Need For Endarterectomy Research Articles

Balloon expandable stents facilitate right renal artery reconstruction during complex open aortic aneurysm repair

Patients undergoing repair of thoracoabdominal (TAA) or visceral aortic segment aneurysms typically require reconstruction of the renal arteries. The use of balloon expandable stents (BES) has been proposed as an alternative to endarterectomy or bypass for renal artery reconstruction (RAR) during open aortic aneurysm repair. We report technical aspects and long-term patency data for this method of right RAR during complex open aortic aneurysm repair. During the interval July 1, 2005 to December 31, 2007, a total of 67 patients underwent right RAR using a BES during concomitant TAA (type I: n = 2 [2.9%], type II: n = 8 [11.9%], type III: n = 13 [19.4%], and type IV: n = 22 [32.8%]), juxtarenal (n = 9 [13.4%]) or suprarenal (n = 13 [19.4%]) AAA repair. Indications for RAR were orificial stenosis (n = 21 [31%]) and/or technical considerations referable to the proximal aortic suture line. Patency of the renal stent was evaluated in patients with computed tomography angiography using three-dimensional reconstruction or with abdominal duplex evaluation at follow-up. The mean patient age was 75.1 years, 54.4% were male, and 18% of operations were in nonelective circumstances. Twenty-seven (39%) out of 67 patients had a preoperative creatinine level > or = 1.4 mg/dL. Two patients (2.9%) developed permanent renal failure postoperatively (neither related to renal artery occlusion). Mean radiologic follow-up was 405 days (11-1281) with 98% stent patency noted. One patient had an early stent occlusion noted at 1 month. An additional patient was noted to have a nonflow-limiting dissection distal to the renal stent, and another was noted to have distal migration of the stent beyond the renal ostium; however, these findings were clinically silent. The use of BES during complex open aortic aneurysm repair affords a rapid and durable mode of RAR, obviating the need for endarterectomy and its associated technical complications.

Internal carotid artery occlusion or subocclusion: Contemporary diagnostic challenges: Case report

Measurement of vessel stenosis using ultrasonography or magnetic resonance is still the principal method for determining the severity of carotid atherosclerosis and need for endarterectomy. A 56-year-old male was admitted to the Cardiovascular Institute "Dedinje" due to a clinically asymptomatic restenosis of the operated left internal carotid artery (ICA). Angiography and magnetic resonance angiography (MRA) in previous hospitalization had revealed occluded right ICA. However, routine duplex ultrasonography revealed a high-grade restenosis (85%) of the left ICA and subocclusion of the right ICA by an ulcerated plaque (confirmed on repeated MRA). Selective arteriography examination could misrepresent the degree of stenosis especially in patents with the ICA that seems to be occluded. MRA is considered the method of choice for identifying pseudo-occlusions of ICA.

Carotid atherosclerotic plaque: noninvasive MR characterization and identification of vulnerable lesions.

Measurement of vessel stenosis by using ultrasonography or angiography remains the principal method for determining the severity of carotid atherosclerosis and the need for endarterectomy. The ipsilateral stroke rate, however--even in patients with severely stenotic vessels--is relatively low, which suggests that the amount of luminal narrowing may not represent the optimal means of assessing clinical risk. As a result, some patients may undergo unnecessary surgery. Improved imaging techniques are, therefore, needed to enable reliable identification of high-risk plaques that lead to cerebrovascular events. High-spatial-resolution magnetic resonance (MR) imaging has been described as one promising modality for this purpose, because the technique allows direct visualization of diseased vessel wall and can be used to characterize the morphology of individual atherosclerotic carotid plaques. The purpose of this report is to review the current state of carotid plaque MR imaging and the use of carotid MR to evaluate plaque morphology and composition.

Invited Commentary

Invited Commentary

The significance of donor leg distal runoff in femorofemoral bypass grafting.

The aim of this study is to determine if femorofemoral bypass grafting is an effective operation for unilateral iliac occlusive disease, and to assess for factors that may predict a poorer outcome. A retrospective review was conducted of cases identified from a prospective audit database. Information was obtained from the clinical notes of 97 patients who had 100 femorofemoral bypass graft operations. All living patients were invited for assessment which included colour duplex sonography of the graft and measurement of the ankle brachial index. Using life-table analysis, the five-year graft secondary patency for claudicants was 79% and for those with critical ischaemia 78%. Five-year survival for claudicants was 65% and for those with critical ischaemia, 38%. Poor distal runoff in the infrapopliteal arteries of the donor limb adversely affected graft patency. Graft survival was not affected by the indication for operation, by donor or recipient superficial femoral artery patency, or by the need for endarterectomy, pre-operative angioplasty or the graft material. Femorofemoral bypass grafting is the procedure of choice for all patients who require surgical intervention for unilateral iliac occlusion and donor limb distal runoff may be an important determinant of graft patency.

27.10 Benefits of simultaneous transluminal balloon dilatation and opened surgery during elective arterial reconstruction

Patients undergoing repair of thoracoabdominal (TAA) or visceral aortic segment aneurysms typically require reconstruction of the renal arteries. The use of balloon expandable stents (BES) has been proposed as an alternative to endarterectomy or bypass for renal artery reconstruction (RAR) during open aortic aneurysm repair. We report technical aspects and long-term patency data for this method of right RAR during complex open aortic aneurysm repair.During the interval July 1, 2005 to December 31, 2007, a total of 67 patients underwent right RAR using a BES during concomitant TAA (type I: n = 2 [2.9%], type II: n = 8 [11.9%], type III: n = 13 [19.4%], and type IV: n = 22 [32.8%]), juxtarenal (n = 9 [13.4%]) or suprarenal (n = 13 [19.4%]) AAA repair. Indications for RAR were orificial stenosis (n = 21 [31%]) and/or technical considerations referable to the proximal aortic suture line. Patency of the renal stent was evaluated in patients with computed tomography angiography using three-dimensional reconstruction or with abdominal duplex evaluation at follow-up.The mean patient age was 75.1 years, 54.4% were male, and 18% of operations were in nonelective circumstances. Twenty-seven (39%) out of 67 patients had a preoperative creatinine level ≥1.4 mg/dL. Two patients (2.9%) developed permanent renal failure postoperatively (neither related to renal artery occlusion). Mean radiologic follow-up was 405 days (11-1281) with 98% stent patency noted. One patient had an early stent occlusion noted at 1 month. An additional patient was noted to have a nonflow-limiting dissection distal to the renal stent, and another was noted to have distal migration of the stent beyond the renal ostium; however, these findings were clinically silent.The use of BES during complex open aortic aneurysm repair affords a rapid and durable mode of RAR, obviating the need for endarterectomy and its associated technical complications.

Early and Late Survival After Coronary Artery Surgery

Between 1970 and 1985, 1801 patients underwent coronary-artery surgery without associated valvular surgery. Eighty-four per cent of patients were male and the mean (+/- SD) age was 55.7 +/- 8.3 years. Of the patients, 18.7% were from the Coronary Care Unit and 6.5% had diabetes. The hospital mortality rate for the whole group was 3.5%. Patients from the Coronary Care Unit had the highest (8.9%) hospital mortality rate compared with those patients who were not from the Coronary Care Unit (2.1%; P less than 0.001). Other factors which increased the hospital mortality rate significantly were the number of diseased vessels (P less than 0.01), the degree of left main coronary-artery stenosis (P less than 0.001), an earlier year of surgery (P less than 0.01) and female sex (P less than 0.01). After these were taken into account, no other factors (for example, age, preoperative infarction, presence of left-ventricular aneurysm, left-ventricular end-diastolic pressure, diabetes, use of mammary-arterial grafts or the need for endarterectomy) affected the mortality rate. Patients were followed-up for a mean (+/- SD) of 4.4 +/- 2.8 years. The five-year survival rate for all patients was 88% and the 10-year survival rate was 65%. Cox regression analysis showed that the significant indicators of decreased long-term survival were undergoing operation directly from the Coronary Care Unit (P less than 0.001), left main coronary-artery stenosis (P less than 0.01), the number of grafted vessels (P less than 0.01), concomitant surgery for aneurysm (P less than 0.001), year of surgery (P less than 0.01). Seventy-nine per cent of patients were free of angina pectoris at five years after operation. The year of surgery (P less than 0.001) and preoperative myocardial infarction (P less than 0.05) were the best predictors of recurrent angina. In the long term, recurrent angina remains a problem, although this may change with the increased use of mammary-arterial grafts.

Early and late survival after coronary‐artery surgery

Between 1970 and 1985, 1801 patients underwent coronary-artery surgery without associated valvular surgery. Eighty-four per cent of patients were male and the mean (+/- SD) age was 55.7 +/- 8.3 years. Of the patients, 18.7% were from the Coronary Care Unit and 6.5% had diabetes. The hospital mortality rate for the whole group was 3.5%. Patients from the Coronary Care Unit had the highest (8.9%) hospital mortality rate compared with those patients who were not from the Coronary Care Unit (2.1%; P less than 0.001). Other factors which increased the hospital mortality rate significantly were the number of diseased vessels (P less than 0.01), the degree of left main coronary-artery stenosis (P less than 0.001), an earlier year of surgery (P less than 0.01) and female sex (P less than 0.01). After these were taken into account, no other factors (for example, age, preoperative infarction, presence of left-ventricular aneurysm, left-ventricular end-diastolic pressure, diabetes, use of mammary-arterial grafts or the need for endarterectomy) affected the mortality rate. Patients were followed-up for a mean (+/- SD) of 4.4 +/- 2.8 years. The five-year survival rate for all patients was 88% and the 10-year survival rate was 65%. Cox regression analysis showed that the significant indicators of decreased long-term survival were undergoing operation directly from the Coronary Care Unit (P less than 0.001), left main coronary-artery stenosis (P less than 0.01), the number of grafted vessels (P less than 0.01), concomitant surgery for aneurysm (P less than 0.001), year of surgery (P less than 0.01). Seventy-nine per cent of patients were free of angina pectoris at five years after operation. The year of surgery (P less than 0.001) and preoperative myocardial infarction (P less than 0.05) were the best predictors of recurrent angina. In the long term, recurrent angina remains a problem, although this may change with the increased use of mammary-arterial grafts.