Surgical reconstruction of the internal carotid artery with contralateral occlusion without use of shunt

Between 1979 and 1989, 133 carotid artery reconstructions were performed in 130 patients with contralateral internal carotid artery occlusion. These 133 reconstructions represent 7.3% of 1815 revascularizations of the internal carotid artery for atheromatous lesions performed during the same period. There were 113 men (87%) and 17 women (13%) whose mean age was 64.8 years (range 38 to 83 years). Forty-two patients (32%) had coronary artery disease and 77 (59%) were hypertensive. Nineteen patients (14%) were asymptomatic; 16 (12%) had symptoms of isolated vertebrobasilar insufficiency; 19 (14%) had ipsilateral carotid symptoms (on the side of operation); 67 (51%) had contralateral symptoms (on the side of occlusion); and 12 (9%) had bilateral carotid symptoms. All procedures were performed under general anesthesia without the use of a shunt. Nine patients (6.8%) died in the postoperative period (eight of neurologic and one of respiratory causes). Twelve patients (9%) sustained a cerebral vascular accident (eight ipsilateral and four contralateral). Four of these cerebral vascular accidents were diagnosed upon awakening, the remaining eight occurred after an initial uneventful recovery. Combined neurologic mortality and morbidity was 9.8%. Patients with occlusive lesions of the contralateral carotid artery undergoing internal carotid artery reconstruction are at high risk for postoperative cerebral vascular accidents. It is in this group of patients that the various methods of monitoring and cerebral protection should be evaluated.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Direct transposition of the distal cervical vertebral artery into the internal carotid artery

From January 1979 to December 1991, 92 revascularizations of the V3 segment of the vertebral artery were performed in 91 patients through a direct transposition of this artery into the internal carotid artery (ICA). These cases represented 15.1% of 610 vertebral revascularizations and 38.8% of 280 distal vertebral revascularizations performed during this period at our institution. The sex ratio of this population was 0.59, and the mean age was 59.4±13.2 years (range 14 to 82 years). Preoperative ischemic symptoms were vertebrobasilar in 87 (94.6%) cases, exclusively hemispheric in one (1.1%), and absent in the remaining four (4.3%). One of these four patients had asymptomatic severe multivessel occlusive disease and three others underwent resection of a spinal tumor involving the vertebral foraminal canal. In 31 (33.7%) cases significant carotid occlusive disease was also present. The distal V3 segment of the artery was directly transposed into the ICA in all cases in this series. In 24 (26.1%) cases the ICA was endarterectomized during the same operation. There were no deaths or strokes in this series but there were two (2.2%) transient ischemic attacks-one vertebrobasilar and the other hemispheric. However, eight (8.7%) transposed vertebral arteries were totally occluded at early follow-up. At 1 month, among the 87 patients with vertebrobasilar insufficiency, 44 (50.6%) were cured, 31 (35.6%) were improved, and 12 (13.8%) remained unchanged. Among the 12 who were unchanged, eight (66.7%) had occlusion or stenosis of the distal transposition at the time of discharge. At 5 years, the primary patency rate in the series was 89.1%±7.2%. At the time of the last follow-up, among the 87 patients with vertebrobasilar insufficiency, 50 (57.5%) were cured, 25 (28.7%) were improved, two (2.3%) had remained unchanged since the operation, two (2.3%) suffered a relapse, and eight (9.2%) exhibited vertebrobasilar symptoms of varying severity and therefore could not be considered improved. Direct transposition of the V3 segment of the vertebral artery into the ICA is a simple, safe, and reliable technique for revascularization of the distal cervical vertebral artery.Presented at the Fourth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Breckenridge, Colo., January 21–23, 1994.     

Risiken und Komplikationen gef??chirurgischer Zugangswege

Reconstruction of the vertebral artery is nowadays rarely indicated and performed even though the number of patients suffering from vertebrobasilar insufficiency is not decreasing. The challenging technical procedures focus on segment V1 and V3 of the vertebral artery. The arterial reconstruction of the proximal vertebral artery takes place in the scalenovertebral spatium and requires preparation of the subclavian artery at its proximal segment. Major risks are injury of the vagus nerve, of the thoracic duct and the sympathetic trunk. The reconstruction of choice is direct transposition of the proximal vertebral artery (V1) into the ipsilateral common carotid artery which has a long-term patency rate greater than 90%. Different reconstructions have individual indications and are rarely performed. The third part of the vertebral artery (V3) can be exposed between C1 and C3 where the atlas loop is formed. Great care has to be taken with respect to the accessory nerve and the venous plexus accompanying the vertebral artery. The most feasible form of revascularization is a venous carotid-to-vertebral artery bypass with patency rates greater than 80%. Other methods are reserved for specific indications. General technical procedure and results equate to carotid artery reconstruction. Therefore open revascularization of the small calibre vertebral artery is preferred to endovascular techniques.     

Results of vertebral artery reconstruction

We summarize here the immediate and long term results of 191 vertebral artery reconstructions. Patient selection criteria included vertebrobasilar insufficiency, appropriate angiographic work up, lack of contraindications, and the availability of a suitable technique. Of the 179 patients who underwent these operations, 170 presented with vertebrobasilar insufficiency that in turn was associated with hemispheric manifestations in 29 cases. Five patients had hemispheric manifestations only, and four were asymptomatic. The operation involved the proximal segment of the vertebral artery in 148 instances and its distal segment in 43 instances. Of the eight deaths recorded in this series (4.2%), one occurred in a group of 118 patients who underwent isolated vertebral artery reconstruction and seven in a group of 72 patients who underwent combined vertebral and carotid surgery. This difference was statistically significant (p less than 0.01). The overall survival rate at seven years was 88.8%, and was higher in the group undergoing isolated vertebral repair. Patency at seven years was 90.4% with better results for proximal vertebral artery repair than for distal repair (94.3% versus 77.3%). With a mean follow-up of 34.6 +/- 19 months, 118 patients are asymptomatic, and 15 are improved, for a success rate of 80.1%. Patients with hemispheric manifestations and associated carotid lesions constitute a high risk population for this type of surgery.     

Atherosclerotic occlusive disease of the superior mesenteric artery: Late results of reconstructive surgery

Between 1975 and 1988, 103 patients underwent reconstruction of the superior mesenteric artery for atherosclerotic occlusive disease. Patients undergoing revascularization with associated mesenteric infarction were excluded. There were 89 men and 14 women whose mean age was 57.2 years. Six patients were operated on emergently for impending mesenteric infarction; six patients underwent revascularization after intestinal resection for ischemic lesions; 20 patients had typical abdominal angina; 39 patients had nonspecific abdominal symptoms, and 32 patients underwent revascularization of their superior mesenteric artery for asymptomatic lesions. Revascularization of the celiac axis and inferior mesenteric artery was associated in 36 and four cases, respectively. Four patients (4%) died postoperatively. Four early occlusions (4%) were observed. During the follow-up period (mean=69 months), 18 patients died; five patients had recurrent intestinal ischemic symptoms, four of whom died. All surviving patients underwent follow-up duplex scanning, examination, and arterial or venous digitalized angiograms in selected cases. Nine patients (9%) had anatomical abnormalities: two stenoses and seven occlusions. Failure of revascularization of the superior mesenteric artery was observed in patients with severe initial intestinal ischemia. Late complications were not statistically significantly related to the different techniques of revascularization used. Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, June 23–24, 1989, Strasbourg, France.     

Stenting of vertebrobasilar arteries in symptomatic atherosclerotic disease and acute occlusion: case series and review of the literature

PURPOSE: Two of three patients with vertebrobasilar stroke harbor a stenosis of the vertebral or basilar arteries. The best treatment for secondary prophylaxis in vertebrobasilar occlusive disease has not been defined. In patients with high-grade stenoses, and especially those refractory to medication, stenting offers the chance to restore normal flow and prevent major strokes. METHODS: We provide data regarding outcome and complications on 20 consecutive patients who underwent vertebrobasilar stenting at our institution (9 V0, 2V3, 5 V4, and 4 basilar artery lesions). Furthermore, we provide a comprehensive overview of the literature on >600 cases of vertebrobasilar stenting, including all published cases up to 2005. RESULTS: Primary interventional success was achieved in all cases, with a mean residual stenosis of 3% +/- 4% in V0, 5% +/- 4% in V3/4, and 7% +/- 3% in basilar artery lesions. No peri-interventional neurologic complications and no transient ischemic attack or stroke at follow-up were noted in patients with vertebral ostial lesions, whereas two transient and three permanent clinical deteriorations occurred in patients with V4 or basilar artery lesions, some of which had presented with acute stroke. Patency rate was 100% at the last examination. According to published data on proximal vertebral artery stenting, mortality is 0.3%, the rate of neurologic complications is 5.5%, and the risk of posterior stroke at follow-up is 0.7%. Interventions for distal vertebral or basilar artery disease carry a 3.2% mortality risk, a 17.3% risk for neurologic complications and a 2% risk for stroke at follow-up. CONCLUSIONS: Stenting of the vertebral origin can be performed safely and with a low rate of cerebral ischemic events at follow-up, although restenosis may occur. Larger comparative trials are needed. Treatment decisions in distal vertebrobasilar disease have been made on an individual basis.     

Stenotic coiling and kinking of the internal carotid artery

Between January 1979 and December 1991, 174 of a total of 2304 carotid reconstructions (7.5%) were performed in 166 patients for stenotic coiling or kinking of the internal carotid artery. There was a 1.4 male predominance and the mean age of the patients was 66.3 ± 9.6 years (range 38 to 91 years). Seventeen patients (9.8%) were asymptomatic, 54 (31%) were symptomatic because of a previous stroke, and 103 (59.2%) had had transient ischemic attacks. The symptoms were hemispheric in 108 (62.1%) cases, ocular in 19 (10.9%), and vertebrobasilar in 30 (17.2%). The stenotic coiling or kinking was isolated in 35 (20.1%) cases and associated with other lesions of the internal carotid artery in 139 (79.9%). These included 119 atherosclerotic stenoses, 14 aneurysms, and six stenotic lesions due to fibromuscular dysplasia. Angioplasty of the carotid bifurcation was performed in 102 (58.6%) patients, associated with endarterectomy in 84 (48.3%) cases and with dilatation of dysplastic lesions in six (3.5%) cases. A bypass graft and resection and anastomosis of the carotid artery were performed in 36 (20.7%) patients each. There were four postoperative deaths (2.3%): two were due to neurologic causes, one to heart disease, and one to complications of an associated surgical procedure. Five patients (2.9%) had postoperative strokes and eight (4.6%) had transient ischemic attacks. At postoperative follow-up investigations four (2.3%) patients had carotid occlusions and 10 (5.7%) had morphologic abnormalities. At 5 years, actuarial survival was 80.97 ± 8.8%, patency was 96.12 ± 2.95%, and the ipsilateral stroke-free rate was 93.12 ± 4.49%. Treatment of stenotic coiling or kinking of the internal carotid artery yields satisfactory results, comparable to those of endarterectomy, for isolated atherosclerotic carotid stenoses and is effective in the prevention of ipsilateral ischemic stroke.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, Reims, France, June 19–20, 1992.     

Concomitant ipsilateral carotid endarterectomy and stenting is an effective treatment for tandem carotid artery lesions

ObjectiveData regarding the treatment of tandem carotid artery lesions at the bifurcation and ipsilateral, proximal common carotid artery (CCA) are limited. It has been suggested that concomitant treatment with carotid endarterectomy (CEA) and proximal ipsilateral carotid artery stenting confers a high risk of stroke and death. The objective of this study was to evaluate the technique and outcomes of this hybrid procedure at a single institution.MethodsA retrospective chart review was performed including patients who underwent CEA + ipsilateral carotid artery stenting for treatment of atherosclerotic carotid artery disease between December 2007 and April 2017. Primary endpoints were postoperative myocardial infarction, neurologic event, and perioperative mortality.ResultsTwenty-two patients (15 male [68%]) underwent CEA + ipsilateral carotid artery stenting with a mean follow-up of 67 ± 77 months. The mean age was 70.0 ± 6.1 years old, all with a prior smoking history (eight current smokers [64%]). Twelve patients (55%) were treated for symptomatic disease and three had a prior ipsilateral CEA (one also with CAS). Computed tomographic angiography imaging was performed preoperatively in 21 patients (95%). CEA was performed first in 18 patients (82%) followed by ipsilateral carotid artery stenting. CEA was performed with a patch in 20 and eversion endarterectomy in two patients. Ipsilateral CCA was stented in 21 patients (96%) and one innominate was stented in a patient with a right CEA. Additional endovascular interventions were performed in three patients: 1 innominate stent, 1 distal ipsilateral internal carotid artery stent, and 1 right subclavian artery stent. All proximal stents were placed with sheath access through the endarterectomy patch in 12 (55%), CCA in 7 (32%), and through the arteriotomy before patching in 3 (14%). Distal internal carotid artery clamping was performed in 18 (90%, available 20) of patients before ipsilateral carotid artery stenting. All proximal lesions were successfully treated endovascularly with no open conversion. One dissection was created and treated effectively with stenting. One perioperative stroke (4.5%) occurred in a patient treated for symptomatic disease, 1 postoperative myocardial infarction (4.5%), and 2 patients (9.1%) with cranial nerve injuries. There was one patient who expired within 30 days, shortly after discharge for unknown reasons. The mean length of stay was 2.6 ± 2.0 days.ConclusionsIn appropriately selected patients, concomitant CEA and ipsilateral carotid artery stenting can be safely performed in high-risk patients with a low risk of myocardial infarction, neurologic events, and perioperative mortality when careful surgical technique is used, using direct carotid access, and distal carotid clamping for cerebral protection before stenting.     

Simultaneous carotid-vertebral reconstruction

Vertebral atherosclerotic lesions frequently coexist with lesions in the carotid arteries. The most common cause of vertebrobasilar symptoms is hypoperfusion which may be relieved by correction of a critical carotid stenosis. A safe record with direct vertebral revascularization has led us to do simultaneous correction of lesions in the carotid and vertebral arteries through a single cervical incision. To evaluate combined carotid and vertebral reconstruction, procedures performed in a five-year period (1982 to 1987) were retrospectively studied. Thirty-six patients had combined carotid-vertebral reconstruction. In 10 patients, the primary indication was critical carotid disease; 26 patients had vertebrobasilar symptoms. The procedures performed were carotid endarterectomy with either vertebral reimplantation (22) or distal vertebral bypass (7), or external carotid angioplasty with either vertebral reimplantation (3) or distal vertebral bypass (4). Combined carotid-vertebral procedures are effective in relieving symptoms of hypoperfusion in the vertebrobasilar system. A specific lesson learned is that a distal vertebral bypass must not be done in conjunction with an external carotid angioplasty.     

Clinical significance of retrograde flow in the vertebral artery

Although retrograde vertebral artery flow was described over 100 years ago, its relationship to symptoms remains unclear. We documented 43 patients who were found by duplex scanning to have reverse flow in the vertebral artery. Of this group, seven patients (16%) were found to have symptoms described as typical for the subclavian steal syndrome. Nearly one-third were asymptomatic. Of the remaining patients, 13 (30%) presented with nonhemispheric symptoms while nine (21%) had hemispheric symptoms. Nine patients had to and fro flow in the vertebral artery. This variant was not found in subclavian steal patients but correlated with nonhemispheric symptoms. During follow-up (mean: 19 months) none of the asymptomatic patients became symptomatic, and there were no strokes or stroke-related deaths. Surgical procedures which restored antegrade vertebral artery flow did not necessarily improve symptoms of posterior circulation ischemia. In some patients improvement in posterior circulation symptoms was noted following carotid endarterectomy. It is concluded that retrograde flow in the vertebral artery is, per se, a benign entity. Accurate selection of surgical candidates remains imprecise. It will require not only identification of vertebrobasilar disease but as yet undefined tests to assure symptoms are due to these stenoses.     

Surgical management of extracranial carotid artery aneurysms

Between 1982 and 1991 we performed eight operations on seven patients with carotid artery aneurysms. Their mean age was 52.8 years (range: 20–67 years). Five aneurysms were atherosclerotic, one was associated with Marfan's syndrome, and two were pseudoaneurysms, one occurring after Dacron patch angioplasty and the other due to tuberculosis. Seven aneurysms were treated electively; one patient underwent an emergency surgical procedure. In one case, the internal carotid artery was ligated. Seven operations were reconstructive. No intraluminal shunt was used. No perioperative deaths occurred. Regressive hemiparesis and ipsilateral Horner's syndrome developed in one patient. The follow-up period ranged from six months to nine and a half years. One patient died of myocardial infarction three months after surgery.     

Vertebral artery injury--diagnosis and management

The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. Six patients (26.1%) developed major neurologic deficits of which five could be directly attributed to CNS missile injury. One patient had transient vertebrobasilar ischemia on the basis of a vertebral AV fistula. Four of the seven vertebral AV fistulae were managed solely by therapeutic embolization and two patients early in the series underwent surgical management alone. One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury. We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1-2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.     

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.     

Vertebral arterial reconstruction: a nineteen-year experience

Between January 1964 and December 1983, 109 operations were performed directly on the vertebral arteries whereas a total of 1727 carotid operations were done, resulting in an incidence of vertebral operations of 5.6%. Unilateral vertebral operations only were performed in the treatment of bilateral flow-restricting lesions with cerebral hemispheric or brain stem symptoms present or persisting despite widely patent carotid arteries or in the presence of inoperable totally occluded internal carotid vessels. The average follow-up period (9.9 years; the longest was 19 years) revealed an overall survival rate of 71% with a stroke rate of 1.5% per average year of follow-up. Specific operative procedures performed were subclavian-vertebral roof-patch angioplasty with plication of associated vertebral kinks in 102 patients, reimplantation of the end of the proximal vertebral artery into the side of the ipsilateral carotid artery in four patients, carotid-vertebral vein bypass in two patients, and decompression of herniated vertebral arteries between segments of foramina transversaria by unroofing the bony canal. The overall operative mortality rate was 3%. The most common neurologic complications were transient phrenic nerve paralysis and usually mild Horner's syndrome.     

Restoration of blood flow in the external carotid artery

The external carotid artery revascularization procedures were performed in 19 cases. Fourteen patients had ischemic stroke history. Ten patients had occluded the ipsilateral internal carotid artery to the stenosed external carotid artery. Six patients had occluded the common as well as internal carotid artery on the same side. Positive neurologic changes were obtained in 73.7% of the operated patients. The external carotid artery revascularization procedures are recommended in cases when the ipsilateral internal carotid artery is occluded.     

Long-term results of thrombectomy for late occlusions of aortofemoral bypass

Sixty-two first episodes of aortofemoral (eight patients) or aortobifemoral (42 patients) bypass thrombosis were operated upon in 50 patients between 1980 and 1985. There were 47 men and three women whose mean age was 58 years. Retrograde thrombectomy through the distal anastomosis was achieved in all cases by using either a balloon catheter or Vollmar rings. If thrombectomy was impossible, revascularization was ensured by an extraanatomic bypass or complete replacement of the graft. Angioplasty, repeat distal anastomosis or femoropopliteal bypass of the native runoff artery were done in 55 (89%) operations. The cause of thrombosis was elucidated in 45 cases. Suture line stenosis and atheromatous stenosis of the native runoff artery were the two most common causes. Three patients died and two required above-knee amputation in the immediate postoperative period. Contralateral embolism occurred in two patients undergoing retrograde thrombectomy. Mean follow-up was 47 months. Thrombectomy was possible in 51 of 62 prosthetic thromboses (Group I). Thirty-nine of these grafts have remained patent. Twelve instances of repeat thrombosis occurred, requiring either repeat thrombectomy or a new bypass. Primary patency in group I was 97.8%, 81.2%, and 71.3% at one, three, and five years, respectively. Thrombectomy was impossible in 11 graft thromboses (Group II). A new bypass was performed in all 11 cases. Primary patency in Group II was 100%, 75% and 50% at one, three, and five years, respectively. Retrograde thrombectomy combined with treatment of native runoff artery anomalies can restore long-term patency when thrombosis occurs late after aortofemoral bypass and is associated with low mortality and morbidity.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Surgical management of extracranial vertebral artery occlusive disease

Thirty-seven consecutive patients underwent vertebral artery (VA) reconstruction over a 6 years period (1983-1989). Detailed neurologic, medical, and angiographic information was obtained for all patients. Indications for surgery were as follows: (1) stenosis of VA with symptoms of vertebrobasilar insufficiency; (2) very tight stenosis (greater than 75%) of the dominant VA with stenosis or occlusion of the contralateral VA; (3) very tight stenosis of VA with bilateral occlusion of the internal carotid artery (ICA); (4) very tight stenosis of VA with homolateral ICA lesion eligible for simultaneous repair; (5) very tight stenosis of VA and very tight stenosis of the homo or contralateral carotid siphon. There were 15 isolated vertebral lesions (group I), and 22 were VA lesions associated with lesions of the supraaortic trunks which were simultaneously treated (group II). The reconstructions of the first portion of the VA were 30 (12 of group I and 18 of group II) and reimplantation of the VA into the common carotid artery was the procedure of choice. There were 7 revascularizations of the third portion of the VA at C1-C2 level (3 of group I and 4 of group II): carotid-vertebral bypass, using an autogenous vein graft, was the procedure of choice. Three patients in group II died in the immediate postoperative period from myocardial infarction but no patient presented immediate postoperative neurologic deficits. All symptomatic patients but one were relieved of their symptoms in a median follow-up of 31 months. No postoperative complications were observed. Long-term results were satisfactory in all the 28 patients at their last follow-up visit.(ABSTRACT TRUNCATED AT 250 WORDS)     

Revascularization of the external carotid artery

Numerous reports describe the relative effectiveness of external carotid artery (ECA) revascularization in patients with ipsilateral internal carotid artery occlusion. Most, however, suffer from small numbers of patients or lack of detailed follow-up data. In addition, controversy persists regarding the safety with which this procedure can be performed. Twenty-two patients underwent a total of 27 ECA revascularizations. There were no perioperative strokes or deaths. During a mean follow-up period of 46 months, no strokes occurred and only two patients suffered transient ischemic attacks. Revascularization of the ECA is an effective means of treating the patient with ipsilateral internal carotid artery occlusion and may be performed with minimal morbidity and mortality.     

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.)     

Pre- and intraoperative transcranial doppler: Prediction and surveillance of tolerance to carotid clamping

We report 91 patients (mean age 70 years) operated upon, prospectively for a total of 100 carotid revascularizations (nine bilateral). Eighty-five of these patients had pre-, intra-, and postoperative transcranial Doppler investigations. Preoperatively, these 85 patients (92 procedures) were classified into two groups based on the results of their Doppler examinations: Group A (65 patients, 72 procedures), those who did not require an intraoperative indwelling shunt and Group B (20 patients, 20 procedures), those who did. The shunt was inserted only when the mean stump (back) pressure was less than 50 mmHg after cross-clamping. Group A all had satisfactory collaterality with a functional anterior and one or two posterior communicating arteries. Group B had no communicating arteries (anterior or posterior) identified by transcranial Doppler. In 17 of 20 patients in this group, the stump pressure was less than 50 mmHg and a shunt was placed. The overall prediction based on Doppler examination of whether or not patients would need a shunt during operation for the two groups A and B (i.e., 92 procedures) was correct in 95.6% (88/92) of cases. Moreover, six hemodynamically significant stenoses (four in the cavernous portion, two in the middle cerebral artery) were disclosed. Sensitivity and specificity of transcranial Doppler as correlated with arteriographic findings were 70 and 90%. Preoperative transcranial Doppler can measure the velocities of the principal cerebral arteries and the collateral capacity of the circle of Willis, and can forecast tolerance to carotid cross-clamping. Intraoperatively, the velocity of flow in the middle carotid artery was correlated with stump pressure, which allowed for surveillance of the shunt.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.