Volume 16 Number 5 November 1992
Dr. Dardik outlines a 44% 2-year patency rate from this third group. H o w then does one conclude that the 2-year patency rate for umbilical vein plus distal arteriovenous fistula exceeds 60%, as mentioned in the previous letter? Personal communication with the author was invaluable in straightening this out. Fig. 3 of his article shows a life-table patency graph of 22 patients who had duplex scan follow-up studies, all taken from the later experience with his group III patients. These patients had a 62.6% patency rate at 2 years. The same communication with Dr. Dardik reveals "about" 30 additional patients since his last published work, with patency at 2 years of around 60%. The author believes that this dramatic patency increase from 18% and 33% to 60% or more with his unpublished work represents a matured patient-selection process. We can only encourage Dr. Dardik to carefully analyze and publish his more recent experience. This would involve defining which patients had venous bypass and which had reconstructions with umbilical vein. Once the information is reviewed and in the public domain, future authors of articles dealing with femoral distal bypass may wish to include it in their manuscripts or discussions. WaiterJ. McCarthy, MD
Division of Vascular Surgery Northwestern University Medical School 251 E. Chicago Ave. Chicago, IL 60611-2614 24/41/41083
Subarachnoid hemorrhage after carotid endarterectomy To the Editors:
The occurrence of a bizarre and never before experienced complication after a routine vascular operation prompts a review of one's own experience and a thorough review of the literature on the subject.
CASE REPORT A right-handed 62-year-old white woman was admitted with a recent history of left amaurosis fugax and bilateral carotid artery bruit. Carotid artery Doppler studies revealed severe bilateral carotid artery occlusive disease.
Letters to the Editors
799
Arteriography confirmed a 90% right internal carotid artery occlusion and total occlusion of the left common carotid artery just proximal to the bifurcation with delayed retrograde filling of the left internal and external carotid arteries. The left-sided intracerebral circulation was poorly visualized because of the total occlusion of the left common carotid artery. Because of her symptoms and the unusual finding of carotid steal phenomenon, a left carotid endarterectomy was recommended and a right carotid endarterectomy was to follow in a few weeks. After an uneventful left carotid endarterectomy the patient was discharged on the third postoperative day. She returned 2 days later with an intense frontal headache. There were no neurologic deficits. A computed tomography scan revealed a massive subarachnoid hemorrhage. Arteriography was repeated to look for evidence of a ruptured intracranial aneurysm; none was found. Neurologic consultation was obtained and the patient was admitted to the neurointensive care unit for observation. Four days later, to be absolutely certain that no intracranial aneurysm might have been in spasm during the first arteriography, arteriography was repeated and once again the left internal carotid artery was normal and there was no evidence of an intracranial aneurysm. The patient's headache diminished and she was discharged 7 days after her second hospital admission. She has subsequently had a normal recovery and returned to flail activity 2 months after the operation.
Discussion A careful review of this patient's first hospital stay revealed no evidence of more than modest hypertension at any time; no etiologic explanation for this subarachnoid hemorrhage can be identified. She was thought to have had an idiopathic subarachnoid hemorrhage temporally but not causally related to the left carotid endarterectomy. The occurrence of subarachnoid hemorrhage as an isolated event after routine carotid endarterectomy is unique in my experience. A 20-year review of the literature fails to reveal any similar reported cases. ¢VaartinL. Dalton, MD
Department of Surgery Mercer University School of Medicine 777 Hemlock St., Box 98 Macon, GA 31208 24/41/40817
Dr. Dardik outlines a 44% 2-year patency rate from this third group. H o w then does one conclude that the 2-year patency rate for umbilical vein plus distal arteriovenous fistula exceeds 60%, as mentioned in the previous letter? Personal communication with the author was invaluable in straightening this out. Fig. 3 of his article shows a life-table patency graph of 22 patients who had duplex scan follow-up studies, all taken from the later experience with his group III patients. These patients had a 62.6% patency rate at 2 years. The same communication with Dr. Dardik reveals "about" 30 additional patients since his last published work, with patency at 2 years of around 60%. The author believes that this dramatic patency increase from 18% and 33% to 60% or more with his unpublished work represents a matured patient-selection process. We can only encourage Dr. Dardik to carefully analyze and publish his more recent experience. This would involve defining which patients had venous bypass and which had reconstructions with umbilical vein. Once the information is reviewed and in the public domain, future authors of articles dealing with femoral distal bypass may wish to include it in their manuscripts or discussions. WaiterJ. McCarthy, MD
Division of Vascular Surgery Northwestern University Medical School 251 E. Chicago Ave. Chicago, IL 60611-2614 24/41/41083
Subarachnoid hemorrhage after carotid endarterectomy To the Editors:
The occurrence of a bizarre and never before experienced complication after a routine vascular operation prompts a review of one's own experience and a thorough review of the literature on the subject.
CASE REPORT A right-handed 62-year-old white woman was admitted with a recent history of left amaurosis fugax and bilateral carotid artery bruit. Carotid artery Doppler studies revealed severe bilateral carotid artery occlusive disease.
Letters to the Editors
799
Arteriography confirmed a 90% right internal carotid artery occlusion and total occlusion of the left common carotid artery just proximal to the bifurcation with delayed retrograde filling of the left internal and external carotid arteries. The left-sided intracerebral circulation was poorly visualized because of the total occlusion of the left common carotid artery. Because of her symptoms and the unusual finding of carotid steal phenomenon, a left carotid endarterectomy was recommended and a right carotid endarterectomy was to follow in a few weeks. After an uneventful left carotid endarterectomy the patient was discharged on the third postoperative day. She returned 2 days later with an intense frontal headache. There were no neurologic deficits. A computed tomography scan revealed a massive subarachnoid hemorrhage. Arteriography was repeated to look for evidence of a ruptured intracranial aneurysm; none was found. Neurologic consultation was obtained and the patient was admitted to the neurointensive care unit for observation. Four days later, to be absolutely certain that no intracranial aneurysm might have been in spasm during the first arteriography, arteriography was repeated and once again the left internal carotid artery was normal and there was no evidence of an intracranial aneurysm. The patient's headache diminished and she was discharged 7 days after her second hospital admission. She has subsequently had a normal recovery and returned to flail activity 2 months after the operation.
Discussion A careful review of this patient's first hospital stay revealed no evidence of more than modest hypertension at any time; no etiologic explanation for this subarachnoid hemorrhage can be identified. She was thought to have had an idiopathic subarachnoid hemorrhage temporally but not causally related to the left carotid endarterectomy. The occurrence of subarachnoid hemorrhage as an isolated event after routine carotid endarterectomy is unique in my experience. A 20-year review of the literature fails to reveal any similar reported cases. ¢VaartinL. Dalton, MD
Department of Surgery Mercer University School of Medicine 777 Hemlock St., Box 98 Macon, GA 31208 24/41/40817
