Complications of carotid artery stenting

AIM: The aim of this study was to deal with complications that can be managed by vascular surgery. METHODS: From March 2000 through May 2004, 171 patients (112 male, 59 female, mean age 66.2 years) underwent carotid artery stenting (CAS). Of these 171 interventions, 154 were CAS with percutaneous trasluminal angioplasty (PTA), 5 CAS without PTA, and 12 patients had only a PTA. RESULTS: In 171 patients who received CAS, 5 suffered a stroke within 7 days and 3 a transient ischemic attack. Twenty-one percent of the patients developed an in-stent restenosis >50% within 6 months following the intervention. Twenty-two patients with a recurrent in-stent restenosis were treated by re-PTA. Eight patients of this group of 22 re-PTAs developed a recurrent in-stent restenosis. They were converted with patch angioplasty or PTFE interposition. These 8 conversions were performed without morbidity or mortality. CONCLUSIONS: The preferable operative technique in patients with recurrent in-stent restenosis is open conventional operation with stent removal and patch angioplasty or graft interposition. The procedure can be performed at a low risk. In our series, we had no morbidity and mortality, and no cranial nerve lesion.     

Reappraisal of Primary Balloon Angioplasty without Stenting for Patients with Symptomatic Middle Cerebral Artery Stenosis

There is a controversy regarding the safety and efficacy of intracranial stenting. We describe our experience with primary balloon angioplasty without stenting for symptomatic middle cerebral artery (MCA) stenosis. All patients who underwent balloon angioplasty without stenting for MCA stenosis between 1996 and 2010 were retrospectively reviewed. We evaluated technical success rates, degrees of stenosis, and stroke or death within 30 days. Among patients who were followed-up for > 1 year we evaluated latest functional outcomes, stroke recurrence at 1 year, and restenosis. In total 45/47 patients (95.7%) were successfully treated. Average pre- and postprocedure stenosis rates were 79.9% and 39.5%, respectively. Three neurological complications occurred within 30 days: one thromboembolism during the procedure; one lacunar infarction; and one fatal intraparenchymal hemorrhage after the procedure. Stroke or death rate within 30 days was 6.4%. Thirty-three patients were available for follow-up analysis with a mean period of 51.5 months. The combined rate of stroke or death within 30 days and ipsilateral ischemic stroke of the followed-up patients within 1 year beyond 30 days was 9.4%. Restenosis was observed in 26.9% of patients and all remained asymptomatic. In our retrospective series, balloon angioplasty without stenting was a safe, effective modality for symptomatic MCA stenosis. For patients refractory to medical therapy, primary balloon angioplasty may offer a better supplemental treatment option.     

Independent predictors of restenosis after percutaneous coronary revascularization in haemodialysis patients.

BACKGROUND: Percutaneous balloon angioplasty has become a well-established and routine procedure for coronary revascularization of haemodialysis patients with coronary artery disease. However, the incidence of restenosis after balloon angioplasty is significantly higher in haemodialysis patients than in the general population. We performed a retrospective study comparing balloon angioplasty with coronary stenting in haemodialysis patients. We evaluated the long-term clinical and angiographic outcome after successful percutaneous coronary revascularization in haemodialysis patients. METHODS: A total of 103 consecutive haemodialysis patients (123 lesions) underwent procedurally and clinically successful percutaneous revascularization. Patients were treated with three different strategies: (i) balloon angioplasty in 55 patients (69 lesions); (ii) coronary stenting with balloon angioplasty in 23 patients (25 lesions); and (iii) coronary stenting with rotational atherectomy in 25 patients (29 lesions) who had severely calcified stenotic coronaries. RESULTS: The rates of in-hospital mortality were similar in the three groups. The 1-year incidence of overall events and major adverse cardiac events (MACE) were significantly higher in the balloon group than in the stent with/without rotational atherectomy groups (75% vs 36 and 28%, P<0.01; 71% vs 32 and 28%, P<0.01). Use of coronary stenting (relative risk=0.006, P<0.001) and the presence of calcified coronary lesion (relative risk=68.2, P<0.001) were independent predictors of the 1-year MACE-free survival after percutaneous revascularization. The 3-year MACE-free survival rate was significantly lower in the balloon group than in the stent with/without rotational atherectomy groups (11% vs 33 and 47%, P<0.005 and P<0.001). CONCLUSIONS: This study shows that coronary stenting reduces the incidence of MACE in haemodialysis patients with/without calcified coronary lesions. Moreover, coronary stenting reduces the restenosis rate of both complex and restenotic lesions, and rotational atherectomy prior to coronary stenting reduces the restenosis rate of the severely calcified coronary lesions. These results suggest that coronary stenting with/without rotational atherectomy has led to an improved long-term outcome in the haemodialysis patients with coronary artery disease.     

Mesenteric stenting for chronic mesenteric ischemia

BACKGROUND: Mesenteric stenting has not been widely adopted for the treatment of chronic mesenteric ischemia (CMI). The recent availability of embolic protection and low-profile devices with the theoretical ability to decrease perioperative bowel necrosis, led us to begin using mesenteric stenting for patients with CMI. We review our initial experience to examine short-term outcomes. METHODS: We performed a retrospective analysis of all patients who were treated by vascular surgeons with mesenteric stenting for CMI. Patients with acute mesenteric ischemia were excluded. We evaluated perioperative morbidity and mortality, restenosis, recurrent symptoms, and reintervention. Kaplan-Meier methods were used to assess events during follow-up. We also compared these outcomes with a historical control group of patients treated with open surgical revascularization. RESULTS: Fourteen patients underwent mesenteric stenting over the past 3 years. Mean age was 73, and 64% were women. There was no perioperative or 30-day mortality or major morbidity. Early restenosis and recurrent symptoms occurred in 10% and 9% of patients at 6 months. At a mean follow-up of 13 months, 53% of patients underwent reintervention. However, 93% were symptom-free at their last follow-up. Compared with open surgery, stent patients had lower perioperative major morbidity (30% vs 0%, P < .01) and shorter hospital and intensive care unit length of stay (median 10 days vs 2 days, and 3 days vs 0 days, respectively, P < .01 for both). However, stent patients were seven times as likely to develop restenosis (P < .01), four times more likely to develop recurrent symptoms (P < .01), and 15 times more likely to undergo reintervention (P < .01). There was one death 13 months after stenting due to mesenteric infarction in a patient lost to follow-up. One patient was successfully converted to open surgery after a second restenosis. He had regained 20 pounds and was determined to be a better operative candidate than at his initial presentation. There was no perioperative or 30-day mortality or major morbidity with reintervention after mesenteric stenting. CONCLUSION: Mesenteric stenting for CMI can be performed with low perioperative risk. However, stenting is associated with early restenosis and recurrent symptoms requiring secondary procedures. Patients with severe nutritional depletion or high surgical risk may benefit from mesenteric stenting for CMI, but close follow-up is required. Later open surgery can be performed for restenosis if nutritional status and surgical risk are improved, or repeat angioplasty and stenting can be effectively performed if operative risk remains high.     

Durability of eversion carotid endarterectomy: comparison with primary closure and carotid patch angioplasty

OBJECTIVES: Despite numerous studies in which various methods for arteriotomy closure after carotid endarterectomy (CEA) have been addressed, the optimum surgical technique to reduce complications and late carotid restenosis has yet to be firmly established. The purpose of this study was to prospectively compare the results of the eversion CEA technique with those of conventional CEA with either primary closure or carotid patch angioplasty, and to determine under clinical conditions whether eversion CEA influences the results and restenosis rate.Patients and Methods: Over a 3-year period, 322 CEAs performed on 296 consecutive patients were concurrently evaluated. This study included 118 eversion CEAs, 97 CEAs with primary closure, and 107 CEAs with patch angioplasty. There were no differences in demographics, in surgical indications, or in the severity of carotid disease (not significant [NS]). The choice of CEA technique was not randomized because of technical considerations and surgeon preference. After entry into the protocol, no patients were excluded or withdrawn. Carotid restenosis was defined as a > 60% lumen reduction at the CEA site with established duplex ultrasonography criteria. RESULTS: The mean operative time for eversion CEA was 31 minutes, for CEA-primary closure it was 39 minutes, and for CEA-patch angioplasty it was 46 minutes (P <.01). The operative mortality rate for eversion CEA was 0.8% (1 patient), for CEA-primary closure it was 1.0% (1 patient), and for CEA-patch angioplasty it was 2.8% (3 patients) (NS). The postoperative stroke rate was 0.8% after eversion CEA, 1.0% after CEA-primary closure, and 2.8% after CEA-patch angioplasty (NS). The combined stroke and death rate in each group was thus 0.8% for eversion CEA (1 stroke-death), 1% for CEA with primary closure (1 stroke-death), and 5% for CEA with patch angioplasty (1 stroke-death, 2 fatal myocardial infarctions, and 2 nonfatal strokes) (NS). Transient ischemic attacks occurred in 2.5% after eversion CEA, in 5.2% after CEA-primary closure, and in 2.9% with CEA-patch angioplasty (NS). The mean clinical follow-up for all three groups was 23 months (range, 6-42 months) (NS). The restenosis rate was 1.7% after eversion CEA, 9.3% after CEA-primary closure, and 6.5% after CEA-patch angioplasty (P <.05). CONCLUSIONS: This prospective, nonrandomized clinical study indicates that eversion CEA is an effective surgical option comparable to conventional CEA with either primary arteriotomy closure or carotid patch angioplasty. No differences were found between eversion CEA and these more widely accepted CEA closure techniques with respect to operative morbidity and mortality. These data indicate, however, that eversion CEA has a lower restenosis rate than conventional CEA closure techniques and thus superior long-term durability.     

In-stent Restenosis After Carotid Angioplasty and Stenting: A Challenge for the Vascular Surgeon

PURPOSE: This study aims to review the incidence of in-stent restenosis (ISR), the factors which determine restenosis, and to evaluate the use of various endovascular techniques for the management of ISR following carotid artery stenting (CAS). METHODS: Four hundred and seven patients (334 men, mean age 63 years, range 46-86, median 65 years) were treated with CAS between December 2000 and March 2004. Three hundred and seventy-two (89%) patients had at least one ultrasound evaluation performed 6 months after procedure (range 6-40). Recurrent stenosis >80% detected with duplex ultrasound scans were further evaluated by angiography and treated with repeat endovascular procedure. RESULTS: CAS was performed successfully in all cases with a Carotid WallStent (Boston Scientific) using a cerebral protection device (filter). Perioperative complications included four (0.9%) minor and two (0.4%) major strokes these latter two patients died at 5 and 12 days after the operation. No other deaths occurred. A total of 15 carotid arteries (3.6%) in 14 patients had ISR. All ISR were treated with a repeat endovascular procedure: three balloon angioplasty alone, eight angioplasty and secondary stenting, four angioplasty with cutting balloon. Postsurgical restenosis was confirmed to be the only predictive factor for the development of in-stent restenosis (OR 14.5, 95% CI 2.3-113.4, p=0.005). Endovascular treatment of ISR achieved technical success without periprocedurale complications and the absence of significant restenosis over a median follow up time of 12.4 months (range 3.5-30.7). CONCLUSION: Our experience with a large cohort of CAS showed an encouragingly low incidence of ISR (3.6%) and successful treatment by repeat endovascular intervention. We recommend attempting all endovascular possibilities before performing stent removal.     

下肢动脉硬化闭塞症腔内治疗后支架内再狭窄的治疗

目的:探讨下肢动脉硬化闭塞症(ASO)腔内治疗后支架内再狭窄的治疗体会。方法:回顾性分析2012年6月至2014年12月收治的支架内再狭窄的31例下肢ASO患者(49条肢体)资料,其中狭窄病变37条肢体,闭塞病变12条肢体;病变长度8.5~35 cm,平均(25.2±7.5)cm。结果:所有患者均接受腔内治疗,包括单纯球囊扩张成形术35例,球囊扩张后导管溶栓术3例,球囊扩张后支架植入术3例,导管溶栓后球囊扩张术7例,斑块旋切术1例。术后所有患者症状均不同程度缓解,平均踝肱指数较术前明显升高(P0.05)。28例获得随访3~32个月,平均(16.2±5.8)个月,期间出现再狭窄6例(21.4%),均再次行球囊扩张成形术,无截肢及死亡病例。结论:结合其他腔内疗法,球囊扩张术治疗下肢动脉支架内再狭窄疗效满意。     

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目的总结逆行锁骨下动脉支架植入治疗重度锁骨下动脉狭窄和闭塞的初步临床经验方法1999年9月至2003年7月采取经肱动脉逆行植入支架治疗锁骨下动脉重度狭窄和闭塞共19例术前诊断包括彩色多普勒超声检查和动脉造影确诊手术方法是经患侧上肢肘部小切口解剖肱动脉，逆行造影和支架植入。结果本组支架植入成功18例，支架植入满意，无移位。失败1例．因病变闭塞完全，导丝无法通过闭塞部位而转行手术治疗。治疗成功的18例中随访16例，随访时间2～48个月，平均24个月失访2例。随访率88.9％一有2例分别于术后11个月和14个月出现再狭窄，1例再次行球囊扩张成功，1例转行手术治疗结论逆行锁骨下动脉支架植入是治疗锁骨下动脉重度狭窄和闭塞安全有效的方法     

Results of emergency aortocoronary venous bypass surgery after failed percutaneous transluminal coronary angioplasty in patients with unstable angina pectoris

During a 4-year period from January 1985 to December 1988 140 patients underwent percutaneous transluminal coronary angioplasty (PTCA) of the culprit-vessel for unstable angina. Seventeen patients (12%) needed emergency aorta coronary bypass surgery (ACVB) for failed angioplasty. In 15 cases the culprit-vessel was the LAD and in 2 cases a dominant right coronary artery. Only in 2 cases a history of myocardial infarction was present. Twelve patients were in hemodynamic stable condition after arriving in the operating-room. Five patients were hemodynamic unstable, 4 of them were in cardiogenic shock. Four patients died representing an operative mortality rate of 23%. Three patients died from pump failure despite intraaortic balloon counterpulsation in 2 cases. One patient died from cerebral damage 12 day after surgery. All patients who died were in cardiogenic shock preoperatively. Two patients who survived suffered an extensive myocardial infarction. Thus including the patients who died from pump failure the perioperative infarction rate was 30%. From these results it is concluded that emergency ACVB after failed PTCA of the culprit-vessel in patients with unstable angina results in a significant higher mortality and morbidity as compared with patients who had primary surgery for unstable angina. The prognosis of patients after failed PTCA for unstable angina depends on the hemodynamic situation thereafter and becomes worse in patients with cardiogenic shock.     

Indications of coronary angioplasty and stenting in 2003: what is left to surgery?

For many years, coronary artery by-pass graft (CABG) remained the only effective treatment of multivessel disease compared to medical treatment. The first technical revolution was in 1977 when Gruentzig introduced balloon percutaneous transluminal coronary angioplasty (PTCA), the 2nd in the 90's with the developments of stents and antiaggregant protocols. The equipment for PTCA became more and more sophisticated, and the skill of cardiologists greater. In the 90's, interventional cardiology played a predominant role in revascularization as the number of CABG decreased at the same time, and emergency CABG for bail out almost disappeared (0% to 0.5%). Systematic stenting decreased the need for repeat revascularization to about 18-20% nowadays in the majority of centers, except in diabetic patients. Despite this fact restenosis remains the pitfall of angioplasty, mostly in diabetic patients presenting multivessel disease in which surgery with "all arterial grafts" gives good long term RESULTS: The first studies comparing PTCA and CABG are favourable to surgery (BARI), then late ones using stents (ARTS, ERACI 2) showed that stenting was at least equivalent to CABG, in terms of mortality or serious complications (major acute coronary events, MACE), despite a higher target vessel revascularisation (TVR) mainly due to restenosis in the angioplasty cohort. The same results are observed by stenting a high risk lesion as the unprotected left main stenosis can be, until then treated surgically. However, high volume centers studies treating by PTCA+stent the unprotected left main artery (LMA) shows that the 1 year survival rate is similar to surgery, but always related to a restenosis rate of 20% at 6 months in the stent group, which represents the only significant difference in terms of MACE; the new drug eluting stents lead us to expect, according to SIRIUS and TAXUS II studies, to reduce the restenosis rate, and by the way, the MACE could be dramatically lowered from 50% to 60%. Randomised studies would be necessary, but the extrapolation of the actual data, more particularly results of subgroups with a high risk of restenosis, diabetic patients and small vessels, lead us to think that stenting could come in first intention before surgery if TVR is significantly reduced. A complex anatomy, failed attempted chronic occlusion, several lesions on tortuous vessels, would remain the last surgical indication if CABG provides a more complete revascularization. The impact of these new drugs seems promising. However, we should await early results of studies in diabetic patients and bifurcations. But in high volume experienced centers, CABG indications would be reduced in the future to the technical pitfalls of stenting (complex or tortuous anatomy, chronic occlusions) or to the adverse additional cost of this device, unless reduction of restenosis or TVR could also cancel this extra cost. We expect randomised studies CABG versus stented angioplasty using drug eluting stents to confirm these preliminary data.     

大动脉炎的介入及外科治疗

目的 探讨介入技术和外科手术在大动脉炎治疗中的应用.方法 2006年1月至2009年12月共收治大动脉炎26例,男女比例为1:4.2,平均年龄(27±15)岁;Lupi-Herre法分型,Ⅰ型16例,Ⅱ型7例,Ⅲ型3例.16例患者实施介入治疗,9例行开放手术,1例患者保守治疗.结果 16例患者实施介入治疗23次,其中1...     

Carotid artery stenting in a vascular surgery practice

PURPOSE: We tested the clinical applicability, technical results, and morbidity of carotid angioplasty-stenting (CAS) in the treatment of severe stenosis of the internal carotid artery (ICA) in patients deemed to be high-risk candidates for carotid endarterectomy (CEA). METHOD: After an initial series (1994-1997) of 52 interventions, we adopted the use of a transfemoral access technique and self-expanding stents in late 1997. From Dec 1, 1997, to Mar 31, 2001, 135 CAS procedures were performed on 132 patients with more than 70% (symptomatic) or more than 80% (asymptomatic) stenoses of the ICA. Sixty percent of the patients had no symptoms, and 40% of patients had symptoms. The interventional technique was standardized with the use of a 7F long interventional sheath, balloon pre-dilatation of the stenotic lesion, placement of a self-expanding stent (Wallstent in 12 patients and a SMART stent in 120 patients), and post-balloon dilatation when necessary. Brain protection devices were not used. Patients were given clopidogrel and aspirin before and after the procedure and heparin during the intervention. RESULTS: All procedures except two were completed as planned, with access failure in three patients (2.2%). Residual in-stent stenosis of less than 20% was detected in 14 of 132 stented vessels (11%) and accepted as a satisfactory angiographic outcome. Neurologic complications included one patient with a single-episode transient ischemic attack (TIA; motor-sensory deficit of the hand) occurring 2 hours after CAS. One patient sustained a major stroke after thrombosis of the stented ICA, which occurred 3 days after the CAS procedure and 24 hours after open-heart surgery. A third patient sustained a minor stroke that began intraprocedurally after post-balloon dilatation of the stent, and a fourth patient had another minor stroke with transient aphasia (beginning during the procedure and resolving after 4 hours) and monoparesis of the hand, which resolved after 1 week. All stented vessels remained patent during the follow-up period (range, 2-41 months; mean, 16 plus minus 9 months), with four instances of hemodynamically significant in-stent restenosis. Re-intervention with balloon angioplasty was undertaken successfully at 4 months in one patient with restenosis. The periprocedural mortality rate was 0. CONCLUSION: Carotid stenting can be performed with acceptable safety on carefully selected patients by using meticulous, standardized interventional techniques. It may offer a possibly superior therapeutic alternative for non-CEA candidates. Evolving technological improvements and brain protection devices are likely to enhance its role in the treatment of carotid artery disease in the future. Surgical endarterectomy remains the standard of care for most patients at the present time.     

Carotid artery stenting with routine cerebral protection in high-risk patients

BACKGROUND: Carotid artery stenting has emerged as an alternative treatment modality in carotid occlusive disease. This study examined our experience of carotid stenting with routine cerebral embolization protection in high-risk patients. METHODS: Clinical variables and treatment outcome of high-risk patients who underwent carotid stenting with neuroprotection were analyzed during a 26-month period. RESULTS: Sixty-eight high-risk patients with 72 carotid artery stenoses were treated. Procedural success was achieved in 70 cases (97%), and symptomatic lesions existed in 17 (24%) patients. Monorail Wallstents stents were used in all cases. Neuroprotective devices used were PercuSurge (28%) and Filterwire (72%). There was no periprocedural mortality or neuroprotective device-related complications. The 30-day stroke and death rate was 2.7%, and the overall complication rate was 6.9%. All stented vessels remained patent during the follow-up period (mean 15.3 +/- 4.2, range 1 to 23 months). Two asymptomatic in-stent restenosis (3%) occurred at 6 and 8 months, which were both successfully treated with balloon angioplasty. CONCLUSIONS: Our study showed that percutaneous carotid stenting with routine use of a cerebral protection device is a feasible and effective treatment in high-risk patients with carotid occlusive disease.     

Durability of surgery for restenosis after carotid endarterectomy

BACKGROUND: The role of carotid surgery for the management of restenosis after carotid endarterectomy (CEA) is challenged by carotid artery stenting (CAS). We reviewed redo CEA in a consecutive series of patients to determine the safety, durability, and long-term benefit associated with repeat surgical treatment for restenosis. METHODS: A consecutive series of 73 redo procedures in 72 patients (57% men) with a mean age 66 years (range, 49-81 years) was analyzed. The mean interval between prior CEA and redo CEA was 53 months (range, 8-192 months). Operative indications included symptomatic restenosis in 28 patients (38%). A patch angioplasty was performed in 62 patients (85%). The main outcome measures included perioperative and late stroke and death, and the development of secondary restenosis. RESULTS: There were no perioperative deaths or strokes. During a mean follow-up of 52 months (range, 12-144 months), the Kaplan-Meier cumulative survival was 85% at 5 years. At 5 years, the cumulative rate of freedom from all strokes was 98%, and the freedom from ipsilateral stroke was 100%. After secondary procedures, re-recurrent stenosis > or =50% occurred in 10 patients (13.7%). The cumulative freedom from re-restenosis (> or =50%) was 85% at 5 years. Five patients (7%) received tertiary carotid reconstructions. CONCLUSION: Repeat CEA for recurrent stenosis can be performed safely with excellent long-term protection from stroke. These data provide a standard against which the results of CAS can be compared.     

Intraoperative balloon angioplasty: a surgical approach.

Percutaneous balloon angioplasty is a recognized treatment for peripheral atherosclerosis involving the iliac and femoropopliteal segments. From their experience in 38 patients the authors have examined the efficacy of intraoperative balloon angioplasty for tandem lesions requiring both balloon angioplasty and surgical intervention. Between January 1988 and July 1990, 43 intraoperative balloon angioplasties were performed in 19 women and 19 men who required inflow or outflow angioplasty in addition to surgical bypass. The indication for surgery was incapacitating claudication in 32 (74%) patients and limb salvage in 11 (26%) patients. Initial technical success was achieved in 17 (89%) of 19 patients who required iliac surgery and in 22 (92%) of 24 patients who required femoropopliteal balloon dilatations. There were four major complications (9%), all requiring surgical intervention. In two cases there was dissection with thrombosis and in two cases failure to improve the pressure gradient. Patients were followed up for up to 24 months. Two of the inflow angioplasties failed between 6 and 9 months. Two of the outflow angioplasties failed between 12 and 15 months. Three patients died in the follow-up period, two from myocardial infarction. In the authors' experience intraoperative balloon angioplasty has proven a worthwhile adjunct for tandem lesions in the iliac and femoropopliteal segments.     

CAROTID ENDARTERECTOMY FOR ASYMPTOMATIC CAROTID ARTERY STENOSIS: PATIENTS WITH SEVERE BILATERAL DISEASE A HIGH RISK SUBGROUP

Carotid endarterectomy if advised for asymptomatic disease must be associated with a low peri-operative morbidity and mortality and satisfactory long-term results. Over a 12 year period between 1978–1989 181 carotid endarterectomies were performed on 163 patients with asymptomatic carotid artery stenosis. There were 112 males and 51 females with a mean age of 64.9 years. All patients had a high-grade lesion (> 70% stenosis). The combined operative mortality and stroke rate was 2.8%. On long-term follow up six patients suffered a stroke. Only one patient however sustained a stroke in the same territory as the previously operated carotid artery. Four years following surgery 78% of patients were alive. Carotid restenosis or occlusion occurred in 8.3% of the remaining patients, all of whom were asymptomatic. All the immediate postoperative strokes occurred in patients with severe bilateral carotid artery disease. These patients with severe bilateral disease appear to constitute a high risk sub-group for peri-operative stroke. The role of ‘normal pressure-hyperperfusion breakthrough’ syndrome as the presumed aetiology of two of the postoperative cerebral haemorrhages is discussed.     

Combined carotid endarterectomy with transluminal angioplasty and primary stenting of the supra-aortic vessels

BACKGROUND: Carotid endarterectomy (CEA) is the standard of care for patients with high-grade carotid artery stenosis who are acceptable surgical candidates. Focal occlusive lesions of the origin of aortic arch vessels can be effectively and safely treated with balloon angioplasty and primary stenting. The purpose of this study was to retrospectively review results of carotid endarterectomy for high-grade carotid bifurcation stenosis combined with intraoperative retrograde transluminal angioplasty and primary stenting of a hemodynamically significant stenosis at the origin of a proximal ipsilateral aortic arch vessel. METHODS: Between October 1994 and August 1998, 592 patients underwent CEA. Six patients were found to have hemodynamically significant tandem lesions affecting one of the aortic arch vessels and the ipsilateral ICA for an overall incidence of 1%. Age ranged from 63 to 78 years (mean 74.7). Four of 6 (67%) patients had asymptomatic lesions, and 2 of 6 (33%) had symptoms of cerebral ischemia. Five patients had tandem lesions affecting the proximal left common carotid artery and the left ICA. One patient had a tandem lesion affecting the innominate artery and the right ICA. Carotid duplex imaging and arch and cerebral arteriography was performed in all six patients. Arteriography confirmed high-grade stenoses in both the ICA and ipsilateral proximal aortic arch vessel. The range of stenoses in the ICA was 70 to 95% (mean 80.8%) measured arteriographically. The range of stenoses at the origin of the aortic arch vessels was 75-90% (mean 79.2%). All six patients underwent combined retrograde transluminal balloon angioplasty and primary stenting of the ipsilateral CCA or innominate artery with temporary occlusion of the ICA for cerebral protection. The endovascular procedure was then followed with standard surgical endarterectomy using an inline shunt. RESULTS: All six procedures were successfully completed. There were no periprocedural strokes or other morbidities. Follow-up ranged from 6 to 43 months (mean 23.6) and showed no evidence of recurrent stenosis by carotid duplex imaging. No TIAs or strokes related to the surgically corrected lesions were noted during the follow-up period. One patient suffered a right hemispheric stroke secondary to a high-grade right carotid stenosis which occurred two months after her procedure surgically correcting tandem lesions on the opposite side. CONCLUSIONS: Carotid endarterectomy with balloon angioplasty and primary stenting of an ipsilateral hemodynamically significant aortic arch trunk vessel stenosis can be safely and successfully accomplished and avoids the need for an intra/extrathoracic bypass procedure.     

Vascular surgeon's experience with intraoperative angioplasty

Background : Intraoperative balloon angioplasty as an adjunct to vascular reconstruction is controversial and radiologists suggest that it may be less effective than preoperative or postoperative percutaneous transluminal angioplasty. The aim of the present study was to explore the role of intraoperative balloon angioplasty as performed by a vascular surgeon. Methods : The notes and angiograms of 63 patients on whom 67 intraoperative angioplasty/stenting procedures were performed were retrieved using a computerized prospective audit system. Results : Although 41 procedures were planned preoperatively, 26 (39%) followed intraoperative angiography. Twenty‐seven were performed to improve inflow for distal reconstructions and 27 were performed to improve outflow for proximal reconstructions. Thirteen (anastomotic stenoses) followed synthetic graft thrombectomy. Twenty‐seven iliac, 15 superficial femoral artery (SFA), 11 popliteal, one anterior tibial and 13 anastomotic lesions were dilated and there were four technical failures. At follow up (median: 24 months; 3‐monthly duplex scan, ankle brachial pressure indices) primary patency rates by lifetable analysis were: iliac, 75%; SFA, 91%; popliteal, 82%; anastomotic, 8%. Conclusions : There are situations in which intraoperative angioplasty would be advantageous and can be performed successfully by a surgeon. Because a significant proportion of procedures was unplanned and a vascular radiologist was not readily available the authors conclude that vascular surgical trainees should be trained in angioplasty techniques. However, balloon angioplasty is ineffective in treating anastomotic stenoses and surgical intervention is required for these lesions.     

血管内支架成形术治疗颅外段颈动脉狭窄

目的:分析总结血管内支架治疗颅外段颈动脉狭窄的方法和并发症的预防.方法2001年10月至2008年6月共271例(300侧)颅外段颈动脉狭窄患者接受血管内支架成形术治疗,术前口服氯吡格雷75 ms/d,肠溶阿司匹林100～200 mg/d,辛伐他丁40 mg/晚,共5～10 d.应用肝素持续静脉滴注(50 mg/d)共2 d.术后继续抗血小板、降脂治疗.结果:271例患者(300侧)手术均获成功,颈动脉狭窄和脑缺血症状得到明显改善.术后1周内并发症7例,1例死亡.226例患者3～24个月行超声或数字减影血管造影,5例发生再狭窄;其中45例患者超声随访超过36个月,无再狭窄病例;所有病例随访期间无脑缺血相关症状发生.结论:血管内支架治疗颈动脉狭窄是安全有效的,正确的围手术期的处理以及娴熟的操作技巧是手术成功的关键.     

Initial clinical experience with a modified excimer laser for coronary angioplasty

A clinical study was conducted in 32 patients to evaluate the efficacy and safety of a modified excimer laser system for percutaneous transluminal coronary angioplasty. In this system, the laser beam is scanned and transmitted into eight fibre bundles of the catheter device, consisting of 20 50 μm fibres, each. Twenty-eight patients were treated with 1.5 mm laser catheters, four patients with 1.8 mm laser catheters. Mean time of energy delivery was 82±39 s using a mean energy fluence of 49±2 mJ mm⁻². In all 32 patients in whom laser angioplasty was attempted, laser irradiation resulted in a stenosis reduction from 85±10% (mean±s.d.) before to 57±20% after laser treatment. In 16 patients, additional balloon angioplasty had to be performed, either due to an insufficient angiographic result in 11 patients or due to abrupt vessel closure in five patients. In these 16 patients, percent stenosis decreased after balloon angioplasty to 35±14%, corresponding to a luminal diameter of 1.6±0.5 mm. In 10 patients, dissection was observed. In one of these patients, the dissection resulted in a reduction in antegrade flow, necessitating balloon dilatation. One perforation occurred which did not require surgery. There were no deaths, bypass surgery or myocardial infarction. During the time of follow-up, restenosis occurred in 14 patients; in two of these patients bypass surgery was performed and five patients were treated with conventional balloon angioplasty. These results suggest that this form of modified excimer energy delivery provides effective therapy for patients with coronary artery disease. Due to the small catheter sizes, however, one-half of the patients still required additional balloon dilatation. To increase the number of stand-alone laser procedures and to address the issue of restenosis in this patient population appropriately, larger catheter devices will be necessary.