Outcomes of Endoluminal Therapy for Ostial Disease of the Major Branches of the Aortic Arch

Outcomes of upper extremity interventions for chronic critical ischemia

BACKGROUND

Critical hand ischemia owing to below-the-elbow atherosclerotic occlusive disease is relatively uncommon. The aim of this study was to examine the outcomes in patients presenting with critical ischemia owing to below-the-elbow arterial atherosclerotic disease who underwent nonoperative and operative management.

METHODS

A database of patients undergoing operative and nonoperative management for symptomatic below-the-elbow atherosclerotic disease between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (tissue loss and rest pain) were identified. Three management groups were identified: no revascularization (None), endovascular revascularization (Endo), and open revascularization by bypass (Bypass). Patients with acute embolism, active vasculitis, end-stage renal disease, ipsilateral dialysis access complications of steal, and ipsilateral trauma were excluded.

RESULTS

One hundred eight patients (56% male; average age, 59 years) presented with symptomatic below-the-elbow disease: 93% presented with digital ulceration and the remainder with rest pain. Eighty-one percent had diabetes and 41% had chronic renal insufficiency (not on dialysis). All underwent catheter-based angiography. Fifty-three patients (49%) had no intervention and subsequently were committed to wound care; 26 of these required no further intervention, 10 had an interval palmar sympathectomy, and 17 underwent either a phalanx or digital amputation. Thirty-four patients (31%) underwent an endovascular intervention with a median of 1.5 vessels (ulnar, radial, or interosseous arteries) intervened on. Technical success was achieved in 29 patients (85%). Of the five technical failures, two went on to bypass, one had a focal endarterectomy and patch angioplasty, and one was treated conservatively. Ten patients in the Endo group required either a phalanx or digital amputation. Twenty-one patients (19%) underwent a saphenous vein bypass (reversed or nonreserved) to the radial in 12 and the ulnar in 11 limbs. In follow-up, 11 patients underwent open or endovascular intervention to maintain patency of the bypass. There were nine phalanx or digital amputations in the Bypass group. No below-the-elbow or above-the-elbow amputations were performed within 30 days. The wound healing rate without amputation was 78% (85 of 108). The predictors of wound healing were technical success of the revascularization, intact palmar arch and presence of digital run-off. The presence of an incomplete arch and poor digital run-off were associated with a phalanx or digital amputation.

CONCLUSIONS

Upper extremity interventions for critical ischemia are associated with a high rate of success. Major amputations are rare and the many can be treated nonoperatively. In appropriately selected patients, both endovascular and open interventions have a high rate of success.

The modified ‘no touch’ technique in the antegrade endovascular approach for left common carotid artery ostial stenosis stenting

Background

Open surgery and the retrograde endovascular approach via the distal left common carotid artery (LCCA) have some limitations in LCCA ostial stenosis treatment. The ‘no touch’ technique used in the renal artery was modified for this situation.

Methods

Fifteen selective LCCA stenosis patients were treated by the modified ‘no touch’ technique in the antegrade endovascular approach from March 2013 to March 2016. Thirteen underwent the transfemoral approach and the other two had the transbrachial approach due to a ‘bovine aortic arch’. Distal embolic protection devices were used in all cases. Follow-up included a neurological examination, carotid duplex scan, and office interview. Mean follow-up time was 18.2±11.5 months.

Results

The initial technical success rate was 100%. The average procedure time was 84.0±16.3 min. There were no procedure-related deaths. No clinical neurological complications occurred during the in-hospital stay. No incidence of death or major stroke occurred during the follow-up period; 6.7% (1/15) of patients had a contralateral minor stroke, 66.7% (4/6) of symptomatic patients were relieved of initial symptoms, and the rest showed improvement. No patient developed new ipsilateral neurological symptoms and no in-stent restenosis occurred during the follow-up period. These results were confirmed by ultrasound.

Conclusions

The modified ‘no touch’ antegrade endovascular technique is a feasible method for treating LCCA ostial lesions with a satisfactory initial success rate, acceptable procedure time, and comparable mid- and long-term results. This technique could be considered as a complementary option for LCCA ostial stenosis in addition to open surgery and the retrograde endovascular approach.

[Endovascular treatment of intra-thoracic left subclavian artery aneurysm]

Aneurysms of the subclavian artery are rare, and remain asymptomatic until complications. We report one case of atherosclerotic aneurysm of the proximal portion of the left subclavian artery fortuitously discovered and successfully treated by endovascular stent graft. This case report aims to illustrate endovascular procedures in the management of difficult access lesions or in high-risk surgical patients.