisted offive repairs, three ligations, and two observations. Nine patients had a focal deficit before operation, of whom five had improvement of symptoms, one had no change in symptoms, and three had worsening of symptoms. Of six patients who died, four had coma and hypotension and two had focal deficits that progressed to coma. These results support repair of carotid arterial injury in patients with GCS 2 9. Patients with GCS 5 8 did poorly regardlessof surgical treatment. We recommend GCS assessment of patients with carotid artery injuries to identify those who may benefit from repair. Stenting of proximal venous obstructions to maintain hemodialysis access Richard Shoenfeld, MD, Andrew Novick, MD, Bruce Brener, MD, David Eisenbud, MD, Pedro Cordero, MD, Suresh Mody, MD, Victor Parsonnet, MD, and Richard Freundlich, MD, Newark Beth Israel Medical Center, Newark, NJ. The maintenance of satisfactory long-term hemodialysis accessin patients with chronic kidney failure presents

SURGERY August 1993

a major challenge to vascular surgeons and interventional radiologists. Obstruction of the innominate or subclavian vein proximal to an arteriovenous fistula after repeated temporary accessprocedures is a major causeof morbidity, resulting in permanent loss of hemodialysis accessfrom the affected limb. Long-term patency after surgical repair or venous angioplasty has been disappointing. We studied self-expanding and balloon-expandable stems as therapeutic devices in patients with end-stage renal failure and no other viable means of venous access.Nineteen stainlesssteel stents (four balloon-expandable, 15 self-expanding) were deployed in seven innominate and nine subclavian veins of 15 patients over a 15-month period. Follow-up revealed one death (unrelated), one occlusion at 1 month, and one caserequiring early reintervention and placement of a second stent. Seventeen of the 18 (94%) veins remain patent (secondary) over a mean follow-up period of 5.6 months (range 1.5 to 15 months). Primary patency was 16 (89%) of 18. Stems effectively relieve venous outflow obstructions proximal to arteriovenous fistulas. Long-term patency is currently being evaluated. Everted cervical vein patch angioplasty for carotid endarterectomy Herbert Dardik, MD, Fred Wolodiger, MD, Silvia Berry, RVT, Ray Vazquez, MD, Fred Silvestri, MD, Ibrahim M. Ibrahim, MD, Mark Kahn, MD, and Barry Sussman,MD, En&wood

Hospital, En&mood,

NJ.

During the 67-month period of June 1987 to December 1992,194 carotid endarterectomies were performed in 174 patients. Primary closure of the arteriotomy was performed in six cases,conventional patches (CP) were used in 101 cases,and everted cervical veins (ECV) were used in 87 cases. CP angioplasty predominantly used saphenous veins (n = 87) but included four Dacron and 10 polytetrafluoroethylene (PTFE) patches. Cervical veins consisted of facial or external jugular veins. The two groups of patients undergoing patch angioplasty were comparable by demographic data and indications for surgery. There were no infections, false aneurysms,or perioperative deaths in either group. Three reversible neurologic deficits and three wound complications occurred in each group, accounting for an incidence of 2.9% for each of these complications in the group undergoing CP angioplasty and 3.4% for each of these complications in the group undergoing ECV angioplasty. There were two (2.0%) early strokes in the group undergoing CP angioplasty and one (1.1%) in the group undergoing ECV angioplasty. Kaplan-Meier curves for stroke-free events showed no significant differences between these groups. Sonographic surveillance was carried out in 115 cases.Severe stenosis ( > 75%) was identified in four (12%) of 33 ECV cases (mean follow- up time of 8.3 2 5 months and in five [ 7%] of 72 saphenous patch cases,mean follow-up of 2 1.O 2 19 months). These findings were not statistically significant