Successful retinal blood flow augmentation after extracranial-intracranial bypass

A 61-year-old woman visited us with recent onset right-side weakness. Magnetic resonance imaging showed ischemic changes at the left internal border zone due to occlusive disease affecting the left proximal internal carotid artery. Prompt oral dual antiplatelet therapy and intravenous fluid were administered with subsequent induced hypertension and without reperfusion therapy. Although the hemiparesis was improved, she complained of a new-onset transient left-side monocular visual loss. Fluorescein angiography confirmed delayed perfusion in the left eye. We performed extracranial-intracranial bypass for flow augmentation. After bypass, the amaurosis fugax resolved. Follow-up retinal fluorescein angiography also showed improved retinal perfusion.

[Immediate and remote results of surgical treatment of patients presenting with pathological tortuosity of internal carotid arteries and accompanying ocular ischaemic syndrome]

The article deals with the data concerning the efficacy of reconstructive operations and conservative treatment in patients presenting with pathological tortuosity of internal carotid arteries. The study included a total of 63 patients. The diagnostic algorithm was as follows: studying the haemodynamics of the internal carotid arteries, assessing the neurological status, and the methods of examining the eye. The patients were subdivided into two groups: Group One consisted of operated on patients (n=37) and Group Two comprising patients treated conservatively (n=26). The patients according to the neurological status were subdivided as follows: an asymptomatic course in 25 (39.7%) patients, transitory ischaemic attacks in 18 (28.6%) patients, dyscirculatory encephalopathy in 12 (19 %) patients, and stroke in 8 (12.7%) patients. Ophthalmological symptomatology was predominantly manifested by fits of amaurosis fugax in 19 (30.2%) patients and processes of maculodystrophy in 49 (77.8 %) patients. We assessed the immediate (day 30) and remote (1 year) results of conservative and surgical treatment. Group One patients demonstrated cessation of the amaurosis fugax attacks, improvement of the acuity of vision by 0.1 and more, enlargement of the borders of the field of vision, disappearance of scotomas, as well as arrest of the processes of maculodystrophy. Patients with transitory ischaemic attacks and dyscirculatory encephalopathy changed to the category of asymptomatic patients. In Group Two patients the dynamics of the neurological status was negative and the patients continued to experience fits of amaurosis fugas. The dynamics of the opthalmological symptomatology was weakly pronounced.

Sirolimus-Eluting Stenting of the External Carotid Artery for the Treatment of Ocular Ischemia

PURPOSE

To present a patient in whom severe external carotid artery (ECA) stenosis causing ocular ischemia was treated with a drug-eluting stent.

CASE REPORT

A 55-year-old woman with severe, diffuse atherosclerosis presented with impaired left ocular perfusion and amaurosis fugax. Duplex ultrasonography and angiography documented bilateral occlusion at the origin of the internal carotid arteries, bilateral subtotal ECA stenoses, and subtotal distal left common carotid artery (CCA) restenosis following endarterectomy. Percutaneous revascularization of the left ECA and CCA stenoses was performed using a short coronary balloon-expandable sirolimus-eluting stent and a self-expanding nitinol stent, respectively. The procedure was uneventful, and the ocular symptoms resolved. At 6 months, the patient remained asymptomatic, with angiographically patent stents.

CONCLUSION

Drug-eluting stenting may be a novel option to treat symptomatic ECA stenosis.

Selective shunting during carotid endarterectomy

Carotid endarterectomy (CEA) is an effective treatment for significant carotid atherosclerosis. Perioperative stroke, a devastating complication, may be partially circumvented by shunting. However, routine shunt use is not without complications and does not benefit every patient. Our study is designed to determine whether CEA under general anesthesia, without cerebral monitoring, can be safely done with shunting only in the presence of poor internal carotid artery back-bleeding or contralateral carotid occlusion or critical stenosis. The medical records of 995 carotid operations were reviewed. A subset of 117 operations was performed on 112 patients using selective shunting. Data were analyzed and outcomes compared. For the selective shunt group, indications for redo operations (n=13) were recurrent asymptomatic high-grade stenosis in 69% and amaurosis fugax or transient ischemic attack in 31%. Indications for primary CEA (n=104) were asymptomatic high-grade stenosis in 59%, amaurosis fugax or transient ischemic attack in 36%, previous stroke in 3%, and global ischemia in 2%. A selective shunt was used in 29% of all symptomatic and 11% of all asymptomatic patients. No cerebral monitoring was used. There were no perioperative deaths and no permanent cranial nerve injuries, and there was one stroke (0.8%) from postoperative carotid thrombosis in a shunted patient. The average length of stay was 1.6 days for the non-shunt group and 2.2 days for the shunt group. The routine shunt group (n=878) had an overall stroke rate of 0.7%, no permanent cranial nerve deficits, and a mean hospital stay of 2.6 days. CEA under general anesthesia with selective shunting can be performed safely without cerebral monitoring.

Reoperation for recurrent carotid stenosis: early results and late outcome in 199 patients

PURPOSE

This study was undertaken to determine the safety and efficacy of reoperations for recurrent carotid stenosis (REDOCEA) at the Cleveland Clinic.

MATERIALS AND METHODS

From 1989 to 1999, 206 consecutive REDOCEAs were performed in 199 patients (131 men, 68 women) with a mean age of 68 years (median, 69 years; range, 47-86 years). A total of 119 procedures (57%) were performed for severe asymptomatic stenosis, 55 (27%) for hemispheric transient ischemic attacks or amaurosis fugax, 26 (13%) for prior stroke, and 6 (3%) for vertebrobasilar symptoms. Eleven REDOCEAs (5%) were combined with myocardial revascularization, and another 19 (9%) represented multiple carotid reoperations (17 second reoperations and 2 third reoperations). Three REDOCEAs (1%) were closed primarily, and nine (4%) required interposition grafts, whereas the remaining 194 (95%) were repaired with either vein patch angioplasty (139 [68%]) or synthetic patches (55 [27%]). Three patients (2%) were lost to follow-up, but late information was available for 196 patients (203 operations) at a mean interval of 4.3 years (median, 3.9 years; maximum, 10.2 years).

RESULTS

Considering all 206 procedures, there were 7 early (< 30 days) postoperative neurologic events (3.4%), including 6 perioperative strokes (2.9%) and 1 occipital hemorrhage (0.5%) on the 12th postoperative day. Seventeen additional neurologic events occurred during the late follow-up period, consisting of eight strokes (3.9%) and nine transient ischemic attacks (4.4 %). With the Kaplan-Meier method, the estimated 5-year freedom from stroke was 92% (95% CI, 88%-96%). There were two early postoperative deaths (1%), both from cardiac complications after REDOCEAs combined with myocardial revascularization procedures. With the Kaplan-Meier method, the estimated 5-year survival was 81% (range, 75%-88%). A univariate Cox regression model yielded the presence of coronary artery disease as the only variable that was significantly associated with survival (P =.024). The presence of pulmonary disease (P =.036), diabetes (P =.01), and advancing age (P =.006) was found to be significantly associated with stroke after REDOCEA. Causes of 53 late deaths were cardiovascular problems in 25 patients (47%), unknown in 14 (26%), renal failure in 4 (8%), stroke in 3 (6%), and miscellaneous in 7 (13%).

CONCLUSIONS

We conclude that REDOCEA may be safely performed in selected patients with recurrent carotid stenosis and that most of these patients enjoy long-term freedom from stroke.

Double-layer everted saphenous vein patch angioplasty for carotid endarterectomy

Saphenous vein patch angioplasty is the preferred method of closure of the arteriotomy site during carotid endarterectomies. A major early complication of the saphenous vein patch is rupture of the patch which can occur within the first few postoperative days. The reported incidence varies from 0.5% to 4%. Patch rupture can result in stroke or death. From May 1992 to April 1999, autogenous everted double-layer saphenous vein patch was used in 192 carotid endarterectomies performed on 168 patients; 96 males and 72 females. The age range was from 54 to 94 years with a mean age of 73 years. The saphenous vein is harvested from the ankle. It is everted and then used as a double-layer patch. The follow-up period was from 3 to 74 months, with a mean of 24 months. Postoperatively, there were no patch ruptures or late aneurysm formation. There was no perioperative mortality. Everted double-layer saphenous vein patch eliminates the risk of patch rupture and at the same time retains the benefits of an autologous nonprosthetic graft. Saphenous vein from the ankle can be safely used for carotid angioplasty as a double layer patch.

[Acute glaucoma following endarterectomy of internal carotid artery]

A 71 year-old woman had 85% and 60% stenoses of the right and left internal carotid arteries, respectively. Right-sided endarterectomy was performed because of amaurosis fugax. Two days postoperatively, she developed classical symptoms and signs of acute glaucoma. Right-sided acute angle closure glaucoma was diagnosed by tonometry and gonioscopy, and treated with laser-iridectomy. The patient was discharged two days later without neurological or ophthalmological deficits. Manifest acute glaucoma postoperatively seems never to have been reported. However, the choroid is not autoregulated, and the intraocular pressure has been reported to increase after internal carotid-endarterectomy.

[Multidisciplinary cooperation behind a quality registry for carotid surgery. Good coverage during the first two years]

Carotid surgery prevents recurrent stroke in patients with symptomatic tight stenosis of the carotid artery. The Swedish Carotid Surgery Monitoring Registry seeks to promote selection of patients with significant spontaneous risk for recurrent stroke, with an eye toward expediting evaluation and minimizing surgical complications. To this end, professionals at participating hospitals are informed about their own patient selection and surgery risk in comparison with those in the country as a whole and with set targets. We report the results from the first two years, during which it is estimated that more than half of all patients eligible for carotid surgery in Sweden were included in the registry. Although almost all patients had recent onset of relevant neurological symptoms, less than 60% had a documented tight (80-99% occlusion) stenosis. While the final decision to operate a patient was made within 4 weeks of onset of symptoms for only 18% of the patients the first year, this proportion increased to 33% in the following year. The total incidence of surgery related stroke, myocardial infarct and death was 7.7%, while the incidence of severe stroke, myocardial infarct and death was 3.0%.

Axillary-to-carotid artery bypass grafting for symptomatic severe common carotid artery occlusive disease

PURPOSE

Revascularization of the internal or external carotid arteries is occasionally indicated for symptomatic atherosclerotic common carotid artery occlusion or long-segment high-grade stenosis beginning at its origin. I report the outcome of axillary artery-based bypass grafts to the distal common, internal, or external carotid arteries.

METHODS

Between 1981 and 1997, 29 axillary-to-carotid bypass grafting procedures were performed on 28 patients, 15 men and 13 women, with a mean age of 68 years. Indications were transient ischemia in nine patients, amaurosis fugax in four patients, completed stroke in six patients, and nonlateralizing global ischemia in nine patients. Twenty-three common carotid arteries were totally occluded, and six had long-segment stenosis of 90% or greater beginning at the origin. Saphenous vein grafts were used in 25 procedures, and synthetic grafts were used in four. Grafts were placed to 13 internal, eight distal common, and eight external carotid arteries.

RESULTS

There were no perioperative deaths; one stroke occurred (3.4%). No lymphatic or peripheral nerve complications occurred. In a 1- to 11-year follow-up period (mean, 4.5 years), there were no graft occlusions, one restenosis of 50% or greater, and two restenoses of 70% or greater. The 1-year stenosis-free rate for 50% or greater stenosis was 93%, and the 5- and 10-year rates were 87%. No late ipsilateral strokes occurred. The 5- and 10-year survival rates were 64% and 28%, respectively. Coronary artery disease was the major cause of late mortality.

CONCLUSION

Axillary-to-carotid bypass grafting for severe symptomatic common carotid occlusive disease is safe, well tolerated, durable, and effective in stroke prevention. There is a high late mortality rate because of coronary artery disease in patients with severe proximal common carotid occlusive disease.