Late results of extra-anatomic bypass.

Clinical progress and results were reviewed in 100 consecutive patients who underwent extra-anatomic bypass procedures for brachiocephalic and aortoiliac occlusive disease during the past 15 years. Of 113 procedures in this group, extra-anatomic bypass of the brachiocephalic vessels, axillo-femoral bypass, and femorofemoral bypass were performed. Although these procedures were performed in high-risk patients to avoid intrathoracic and intra-abdominal reconstruction or to circumvent undesirable anatomic areas, a low operative mortality was achieved. Symptomatic improvement, augmented Doppler ankle pressure index, and high limb-salvage rate were noted. Life-table analysis has confirmed prolonged five-year graft patency. The suspected high-risk characteristic in this group was corroborated by high progressive mortality observed particularly after axillo-femoral bypass and was due primarily to the severity of associated diseases. Analysis of the late results of extraanatomic bypass confirms the safety and effectiveness of this procedure in poor-risk patients.     

Partial brachiocephalic perfusion in aortic arch replacement

Eleven patients who underwent replacement of the aortic arch or adjacent areas for aneurysmal disease between 1989 and 1991, using hypothermic cardiopulmonary bypass at 20° to 23°C with partial brachiocephalic perfusion, were studied. Selective perfusion of the innominate artery was performed in all 11 patients through the right axillary artery, while partial brachiocephalic perfusion was carried out using a separate arterial roller pump with a perfusion flow rate of 10ml/kg per min. Direct cannulation to the left common carotid and left subclavian artery was not performed in this method. There were 4 men and 7 women who ranged in age from 26 to 78 years, with a mean age of 56 years. The etiology of aneurysmal disease was aortic dissection in 10 patients, and aortitis syndrome in 1. The cardiopulmonary bypass time was 214.3±39.3 min, aortic cross-clamp time 131.5±33.4 min, and partial brachiocephalic perfusion time 57.6±15.1 min. There were three operative deaths (27.3%), the causes being multiple organ failure, acute peritonitis, and infection of the composite graft in the ascending aorta, in one patient each, respectively. However, there were no deaths related to the technique of partial brachiocephalic perfusion and no neurological complications were seen in this series. Thus, we believe that partial brachiocephalic perfusion under hypothermic cardiopulmonary bypass is safe and effective in surgery for aortic aneurysms involving the aortic arch.     

Brachiocephalic reconstruction II: operative and endovascular management of single-vessel disease

OBJECTIVE: Although the surgical management of brachiocephalic disease is well established, evolving endovascular techniques present new options for treatment. We explored the potential benefits and drawbacks of these interventions in terms of outcome. METHODS: From 1966 to 2004, 391 consecutive patients (43.7% male; mean age, 61.9 years) with single-vessel brachiocephalic disease were treated with either operative bypass (group A; n = 229) or percutaneous transluminal angioplasty and stenting (group B; n = 162). RESULTS: All patients were asymptomatic after surgery or endovascular intervention. Group A and group B had similar operative mortality (0.9% vs 0.6%) and stroke (1.3% vs 0%) rates. However, 5 years after the procedure, group A had significantly better freedom from graft or intervention failure (92.7% +/- 2.1%) than did group B (83.9% +/- 3.7%; P = .03, Kaplan-Meier analysis; P = .001, Cox regression analysis). At 10 years, group A had the following rates of actuarial freedom from specific events: death, 73.7% +/- 4.6%; myocardial infarction, 84.2% +/- 3.6%; stroke, 91.4% +/- 3.4%; graft failure, 88.1% +/- 3.3%; coronary revascularization, 69.8% +/- 5.1%; and other vascular operation, 70.7% +/- 4.6%. Endovascular intervention involved less initial cost (mean savings, $8787 per procedure), was less invasive, and did not necessitate general anesthesia. On satisfaction questionnaires, 96.5% of patients receiving an endovascular intervention and 95.1% of patients receiving operative bypass for single-vessel brachiocephalic disease subjectively rated their treatment as "good" or "very good." CONCLUSIONS: Operative bypass and endovascular intervention for single-vessel brachiocephalic disease are both associated with acceptably low operative morbidity and mortality. Operative bypass produces significantly better mid-term freedom from graft or intervention failure than endovascular intervention and produces excellent long-term freedom from failure. Endovascular intervention offers tangible benefits regarding cost, level of invasiveness, and subjective patient satisfaction. Undetermined are the differences between the procedures regarding long-term durability, patterns of failure, efficacy as an adjunct to coronary artery bypass grafting, need for anticoagulation, efficacy as treatment for complex (multivessel) disease, and long-term cost.     

Surgical treatment of multivessel lesions in Takayasu’s arteritis: Report of a case

Takayasu’s arteritis (TA) is a chronic vasculitis involving the aorta and its main branches, the pulmonary arteries, and the coronary tree. Here we report a case of TA complicated by severe stenosis of the left coronary ostium with multivessel brachiocephalic involvement. A combination of these abnormalities could complicate underlying illness in patients, posing an increased risk of surgical morbidity. Simultaneous surgical treatment of the ascending aorta to left carotid artery bypass and coronary artery bypass using the great saphenous vein were performed. We discuss the choice of simultaneous surgery and the options for surgical treatment of complicated lesions due to TA.     

Brachiocephalic arterial reconstruction

From 1965 through 1980, 51 men and 49 women (mean age: 55 years) underwent transthoracic or extrathoracic revascularization of the innominate, common carotid, subclavian, or vertebral arteries. Preoperative symptoms were limited to the vertebrobasilar syndrome in 29 patients, to hemispheric neurologic or monocular visual events in 19, and to upper extremity ischemia in 13. Multiple symptoms were present in 27 other patients, and 12 patients were asymptomatic before operation. Median sternotomy was performed for correction of innominate, common carotid, or subclavian lesions in 34 patients, including six simultaneous brachiocephalic and cardiac procedures, with five operative deaths (14.7%). Extrathoracic reconstruction, such as carotosubclavian and axilloaxillary bypass or vertebral endarterectomy and reimplantation, was employed in 66 patients, with two operative strokes but no mortality (p less than .01). Late results were obtained from two to 189 months after operation (mean: 52 months). Considering their original symptoms, 82 patients have been classified as asymptomatic or improved, nine as unchanged, and nine others, including those who had operative complications, as worse. Twelve patients have eventually sustained either transient cerebral ischemia (six) or strokes (six), most of which were unrelated to eight documented late operative failures. In addition to 20 patients who required combined brachiocephalic and carotid bifurcation reconstruction, 27 additional carotid endarterectomies have at some time been necessary for patients having extensive cerebrovascular disease. Twenty patients have died during the follow-up interval, including eight with myocardial infarctions, but only one with a fatal stroke.     

A case of traumatic aneurysm of the brachiocephalic artery

Traumatic aneurysm of the brachiocephalic artery is rate. We presented a case of traumatic aneurysm of the brachiocephalic artery caused by traffic accident. A 28-year-old woman suffered a blunt chest trauma. A chest X-ray revealed a widening of the superior mediastinum and multiple rib fractures. CT scanning demonstrated left hemothorax with lung contusion and upper mediastinal hematoma. An aortography was performed which showed aneurysmal dilatation at the origin of the brachiocephalic artery. The patient underwent an operation 24 hours after chest injury. An aorto-right common carotid artery and right subclavian artery bypass with bifurcated Dacron graft was performed while monitoring temporary artery pressure. After resection of aneurysm, We found that about 3 cm longitudinal laceration of intima on the posterior wall of brachiocephalic artery. Her post operative condition was good and no neurological defect was noted.     

Preoperative coronary artery bypass grafting in patients undergoing abdominal aortic reconstruction

The effect of preoperative aortocoronary bypass grafting on the operative mortality of patients undergoing elective abdominal aortic reconstruction was examined by reviewing a series of 224 consecutive patients (1980 to 1983) (Group I) in whom selective preoperative noninvasive and invasive cardiac screening was used to identify patients with significant coronary stenoses. One patient died during cardiac catheterization. Twenty-seven patients (12 percent) underwent aortocoronary bypass grafting with one operative death (3.7 percent) and one nonfatal myocardial infarction (3.7 percent). These 26 patients subsequently underwent abdominal aortic reconstruction with no mortality and no postoperative myocardial infarction. One hundred ninety-six patients (88 percent) underwent aortic reconstruction without prior aortocoronary bypass grafting with four operative deaths (2 percent), including two fatal myocardial infarctions. The combined operative mortality for Group I patients was 2.3 percent. Three hundred twenty-six patients (Group II) who underwent abdominal aortic reconstruction at this institution from 1970 to 1976 had an 8 percent operative mortality, of which 50 percent of the deaths were due to myocardial infarctions (Group I versus Group II, p less than 0.01). Selective preoperative screening for coronary artery disease in patients undergoing elective abdominal aortic reconstruction with aortocoronary bypass grafting in selected patients is safe and may help reduce the operative mortality.     

Chronic visceral ischemia. Three decades of progress.

Symptomatic visceral atherosclerosis is a major surgical challenge because of its life-threatening course and the complexity of its definitive operative treatment. Evolution in the operative approach to the visceral aorta and progress in the intraoperative management of patients undergoing complex vascular reconstructions prompted a review of the authors' cumulative experience in the surgical management of chronic visceral ischemia. Among all patients undergoing visceral revascularization at the University of California, San Francisco during the past three decades, 74 patients were identified whose primary reconstruction used transaortic endarterectomy (TA TEA) (n = 48) or antegrade bypass (AB) (n = 26), the authors' preferred revascularization techniques. The two treatment groups were comparable in gender distribution, age, presenting symptoms, and physical findings, although the amount of preoperative weight loss was greater in the AB group (35.8 +/- 19.5 versus 22.4 +/- 12.0, p = 0.003). The groups were also comparable in the prevalence of atherosclerosis risk factors, symptomatic vascular disease at other sites, and previous vascular operations. However associated renal artery atherosclerosis was slightly greater in the TA TEA group (58.3% versus 23.1%, p = 0.07) when compared to the AB group. Antegrade bypass was usually performed transabdominally (88.5%), while TA TEA was approached thoracoretroperitoneally (75.0%). Celiac revascularization was almost universal in both treatment groups, but the TA TEA group underwent significantly more frequent superior mesenteric artery (SMA) revascularization (93.8% versus 46.2%, p = 0.0001) and slightly more frequent inferior mesenteric repair (18.8% versus 3.8%, p = 0.07) than the AB group. In addition the frequency of combined renal and visceral repair (25.0% versus 0.0%, p = 0.01) as well as combined aortic, renal, and visceral repair (22.9% versus 3.8%, p = 0.03) was significantly greater in the TA TEA group. The obligatory interval of renal and visceral ischemia did not differ between the two approaches. The perioperative mortality rate was 12.2% and was the same for TA TEA (14.6%) and AB (7.7%). Overall the incidence of complications was the same with either operative approach, although patients in the TA TEA group tended to have multiple complications (17.1% versus 0.0, p = 0.03) and all significant pulmonary complications occurred in this group. Two patients were lost to follow-up. The cumulative percentage of patients who remained asymptomatic following AB or TA TEA was (respectively) 95.8% and 97.3% at 1 year and 86.5% and 86.1% at 5 years. Both of these operative approaches provide durable symptom relief with acceptable operative morbidity and mortality rates.(ABSTRACT TRUNCATED AT 400 WORDS)     

Surgical treatment of the aortic arch dissection--a report of two cases operated by partial brachiocephalic perfusion, and open aortic anastomosis

Two patients underwent aortic arch replacement for the dissecting aneurysm of the aorta using a simplified cardiopulmonary bypass (CPB) technique with partial brachiocephalic perfusion, moderate systemic cooling (22 degrees to 23 degrees C), and open aortic anastomosis were reported. The partial brachiocephalic perfusion was accomplished by perfusion to the right axillary artery using separate pump. Open distal anastomosis was performed under low flow hypothermic perfusion of the lower body during selective perfusion to the brain. Cardiopulmonary bypass and partial brachiocephalic perfusion time were 170 minutes, and 30 minutes in one case, and 207 minutes, 56 minutes in the other case. Both patients survived operations, and there were no postoperative strokes, and neurological complications. On the basis of these results, we discussed about supportive methods for aortic arch surgery.     

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

OBJECTIVES: Complex brachiocephalic disease involves multiple vessels and is frequently associated with multisystem atherosclerosis. We reviewed surgical outcome and examined the impact of this problem on decision making regarding operative staging, technique, and choice of conduit. METHODS: Between 1966 and 2000, 157 consecutive patients (mean age, 54.0 years; 48.4% male) with innominate artery or multivessel brachiocephalic disease underwent operative reconstruction using either a transthoracic approach (group A, n = 113) or a less invasive, extrathoracic approach (group B, n = 44). Reconstruction required multiple distal anastomoses in 70 patients (44.6%), concomitant coronary artery bypass grafting (CABG) in 37 patients (23.6%), and concomitant carotid endarterectomy (CEA) in 26 patients (16.6%). RESULTS: No significant differences were found between group A and group B when operative mortality (2.7% vs 2.3%) and stroke rates (2.7% vs 6.8%) were analyzed. However, 10 years after surgery, freedom from graft failure was significantly better in group A (94.4% +/- 4.4%) than in group B (60.3% +/- 13.4%) ( P = .002). Freedom from graft failure was adversely affected by nonaortic inflow ( P = .002) and axillo-axillary cervical grafts ( P = .0001). Mortality and stroke rates for subgroups having multiple distal anastomoses (2.9%, 2/70 and 4.3%, 3/70), concomitant CABG (5.4%, 2/37 and 0, 0/37), and concomitant CEA (3.8%, 1/26 and 3.8%, 1/26) were similar to those of other patients. For the entire patient group, 10-year rates of actuarial freedom from specific events were death, 68.8% +/- 6.0%; myocardial infarction, 86.7% +/- 4.5%; stroke, 87.0% +/- 4.4%; coronary revascularization, 88.0% +/- 3.6%, and other vascular operation, 79.9% +/- 4.4%. CONCLUSIONS: Transthoracic arch reconstruction for complex brachiocephalic disease can be done with acceptably low morbidity and mortality similar to those of a less invasive, extrathoracic approach. Furthermore, the transthoracic approach is associated with significantly better long-term freedom from graft failure, possibly because it preserves aortic inflow to the great vessels. Nonetheless, the high frequency of late events in this relatively young patient population reflects the presence of multisystem atherosclerosis and suggests the need for close follow-up and lifestyle modification.     

Palliation of malignant hilar obstruction at a single centre--review of operative and non-operative techniques

INTRODUCTION: Jaundice secondary to a malignant hilar obstruction can be relieved by operative bypass or percutaneous stenting. Comparative trials involving these techniques are scarce. We reviewed our experience with these competing techniques in the palliation of malignant hilar obstruction. PATIENTS AND METHODS: All patients with malignant hilar obstruction managed at our institution during the period 1992-2002 were identified for review. RESULTS: A total of 36 deeply jaundiced patients with hilar obstruction were identified. Twenty-two patients underwent exploration with the intention of performing an operative bypass and 14 patients underwent percutaneous transhepatic cholangiography (PTC) with intention to stent. Procedure-related mortality was similar in both groups. Morbidity was much higher in the operative group. Effective symptom relief was achieved with both techniques. In the PTC group recurrent biliary obstruction in 2 patients necessitated salvage non-operative procedures. Although survival rates were slightly longer in the operative group, this was not significant. There were no long-term survivors. CONCLUSION: Operative bypass provides better sustained relief of jaundice than PTC. However long-term survival in both groups is poor and operative bypass is best reserved for younger patients with no technical contraindications. Despite early and late procedural failures PTC is the method of choice for patients with advanced-stage disease and those with significant co-morbidities.     

Common brachiocephalic trunk: strategies for revascularization

BACKGROUND: A common brachiocephalic trunk, in which both common carotid arteries and the right subclavian artery arise from a single trunk off the arch, is a normal variant of aortic arch branching that occurs in approximately 10% of the population. Because three of the four primary sources of cerebral blood flow arise from a single aortic branch, stenosis or occlusion of a common trunk can cause severe ischemic consequences. Common trunk revascularization has been described, but there have been no reports focusing on the management options for occlusive disease of this vascular anatomy. METHODS: A retrospective review of our experience with innominate artery revascularization identified 6 patients who underwent revascularization of a common brachiocephalic trunk between 1977 and 1997. All patients were symptomatic, with either total occlusion (n = 3) or critical stenosis (n = 3) caused by atherosclerosis (n = 5) or Takayasu's arteritis (n = 1). Revascularization was achieved by a prosthetic bypass graft from the ascending aorta to the innominate or left common carotid arteries or both (n = 5); or transarterial endarterectomy (n = 1). Concomitant endarterectomy of branch vessels was performed in 3 patients. RESULTS: There was one perioperative death from myocardial infarction, and one perioperative stroke, with death occurring 1 month after hospital discharge. One patient developed cerebral hyperperfusion syndrome 1 week after endarterectomy that resolved without sequelae with antihypertensive medications. During a follow-up period ranging from 1 to 20 years, there was one late death from congestive heart failure 5 years after operation. All surviving patients are alive and free from symptomatic recurrence. CONCLUSIONS: Revascularization for occlusive disease of a common brachiocephalic trunk can be achieved with effective and durable relief of symptoms using either a prosthetic bypass graft or endarterectomy. However, neurologic complications in 2 patients, which were fatal in 1, attest to the potential cerebral ischemic threat posed by occlusive disease of a common brachiocephalic trunk.     

Management of acute aortic occlusion.

Acute aortic occlusion is most often seen in elderly patients with advanced cardiac disease. The management of these patients has been facilitated by the use of extraanatomic bypass. Over the past 2 years, six patients aged 55 to 87 years presented to our medical center with acute aortic occlusion, three after major operative procedures. One patient had a thrombosed abdominal aortic aneurysm; in the other five patients differentiation between saddle embolus and thrombosis of the distal aorta was impossible. There was one operative death. Four of the other five patients underwent axillobifemoral bypass and one underwent aortofemoral thrombectomy. All survived, and none required amputation. Two of the three patients who underwent preoperative aortography developed transient renal failure postoperatively. Aortography is of little value in diagnosis and is probably contraindicated in acute aortic occlusion. Our recommendation for operative management includes (1) preparation of the patient for possible axillobifemoral bypass, (2) angiography of distal runoff via both femoral arteries, (3) attempt at bilateral aortofemoral embolectomy with Fogarty catheters, and (4) axillobifemoral bypass if embolectomy fails to restore normal pulsatile flow.     

Superficial Femoral-Popliteal Vein as a Conduit for Brachiocephalic Arterial Reconstructions

Revascularization of brachiocephalic arteries with prosthetic graft offers excellent patency for most reconstructions. For complex brachiocephalic reconstructions, such as redo operations or reconstructions for infection, autogenous conduit may be preferable. Occasionally saphenous vein is inadequate or absent. The purpose of this study was to evaluate the indications and intermediate-term outcomes of superficial femoral-popliteal vein (SFPV) as an alternative conduit for brachiocephalic reconstructions. Over a 6-year period, 71 patients underwent carotid, subclavian, or axillary artery bypass. In 18 (25%) of these reconstruction SFPV was used as the conduit. Ten bypasses (55%) were redo operations. Three bypasses (17%) were performed after failed prosthetic grafts. Three grafts (17%) were required in infected patients. Indications for the use of SFPV included inadequate saphenous vein (n = 13), infection (n = 3), and failed prosthetic bypass (n = 3). Thirty-day mortality was 5.5%. The neurologic event rate was 5.5%. During a mean follow-up of 26 ± 5 months, there were no graft thromboses or graft infections. Revision-free primary patency was 92% at 48 months. Assisted primary patency was 100%. These data suggest that SFPV is a safe, durable conduit for brachiocephalic reconstructions. SFPV yielded excellent results for a disadvantaged patient population.     

��-��������·������ͷ���ʹ�����8������

目的 探讨左髂动脉—左颈动脉旁路术治疗头臂型大动脉炎这一新方法的治疗效果。方法 2001年6月至2002年7月，对8例头臂型大动脉炎病人，通过左髂动脉—左颈动脉聚四氟乙烯(PTFE)人造血管旁路术治疗颈动脉闭塞所致的脑缺血症状。结果 8例病人在平均8．7个月(3—16个月)的随访期内，7例人造血管保持通畅，脑缺血症状明显好转。结论 对于头臂型大动脉炎病人，髂动脉—颈动脉解剖外动脉旁路术是一种简单、安全、可靠的手术方式，为该病提供了一种新的治疗手段。     

Simultaneous operative repair of multilevel lower extremity occlusive disease

Sixty-two patients (39 men (63%), 23 women (27%), mean age 68 years) with multilevel lower extremity arterial occlusive disease underwent simultaneous inflow and outflow operative arterial repair consisting of aortofemoral bypass in 22 (35%), axillofemoral bypass in 17 (28%), femorofemoral bypass in 15 (24%), iliac endarterectomy in 7 (11%), and unilateral aortoiliac bypass in 1 (2%), combined with 69 outflow procedures (unilateral in 55 patients, 89%), including above-knee femoropopliteal in 12 (17%), below-knee femoropopliteal in 35 (51%), femoroinfrapopliteal in 20 (29%), popliteal tibial in 1 (1%), and femoropedal bypass in 1 (1%). Multiple criteria were used to identify patients with multilevel disease likely to benefit from multilevel procedures. The operations were performed by two operating teams in a median time of 240 minutes. Prosthetic grafts were used for eight (13%) distal bypasses, the remainder were autogenous vein. There was one operative death (1.8%). The mortality rate, morbidity rate, and operative time were not significantly different from a group of patients who underwent concurrent, isolated inflow operations (aortofemoral, axillobifemoral, femorofemoral bypass or iliac endarterectomy). Mean follow-up was 14.9 months (range, 0 to 120). The life-table primary patency for the inflow procedures was 92.6% at 24 months, the outflow was 94.9% at 24 months. Cumulative limb salvage was 90.9% at 48-month follow-up. All patients with claudication were relieved of their symptoms. We conclude that complete correction of multilevel disease can be accomplished with operative time, morbidity rate, and patency equal to that of single level repair. Multilevel procedures provide complete relief of symptoms in a higher percentage of patients than has been reported after single level repair.     

Ten-year survival following aortic valve replacement: A multivariate analysis of coronary bypass as a risk factor

The additional risk of coronary bypass surgery was analysed in 664 patients over 40 years of age undergoing aortic valve replacement between 1969 and 1981. Four hundred sixty-seven patients underwent aortic valve replacement alone, while 197 patients with coronary artery disease underwent combined aortic valve replacement and coronary bypass surgery. There were no significant differences in the preoperative hemodynamic characteristics of the two groups of patients. There were 41 (9%) operative deaths following aortic valve replacement alone and 20 (10%) following aortic valve replacement with coronary bypass surgery. Since 1976, operative mortality has fallen to 5% and perioperative myocardial infarction to 2% following the combined procedure. Ten-year actuarial survival (standard error) was 56 (3%) following aortic valve replacement and 49 (6%) following aortic valve replacement and coronary bypass surgery. A multivariate analysis including both groups of patients revealed that age, functional class and year of operation significantly affected ten-year survival (p less than 0.05). The same analysis showed that coronary artery disease requiring coronary bypass surgery also decreased ten year survival in patients undergoing aortic valve replacement (p = 0.06).     

The role of venography and surgery in the management of patients with superior vena cava obstruction

Venacavography proved to be an excellent guide for the design of patient management programs. Type 1 patients with incomplete obstruction of the superior vena cava (SVC) are best managed by irradiation and chemotherapy regimens and usually do not require operation to bypass the SVC. Types II and IV patients are treated by operation when symptoms of airway obstruction or cerebral venous hypertension are present. Type III patients should be considered for SVC bypass as an initial therapeutic intervention. This group is more likely to have cerebral or airway symptoms and would benefit most from the bypass operation. In terms of operative considerations, type III patients are ideal for operation because the left brachiocephalic vein is usually available for bypass. Type IV patients may also be considered, but operation is more difficult and may require venous thrombectomy or extension of the bypass graft above the thoracic inlet to obtain head and neck decompression.     

Brachiocephalic arterial occlusions and stenoses. Manifestations and management of complex lesions

Complex stenotic and occlusive lesions involving multiple brachiocephalic arteries were encountered in 17 symptomatic patients, 25 to 76 years of age. Symptoms included hemispheric transient ischemic attacks (16), visual symptoms (ten), global cerebral ischemia (11), true syncope (six), upper extremity ischemic symptoms (eight), and frank tissue loss (one). Of 68 brachiocephalic arteries, 53 exhibited hemodynamically significant stenoses, including 21 that were totally occluded. Transthoracic surgical reconstruction consisted of bypass grafting (11), innominate artery endarterectomy (five), or proximal left common carotid endarterectomy with reimplantation into the contralateral carotid artery (one). There were no operative deaths and only one transient perioperative neurologic deficit. All patients had relief of symptoms. When multiple brachiocephalic arterial occlusions and stenoses preclude standard cervical reconstructive procedures, direct transthoracic reconstruction is appropriate and may be undertaken with acceptable risk in properly selected patients.     

A surgical case of concomitant aneurysms of the brachiocephalic and coronary arteries.

Brachiocephalic artery aneurysm with concomitant coronary artery aneurysm is rare. We describe a case of a patient with a history of prosthetic graft placement following resection of an abdominal aortic aneurysm and was subsequently found to have a brachiocephalic artery aneurysm. After surgical correction of the brachiocephalic aneurysm, postoperative coronary arteriography demonstrated coronary artery aneurysms, and the patient subsequently underwent coronary artery bypass grafting (CABG).