OBJECTIVE Distal cerebral embolization is a known complication of carotid interventions. Here we prospectively investigate whether subclinical microembolization seen on post-operative MRI leads to cognitive deficits in a cohort of patients undergoing carotid revascularization procedures. METHODS Patients undergoing carotid interventions and eligible for MRI scanning were recruited to participate. Among 247 patients who received both preoperative and postoperative MRI evaluations, a total of 51 patients also completed neuropsychological testing prior to and at one month following the procedures. Cognitive evaluation included the Rey Auditory Verbal Learning Test (RAVLT) for memory evaluation and the Mini-Mental State Examination (MMSE) for general cognitive impairment screening. RESULTS All 51 patients (16 CAS and 35 CEA) were male with a mean age of 71 years, ranging 54 to 89 years. Among them, 27 patients (53%) were symptomatic preoperatively including 11 patients who had prior stroke and 16 patients who had prior TIA. The majority of the patients had significant medical comorbidities including hypertension (96%), diabetes (31.3%), coronary artery disease (47%), and COPD (15.7%). Two patients (4%) had prior ipsilateral CEA and 8 had contralateral carotid occlusion (15.7%). Memory decline evident on RAVLT was identified in 21 patients including 8 CAS patients and 13 CEA patients. Eleven patients had evidence of procedure-related microemboli. Although there was no significant difference in baseline cognitive function or memory change between CEA and CAS cohort, the CAS cohort had significantly higher incidence of microembolic lesions. Multivariate regression analysis showed that procedure-related microembolization was associated with memory decline (P=0.016) as evident by change in RAVLT. Prior history of neurologic symptom was significantly associated with poor baseline cognitive function (MMSE) (P=0.03) and overall cognitive deterioration (change in MMSE) (P=0.026) as determined by Wilcoxon Rank Sum test and linear regression analysis respectively. CONCLUSIONS Although both CEA and CAS are effective in stroke prevention with minimal neurologic complication, neurocognitive effects remain uncertain. Procedure-associated microembolization and pre-existing neurologic symptoms are associated with poor baseline cognitive function and memory decline following the procedures. Further comprehensive cognitive evaluation to determine the benefit of carotid interventions is warranted.

Objectives: Blunt abdominal aortic injury (BAAI) is very rare. Current literature is limited to case series of single center experience. Through an analysis of the National Trauma Databank (NTBD), the largest aggregation of United States trauma registry data, our aim was to more accurately characterize the injury patterns, management strategy and mortality of patients with BAAI.Methods: We used a nested case-control design. The cohort was patients ageϾ16 years, with injury severity score (ISS) Ն16, treated at a level 1 or 2 trauma center in years 2007-2009. Cases were patients with BAAI and were matched by age and mechanism to 1815 randomly selected controls without BAAI. Data collected included age, gender, comorbidities, ISS, associated injuries, type and timing of vascular interventions and hospital disposition.Results: We identified 363 patients with BAAI from 156 centers. The mean ISS was 34 Ϯ15 and the average age was 49 Ϯ21 years. Most patients were injured in motor vehicle crashes (84%). In comparison to controls, lumbar spine fractures, pelvic fractures as well as injuries to the kidneys, liver, spleen, pancreas, small bowel and colon were all more frequent in association with BAAI (pϽ0.001). Mortality was greater in patients with BAAI (32% vs. 10% in controls, pϽ0.001), with two thirds of deaths occurring in the first 24 hours.Of the 286 patients surviving beyond 24 hours, 249 (87%) were managed non-operatively, 26 (9%) underwent endovascular repair and 11 (4%) underwent open repair (9 with aortic interposition graft, 2 with extra-anatomic bypass). 81% of repairs were performed within 48 hours. 216 (86%) patients managed non-operatively survived to hospital discharge.Conclusions: The index of suspicion for BAAI should be raised in severely injured patients by the presence of lumbar and pelvic fractures as well as intra-abdominal injury. While endovascular repair is the most common intervention, most patients are managed non-operatively and survive to hospital discharge.

Objectives: Endovascular stent grafts are used in the rescue of failing arteriovenous access. Reports claim the superiority of stent grafts and recommended these as a first-line treatment. We have observed a rise in the number of complications related to stent grafts in our patients. The following study was undertaken to assess the severity of these complications and their effect on access site maintenance.Methods: We reviewed all patients who had endovascular stent grafts placed for treatment of failing dialysis access over the last 44 months. A series of 38 consecutively placed stent grafts was reviewed for stent migration, fracture, erosion, hemorrhage, and rupture at the site of the stent grafts. Hospital records were reviewed to assess for indications, hemodynamic stability, transfusion requirement, and outcome.Results: Of 38 stent grafts placed, 9 were for pseudoaneurysm (PS), 20 for stenosis (ST), and 9 for a combination (PS/ST). The average length of follow-up was 218.6 days. Primary patency was 49%, with an assisted primary patency of 76%. Eleven patients (28.9%) presented with complications (Table) related to migration, fracture, erosion, or rupture. Six were in the PS, three in the PS/ST, and two in the ST treatment groups. In all cases, migration or fracture of the stent graft led to recurrent pseudoaneurysm formation or erosion. Rupture occurred after a herald bleed in four cases. Once complication occurred, 10 of the 11 access sites had to be abandoned.Conclusions: Significant life-threatening complication can arise when fracture and migration of the stent grafts used for treating arteriovenous access occur. Herald bleed with a previously placed stent graft may be a harbinger of future rupture. Complications appear less likely when stent grafts are used to treat stenosis; however, when complications occur access site salvage is rare. Surgical revision in the case of pseudoaneurysm should be considered for access preservation.

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