Rupture of the external iliac artery during balloon angioplasty: endovascular treatment using a covered stent.

PURPOSE: To report the emergent endovascular management of an external iliac artery (EIA) rupture after standard guidewire recanalization and balloon angioplasty. METHOD AND RESULTS: A 54-year-old diabetic male presented with an occlusion of the EIA associated with severe stenotic lesions of the femoral bifurcation. Guidewire recanalization of the lumen was followed by balloon angioplasty, but evidence of EIA rupture was detected on the intraoperative arteriogram. Temporary homeostasis was achieved using the angioplasty balloon, and a Cragg EndoPro System 1 stent-graft was inserted transluminally to repair the injury. At 18 months poststenting, routine color Doppler confirmed continued patency of the vessel repair. CONCLUSIONS: While rupture of the EIA during angioplasty usually demands open surgical correction, an endovascular procedure can provide a fast, efficient, and less aggressive method of treating this serious complication.

Carotid angioplasty and stenting: will periprocedural transcranial Doppler monitoring be important?

PURPOSE: To explore the value of transcranial Doppler (TCD) ultrasonography in the periprocedural monitoring of patients undergoing angioplasty procedures for stenosis of the internal carotid artery. METHODS: Thirty-two patients were included in the study between April 1991 and September 1995 (6 females, 26 males; average age 66 years). All patients were interrogated before and after angioplasty by a standard TCD examination protocol. Intraprocedurally, TCD was used continuously to monitor cerebral blood flow and supply evidence of embolic particulates. Nineteen patients were treated by percutaneous transluminal angioplasty (PTA) alone; the other 13 underwent primary stent (PS) implantation. RESULTS: High-intensity transient signals indicative of emboli appeared to be more frequent in the PTA group than in the PS cohort. Preoperative TCD identified 3 (9%) high-risk patients with incompetent collateral pathways through the circle of Willis. Intraoperatively, TCD detected two postdilation carotid occlusions, a sylvian embolism, and one case of arterial spasm. The preprocedural TCD in a patient with contralateral carotid occlusion showed good collateral circulation, providing reassurance during conversion to endarterectomy when an undeployed stent obstructed blood flow. Postoperatively, TCD confirmed restored intracerebral circulation and identified one hyperperfusion syndrome. CONCLUSIONS: TCD is a simple, relatively inexpensive examination that can preprocedurally identify carotid stenosis patients at high risk for intraoperative cerebral ischemia in whom PTA might be preferable to surgery. During the procedure, TCD can document the benefits of endovascular treatment and offer early detection of ischemic complications.

Recurrent carotid disease: will stents be an alternative to surgery?

PURPOSE: To report the results of balloon angioplasty in recurrent carotid occlusive disease and evaluate the potential for stent implantation. METHODS AND RESULTS: Between April 1991 and September 1995, 15 patients with carotid restenosis underwent 17 endoluminal procedures in 3 common carotid and 14 internal carotid arteries. Two postdilation complications (dissection and acute occlusion) required prompt stenting; one common carotid artery was stented for postdilation residual stenosis. One recurrent lesion was also stented 6 months after initial angioplasty. One stroke, 1 silent cerebral infarction, and 3 transient ischemic attacks occurred in the balloon angioplasty patients (33% neurological complication rate). The common carotid stent patient died 3 days postoperatively due to hyperperfusion syndrome. Long-term follow-up in two stent patients showed no restenosis at 18 and 48 months, respectively. The 11 balloon angioplasty patients likewise have not demonstrated restenosis. CONCLUSIONS: Balloon angioplasty alone appears too risky for treating recurrent carotid disease. Stents may offer a safer alternative, particularly when implanted primarily.

[Endovascular treatment of arteries with cerebral destination: failures and limits]. / Traitement endovasculaire des artères a destinée cérébrale: echecs et limites.

OBJECTIVE: Evaluate endovascular treatment of vessels irrigating the brain. Assess risks and indications of balloon angioplasty and stents. METHODS: Retrospective study in 38 patients (6 females, 32 males) who underwent revascularization from December 1990 to July 1995: 47 balloon angioplasties and 17 stents (36%). Three patients were asymtomatic, 17 had a past history of transient ischaemia, 5 had amauraosis, 9 signs of vertebrobasilar insufficiency and 2 had an ischaemia of the upper limbs. Endoluminal treatment was performed in 4 brachiocephalic trunks with implantation of 1 stent, in 7 common carotid arteries with 4 stents, in 24 internal carotid arteries with 9 stents, 2 osteal stenosis of the vertebral artery and one external carotid. RESULTS: There were no complications in patients treated for lesions of the brachiocephalic trunk, the subclavian artery and the vertebral arteries. Among the 7 patients with a stenosis of the common carotid artery, there was one death after reperfusion due to cerebral oedema. For the carotid internal, two groups of patients could be distinguished. In one group of 13 patients with restenosis of the internal carotid artery who were treated by balloon angioplasty, there were 3 transient episodes of ischaemia, one reversible hemiplegia and one silent infarction. A second group of 8 patients had atheromatous stenosis. One was treated by balloon angioplasty with one transient episode of ischaemia and the 7 others were treated with a stent without complications. The rate of neurological complications was 15.7% (6 deficits in 38 patients). The permeability after revascularization was verified at mid-term with repeated echo-Doppler examinations and by angiography one year after operation. Restenosis occurred early after one subclavian stent covered with a patch. Among the 16 Palmaz stents, one implanted in a post-irradiation common carotid occluded after 2 months. The other 15 stents were patent at a mean follow-up of 18 months (2-56), i.e. 93%. There were 2 restenoses after balloon angioplasty in the group of carotid restenosis, i.e. 15%. CONCLUSIONS: Risk in balloon angioplasty of arteries irrigating the brain is a serious problem. Stenosis of the subclavian artery and the vertebral arteries appears to be a good indication. Lesions of the carotid bifurcation should not be treated with balloon angioplasty due to the risk of neurological complications. Among the restenosis after endarterectomy, only those lesions situated in the distal internal carotid are good indications. Stents have greatly improved treatment possibilities. They should be implanted whenever there is a risk of supra-aortic lesions and in certain lesions of the carotid bifurcation in high-risk, patients. Their application in all situations cannot be proposed yet before long-term outcome is established.

Long-term results with the Palmaz stent in the superficial femoral artery.

PURPOSE: Femoral stenting has demonstrated inconsistent and often disappointing long-term results. To compare out experience, we retrospectively analyzed a series of patients who had Palmaz balloon-expandable stents placed exclusively for superficial femoral artery (SFA) lesions. METHODS: From January 1990 to November 1993, 39 patients were evaluated for claudication (79%) or critical ischemia in 42 limbs. The culprit lesions were confined to the SFA: 24 (57%) occlusions and 18 (43%) stenoses, including 3 restenotic lesions. Stenting was elective in 12 (29%) cases: the 3 restenoses and 9 chronic, calcified occlusions. The remaining stents were applied for postangioplasty residual stenosis or angioscopic findings of thrombogenic luminal irregularities. A total of 55 prostheses were successfully implanted. All patients were maintained on ticlopidine and followed by routine duplex scanning. Follow-up angiography was performed in 28 (72%) patients between 4 and 45 months. RESULTS: In the postprocedural period, two acute thromboses (4.8%) occurred within 48 hours in patients who had long occlusions and poor runoff; no other major complications were encountered, for a clinical success rate of 95%. Follow-up evaluation ranged from 4 months to 4 years with a mean of 25 months. The restenosis rate was 19% (34% in occlusions; 10% in stenotic lesions, p = NS). At 24 months, cumulative primary patency was 77% and secondary patency 89%. CONCLUSIONS: Palmaz stents performed will in the SFA, demonstrating a low acute thrombosis rate and good long-term patency. The incidence of restenosis is likely to be greater in occlusions than in stenoses.

Transluminal angioplasty for recurrent stenosis after carotid endarterectomy. Prognostic factors and indications.

Over a 15-month period ending in July 1992, 9 patients (7 male, 2 female; mean age 67 years) with recurrent stenosis of the internal carotid artery underwent transluminal angioplasty (TLA). The mean interval between endarterectomy and treatment of recurrent stenosis was 45 months (range: 9 to 84 months). All patients were symptomatic except one with extensive bilateral carotid dysplasia. Three patients had recurrence proximal to the endarterectomized segment (Group I); in one of these patients the narrowing was extensive. The other 6 patients (Group II) demonstrated stenoses distally. In one of these latter patients, the narrowing developed in a vein bypass. Balloon dilation was performed by the surgical route in 3 patients and percutaneously in the other 6. Perioperative transcranial Doppler (TCD) monitoring was employed in all procedures. Postoperative treatment consisted of oral Ticlopicine. In Group I (proximal recurrence), immediate complications included one case of reversible spasm and two dissections that led to acute thrombosis treated by emergency bypass and to sylvian artery embolism complicated by transient hemiplegia. In Group II (distal disease), dissection was not encountered, and only one case of transient neurologic manifestations due to cerebral edema following reperfusion was observed. Mean follow-up has been 18 months (range: 9 to 24 months). All patients are presently asymptomatic. In Group II, 2 patients presented with secondary recurrence at 6 months and were treated again by angioplasty. In one of these cases, a Palmaz stent was placed to prevent restenosis by elastic recoil.(ABSTRACT TRUNCATED AT 250 WORDS)

[Associated surgery of the carotid and subclavian arteries: indications and results]. / Chirurgie carotidienne et sous-clavière associée: indications et résultats.

Over a 5 year period (1988-1992), 6 patients were treated by combined carotid and subclavian artery surgery, representing 0.7% of carotid interventions practised during this period. The carotid lesion clinical stage was 0 (2 cases), 1 (2 cases) and 3 (2 cases). While for the subclavian artery 4 patients were asymptomatic and 2 had vertebrobasilar syndromes, one associated with ischemia of upper limb. Only one patient was globally asymptomatic but the diagnosis was a prethrombotic carotid restenosis. Radiographs showed that the atheromatous lesion of the cervical trunks was equivalent to 2.83 stenoses per patient. The decision to use the combined interventions was based on either the clinical condition (combined carotid and vertebrobasilar symptomatology) or hemodynamic data (improvement in subclavian flow during carotid surgery). This hemodynamic component could be determined by transcranial Doppler. Operation consisted always of initial subclavian revascularization (1 reimplantation, 5 bypasses), followed by carotid surgery (2 grafts, 4 endarterectomies). The postoperative course was uneventful in 5 patients, the 6th patient requiring recovery surgery for early carotid thrombosis without worsening of the neurologic state. Mean follow up was 9 months (range 1 to 27 months). Combining these two interventions in this small series did not appear to increase carotid surgery complication. Initial revascularization of the subclavian artery in the patient with multiple trunk lesions corrected the posterior hemodynamic supply to the circle of Willis.

Stroke prevention during carotid surgery in high risk patients (value of transcranial Doppler and local anesthesia).

In a series of 114 cases, carotid surgery was performed under local anesthesia by cervical block in order to assess cerebral status. Preoperative transcranial Doppler was used to select high risk patients for shunting. Intraoperatively brain function was checked by carotid arterial blood pressure monitoring and transcranial Doppler. No stroke occurred during the procedure. Postoperatively two deaths (1.8%) occurred, one due to intracerebral hemorrhage and one to a late myocardial infarct. The predictive value of both transcranial Doppler and stump pressure monitoring for shunting was 97% respectively. In combination, the two methods provided 100% protection. During the same period, 1406 patients underwent carotid surgery under general anesthesia. Carotid surgery stroke can be prevented either by using transcranial Doppler together with carotid stump pressure monitoring when the procedure is performed under general anesthesia or by operating under local anesthesia.

Pre- and intraoperative transcranial Doppler: prediction and surveillance of tolerance to carotid clamping.

We report 91 patients (mean age 70 years) operated upon, prospectively for a total of 100 carotid revascularizations (nine bilateral). Eighty-five of these patients had pre-, intra-, and postoperative transcranial Doppler investigations. Preoperatively, these 85 patients (92 procedures) were classified into two groups based on the results of their Doppler examinations: Group A (65 patients, 72 procedures), those who did not require an intraoperative indwelling shunt and Group B (20 patients, 20 procedures), those who did. The shunt was inserted only when the mean stump (back) pressure was less than 50 mmHg after cross-clamping. Group A all had satisfactory collaterality with a functional anterior and one or two posterior communicating arteries. Group B had no communicating arteries (anterior or posterior) identified by transcranial Doppler. In 17 of 20 patients in this group, the stump pressure was less than 50 mmHg and a shunt was placed. The overall prediction based on Doppler examination of whether or not patients would need a shunt during operation for the two groups A and B (i.e., 92 procedures) was correct in 95.6% (88/92) of cases. Moreover, six hemodynamically significant stenoses (four in the cavernous portion, two in the middle cerebral artery) were disclosed. Sensitivity and specificity of transcranial Doppler as correlated with arteriographic findings were 70 and 90%. Preoperative transcranial Doppler can measure the velocities of the principal cerebral arteries and the collateral capacity of the circle of Willis, and can forecast tolerance to carotid cross-clamping. Intraoperatively, the velocity of flow in the middle carotid artery was correlated with stump pressure, which allowed for surveillance of the shunt.

[Axillo-femoral bypass. Long-term results]. / Pontages axillo-fémoraux. Résultats à long terme.

182 patients underwent axillo-femoral bypass between April 1974 and December 1981 (29 women and 153 men). Mean survival was 43 months. The mean age was 68 years (range: 40-90). 10.9% of patients were Leriche stage II, stages III and IV accounted for 69.7% of cases. All presented a high surgical risk with cardiac disease present in 43.4% and severe respiratory failure in 36.8%. Depending on the year studied, this procedure represented 10 to 15% of the aorto-iliac revascularisations carried out. Mortality was low (5 cases = 2.7%). Early complications (15%) included 11 cases (6%) of early thrombosis requiring reintervention, and late complications included 48 cardiac problems (26.3%). Analysis of the results in the long term was carried out according to an actuarial method over a period of 10 years. The secondary permeability rate was 86.4% at 5 years and 68.8% at 10 years with a 30% secondary thrombectomy rate (25% long term). Limb conservation at 5 and 10 years was respectively 91.1% and 82.7% while for the same periods survival was 46.7% and 19.7%, confirming the grave condition of the patients. We can conclude that axillo-femoral bypass remains a simple and reliable method with good long term results. When extra-anatomical revascularisation seems indicated, it is particularly suitable for subjects in very poor general health.

Carotid surgery under cervical block anesthesia. A simple method of heart and brain protection in high risk patients.

Between January 1, 1985, and December 15, 1987, 60 patients underwent surgery for carotid lesions under local cervical block anesthesia. Sixty-seven reconstruction procedures were performed including 64 endarterectomies and 3 vein bypasses. During the same 3 year period, 938 other reconstruction procedures were carried out under general anesthesia for a total of 1005 procedures. These 60 patients, who accounted for 6.7% of our indications, were selected for surgery under local anesthesia because they were at high risk for cardiac and neurologic complications. As far as staging is concerned, this subgroup of patients included: 14 asymptomatic cases (stage 0), i.e., 21%; 44 transient ischemic attacks (stage I), i.e., 66%; 2 progressive stroke (stage II), i.e., 3%; 7 patients with neurologic sequels (stage III), i.e., 10%. In all 79% of the patients were symptomatic. The asymptomatic patients all presented bilateral tight stenosis sometimes with thrombosis of the contralateral carotid. The technique of local anesthesia and endarterectomy were classic: closing with a bougie to calibrate the lumen, systematic intraoperative arteriography and immediate correction of technical failures (2 times); no death occurred among the patients in stages 0, 1 and II; 1 early asymptomatic occlusion that was not corrected was noted; in one case, a ligation of the carotid was necessary after technical failure, without consequences; one death occurred in stage III after intracerebral hemorrhage. On the basis of our experience local cervical block anesthesia appears to be a simple and reliable method of ensuring intraoperative diagnosis of cerebral ischemia. It eliminates all intraoperative cerebral complications secondary to ischemia and allows a better understanding of the physiopathologic mechanisms underlying perioperative neurologic complications. The absence of neurologic and cardiac complications in this series of very high risk patients enables us to extend eligibility for surgery to include patients with unstable cardiac and cerebral disease.