Surgery of the innominate artery.

The authors describe their experience with the surgical treatment of 28 patients with obliteration or stenosis of the innominate artery. In 18 (64.3%) patients an intrathoracic operation was done and in three of these a multiple bypass from the aorta to the affected trunks was carried out. In the remaining 10 patients (35.7%) extrathoracic operations were carried out. Immediate results were good in 24 (85.7%) of cases. Thrombosis occurred in 3 during the first 30 days after operation. One patient suffered thrombosis of the bypass and following removal of this became comatose and subsequently died. Long term results were good inasmuch as at 5 years 94.8% of patients survived with a patent reconstruction. The clinical procedures reviewed as is the topography of associated lesions of the other supra-aortic trunks together with the different techniques employed and their indications. The authors express their preference for the technique of an end to side graft in the aorta and end to end in the innominate artery, when the distal portion of this artery is patent and the age and general state of the patient permits a thoracic approach. This technique assures revascularization of the right carotid and vertebral areas, apart from complying with optimal hemodynamic conditions.

[Diagnostic and therapeutic management of pseudo-occlusions of the carotid artery]. / Manejo diagnóstico y terapéutico de la pseudooclusién carotídea.

AIMS: The aim of this study was to evaluate the diagnostic attitude and the results obtained after surgery in cases of pseudo occlusions of the carotid artery. PATIENTS AND METHODS: Between 1995 and 2000, 13 cases of pseudo occlusion of the internal carotid artery were performed (3.06% of carotid surgery carried out). Diagnostic criteria were as follows. Echo Doppler: complete occlusion with its origin in the internal carotid artery, damped distal signal; arteriography: occlusion with its origin in the internal carotid artery, filiform distal part, string sign. Clinical presentation was: 53.84% cerebral infarction, 23.07% TIA and 23.07% were asymptomatic. The 13 patients were submitted to echo Doppler and nine were examined using arteriography. Two patients were operated on without arteriography because of unstable neurological clinical features. A surgical exploration was performed in 100% of the cases. RESULTS: In seven cases, revascularisation of the internal carotid artery was carried out (53.84%) and in six cases it was ligated (46.16%). Echographic monitoring (from 1 4 years, average 2 years) showed permeability in the seven revascularised cases; in one case restenosis was detected between 31 50% at 2 years follow up. In the clinical controls (from 2 months to 4 years, average 30 months), one patient who was not revascularised was seen to have symptoms of TIA at one year and two months. DISCUSSION: Since neither arteriography nor echo Doppler can predict when it will be possible to revascularise the internal carotid artery, and because we did not observe an increase in surgical morbidity mortality, we believe surgical exploration is useful. In our study 53.84% of the series were successfully revascularised.

Intraarterial urokinase for acute native arterial occlusion of the limbs.

Since 1988, 49 limbs of 47 patients underwent intraarterial urokinase infusion for acute native artery occlusion. The time from the onset of ischemic symptoms ranged from 1 to 45 days (mean = 17.5). The arterial sectors involved were femoropopliteal in 32 cases, followed by aortoiliac in 13 cases, distal in three cases, and subclavian in one case. Treatment consisted of placing a catheter in the clot and the infusion of 4400 U/kg in 20', followed by a series of 4400 U/kg weight/hour during 6 hours. Clinical evaluation, hemodynamic and coagulation parameters, and angiographical changes were assessed periodically. Infusion time ranged from 6 to 24 hours (mean = 13.2 hours). Improvement of ischemic was achieved in 43 (87.75%) patients. In five patients (12.25%) there was no improvement. Total immediate lysis was achieved in 35 cases (71.5%), and among them, 13 patients (26%) required no associated treatment, 16 (48%) underwent PTA, and four (12%) had surgery of underlying peripheral aneurysms revealed after thrombolysis. Partial lysis was achieved in 13 cases (26.5%), that was enough in four of them, but the remaining nine required further treatment (four PTA, and five arterial surgery). In one case no lysis was achieved, and arterial surgery was carried out. No mortality was recorded, and major complications included one upper gastrointestinal bleeding, and one cerebral hematoma. Late follow-up of successfully treated patients who did not require further surgery shows a cumulative patency rate of 81% at 24 months.