Endovascular management of brachiocephalic arterial occlusive disease

Thoracic mural thrombi: a case series and literature review

Thoracic mural thrombi (TMT) are rare but an important source of distal emboli. Treatment options are dynamic, ranging from open, endovascular to conservative therapies. We report two cases of TMT, one successfully treated with thoracic aortic endoluminal stent placement for visceral and peripheral embolization, the second treated conservatively for digital embolization secondary to TMT in the innominate artery.

Chronic hand ischemia treated with radial artery balloon angioplasty: case report

Although balloon angioplasty in heart and lower extremity vessels has been extensively studied and reported, little information exists regarding its use for digital ischemia in the hand. We report a case of successful balloon angioplasty of the distal radial artery to reverse present and prevent further digital tip cyanosis and necrosis.

Endovascular Stenting for Stenoses in Surgically Reconstructed Brachiocephalic Bypass Grafts:Immediate and Midterm Outcomes

PURPOSE

To report the use of endovascular stenting for treatment of patients with symptomatic obstruction of brachiocephalic surgical reconstructions.

METHODS

Twenty-two patients (17 men; mean age 65+/-6 years) with 24 symptomatic obstructions of brachiocephalic Dacron bypass grafts (2 aorto-innominate, 9 subclavian-carotid, and 11 carotid-subclavian) were treated with balloon-expandable stents delivered via a percutaneous brachial access or surgical exposure of the common carotid artery. A distal protection device was utilized in the 9 patients with subclavian-carotid bypass grafts. All patients were followed by clinical and Doppler examinations.

RESULTS

Procedural success was 100%; 1 (4.5%) patient developed transient intraprocedural aphasia owing to intolerance to the distal protection balloon occlusion. All 22 patients reported complete relief of their presenting symptoms. Over a 29-month follow-up, 3 (13.6%) restenoses were found, but none was due to stent compression.

CONCLUSIONS

Stenting for obstructed brachiocephalic reconstructions appears to be a safe, effective, and durable therapeutic strategy.

Synchronous Carotid Endarterectomy and Retrograde Endovascular Treatment of Brachiocephalic or Common Carotid Artery Stenosis

OBJECTIVES

To retrospectively evaluate the safety and the long-term results of retrograde brachiocephalic and common carotid angioplasty and stenting (AS) performed for >70% stenosis synchronously with the carotid endarterectomy (CEA).

PATIENTS

Sixteen patients operated between April 1999 and March 2002.

RESULTS

14/16 procedures were successful. There was no neurological morbidity or mortality. Per-operative angiography showed the optimal stent positioning and patency of both proximal and distal arteries in all patients. In the follow-up, all patients showed patency of the treated vessels without restenosis and the absence of any cerebrovascular symptoms.

CONCLUSION

Intra-operative retrograde AS combined with CEA is an effective, safe and durable alternative to conventional surgery when a tandem significant proximal lesion is identified in a patient with an high grade carotid stenosis.

Endovascular treatment of innominate artery stenosis in a bovine aortic arch--a case report

Recent reports have established the feasibility and safety of percutaneous transluminal angioplasty and stent placement in the treatment of innominate artery occlusive disease. Although the long-term durability of these endovascular approaches has not been clearly established, they are particularly attractive in patients who are not considered good candidates for surgical reconstruction. The authors present a case involving a morbidly obese Hispanic woman who had undergone previous coronary artery bypass and complained of right visual symptoms, dizziness, and right upper extremity claudication. Because of her unusual bovine anatomy and the desire to avoid reoperating in her chest, a unique approach with a left subclavian-to-carotid bypass and innominate artery angioplasty and stenting was used.

Vascular complications arising from maldeployed stents

The authors present 6 unusual vascular complications secondary to maldeployed or undeployed vascular stents. They retrospectively reviewed patients referred for complications of vascular stent placement from September 1998 to March 1999. Information on patient history was obtained from a computerized database and clinical document file. Radiographic information was obtained from arteriograms, ultrasound, and computed tomography imaging. Case 1 describes an undeployed stent in the superior mesenteric artery with subsequent thrombosis in addition to celiac occlusion secondary to attempted balloon angioplasty. Case 2 refers to a malpositioned stent placed in the aortic arch and proximal left common carotid artery. Case 3 involves an undeployed coronary stent that migrated to the right distal posterior tibial artery, causing vascular occlusion and chronic pain. In Case 4, an attempted stent placement into the left iliac artery resulted in an undeployed stent lodged across the aortic bifurcation. Case 5 illustrates a partially deployed stent occluding the left renal artery that was unamenable to further angioplasty. Case 6 demonstrates arterial dissection with a pseudoaneurysm following stent placement for right subclavian stenosis. Five patients required operative intervention. Increased use of stents may escalate the number of complications requiring operative intervention. Foreign bodies can migrate distally and potentiate thrombotic occlusion of vessels. Caution must be used not only at the time of deployment but also in the follow-up period. Continued surveillance becomes important after vascular stent placement.