Crossover Bypass Research Articles

Outcomes of fenestrated and branched endovascular aneurysm repair with an inverted contralateral limb

ObjectiveTo report technical success and evaluate clinical outcomes of fenestrated and branched endovascular aortic repair (F/B-EVAR) incorporating a contralateral inverted limb. MethodsPatients who underwent F/B-EVAR with a custom-made bifurcated device containing an inverted limb between January 2010 and September 2023 were retrospectively analyzed. Time-to-event data were analyzed using the Kaplan-Meier method. ResultsA total of 32 patients (26 men; mean age 77±6.2 years) were included in the analysis. Technical success was achieved in 28 patients (87.5%). Two technical failures resulted from misplaced contralateral limbs in patients with previous endovascular aortic repair (EVAR), necessitating one open conversion due to a type 3b endoleak, and one femoro-femoral crossover bypass after occlusion of a misplaced contralateral limb. Additionally, two technical failures were attributed to a type 3c endoleak and a type 1c endoleak, originating from a fenestrated device at the level of the left and right renal artery, respectively. One patient (3.1%) died <30 days post-operatively due to a subdural hemorrhage. Estimated patient survival after 1 and 2 years was 92.7%±5.1%, and 74.3%±10.1%, respectively. No aneurysm-related deaths were observed. During the median follow-up of 13 months, one (3.1%) inverted limb occluded, in addition to the occlusion resulting from a misplaced contralateral limb, and was treated with a femoro-femoral crossover bypass. One target vessel (right renal artery) occluded (0.9%), resulting in a permanent, significantly reduced renal function. Freedom from overall reintervention after 1 and 2 years was 73.5%±8.0% and 68.3%±9.0%, respectively. An additional four patients (12.5%) presented with a type 3c endoleak during follow-up scans, three of which originated from fenestrations at the level of the renal stents. There were no junctional problems between the inverted limb device and the main endograft, and no significant correlation was found between the one-sealing-stent inverted limb device design and the onset of type 3 endoleak (log-rank p=.064). ConclusionF/B-EVAR incorporating an inverted limb can be a viable endovascular option to manage complex aneurysms with a short renal artery to bifurcation distance. However, using the inverted limb presents a notable technical challenge and could be associated with a higher need for reintervention. Carefully confirming correct cannulation of the inverted limb is warranted.

Tailoring Management of May-Thurner Syndrome : Case Comparison

Background: May-Thurner syndrome (MTS) is a post-thrombosis syndrome (PTS) of the lower extremity. This disorder results from compression and/or irritation from adjacent crossing the right common iliac artery to the left iliac venous. In this report, we present two management comparisons of patients with left lower DVT with consideration of MTS. Case Illustration: The first patient is a 49-year-old male soldier presented with chronic unilateral left leg edema and a mild clinical presentation for 9 months. Previous Doppler ultrasonography (DUS) revealed a thrombus in the left venous femoralis. Anticoagulant was given for six months. DUS and CT venography following anticoagulant treatment revealed a thrombus in the left venous femoralis. Venography revealed entire blockage of the left common femoral and left iliac veins, with adequate collateral flow. PTV was attempted twice and failed both times. The patient was following a conservative therapy (walking exercise and stocking compression) that yielded positive outcomes. The second patient is a 53-year-old male soldier has had unilateral left leg edema for three years, which has increased during the previous three months with ulceration and active bleeding. Previous Doppler ultrasonography revealed a thrombus in the left iliac externa. Anticoagulants and compression stockings were given for eight months, but the symptoms persisted. CT and venography revealed a complete blockage from the left popliteal vein to the iliac vein. Femoral crossover bypass surgery yielded favorable results. Conclusion: Clinically moderate MTS demonstrated fair results with conservative treatment, whereas clinically severe MTS showed superior results with bypass surgery. Keyword: Anticoagulant, May-Thurner Syndrome, Palma Procedure.

The Use of Autologous Subcutaneous Fat Tissue to Embolize an Infected Iliac Artery Pseudoaneurysm.

We describe a patient with a fistula between small bowel and a polyester patch of the common iliac artery. After emergency treatment with an endograft, the patch was replaced by a venous patch. Within 3-week a symptomatic pseudoaneurysm developed. It was decided to embolize the pseudoaneurysm using autologous subcutaneous fat, followed by a femoro-femoral crossover bypass using an allograft. Using this technique, the pseudoaneurysm was successfully excluded. This case shows that subcutaneous fat tissue can be used as an autologous embolic material, also in larger vessel pathology and in cases of ongoing infection, where regular embolization material cannot be used.

Double-Barrel Technique With Reversed Gore Excluder Stent Graft Limb for Common Iliac Aneurysm Exclusion in a Patient With Prior Aortic Surgical Repair.

Surgical repair of a common iliac artery aneurysm (CIA) after previous open aortic reconstruction is associated with significant morbidity and mortality. Endovascular repair is considered less invasive than surgery. However, if preservation of the internal iliac artery (IIA) is required, the applicability of endovascular techniques may represent a challenge and a limitation to the use of standard aortic endografts or iliac branch devices. In these cases, the off-label use of endovascular devices may be an effective alternative. Herein, we report a successful hybrid approach to treat CIA using a reversed iliac limb endograft coupled with a double-barrel technique with femoro-femoral crossover bypass in a patient who had previously undergone open aortic reconstruction.

Outcomes of Omniflow® II prosthesis used for revascularization in the femoral tract both in infected and non-infected setting.

Evidence regarding the outcomes of Omniflow® II prosthesis in peripheral arterial revascularization at different anatomical sites and for different indications is scarce. Therefore, the aim of this study was to evaluate the outcomes of the Omniflow® II used at various positions within the femoral tract both in infected and non-infected setting. Patients who underwent reconstructive lower leg vascular surgery with implantation of an Omniflow® II from 2014 until 2021 at five medical centers were retrospectively included (N.=142). Patients were subdivided into the following categories: femoro-femoral crossover (N.=19), femoral interposition (N.=18), femoro-popliteal (above-the-knee [N.=25; AK] or below-the-knee [N.=47; BK]), and femoro-crural bypass grafts (N.=33). Primary outcome was primary patency and secondary outcomes included primary assisted patency, secondary patency, major amputation, vascular graft infection, and mortality. Outcomes were compared according to different subgroups and the surgical setting (infected versus non-infected). The median follow-up was 35.0 (17.5-54.3) months. Three years primary patency of 58% was observed for femoro-femoral crossover bypass, 75% for femoral interposition graft, 44% for femoro-popliteal above-the-knee bypass, 42% for femoro-popliteal below-the-knee bypass, and 27% in the femoro-crural position (P=0.006). Freedom from major amputation at three years were 84% for femoro-femoral crossover bypass, 88% for femoral interposition bypass, 90% for femoro-popliteal AK bypass, 83% for femoro-popliteal BK bypass, and 50% for femoro-crural bypass (P<0.001). This study demonstrates the safety and feasibility of the use of Omniflow® II for femoro-femoral crossover-, femoral interposition-, and femoro-popliteal (AK and BK) bypass. Omniflow® II seems to be less suitable for femoro-crural bypass with a significantly lower patency compared to other positions.

A Case of Prosthesis Penetrating the Bladder by Crossover Bypass in the Pelvic Cavity

症例は73歳男性，60歳時に骨盤大腿型閉塞性動脈硬化症で右総腸骨-右大腿-左大腿動脈バイパス，左大腿-膝上膝窩動脈バイパス，69歳時に急拡大した腹部大動脈瘤に腹部ステントグラフト内挿術，その後に左大腿動脈吻合部仮性瘤切除術などの既往歴があった．人工血管周囲に体液貯留が持続し，72歳時にドレナージと右大腿動脈吻合部に縫工筋充填術を行った．73歳時に，左膝窩動脈バイパス閉塞にともない右腸骨動脈位人工血管から左閉鎖孔経路を通し左膝上膝窩動脈へcross overバイパス術を行った．1カ月後のCTで，人工血管の膀胱貫通が判明した．開腹手術で膀胱を切開して人工血管を膀胱外へ出した．術後経過は良好であったが，人工血管が尿に曝露されていたので3カ月間は経口抗生剤を続けた．現在，感染徴候もなく外来で経過観察中である．骨盤腔で交叉する閉鎖孔経路を選択する機会はきわめて稀だが，直視下で膀胱壁を識別し，十分な注意のもと人工血管を通す必要がある．

Decrease of Graft Failure Rate by Improving Tactics and Surgical Techniques in Extraanatomic Bypass Operations

We analized the early and late postoperative complications that occurred after 693 bypass operations (574 anatomic and 119 extra-anatomic) performed in 10 consecutive years (1997-2006). The bypass graft failures (infection + thrombosis) treatment and the subsequent evolution of the patients were detected by analyzing patients’ readmissions made to solve these major post-bypass complications. The follow-up period extended up to 12 years after the primary arterial bypass reconstruction. In this period we registered: 89 secondary arterial reconstructions for early and late graft thrombosis; 8 healings after removal of the infected prostheses, followed by extraanatomic bypass operations (7 obturator bypass + 1 axillo-bifemoral bypass). The most frequent vascular prosthesis infection sites were the Scarpa triangle and the thoraco-abdominal subcutaneous segment of the axillo(bi)-femoral graft. Major amputations after extraanatomic bypass operations: at 4 years postoperatively for axillo(bi)-femoral operations the amputation rate was 17.6%, while for crossover operations it was 7.5%. Perioperatory mortality after anatomic bypass operations = 2 intraoperatory and 8 postoperatory (1.38%/574 operations); perioperatory mortality after extraanatomic bypass operations: 2 postoperatory deaths (1.68%/119 operations), 1 after axillo-femoral prosthesis infection and 1 after acute myocardial infarction. In order to reduce the graft major complication rate after extraanatomic bypass operations we took the following measures: 1. When there are arterial occlusive lesions distal to the femoral tripod we ensured an adequate outflow which favores the long-term patency of the extraanatomic graft; this goal was obtained by 2 methods: by enlargement profundoplasty and/or by performing an additional distal bypass towards the popliteal artery or towards the subgenicular arteries. The distal subgenicular anastomosis was made between a venous graft and the distal outflow artery for reducing the intimal hyperplasia. 2. For crossover bypass operations we often used autologous vein grafts; 3. In crossover ilio-femoral bypass operation with venous graft we avoid the graft compression in its path through abdominal wall by passing the graft through a stable caliber hole made in a polypropylene closure mesh of the abdominal wall. 4. We promote the tunneling of the axillo-femoral prosthesis through the subaponeurotic muscular tissue because this tissue better protects the prosthetic graft against infection. 5. In order to reduce the groin prosthesis infections, we prefer performing ilio-femoral crossover bypass instead of femoro-femoral one. 6. The obturator bypass remains a valuable tratment for groin infected prosthesis.

Successful Crossover Bypass Using a Lateral Femoral Circumflex Artery as an Outflow Vessel for Indirect Revascularization in Critical Limb Ischemia: A Case Report.

A 78-year-old man presented with severe stage 3 (Fontaine IV, Rutherford 5, W1 I3 FI0) right limb ischemia. Although his artery was completely occluded from below the right external iliac to the popliteal artery, collateral circulation from the right lateral femoral circumflex artery was well developed and supplied the lower extremity arteries. We selected an uncommon crossover bypass strategy with the left common femoral artery to the right lateral femoral circumflex artery to improve lower extremity perfusion via indirect revascularization. Bypass using the lateral femoral circumflex artery as an outflow is an option for patients with major lower extremity artery occlusions.

Fenestrated/branched endovascular aortic repair using unilateral femoral access in patients with iliac occlusive disease

ObjectiveFenestrated/branched endovascular aortic repair (F/BEVAR) in patients with occluded iliac arteries is challenging owing to limited access for branch vessel catheterization and increased risk for leg and spinal ischemic complications. The aim of this study was to analyze technical strategies and outcomes of F/BEVAR in patients with unilateral iliofemoral occlusive disease. MethodsWe performed a retrospective review of all consecutive patients treated by F/BEVAR in two institutions (2003-2021). Patients with unilateral iliofemoral occlusive disease were included in the analysis. All patients had one patent iliac artery that was used for advancement of the fenestrated-branch component. Preloaded catheter/guidewire systems or steerable sheaths were used as adjuncts to facilitate catheterization. Primary endpoints were technical success, mortality, major adverse events (stroke, spinal cord injury, dialysis or decrease in the glomerular filtration rate of more than 50%, bowel ischemia, myocardial infarction, or respiratory failure), primary iliac patency, and freedom from reinterventions. ResultsThere were 959 patients treated with F/BEVAR. Of these, 15 patients (1.56%; mean age, 74 years; 80% male) had occluded iliac arteries and 1 patent iliofemoral access and were treated for a thoracoabdominal aortic aneurysm (n = 8) or juxtarenal abdominal aortic aneurysm (n = 7). Brachial access was used in 14 of the 15 patients and preloaded systems in 7 of the 15 patients (47%). The remaining 53% had staggered deployment of stent grafts. There were seven physician-modified endovascular grafts, seven custom-made devices, and one off-the-shelf device used. Thirteen patients (87%) had distal seal using aortouni-iliac stent grafts and two (13%) had distal seal in the infrarenal aorta. Concomitant femoral crossover bypass (FCB) was performed in two patients and six patients had a prior FCB. Technical success was 100%. There were no intraoperative complications or early lower extremity ischemic complications, and all FCB were preserved. There was one mortality (7%) within 30 days owing to retrograde type A dissection. Major adverse events occurred in 20% of patients. The median follow-up was 12 months (range, 0-85 months). Two patients (13%) required three reinterventions. One patient required proximal stent graft extension for an acute type B dissection (3 months) and another required iliac extension for type Ib endoleak of an aortouni-iliac graft (21 months) and thrombolysis of that extension (50 months). At last follow-up, all patients had primary graft patency except one with secondary graft patency without new claudication. One patient had a single renal artery stent occlusion at follow-up with no r-intervention. The overall survival rate was 60%, without aortic-related deaths. ConclusionsAlthough challenging, F/BEVAR with unilateral femoral/brachial approach is feasible in patients with occluded iliac limbs, with an important rate of ischemic complications, but satisfactory outcomes.

Femorofemoral Crossover Bypass for Unilateral Iliac Artery Occlusive Disease or Secondary Aortoenetric Fistula

Femorofemoral bypass is indicated in symptomatic lower-extremity ischemia due to acute or chronic occlusion of a unilateral Iliac Artery, adjunct to an endovascular unilateral Aortoiliac(AI) exclusion of an Abdominal Aortic Aneurysm (AAA), unavailability of endovascular options for management of iliac occlusive disease,etc.It’s contraindicated compromised inflow AI arterial segment, significant obesity that may cause unfavorable graft geometry ,etc. The complication of which leads to femoral nerve injury , hematoma, graft thrombosis and distal emboli etc. Here, We present several cases of Femorofemoral crossover bypass cases in this case study.

Acute Limb Arterial Ischemia Following Iliac Vein Stenting in the Setting of a Frozen Pelvis.

The authors report on a young patient with previous radiation to her pelvis who presented with acute limb ischemia following iliac vein stenting believed to be secondary to extrinsic iliac artery compression in the setting of a frozen pelvis. She underwent revascularization and a trans-femoral amputation, ultimately needing a femoral to femoral artery crossover bypass in order to achieve amputation stump healing. This case describes a potential arterial complication of venous stenting in a previously irradiated field.

Hybrid single staged treatment of coronary arteries and aorto-iliac obstruction disease: a case report

BackgroundIf the internal thoracic artery is a collateral circulation to the lower extremities, careful consideration should be given to its use when coronary artery bypass grafting is required. We report a case of CABG with bilateral common iliac artery lesions and collateral circulation from the bilateral ITAs on the peripheral side.Case presentationA 58-year-old man was admitted to our department with claudication and dyspnea upon exertion. He was diagnosed with right common iliac artery obstruction and 90% stenosis of the left common iliac artery. Coronary angiography revealed three-vessel disease with 50% stenosis of the left main trunk. The bilateral ITA showed a rich collateral flow to the lower extremities. Hybrid single staged repair with percutaneous transluminal angioplasty for the left iliac lesion was performed, followed by off-pump coronary artery bypass grafting (CABG) and femoro-femoral crossover bypass. Postoperative angiography revealed that all grafts were patent. The postoperative course was uneventful, except that the patient’s creatinine kinase level increased to 7177 U/L on postoperative day 1.ConclusionTo treat coronary artery disease with peripheral artery disease, especially those with iliac artery occlusion lesions with collateral circulation from the ITA, not only graft selection but also the treatment strategies for peripheral lesions are considered extremely important. Hybrid single staged coronary and lower limb artery revascularization could be safely achieved by multidisciplinary team strategies.

Temporary Extracorporeal Femoro-Femoral Crossover Bypass to Treat Acute Limb Ischemia due to Occlusive Femoral Transaortic Microaxial Left Ventricular Assist Device – A Novel Technique and Case Series

The Impella transaortic microaxial left ventricular assist device (MLVAD) bears the risk of severe ipsilateral limb ischemia due to its percutaneous insertion through the common femoral artery (CFA). As long as the MLVAD is required for cardio - circulatory support, treatment options are limited. Therefore, we developed a temporary extracorporeal femoral - femoral crossover bypass to restore and maintain perfusion of the affected leg. From October 2018, we treated all patients with severe limb ischemia due to the MLAVD with a femoral - femoral crossover bypass. For comparison, a consecutive cohort of patients undergoing placement of the MLAVD between January 2011 and October 2018 was identified. The primary outcome is the feasibility and safety of our percutaneously established extracorporeal femoral - femoral crossover bypass. Between January 2011 and July 2019, 25 of 245 (10.3%) patients developed a severe ipsilateral limb ischemia following the MLVAD placement. Until October 2018, 20 patients were treated conventionally (C - cohort) and since October 2018, five (consecutive) patients have been treated by an extracorporeal femoral - femoral cross over bypass (BP - Cohort). Following the BP - procedure, an immediate improvement of the perfusion was seen in all patients. Limb salvage was documented in 100% of our patients and 30 - day mortality was 60% in both groups. This is the first case series reporting on this novel technique. We demonstrated that the percutaneous creation of an extracorporeal crossover bypass is feasible, safe and effective and should therefore be promoted.

Hybrid Revascularization for Aorto-Iliac Occlusive Disease with Common Femoral Artery Involvement: Early Outcomes of a Single Centre.

To study the early outcomes of aorto-iliac occlusive disease with common femoral artery involvement by hybrid methods of revascularization - iliac stenting with femoral endarterectomy. We report the initial experiences of a single centre and discuss issues that arose. Ninety-eight critical limb ischaemia (CLI) patients with aorto-iliac occlusive lesions TASC-II C and D were treated using HR between January 2017 and September 2020 in the Ivano-Frankivsk Regional Clinical Hospital. Prospective data were recorded and analysed including demographics, technical success, 30-day and early patency outcomes, re-intervention, and death. The mean age of patients was 65 ± 7.2 years (61 men and 37 women). Using classification by TASC-II, 77% of the lesions were class D. Technical success was seen in 98% of patients. Two patients underwent a crossover femoro-femoral bypass due to failure to re-enter the true lumen of the aorta during endovascular lesion crossing. There were no deaths during the 30-day period. No re-interventions for thrombosis were needed. Additional delayed bypass procedures were required in 19 patients (19.3%) with distal occlusions and minor and major tissue loss. The overall complication rate was 16.3% (16 patients). The 30-day patency rate was 100%. The median follow-up period was 18 months (range 1-36 months) with a primary patency rate of 87.2%, and cumulative primary assisted and secondary patency rate of 93.4%. Four patients died during the study period. Hybrid revascularization is a safe and less traumatic method of managing aorto-iliac occlusive disease with common femoral artery involvement. Good early patency results and low major complication rates indicate that HR is an excellent alternative to traditional open surgery, especially for high-risk patients.

Fatal Case of a Contained Ruptured of the Infrarenal Aorta due to Simultaneous Primary Aortocaval Fistula and Aortoenteric Fistula

We report an extremely rare case of primary aortocaval fistula with simultaneous development of an aortoenteric fistula in a 68-year-old man. The patient developed under oral anticoagulation a spontaneous intracaval aortic rupture. An emergency intervention was performed with a covering of the fistula with an aorto-uniiliac stent graft and a femoro-femoral crossover bypass. One week later, the patient was transferred to our institution with the diagnosis of a psoas abscess and a suspected concomitant aortoenteric fistula. We performed a complete explantation of the endograft and implanted it after extensive debridement an aortobiiliac bypass, made of bovine pericardium. The postoperative course was complicated, first by bleeding from the left iliac anastomosis, and then by bleeding from the proximal aortic anastomosis. The entire graft was explanted and an axillo-femoral bypass was implanted. The patient then developed a multi-organ failure and died 3 months later. If possible, an extended surgical debridement and resection of all infected tissue with in situ reconstruction is the gold standard. However, with this therapy, there is still a high risk of reinfection. Long-term antibiotic management is mandatory.

Temporary extracorporeal femoro-femoral crossover bypass to treat critical limb ischemia due to occlusive femoral transaortic microaxial left ventricular assist device – a novel technique and case series

Abstract Objective The Impella transaortic microaxial left ventricular assist device (MLVAD) bears the risk of severe ipsilateral limb ischemia due to it´s percutaneous insertion through the common femoral artery (CFA). As long as the MLVAD is required for cardio-circulatory support, treatment options are limited. Therefore, we developed a temporary extracorporeal femoro-femoral crossover bypass to restore and maintain perfusion of the affected leg. Methods From October 2018, we treated all patients with severe limb ischemia due to the MLAVD with a femoro-femoral crossover bypass. For comparison, a consecutive cohort of patients undergoing placement of the MLAVD between January 2011 and July 2019 was identified. For those patients who experienced limb ischemia after Impella placement, data on age, gender, BMI and diabetes, underlying cardiac condition, duration of Impella pump in place, limb complications, limb salvage procedure, need for additional surgical procedure on the affected limb (e.g. fasciotomy) were recorded. The primary outcome is the feasibility and safety of our percutaneously established extracorporeal femoro-femoral crossover bypass. As secondary outcomes, we report overall 30 day mortality and limb salvage rates. Results Between January 2011 and July 2019, 25 of 245 (10.3%) patients developed a severe ipsilateral limb ischemia following the MLVAD placement. Until October 2018, 20 patients were treated conventionally (C-cohort) and since October 2018, five (consecutive) patients have been treated by an extracorporeal femoro-femoral cross over bypass (BP-Cohort). Following the BP-procedure, an immediate improvement of the perfusion was seen in all patients. The bypass remained in place during a median of 5 days. Limb salvage was documented in 100% of our patients and 30 days mortality was 60% in both groups. Conclusion This is the first case series reporting on this novel technique. We demonstrated that the percutaneous creation of an extracorporeal femoro-femoral crossover bypass is feasible, safe and effective and should therefore be promoted in the future.

Remembering an Old Technique: Retroscrotal Perineal Femorofemoral Bypass for Ischaemic Ulcer of the Anterior Thigh

A 61 year old male (after multiple previous bilateral peripheral arterial procedures and fenestrated endovascular aortic aneurysm repair) consulted for buttock claudication and ischaemic ulceration of the anterior right thigh. Computed tomography angiography showed patent common and external iliac arteries, common and superficial femoral arteries (previously stented), and occlusions of right internal iliac, deep circumflex iliac, and proximal deep femoral arteries. After failed endovascular attempts, a femorofemoral crossover bypass was performed using a cryopreserved venous allograft. Owing to ischaemic necrosis of the thigh, perineal retroscrotal tunnelling was preferred. Dual antiplatelet therapy was initiated post-operatively. Tunnelling in this lesser known region allowed successful wound healing after several months.Image 1

Ovation Relining with Ovation Stent Graft

A 72 year old patient was diagnosed with a right common iliac aneurysm (77 mm) and an aortic aneurysm (44 mm, neck length 50 mm). After embolisation of the right internal iliac artery (asterisk; A and B), the aneurysms were treated with an Ovation iX stent graft (Endologix, Santa Rosa, CA, USA). Eleven per cent oversizing was applied (TV-AB2980, IR + 13 = 25.9 mm). Significant distal migration (over a 9 cm distance) of the main body with type Ia endoleakage occurred (arrow indicating the level of lowest renal artery; A and B). (B) Total relining with an Ovation iX stent graft (main body length 8 cm) was performed. After one month, a crossover bypass was created for right limb occlusion.Image 1

Long Term Degeneration and Spontaneous Rupture of an Expanded Polytetrafluoroethylene Graft

A 70 year old female presented acutely with a suprapubic pulsating mass 35 years after a femorofemoral crossover bypass. (A) Computed tomography angiography showed a pseudoaneurysm in the middle of an expanded polytetrafluoroethylene prosthetic graft (manufacturer unknown). Intra-operatively, there was severe plastic deformation and graft calcification without infection. It could neither be cross clamped nor oversewn and so was explanted and a new femorofemoral reconstruction with an 8 mm knitted polyester tube graft (Flownit Bioseal, Jotec GmbH, Hechingen, Germany) was performed. It is likely that due to these long term changes it spontaneously ruptured as a hole was found in its middle (B). The post-operative course was uneventful.Image 1

Comparison of the Effectiveness of Ring-Stripping Retrograde Endarterectomy and Carotid Artery Crossover Bypass in the Treatment of Patients with Symptomatic Riles Type 1A Common Carotid Artery Occlusion

Objective: The surgical procedure most appropriate for treating symptomatic Riles type 1A common carotid artery occlusion (CCAO) is unclear. This study compares the effects of ring-stripping retrograde endarterectomy (RSRE) and carotid artery crossover bypass (CACB) on cerebral perfusion improvement in patients with symptomatic Riles type 1A CCAO. Methods: We conducted a retrospective analysis of symptomatic Riles type 1A CCAO patients treated at our centre. Postoperative improvements in the ipsilateral internal carotid artery (ICA) flow rate, ipsilateral cerebral blood perfusion (CBP) and the stroke recurrence rate were compared between patients who underwent RSRE and those who underwent CACB. Results: A total of 20 CCAO patients were surgically treated at our centre from 2011 to 2018. Nine of these patients underwent RSRE, and eleven underwent CACB. No significant differences were identified between the groups in the ipsilateral blood flow rate of the ICA immediately after surgery and the ipsilateral-to-contralateral mean transit time ratios 1 day after surgery. However, the flow rate in the ICA was significantly higher in the RSRE group than in the CACB group 1 year after surgery (135.44 ± 19.22 ml/min vs. 116.36 ± 17.70 ml/min, p = 0.033). For CBP, the ipsilateral-to-contralateral mean transit time ratios were significantly lower in RSRE patients than in CACB patients 1 year after surgery (1.005 ± 0.052 vs. 1.064 ± 0.066, p = 0.044). In addition, the postoperative modified Rankin scale (mRS) score at the latest follow-up point (p = 0.884) and the stroke recurrence rate during the follow-up (88.9% vs. 90.9%, p > 0.999) were not significantly different between the two groups. Conclusions: Although the postoperative mRS score and the stroke recurrence rate were not significantly different between RSRE and CACB patients, compared to CACB, RSRE was better for improving the ipsilateral ICA flow rate and cerebral perfusion in symptomatic Riles type 1A CCAO patients.