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Article ; Online: Durability of eversion carotid endarterectomy.

Ballotta, Enzo / Toniato, Antonio / Da Giau, Giuseppe / Lorenzetti, Renata / Da Roit, Anna / Baracchini, Claudio

2014 Volume 59, Issue 5, Page(s) 1274–1281

Abstract: Objective: Carotid endarterectomy (CEA) remains the gold standard for treating carotid disease in selected symptomatic and asymptomatic patients, though carotid angioplasty and stenting has emerged as a safe alternative. The aim of this study was to ... ...

Abstract	Objective: Carotid endarterectomy (CEA) remains the gold standard for treating carotid disease in selected symptomatic and asymptomatic patients, though carotid angioplasty and stenting has emerged as a safe alternative. The aim of this study was to assess the durability of CEA in a large series of patients followed up according to a strict clinical and ultrasonographic protocol. Methods: Over a 23-year period (1990-2012) a total of 1773 patients (1251 men and 522 women) with a mean age of 75.2 years (range, 31 to 96 years) who underwent 2007 consecutive primary eversion CEAs performed by the same surgeon under general anesthesia with electroencephalographic monitoring and selective shunting were prospectively followed up with ultrasonography at 1, 6, and 12 months, then yearly. A long-term follow-up (median, 11.2 years; mean, 12.9 years) was obtained for 1680 patients (94.8%). End points were perioperative (30-day) stroke and death and late carotid restenosis/occlusion rates. Results: More than two in three of the lesions (1446 of 2007, 72.1%) were symptomatic at the time of surgery, with a 25% rate of preoperative stroke. Preoperative antiplatelet or anticoagulant therapy was used by 1675 patients (94.4%), whereas 918 (51.8%) were receiving statin treatment. Overall, there were eight (0.4%) perioperative strokes and no deaths. During the follow-up, there were nine (0.47%) asymptomatic late carotid restenoses (six moderate [50%-69%] and three severe [≥ 70%]) and one (0.05%) carotid occlusion. Nine patients (0.47%) had late ipsilateral strokes, none of them related to restenosis/occlusion. Overall, there were 159 late deaths (9.4%). Conclusions: The results of this study show that eversion CEA can be performed in symptomatic and asymptomatic patients with an extremely low perioperative stroke/death risk and a negligible incidence of late restenosis/occlusion, thus assuring a persistently good protection against the risk of cerebral ischemia.
MeSH term(s)	Adult ; Aged ; Aged, 80 and over ; Anesthesia, General ; Anticoagulants/therapeutic use ; Asymptomatic Diseases ; Brain Ischemia/etiology ; Brain Ischemia/mortality ; Carotid Stenosis/complications ; Carotid Stenosis/diagnostic imaging ; Carotid Stenosis/mortality ; Carotid Stenosis/surgery ; Electroencephalography ; Endarterectomy, Carotid/adverse effects ; Endarterectomy, Carotid/methods ; Endarterectomy, Carotid/mortality ; Female ; Humans ; Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use ; Kaplan-Meier Estimate ; Male ; Middle Aged ; Monitoring, Intraoperative/methods ; Platelet Aggregation Inhibitors/therapeutic use ; Recurrence ; Retrospective Studies ; Risk Factors ; Stroke/etiology ; Stroke/mortality ; Time Factors ; Treatment Outcome ; Ultrasonography
Chemical Substances	Anticoagulants ; Hydroxymethylglutaryl-CoA Reductase Inhibitors ; Platelet Aggregation Inhibitors
Language	English
Publishing date	2014-05
Publishing country	United States
Document type	Journal Article ; Observational Study
ZDB-ID	605700-7
ISSN	1097-6809 ; 0741-5214
ISSN (online)	1097-6809
ISSN	0741-5214
DOI	10.1016/j.jvs.2013.11.088
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Article ; Online: Lower extremity arterial reconstruction for critical limb ischemia in diabetes.

Ballotta, Enzo / Toniato, Antonio / Piatto, Giacomo / Mazzalai, Franco / Da Giau, Giuseppe

Journal of vascular surgery

2014 Volume 59, Issue 3, Page(s) 708–719

Abstract: Background: The impact of diabetes mellitus on the technical and clinical outcomes of infrainguinal arterial reconstruction (IAR) for critical limb ischemia (CLI) remains controversial. This study analyzed the outcome of IAR in diabetic patients with ... ...

Abstract	Background: The impact of diabetes mellitus on the technical and clinical outcomes of infrainguinal arterial reconstruction (IAR) for critical limb ischemia (CLI) remains controversial. This study analyzed the outcome of IAR in diabetic patients with CLI over a 17-year period. Methods: Details on all consecutive patients undergoing primary IAR at our institution were stored prospectively in a vascular registry from 1995 to 2011. Demographics, risk factors, indications for surgery, inflow sources and outflow target vessels, types of conduit, and adverse outcomes were analyzed. Postoperative surveillance included clinical examination, duplex scans, and ankle-brachial index measurements in all patients at discharge, 1 and 6 months after surgery, and every 6 months thereafter. End points were patency, limb salvage, survival, and amputation-free survival rates, and were assessed using Kaplan-Meier life-table analysis. The χ(2) or Fisher exact, Student t, and log-rank tests were used to establish statistical significance. Results: Overall, 1407 IARs were performed in 1310 patients with CLI by the same surgeon, 705 (50.2%) in 643 diabetic patients and 702 in 667 nondiabetic patients. Autogenous vein conduits were used in 87% of the IARs. There were no perioperative deaths. Diabetic patients had significantly more major (16.7% vs 11.8%; P = .02) and minor complications (9.7% vs 6.5%; P = .02) than nondiabetic patients. At 5 and 10 years, there were no significant differences between diabetic and nondiabetic patients in the rates of primary patency (65% and 46% vs 69.5% and 57%; log-rank test, P = .09), secondary patency (76% and 60% vs 80% and 68%; log-rank test, P = .20), limb salvage (88% and 76% vs 91% and 83%; log-rank test, P = .12) survival (51% and 34% vs 57% and 38%; log-rank test, P = .41), or amputation-free survival (45.5% and 27% vs 51% and 29%; log-rank test, P = .19). The type of conduit did not affect patency or limb salvage rates in either group. Conclusions: Diabetic patients receiving IAR for CLI can have the same survival and amputation-free survival rates as nondiabetic patients. Their comparable technical and clinical outcomes strongly demonstrate that diabetics with CLI can expect the same quantity and quality of life as nondiabetics with CLI, and aggressive attempts at limb salvage in patients with diabetes mellitus, including distal and foot level bypass grafting, should not be discouraged.
MeSH term(s)	Aged ; Aged, 80 and over ; Amputation ; Autografts ; Chi-Square Distribution ; Critical Illness ; Diabetic Angiopathies/diagnosis ; Diabetic Angiopathies/mortality ; Diabetic Angiopathies/physiopathology ; Diabetic Angiopathies/surgery ; Disease-Free Survival ; Female ; Graft Occlusion, Vascular/etiology ; Graft Occlusion, Vascular/physiopathology ; Graft Occlusion, Vascular/surgery ; Humans ; Ischemia/diagnosis ; Ischemia/mortality ; Ischemia/physiopathology ; Ischemia/surgery ; Kaplan-Meier Estimate ; Limb Salvage ; Lower Extremity/blood supply ; Male ; Middle Aged ; Odds Ratio ; Patient Selection ; Proportional Hazards Models ; Quality of Life ; Reconstructive Surgical Procedures/adverse effects ; Reconstructive Surgical Procedures/mortality ; Registries ; Reoperation ; Retrospective Studies ; Risk Factors ; Time Factors ; Treatment Outcome ; Vascular Grafting/adverse effects ; Vascular Grafting/mortality ; Vascular Patency ; Veins/transplantation
Language	English
Publishing date	2014-03
Publishing country	United States
Document type	Journal Article
ZDB-ID	605700-7
ISSN	1097-6809 ; 0741-5214
ISSN (online)	1097-6809
ISSN	0741-5214
DOI	10.1016/j.jvs.2013.08.103
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Article: Selective shunting with eversion carotid endarterectomy.

Ballotta, Enzo / Da Giau, Giuseppe

Journal of vascular surgery

2003 Volume 38, Issue 5, Page(s) 1045–1050

Abstract: Purpose: The consensus is that eversion carotid endarterectomy (CEA) is a safe, effective, and durable surgical technique. Concern remains, however, regarding insertion of a shunt during the procedure. We studied the advisability of shunting with ... ...

Abstract	Purpose: The consensus is that eversion carotid endarterectomy (CEA) is a safe, effective, and durable surgical technique. Concern remains, however, regarding insertion of a shunt during the procedure. We studied the advisability of shunting with eversion CEA by comparing patients who underwent eversion CEA with and without shunting. Methods: Over 9 years, 624 primary eversion CEAs were performed in 580 selected patients to treat symptomatic (n = 398, 63.8%) and asymptomatic (n = 226, 36.2%) carotid lesions. All eversion CEAs were performed by the same surgeon (E.B.), with the patient under deep general anesthesia, with continuous electroencephalographic (EEG) monitoring for selective shunting, based exclusively on EEG changes consistent with cerebral ischemia. A Pruitt-Inahara shunt was used in 43 eversion CEAs (6.9%). All patients underwent postoperative duplex ultrasound scanning and clinical follow-up at 1, 6, and 12 months and once a year thereafter. Mean follow-up was 52 months (range, 3-91 months). The main end points were perioperative (30-day) stroke and death, and recurrent stenosis. Results: No perioperative death occurred in this series. Overall, ischemic perioperative stroke occurred in 4 of 624 patients (0.6%). Two strokes were minor and two were major. Only one (major) stroke occurred in the group with shunt insertion (1 of 43, 2.3%; P = not significant); the everted internal carotid artery was patent. Long-term follow-up was performed in all living patients. There was no late recurrent stenosis (>50%), and one late asymptomatic occlusive event occurred in the group without shunt insertion. Conclusions: Shunt insertion can be safely performed during eversion CEA. Perioperative mortality and morbidity after eversion CEA are not statistically modified with shunting.
MeSH term(s)	Adult ; Aged ; Aged, 80 and over ; Brain Ischemia/diagnosis ; Brain Ischemia/prevention & control ; Carotid Artery, Internal/surgery ; Carotid Stenosis/surgery ; Electroencephalography ; Endarterectomy, Carotid/methods ; Female ; Humans ; Male ; Middle Aged ; Prospective Studies ; Retrospective Studies ; Treatment Outcome ; Vascular Surgical Procedures/methods
Language	English
Publishing date	2003-09-29
Publishing country	United States
Document type	Journal Article
ZDB-ID	605700-7
ISSN	1097-6809 ; 0741-5214
ISSN (online)	1097-6809
ISSN	0741-5214
DOI	10.1016/s0741-5214(03)00605-0
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Article ; Online: Common femoral artery endarterectomy for occlusive disease: an 8-year single-center prospective study.

Ballotta, Enzo / Gruppo, Mario / Mazzalai, Franco / Da Giau, Giuseppe

Surgery

2010 Volume 147, Issue 2, Page(s) 268–274

Abstract: Background: Only a few operative or interventional studies have addressed the issue of isolated arterial occlusive disease at the femoral bifurcation, the early and late results reportedly being favorable in the former, controversial in the latter. The ... ...

Abstract	Background: Only a few operative or interventional studies have addressed the issue of isolated arterial occlusive disease at the femoral bifurcation, the early and late results reportedly being favorable in the former, controversial in the latter. The purpose of this study was to analyze the peri-operative (30-day) and long-term outcomes of isolated surgical endarterectomy in patients with occlusive disease at the common femoral artery (CFA), providing a baseline for comparison with emerging endovascular procedures. Methods: Over an 8-year period, all consecutive patients referred to our institution for claudication, rest pain, nonhealing ulcer(s), or minor tissue loss, with imaging findings of CFA occlusive disease (isolated or with additional infrainguinal lesions in the ipsilateral limb) amenable to endarterectomy of the CFA (isolated or combined with a profundoplasty or with the endarterectomy of the superficial or deep femoral artery first tract, not >1 cm long) were enrolled in the study. We excluded all patients with major tissue loss for which a contemporary infrainguinal revascularization was performed because treating the inflow disease alone would not be sufficient to heal the ischemic wound(s) owing to the presence of concomitant femoral and/or distal lesions, inadequate collateralization, or poor runoff. Descriptive demographic data, risk factors, clinical manifestations, and operative details were recorded. Primary patency (PP), assisted PP (APP), and limb salvage (LS) rates, freedom from additional proximal or distal revascularization in the ipsilateral limb, and survival were assessed using Kaplan-Meier life tables. Univariate and multivariate analyses were performed to identify which factors could influence CFA segment patency or other parameters. Results: In all, 117 patients were enrolled and underwent 121 CFA endarterectomies, 60.3% for claudication and 39.7% for critical limb ischemia (CLI); 30 patients were excluded because they underwent a contemporary infrainguinal revascularization. All procedures were performed with patients under regional anesthesia and took an average operating time of 1.3 +/- 0.7 hours. There were no perioperative deaths or major complications, but 8 (6.6%) local complications. A complete follow-up (mean 4.2 years) was obtained in 111 patients (115 limbs). The 7-year PP, APP, and LS rates were 96%, 100%, and 100%, respectively; the 7-year rates of freedom from further revascularization and survival were 79% and 80%, respectively. Conclusion: Operative endarterectomy in patients with claudication or CLI for occlusive CFA disease proved safe, effective, and durable, and should provide a baseline for comparison with endovascular treatment. Proponents of endovascular procedures as a routine alternative treatment option should bear this in mind.
MeSH term(s)	Aged ; Arterial Occlusive Diseases/complications ; Arterial Occlusive Diseases/surgery ; Endarterectomy/adverse effects ; Female ; Femoral Artery/surgery ; Humans ; Male ; Postoperative Complications ; Recurrence ; Reoperation
Language	English
Publishing date	2010-02
Publishing country	United States
Document type	Journal Article
ZDB-ID	202467-6
ISSN	1532-7361 ; 0039-6060
ISSN (online)	1532-7361
ISSN	0039-6060
DOI	10.1016/j.surg.2009.08.004
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Article: Infrapopliteal arterial revascularization for limb-threatening ischemia in patients with chronic kidney disease.

Ballotta, Enzo / Da Giau, Giuseppe / Piccoli, Antonio

Journal of nephrology

2007 Volume 20, Issue 1, Page(s) 80–87

Abstract: Background: This study was undertaken to ascertain whether infrapopliteal arterial revascularization (IAR) for limb-threatening ischemia is worthwhile in patients with severe chronic kidney disease (CKD).: Methods: With prospectively entered data ... ...

Abstract	Background: This study was undertaken to ascertain whether infrapopliteal arterial revascularization (IAR) for limb-threatening ischemia is worthwhile in patients with severe chronic kidney disease (CKD). Methods: With prospectively entered data from a university teaching hospital's vascular registry, we reviewed the records of all patients with CKD who underwent IAR between January 1, 1990, and December 31, 2002. Primary, assisted primary and secondary patency rates, limb salvage, patient survival and amputation-free survival were assessed using Kaplan-Meier analysis. Factors influencing the outcome were evaluated with univariate and multivariate analyses. Results: Eighty-seven consecutive patients underwent 93 IARs; more than half (53%) of the patients were diabetic and nearly all (84%) had foot tissue loss. No patients died during the perioperative (30-day) period. At 1 and 5 years, primary patency rates were 92.3% and 77.2% in the series as a whole, 89.5% and 71.4% for diabetics vs. 95.3% and 83.4% for nondiabetics (p=0.164), and 78.9% and 49.1% for patients on dialysis vs. 95.7% and 85.3% for those not on dialysis (p=0.006). At 1 and 5 years, the secondary patency rates were 93.4% and 85.6% in the series as a whole, 91.7% and 82.1% for diabetics vs. 95.3% and 88.7% for nondiabetics (p=0.381), and 84.2% and 68% for patients on dialysis vs. 95.7% and 90.1% for those not on dialysis (p=0.002). At 1 and 5 years, the limb salvage rates were 96.8% and 80.6% in the series as a whole, 98% and 71.4% for diabetics vs. 100% and 88.7% for nondiabetics (p=0.104), and 94.7% and 61.7% for patients on dialysis vs 97.3% and 85.9% for those not on dialysis (p=0.020). There were 31 late deaths in the series as a whole, with a 5-year survival rate of 62.5%. At 1 and 5 years, the amputation-free survival probabilities were 93.4% and 54.4% in the series as a whole, 91.7% and 38.6% for diabetics vs. 95.2% and 70.2% for nondiabetics (p=0.011), and 89.5% and 39% for patients on dialysis vs. 94.4% and 58.8% for those not on dialysis (p=0.097). The dialysis treatment was the only predictor of primary patency failure (p=0.04). Conclusions: Although the overall outcome was poorer in patients on dialysis, IARs for limb-threatening ischemia in patients with CKD can achieve satisfactory results in terms of graft patency, limb salvage and amputation-free survival, especially if the tissue loss is manageable and an adequate autologous conduit is available.
MeSH term(s)	Aged ; Aged, 80 and over ; Blood Circulation/physiology ; Chronic Disease ; Female ; Humans ; Ischemia/etiology ; Ischemia/surgery ; Kidney Diseases/complications ; Leg/blood supply ; Limb Salvage/methods ; Male ; Middle Aged ; Popliteal Artery/physiology ; Popliteal Artery/surgery ; Prospective Studies ; Regional Blood Flow/physiology ; Regression Analysis ; Retrospective Studies ; Saphenous Vein/surgery ; Survival Analysis ; Treatment Outcome ; Vascular Surgical Procedures/methods
Language	English
Publishing date	2007-01
Publishing country	Italy
Document type	Journal Article
ZDB-ID	1093991-x
ISSN	1724-6059 ; 1121-8428 ; 1120-3625
ISSN (online)	1724-6059
ISSN	1121-8428 ; 1120-3625
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Article ; Online: The impact of gender on outcome after infrainguinal arterial reconstructions for peripheral occlusive disease.

Ballotta, Enzo / Gruppo, Mario / Lorenzetti, Renata / Piatto, Giacomo / DaGiau, Giuseppe / Toniato, Antonio

Journal of vascular surgery

2012 Volume 56, Issue 2, Page(s) 343–352

Abstract: Objective: The role of gender on the outcome of infrainguinal arterial revascularization (IAR) for peripheral arterial occlusive disease remains uncertain. This study analyzed the outcome of IARs performed over 15 years, stratifying the results by sex.!# ...

Abstract	Objective: The role of gender on the outcome of infrainguinal arterial revascularization (IAR) for peripheral arterial occlusive disease remains uncertain. This study analyzed the outcome of IARs performed over 15 years, stratifying the results by sex. Methods: Details of consecutive patients undergoing primary IAR for peripheral arterial occlusive disease from 1995 to 2009 at our institution were prospectively stored in a vascular registry. Demographics, risk factors, indications for surgery, inflow sources, outflow target vessels, types of conduit, and adverse outcomes were analyzed. Postoperative surveillance included clinical examination supplemented with duplex scans and ankle-brachial index measurements in all patients at discharge, 30 days, 6 months, and every 6 months thereafter. End points of the study, ie, patency, limb salvage, and survival rates, were assessed using Kaplan-Meier life-table analysis. The χ(2) or Fisher exact, Student t, and log-rank tests were used to establish statistical significance. Results: Our sample consisted of 1459 IARs performed in 1333 patients, comprising 496 women (37.2%; 531 IARs), who were a mean 3 years older than the men (74 vs 71 years; P < .001) and had a higher incidence of diabetes mellitus (52% vs 46%; P = .03) and surgery for limb salvage (91% vs 87%; P = .02). An autogenous vein conduit (great or small saphenous, or both, spliced, arm, or composite veins) was used in 87% of the IARs. No deaths occurred perioperatively (30 days). The major and minor complication rates were comparable between men and women. At 10 years, the primary patency rate was 47% in women vs 49% in men (P = .67), the assisted primary patency rate was, respectively, 53% vs 50% (P = .69), the secondary patency rate was 61% vs 61% (P = .66), limb salvage rate was 93% vs 91% (P = .54), and survival rate was 43% vs 49% (P = .65). Stratifying by type of conduit revealed no differences in patency or limb salvage rates. Conclusions: Despite an older age and more advanced stages of disease on presentation in women, IAR performed in women can achieve patency and limb salvage rates statistically no different from those recorded in their male counterparts, supporting the conviction that sex per se does not influence the outcome of lower extremity revascularization.
MeSH term(s)	Aged ; Arterial Occlusive Diseases/surgery ; Female ; Humans ; Inguinal Canal/blood supply ; Life Tables ; Limb Salvage ; Male ; Reconstructive Surgical Procedures ; Sex Factors ; Treatment Outcome ; Vascular Patency
Language	English
Publishing date	2012-08
Publishing country	United States
Document type	Journal Article
ZDB-ID	605700-7
ISSN	1097-6809 ; 0741-5214
ISSN (online)	1097-6809
ISSN	0741-5214
DOI	10.1016/j.jvs.2012.01.040
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Article ; Online: Reconstructive surgery for complex aortoiliac occlusive disease in young adults.

Ballotta, Enzo / Lorenzetti, Renata / Piatto, Giacomo / Tolin, Francesca / Da Giau, Giuseppe / Toniato, Antonio

Journal of vascular surgery

2012 Volume 56, Issue 6, Page(s) 1606–1614

Abstract: Background: Although aortoiliofemoral bypass grafting is the optimal revascularization method for patients with severe aortoiliac occlusive disease (AIOD), previous studies have documented poor patency rates in young adults. This study investigated ... ...

Abstract	Background: Although aortoiliofemoral bypass grafting is the optimal revascularization method for patients with severe aortoiliac occlusive disease (AIOD), previous studies have documented poor patency rates in young adults. This study investigated whether young patients with AIOD have worse outcomes in patency, limb salvage, and long-term survival rates after reconstructive surgery than their older counterparts. Methods: Patients aged≤50 years undergoing reconstructive surgery at our institution for AIOD between 1995 and 2010 were compared with a cohort of randomly selected patients aged≥60 years (two for each of the young patients, matched for year of operation), analyzing demographics, risk factors, indications for surgery, operative details, and outcomes. Results: Among 927 consecutive patients undergoing primary surgery for AIOD, 78 (8.4%) aged≤50 years (mean age, 48.4 years) and 156 older control patients (mean age, 71.2 years) were identified. The younger patients were mainly men (81%) and 59% had surgery for limb salvage and 41% for disabling claudication (P=.02). Compared with older patients, they were significantly more likely to be smokers (90% vs 72%; P=.002) and had previously needed significantly more inflow procedures (28% vs 16%; P=.03). Only one death occurred perioperatively (30-day) among the control patients, and no major amputations or graft infections occurred in either group. The need for subsequent infrainguinal reconstructions was greater in the younger patients (18% vs 7%; P=.01). The primary patency rates were inferior in the younger patients at 5 years (82% and 75%) and 10 years (95% and 90%; P=.01), whereas assisted secondary patency (89% and 82% vs 96% and 91%; P=.08), secondary patency (93% and 86% vs 98% and 92%; P=.19), limb salvage (88% and 83% vs 95% and 91%; P=.13), and survival rates (87% and 76% vs 91% and 84%; P=.32) were comparable in the two groups. Conclusions: This study shows that despite a higher primary graft failure rate than that in older patients, aortoiliofemoral revascularization for complex AIOD is a safe procedure for younger patients with disabling claudication or limb-threatening ischemia, providing they are willing to follow a regular protocol to complete their postoperative surveillance and to undergo graft revision as necessary.
MeSH term(s)	Adult ; Age Factors ; Aged ; Aortic Diseases/mortality ; Aortic Diseases/pathology ; Aortic Diseases/surgery ; Arterial Occlusive Diseases/mortality ; Arterial Occlusive Diseases/pathology ; Arterial Occlusive Diseases/surgery ; Blood Vessel Prosthesis Implantation ; Cohort Studies ; Endarterectomy ; Female ; Humans ; Iliac Artery ; Male ; Middle Aged ; Survival Rate ; Treatment Outcome ; Vascular Patency
Language	English
Publishing date	2012-12
Publishing country	United States
Document type	Journal Article
ZDB-ID	605700-7
ISSN	1097-6809 ; 0741-5214
ISSN (online)	1097-6809
ISSN	0741-5214
DOI	10.1016/j.jvs.2012.05.105
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Article ; Online: Gender-based outcomes after eversion carotid endarterectomy from 1998 to 2009.

Baracchini, Claudio / Saladini, Marina / Lorenzetti, Renata / Manara, Renzo / Da Giau, Giuseppe / Ballotta, Enzo

Journal of vascular surgery

2012 Volume 55, Issue 2, Page(s) 338–345

Abstract: Background and purpose: Although the benefit of carotid endarterectomy (CEA) in reducing the risk of stroke in selected symptomatic and asymptomatic patients has been well documented, the higher incidence of adverse events after CEA for women than for ... ...

Abstract	Background and purpose: Although the benefit of carotid endarterectomy (CEA) in reducing the risk of stroke in selected symptomatic and asymptomatic patients has been well documented, the higher incidence of adverse events after CEA for women than for men remains controversial. The purpose of this study was to analyze the effect of female gender on perioperative (30-day) and long-term outcomes after eversion CEA (eCEA). Methods: Patients entered into a prospectively compiled computerized database of all primary consecutive eCEAs performed at our institution from September 1998 to December 2009 were analyzed. Endpoints were perioperative death and stroke, late carotid restenosis or occlusion, and long-term freedom from stroke and survival rates. Long-term follow-up was obtained in 96.8% of patients (97.5% of the women). Results: Among 1294 patients who underwent 1458 eCEAs under general anesthesia with continuous electroencephalographic monitoring and selective shunting, 409 (31.6%) were women (466 eCEAs). More women than men were over 80 years old (P = .001), and female patients were more likely to have arterial hypertension (P = .02) or hyperlipidemia (P = .006) than male patients. Preoperative statin medication (P = .01), contralateral carotid occlusion (P = .02), and shunting use (P = .03) were more frequent among female patients. No perioperative deaths occurred in the series as a whole, while the perioperative stroke risk (0.6% vs 0.5%), and the combined late carotid restenosis and occlusion rate (1.1% vs 0.4%) were comparable between female and male patients. The 7-year stroke-free survival and overall survival rates did not differ significantly between female and male patients (98.3% vs 98.8% and 87.2% vs 93.8%, respectively). Conclusions: This single-center university hospital study shows that although women have a different cardiovascular risk profile from men when they undergo eCEA, there is no evidence of a different gender effect on perioperative and long-term outcomes.
MeSH term(s)	Aged ; Aged, 80 and over ; Carotid Stenosis/complications ; Carotid Stenosis/diagnosis ; Carotid Stenosis/mortality ; Carotid Stenosis/surgery ; Chi-Square Distribution ; Disease-Free Survival ; Electroencephalography ; Endarterectomy, Carotid/adverse effects ; Endarterectomy, Carotid/mortality ; Female ; Hospitals, University ; Humans ; Ischemic Attack, Transient/etiology ; Italy/epidemiology ; Kaplan-Meier Estimate ; Male ; Odds Ratio ; Prospective Studies ; Recurrence ; Risk Assessment ; Risk Factors ; Sex Factors ; Stroke/etiology ; Survival Rate ; Time Factors ; Treatment Outcome
Language	English
Publishing date	2012-02
Publishing country	United States
Document type	Journal Article
ZDB-ID	605700-7
ISSN	1097-6809 ; 0741-5214
ISSN (online)	1097-6809
ISSN	0741-5214
DOI	10.1016/j.jvs.2011.08.018
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Article ; Online: Predictors of electroencephalographic changes needing shunting during carotid endarterectomy.

Ballotta, Enzo / Saladini, Marina / Gruppo, Mario / Mazzalai, Franco / Da Giau, Giuseppe / Baracchini, Claudio

Annals of vascular surgery

2010 Volume 24, Issue 8, Page(s) 1045–1052

Abstract: Background: Carotid endarterectomy (CEA) is associated with a risk of cerebral ischemia during carotid clamping, hence various cerebral protection strategies, including pharmacological management and routine or selective shunting, are commonly available. ...

Abstract	Background: Carotid endarterectomy (CEA) is associated with a risk of cerebral ischemia during carotid clamping, hence various cerebral protection strategies, including pharmacological management and routine or selective shunting, are commonly available. This study aimed to analyze the results of CEA with intraoperative electroencephalographic (EEG) monitoring to identify factors associated with EEG changes consistent with cerebral ischemia which needed shunting. Methods: A prospectively compiled, computerized database of all primary CEAs performed at our institution with EEG monitoring for symptomatic or asymptomatic severe carotid lesions between January 1990 and June 2009 was analyzed. Results: In all, 1,914 CEA procedures were performed on 1,696 patients, of which 218 had staged bilateral CEAs. EEG changes were recorded in 392 patients (20.5%), but a shunt was inserted during 312 CEA procedures (16.3%). Multivariate analysis showed that a symptomatic presentation (odds ratio [OR], 1.37; 95% confidence intervals [CI], 1.07-1.76; p = 0.012), prior stroke (OR, 2.28; 95% CI, 1.66-3.13; p < 0.001), contralateral carotid occlusion (OR, 2.14; 95% CI, 1.18-3.91; p = 0.019), and moderate (<80%) ipsilateral carotid disease (OR, 1.95; 95% CI, 1.08-3.52; p = 0.033) predicted the need for shunting. Conclusions: EEG was an excellent detector of cerebral ischemia and a valuable tool in guiding the need for shunting. Patients who were symptomatic or had a history of stroke, a contralateral carotid occlusion, or an ipsilateral moderate carotid stenosis were more prone to EEG changes consistent with cerebral ischemia. Surgeons should consider EEG changes during clamping as an effective criterion for selective shunting.
MeSH term(s)	Adult ; Aged ; Aged, 80 and over ; Brain Ischemia/diagnosis ; Brain Ischemia/etiology ; Brain Ischemia/physiopathology ; Brain Ischemia/prevention & control ; Carotid Stenosis/physiopathology ; Carotid Stenosis/surgery ; Cerebrovascular Circulation ; Chi-Square Distribution ; Constriction ; Electroencephalography ; Endarterectomy, Carotid/adverse effects ; Female ; Humans ; Italy ; Male ; Middle Aged ; Monitoring, Intraoperative/methods ; Odds Ratio ; Predictive Value of Tests ; Proportional Hazards Models ; Registries ; Retrospective Studies ; Risk Assessment ; Risk Factors ; Severity of Illness Index
Language	English
Publishing date	2010-11
Publishing country	Netherlands
Document type	Journal Article
ZDB-ID	1027366-9
ISSN	1615-5947 ; 0890-5096
ISSN (online)	1615-5947
ISSN	0890-5096
DOI	10.1016/j.avsg.2010.06.005
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Article ; Online: Infrapopliteal arterial reconstructions for limb salvage in patients aged > or =80 years according to preoperative ambulatory function and residential status.

Ballotta, Enzo / Gruppo, Mario / Mazzalai, Franco / Martella, Bruno / Terranova, Oreste / Da Giau, Giuseppe

Surgery

2010 Volume 148, Issue 1, Page(s) 119–128

Abstract: Background: Although numerous studies have addressed peripheral revascularizations for critical limb ischemia (CLI) in patients aged > or =80 years, few have focused exclusively on infrapopliteal arterial reconstructions. This study aimed to analyze ... ...

Abstract	Background: Although numerous studies have addressed peripheral revascularizations for critical limb ischemia (CLI) in patients aged > or =80 years, few have focused exclusively on infrapopliteal arterial reconstructions. This study aimed to analyze early and long-term outcomes in very elderly patients who underwent surgical infrapopliteal revascularization for CLI according to their pre-operative ambulatory function and residential status. Methods: Over an 18-year period, all consecutive patients aged > or =80 years referred to our institution for CLI requiring primary infrapopliteal or inframalleolar arterial reconstruction were enrolled in the study. All procedures were completed by the same surgeon with patients under regional anesthesia. Patency, limb salvage, amputation-free survival, and cumulative survival rates were assessed by Kaplan-Meier analysis. The patient's pre- and postoperative ambulatory function and residential status (at home vs in a nursing home) were also analyzed. The mean follow-up was 6.2 years (range, 0.1-11.5) and was obtained for 98% of patients. Results: In all, 197 patients (134 men; mean +/- SD age, 82.8 +/- 1.7 years) with 201 critically ischemic limbs were enrolled in the study. No deaths or fatal major complications occurred in the peri-operative period (first 30 days); the local complication rate was 6%. After 1 and 7 years, the primary patency rates were 88% and 68%, the limb salvage rates were 96% and 87%, the amputation-free survival rates were 88% and 39%, and the survival rates were 91% and 44%, respectively. At last follow-up or death, 80% of the patients were ambulatory and 20% were not; 80% lived at home and were independent, another 9% lived at home with assistance, and 76% of the sample lived at home and were ambulatory. Conclusion: Infrapopliteal arterial revascularization in the very elderly with CLI proved safe, effective, and durable, confirming that age per se and concomitant comorbidities do not necessarily affect technical and clinical outcomes. Ambulatory function and independent living status are well preserved because, despite a relatively short life expectancy, the majority of very elderly revascularized CLI patients can be expected to spend their remaining years ambulatory and at home. In contrast, patients with poor ambulatory function or who required assistance pre-operatively were less likely to improve their status after limb revascularization despite a successful technical result.
MeSH term(s)	Aged ; Aged, 80 and over ; Extremities/blood supply ; Female ; Follow-Up Studies ; Humans ; Ischemia/physiopathology ; Ischemia/surgery ; Limb Salvage ; Male ; Popliteal Artery/surgery ; Reconstructive Surgical Procedures ; Survival Rate ; Vascular Surgical Procedures
Language	English
Publishing date	2010-07
Publishing country	United States
Document type	Journal Article
ZDB-ID	202467-6
ISSN	1532-7361 ; 0039-6060
ISSN (online)	1532-7361
ISSN	0039-6060
DOI	10.1016/j.surg.2009.12.013
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