Contemporary relevancy of carotid-subclavian bypass defined by an experience spanning five decades.

BACKGROUND: The contemporary impact of and indications for carotid-subclavian bypass (CSB) are essential considerations in decision making for brachiocephalic reconstruction. METHODS: We analyzed operative outcomes, long-term graft patency, and the extended epidemiological impact of the primary disease process in 287 consecutive patients (mean age, 60.6 years; 43.2% male) who received CSB for symptomatic brachiocephalic disease. RESULTS: Technical success was achieved in each patient. Operative mortality was 1.0% (3/287) and total (ipsilateral [1.4%, 4/287] plus contralateral [0.7%, 2/287]) stroke rate was 2.1% (6/287). Primary patency rates at 5, 10, and 15 years were 94.2 ± 1.9%, 88.6 ± 3.2%, and 86.5 ± 3.8%, respectively. Kaplan-Meier freedom from specific events at 15 years was as follows: restenosis, 86.5 ± 3.8%; death, 67.5 ± 5.2%; coronary revascularization, 59.6 ± 6.3%; myocardial infarction, 82.8 ± 3.9%; stroke, 85.6 ± 4.9%; other vascular procedure, 60.0 ± 5.5%; adverse cardiac outcome (death, myocardial infarction, or coronary revascularization), 44.5 ± 5.5%; and adverse vascular outcome (restenosis, stroke, or other vascular procedure), 48.7 ± 5.3%. CONCLUSIONS: CSB produces excellent long-term patency and extended symptom relief, with acceptably low operative morbidity and mortality. Despite the durability and success of CSB, the primary disease process has an adverse impact on long-term prognosis and significantly influences decision making with regard to management. The proven durability may offer extended symptom relief to the relatively younger patient, a survival advantage associated with preservation of internal mammary artery perfusion in patients at risk for myocardial revascularization, optimal durability in patients requiring a concomitant open procedure, and preservation of limb function in patients who require aortic endovascular graft placement.

Ovarian vein and caval thrombosis.

We present an illustrative case of postpartum ovarian vein thrombosis and describe its clinical presentation, differential diagnosis, and management. This pathologic process may produce clinical complications or a catastrophic outcome. These adverse events may be avoided if an expeditious diagnosis is made and appropriate treatment is instituted. This mandates a high index of suspicion, the ability to rule out the presence of other processes that may produce similar symptoms in the postpartum patient, and the appropriate triage of specific patients to either medical or surgical management.

Aortic pseudoaneurysm.

Reoperative aortic surgery is a therapeutic challenge. We examine a case of reoperative aortic surgery involving a pseudoaneurysm that occurred after surgical treatment of an abdominal aneurysm. A systematic approach to diagnosis, followed by treatment tailored to diagnostic findings, can minimize morbidity.

Posttransplant off-pump coronary bypass and laser revascularization in a Jehovah's Witness.

A 57-year-old man, who had received a heart transplant 14 years earlier, underwent coronary artery bypass grafting and transmyocardial laser revascularization for left main, left anterior descending, and circumflex coronary artery disease. The procedures were performed through a left thoracotomy incision without cardiopulmonary bypass. Because the patient was of the Jehovah's Witness faith, no blood or blood products were transfused.

Left ventricular assist device implantation in a patient with congenitally corrected transposition of the great arteries.

Congenitally corrected transposition of the great arteries (ccTGA) is a rare anomaly characterized by atrioventricular and ventriculo-arterial discordance and several other malformations that eventually lead to heart failure. We describe the case of a 53-year-old woman with ccTGA and aortic insufficiency who was a candidate for heart transplantation due to end-stage congestive heart failure. Her condition deteriorated before a suitable donor heart could be found; therefore, we placed a left ventricular assist device in the right (systemic) ventricle. Concomitantly, we removed the aortic (systemic) valve, closed the aortic annulus with a bovine pericardial patch, and repaired the mitral valve. The patient recovered uneventfully and was discharged from the hospital 2 months postoperatively. She underwent cardiac transplantation approximately 6 months later and continued to do well after 18 months.

Deployment of proximal thoracic endograft in zone 0 of the ascending aorta: treatment options and early outcomes for aortic arch aneurysms in a high-risk population.

OBJECTIVES: Open repair of aortic arch aneurysms can be technically challenging. Hybrid approaches have been developed to facilitate arch repairs and improve their clinical outcomes in high-risk patients. We examined treatment options and early outcomes in patients whose thoracic endografts were deployed to include Zone 0. METHODS: Between 2005 and 2011, a hybrid approach in which the endograft was deployed in the ascending aorta was used in 29 patients (median age 67 years, range 32-85 years). The indication for surgery was saccular arch aneurysm in 11 patients (37.9%), fusiform arch aneurysm with or without involvement of the proximal descending aorta in 10 (34.5%), proximal Type I endoleak after endovascular repair of the descending aorta in 5 (17.2%), chronic Type III (Type B) aortic dissection with aneurysmal arch formation in 2 (6.9%) and acute Type I (Type A) dissection with prior repair of an extent I thoracoabdominal aneurysm in 1 (3.4%). Six patients (20.7%) had previously undergone a sternotomy. One-, two- or three-branch aortobrachiocephalic de-branching, with or without concomitant heart surgery, was performed in 28 patients and extra-anatomic bypass in 1. RESULTS: Two patients (6.9%) died during postoperative hospitalization. Overall survival during the follow-up period (median 411 days) was 79.3%. Five neurological events occurred: one extensive stroke, two minor strokes (10.3%) and two episodes of paraparesis (6.9%), one with partial recovery and one with full recovery. CONCLUSIONS: The hybrid approach enables the treatment of aortic arch disease in high-risk individuals. Long-term follow-up data are needed.

Aortic valve regurgitation that resolved after a ruptured coronary sinus aneurysm was patched.

Sinus of Valsalva aneurysms appear to be rare. They occur most frequently in the right sinus of Valsalva (52%) and the noncoronary sinus (33%). More of these aneurysms originate from the right coronary cusp than from the noncoronary cusp. Surgical intervention is usually recommended when symptoms become evident. We report the case of a 34-year-old woman who presented with a congenital, ruptured sinus of Valsalva aneurysm that originated from the noncoronary cusp. Moderate aortic regurgitation was associated with this lesion. Simple, direct patch closure of the ruptured aneurysm resolved the patient's left-to-right shunt and was associated with decreased aortic regurgitation to a degree that valve replacement was not necessary. Only trace residual aortic regurgitation was evident after 3 months, and the patient remained free of symptoms after 6 months. Our observations support the idea that substantial runoff blood flow in the immediate supra-annular region can be responsible for aortic regurgitation in the absence of a notable structural defect in the aortic valve, and that restoring physiologic flow in this region and equalizing aortic-cusp closure pressure can largely or completely resolve aortic insufficiency. Accordingly, valve replacement may not be necessary in all cases of ruptured sinus of Valsalva aneurysms with associated aortic valve regurgitation.

Brachiocephalic reconstruction I: operative and long-term results for complex disease.

OBJECTIVES: Complex brachiocephalic disease involves multiple vessels and is frequently associated with multisystem atherosclerosis. We reviewed surgical outcome and examined the impact of this problem on decision making regarding operative staging, technique, and choice of conduit. METHODS: Between 1966 and 2000, 157 consecutive patients (mean age, 54.0 years; 48.4% male) with innominate artery or multivessel brachiocephalic disease underwent operative reconstruction using either a transthoracic approach (group A, n = 113) or a less invasive, extrathoracic approach (group B, n = 44). Reconstruction required multiple distal anastomoses in 70 patients (44.6%), concomitant coronary artery bypass grafting (CABG) in 37 patients (23.6%), and concomitant carotid endarterectomy (CEA) in 26 patients (16.6%). RESULTS: No significant differences were found between group A and group B when operative mortality (2.7% vs 2.3%) and stroke rates (2.7% vs 6.8%) were analyzed. However, 10 years after surgery, freedom from graft failure was significantly better in group A (94.4% +/- 4.4%) than in group B (60.3% +/- 13.4%) ( P = .002). Freedom from graft failure was adversely affected by nonaortic inflow ( P = .002) and axillo-axillary cervical grafts ( P = .0001). Mortality and stroke rates for subgroups having multiple distal anastomoses (2.9%, 2/70 and 4.3%, 3/70), concomitant CABG (5.4%, 2/37 and 0, 0/37), and concomitant CEA (3.8%, 1/26 and 3.8%, 1/26) were similar to those of other patients. For the entire patient group, 10-year rates of actuarial freedom from specific events were death, 68.8% +/- 6.0%; myocardial infarction, 86.7% +/- 4.5%; stroke, 87.0% +/- 4.4%; coronary revascularization, 88.0% +/- 3.6%, and other vascular operation, 79.9% +/- 4.4%. CONCLUSIONS: Transthoracic arch reconstruction for complex brachiocephalic disease can be done with acceptably low morbidity and mortality similar to those of a less invasive, extrathoracic approach. Furthermore, the transthoracic approach is associated with significantly better long-term freedom from graft failure, possibly because it preserves aortic inflow to the great vessels. Nonetheless, the high frequency of late events in this relatively young patient population reflects the presence of multisystem atherosclerosis and suggests the need for close follow-up and lifestyle modification.

Brachiocephalic reconstruction II: operative and endovascular management of single-vessel disease.

OBJECTIVE: Although the surgical management of brachiocephalic disease is well established, evolving endovascular techniques present new options for treatment. We explored the potential benefits and drawbacks of these interventions in terms of outcome. METHODS: From 1966 to 2004, 391 consecutive patients (43.7% male; mean age, 61.9 years) with single-vessel brachiocephalic disease were treated with either operative bypass (group A; n = 229) or percutaneous transluminal angioplasty and stenting (group B; n = 162). RESULTS: All patients were asymptomatic after surgery or endovascular intervention. Group A and group B had similar operative mortality (0.9% vs 0.6%) and stroke (1.3% vs 0%) rates. However, 5 years after the procedure, group A had significantly better freedom from graft or intervention failure (92.7% +/- 2.1%) than did group B (83.9% +/- 3.7%; P = .03, Kaplan-Meier analysis; P = .001, Cox regression analysis). At 10 years, group A had the following rates of actuarial freedom from specific events: death, 73.7% +/- 4.6%; myocardial infarction, 84.2% +/- 3.6%; stroke, 91.4% +/- 3.4%; graft failure, 88.1% +/- 3.3%; coronary revascularization, 69.8% +/- 5.1%; and other vascular operation, 70.7% +/- 4.6%. Endovascular intervention involved less initial cost (mean savings, $8787 per procedure), was less invasive, and did not necessitate general anesthesia. On satisfaction questionnaires, 96.5% of patients receiving an endovascular intervention and 95.1% of patients receiving operative bypass for single-vessel brachiocephalic disease subjectively rated their treatment as "good" or "very good." CONCLUSIONS: Operative bypass and endovascular intervention for single-vessel brachiocephalic disease are both associated with acceptably low operative morbidity and mortality. Operative bypass produces significantly better mid-term freedom from graft or intervention failure than endovascular intervention and produces excellent long-term freedom from failure. Endovascular intervention offers tangible benefits regarding cost, level of invasiveness, and subjective patient satisfaction. Undetermined are the differences between the procedures regarding long-term durability, patterns of failure, efficacy as an adjunct to coronary artery bypass grafting, need for anticoagulation, efficacy as treatment for complex (multivessel) disease, and long-term cost.

Concomitant brachiocephalic and coronary artery disease: outcome and decision analysis.

BACKGROUND: In patients with coronary artery disease, concomitant brachiocephalic disease may affect outcome and influence decision making regarding operative staging, technique, and choice of conduit. METHODS: Eighty consecutive patients (mean age, 59.3 years; 60.0% male) with concomitant brachiocephalic and coronary artery disease were identified either before (group A, n = 48) or after (group B, n = 32) coronary artery bypass grafting. Patients who had symptomatic brachiocephalic and coronary artery disease before surgery underwent concomitant brachiocephalic reconstruction and coronary artery bypass grafting using either all-vein coronary conduits (n = 41) or vein-and-internal mammary artery conduits (n = 7). Patients who had coronary-subclavian steal syndrome after coronary artery bypass (group B, n = 32) underwent either surgical (n = 5) or endovascular (n = 27) brachiocephalic reconstruction only. RESULTS: All patients were asymptomatic after intervention. Operative mortality was 4.2% for group A and 3.1% for group B. The perioperative stroke rate was 2.1% for group A and 0% for group B. Actuarial 10-year freedom from specific events for group A was as follows: death 59.9 +/- 12.8%, brachiocephalic restenosis 100%, coronary-subclavian steal syndrome 100%, myocardial infarction 83.5 +/- 10.5%, stroke 82.1 +/- 9.9%, redo coronary artery bypass grafting 95.8 +/- 4.1%, other vascular operation 82.2 +/- 8.9%, and adverse cardiac outcome (death, redo coronary artery bypass grafting, or myocardial infarction) 52.9% +/- 13.2% (for patients with all-vein conduits) or 100% (for patients with vein-and-internal mammary artery conduits). At midterm follow-up (mean, 2.92 years), both the surgical and the endovascular treatment subgroups of group B had 100% brachiocephalic patency. CONCLUSIONS: Long-term results in a limited population support continued evaluation of concomitant brachiocephalic reconstruction and coronary artery bypass grafting with use of the internal mammary artery conduit in an attempt to improve late survival in patients with concomitant disease. The excellent midterm brachiocephalic patency after either surgical or endovascular treatment of patients with coronary-subclavian steal syndrome supports continued evaluation of both methods.