Search

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 IAlesion along with peri-operative risk assessment determine a proper surgical approach.

Les donnees s'accumulent suggerant que le traitement endovasculaire (TE) des anevrysmes de l'aorte abdominale rompus (AAAR) entraine une diminution de la mortalite mais le probleme est pose de savoir si cela ne pourrait pas refleter un biais de selection. Nous avons etudie notre experience globale des AAAR apres l'institution de notre protocole pour explorer cette question. Nous avons etabli un protocole defini pour les AAAR en insistant sur le TE en Juillet 2002, comportant la disponibilite des dispositifs, un entrainement pre-operatoire, un acces 24 heures sur 24 a notre salle d'endovasculaire, avec la possibilite d'une imagerie en urgence et la disponibilite immediate d'un kit chirurgical pour mise en place d'un ballon par voie transhumerale dans tous les cas. Les dossiers de tous les malades ayant un AAAR arrives vivants en salle d'operation depuis l'institution de notre protocole ont ete etudies. Les tomodensitometries (TDM) ont ete reetudiees pour apprecier les candidats anatomiques potentiellement favorables. De Juillet 2002 a Mai 2006, un total de 52 AAAR ont ete traites dans notre institution : 15 AAAR para-renaux, tous traites par chirurgie classique (PR-CHIR) et 37 AAAR sous-renaux, dont 20 traites par chirurgie conventionnelle (IR-CHIR) et 17 traites par TE (IR-TE, 32% de l'ensemble des ruptures). Les taux de mortalite dans les trois groupes etaient respectivement de 47%, 75% et 35% (p

Therapy for atherosclerotic occlusive subclavian arterial disease is undergoing a paradigm shift from open to endoluminal therapy. The aim of this study was to review the changing patterns of presentation and clinical outcomes based on presenting symptoms of subclavian artery revascularization. We performed a retrospective analysis of consecutive patients treated for symptomatic atherosclerotic occlusive subclavian arterial disease from 1992 through 2006. Mean follow-up was 4 years. One hundred fourteen patients with a mean age of 63 years (range 33-89, 61% female) underwent 137 procedures. Of these, 89% had hypertension, 32% were diabetic, 69% had hyperlipidemia, and 13% had chronic renal insufficiency. Sixty-seven primary stent attempts (five technical failures) and 70 open (64 carotid-subclavian bypasses, six subclavian-carotid transpositions) were performed. No deaths occurred within the 30-day perioperative period. Fifty-seven percent of the patients presented with symptoms of arm ischemia: exertional pain (84%), rest pain (12%), and ulceration (4%). The assisted primary patency was 81 +/- 7% and 80 +/- 10% at 5 and 10 years, respectively. Symptoms resolved in all patients, and none required major or minor amputations. Freedom from recurrent arm symptoms was 71 +/- 8% and 71 +/- 10% at 5 and 10 years, respectively. Twenty-five percent of the patients presented with a cardiac indication: preparation for a left internal mammary artery (IMA) bypass in 61% and recurrent cardiac ischemia in the remainder. The assisted primary patency was 97 +/- 6% at 5 years. No IMAs were abandoned in this group, and the freedom from recurrent cardiac symptoms related to IMA distribution was 79 +/- 10% at 5 years. Eighteen percent of patients presented with posterior circulation symptoms secondary to vertebrobasilar disease. The assisted primary patency was 100 +/- 0% and 100 +/- 0% at 5 and 10 years, respectively. Freedom from recurrent vertebrobasilar symptoms was 95 +/- 6% and 95 +/- 10% at 5 and 10 years, respectively. Subclavian artery revascularization is safe and effective, but long-term outcomes are determined by the presenting symptomatology.

Le traitement des lesions occlusives atherosclereuses de l'artere sous-claviere est en train de passer de la chirurgie conventionnelle au traitement endoluminal. Le but de ce travail est d'etudier les changements de presentation et d'evolution clinique bases sur les symptomes de la revascularisation de l'artere sous-claviere. Nous avons realise une analyse retrospective des malades consecutifs traites pour des lesions occlusives atherosclereuses symptomatiques de l'artere sous-claviere de 1992 a 2006. Le suivi moyen etait de quatre ans. Cent quatorze malades d'un âge moyen de 63 ans (extremes 33 et 89 ans, 61% de femmes) ont eu 137 procedures. Parmi eux, 89% avaient une hypertension arterielle, 32% etaient diabetiques, 69% avaient une hyperlipidemie et 13% avaient une insuffisance renale chronique. Soixante-sept tentatives de mise en place de stents (5 echecs techniques) et 70 interventions chirurgicales (64 pontages carotido-sous-claviers, 10 transpositions sous-clavieres) ont ete realisees. Aucun deces n'est survenu dans la periode de 30 jours post-operatoire. Cinquante-sept pour cent des malades presentaient des symptomes d'ischemie du membre superieur : douleurs a l'effort (84%), douleurs de repos (12%) et ulcerations (4%). La permeabilite primaire assistee etait de 81 ± 7% et 80 ± 10% respectivement a 5 et 10 ans. Les symptomes ont disparu chez tous les malades et aucun n'a necessite d'amputation majeure ou mineure. L'indemnite de recidive des symptomes du membre superieur etait de 71 ± 8% et 71 ± 10% respectivement a 5 et 10 ans. Vingt-cinq pour cent des malades se presentaient avec une indication cardiaque : preparation pour un pontage a l'aide de l'artere mammaire interne (AMI) gauche chez 61% et ischemie cardiaque recidivante chez les autres. La permeabilite primaire assistee etait de 97 ± 6% a 5 ans. Aucune AMI n'a ete abandonnee dans ce groupe et l'indemnite de symptomes cardiaques recidivants en rapport avec la distribution de l'AMI etait de 79 ± 10% a 5 ans. Dix-huit pour cent des malades se presentaient avec des symptomes au niveau de la circulation posterieure secondaire a une insuffisance vertebro-basilaire. La permeabilite primaire associee etait de 100 ± 0% et 100 ± 0% a respectivement 5 et 10 ans. L'indemnite de recidive de symptomes vertebro-basilaires etait de 95 ± 6% et 95 ± 10% respectivement a 5 et 10 ans. La revascularisation de l'artere sous-claviere est sure et efficace mais les resultats a long terme sont determines par la symptomatologie initiale.

La thrombose « spontanee » de la veine sous-claviere (d'« effort ») est habituellement liee a la compression extrinseque de la veine a la jonction costo-claviculaire. Nous avons revu notre experience de cette entite au cours de la derniere decennie en nous concentrant sur le role de la thrombolyse et sur notre algorithme therapeutique. Tous les patients soignes pour ce probleme a l'universite de Rochester pendant la derniere decennie ont ete identifies et leurs dossiers ont ete revus retrospectivement. De 1996 a juin 2006, 34 patients presentant une occlusion complete spontanee de la veine sous-claviere documentee par phlebographie ont ete soignes, dont la moitie avec la notion d'un facteur d'exercice. Une thrombolyse par catheter dirige avant decompression immediate programmee du defile thoracique (DDT) a ete executee chez 26 patients, alors que la DDT etait faite seule chez huit patients. Le delai ecoule depuis le debut des symptomes etait le facteur principal influencant la decision, avec une moyenne de 5,5 jours chez les 26 patients adresses pour thrombolyse, et compris entre 1 mois et plusieurs annees dans le groupe qui a seulement ete opere. Chez les patients ayant une lyse, la repermeabilisation a ete obtenue 16 fois (62%), avec neuf fois une lesion residuelle. Tous sauf deux des 26 traites par thrombolyse ont eu une DDT avec ou sans angioplastie, et 13 ont egalement eu une reconstruction veineuse (huit des 16 chez qui la permeabilite avait ete reconstituee et cinq des huit chez qui elle ne l'avait pas ete). Les patients n'ayant pas de lyse ont ete traites par DDT, cinq (62%) n'ayant qu'une decompression et trois (38%) ayant une reconstruction veineuse. La thrombolyse n'a pas ete tentee (huit) ou a echoue (quatre) chez les 12 patients dont les symptomes etaient presents depuis plus de 14 jours. Avec un suivi moyen de 33 mois, la resolution des symptomes etait presque constante. La permeabilite primaire a 5 ans etait de 84% dans le groupe thrombolyse et de 83% dans le groupe de DDT isolee. En conclusion, le principal facteur influencant le choix therapeutique dans notre etablissement a ete le delai depuis le debut des symptomes. Les patients vus peu apres le debut de symptome ont eu une thrombolyse suivie d'une DDT, alors que les patients se presentant avec des symptomes chroniques n'avaient qu'une DDT ; dans les deux cas la reconstruction veineuse etait basee sur des resultats incomplets apres lyse. Nous n'avons pas eu de thrombolyse reussie chez un patient se presentant avec 14 jours ou plus de symptomes. Meme si le traitement optimal ne peut pas etre defini a partir de cette revue retrospective, notre algorithme a eu comme consequence un excellent controle a long terme de la permeabilite et des symptomes.

Background The Dialysis Outcomes Quality Initiative (DOQI)-inspired push to create autogenous fistulas has led to a resurgence of interest in basilic vein transposition as an autogenous access conduit. We reviewed our experience with autogenous brachial-basilic upper arm transpositions (BTX) to clarify current maturation and patency rates and provide realistic expectations for a tertiary referral vascular practice. Methods We follow an aggressive "all-autogenous" policy with regard to dialysis access and recommend BTX when all cephalic options are exhausted. Prosthetic grafts are not attempted unless all upper extremity veins are unusable. The records of all patients undergoing autogenous basilic and brachial vein upper arm transpositions for hemodialysis access between April 2001 and December 2004 were retrospectively evaluated. Mean follow-up was 10 months (range, 0 to 38 months). Results Eighty-seven patients underwent 100 basilic and 3 brachial vein transpositions. Most of the patients were already receiving hemodialysis (83%), with a mean of 1.1 (range, 0 to 4) previous access attempts. Perioperative complications included 1 death secondary to a myocardial infarction, 7 hematomas (4 requiring reoperation), and 6 infections (2 requiring reoperation). Steal syndrome developed in five patients. Maturation rate was 79%. Functional primary and secondary patency rates were 23% ± 5% and 47% ± 6% at 1 year and 11% ± 5% and 40% ± 10% at 2 years, respectively (mean ± SE). The most common causes of failure for a matured fistula were stenosis within the body of the basilic vein (44%) followed by central venous outflow stenosis (20%). No preoperative variable, including gender, age, diabetes mellitus, presence of ipsilateral hemodialysis catheter, number of previous access attempts, maximal or minimal vein diameter, or obesity, had a significant impact on rate of maturation or long term patency. Conclusions In our experience, autogenous brachial-basilic upper arm transposition fistulas have initial maturation rates that exceed DOQI guidelines, but disappointing short- to medium-term patency rates. Although these outcomes were obtained within the context of an aggressive all-autogenous policy, the poor durability of these transpositions should prompt further investigation of current access algorithms.

Purpose To report our early experience with the endovascular placement of stacked Zenith main body extensions (cuffs) in the treatment of focal thoracic aortic pathology in high-risk patients. Methods Between January 2003 and May 2004, 6 patients (3 men; mean age 59 years, range 37-82) with focal aortic pathology underwent endovascular repair using stacked 30 and 32-mm-diameter Zenith main body extensions. The setting was a university tertiary referral center for vascular disease. Indication for treatment included 2 descending thoracic aneurysms and individual cases of traumatic thoracic tear, diverticulum of Kommerell, thoracic pseudoaneurysm, and aortoesophageal fistula. Results All procedures were performed successfully, with a mean of 3 cuffs used. The patient with an aortoesophageal fistula expired after successful cuff placement due to sequela of massive pretreatment hemorrhage; fistula coverage was confirmed at autopsy. There were no type I endoleaks. Morbidity included an occluded right subclavian artery from traumatic passage of the device through the artery. No left subclavian arteries were covered. No neurological deficits or paraplegia was observed. The cuffs were patent in all surviving patients at an average follow-up of 7 months (range 3-12). Computed tomography in all survivors confirmed adequate cuff placement, absence of endoleak, and lack of cuff migration. Based on this experience, the following technical recommendations are offered: (1) right subclavian cutdown when needed to reach a lesion beyond the range of the sheath, (2) Dacron chimney placement, (3) stiff guidewire usage, (4) wire placement from the right subclavian artery through the common femoral artery if necessary to ease a sharp bend in the arch, and (5) cuff overlap of 25% to 50%. Conclusions In high-risk patients, focal aortic pathology can be successfully treated with off-the-shelf commercially available cuffs using a stacking technique with acceptable mortality, morbidity, and short-term durability.

"Spontaneous" subclavian vein ("effort") thrombosis is usually related to extrinsic compression of the vein at the costoclavicular junction. Our experience with this entity over the past decade was reviewed with specific focus on the role of thrombolysis and our selection algorithm. All patients treated for this problem at the University of Rochester over the past decade were identified and records retrospectively reviewed. From 1996 to June 2006, a total of 34 patients with spontaneous complete occlusion of the subclavian vein documented by venography were treated, half with a history of an antecedent exertional factor. Catheter-directed thrombolysis prior to planned immediate thoracic outlet decompression (TOD) was performed in 26 patients, while TOD alone was performed in eight. Time since onset of symptoms was the major factor influencing the decision, being a mean of 5.5 days in the 26 referred for lysis but 1 month to many years in the group who underwent surgery alone. In patients undergoing lysis, flow was restored in 16 (62%), of whom nine had a residual lesion. All but two of the 26 who received thrombolysis then underwent TOD with or without angioplasty, and 13 underwent venous reconstruction as well (eight of the 16 in whom patency had been restored and five of eight in whom it had not). Patients not undergoing lysis were managed by TOD, with five (62%) undergoing decompression alone and three (38%) undergoing formal venous reconstruction. Thrombolysis was not attempted (eight) or unsuccessful (four) in all 12 patients whose symptoms had been present for more than 14 days at presentation. At mean follow-up of 33 months, symptom resolution was almost universal. Primary patency at 5 years was 84% in the thrombolysis group and 83% in the TOD-only group. In conclusion, the primary factor influencing treatment choice at our institution has been time since onset of symptoms. Patients presenting soon after symptom onset underwent thrombolysis followed by TOD, while patients presenting with chronic symptoms underwent TOD alone; in both cases venous reconstruction was based on residual findings after lysis. We have not had successful thrombolysis in a patient presenting with 14 days or more of symptoms. While optimal therapy cannot be defined based on this retrospective review, our algorithm resulted in excellent overall long-term patency and symptom relief.

This case report illustrates that postinjury aortic grafts may become infected. A high index of suspicion should be maintained in the postoperative period to detect these infections as early as possible. Prevention and treatment strategies will continue to evolve.