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ORIGINAL ARTICLES  VASCULAR PAPERS 

The Journal of Cardiovascular Surgery 2000 October;41(5):737-42

Copyright © 2009 EDIZIONI MINERVA MEDICA

language: English

Combined carotid endarterectomy with transluminal angioplasty and primary stenting of the supra-aortic vessels

Arko F. R., Buckley C. J., Lee S. D., Manning L. G., Patterson D. E.

From the Division of Vascular Surgery Texas A&M University Health Science Center Scott & White Clinic, Temple, USA


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Back­ground. ­Carotid endar­te­rec­tomy (CEA) is the stan­dard of ­care for ­patients ­with ­high-­grade ­carotid ­artery sten­osis who are accept­able sur­gical can­di­dates. ­Focal occlu­sive ­lesions of the ­origin of ­aortic ­arch ves­sels can be effec­tively and ­safely ­treated ­with bal­loon angio­plasty and pri­mary ­stenting. The pur­pose of ­this ­study was to ret­ro­spec­tively ­review ­results of ­carotid endar­te­rec­tomy for ­high-­grade ­carotid bifur­ca­tion sten­osis com­bined ­with intra­op­er­a­tive ret­ro­grade trans­lu­minal angio­plasty and pri­mary ­stenting of a hemo­dy­nam­i­cally sig­nif­i­cant sten­osis at the ­origin of a prox­imal ipsi­lat­eral ­aortic ­arch ­vessel.
­Methods. ­Between ­October 1994 and ­August 1998, 592 ­patients under­went CEA. Six ­patients ­were ­found to ­have hemo­dy­nam­i­cally sig­nif­i­cant ­tandem ­lesions ­affecting one of the ­aortic ­arch ves­sels and the ipsi­lat­eral ICA for an ­overall inci­dence of 1%. Age ­ranged ­from 63 to 78 ­years (­mean 74.7). ­Four of 6 (67%) ­patients had asymp­to­matic ­lesions, and 2 of 6 (33%) had symp­toms of cere­bral ­ischemia. ­Five ­patients had ­tandem ­lesions ­affecting the prox­imal ­left ­common ­carotid ­artery and the ­left ICA. One ­patient had a ­tandem ­lesion ­affecting the innom­i­nate ­artery and the ­right ICA. ­Carotid ­duplex ­imaging and ­arch and cere­bral arter­i­og­raphy was per­formed in all six ­patients. Arter­i­og­raphy con­firmed ­high-­grade ste­noses in ­both the ICA and ipsi­lat­eral prox­imal ­aortic ­arch ­vessel. The ­range of ste­noses in the ICA was 70 to 95% (­mean 80.8%) meas­ured arte­ri­o­graph­i­cally. The ­range of ste­noses at the ­origin of the ­aortic ­arch ves­sels was 75-90% (­mean 79.2%). All six ­patients under­went com­bined ret­ro­grade trans­lu­minal bal­loon angio­plasty and pri­mary ­stenting of the ipsi­lat­eral CCA or innom­i­nate ­artery ­with tem­po­rary occlu­sion of the ICA for cere­bral pro­tec­tion. The endo­vas­cular pro­ce­dure was ­then fol­lowed ­with stan­dard sur­gical endar­te­rec­tomy ­using an ­inline ­shunt.
­Results. All six pro­ce­dures ­were suc­cess­fully com­pleted. ­There ­were no per­i­pro­ced­ural ­strokes or ­other mor­bid­ities. ­Follow-up ­ranged ­from 6 to 43 ­months (­mean 23.6) and ­showed no evi­dence of recur­rent sten­osis by ­carotid ­duplex ­imaging. No ­TIAs or ­strokes ­related to the sur­gi­cally cor­rected ­lesions ­were ­noted ­during the ­follow-up ­period. One ­patient suf­fered a ­right hem­i­spheric ­stroke sec­on­dary to a ­high-­grade ­right ­carotid sten­osis ­which ­occurred two ­months ­after her pro­ce­dure sur­gi­cally cor­recting ­tandem ­lesions on the oppo­site ­side.
Con­clu­sions. ­Carotid endar­te­rec­tomy ­with bal­loon angio­plasty and pri­mary ­stenting of an ipsi­lat­eral hemo­dy­nam­i­cally sig­nif­i­cant ­aortic ­arch ­trunk ­vessel sten­osis can be ­safely and suc­cess­fully accom­plished and ­avoids the ­need for an ­intra/extrath­o­racic ­bypass pro­ce­dure.

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