Improved carotid hemodynamics with vertebral reconstruction

[Simultaneous reconstruction of the carotid and vertebral arteries using a temporary intraluminal shunt (a clinical case)]

The article describes a case of one-stage surgical treatment of a patient with progressive chronic cerebral ischemia caused by combined steno-occlusive lesions of the carotid and vertebral arteries. The disease was complicated by intolerance to temporary occlusion of the carotid artery due to an incomplete circle of Willis. We performed extra-anatomic carotid-vertebral artery bypass with subsequent ipsilateral carotid endarterectomy. A temporary intraluminal shunt was used at the main stage of reconstructive surgery. We use this clinical case to analyze the issues of surgical treatment for combined lesions of the carotid and vertebral arteries and the techniques for prevention of associated ischemic complications.

Combined Carotid Endarterectomy and Vertebral Transposition or Bypass for Cerebral and Vertebrobasilar Insufficiency

The purpose of this report is to determine the indication for a combined carotid endarterectomy and vertebral transposition or bypass in patients who have transient ischemic attack (TIA) or stroke and intractable vertebral ischemic symptoms of dizziness and syncope. A retrospective review was made on 49 patients with the combined symptoms of generalized global ischemia, TIA, amaurosis fugax or stroke, and vertebral basilar insufficiency manifested as syncope, intractable dizziness, and unsteady gait. Diagnostic studies employed were carotid duplex scan, computed tomography (CT) or magnetic resonance imaging (MRI) brain scan, xenon blood flow study, transcranial Doppler analysis, electronystagmography, electroencephalography, and cardiac arrhythmia evaluation. Twenty-one of 49 patients (43%) with internal carotid occlusion underwent carotid endarterectomy plus vein patch or internal carotid to external carotid onlay patch angioplasty and proximal vertebral to common carotid artery transposition (n: 19), or bypass (n:2). Twenty-seven of 49 patients (57%) received carotid endarterec tomy and vertebral transposition (n:27) or bypass (n:2) for carotid and vertebral stenosis. There was no operative mortality, stroke, or neurologic deficit following the carotid and vertebral operations in the 49 patients. Six patients had transient palpebral ptosis. Postoperative cerebral angiogram or magnetic resonance angiogram showed patent vertebral arteries. All 49 patients have resolution of TIA, dizziness, syncope, and unsteady gait. Combined carotid endarterectomy and vertebral transposition or bypass should be considered in patients with solitary, dominant, or bilateral vertebral artery critical stenosis whose symptoms are unrelated to vestibular, cardiac, or seizure disorders and lateralized TIA or stroke.

Axilloaxillary bypass for the treatment of subclavian artery stenosis complicated by bilateral common carotid artery occlusion: technical case report

OBJECTIVE AND IMPORTANCE

We successfully treated a patient with stenosis of the left subclavian artery, complicated by bilateral common carotid artery occlusion, via axilloaxillary bypass surgery.

CLINICAL PRESENTATION

A 67-year-old patient with a history of hypertension and cerebral infarction underwent neck irradiation for treatment of a vocal cord tumor. Three months later, he began to experience transient tetraparesis several times per day. The blood pressure measurements for his right and left arms were different. Supratentorial blood flow was markedly low. The common carotid arteries were bilaterally occluded, and the right vertebral artery was hypoplastic. Therefore, only the left vertebral artery contributed to the patient's cerebral circulation; his left subclavian artery was severely stenotic.

INTERVENTION

The patient underwent axilloaxillary bypass surgery because the procedure avoids thoracotomy or sternotomy, manipulation of the carotid artery, and interruption of the vertebral artery blood flow. The patient has been free of symptoms for more than 5 years.

CONCLUSION

Neurosurgeons should be aware that extra-anatomic bypass surgery is an effective treatment option for selected patients with cerebral ischemia.

Long-term results and outcomes of crossover axilloaxillary bypass grafting: A 24-year experience

OBJECTIVE

The outcome of crossover axilloaxillary bypass grafting in patients with stenosis or occlusion of the innominate or subclavian arteries was investigated.

METHODS

The study was designed as a retrospective clinical study in a university hospital setting with 61 patients as the basis of the study. Fifty-eight patients (95.1%) had at least two risk factors or associated medical illnesses for atherosclerosis, and 35 patients (57.4%) had concomitant carotid artery stenosis that necessitated a staged procedure in 12 patients (19.7%). The patients underwent a total of 63 crossover axilloaxillary bypass grafting procedures. Demographics, risk factors and associated medical illnesses, preoperative symptoms and angiographic data, blood flow inversion in the vertebral artery, concomitant carotid artery disease, graft shape, caliber and material, and intraoperative and postoperative complications were studied to assess the specific influence in determining the outcome.

RESULTS

One postoperative death (1.6%), four early graft thromboses (6.2%), and six minor complications (9. 8%) occurred. The overall mortality and morbidity rates were 1.6% and 16.1%, respectively. During the follow-up period (mean, 97.3 +/- 7.9 months), we observed five graft thromboses (8.3%). Primary and secondary patency rates at 5 and 10 years were 86.5% and 82.8% and 88.1% and 84.3%, respectively. Overall, two patients (3.3%) had recurrence of upper limb symptoms and none had recurrence of symptoms in the carotid or vertebrobasilar territory. The 5-year and 10-year symptom-free interval rates were 97.7% and 93.5%, respectively. Nine patients (15%) died of unrelated causes. The 5-year and 10-year survival rates were 93.2% and 67.3%, respectively. Multivariate analysis showed that no specific variables exerted an influence in the short-term and long-term results and the outcome.

CONCLUSION

The optimal outcome of axilloaxillary bypass grafting supports its use as the most valuable surgical alternative to transthoracic anatomic reconstructions for innominate lesion, long stenosis of the subclavian artery, and short subclavian artery stenosis associated with ispilateral carotid artery lesions.

The influence of the state of the vertebral arteries on the peri- and postoperative risk in carotid surgery

OBJECTIVES

To assess the significance of the vertebral arteries (VA) as a prognostic factor within the framework of carotid surgery.

DESIGN

Prospective observational study.

MATERIALS

A total of 1338 operations were performed on 1182 patients. Three hundred and six of the patients had angiographically confirmed unilateral (299) or bilateral (seven) involvement of the VA. In 31 cases it was not possible to assess the VA.

METHODS

Life table analysis.

RESULTS

Thirty-day mortality rate was 1.6% (21 out of 1338) for all reconstructions of the internal carotid artery. In addition to three fatal strokes, 22 hemispheric events were noted (1.6%, 22/1338). Follow-up varied between 1 and 96 months (mean 34, S.E.M. 0.76, median 29) and covered a total of 3361 patient years. The cumulative 5-year survival rate was 69%. Irrespective of age, cardiac events were the leading cause of death. In patients with VA involvement, both the 30-day stroke and mortality rate (p < 0.01) and the long-term survival rate (p < 0.01) were significantly poorer.

CONCLUSION

Concomitant vertebral artery disease increases the morbidity and mortality of carotid surgery, presumably due to reduced collateral perfusion during cross-clamping. However, the overall risk of surgery remains acceptable.

Long-term results with axillo-axillary bypass grafts for symptomatic subclavian artery insufficiency

PURPOSE

The surgical treatment for patients with a subclavian steal is controversial, especially for patients with coexisting severe carotid stenosis. This study determines the long-term efficacy of axillo-axillary bypass grafts in patients with and without a simultaneous carotid endarterectomy.

METHODS

The axillo-axillary bypass was done in 39 patients who were monitored for 5.8 +/- 3.9 years. Fifteen of these patients with severe carotid artery disease had a carotid endarterectomy done simultaneously. Twenty-four patients had an axillo-axillary bypass alone; four of these patients later had a carotid endarterectomy at 0.5 to 10 years. Graft patency was evaluated at intervals of 6 to 12 months by clinical evaluation and noninvasive vascular studies.

RESULTS

Ten-year primary and secondary patency rates for all axillo-axillary bypass grafts were 88% and 91%, respectively. When carotid endarterectomy was done with axillo-axillary bypass, these patency rates were 86% and 93%, respectively. Patients with only axillo-axillary grafts had 10-year primary and secondary patency rates of 89% and 89%, respectively. Most patients had complete relief from symptoms of arm ischemia (90%) and vertebrobasilar insufficiency (85%). No perioperative mortality or permanent neurologic deficit occurred.

CONCLUSIONS

Axillo-axillary bypass is a safe and effective method for revascularization of the subclavian artery and should be considered for patients at high risk.