- Email: [email protected]
Regarding "Is transcranial Doppler a worthwhile addition to screening tests for cerebrovascular disease?"
JOURNALOF VASCULARSURGERY Volume 22, Number 6
Outcome of surgery to a large extent is influenced by the severity of disease and consequently any discussion of outcome must include such parameters. Table I shows the distribution of outcome of carotid endarterectomy in relation to the indication of the procedure. It should be noted that asymptomatic stenosis rarely leads to surgery in Sweden; most of these patients have other symptomatic vessels, carotid or other, that have led them to medical treatment. Outcome o f aortic aneurysm surgery is seen in Table II. We use the five-category subdivision suggested by Eriksson et al. 3 It is obvious that emergency surgery has a very different outcome if the patient is in shock or not. Table III presents quality parameters after femoropopliteal bypass. Indication for the procedure and level of reconstruction has a profound influence on not only amputation rate but also on the mortality rate. Discussing these and other registry data, the Swedish vascular surgeons are now establishing standards for acceptable outcome. This will be a complicated process where the profession must agree on principles, percentages, and possible safety moves to take in case of deviance. Table IV presents some suggested standards put forward in these discussions. The Steering Committee of Swedvasc Thomas Tr~eng David Bergqvist Johan Elfitrb'm Bengt Hedberg K- G Ljungstr#m Per Ortenwall Lars Norgren Department of Surgery Central Hospital 5-371 85 Kariskrona Sweden REFERENCES
1. Hertzer NR. Presidential address: outcome assessment in vascular surgery-results mean everything. J VAse SURG 1995;21:6-15. 2. Bergqvist D, Einarsson E, Elfstr6m J, Norgren L, Tro~ng T. Experiences with the Swedish vascular registry. Vasc Med Review 1994;5:92-101. 3. Eriksson I, Halldn A, Simonsson N, Aberg T. Surgical classification of abdominal aortic aneurysm. Acta Chir Scand 1979; 145:455-8. 24/41/67373
Letters to the Editors
811
perhaps unattainable system for additional severity indexing. In principle, there are many similarities between Swedvasc and the plan for prospective hospital audits that has been proposed for the United States by the Joint Council of the Society for Vascular Surgery/International Society for Cardiovascular Surgery, North American Chapter. Unlike Sweden, however, it would be necessary to collect and validate the data from these audits in every community because of the sheer volume of vascular surgery and the number of surgeons who perform it in the United States. In March 1995, I represented the Joint Council at a meeting to discuss outcome assessment with Administrator Bruce Vladek and his stafffrom the Health Care Financing Administration ( H e r A ) . In summary, HCFA now intends to conduct statewide demonstration projects during the next 3 years to document the hospital-specific complication rates of elective carotid endarterectomy, infrarenal aortic aneurysm resection, and infrainguinal bypass among Medicare beneficiaries in Ohio, Pennsylvania, and Iowa. Established vascular surgeons will be asked to participate in the retrieval and the analysis of the information to be generated by these projects, and HCFA has indicated that this information will be protected from public disclosure because of a statutory exemption related to the quality assurance activities of its Peer Review Organizations. Provided these pilot projects suggest that prospective hospital audits favorably influence the outcome of vascular surgery, HCFA will consider their adoption as a national policy. In my view and that shared by the Joint Council, legitimate outcome assessment has several potential advantages. First, it probably would serve as an incentive for truly "occasional" surgeons or surgeons whose results are indefensibly poor to withdraw voluntarily from the practice of vascular surgery. Conversely, it should enhance the reputation of surgeons in a number of specialty fields who, by virtue of their training or experience, consistently perform at or above an acceptable level of competence with standard vascular procedures. Finally, as Tro~ng et al. have clearly shown by their work with the Swedvasc registry, documentation of the results of vascular surgery also happens to be a responsible thing to d o - and there is a good deal to be said for that aspect of outcome assessment as well. Norman R. Hertzer, MD Department of Vascular Surgery The Cleveland Clinic Foundation 9500 Euclid Ave. Cleveland, OH 44106
24/41/67372 Reply To the Editors: I genuinely appreciate the interest expressed by the leadership of the Swedish Vascular Registry regarding my remarks to the Society for Vascular Surgery last year. Their results underscore the reliability of conventional surgical indications in predicting the outcome of carotid endarterectomy, aortic aneurysm resection, and lower extremity revascularization even in the absence of a sophisticated and
Regarding "Is transcranial Doppler a worthwhile addition to screening tests for cerebrovascular disease?" To the Editors: We have read with interest the article by Comerota et al. concerning the efficacy of transcranial Doppler (TCD) as a screening test for cerebrovascular disease and agree with the conclusion that the selection criteria for T e D
812
Letters to the Editors
should be refined (J VASC SURG 1995;21:90-7). However the validity of the article is negated by the high failure rate in obtaining a transtemporal window. It is widely accepted that the lack of a transtemporal window is encountered in a high percentage of black and female patients and that the failure rate increases with age, but the reported failure rate of 48% in white men and 68% in white women aged 60 years or older is excessively high. In our institution TCD is routinely used for preoperative evaluation of collateral flow and intraoperative monitoring in patients undergoing carotid endarterectomy. We have reviewed the last consecutive 100 carotid endarterectomies performed in 92 patients. All except one of the patients (an Eastern Mediterranean woman) were white, comprising 68 men (median age 66.5 years; range 44 to 84 years) and 24 women (median age 68 years; range 47 to 84 years). In the patients aged 60 years or older we have failed to locate a transtemporal window in 4% of men (2 of 56) and 22% of women (4 of 18), results that are representative of other North American and European series. 1,2 It is assumed that variation in temporal bone thickness is uniform among white men and women in the Western world, but clearly there are geographic variations, and the success of the TCD technique may be dependent on the geographic location of the unit and local demography. Mr. J. 214. T. Perkins, FRCS Mr. T. tL Magee, FRCS
Nuffield Department of Surgery University of Oxford The John Radcliffe Hospital Headington Oxford OX3 9DU United Kingdom REFERENCES 1. McDowell HA, Gross GM, Halsey JM. Carotid endarterectomy monitored with transcranial Doppler. Ann Surg 1992; 215:514-9. 2. Chiesa R, Minicucci F, Melissano G, et al. The role of transcranial Doppler in carotid artery surgery. Eur J Vasc Surg 1992;6:211-6. 24/41/67554 A rare case o f a traumatic aneurysm o f the inferior thyroid artery To the Editors:
We report on a rare case of a traumatic aneurysm of the inferior thyroid artery, which occurred after a minor trauma, causing a life-threatening situation. Vascular lesions in the neck region occur rarely, and few case reports exist. Traumatic aneurysms in the neck are usually related to the thyrocervical trunk.1 A 53-year-old male patient was brought to the local hospital after a fall during hiking. Primary symptoms were hoarseness, and the patient showed a diffuse swelling of the neck. The radiograms showed diffuse prevertebral swelling,
1OURNALOF VASCULARSURGERY December 1995
Fig. 1. Primary ncgative angiogram.
and the patient was transferred to our institution. He arrived in a stable hemodynamic and respiratory condition. During computed tomography evaluation he had development of acute respiratory failure with massive enlargement of the neck. Intubation attempts failed because of the compression of the trachea so that an emergency tracheotomy had to be performed. The primary angiogram did not show any vascular injury to the thyrocervical trunk (Fig. 1). The patient was admitted to the intensive care unit. Two days later the routine chest radiogram showed a hematothorax on the right side. A second angiogram showed a ruptured aneurysm of the left inferior thyroid artery (Fig. 2). Angiographic embolization of the aneurysm failed. During operative revision the lesion was identified as a traumatic aneurysm and was excised. A week later an early decortication had to be performed because of an old and solid hematothorax and respiratory insufficiency. Three weeks after the accident the patient could be discharged home. The causes of peripheral arterial aneurysms are mainly arteriosclerosis, blunt and penetrating trauma, iatrogenic injuries, and, occasionally, angiitis and syphilis. A rupture of an extracranial aneurysm is usually not as dramatic as a perforation of a cranial aneurysm, but it can lead to fatal complications if it is not noticed. In our case we suspect a primary traumatic cause, but arteriosclerosis may have promoted its development. We do not know if the aneurysm existed before the trauma. Few cases of thyrocervical aneurysms have been documented. Surgery was performed on all patients, and this allowed further uncomplicated healingf1-4 Habib 5 published a case in which a spontaneous rupture led to the
Outcome of surgery to a large extent is influenced by the severity of disease and consequently any discussion of outcome must include such parameters. Table I shows the distribution of outcome of carotid endarterectomy in relation to the indication of the procedure. It should be noted that asymptomatic stenosis rarely leads to surgery in Sweden; most of these patients have other symptomatic vessels, carotid or other, that have led them to medical treatment. Outcome o f aortic aneurysm surgery is seen in Table II. We use the five-category subdivision suggested by Eriksson et al. 3 It is obvious that emergency surgery has a very different outcome if the patient is in shock or not. Table III presents quality parameters after femoropopliteal bypass. Indication for the procedure and level of reconstruction has a profound influence on not only amputation rate but also on the mortality rate. Discussing these and other registry data, the Swedish vascular surgeons are now establishing standards for acceptable outcome. This will be a complicated process where the profession must agree on principles, percentages, and possible safety moves to take in case of deviance. Table IV presents some suggested standards put forward in these discussions. The Steering Committee of Swedvasc Thomas Tr~eng David Bergqvist Johan Elfitrb'm Bengt Hedberg K- G Ljungstr#m Per Ortenwall Lars Norgren Department of Surgery Central Hospital 5-371 85 Kariskrona Sweden REFERENCES
1. Hertzer NR. Presidential address: outcome assessment in vascular surgery-results mean everything. J VAse SURG 1995;21:6-15. 2. Bergqvist D, Einarsson E, Elfstr6m J, Norgren L, Tro~ng T. Experiences with the Swedish vascular registry. Vasc Med Review 1994;5:92-101. 3. Eriksson I, Halldn A, Simonsson N, Aberg T. Surgical classification of abdominal aortic aneurysm. Acta Chir Scand 1979; 145:455-8. 24/41/67373
Letters to the Editors
811
perhaps unattainable system for additional severity indexing. In principle, there are many similarities between Swedvasc and the plan for prospective hospital audits that has been proposed for the United States by the Joint Council of the Society for Vascular Surgery/International Society for Cardiovascular Surgery, North American Chapter. Unlike Sweden, however, it would be necessary to collect and validate the data from these audits in every community because of the sheer volume of vascular surgery and the number of surgeons who perform it in the United States. In March 1995, I represented the Joint Council at a meeting to discuss outcome assessment with Administrator Bruce Vladek and his stafffrom the Health Care Financing Administration ( H e r A ) . In summary, HCFA now intends to conduct statewide demonstration projects during the next 3 years to document the hospital-specific complication rates of elective carotid endarterectomy, infrarenal aortic aneurysm resection, and infrainguinal bypass among Medicare beneficiaries in Ohio, Pennsylvania, and Iowa. Established vascular surgeons will be asked to participate in the retrieval and the analysis of the information to be generated by these projects, and HCFA has indicated that this information will be protected from public disclosure because of a statutory exemption related to the quality assurance activities of its Peer Review Organizations. Provided these pilot projects suggest that prospective hospital audits favorably influence the outcome of vascular surgery, HCFA will consider their adoption as a national policy. In my view and that shared by the Joint Council, legitimate outcome assessment has several potential advantages. First, it probably would serve as an incentive for truly "occasional" surgeons or surgeons whose results are indefensibly poor to withdraw voluntarily from the practice of vascular surgery. Conversely, it should enhance the reputation of surgeons in a number of specialty fields who, by virtue of their training or experience, consistently perform at or above an acceptable level of competence with standard vascular procedures. Finally, as Tro~ng et al. have clearly shown by their work with the Swedvasc registry, documentation of the results of vascular surgery also happens to be a responsible thing to d o - and there is a good deal to be said for that aspect of outcome assessment as well. Norman R. Hertzer, MD Department of Vascular Surgery The Cleveland Clinic Foundation 9500 Euclid Ave. Cleveland, OH 44106
24/41/67372 Reply To the Editors: I genuinely appreciate the interest expressed by the leadership of the Swedish Vascular Registry regarding my remarks to the Society for Vascular Surgery last year. Their results underscore the reliability of conventional surgical indications in predicting the outcome of carotid endarterectomy, aortic aneurysm resection, and lower extremity revascularization even in the absence of a sophisticated and
Regarding "Is transcranial Doppler a worthwhile addition to screening tests for cerebrovascular disease?" To the Editors: We have read with interest the article by Comerota et al. concerning the efficacy of transcranial Doppler (TCD) as a screening test for cerebrovascular disease and agree with the conclusion that the selection criteria for T e D
812
Letters to the Editors
should be refined (J VASC SURG 1995;21:90-7). However the validity of the article is negated by the high failure rate in obtaining a transtemporal window. It is widely accepted that the lack of a transtemporal window is encountered in a high percentage of black and female patients and that the failure rate increases with age, but the reported failure rate of 48% in white men and 68% in white women aged 60 years or older is excessively high. In our institution TCD is routinely used for preoperative evaluation of collateral flow and intraoperative monitoring in patients undergoing carotid endarterectomy. We have reviewed the last consecutive 100 carotid endarterectomies performed in 92 patients. All except one of the patients (an Eastern Mediterranean woman) were white, comprising 68 men (median age 66.5 years; range 44 to 84 years) and 24 women (median age 68 years; range 47 to 84 years). In the patients aged 60 years or older we have failed to locate a transtemporal window in 4% of men (2 of 56) and 22% of women (4 of 18), results that are representative of other North American and European series. 1,2 It is assumed that variation in temporal bone thickness is uniform among white men and women in the Western world, but clearly there are geographic variations, and the success of the TCD technique may be dependent on the geographic location of the unit and local demography. Mr. J. 214. T. Perkins, FRCS Mr. T. tL Magee, FRCS
Nuffield Department of Surgery University of Oxford The John Radcliffe Hospital Headington Oxford OX3 9DU United Kingdom REFERENCES 1. McDowell HA, Gross GM, Halsey JM. Carotid endarterectomy monitored with transcranial Doppler. Ann Surg 1992; 215:514-9. 2. Chiesa R, Minicucci F, Melissano G, et al. The role of transcranial Doppler in carotid artery surgery. Eur J Vasc Surg 1992;6:211-6. 24/41/67554 A rare case o f a traumatic aneurysm o f the inferior thyroid artery To the Editors:
We report on a rare case of a traumatic aneurysm of the inferior thyroid artery, which occurred after a minor trauma, causing a life-threatening situation. Vascular lesions in the neck region occur rarely, and few case reports exist. Traumatic aneurysms in the neck are usually related to the thyrocervical trunk.1 A 53-year-old male patient was brought to the local hospital after a fall during hiking. Primary symptoms were hoarseness, and the patient showed a diffuse swelling of the neck. The radiograms showed diffuse prevertebral swelling,
1OURNALOF VASCULARSURGERY December 1995
Fig. 1. Primary ncgative angiogram.
and the patient was transferred to our institution. He arrived in a stable hemodynamic and respiratory condition. During computed tomography evaluation he had development of acute respiratory failure with massive enlargement of the neck. Intubation attempts failed because of the compression of the trachea so that an emergency tracheotomy had to be performed. The primary angiogram did not show any vascular injury to the thyrocervical trunk (Fig. 1). The patient was admitted to the intensive care unit. Two days later the routine chest radiogram showed a hematothorax on the right side. A second angiogram showed a ruptured aneurysm of the left inferior thyroid artery (Fig. 2). Angiographic embolization of the aneurysm failed. During operative revision the lesion was identified as a traumatic aneurysm and was excised. A week later an early decortication had to be performed because of an old and solid hematothorax and respiratory insufficiency. Three weeks after the accident the patient could be discharged home. The causes of peripheral arterial aneurysms are mainly arteriosclerosis, blunt and penetrating trauma, iatrogenic injuries, and, occasionally, angiitis and syphilis. A rupture of an extracranial aneurysm is usually not as dramatic as a perforation of a cranial aneurysm, but it can lead to fatal complications if it is not noticed. In our case we suspect a primary traumatic cause, but arteriosclerosis may have promoted its development. We do not know if the aneurysm existed before the trauma. Few cases of thyrocervical aneurysms have been documented. Surgery was performed on all patients, and this allowed further uncomplicated healingf1-4 Habib 5 published a case in which a spontaneous rupture led to the