Carotid Artery Bypass Research Articles

Carotid Artery Bypass Surgery of In-Body Tissue Architecture-Induced Small-Diameter Biotube in a Goat Model: A Pilot Study.

Biotubes are autologous tubular tissues developed within a patient's body through in-body tissue architecture, and they demonstrate high potential for early clinical application as a vascular replacement. In this pilot study, we used large animals to perform implantation experiments in preparation for preclinical testing of Biotube. The biological response after Biotube implantation was histologically evaluated. The designed Biotubes (length: 50 cm, internal diameter: 4 mm, and wall thickness: 0.85 mm) were obtained by embedding molds on the backs of six goats for a predetermined period (1-5 months). The same goats underwent bypass surgery on the carotid arteries using Biotubes (average length: 12 cm). After implantation, echocardiography was used to periodically monitor patency and blood flow velocity. The maximum observation period was 6 months, and tissue analysis was conducted after graft removal, including the anastomosis. All molds generated Biotubes that exceeded the tensile strength of normal goat carotid arteries, and eight randomly selected Biotubes were implanted. Thrombotic occlusion occurred immediately postoperatively (1 tube) if anticoagulation was insufficient, and two tubes, with insufficient Biotube strength (<5 N), were ruptured within a week. Five tubes maintained patency for >2 months without aneurysm formation. The spots far from the anastomosis became stenosed within 3 months (3 tubes) when Biotubes had a wide intensity distribution, but the shape of the remaining two tubes remained unchanged for 6 months. The entire length of the bypass region was walled with an αSMA-positive cell layer, and an endothelial cell layer covered most of the lumen at 2 months. Complete endothelial laying of the luminal surface was obtained at 3 months after implantation, and a vascular wall structure similar to that of native blood vessels was formed, which was maintained even at 6 months. The stenosis was indicated to be caused by fibrin adhesion on the luminal surface, migration of repair macrophages, and granulation formation due to the overproliferation of αSMA-positive fibroblasts. We revealed the importance of Biotubes that are homogeneous, demonstrate a tensile strength > 5 N, and are implanted under appropriate antithrombotic conditions to achieve long-term patency of Biotube. Further, we clarified the Biotube regeneration process and the mechanism of stenosis. Finally, we obtained the necessary conditions for a confirmatory implant study planned shortly.

Moya –Moya disease revealed by a subarachnoid hemorrhage: A case report

Background: Hemorrhage is a major category of the clinical symptoms of moyamoya disease (MMD). Intracerebral and intraventricular hemorrhages are the most common hemorrhages in MMD, and subarachnoid hemorrhages (SAHs) are notably rare. Case report: A 43 year old female patient, with no previous pathological history, admitted with a frank meningeal syndrome followed by a disorder of consciousness.She was admitted with a GCS at 15, which was subsequently reduced to 10. She was hemodynamically and respiratory stable with a BP of 12/8 cm/Hg, a respiratory rate of 16 cycles/min and a heart rate of 92 beats/min. Initial imaging showed subarachnoid hemorrhage Fisher IV. A cerebral angiography-CT showed vascular thrombosis of the internal carotid artery whitout aneurysm and arteriovenous malformation and dural fistulas. An EVD (external ventricular drain) was placed. After three days of hospitalization in the intensive care unit, a cerebral arteriogram was performed showing vascular arrest in the right internal carotid artery in its pre-cavernous portion with absence of visualization of the right sylvian artery and the presence of several perforating cerebral artery and external carotid artery bypass systems suggestive of Moya Moya. Conclusion: Moya Moya disease is a rare entity of unknown origin. Subarachnoid hemorrhage is a rare manifestation. It’s mainly occurs in a young adult. Cerebral angiography remains the gold standard for diagnosis.

Duplex ultrasound and cross-sectional imaging in carotid artery occlusion diagnosis

ObjectiveInvestigations into imaging modalities in the diagnosis of extracranial carotid artery occlusion (CAO) have raised questions about the inter-modality comparability of duplex ultrasound (DUS) and cross-sectional imaging (CSI). This study examines the relationship between DUS and CSI diagnoses of extracranial CAO. MethodsThis single-institution retrospective analysis studied patients with CAO diagnosed by DUS from 2010 to 2021. Patients were identified in our office-based accredited vascular laboratory database. Imaging and clinical data was obtained via our institutional electronic medical record. Primary outcome was discrepancy between DUS and CSI modalities. Secondary outcomes included incidence of stroke and intervention subsequent to CAO diagnosis. ResultsOf our 140-patient cohort, 95 patients (67.9%) had DUS follow-up (mean, 42.7 ± 31.3 months). At index duplex, 68.0% of individuals (n = 51) were asymptomatic. Seventy-five patients (53.6%) had CSI of the carotids after DUS CAO diagnosis; 18 (24%) underwent magnetic resonance imaging and 57 (76%) underwent computed tomography. Indications for CSI included follow-up of DUS findings of carotid stenosis/occlusion (44%), stroke/transient ischemic attack (16%), other symptoms (12%), preoperative evaluation (2.7%), unrelated pathology follow-up (9.3%), and outside institution imaging with unavailable indications (16%). When comparing patients with CSI and those without, there were no differences with regard to symptoms at diagnosis, prior neck interventions, or hypertension. There was a significant difference between cross-sectionally imaged and non-imaged patients in anti-hypertensive medications (72% vs 53.8%; P = .04). Despite initial DUS diagnoses of carotid occlusion, 10 patients (13.3%) ultimately had CSI indicating patent carotids. Four of these 10 patients had stenoses of ∼99% (with 1 string sign), four of 70% to 99%, one of 50% to 69%, and one of less than 50% on CSI. The majority of patients (70%) had CSI within 1 month of the index ultrasound. There were no significant relationships between imaging discrepancies and body mass index, heart failure, upper body edema, carotid artery calcification, and neck hardware. Eight individuals (10.7%) underwent ipsilateral revascularization; 62.5% (n = 5) were carotid endarterectomy procedures, and the remaining three procedures were a transcervical carotid revascularization, subclavian to internal carotid artery bypass, and transfemoral carotid artery stenting. Eight patients (10.7%) underwent contralateral revascularization, with the same distribution of procedures as those ipsilateral to occlusions. Two of the 10 patients with discrepancies underwent carotid endarterectomy, and one underwent carotid stenting. ConclusionsIn our experience, duplex diagnosis of CAO is associated with a greater than 10% discordance when compared with CSI. These patients may benefit from closer surveillance as well as confirmatory computed tomography or magnetic resonance angiography. Further work is needed to determine the optimal diagnostic modality for CAO.

Extra-anatomical left common carotid and subclavian artery bypass followed by aortic arch replacement with frozen elephant trunk

BackgroundTotal arch replacement (TAR) using a frozen elephant trunk (FET) allows for simultaneous treatment of the aortic arch and descending aortic pathology via median sternotomy. In addition, an extra-anatomical bypass performed between the left common carotid artery (CCA) and subclavian artery (SCA) prior to TAR allowed further proximalisation of the FET prosthesis, facilitated distal anastomosis of the TAR and spared the demanding left subclavian artery (LSA) anastomosis in the deep thorax. We investigated the efficacy of this debranching-first technique, followed by TAR using a frozen elephant trunk, as a two-stage operation for extensive thoracic aortic aneurysms in high-risk patients.MethodsForty-nine consecutive patients with diffuse degenerative aneurysms from the aortic arch to the descending aorta or chronic aortic dissection who underwent left common carotid to subclavian artery bypass followed by TAR using a frozen elephant trunk and subsequent thoracic endovascular aortic repair between 2016 and 2021 were analysed. The baseline characteristics and clinical outcomes were assessed. The estimated overall survival, 5-year aortic event-free survival, and aortic reintervention rates were analysed.ResultsThe average European System for Cardiac Operative Risk Evaluation (EuroSCORE II) was 4.7 ± 2.5. The operative mortality rate was 4.1%, with no paraplegia events. The estimated 5-year overall survival, cumulative aortic-related mortality rates were 76.8% and 2%, respectively. The estimated 5-year overall cumulative aortic reintervention rate, including the intended intervention, was 31.3%. The estimated 5-year cumulative rate of non-intended reintervention was 4.5%.ConclusionsThe assessed technique enables a less technically demanding surgery with reasonable outcomes. The estimated 5-year aortic event-free survival and reintervention rates were acceptable, suggesting that multiple stages of alternative open and endovascular interventions, such as this technique, may reduce the morbidity and mortality rates of high-risk patients with diffuse thoracic aortic aneurysm.UMIN-CTR (University hospital Medical Information Network-Clinical Trial Registry)https://center6.umin.ac.jp/cgi-open-bin/ctr_e/index.cgiClinical registration number: UMIN000051531

Quantitative analysis of external carotid artery bypass donor vessels by recipient and approach

IntroductionUtilization an in-situ pedicle of the external carotid artery (ECA) as an arterial donor can allow for the successful augmentation or replacement of flow to a large vascular territory. We propose a mathematical model for quantitatively analyzing and grading the suitability of donor and recipient bypass vessels based on a set of anatomical and surgical variables in order to predict which pair has the greatest possibility for success. Using this method, we analyze all of the potential donor-recipient pairs for each ECA donor vessel—including the superficial temporal (STA), middle meningeal (MMA), and occipital (OA) arteries. MethodsThe ECA pedicles were dissected in frontotemporal, middle fossa, subtemporal, retrosigmoid, far lateral, suboccipital, supracerebellar, and occipital transtentorial approaches. For each approach, every potential donor-recipient pair was identified, and donor length and diameter were measured as well as depth of field, angle of exposure, ease of proximal control, maneuverability, and length and diameter of the recipient segment. Anastomotic pair scores were determined by adding the weighted donor and recipient. ResultsThe best overall anastomotic pairs were OA-vertebral artery (V3, 17.1) and STA-insular (M2, 16.3) and STA-sylvian (M3, 15.9) segments of the middle cerebral artery. Other strong anastomotic combinations were OA- telovelotonsillar (15) and OA- tonsilomedullary (14.9) segments of the posterior inferior cerebellar artery, and MMA-lateral pontomesencephalic segment of the superior cerebellar artery (14.2). ConclusionsThis novel model for anastamotic pair scoring can serve as a useful clinical tool for selecting the optimal donor, recipient, and approach combination that can help facilitate a successful bypass.

Subclavian Artery-Carotid Artery Bypass for Subclavian Artery or Common Carotid Artery Severe Stenosis or Occlusion.

Various surgical treatments are available for occlusive subclavian and common carotid artery diseases. Nevertheless, to date, when cerebral endovascular treatment is utilized, revascularization via direct surgery may be required. This study reported five symptomatic cases of revascularization for CCA and SCA occlusive and stenotic lesions that were expected to be challenging to treat with endovascular treatment. We performed subclavian artery-common carotid artery or internal carotid artery bypass using artificial blood vessels or saphenous vein grafts in five patients with subclavian steal syndrome, symptomatic common carotid artery occlusion, and severe proximal common carotid artery stenosis. In this study, good bypass patency was achieved in all five cases. Although there were no intraoperative complications, one patient had a postoperative lymphatic leak. Moreover, there was no recurrence of stroke during postoperative follow-up for an average of 2 years. Conclusively, subclavian artery-common carotid artery bypass can be an effective surgical treatment for common carotid artery occlusion, proximal common carotid artery stenosis, and subclavian artery occlusion.

Bypass and other modified reconstruction techniques for 'challenging' carotid cases: A comparison with conventional endarterectomy.

Standard carotid endarterectomy (CEA) is usually performed with patch closure or eversion. However, sometimes a 'modified' carotid artery revascularization (MCAR) technique is required if the lesion is complex, extended and anatomically or technically challenging. MCAR is defined as carotid artery bypass; otherwise, it is the combination of common carotid artery (CCA) primary suture or patch angioplasty, associated with internal carotid artery (ICA) patch closure or eversion. The aim of this study was to evaluate the outcomes of MCAR during complex carotid procedures, comparing them with standard CEA. A retrospective analysis of asymptomatic patients who underwent CEA during a 16-year period (June 2005 to June 2021) was performed. Patients were divided into three different groups: ECEA (eversion CEA), PCEA (CEA with patch angioplasty) and MCAR. Primary endpoints were relevant neurological complication rate (RNCR), death within 30days, freedom from ipsilateral stroke, reintervention rates and freedom from carotid artery restenosis. A total of 1,752 patients were included (ECEA: 699; PCEA: 948; MCAR: 105) in the study. Patients treated with MCAR were significantly older and had a higher SVS score for arterial hypertension compared with ECEA and PCEA groups. A long plaque in the CCA was the most common indication for MCAR (40.1%); inadequate distal plaque-end or distal dissection (25.7%) was the second most prevalent indication. Overall perioperative RNCR, defined as minor and major stroke, was 0.7% (ECEA: 0.4%; PCEA: 0.7%; MCAR: 1.9%; p = 0.22), without any significant difference among the three groups. However, patients treated with MCAR had a significantly higher rate of global central neurological complications (defined as transient ischaemic attack, minor stroke and major stroke) than the other cohorts (ECEA: 0.7%; PCEA: 1.2%; MCAR: 3.8%; p = 0.02). One patient (0.05%) died perioperatively of a major cerebral infarction. Long-term follow-up (66.7 ± 43.9) showed a significantly lower rate of freedom from ipsilateral stroke for the MCAR group (96.8%) compared with ECEA and PCEA groups (99.8% and 98.9%, respectively, p = 0.03). Similar reintervention rates (ECEA: 2.7%; PCEA: 3.3%; MCAR: 3.8%; p = 0.74) and freedom from carotid restenosis rates (ECEA: 1.3%; PCEA: 2.6%; MCAR: 1.9%; p = 0.16) were observed. Patients who underwent ICA revascularization with MCAR showed risks of perioperative death, major or minor stroke (<2%), reintervention rates and carotid restenosis rates that are comparable with PCEA or ECEA groups. Nevertheless, the MCAR group showed a significantly higher rate of global central neurological complications (considering together TIA, minor stroke and major stroke) than patients treated with standard CEA. MCAR techniques appear to be effective alternatives to standard CEAs, with an acceptable surgical risk. However, these should be performed mainly in selected cases, for example, in complex anatomy (detected in a non-negligible percentage of patients by preoperative imaging), or in the case of unexpected intraoperative technical issues.

Optimal cutoff value of carotid stump pressure for determining the need for a carotid shunt in carotid artery endarterectomy.

This study was conducted to identify the diagnostic value of carotid stump pressure for determining the need for a carotid artery shunt in patients undergoing carotid artery endarterectomy. Carotid stump pressure was prospectively measured in all carotid artery endarterectomies performed under local anesthesia between January 2020 and April 2022. The shunt was selectively used when neurological symptoms appeared after carotid cross-clamping. Carotid stump pressure was compared between patients who needed shunting and those who did not. Demographic and clinical characteristics, hematological and biochemical parameters, and carotid stump pressure of the patients with and without shunts were statistically compared. To determine the optimal cutoff value and diagnostic performance of carotid stump pressure for identifying the patients who need a shunt, receiver operating characteristic analysis was performed. Overall, 102 patients (61 men and 41 women) who underwent carotid artery endarterectomy under local anesthesia were included, with an age range of 51-88years. A carotid artery shunt was used in 16 (8 men and 8 women) patients. The carotid stump pressure values of the patients with a shunt were lower than those without a shunt (median (min-max): 42 (20-55) vs 51 (20-104), p < 0.0006). In the receiver operating characteristic curve analysis performed to determine the need for a shunt, the optimal cutoff value of carotid stump pressure was ≤48mmHg, sensitivity was 93.8%, and specificity was 61.6% (area under the curve: 0.773, p < 0.0001). Carotid stump pressure has sufficient diagnostic power to determine the need for a shunt, but it cannot be used alone in the clinical setting. Instead, it can be used in combination with other neurological monitoring methods.

Assessment of bypass patency using transcranial Doppler sonography: correlations with computerized tomography angiography findings in patients with moyamoya disease

To explore the utility of transcranial Doppler (TCD) findings when assessing bypass patency in patients with Moyamoya disease (MMD). Computed tomography angiography (CTA) and TCD sonography (TCDS) were performed before and after surgery to evaluate bypass patency. The peak systolic flow velocity (PSV) of the superficial temporal artery (STA) and the pulsatility index (PI) were compared between the groups that achieved patency and not, and receiver operating characteristic (ROC) curve analyses were used to define the TCDS criteria revealing patency. This study included 35 hemispheres (15 women; mean age 47 years) with Moyamoya disease who underwent STA-middle carotid artery bypass in our institution between January 2022 and October 2022. The PSV first increased on postoperative days 4-5 and then decreased on postoperative days 6-7 and 7-8. Patients with transient neurological diseases (TNDs), compared to those without, evidenced a significantly lower PSV value (P < 0.05). Compared with the non-patency group, the PSV was higher (P < 0.001) in the patency group. The cutoff values reflecting patency with good sensitivity and specificity were PSV > 49.00; PSV ratio (postoperative/preoperative) > 1.218; PSV ratio (operation side/contralateral side) > 1.082; and PSV ratio (adjusted) > 1.202. In the patency group, the PSV and PI significantly increased (P < 0.001) and decreased (P < 0.001) respectively. Bypass patency can be noninvasively and accurately evaluated via TCDS, affording an objective basis for assessment of the effect of revascularization surgery on patients with MMD.

Carotid artery bypass versus endarterectomy as an alternative treatment of carotid artery stenosis: A propensity score matching analysis

ObjectivesThe main focus of this study is to evaluate the reliability and durability of saphenous vein bypass grafting from common carotid artery to internal carotid artery (CBG) asan alternative treatment of patients with carotid artery stenosis. Methods459 patients with carotid artery stenosis underwent initial carotid endarterectomy (CEA) or CBG between 2009 and 2019. Propensity score matching was performed, and outcomes of two different surgical procedures were analyzed. ResultsOutcomes of the 142 pairs of matched patients were investigated. There were no significant differences in the preoperative characteristics of these matched groups. Overall mean time of follow-up was 91.364 ± 3.265 months. Mortality rate during the follow-up period was 18.309% (26 patients) in the CEA group, and 11.971% (17 patients) in the CBG group. Stroke was encountered in 8 patients in the CEA group (5.63%), and 3 patients in the CBG group (2.11%) during follow-up. Restenosis was detected in 11 patients in the CEA group (7.75%), and 3 patients in the CBG group (3.52%) during follow-up. There were no significant differences in the survival, stroke – free survival, and restenosis - free survival distributions of both groups. ConclusionsIn carotid artery stenosis, it is reasonable to consider CBG as an alternative surgical option when adequate disease-free inflow (common carotid artery) and outflow (distal internal carotid artery) segments are present.

Ruptured innominate artery pseudoaneurysm presenting as hoarseness in Behçet’s syndrome: a case report

BackgroundVascular involvement is an infrequent clinical manifestation of Behçet’s syndrome. Owing to the rarity of arterial involvement in Behçet’s syndrome, there is limited experience in managing this phenomenon.Case presentationHere, we report a 28-year-old Iranian man with a Behçet’s syndrome background, who presented with shoulder pain and hoarseness. Chest computed tomography angiography was conducted with a suspicion of a vascular pathology causing pressure on the recurrent laryngeal nerves. The patient was diagnosed with a ruptured innominate artery pseudoaneurysm. An innominate artery to the right common carotid artery bypass was performed, and the pseudoaneurysm was excised and replaced with an expandable polytetrafluoroethylene graft. Eventually, the patient was discharged after an uneventful hospital course.ConclusionIt appears that we are still a long way from finding the optimal treatment for Behçet’s syndrome vascular involvement, and a combination of surgical and medicinal treatments is required.

Eş zamanlı karotis endarterektomi ve koroner arter baypas greftleme operasyonu yapılan hastalarda otolog perikard alternatif bir karotis yama materyali olabilir.

Backround: Dacron, polytetrafluoroethylene, great saphenous vein, and bovine pericardium are the commonly used as patch materials. However, there is no study about autologous pericardial as a patch material in carotid endarterectomy surgery. We aimed to assess the results of the use of autologous pericardial patch in patients undergoing concomitant carotid endarterectomy and coronary artery by-pass graft surgery.&#x0D; Materials and Methods:: The study involved 30 patients who underwent concomitant carotid endarterectomy with patch angioplasty and coronary artery bypass grafting surgery from January 2016 to February 2020. Patchplasty is performed with autologous pericardium for 13 patients and dacron patch for 17 patients during carotid endarterectomy. &#x0D; Results: No statistical difference was found between the groups in terms of reoperation, arterial occlusion, restenosis, operation time, and neurological events. In the postoperative follow-up, it was determined that the amount of drainage from the area on which the carotid surgery was applied was less in the those in whom autologous pericardium was used compared to those in whom Dacron patch was used. (p=0.001)&#x0D; Conclusion: We concluded that the use of autologous pericardium as a carotid artery patch is a safe, feasible, and effective method in patients undergoing combined carotid artery and coronary bypass surgery.

What are the benefits and harms of routine carotid artery shunting for adults undergoing carotid endarterectomy?

What are the benefits and harms of routine carotid artery shunting for adults undergoing carotid endarterectomy?

Retro Jugular, Retro Sternocleidomastoid Approach for Subclavian Artery to Common Carotid Artery Bypass Using a Radial Artery Interposition Graft: 2-Dimensional Operative Video.

Retro Jugular, Retro Sternocleidomastoid Approach for Subclavian Artery to Common Carotid Artery Bypass Using a Radial Artery Interposition Graft: 2-Dimensional Operative Video.

Single-stage repair for ascending aortic aneurysm, artery stenosis and occlusion of neck vessels caused by Takayasu arteritis

Takayasu arteritis results in a variety of vascular symptoms, and there are some cases in which progressive vascular lesions require surgical intervention. We present a case with ascending aortic aneurysm, right common carotid artery stenosis, left common carotid artery occlusion and left subclavian artery stenosis caused by Takayasu arteritis that was successfully treated with total arch replacement and ascending aorta to right internal carotid artery bypass.

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting).

Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. The shunt may improve the outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2002, 2009, and 2014. To assess the effect of routine versus selective or no shunting, and to assess the best method for selective shunting on death, stroke, and other complications in people undergoing carotid endarterectomy under general anaesthesia. We searched the Cochrane Stroke Group Trials Register (last searched April 2021), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2021, Issue 4), MEDLINE (1966 to April 2021), Embase (1980 to April 2021), and the Science Citation Index Expanded (SCI-EXPANDED) (1980 to April 2021). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform, and handsearched relevant journals, conference proceedings, and reference lists. Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy. Three independent review authors performed data extraction, selection, and analysis. A pooled Peto odds ratio (OR) and 95% confidence interval (CI) were computed for all outcomes of interest. Best and worse case scenarios were also calculated in case of unavailable data. Two authors independently assessed risk of bias, and quality of evidence using GRADE. No new trials were found for this updated review. Thus, six trials involving 1270 participants are included in this latest review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. Only three trials comparing routine shunting and no shunting were eligible for meta-analysis. Major findings of this comparison found that the routine shunting had less risk of stroke-related death within 30 days of surgery (best case) than no shunting (Peto odds ratio (OR) 0.13, 95% confidence interval (CI) 0.02 to 0.96, I2 not applicable, P = 0.05, low-quality evidence), the routine shunting group had a lower stroke rate within 24 hours of surgery (Peto odds ratio (OR) 0.15, 95% CI 0.03 to 0.78, I2 = not applicable, P = 0.02, low-quality evidence), and ipsilateral stroke within 30 days of surgery (best case) (Peto OR 0.41, 95% CI 0.18 to 0.97, I2 = 52%, P = 0.04, low-quality evidence) than the no shunting group. No difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring. However, this analysis was inadequately powered to reliably detect the effect. There was no difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with pressure assessment alone, although again the data were limited. This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy when performed under general anaesthesia. Large-scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.

New strategy of using double-network hydrogel extravascular stent for preventing venous graft restenosis after coronary artery bypass grafting.

Effective therapies for the prevention of vein graft failure, which frequently occurs in coronary artery bypass grafting (CABG) due to intimal hyperplasia (IH), are still lacking. Here, we investigated the effects of the perivenous application of double-network hydrogel on vein grafts in carotid artery bypass grafting in a rabbit model. Healthy New Zealand white rabbits were randomized into the following groups: no graft, graft, or graft + Double-network hydrogel external stent (DNHES). The rabbits' carotid artery was bypassed via the jugular vein. Double-network hydrogel external stent was wrapped around the jugular graft after the anastomoses were completed. Blood flow parameters and tissue histology of the vein grafts were evaluated. Compared with the untreated vein grafts at 12 weeks after the surgery, the DNHES significantly improved graft flow, attenuated intimal and medial thickening, reduced the anti-proliferating cell nuclear antigen proliferation index of the vein grafts, decreased the mRNA and protein expression of Mitogen-Activated Protein Kinase (MAPK) and Transforming Growth Factor-β (TGF-β), and increased the mRNA and protein expression of endothelial Nitric Oxide Synthase (eNOS). The perivenous application of DNHES exerts beneficial effects on vein grafts, reduces the inflammatory response in carotid artery bypass grafting in a rabbit model, and appears to be a safe and promising strategy to prevent vein graft failure.

Acutely Symptomatic Hypoperfusion Through an Occluded Subclavian to Internal Carotid Artery Bypass Graft: Salvage Mechanical Thrombectomy and Graft Revascularization.

This middle-aged patient had undergone surgical placement of a left subclavian to internal carotid artery bypass graft five years ago for treatment of symptomatic, chronic, bilateral carotid occlusions. The patient was neurologically intact after the procedure and until the day of presentation with symptoms of an acute left anterior circulation stroke. Initial workup confirmed acute occlusion of the graft as the cause of the patient’s symptoms. Endovascular recanalization of the bypass graft in the setting of chronic bilateral carotid occlusions was a technical and conceptual challenge. Simultaneous radial and femoral vascular access allowed for direct recanalization of the graft (through thrombectomy, angioplasty, and stent placement) with intraoperative patency surveillance of the circle of Willis via the posterior circulation. Most of the neurological deficits improved, and the patient was discharged to rehabilitation close to neurologic baseline.

North Atlanta external carotid-to-internal carotid artery bypass early experience: a retrospective case series

North Atlanta external carotid-to-internal carotid artery bypass early experience: a retrospective case series

Common Carotid to Common Carotid Artery Transposition for Brachiocephalic Trunk Occlusion

The patient was a 76-year-old man who had been admitted to the hospital with right carotid distribution transient ischemic attack. The patient had a history of transient ischemic attacks in a right hemispheric distribution. Workup with a computed tomography angiography revealed complete occlusion of the brachiocephalic trunk with highly calcified plaque. Retrograde flow was present in the right vertebral artery into the right common carotid artery. The patient had multiple comorbidities and was not considered a good candidate for aorta to carotid artery bypass.