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

Abstract: Objectives: To compare practice in lower limb bypass surgery in nine countries. Design: A prospective study amalgamating and analysing data from national and regional vascular registries. Methods: A table of data fields and definitions was agreed by all member countries of the Vascunet Collaboration. Data from January 2005 to December 2009 was submitted to a central database. Results: 32,084 cases of infrainguinal bypass (IIB) in nine countries were analysed. Procedures per 100,000 population varied between 2.3 in the UK and 24.6 in Finland. The proportion of women varied from 25% to 43.5%. The median age for all countries was 70 for men and 76 for women. Hungary treated the youngest patients. IIB was performed for claudication for between 15.7% and 40.8% of all procedures. Vein grafts were used in patients operated on for claudication (52.9%), for rest pain (66.7%) and tissue loss (74.1%). Italy had the highest use of synthetic grafts. Among claudicants 45% of bypasses were performed to the below knee popliteal artery or more distally. Graft patency at 30 days varied between 86% and 99%. Conclusions: Significant variations in practice between countries were demonstrated. These results should be interpreted alongside the known limitations of such registry data with respect to quality and completeness of the data. Variation in data completeness and data validation between countries needs to be improved for useful international comparison of outcomes. [Copyright &y& Elsevier]

Abstract: Objectives: The aim of the study is to study contemporary presentation patterns and clinical results in patients undergoing aortofemoral bypass (AFB) surgery. Design: This was a retrospective comparative study. Material and methods: During a 14-year period, 269 consecutive patients (mean age 65 years) underwent AFB. Indications included occlusive disease with severe intermittent claudication (IC) (n = 86), critical limb ischaemia (CLI, n = 97) and aneurysmo-occlusive disease (n = 86). Results: From 2000–07 on, AFB was performed more frequently for occlusive disease with CLI than for other indications (48% vs. 31% before 2000, P = 0.009) and also in women (51% vs. 32% before 2000, P = 0.003), compared to the period before 2000. Thirty-day mortality was reduced during 2000–2007 to 2.4%, compared with 4.3% during 1993–1999, although this difference was not statistically significant (P = 0.73). Morbidity did not change substantially over the study period. Predictors of 30-day mortality included indication (CLI = 4.1% vs. claudication = 1.2% (P = 0.37)) and chronic kidney disease (CKD, serum creatinine > 1.5 mg dl−1) (11.1% vs. 2.9% in normal renal function, P = 0.07), the latter being the single predictor on multivariate analysis (hazard risk 4.2, P = 0.047). Overall 5 and 10-year assisted primary and secondary patency was 95% and 88%, and 99% and 95%, respectively. Survival at 5 and 10 years was 69% and 48%, respectively. Patient age (hazard risk 1.05, P < 0.001), CKD (hazard risk 1.79, P = 0.018) and diabetes (hazard risk 1.56, P = 0.022) were independent predictors of worse long-term survival. Long-term outcome did not change over the course of the study. Conclusions: In the contemporary era, AFB is more likely to be performed for CLI and in women than in the past. Despite these changes, perioperative mortality and morbidity remain low and long-term outcome excellent. [Copyright &y& Elsevier]

: BackgroundThe complementary graft of choice to the right coronary artery system in patients undergoing left-sided bilateral internal thoracic artery grafting has yet to be determined. Saphenous vein graft (SVG) was compared with right gastroepiploic artery (RGEA) as the supplemental conduit to the right coronary artery when left-sided bilateral internal thoracic artery grafting is implemented.: MethodsFrom April 1996 to July 1999, 234 patients underwent bilateral internal thoracic artery grafting to the left coronary system with RGEA grafted to the posterior descending artery (RGEA group). They were compared with 127 patients with left-sided bilateral internal thoracic artery in whom SVG was used for grafting the right coronary system (SVG group).: ResultsFemale sex (27% versus 14.5%), diabetic patients (40% versus 27%), emergency cases (21% versus 7.3%), and left main coronary artery disease (34% versus 23%) were more prevalent in the SVG group. Number of grafts per patient was higher in the SVG group (3.8 versus 3.5, p = 0.04). Thirty-day mortality was 3.9% in the SVG and 2.6% in the RGEA group (not significant). Occurrence of postoperative complications (myocardial infarctions, strokes, bleeding, and sternal infections) was similar. Return of angina was similar (1.6% versus 3.8% in the SVG and RGEA groups, respectively). Midterm follow-up (4 to 56 months) showed comparable 1-year and 4-year survival (Kaplan-Meier) for both groups (92.8% and 91.7% in the SVG group, and 94.7% and 88% in the RGEA group, respectively).: ConclusionsIn patients undergoing left-sided bilateral internal thoracic artery grafting, the use of RGEA for revascularization of the right coronary system does not confer clinical benefits over SVG after midterm follow-up. [Copyright &y& Elsevier]

The internal thoracic artery (ITA) is the principal choice for coronary artery bypass grafting (CABG) due to its mechanical compatibility, histological composition, anti-thrombogenic lumen, and single anastomotic junction. Originating at the subclavian artery, traversing the thoracic cavity, and terminating at the superior epigastric and musculophrenic bifurcation, bilateral ITAs follow a protracted circuitous pathway. The physiological hemodynamics, anatomical configuration, and perivascular changes that occur throughout this length influence the tissue's microstructure and gross mechanical properties. Since histomechanics play a major role in premature graft failure we used inflation-extension testing to quantify the regional material and biaxial mechanical properties at four distinct locations along the left (L) and right (R) ITA and fit the results to a structurally-motivated constitutive model. Our comparative analysis of 44 vessel segments revealed a significant increase in the amount of collagen but not smooth muscle and a significant decrease in elastin and elastic lamellae present with distance from the heart. A subsequent decrease in the total deformation energy and isotropic contribution to the strain energy was present in the LITA but not RITA. Circumferential stress and compliance generally decreased along the length of the LITA while axial stress increased in the RITA. When comparing RITAs to LITAs, some morphological and histological differences were found in proximal sections while distal sections revealed differences predominantly in compliance and axial stress. Overall, this information can be used to better guide graft selection, graft preparation, and xenograft-based tissue-engineering strategies for CABG. [ABSTRACT FROM AUTHOR]

Using animal models in experimental medicine requires mapping of their anatomical variability. Porcine common carotid arteries (CCA) are often preferred for the preclinical testing of vascular grafts due to their anatomical and physiological similarity to human small-diameter arteries. Comparing the microscopic structure of animal model organs to their human counterparts reveals the benefits and limitations of translational medicine. Using quantitative histology and stereology, we performed an extensive mapping of the regional proximodistal differences in the fractions of elastin, collagen, and smooth muscle actin as well as the intima-media and wall thicknesses among 404 segments (every 1 cm) of porcine CCAs collected from male and female pigs (n = 21). We also compared the microscopic structure of porcine CCAs with segments of human coronary arteries and one of the preferred arterial conduits used for the coronary artery bypass grafting (CABG), namely, the internal thoracic artery (ITA) (n = 21 human cadavers). The results showed that the histological structure of left and right porcine CCA can be considered equivalent, provided that gross anatomical variations of the regular branching patterns are excluded. The proximal elastic carotid (51.2% elastin, 4.2% collagen, and 37.2% actin) transitioned to more muscular middle segments (23.5% elastin, 4.9% collagen, 54.3% actin) at the range of 2–3 centimeters and then to even more muscular distal segments (17.2% elastin, 4.9% collagen, 64.0% actin). The resulting morphometric data set shows the biological variability of the artery and is made available for biomechanical modeling and for performing a power analysis and calculating the minimum number of samples per group when planning further experiments with this widely used large animal model. Comparison of porcine carotids with human coronary arteries and ITA revealed the benefits and the limitations of using porcine CCAs as a valid model for testing bioengineered small-diameter CABG vascular conduits. Morphometry of human coronary arteries and ITA provided more realistic data for tailoring multilayered artificial vascular prostheses and the ranges of values within which the conduits should be tested in the future. Despite their limitations, porcine CCAs remain a widely used and well-characterized large animal model that is available for a variety of experiments in vascular surgery. [ABSTRACT FROM AUTHOR]

Objective To compare long-term survival with multiple arterial coronary artery bypass grafting (CABG) (MultArt) versus percutaneous coronary intervention (PCI) in patients with multivessel disease (MVD). Methods We reviewed 12,615 patients with MVD with isolated primary CABG or PCI from 1993 to 2009. Patients with CABG (n = 6667) were grouped according to the number of arterial grafts into left internal thoracic artery (LITA)/saphenous vein (SV) (n = 5712) or MultArt (n = 955); patients with PCI (n = 5948) were grouped into balloon angioplasty (BA) (n = 1020), drug-eluting stent (DES) (n = 1686), and bare metal stent (BMS) (n = 3242). Results Unadjusted long-term survival was lower for CABG than PCI (15-year survival, 34% vs 46%; P < .001); however, in patients with MultArt, survival was greater than LITA/SV, BA, BMS (15-year survival, 65% vs 31%, 47%, 45%, respectively; P < .001), and DES (8-year survival, 87% vs 70%; P < .001). In matched analyses, 15-year survival of MultArt was higher than BA (66% vs 57%; P = .002), LITA/SV (64% vs 56%; P = .02), and BMS (5-year survival 94% vs 90%; P = .01), and similar to DES at 8 years. In multivariate analysis, compared with MultArt, LITA/SV had worse survival (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.09-1.52; P = .003). BMS (HR, 0.87; 95% CI, 0.80-0.94; P < .001) and DES (HR, 0.76; 95% CI, 0.66-0.88; P < .001) had improved survival versus LITA/SV but not versus MultArt (HR, 1.12; 95% CI, 0.94-1.34; P = .21, and HR, 0.98; 95% CI, 0.79-1.21; P = .83, respectively). Secondary analyses for treatment crossover indicated lower survival for LITA/SV versus MultArt and PCI. Conclusions In patients with MVD undergoing primary revascularization, MultArt increased survival benefit versus LITA/SV compared with PCI. Use of MultArt must increase. [ABSTRACT FROM AUTHOR]