Brachiocephalic reconstruction I: Operative and long-term results for complex disease

Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease

Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

Current Transthoracic Supra-Aortic Trunk Surgical Reconstruction Has Similar 30-Day Cardiovascular Outcomes Compared to Extra-Anatomic Revascularization but With Higher Morbidity Burden

BACKGROUND

Operative risk for supra-aortic trunk (SAT) surgical revascularization for occlusive disease, particularly transthoracic reconstruction (TR), remains ill-defined. This study sought to describe and compare 30-day outcomes of TR and extra-anatomic (ER) SAT surgical reconstruction for an occlusive indication across the United States over a contemporary 15-year period.

METHODS

Using the National Surgical Quality Improvement Program, TR and ER performed during 2005-2019 were identified. Procedures performed for nonocclusive indications and those concomitant with coronary or valve operations were excluded. Rates of stroke, death, myocardial infarction (MI) and these as composite outcome (S/D/M) were compared. Logistic regression with stabilized inverse probability weighting (IPW) was used to compare groups via average treatment effect (ATE) while adjusting for covariate imbalances.

RESULTS

Over the 15-year period, 166 TR and 1,900 ER patients were identified. The majority of ERs were carotid-subclavian bypass (n = 1,344; 70.7%) followed by carotid-carotid bypass (n = 261; 13.7%) and subclavian/carotid transpositions (n = 123; 6.5%). TR consisted of aorto-SAT bypass (n = 120; 72.3%) and endarterectomy (n = 46; 27.7%). The median age was 64 years for TR and 65 years in ER (P = 0.039). Those undergoing TR were more often women (69.0% vs. 56.9%; P = 0.001) and less likely to have undergone previous cardiac surgery (9.2% vs. 20.8%; P = 0.006). TR were also less frequently hypertensive (68.1% vs. 75.4%; P = 0.038) and had statistically lower preoperative creatinine levels (0.86 vs 0.91; P = 0.002). Unadjusted rates of MI (0.6% vs. 1.3%; P = 0.72) and stroke (3.6% vs. 1.9%; P = 0.15) were similar between groups with mortality (3.6% vs. 1.5%; P = 0.05) and S/D/M (6.6% vs. 3.9%; P = 0.10) trending higher with TR. IPWs could be calculated for 1,754 patients (148 TR; 1,606 ER). The estimated probability of S/D/M was 3.8% in the ER group and 6.2% in TR; no difference was seen in ATE (2.4%; 95% confidence interval [CI]: -1.5 to 6.2; P = 0.23). No differences were seen in individual component ATEs (stroke: 3.0% vs. 1.7%; ATE = 1.3%; 95% CI: -3.9 to 1.3; P = 0.32; mortality: 3.8% vs. 1.4%; ATE = 2.4%; 95% CI: -5.6 to 0.7; P = 0.13). Secondary outcomes showed TR patients were more likely to have non-home discharge (18.7% vs. 6.6%; ATE = 12.1%; 95% CI: 5.0-19.2; P < 0.001) and longer lengths of stay (6.1 vs. 4.0; ATE = 2.2 days; 95% CI: 0.9-3.4; P < 0.001). Moreover, TR patients were more likely to require transfusion (22.7% vs. 5.0%; ATE = 17.7%; 95% CI: 10.2-25.2; P < 0.001) and develop sepsis (2.7% vs. 0.2%; ATE = 2.5%; 95% CI: 0.1-5.0; P = 0.04).

CONCLUSIONS

Transthoracic and extra-anatomic surgical reconstruction of the SATs for occlusive disease have similar operative cardiovascular risk. However, morbidity tends to be higher with TR due to higher transfusion requirements, sepsis risk, and need for facility stay. These results suggest ER as a first-line approach in those with proper disease anatomy is reasonable with lower morbidity, while TR remains justified in appropriate patients.

[The value of revascularisation of atherosclerotic lesions of the innominate artery at the asymptomatic stage of the disease]

OBJECTIVE

To analyze the natural course of asymptomatic atherosclerotic lesions of the innominate artery and to study the long-term results of surgical interventions performed at the asymptomatic stage and to compare them with similar results at the symptomatic stage of the disease.

MATERIAL AND METHODS

The analysis of the natural course of the disease was performed in 74 asymptomatic patients who were divided into 3 groups depending on the initial degree of severity of the stenosis of the innominate artery: insignificant stenoses (less than 50%), moderate stenoses (50-69%) and haemodynamically significant lesions (70% and more). The analysis of the long-term results of surgical treatment was performed in 62 patients, in 29 of whom intrathoracic reconstructions were performed at the asymptomatic stage of the disease, in 33 - at the symptomatic stage.

RESULTS

Cumulative freedom from stroke by the 10th year of follow-up was significantly higher in patients with insignificant stenoses and amounted to 100% in the groups of moderate stenoses and hemodynamically significant lesions - 25% and 0, respectively (log-rank p=0.000). Neurological fatality in patients with hemodynamically significant (initial or developed) lesions was 26.3%, while in patients with hemodynamically insignificant lesions it was 0 (log-rank p=0.004), which is confirmed by cumulative indices (log-rank p=0.008). Asymptomatic innominate artery reconstructions were associated with a lower incidence of stroke: the long-term incidence of stroke in such patients was 3.4%, while in initially symptomatic patients it was 18.2% (p=0.038). Initial degree II or IV cerebrovascular insufficiency was a predictor of stroke in the long-term period (OR=1.71; p=0.000). The cumulative freedom from stroke in asymptomatic patients by the 20th year of follow-up was 95% compared with 74% in symptomatic patients (log-rank p=0.032).

CONCLUSION

Surgical interventions in asymptomatic hemodynamically significant lesions of the innominate artery should be performed to prevent primary cerebral circulatory disorders.

Simultaneous treatment of common carotid lesions increases the risk of stroke and death after carotid artery stenting

BACKGROUND

Tandem carotid artery lesions that involve simultaneous internal carotid artery (ICA) and common carotid artery (CCA) stenoses present a complex clinical problem. Some studies have shown that the addition of a retrograde proximal intervention to treat a CCA lesion during a carotid endarterectomy (CEA) increases the risk of stroke and death. However, the stroke and death risks associated with a totally endovascular approach to tandem lesions is unknown and is the subject of this study.

METHODS

Vascular Study Group of New England data for the years 2005 to 2020 were queried for carotid artery stenting (CAS) procedures. Emergent and bilateral procedures, procedures for indications other than atherosclerosis, patients with prior ipsilateral CAS, ICA lesions with stenosis of less than 50%, and transcarotid procedures were excluded. The cohort was divided into tandem and isolated lesion groups. The primary outcome was the composite of stroke and death. Predictors of stroke or death were determined with multivariable logistic regression.

RESULTS

There were 2016 carotid arteries stented in 1950 patients-1881 (96%) with isolated lesions and 135 (4%) with tandem lesions. The mean patient age was 69.6 ± 9.0 years. Tandem lesions were more likely to be present in women (50.4% vs 33.0%; P < .001) and in patients with a prior carotid endarterectomy (45.9% vs 35.4%; P = .014). Other covariates were similar between the groups. Symptomatic lesions accounted for 42.3% of cases (isolated, 42.2% vs tandem, 43.0%; P = .86). Arteries in the tandem group more often required multiple stents to treat the ICA lesion (9.6% vs 5.2%; P = .027). ICA neuroprotection had similar outcomes in both groups (tandem: success 94.1%, failure 3.7%; isolated: success 96.3%, failure 1.8%; P = .29). The tandem group experienced a higher 30-day mortality (2.2% vs 0.6%; P = .039), more perioperative neurologic events (stroke or transient ischemic attack) (8.1% vs 2.0%; P < .001), and a higher incidence of stroke or death (5.9% vs 1.9%; P = .002). Predictors of the primary outcome in the multivariable model included treatment of tandem lesions (odds ratio [OR], 3.10; 95% confidence interval [CI], 1.39-6.89; P = .006), symptomatic lesions (OR, 2.24; 95% CI, 1.21-4.17; P = .010), chronic obstructive pulmonary disease (OR, 2.14; 95% CI, 1.17-3.92; P = .014), general anesthesia (OR, 3.34; 95% CI, 1.35-8.26; P = .009), and advancing age (OR, 1.05 per year; 95% CI, 1.01-1.09; P = .006).

CONCLUSIONS

The addition of endovascular treatment of tandem CCA lesions with CAS is associated with a three-fold increase in perioperative stroke and death and should be avoided if possible.

Adding Supra-Aortic Trunk Surgical Reconstruction to Carotid Endarterectomy: Implications on Risk of Stroke and Death

BACKGROUND

Additive risks of combining supra-aortic trunk surgical reconstruction (SAT) with carotid endarterectomy (CEA) for associated carotid bifurcation and great vessel disease management are not well defined. This study sought to define risk of combining SAT with CEA.

STUDY DESIGN

Isolated CEA (ICEA) and CEA+SAT (from 2005 to 2015) were identified from NSQIP, excluding nonocclusive indications. CEA+SAT were compared with ICEA as well as a propensity-matched ICEA cohort. Primary outcomes included 30-day stroke, death, and composite (SD). Outcomes were then weighted by symptomatic status. Univariate and logistic regression analyses were performed.

RESULTS

Patients included 79,477 ICEA and 270 CEA+SAT. SAT reconstructions included 19 (7%) aorto-carotid bypasses, 21 (8%) carotid-subclavian transpositions, 85 (31%) carotid-carotid bypasses, and 145 (54%) carotid-subclavian bypasses. There was no difference in 30-day mortality (vs CEA+SAT 1.5% vs ICEA 0.7% p = 0.12). CEA+SAT had higher rates of stroke (3.7% vs 1.6%, p = 0.005) and stroke and death (SD) (4.8% vs 2.1%, p = 0.001). Predictors of SD included CEA+SAT (odds ratio [OR] 5.2, 95% CI 1.03-26.3, p = 0.046) and symptomatic status (OR 1.9, 95% CI 1.1-3.2, p = 0.02). After propensity matching, CEA+SAT continued to have higher rates of stroke (3.4% vs 0.4%, p = 0.01) and SD (4.5% vs 1.5%, p = 0.04), with similar mortality (1.5% vs 1.1%, p = 0.70). No differences were noted in primary endpoints in asymptomatic patients. In symptomatic patients, CEA+SAT carried significantly higher stroke (5.6% vs 2.1%, p = 0.04) and SD risk (7.0% vs 2.8%, p = 0.03).

CONCLUSIONS

CEA+SAT confers increased risk of stroke and SD over ICEA. Symptomatic status and concomitant procedure contribute to this risk. Management should be considered within the context of lesion characteristics, patient longevity, and individual operative risk profile.

Middle and Distal Common Carotid Artery Stenting: Long-Term Patency Rates and Risk Factors for In-Stent Restenosis

PURPOSE

In the absence of literature data, we aimed to determine the long-term patency rates of middle/distal common carotid artery (CCA) stenting and to investigate predisposing factors in the development of in-stent restenosis (ISR).

MATERIALS AND METHODS

Fifty-one patients (30 males, median age 63.5 years), who underwent stenting with 51 self-expandable stents for significant (≥ 60%) stenosis of the middle/distal CCA, were analyzed retrospectively. Patient (atherosclerotic risk factors, comorbidities, medications), vessel (elongation), lesion (stenosis grade, length, calcification, location), and stent characteristics (material, diameter, length, fracture) were examined. Duplex ultrasonography was used to monitor stent patency. The Mann-Whitney U and Fisher's exact tests, Kaplan-Meier analyses, and a log-rank test were used statistically.

RESULTS

The median follow-up time was 35 months (interquartile range, 20-102 months). Significant (≥ 70%) ISR developed in 14 patients (27.5%; stenosis, N = 10; entire CCA occlusion, N = 4). Primary patency rates were 98%, 92%, 83%, 73%, and 61% at 6, 12, 24, 60, and 96 months, respectively. Reintervention was performed in six patients (11.8%) with nonocclusive ISR. Secondary patency rates were 100% at 6 and 12 months and 96% at 24, 60, and 96 months. In-stent restenosis developed more frequently (P < .001) in patients with hyperlipidemia; primary patency rates were also significantly worse (Chi-square, 11.08; degrees of freedom, 1; P < .001) in patients with hyperlipidemia compared to those without.

CONCLUSION

Stenting of the middle/distal CCA can be performed with acceptable patency rates. If intervention is unequivocally needed, patients with hyperlipidemia will require closer follow-up care.

LEVEL OF EVIDENCE

Level 3, Local non-random sample.

Impact of Adding Carotid Endarterectomy to Supra-aortic Trunk Surgical Reconstruction

BACKGROUND

Up to 20% of patients requiring open supra-aortic trunk (SAT) reconstruction have significant carotid artery stenosis. The addition of carotid endarterectomy (CEA) to SAT has been described. Yet, additive risks are not well defined and controversy remains as to whether concomitant CEA increases stroke risk. This study assessed the perioperative effects of adding CEA to SAT.

METHODS

Using the National Surgical Quality Improvement Program (NSQIP), patients who underwent SAT from 2005 to 2015 were evaluated. SAT + CEA were identified. An isolated SAT (ISAT) cohort was created by removing patients who underwent concurrent secondary procedures. Nonocclusive indications were excluded. SAT + CEA were compared with ISAT as well as a propensity-matched ISAT cohort. Primary outcomes were 30-day stroke, death, and composite stroke/death/myocardial infarction (SDM). Univariate and logistic regression analyses were performed.

RESULTS

After review, 1,515 patients were identified: 1,245 ISAT (82%) and 270 SAT + CEA (18%). Most were women (56%), 86% were Caucasian, and 24% were symptomatic. Average age was 65 ± 12 years and SAT + CEA were older (69 vs. 64 years, P < 0.001). CEA + SAT were more likely to be men (53% vs. 42%, P < 0.001), have hypertension (86% vs. 75%, P < 0.001) and diabetes (26% vs. 20%, P = 0.04). SAT procedures included the following: carotid-subclavian bypass (68%), carotid-carotid bypass (16%), aorta-great vessel bypass (9%), and carotid-subclavian transposition (7%). ISAT were more likely to undergo carotid-subclavian bypass than SAT + CEA (71% vs. 54%, P < 0.001). Overall stroke was 2.3%, death 1.4%, and SDM 4.6%. There were no differences in 30-day stroke (ISAT 2.0% vs. SAT + CEA 3.7%, P = 0.09) or mortality (1.4% vs. 1.5%, P = 0.88). SAT + CEA had higher rates of SDM (7% vs. 4%, P = 0.03). On logistic regression, urgency was a predictor of SDM (operating room [OR] 3.6, 95% confidence interval [CI] 1.5-8.4, P = 0.003); addition of CEA was not predictive of stroke (OR 1.4, 95% CI 0.5-4.2, P = 0.52) or SDM (OR 1.5, 95% CI 0.6-3.6, P = 0.40). After propensity matching, there were no longer differences in demographics or primary end points between the 2 cohorts.

CONCLUSIONS

Addition of CEA does not confer increased perioperative stroke or SDM risk over ISAT. Perioperative outcomes appear to be more affected by disseminated disease risk factors than the addition of CEA. In patients undergoing SAT, it is reasonable to consider performing combined CEA in populations with tandem carotid bifurcation disease and appropriate operative risk profile.

Outcomes of Innominate Artery Revascularization Through Endovascular, Hybrid, or Open Approach

BACKGROUND

Atherosclerotic disease of the innominate artery (IA) is rare and can lead to cerebral, upper extremity, and vertebral steal symptoms. Nonocclusive lesions can be treated with endovascular interventions, often with a hybrid approach while performing a right carotid endarterectomy (RCEA). Calcified IA lesions have a high risk of embolization to bilateral cerebral hemispheres. Occlusive lesions may require treatment through a median sternotomy and bypass. The purpose of our study is to review our short-term and long-term outcomes of IA revascularization.

METHODS

Our operative database was used to identify patients who underwent IA revascularization between January 1998 and December 2018. Patients who underwent innominate artery stenting (IAS), combined with RCEA and IAS as well as aortoinnominate bypass (AIB), were identified. Our primary end points were freedom from neurologic event, all-cause mortality, and need for reintervention.

RESULTS

Thirty-three patients (18 females [55%]) who underwent IA revascularization were identified. Average age was 67 ± 8 years, and mean clinical follow-up was 51 ± 21 months. Most patients (30 [91%]) were on a statin and antiplatelet therapy. Twenty-one patients (64%) were symptomatic. Twelve patients (36%) were asymptomatic and underwent combined RCEA with retrograde IAS for critical right carotid stenosis and IA stenosis. Preoperative imaging included a carotid duplex and computed tomography angiography. Eighteen patients (55%) underwent RCEA + IAS, 11 patients (33%) underwent isolated IAS, and 4 patients (12%) underwent AIB. In our attempt to protect bilateral hemispheres during IAS for heavily calcified lesions, we used right common carotid artery (CCA) clamping although open exposure and left CCA embolic protection filter was placed through transfemoral approach. Patients who underwent AIB had chronic heavily calcified IA occlusions or occluded IA stents with failed endovascular interventions. Perioperative stroke rate was 3%, involving 1 patient who developed reperfusion syndrome after RCEA + IAS. Perioperative mortality was 0%. Long-term stroke rate was 0%, and long-term mortality was 15% (5 of 33) because of cardiac disease. Overall restenosis rate was 9%, involving 3 patients who required secondary interventions for IA in-stent restenosis.

CONCLUSIONS

IA interventions through a hybrid approach or an open approach are safe, with acceptable perioperative stroke and mortality rates. Long-term patency of these interventions is acceptable. Bilateral cerebral embolic protection can be accomplished by clamping the right CCA through an open exposure and placing a filter in the left CCA through a transfemoral approach. Patients undergoing IAS appear to have a higher rate of restenosis compared with AIB, and therefore, close follow-up with noninvasive imaging is recommended.

Coronary Subclavian Steal Syndrome: An Unusual Cause of Angina in a Post-CABG Patient

Coronary subclavian steal syndrome is a rare complication of coronary artery bypass grafting surgery (CABG) when a left internal mammary artery (LIMA) graft is utilized. This syndrome is characterized by retrograde flow from the LIMA to the left subclavian artery (SA) when a proximal left SA stenosis is present. We describe a unique case of an elderly male who underwent CABG 6 years ago who presented with prolonged chest pain, mildly elevated troponins, and unequal pulses in his arms. A CTA of the chest demonstrated a severely calcified occluded proximal left SA jeopardizing his LIMA graft. Subclavian angiography was performed with an attempt to revascularize the patient's occluded left SA which was unsuccessful. We referred the patient for nuclear stress testing which demonstrated a moderate size area of anterior ischemia on imaging; the patient exercised to a fair exercise capacity of 7 METS with no chest pain and no ECG changes. Subsequent coronary angiography showed severe native three-vessel coronary artery disease with intermittent retrograde blood flow from the LIMA to the left SA distal to the occlusion, jeopardizing perfusion to the left anterior descending (LAD) coronary artery distribution. He declined further options for revascularization and was discharged with medical management.

Unusual suspect-coronary subclavian steal syndrome caused severe myocardial ischemia

Coronary-subclavian steal syndrome represents a reversal of blood flow in left internal mammary artery. The most common cause of the syndrome is atherosclerotic disease in the ipsilateral, proximal subclavian artery. We present a case of 72 years old male, who developed severe anginal and neurological complaints three years after coronary artery bypass graft surgery(CABG).

Subclavian revascularization in the age of thoracic endovascular aortic repair and comparison of outcomes in patients with occlusive disease

OBJECTIVE

Open surgical revascularization for subclavian artery occlusive disease (OD) has largely been supplanted by endovascular treatment despite the excellent long-term patency of bypass. The indications for carotid-subclavian bypass (C-SBP) and subclavian transposition (ST) have been recently expanded with the widespread application of thoracic endovascular aortic repair (TEVAR), primarily to augment proximal landing zones or treat endovascular failures. This study was performed to determine the outcomes of patients undergoing C-SBP/ST in the context of contemporary endovascular therapies and evolving indications.

METHODS

A prospective database including all procedures performed at a single institution from 2002 to 2012 was retrospectively queried for patients who underwent subclavian revascularization for TEVAR or OD indications. Patient demographics and perioperative outcomes were recorded. Patency was determined by computed tomography angiography in the TEVAR group. Noninvasive studies were used for the OD patients. Life-table methods were used to estimate patency, reintervention, and survival.

RESULTS

Of 139 procedures identified, 101 were performed for TEVAR and 38 for OD. All TEVAR patients underwent C-SBP/ST to augment landing zones (49% preoperative; 41% intraoperative), treat arm ischemia (8% postoperative), or for internal mammary artery salvage (2%). OD patients had a variety of indications, including failed stent/arm fatigue, 49%; asymptomatic >80% internal carotid stenosis with concurrent subclavian occlusion, 18%; symptomatic cerebrovascular OD, 13%; redo bypass, 8%; and coronary-subclavian steal, 5%. Differences in postoperative stroke and death, primary patency, or freedom from reintervention were not significant. The 30-day postoperative stroke, death, and combined stroke/death rates were, respectively, 10.8%, 5.8%, and 13.7% for the entire cohort; 8.9%, 7.1%, and 12.9% in TEVAR patients; and 15.8%, 2.6%, and 15.8% in OD patients. The 1- and 3-year primary patencies were, respectively, 94% and 94% for TEVAR and 93% and 73% for OD patients. Survival was similar between the groups, with an estimated survival rate of 88% at 1 year and 76% at 5 years.

CONCLUSIONS

Stroke risk in this contemporary series of C-SBP/ST performed for TEVAR and OD indications may be higher than previously reported in historical series. In TEVAR patients, this may be attributed to procedural complexity of the TEVAR in patients requiring subclavian revascularization. In OD patients, this is likely due to the changing patient population that requires more frequent concomitant carotid interventions. Despite the short-term morbidity, excellent bypass durability and equivalent long-term patient survival can be anticipated.

Endovascular Management of Aortic Arch Vessel Occlusion

A 56-year-old female presented with pain in her bilateral upper extremities. Angiogram demonstrated occlusion of her left subclavian and innominate arteries (IAs). The patient’s left subclavian occlusion was successfully treated with percutaneous mechanical thrombectomy, angioplasty, and stenting. One month later, endovascular revascularization of the IA was performed. Initially the lesion could not be directly transversed from neither an antegrade nor a retrograde approach. Wires were passed from the brachial and femoral arteries into the right common carotid artery where the femoral wire was snared and brought out through the right brachial access. Over this through-and-through wire access, angioplasty and stenting of the IA was performed with an excellent angiographic result. In follow-up, the patient remained free of upper extremity symptoms. Occlusive lesions of the aortic arch vessels can be successfully managed with antegrade and retrograde endovascular techniques.

Combined surgical and endovascular approach to treat symptomatic in-stent occlusion of the left common carotid artery origin

Symptomatic occlusive lesions at the origins of the supra-aortic vessels pose challenges for treatment. Endovascular angioplasty and stent placement via the transfemoral approach is possible, but obtaining a stable position for the guide catheter via this approach is technically difficult. The authors describe the case of a 56-year-old man presenting with symptomatic occlusion of a previously placed stent at the origin of the left common carotid artery (CCA). An endovascular revascularization of the left CCA was planned. However, the absence of a lumen proximal to the stent prevented stable placement of a guide catheter via the transfemoral route. Consequently, the authors used a combined surgical and endovascular approach to gain access to the lesion. The left CCA was exposed surgically distal to the occlusion and clamped just proximal to its bifurcation to preserve flow from the external to the internal carotid artery (ICA) and to prevent embolism into the ICA. A wire was passed retrograde through the occlusive lesion and then was subsequently advanced proximally into the femoral sheath. This allowed transfemoral advancement of the appropriate endovascular devices to perform an angioplasty and placement of a stent. The patient remained neurologically stable, and postoperative studies showed improvement in cerebral perfusion. This case demonstrates the feasibility of distal-to-proximal stent delivery with a combined endovascular and surgical approach.

Endovascular treatment of aortic arch aneurysms

BACKGROUND: Endovascular approach to the aortic arch is an appealing solution for selected patients. OBJECTIVE: To compare the technical and clinical success recorded in the different anatomical settings of endografting for aortic arch disease. METHODS: Between June 1999 and October 2006, among 178 patients treated at our institution for thoracic aorta disease with a stent-graft, the aortic arch was involved in 64 cases. According to the classification proposed by Ishimaru, aortic zone 0 was involved in 14 cases, zone 1 in 12 cases and zone 2 in 38 cases. A hybrid surgical procedure of supra-aortic debranching and revascularization was performed in 37 cases. RESULTS: Zone 0. Proximal neck length: 44±6 mm. Initial clinical success was 78.6%: two deaths (stroke), one type Ia endoleak. At a mean follow-up of 16.4±11 months the midterm clinical success was 85.7%. Zone 1. Proximal neck length: 28±5 mm. Initial clinical success was 66.7%: 0 deaths, four type Ia endoleaks. At a mean follow-up of 16.9±17.2 months the midterm clinical success was 75.0%. Zone 2. Proximal neck length: 30±5 mm. Initial clinical success was 84.2%: two deaths (one cardiac arrest, one multiorgan embolization), three type Ia endoleaks, one case of open conversion. Two cases of delayed transitory paraparesis/paraplegia were observed. At a mean follow-up of 28.0±17.2 months the midterm clinical success was 89.5%. CONCLUSIONS: This study and a literature review demonstrated that hybrid procedure for aortic arch pathology is feasible in selected patients at high risk for conventional surgery. Our experience is still limited by the relatively small sample size. We propose to reserve zone 1 for patients unfit for sternotomy or in cases with aortic neck length > 30 mm following left common carotid artery debranching. We recommend to perform complete aortic rerouting of the aortic arch in cases with lesser comorbidities and shorter aortic neck.

Innominate artery aneurysm: axial reconstruction via a cervical approach

True aneurysms of the innominate artery are rare. Successful axial reconstruction in the past has required a combined cervical and transthoracic approach with placement of a prosthetic graft. We describe herein the occurrence of an innominate artery aneurysm that extended to and involved the proximal common carotid artery and subclavian artery in a 63-year-old woman. The patient presented with thomboembolic sequelae in her fingertips and had a pulseless upper extremity. Successful aneurysmectomy and axial reconstruction with a bifurcated graft was achieved by using cervical exposure alone. A subsequent staged revascularization of the upper extremity was successfully accomplished with a brachial to radial artery bypass and ulnar artery transposition.

Long term outcome for extra-anatomic arch reconstruction. An analysis of 143 procedures

PURPOSE

With the FDA approval of thoracic endografts, extra-anatomic reconstruction of the aortic arch has allowed for more suitable proximal landing zones and increased applicability of thoracic endovascular procedures. We evaluated our short term and long term results of extra-anatomic reconstruction of the carotid and subclavian vessels.

METHODS

One hundred and forty three (143) procedures were performed for extra-anatomic carotid and subclavian reconstruction. Of these 143 operations: 85 were carotid subclavian reconstructions, 22 were carotid crossover bypasses, 30 were subclavian carotid reconstructions and 6 were carotid subclavian transpositions. Sixty (42%) were male, 20 (14%) were diabetic, and 63 (44%) were current smokers. Mean age was 63 (SD +/- 12.3). Indication for surgery was primarily for occlusive or embolic disease (97%). In those patients undergoing bypass graft, prosthetic (ePTFE) was used in 93%. Follow-up was performed at 3 and 6 month intervals by ultrasound and pulse volume recordings where indicated. Life table analyses were used to analyze patency.

RESULTS

Of the 143 reconstructions operative mortality was 1 (0.7%). Non-fatal complications included 3 (2.1%) for bleeding, 1 (0.7%) wound infection, 2 (1.4%) TIA, 1 (0.7%) suffered a non-fatal stroke, 2 (1.4%) had postoperative myocardial infarctions, and 6 (4.3%) late (>30-day) occlusions. Follow-up was 1 to 124 months (mean: 39 months). Primary patency at 1 year was 98%, 3 years 96%, and 5 years was 92%.

CONCLUSION

Extra-anatomic arch reconstruction can be performed safely and appears to be durable over long term follow-up. Its use with endovascular grafting should provide a durable reconstruction for patients who require aortic "debranching" prior endovascular thoracic aortic aneurysm repair.

Results of Endografting of the Aortic Arch in Different Landing Zones

INTRODUCTION

Endovascular approach to the aortic arch is an appealing solution for selected patients. Aim of this study is to compare the technical and clinical success recorded in the different anatomical settings of endografting for aortic arch disease.

METHODS

Between June 1999 and October 2006, among 178 patients treated at our Institution for thoracic aorta disease with a stent-graft, the aortic arch was involved in 64 cases. According to the classification proposed by Ishimaru, aortic "zone 0" was involved in 14 cases, "zone 1" in 12 cases and "zone 2" in 38 cases. A hybrid surgical procedure of supraortic debranching and revascularization was performed in 37 cases to obtain an adequate proximal aortic landing zone.

RESULTS

"Zone 0" (14 cases). Proximal neck length: 44+/-6mm. Initial clinical success 78.6%: 2 deaths (stroke), 1 type Ia endoleak. At a mean follow-up of 16.4+/-11 months the midterm clinical success was 85.7%. "Zone 1" (12 cases). Proximal neck length: 28+/-5mm. Initial clinical success 66.7%: 0 deaths, 4 type Ia endoleaks. At a mean follow-up of 16.9+/-17.2 months the midterm clinical success was 75.0%. "Zone 2" (38 cases) Proximal neck length: 30+/-5mm. Initial clinical success 84.2%: 2 deaths (1 cardiac arrest, 1 multiorgan embolization), 3 type Ia endoleaks, 1 case of open conversion. Two cases of delayed transitory paraparesis/paraplegia were observed. At a mean follow-up of 28.0+/-17.2 months the midterm clinical success was 89.5%.

CONCLUSIONS

Total debranching of the arch for "zone 0" aneurysms allowed to obtain a longer proximal aortic landing zone with lower incidence of endoleak, however a higher risk of cerebrovascular accident was observed. The relatively high incidence of adverse events in "zone 1" could be associated to a shorter proximal neck, therefore this landing zone is reserved for patients unfit for sternotomy. In case of endoleak, discovered after a satisfactorily positioned endograft in the arch, the rate of spontaneous resolution within the first 6 months is high.

Myocardial thievery: the coronary-subclavian steal syndrome

Coronary-subclavian steal syndrome entails the reversal of blood flow in a previously constructed internal mammary artery coronary conduit, which produces myocardial ischemia. The most frequent cause of the syndrome is atherosclerotic disease in the ipsilateral, proximal subclavian artery. Although coronary-subclavian steal was initially reported to be rare, the increasing documentation of this phenomenon and its potentially catastrophic consequences in recent series suggests that the incidence of the problem has been underreported and that its clinical impact has been underestimated. We review the causes and background of coronary-subclavian steal; methods of preventing, diagnosing, and treating it; and the potential influence of various treatment regimens on long-term survival and the likelihood of late adverse events in patients with coronary-subclavian steal syndrome.