The role of subclavian-carotid transposition in surgery for supra-aortic occlusive disease

From 1977 through 1985, 1043 patients underwent operation for supra-aortic occlusive disease. One hundred thirty-four of these patients (13%) with 146 lesions of the aortic arch branches (innominate, 25; subclavian, 103; and multiple, 10) had one or more symptoms of subclavian steal (78%), transient ischemic attacks (37%), arm ischemia (37%), and others (7%). However, according to results of a critical prospective neurologic examination, the classic steal syndrome appeared in only 13 patients (10%), vertebrobasilar insufficiency in 32 patients (24%), and hemispheric symptoms in 48 patients (36%). Symptomatic and/or significant internal carotid occlusive disease was present, ipsilateral in 28% and contralateral in 31% of the patients. Other supra-aortic vessels were involved in 49% of the patients. During the same period 192 patients with supra-aortic occlusive disease were treated without surgical intervention for various reasons. Fifty-five patients (27%) were completely asymptomatic except for the presence of reversed flow within the vertebral artery. The surgical approach in 138 operations was extrathoracic (ET) in 71% of patients (innominate artery, 2; subclavian artery, 95; and arch syndrome, 1) and transthoracic (TT) in 29% of patients (innominate artery, 23; subclavian artery, 8; and arch syndrome, 9). Generally, bypass procedures were preferred, but for 72 (71%) of the subclavian lesions subclavian-carotid transposition (SCT) was performed. Three patients had been referred for complications of previous carotid-subclavian bypass. The grafts were removed and vertebral and arm circulation restored by SCT. Carotid end-arterectomy was performed simultaneously (20%) or staged (3%) in 8% of the innominate procedures and 25% of the subclavian reconstructive procedures.(ABSTRACT TRUNCATED AT 250 WORDS)     

Polytetrafluoroethylene bypass for revascularization of the atherosclerotic internal carotid artery: late results

Between 1979 and 1986, 60 patients underwent a total of 62 revascularizations of the internal carotid artery with an expanded polytetrafluoroethylene (ePTFE) bypass. In 54 cases, the indication for surgery was the presence of extensive lesions in both the internal and common carotid arteries and, in 8 cases, a late complication of a previous surgical procedure. There were no early postoperative deaths (within 30 days). Three patients (5%) experienced postoperative neurologic complications. Two complications resolved completely whereas one left minimal residua. The bypasses remained patent in all three cases. All patients had early postoperative Doppler B-mode ultrasonography. Two early occlusions (3.2%) were disclosed but the patients remained symptom-free. Four neurologic complications were observed over long-term (average 23 months) follow-up. None were related to the operated carotid artery. There were no cases of infection or late occlusion. No hemodynamic or morphologic anomalies were observed on late follow-up ultrasound studies. These favorable results support the use of ePTFE as a reliable substitute when adequate autologous saphenous vein is not available for carotid bypass. Routine utilization might be indicated in cases of long bypasses, especially when it is necessary to implant the bypass on the ascending aorta, or when the proximal site of implantation is made on a thickened arterial wall.     

Treatment of intracranial aneurysms by combined proximal ligation and extracranial-intracranial bypass with vein graft

Seven patients with internal carotid artery aneurysms, and one patient with a middle cerebral artery aneurysm, were managed by combining proximal ligation with an extracranial-intracranial bypass procedure. Five bypasses were done with an interposed vein graft between the external carotid artery and the distal middle cerebral artery (vein graft), and three were superficial temporal-middle cerebral artery bypasses (superficial temporal artery grafts). As demonstrated in postoperative angiograms, all eight patients had patent bypasses with nonfilling of the aneurysm. One patient developed transient dysphasia, but there were no permanent neurological deficits associated with carotid occlusion. Four patients had resolution of their neurological problems, and another three patients improved. The distribution of flow from vein grafts is more extensive than from superficial temporal artery grafts. This offers increased protection against ischemia, and increases the likelihood of internal carotid artery aneurysm thrombosis by reducing the turbulence in the distal internal carotid artery.     

Axilloaxillary bypass: is it worthwhile?

To evaluate the efficacy and long-term patency results of axilloaxillary bypass, a review of 32 patients with follow-up extending to 11 years was done. Twenty-two bypasses were performed for vertebrobasilar symptoms or subclavian steal and 10 for upper extremity claudication and/or ischemia. The mean age of the operative group was 66 years, 94% of patients had more than one atherosclerotic risk factor (hypertension, diabetes, coronary artery disease, smoking), and 75% had undergone a previous arterial reconstruction operation. There were no operative deaths, and the only postoperative complication was a sterile seroma which responded to aspiration. At late follow-up extending to 11 years, three grafts had thrombosed while another became infected and had to be removed; no limb loss resulted from these graft failures and the actual late patency rate was 87%. Carotid-subclavian bypass, intrathoracic bypasses, and endarterectomy at the site of occlusion have all been suggested for the treatment of symptomatic proximal subclavian artery disease. With axilloaxillary bypass, however, the hazards associated with carotid artery manipulation, operation on the notoriously treacherous subclavian artery, and the morbidity related to thoracotomy in this older, high-risk patient population can be avoided. The axilloaxillary bypass is safe and simple, and the excellent long-term patency rates make it the procedure of choice for symptomatic subclavian artery disease.     

Extracranial-intracranial bypass to the proximal posterior cerebral artery and to the proximal middle cerebral artery for multiple occlusive cerebrovascular disease

A 48-year-old man with a multiple occlusive cerebrovascular disease involving both the carotid and the vertebrobasilar systems is reported. Faced with noneffective conservative treatment, a surgical approach was carried out. As the patient had poorly developed posterior communicating arteries, two extracranial-intracranial bypasses were performed for both the carotid and the vertebrobasilar circulations; extracranial-intracranial bypasses with interposed saphenous vein grafts between the left external carotid artery and the proximal segment of the left middle cerebral artery, and between the right external carotid artery and the proximal segment of the right posterior cerebral artery. Advantages, precautions, and techniques of this kind of bypass procedure are discussed.     

Clinical outcome of standard extracranial-intracranial bypass surgery in patients with symptomatic atherosclerotic occlusion of the internal carotid artery

Summary Objective. In this retrospective study we wanted to determine the role of cerebral revascularization in patients with symptomatic occlusive cerebrovascular disease. Special emphasis was put on subsequent cerebrovascular events, benefit in neurological functioning and bypass patency, as evaluated during the follow-up period.Methods. A total of 73 superficial temporal artery to the middle cerebral artery bypasses were performed on 67 patients from 1986–2000. All patients exhibited a symptomatic occlusion of the internal carotid artery verified by angiography. All patients in our group were refractory to medical treatment. 65 patients (69 bypasses) with a mean age of 61 years (range: 38–79 years) were followed up over an average time of 44 months (range: 1.5–150 months).Results. The peri-operative morbidity rate was 3% with no mortality. 55 patients (85%) had no further cerebrovascular events after surgery, and only 7 (11%) patients experienced another cerebrovascular event. 57 (88%) patients showed an improvement of symptoms after surgery and only 1 patient fared worse during the follow-up peroid due to a stroke he suffered two years after bypass surgery. 90% of all bypasses remained patent during the follow-up.Conclusions. Although bypass surgery for occlusive cerebrovascular disease is still controversial, our retrospective study suggests both an improvement of symptoms and signs and a risk-reduction for future cerebrovascular events after surgery.     

Asymptomatic carotid stenosis and unrelated operations: should we be more aggressive?

BACKGROUND: Carotid lesions will often remain asymptomatic during the perioperative period, so prophylactic carotid endarterectomy (CEA) has not been advocated before other operations. The purpose of this study was to characterize the clinical manifestations of new neurologic symptoms occurring in patients with previously asymptomatic carotid occlusive disease who have undergone recent operations. STUDY DESIGN: We performed a retrospective review of patients developing neurologic symptoms attributable to carotid occlusive disease after unrelated operations. RESULTS: Eleven patients (mean age 68+/-6.4 years, 8 men, 3 women) developed new neurologic symptoms from previously asymptomatic extracranial carotid stenoses after 11 unrelated procedures. Neurologic events included hemispheric stroke (n = 10) and amaurosis fugax (n = 1). Two intraoperative strokes occurred (one mastectomy, one prostatectomy). Other events occurred a mean of 5.8+/-5 (range 1 to 16) days after aortic surgery (n = 2), infrainguinal bypass (n = 3), contralateral CEA for symptomatic disease (n = 2), incisional herniorrhaphy (n = 1), and prostate surgery (n = 1). Responsible internal carotid artery lesions were all stenoses greater than 80%; seven were clearly greater than 90%. Those suffering intraoperative stroke or stroke within 24 hours of operation (n = 3) were not receiving antithrombotic therapy. All other events (n = 8) occurred despite the use ofantiplatelet or anticoagulant agents. Four underwent emergent CEA. Four had elective CEA performed after reaching a neurological recovery plateau. CONCLUSIONS: Critical, asymptomatic internal carotid artery stenoses may cause neurologic symptoms after unrelated surgical procedures.     

The profunda femoris: a durable outflow vessel in aortofemoral surgery.

Aorta-common femoral artery bypass is the standard operation for relief of aortoiliac occlusive disease. When extensive superficial femoral artery disease coexists, the profunda femoris, even in its distal portion, may be used as the outflow vessel. To test this assumption we compared cumulative patency, limb salvage, and the need for distal bypass of 134 aorta-profunda femoris and 151 aorta-common femoral artery bypasses performed consecutively for aortoiliac occlusive disease over a 12-year period. We also analyzed results of proximal (n = 103) and distal (n = 31) aortoprofunda bypasses. Angiographic and noninvasive studies showed greater disease in limbs undergoing aorta-profunda femoris bypass. However, no difference was observed in cumulative patency (91% +/- 6% vs 96% +/- 3%) or limb salvage (90% +/- 6% vs 94% +/- 3%) at 5 years. Seventeen distal bypasses in the group undergoing profunda femoris bypass and 20 distal bypasses in the group undergoing common femoral artery bypass were required to maintain limb salvage. Proximal and distal aorta-profunda femoris bypasses showed no difference in cumulative patency (91% +/- 9% vs 95% +/- 6%) or limb salvage (94% in each group) at 3 years. Standard aorta-common femoral artery and aorta-profunda femoris bypass provide cumulative patency and limb salvage exceeding 90% at 5 years; concomitant or subsequent distal bypass was required in 12% or limbs undergoing aorta-profunda femoris bypasses. Both proximal and distal profunda femoris arteries provide a durable outflow tract when aortoiliac and femoropopliteal occlusive disease are combined.     

Improved carotid hemodynamics with vertebral reconstruction

This study tests the hypothesis that vertebral artery reconstruction improves carotid distribution hemodynamics during carotid occlusion. Twelve patients with vertebrobasilar symptoms underwent either direct (9) or indirect (3) vertebral reconstruction. There were six proximal vertebral to common carotid reimplantations, one proximal carotid-vertebral bypass and two distal carotid-vertebral bypasses, all with saphenous vein. Three patients with carotid-subclavian or axillo-axillary bypasses performed for symptomatic vertebral steal were studied at the time of carotid endarterectomy. During temporary ipsilateral carotid occlusion, vertebral reconstruction increased carotid back pressure from 39.3±10.2 mmHg to 46.8±9.5 mmHg (p<0.0001), increased cerebral perfusion pressure from 33.4±10.8 mmHg to 41.0±9.1 mmHg (p<0.0001), decreased the carotid collateral resistance to cerebral vascular resistance ratio from 1.68±0.90 to 1.24±0.64 (p<0.001), and increased the ratio of carotid back pressure to mean systemic arterial pressure from 0.452±0.122 to 0.515±0.118 (p=0.0005). These results are presumed due to increased posterior-to-anterior blood flow in the posterior communicating arteries. Direct or indirect vertebral reconstruction may be a consideration in patients with cerebral ischemic symptomatic and nonreconstructible carotid occlusive disease.     

A combined approach to the noninvasive diagnosis of carotid artery occlusive disease.

A combined approach utilizing ophthalmosonometry (OSM), carotid phonoangiography (CPA), and ocular pneumoplethysmography (OPG) was applied to 31 patients with symptoms of carotid artery occlusive disease. Arteriograms were subsequently obtained in 70 of these patients, thus allowing the accuracy of each technique to be assessed in 140 carotid arteries. Both Doppler OSM and OPG correctly identified all complete occlusions of the internal carotid artery. However, greater than 50% stenoses were detected by OSM in only 52% and by OPG in 87%. Thus the cumulative accuracy in detecting hemodynamically significant lesions was 76% for OSM and 93% for OPG. The addition of CPA to OPG raised the combined accuracy of the two techniques to 98% for significant carotid lesions. The development of a regression line criterion for the OPG, in combination with CPA, permitted identification of 100% of patients with bilateral carotid artery lesions. However 75% of patients with symptomatic, ulcerating plaques were missed by all three tests, thereby emphasizing the need for angiography in appropriately symptomatic patients. The principal usefulness of noninvasive testing in evaluating patients with carotid artery occlusive disease is for: (1) asymptomatic bruits, (2) atypical, nonhemispheric symptoms, or (3) following carotid endarterectomy.     

Flow quantification of the non-occlusive excimer laser-assisted EC-IC bypass

Summary  Background. For six years, we used the Excimer laser-assisted nonocclusive anastomosis technique for high-flow revascularization of the brain in patients with either nonclippable and noncoilable giant aneurysms of the internal carotid or basilar artery or progressive stroke associated with occlusive disease of the internal carotid artery. The aim of this study is to assess the blood flow capacity of this type of Extra-Intracranial bypass and its haemodynamic behaviour over time.  Methods. Twenty-six patients with a giant aneurysms and 8 patients with occlusive disease of the internal carotid artery were treated with the nonocclusive Excimer laser assisted EC-IC bypass. intra-operatively, direct measurements of flow in the EC-IC bypass were performed in all patients (Transonic Systems, Inc., Ithaca, NY). Postoperatively, follow up measurements of flow were performed with MR angiography in 14 patients with a giant aneurysm after occluding the internal carotid artery, and 7 patients with occlusive carotid disease.  Results. The mean flow in the laser assisted bypasses in the group of patients with a giant aneurysm was 158 ml/min after ligation or balloon oclusion of the ICA. The mean flow of the laser assisted bypass in the group of patients with ICA occlusive disease was 130 ml/min. A comparison with data on flow capacity of conventional EC IC bypasses is made. A demonstrated increase of flow in the bypass during follow up is discussed from a haemodynamic point of view.  Conclusions. The results of this study demonstrate that the flow capacity of the nonoccluding excimer laser assisted bypass is much higher than the capacity of the conventional, more peripherally located conventional EC IC bypass, and should therefore be denoted as High-Flow EC IC bypass. Consequently, this type of bypass can be a powerful and safe tool in new revascularization strategies.     

Large-vessel arterial occlusive disease in symptomatic upper extremity

Subclavian and axillary artery occlusive disease resulted in sufficient upper extremity symptoms to necessitate 30 vascular reconstructions in 28 patients over the past ten years. Female patients predominated, with a ratio of 2.5:1. The average age of the patients was 61 years. The incidence of diabetes mellitus was low (7%). Sixteen of 18 proximal subclavian lesions were on the left side, while more distal lesions were equally distributed on the left and right. Extrathoracic bypasses were used in all cases. Dacron grafts were used in 16 of 17 carotid-subclavian bypasses. Autogenous vein grafts were used in 11 of 13 bypasses to the axillary or brachial artery. Concomitant cervicodorsal sympathectomy was done in only four patients. The in-hospital graft patency rate was 93% and the long-term graft patency rate at one year and beyond was 88%.     

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.     

Revascularization of vertebro-basilar occlusive disease

Various surgical techniques have been reported for vascular reconstruction in cases of vertebro-basilar occlusive disease, but sufficient study has not been made on the question of which technique should be applied in various pathological conditions. Based on our experience, we have examined the advantages and disadvantages of these techniques. In 34 patients with clinically and angiographically diagnosed vertebro-basilar insufficiency, the reconstructive vascular surgery to the posterior circulation was performed. Preoperatively, 24 had vertebro-basilar TIAs, 2 had RIND, 3 had progressing symptoms and 5 had brain stem infarctions verified by persistent deficits. In the 18 patients with intracranial vertebro-basilar occlusive lesions, the bypass were done to the proximal posterior inferior cerebellar artery in 7 cases, proximal superior cerebellar artery in 9 cases, posterior cerebral artery in one and anterior inferior cerebellar artery in one. In the 16 patients with extracranial occlusive lesions of vertebral artery, endarterectomy or subclavian-vertebral transposition was performed. With the exception of one of the progressing stroke cases, in which the surgery was ultimately too late, there were no cases in which neurological symptoms become aggravated following operation. Patency was 94% (32/34). In light of these findings, the following conclusions concerning the operative indication and the selection of the technique have been drawn. In cases with occlusive lesions of basilar artery, the first choice should be bypass to the proximal superior cerebellar artery. In cases with occlusive lesions of vertebral artery, bypass to the posterior inferior cerebellar or superior cerebellar or anterior inferior cerebellar artery should be performed.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Subclavian carotid transposition and bypass grafting: consecutive cohort study and systematic review

PURPOSE: We describe outcomes in a cohort of patients undergoing subclavian carotid transposition (SCT) for occlusive disease of the first segment of the subclavian artery and perform a systematic review of the literature on SCT and carotid subclavian bypass grafting (CSB). METHODS: Relevance, validity and extraction of review results were done in duplicate. Data were collected prospectively in our consecutive cohort of patients. RESULTS: From September 1990 to February 2001, we performed 27 SCTs, four for aneurysmal disease and 23 for occlusive disease. SCTs done for aneurysms were excluded from the current analysis. In patients with occlusive disease, the primary indications for surgery were vertebrobasilar and carotid symptoms (10, 44%), vertebrobasilar insufficiency (7, 30%), vertebrobasilar and arm symptoms (4, 17%), carotid symptoms (1, 4%), and vertebrobasilar, carotid, and arm symptoms (1, 4%). An SCT was performed in conjunction with an endarterectomy of the carotid artery in 12 patients (52%), with an endarterectomy of the subclavian artery in seven patients (30%), and with an endarterectomy of the vertebral artery in six patients (26%). A lymph leak complicated two surgeries (9%). In our series, patients improved clinically after surgery, and reconstructions were all found to be patent by means of Doppler ultrasound scanning at a mean follow-up of 25 +/- 21 months. Three patients (13%) died during follow-up of complications of coronary artery disease. From 1966 to 2000, 516 patients who underwent CSB and 511 patients who underwent a SCT were reported in the literature. Patency rates were 84% and 98%, respectively (P <.0001; absolute risk reduction, 15%; number-needed-to-treat-differently, 7), and the rates of freedom from symptoms were 88% and 99%, respectively, at a mean follow-up of 59 +/- 17 months (range, 1-228 months). CONCLUSION: Our cohort study showed that SCT is safe and effective for reconstruction of the first segment of the subclavian artery. The systematic review suggested that rates of patency and freedom from clinical symptoms are higher with SCT than with CSB.     

Atherosclerotic disease of the innominate artery: current management and results.

Arterial repair through a sternotomy has long been considered the procedure of choice for innominate artery atherosclerotic disease. Of 22 patients presenting with 21 occlusive lesions and one aneurysm, 17 patients underwent a bypass procedure, and two, an endarterectomy through a sternotomy, whereas three patients underwent cervical procedures. Their postoperative course was uneventful. Early and late results were satisfactory. We conclude that in patients with innominate artery atherosclerotic disease, the procedure employed depends on both the type of lesion and the clinical status of the patient. In most cases, a bypass graft via a sternotomy is the best option, since endarterectomy is not always possible and risks an aortic tear or dissection. In selected cases, balloon angioplasty performed either percutaneously, combined with cerebral protection by an occlusive balloon in the carotid artery or through a carotid arteriotomy in order to flush out embolic material may be sufficient. A by-pass graft from the right to the left common carotid artery is the best procedure in patients with neurological symptoms when angioplasty seems inappropriate, and when sternotomy is contraindicated for either reasons of poor health or a prior mediastinal operation.     

Surgical reconstruction for subclavian arterial obstruction at its origin

The authors, having experienced 17 cases of subclavian arterial obstruction at its origin in Montpellier, France and in Japan, performed direct anastomosis between the divided end of the proximal subclavian artery and the ipsilateral common carotid artery (transposition technique) in 12 cases. Our series of 17 patients ranging in age from 30 to 73 years who were evaluated for variety of symptoms: 8 had subclavian steal syndrome; 12 had claudication of upper extremity; 1 had visual disturbance; 3 had vertigo; and 1 had ear throbbing. Twelve patients were treated surgically with division of the proximal subclavian artery and its anastomosis to the common carotid artery by means of supraclavicular cervicotomy. One was treated with carotid subclavian bypass grafting, and 4 were placed aorto-carotid-subclavian bypass grafting with median sternotomy because of the proximal occlusive lesions at the origins of common carotid and subclavian artery due to aortitis syndrome. All the patients were relieved from the symptoms which had been existed in pre-operative stage. The transposition technique is simple, effective and few complications.     

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

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

Is long vein bypass from groin to ankle a durable procedure? An analysis of a ten-year experience.

Long vein bypass from the femoral artery to the level of the ankle may be performed with good initial success despite extreme bypass length and limited outflow tracts. However, the long-term performance of these bypasses remains to be defined. During the last 10 years we have performed single greater saphenous vein in situ bypass to the ankle level in 270 patients. There were 187 male and 83 female patients, and 61% of the patients were diabetic. The operative mortality rate was 3.7%. Cumulative bypass patency was 79% at 3 years and 73% at 5 years. In a similar manner, limb salvage was 93% at 3 years and 89% at 5 years. The patency rate was similar for various inflow arteries (common femoral, 88 cases; proximal superficial femoral, 135 cases; and deep femoral, 41 cases) and outflow tracts (dorsal pedal, 72 cases; anterior tibial, 59 cases; posterior tibial, 72 cases, and peroneal, 67 cases). Short bypasses, composite bypasses, free-vein grafts, and bypasses proximal to 10 cm above the ankle were excluded from this analysis. These data show that a long bypass to the ankle level for limb salvage is a durable procedure. The basic concept of bypassing all occlusive disease to the distal open artery in patients undergoing limb salvage should be an acceptable dictum. Excellent long-term patency and limb salvage rates are achievable by following this principle.