Carotid-subclavian Bypass Grafting Research Articles

Abstract 11589: Late Complications After Interrupted Aortic Arch Repair

Description of Case: A 38-year-old man with known type B interrupted aortic arch (IAA), bicuspid aortic valve, and a complex surgical history (including IAA repair with an ascending-descending aortic conduit, later conduit graft revision, and left pulmonary artery [LPA] stent) presented after many years of loss to follow-up and was found to have hypertensive urgency. Echocardiogram showed turbulent flow in the proximal descending aorta concerning for arch obstruction. Computed tomography angiography (CTA) (Fig. 1 A–C) showed: narrowed proximal graft anastomosis, dilation of the aortic root and ascending aorta, a large pseudoaneurysm arising from the distal graft anastomosis, and LPA stenosis due to compression from the descending aorta. Following improved hypertension, the patient underwent placement of a left carotid-subclavian bypass graft followed by thoracic endovascular aortic repair (TEVAR) with an endograft positioned across the distal aortic jump graft suture line. CTA one month postoperatively (Fig. 1 D–F) confirmed exclusion of the pseudoaneurysm. Discussion: Type B IAA is considered the most common subtype of IAA among cases diagnosed in infancy, though recent data regarding IAA epidemiology are scarce. IAA is associated with other congenital abnormalities, such as ventricular septal defect (VSD), LV outflow tract abnormalities, and 22q11 deletion syndrome. Additional surgical aortic arch procedures in these patients are not uncommon, perhaps especially among patients who required reintervention for LV outflow tract obstruction. While most studies examining long-term outcomes after IAA repair have not commented specifically on late risk of aneurysm or pseudoaneurysm, such findings have been described in the literature. Additionally, use of polytetrafluoroethylene material in arch repair and arch repair by a method other than direct anastomosis—such as were seen in our patient—have been observed to be risk factors for late reintervention.

Long-Term Outcome of Carotid-Subclavian Bypass in the Management of Coronary-Subclavian Steal Syndrome.

The presence of a significant left subclavian artery stenosis may occasionally lead to blood flow reversal through a LIMA-to-coronary artery bypass graft during left arm exertion; with "stealing" of myocardial blood supply. The aim of this study was to review our experience with carotid-subclavian bypass in patients with post-CABG coronary-subclavian steal syndrome. This is a retrospective review of all patients who underwent carotid-subclavian bypass grafting for post-CABG coronary-subclavian steal syndrome at Mainz University Hospital between 2006 and 2015. Cases were identified in our institutional database, and data were retrieved from surgical records, imaging studies, and follow-up records. Nine patients (all males, mean age of 69.1years) underwent surgical treatment for post-CABG coronary-subclavian steal syndrome. Medium interval between original CABG and carotid-subclavian bypass grafting was 86.1months. There were no perioperative deaths, strokes or myocardial infarctions. At a mean follow-up period of 79.9months, all patients remained asymptomatic and all carotid-subclavian bypass grafts remained patent. One patient required stenting of a common carotid artery stenosis proximal to the graft anastomosis site, and coronary artery stenting was required in four patients in regions other than those supplied by the patent LIMA graft. Carotid-subclavian bypass surgery is a safe treatment option even in patients with multivessel disease and severe comorbidities and should be taken into consideration in patients who are deemed fit for surgery and those who would benefit from the excellent long-term patency rates.

Single vs Multibranched/Fenestrated Endovascular Aortic Arch Repair

To evaluate results of single vs multibranched/fenestrated endovascular aortic arch repair at a single institution. A retrospective review was performed of all endovascular aortic arch endografts at a single institution. Demographics, clinical records, and imaging were evaluated. Outcomes reviewed included debranching complications and early (within 30 days) and late (>30 days) procedural complications including death, stroke, myocardial infarction, spinal cord ischemia, endoleak, infection, and any return to the operating room. Patient were divided into two cohorts based on number of cervical vessel branches/fenestrations: group A (0 or 1 branch/fenestration) and group B (2 or 3 branches/fenestrations). Between March 2014 and May 2022, 24 patients underwent endovascular aortic arch repair. All procedures were elective. Technical success was achieved in 23 (95.8%) patients; one patient in group A had migration of the ascending Nexus module. Indications for surgery were arch aneurysm (58.3%) and proximal landing zone creation for descending thoracic aortic aneurysm repair (41.2%). The Cook CMD endograft was most commonly use overall (group A 53.8%, group B 100%), while the Nexus arch endograft was used in nearly one-half of all group A procedures (46.2%). The majority of grafts were landed in zone 0 (group A 69.2%, group B 100%) (Table). Debranching procedures were most frequently performed in group A; in particular, carotid-carotid bypass was necessary in all group A patients with proximal landing in zone 0 (53.8%). This led to graft infection in two patients requiring explant. Additional debranching complications included one carotid-subclavian bypass graft explant and one Amplatzer plug migration in a subclavian artery resulting in false lumen expansion (all group A). Overall 30-day mortality was 8.3% and stroke rate was 12.5% with no significant difference between the two groups. There were no instances of spinal cord ischemia. Early type Ia endoleaks were noted in three (12.5%) patients. There were two retrograde type A dissections on postoperative imaging; one required ascending/hemiarch replacement and partial graft explant at 3 months (group A); the other was managed nonoperatively (group B). One type III endoleak at 3 years required TEVAR (group A). Median follow-up was 6 months (interquartile range, 4-18). Endovascular aortic arch grafts have high technical success rate with acceptable morbidity and mortality. Single-branched/fenestrated grafts designed to land in zone 0 are more likely to require more in-hospital days and are prone to debranching complications without any added mortality or stroke benefit. Multibranched grafts are preferable for zone 0 landings when anatomically feasible.TableSingle vs multibranched/fenestrated endovascular aortic arch repairGroup A (n = 13) (0-1 branched/fenestrated)Group B (n = 11) (2-3 branched/fenestrated)P valueAge72 (65-77)79 (73-82).08Female sex6 (46.2)4 (36.4).95Indication for surgery.08 Arch aneurysm5 (38.5)9 (81.8) Create proximal landing zone8 (61.5)2 (18.2)Proximal landing zone.131 09 (69.2)11 12 (15.4)0 22 (15.4)0Endograft.03 Nexus6 (46.2)0 Cook CMD7 (53.8)11 (100)Technical success12 (92.3)11 (100)1Total hospital days (including debranching)7 (2-15)8 (7.5-9.5).43Debranching Carotid-carotid bypass7 (53.8)0.02 Carotid-to-subclavian bypass7 (53.8)3 (27.3).37 Carotid-to-subclavian transp1 (7.7)1 (9.1)1 Subclavian-to-carotid bypass2 (15.4)3 (27.3).83Debranching complications Infection requiring explant2 (15.4)0.54Complications (<30 days) Death1 (7.7)1 (9.1)1 StrokeDisabling02 (18.2).39Nondisabling01 (9.1).93Myocardial infarct01 (9.1).93Spinal cord ischemia00Reintervention Access-related1 (7.7)3 (27.3).46 Other01 (9.1).93Early endoleak IA2 (15.4)1 (9.1)1 IB00 III00Retrograde type A1 (7.7)1 (9.1)1Values are median (interquartile range) or number (%). Open table in a new tab

Endovascular Treatment with Arch Vessel Reconstruction on Patients with Kommerell Diverticulum and Aberrant Left Subclavian Artery

No guidelines for the treatment of Kommerell diverticulum (KD) have been established. Endovascular treatment with arch vessel reconstruction of 4 patients with a right-sided aortic arch and aberrant left subclavian artery are presented herein. A 39-year-old woman and 47-year-old man experienced dyspnea and retrosternal pain. The first patient concomitantly underwent left subclavian transposition and thoracic endovascular aortic repair (TEVAR). The second patient underwent bilateral carotid-subclavian bypass grafting, followed by TEVAR and KD embolization. The 2 other patients were 72- and 75-year old men who presented with KD and type B dissection, in which these conditions were characterized by acute thoracic pain in the former patient and were noted on incidental body scan for prostatic adenocarcinoma in the latter. The third patient underwent carotid-subclavian bypass grafting, followed by TEVAR and subclavian plugs, and in the fourth patient, regular follow-up with antihypertensive therapy was scheduled. After a mean follow-up period of 12 months, all patients were alive.

ЛЕЧЕНИЕ ПОСТТРАВМАТИЧЕСКОГО РАССЛОЕНИЯ АОРТЫ ТИПА «В» У ПОДРОСТКА: КЛИНИЧЕСКОЕ НАБЛЮДЕНИЕ

Post-traumatic aortic dissection is one of the most dangerous, life-threatening clinical conditions that is rarely encountered in pediatric clinical practice. The article represents a case of post-traumatic aortic dissection in a teenager. A 14 years old male patient, M., had been admitted to the pediatric clinic of the Saint Petersburg State Pediatric Medical University (Saint Petersburg, Russia) on Dec. 29, 2020, with a preliminary diagnosis as follows: car accident injury, post-traumatic injury of the thoracic aorta with the formation of a true aneurysm in the initial section of the descending thoracic aorta. During the examination, the diagnosis was clarified towards post-traumatic type B aortic dissection. The damages to the ascending aorta and aortic arch were excluded. Within 48 hours after admission a single-stage hybrid surgical intervention was performed using advanced diagnostic algorithms in the form of 3D printing, as well as combined surgical treatment, which included endovascular intervention with previous carotid-subclavian bypass grafting, resulting in positive immediate and long-term clinical outcomes. The active surgical tactics minimized the likelihood of life-threatening complications that could affect the outcome of treatment in the observed case.

Mid-Term Results of Left Carotid-Subclavian Bypass in Patients Undergoing Zone 2 TEVAR.

The aim of this study was to present the mid-term results of patients who had undergone a carotid-subclavian bypass surgery after a thoracic endovascular aortic repair (TEVAR) stent-graft implantation with proximal landing at zone 2 of the aorta. A total of 66 patients had undergone TEVAR and carotid-subclavian bypass between January 2015 and May 2020 at our clinic. Five of these patients were lost to follow-up, so 61 patients were included in this retrospective study. At follow-up visits, patency of the carotid-subclavian bypass grafts was evaluated with physical examination and radiological imaging. The mean follow-up time was 15.11±12.29 months (ranging from 1 to 56 months). There were 3 (4.91%) in-hospital deaths of patients admitted with bilateral lower limb and visceral malperfusion. There were also 2 (3.27%) deaths unrelated to the procedure. Carotid-subclavian graft occlusion occurred in 3 (4.91%) patients. The occlusion was detected with radiological imaging within a period of 12 to 24 months. The graft patency rate was 100% in the first 12 months. The mean graft patency time (survival) was 52.56±2.10 months. Periprocedural carotid-subclavian bypass surgery with synthetic grafts is a recommended procedure with high patency and acceptably low mortality and morbidity rates in TEVAR.

Angina pectoris in a patient with prior coronary artery bypass graft and carotid-subclavian bypass grafting

Angina pectoris in a patient with prior coronary artery bypass graft and carotid-subclavian bypass grafting

Autogenous Femoral Vein for Secondary Repair of Subclavian Arteries: A Salvage Solution for Complex Clinical Scenarios

Endovascular stents and prosthetic grafts are commonplace techniques for correction of subclavian artery (SCA) lesions. However, when initial surgical repair of the SCA becomes complicated by subsequent infection or thrombosis of the repair site, stents and prosthetic grafts are no longer suitable for secondary repair because of the risk of recurrent failure and limited longevity. Autogenous tissue is more resistant to infection and has improved long-term patency and thus may be a better option for secondary reconstruction in these complex clinical scenarios. The most commonly used autogenous conduit for SCA reconstruction is the great saphenous vein; however, the significant size mismatch makes this unsuitable in many circumstances. The autogenous femoral vein is a promising alternative conduit for SCA repair. Here, we present three successful cases of its use as a salvage technique after iatrogenic complications of prior surgical repair. From 2015 to 2019, three patients underwent harvest of the femoral vein for use in SCA repair, with two carotid-axillary bypasses and one carotid-subclavian bypass. Indications included a mycotic pseudoaneurysm secondary to an infected SCA stent, an SCA avulsion secondary to an infected carotid-subclavian bypass graft, and an occluded SCA stent in a young patient. Postoperative graft patency was monitored through clinical resolution of symptoms and maintenance of perfusion, intact pulses, and arterial duplex ultrasound or computed tomography scan. All of these patients had a good outcome after their procedures. Each had intact radial pulses immediately postoperatively and maintained normal perfusion to the upper extremity for the duration of follow-up, with bypass patency confirmed by computed tomography scan (Fig 1) or arterial duplex ultrasound (Fig 2). The SCA repair also allowed salvage of the upper extremity and symptomatic relief in all patients. None of the patients developed deep venous thrombosis in the donor extremity, and neither of the infected patients developed recurrent infection of the repair site. The success of these cases demonstrates that the autogenous femoral vein is an effective and safe option for SCA reconstruction. It is particularly useful for secondary salvage when prior surgical repair by standard techniques is complicated by infection or thrombosis and when target vessel size precludes the use of the great saphenous vein. This is an excellent choice of conduit that vascular surgeons should consider for use in complex SCA repairs.Fig 2Postoperative arterial Duplex scan of carotid-subclavian bypass graft via femoral vein.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Safety and durability of concomitant carotid endarterectomy with carotid-subclavian bypass grafting

BackgroundConcomitant carotid endarterectomy (CEA; for severe internal carotid artery stenosis) with carotid-subclavian bypass grafting (CSBG; for proximal common carotid artery or subclavian artery occlusion) is rarely used. Only a few studies have been reported. This report analyzed early and late clinical outcomes of the largest study to date of the combined procedures in our institution. MethodsElectronic medical records of patients who had concomitant CEA with CSBG during three decades were analyzed. Indications for surgery were arm ischemia, neurologic events, and clinical subclavian steal. Early (30 days) perioperative complications (stroke, death, and others) and late complications (stroke, death) were recorded. Kaplan-Meier analysis was used to estimate late graft/CEA primary patency, freedom from stroke, and stroke-free survival rates. Graft patency was determined clinically and confirmed using duplex ultrasound. Outcomes were compared with previously published data on isolated CSBG by the same group. ResultsThere were 37 combined procedures analyzed. Mean age was 64 years (range, 45-81 years). Indications for surgery were arm ischemia in 12 (32%), hemispheric transient ischemic attack or stroke in 15 (41%), vertebrobasilar insufficiency in 4 (11%), symptomatic subclavian steal in 10 (27%), and asymptomatic common carotid artery occlusion with severe internal carotid artery stenosis in 6 (16%). The 30-day perioperative (stroke and death) rate was 5.4% (one stroke and one death). Immediate symptom relief was noted in 100%, with 2.7% (transient ischemic attack) symptom recurrence. The crude patency rate of both CEA and CSBG was 92%. At 1 year, 2 years, 3 years, 4 years, and 5 years, respectively, primary patency rates were 100%, 96%, 96%, 96%, and 85%; freedom from stroke rates were 97%, 97%, 97%, 97%, and 97%; and stroke-free survival rates were 94%, 94%, 87%, 82%, and 78%. When these outcomes were compared with the isolated CSBG group alone (28 patients), there was no difference in perioperative stroke (2.7% for concomitant CEA/CSBG vs 0% for isolated CSBG), perioperative death (2.7% vs 2.8%), or late patency rates (92% vs 96%). ConclusionsConcomitant CEA/CSBG is safe and durable. There was no significant difference in perioperative stroke/death or late patency rates compared with isolated CSBG.

Parallel stenting for the left subclavian works in some, but selective use is warranted

Darling and colleagues present a contemporary cohort of patients undergoing zone 2 thoracic endovascular aortic repair (TEVAR) placement with left subclavian revascularization either by carotid-subclavian bypass (CSB) or chimney stent graft (CSG).1 Given the limited existing data in the literature, the authors' work serves as additional proof of concept for parallel stent grafting for left subclavian artery (LSA) revascularization. They have demonstrated excellent early results, notable for no type 1A endoleaks during the study period.

Optimal method of reconstruction in patients with pathology of the 1st segment of the subclavian artery

The study enrolled a total of 318 patients presenting with lesions of the 1st segment of the subclavian artery and the clinical course of vertebrobasilar insufficiency. All patients prior to admission had been receiving the best course of medicamentous therapy under the supervision of a neurologist for more than 6 months but with no significant clinical improvement. According to the type of the reconstructive operation on the 1st segment of the subclavian artery, all patients were subdivided into three groups. Group I included 48 (15.1%) patients presenting with occlusion of the subclavian artery and undergoing carotid subclavian bypass grafting. Group II consisted of 224 (70.4%) patients who underwent endarterectomy from the subclavian artery and its transposition to the common carotid artery. Group III was composed of 46 (14.5%) patients presenting with local stenosis of the subclavian artery and subjected to stenting of the 1st segment of the subclavian artery. The main criteria for assessment of the results were patency of the zone of reconstruction and clinical improvement of the patient after surgery. RESULTS: Clinical improvement in the early postoperative period was observed in 301 (94%) patients. In Group I, in the early postoperative period, clinical improvement was achieved in 32 (66.7%) patients. Clinical improvement after 3 years persisted only in 16 (33.3%) patients. In Group II comprising patients with transposition of the subclavian artery to the common carotid artery, clinical improvement was observed in 223 (99.6%) patients. Within 3 years of follow-up, 13 (6.4%) patients were found to have a relapse of the clinical picture of vertebrobasilar insufficiency. Clinical improvement after transposition of the subclavian artery to the common carotid artery at 3 years persisted in 210 (93.6%) patients. In Group III patients after stenting of the 1st segment of the subclavian artery in the early postoperative period and during the follow-up period up to 1 year, the angiographic and clinical success amounted to 100%. After 3 years, 8 (17.3%) patients developed relapse of the clinical course because of restenosis, fracture, and thrombosis of the stent. Clinical improvement at 3 years persisted only in 38 (82.6%) patients after stenting. Comparing the remote results demonstrated that transposition of the subclavian artery to the common carotid artery turned out to be the most justified (p<0.05). CONCLUSION: For reconstruction of the 1st segment of the subclavian artery, an operation of choice is transposition of the subclavian artery to the common carotid artery.

Left Subclavian Artery Revascularization for Thoracic Aortic Stentgrafting: Single Center Experience in 101 Patients

Introduction - Endovascular treatment of thoracic aortic pathology (TEVAR) requires a landing zone of at least 20mm in length, necessitating coverage of the left subclavian artery (LSA) in approximately 40% of the patients.1 Coverage of the LSA may increase the risk of ischaemic stroke, spinal cord ischaemia (SCI) and/or left arm claudication. Besides some endovascular options to preserve LSA flow, in the majority of cases the LSA is surgically revascularized by either a carotid-to-subclavian bypass graft or subclavian-carotid transposition. A relatively safe option, which has been shown to decrease the risk of stroke compared to LSA coverage without revascularization.2,3 Conflicting data and opinions exist in literature on the (additional) risk of surgical LSA revascularization (requiring temporary occlusion of the left common carotid artery (LCCA) for the anastomosis).4,5,6 In this study, we retrospectively analysed the indications, as well as the operative results of LSA revascularization in 97 patients, in our single centre TEVAR experience. Methods - Between 2000 and 2017, a total of 101 consecutive patients underwent surgical revascularization of the LSA prior to, concomitant, or following TEVAR. Data were retrospective collected. Revascularization was performed through a small supraclavicular incision and consisted of a transposition or bypass graft, using perioperative transcranial Doppler. Data regarding the indication for LSA revascularization, procedural details and early and late postoperative results were analysed. Results - A total of 64 carotid-subclavian bypass grafts and 33 subclavian-carotid transpositions were performed in the context of TEVAR. The majority was performed prior to stentgrafting, indicated to reduce the risk of stroke (n=58, incomplete Willis’ circle, dominant left vertebral artery (LVA) and/or exclusion of an arteria lusoria), to reduce the risk of SCI (n=18, in case of previous aortic repair, and/or stenting the entire descending aorta) or to reduce the risk of left arm malperfusion (n=8, small or absent LVA or LVA originating from the aortic arch). In two patients there was a patent left internal mammary artery to coronary artery bypass graft. In fourteen patients LSA revascularization was performed secondary to the stentgraft procedure, either immediately due to acute left arm malperfusion (n=2) or during follow-up due to invalidating left arm claudication (n=12). There was no in-hospital mortality, two ischaemic strokes (2%) were noted and one patient experienced permanent SCI (1%). Both strokes were considered to be related to the stentgraft procedure rather than the preceding LSA bypass. Additional complications observed were sympathetic chain nerve palsy (Horner’s syndrome) (n=6), phrenic nerve palsy (n=5), recurrent nerve palsy (n=4), chyle leakage requiring diet or re-exploration (n=6). In one patient, the LSA bypass occluded during follow-up requiring a redo surgical bypass. Conclusion - Selective surgical revascularization of the left subclavian artery in case of LSA coverage in TEVAR may be indicated to lower the risk of stroke, spinal cord ischaemia, and left arm malperfusion. The procedure can be performed safely when using perioperative monitoring and result in a low risk of stroke and peripheral nerve injury. References1)Kotelis D, Geisbüsch P, Hinz U, Hyhlik-Dürr A, von Tengg-Kobligk H, Allenberg JR, Böckler D. Short and midterm results after left subclavian artery coverage during endovascular repair of the thoracic aorta. J Vasc Surg. 2009 Dec;50(6):1285-1292.2)Patterson BO, Holt PJ, Nienaber C, Fairman RM, Heijmen RH, Thompson MM. Management of the left subclavian artery and neurologic complications after thoracic endovascular aortic repair. J Vasc Surg 2014;60:1491-1497.3)Saouti N, Hindori V, Morshuis WJ, et al. Left subclavian artery revascularization as part of thoracic stent grafting. Eur J Cardiothorac Surg. 2015 Jan;47(1):120-125; discussion 125.4)Maldonado TS, Dexter D, Rockman CB, Veith FJ, Garg K, Arko F, Bertoni H, Ellozy S, Jordan W, Woo E. Left subclavian artery coverage during thoracic endovascular aortic aneurysm repair does not mandate revascularization. J Vasc Surg. 2013 Jan;57(1):116-124.5)Cooper DG, Walsh SR, Sadat U, Noorani A, Hayes PD, Boyle JR. Neurological complications after left subclavian artery coverage during thoracic endovascular aortic repair: a systematic review and meta-analysis. J Vasc Surg. 2009 Jun;49(6):1594-1601.6)Contrella BN, Sabri SS, Tracci MC, Stone JR, Kern JA, Upchurch GR, Matsumoto AH, Angle JF. Outcomes of Coverage of the Left Subclavian Artery during Endovascular Repair of the Thoracic Aorta. J Vasc Interv Radiol. 2015 Nov;26(11):1609-1614.

Comparison of Two Different Techniques for Isolated Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair in Zone 2

Purpose: To analyze the results of isolated left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR) using carotid-subclavian bypass (CSbp) or chimney grafts (CGs). Methods: A retrospective multicenter, observational study identified 73 patients (mean age 68±13 years, range 22–87; 56 men) with acute or chronic thoracic aortic lesions who underwent TEVAR with isolated LSA revascularization using either CSbp (n=42) or CGs (n=31) from January 2010 and February 2017. Primary endpoints were TEVAR-related mortality, postoperative stroke, freedom from type Ia endoleak, and LSA patency. Results: Primary technical success was achieved in all cases. Early TEVAR-related mortality was 4.2% (CSbp 2% vs CG 6%, p=0.571). Two (3%) patients had major ischemic strokes (one in each group). Mean follow-up was 24±21 months (range 1–72; median 15). Estimated freedom from TEVAR-related mortality was 93%±3% (95% CI 84.3% to 97.0%) at 12 and 36 months, with no significant difference between CSbp and CG (p=0.258). Aortic reintervention did not differ between the groups (CSbp 5% vs CG 6%, p=0.356); nor did freedom from type Ia endoleak (CSbp 98% vs CG 87%, p=0.134). Gutter-related endoleaks occurred in 4 (13%) CG patients, but none of the patients experienced sac enlargement or the need for reintervention and none died. Primary patency of the LSA was 100% for the entire group during the observation period. Conclusion: In our experience, LSA revascularization proved most satisfactory and equally effective with both the CSbp and CG techniques, without discernible differences at midterm follow-up.

Subclavian steal syndrome - surgical or endovascular treatment

Background/Aim. A phenomenon of subclavian steal is caused by occlusion or stenosis of the proximal subclavian artery with subsequent retrograde filling of the subclavian artery via the ipsilateral vertebral artery. The aim of this research was to compare surgical method [carotid-subclavian bypass grafts (CSBG)] and endovascular methods [percutaneous transluminal angioplasty (PTA) and stenting of subclavian artery] from the aspect of immediate and long-term results. Methods. Thirty patients [16 (53.33%) males], of average age between 60.1 ± 8.25 years were treated with CSBG and compared with a group of forty patients [18 (45%) males], of the average age between 57.75 ± 6.15 years treated by PTA and stenting of subclavian artery. Immediate and long-term results were determined clinically and confirmed by Doppler pressures and duplex ultrasound/angiography. All patients were followed-up after 1, 6 and 12 months post-procedure, and annually thereafter. Results. The average follow-up for both groups was 22.37 ± 11.95 months. There were 2 (6.67%) procedural complications in the CSBG group (transient ischemic attack in 2 patients) and 3 (7.5%) ones in the PTA/stent group (dissection and distal embolization in one patient and puncture site hematoma in one patient). Systolic blood pressure difference between the two brachial arteries in CSBG group was: 42.6 ± 14.5 mmHg vs 4.75 ± 12.94 mmHg (p 0.05). Conclusions. Both, the CSBG and PTA/stenting of subclavian artery are safe, efficacious and durable procedures. They have similar immediate and long-term results. PTA and stenting are the methods of choice for high grade stenosis, near total occlusions and segment occlusions of subclavian artery. CSBG is indicated in case of diffuse occlusive lesions and when the PTA and stenting do not succeed or cause complications.

Hybrid Treatment of Multilevel Aortic Disease in an Adolescent :A Case Report

Bicuspid aortic valve is a common congenital defect associated with several other pathological processes. We describe a complex case in a 13-year-old boy where there was significant aortic valve insufficiency and a severely dilated ascending aorta. In addition, there was complex coarctation of the aorta in which both subclavian arteries arose from the coarctation site. A hybrid bilateral carotid-subclavian bypass grafting with coarctation stenting procedure was performed followed by a modified Bentall procedure. This case illustrates a successful two-stage, hybrid technique in a late-diagnosed paediatric patient.

Immediate Results of Open Surgery for Subclavian Artery Atherosclerotic Lesions Treatment Complicated by Internal Carotid Artery Stenosis

Цель исследования: оценить непосредственные результаты открытых операций при изолированном атеро-склеротическом поражении подключичной артерии и в сочетании со стенозом внутренней сонной артерии.Материалы и методы: В Центре хирургии сердца и сосудов Челябинской областной клинической больницы с марта2007 по декабрь 2012 года было оперировано 104 пациента с атеросклеротическим стенозом подключичной артерии(ПКА). У 30 из них имелось сочетанное поражение внутренней сонной артерии (ВСА) на стороне поражения ПКА. Па-циенты были разделены на две группы. В первой группе, 29 пациентов, была выполнена сочетанная коррекция каротид-ного и подключичного бассейнов. Во второй группе, 75 пациентов, выполнялась изолированная пластика ПКА. В первойгруппе были выполнены следующие виды симультанных операций: подключично-сонная транспозиция (ПСТ) и каротид-ная эндартерэктомия (КЭАЭ) у 13 пациентов; сонно-подключичное шунтирование (СПШ) и КЭАЭ у 16 пациентов. Вовторой группе 39 пациентам была выполнена ПСТ, 36 пациентам выполнялось СПШ. Статистический анализ резуль-татов исследования проводили с использованием пакета программ STATISTICA 6.0, а также пакета Microsoft Excel 5.0Результаты: Среди пациентов первой группы в раннем послеоперационном периоде не зарегистрировано ни одногослучая смерти или инфаркта миокарда (ИМ). У 1(2,9%) пациента клиника ОНМК по типу ишемического инфаркта го-ловного мозга на стороне операции, и у еще 1 (2,9%) на противоположной стороне. Во второй группе ни одного слу-чая ОНМК или смерти. У 2 (2,5%) пациентов второй группы в раннем послеоперационном периоде развился острыйИМ. Статистически доказано отсутствие разницы по непосредственным результатам между группами (P&gt;0,05).Заключение: Учитывая данные сравнительного анализа, считаем, что сочетанные операции при одно-стороннем поражении ВСА и ПКА являются эффективными и безопасными, и могут быть рекомендова-ны. При контралатеральном стенозе ПКА и ВСА необходима этапная операция, с выполнением КЭАЭ пер-вым этапом. На наш взгляд, подключично-сонная транспозиция является методом выбора при пластике ПКАКлючевые слова: сонная артерия, подключичная артерия, каротидная эндартерэктомия, подключично-сонная транспози-ция, сонно-подключичное шунтирование.

Ulcère pénétrant de l’aorte : à propos de quinze cas traités aux niveaux thoracique et thoraco-abdominal

Penetrating aortic ulcer (PAU) consists of an ulcer located in the aortic wall that can cause sudden-onset thoracic or thoraco-abdominal pain. Symptomatic PAU is a life-threatening emergency because of the high risk of aortic rupture. First described in 1934, PAU was for many years seen only at autopsy. Now, multislice CT is the diagnostic method of choice. We report the cases of 15 such patients. Ten patients were symptomatic, with severe sudden-onset thoracic or thoraco-abdominal pain (7 cases) or less acute pain (3 cases). Surgical treatment consisted of aortic stent-grafting in 13 cases, with one or more endoprostheses. Bypass surgery was also necessary in 6 cases, using a hybrid technique (ilio-hepatic bypass graft in 1 case, multiple visceral bypass grafts in 3 cases, carotid-carotid bypass graft in 1 case, and carotid left subclavian bypass graft in 1 case), or a combined technique (aneurysmectomy and infrarenal Dacron tube repair in 1 case). Open thoraco-abdominal aortic repair was performed in two cases, with proximal anastomosis at the thoracoabdominal level and distal anastomosis at the level of the aortic carre four (with the Crawford inclusion technique in one case). Perioperative results were satisfactory, but one patient died of multiple organ failure on postoperative day 14. Four patients died during follow-up (mean 16.2 months ; range 1-44 months), 1 of stroke, 1 of a complicated esophageal-aortic fistula, and 2 of unknown causes. Follow-up has been uneventful in the other 10 patients.

Type B Aortic Dissections:Treating the Many to Benefit the Few?

It is now more than a decade since aortic stent-grafts were introduced clinically to provide a less invasive and potentially less harmful therapeutic option to treat type B aortic dissections. However, recent publications on best medical treatment and quality of life in patients with chronic type B dissection support conservative treatment due to the low incidence of aneurysm formation, rupture, and disease-related complications. Against this backdrop, we analyzed our experiences and now discuss whether the availability of endografts allowed us to change indications toward a more aggressive endovascular approach to acute and non-complex type B dissections, seeking to determine which patients we should treat and which ones we should observe. Between 1997 and 2008 in our institution in Heidelberg, we treated 172 patients with acute and chronic type B dissections, most (n = 118, 69%) conservatively. However, 54 patients (40 men; mean age 57 years, range 30-82) underwent endovascular repair; 43% (n = 23) were emergency cases. Patients were followed periodically with computed tomographic angiography. Correct stent-graft deployment was achieved in 50 (93%) patients; the left subclavian artery was intentionally covered in 30 (55%) cases. Two carotid-subclavian bypass grafts were performed at the time of the endovascular repair due to partial coverage of the left common carotid artery. The perioperative complication rate was 19% (n = 10), but there were no neurological sequelae. The 30-day mortality rate was 11% (n = 6). Over a mean 32.1+/-25 months, 4 other patients died (18.5% overall mortality rate); survival estimates by Kaplan-Meier analysis were 80.4% and 66.1% after 1 and 5 years, respectively. Complete false lumen thrombosis was observed in 32 (60%) and a persisting completely patent false lumen in 3. The aortic expansion rate was 31% (17/54) overall. No difference was found between acute and chronic dissections in terms of survival (p = 0.247). Despite a minimally invasive approach, complication and mortality rates for endovascular therapy of type B aortic dissections are considerable. Endografting is limited to symptomatic patients and those with chronic large aneurysmal expansion. At this stage in stent-graft development, asymptomatic patients benefit more from conservative treatment.

Angioplasty and Stenting versus Carotid-Subclavian Bypass for the Treatment of Isolated Subclavian Artery Disease

To compare the results of a large series of percutaneous transluminal angioplasty (PTA)/stenting procedures in the subclavian artery with the results of a series of carotid-subclavian bypass grafts (CSBG) performed at the same institution for subclavian artery disease. Between 1993 and 2006, 121 patients (43 men; mean age 63 years, range 38-85) underwent subclavian artery PTA/stenting and were compared to a group of 51 patients (29 men; mean age 62 years, range 46-75) with isolated subclavian artery occlusive disease treated with CSBG using polytetrafluoroethylene grafts. Graft or PTA/stenting patency was determined clinically and confirmed by Doppler pressures and/or duplex ultrasound/angiography. The cumulative patency and overall survival rates were calculated using the life-table method. The mean follow-up for the PTA/stent group was 3.4 years versus 7.7 years for the CSBG group. The technical success rate for the CSBG group was 100% versus 98% (119/121) for the PTA/stent group. The overall perioperative complication rate in the stent group was 15.1% (18/119: 11 minor and 7 major complications) versus 5.9% (3/51: 2 phrenic nerve palsy and 1 myocardial infarction) in the bypass group (p=0.093). There was no perioperative stroke or mortality in the CSBG group. The major perioperative complications in the stent group included 4 thromboembolic events, 1 congestive heart failure, 1 reperfusion arm edema, and 1 pseudoaneurysm. There was 1 perioperative death in the stent group. The 30-day patency rate was 100% for the bypass group and 97% (118/121) for the PTA/stent group. The primary patency rates at 1, 3, and 5 years were 100%, 98%, and 96% for the CSBG group versus 93%, 78%, and 70% for the stent group, respectively (p<0.0001). Freedom from symptom recurrence was also statistically superior in the bypass group versus the stent group (p<0.0001). There were no significant differences in the survival rates between both groups at any time point (p=0.322). Both CSBGs using PTFE grafts and subclavian PTA/stenting are safe, effective, and durable; however, CSBG is more durable in the long term. PTA/stenting of the subclavian artery should be the procedure of choice for high-risk patients; however, CSBG should be offered to good-risk surgical candidates who may be seeking a more durable procedure.

Thoracic Endograft Positioning and Carotid-Subclavian Bypass Grafting in a Patient with a Saccular Aneurysm at the Aortic Arch

A 75-year-old man was referred to our hospital because of sudden thoracic pain. A saccular aneurysm of the aortic arch extending on the anterior surface of the aortic arch was found on computed tomographic arteriography. The patient was hemodynamically stable and he was programmed for a staged surgical and endovascular approach (hybrid approach). As a first stage and in order to prevent major cardiac complications due to the overstenting of the left subclavian artery (LSA) with the occlusion of the aortocoronary bypass, the patient underwent a polytetrafluoroethylene bypass graft (GORE-TEX, W.L. Gore & Associates, Flagstaff, AZ) between the LSA and the left carotid artery. Intraoperative arteriography revealed a good patency of the left carotid-subclavian bypass and of the left internal mammary bypass on the left anterior descending artery. As a second stage the endovascular procedure was accomplished 5 days later in the operating room. A Gore TAG stent graft (W.L. Gore & Associates) was deployed in the aortic arch 20 mm proximally to the aneurysmatic segment covering the ostium of the LSA. The postoperative course was uneventful and the patient was discharged on the fifth postoperative day in good general conditions. Hybrid procedures for treatment of aneurysms of the aortic arch or of the descending thoracic aorta are a promising alternative to open surgery especially in high-risk patients, with lower early morbidity and mortality rates. Long-term effectiveness remains to be fully elucidated.