RESUMO
This review examines current evidence regarding management of patients with both coronary and carotid artery disease. It highlights the elevated stroke risk after surgery for this cohort and scrutinizes approaches to minimize this risk. Various revascularization methods are outlined, including carotid endarterectomy (CEA), carotid artery stenting (CAS), and staged versus simultaneous surgical approaches. The importance of judiciously screening coronary artery bypass grafting (CABG) candidates for carotid stenosis is emphasized, suggesting risk factor-based targeted screening is non-inferior to indiscriminate screening. Efficacy comparisons are made between revascularization strategies such as staged versus synchronous CEA/CABG, CAS, and off-pump CABG techniques. Controversies surrounding necessity and optimal timing of carotid revascularization in asymptomatic patients are addressed, indicating a need for rigorous randomized controlled trials to establish definitive treatment algorithms.
RESUMO
A 65-year-old woman had presented with a ruptured type B intramural hematoma associated with a right-sided aortic arch aneurysm, a large Kommerell diverticulum (KD) and an aberrant left subclavian artery (LSA). She underwent total aortic arch replacement with elephant trunk, thoracic endovascular aortic repair, and LSA ligation distal to the left vertebral artery. She subsequently developed a brisk type II endoleak into the KD via retrograde flow from the left vertebral artery. Percutaneous access of the left internal mammary artery with coil embolization of the proximal LSA and KD was performed. At 5 years, computed tomography angiogram showed complete thoracic aortic remodeling without an endoleak. The results from the present case have illustrated the novel use of the left internal mammary artery as an alternative access for LSA embolization in patients with type II endoleak and limited access options.