Does the arterial cannulation site for circulatory arrest influence stroke risk?

BACKGROUND

We investigated whether axillary/subclavian artery inflow with a side graft decreases the risk of stroke versus cannulation at other sites during hypothermic circulatory arrest.

METHODS

Between January 1993 and May 2003, 1,352 operations with circulatory arrest were performed for complex adult cardiac problems. A single arterial inflow cannulation site was used in 1,336 operations, and these formed the basis for comparative analyses. Cannulation sites were axillary plus graft in 299 operations, direct cannulation of the aorta in 471, femoral in 375, innominate in 24, and axillary or subclavian without a side graft in 167. Retrograde brain perfusion was used in 933 (69%). A total of 272 (20%) were for emergencies, 432 (32%) were reoperations, and 439 (32%) were for dissections. A total of 617 (46%) had aortic valve replacement and 1,160 (87%) ascending, 415 arch (31%), and 248 descending (18%) aortic replacements. Indications also included arteriosclerosis (n = 301) and calcified aorta (n = 278). Primary comparisons were made by using propensity matching, and, secondarily, risk factors for stroke or hospital mortality were identified by multivariable logistic regression.

RESULTS

Stroke occurred in 6.1% of patients (81/1,336): 4.0% (12/299) of those had axillary plus graft and 6.7% who had direct cannulation (69/1,037; p = 0.09; p = 0.05 among propensity-matched pairs). Operative variables associated with stroke included direct aortic cannulation, aortic arteriosclerosis, descending aorta repair, and mitral valve replacement. The risk of hospital mortality was higher (11%; 42/375) for patients who had femoral cannulation than axillary plus graft (7.0%; 21/299; p = 0.06; p = 0.02 among propensity-matched pairs).

CONCLUSIONS

Axillary inflow plus graft reduces stroke and is our method of choice for complex cardiac and cardioaortic operations that necessitate circulatory arrest. Retrograde or antegrade perfusion is used selectively.

Aortic and extracranial large vessel giant cell arteritis: a review of 72 cases with histopathologic documentation

Giant cell arteritis (GCA) is closely identified with the temporal arteritis-polymyalgia rheumatica syndrome of the elderly. It is also a systemic disease that can cripple and kill. Up to 15% of patients with temporal arteritis may have angiographic evidence of extracranial GCA, and aortic insufficiency, ruptured aortic aneurysm, aortic dissection, stroke, or myocardial infarction may be the initial manifestation of systemic GCA. A review of 72 cases of aortic and extracranial GCA, all with histopathologic verification of the disease, revealed that 25% of patients with aortic and extracranial large-vessel GCA had asymptomatic temporal arteritis; the ascending aorta and aortic arch were most frequently involved (39%), followed by the subclavian and axillary arteries (26%), and the femoropopliteal arteries (18%). Nine patients (12.5%) underwent an upper or lower limb amputation. Of the 18 patients whose death was directly attributable to extracranial GCA the causes were ruptured aortic aneurysm (6), aortic dissection (6), stroke (3), and myocardial infarction (3). The findings of these 72 cases caution against attributing all aortic and large-vessel arterial disease in the elderly to atherosclerosis and emphasize that timely surgical intervention may be necessary for life-saving and limb-salvage in patients with aortic and extracranial GCA.

In Situ Stent-Graft Fenestration to Preserve the Left Subclavian Artery

PURPOSE

To report our first clinical application of a new technique for in situ fenestration of a thoracic stent-graft.

CASE REPORT

After completing a series of in vitro and in vivo experiments, in situ stent-graft fenestration was employed during endograft repair of a saccular thoracic aortic aneurysm in a 77-year-old woman. Because the stent-graft would have covered the left subclavian artery ostium, a modified Zenith TX1 thoracic stent-graft was deployed then fenestrated transluminally using a guidewire followed by serial cutting balloons, which created a fenestration over the LSA sufficiently large to accommodate a Jomed covered stent on an 8-mm balloon. Completion angiography showed exclusion of the aneurysm and brisk flow into the LSA. Following the procedure, the arm pressures were nearly equal. The 6-month CT scan showed no endoleak and a patent subclavian artery stent.

CONCLUSIONS

In situ graft fenestration to preserve the left subclavian artery after deliberate coverage during endovascular repair of a thoracic aortic aneurysm appears feasible in this initial clinical application. There are uncertainties regarding the long-term stability of the fabric tears that are an inherent part of this technique.

New arguments for a vasculitic nature of polymyalgia rheumatica using positron emission tomography

OBJECTIVE

To study the possible contribution of fluorodeoxyglucose (FDG)-positron emission tomography (PET) in the diagnosis of giant cell arteritis and polymyalgia rheumatica.

METHODS

A consecutive case series consisting of five patients with polymyalgia rheumatica, six patients with temporal arteritis and 23 age-matched patients with other inflammatory conditions were evaluated with FDG-PET. Studies were performed before therapy with steroids was started.

RESULTS

A total of 4/6 patients with giant cell arteritis and 4/5 patients with polymyalgia had increased FDG uptake in their thoracic vessels, compared to 1/23 controls (P < 0.001). Increased vascular FDG uptake in the upper legs was seen in 8/11 patients with giant cell arteritis or polymyalgia compared to 8/23 control patients (P < 0.05), and in the lower legs in 6/11 patients compared to 6/23 controls (P = not significant).

CONCLUSIONS

FDG-PET scan is the first non-invasive technique which may indicate large-vessel vasculitis and which can show its extension throughout the body. It strongly suggests that polymyalgia rheumatica is a form of vasculitis.

Percutaneous placement of a balloon-expandable intraluminal graft for life-threatening subclavian arterial hemorrhage

A balloon-expandable intraluminal graft was percutaneously deployed in the left subclavian artery of a 43-year-old woman. This graft was made of a stainless steel, 30-mm Palmaz balloon-expandable iliac stent completely covered with a thin coat of silicone. The procedure was successful in managing and preventing life-threatening hemorrhage as a large-bore catheter was removed from the subclavian artery via its subcutaneous tunnel. Surgical repair of the high brachial-axillary sheath insertion site was required after percutaneous deployment of the graft. However, the grafting procedure succeeded in obviating a thoracotomy. At follow-up of 6 months, despite diminution in brachial pulse volume recordings, the patient is asymptomatic at rest. She experiences mild fatigue with extremes of upper extremity exercise and declines angiographic follow-up and further intervention.

Angioplasty and primary stenting of the subclavian, innominate, and common carotid arteries in 83 patients

PURPOSE

The initial and long-term results of angioplasty and primary stenting for the treatment of occlusive lesions involving the supra-aortic trunks were studied.

METHODS

All patients in whom angioplasty and stenting of the supra-aortic trunks was attempted were included in a prospective registry. Results are, therefore, reported on an intent-to-treat basis. The preprocedural and postprocedural clinical records, arteriograms, and noninvasive vascular laboratory examinations of 83 patients (41 men [49.4%] and 42 women [50.6%]; mean age at intervention, 63 years) in whom endovascular repair of the subclavian (66, 75.9%), left common carotid (14, 16.1%), and innominate (7, 8.0%) arteries was attempted were retrospectively reviewed.

RESULTS

Initial technical success was achieved in 82 of 87 procedures (94.3%). The inability to cross 4 complete subclavian occlusions and the iatrogenic dissection of 1 common carotid artery lesion accounted for the 5 initial failures. Complications occurred in 17.8% of 73 subclavian and innominate procedures, including access-site bleeding in 6 and distal embolization in 2. Ischemic strokes occurred in 2 of 14 common carotid interventions (14.3%), both of which were performed in conjunction with ipsilateral carotid bifurcation endarterectomy. The 30-day mortality rate was 4.8% for the entire group. By means of life-table analysis, 84% of the subclavian and innominate interventions, including initial failures, remain patent by objective means at 35 months. No patients have required reintervention or surgical conversion for recurrence of symptoms. Of the 11 patients available for follow-up study who underwent common carotid interventions, 10 remain stroke-free at a mean of 14.3 months.

CONCLUSION

Angioplasty and primary stenting of the subclavian and innominate arteries can be performed with relative safety and expectations of satisfactory midterm success. Endovascular repair of common carotid artery lesions can be performed with a high degree of technical success, but should be approached with caution when performed in conjunction with ipsilateral bifurcation endarterectomy.

Stenting for atherosclerotic occlusive disease of the subclavian artery

The purpose of this study was to evaluate the results of stenting subclavian artery pathologic lesions. Between July 1991 and December 1995, 69 patients (36 males: mean age 67 years, range 34-87 years) underwent intraluminal balloon dilatations followed by stent implantations in 70 subclavian arteries to treat primary atherosclerotic stenoses > 70%. Twenty-three patients (34%) were treated for vertebrobasilar insufficiency (VBI), 25 patients (36%) were treated for upper limb ischemia (ULI), and 10 patients (15%) were treated for both VBI and ULI. Other indications included symptomatic subclavian steal phenomenon (SSS), protection of dialysis arteriovenous fistula, coronary steal syndrome, protection of axilloaxillary bypass, distal embolization, and protection of left internal mammary artery (LIMA)-coronary bypass. Fifty-three cases (78%) were treated for stenosis and 17 cases (22%) for total occlusion of the origin of the subclavian artery. The results of this series indicate that stenting of subclavian artery stenosis appears safe and feasible with good short and mid-term patency, improving at those intervals the initial disappointing reports of balloon angioplasty alone. However, its long-term durability is at present unknown.

Recovery of neuronal function after prolonged cerebral ischemia

Cats were submitted to complete cerebral ischemia by clamping the innominate and subclavian arteries and simultaneously lowering the systemic blood pressure. Neuronal function was assessed by recording the electroencephalogram and the anti- and orthodromic activation of the pyramidal tract. A full recovery of the pyramidal response and even of evoked electroencephalographic activity occurred after ischemia of more than 1 hour's duration.

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.

Migraine--a risk factor for dissection of cervical arteries

A case control study technique was employed to test for an association between non-traumatic cervical artery dissection and several possible risk factors. A significant positive association was shown with migraine, independent of type and treatment regimen. No such relationship was found with smoking history, hypertension or past oral contraceptive use. There was, however a significant and independent association with current oral contraceptive use.

A follow-up study of balloon angioplasty and de-novo stenting in Takayasu arteritis

Percutaneous balloon angioplasty (PTBA) is a universally accepted mode of therapy for stenotic coronary and peripheral arterial lesions. To establish the role of PTBA and stent placement in patients with Takayasu's arteritis (TA), these procedures were performed in 20 patients with TA. All patients received steroids, aspirin and ticlodipine (for stent placement) prior to procedure. Angioplasty was carried in patients with symptomatic stenotic vessel of more than 70% of normal diameter or a peak systolic gradient of more than 50 mm across stenotic aortic lesion. Stenting was performed for ostial lesion, long segment lesion or incomplete relief of stenosis and dissection following angioplasty. Carotid angioplasty and stenting was performed in five patients, aortic angioplasty in nine patients, aortic angioplasty and stenting in four patients, renal angioplasty in three patients, renal angioplasty and stenting in two patients and subclavian angioplasty in two patients, subclavian, angioplasty and stenting in three patients and coronary angioplasty and stent placement in one patient. The procedure was successful in all but one patient. On following up, two patients with carotid stent placement had restenosis. A saccular aneurysm developed at the lower end of stent in one patient with aortic stent placement. The PTBA with or without stent placement is a safe and effective method for relief of stenotic lesion in patients with TA.

Aortic and arterial aneurysms in behçet disease: management with stent-grafts--initial experience

PURPOSE

To assess the application of stent-grafts in the management of aortic and arterial aneurysms in patients with Behçet disease.

MATERIALS AND METHODS

Nine aneurysms in seven patients were managed with various types of stent-grafts. Diagnoses were based on clinical findings. The aortic aneurysms (n = 3) were thoracic (n = 1), suprarenal (n = 1), or infrarenal (n = 1). The arterial aneurysms (n = 6) were in the right and left subclavian (n = 2), right common carotid (n = 2), right brachiocephalic (n = 1), or left common iliac arteries (n = 1). A tandem connection of Gianturco stent covered with polytetrafluorethylene was placed in three aneurysms, and a balloon-expandable stent was placed in six.

RESULTS

The stent-graft was successfully placed in all patients. Immediate follow-up angiography revealed complete exclusion of the aneurysm in all cases. Follow-up computed tomography performed 3 days to 2 weeks later revealed complete exclusion and thrombosis of the aneurysm and patency of the stent-graft in six patients. In one patient, total occlusion of the artery with a stent occurred due to flow disturbance caused by double lesions. During follow-up (range, 6-59 months; mean, 28 months), the aneurysm resolved and completely regressed in four patients. A recurrent aneurysm at the distal margin of previously inserted stent-graft was successfully managed with an additional stent-graft.

CONCLUSION

The findings in this initial experience suggest that stent-graft insertion may be a safe and effective alternative to surgical treatment of aortic and arterial aneurysms in patients with Behçet disease.

The "sport model": extracorporeal membrane oxygenation using the subclavian artery

Venoarterial extracorporeal membrane oxygenation is used for patients with refractory cardiopulmonary failure. Arterial cannulation by means of femoral arteries is fraught with potential complications. We present a technique for subclavian artery cannulation to provide a safe and durable means of venoarterial extracorporeal membrane oxygenation support.

Percutaneous transluminal angioplasty of proximal subclavian artery occlusions

Percutaneous transluminal angioplasty (PTA) is a well-established treatment for patients with subclavian artery stenosis and brachial or cerebral symptoms. Its efficacy for treatment of subclavian occlusions, however, is not yet established. We attempted to recanalize the subclavian artery in 46 patients with proximal subclavian artery occlusion and were successful in 38 (83%). In two patients, residual stenosis, and in five patients, thrombotic material on the arterial wall required subsequent implantation of a self-expandable stent. Two additional patients were left with residual stenoses because stents were not available at that time. There were no cerebral or brachial complications. During a mean follow-up of 33 months, occlusion recurred in one patient after 3 months and stenosis recurred in five.

Coverage of the left subclavian artery during thoracic endovascular aortic repair

BACKGROUND

Thoracic aortic stent grafts require proximal and distal landing zones of adequate length to effectively exclude thoracic aortic lesions. The origins of the left subclavian artery and other aortic arch branch vessels often impose limitations on the proximal landing zone, thereby disallowing endovascular repair of more proximal thoracic lesions.

METHODS

Between October 2000 and November 2005, 112 patients received stent grafts to treat lesions involving the thoracic aorta. The proximal aspect of the stent graft partially or totally occluded the origin of at least one great vessel in 28 patients (25%). The proximal attachment site was in zone 0 in one patient (3.6%), zone 1 in three patients (10.7%), and zone 2 in 24 patients (85.7%). Patients with proximal implantation in zones 0 or 1 underwent debranching procedures of the supra-aortic vessels before stent graft repair. In one patient who underwent zone 1 deployment, the left subclavian artery was revascularized before stent graft deployment. Among patients who underwent zone 2 deployment with partial or complete occlusion of the left subclavian artery, none underwent prior revascularization. Patients were assessed postoperatively and at follow-up for development of neurologic symptoms as well as symptoms of left upper extremity claudication or ischemia.

RESULTS

Mean follow-up was 7.3 months. Among the 24 patients with zone 2 implantation, 10 (42%) had partial left subclavian artery coverage at the time of their primary procedure. A total of 19 patients experienced complete cessation of antegrade flow through the origin of the left subclavian artery without revascularization at the time of the initial endograft repair as a result of a secondary procedure or as a consequence of left subclavian artery thrombosis. Left upper extremity symptoms developed in three (15.8%) patients that did not warrant intervention, and rest pain developed in one (5.3%), which was treated with the deployment of a left subclavian artery stent. Two primary (type IA and type III) endoleaks (7.1%) and one secondary endoleak (type IA) (3.6%) were observed in patients who underwent zone 2 deployment. Three cerebrovascular accidents were observed. Thoracic aortic lesions were successfully excluded in all patients who underwent supra-aortic debranching procedures.

CONCLUSION

Intentional coverage of the origin of the left subclavian artery to obtain an adequate proximal landing zone during endovascular repair of thoracic aortic lesions is well tolerated and may be managed expectantly, with some exceptions.

Application of the Doppler ultrasound bloodflow detector in supraclavicular brachial plexus block

A Doppler ultrasound bloodflow detector was used to localize the third division of the subclavian artery, rendering the supraclavicular approach to the brachial plexus safer and highly successful.

Percutaneous transluminal angioplasty of the brachiocephalic arteries

Percutaneous transluminal angioplasty was used to treat atherosclerotic lesions in 22 brachiocephalic arteries in 20 patients during a 2 1/2 year period. Seven subclavian, 13 vertebral, one external carotid, and one common carotid arteries were involved. Nineteen arteries were successfully dilated, but dilatation of two vertebral arteries and attempted recanalization of one subclavian artery failed. The first patient treated was still asymptomatic at 30 months and no symptoms recurred in any of the successfully treated patients. No complications were encountered during these procedures.