Luis A. Queral

The treatment of focal aortic arch branch lesions with Palmaz stents

PURPOSE The purpose of this study was to evaluate the safety and effectiveness of Palmaz stents as a less morbid alternative to traditional surgery for focal aortic arch branch lesions. METHODS Twenty-two patients with symptoms and a mean age of 61.3 years were treated from July 1991 to May 1995 with 26 stents at the following locations: 8 innominate artery, 5 left common carotid artery, 1 right common carotid artery, and 12 left subclavian. Procedures were carried out in an operating room with patients receiving either local anesthetic in 12 cases or general anesthetic in 10. Surgical exposure of either the cervical common carotid or brachial artery allowed precautionary distal clamping before retrograde stent deployment to prevent atheroembolization. RESULTS Initial success was possible in 92.3% (24 of 26) of cases. There were no strokes or deaths. During a mean follow-up period of 27 months, 22 of 26 (85%) vessels have remained patent and the patients symptom free. CONCLUSION Focal aortic branch lesions can be effectively and safely treated with Palmaz stents.

Endoluminal Aortic Aneurysm Repair Using a Balloon-Expandable Stent-Graft Device: A Progress Report

We describe our experience with endoluminal repair of abdominal aortic aneurysms using the stent-graft device. Twenty-four patients underwent 25 procedures in the 27-month period ending December 31, 1992. Twenty-one of the patients were considered high-risk candidates for conventional surgical repair. The endoluminal stented grafts were aortoaortic in 16 procedures and unilateral aortoiliac in eight. One patient underwent a second procedure consisting of an ilioiliac graft to repair a separate common iliac artery aneurysm. Technical problems were primarily related to retrograde transluminal access across the iliac arteries, tortuous aneurysms, and misjudgments as to measurement of length. One patient died and another required secondary deployment of a distal stent at 4 months; subsequent aneurysm expansion mandated surgical replacement at 18 months. It is clear that this device and methodology will have to undergo further refinement before the technique is acceptable for wider clinical application. Current experience, however, is encouraging. Aneurysm exclusion with an endoluminal prosthesis is likely to become an important therapeutic alternative over the next several years.

Retrograde iliofemoral endarterectomy facilitated by balloon angioplasty

PURPOSE The purpose of this study was to explore the feasibility of iliofemoral endarterectomy performed through a single groin incision. METHODS Thirty-two patients aged 34 to 75 years (mean age 63.4 years) with a male/female ratio of 20:12 underwent 36 lower extremity inflow reconstructions from July 1989 to September 1994. Surgical indications were for limb-threatening ischemia in 24 patients and for claudication in eight patients. The procedures were done for occlusive disease of the external iliac artery and common femoral artery with patients under either spinal (n = 24) or local (n = 12) anesthesia. Intraoperative balloon angioplasty with fluoroscopic guidance preceded open retrograde iliofemoral endarterectomy. Adjunctive procedures included 18 profundaplasties, eight femorofemoral, nine femoropopliteal, and one femorotibial bypasses. RESULTS Thirty-three of the 36 cases were initially successful. The three failures were in patients with extensive calcification. The mean follow-up has been 36.4 months, and the patency rate was 80.5% at 3 and 4 years. The four failures noted on follow-up were caused by three common iliac artery stenoses and one iliac system occlusion. The former group was successfully treated with balloon angioplasty/stent, and the latter patient required an aortofemoral bypass. No operative deaths or limb loss occurred in this series. CONCLUSIONS Retrograde iliofemoral endarterectomy facilitated by balloon angioplasty is a safe, easy-to-perform, and viable option for patients with combined external iliac artery and common femoral artery occlusive disease. Midterm results (36.4 months) are favorable, and most hemodynamic failures are easy to correct with standard endovascular techniques.

Carotid-axillary artery bypass: A ten-year experience

PURPOSE The purpose of this study was to review our 10-year experience with carotid-axillary artery bypass in the treatment of occlusive lesions of the proximal subclavian artery. METHODS Our 10-year experience with 26 carotid axillary bypasses for occlusive disease of the subclavian artery was reviewed retrospectively. The review focused on the indication for the operation, the surgical technique used, and the development of immediate and late postoperative complications. Long-term bypass graft patency and clinical success were determined on the basis of information gleaned from the office records of all patients. Only three patients were lost to follow-up at 12, 36, and 38 months. RESULTS There were no operative deaths. Two patients had small cervical wound hematomas, and two others experienced transient symptoms of brachial plexus irritation, which subsided spontaneously. Permanent nerve or lymphatic complications did not occur. In a mean follow-up of 47 months, carotid-axillary bypass graft patency was 96%, and 88% of the patients enjoyed symptom-free sustained clinical success. CONCLUSIONS This retrospective review demonstrates that a carotid-axillary bypass constructed with ringed synthetic graft material tunneled under the clavicle performs well and can be considered a reasonable alternative to the more standard carotid-subclavian bypass for the same indications.

The Kimray-Greenfield vena cava filter: A case of unusual misplacement

An unusual case of misplacement of a Kimray-Greenfield filter in an hepatic vein is described and preventive measures are suggested.