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Objective: Endovascular treatment has largely replaced open reconstruction of proximal brachiocephalic and left common carotid ostial arterial stenoses. The objective of this study was to report the technical feasibility and safety of a flow-based embolic protection system in stenting of single and tandem stenotic lesions of supra-aortic arch vessels., Methods: All cases used flow-based neuroprotection by the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif). Case specifics, such as the stents used, the details of flow-based neuroprotection, the order in which lesions were treated, and the case-specific exceptions, are detailed in the body of the publication. The primary end point of this study was the occurrence of stroke or transient ischemic attack., Results: Sixteen patients (12 women) with an average age of 68 years (range, 54-83 years) underwent endovascular stenting to treat single (11 patients) or tandem (5 patients) stenotic lesions of supra-aortic arch vessels. A total of 21 lesions were treated: 7 in the innominate artery, 1 in the right common carotid artery, 8 in the left common carotid artery, and 5 in the internal carotid artery (tandem cases). Eleven patients (69%) were symptomatic, and the stenoses of the five asymptomatic patients were identified during routine workup for comorbidities. Technical success was obtained in all cases. There were no strokes or transient ischemic attacks during the 30 days after the procedure. Minor complications included a minor wound dehiscence that healed secondarily without sequelae and a hematoma at the neck incision that resolved spontaneously without further intervention., Conclusions: The use of a transcarotid retrograde approach with flow-based neuroprotection is technically feasible for the endovascular stenting of single and tandem stenotic lesions of the supra-aortic arch vessels. These data further support the advantages of a transcarotid approach and flow-based neuroprotection to minimize the risk of intraoperative complications and embolic events during and after the procedure., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: We introduce the "kissing stent-grafts technique" for a patient who suffered from a pseudoaneurysm in bifurcation of innominate artery. This technique repaired an innominate artery bifurcation pseudoaneurysm; it successfully isolated the pseudoaneurysm and preserved both right subclavian and right common carotid artery., Case Presentation: A 60-year-old Asian (Chinese) woman complained of discovering a cervical pulsatile mass. A pseudoaneurysm at the location of innominate artery bifurcation is a rare and difficult situation that should be treated by vascular surgeons. To our knowledge, this is the first case to use the "kissing stent-grafts technique" in treating innominate bifurcation pseudoaneurysm. With this minimally invasive endovascular treatment, our patient avoided open surgery and recovered quickly., Conclusions: When treating vascular lesions with complicated anatomy, endovascular treatment always has the merit of being minimally invasive. "Kissing stent-grafts technique" can be useful in locations other than coronary and aortic bifurcation.

Limb-shaking transient ischemic attacks (LSTIAs) are a phenomenon that occurs due to transient hypoperfusion to a cerebral motor territory with a chronically outstripped autoregulatory vascular reserve. First described in 1962 by Miller Fisher, the pathogenesis and the global understanding of this presentation have undergone a significant advancement throughout the years. Typically, patients will present with this syndrome of transient hypoperfusion in the context of extracranial carotid intrinsic vessel stenosis or by intracranial vascular stenosis to select motor pathways. We present within this case report a novel mechanism by which LSTIAs may emerge. Through this knowledge, clinicians may need to consider expansion of their diagnostic breadth to include proximal vasculature luminal integrity., (Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Aims: Incidence and determinants of restenosis and adverse events after endovascular management (PTA±stent) of the subclavian/innominate artery (SA/IA) stenosis/occlusion remain unclear due to the relatively short-term follow-up or limited size of prior studies. This large-scale, long-term prospective study investigated safety, efficacy, and prognosis after SA/IA PTA±stent., Methods and Results: The study involved 411 consecutive patients with symptomatic SA/IA stenosis/ occlusion; 393 were followed annually after successful PTA±stent for up to 16 (minimum one) years. Primary outcomes were freedom from restenosis and MACCE (cardiovascular death, myocardial infarction, stroke). Angiographic success rate was 99.7% in stenoses and 76.1% in occlusions. The incidence of any periprocedural complication was 4.4% (serious - 1.2%). Symptoms of limb ischaemia, vertebrobasilar insufficiency or angina resolved in 79.1%, decreased in 19.6%. Freedom from restenosis was 82.6% and 77.9% whereas freedom from MACCE was 86.6% and 78.3% at five and 10 years, respectively. MACCE determinants (HR; 95% CI) were previous myocardial infarction (5.36; 2.9-9.91), ischaemic stroke (2.03; 1.12-3.66), hs-CRP (1.04; 1.02-1.07), concurrent atherosclerosis (1.35; 1.00-1.82). Restenosis determinants were implantation of ≥2 stents (2.65; 1.23-5.72), stent diameter (0.45; 0.34-0.59), hs-CRP (1.06; 1.02-1.1), WBC (1.2; 1.07-1.35), age (0.97; 0.94-0.99), concurrent carotid or vertebral disease (1.85; 1.07-3.18), IA intervention (2.28; 1.08-4.84)., Conclusions: This study established long-term durability of stent-assisted PTA of symptomatic SA/IA disease and identified risk factors for restenosis and long-term MACCE. Patients at increased risk might benefit from targeted, intensified prevention measures.

Background: Atherosclerosis of the carotid artery is a major source of stroke. In some cases, atherosclerosis occurs at several positions within the carotid artery. Carotid endarterectomy (CEA) in combination with retrograde balloon angioplasty and stenting of a brachiocephalic or common carotid artery stenosis has been described as efficacious and safe procedure to prevent stroke in these cases. The aim of this study was to analyze the impact of anesthetic techniques on hemodynamic factors, operation time, duration of clamping, and postoperative pain., Methods: A retrospective analysis of patients undergoing CEA in combination with retrograde stenting under either general anesthesia (GA) or cervical block (CB) was carried out. Preoperative risk factors were analyzed as well as operating and cross-clamping time, hemodynamic factors, perioperative complications, postoperative pain, application of pain killers, and duration of intensive care unit (ICU) and hospital stay., Results: Operating (GA: 193 ± 91 min vs. CB: 125 ± 52 min, P = 0.029) and cross-clamping time (GA: 34 ± 12 min vs. CB: 26 ± 9 min, P < 0.001) were shorter under CB. Patients under CB were hemodynamically more stable and required less norepinephrine (GA: 1.1 ± 0.6 mg vs. CB: 0.1 ± 0.1 mg, P < 0.001) and crystalloids (GA: 2,813 ± 1,173 mL vs. CB: 1,088 ± 472 mL, P < 0.001). Postoperative pain levels (GA: numeric rating scale 4.3/10 vs. 2.0/10; P = 0.004) and requirement of pain killers were also lower within the CB group., Conclusions: Synchronous CEA and retrograde balloon angioplasty and stenting of a brachiocephalic or common carotid artery stenosis under CB is associated with reduction of operating and cross-clamping time, improved hemodynamical stability, lower postoperative pain, shorter ICU and hospital stay, and it offers the advantage of a continuous neurological monitoring., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Endovascular treatment of proximal supra-aortic trunks (SAT) has become a safe and reliable alternative to conventional open surgery, with a lower morbimortality rate and good short- and middle-term patency rates. The aim of our study was to assess the long-term results of endovascular treatment of proximal lesions of the SAT (brachiocephalic trunk, common carotid artery, and subclavian artery) and identify predictive risk factors of restenosis., Methods: From 1999 to 2013, 67 consecutive stenotic lesions of the proximal SAT were treated by angioplasty (13.4%) or stenting (86.6%) in 63 patients with a mean age of 65.5 years (40-87). Procedures were performed under general (69%), local (24%), or locoregional (7%) anesthesia, with percutaneous puncture (47.8%) or open access (52.2%). Patients were followed up for 3, 6, and 12 months, and then every year with clinical examination, Doppler ultrasound and if required an angio-CT scan., Results: The technical success rate was 98.5%. There was no postoperative death or strokes. One myocardial infarction occurred at day 2. There were 2 access complications: a nonsurgical hematoma after brachial access and a brachial thrombosis postpuncture. The mean follow-up was 4.5 years (2-163 months). The primary- and assisted-patency rates were 90.1%, 86.4%, 77.9% and 93.3%, 91.4%, 82.9% at 1, 2, and 5 years, respectively. Eleven restenosis (16.4%) occurred at 28.5 months (3, 0-112, 0) of follow-up. Four of them required an endovascular repair and 3 required a surgical one. The restenosis rate was 17.5% in the stented group on average at 30.2 months of follow-up (range, 3.0-112.0) and 10% in the group of patients with angioplasty alone at 8 months of follow-up, without significant statistically difference (P = 0.9). No predictive risk factor of restenosis was statistically identified., Conclusions: The endovascular treatment of proximal stenosis of SAT is a safe, reliable, and efficient technique with a low morbidity and mortality. The long-term results are good, but restenosis can occur. Long-term follow-up should be performed to detect and treat restenosis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Symptomatic acute carotid occlusion demands treatment, but the exact treatment to be provided in the case of acute occlusion of 3 supra-aortic vessels is not well established. Herein, we describe the successful emergency hybrid management of a massive thromboembolic occlusion of the right subclavian artery, common carotid artery, and innominate trunk, associated with left arm hemiparesis, motor aphasia, and confusion, and extensive pulmonary embolism. The diagnostic work-up and the hybrid surgical strategy adopted are described. Neurologic symptoms had completely regressed at discharge and the patient was free of any complications at the 3-month follow-up., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Stenosis or occlusion of the brachiocephalic artery represents an uncommon cause of cerebrovascular insufficiency. We report a patient with combined brachiocephalic and left subclavian obstruction with clinical manifestations of lightheadedness, syncope, and left-sided weakness who remained misdiagnosed essentially because of symmetrical pressures in the upper extremities. Aortic valve replacement for aortic stenosis failed to provide symptomatic relief. Eventual stenting of the brachiocephalic trunk resolved the patient's symptoms. Our report highlights the diagnostic challenges in this case of bilateral supraaortic vessel disease and shows that equal upper extremity pressures do not rule out brachiocephalic artery obstruction., (Published by Elsevier Inc.)

A 56-year-old female presented with pain in her bilateral upper extremities. Angiogram demonstrated occlusion of her left subclavian and innominate arteries (IAs). The patient's left subclavian occlusion was successfully treated with percutaneous mechanical thrombectomy, angioplasty, and stenting. One month later, endovascular revascularization of the IA was performed. Initially the lesion could not be directly transversed from neither an antegrade nor a retrograde approach. Wires were passed from the brachial and femoral arteries into the right common carotid artery where the femoral wire was snared and brought out through the right brachial access. Over this through-and-through wire access, angioplasty and stenting of the IA was performed with an excellent angiographic result. In follow-up, the patient remained free of upper extremity symptoms. Occlusive lesions of the aortic arch vessels can be successfully managed with antegrade and retrograde endovascular techniques.

Innominate and subclavian artery lesions run a wide spectrum of disease manifestation and treatment options. Since the first surgical treatment, multiple variances have been attempted with the desire to maintain high long-term patency rates while reducing perioperative morbidity and mortality. The advent of endovascular procedures in the 1970s provided the opportunity to seek alternative treatment options, but the fear of serious neurologic sequela stalled the adoption of these new techniques. The advancement in endovascular techniques and technology, along with proven clinical success and decreased morbidity and mortality, has led to their adoption as the first-line treatment., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: To assess primary success and safety of percutaneous transluminal angioplasty and/or stenting of innominate artery lesions and to compare its 30-day stroke/mortality level with the literature data., Methods: A total of 72 patients (77 stenoses, five recurrent, 58 symptomatic and 39 female) with seven innominate vessel occlusions, nine subocclusive lesions and 61 significant (>60%) stenoses of innominate artery treated between 2000 and 2009 were retrospectively reviewed. With the exception of seven, all procedures were performed using a transfemoral approach. A stent was implanted in 49 (63.6%) cases. Follow-up included neurological examination, carotid duplex scan and office/telephone interview., Results: Primary technical success was 93.5% (72/77). There was neither periprocedural (<48 h) death, nor major neurological complication. Minor periprocedural neurological complications consisted of 2/72 (2.6%) ipsilateral TIAs. Access site complications included 4 (5.2%) access site bleedings. Follow-up was achieved in 65/72 (90.3%) of all patients and 68 (88.3%) of all procedures for a mean of 42.3 months and revealed neither major neurological complication, nor additional TIA. The cumulative primary patency rate was 100% at 12 months, 98+/-1.6% at 24 months, and 69.9+/-8.5% at 96 months. The cumulative secondary patency rate was 100% at 12 and at 24 months, and 81.5+/-7.7% at 96 months. Log-rank test showed no significant difference (p=0.79) in primary cumulative patencies between PTA alone (n=28) or PTA/stent (n=49)., Conclusion: Transfemoral PTA with or without stent appears to be a safe treatment option for innominate artery lesions., (Copyright 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Management of symptomatic multifocal supra-aortic atherosclerotic disease presents a complex surgical challenge. We describe a novel approach where a temporary extra-corporeal femoro-carotid shunt was used to maintain cerebral perfusion during hybrid surgical and endovascular treatment for tandem supra-aortic lesions.

Purpose: To examine the evolving roles of endovascular and open approaches in treatment of symptomatic innominate artery (IA) disease., Methods: Patients treated for symptomatic IA lesions with or without involvement of the right common carotid and/or right subclavian arteries between 1997 and 2006 were identified. Charts and diagnostic studies were retrospectively reviewed., Results: Of 18 patients treated, 8 required open reconstruction. Ten patients with high-grade focal stenosis were stented. Immediate technical and clinical success was 100% among all patients. Mean follow-up time was 25 and 27 months for endovascular and open interventions, respectively. The primary patency rates were 78% +/- 14 and 80% +/- 10 for endovascular and open groups, respectively. Assisted primary patency rate was 100% for both groups. There were no peri-operative mortalities or neurological events. We encountered two systemic (pulmonary) complications and one access-related complication among open and endovascular patients, respectively., Conclusion: Endovascular repair is evolving as a primary mode of therapy for focal IA lesions while open approach is reserved for more extensive disease. Patho-anatomical characteristics of a given IA lesion along with peri-operative risk assessment determine a proper surgical approach.

Treatment results of 364 patients with multifocal lesions of brachiocephalic and lower limb arteries are analyzed. Indications for surgical treatment were based on priority principle. Staged surgical policy results in 5-year survival of 88-93% patients, improves life quality and saved limbs in 90-93% patients compared with conservative treatment. One-stage surgical interventions are associated with high lethality and should be performed with strong indications only. Conservative treatment cannot be regarded as alternative to surgical procedures.

Our patient had 80% stenosis of the brachiocephalic artery and total occlusion of the left carotid and left subclavian arteries. Ascending aorta to brachiocephalic artery bypass grafting was performed, with a 10 mm Dacron graft. The right axillary artery was cannulated, and during construction of the distal anastomosis cerebral blood flow was from the right axillary artery. We believe this technique may be beneficial in surgery on an artery in which cerebral blood flow depends exclusively.

Annually, about 400,000 new patients with strokes are recorded in Russia. Of these, 80% of patients may develop ischemic brain infarctions. In approximately 30-40% of cases, ischemic lesion of the brain eventuates in lethal outcome; the same number of patients remain heavily disabled and only 15-20% of patients return to the previous level of work fitness. In 30-50% of cases, the development of ischemic stroke and other forms of cerebrovascular insufficiency is caused by stenotic and occlusive lesion of aortic arch branches, being more frequently of atherosclerotic origin. Patients with brachiocephalic artery (BCA) lesion face an important problem of the origin and progression of different forms of cardiac rhythm disorders. In the presence of hemodynamically significant stenotic and occlusive lesion of brain vessels, even transient changes in cardiac rhythm may induce an additional deterioration of cerebral flow. In turn, the origin of arrhythmias in the immediate postoperative period in patients after reconstructions on the BCA is a serious complication which may lead to sudden death. The aim of the present study was to examine the long-term results of the surgical treatment in patients with associated BCA lesion and paroxysmal disorders of cardiac rhythm (PDCR). The treatment results were analyzed in 89 patients aged 35 to 70 years. There were 66 (74.2%) men and 23 (25.8%) women. All the patients had undergone different BCA reconstructions. In the long-term period, this resulted in the lowering of the death rate. Besides, in the long-term period, vascular reconstructions carried out in patients with associated BCA lesion and PDCR not only improved the neurologic status but also favoured the positive course of changes in arrhythmias in 36.4% of patients.

In 14 patients with severe stenosis or occlusion of the innominate artery a new high-energy, low-frequency (2 MHz) pulsed Doppler ultrasound method was used to investigate blood flow velocity patterns of both intrathoracic and intracranial cerebral arteries. Direct acquisition and evaluation of the innominate artery at its origin near the aortic arch enabled separation of it from adjacent arteries and reliable differentiation of stenosis from occlusion. Transcranial recordings from the basal cerebral arteries showed abnormal Doppler signals in 12 patients (86%). Among these abnormalities, observation of a latent steal phenomenon was closely related to the prevalence of cerebrovascular events. This latent steal phenomenon was characterized by a transient reduction of orthograde blood flow in the ipsilateral anterior, middle, and posterior cerebral arteries or in the basilar artery during postischemic hyperemia of the upper extremities. The predictive value of the latent steal phenomenon for the management and follow-up of asymptomatic patients with severe innominate artery obstructions is discussed.

A peroperative study of blood flow and flow direction was performed in series of patients with occlusive disease of the subclavian artery. Particular attention was focused on the flow variations caused by arm ischaemia and postischaemic hyperaemia and on the effect of injection of a vasodilator into the distal subclavian artery. The effect on blood flow and flow direction was measured with the aid of an electromagnetic flowmeter. During arm ischaemia induced by an inflated cuff on the arm, the subclavian flow diminished, as did the vertebral artery flow when it was retrograde. If the vertebral artery flow was anterograde, it increased during arm ischaemia. The postischaemic hyperaemia caused an increase of the subclavian flow and of reversed vertebral flow. If the vertebral flow was anterograde, it diminished during the postischaemic hyperaemia. Similar findings were obtained with intra-arterial injection of a vasodilator. The large amount of blood flow passing through the vertebral artery, as well as the flow variations caused by reactive arm hyperaemia, emphasize the role of this artery as a collateral vessel to the upper limb in cases of the subclavian steal phenomenon.

Hemodynamic borrowing and stealing phenomena in various vascular basins have been detected and quantified, using ultrasonic dopplerography and transcutaneous oxygen tension measurement, in 74 patients. The results were confirmed by aorto-arteriography. These noninvasive procedures are shown to be highly valuable for the diagnosis of blood borrowing and stealing.

Patients with occlusive disease of the subclavian artery or brachiocephalic trunk were examined by oscillography (17 cases) and digital pulse plethysmography (19 cases) before and after reconstruction of the occluded vessel. Before surgery the oscillographic amplitudes were significantly lower on the occluded than the contralateral arm, with no difference between the registration levels. Shape analysis of the digital pulse curve recordings gave significant differences in all variables, between the occluded and the contralateral arm, inclination time and RAMP25 being most sensitive. Idential studies repeated up to 6 months after surgery demonstrated a marked increase in oscillometric amplitudes at all levels on the operated side. In the digital pulse-curve recordings the greatest improvement was found in inclination time and RAMP25.

Between 1976 and 1987 we saw 20 patients presenting with stenosis or occlusion of the innominate artery with a measurable hemodynamic effect. This corresponds to less than 0.1% of our patients subjected to noninvasive vascular testing. The hemodynamic sequelae involved the vertebral as well as the carotid arteries. The majority of the cases (n = 17) showed a vertebral steal and only minor concomitant alterations of carotid artery flow. Only three patients had a carotid steal in addition to the vertebral steal. In general, the vertebral steal is predominant over the carotid steal and precedes the latter. We propose a phenomenological classification of innominate artery disease following the severity of hemodynamic changes. Type I shows systolic deceleration or alternating flow in the right vertebral artery and only minor changes in the carotid arteries. Type II is characterized by reversed flow in the ipsilateral vertebral artery and systolic deceleration in the carotid arteries and type III by alternating flow or even complete steal in the carotid arteries in addition to vertebral artery steal. Continuous wave Doppler ultrasound is a valuable noninvasive method for examinating innominate artery occlusive disease and its hemodynamic sequelae. In special cases the additional use of duplex- and transcranial sonography is useful.