Background Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence.Methods ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362.

Aortoesophageal fistula induced by atherosclerotic thoracic aortic aneurysm is rare, but is usually a fatal disorder, with few survivors reported. We report the case of a 72-year-old man with aortoesophageal fistula successfully treated in a two-stage operation. In the first stage, we performed resection and replacement of the aortic aneurysm with a prosthetic graft in situ, esophagectomy, cervical esophagostomy, and jejunostomy. After the patient recovered well postoperatively, a transmediastinal retrosternal interposition of the stomach was performed, with esophagogastroanastomosis in the cervical area, to re-establish the gastrointestinal tract. We include a discussion of the causes, diagnostic approach, management of the aorta and esophagus, and review of the literature.

No abstract

No abstract

Angioplasty and Stent Placement in Symptomatic Internal Carotid OcclusionPuech-Leão P, Bregalda Neves CR, Simão da Silva E, et al. J Vasc Intervent Rad 2010;21:465-9. Conclusion: Carotid artery angioplasty and stenting can be successfully performed in patients with internal carotid artery pseudo-occlusion or string sign.Summary: This report focuses on carotid angioplasty and stenting in a series of patients in whom the internal carotid artery (ICA) was thought occluded by conventional ultrasound but who actually had string signs. The authors treated 16 patients. Contrast computed tomography (CT) showed a patent distal ICA in 14 of the 16 patients treated. Contrast-enhanced ultrasound imaging also showed patent distal ICAs in 13 cases. This is actually a series of very high-grade ICA stenosis and/or string signs treated with angioplasty and stenting. The authors performed the angioplasty and stent placement under cerebral protection. Duplex imaging was performed at 14 days, 3 months, and every 6 months thereafter. CT scans were obtained at 2 to 9 months, and the mean follow-up period was 9.9 months. Most patients had nonhemispheric symptoms as the indication for treatment. Patients were treated with clopidogrel and aspirin before the procedure and were maintained on clopidogrel 90 days after treatment and on aspirin indefinitely. A 6F sheath was placed in the common carotid artery and the ICA accessed with a 5F diagnostic vertebral catheter. A 0.035-inch hydrophilic guide wire was then passed into the ICA, followed by the catheter. An interceptor filter (Medtronic, Minneapolis, MN) was passed through the catheter and opened in the lumen, and then the catheter was withdrawn. Predilation was performed with a 3-mm balloon through the filter wire, and then a self-expanding stent was placed in the proximal ICA and dilated with a 5-mm balloon. If necessary, a second distal stent was placed.Stent placement was successful in 13 of 16 patients. There were no deaths, conversions, or cardiac complications. One patient had paresis in the upper limb with recovery in 3 months. At follow-up, all 13 patients remained with patent arterial lumens and were symptom free. After 2 to 9 months, so-called string signs had calibers close or equal to those of normal arteries.Comment: The title of this article is misleading. Although conventional duplex ultrasound imaging showed the patients had occluded ICAs, all in fact had patent distal ICAs either by contrast-enhanced ultrasound or contrast CT scanning. The authors of the article, the Journal of Vascular and Interventional Radiology reviewers, and the editors should be ashamed for permitting such a misleading title. What the authors have shown us is that in their institution, conventional duplex ultrasound imaging is likely below standard in distinguishing high-grade carotid stenosis from occlusion. They have shown us that CT angiography and contrast-enhanced ultrasound imaging can detect carotid string signs, something we already knew. They have also shown us that if you can get a ...