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1.
J Vasc Surg ; 75(3): 968-975.e1, 2022 03.
Artículo en Inglés | MEDLINE | ID: mdl-34695555

RESUMEN

OBJECTIVE: Over the past two decades, vascular surgeons have successfully incorporated endovascular techniques to the routine care of patients with arterial thoracic outlet syndrome (ATOS). However, no reports have documented the impact of endovascular therapy. This study describes the trends in management of ATOS by vascular surgeons and outcomes after both endovascular and open repair of the subclavian artery. METHODS: We queried a single-institution, prospectively maintained thoracic outlet syndrome database for ATOS cases managed by vascular surgeons. For comparison, cases were divided into two equal time periods, January 1986 to August 2003 (P-1) vs September 2003 to March 2021 (P-2), and by treatment modality, open vs endovascular. Clinical presentation, outcomes, and the involvement of vascular surgeons in endovascular therapy were compared between groups. RESULTS: Of 2200 thoracic outlet syndrome cases, 51 were ATOS (27 P-1, 24 P-2) and underwent 50 transaxillary decompressive operations. Forty-eight cases (92%) presented with ischemic symptoms. Thrombolysis was done in 15 (29%). During P-1, vascular surgeons performed none of the catheter-based interventions. During P-2, vascular surgeons performed 60% of the angiograms, 50% of thrombolysis, and 100% of stent grafting. Subclavian artery pathology included 16 aneurysms (31%), 15 stenoses (29%), and 19 occlusions (37%). Compared with open aneurysmal repair, endovascular stent graft repairs took less time (241 vs 330 minutes; P = .09), incurred lower estimated blood loss (103 vs 150 mL; P = .36), and had a shorter length of stay (2.4 vs 5.0 days; P = .10). Yet the endovascular group had decreased primary (63% vs 77%; P = .481), primary assisted (75% vs 85%; P = .590), and secondary patency rates (88% vs 92%; P = .719), at a mean follow-up time of 3.0 years for the endovascular group and 6.9 years for the open group (P = .324). These differences did not achieve statistical significance. Functionally, 84% of patients were able to resume work or school. A majority of patients (88%) had a good to excellent functional outcome based on their Derkash score. Somatic pain scores and QuickDASH (disabilities of the arm, shoulder, and hand) scores decreased postoperatively, 2.9 vs 0.8 (P = .015) and 42.6 vs 12.6 (P = .004), respectively. CONCLUSIONS: This study describes the evolving role of endovascular management of ATOS over the past two decades and documents the expanded role of vascular surgeons in the endovascular management of ATOS at a single institution. Compared with open repair, stent graft repair of the subclavian artery may be associated with shorter operative times, less blood loss, but decreased patency, without changes in long-term functional outcomes.


Asunto(s)
Implantación de Prótesis Vascular/tendencias , Descompresión Quirúrgica/tendencias , Procedimientos Endovasculares/tendencias , Pautas de la Práctica en Medicina/tendencias , Arteria Subclavia/cirugía , Cirujanos/tendencias , Síndrome del Desfiladero Torácico/cirugía , Adulto , Implantación de Prótesis Vascular/efectos adversos , Bases de Datos Factuales , Descompresión Quirúrgica/efectos adversos , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Rol del Médico , Complicaciones Posoperatorias/etiología , Recuperación de la Función , Estudios Retrospectivos , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Síndrome del Desfiladero Torácico/diagnóstico por imagen , Síndrome del Desfiladero Torácico/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Adulto Joven
2.
Ann Vasc Surg ; 79: 25-30, 2022 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-34656717

RESUMEN

BACKGROUND: In traumatic axillo-subclavian vessel injuries, endovascular repair has been increasingly described, despite ongoing questions regarding infection risk and long-term durability. We sought to compare the clinical and safety outcomes between endovascular and surgical treatment of traumatic axillo-subclavian vessel injuries. METHOD: A search query of the prospectively maintained PROOVIT registry for patients older than 18 years of age with a diagnosis of axillary or subclavian vessel injury between 2014-2019 was performed at a Level 1 Trauma Center. Patient demographics, severity of injury, Mangled Extremity Severity Score (MESS), Injury Severity Score (ISS), procedural interventions, complications, and patency outcomes were collected and analyzed. RESULTS: Twenty-three patients with traumatic axillo-subclavian vessel injuries were included. There were similar rates of penetrating and blunt injuries (48% vs. 52%, respectively). Eighteen patients (78%) underwent intervention: 11 underwent endovascular stenting or diagnostic angiography; 7 underwent open surgical repair. There was similar severity of arterial injuries between the endovascular and open surgical groups: transection (30% vs. 40%, respectively), occlusion (30% vs. 40%, respectively). The open surgical group had worse initial clinical comorbidities: higher ISS scores (17.0 vs 13.5, p = 0.034), higher median MESS scores (6 vs. 3.5, P = 0.001). The technical success for the endovascular group was 100%. The endovascular group had a lower estimated procedural blood loss (27.5 mL vs. 624 mL, P = 0.03). The endovascular arterial group trended toward a shorter length of hospital stay (5.6 days vs. 27.6 days, P = 0.09) and slightly reduced procedural time (191.0 min vs. 223.5 min, P = 0.165). Regarding imaging follow up (average of 60 days post-discharge), 7 patients (54%) underwent surveillance imaging (5 with duplex ultrasound, 2 with computed tomography angiography CTA) that demonstrated 100% patency. Regardless of ISS or MESS scores, at long term clinical follow up (average of 214 days), there were no limb losses, graft infections or vascular complications in either the endovascular or open surgical group. CONCLUSIONS: Endovascular treatment is a viable option for axillo-subclavian vessel injuries. Preliminary results demonstrate that endovascular treatment, when compared to open surgical repair, can have similar rates of technical success and long-term outcomes in patency, infection and vascular complications.


Asunto(s)
Arteria Axilar/cirugía , Procedimientos Endovasculares , Arteria Subclavia/cirugía , Procedimientos Quirúrgicos Vasculares , Lesiones del Sistema Vascular/cirugía , Adulto , Anciano , Arteria Axilar/diagnóstico por imagen , Arteria Axilar/lesiones , Arteria Axilar/fisiopatología , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Sistema de Registros , Estudios Retrospectivos , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/lesiones , Arteria Subclavia/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversos , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/fisiopatología , Adulto Joven
4.
Ann Vasc Surg ; 77: 349.e19-349.e23, 2021 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-34437974

RESUMEN

BACKGROUND: An aberrant right subclavian artery is the most common congenital anomaly of the aortic arch and may cause symptoms due to aneurysmal dilatation, stenosis or occlusion. We present a case of subclavian-steal syndrome due to post-traumatic dissection of an aberrant right subclavian artery. METHODS AND RESULTS: A 50 year-old man presented with dizziness and fainting episodes after exercising his right arm and a systolic blood pressure gradient of 40 mm Hg between the 2 arms. Suspecting a subclavian steal syndrome, a computed tomography angiography was requested which revealed an aberrant right subclavian artery with a severe stenosis proximal to the ostium of the vertebral artery. Transfemoral digital subtraction angiography showed a local dissection of the aberrant right subclavian artery with late retrograde filling of the ipsilateral vertebral artery. The lesion was successfully treated with primary stent implantation (9 mm x 40 mm, LIFESTAR, BARD). On interrogation, the patient recalled an injury to the right arm after falling off a ladder 10 years earlier, as a possible post-traumatic cause for the dissection. He had an uneventful outcome and is symptom-free 12 months down the line. CONCLUSIONS: The combination of post-traumatic dissection of an aberrant right subclavian artery resulting to subclavian steal syndrome is an extremely rare scenario. Endovascular management is a safe, minimally invasive alternative to open surgery.


Asunto(s)
Accidentes por Caídas , Angioplastia , Disección Aórtica/terapia , Anomalías Cardiovasculares/complicaciones , Arteria Subclavia/anomalías , Síndrome del Robo de la Subclavia/terapia , Lesiones del Sistema Vascular/terapia , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/etiología , Disección Aórtica/fisiopatología , Angioplastia/instrumentación , Anomalías Cardiovasculares/diagnóstico por imagen , Anomalías Cardiovasculares/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Stents , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Síndrome del Robo de la Subclavia/diagnóstico por imagen , Síndrome del Robo de la Subclavia/etiología , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/etiología , Lesiones del Sistema Vascular/fisiopatología
5.
Ann Vasc Surg ; 74: 524.e9-524.e15, 2021 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-33836226

RESUMEN

The coronary-subclavian steal syndrome is a hemodynamic phenomenon in which a subclavian artery stenosis or occlusion impairs blood flow at the origin of the left internal mammary artery used for coronary artery bypass grafting (CABG), causing retrograde blood flow and thus provoking symptoms of cardiac ischemia and its complications. Once considered the gold-standard operation of choice, open revascularization has now been abandoned as a first line treatment and replaced by endovascular techniques. In all cases, detailed and oriented physical examination in combination with further imaging in high clinical suspicion for coronary-subclavian steal syndrome remains the sine qua non of the preoperative examination of the patient. We report the case of a 50-year-old male patient suffering from acute onset angina post- coronary artery bypass grafting and managed by endovascular means.


Asunto(s)
Angina Inestable/diagnóstico , Circulación Coronaria , Síndrome de Robo Coronario-Subclavio/diagnóstico , Hemodinámica , Anastomosis Interna Mamario-Coronaria/efectos adversos , Arteria Subclavia/fisiopatología , Síndrome del Robo de la Subclavia/diagnóstico , Angina Inestable/etiología , Angina Inestable/fisiopatología , Angina Inestable/terapia , Angioplastia de Balón/instrumentación , Síndrome de Robo Coronario-Subclavio/etiología , Síndrome de Robo Coronario-Subclavio/fisiopatología , Síndrome de Robo Coronario-Subclavio/terapia , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Flujo Sanguíneo Regional , Factores de Riesgo , Stents , Arteria Subclavia/diagnóstico por imagen , Síndrome del Robo de la Subclavia/etiología , Síndrome del Robo de la Subclavia/fisiopatología , Síndrome del Robo de la Subclavia/terapia , Resultado del Tratamiento
6.
Ann Vasc Surg ; 75: 301-307, 2021 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-33823262

RESUMEN

OBJECTIVE: Subclavian artery aneurysms (SAAs) are uncommon but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for SAAs. METHODS: The clinical data of 18 SAA patients who underwent endovascular repair at 3 hospitals from January 2009 to December 2019 were retrospectively collected and analyzed. RESULTS: Eighteen patients (12 men and 6 women) with a mean age of 61 years were included. Six patients (33.3%) had a history of hypertension, and 5 (27.8%) had a history of chest trauma. Five patients (27.8%) were asymptomatic. Thirteen (72.2%) SAAs were true aneurysms, and the others (27.8%) were posttraumatic false aneurysms. Endovascular stent graft repair was performed in all patients without conversion to open surgery. The immediate technique success rate was 94.4%, with no postoperative death and only one case (5.6%) of endoleak that was observed on intraoperative angiography and later resolved spontaneously. All patients survived over a median follow-up time of 57 months. Follow-up imaging showed that all stent grafts remained patent, with no endoleak. CONCLUSIONS: Endovascular stent graft repair is feasible, safe, and effective for true and posttraumatic false SAAs and represents a promising treatment option for these SAAs.


Asunto(s)
Aneurisma Falso/cirugía , Aneurisma/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Arteria Subclavia/cirugía , Lesiones del Sistema Vascular/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma/diagnóstico por imagen , Aneurisma/fisiopatología , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Stents , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/lesiones , Arteria Subclavia/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/fisiopatología
7.
Vasc Endovascular Surg ; 55(6): 551-559, 2021 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-33764219

RESUMEN

OBJECTIVE: In this retrospective study, we presented the results of Castor single-branched stent-graft in a small series of patients with acute type B aortic syndrome and aberrant right subclavian artery (ARSA). METHODS: Between January 2019 and November 2019, 5 patients were diagnosed with acute type B aortic syndrome and ARSA (4 patients with intramural hematoma and ARSA, 1 patient with type B aortic dissection and ARSA). All the patients underwent thoracic endovascular aortic repair (TEVAR) using Castor single-branched stent-graft. In-hospital and 3-month outcomes were collected. RESULTS: The mean operative time was 116 ± 20.43 minutes (range 90-145). All the TEVAR procedures were successfully performed without conversion to open surgery (100% success rate). All the ARSAs of the 5 patients were revascularized in situ by Castor single-branched stent-grafts. No deaths and complications were observed in the 3-month follow-up. The maximal diameters of diseased aortas in the 4 patients with IMH decreased 3 months after TEVAR. The false lumen in the graft-covered segment was completely thrombosed in the patient with type B aortic dissection. CONCLUSIONS: Castor single-branched stent-graft may be a good choice in treatment of acute type B aortic syndrome and aberrant right subclavian artery.


Asunto(s)
Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Anomalías Cardiovasculares/cirugía , Procedimientos Endovasculares/instrumentación , Stents , Arteria Subclavia/anomalías , Anciano , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/fisiopatología , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Anomalías Cardiovasculares/diagnóstico por imagen , Anomalías Cardiovasculares/fisiopatología , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tempo Operativo , Diseño de Prótesis , Estudios Retrospectivos , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Arteria Subclavia/cirugía , Síndrome , Factores de Tiempo , Resultado del Tratamiento
8.
Prog Cardiovasc Dis ; 65: 44-48, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33744380

RESUMEN

Brachiocephalic and subclavian artery stenoses are less common manifestations of peripheral arterial disease (PAD) compared to lower extremity PAD. However, even among asymptomatic patients, a diagnosis of PAD portends worse long-term mortality. Symptoms may include subclavian steal syndrome and arm claudication. Among patients with internal mammary coronary bypass grafts, symptoms may include those of myocardial ischemia. Symptomatic subclavian stenosis can be readily treated using endovascular techniques with durable outcomes.


Asunto(s)
Implantación de Prótesis Vascular , Tronco Braquiocefálico/cirugía , Fármacos Cardiovasculares/uso terapéutico , Procedimientos Endovasculares , Claudicación Intermitente/terapia , Enfermedad Arterial Periférica/terapia , Arteria Subclavia/cirugía , Síndrome del Robo de la Subclavia/terapia , Venas/trasplante , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Tronco Braquiocefálico/diagnóstico por imagen , Tronco Braquiocefálico/fisiopatología , Fármacos Cardiovasculares/efectos adversos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Humanos , Claudicación Intermitente/diagnóstico por imagen , Claudicación Intermitente/epidemiología , Claudicación Intermitente/fisiopatología , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/epidemiología , Enfermedad Arterial Periférica/fisiopatología , Factores de Riesgo , Stents , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Síndrome del Robo de la Subclavia/diagnóstico por imagen , Síndrome del Robo de la Subclavia/epidemiología , Síndrome del Robo de la Subclavia/fisiopatología , Resultado del Tratamiento , Grado de Desobstrucción Vascular
9.
Vasc Endovascular Surg ; 55(4): 355-360, 2021 May.
Artículo en Inglés | MEDLINE | ID: mdl-33535904

RESUMEN

BACKGROUND: Adequate seal for thoracic endovascular aortic repair (TEVAR) commonly requires landing in zone 2, but can prove to be challenging due to the tortuous and angulated anatomy of the region. OBJECTIVES: Our objective was to determine the proximal landing accuracy of zone 2-targeted TEVARs following carotid-subclavian revascularization (CSR) and its impact on clinical outcomes. METHODS: Retrospective review of patients that underwent CSR for zone 2 endograft delivery at a tertiary institute between January 2008 and March 2018 was conducted. Technical outcomes were assessed by examining the incidence of intraoperative corrective maneuvers, 1a endoleaks and reinterventions. Distance to target and incidence of LSA stump filling were examined as radiographic markers of landing accuracy. RESULTS: Zone 2-targeted TEVAR with CSR was performed in 53 patients for treatment of dissections (49%), aneurysms (30%) or trauma (21%). Nine (17%) cases required intraoperative corrective procedures: 5 (9%) proximal cuffs due to type 1a endoleak and 4 (8%) left common carotid artery (LCCA) stenting due to inadvertent coverage. Cases performed using higher resolution hybrid fluoroscopy machine compared to mobile C-arm were associated with increased proximal cuff use (OR 8.8; 95% CI 1.2-62.4). Average distance between the proximal edge of the covered graft to LCCA was 8 ± 1 mm and larger distances were not associated with higher rates of 1a endoleak. Twenty-eight (53%) cases of antegrade LSA stump filling were noted on follow-up imaging, but were not associated with higher rates of reinterventions (OR 0.8, 95% CI [0.2-4.6]). Three (6%) patients had a stroke within 30 days and 4 (8%) patients expired within 1 month. Intraoperative corrective maneuvers, post-operative 1a endoleak and reinterventions were not associated with higher rates of stroke or mortality. CONCLUSION: Using current endografts and imaging modalities, zone 2-targeted TEVARs have suboptimal technical accuracy.


Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Arterias Carótidas/cirugía , Procedimientos Endovasculares , Arteria Subclavia/cirugía , Anciano , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Disección Aórtica/fisiopatología , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/fisiopatología , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Aneurisma de la Aorta Torácica/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Arterias Carótidas/diagnóstico por imagen , Arterias Carótidas/fisiopatología , Endofuga/etiología , Endofuga/mortalidad , Endofuga/terapia , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Factores de Tiempo , Resultado del Tratamiento
10.
Dig Dis Sci ; 66(9): 2882-2887, 2021 09.
Artículo en Inglés | MEDLINE | ID: mdl-33433797
11.
Vasc Endovascular Surg ; 55(3): 265-268, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-33357042

RESUMEN

INTRODUCTION: Thoracic Endovascular Aortic Repair (TEVAR) has become the procedure of choice for pathology involving the descending thoracic aorta since its approval by the FDA in 2005. Left subclavian artery (LSA) coverage is commonly required to facilitate an adequate proximal landing zone for the endograft. The traditional revascularization procedure of choice is carotid-subclavian bypass, however recent studies report complication rates as high as 29%-specifically phrenic nerve palsy in 25% of patients undergoing this procedure. Our aim is to present our experience using carotid-axillary bypass as a safe alternative to carotid-subclavian bypass. METHODS: All patients undergoing carotid-axillary bypass for TEVAR with LSA coverage between June 2016 and September 2019 at a tertiary medical center were retrospectively identified. Short-term and long-term complications were identified and analyzed including: phrenic nerve, recurrent laryngeal nerve, and axillary nerve injuries, as well as local vascular complications requiring re-intervention. All perioperative chest radiographs were reviewed for new hemidiaphragm elevation to assess for phrenic nerve injuries. RESULTS: 35 patients underwent carotid-axillary bypass in conjunction with TEVAR during this time period. The majority of bypasses were performed concurrently with TEVAR (80.0%, 28/35) utilizing GORE PROPATEN 8 mm externally supported vascular graft (91.4%, 32/35). The complication rate specific to carotid-axillary bypass was 14.3% (5/35). We observed a significantly lower (0%, 0/35, P < 0.01) rate of phrenic nerve palsy for carotid-axillary bypass compared to the previously reported 25% (27/107) for carotid-subclavian bypass. For patients with available follow-up imaging (85.7%, 30/35), there was a 100% patency rate at time intervals ranging from 0-1066 days (IQR = 3-37.8). CONCLUSION: Carotid-axillary bypass can be performed as a safe alternative to carotid-subclavian bypass for LSA coverage during TEVAR involving a more superficial anatomic course of dissection. Phrenic nerve palsy, a well-described complication of the traditional carotid-subclavian bypass, was not observed in this retrospective series.


Asunto(s)
Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Arteria Axilar/cirugía , Implantación de Prótesis Vascular , Arterias Carótidas/cirugía , Procedimientos Endovasculares , Arteria Subclavia/cirugía , Anciano , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/fisiopatología , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/fisiopatología , Arteria Axilar/diagnóstico por imagen , Arteria Axilar/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Arterias Carótidas/diagnóstico por imagen , Arterias Carótidas/fisiopatología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Diseño de Prótesis , Retratamiento , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular
12.
J Vasc Surg ; 73(3): 968-974, 2021 03.
Artículo en Inglés | MEDLINE | ID: mdl-32361068

RESUMEN

BACKGROUND: 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. METHODS: 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. RESULTS: 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%). CONCLUSIONS: Concomitant CEA/CSBG is safe and durable. There was no significant difference in perioperative stroke/death or late patency rates compared with isolated CSBG.


Asunto(s)
Arteria Carótida Interna/cirugía , Estenosis Carotídea/cirugía , Endarterectomía Carotidea , Arteria Subclavia/cirugía , Síndrome del Robo de la Subclavia/cirugía , Injerto Vascular , Anciano , Anciano de 80 o más Años , Arteria Carótida Interna/fisiopatología , Estenosis Carotídea/complicaciones , Estenosis Carotídea/mortalidad , Estenosis Carotídea/fisiopatología , Registros Electrónicos de Salud , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Femenino , Humanos , Ataque Isquémico Transitorio/etiología , Ataque Isquémico Transitorio/mortalidad , Masculino , Persona de Mediana Edad , Flujo Sanguíneo Regional , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Arteria Subclavia/fisiopatología , Síndrome del Robo de la Subclavia/complicaciones , Síndrome del Robo de la Subclavia/mortalidad , Síndrome del Robo de la Subclavia/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidad , Grado de Desobstrucción Vascular
13.
Vascular ; 29(5): 723-732, 2021 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-33249978

RESUMEN

OBJECTIVES: The aim of the present study was to review our institutional experience of endovascular treatment for isolated subclavian artery aneurysms and evaluate the long-term outcomes. METHODS: A retrospective review of all patients with isolated subclavian artery aneurysms who underwent endovascular treatment between March 2008 and March 2020 was performed. The demographics, aneurysmal characteristics, treatment strategies, and in-hospital and follow-up outcomes were recorded and then analyzed. RESULTS: From March 2008 to March 2020, 35 isolated subclavian artery aneurysms were endovascularly treated at our institution. Atherosclerosis was the most common cause of aneurysms in this series. Most aneurysms were intrathoracic (91.4%) and located at the right side (77.1%). There were 26 true aneurysms, seven pseudoaneurysms, and two ruptured isolated subclavian artery aneurysms. Five types of endovascular strategies were performed. Covered stent placement across the aneurysm was the most (54.3%) commonly used method. Technical success was achieved in all patients. The median postoperative in-hospital stay was 4.0 days (range, 1-15 days). One patient died after discharge but within 30 days of surgery due to myocardial infarction. The median follow-up time was 62.0 months (range, 3-132 months). No death, stroke, stent fractures, or severe upper limb ischemia developed during the follow-up period. The cumulative survival rate at five years was 97.1%. The overall complication rate was 25.7% and one-third of complications (8.6%) required reinterventions. CONCLUSIONS: Endovascular treatment for isolated subclavian artery aneurysms is safe, effective and technically achievable in most patients. Short- and long-term outcomes are promising. Reasonable and flexible use of covered stents can also get satisfactory outcomes in some complicated lesions such as isolated subclavian artery aneurysms located at the origin of the right subclavian artery, avoiding the huge surgical trauma caused by conventional open repair.


Asunto(s)
Aneurisma Falso/terapia , Aneurisma Roto/terapia , Procedimientos Endovasculares , Arteria Subclavia , Adulto , Anciano , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/fisiopatología , Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/fisiopatología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Retratamiento , Estudios Retrospectivos , Stents , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Adulto Joven
14.
Ann Vasc Surg ; 73: 321-328, 2021 May.
Artículo en Inglés | MEDLINE | ID: mdl-33249129

RESUMEN

BACKGROUND: Subclavian or innominate artery stenosis (SAS) may cause upper extremity and cerebral ischemia. In patients with symptomatic subclavian or innominate artery stenosis, percutaneous transluminal angioplasty is the treatment of first choice. When percutaneous transluminal angioplasty is technically restricted or unsuccessful, an extrathoracic bypass grafting, such as an axillo-axillary bypass can be considered. The patency rate of axillo-axillary bypass is often questioned. The aim of this study was to assess long-term outcomes of patients undergoing axillo-axillary bypass for subclavian or innominate artery stenosis (SAS) and to provide a literature overview. METHODS: In this single-center study, data from patients who underwent axillo-axillary bypass for symptomatic SAS between 2002 and 2018 were retrospectively analyzed. Bypass material was Dacron® (54%) or polytetrafluoroethylene (PTFE) (46%). Primary outcome was graft patency and secondary outcome was the occurrence of mortality and stroke. In addition, a systematic literature search was performed in MEDLINE and EMBASE databases including all studies describing patency of axillo-axillary bypass. RESULTS: In total, 28 axillo-axillary bypasses had been performed. Cumulative primary, primary-assisted, and secondary patency rates at one year were 89%, 93%, and 96%, respectively. Cumulative primary, primary-assisted, and secondary patency rates at five years were 76%, 84%, and 87%, respectively. The primary-assisted patency rates at five years for Dacron® and PTFE were 93% and 73%, respectively. A total of four primary axillo-axillary bypass occlusions occurred (14%), with a mean of 12 months (range, 0.4-25) after operation. The 30-day mortality was 7%; one patient died after a stroke and one died of a myocardial infarction. At the first postoperative follow-up control, 22 of the 26 remaining patients (85%) had relief of symptoms. The literature search included 7 studies and described a one-year primary patency range of 93-100% (n = 137) and early postoperative adverse events included death (range, 0-13%) and stroke (range, 0-5%). CONCLUSIONS: Patency rates of axillo-axillary bypasses for patients with a symptomatic SAS are good. However, the procedural complication rate in this series is high and attention should be paid to intervention indication.


Asunto(s)
Arteria Axilar/cirugía , Implantación de Prótesis Vascular , Tronco Braquiocefálico/cirugía , Arteria Subclavia/cirugía , Síndrome del Robo de la Subclavia/cirugía , Anciano , Anciano de 80 o más Años , Arteria Axilar/diagnóstico por imagen , Arteria Axilar/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Tronco Braquiocefálico/diagnóstico por imagen , Tronco Braquiocefálico/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tereftalatos Polietilenos , Politetrafluoroetileno , Diseño de Prótesis , Estudios Retrospectivos , Factores de Riesgo , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Síndrome del Robo de la Subclavia/diagnóstico por imagen , Síndrome del Robo de la Subclavia/mortalidad , Síndrome del Robo de la Subclavia/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular
15.
J Vasc Surg ; 73(2): 466-475.e3, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-32622076

RESUMEN

OBJECTIVE: Revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) maintains collateral circulation to decrease ischemic complications, including stroke, spinal cord ischemia, and upper extremity ischemia. Both open surgical and endovascular LSA revascularization techniques have been described, each with unique risks and benefits. We describe our "periscope sandwich" technique for the LSA during zone 2 TEVAR, which maintains antegrade access to the distal abdominal aorta if subsequent interventions are necessary. Technical results and short-term outcomes are compared with LSA open surgical debranching. METHODS: A single-institution retrospective review was performed for patients requiring zone 2 TEVAR with LSA revascularization by periscope sandwich technique or open surgical debranching with subclavian to carotid transposition (SCT) or carotid-subclavian bypass (CSB). The presenting aortic disease and perioperative details were recorded. Intraoperative angiography and postoperative computed tomography images were reviewed for occurrence of endoleak and branch patency. RESULTS: Between January 2013 and December 2018, the LSA was revascularized by periscope sandwich in 18 patients, SCT in 22 patients, and CSB in 13 patients. Compared with open surgical debranching, periscope sandwich had a lower median estimated blood loss (100 mL vs 200 mL for pooled SCT and CSB; P = .03) and lower median case duration (133.5 minutes vs 226 minutes; P < .001). Contrast material volume (120 mL vs 120 mL; P = .98) and fluoroscopy time (13.1 minutes vs 13.3 minutes; P = .92) did not differ significantly between the groups. There was no difference in aorta-related mortality (P = .14), and LSA patency was 100%. Median follow-up for the periscope sandwich group was 11 months, with an overall estimated 91% freedom from gutter leak at 6 months. CONCLUSIONS: LSA periscope sandwich technique provides safe and effective LSA revascularization during zone 2 TEVAR. LSA periscope sandwich can be used emergently with off-the-shelf endovascular components and facilitates future branched-fenestrated endovascular repair of thoracoabdominal aortic diseases.


Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Arteria Subclavia/cirugía , Úlcera/cirugía , Anciano , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Disección Aórtica/fisiopatología , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/fisiopatología , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Aneurisma de la Aorta Torácica/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Oclusión de Injerto Vascular/etiología , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Stents , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Úlcera/diagnóstico por imagen , Úlcera/mortalidad , Úlcera/fisiopatología , Grado de Desobstrucción Vascular
16.
BMC Cardiovasc Disord ; 20(1): 376, 2020 08 17.
Artículo en Inglés | MEDLINE | ID: mdl-32807103

RESUMEN

BACKGROUND: A subclavian-superior vena cava arteriovenous fistula is usually acquired and secondary to trauma or operations, while congenital causes are very rare. A congenital arteriovenous fistula leads to congestive heart failure soon after birth and is typically diagnosed in early infancy. CASE PRESENTATION: We present an unusual case of a 21-year-old female suffering from new-onset heart failure at 20 years old who was diagnosed with a congenital arteriovenous fistula from the right subclavian artery to the superior vena cava (RSA-to-SVC) with stenosis at the proximal initial site of the fistula. The patient successfully underwent transcatheter occlusion for the fistula and had a significant improvement in symptoms at the 3-month follow-up. CONCLUSIONS: An RSA-to-SVC fistula is a very rare congenital disorder that can lead to shunt-related heart failure. If there is an indication for closure, as with the patient presented, percutaneous device closure can be considered a reasonable option.


Asunto(s)
Fístula Arteriovenosa/complicaciones , Insuficiencia Cardíaca/etiología , Arteria Subclavia/anomalías , Vena Cava Superior/anomalías , Fístula Arteriovenosa/diagnóstico por imagen , Fístula Arteriovenosa/fisiopatología , Fístula Arteriovenosa/terapia , Cateterismo Cardíaco/instrumentación , Constricción Patológica , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/fisiopatología , Humanos , Recuperación de la Función , Dispositivo Oclusor Septal , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Resultado del Tratamiento , Vena Cava Superior/diagnóstico por imagen , Vena Cava Superior/fisiopatología , Adulto Joven
17.
Vasc Endovascular Surg ; 54(7): 586-591, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-32700643

RESUMEN

OBJECTIVES: Left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) remains controversial. Left subclavian artery coverage without revascularization can cause stroke and death. TEVAR has gained popularity for the treatment of chronic type B aortic dissection (cTBD). Using the Vascular Quality Initiative (VQI) database, we reviewed outcomes of LSA revascularization in TEVAR for cTBD. METHODS: The VQI registry identified 5683 patients treated with TEVAR from July 2010 to July 2016, including 208 repairs for cTBD. We analyzed outcomes per the Society for Vascular Surgery reporting standards. RESULTS: Of the 208 patients, 150 (72.1%) were male with a median age of 65.0 years (interquartile range [IQR], 55.0-72.0). Median aneurysm diameter was 5.7 cm (IQR, 5.0-6.5 cm). Data on the patency of the LSA was available in 131 (63.0%) patients. Twenty-five (19.1%) had occlusion of the LSA without revascularization, while 106 (80.9%) maintained patency or had revascularization. Successful device delivery occurred in all 131 (100%) patients. Maintaining LSA patency did not affect the rate of cerebrovascular accident (P = .16), spinal cord ischemia (P = 1.00), or death (P = 1.00). This was also nonsignificant when analyzing the subgroup of 98 elective cases. There was no difference in the rates of endoleak. Any intervention for the LSA (revascularization or occlusion) led to a longer procedure time (203.6 minutes vs 163.7 minutes, P = .04). CONCLUSIONS: Maintaining LSA patency during TEVAR for cTBD offers no advantage in perioperative morbidity or endoleak. Occlusion of LSA may be performed safely in this cohort and revascularization reserved for those who have anatomy that compromises perfusion to critical organs.


Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Arteria Subclavia/cirugía , Anciano , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/fisiopatología , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/fisiopatología , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Enfermedad Crónica , Bases de Datos Factuales , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular
19.
J Endovasc Ther ; 27(5): 769-776, 2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32436807

RESUMEN

Purpose: To evaluate the perioperative stroke incidence following thoracic endovascular aortic repair (TEVAR) with differing left subclavian artery (LSA) coverage and revascularization approaches in a real-world setting of a nationwide clinical registry. Materials and Methods: The National Surgical Quality Improvement Program registry was interrogated from 2005 to 2017 to identify all nonemergent TEVAR and/or open LSA revascularization procedures. In this time frame, 2346 TEVAR cases met the selection criteria for analysis. The 30-day stroke incidence was compared between patients undergoing TEVAR with (n=888) vs without (n=1458) LSA coverage, for those with (n=228) vs without (n=660) concomitant LSA revascularization among those with coverage, and following isolated LSA revascularization for occlusive disease (n=768). Multivariable logistic regression was employed for risk-adjusted analyses and to identify factors associated with stroke following TEVAR. Results of the regression analyses are presented as the adjusted odds ratio (OR) with 95% confidence interval (CI). Results: The stroke incidence was 2.3% following TEVAR without vs 5.2% with LSA coverage (p<0.001). In TEVARs with LSA coverage, the stroke incidence was 7.5% when the LSA was concomitantly revascularized and 4.4% without concomitant revascularization, while stroke occurred in 0.5% of isolated LSA revascularizations. Of 33 TEVAR patients experiencing a perioperative stroke, 8 (24%) died within 30 days. LSA coverage was associated with stroke both with concomitant revascularization (OR 4.0, 95% CI 2.2 to 7.5, p<0.001) and without concomitant revascularization (OR 2.2, 95% CI 1.3 to 3.8, p=0.002). Other preoperative factors associated with stroke were dyspnea (OR 1.8, 95% CI 1.1 to 3.0, p=0.014), renal dysfunction (OR 2.2, 95% CI 1.0 to 3.8, p=0.049), and international normalized ratio ≥2.0 (OR 3.6, 95% CI 1.0 to 13, p=0.045). Conclusion: Stroke following TEVAR with LSA coverage occurs frequently in the real-world setting, and concurrent LSA revascularization was not associated with a lower stroke incidence.


Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Diseño de Prótesis , Accidente Cerebrovascular/epidemiología , Arteria Subclavia/cirugía , Anciano , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Aneurisma de la Aorta Torácica/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Stents , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiología
20.
Ann Vasc Surg ; 67: 566.e11-566.e15, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-32335248

RESUMEN

The endovascular repair of subclavian aneurysms or pseudoaneurysms is now widely adopted. However, controversies still prevail in the management of dominant vertebral arteries originating close to aneurysms, as coverage of the vertebral artery might be complicated by either endoleaks or ischemic events. Here, we present a rare case of multiple aneurysmal lesions involving the right subclavian artery and bilateral internal carotid arteries treated by way of a total endovascular method using parallel stent grafts for the simultaneous exclusion of a subclavian artery pseudoaneurysm and flow preservation of the adjacent vertebral artery. To the best of our knowledge, this is the first study to report the use of this technique for the endovascular repair of juxta-vertebral subclavian artery pseudoaneurysms.


Asunto(s)
Aneurisma Falso/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Stents , Arteria Subclavia/cirugía , Arteria Vertebral/cirugía , Adulto , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/fisiopatología , Humanos , Masculino , Diseño de Prótesis , Flujo Sanguíneo Regional , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Resultado del Tratamiento , Arteria Vertebral/diagnóstico por imagen , Arteria Vertebral/fisiopatología
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