Volume 11 Number 5 May 1990
eighth decade of life? We observed an 18% mortality over a lO.3-month average follow-up period in a group of patients who survived operation with a mean age of 68 years. Furthermore, four of five follow-up deaths occurred in patients considered management failures--two patients were considered hypertension failures and two patients were not removed from dialysis dependence by operation. Rather than presume that these deaths were "the direct result o f the operative procedure" as Dr. Imparato suggests, the observed mortality in these elderly patients may reflect the accelerated death rate when hypertension and renal insufficiency are not improved. In summary, we have not advocated complex renal revascularization with or without aortic reconstruction in elderly patients who have mild or well-controlled hypertension. When hypertension is poorly controlled and/or combined with severe renal insufficiency, we still believe that aggressive management is meritorious in experienced centers. We accept that this is associated with an increased operative risk, yet believe that survival without intervention is worse. Finally, we assure Dr. Imparato that we have asked ourselves these questions both before publication of our experience and in response to his criticisms. In neither instance have we found the questions "embarrassing" and we reassert that in properly selected patients, operative management in the elderly is appropriate and beneficial. Richard H. Dean, zl/ID KimberleyJ. Hansen, MD
Department of Surgery Bowman Gray School of Medicine 300 South Hawthorne Rd. Winston-Salen, NC 27103 REFERENCES 1. Gifford RW. Myths about hypertension in the elderly. Med Clin North Am 1987;71:I003-I1. 2. Amery A, Brisko P, Clement D, et al. Mortality and morbidity results from the European working party on high blood pressure in the elderly trial. Lancet 1985;1:1349-54. 3. U.S. Renal Data System, USRDS 1989 Annual Data Report, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md, August 1989.
Letters to the editors 729
Total occlusion of the common carotid artery with a patent internal carotid artery; identification by duplex ultrasonography: Report of a case To the Editors:
The recent letter by Bebry and Hines (J VAse Suv,~ 1989;10:469-70.) concerning diagnosis of common carotid occlusion with patency of the extracranial internal carotid artery by duplex scanning confirms our own experience. In 19851 presented to the lalternational Cardiovascular Society in Monte Carlo a series of 17 patients with common carotid artery occlusion studied by duplex scanning. Nine of these patients had symptoms and had confirmed patency of the cervical internal carotid artery at the time of surgery. A number of points were emphasized by the study. Cause of occlusion of the common carotid artery may be of two types: (1) Occlusive plaque at the origin of the common carotid artery, and (2) occlusive plaque at the bifurcation of the common carotid artery. When the common carotid artery occluded because of bifurcation plaque the internal carotid artery almost always is occluded in the neck. Conversely when the occlusive plaque is at the origin of the common carotid artery, the cervical internal carotid artery usually remains patent. The presence of significant plaque at the bifurcation of the common carotid artery can easily be seen with duplex scanning, whereas arteriography is of little value in differentiating these two points. In addition to searching for plaque at the common carotid bifurcation, Doppler flow studies will show mixed or reversed flow in the proximal external carotid artery, mixed or forward flow in the proximal internal carotid artery, and forward flow in the mid and distal internal carotid artery. Angiographic confirmation of patency of the cervical internal carotid artery can often be obtained at angiography with selective injection of the ipsilateral vertebral artery, which demonstrates collateral flow from the cervical branches of the vertebral artery through the occipital artery into the external carotid artery and reversal of external carotid flow into the internal carotid artery. E. Kent Carney, MD
145 E. Carroll St. Salisbury, MD 21801
eighth decade of life? We observed an 18% mortality over a lO.3-month average follow-up period in a group of patients who survived operation with a mean age of 68 years. Furthermore, four of five follow-up deaths occurred in patients considered management failures--two patients were considered hypertension failures and two patients were not removed from dialysis dependence by operation. Rather than presume that these deaths were "the direct result o f the operative procedure" as Dr. Imparato suggests, the observed mortality in these elderly patients may reflect the accelerated death rate when hypertension and renal insufficiency are not improved. In summary, we have not advocated complex renal revascularization with or without aortic reconstruction in elderly patients who have mild or well-controlled hypertension. When hypertension is poorly controlled and/or combined with severe renal insufficiency, we still believe that aggressive management is meritorious in experienced centers. We accept that this is associated with an increased operative risk, yet believe that survival without intervention is worse. Finally, we assure Dr. Imparato that we have asked ourselves these questions both before publication of our experience and in response to his criticisms. In neither instance have we found the questions "embarrassing" and we reassert that in properly selected patients, operative management in the elderly is appropriate and beneficial. Richard H. Dean, zl/ID KimberleyJ. Hansen, MD
Department of Surgery Bowman Gray School of Medicine 300 South Hawthorne Rd. Winston-Salen, NC 27103 REFERENCES 1. Gifford RW. Myths about hypertension in the elderly. Med Clin North Am 1987;71:I003-I1. 2. Amery A, Brisko P, Clement D, et al. Mortality and morbidity results from the European working party on high blood pressure in the elderly trial. Lancet 1985;1:1349-54. 3. U.S. Renal Data System, USRDS 1989 Annual Data Report, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md, August 1989.
Letters to the editors 729
Total occlusion of the common carotid artery with a patent internal carotid artery; identification by duplex ultrasonography: Report of a case To the Editors:
The recent letter by Bebry and Hines (J VAse Suv,~ 1989;10:469-70.) concerning diagnosis of common carotid occlusion with patency of the extracranial internal carotid artery by duplex scanning confirms our own experience. In 19851 presented to the lalternational Cardiovascular Society in Monte Carlo a series of 17 patients with common carotid artery occlusion studied by duplex scanning. Nine of these patients had symptoms and had confirmed patency of the cervical internal carotid artery at the time of surgery. A number of points were emphasized by the study. Cause of occlusion of the common carotid artery may be of two types: (1) Occlusive plaque at the origin of the common carotid artery, and (2) occlusive plaque at the bifurcation of the common carotid artery. When the common carotid artery occluded because of bifurcation plaque the internal carotid artery almost always is occluded in the neck. Conversely when the occlusive plaque is at the origin of the common carotid artery, the cervical internal carotid artery usually remains patent. The presence of significant plaque at the bifurcation of the common carotid artery can easily be seen with duplex scanning, whereas arteriography is of little value in differentiating these two points. In addition to searching for plaque at the common carotid bifurcation, Doppler flow studies will show mixed or reversed flow in the proximal external carotid artery, mixed or forward flow in the proximal internal carotid artery, and forward flow in the mid and distal internal carotid artery. Angiographic confirmation of patency of the cervical internal carotid artery can often be obtained at angiography with selective injection of the ipsilateral vertebral artery, which demonstrates collateral flow from the cervical branches of the vertebral artery through the occipital artery into the external carotid artery and reversal of external carotid flow into the internal carotid artery. E. Kent Carney, MD
145 E. Carroll St. Salisbury, MD 21801
