Prosthetic Carotid Bypass Grafts for Atherosclerotic Lesions: A Prospective Study of 198 Consecutive Cases

ObjectivesCarotid endarterectomy (CEA) is the standard treatment for atherosclerotic lesions involving the carotid bifurcation. However, CEA can be challenging under some conditions. The goal of this study was to determine the outcome and durability of prosthetic carotid bypass grafting (PCB) with polytetrafluoroethylene (PTFE) grafts as an alternative to CEA.MethodsThis is a prospective series of 198 consecutive patients with PCB, representing 12.4% of 1595 patients with a carotid reconstruction procedure performed in our department between September 1986 and December 2006. Qualifying event was stroke in 67 patients (34%) and transient ischaemic attack (TIA) in 45 (23%), and 86 patients (43%) were asymptomatic. Primary indications for PCB were extensive atherosclerotic lesions (n = 71; 36%), carotid stenosis associated with kinking (n = 49; 25%), recurrent stenosis (n = 47; 23%), stenosis after radiation therapy (n = 18; 9%) and technical failure of CEA (n = 13; 7%), with excessive arterial wall thinning and perforation after endarterectomy (n = 10) or intimal flap on completion digital angiography (n = 3).ResultsThe combined stroke and death rate at 30 days were 0.5% (one stroke). Median follow-up was 9.5 years (interquartile range (IQR): 6.2–18.3 years). At 10 years, primary patency was 97.9 ± 3.4%. Six PCBs (3.0%) became occluded during follow-up; one patient had a restenosis greater than 50% and 18 patients (9.1%) had a restenosis of less than 50%. Five patients had an ipsilateral stroke (one postoperative stroke, one at 103 days with a patent PCB and three related to occlusion of the PCB at 4, 13 and 15 years after the procedure). At 10 years, cumulative stroke-free survival was 98.4 ± 3.2%, and cumulative survival was 78.8 ± 7.0%.ConclusionsPCB is a safe surgical alternative and is durable, with a low incidence of graft restenosis, when CEA seems hazardous.     

Outcomes of carotid stenting in patients with fibromuscular dysplasia

ObjectiveFibromuscular dysplasia (FMD) is a noninflammatory arterial disease that affects the extracranial carotid arteries in young patients. The ideal treatment of FMD has continued to be debated, and the role of carotid artery stenting (CAS) is controversial. The aim of the present study was to assess the feasibility and outcomes of CAS for patients with FMD.MethodsA retrospective analysis of patients who had undergone CAS was performed using the Vascular Quality Initiative database from December 2012 to May 2021. Patients who had undergone CAS for atherosclerosis and FMD were included and matched 1:1 by age, gender, and clinical presentation. The demographics, clinical parameters, and procedural data were analyzed. The end points included postoperative stroke and transient ischemic attack (TIA), and adverse events (perioperative and 1-year mortality, neurologic changes, access site complications, hematoma or bleeding, infection, congestive heart failure, arrhythmia, myocardial infarction, reperfusion symptoms), and hospital length of stay.ResultsAfter matching, 55 patients had undergone CAS for FMD (mean age, 58.7 ± 14 years; 62% women; 69% White; mean body mass index, 28 ± 6 kg/m²). Most of these procedures (69%) were elective. The FMD group had had a lower rate of hypertension (55% vs 82%; P = .002), smoking (35% vs 80%; P < .001), diabetes (13% vs 45%; P < .001), and coronary artery disease (9% vs 45%; P < .001) compared with the non-FMD group. In the FMD group, prior TIA and stroke was identified in 39 (71%) and 31 (57%) patients, respectively. The mean interval from a prior stroke or TIA to the index surgery was 160 days. Additionally, 23 patients (42%) had had anatomically high lesions above the level of the second cervical vertebra. In the FMD group, the transfemoral approach was used for 43 patients (78%), with distal embolic protection used for 40 patients (93%). Flow reversal was used for nine patients (23%). Most cases were performed with local anesthesia (58%). Three patients (6%) in the FMD group had had access site complications that were managed nonoperatively. No differences were found between the FMD and non-FMD groups in perioperative stroke, TIA, or 30-day mortality. The length of stay was similar between the two groups, and the 1-year survival was 100% for both groups. All the patients in the FMD group were discharged without neurologic complications, and 50 patients (91%) were receiving dual antiplatelet therapy. The median follow-up was 328 days (interquartile range, 1-732 days) with no mortality or reinterventions during follow-up.ConclusionsCAS for FMD is a feasible and safe procedure with favorable technical success, a low incidence of neurologic complications, and good clinical outcomes at 1 year of follow-up.     

Combined infrarenal aorta and carotid artery reconstruction: Early and late outcome in 152 patients

Between January 1, 1985 and December 31, 1998, we performed combined infrarenal aorta and carotid artery reconstruction in 152 consecutive patients. The mean age of these patients was 65.4 ± 8.6 years (range, 43-88 years). Infrarenal aortic disease involved abdominal aortic aneurysm in 78 patients (44.7%) and occlusive aortoiliac lesions in 84 (55.3%). Carotid artery disease was detected by performing routine Doppler ultrasonography prior to aortic reconstruction. A total of 121 carotid lesions were asymptomatic (79.6%). A total of 32 patients (21%) had a history of contralateral carotid repair. Eighty-one patients (53.2%) presented with coronary artery disease diagnosed on the basis of clinical and/or laboratory testing. Concurrent lesions were diagnosed in the renal arteries of 43 patients (28.3%) and in the visceral arteries of 16 (10.5%). Based on the results of cardiac evaluation, eight patients underwent coronary revascularization before combined reconstruction. Renal or visceral artery reconstruction was carried out during the same procedure in 30 (19.7%) and 10 (6.6%) patients, respectively. Univariate analysis demonstrated six factors that were significantly associated with perioperative mortality and morbidity: age, coronary artery disease, chronic obstructive pulmonary disease, procedure time, intraoperative blood loss, and creatinemia over 140 mmol/L. Multivariate analysis showed that only the first four of these factors were independent. Actuarial survival in the overall population, including the patients who died during the perioperative period, was 73.9 ± 7.1% at 5 years and 50.9 ± 10% at 10 years. From our experience, we conclude that combined infrarenal aorta and carotid artery reconstruction can be performed with no additional operative risks and consequently is the strategy of choice. In our series neither procedure had any effect on the early or late outcome of the other. Our experience suggests that combined surgery is a safe alternative to staged surgery in patients with concurrent lesions involving the infrarenal aorta and carotid artery bifurcation.     

Subclavian-carotid bypass to an “isolated” carotid bifurcation: A retrospective analysis

Most patients with occlusion of the common carotid artery will have concomitant occlusion of the internal and external carotid arteries. A few, however, will maintain antegrade internal carotid flow via retrograde flow from the ipsilateral external carotid artery. These patients remain at risk for hemispheric transient ischemic attacks (TIAs), ischemic stroke, or vertebrobasilar insufficiency/global cerebral ischemia. Historically, diagnosis of this condition has relied on cerebral arteriography and/or blind exploration of the carotid bifurcation. More recently, color-enhanced duplex ultrasonography has been used to facilitate the diagnosis and has allowed focused, delayed arteriographic views of the appropriate carotid bifurcation, making blind exploration unnecessary. From 1985 to 1994, nine patients with TIAs (n=5), completed stroke with minimal residual deficit (n=2), or vertebrobasilar insufficiency (n=2) were found to have occlusion of the common carotid artery with a patent carotid bifurcation on duplex ultrasound images. All nine had this particular anatomic condition confirmed by arteriography and were subsequently treated by subclavian-carotid bypass using autologous reversed saphenous vein (n=5) or synthetic (n=4) grafts. Five of nine patients required concomitant bifurcation endarterectomy. There were no perioperative strokes or TIAs and no operative deaths. Six of eight survivors remain asymptomatic at 1 to 92 months' follow-up (mean 37.1 months). Symptomatic patients with occluded common carotid arteries and patent bifurcations can be treated surgically with low operative morbidity and good long-term results.Presented at the Fifth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Breckenridge, Colo., January 29, 1995.     

Diagnosis, management, and future developments of fibromuscular dysplasia

Fibromuscular dysplasia (FMD) is a nonatherosclerotic noninflammatory vascular disease that primarily affects women from age 20 to 60, but may also occur in infants and children, men, and the elderly. It most commonly affects the renal and carotid arteries but has been observed in almost every artery in the body. FMD has been considered rare and thus is often underdiagnosed and poorly understood by many health care providers. There are, however, data to suggest that FMD is much more common than previously thought, perhaps affecting as many as 4% of adult women. When it affects the renal arteries, the most common presentation is hypertension. When it affects the carotid or vertebral arteries, the patient may present with transient ischemic attack or stroke, or dissection. An increasing number of patients are asymptomatic and are only discovered incidentally when imaging is performed for some other reason or by the detection of an asymptomatic bruit. FMD should be considered in the differential diagnosis of a young person with a cervical bruit; a "swishing" sound in the ear(s); transient ischemic attack, stroke, or dissection of an artery; or in individuals aged ≤ 35 years with onset hypertension. Treatment consists of antiplatelet therapy for asymptomatic individuals and percutaneous balloon angioplasty for patients with indications for intervention. Patients with aneurysms should be treated with a covered stent or open surgical repair. Little new information has been published about FMD in the last 40 years. The recently instituted International Registry for Fibromuscular Dysplasia will remedy that situation and provide observational data on a large numbers of patients with FMD.     

Die chirurgische Therapie des extrakraniellen Karotisaneurysmas

Background. Aneurysms of the extracranial carotid artery are very rare. Indications for surgical therapeutic intervention, surgical techniques, perioperative complications and long-term results after operative reconstruction during an observation period of 16 years were analyzed. Patient collective. Continuous clinical follow-up of 36 patients (mean age: 60.2 years, range: 30–79 years) who underwent 41 carotid artery reconstructions due to aneurysm of the extracranial carotid arteries between 1980 and 1996. Postoperative investigation included physical and neurological examination and telephone interviews. Clinical symptoms. Fifteen patients presented with pulsatile cervical tumors, 53% of these patients had experienced an episode of cerebral ischemia prior to surgery. Anatomical localization and OP-techniques. Isolated aneurysms of the internal carotid artery (type I, end-to-end anastomosis, interposition, n=14) extensive long distance aneurysms of the internal carotid artery (type II, n=7, interposition), aneurysms of the carotid bifurcation (type III, n=13, direct suture, patch-plasty) combined aneurysm of the internal and common carotid artery (type IV, n=4, interposition), isolated aneurysm of the common carotid artery (type V, n=3, interposition). Postoperative complications. After 3 of 41 carotid reconstructions a cerebral ischemia was encountered (TIA, n=1, PRIND n=1, minor stroke n=1). In nine cases, perioperative cranio-facial nerve palsies were detected. Six nerve palsies were temporary, while three were permanent. Long-term results. One year, 5 years and 10 years after surgery 100%, 94% and 80.8% of the patients are alive and 97.5%, 88.7% and 78.8%, respectively, have not experienced an ipsilateral ischemic stroke. Conclusion. Surgical intervention for extracranial carotid aneurysm is a safe procedure with good long-term results. The risk of a permanent neurological deficit is low (2.4%). Permanent cranio-facial nerve palsies were detected in 7.3% of patients.     

A review of 100 consecutive reconstructions of the distal vertebral artery for embolic and hemodynamic disease

Purpose: The aim of our study was to assess the outcome of distal vertebral artery (VA) reconstructions through a retrospective review conducted at a university-affiliated referral center. Methods: One hundred consecutive distal VA reconstructions had been performed during a period of 14 years (98 patients) and included reversed saphenous vein bypass from the ipsilateral common, internal, or external carotid to the third portion of the VA at the Cl-2 level (68 reconstructions) or the C0-l level (4); transposition of the external carotid or its occipital branch to the VA (23); and transposition of the third portion of the VA onto the internal carotid artery (2). Other methods were used in 3 additional patients. Eighteen patients underwent concomitant carotid operations, and 1 patient underwent a concomitant subclavian transposition. Symptoms were present in 98% of patients and included vertebrobasilar ischemia (89%), vertebrobasilar plus hemispheric ischemia (7%), and hemispheric ischemia (2%). Two asymptomatic patients with bilateral carotid occlusions underwent operations to provide a single artery for cerebral perfusion (2%). Sixty-three lesions were atherosclerotic, 18 were dynamic bony compressions, and 14 were dissection, fibromuscular dysplasia, arteritis, or aneurysm. Five had miscellaneous anatomic indications. Results: Stroke caused the four perioperative deaths that occurred. There was one occurrence of nonfatal hemispheric stroke. Routine postoperative arteriography identified 16 graft abnormalities; 11 patients underwent attempted revision. The introduction of the use of intraoperative angiography in 1990, halfway through the series, lowered the incidence of graft abnormalities from 28% to 4% and the incidence of perioperative death from 6% to 2%. Eighty-seven percent of patients had complete or significant resolution of symptoms. Follow-up ranged from 1 to 168 months (mean, 79 months). Ten patients were lost to follow-up. Twenty late deaths occurred; none were stroke related. Five reconstructions required late revision. The cumulative primary patency at 5 and 10 years was 75% ± 6 and 70% ± 7 (mean ± SE), respectively; cumulative secondary patency was 84% ± 5 and 80% ± 6 at 5 and 10 years, respectively. Median survival was 107 months. Conclusions: Distal VA reconstruction provides excellent long-term patency and stroke protection. Intraoperative angiography is mandatory. (J Vasc Surg 1998;27:852-9.)     

The Presence and Severity of Vertebral Fractures is Associated with the Presence of Esophageal Hiatal Hernia in Postmenopausal Women

We examined the relationship between the presence of esophageal hiatal hernia (HH) assessed by endoscopy and the presence of vertebral fractures (VFs) in 87 Japanese postmenopausal women (age range 52–87 years). We found that 29 (63%) of 46 patients with HH (71.2 ± 6.1 years, mean ± SD) had one or more VFs, compared with 14 (34%) of 41 patients without HH (70.8 ± 6.8 years), which was a significant difference in the frequency of VFs (c²= 7.242; p= 0.0071). The average number of VFs per patient was significantly higher for the patients with HH than for those without HH (1.67 ± 1.75 vs 0.68 ± 1.21, p= 0.0032). There were no significant differences in absolute or age-matched bone mineral density (BMD) values at the lumbar spine (0.656 ± 0.131 vs 0.662 ± 0.148 g/cm²; Z-score, –0.35 ± 1.17 vs –0.26 ± 1.00) and there were no significant differences in biochemical parameters, age, years since menopause or body mass index (BMI) between the two groups. When patients were divided into those with reflux esophagitis (RE) (n= 30, 70.2 ± 7.3 years) and those without RE (n= 57, 71.4 ± 5.9 years), no significant differences were detected in any of the above parameters including the presence or number of VFs. The patients were further subdivided into four groups: those with ‘HH only’ (n= 23, 72.3 ± 4.6 years), with ‘RE only’ (n= 7, 70.9 ± 7.7 years), with ‘both’ (n= 23, 70.0 ± 7.3 years) and with ‘neither’ (n= 34, 70.8 ± 6.7 years). One or more VFs were found in 12 (52%), 1 (14%), 17 (74%), and 13 (38%) patients in each group, respectively, and the difference in frequency was significant (c²= 10.748; p= 0.0132). The average number of VFs per patient in each group was 1.57 ± 2.06, 0.14 ± 0.38, 1.78 ± 1.41 and 0.79 ± 1.30, respectively, and there were significant differences between the ‘both’ and ‘neither’ groups, and between the ‘both’ and ‘RE only’ groups (p<0.05). When univariate logistic regression analysis was performed with the presence of HH as a dependent variable and each of the presence of VFs, the number of VFs per patient, absolute or age-matched BMD values at the lumbar spine, BMI and plasma albumin as independent variables, the presence of VFs and the number of VFs per patient were selected as indices affecting the presence of HH (odds ratio: 3.29 and 1.59, 95% confidence interval: 1.36–7.94 and 1.14–2.23; p = 0.0080 and 0.0064, respectively). These results show that the presence and severity of VFs are associated with the presence of HH but not of RE in Japanese postmenopausal women, and suggest that kyphosis induced by multiple VFs might predispose elderly women to a complication with HH. Received: 2 March 2001 / Accepted: 11 June 2001     

Clinical significance of reversal of flow in the vertebral artery identified on cerebrovascular duplex ultrasound

Background

Reversal of flow in the vertebral artery (RFVA) is an uncommon finding on cerebrovascular duplex ultrasound examination. The clinical significance of RFVA and the natural history of patients presenting with it are poorly understood. Our objective was to better characterize the symptoms and outcomes of patients presenting with RFVA.

Infrarenal Abdominal Aortic Aneurysm Repair: Detection and Treatment of Associated Carotid and Coronary Lesions

Management of carotid or coronary lesions associated with abdominal aortic aneurysm (AAA) remains controversial. To determine the influence of these lesions on the outcome of elective infrarenal AAA repair, we review our experience between January 1978 and December 1992. A total of 345 consecutive patients underwent infrarenal AAA repair. Procedures were performed under emergency conditions in 62 patients (18%) and electively in 283 patients (82%). Carotid and coronary risk was assessed in all 283 patients undergoing elective operations. There were 259 men (91.5%) with a mean age of 68 years (range: 45-88 years) and 24 women (8.5%) with a mean age of 76 years (range: 59–92 years). Previous cardiac manifestations included myocardial infarction in 57 patients (20%), angina in 50 patients (17.6%), coronary bypass grafting in 14 patients (14.9%), and coronary transluminal angioplasty in two patients. Cerebral ischemic attacks had been observed in 11 patients (3.8%) including transient events in two cases. Carotid endarterectomy had been performed in two patients. Assessment of carotid artery risk using Doppler ultrasonography led to selective carotid angiography in six patients and carotid endarterectomy in two patients. Assessment of coronary risk using a cardiac stress test was performed in 204 patients. Results were normal or subnormal in 132 patients (46.6%), abnormal in 21 patients (7.4%), and uninterpretable in 51 patients (18%). Coronary arteriography was performed in 151 patients (53.3%) for secondary assessment after the cardiac stress testing in 72 patients (25%) and for primary assessment in 79 patients (27.9%). Significant coronary lesions were demonstrated in 52 patients (18% of the overall population; 34% of coronary arteriography procedures). In 12 cases the lesions were not considered as threatening. In four cases the lesions were deemed inoperable. In the remaining 36 cases the lesions were treated either by aortocoronary bypass grafting (34 cases) or percutaneous transluminal angioplasty (two cases). In 11 of the 36 treated cases the patient was asymptomatic and had no history of coronary disease. In all cases AAA was treated by resection graft. Eight patients (2.8 ± 1%) died during hospitalization including two deaths related to preexisting cardiac insufficiency. No death was attributed to preoperative work-up or treatment of associated lesions. With a mean follow-up of 62 months (range: 1–14 years), late mortality involved 96 patients (33.9 ± 3%) including 16 deaths due to cardiac causes (16.7 ± 4%) and 10 due to stroke (10.4 ± 3%). Actuarial survival including deaths during hospitalization was 70.5 ± 3% at 5 years and 41.4 ± 5% at 10 years. Comparison of these results with those previously reported supports our policy of performing carotid or coronary angiography in patients selected by noninvasive tests. (Ann Vasc Surg 1997;11:467–472.)     

Cardiac myxomas: experience over one decade

Abstract Background: This single‐center study reviews our experience with cardiac myxomas over the past decade. Methods: Sixty‐two patients (23 male) with median age 38 years (range: 8 to 69 years) underwent excision of primary or recurrent cardiac myxomas between 2000 and 2009. Patients were evaluated with echocardiography preoperatively and annually postoperatively. Follow‐up is current for all survivors (range 13 months to 10 years). Results: Fifty‐two patients had left atrial myxomas, seven right atrial, two biatrial, and one right ventricular. Three cases were familial. Maximum number of myxomas in a single patient was four. Symptom duration ranged from two to eight months. Two early deaths were due to low cardiac output and embolic cerebrovascular accident; one late death was due to a noncardiac cause. Actuarial survival was 96.8 ± 1.8% at 10 years. Most patients were asymptomatic following surgery. No sporadic, multiple, or biatrial myxomas recurred. Recurrence occurred in two familial cases, both with single, left atrial myxoma. Freedom from reoperation was 98.4 ± 1.3% at five years and 96.8 ± 1.8% at 10 years. Conclusions: Biatrial involvement or multiplicity of myxomas does not mandate recurrence. Surgical excision has excellent overall survival and freedom from reoperation rates, but annual follow‐up including echocardiographic surveillance is recommended as familial cases tend to recur. (J Card Surg 2011;26:355‐359)     

Revascularization of the carotid and vertebral arteries in the elderly

From January 1994 to July 2004, 323 patients underwent 348 revascularization of carotid bifurcation for atherosclerotic stenoses. Eighty eight patients (group A) were 75 year-old or older, whereas 235 (group B) were younger than 75 years. Postoperative mortality/neurologic morbidity rate was 1% in group A, and 1.4% in group B. At 5 years, patency and freedom from symptoms/stroke were, respectively, 91% and 92% in group A, and 89% and 91% in group B. None of these differences was statistically significant. In the same time period, 26 internal carotid arteries were revascularized in 24 patients, 75 or more aged, for a symptomatic kinking. Postoperative mortality/morbidity rate was absent, whereas, at 5 years, patency and freedom from symptoms/stroke were, respectively, 88% and 92%. Twelve vertebral arteries were revascularized in 12 patients, 75 or more aged, for invalidating symptoms of vertebrobasilar insufficiency. Postoperative mortality/neurologic morbidity rate was absent. In one case postoperative recurrence of symptoms occurred, despite a patent revascularization. Patency and freedom from symptoms/stroke were 84% and 75%, at 5 years. Revascularization of carotid and vertebral arteries in the elderly can be accomplished with good results, superposable to those of standard revascularization of carotid bifurcation in a younger patients' population.     

Surgery for Asymptomatic Carotid Stenosis: A Study of Three Patient Subgroups

p < 0.01). Seven patients died within the first 30 postoperative days, including three who underwent combined single-stage procedures. Nine patients presented nonfatal stroke, including three who progressively recovered. The cumulative death-stroke rate (CDSR) was 5.12% overall, 3.54% in group I, 12.24% in group II, and 4.09% in group III. The difference between groups I and II was statistically significant (p < 0.05). Taking into account only deaths related to carotid surgery and stroke with permanent disability, the CDSR was 2.83% in group I and 3.25% in group III. Follow-up ranged from 24 to 132 months (mean: 66.2) with a total of 11 patients being lost from follow-up. Actuarial 5-year survival was 81.99 ± 7.13% in group I, 70.65 ± 13.72% in group II, and 68.51 ± 8.93% in group III. Differences between group I and both groups II (p < 0.01) and III (p < 0.05) were statistically significant. Overall 5-year patency was 95.59 ± 2.28%. Stroke occurred during follow-up in 13 patients. The probability of stroke-free survival was 95.29 ± 3.76% in group I, 91.03 ± 8.52% in group II, and 89.09 ± 6.39% in group III. The difference between groups I and III was statistically significant (p < 0.05). Patients with asymptomatic carotid lesions can be divided into different prognostic groups. Life expectancy is shorter for patients with multiple artery disease. Long-term stroke risk is higher in patients with nonhemispheric neurological manifestations.     

Results of carotid endarterectomy in patients 75 years of age and older.

From April 1980 to September 1989, 69 patients over 75 years of age (mean 78 years, range 75 to 86) underwent 81 carotid endarterectomies. Twenty three percent were asymptomatic, 56.5% had symptoms appropriate to lesion location and 20.5% had a non hemispheric syndrome. Nine patients required an associated procedure (combined cardiac surgery 6 pts; vascular surgery 3 pts). Perioperative mortality was 3.7%. The combined early lethal and non lethal stroke rate was 6.1%. Actuarial survival, at 10 years, was 58.4% +/- 10, and the incidence of freedom from stroke at 10 years was 86.2% +/- 5. Despite the fact that the hospital mortality of patients over 75 years undergoing carotid endarterectomy is more than three times that of patients operated on under 75 years of age (1.2%), the combined stroke and neurologic mortality rate is similar to that of patients under 75 years (5.3%). Carotid surgery in patients over 75 years of age does not increase life expectancy but does improve the quality of survival which depends mainly on cardiac events.     

Surgical closure of patent foramen ovale in patients with suspected paradoxical embolism: long‐term results

Objective—It is thought that a patent foramen ovale (PFO) is the crucial mechanism in patients with suspected paradoxical embolism and cryptogenic stroke. It has been hypothesized that closure of the PFO would prevent further cerebrovascular incidents. We describe our early and late experience with surgical closure of PFO in patients with paradoxical embolism.

Patients and methods—Between May 1994 and December 2001, 33 patients (26 men, 7 women; mean age, 55.2?±?8.7 years; range, 37–74 years) underwent surgical closure of a PFO at our institution. All patients had preoperatively suffered from a stroke and/or a transient ischemic attack, after which echocardiography showed a PFO. Mean follow‐up at 99?±?30 months (range, 10–111 months) was 100% complete.

Results—All patients survived the operative procedure. Early complications occurred in four patients (12%). Actuarial survival at 1, 5 and 8 years was 97?±?3%, 97?±?5% and 94?±?8%, respectively. At long‐term follow‐up all but two patients were alive. The deaths of these two patients were related to malignancy and ischemic heart disease, respectively. Two patients (6%) had suffered a residual cerebrovascular event after successful surgery.

Conclusion—Surgical closure of PFO in patients with paradoxical embolism can safely be performed with a low risk of early mortality. Residual thromboembolic events were rare and in those few it occurred it did so with the interatrial septum being closed, indicating that in those patients the PFO was not the mechanism of the thromboembolic event in the first place.     

A 10-year follow-up of extracranial–intracranial bypass for the treatment of bilateral giant internal carotid artery aneurysms in a patient with fibromuscular dysplasia: case report

Cervicocephalic fibromuscular dysplasia (FMD) is an idiopathic, non-inflammatory and non-atherosclerotic arteriopathy which usually affects small- and medium-sized cervical arteries distributed at the atlas and axis interspace. Few cervicocephalic FMD patients are associated with multiple intracranial aneurysms which may rupture or develop. So the authors describe a cervicocephalic FMD patient with a history of right oculomotor palsy in 2000. Angiography revealed bilateral internal carotid artery (ICA) aneurysms and a fusiform aneurysm in right vertebral artery. Typical “string-of-beads” phenomenon was observed in V2 segment of left vertebral artery. The right ICA giant aneurysm was treated by right ICA occlusion and superficial temporal artery (STA)-middle cerebral artery (MCA) bypass at that time. Five years later, the patient presented with paroxysmal weakness in right limbs. The subsequent angiography showed the enlargement of left ICA aneurysm. It was treated satisfactorily with left external carotid artery-saphenous vein-MCA bypass and left ICA ligation. During the long-term follow-up, the patient kept no neurological deficit and the angiography showed good patency of bilateral grafts and the lesions in bilateral vertebral arteries remained unchanged.     

Video-assisted thoracoscopic major pulmonary resections: technical aspects,personal series of 259 patients,and review of the literature

Background Although more than 10 years have passed since the first video-assisted thoracoscopic lobectomies, these procedures have not gained widespread acceptance. We discuss the technical aspects and major problems associated with these operations, focusing on their present status and future perspectives. The results of our clinical series are presented and the relevant literature is reviewed. Methods From October 1991 to June 2003, 344 patients were submitted to surgery for an intended video major pulmonary resection. Results Of the 344 patients, seven (2.0%) were deemed inoperable at video exploration; 78 (23.1%) required conversion, either for technical reasons (n = 3), anatomical problems (n = 49), oncological conditions (n = 20), or intraoperative complications (n = 6). We carried out 253 video-assisted lobectomies and six pneumonectomies (209 for primary lung tumor, 43 for benign disease, and seven for metastases). There were no intraoperative deaths. Two patients died postoperatively. Complications occurred in 20 patients (7.7%). Global survival at 3 and 5 years was 83.24% (±6.9) and 68.87% (±9.7), respectively. Patients with T1 N0 cancer had a better survival rate at 3 and 5 years (87.13 ± 8.3% and 75.12 ± 12.2%) than those with T2 N0 cancer (78.49 ± 11.2% and 61.2 ± 15%). Conclusions Based on our experience and a review of the literature, we conclude that video-assisted thoracoscopic lobectomies offer less postoperative pain, a more rapid recovery, and better cosmetic results than their conventional counterpart. The results at 3- and 5-year follow-up for cancer are attractive. However, because no randomized study has yet proved these benefits definitively, further studies are still needed. The video for this paper is available at     

Natural history of subclavian steal syndrome

Eighty-two patients presenting with subclavian steal syndrome (36 men, 46 women; median age, 66.5 years) were studied. All patients underwent clinical and noninvasive evaluation. Diagnosis was based on both a 20 mmHg difference in blood pressure between arms and reversed blood flow in the vertebral artery. Twenty-one patients (25.6%) had a transient ischemic attack or cerebrovascular accident before the study. In 16 patients (19.5%), the anterior circulation was involved and the vertebrobasilar circulation was effected in 5 patients (4.8%). Fifty-five patients were followed for one to six years (mean 4.1 years). During this period three patients died. Noninvasive studies showed that 39 patients (70.9%) had progression of disease in the carotid arteries and that 10 of these 39 (12.1%) exhibited a transient ischemic attack or cerebrovascular accident, and eight patients (9.7%) required carotid endarterectomy. No patient had a stroke involving the vertebrobasilar circulation, but four patients (4.8%) had a transient ischemic attack. Three other patients had revascularization procedures performed for arm ischemia. Patients with subclavian steal syndrome are more likely to experience a transient ischemic attack or cerebrovascular accident involving the carotid circulation than the vertebrobasilar circulation. Noninvasive evaluation of the carotid arteries and the posterior circulation should be included in the long-term follow-up of these patients.     

Anterior thoracolumbar column reconstruction with the vertebral body stent—safety and efficacy

Purpose

The aim of this study was to assess safety and efficacy of vertebral body stenting (VBS) by analyzing (1) radiographic outcome, (2) clinical outcome, and (3) perioperative complications in patients with vertebral compression fractures treated with VBS at minimum 6-month follow-up.

Methods

In this retrospective cohort study, 78 patients (61 ± 14 [21–90] years; 67% female) who have received a vertebral body stent due to a traumatic, osteoporotic or metastatic thoracolumbar compression fracture at our hospital between 2012 and 2020 were included. Median follow-up was 0.9 years with a minimum follow-up of 6 months. Radiographic and clinical outcome was analyzed directly, 6 weeks, 12 weeks, 6 months postoperatively, and at last follow-up.

Results

Anterior vertebral body height of all patients improved significantly by mean 6.2 ± 4.8 mm directly postoperatively (p < 0.0001) and remained at 4.3 ± 5.1 mm at last follow-up compared to preoperatively (p < 0.0001). The fracture kyphosis angle of all patients improved significantly by mean 5.8 ± 6.9 degrees directly postoperatively (p < 0.0001) and remained at mean 4.9 ± 6.9 degrees at last follow-up compared to preoperatively (p < 0.0001). The segmental kyphosis angle of all patients improved significantly by mean 7.1 ± 7.6 degrees directly postoperatively (p < 0.0001) and remained at mean 2.8 ± 7.8 degrees at last follow-up compared to preoperatively (p = 0.03). Back pain was ameliorated from a preoperative median Numeric Rating Scale value of 6.5 to 3.0 directly postoperatively and further bettered to 1.0 six months postoperatively (p = 0.0001). Revision surgery was required in one patient after 0.4 years.

Conclusion

Vertebral body stenting is a safe and effective treatment option for osteoporotic, traumatic and metastatic compression fractures.

     

Hemodynamic vertebrobasilar insufficiency caused by multiple arterial lesions: Results of surgical treatment

From 1982 to 1990, 111 of 1013 patients undergoing cerebral artery reconstruction presented with signs of vertebrobasilar insufficiency associated with hemodynamically significant lesions of at least three cerebral arteries. There were 71 men and 40 women whose mean age was 70.3 ± 8.4 years. Forty patients also had hemispheric symptoms, whereas three had ophthalmic symptoms as well. A total of 191 arteries were reconstructed in 139 procedures. During the first 30 postoperative days there were nine deaths (8.1%) attributable to four neurologic events — one myocardial infarction, two hemorrhages, and one acute kidney failure. There were 18 complications including seven neurologic events (four reversible and three irreversible), one myocardial infarction, and 10 reversible local complications. Mortality and morbidity were not affected if one (87 cases) or several (52 cases) cerebral arteries were reconstructed. Of 179 arteries for which follow-up arteriograms were obtained, two (1%) were found to be occluded. Mean follow-up was 41.2+27.7 months. Four patients were lost to follow-up, and 28 died: five of cerebrovascular causes in the 21 who died of cardiovascular causes and seven secondary to noncardiovascular events. Actuarial 5-year survival and patency rates were 63.3±10.9% and 97.3±2.8%, respectively. Functional results were evaluated in 98 patients. At the last follow-up visit 73 were asymptomatic, 13 were improved (80% good results), 5 were unchanged, and 7 were worse. Mortality and morbidity rates were superior to that for isolated carotid or vertebral artery surgery performed during the same period. Functional results of combined vertebral and carotid artery surgery are good, but the operative risk is higher in this group of patients than for either type of surgery alone.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, Marseille, France, June 21–22, 1991.