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Objective: Bovine pericardial patch (BPP) is currently used in femoral angioplasty as an alternative for autologous vein patch (AVP), but studies comparing the results of the two methods are scarce. In this retrospective study, we aimed to discover the differences between BPP and AVP closure in long-term durability.Methods: This study consisted of all femoral endarterectomies with BPP closure performed in Helsinki University Hospital from January 1, 2014, to December 31, 2017. For comparison, the same number of consecutive patients who underwent femoral endarterectomy with AVP closure from January 1, 2014, to October 16, 2016, were reviewed. Follow-up ended December 31, 2020. The mean follow-up was 19 months (range, 0-74 months) in the BPP group and 22 months (range, 079 months) in the AVP group. The primary endpoint was primary patency. Secondary endpoints were restenosis at patch site detected by imaging or perioperatively, patch rupture, and deep surgical wound infection. Propensity score analysis was performed for adjustment of differences between the AVP and BPP groups.Results: Overall primary patency was superior in the AVP group compared with the BPP group: at 1 year, 96.5% vs 85.0% and at 5 years, 83.0% vs 72.3% (P =.04). In propensity score-matched pairs (n = 92), no difference was found between the groups in primary patency: 95.7% and 95.7% at 1 year and 92.5% and 78.6% at 5 years (P =.861) or in freedom from restenosis: 100% and 100% at 1 year and 89.1% and 84.0% at 5 years (P =.057). Deep wound infections occurred slightly more often after BPP closure (8%) than after AVP closure (4%), but the difference was not statistically significant (P =.144). There were no patch ruptures in the BPP group, but in the AVP group, there were five ruptures (3.5%) (P =.024).Conclusions: BPP is compatible to AVP in femoral endarterectomy in patency and can be regarded as the safer choice considering the risk of patch rupture.

Takayasu arteritis (TA) occasionally involves the coronary ostium leading to myocardial ischemia. Although surgical coronary ostial angioplasty is desirable for ostial stenosis, the patch materials and long-term results are controversial. We used femoral artery (FA) as a patch material for coronary ostial angioplasty in 3 TA patients. Coronary ostial enlargement with a longitudinal incision followed by rectangular FA patch augmentation was performed to extend the narrowing coronary ostium. In all patients, coronary ostial stenosis was successfully repaired. Ostial angioplasty using an FA patch would be a reasonable surgical strategy to treat coronary ostial stenosis in TA.

In this retrospective study, we review the outcome of femoral eversion endarterectomy (EE) and standard endarterectomy with patch angioplasty (SEP) over a 10-year period. EE technique involves transection of common femoral artery (CFA), eversion endarterectomy of the distal CFA, and primary end-to-end reconstruction. One hundred forty-two patients underwent femoral endarterectomy, among which 38 (26.8%) endarterectomies were performed using the eversion technique. The cumulative 2-year primary patency of EE with or without a concurrent procedure was greater than 86% and did not statistically differ from SEP. EE is a feasible technique when the use of a patch needs to be avoided.

Pseudoaneurysms and patch infections are known complications of carotid endarterectomy with patch angioplasty. Although they are rare occurrences, they carry high morbidity and almost uniformly require surgical intervention. Infectious pathogens are often gram-positive bacteria, most commonly Staphylococcus species, whereas gram-negative infections are less frequently observed. We present a case of recurrent pseudoaneurysm in a patient who had a carotid endarterectomy with bovine pericardial patch angioplasty complicated by Pasteurella multocida infection. This case demonstrates the need for recognition and consideration of a broad differential of pathogens in evaluating and treating vascular infections. Keywords: Carotid endarterectomy, Infection, Bovine patch, Angioplasty, Pseudoaneurysm, Complication

Fatigue is a material-based phenomenon playing a significant role in the mechanical behavior of components and structures. Although fatigue has been well studied for traditional materials, such as metals, its underlying mechanisms are not thoroughly understood in novel applications such as the case of textiles used as patches to close the arteriotomy in carotid endarterectomy. The latter is a type of vascular surgery for the treatment of carotid artery disease in which after an arteriotomy and removal of atherosclerotic plaque closure is made with a patch sutured on the artery. Completion of the operation signals the initiation of complex mechanical and hemodynamic phenomena. Fatigue performance of the patch eventually determines the successful outcome of carotid endarterectomy. In this study, we evaluate with a two-fold approach the mechanics of patch angioplasty in carotid endarterectomy. First, an analytical model for the fatigue behavior of textiles is developed, considering the microstructure and geometry of the fabric. Then, the surgical procedure is simulated and a finite element analysis of the endarterectomized and patched carotid artery is employed. Stress fields are calculated, while deformation at the site of patch angioplasty indicates a potential cause for the formation of aneurismal degeneration after the surgery. Such analysis can provide a better understanding in the establishment of follow-up protocols.

Women have been under-represented in trials that set guidelines for the management of aortic aneurysms. Several studies reported inferior outcomes in women compared with men after endovascular aneurysm repair (EVAR). We investigated the relationship between gender and outcomes after EVAR.A total of 1380 consecutive patients underwent elective EVAR from 1992 to 2012. Baseline, intraoperative, and postoperative variables by gender were analyzed from a prospective database.The cohort comprised 214 women (15.5%) and 1166 men (84.5%). Women were older than men at repair (77.8 vs 74.5 years, P.001) and had less cardiac disease (P = .005). They had shorter (19.8 ± 12.9 vs 26.3 ± 14.7 mm; P.001) more angulated aortic necks (38.8° ± 16.1° vs 31.2° ± 14.7°; P.001) and fewer iliac aneurysms (P = .002). Women had more arterial reconstructions (iliac conduits, P = .006; thrombolysis and thrombectomy, P = .013; patch angioplasty, P.001; endarterectomy, P.001), more perioperative complications (16.9% vs 9.1%; P = .001), and more in-hospital days (4.1 vs 3.4 days; P = .029). Perioperative mortality was equivalent (women: 2% vs men: 2.3%; P = .73). Mean follow-up was 30.9 months. Women and men experienced equivalent aneurysm-related deaths and overall survival. Survival curve analysis showed endoleaks were more likely to develop in women than men (P = .005); however, there was no difference in rates of arterial reinterventions required for each gender during the follow-up period.Female gender is associated with more periprocedural complications, adjunctive arterial procedures, and increased endoleaks but does not affect long-term reinterventions or survival. Further studies are warranted to elucidate the effect of gender on outcomes. These data should be considered when selecting EVAR for men and women.

OBJECTIVES: To compare outcomes after carotid endarterectomy (CEA) with saphenous vein patch closure (SV), with cervical vein (external jugular and common facial) patch closure (CV). DESIGN: A total of 322 cases of CEA was achieved consecutively by using venous patch angioplasty. Propensity scores were calculated followed by a one-to-one basis case-matching. MATERIALS: This resulted into 90 SV and 90 CV matched cases. METHODS: The primary endpoint was the incidence of ipsilateral stroke and transient ischaemic attack at any time during follow-up. RESULTS: Ten-year freedom from stroke was 94.1% ± 3.5% for the SV group and 90.5% ± 4.2% for the CV group (log rank P = 0.230). Ten-year freedom from ipsilateral neurological events (stroke and transient ischaemic attack) was 93.5% ± 3.3% for SV group and 92.4% ± 3.0% for the CV group (log rank P = 0.403). Ten-year freedom from ≥75% stenosis/occlusion was 93.1 ± 4.8% for the SV group and 89.9 ± 6.0% for the CV group (log rank P = 0.481). CONCLUSIONS: CV is a good alternative to SV patching, particularly when the SV needs to be preserved for further use or is unsuitable.

An isolated external iliac artery chronic total occlusion is currently treated either with subintimal percutaneous transluminal angioplasty and stent or with a bypass. This article describes a new application of an old technique, endarterectomy and patch angioplasty, performed on the external iliac artery through a single flank incision. This novel approach can provide lasting patency with a low risk of complications. We present four cases and a review of the literature on the other available treatment options. This minimally invasive technique may provide a viable alternative that can be used alone or in combination with other open or endovascular techniques and can be applied in cases of groin sepsis.

Background: Invasive therapeutic and diagnostic procedures remain the most frequent causes of pediatric vascular injuries. Ideal management, especially the indication for surgical treatment, remains controversial. This study evaluates the outcome of surgical repair for iatrogenic common femoral artery (CFA) injuries in pediatric patients using primary vein patch angioplasty. Methods: From January 1996 through February 2006, 8 patients were identified in the vascular registry of the Vienna General Hospital in Austria. A retrospective office chart review was performed on this consecutive series of patients treated for iatrogenic CFA injuries using primary vein patch angioplasty. Results: The mean age was 5.8 years (range, 0.3-10.9 years). Surgical repair was performed for 5 ischemic limbs and 3 pseudoaneurysms. Urgent repair was necessary in 5 children (62.5%). After a median follow-up of 9 months (range, 1.8-77.6 months), palpable pedal pulses were present in all patients. No aneurysmatic degeneration of vein patches occurred, and no patient sustained any additional sequelae related to the arterial reconstruction. Conclusion: Routine use of a vein patch eases CFA repair, especially in the very young.

Purpose To present our technique of pre-arteriotomy guidewire access (PAGA). Summary Placement of a guidewire across inflow lesions before performing the arteriotomy during combined endovascular/open procedures while treating patients with complex iliofemoral occlusive disease is a crucial maneouvre. We routinely utilize this approach in patients in whom endarterectomy and/or patch angioplasty is planned as the central part of the revascularization procedure, or when we find an unsuspected severely diseased EIA in a patient undergoing leg revascularization.

We present the case of a 62-year-old man who presented with a methicillin-resistant Staphlococus aureus carotid patch infection. He was treated successfully by carotid patch explantation and revision saphenous vein-patch angioplasty to his carotid artery. This case suggests successful outcomes can be obtained with early revision surgery in this rare but potentially fatal post-operative infection.

Patch angioplasty is performed to prevent recurrent stenosis after carotid endarterectomy (CEA). Controversy surrounds the selection of the patch material, with supporters for both autogenous tissue and synthetic patches. We reported on the efficacy of synthetic patch angioplasty. Thirty-four carotid endarterectomies with synthetic patch angioplasty, Hemashield Finesse® and Gore-Tex®, were performed on 32 patients. Twenty-eight of the thirty-four cases were classified as elective CEA and six were emergency CEA. The clinical outcome, perioperative complications, and incidence of recurrent stenosis (> or =50%), as detected by MRA and ultrasonography, were examined. Postoperatively, one severe acute stroke patient who underwent emergency CEA died from gastrointestinal bleeding. The perioperative permanent neurologic morbidity was 0% in elective CEA, and five of the six emergency CEA patients recovered. The total permanent morbidity and mortality rate in all CEA with synthetic patch angioplasty was 2.9%. No recurrent stenosis or further stroke occurred in the postoperative long-term follow-up period. Synthetic patch angioplasty in CEA is considered useful to prevent recurrent stenosis, and to avoid vein harvest site complications and patch rupture as previously described with vein patch angioplasty. Finally, there have been no thrombotic complications using synthetic patch angioplasty in emergency CEA.

Technical requirements for performance of carotid endarterectomy are described. Patient selection is emphasized, and issues about use of shunts and patch angioplasty are described. Special management considerations—including the anatomically high carotid bifurcation, intraarterial thrombi, and postoperative stroke—are carefully reviewed. Finally, clinical activities designed to decrease length of stay for carotid endarterectomy are reported. Forty percent of patients are now being discharged home on the day of operation.

Our study objective was to determine if patch angioplasty after carotid endarterectomy decreases the incidence of post-reconstruction technical defects and recurrent stenosis. This was a retrospective review of a prospectively maintained database from February 1980 to February 2000. Main outcome measures included incidence of intraoperative technical defects, residual disease within 3 months of endarterectomy, and early/late carotid restenosis50%. During the study period, 71% (1053) of patients had primary closure and 29% (435) had patch closure. Immediate post-reconstruction intraoperative imaging with angiography or duplex ultrasound was accomplished in all cases. Technical defects prompted the reopening of 136 (13%) carotid arteries closed primarily but only 9 (2%) of those that were patched (p0.0001). There were no instances of residual disease in either group. Overall rate of recurrent stenosis was 2%, 3%, and 3.5% at 5, 10, and 15 years, respectively by life-table analysis. Early and late restenosis was significantly reduced by patch angioplasty (p = 0.024 and 0.006, respectively). This study demonstrates that carotid artery patch angioplasty significantly reduces the incidence of detectable technical defects and the early/late recurrent stenosis rate.

Common iliac artery (CIA) occlusion as a result of blunt trauma is rare and seldom reported. This has been associated with pelvic fractures and other great vessel lesions. Management options include endovascular covered stent placement, open anatomic repair with autogenous conduit, or open extra-anatomic repair with prosthetic material. We report the case of a middle-aged male with a right CIA injury secondary to blunt trauma who underwent a successful repair using an internal iliac artery patch for injury to a 2 cm segment of CIA with peritoneal contamination. There is no definitively superior method to address CIA injuries in this setting reported in the literature. The use of the internal iliac artery as a patch can be regarded as an additional safe repair option when an autogenous repair is required for a large defect in the CIA as this can enable mobilization of the vessel for primary repair and offer a source for an autogenous patch.

Objectives: Despite numerous studies in which various methods for arteriotomy closure after carotid endarterectomy (CEA) have been addressed, the optimum surgical technique to reduce complications and late carotid restenosis has yet to be firmly established. The purpose of this study was to prospectively compare the results of the eversion CEA technique with those of conventional CEA with either primary closure or carotid patch angioplasty, and to determine under clinical conditions whether eversion CEA influences the results and restenosis rate. Patients and Methods: Over a 3-year period, 322 CEAs performed on 296 consecutive patients were concurrently evaluated. This study included 118 eversion CEAs, 97 CEAs with primary closure, and 107 CEAs with patch angioplasty. There were no differences in demographics, in surgical indications, or in the severity of carotid disease (not significant [NS]). The choice of CEA technique was not randomized because of technical considerations and surgeon preference. After entry into the protocol, no patients were excluded or withdrawn. Carotid restenosis was defined as a > 60% lumen reduction at the CEA site with established duplex ultrasonography criteria. Results: The mean operative time for eversion CEA was 31 minutes, for CEA-primary closure it was 39 minutes, and for CEA-patch angioplasty it was 46 minutes (P

Background While pelvic arterial insufficiency, either acute or chronic, results in stereotypic clinical findings which may readily be reversed by indirect techniques of revascularization, few reports document the indications for, techniques of, and results following direct pelvic revascularization by reconstruction of the hypogastric artery. Methods Retrospective review of 8 patients with symptomatic pelvic arterial insufficiency undergoing direct hypogastric artery reconstruction during the period from 1984 to 1995. Results Eight patients underwent unilateral hypogastric artery reconstruction by bypass graft (3 patients) or endarterectomy and patch angioplasty (5 patients). One patient had immediate symptomatic relief of his symptoms, but was lost to follow-up after 1 month. One patient manifested no symptomatic improvement despite a technically successful operation. The remaining 6 patients experienced significant symptomatic relief that has persisted during follow-up from 3 months to 11 years postoperatively. Among 4 men in whom erectile impotence comprised one of the indications for intervention, 3 reported sustained restoration of sexual function. Conclusion In properly selected patients, direct pelvic revascularization by hypogastric artery reconstruction may predictably and durably relieve symptoms of pelvic arterial insufficiency.

Patient initials or identifier number HMY ### Relevant clinical history and physical exam [CASE] 67 year old male [Clinical data]Both Claudication (Rutherford class 4) Hypertension, ICMP(EF 26%) PCI(2004'08): mLAD Cypher 3.0/18mm, pLCX Cypher 3.5/15mm PCI(2015’03): pLAD Promus Premier 3

Results of 21 external carotid endarterectomies (ECEAs) in 19 patients with symptoms were reviewed retrospectively. No patients died or had new strokes referable to ECEA within 30 days of surgery. Overall, six (32%) patients died during an average 41 months of follow-up (range 1 to 134 months). Persistent symptoms followed five (71%) of seven ECEAs performed for cerebrovascular insufficiency or transient ischemic attacks. One patient treated urgently for an evolving stroke failed to improve and died after hospital discharge. Another patient with crescendo transient ischemic attacks had a preoperative deficit that did not resolve for 6 months and had a second stroke 2 years later. Another patient had a stroke after a contralateral carotid reconstruction but recovered. In contrast, only two (14%) of 14 ECEAs performed for monocular amaurosis fugax had persistent symptoms after surgery. Durability of 16 ECEAs was evaluated by arteriography or duplex scanning. Of six ECEAs closed primarily, three (50%) occluded, one has 60% restenosis, and only two (33%) had no restenosis (mean follow-up 36 months). Of 10 ECEAs closed by patch angioplasty, none occluded, 2 had 20% restenosis, and eight (80%) had no restenosis (mean follow-up 47 months). Life-table analysis indicated improvement in ECEA patency and durability with patch angioplasty ( p = 0.011). From these data, ECEA can be performed with relative safety but is more effective for treatment of monocular amaurosis fugax in patients with a microembolic source at the external carotid origin. Patients with any other indications for ECEA did not benefit consistently from this operation. (J Vasc Surg 1992;16:407–13.)

To assess renal duplex sonography as an intraoperative study to detect technical defects during repair, 57 renal artery reconstructions in 35 patients were studied. Sixteen men and 19 women (mean age, 62 years) underwent unilateral (13 patients) or bilateral (22 patients) renal artery repair to 57 kidneys. Methods of repair included aortorenal bypass grafting in 29 cases (20 saphenous vein, 5 polytetrafluoroethylene, 4 Dacron), reimplantation in 7, transrenal thromboendarterectomy with patch angioplasty in 13, and transaortic extraction thromboendarterectomy in 8. Branch renal artery repair was required in six cases (five in vivo, one ex vivo). Fourteen patients had combined aortic replacement (11 patients: 8 abdominal aortic aneurysms, 3 aortic occlusions) or visceral artery reconstruction (three patients: three superior mesenteric artery thromboendarterectomies, one inferior mesenteric artery thromboendarterectomy). Intraoperative renal duplex sonography (mean scan time, 4.5 minutes) was complete in 56 of 57 repairs (98%), and renal duplex sonography was normal in 44 repairs (77%). Overall, B-scan defects were present in 13 repairs (23%). Six of these (11%) were defined as major B-scan defects by Doppler spectra with focal increases in peak systolic velocity ≥2.0 meters/sec (major defect, mean renal artery peak systolic velocity, 3.1 m/sec), which prompted immediate operative revision. Seven B-scan defects were defined as minor by Doppler spectra (minor defect, mean renal artery, peak systolic velocity, 0.7 m/sec) and were not revised. Postoperative evaluation (range, 1 to 22 months; mean follow-up, 12.4 months) of 55 renal artery repairs in 34 operative survivors (surface renal duplex sonography, 33 patients; renal angiography, 9 patients) demonstrated 42/43 renal artery repairs with normal intraoperative renal duplex sonography, and 6/6 repairs with minor B-scan defects were patent and free of critical stenosis. Of the 6 renal artery revisions prompted by major B-scan defects, 4 remained patent, 1 stenosed, and 1 occluded. Our experience suggests that intraoperative renal duplex sonography during renal artery repair provides valuable anatomic and physiologic information. Renal artery repairs with normal renal duplex sonography and minor B-scan defects without Doppler spectral changes demonstrated 98% patency without critical stenosis at 12.4 months of mean follow-up. However, major B-scan defects defined by a focal increase in renal artery peak systolic velocity should be considered for immediate correction. (J VASC SURG 1991;14:364-74.)

Ninety carotid endarterectomies with venous patch angioplasty were performed in 83 patients between July 1980 and December 1985. The primary indication for patching was a small-caliber internal carotid artery (ICA) with a diameter less than 3.0 mm in 54 arteriotomies (60%). Patency of the endarterectomy was evaluated by completion arteriography in all instances. Follow-up was conducted after an intermediate postoperative period of 21 ± 12.5 months in 69 sides by arteriography. A late follow-up was conducted at 55.4 ± 11.2 months either by arteriography (in 45 sides) or by carotid duplex scanning (in 11 sides). Twenty-one patients with 23 endarterectomies died, only 1 of a cerebral event. Seven patients moved or refused study and five were lost to follow-up. Three recurrent stenoses and five carotid occlusions developed by the time of the intermediate follow-up. By the time of late follow-up, three additional patients developed recurrent stenoses. Our results suggest that recurrent stenosis continues to develop with a longer period of follow-up in patients undergoing venous patch angioplasty with carotid endarterectomy.

Reluctance to use saphenous vein (SV) for patch closure of the carotid arteriotomy is due in part to the concern of vascular surgeons that the SV should be preserved for possible future coronary or lower extremity reconstruction. Even among those who favour vein patch closure of the arteriotomy for improved immediate and late results, an effort has been made to use the ankle portion of the SV, preserving the upper, larger segment for later surgery. Recent reports of rupture of the patches formed from ankle SV and a study showing a decrease in strength of the ankle segment of vein, raised the question of the importance of trying to preserve the proximal SV and the impact of use of this segment in those patients requiring secondary vascular procedures. We reviewed 134 consecutive carotid patients from 1981 who had proximal SV harvested for patch angioplasty. Of those 122 were available (mean 44.9 months). Thirteen had secondary vascular procedures. Adequate saphenous vein was available in twelve. We conclude from this study that (1) less than 15% of patients undergoing carotid surgery will require a secondary vascular surgery within 5 years and (2) harvesting SV from the thigh rarely compromises future revascularisation.

We present an original technique which precludes narrowing of the internal carotid artery after simple closure of a longitudinal arteriotomy for endarterectomy. Derived from the technique used to treat excess length of the internal carotid artery, this procedure includes the following steps: (1) division of the internal carotid artery at its base; (2) slitting the carotid artery until reaching the distal part of the plaque; (3) endarterectomy of the internal carotid and common carotid-external carotid axis; and (4) reimplantation of the internal carotid into its ostium, enlarged to the new size of the divided carotid artery. It has been possible to use this technique in eight consecutive cases. Postoperative arteriograms and duplex scanning have shown that anatomic and functional results were excellent. Presently, this technique has our preference in the surgical treatment of atheromatous stenoses of the internal carotid artery.

Background: The optimal material for carotid patch angioplasty after endarterectomy remains uncertain. This study compares the early outcome and recurrent stenosis rates between saphenous vein (SV) and expanded polytetrafluoroethylene (ePTFE) carotid patch angioplasty. Methods: The results of 421 consecutive carotid endarterectomies performed over a 72-month period were reviewed. Postoperative complications and restenosis rates, defined as ≥ 60% narrowing measured by color flow duplex, were compared. Results: Patch angioplasty was performed with SV in 287 and with ePTFE in 110 cases. Patients who had undergone primary closure (n = 20) or whose form of closure was unknown (n = 4) were excluded. The mean age of patients and length of follow-up was similar between groups. Women were more likely to be patched with ePTFE than were men (36% versus 23%, P = 0.02). One death occurred in each group (0.3% SV, 0.9% ePTFE, P = 0.47), and four strokes occurred in each group (1.4% SV, 3.6% ePTFE, P = 0.22). Cervical hematomas requiring operative evacuation occurred in five SV closures and in three ePTFE closures (1.7% versus 2.7%, P = 0.69). Vein harvest site complications occurred in 6 patients (2%) who had undergone SV patch angioplasty. Recurrent stenosis occurred in 3 patients with SV closure and in 3 patients with ePTFE closure (1.0% versus 2.7%, P = 0.35). The 60-month restenosis rates by life table analysis were 2.6% ± 2.1% for SV and 10.7% ± 7.9% for ePTFE (P = 0.17). Conclusions : The incidence of postoperative complications is similar with SV or ePTFE patch angioplasty; however, vein harvest site complications are avoided with the use of ePTFE. Recurrent stenosis at 5 years occurs infrequently with either SV or ePTFE.

Objectives and design: Synthetic and saphenous vein patches, when used in the carotid territory, are disadvantaged by complications. We tested the feasibility of using a locally harvested artery, the ipsilateral superior thyroid artery (STA), as a source of patching material following carotid endarterectomy (CEA). Materials and methods: Twenty-two consecutive patients (15 male) with a median age of 70 (range 53–82) years underwent CEA with an intention to use the STA for patch angioplasty. The STA was harvested via a standard carotid incision and opened longitudinally to fashion a patch. Results: Of the 22 STAs harvested, only two were rejected due to small calibre. Mean harvesting time was 12 min and there were no immediate complications. Duplex scanning has not revealed restenosis (mean peak velocity=0.78 [range 0.45–1.16] m/s) in any patient with a median follow-up of 13 (range 3–19) months. Conclusions: This technique is quick, convenient and obviates many of the disadvantages associated with conventional patches. Follow-up has shown the technique to be both efficacious and durable in the medium term.

Femoral endarterectomy with patch angioplasty has long been the favored approach to the treatment of patients with symptomatic common femoral artery (CFA) occlusive disease. The procedure can be performed through a small incision, and the plaque can often be removed en bloc, followed by enlargement

From 1964 through 1991 we performed primary closure of the arteriotomy in 1173 patients and patch angioplasty in 506 patients after carotid endarterectomy. The decision to patch was made at the surgeon's discretion. In general a patch was used for small arteries. In the primary closure group 32 patients (2.7%) had a perioperative stroke and in the patch angioplasty group 17 (3.4%) had a stroke. The difference (2.7% vs. 3.4%) was not significant (p

A 35-year-old woman who had left coronary ostial stenosis and aortic valve regurgitation due to Takayasu's aortitis underwent transaortic patch enlargement of the stenosed left coronary ostium in combination with aortic valve replacement. This technique may be suitable and recommendable as an alternative to aortocoronary bypass grafting or endarterectomy for coronary ostial stenosis in Takayasu's aortitis.

anastomosis (ES) and a patch angioplasty (Patch). A third model required suturing around a clock-face design printed on patch material (CF). ACGME log experience was recorded. Secondary evaluations of the finished models were then performed by four blinded assessors. Results: Inter-rater reliability among the seven assessors was high (a 1⁄4 .91). Evaluations acquired by direct observation correlated well with participants’ training level/experience for all three models (ES r 1⁄4 .85/.83, Patch r 1⁄4 .71/.69, CF r 1⁄4 .82/.84). Highest correlation with training level/experience was obtained with a combined score for each participant incorporating all observed ratings on each model (r 1⁄4 .90/.93). Construct validity was demonstrated by each model’s ability to discern junior (Pre-MD to PGY2) from senior (PGY 3-5) trainees (ES P < .005, Patch P < .05, CF P < .001). Internal consistency was confirmed for each participant on all three models (a 1⁄4 .89). Finished product evaluation demonstrated fair to poor correlation with training level/experience (ES r 1⁄4 .58/.51, Patch r 1⁄4 .53/.44, CF r 1⁄4 .24/.12). Conclusions: These results provide construct validity for three vascular skill assessment models. Our data also demonstrates that the most accurate assessments are obtained by direct observation with trained evaluators. Validated models and experienced assessors should be considered obligatory components of a meaningful system for vascular skill testing and improvement.

Controversy continues to surround the use of patch angioplasty after carotid endarterectomy. Vein patch rupture is considered to be an uncommon occurrence with an incidence of 0.4-4% 1-3 related to the use of long saphenous vein harvested from the ankle. A recent publication has suggested this can be avoided by using long saphenous vein from the upper thigh. However this case confirms that there is still a risk of rupture even when vein patches are taken from the upper thigh long saphenous vein.

In a recent issue of the JOURNAL of VASCULAR SURGERY, Katz et al. l described a prospective series of 100 operations in 87 patients who were random­ ized to undergo either primary arteriotomy closure or patch angioplasty (polytetrafluoroethylene) in con­ junction with carotid endarterectomy. The overall results in this study were quite good, with a perioperative stroke rate of only 3 % and an incidence of recurrent ( ~ 50%) stenosis of just 2% documented by Doppler ultrasound (duplex) scanning at a mean surveillance interval of29 months. Most importantly there were no significant distinctions in either the early or the intermediate-term outcome between the patched and nonpatched cohorts, a feature that may imply to many readers that carotid patching is unnecessary. Although this conclusion seems appro­ priate enough for the 49 men and 38 women treated by Katz and his associates in Norfolk, how applicable is it to nearly 100,000 other patients who undergo carotid endarterectomy in the United States each

When dense hemiparesis has developed appropriate to the operated vessel after carotid surgery, the patient has been immediately returned to the operating room for reexploration of the vessel and thrombectomy. Over a 5-year period, we identified four patients who developed dense hemiparesis in the recovery room postoperatively. A fifth patient with a similar problem after carotid subclavian bypass was included for analysis. All patients were found to have thrombosis of the operated vessel. Direct closure had been used after endarterectomy. All vessels were thrombectomized and patched with autogenous vein. Interposition graft was used in the patient who underwent carotid subclavian bypass. There were no deaths, and only one patient did not improve. Our experience encourages us to continue this practice but also suggests that the frequency of this problem may be reduced further by patch angioplasty.

We have used most of the modalities of cerebral protection mentioned in this symposium, and are well aware of all the data. We finally settled on general anaesthesia and routine shunting for all carotid endarterectomies, using a No. 8 or No. 10 Fr straight plastic catheter about 9cm long. We have had no technical problems and only one instance in which the shunt clotted in about 3000 operations done over the last 25 years by our group. In a personal series of 707 operations, operative mortality was 0.42%, mostly cardiac, the incidence of severe deficits was 0.56% and that of mild deficits 1%, a total of 1.56%. The advantages of a shunt are: simple, quick, safe, always available, effective, allows for no-haste surgery, which is especially important when training residents and fellows, and acts as a stent for closure. This is of special importance in complicated lesions and when patch angioplasty is required. The majority of the practicing clinical vascular surgeons present at meetings in the U.S. use a shunt routinely. Finally, in the U.S.A. the legal implications of shunting versus non-shunting are very important. The disadvantages of the shunt are in practice minimal.

To determine the benefit of carotid patch angioplasty, a retrospective study of 1000 consecutive carotid endarterectomies was done. Based on the type of carotid endarterectomy closure, patients were divided into four groups: 250 had primary closure, 250 had expanded polytetrafluoroethylene patch, 250 had Dacron patch, and 250 had saphenous vein patch. On the basis of operative technique or type of carotid artery closure, no statistical difference was found in the incidence of postoperative stroke ( p > 0.25): primary closure 1.6% (4), expanded polytetrafluoroethylene 2.0% (5), Dacron patch 1.6% (4), and saphenous vein patch (0). Postoperative carotid patency was determined by B-mode ultrasonography, and 717 patients were evaluated in follow-up extending to 6 years (mean 37.8 months). Based on the method of carotid endarterectomy closure, no significant difference ( p > 0.25) was found in the incidence of significant restenosis (>50% diameter reduction): primary closure 4.0% (7), expanded polytetrafluoroethylene 4.0% (6), Dacron 5.4% (9), and saphenous vein 1.0% (2). Significant restenosis was most frequent in habitual smokers (93%, 25/28) and females (78%, 22/28) despite the method of carotid endarterectomy closure. No statistical difference was found in the incidence of late ipsilateral stroke either ( p > 0.25): primary closure 2.9% (5), expanded polytetrafluoroethylene 2% (3), Dacron 5% (3), and saphenous vein 0%. These results indicate that the incidence of postoperative stroke, regardless of method of arterial closure, was not statistically different. The method of carotid closure did not appear to affect the occurrence of late ipsilateral stroke or restenosis; however, patch angioplasty with saphenous vein appears appropriate in habitual smokers, and likely in patients with small internal carotid arteries. (J V ASC S URG 1990;12:326-33.)

A patient presented with chronic visceral ischemia caused by spontaneous dissection of the superior mesenteric artery; this was treated successfully by "intimectomy" and patch angioplasty. Operative rather than expectant management is recommended for this rare but surgically accessible lesion. (J VASC SURG 1985;2:731-4.)

The 3.4 percent rate of symptomatic recurrent carotid stenosis after carotid endarterectomy confirms previous reports [7]. Most of the recurrent stenoses occurred in women, and it is postulated that small arteries have less tolerance for myointimal proliferation seen after endarterectomy and that primary patch angioplasty should be considered when the internal carotid artery is less than 3 mm in diameter. When recurrent stenosis of the nonarteriosclerotic type is encountered, patch angioplasty without endarterectomy is the procedure of choice.

A technique for inserting and removing the intraaortic balloon pump without vascular complications is described. Prevention of clot formation at the graft-arterial junction, preservation of collateral circulation by insertion in the common femoral artery, removal of potentially infected graft material, and enlargement of the common femoral artery by patch angioplasty are important factors.