Early and late outcome after carotid artery bypass grafting with saphenous vein

OBJECTIVES: This study was undertaken to determine outcome and durability of internal carotid artery bypass grafting with saphenous vein. METHODS: Data for 50 patients undergoing serial clinical and ultrasound surveillance were collected prospectively and analyzed retrospectively. RESULTS: Bypass grafting was performed in 50 patients between 1995 and 2002, the commonest reasons being excessive endarterectomy zone thinning or penetrating atheroma (n = 22), severe internal carotid artery coiling above the endarterectomy zone (n = 14), and patch infection (n = 5). Perioperative mortality was 2%, and death and stroke rate was 6%. Perioperative complications were associated with complex cardiovascular events, including hemorrhage after prosthetic patch infection, on-table thrombosis after endarterectomy, and synchronous carotid artery-cardiac reconstruction. One patient had a late ipsilateral stroke (10 months; normal scan). Cumulative stroke-free survival at 3 years (including operative events) was 91%. Cumulative freedom from recurrent stenosis greater than 70% or occlusion was 86% at 1 year and 83% at 3 years. Severe recurrent stenosis or occlusion developed in 7 patients, within 9 months of surgery in 6 patients and with 18 months in 1 patient. Angioplasty was performed without complication (no protection device, no stent) in 5 patients, 3 of whom required repeat angioplasty on at least one further occasion. CONCLUSIONS: In common with venous conduits elsewhere, carotid artery bypass grafting with saphenous vein is associated with a high incidence of early graft stenosis. The long-term stroke risk, however, is low. Carotid artery bypass grafting is a safe and durable alternative when endarterectomy would prove hazardous or inadvisable, but regular surveillance is necessary.     

Common brachiocephalic trunk: strategies for revascularization

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

Crossover iliofemoral bypass grafting for treatment of unilateral iliac atherosclerotic disease.

PURPOSE: In patients with unilateral iliac disease, a less invasive procedure than aortobifemoral bypass grafting may be desirable, especially in poor-risk patients or when sexual dysfunction is feared. In these cases, femorofemoral (FF) bypass grafting is often proposed. Compared with FF bypass grafting, iliofemoral (IF) bypass grafting avoids bilateral exposure of the groins, which may reduce the risk of infection. When the primitive iliac artery is occluded from its origin or heavily calcified, one may use the contralateral artery as inflow, after a small retroperitoneal exposure, to perform a crossover iliofemoral (CIF) bypass grafting procedure, through the Retzius space. Our 10-year experience with CIF bypass grafting in a select group of patients was studied. METHODS: Between 1986 and 1996, 36 patients underwent CIF bypass grafting for symptomatic unilateral iliac occlusion or stenosis. All patients were examined by means of Doppler ultrasound scanning and underwent bilateral multiplane angiography. Patients were considered for this procedure when the ipsilateral common iliac artery was occluded from its origin or was diffusely and heavily calcified. The decision to perform a CIF bypass grafting procedure was made when no significant disease of the contralateral common iliac artery was seen, and patients who had features of contralateral iliac disease were excluded. The main outcomes were perioperative mortality and morbidity, long-term primary and secondary patency rates, and limb salvage rate. RESULTS: The study included 31 men and five women, with a mean age of 58.8 years. Indications for bypass grafting were disabling claudication (26 of 36 patients, 72%) and limb-threatening ischemia (10 of 26 patients, 28%). Twelve procedures were performed simultaneously: endarterectomy of the recipient common femoral artery (n = 3), femoropopliteal bypass grafting (n = 4, 11.1%), profundoplasty (n = 4, 11%), and right internal carotid endarterectomy (n = 1). New postoperative erectile dysfunction did not develop in any of the patients. The survival rate was 97.3% at 1 year and 68.5% at 5 years. The primary and secondary patency rates were 94% and 100%, respectively, at 1 year and 76.7% and 95%, respectively, at 5 years. The limb salvage rate was 100% at 1 year and 87% at 3 years. CONCLUSION: The operative mortality associated with CIF is low. The long-term primary and secondary patency rates are satisfactory, and they are lower than those reported for aortobifemoral bypass grafting. This procedure does not preclude a later performance of an aortobifemoral bypass grafting procedure. CIF bypass grafting is not only suitable for poor-risk patients with a limited life expectancy who have the appropriate arterial anatomy, but also may be warranted for young patients in whom erectile dysfunction is feared.     

Carotid bypass with polytetrafluoroethylene grafts: a study of 110 consecutive patients

BACKGROUND: Carotid endarterectomy (CEA) is the standard treatment for atherosclerotic lesions involving the carotid bifurcation. However, CEA can be challenging under some conditions. We describe the technique and outcome of prosthetic carotid bypass grafting (PCB) with polytetrafluoroethylene (PTFE) grafts as an elective alternative to CEA. PATIENTS AND METHODS: This retrospective analysis of prospectively collected data came from a series of 110 consecutive PCBs, that is, 9.6% of 1140 carotid revascularization procedures performed in our department between September 1986 and July 2002. Primary indications for PCB were extensive atherosclerotic lesions (n = 45, 40.9%), carotid stenosis associated with kinking (n = 29, 26.4%), recurrent stenosis (n = 18, 16.4%), and stenosis after radiation therapy (n = 7, 6.4%). RESULTS: The combined stroke and death rate at 30 days was 0.9%. Mean duration of follow-up was 647 +/- 71 days. Four carotid bypass grafts (3.6%) became occluded, and stenosis recurred in 1 (0.9%). At 3 years, overall actuarial survival was 81.4 +/- 11.5 and actuarial stroke-free rate was 97.7 +/- 2.3. There were no fatal strokes. CONCLUSION: PCB is a viable technique for treatment of extensive atherosclerotic carotid lesions, recurrent carotid stenosis, and carotid stenosis after radiation therapy. Postoperative stroke, occlusion, and recurrent stenosis rates are comparable to those associated with CEA performed under optimal conditions.     

Operative strategy in combined coronary and carotid artery disease

In the period between the opening of our heart center in November 1984 and May 1986, 2001 cardiac operations were performed with the aid of cardiopulmonary bypass. Almost three quarters (73.5%, n = 1471) of the patients had coronary artery disease and 20% (n = 359) had acquired valvular heart disease. In 47 of 1471 patients who underwent coronary artery bypass grafting, a simultaneous carotid endarterectomy was performed. They included 36 men and 11 women, aged between 51 and 78 years (mean 64 years). Preoperatively, 12 patients had cerebrovascular symptoms and 35 were neurologically asymptomatic. Twenty-three had unilateral carotid stenosis and 24 had bilateral or multiple vessel disease of the extracranial arteries. All except four patients had triple-vessel coronary artery disease. In three patients with aortic valve disease, coronary bypass, carotid endarterectomy, and aortic valve replacement were performed simultaneously. Cardiopulmonary bypass was instituted before carotid endarterectomy was performed, with mild hypothermia and hemodilution for added protection. Electroencephalographic monitoring was used throughout the operation. Forty-six of the 47 patients survived the operation without neurologic or cardiac complications. One patient had a neurologic deficit with hemiplegia and coma, which was lethal. We conclude that simultaneous endarterectomy of significant extracranial artery stenosis in candidates for coronary bypass is a method safe enough to justify its routine use.     

Safety and efficacy of one stage off-pump coronary artery operation and carotid endarterectomy

BACKGROUND: Patients with concomitant occlusive disease of coronary and carotid arteries remain at high risk of perioperative stroke and myocardial infarction. Combined coronary artery bypass grafting on cardiopulmonary bypass and carotid endarterectomy has been shown to give good results for this category of patients. In the present study, we analyzed our results of off-pump coronary artery bypass grafting and carotid endarterectomy as a one-stage procedure. METHODS: Between January 1997 and December 2000, 82 patients underwent combined off-pump coronary artery bypass grafting and carotid endarterectomy. All patients were evaluated by preoperative carotid duplex scanning and carotid angiography. All patients had more than or equal to 70% carotid artery stenosis. There were 35 asymptomatic patients (42.7%) and 47 symptomatic patients (57.3%). Carotid endarterectomy was performed before coronary artery bypass grafting in all the patients. RESULTS: There were 66 males (80.5%) and 16 females (19.5%) with a mean age of 63+/-8 years. The average number of grafts was 3.4+/-0.8. There was no hospital mortality. One patient had perioperative myocardial infarction. None of the patients had stroke. One patient had transient neurologic deficit and 1 patient had temporary 12th nerve dysfunction; both recovered completely. There was no incidence of neck wound infection, although 1 patient developed neck hematoma that required reexploration. At a mean follow-up of 2.2+/-0.7 years, 1 patient required contralateral carotid endarterectomy and 1 patient died because of cardiac failure. CONCLUSIONS: Combined off-pump coronary artery bypass grafting and carotid endarterectomy is a safe and effective procedure in patients with significant concomitant carotid and coronary artery disease.     

Aortic arch vessel stenting: a single-center experience using cerebral protection

HYPOTHESIS: Endovascular interventions have revolutionized the contemporary treatment of peripheral vascular occlusive disease. Traditional management of supra-aortic trunk disease has employed surgical extra-anatomic bypass via a cervical approach or median sternotomy. Endoluminal therapy may be a less morbid alternative. DESIGN AND SETTING: A retrospective review of procedures performed by vascular surgeons in an operating room angiosuite at a single university-based, tertiary referral center. PATIENTS: Eighteen consecutive patients with 20 brachiocephalic-origin stenoses. INTERVENTIONS: From December 2001 through September 2005, 20 brachiocephalic-origin stenoses were treated endoluminally with balloon-expandable stents. Treated vessels were innominate (n = 8), common carotid (n = 9), and subclavian (n = 3). The target lesion was accessed by one of the following methods: antegrade via the femoral artery (n = 5), retrograde through the brachial artery (n = 1), or via a retrograde cut-down on the common carotid artery (n = 14). Cerebral protection was achieved with either a distal embolic filter device or with open surgical occlusion of the distal common carotid artery. MAIN OUTCOME MEASURES: We report immediate and midterm outcomes of all aortic arch vessel stenting procedures with mean follow-up of 12 months. RESULTS: Mean age was 68 years (6 men and 12 women) and overall mean stenosis was 85%. Preprocedural symptoms including stroke, transient ischemic attack, arm fatigue, digital ischemia, and angina were present in 16 of 20 cases (80%). The 4 asymptomatic patients all had more than 90% stenosis on angiography. At 30-day follow-up, there were no deaths, myocardial infarctions, or strokes. During follow-up, there were no cases of restenosis. CONCLUSION: Endoluminal arterial stenting of brachiocephalic arch vessels may be a viable alternative to traditional open bypass in cases of focal stenotic disease.     

Radiotherapy-induced supra-aortic trunk disease: early and long-term results of surgical and endovascular reconstruction

PURPOSE: Few articles have dealt specifically with management of radiotherapy-induced supra-aortic trunk disease. We investigated the results of surgical and endovascular treatment of these lesions, and present our findings in a large series of patients. METHODS: The study was conducted at 11 centers. Over 10 years 64 patients with radiotherapy-induced supra-aortic trunk disease underwent surgical or endovascular treatment. Data were collected retrospectively in a consecutive cohort of patients, and were analyzed with the Kaplan-Meier method. RESULTS: Mean patient age was 64.4 years. The indications for radiotherapy included breast cancer (30%), head and neck malignancies (50%), and lymphomas (19%). The mean interval between irradiation and arterial revascularization was 15.2 years. Thirteen of the 64 patients (20%) had asymptomatic disease, and 51 patients (80%) had symptomatic disease. Ninety-two stenotic or occlusive lesions were observed, which involved the common carotid artery (n = 62), the subclavian artery (n = 26), or the innominate artery (n = 4). Twenty-three patients (36%) had multiple supra-aortic trunk lesions, but only 8 patients underwent reconstruction of multiple supra-aortic trunks. Five patients (8%) underwent sternotomy for revascularization from the ascending aorta. Forty-seven patients required revascularization of a common carotid artery; procedures included bypass grafting (n = 30), angioplasty with stent placement (n = 13), carotid-carotid transposition (n = 2), and endarterectomy (n = 2). Fifteen patients underwent restoration of a subclavian artery. One patient died on postoperative day 5, of stroke after early occlusion of an intercarotid crossover bypass graft. Mean follow-up was 37 months (range, 2-120 months). Ten late deaths occurred during follow-up. The probability of survival at 4 years was 78.1% +/- 8.6%. During follow-up, 6 patients had stroke, 4 bypass occlusions occurred and 3 stenoses occurred in the revascularized arteries. At 4 years the probability of freedom from stroke was 85% +/- 8.8%. At 4 years the primary patency rate was 79.3% +/- 8.5% and the secondary patency rate was 87.9% +/- 7.2%. CONCLUSIONS: In light of the context, the results of arterial revascularization to treat radiation-induced arterial lesions of the supra-aortic trunk are satisfactory.     

Coronary artery bypass combined with bilateral carotid endarterectomy

BACKGROUND: Surgical management of patients presenting for coronary artery bypass grafting with significant bilateral carotid artery stenosis has not been well defined. In this study, our preliminary results of coronary artery bypass grafting with concomitant bilateral carotid endarterectomy have been reviewed. METHODS: A retrospective nonrandomized chart review was performed in 33 patients with unstable angina and bilateral carotid artery stenosis, more than 70%, undergoing simultaneous coronary artery bypass grafting and bilateral carotid endarterectomy using an eversion technique. RESULTS: Concomitant coronary artery bypass grafting with bilateral carotid endarterectomy was performed urgently in 24 (73%) and electively in 9 (27%) patients. The average carotid artery cross-clamp and total perfusion times were 14.7 +/- 4.9 minutes and 123 +/- 29.2 minutes, respectively. The average length of stay in the cardiopulmonary intensive care unit was 4.2 +/- 14.2 days and total hospital stay was 16.2 +/- 20.5 days. Postoperative in-hospital stay was 14.9 +/- 20.3 days. There were no postoperative strokes. Twenty-one (64%) patients were discharged before the tenth postoperative day. Nonfatal postoperative complications occurred in 27% (9 of 33) of patients. The overall 30-day mortality was 6.1% (2 of 33) and that was unrelated to primary cardiac or cerebrovascular events. CONCLUSIONS: Favorable outcome supports the justification for performing concomitant coronary artery bypass grafting with bilateral carotid endarterectomies in selected patients.     

Carotid artery revascularization through a radiated field

OBJECTIVE: Extracranial carotid stenosis is a complication of external head and neck irradiation. The safety and durability of carotid artery revascularization through a radiated field has been debated. We describe the immediate and long-term results in a series of 27 consecutive patients who received treatment over 12 years. METHODS: From May 1990 to May 2002, 27 consecutive patients underwent 30 primary carotid artery revascularization procedures. All patients had received previous radiation therapy within a mean interval of 10 years (range, 1-26 years), with average radiation dose of 62 Gy (range, 50-70 Gy). Moderate to severe scarring of the skin or radiation fibrosis was present in three fourths of patients. Thirteen patients (48%) had undergone radical neck dissection, and 2 patients had a permanent tracheotomy. The indications for carotid surgery included high-grade (>70%) symptomatic stenosis in 18 patients (60%) and high-grade asymptomatic stenosis in 12 patients (40%). General anesthesia with systematic shunting was used in 18 patients (60%), and regional anesthesia with selective shunting was used in 12 patients (40%). Operations included standard carotid endarterectomy (n = 20), with patch angioplasty (n = 12) or direct closure (n = 8); carotid interposition bypass grafting (n = 7); and subclavian to carotid bypass grafting (n = 3). Primary closure of the surgical wound was performed in all procedures without any special muscular or skin flaps. All patients were followed up for a mean of 40 months (range, 3-99 months). RESULTS: There was one (3.3%) perioperative death, from massive intracerebral hemorrhage; and 1 patient had a transient ischemic attack. In-hospital complications included neck hematoma in 2 patients, which required surgical drainage in 1 patient. There was neither delayed wound healing nor infection. Twelve patients died during follow-up, of causes not related to treatment. None of the surviving patients had further stroke, and all remained asymptomatic. Follow-up duplex scans showed asymptomatic recurrent stenosis greater than 60% in 3 patients, 2 of whom with stenosis greater than 80% underwent repeat operation. Risk for recurrent stenosis greater than 60% at 18 months was 16.6%. Recurrent stenosis occurred in 2 of these patients after saphenous vein bypass, and in 1 patient after endarterectomy with vein patch angioplasty. CONCLUSION: The clinical results and sustained freedom from symptoms and stroke over 40-month follow-up suggests that carotid revascularization through a radiated field is a safe and durable procedure in patients at high surgical risk, despite a marked incidence of recurrent stenosis.     

Simultaneous carotid endarterectomy and coronary revascularization

BACKGROUND: Combined cardiac operation and carotid endarterectomy using our technique is an acceptable approach to simultaneous correction of both carotid and cardiac disease. METHODS: From August 1989 to March 1998, 121 consecutive patients underwent combined operations. Of these patients, 112 had coronary artery bypass grafting and carotid endarterectomy, and 9 had coronary artery bypass grafting, carotid endarterectomy, and valve repair or replacement. All patients had a critical stenosis of 85% or more of the carotid artery. Mean age of the patients was 69.2 years; 80 patients were 65 years old or older. There were 88 men and 33 women. Notable risk factors included chronic obstructive pulmonary disease (19.8%), congestive heart failure (28%), preoperative myocardial infarction and unstable angina (66.9%). Of the patients, 20.7% had a stenosis of greater than 50% of the left main coronary artery. The technique used was correction of both the carotid and coronary lesions during a single aortic cross-clamp period using retrograde continuous blood cardioplegia for myocardial protection. Systemic hypothermia to 25 degrees C was used for cerebral protection. RESULTS: Mean cross-clamp time was 118 minutes. Seven patients (5.8%) sustained perioperative cerebrovascular accidents. Two patients had transient ischemic attacks. The procedure-related mortality rate was 5.8%. CONCLUSIONS: The described technique is a good method for simultaneous repair of coronary and carotid lesions in a high-risk group of patients with concomitant disease. We will continue to use it.     

Changing profiles of failed coronary angioplasty patients: impact on surgical results.

As more high-risk patients undergo percutaneous transluminal coronary angioplasty (PTCA), the changing profiles of PTCA patients who may require emergent coronary artery bypass grafting may alter operative morbidity and mortality. This study compared profiles of recent patients undergoing emergent coronary artery bypass grafting after a failed PTCA with earlier patients to determine their impact on operative results. From 1980 to 1988, 53 patients underwent emergent coronary artery bypass grafting after a failed PTCA at the Boston University Medical Center. These patients were divided into two groups based on the year of the PTCA: group I, 1980 to 1985 (n = 18); and group II, 1986 to 1988 (n = 35). Group II patients tended to be older (age greater than or equal to 65 years, 47% group II versus 11% group I), were more likely to have unstable angina before PTCA (74% versus 33%), and had lower ejection fractions (0.53 +/- 0.02 versus 0.63 +/- 0.05) and more vessels with 50% or greater stenosis (2.1 +/- 0.2 versus 1.6 +/- 0.2). Nevertheless, there was no significant difference in the incidence of perioperative myocardial infarcts using enzyme and electrocardiographic criteria (37% in group II versus 39% in group I), 30-day operative mortality (11% in group II versus 11% in group I), or major postoperative complications (14% in group II versus 22% in group I). We conclude that despite the changing profiles of patients undergoing PTCA, which include older patients with more extensive coronary artery disease and lower ejection fractions, operative results after emergent coronary artery bypass grafting for failed PTCAs remain unchanged.     

Magnesium sulphate and amiodarone prophylaxis for prevention of postoperative arrhythmia in coronary by-pass operations

Background

Despite the existence of controversial debates on the efficiency of coronary endarterectomy (CE), it is still used as an adjunct to coronary artery bypass grafting (CABG). This is particularly true in patients with endstage coronary artery disease. Given the improvements in cardiac surgery and postoperative care, as well as the rising number of elderly patient with numerous co-morbidities, re-evaluating the pros and cons of this technique is needed.

Methods

Patient demographic information, operative details and outcome data of 104 patients with diffuse calcified coronary artery disease were retrospectively analyzed with respect to functional capacity (NYHA), angina pectoris (CCS) and mortality. Actuarial survival was reported using a Kaplan-Meyer analysis.

Results

Between August 2001 and March 2005, 104 patients underwent coronary artery bypass grafting (CABG) with adjunctive coronary endarterectomy (CE) in the Department of Thoracic-, Cardiac- and Vascular Surgery, University of Goettingen. Four patients were lost during follow-up. Data were gained from 88 male and 12 female patients; mean age was 65.5 ± 9 years. A total of 396 vessels were bypassed (4 ± 0.9 vessels per patient). In 98% left internal thoracic artery (LITA) was used as arterial bypass graft and a total of 114 vessels were endarterectomized. CE was performed on right coronary artery (RCA) (n = 55), on left anterior descending artery (LAD) (n = 52) and circumflex artery (RCX) (n = 7). Ninety-five patients suffered from 3-vessel-disease, 3 from 2-vessel- and 2 from 1-vessel-disease. Closed technique was used in 18%, open technique in 79% and in 3% a combination of both. The most frequent endarterectomized localization was right coronary artery (RCA = 55%). Despite the severity of endstage atherosclerosis, hospital mortality was only 5% (n = 5). During follow-up (24.5 ± 13.4 months), which is 96% complete (4 patients were lost caused by unknown address) 8 patients died (cardiac failure: 3; stroke: 1; cancer: 1; unknown reasons: 3). NYHA-classification significantly improved after CABG with CE from 2.2 ± 0.9 preoperative to 1.7 ± 0.9 postoperative. CCS also changed from 2.4 ± 1.0 to 1.5 ± 0.8

Conclusion

Early results of coronary endarterectomy are acceptable with respect to mortality, NYHA & CCS. This technique offers a valuable surgical option for patients with endstage coronary artery disease in whom complete revascularization otherwise can not be obtained. Careful patient selection will be necessary to assure the long-term benefit of this procedure.     

Coronary and carotid operations under prospective standardized conditions: incidence and outcome

Background. No randomized trial has yet evaluated the hypothetical benefit of carotid endarterectomy with coronary artery bypass grafting. This prospective review was undertaken to determine the differences between observed and predicted complication rates, as well as to define new predictors and assess costs in a standardized population.

Methods. A prospective nonrandomized study was undertaken over a 4-year period involving all coronary artery bypass graftings done at one institution. Operative procedure was standardized. All patients underwent preoperative screening for carotid disease. If 80% or more stenosis was present, combined coronary artery bypass grafting and carotid endarterectomy was performed.

Results. Of 2,071 patients, 1,987 had coronary artery bypass grafting only. In that group there were 34 strokes (1.7%) and 41 deaths (2.0%). Eighty-four patients underwent combined coronary artery bypass grafting/carotid endarterectomy and in that group there were four strokes (4.7%) and five deaths (5.9%). Independent risk factors for postoperative stroke were age (odds ratio 1.09; 95% confidence interval 1.04, 1.3), hypertension (odds ratio 2.67; 95% confidence interval 1.22, 5.23), extensively calcified aorta (odds ratio 2.82; 95% confidence interval 1.34, 5.97), and bypass time (odds ratio 1.01; 95% confidence interval 1.00, 1.02). Cost of a stroke was significant (p < 0.05) in both groups.

Conclusions. Patients with carotid disease fall into a higher risk group than patients without it. This increased risk is not because of carotid disease alone. Patients without significant carotid disease, who suffered a perioperative stroke, fell into an even higher risk category. Furthermore, carotid endarterectomy was not a significant risk factor by either the univariate or the multivariate analysis.     

Innominate artery occlusive disease: surgical approach and long-term results.

We reviewed our experience with 54 patients who underwent innominate artery revascularization during a 10-year period. Their age range was from 16 to 75 years (mean, 49.8 years). The innominate artery alone was involved in 21 patients (39%); the remaining patients had additional arch vessel obstructions. Before operation, neurologic symptoms occurred in 25 patients (46%), arm ischemia related to claudication and microembolization occurred in 8 patients (14%), a combination of symptoms occurred in 17 patients (32%), and no symptoms were noted in 4 patients (8%). The extrathoracic approach to surgery was used in 16 patients (30%). Eleven of the 38 patients in whom the intrathoracic approach was used had endarterectomy of the innominate artery; in three of those, the procedure was combined with left common carotid endarterectomy. Bypass grafts were used in the other 27 patients undergoing procedures with an intrathoracic approach; in six of those, bypass was combined with carotid endarterectomy. No operative deaths occurred. Perioperative revascularization failure occurred in four cases; all of those patients underwent a second revascularization procedure, with a secondary patency rate of 100%. In four patients, late occlusion was noted at 6 months and at 1, 1.5, and 10 years. One patient had a permanent perioperative neurologic deficit in the distribution of the left carotid artery after a combined common carotid endarterectomy/innominate endarterectomy procedure. No neurologic deficits were directly related to the innominate artery territory. Long-term actuarial survival was 83% at 10 years. Early and late graft failures were related to inadequate inflow in bypass grafts, progression of distal disease in arteritis, and primary closure in endarterectomy.     

Long-term results and outcomes of crossover axilloaxillary bypass grafting: A 24-year experience

OBJECTIVE: The outcome of crossover axilloaxillary bypass grafting in patients with stenosis or occlusion of the innominate or subclavian arteries was investigated. METHODS: The study was designed as a retrospective clinical study in a university hospital setting with 61 patients as the basis of the study. Fifty-eight patients (95.1%) had at least two risk factors or associated medical illnesses for atherosclerosis, and 35 patients (57.4%) had concomitant carotid artery stenosis that necessitated a staged procedure in 12 patients (19.7%). The patients underwent a total of 63 crossover axilloaxillary bypass grafting procedures. Demographics, risk factors and associated medical illnesses, preoperative symptoms and angiographic data, blood flow inversion in the vertebral artery, concomitant carotid artery disease, graft shape, caliber and material, and intraoperative and postoperative complications were studied to assess the specific influence in determining the outcome. RESULTS: One postoperative death (1.6%), four early graft thromboses (6.2%), and six minor complications (9. 8%) occurred. The overall mortality and morbidity rates were 1.6% and 16.1%, respectively. During the follow-up period (mean, 97.3 +/- 7.9 months), we observed five graft thromboses (8.3%). Primary and secondary patency rates at 5 and 10 years were 86.5% and 82.8% and 88.1% and 84.3%, respectively. Overall, two patients (3.3%) had recurrence of upper limb symptoms and none had recurrence of symptoms in the carotid or vertebrobasilar territory. The 5-year and 10-year symptom-free interval rates were 97.7% and 93.5%, respectively. Nine patients (15%) died of unrelated causes. The 5-year and 10-year survival rates were 93.2% and 67.3%, respectively. Multivariate analysis showed that no specific variables exerted an influence in the short-term and long-term results and the outcome. CONCLUSION: The optimal outcome of axilloaxillary bypass grafting supports its use as the most valuable surgical alternative to transthoracic anatomic reconstructions for innominate lesion, long stenosis of the subclavian artery, and short subclavian artery stenosis associated with ispilateral carotid artery lesions.     

Surgical treatment of subclavian steal syndrome and innominate steal syndrome. Long-term results

Thirty-four patients who underwent carotid-subclavian bypass (64.7%), aorto-carotid bypass (17.6%), endarterectomy of subclavian artery (5.8%) or endarterectomy of innominate artery for "subclavian" or "innominate steal" syndromes, had a follow-up studies 3-8 years since surgery. All patients demonstrated originally a differential in systolic blood pressure in the upper extremities. The surgical indications were posed on the basis of neurologic symptoms of vertebrobasilar insufficiency and the angiographic evidence of "subclavian (79.4%)" or "innominate (20.6%) steal". The carotid-subclavian bypass has been the preferred surgical treatment technique in patients with "subclavian steal". This operation is indicated also in nearby asymptomatic patients in order to prevent the evolution of the natural history of vertebrobasilar insufficiency. Longterm results are considered satisfactory in surgically treated patients.     

Surgical considerations of occlusive lesions associated with Takayasu's arteritis.

OBJECTIVE: Takayasu's arteritis is an inflammatory vascular disease of unknown etiology that affects the aorta and its main branches, requiring surgical intervention due to occlusive lesions. We studied early and late surgical results. METHODS: Between 1979 and December 1998, 46 patients--1 man and 45 women aged 15 to 72 years (mean: 46 +/- 13 years)--with occlusive lesions caused by Takayasu's arteritis underwent surgery. Preoperative steroids were administered to 22 patients having inflammation. Diagnosis indicating surgery included obstructive cervical vessel disease in 13 patients, obstructive coronary artery disease in 19, aortic coarctation in 15, and abdominal branch stenosis in 3. Surgical procedures involved bypass grafting in 31 (cervical vessel bypass in 13, ascending-abdominal aortic bypass in 4, axillary artery-abdominal aortic bypass in 10, descending-abdominal aortic bypass in 1, abdominal branch bypass in 3), coronary artery bypass grafting in 10, and coronary ostial endarterectomy in 9. RESULTS: Four (8.7%) died during hospitalization. Follow-up ranged from 1 to 240 months (mean: 117 months). Eight suffered late deaths and 6 patients died of cardiovascular problems. The total actuarial survival rate was 76.2% at 5 years and 70.5% at 10 years. CONCLUSIONS: Steroid therapy before and after surgery appears to affect the overall prognosis positively in patients with Takayasu's arteritis.     

Surgical treatment of aortic arch aneurysm combined with coronary artery stenosis.

OBJECTIVE: We present operative results of aortic arch aneurysm associated with coronary artery stenosis, and evaluate the operative risk of graft replacement of the aortic arch and concomitant coronary artery bypass grafting (CABG). PATIENTS AND METHODS: From January 1991 to December 2001, we treated 16 patients with aortic arch aneurysm and coronary artery stenosis. The patients, 3 women and 13 men (study group) ranged from 58 to 79 years of age, average 68.1 5.3 years. With the aid of deep hypothermic cardiopulmonary bypass, we performed graft replacement of the aortic arch aneurysm and concomitant CABG. We bypassed 31 coronary arteries. The bypass grafts included saphenous vein (n=16), left internal thoracic artery (n=4), right internal thoracic artery (n=1), right gastroepiploic artery (n=5) and inferior epigastric artery (n=2). The number of bypassed coronary arteries per patient ranged from 1 to 3, average 2.1 0.8/patient. A comparative study was performed between the study group and a control group of patients (n=39) who had undergone only graft replacement of the aortic arch. RESULTS: There was no significant difference between the two groups regarding: operation time, cardiopulmonary bypass time, cardiac arrest time, intraoperative bleeding volume, and early mortality rate. However, in the patients (n=4) of the study group who had undergone total arch graft replacement with three vessel CABG, the cardiopulmonary bypass time was significantly longer than that of the patients in the control group who underwent total arch graft replacement (n=19, P<0.05). Two of the 16 study group patients died in the early postoperative period, resulting in 12.5% early mortality rate. In the control group, four of 39 patients (10.3%) died in the early postoperative period. CONCLUSIONS: CABG combined with graft replacement of the aortic arch does not increase operative risk when the number of bypassed vessels is within two vessels, but may increase risk when three or more vessels are bypassed.     

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.