Indication For Surgical Revascularization Research Articles

Endo-Aortic Clamping with the IntraClude® Device in Minimally Invasive Total Coronary Revascularization via Left Anterior Thoracotomy (TCRAT)

Minimally invasive, sternum-sparing total coronary revascularization in multivessel disease via left anterior mini-thoracotomy (TCRAT) was introduced recently. Intra-aortic balloon occlusion is a conceivable option to avoid manipulation of the ascending aorta, to reduce the risk of stroke and to be able to treat patients with severe calcifications and unfavorable aortic anatomies. Background/Objectives: The aim of our study was to show that the use of the IntraClude® device, as part of minimally invasive coronary artery bypass grafting (CABG) via left anterior mini-thoracotomy, is feasible. Methods: From May to December 2023, CABG via left anterior mini-thoracotomy on cardiopulmonary bypass and cardioplegic arrest was successfully performed in 20 patients (17 male, 67.6 ± 8.2 (51–82) years). All patients had significant coronary artery disease (three-vessel: n = 6; two-vessel: n = 11; one-vessel: n = 3) with indication for surgical revascularization. The mean EuroScore2 was 2.6. Results: All patients successfully underwent minimally invasive CABG using endo-aortic balloon occlusion. A total of 43 distal anastomoses (2.2 ± 0.6 (1–3) per patient) were performed by using left internal artery mammary (n = 20) and radial artery (n = 14) for grafting the left anterior descending (n = 19), circumflex (n = 15) and right (n = 6) coronary artery. There was no hospital mortality, no stroke, no myocardial infarction or repeat revascularization. A total of 15 out of 20 patients left hospital within 8 days after surgery. Conclusions: TCRAT by using the IntraClude® device is feasible without compromising surgical principles while avoiding the external manipulation of the ascending aorta. The use of intra-aortic balloon occlusion instead of transthoracic clamps further reduces the invasiveness of the procedure.

Minimally invasive coronary artery bypass (MICS CABG) in Bosnia and Herzegovina: a single centre, single surgeon cohort experience.

Aim This is the first research in Bosnia and Herzegovina presenting minimally invasive coronary artery bypass grafting surgery (MICS CABG) experience, advantages, and outcomes as compared to conventional surgery (OPEN CABG). Methods This retrospective cross-sectional study was conducted between January 2019 and November 2022 and included patients with indication for surgical revascularization. Results Among 237 patients, males predominated, 182 (76.7%), with a mean body mass index (BMI) of 28.4±3.9, median The Society of Thoracic Surgery Risk (STS) score of 1.55 (0.8, 4.0), short term STS score of 11.2 (6.8, 23.7), mean age of 64.8±8.7 (ranging 41-83) years, 122 (51.4%) underwent OPEN CABG and 115 (48.6%) MICS CABG. MICS CABG took less time (p<0.001; OPEN 3.5±0.8h; MICS 2.8±0.8h) and needed less mechanical ventilation (p<0.001, OPEN 17.3±11.9h; MICS 13.0±12.5h) than OPEN CABG. Even though there was no difference in hospitalization length between groups (OPEN (7.5±3.2), MICS (7.1±4.0)), patients receiving MICS (2.9±1.5) spent less time in the ICU (p=0.0013) than OPEN CABG (3.6±2.8). OPEN CABG used also more blood derivatives, red blood cells (OPEN 292 vs MICS 55), plasma (OPEN 270 vs MICS 86) and platelets (OPEN 71 vs MICS 28). Conclusion Patients undergoing MICS CABG in Bosnia and Herzegovina had less mechanical ventilation hours and less ICU duration compared to OPEN CABG even though the hospitalization duration was very similar. MICS CABG takes less time to be conducted, has fewer CPRs postoperatively, uses less blood derivatives including red blood cells, plasma and platelets.

P165 ARRHYTHMIC STORM IN SUBACUTE MYOCARDIAL INFARCTION: A CASE REPORT

Abstract Introduction Ventricular arrhythmias (VA) represent a common complication of myocardial infarction (MI). Typically, they occur in two scenarios: during acute MI, related to ongoing ischemia, as ventricular tachycardia (VT) or ventricular fibrillation (VF), or in the context of a late phase of MI, related to the presence of a scar, as monomorphic VT (mVT). Despite the above, their occurrence may be atypical. Clinical Case 55–year–old man affected by obesity, diabetes and hypertension, admitted to our department for subacute MI. Coronarography showed three–vessel disease with indication for surgical revascularization. Thirty hours after admission, in absence of symptoms, occurrence of cardiovascular arrest due to mVT, which degenerated into VF. After resuscitation, ECG and Echo findings did not change compared to those observed at admission, excluding the presence of current ischemia. A blood gas analysis excluded dysionias. Few minutes later, arrhythmic recurrence of mVT degenerated into VF. This was refractory to electrical and antiarrhythmic therapy and stopped only after percutaneous left stellate ganglion block (LSGB) and deep sedation. Then, emergency surgical revascularization was performed. In the early postoperative days, during weaning attempts from sedation and ECMO support, that had become necessary due to hemodynamic instability after surgery, numerous recurrences of mVT, regressed only after deepening of sedation, multiple external shocks, antiarrhythmic polytherapy, and LSGB. A new coronarography documented patency of coronary artery bypass grafts. On 6th postoperative day, discontinuation of deep sedation and weaning from circulatory support without recurrence of VA. The patient was discharged from the intensive care unit and started on a rehabilitation pathway. Conclusions mVTs are commonly related to the presence of a scar, formed late after MI, or to the context of ongoing ischemia in acute MI. However, it should be remembered that even during the subacute phase of MI, arrhythmic instability might still occur. The responsible mechanisms are not completely known but it can be assumed that, even in the absence of a new ischemic event, the process of scar maturation may have led to a transient proarrhythmic substrate, responsible for the arrhythmic storm. Further studies are needed to clarify the mechanisms of arrhythmogenesis in the subacute phase of MI.

Effects of non-surgical periodontal treatment on complete blood count, lipid and glycemic profiles of patients with an indication for surgical coronary revascularization

Objetivo: o objetivo deste estudo foi avaliar os efeitos do tratamento periodontal não cirúrgico no hemograma completo, perfil glicêmico e lipídico em pacientes cardiopatas com indicação de revascularização cirúrgica. Material e Métodos: este estudo avaliou 22 pacientes com periodontite crônica, com mais de 35 anos de idade (média de idade de 59,45 anos) aleatoriamente divididos em 2 grupos. O grupo teste (n = 11) recebeu tratamento periodontal antes do procedimento cirúrgico e o grupo controle (n = 11) não recebeu tratamento periodontal antes da cirurgia. Resultados: o tratamento periodontal resultou em uma redução significativa na profundidade de sondagem em locais com profundidade de sondagem periodontal&gt; 3 mm (redução de 11,4%) e&gt; 5 mm (redução de 6,3%) (P &lt;0,05). As diferenças no nível clínico de inserção não foram estatisticamente significantes entre os grupos (P&gt; 0,05). Os valores referentes à contagem de leucócitos, glicose, hemócitos e hemoglobina não diferiram significativamente entre os grupos (P&gt; 0,05). O colesterol total e lipoproteína de alta densidade apresentaram uma redução estatisticamente significativa no grupo teste (P &lt;0,05). A lipoproteína de densidade leve não mostrou diferença estatisticamente significante entre os grupos (P&gt; 0,05). Conclusão: o tratamento periodontal não cirúrgico foi efetivo no controle da doença periodontal e diminuição dos níveis séricos de colesterol total e lipoproteínas de alta densidade. Os demais componentes do sangue não apresentaram alterações significativas.

Outcome of percutaneous coronary intervention with drug-eluting stents in unprotected left main versus non-left main native coronary artery disease: results from the prospective multicenter German DES.DE registry

Unprotected left main coronary artery (ULMCA) disease is considered an indication for surgical revascularization. However, refined percutaneous coronary intervention (PCI) technology and modern drug-eluting stents (DES) render the ULMCA a target for interventional treatment. Between October 2005 and September 2009, 374 patients receiving DES in ULMCA and 18,678 patients receiving DES in non-left main coronary arteries (nLMCA) with no previous coronary artery bypass graft surgery, were registered at 130 DES.DE sites. The composite of death, myocardial infarction (MI), and stroke defined as major adverse cardiac and cerebrovascular events (MACCE) and target vessel revascularization (TVR) were defined as primary endpoints. Baseline clinical and descriptive morphology of coronary artery disease revealed more comorbidities and more complex anatomies in the ULMCA group. At 1-year follow-up, the ULMCA group suffered from higher rates of overall death (5.6 versus 2.3 %; p < 0.0001), stroke (2.0 versus 0.8 %; p < 0.05), MACCE (8.6 versus 4.9 %; p < 0.01); whereas rates for definite/probable stent thrombosis (2.4 versus 1.6 %; p = 0.29), TVR (14.2 versus 10.8 %; p = 0.06) and MI (1.3 versus 1.9 %; p = 0.44) were not statistically different. These results persisted even after adjustment for different baseline characteristics, except MACCE that was no longer statistically significant. Data collected in DES.DE revealed that ULMCA PCI with DES result in similar TVR rates as compared to PCI in nLMCA. Moreover, modern DES have not offset the higher comorbidity index and higher procedure-related complication rate with PCI of ULMCA lesions.

Comparison of Precuffed Expanded Polytetrafluorothylene and Heparin-Bonded Polytetrafluorothylene Graft in Crural Bypass

The purpose of this study was to evaluate early and midterm results of tibial bypasses comparing precuffed expanded polytetrafluoroethylene (PTFE) graft (Distaflo) and heparin-bonded PTFE graft (Propaten) with a distal vein patch. This is a retrospective cohort analysis evaluating patients who underwent PTFE femorocrural bypasses between April 2004 and December 2010 at the Vascular Surgery Division of the Poliambulanza Foundation Hospital (Brescia, Italy). Results were analyzed in terms of primary and secondary graft patency, limb salvage, and survival with univariate (Kaplan-Meier curves and log-rank test) and multivariate (Cox regression) analyses. After analyzing many patients, we found 79 femorotibial bypass PTFE grafts. We used a Propaten graft and vein patch in 40 patients and a Distaflo graft in 39 patients. The two groups were comparable for main risk factors, except for age. Indication for surgical revascularization was critical limb ischemia in all patients. In 54 cases (68%), it was a redo bypass because of a previously failed revascularization. Perioperative mortality within 30 days from intervention was 2.5%, whereas overall mortality during follow-up was 29%, with a 36-month survival rate of 58% (95% confidence interval [CI]: 0.44-0.77) on life table analysis. We observed a significant difference between two groups in terms of survival at 36 months (Propaten: 0.84 [95% CI: 0.69-1]; Distaflo: 0.21 [95% CI: 0.07-0.63]; P < 0.001; 95% CI: 0.07-0.63; odds ratio [OR]: 0.21). At 24 months, the two groups (Propaten vs. Distaflo) were equivalent in terms of primary patency (Propaten: 0.33 [95% CI: 0.21-0.53]; Distaflo: 0.47 [95% CI: 0.32-0.70]; P = 0.793), secondary patency (Propaten: 0.36 [95% CI: 0.23-0.57]; Distaflo: 0.49 [95% CI: 0.33-0.72]; P = 0.855), and limb salvage (Propaten: 0.65 [95% CI: 0.51-0.84]; Distaflo: 0.57 [95% CI: 0.41-0.79]; P = 0.18). At Cox regression analysis, age of >80 years (P < 0.04; 95% CI: 0.23-0.95; OR: 0.47), peroneal artery distal anastomosis (P < 0.04; 95% CI: 1.04-5.62; OR: 2.42), simultaneous adjunctive procedures (P < 0.02; 95% CI: 1.21-17.74; OR: 4.64), and redo bypass (P < 0.05; 95% CI: 1-6.26; OR: 2.5) were associated with long-term poorer primary patency rates. Postoperative treatment with warfarin therapy compared with antiplatelet therapy was independently associated with better secondary patency (P < 0.04; 95% CI: 0.20-0.95; OR: 0.44) and limb salvage (P < 0.03; 95% CI: 0.11-0.87; OR: 0.32) rates. Distaflo and Propaten with a distal vein patch in our experience have similar patency and limb salvage results, although further randomized and larger studies are necessary. Postoperative anticoagulation therapy seems better than antiplatelet therapy in terms of patency and limb salvage rate.

Validating intramyocardial bone marrow stem cell therapy in combination with coronary artery bypass grafting, the PERFECT Phase III randomized multicenter trial: study protocol for a randomized controlled trial

BackgroundFor the last decade continuous efforts have been made to translate regenerative cell therapy protocols in the cardiovascular field from ‘bench to bedside’. Successful clinical introduction, supporting safety, and feasibility of this new therapeutic approach, led to the initiation of the German, Phase III, multicenter trial - termed the PERFECT trial (ClinicalTrials.gov Identifier: NCT00950274), in order to evaluate the efficacy of surgical cardiac cell therapy on left ventricular function.Methods/DesignThe PERFECT trial has been designed as a prospective, randomized, double-blind, placebo controlled, multicenter trial, analyzing the effect of intramyocardial CD 133+ bone marrow stem cell injection in combination with coronary artery bypass grafting on postoperative left ventricular function. The trial includes patients aged between 18 and 79 years presenting with a coronary disease with indication for surgical revascularization and reduced global left ventricular ejection fraction as assessed by cardiac magnet resonance imaging. The included patients are treated in the chronic phase of ischemic cardiomyopathy after previous myocardial infarction.DiscussionPatients undergoing coronary artery bypass grafting in combination with intramyocardial CD133+ cell injection will have a higher LV ejection fraction than patient who undergo CABG alone, measured 6 months after the operation.Trial registrationClinicalTrials.gov Identifier: NCT00950274

Drug-Eluting Stents and the Use of Percutaneous Coronary Intervention Among Patients With Class I Indications for Coronary Artery Bypass Surgery Undergoing Index Revascularization: Analysis From the NCDR (National Cardiovascular Data Registry)

Our purpose was to evaluate percutaneous coronary intervention (PCI) attempt rates in patients with class I indications for coronary artery bypass graft (CABG) surgery after the introduction of drug-eluting stents (DES). In patients with severe, multivessel coronary disease, CABG has historically been recommended over PCI. Practice guidelines for CABG were last updated before the emergence of data on DES efficacy. We analyzed 265,028 procedures from the NCDR (National Cardiovascular Data Registry) meeting American College of Cardiology/American Heart Association class I indications for surgical revascularization. Temporal trends in PCI attempt rates were analyzed during 3 consecutive time periods: pre-DES (before April 1, 2003), DES diffusion (April 1, 2003 to December 31, 2004), and DES (January 1, 2005 to September 30, 2006). The attempted rate of PCI in patients with class I indications for CABG increased over the 3 time periods (pre-DES: 29.4%, DES diffusion: 33.4%, and DES era: 34.7%, p < 0.001). In a hierarchical multivariable logistic model adjusting for patient and PCI site characteristics, PCI attempts were more likely in the DES compared with pre-DES era (odds ratio: 1.44, 95% confidence interval: 1.40 to 1.48) and the DES diffusion era (odds ratio: 1.20, 95% confidence interval: 1.17 to 1.23). PCI attempt rates increased in all 3 time periods, although the average rate of increase during the DES era was 0.6% per quarter compared with 0.3% per quarter for both the DES diffusion and the pre-DES eras (p = 0.03). DES use in clinical practice was associated with a significant overall increase in PCI to treat patients with class I indications for CABG. Long-term follow-up of this cohort of patients is warranted.

Lower Limb Revascularization with a New Bioactive Prosthetic Graft: Early and Late Results

The aim of the study was to evaluate the immediate and long-term results of femoropopliteal bypasses performed with a new bioactive heparin-treated expanded polytetrafluoroethylene (ePTFE) graft in a single-center experience. From March 2002 to April 2006, 51 patients underwent lower limb revascularization with a new bioactive ePTFE prosthetic graft with covalent end-point attachment of heparin to the graft surface. Data concerning preoperative assessment, intraoperative strategy, drug administration, and follow-up surveillance program were prospectively collected in a dedicated database; early results were analyzed in terms of graft patency, amputation rate, and deaths. Follow-up consisted of clinical and duplex scan examination at 1, 6, and 12 months and yearly thereafter. Midterm results in terms of primary and secondary patency, limb salvage, and survival were analyzed. Patients were predominantly male (35 patients, 71%), with a mean age of 71 years (SD = 9.05). Indications for surgical revascularization were critical limb ischemia in 36 patients and severe intermittent claudication in 15 patients. Interventions were performed for occlusion of a native vessel in 35 cases, whereas 12 patients had late thrombosis of a femoropopliteal bypass; the remaining four patients were operated on for an occluded popliteal artery aneurysm. Intervention consisted of below-knee bypass in 34 patients, while the other 17 had an above-knee revascularization. No perioperative deaths occurred. Cumulative 30-day graft patency was 88%, with an amputation rate of 4% (two cases). Results were similar in above- and below-knee revascularizatons. Mean duration of follow-up was 18 months (SD = 7). Cumulative estimated 24-month survival and primary patency rates were 97% and 80.2%, respectively; the corresponding limb salvage rate was 85.7%. Long-term results did not significantly differ in above- and below-knee revascularizatons. In our experience, the use of a modified ePTFE graft with covalent end-point linkage of heparin molecules on the graft surface provides good early and midterm results, with low rates of graft thrombosis and amputation.

The Argument to Support Broader Application of Extracranial Carotid Artery Stent Technology

As new technology becomes available, the stent technique for the extracranial carotid artery continues to evolve into a safer, more effective therapy for stroke prevention. With the availability of embolic protection, improved stent designs, and added endovascular physician experience, outcomes for carotid artery stenting (CAS) now consistently parallel those for carotid endarterectomy (CEA). Although carotid endarterectomy was established as the gold standard for carotid revascularization, the available scientific evidence must continue to be interpreted in the context of further advancements in nearly all related areas of medicine. One multicenter randomized trial and several nonrandomized registries have successfully established the CAS indications for patients with high surgical risk and have provided evidence to support the use of CAS techniques in patients with low surgical risk. Clinicians must continue to improve their understanding of patient-specific factors and conduct research that will refine indications while optimizing current medical therapy and that will integrate CAS and carotid endarterectomy as complementary treatments. Response by LoGerfo p 1610 The outcomes for CAS have been improving over the past 10 years and now appear nearly equivalent to those for CEA. In fact, many historical similarities are seen in the development of these 2 techniques. Although CEA was established as the gold standard for extracranial carotid revascularization, the available scientific evidence must continue to be interpreted in the context of further advancements in nearly all related areas of medicine. The current research comparing CAS and CEA has not shown a clinically robust and statistically significant difference between the 2 treatments. When differences do exist, clinicians must continue to refine patient-specific indications and to conduct further research to understand these complex risk-benefit analyses in the context of advanced medical treatments and complementary revascularization techniques. The following review details the argument to support implementation of CAS technology for athero-occlusive carotid …

2. 臨床脳虚血の脳循環代謝と血行再建術の適応(PS2-3 頭蓋内血行再建のすべて, 第27回 日本脳神経外科コングレス総会)

2. 臨床脳虚血の脳循環代謝と血行再建術の適応(PS2-3 頭蓋内血行再建のすべて, 第27回 日本脳神経外科コングレス総会)

Exercise After Heparin Administration

A prospective study examined whether a combination of an exercise program and heparin administration improves the clinical symptoms of patients with arteriosclerosis obliterans (ASO) without an indication for surgical revascularization because of the lack of distal target vessels or other reasons such as high surgical risk or lack of a vein conduit from previous coronary artery bypass surgery. A total of 19 consecutive patients with symptomatic non-option ASO diagnosed by angiography were randomly assigned to 3 groups: heparin + exercise (walking for 60 min after heparin injection [3,000 units/day IV for 14 days], n = 6), heparin administration only (n = 6), and exercise only (n = 7). Plasma levels of hepatocyte growth factor (HGF) were serially measured before and after intravenous administration of heparin. Ankle brachial pressure index was measured and treadmill exercise test (2.5 km/h, 12% slope) was performed before the 2-week treatment, just after finishing treatment, and 12 weeks after beginning the treatment. Ophthalmic examinations, including visual acuity test, ocular fundoscopy and fluorescein angiographic fundus photography, were performed before and 12 weeks after the treatment program. In all patients, HGF levels increased more than 4-fold of the basal level at 30 min after heparin injection. Maximum walking time was significantly higher in the heparin + exercise group than in the other 2 groups (p < 0.05). There were no patients who showed pathological retinal angiogenesis. The combination of an exercise program and heparin administration improves the clinical symptoms of patients with non-option ASO.

Long-Term Outcome After Surgical Kidney Revascularization for Fibromuscular Dysplasia and Atherosclerotic Renal Artery Stenosis

At a time of minimally invasive surgery in urology, the role of surgical kidney revascularization in the management of renal artery disease has changed during the last decade. Our experience with surgical kidney revascularization, and the long-term clinical outcomes of fibromuscular dysplasia (FMD) and atherosclerotic renal artery stenosis are reviewed. The study group comprised 140 patients with renovascular hypertension, 72 with FMD and 68 with atherosclerotic renal artery disease, who underwent surgical revascularization between 1982 and 1999. The indications for surgical revascularization were the treatment of hypertension and the preservation of renal function in 17 patients with renal artery occlusion, 55 with ostial stenosis, 52 with branch stenosis, 6 with bilateral artery stenosis, 7 with solitary kidney renal artery stenosis and 3 with solitary kidney renal artery occlusion. Postoperative blood pressure and renal function were monitored for 1 to 17 years (mean 11.3). Long-term blood pressure control was observed in 93% of patients with FMD and in 71% of those with atherosclerosis. Improvement or stabilization of renal function was observed in 92% of patients with FMD and in 68% of those with atherosclerosis. The preoperative estimated glomerular filtration rate compared to postoperative was significantly increased in both groups. Surgical kidney revascularization is effective in secondary hypertension with a high long-term efficacy in the normalization of blood pressure and in the preservation of renal function, especially in patients with a solitary or 1 functional kidney.

Factors that predict site of outflow target artery anastomosis in infrainguinal revascularization.

Lower extremity revascularization is indicated for limb salvage and incapacitating leg claudication. Many risk factors (age, hypertension, diabetes, tobacco use, dyslipidemia, etc) have been associated with atherosclerosis and the development of peripheral arterial occlusive disease. However, whether these risk factors or the surgical indication (claudication or limb salvage) influences the extent and location of infrainguinal disease and hence the target artery (distal anastomosis) is unclear. This study examines the risk factors and indication for infrainguinal revascularization with respect to the type of bypass performed. Three hundred fifty-two infrainguinal revascularizations in 282 patients were retrospectively reviewed. Patient data, including demographics, cardiovascular risk factors, indications, types of revascularization, and perioperative complications and mortality, were collected. Data were analyzed with t test, chi(2) test, Fisher exact test, and multiple logistic regression. The indication for surgical revascularization was claudication in 70 patients and limb salvage in 282. The likelihood of a popliteal anastomosis (above or below knee) versus a tibial or pedal anastomosis was decreased with increasing age (P =.002) and diabetes (P =.0001), and smoking increased the likelihood (P =.056). However, popliteal bypass also was strongly associated with claudication as the surgical indication (odds ratio [OR], 8.7; P =.0001), and 90% of the claudicant group had undergone popliteal anastomosis. Claudication and popliteal anastomosis were both linked to smoking; 97% of subjects who underwent operation for claudication were smokers compared with 75% of subjects who underwent tibial or pedal anastomosis for limb salvage (P =.001). After adjustment for indication, the likelihood of popliteal anastomosis was still decreased with diabetes (OR, 0.46; P =.002), and age had a borderline significant effect (P =.077). When the analysis was stratified by indication for surgery, the likelihood of popliteal bypass among patients who underwent operation for claudication was not influenced by age, diabetes, or smoking. However, within the subset of patients who underwent operation for limb salvage, the likelihood of any popliteal anastomosis was diminished by diabetes (OR, 0.50; P =.007), age (OR, 0.968 per year; P =.01), and chronic renal insufficiency (OR, 0.476; P =.04). Infrainguinal peripheral arterial occlusive disease is not a homogenous disease entity. Claudication and limb salvage are associated with two distinct patterns of vascular disease with different risk factors. Patients who undergo operation for claudication are seen at an earlier age, have a high prevalence of smoking, and have proximal disease and a greater likelihood of a popliteal anastomosis. In contrast, patients for limb salvage are less likely to have a popliteal bypass, favoring a more distal target outflow anastomosis that is strongly influenced by advanced age, diabetes, and chronic renal insufficiency.

Cerebral revascularization for moyamoya disease

Eighty-four patients with moyamoya disease, including 36 pediatric cases and 48 adult cases, were treated by revascularization surgery. Ischemic onset is a good indication for surgical revascularization in both pediatric and adult cases. Combined surgery of superficial temporal artery-middle cerebral artery anastomosis and indirect revascularization of encephalo-duro-arterio-myo-synangiosis (EDAMS) or encephalo-duro-myo-arterio-pericranio-synangiosis (EDAMPS), which is a minor modification of EDAMS, was performed. Ischemic attacks disappeared in most patients within 1 year (mean) after surgery. However, in adult cases with hemorrhagic onset, rebleeding was seen in 6 of 48 cases (12.5%; mean follow-up, 6 years). Recent advances in clinical and basic studies of moyamoya disease are reviewed.

Cardiac complications in non-insulin-dependent diabetes mellitus

There is clear evidence of the negative influence of type I or II diabetes non-insulin-dependent diabetes mellitus (NIDDM) on the prevalence, severity, and prognosis of cardiovascular disease. Epidemiologic studies have confirmed the relationship between NIDDM and the occurrence of coronary artery disease (CAD) and cardiac heart failure (CHF). The clinical aspects of NIDDM cardiac complications include a high rate of silent events, which merit an improvement in their diagnosis and treatment. Besides pharmacological therapy, aggressive approaches including percutaneous transluminal coronary angioplasty (PTCA), and coronary surgery should be considered for the treatment of stable angina. In some subgroups, the benefit of surgery has been proven. Available data indicate that diabetes (both type I and II) is a risk factor for an increase in morbidity and mortality following coronary bypass surgery. These data do not differentiate results between type I and type II diabetes. The indications for surgical revascularization are: three-vessel disease, left main artery stenosis, two-vessel disease including proximal left anterior descending artery stenosis, and two-vessel disease with left ventricular dysfunction. For PTCA, diabetes (type I more than type II) renders the technique more difficult and restenosis more frequent. From the results obtained in the general population and from a few specific studies, it is suspected that, in type II diabetes, PTCA and CABG are superior to conventional medical treatment. However, further specific studies on the beneficial effects of PTCA/CABG over optimal medical therapy are needed, at least in some angiographic conditions. Management of the diabetic patient with acute myocardial infarction is for the most part similar to the nondiabetic patient, with certain special considerations. Treatment includes thrombolytic therapy, invasive management, surgery, FTCA, β blocker use, and aspirin use. Finally, diabetes mellitus is a cause of systolic and diastolic function, leading to clinical signs of CHF. Conventional medical therapy also applies to cardiac failure complicating diabetes. Medical therapy includes as the first line diuretics and angiotensin-converting enzyme inhibitors. We conclude that cardiac care can be improved in diabetic patients. For the time being, the first step is to improve the detection of coronary artery disease. As serious events are more likely to occur in the diabetic population, it would be easier (shorter studies and less patients) to demonstrate the benefit of a selected therapy. Further studies are therefore required. In the meantime, special efforts can be made: (1) prevent the development of coronary artery disease. Preventive measures aimed at the control of risk factors at the individual level must be optimal. What should be promoted is a more global approach to the patient, taking into account all parts of the risk factor profile, in order to amplify the reduction in risk and in cardiovascular morbidity and mortality. (2) When CAD is confirmed: the goal is to prevent all major cardiac events: unstable angina, myocardial infarction, sudden death, and CHF secondary to silent ischemic events. This can be achieved through the improvement of the accuracy of noninvasive diagnostic procedures, taking into account the cost of these procedures and the absence of pain perception in diabetic patients.

Isolated congenital atresia of the left main coronary artery and atherosclerosis

Successful surgical revascularization in an adult with isolated congenital atresia of the left main coronary artery; with coexistent two-vessel atherosclerosis is described. This extremely rare anomaly must be differentiated from single right coronary artery and acquired occlusion of the left main coronary artery. Symptomatic myocardial ischemia in patients surviving to adulthood is an indication for surgical revascularization in them.

Surgical Revascularization in Women

Surgical revascularization is an important therapeutic option for both men and women with symptomatic coronary heart disease (CHD). Although men have a higher incidence of CHD, a selection bias in currently utilized evaluation processes for persons with chest pain syndromes may also add to the observed gender difference in revascularization rates. The clinical and anatomical indications for surgical revascularization have been determined by studies which included mostly men. However, surgery should be considered in women with significant left main coronary stenosis, severe three-vessel coronary disease, severe two-vessel coronary disease (including a proximal left anterior descending artery stenosis) and unstable angina with left ventricular dysfunction. Surgical mortality, incomplete revascularization, recurrent symptoms and graft occlusion are more common in women than in men. However, the long-term prognosis for women surviving surgery is favorable.