Intraoperative Ultrasound Scan Research Articles

Automated robotic systems in surgical practice

The use of robotic systems has long gone beyond experimental medicine. More than 200 thousand operations per year are carried out with the use of just the most popular robotic complex Da Vinci. Further development of robotics will contribute to improvement of quality and accuracy of surgical interventions. Even now, it enables reduction of postoperative complications to almost zero. This review presents the analysis of the results of introducing robots into surgery. An overview of the data presented in PubMed, Cochrane Library, Science Direct and eLIBRARY was performed.

Efficacy of surgeon performed intraoperative ultrasound scan for localisation of parathyroid adenomas in patients with primary hyperparathyroidism.

In the UK, guidance recommends ultrasound scanning alone or in combination with sestamibi scintigraphy to guide surgery in patients with primary hyperparathyroidism. If an adenoma is localised on imaging, this can facilitate targeted or minimally invasive surgery. Surgeon-performed ultrasound scan on the operating table benefits from being performed on an anaesthetised patient with optimal positioning. The aim of this study was to investigate the efficacy of intra-operative, blinded, surgeon-performed ultrasound scan in localisation of parathyroid adenomas. Prospective data were collected on consecutive patients undergoing surgery for primary hyperparathyroidism at a single tertiary centre from November 2019 to June 2021. Patients underwent blinded, surgeon-performed ultrasound scan under general anaesthesia immediately prior to surgery. Localisation results from pre-operative imaging and surgeon-performed ultrasound scan were then compared with the intra-operative findings. Forty-nine patients underwent surgery and were found to have single-gland disease. Sestamibi scintigraphy, radiologist-performed ultrasound scan and surgeon-performed ultrasound scan had sensitivities of 59.4, 43.75 and 73.8 per cent, respectively. Surgeon-performed ultrasound scan had a statistically significantly increased sensitivity compared with radiologist-performed ultrasound (p < 0.05). Intra-operative, surgeon-performed ultrasound scan is effective in localising parathyroid adenomas and may be a useful adjunct to facilitate minimally invasive parathyroid surgery.

Robotic CME in obese patients: advantage of robotic ultrasound scan for vascular dissection

Complete mesocolic excision (CME) in right-sided colon cancers appears to confer oncological benefits compared to conventional colectomy. Identification of the superior mesenteric vein (SMV) remains challenging. We describe the novel use of intra-operative robotic ultrasound scan (rUSS) in obese patients (BMI ≥ 29). All consecutive patients having robotic CME for colon cancer between 2014 and 2017 were included in this retrospective cohort study. Data were recorded on an ethics approved prospective database and included patient demographics, clinical and oncological outcomes. Patients were divided into group 1 (BMI ≤ 28) and group 2 (BMI ≥ 29). SMV first approach was employed in all cases and SMV detection was aided using rUSS in group 2. Primary outcome was postoperative morbidity. Secondary outcomes included conversion rate, operative time and length of stay (LOS). 41 (group 1, median 66 years) were compared to 32 patients (group 2, median 63 years). There were no conversions to laparoscopy or laparotomy. Median operative times for group 2 were 30 min longer (186 vs. 216 min, p = 0.05). Overall morbidity was similar (20% vs. 19% in group 1 and 2, p = 0.26). There was no significant difference between the two groups with regard to LOS (median 7 vs. 6 days, p = 0.48), readmissions (2 vs. 5, p = 0.13), R0 resection rate (98% vs. 94%, p = 0.43) and lymph node harvest (median 31 vs. 30, p = 0.28).CME can be technically more challenging than conventional colectomy in obese patients and is associated with longer operative times. The use of rUSS in obese patients can help to identify SMV and allow safer dissection.

Renal biopsy under augmented reality guidance.

Kidney biopsies are currently performed using preoperative imaging to identify the lesion of interest and intraoperative imaging used to guide the biopsy needle to the tissue of interest. Often, these are not the same modalities forcing the physician to perform a mental cross-modality fusion of the preoperative and intraoperative scans. This limits the accuracy and reproducibility of the biopsy procedure. In this study, we developed an augmented reality system to display holographic representations of lesions superimposed on a phantom. This system allows the integration of preoperative CT scans with intraoperative ultrasound scans to better determine the lesion's real-time location. An automated deformable registration algorithm was used to increase the accuracy of the holographic lesion locations, and a magnetic tracking system was developed to provide guidance for the biopsy procedure. Our method achieved a targeting accuracy of 2.9 ± 1.5 mm in a renal phantom study.

Intraoperative sonography for nonpalpable breast lesions: Additional indications for a consolidate technique.

This prospective study evaluated the intraoperative ultrasound scan (IUSS) for nonpalpable breast lesions' detection. A total of 108 consecutive female patients underwent surgery using IUSS: Frozen sections demonstrated clear margins in 95.5% of neoplastic patients. Only four (4.5%) patients underwent local re-excision in the same operation. IUSS demonstrated to be quick, accurate, useful, effective, and safe for the intraoperative management of neoplastic nonpalpable breast lesions when performed by a surgeon who has undergone US training, particularly for people in whom alternative approaches can show some limitations due to contraindications or because of scheduling constraints, costs, and patient discomfort.

Fence Angioplasty Prevents Narrowing of Venous Anastomosis in Solitary Pancreas Transplant.

BackgroundGraft thrombosis is the leading cause of early graft failure in pancreas transplants. Direct anastomosis grafting of the portal vein to the iliac vein or vena cava generally appears narrowed on postoperative computed tomography (CT) scans. However, modification of surgical techniques may prevent venous narrowing, which also prevents thrombosis-related graft failure.Material/MethodsWe performed 31 solitary pancreas transplants since 2015. Retrospective analysis of these patients was performed.ResultsFence angioplasty was applied in the final 12 cases, and no technical failures or early graft losses occurred in these cases. Three graft losses, including 2 immunologic losses and 1 patient death with functioning graft, occurred after at least postoperative 4 months. The venous anastomoses were evaluated via intraoperative Doppler ultrasound and postoperative CT scans. Intraoperative Doppler ultrasound revealed improved spectral waves of venous anastomoses in the fence group (monophasic spectral wave, 42.9% vs. 0%, p=0.017). The fence-graft applied group had no cases of narrowing, whereas the non-fence group had high narrowing rates on CT scans (84.2% vs. 0%, p<0.001). Furthermore, with less use of postoperative heparin, postoperative bleeding rates were lower in the fence group (36% vs. 0%, p=0.026).ConclusionsFence angioplasty is a definitive method for avoiding venous anastomotic stenosis and preventing graft failure due to thrombosis.

Intraoperative ultrasound for the colorectal surgeon: current trends and barriers.

Up to two thirds of patients diagnosed with colorectal cancer (CRC) develop colorectal liver metastases (CRLMs) and one quarter of patients present with synchronous metastases. Early detection of CRLM widens the scope of potential treatment. Surgery for CRLM offers the best chance of a cure. Current preoperative staging of CRC relies on computerized tomography and magnetic resonance imaging. Intraoperative ultrasound (IOUS) scans and contrast-enhanced IOUS (CE-IOUS) have been demonstrated to detect additional metastases not seen on routine preoperative imaging. IOUS is not widely used by colorectal surgeons during primary resection for CRC. Confident use of IOUS/CE-IOUS during primary resection of CRC may improve decision-making by providing the most sensitive form of liver staging even when compared with magnetic resonance imaging. This may be particularly important in the era of laparoscopic resections, where the colorectal surgeon loses the opportunity to palpate the liver. There are several implied barriers to the routine use of IOUS/CE-IOUS by colorectal surgeons. These include time pressure, familiarity with techniques, a perceived learning curve, cost implications and limitation of the modality due to operator variations. Inclusion of IOUS in the training of colorectal surgeons and further investigation of potential benefits of IOUS/CE-IOUS could potentially reduce these barriers, enabling usage during primary resection for CRC to become more widespread.

REtroSpective Evaluation of Cerebral Tumors (RESECT): A clinical database of pre-operative MRI and intra-operative ultrasound in low-grade glioma surgeries.

The advancement of medical image processing techniques, such as image registration, can effectively help improve the accuracy and efficiency of brain tumor surgeries. However, it is often challenging to validate these techniques with real clinical data due to the rarity of such publicly available repositories. Pre-operative magnetic resonance images (MRI), and intra-operative ultrasound (US) scans were acquired from 23 patients with low-grade gliomas who underwent surgeries at St. Olavs University Hospital between 2011 and 2016. Each patient was scanned by Gadolinium-enhanced T1w and T2-FLAIR MRI protocols to reveal the anatomy and pathology, and series of B-mode ultrasound images were obtained before, during, and after tumor resection to track the surgical progress and tissue deformation. Retrospectively, corresponding anatomical landmarks were identified across US images of different surgical stages, and between MRI and US, and can be used to validate image registration algorithms. Quality of landmark identification was assessed with intra- and inter-rater variability. In addition to co-registered MRIs, each series of US scans are provided as a reconstructed 3D volume. All images are accessible in MINC2 and NIFTI formats, and the anatomical landmarks were annotated in MNI tag files. Both the imaging data and the corresponding landmarks are available online as the RESECT database at https://archive.norstore.no (search for "RESECT"). The proposed database provides real high-quality multi-modal clinical data to validate and compare image registration algorithms that can potentially benefit the accuracy and efficiency of brain tumor resection. Furthermore, the database can also be used to test other image processing methods and neuro-navigation software platforms.

A step-wise approach to laparoscopic right hepatectomy: video

Aims: Laparoscopic liver resections are now performed routinely with over 3000 cases performed world-wide. Performing liver resections laparoscopically has been shown to be associated with reduced mortality and morbidity and has all the benefits of laparoscopic surgery compared to open operations; reduced hospital stay, post-operative pain and complications. Major resections such as right hepatectomy can be complex and the laparoscopic procedure has a significant learning curve. Methods: We have adapted a step-wise approach to laparoscopic right hepatectomy and aim to showcase this in a teaching video to reduce the learning curve associated with the laparoscopic technique. The ten minute video is a training aid for higher surgical trainees as well as novices in this procedure to familiarise themselves with the steps and relevant anatomy. The steps include: 1) Setup, port insertion & laparoscopy 2) Division of the falciform and mobilising the right liver 3) Intra-operative ultrasound scan 4) Division of retro-hepatic veins 5) Calots triangle dissection and ligation of the right hepatic artery and right portal vein 6) Marking of the transaction line 7) Parenchymal dissection and intra-hepatic ligation of the right hepatic duct and right hepatic vein 8) Specimen retrieval 9) Haemostasis and closure. Results: The case chosen for this presentation is a 60 year old male with synchronous left colonic tumour with liver metastases found on bowel cancer surveillance programme. He had a laparoscopic left hemi colectomy (Dukes B – pT3 N0) a month prior to his liver operation to remove a single metastases in right lobe of liver (Segment 8). There was minimal intra-operative blood loss. He made a good recovery and left hospital on day two post-operation. Conclusions: A step-wise approach to laparoscopic right hepatectomy video can be used as a training aid for higher surgical trainees and those training in laparoscopic liver surgery.

Vaccum drainage system application in the management of operation-related non-regional epidural hematoma

BackgroundEpidural intracranial hematoma is one of the most common complications of surgeries for intracranial tumors. The non-regional epidural hematoma is related to severe fluctuation of the intracranial pressure during the operation. The traditional management of hematoma evacuation through craniotomy is time-consuming and may aggravate intracranial pressure imbalance, which causes further complications. We designed a method using vaccum epidural drainage system, and tried to evaluate advantage and the disadvantage of this new technique.MethodsSeven patients of intracranial tumors were selected. All of the patients received tumor resection and intra-operative non-regional epidural hematoma was confirmed through intra-operative ultrasound or CT scan. The vaccum drainage system was applied. Another ten patients who received craniotomy for intra-operative non-regional epidural hematoma evacuation were selected as comparison. Regular tests, like serial CT scan, were performed afterward to evaluate the effectiveness and to help deciding when to remove the drainage system.ResultsThe vaccum drainage method was effective in epidual hemotoma clearance and prevented recurrent epidural hemorrhage. The drainage systems were removed within 4 days. All of the patients recovered well. No complications related to the drainage system were observed.ConclusionsCompared to the traditional craniotomy, the new method of epidural hemoatoma management using vaccum epidural drainage system proved to be as effective in hematoma clearance, and was less-invasive and easier to perform, with less complication, shorter hospitalization, less economic burden, and better prognosis.

Occlusion Angiography Using Intraoperative Contrast-enhanced Ultrasound Scan (CEUS): A Novel Technique Demonstrating Segmental Renal Blood Supply to Assist Zero-ischaemia Robot-assisted Partial Nephrectomy

BackgroundRecent innovations in technology and operative techniques have enabled safe performance of robot-assisted zero-ischaemia partial nephrectomy (PN), thus preventing the deleterious effect of warm ischaemia time. ObjectiveTo describe a novel technique of occlusion angiography using intraoperative contrast-enhanced ultrasound scan (CEUS) for zero-ischaemia robot-assisted PN (RAPN). Design, setting, and participantsWe used a prospective cohort evaluation of five patients who had imaging suspicious of renal cell carcinoma (RCC) treated at a single centre. Surgical procedureWe used computed tomography with three-dimensional reconstruction to identify renal arterial anatomy and its relationship to the tumour. Then, RAPN was performed with selective clamping and demonstration of a nonperfused segment of kidney (occlusion angiography) using intraoperative CEUS. Outcome measurements and statistical analysisWe prospectively collected data on baseline, perioperative, and postoperative parameters. Results and limitationsWe describe the effects seen on ultrasound contrast administration. Contrast flare is seen in the segment of the kidney that is perfused. When selective clamping is performed, a watershed (line of demarcation) between the perfused and nonperfused segments of the kidney is clearly seen, allowing excision of the tumour in a relatively avascular plane and ensuring an adequate oncologic margin, when feasible. The mean age was 68.2 yr of age (range: 36–85), and the mean tumour size was 29.6mm (range: 20–42). The mean intraparenchymal extension of the tumour was 22.6mm (range: 12–30). Three tumours were located on the right kidney and two on the left. The mean blood loss was 420ml (range: 200–1000). The histology revealed clear cell RCC in two patients, oncocytoma in two patients, and type 1 papillary RCC in one patient. All the surgical specimens had negative surgical margins. The mean decrease in glomerular filtration rate was 8.4ml (range: 0–24). The mean follow-up was 6.4 mo (range: 5–8), with no evidence of recurrence in any patient. The only limitation in adopting this technique is the need for an intraoperative ultrasound probe with a CEUS mode. However, most specialists who perform minimally invasive surgery for small renal tumours believe that intraoperative ultrasound scan imaging is essential to achieving adequate resection margins. ConclusionsIntraoperative CEUS can be a useful adjunct in determining whether zero-ischaemia RAPN is feasible by delineating the area of nonperfusion. This technique has several advantages over the currently available techniques, such as indigo carmine green and Doppler probes.

Reconstruction of portal vein in liver surgery

As an essential technique involved in complicated liver surgery,portal vein reconstruction results in eradication of macro- or microscopic tumor residual on surgical margins when combined with precise hepatectomy,improving both the living quality and the survival rate of patients.The application of this reconstruction technique needs precise evaluation of pre-operational image data,clearly dissection of portal vessels and tremendous amount of collaborative effort by the surgery team. Other techniques performed during the surgical procedure include intra-operative ultrasound scan,revitalizing the cryopreserved vessels,and angioplasty. Key words: Portal vein reconstruction; Liver surgery; Hepatocellular carcinoma; Hilar carcinoma; Gallbladder carcinoma

Great saphenous vein patency and endovenous heat-induced thrombosis after endovenous thermal ablation with modified catheter tip positioning

Thrombus extension into a deep vein after superficial venous thermoablation remains a unique complication in the treatment of superficial reflux disease of the great saphenous vein (GSV). In this study, we evaluate if catheter tip positioning or vein diameter correlate with the length of proximal patent segment of GSV after ablation and more caudal catheter positioning decreases the incidence of proximal thrombus extension into the femoral vein. This was a prospective study conducted from January 2008 to November 2009 of 73 patients undergoing radiofrequency ablation (RFA). Preoperative, intraoperative, and postoperative duplex ultrasound scans were obtained using standard protocols to establish reflux and target vein diameter. Intraoperative measurements were performed from the catheter tip to the femoral vein margin. Duplex ultrasound studies were obtained between 5 and 7 days after the procedure, with 1-month follow-up. The relationship between catheter tip positioning and vein diameter with the length of the proximal patent GSV segment after ablation and the incidence of proximal thrombus extension were analyzed. RFA was performed in 73 patients. Intraoperatively, the mean catheter tip positioning distance was 2.75 cm (range, 2.4-3.0 cm) from the saphenofemoral junction (SFJ), with 93% of the catheters placed within 2.6 to 2.9 cm of the femoral vein. The GSV mean diameter at the SFJ was 0.90 cm (range, 0.37-1.88 cm). After RFA, all GSVs were occluded, with a mean residual patent proximal GSV length of 1.17 cm (range, 0.3-10 cm). Two patients demonstrated thrombus extension from the SFJ into the femoral vein for a 2.7% incidence of endovenous heat-induced thrombosis. In patients undergoing RFA for saphenous reflux, neither catheter tip positioning nor vein diameter correlates with the length of the proximal patent segment of GSV after ablation. In addition, catheter positioning does not decrease the incidence of proximal thrombus extension into the femoral vein.

Intraosseous Ultrasound in the Placement of Pedicle Screws in the Lumbar Spine

Experimental and intraoperative evaluation of the efficiency of a novel technique. To determine the accuracy of pedicle screw hole placements before screw implantation in the lumbar spine. Deviations from planned trajectories occur in a significant number of screw placements in posterior lumbar fixation. Several techniques have been proposed to minimize this complication, although none has gained general acceptance. This may be due to costs associated with their implementation or considerably extended operating times required by some techniques. Pedicle screw holes were placed in 24 pedicles of 2 postmortem human lumbar spine specimens. Sixteen optimal trajectories were placed and 8 intentional cortical breaches. Each pedicular drill hole was examined using a 360 degrees ultrasound transducer and CT scanning. The ultrasonographic images were reviewed by 3 independent investigators who were blinded to the CT findings. In addition, 20 screw holes were placed intraoperatively in 3 patients, and equally assessed by intraoperative intraosseous ultrasonography and postoperative CT scanning. Ultrasonographic images of pedicle screw holes in postmortem human spine specimen were correctly interpreted in 99% of cases. No cortical breech was missed, i.e., no false-negatives occurred. Intraoperative findings closely matched the experimental data. None of the intraoperative ultrasound scans demonstrated a cortical breach, a finding confirmed by postoperative CT. The intraoperative time required for the ultrasonographic analysis of each pedicle was about 1 minute and the interpretation of the resulting images was judged intuitive by the evaluating neurosurgeons. Intraosseous ultrasound is a highly reliable technique for the intraoperative assessment of pedicle screw holes before pedicle screw placement. Additional expenses with respect to procedure time and manpower are minimal.

Evaluation of tumor thrombi in the inferior vena cava with intraoperative ultrasound

To report and discuss four cases of renal cell carcinoma (RCC) in which preoperative investigations yielded contradictory results regarding the cranial extension of propagation of the tumor thrombus into the vena cava. An intraoperative ultrasound scan (IOU) was performed in all cases to identify the exact level of the tumor thrombus. We have performed an IOU of the vena cava in four patients with RCC propagation into the inferior vena cava. Preoperative investigations were performed in all patients and consisted of abdominal Ultrasound scan (USS), contrast enhanced CT scan and gadolinium enhanced MRI scan. Intraoperative ultrasound has identified correctly the cranial extension and the absence of tumor thrombus infiltration in all patients. The thrombus reached the suprahepatic vena cava in two cases and was confined to the infrahepatic vena cava in the remainder. Preoperative imaging investigation had failed to determine the correct cranial extension of the tumor thrombus in two patients.IOU is a very useful tool to accurately assess the precise extent of tumor thrombus and eventually the presence of vein wall infiltration. These data are of paramount importance to plan the optimal surgical approach. According to our experience this type of investigation identifies the cranial extent of a tumor thrombus inside the vena cava better than standard imaging techniques.

Surgical Experiences of Functioning Neuroendocrine Neoplasm of the Pancreas

We present our surgical experiences with functioning neuroendocrine neoplasms of the pancreas to define its natural history, and to suggest its proper management. From June 1990 to June 2005, patients with diagnosis of functioning neuroendocrine (islet cell) neoplasms of the pancreas were retrospectively reviewed. Fourteen patients (5 men and 9 women) with a median age of 49 years (range, 12 - 68 years) were identified. Twelve patients (86%) had insulinoma, two (14%) had gastrinoma. One (7%) with pancreatic insulinoma was multiple endocrine neoplasia type 1. Intraoperative ultrasound scan (sensitivity, 83%) was the most powerful modality for tumor localization. Fifteen neoplasms with median tumor size 1 cm (range 0-3 cm) were resected. Four insulinomas (26.7%) were located in the head of the pancreas and 5 (36%), in the tail. Another 5 (36%) insulinomas and 1 (7%) gastrinoma were located around the neck area near the SMV or PV. Eleven patients (79%) underwent enucleation, and 2 patients (14%), distal pancreatectomy with splenectomy. 100% of patients with functioning neuroendocrine neoplasms of the pancreas have survived. The overall disease free 10-year survival was found to be about 81%. Exact localization of tumor by intraoperative ultrasound and surgical removal are promising for good prognosis.

Inverse automated treatment planning with and without individual optimization in interstitial permanent prostate brachytherapy with high- and low-activity 125I.

To determine whether dose distribution achieved with treatment plans using high- and low-activity (125)I implants differs. Based on intraoperative transrectal ultrasound scans of 71 patients, inverse automated treatment plans (IATP) were performed with 15.5-kBq (0.42-mCi) and 25.2-kBq (0.68-mCi) (125)I implants using a commercial 3-D planning system (Variseed). A prescription dose of 145 Gy in 98% of the prostate volume (V100), a maximum dose to the urethra of 250 Gy (D1), and a maximum dose to 10% of the anterior rectal wall of 145 Gy (D10) were required. The plans were manually corrected, if necessary. In the IATP, a better dose coverage of the prostate was found for high-activity seeds (V100 of 98% vs 84%). The prostate dose values increased with the prostate volume. After manual optimization, the differences were only marginal with a prostate V100 of 99% for both activities, a urethra D1 of 247 Gy and 239 Gy, and a rectum D10 of 135 Gy and 124 Gy for high- and low-activity seeds. Low-activity seeds required more sources (66 vs 47) and needles (24 vs 17; all numbers are median values). Concerning the prostate dose coverage, high-activity seeds are superior in the IATP. After manual adjustment, the dose values for the prostate and the organs at risk are similar. Considering a supposedly decreased toxicity and a shorter implantation time for a lower number of seeds, we recommend high-activity seeds for experienced teams.

Intraoperative ultrasound reduces ECMO catheter malposition requiring surgical correction

Background/Purpose: One hundred ninety-three cannulation procedures for extracorporeal membrane oxygenation (ECMO) have been performed at the authors' institution from 1994 to now. Before 1996, their practice had been to position these catheters exclusively by clinical assessment and chest radiograph. Since then, the authors have utilized intraoperative ultrasound guidance during cannulation procedures to confirm proper tip position. This retrospective analysis was undertaken to establish whether this practice has reduced the rate of surgical repositioning of ECMO catheters in these patients. Methods: A retrospective chart review was performed for all infants who underwent ECMO cannulation procedures at the authors' institution. Numbers of infants requiring surgery to readjust ECMO catheter position were totaled. Cases were categorized according to the presence or absence of intraoperative ultrasound scan. Statistical significance was determined using X2 analysis, Student's t test, or analysis of variance where appropriate. Results: There were 193 ECMO cannulations performed. Of the 101 procedures done without ultrasound scan, 18 necessitated surgical repositioning. In contrast, only 3 of the 92 catheters placed with ultrasound assistance required reoperation. This represents a reduction the rate of repositioning from 17.8% to 3.3% of cannulations (P =.003). Conclusions: Based on these findings, the authors advocate the use of intraoperative ultrasound imaging to optimize the position of ECMO catheters. This high rate of initial success helps avoid the potential morbidity of ECMO circuit malfunction, repeat neck dissection, and catheter manipulation in these critically ill, anticoagulated patients. J Pediatr Surg 37:691-694. Copyright 2002, Elsevier Science (USA). All rights reserved.

Intraoperative use of stents for the management of unacceptable distal internal carotid artery end points during carotid endarterectomy: Short-term and midterm results

Purpose: The management of unacceptable distal internal carotid artery (ICA) end points during carotid endarterectomy presents multiple dilemmas. The problem may be expeditiously solved by placement of an intraluminal stent, but reported clinical experience with this technique is limited. We retrospectively reviewed our experience with intraoperative stenting of the ICA for the correction of unacceptable distal ICA end points during carotid endarterectomy. We report our techniques and document the 30-day stroke morbidity-death rate and midterm outcomes of patients treated in this manner. Method: The records of 316 consecutive carotid endarterectomies performed by the authors from January 1997 through June 1999 were reviewed to identify those cases in which adjunctive intraoperative stenting of the distal ICA was used. For those patients treated with adjunctive ICA stents, we assessed technique, 30-day outcomes, and midterm outcomes. Results: The 30-day combined stroke and death rate for the entire group of 316 carotid endarterectomies was 1.9%. Adjunctive distal ICA stents were used in 13 cases—4.1% of the total carotid endarterectomy group—for the correction of unacceptable distal ICA end points. All patients were male; the average age was 70 years. Stents were used in 11 patients because in each of these cases the surgeon recognized an unacceptable end point and desired to limit further distal anatomic exposures and/or ischemia times. Stents were used in two patients to correct unexpected defects identified on intraoperative completion ultrasound scan. No 30-day periprocedural deaths, strokes, or transient ischemic attacks were observed. Average postoperative length of stay was 1.8 days (range, 1-5 days). All patients have been followed up with serial carotid duplex scans, and one patient has been studied by means of angiography. No patients have died, and all remain in active clinical follow-up. Mean length of follow-up has been 15 months. No significant asymptomatic recurrences have been observed, but one patient experienced an isolated episode of amaurosis fugax without demonstrable restenosis at 8 months postoperatively. Conclusion: Our experience suggests that the adjunctive use of stents for the correction of unacceptable distal ICA end points during carotid endarterectomy is safe and provides acceptable short-term and midterm outcomes. Continued follow-up will be required before this technique can be considered a primary choice rather than an expeditious secondary alternative in this infrequent clinical circumstance. (J Vasc Surg 2000;32:420-8.)

May-Thurner syndrome in an adolescent: Persistence despite operative management

We describe a patient with May-Thurner syndrome who underwent operative transection and transposition of the right common iliac artery without direct venous repair, because preoperative and intraoperative intravascular ultrasound scans were negative for “spurs” in the left common iliac vein. When symptoms and signs persisted, a postoperative magnetic resonance venogram (MRV) showed severe stenosis in the left common iliac vein. Progressive, but incomplete, clinical improvement occurred with conservative management. (J Vasc Surg 1999;30:950-3.)