Prosthetic versus native artery inflow for infrainguinal bypass.

BACKGROUND: Infrainguinal bypass performed after previous prosthetic inflow reconstruction offers a choice of where to perform the proximal anastomosis. The hood of a previous inflow bypass might be technically easier to isolate during reoperative surgery. However, the more distal native artery might offer better patency to the outflow revascularization. The purpose of the present study was to compare the outcomes of infrainguinal bypass using the hood of a previous inflow bypass vs the native artery as the inflow source. METHODS: A single vascular group's database was queried for all cases of infrainguinal bypass performed after previous prosthetic inflow bypass to a femoral artery from January 2006 to December 2016. The demographics, indications, operative details, and long-term results were recorded and analyzed. Two groups were compared stratified by the location of the proximal anastomosis for the distal bypass. In one group, the inflow source for the distal bypass was from the hood of a previous inflow graft (prosthetic). In the second group, the distal native arterial tree was used as the inflow source. A subset analysis of the patency of the distal bypass was also performed between the two groups for those in which the previous inflow reconstruction had become occluded. Patency was calculated using the Kaplan-Meier method. RESULTS: A total of 197 patients had undergone infrainguinal bypass after previous inflow bypass from 2006 to 2016. Of the 197 procedures, 59 (30%) had used the hood of the previous bypass as the inflow source (prosthetic group) and 138 (70%) had used the native artery distal to the hood of the inflow bypass as the inflow source (native group). The indications were similar between the two groups. The two groups had a similar proportion of men and a similar incidence of hypertension, hyperlipidemia, coronary artery disease, tobacco use, and renal disease. The previous inflow procedures were also similar between the two groups. The native artery used for the inflow source in the native group was the profunda femoris in 80 (58%), common femoral artery in 51 (37%), and superficial femoral artery in 7 (5.1%). Patency was significantly greater for the native group at 1 year (91% vs 75%; P = .0221). Also, the patency after inflow bypass occlusion significantly favored the native group at 1 year (87% vs 40%; P = .0035). CONCLUSIONS: Infrainguinal bypass performed after previous ipsilateral inflow bypass offers the option of using the hood of the bypass or a native artery as the inflow source. The present study demonstrated greater patency rates when using the distal native artery as the inflow source. The native artery option also offered continued patency when the inflow bypass occluded.

Chimney stent graft for left subclavian artery preservation during thoracic endograft placement.

OBJECTIVE: Carotid to subclavian artery bypass (CSB) has been the standard for revascularizing the left subclavian artery during coverage by thoracic endovascular aortic repair (TEVAR). The purpose of this study is to determine if a chimney stent graft (CSG) offers similar outcomes as an alternative to open bypass. METHODS: A retrospective review of a single vascular surgery registry between February 2011 and September 2017 was performed of all left subclavian revascularization during elective TEVAR. Arch reconstructions involving more than just the left subclavian artery were excluded. Indications, demographics, procedural details, and outcomes were analyzed using standard statistical analysis. RESULTS: Eighty-one patients with a mean age of 68 years (range, 32-87 years) had left subclavian revascularization (64 [79%] CSB vs 17 [21%] CSG) during TEVAR. Median follow-up for CSG was 8 months (range, 0-52 months) and for CSB was 14.5 months (range, 3-72). Demographics between the groups were similar except for more males in both groups (43 [67%] in CSB vs 10 [59%] in CSG; P = .28). The CSB group had significantly more aneurysms than dissections compared with CSG (45 [70%] vs 6 [35%]; P = .008). There were no perioperative occlusions or ischemic issues for either group in the perioperative period. Postoperative hematoma rates trended higher in the CSB (7.11% vs 1.6%; P = .53) with three (4.6%) of the CSB requiring evacuation of hematoma. Left hemispheric strokes were 6% in the CSB with none occurring in the CSG group. Perioperatively, the CSB group had one recurrent laryngeal nerve and one graft infection. Length of stay was similar in both groups (CSB, 8.4 days vs CSG, 9.1 days). Perioperative mortality was not statistically significant between both groups with two deaths (3%) in the CSB and none in the CSG group. No gutter leaks were identified on follow-up computed tomography scan during long-term follow-up. Patency rates were similar with only one occlusion in the CSB group at 23 months. CONCLUSIONS: Left common carotid to subclavian artery bypass has been the standard for revascularization of the left subclavian artery during coverage by TEVAR. Chimney stent grafting to perfuse the left arm appears to offer equivalent results as a minimally invasive alternative.

Outcomes for carotid endarterectomy in nonagenarians.

OBJECTIVE: Carotid endarterectomy (CEA) is a well-established procedure with prospective randomized data demonstrating the benefit of stroke prevention. With the aging of the population, there are limited data published for nonagenarians, especially for asymptomatic stenosis. This study investigated 30-day morbidity and mortality as well as late survival in symptomatic and asymptomatic nonagenarians with severe carotid stenosis undergoing CEA. METHODS: A retrospective review was conducted of a single vascular surgery group's registry involving multiple hospitals between November 1994 and June 2017 for all primary CEAs of patients ≥90 years old at the time of surgery. The exclusion criterion was redo surgery or bilateral CEAs. Demographic data, sex, symptoms, risk factors, and postoperative complications were analyzed. Survival analysis was conducted using SPSS software (IBM Corp, Armonk, NY) for the specific end point 30-day morbidity or mortality and late survival. RESULTS: There were 77 patients (44 male [57%]) who underwent CEA for symptomatic (44 [57%]) and asymptomatic (33 [43%]) internal carotid artery stenosis with a median age of 92 years; 23 women were symptomatic compared with 21 men, and 23 men were asymptomatic compared with 10 women. Symptomatic patients included amaurosis fugax (n = 3), stroke (n = 16), and transient ischemic attack (n = 25). CEAs were performed using the eversion technique under cervical block with selective shunting. The 30-day morbidity included one (2.3%) nonfatal myocardial infarction and one (2.3%) ischemic stroke in the symptomatic group compared with one (3%) patient having a nonfatal myocardial infarction and none with ischemic stroke in the asymptomatic group. One patient of the symptomatic group required return to the operating room for hematoma evacuation. The 30-day mortality was 2.3% in the symptomatic group compared with 6.1% in the asymptomatic group. There was no statistical difference in survival based on sex (P = .444). The symptomatic and asymptomatic groups had similar median survival of 27.7 months and 29.4 months (P = .987), respectively. CONCLUSIONS: The aging population adds increasing difficulty in decision-making for surgical intervention on carotid stenosis. CEA in nonagenarians is associated with reasonably low 30-day rates of ischemic stroke and myocardial infarction in our small study. However, enthusiasm for asymptomatic CEA in this population must be tempered by low survival rates.

Targeted treatments for symptom domains in child and adolescent autism.

CONTEXT: The number of people with autism spectrum disorders has dramatically increased over the past decade, and problem behaviours in autism are an increasing challenge to families, schools, physicians, and other health-care professionals. Pharmacological treatments can effectively target problem behaviours associated with autism. STARTING POINT: Recently, L Namerow and colleagues (J Dev Behav Pediatr 2003; 24: 104-08) presented preliminary data in children and adolescents with autism treated with citalopram, which suggested that selective serotonin-reuptake inhibitors are useful in the reduction of symptom domains such as repetitive behaviours and mood disorders. J McCracken and colleagues (N Engl J Med 2000; 347: 314-21) showed that the atypical antipsychotic risperidone reduced serious behavioural problems, such as tantrums, aggression, or self-injury in children with autism and in children with below-average intelligence quotients. These and other studies show how developments in study design, selection of patients, and outcome measures have allowed treatment trials in autism to progress beyond anecdotal reports and case observations, and show reduction in the severity of specific symptom domains within these disorders. WHERE NEXT? In therapeutic intervention the risk of treatment toxicity must be balanced against the benefits of improved symptom severity. The newer methods enable informed decisions about which patients will benefit from which treatments. Other symptom domains within autism and effects on development need to be evaluated in adequately designed clinical trials. Future strategies include extending treatment to children as young as the preschool years.