Brachiocephalic Artery Stenosis Research Articles

The Influence of Carbohydrate Metabolism Disorders on the Course of Perioperative Period in Cardiac Surgery Patients with Post-Infarction Left Ventricular Aneurysms

The aim. To study the impact of carbohydrate metabolism disorders on perioperative period in cardiac surgery pa-tients with post-infarction left ventricular (LV) aneurysms.
 Materials and methods. Retrospective analysis of perioperative period in random 132 patients with post-infarction LV aneurysms of various locations, who were operated on and discharged from the department of surgical treatment of ischemic heart disease of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine. Disorders of carbohydrate metabolism (DCM) were detected in 98 (74.2%) patients, among whom type 2 diabetes mellitus (DM) was diagnosed in 34 (25.7%) patients, impaired glucose tolerance (IGT) in 64 (48.5%). All the patients underwent general clinical examination, electrocardiography, echocardiography, coronary angiography and surgical treatment.
 Results. When analyzing the clinical picture in patients with post-infarction LV aneurysms, painless myocardial isch-emia was diagnosed in 41 (31.06%) patients, among whom type 2 DM in 11 (26.8%) cases and IGT in 18 (43.9%). No statistically significant difference was found in patients with and without DCM in the LV contractile function, presence of LV thrombosis, atrial fibrillation, chronic kidney disease, stenosis of brachiocephalic arteries and arteries of the lower extremities, gouty arthritis, and body weight. Intraoperatively, diameter of the coronary arteries in patients with type 2 DM was slightly smaller compared to patients without DCM. Its increase in cases of calcification of coronary arteries and aorta among patients of the study group with DCM was statistically insignificant. A careful analysis of the postoperative period in patients with and without DCM showed a statistically significant occurrence of paroxysms of atrial fibrillation in 30 (90.9%) and 3 (9.1%) cases, respectively (p=0.0115). The patients with DCM had longer stay in the intensive care unit: 4.03 ± 2.3 vs. 3.2 ± 1.3 days (p=0.0483). Acute kidney injury in the early postoperative period occurred in 8 (6.06%) patients, including 5 (62.5%) with type 2 DM (p=0.0142). Sternal wound infection occurred in 2 (1.5%) patients with type 2 DM (p=0.0156).
 Conclusions. Among cardiac surgical patients with postinfarction LV aneurysms, the major part is formed by patients with DCM (74.2%), the presence of which complicates the course of the postoperative period with the development of paroxysms of atrial fibrillation (p=0.0115), acute kidney injury (p=0.0142), sternal wound infection (p=0.0156), a long stay in the intensive care unit (p=0.0483).

ANNUAL OUTCOMES OF ACUTE MYOCARDIAL INFARCTION COMBINED WITH TYPE 2 DIABETES MELLITUS

Abstract. Relevance. The combination of acute myocardial infarction (AMI) and type 2 diabetes mellitus (DM2) entails early disability and mortality of the population, including among people of working age. The study of long-term outcomes of AMI in patients with type 2 diabetes is necessary to improve secondary prevention programs and reduce cardiovascular mortality. Aim of the study. To evaluate the prognosis of myocardial infarction in combination with type 2 diabetes mellitus for 1 year. Material and methods. He main group consisted of 115 patients with AMI and DM 2 (55 men and 60 women, the average age of patients was 63,2±5,3 years, men 62,3±5,5 years, women 64,3±4,9 years). The comparison group included 116 patients with AMI without concomitant DM 2 (in the comparison group 60 men, 56 women (mean age of patients 63,6±5,4 years, men 62,1±4,2 years, women 65,2±5,7 years). 12 months after the inclusion of patients in the study, an assessment of "endpoints" was carried out. Statistical data analysis was carried out using the modules of the SPSS Statistics 23.0 program. Results. It was revealed that a history of type 2 diabetes increases the risk of cardiovascular death by 7.9 times (OR 7,929, 95% CI 1,758-35,758, p=0,002), 2.1 times (OR 2,138, 95% CI 1,050- 4,353, p= 0,034) the risk of repeated hospitalizations for myocardial ischemia. The annual unfavorable prognosis of AMI is affected by: a history of coronary artery disease (OR 5,653 CI 2,114- 5,114, p≤ 0,001); CHF II-IV FC according to NYHA (OR 4,316 CI 0,916-20,330, p= 0,048); multivessel coronary lesion (OR 4,759 CI 1,018-22,248, p= 0,032); anterior localization of AMI (OR 3,646 CI 1,630-8,156, p=0,01); brachiocephalic artery stenosis (OR 4,278 CI 1,042- 17,559, p=0,031); stage 3-4 chronic kidney disease (OR 6,406 CI 2,589- 15,852, p≤0,01); obesity (OR 2,368 CI 1,086- 5,164, p= 0,029). Conclusion. The ideas about the annual outcomes of AMI in combination with type 2 diabetes in patients treated with modern methods of reperfusion therapy have been expanded.

Takayasu's Arteritis with Symptomatic Brachiocephalic Artery Stenosis and Left Common Carotid Artery Occlusion Undergoing Partial Arch Replacement after Coronary Artery Bypass Grafting

Takayasu's Arteritis with Symptomatic Brachiocephalic Artery Stenosis and Left Common Carotid Artery Occlusion Undergoing Partial Arch Replacement after Coronary Artery Bypass Grafting

Successful treatment of ischemic stroke associated with brachiocephalic artery stenosis using alteplase.

Introduction: Brachiocephalic artery stenosis rarely causes right hemispheric infarction with associated left hemiparesis. To date, there have been no reported cases of stroke associated with brachiocephalic artery stenosis that were successfully treated with recombinant tissue-type plasminogen activator (rt-PA), alteplase.Case Report: An 80-year-old woman presented with left hemiparesis. Brain computed tomography showed no hemorrhage, and computed tomography angiography demonstrated brachiocephalic artery stenosis. Alteplase was administered based on a diagnosis of ischemic stroke. Brain magnetic resonance imaging showed multiple acute infarctions. Thereafter, the blood pressure of the right arm was found to be lower than that of the left arm. The patient’s neurological deficits gradually improved; she was eventually able to walk again and was thus discharged home.Conclusion: While the combination of left hemiparesis and a decrease in blood pressure in the right arm are well known in patients with stroke associated with Stanford type A aortic dissections, it may also occur in patients with stroke due to brachiocephalic artery stenosis. Unlike stroke associated with Stanford type A aortic dissections, stroke due to brachiocephalic artery stenosis may be treated with alteplase.

Predicting the development of adverse events in patients with acute coronary syndrome including genetics in the long-term follow-up

AimTo study a relationship of several factors (clinical and genetical markers) with unfavorable outcomes in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in long-term follow-up.Material and methods This full-design, prospective study included 415 patients with NSTE-ACS. 266 patients were evaluated for the presence of multifocal atherosclerosis (MFA). Typing of polymorphic variants rs1041981 LTA, rs1800629 TNF, rs4986790, and rs498679 TLR4, and also rs3024491 and rs1800872 IL10 was performed. Follow-up period lasted for 67±4 months. By the end of this period, information about clinical outcomes for 396 patients became available.Results During the entire follow-up period, unfavorable outcomes were observed in 239 (57.5 %) patients with NSTE-ACS. The following clinical signs were associated with unfavorable outcomes: history of myocardial infarction, age >56 years, left ventricular ejection fraction (LV EF) ≤50 % and GRACE score ≥100, significant stenosis of brachiocephalic arteries, MFA, carriage of genotype А / А rs1041981 LTA (OR, 6.1; р=0.02) and allele А (OR, 1.9; р=0.01). According to results of a multifactorial analysis, the most significant predictors included LV EF <50 %, MFA, and carriage of genotype А / А rs1041981 LTA.Conclusion Stratification of patients with NSTE-ACS into groups of high or low risk for having an unfavorable outcome within the next 6 years is possible using the prognostic model developed and presented in this study. The model includes the following signs: LV EF <50 %, MFA, and carriage of genotype А / А rs1041981 LTA.

Increased Serum Parathyroid Hormone, Osteocalcin and Alkaline Phosphatase Are Associated with a Long-Term Adverse Cardiovascular Outcome after Coronary Artery Bypass Graft Surgery.

Despite the fact that an association of osteopoenia/osteoporosis with elevated risk of coronary artery calcification (CAC) and coronary atherosclerosis (CA) is well-established, it remains unclear whether bone turnover markers can be employed in long-term prognostication of such patients. Here we measured serum calcium, phosphate, calcitonin, parathyroid hormone (PTH), osteoprotegerin, osteocalcin, osteopontin, alkaline phosphatase and its bone isoenzyme, subsequently correlating them with an adverse cardiovascular outcome after 3 years of follow-up. The extent of brachiocephalic artery stenosis, CA, or CAC, as well as prevalence of osteopoenia/osteoporosis before the coronary artery bypass graft (CABG) surgery, did not differ between outcome groups, suggesting that subtle molecular mechanisms might be involved in determining the outcome rather than clinical or subclinical disease. After stepwise logistic regression, serum osteocalcin > 26.8 ng/mL and PTH > 49.1 pg/mL were independent predictors of an adverse outcome. Serum ionised calcium correlated with multivessel coronary artery disease; moreover, patients with severe CA (SYNTAX score > 21) had higher serum ionised calcium than those with mild CA. Likewise, serum alkaline phosphatase was associated with severe CA and CAC (Agatston score > 400). In conclusion, serum PTH, osteocalcin, and alkaline phosphatase are associated with an adverse cardiovascular outcome 3 years after CABG surgery regardless of osteopoenia/osteoporosis, coronary/peripheral atherosclerosis, and CAC.

The effect of spinal card stimulation on quality of life in patients with critical lower limb ischemia

To study the dynamics of QoL in patients with critical lower limb ischemia one year after spinal cord stimulation. QoL analysis was performed in 43 patients with critical lower limb ischemia using the SF-36 questionnaire before and one year after spinal cord stimulation. At baseline, we detected reduced QoL parameters corresponding to the physical function (≤30 points). The parameters of mental health corresponded to the moderate level (the score ranged between 42 and 59 points). The total score of physical well-being was reduced: 22.8 (20.2-29.3); the mean score of mental well-being was 41 (32.8-49.2) (p<0.001). One year after spinal cord stimulation, the level of all QoL parameters was increased but the total score of physical well-being remained low 33.2 (24-44.1). The mean score of mental well-being corresponded to the moderate level of QoL 56.5 (49-60.4) (p<0.001). Multivariate regression analysis showed that the physical parameters of QoL after spinal cord stimulation are adversely affected by such factors as age, the history of stroke, the ankle-brachial index (ABI), the presence of type 2 diabetes mellitus (DM), and ischemic heart disease (IHD) in combination with stenosis of brachiocephalic arteries (BCA). The mental health is affected by age and the presence of stenosis of brachiocephalic arteries. When selecting patients with critical lower limb ischemia for spinal cord stimulation, such factors as the baseline clinical status (comorbidities), age, history of stroke, and the severity of peripheral artery ischemia need to be taken into account to improve treatment effectiveness and QoL.

A clinical and genetic analysis of risk factors for the development of acute and chronic cerebral ischemia

To study the association between polymorphic markers in the ACE, SERPINE1, FGB, F5, F7, F12, GP1BA, GPIIIa, MTHFR, CYP11B2, PON1, PON2, NOS2, NOS2, HIFla, LTA, ALOX5AP genes and clinical characteristics of acute and chronic forms of circulatory disorders of the brain. MATERIAL AND METHODS: The analysis of polymorphic variants in ACE, FGB, F5, F7, F12, GP1BA, GPIIIa, SERPINE1, MTHFR, CYP11B2, PON1, PON2, NOS2, NOS3, PDE4D, HIF1a, LTA, ALOX5AP in 81 patients with chronic cerebral ischemia (CCI) and 69 patients with ischemic stroke (IS), and their interrelation with clinical manifestations of disease were investigated. RESULTS AND CONCLUSION: The association between the T/T genotype of the PDE4D SNP 83C>T polymorphism and a rapid progression of hypertensive disease (GB) was revealed (OR=6.22, CI=1.86-20.79, p=0.0036) in the group of patients with CCI. The association of the allele D and the DD genotype of the ACE (I>D, rs1799752) with cardioembolic stroke (OR=2.67, 95% CI=1.23-5.8, p=0.02 and OR=7.14, 95% CI=1.72-29.69, p=0.0057) was found. When comparing subgroups of patients with different degrees of stenosis of brachiocephalic arteries (BCA), the association of the allele C and the TC genotype of the GP1BA (rs2243093, -5T/C) with BCA occlusion and expressed hemodynamically significant stenosis (>75%) was revealed (OR=3.39, 95% CI=1.12-10.25, p=0.03 and OR=4.44, 95% CI=1.27-15.54, p=0.023, respectively). Thus, polymorphic markers in PDE4D, ACE, GP1BA in combination with certain clinical characteristics are risk factors for the progression of CCI and development of IS.

Оценка исходов и тактики лечения пациентов с острым коронарным синдромом без подъема сегмента ST по данным 5‑летнего наблюдения

to study the role of clinical factors and treatment tactics in the development of adverse outcomes in patients with non-STelevation acute coronary syndrome (NSTEACS) for five years follow up. The study included 415 patients with NSTEACS observed for 60±4 months from the date of discharge. Adverse events (AE) were unstable angina (UA), myocardial infarction (MI), ischemic stroke or patient's death. The favorable 5-year outcome was identified in 200, adverse outcome - in 178 patients. Statistical processing was performed using STATISTICA 8.0 software package and MedCalc 11.0. Total mortality for 60 months was 16.1% (n=61). Highest mortality, maximal number of hospitalizations due to MI (41.1%) and UA (49.6%) were observed during first 12 months. Greatest impact on the development of AE produced: history of MI, higher GRACE score, age >54 years (p=0.0021), stenosis in brachiocephalic arteries, ischemic changes on admission ECG and reduced left ventricular ejection fraction (LVEF) ≤ 52% (p=0.0001). Five-year survival rate was influenced by coronary angiography (p=0.0001) and percutaneous coronary intervention (PCI) during index hospitalization (p=0.0039). Mortality and frequency of AE in this register were close to generally reported. The observed adverse impact on the long-term outcome of such risk factors such as age over 60 years, history of MI, ischemic ECG changes at admission, decreased LVEF corresponded to literature data. Our study proved the need for coronary imaging in patients with NSTEACS to determine treatment strategy in in hospital period as these factors affected the 5-year survival. During five-year follow-up AE occurred in 47.1% of patients with NSTEACS. Maximal number of patients with AE was registered during the first (24.7%) and fifth (13.8%) year of observation. The development of AE was associated with older age, history of MI and coronary artery bypass grafting, ischemic ECG changes, decreased LVEF, higher GRACE score, and brachiocephalic artery stenosis. Carrying out diagnostic coronary angiography and PCI with stenting during hospitalization in patients with NSTEACS was associated with favorable 5-year outcome.

Concomitant aorto-right subclavian artery bypass with off-pump coronary artery bypass grafting: a case report

BackgroundAtherosclerotic stenosis of the brachiocephalic artery sometimes occurs in patients with coronary artery disease, and can cause stroke during the perioperative period of coronary artery bypass grafting.Case presentationWe describe the case of a 77-year old male with severe stenosis of the brachiocephalic artery and severe coronary artery disease. He successfully underwent aorto-right subclavian artery bypass that was performed concomitantly with off-pump coronary artery bypass.ConclusionConcomitant aorto-subclavian artery bypass with off-pump coronary artery bypass grafting is a therapeutic option that minimizes the risk of perioperative stroke in patients with brachiocephalic artery stenosis and coronary artery disease.

Role of brachiocephalic arterial stenosis in development of postoperative complications after cardiosurgery

OBJECTIVE. The study investigated the role of stenosis of brachiocephalic arteries in development of postoperative complications in patients, who underwent the coronary bypass grafting (CABG) and operations concerning heart valve pathology in conditions of extracorporeal circulation. There were observed such complications as stroke (n = 4) and hypoxic ischemic encephalopathy with delirium in postoperative period. MATERIAL AND METHODS. The research was carried out in 21 patients on the base of Center of сardiosurgery and interventional cardiology of St. Petersburg Multifield Center. All the patients were male aged 64±6,9 years. RESULTS. The study showed that risk of cerebral complications, especially hypoxic ischemic encephalopathy with delirium, could increase in case of bilateral carotid stenosis combined with hemodynamically insignificant unilateral vertebral artery stenosis. The significant hemodynamic branchiocephalic arterial stenosis caused chronic and acute clinical signs of cerebrovascular insufficiency in anamnesis. CONCLUSIONS. The high risk of development of severe cerebral complications was associated with hemodynamically significant bilateral carotid stenosis accompanied by hemodynamically significant uni- and bilateral stenosis or one-sided occlusion of cerebral artery. Management of treatment should take into account risk factors of cardiosurgical patients.

Importance of atherosclerotic stenotic lesion of the brachiocephalic arteries in the development of cognitive impairments

The impact of the pattern of atherosclerotic stenotic lesion on the clinical presentation of cognitive impairments (CIs) has been inadequately investigated. Objective : to estimate the impact of the degree and site of an atherosclerotic stenotic process on cerebral perfusion and cognitive functions. Patients and methods. A total of 123 patients (65 men and 58 women) aged 50 to 75 years with brachiocephalic artery stenosis of at least 40%, without hypertension, diabetes mellitus, or other systemic vascular pathology were examined. The structural state of the brain substance and the state of cerebral blood flow were evaluated by magnetic resonance imaging and magnetic resonance angiography. The scale described by P. Scheltens et al. was used to determine changes in the white matter. The site and degree of a stenotic process were estimated by extracranial and transcranial duplex scanning. CIs were identified applying a set of neuropsychological assessment scales. The Hamilton hospital depression rating scale was also employed. Results and discussion. Varying degrees of CIs were detected in the majority of the examinees with brachiocephalic artery atherosclerosis. The most severe CIs were associated with the involvement of parietal and frontal lobes. There was significant deterioration in cognitive functions with a higher percentage of stenosis: more severe CIs were seen in the presence of stenosis in the carotid system than in those in the vertebrobasilar bed. In addition, the patients with concomitant stenoses and tandem stenoses were observed to have more pronounced CIs than those with single artery stenosis. Cerebral atherosclerosis is shown to be one of the major risk factors for CIs. Not only the degree of stenoses, but also to a greater extent their site was observed to impact the occurrence of CIs accompanied by the development of a perfusion deficit in the specific vascular beds. The determination of the pattern of a stenotic process will be able to predict the development of CIs in patients with atherosclerosis and to choose an appropriate treatment policy.

総頚動脈外科的露出下での直接穿刺によりステント併用血管形成術を行った腕頭動脈狭窄症の1 例

総頚動脈外科的露出下での直接穿刺によりステント併用血管形成術を行った腕頭動脈狭窄症の1 例

総頚動脈外科的露出下での直接穿刺によりステント併用血管形成術を行った腕頭動脈狭窄症の1 例

総頚動脈外科的露出下での直接穿刺によりステント併用血管形成術を行った腕頭動脈狭窄症の1 例

How should aortic arch aneurysms be treated in the endovascular aortic repair era? A risk-adjusted comparison between open and hybrid arch repair using propensity score-matching analysis

Recent advances in endovascular aortic repair have changed the treatment of aortic arch aneurysms. The purpose of this study was to compare the early and mid-term outcomes of open repair and hybrid arch repair for aortic arch aneurysms. This study included 143 and 50 patients who underwent open aortic repair and hybrid thoracic endovascular aortic repair (TEVAR), respectively, for non-dissecting aortic arch aneurysms from 2008 to 2013. The European System for Cardiac Operative Risk Evaluation II scores were 4.35 ± 3.65% and 7.78 ± 5.49% for the open and hybrid TEVAR groups, respectively (P < 0.001). Furthermore, 35 patients from each group were matched using propensity scores to adjust for differences in patient characteristics. There was no significant difference in early mortality between the open and hybrid groups (3 vs 2%, P = 0.76). Early morbidity was equivalent in both groups, but intensive care unit (ICU) lengths of stay were shorter in members of the hybrid group (4.7 vs 1.6 days, P = 0.018). During the follow-up, survival rates were not significantly different (87 vs 81% at 3 years, P = 0.13), but reinterventions for the aortic arch were required in 1 patient (pseudoaneurysm) in the open group and 5 (endoleak in 4, brachiocephalic artery stenosis in 1) in the hybrid group. The rates of freedom from reintervention at 3 years were 99% in the open group and 80% in the hybrid group (P < 0.001). Propensity score matching yielded similar results for shorter ICU and hospital lengths of stay and more frequent reintervention in the hybrid group. Surgical outcomes in both groups were satisfactory. Hybrid TEVAR was superior in terms of early recovery from surgery; however, open arch repair showed more reliable long-term outcomes. When properly selected according to patient risk, these two strategies improve the surgical results in all patients with aortic arch aneurysms.

EXPERIENCE IN HYBRID SURGERY FOR COMBINED LESIONS OF BRACHIO-CEPHALIC ARTERIES AND THORACOABDOMINAL AORTIC ANEURYSM

We presented the case history of successful surgical treatment of patient with aortic arch aneurysm, thoracoabdominal aortic aneurysm and stenosis of brachiocephalic arteries. She was underwent hybrid reconstruction (open and endovascular intervention): open reconstruction of both carotid bifurcations and the right subclavian artery and arc and descending thoracic aortic endoprosthesis.

Intraoperative Stenting for Brachiocephalic and Carotid Artery Stenosis

Endovascular stenting is an alternative treatment for brachiocephalic artery stenosis, replacing standard surgical approaches such as carotid endarterectomy. However, a percutaneous approach may be difficult because various conditions such as severe arteriosclerosis of iliac or femoral arteries and aortic disease. We report our experience with intraoperative stenting for these lesions, presenting indications, strategy, and results. Seven patients underwent intraoperative stent placement via an open cervical approach. The sites of lesions included 1 innominate artery, 1 common carotid artery, and 5 cervical carotid arteries. Stenting was performed with a sheath introducer placed through a surgically exposed common carotid artery via a small skin incision or common carotid artery exposed for simultaneously performed carotid endarterectomy. Distal protection was used in 6 patients with an endovascular protective balloon or external clamping with forceps. Sufficient dilation of stenosis was obtained in all cases. No complications such as transient ischemic attack, cerebral infarction, and hyperperfusion were encountered. Wound hematoma was not experienced despite perioperative antiplatelet therapy and heparinization during the procedure. Angiographic follow-up over 1 year showed no restenosis in 5 available patients. Intraoperative stenting may be an excellent alternative for patients in whom both direct surgical approach and standard percutaneous endovascular approach are not possible.

大動脈上部動脈狭窄症に対するｓｔｅｎｔｉｎｇ―Ｍｏｕｓｅ Ｔｒａｐ法の応用による血栓／塞栓の予防―

For the supra-aortic atherosclerotic stenoses, neurovascular and neuro-interventional approaches have been performed. Interventional approaches have risk of thrombo-embolic events, while vascular approaches have surgical stress. We developed and applied a method for cerebral protection for stenting of supra-aortic stenoses and introduce our method in this article. We performed stenting in 20 supra-aortic stenoses from April 2006 to March 2008. Our cerebral protection method, a modified application of the “Mouse Trap” (“Mouse in a Trap”) method usually used for CAS patients, was applied for 5 patients (1 CCA origin stenosis, 1 brachio-cephalic artery stenosis, 1 SA stenosis, 1 VA V3-V4 stenosis, 1 ICA petrous segment stenosis). The stenotic lesion was dilated and stented, while the lesion was endovascularily trapped with the occlusion balloon and so on. After each manipulation (predilation, stenting, post-dilation), the blood with the clots and debris was aspirated, filtrated, and returned to the body via the vein. We modified the method for supra-aortic stenotic lesions according to their anatomical location, but maintained the principle of the “Mouse Trap” method. In all 5 cases, the protection procedure was done without worsening of clinical findings. However, high intensity areas on DWI were subclinically found in 2 patients. Although this study covered only a small number of cases, non-CAS supra-aortic atherosclerotic stenoses cases were safely stented under a modified “Mouse Trap” cerebral protection system.