Radial Artery Graft Research Articles

Endoscopic Radial Artery Harvesting During Anesthesia Line Placement Reduces the Time and Cost of Multivessel Coronary Artery Bypass Grafting.

Endoscopic radial artery (RA) harvesting performed concurrently with internal mammary artery (IMA) takedown and endoscopic saphenous vein (SV) harvesting creates a crowded and inefficient operating room environment. We assessed the effect of a presternotomy RA harvest strategy on surgery time and costs. A total of 41 patients underwent elective, first-time, isolated multivessel on-pump coronary artery bypass grafting including an IMA, RA, and SV graft. The first 20 patients (Phase I) underwent endoscopic RA harvesting concurrently with IMA takedown and endoscopic SV harvesting after sternotomy, requiring two sets of endoscopic harvesting equipment per case, each used by a separate individual. The final 21 patients (Phase II) underwent endoscopic RA harvesting during anesthesia line placement, completing the procedure before sternotomy, thus requiring only one set of endoscopic harvesting equipment reused by a single individual. There were no differences in baseline patient characteristics, number of bypasses, duration of SV or RA harvest time, or duration of cardiopulmonary bypass or cross-clamp time between the two groups. Total surgery time was reduced by 32 minutes in Phase II (P = 0.044). Relative to a total hospital direct cost of 100.00 units, total surgery costs were reduced from 29.33 units in Phase I to 25.62 units in Phase II (P = 0.001). No anesthesia- or RA harvest-related complications occurred in either group. Endoscopic RA harvesting can be safely performed during anesthesia line placement prior to sternotomy. Our simple but innovative strategy improves intraoperative workflow, reduces the time and cost of surgery, and advances the delivery of high-quality patient care.

ANGIOGRAPHIC EVALUATION OF GRAFT PATENCY AFTER MINIMALLY INVASIVE MULTIVESSEL CORONARY BYPASS SURGERY

The OBJECTIVE was to demonstrate perioperative outcomes and angiographic graft patency rates in the mediumterm period in patients after multivessel minimally invasive coronary artery bypass grafting (MICS CABG) procedures.MATERIAL AND METHODS. In the period from 2014 to 2019, 270 patients with stable forms of coronary artery disease were operated on. All patients received left internal thoracic artery (LITA) and venous or arterial (radial artery) grafts. Off-pump surgery was performed in 264 cases (97.8 %). 127 patients underwent CT-bypass angiography (CT-BA) on a 128-slice computed tomography at least after 1 year after the operation. Mean follow-up duration was (30.3±7.9) months.RESULTS. All patients received full myocardial revascularization. Mean number of grafts was (2.6±0.5). Perioperative mortality rate was 0.4 % (1 patient). Perioperative myocardial infarctions or cerebrovascular accident occurred in 3 (1.1 %) and 1 (0.4 %) patients. Overall graft patency rate in examined patients was 89.8 % (290 of 323). At the time of LITA, the patency of mammary grafts was 98.4 % (124 of 126), venous graft –84.0 % (163 of 194) and radial artery grafts – 100 % (3 of 3).CONCLUSION. MICS CABG was safe and effective and was characterized by minimal rate of perioperative complications. This procedure allowed to achieve complete revascularization of the myocardium without sternotomy and could be performed off-pump (in most cases). MICS CABG provide excellent long-term graft patency rates.The authors declare no conflict of interest.The authors confirm that they respect the rights of the people participated in the study, including obtaining informed consent when it is necessary, and the rules of treatment of animals when they are used in the study. Author Guidelines contains the detailed information.

Surgical Trapping With Revascularization of Concomitant Cervical and Petrous Internal Carotid Artery Aneurysms: 2-Dimensional Operative Video.

Petrous internal carotid artery (ICA) aneurysms are rare, complicated lesions to treat. The management paradigms include observation, endovascular exclusion, or surgical trapping with or without revascularization. The case described in this video involved a 67-yr-old woman with a known history of chronic lymphocytic leukemia, who presented after a mechanical ground-level fall. Clinically, she had a nasal deformity and resolving epistaxis consistent with mild facial trauma. Computed tomography (CT) revealed a comminuted nasal bone fracture and an incidental 3-cm right petrous ICA aneurysm. Subsequent vascular imaging demonstrated a concurrent 1.5-cm right cervical ICA dissecting pseudoaneurysm. Flow diversion with a Pipeline stent (Medtronic, Dublin, Ireland) was unsuccessful because the aneurysm's size precluded microcatheter selection of the ICA distal to the lesion. When the patient did not tolerate balloon test occlusion of the ICA, we proceeded with surgical trapping of both aneurysms and high-flow extracranial-to-intracranial bypass. The patient underwent a right frontotemporal craniotomy and an external carotid artery-to-frontal M2 middle cerebral artery bypass with a radial artery graft. Following a clinoidectomy, an aneurysm clip was applied to the paraclinoid ICA, and the cervical ICA was ligated just distal to the bifurcation, effectively trapping both aneurysms. The patient tolerated the procedure well. Postoperatively, she experienced symptomatic hypotension requiring vasopressor therapy and a transient partial oculomotor palsy that resolved during her hospital course. She was discharged home without neurological sequelae. Postoperative CT angiography demonstrated complete exclusion of the ICA aneurysms and a patent radial bypass graft after surgery and at 6-month follow-up. The patient provided consent for publication.

Application of radial artery in arterialized coronary artery bypass grafting in Chinese patients

Objective: To summarize the application of radial artery (RA) as the second arterial graft in coronary artery bypass grafting (CABG). Methods: From January 1, 2015 to June 11, 2019, the clinical data of all patients undergoing CABG in TEDA International Cardiovascular Hospital was retrospectively reviewed. The patients who underwent RA grafting were included. The application of RA, internal mammary artery (IMA) and the saphenous vein, their target vessels, and the operative results were analyzed. Results: A total of 2 901 patients underwent CABG. Of those, 208 patients (7.2%) had RA grafting, with 197 males and 11 females. The average age was (53±8) years old and the average grafts per patient was 3.79. The target vessel for RA was first obtuse marginal (OM, 102 cases), first diagonal (50 cases), right coronary artery (RCA) or posterior descending artery (PDA) (40 cases), intermediate (22 cases), respectively. Among those, 172 were single distal anastomosis with the proximal end anastomosed to the ascending aorta (168 cases), saphenous vein (SV) graft (3 cases) and IMA (1 case). Seventy-two patients accept sequential grafting with the proximal to the ascending aorta (58 cases), SV graft (13 cases) and IMA (1 case). The left IMA was mainly anastomosed to left descending artery (LAD) (188 cases) and diagonal (10 cases). The target vessels for SV were remaining coronary arteries when the IMA and RA were used. The operative time was (5.0±1.5) h. The hospital stay was (17.4±6.4) d. There were 6 cases undergoing exploratory thoracotomy for bleeding (5 cases) or hemodynamic instability due to ventricular arrhythmia (1 case). There was no death. All patients were successfully discharged. Conclusions: Use of the RA and IMA with additional SV for CABG exhibits good results in the Chinese patients. Currently available clinical protocols are effective and safe.

Mid-term outcomes of coronary artery bypass surgery with left radial artery bypassed to right main coronary artery of severe stenosis

Objective: To evaluate the mid-term outcomes of coronary artery bypass grafting (CABG) with left radial artery (RA) graft bypassed to right main coronary artery (RCA) of severe stenosis. Methods: Between September 2014 and April 2019, a total of consecutive 47 patients who had severe stenosis (≥90%) of RCA underwent total arterial revascularization, with left RA bypassed to RCA. There were 31 males and 16 females, with a mean age of (56.5±9.7) years old. The perioperative outcomes were observed and mid-term results were followed up. Results: A total of 46 left internal mammary artery (LIMA) grafts, 47 left radial artery (LRA), and 40 right RA grafts (RRA) were harvested with pedicles. LIMA was bypassed to LAD in 43 patients, RRA was to diagonal branches, ramus or oblique marginal in 37 cases, and LRA was to RCA. All grafts (except 3 composite Y or T grafts) were single. Mean graft number was 2-4 (2.7±0.9). There was one death due to cardiac tamponade. Three patients had postoperative atrial fibrillation, 1 had a forearm hematoma, 1 had acute renal insufficiency, and 2 had acute myocardial infarction. The mean tracheal intubation duration was 3.5-20.3 (8.3±4.7) hours, and the mean hospital stay was 6-13 (7.1±2.9) days. The average follow-up was 3-47 (23.3±7.5) months, with a follow-up rate of 86.96% (40/46). There were no major cardiovascular events during the follow-up. Three month after surgery, the mean left ventricular ejection fraction was significantly improved than that of pre-operation (60.0%±4.0% vs 42.4%±7.5%, P=0.003). Computed tomography angiography (CTA) examination showed that 58.7% (27/46) of patients had patent LRA after a mean follow-up duration of (19.5±7.3) months. Conclusion: CABG with LRA bypassed to RCA of severe stenosis proves to be safe and effective, with good mid-term outcomes.

Short-term outcomes of sequential radial artery grafting in patients with coronary artery disease

Objective: To explore the short-term outcomes of patients with coronary artery disease (CAD) who underwent coronary artery bypass graft (CABG) with sequential radial artery graft. Methods: Clinical data of patients with CAD who underwent CABG with sequential radial artery graft from August to December 2018 in Beijing Anzhen Hospital was retrospectively analyzed. Computer tomography angiography was employed to evaluate the patency of grafts and the incidence of adverse cardiovascular events was followed up 3 months after surgery. Results: A total of thirty patients were included, with an average age of (60.2±7.3) years old, among whom 83.3% were male, and 93.3% had three-vessel disease detected by coronary angiography. All patients had left internal mammary artery (LIMA) anastomosed to the left anterior descending (LAD) and sequential radial artery graft. Among sequential radial artery grafts, the most frequent anastomosis of sequential radial artery graft was aortic artery (AO)-first diagonal branch (D1)-first obtuse marginal branch (OM1) (13 patients, 43.3%), followed by AO-OM1-second obtuse marginal branch (OM2) (9 patients, 30.0%), and 18 patients also underwent saphenous vein graft. None of 30 patients experienced adverse cardiovascular events during postoperative period in hospital. Three-months follow-up outcomes showed that LIMA-LAD in 1 patient (3.3%) occluded, 3 patients had occluded anastomosis of sequential radial artery graft, 1 patient (3.3%) had heart failure, and 1 patient (3.3%) had recurrent angina. Conclusion: The radial artery could be used as the second arterial graft for CAD patients undergoing CABG with a sequential anastomosis technique, and these patients need regular anti-arterial spasm drug treatment after CABG.

Pay more attention to the growing role of radial artery graft in coronary artery bypass grafting and promote its wide use in Chinese population

桡动脉桥在冠状动脉旁路移植术中的地位日益突出。本期重点栏目探讨桡动脉桥在中国人群冠状动脉旁路移植术中作为第二血管桥的观点，并集中报道我国几个中心桡动脉应用的初步经验，包括桡动脉在重度狭窄的右主干的应用及桡动脉序贯桥的应用等，期望我国冠状动脉外科医师重视桡动脉的应用，大力推进其应用比例及使用范围，以使更多的中国冠心病患者受益。.

The no-touch saphenous vein is an excellent alternative conduit to the radial artery 8 years after coronary artery bypass grafting: A randomized trial

BackgroundIn 2004, a prospective randomized trial demonstrated that after 3 years, saphenous veins (SVs) harvested with a no touch (NT) technique had a greater patency than radial grafts for coronary bypass surgery. Here we report the 8-year follow-up data of this trial. MethodsThe trial included 108 patients undergoing coronary artery bypass grafting (CABG). Each patient was assigned to receive 1 NT SV and 1 radial artery (RA) graft to either the left or right coronary territory to complement the left internal thoracic artery (LITA). Sequential grafting was common, so overall graft patency as well as the patency of each anastomosis were assessed. ResultsAngiography was performed in 84 patients (78%) at mean of 97 months postoperatively. Graft patency were high and similar for both NT and RA: 86% for NT versus 79% for RA (P = .22). The patency of coronary anastomoses was significantly higher with the NT SV grafts (91% vs 81%; P = .046). The NT grafts also had excellent patency in coronary arteries with <90% stenosis (93% patency) and in coronary arteries of small diameter (87% patency) or with mild calcification (88% patency). Patency for the LITA was 92%. ConclusionsNT SV grafts have excellent patency similar to that of RA grafts after 8 years. In addition, NT SV grafts can be used in situations that are not ideal for RA grafts.

Left External Carotid Artery to the Middle Cerebral Artery Bypass with Radial Artery Graft and Clip Reconstruction of a Large Middle Cerebral Artery Fusiform Aneurysm: 3-Dimensional Operative Video.

This 16-yr-old boy presented with episodes of severe headaches, blurred vision, dizziness, and muffled hearing and was discovered to have a large fusiform aneurysm of the left middle cerebral artery (MCA), M1 segment, 20×12 mm in dimension. The lenticulostriate arteries were arising proximal and distal to the aneurysm, but the anterior temporal artery was arising from the aneurysm. The aneurysm culminated in the distal M1 segment, and M1 immediately branched into 3 M2 vessels, the lower one being the larger. Due to origin of the lenticulostriate arteries and the anterior temporal artery and patient's age, a bypass was preferred to a flow diversion stent. He underwent left frontotemporal craniotomy and orbital osteotomy, left cervical external carotid artery exposure followed by radial artery graft extraction. The Sylvian fissure was opened and intracranial ICA was exposed for proximal control. The distal M2 vessels traced back toward the aneurysm. The aneurysm was not clippable and a bypass to the larger inferior M2 branch was performed followed by aneurysm trapping. The radial artery graft bypass was placed from the left external carotid artery to the M2 segment of left MCA, followed by clip reconstruction and occlusion of the MCA aneurysm with the preservation of the anterior temporal branch and the lenticulostriate vessels. The patient had no postoperative complications. At the follow-up, one month after surgery, he was doing well, and his angiogram demonstrated patency of the bypass. This video shows the management of a complex fusiform M1 aneurysm with bypass and trapping. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

Extracranial-Intracranial High-Flow Bypass with Internal Carotid Artery Ligation at Neck for Giant Cavernous Internal Carotid Artery Dissecting Aneurysm in a Teen Girl with Postoperative Unusual Complication of Mono-ocular Blindness: A Case Report

AbstractExtracranial-intracranial (EC-IC) high-flow bypass with internal carotid artery (ICA) ligation at the neck is an important treatment option for giant cavernous ICA dissecting aneurysm. Such treatment may be associated with many complications. We report a case that developed postoperative mono-ocular blindness. So far to our knowledge such complication has not been reported in the literature. A 14-year-old girl presented with recent headache, eye ache, occasional double vision, and occasional right-sided visual impairment. Neurologic examination revealed no abnormality. Computed tomographic (CT) scan of the head showed a large, right parasellar, and mostly hyperdense space-occupying lesion. CT angiogram of the brain showed giant dissecting aneurysm of right-sided cavernous segment ICA. A right-sided external carotid artery–radial artery graft–middle cerebral artery (ECA-RAG-MCA [M2]) high-flow bypass was done with ligation of the right ICA in the neck. Postoperatively, the patient developed complete, mono-ocular, and permanent blindness on right side. Mono-ocular blindness is a serious complication from ophthalmic/central retinal artery thrombosis in high-flow EC-IC bypass with ICA ligation. Strategy is required to find and to set for its prevention.

The RADial artery International ALliance (RADIAL) extended follow-up study: rationale and study protocol.

It is generally accepted that radial artery (RA) grafts have better mid-term patency rate compared to saphenous vein grafts. However, the clinical correlates of the improved patency rate are still debated. Observational studies have suggested increased survival and event-free survival for patients who receive an RA rather than a saphenous vein, but they are open to bias and confounders. The only evidence based on randomized data is a pooled meta-analysis of 6 randomized controlled trial comparing the RA and the saphenous vein published by the RADial artery International Alliance (RADIAL). In the RADIAL database, improved freedom from follow-up cardiac events (death, myocardial infarction and repeat revascularization) was found at 5-year follow-up in the RA arm. The most important limitation of the RADIAL analysis is that most of the included trials had an angiographic follow-up in the first 5 years and it is unclear whether the rate of repeat revascularization (the main driver of the composite outcome) was clinically indicated due to per-protocol angiographies. Here, we present the protocol for the long-term analysis of the RADIAL database. By extending the follow-up beyond the 5th postoperative year (all trials except 1 did not have angiographic follow-up beyond 5 years), we aim to provide data on the role of RA in coronary artery bypass surgery with respect to long-term outcomes.

Assessing the Long-term Patency and Clinical Outcomes of Venous and Arterial Grafts Used in Coronary Artery Bypass Grafting: A Meta-analysis.

IntroductionThe long-term patency of the grafts used during the coronary artery bypass grafting (CABG) is one of the most significant predictors of the clinical outcomes. The gold standard graft used during CABG with the best long-term patency rate and the better clinical outcomes is left internal thoracic artery (LITA) grafted to the left coronary artery (LCA). The controversy lies in choosing the second-best conduit for the non-left coronary artery (NLCA) with similar patency rate as LITA. This meta-analysis examines the long-term patency and clinical outcomes of all arterial grafts versus all venous grafts used during the CABG.MethodsA comprehensive literature search of all published randomized control trials (RCTs) assessing long-term patency and clinical outcomes of grafts used in CABG was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2018). Keywords searched included combinations of “CABG”, “venous grafts in CABG”, “arterial grafts in CABG”, “radial artery grafts in CABG”, “gastroepiploic artery grafts in CABG”, “patency and clinical outcomes”. Inclusion criteria included: RCTs comparing the long-term patency, and clinical outcomes of radial artery, right internal thoracic artery, gastroduodenal artery, and saphenous vein grafts used in CABG. Long-term patency of the grafts and clinical outcomes were analyzed.ResultsEight RCTs involving 2,091 patients with 1,164 patients receiving arterial grafts and 927 patients receiving venous grafts were included. There was no difference between the long-term patency rate (relative risk (RR) = 1.050, 95% confidence interval (CI) = 0.949 to 1.162, and p = 0.344), overall mortality rate (RR = 1.095, 95% CI = 0.561 to 2.136, and p = 0.790), rate of myocardial infarction (MI) (RR = 0.860, 95% CI = 0.409 to 1.812, and P = 0.692), and re-intervention rate (RR = 0.0768, 95% CI = 0.419 to 1.406, and P = 0.392) between arterial and venous grafts.ConclusionThe use of arterial conduits over the venous conduits has no significant superiority regarding the long-term graft patency, the rate of MI, overall mortality, and the rate of revascularization following CABG. Additional adequately powered studies are needed to further evaluate the long-term outcomes of arterial and venous grafts following the CABG.

Cerebral glucose metabolism changes in chronic ischemia patients following subcranial-intracranial bypass.

The use of the internal maxillary artery (IMA) in intracranial artery bypass or subcranial-intracranial (SC-IC) bypass has recently been described as an alternative to traditional bypass. This study explores cerebral glucose metabolism characteristics of SC-IC bypass. Ten crescendo transient ischemic attack (TIA) patients with chronic occlusion of the middle cerebral artery (MCA) received bypass surgery of IMA with the radial artery graft (RAG) to the branch of MCA. The graft's flow volume (FV) was measured by operative intraoperative duplex ultrasonography. Positron emission tomography (PET)/computed tomography (CT) was used to calculate the preoperational and postoperational average of the standard uptake value (SUVavg) of the 18-fluoro-2-deoxy-D-glucose (18F-FDG) in the region of interest (ROI). The asymmetric index (AI) is recommended to reflect the SUVavg changes, and subsequently, cerebral glucose metabolism changes are supposedly clarified. Patent IMA-RAG-MCA bypass in ten chronic ischemia patients was confirmed by angiography after surgery. The intraoperative FV measurement value was 65.64 ± 10.52 (58.11-73.17) ml/min. Before the operation, the SUVavg of the ROI in the ischemic hemisphere (4.76 ± 2.35 (3.08-6.04)) clearly decreased compared to the one (5.99 ± 2.63 (4.11-7.87)) in the contralateral mirror region (P = 0.003). The result of AI of preoperation minus AI of postoperation was more than 10% (P = 0.031), which indicated suspicious significant changes in cerebral metabolism. All symptoms of study patients having crescendo ischemia were resolved in 1month after the operation. In the cerebral hypoperfusion territory, uptake of 18F-FDG deceased. Improving the flow volume via SC-IC bypass makes available an elevated uptake of 18F-FDG.

Tratamiento neuroquirúrgico de la isquemia cerebral

Introducción: El manejo actual de la isquemia cerebral aguda (IA) contempla el uso de r-tPA y terapia endovascular, mientras que en la isquemia cerebral crónica (IC) la mejor terapia aún no está definida. La revascularización cerebral microquirúrgica ha sido descrita como tratamiento alternativo para pacientes con IA y contraindicación para r-tPA o terapia endovascular, así como para pacientes con IC en quienes la terapia médica ha fracasado. Objetivo: Comunicar la experiencia inicial en cirugía de revascularización cerebral, con énfasis en la utilidad de la embolectomía microquirúrgica y del bypass cerebral como terapia de rescate en IA, así como del bypass cerebral en IC. Pacientes y Método: Serie prospectiva de 5 pacientes con isquemia cerebral tratados con cirugía de revascularización cerebral en el período 2013 a 2016. Se describe la técnica y resultados quirúrgicos, así como el estado funcional a los 3, 6 y 12 meses de seguimiento según modified Rankin Scale (mRS). Resultados: Se realizó embolectomía microquirúrgica de emergencia por IA en 3 pacientes con oclusión embólica de arteria cerebral media, bypass extra-intracraneal (EC-IC) en 1 paciente con IA secundaria a oclusión de arteria carótida interna por disección arterial y bypass cerebral combinado directo e indirecto en 1 paciente con IC secundaria a vasculopatía estenótica progresiva moyamoya-like. En los pacientes en quienes se efectuó embolectomía, se obtuvo recanalización completa en 2casos y parcial en 1 caso. En los 3 pacientes el estado funcional a 3 meses fue mRS = 3 (discapacidad moderada), mientras que a 12 meses de seguimiento en 2 casos hubo mejoría a mRS = 2 (discapacidad leve). En el paciente sometido a bypass EC-IC por IA, el estado funcional a 3, 6 y 12 meses fue mRS = 2, mRS = 1 y mRS = 0 (asintomático), respectivamente. En el paciente tratado con bypass combinado por IC, se obtuvo mejoría funcional a los 3 y 6 meses de seguimiento (mRS = 3 y mRS = 2, respectivamente), con respecto a su estado preoperatorio (mRS = 5; discapacidad severa). Conclusiones: La embolectomía microquirúrgica y el bypass cerebral son opciones terapéuticas efectivas en pacientes seleccionados con IA e IC.

Two-Stage Revascularization and Clip Reconstruction of a Giant Ophthalmic Artery Aneurysm: 3-Dimensional Operative Video.

Ophthalmic segment aneurysms (OSAs) are technically challenging lesions with a wide-neck morphology and proximity to the optic nerve. Revascularization and aneurysm trapping are occasionally needed to manage unclippable OSAs. Microsurgical treatment requires anterior clinoidectomy, optic strut drilling, and proximal/distal dural ring dissection for adequate exposure. This video demonstrates a two-stage revascularization and clip reconstruction of an OSA. A 62-yr-old woman was presented, with acute-onset expressive aphasia, right hemineglect, and hemiparesis. Neuroimaging revealed a partially thrombosed giant OSA measuring 2.5×2.3 cm2. Patient consent was obtained for bypassing, trapping, and decompressing the aneurysm. A pterional craniotomy was performed and an external carotid artery - radial artery graft - middle cerebral artery bypass was performed. The aneurysm was proximally occluded with a permanent clip on the clinoidal internal carotid artery (ICA). Adherence of the distal supraclinoid ICA to the aneurysm wall did not allow for aneurysm trapping. On postoperative day 8, the patient experienced acute mental status decline due to a frontal intraparenchymal hemorrhage. The aneurysm was trapped in a second surgery to occlude persistent retrograde aneurysm filling. The aneurysm sac was circumferentially dissected with temporary parent artery trapping. The OSA was opened and thrombectomized using an ultrasonic aspirator followed by trapping clip application. Postoperatively, the patient gradually returned to neurological baseline with minimal expressive aphasia. Although OSAs are preferentially treated with flow diversion, giant OSAs with significant mass effect may necessitate microsurgical clipping or trapping with decompressive thrombectomy. This case demonstrates that proximal clip occlusion may not be sufficient for aneurysm thrombosis and rupture prevention. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Complex Internal Carotid Aneurysms Treated by Superficial Temporal Artery Trunk–Radial Artery–Middle Cerebral Artery Bypass Combined with Balloon Occlusion of Internal Carotid Artery

To evaluate the feasibility to treat complex internal carotid aneurysms by superficial temporal artery trunk-radial artery-middle cerebral artery (STAT-RA-MCA) bypass combined with balloon occlusion of internal carotid artery. Postoperative clinical symptoms, the patency of bridge vessels (radial artery graft [RAG]), STAT and RAG diameters, RAG flow, cerebral blood flow (CBF), and mean transit time (MTT) were observed in 14 cases. Their correlations were analyzed. Except 1 case, RAG was patent in 13 cases. Glasgow Outcome Scale score was 4 in one case and 5 in 13 cases. In the 13 cases with postoperative RAG patency, the mean diameter of STAT increased from 2.1 mm before operation to 3.0 mm on the first day after operation; the mean diameter of RAG was 3.7 mm on the first day after operation. In 3 of the 13 cases, STAT and RAG diameters further increased to 4.0 mm and 4.7 mm, respectively, 3 months after operation. There was a positive correlation between STAT and RAG diameters (P= 0.0005). The STAT (P< 0.0001, P < 0.0001) and RAG (P < 0.0001, P= 0.0042) diameters were positively correlated with RAG flow and CBF, but the STAT (r2= 0.762, P < 0.0001) and RAG (r2= 0.54, P= 0.0042) diameters were negatively correlated with MTT. STAT-RA-MCA bypass combined with balloon occlusion of internal carotid artery is feasible for the treatment of complex internal carotid aneurysms.

Predictors of the Resolution of Cavernous Sinus Syndrome Caused by Large/Giant Cavernous Carotid Aneurysms After Parent Artery Occlusion with High-Flow Bypass

To evaluate the clinical results and factors related to the resolution of preoperative cranial neuropathy after internal carotid artery ligation with high-flow bypass in patients with symptomatic large or giant cavernous carotid aneurysms. This study included 18 consecutive patients (15 women) with cranial neuropathy. All patients underwent therapeutic internal carotid artery ligation with high-flow bypass using a radial artery graft. Patient demographics, duration of symptoms, clinical outcomes, complications, and radiographic findings were retrospectively analyzed. The mean follow-up period was 31.0 months (range: 3-74 months). Patients' mean age was 66.6 years, and the mean aneurysm size was 23.7 mm. Six patients (33%) had partially thrombosed aneurysms. Preoperatively, 16 (89%) and 8 (44%) patients presented with ophthalmoplegia and facial pain, respectively. Bypass patency was confirmed in 15 patients (83%), and obliteration of the aneurysm was confirmed in all patients at the final follow-up. Preoperative ophthalmoplegia resolved in 10 patients (63%), and trigeminal pain resolved in all patients. Postoperative resolution of patients' ophthalmoplegia was significantly associated with age (P= 0.044), symptom duration before treatment (P= 0.042), and the degree of ophthalmoplegia (P= 0.046). The degree of postoperative residual ophthalmoplegia was positively correlated with the duration of ophthalmoplegia from onset to surgery (r= 0.619; P=0.011). Preoperative trigeminal pain resolved regardless of the preoperative duration of this symptom in all patients. Early treatment is recommended when treating large or giant cavernous carotid aneurysms with cranial neuropathy. Complete resolution is possible in younger patients with partial neuropathy.

Bypass strategies for common carotid artery occlusion.

Common carotid artery occlusion (CCA-occlusion) is a rare condition where standard revascularization is not feasible. Here, we analyzed our experience with surgical revascularization of CCA-occlusion to develop an algorithm for selection of the most suitable bypass strategy according to the Riles classification. During a 10-year period, 16 out of 288 patients with cerebrovascular disease and compromised hemodynamic reserve underwent revascularization for unilateral CCA-occlusion. The utilized bypass strategies included (1) a saphenous vein graft from the subclavian artery (SA) to the internal carotid artery (ICA), (2) a radial artery graft from the V3 segment of the vertebral artery (VA) to a superficial branch of the middle cerebral artery (MCA), or (3) a saphenous vein graft from the SA to a deep branch of the MCA. In CCA-occlusion with maintained external carotid artery (ECA)/ICA patency (Riles type 1A), an SA-ICA bypass was performed (25%). In cases without ECA/ICA patency (Riles type 1B or 2) but suitable VA, a VA-MCA bypass was grafted (31%). In cases with unsuitable VA, a long SA-MCA interposition bypass was performed (38%). Transient postoperative neurological deficits occurred in 5 patients (31%) with 1 patient (6%) suffering permanent neurological worsening and 1 mortality (6%). Overall, no difference was found between the median preoperative mRS (2; range, 1-4) and the mRS at the time point of the last follow-up (2; range, 1-6; p = 0.75). The long-term graft patency was 94%. Although surgical revascularization for CCA-occlusion is feasible, it is associated with a higher risk than standard bypass grafting. Considering the poor natural history of CCA-occlusion, however, this risk may be justified in carefully selected patients.

A Retrospective Analysis of Treatment Outcomes of 40 Incidental Cavernous Carotid Aneurysms

The management of cavernous carotid aneurysms (CCAs) poses a significant dilemma to the treating surgeon. Asymptomatic CCAs usually are managed conservatively with clinical and radiologic follow-up. Large size, intradural extension, sphenoid bone erosion, and increasing size on follow-up are usual indications for treating asymptomatic CCAs. However, there are no clear-cut guidelines in literature. We share our experience of 40 asymptomatic CCAs treated by endovascular and surgical methods. All the asymptomatic CCAs treated between January 2014 and December 2018 were analyzed retrospectively. Patient demographics, aneurysm characteristics, postprocedural complications, and clinical and radiologic follow-up data were obtained from records. Outcome was evaluated in terms of aneurysm obliteration and maintained cerebral perfusion, postoperative complications, recurrence, and clinically significant complications during follow-up. Endovascular coiling, balloon-assisted coiling, and stent-assisted coiling were performed in 27 (75%), 5 (13.9%), and 4 (11.1%), respectively. Raymond-Roy occlusion classification grade I occlusion was achieved in 88.9% of cases. No immediate or delayed complications were noted. Coil compaction was seen in 4 (11.1%) patients. In the surgery group, all patient underwent high-flow bypass with radial artery graft. Aneurysm exclusion with good graft patency was achieved in all 4 cases without any permanent morbidity or mortality. The current study demonstrates excellent outcomes of asymptomatic CCAs after treatment. In view of the technical advancements of both surgical and endovascular methods, consideration for treatment should be given to asymptomatic CCAs. Each aneurysm should be individually assessed by experts for choosing the best endovascular or surgical treatment option.

On-Pump Coronary Artery Bypass Graft: The State of the Art.

Coronary artery bypass grafting (CABG) remains the standard of care for patients with coronary artery disease (CAD). Debate exists concerning several factors, which include percutaneous coronary intervention (PCI) vs. CABG, single vs. bilateral mammary artery grafts, radial artery vs. saphenous vein grafts, right internal mammary artery vs. radial artery grafts, endoscopic vs. open vein-graft harvesting, and on-pump vs. off- pump surgery. Moreover, challenging is the management of diabetic patients with CAD undergoing CABG. This review reports current indications, practice patterns, and outcomes of CABG. Randomized controlled trials comparing CABG to other therapeutical strategies for CAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. Large multicenter randomized and observational studies (SYNTAX, BEST, PRECOMBAT, ASCERT) have reported excellent outcomes in CABG patients, with always fewer rates of operative mortality and major morbidity, than PCI. The 10-year follow-up of ARTS II trial showed no difference between single and bilateral mammary artery. BARI 2D, MASS II, CARDia, FREEDOM trials showed that CABG is the best choice for diabetic patients. CABG still represents one of the most widespread major surgeries, with well-known benefits on symptoms and prognosis in patients with CAD. However, further studies and follow-up data are needed to validate these evidences.