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Norman AV, Smolkin ME, Farivar BS, Tracci MC, Weaver ML, Kern JA, Ratcliffe SJ, Clouse WD. Current Transthoracic Supra-Aortic Trunk Surgical Reconstruction Has Similar 30-Day Cardiovascular Outcomes Compared to Extra-Anatomic Revascularization but With Higher Morbidity Burden. Ann Vasc Surg 2024; 100:155-164. [PMID: 37852366 DOI: 10.1016/j.avsg.2023.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 10/20/2023]
Abstract
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.
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Affiliation(s)
- Anthony V Norman
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - Mark E Smolkin
- Division of Biostatistics, Department of Public Health Sciences, Old Med School, University of Virginia, Charlottesville, VA
| | - Behzad S Farivar
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - Margaret C Tracci
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - M Libby Weaver
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - John A Kern
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - Sarah J Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, Old Med School, University of Virginia, Charlottesville, VA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA.
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Chen DW, Gao YH, Shi J, Yin YW, Zhang WQ. Significance of hemodynamic assessment by pressure wire for endovascular therapy of subclavian steal syndrome. Interv Neuroradiol 2020; 26:321-328. [PMID: 31969074 DOI: 10.1177/1591019919897765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Subclavian steal syndrome results from hemodynamic impairment due to stenosis or occlusion of subclavian artery. Therefore, it is important for subclavian steal syndrome patients to assess hemodynamic status during endovascular therapy. METHODS Eleven subclavian steal syndrome patients undergoing endovascular therapy attended this study. Pressure wire was used to measure trans-stenosis pressure difference (ΔP). Digital subtraction angiography, Transcranial Doppler and Electronic sphygmomanometer were introduced to assess stenotic rate, steal grade and inter-arm systolic pressure difference, respectively. Clinical symptoms and restenosis were followed up after endovascular therapy. The associations of ΔP with stenotic rate, inter-arm pressure difference, steal degree, clinic symptoms and restenosis were analyzed in this paper. RESULTS Prior to the therapy, ΔP moderately correlated with stenotic rate (r = 0.757, p = 0.007) and inter-arm pressure difference (r = 0.701, p = 0.016). ΔP was ≥6 mmHg in all patients, and 6-9 mmHg for grade 1 steal and ≥10 mmHg for grade 2 and 3 steals. After the therapy, all patients had technique success, and 10 patients had clinic success, and 1 patient appeared restenosis. ΔP was ≤3 mmHg and steal disappeared in the patients with clinical success. ΔP was 18 mmHg and grade 3 steal still existed in one patient without clinical success. One patient with 1 mmHg of ΔP after therapy appeared restenosis in the follow-up. CONCLUSION The trans-stenosis pressure difference is closely related to steal degree and clinical symptoms. The measurement of hemodynamic status by pressure wire is very useful to guide endovascular therapy in subclavian steal syndrome patients. However, the restenosis may still occur, even though the hemodynamic impairment is improved.
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Affiliation(s)
- Da-Wei Chen
- Department of Neurology, Air Force Medical Center, PLA (People's Liberation Army), Beijing, China
| | - Yu-Hai Gao
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Jin Shi
- Department of Neurology, Air Force Medical Center, PLA (People's Liberation Army), Beijing, China
| | - Yan-Wei Yin
- Department of Neurology, Air Force Medical Center, PLA (People's Liberation Army), Beijing, China
| | - Wei-Qing Zhang
- Department of Neurology, Air Force Medical Center, PLA (People's Liberation Army), Beijing, China
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Bouziane Z, Malikov S, Bracard S, Fouilhé L, Berger L, Settembre N. Endovascular Treatment of Aortic Arch Vessel Stent Migration: Three Case Reports. Ann Vasc Surg 2019; 59:313.e11-313.e17. [DOI: 10.1016/j.avsg.2019.01.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/16/2019] [Accepted: 01/19/2019] [Indexed: 11/25/2022]
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Usai MV, Bosiers MJ, Bisdas T, Torsello G, Beropoulis E, Kasprzak B, Stachmann A, Stavroulakis K. Surgical versus endovascular revascularization of subclavian artery arteriosclerotic disease. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 61:53-59. [PMID: 29786405 DOI: 10.23736/s0021-9509.18.10144-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Endovascular treatment offers an alternative, less invasive approach to open repair for subclavian artery atherosclerotic disease (SAAD). However, only few studies compared the outcomes of both strategies in the long run. This study reports on the performance of endovascular and surgical revascularization for SAAD. METHODS A retrospective review was conducted on patients treated for SAAD at two institutions between January 1998 and December 2015. Primary outcome of this study was the composite endpoint of reintervention-free survival (RFS) defined as time to reintervention and/or death from any cause. Secondary endpoints included primary patency (PPR) and secondary patency (SPR) rates as well as overall survival and time to reintervention. RESULTS Surgical treatment was the preferred treatment option in 27 (25%) patients, while 83 (75%) patients underwent primary stent therapy. The median follow-up was 87 months (interquartile range [IQR]: 38 to 151) in the surgical group and 27 (IQR: 12 to 59) in the endovascular (P=0.0001). Severe arterial wall calcification was more commonly observed in the surgical arm (P<0.0001), while mild and moderate calcification in the endovascular (P=0.0004 and P=0.014). Vessel occlusion was more frequent among patients treated surgically (100% vs. 34%, P<0.0001). At 98 months RFS was significantly higher after surgical treatment (95% vs. 54%, HR: 8.4, 95% CI: 3.9 to 18.1, P=0.0002). Although overall survival did not differ significantly between the two groups (HR: 4.28, 95% CI: 0.86 to 21.22, P=0.093), open repair was associated with reduced reintervention rate (HR: 12.04, 95% CI: 4.98 to 29.12, P=0.001). The PPR at 98 months following surgical and endovascular therapy amounted to 96% and 65% (HR: 12.87, 95% CI: 5.44 to 30.44, P=0.0008) respectively. No significant difference was observed regarding the SPR between the two groups (100% vs. 95%, P=0.090). CONCLUSIONS Surgical treatment was associated in this cohort with increased patency and a significant reduction of reinterventions compared to the endovascular approach.
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Affiliation(s)
- Marco V Usai
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany - .,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany -
| | - Michel J Bosiers
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
| | - Theodosios Bisdas
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
| | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
| | - Efthymis Beropoulis
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
| | - Bernd Kasprzak
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
| | - Arne Stachmann
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
| | - Konstantinos Stavroulakis
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
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Zhang JL, Tong W, Lv JF, Chi LX. Endovascular treatment and morphology typing of chronic ostial occlusion of the subclavian artery. Exp Ther Med 2017; 13:2022-2028. [PMID: 28565803 DOI: 10.3892/etm.2017.4203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 01/13/2017] [Indexed: 12/14/2022] Open
Abstract
Chronic obstructive lesions of the subclavian artery (SCA) often result in subclavian steal syndrome, which leads to arm claudication, transient cerebral ischemia, and other serious complications. The lesions are classified as stenosis and occlusion, according to the degree of obstruction. Unlike totally occlusive lesions, including ostial occlusions, stenotic lesions have an excellent technical success rate. In the present study, ostial occlusions were classified into 4 types according to their angiographic appearance. A total of 8 patients (6 male, 2 female) with SCA occlusions were treated with percutaneous transluminal angioplasty and stenting over a 4-year period. Mean patient age was 65.6 years (range, 60-72 years). In total, 9 self-expanding and 1 balloon-expandable stent were implanted at the ostia of the SCA in 7 of the patients. One female patient did not undergo stenting. Bleeding at the access site was noted in 2 patients and was controlled by gauze pressure. The patient that did not undergo stenting was lost to follow-up with symptoms of a transient ischemic attack at 3 months. The mean follow-up time for the remaining 7 patients was 15.7 months (range, 1-36 months). No ischemic symptoms, neointimal hyperplasia, or restenosis was observed in these patients. The transfemoral artery operation approach is preferred for rat-tail and peak type occlusions, whereas the dual approach involving both femoral and radial arteries is preferred for hilly and plain type occlusions. The angiographic morphology typing used in the present study may serve as a reference to decide upon the interventional operation strategy to be used for improving the technical success rate.
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Affiliation(s)
- Jing-Liang Zhang
- Department of Aerospace Medicine, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China.,Department of Cardiology, Southwest Hospital, The Third Military Medical University, Chongqing 400038, P.R. China
| | - Wei Tong
- Department of Cardiology, Chinese PLA General Hospital, Beijing 100853, P.R. China
| | - Jian-Feng Lv
- Department of Cardiology, Southwest Hospital, The Third Military Medical University, Chongqing 400038, P.R. China
| | - Lu-Xiang Chi
- Department of Cardiology, Southwest Hospital, The Third Military Medical University, Chongqing 400038, P.R. China
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Kargiotis O, Siahos S, Safouris A, Feleskouras A, Magoufis G, Tsivgoulis G. Subclavian Steal Syndrome with or without Arterial Stenosis: A Review. J Neuroimaging 2016; 26:473-80. [DOI: 10.1111/jon.12371] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 05/07/2016] [Indexed: 12/13/2022] Open
Affiliation(s)
- Odysseas Kargiotis
- Department of Neurology; Olympion General Clinic; Volou & Meilichou, Kato Sichena 26443 Patra Greece
- Stroke Unit; Metropolitan Hospital; Ethnarchou Makariou 9 & Elefth. Venizelou 1 18547 Piraeus Greece
| | - Simos Siahos
- Department of Cardiology; Olympion General Clinic; Volou & Meilichou, Kato Sichena 26443 Patra Greece
| | - Apostolos Safouris
- Stroke Unit; Metropolitan Hospital; Ethnarchou Makariou 9 & Elefth. Venizelou 1 18547 Piraeus Greece
- Stroke Unit, Department of Neurology; Brugmann University Hospital; Place Van Gehuchten 4 1020 Bruxelles Belgium
| | - Agisilaos Feleskouras
- Dialysis Unit; Olympion General Clinic; Volou & Meilichou, Kato Sichena 26443 Patra Greece
| | - Georgios Magoufis
- Stroke Unit; Metropolitan Hospital; Ethnarchou Makariou 9 & Elefth. Venizelou 1 18547 Piraeus Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” Hospital, School of Medicine; University of Athens; Athens Greece
- Department of Neurology; The University of Tennessee Health Science Center; Memphis TN
- International Clinical Research Center, Department of Neurology; St. Anne's University Hospital in Brno; Brno Czech Republic
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T. Borne R, Aghel A, C. Patel A, K. Rogers R. Innominate Steal Syndrome: A Two Patient Case Report and Review. AIMS MEDICAL SCIENCE 2015. [DOI: 10.3934/medsci.2015.4.360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Kedev S, Jovkovski A, Zafirovska B. Bilateral trans-radial approach in stenting of occluded right axillary artery. J Cardiothorac Surg 2014; 9:138. [PMID: 25149874 PMCID: PMC4164749 DOI: 10.1186/s13019-014-0138-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 07/18/2014] [Indexed: 12/04/2022] Open
Abstract
With recent advancement in percutaneous endovascular interventions, angioplasty and stenting of axillary artery lesions could become the treatment of choice vs. surgical intervention owing to its lower complication and mortality rates and shorter hospital stay. We report a Caucasian female case with axillary artery chronic total occlusion (CTO) with dual etiology (atherosclerotic and radiation induced), which was successfully managed with stent angioplasty. The strategy used was right radial retrograde approach with contralateral injections from left radial catheter. Two year follow-up revealed widely patent axillary stents.
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Affiliation(s)
- Sasko Kedev
- Interventional Cardiology Department, University Clinic of Cardiology, Medical Faculty, University of St,Cyril & Methodius, Vodnjanska 17, Skopje 1000, Macedonia.
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Contemporary comparison of supra-aortic trunk surgical reconstructions for occlusive disease. J Vasc Surg 2014; 59:1577-82, 1582.e1-2. [DOI: 10.1016/j.jvs.2013.12.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 12/06/2013] [Accepted: 12/07/2013] [Indexed: 11/15/2022]
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