Matteo Longhi

Impact of postoperative transient ischemic attack on survival after carotid revascularization.

OBJECTIVE Major postoperative complications such as stroke and myocardial infarction are usually carefully evaluated in the analysis of carotid revascularization performance. Although transient ischemic attacks (TIAs) are often left unreported, they also may influence long-term outcome. The aim of our study was to evaluate the influence of postoperative TIA in the long-term survival of patients submitted to carotid revascularization. METHODS All consecutive patients submitted to either carotid artery stenting or carotid endarterectomy for symptomatic or asymptomatic carotid stenosis from 2005 to 2012 were retrospectively analyzed. Patients were stratified according to their postoperative (30-day) neurologic course (no symptoms, TIA, or stroke). Kaplan-Maier with log-rank analysis was performed to compare the 5-year survival of patients with postoperative TIA, stroke, or neither; factors affecting the 5-year mortality were evaluated by multivariable Cox proportional hazards models. RESULTS Over a total of 1390 carotid revascularizations (carotid endarterectomy, n = 868 [62.4%]; carotid artery stenting, n = 522 [37.6%]), neurological perioperative complications occurred in 67 (4.7%) cases (38, 2.7% TIA; 29, 2.0% stroke). At 5-year follow-up, overall survival was significantly lower in patients with postoperative TIA (78.4 ± 8.0% vs 97.4 ± 0.6%; P < .001) and postoperative stroke (68.2 ± 14.4% vs 97.4 ± 0.6%; P = .03) compared with patients without neurological complications. By means of multivariate Cox analysis, postoperative TIA and stroke were independent predictors of decreased survival (hazard ratio [HR], 3.10; 95% confidence interval [CI], 1.01-9.72; P = .04, and HR, 3.87; 95% CI, 1.13-13.19; P = .03, respectively), other than age >80 years, postoperative myocardial infarction, and chronic renal failure (HR, 2.07; 95% CI, 1.41-4.90; P = .01; HR, 4.33; 95% CI, 2.74-23.79; P = .04; HR, 2.54; 95% CI, 1.04-6.19; P = .04, respectively). CONCLUSIONS TIAs are significant events, possibly determined by a wider extent of atherosclerotic disease, with important effects on long-term mortality similar to that in strokes. Different from most trials evaluating the outcomes of revascularization techniques, the incidence of perioperative TIA should be accurately considered in the analysis.

Endovascular treatment of late coronary-subclavian steal syndrome

OBJECTIVE Coronary-subclavian steal syndrome (CSSS) is a rare cause of myocardial ischemia subsequent to stenosis or occlusion of the subclavian artery (SA) proximal to internal thoracic artery (ITA) coronary bypass. Only single cases have been reported in published studies to date. We report a significant series of patients with late CSSS treated through an endovascular approach. METHODS We reviewed a series of consecutive patients treated for CSSS. The clinical, anatomic, and technical characteristics of the procedures were considered. Follow-up was performed through clinical and laboratory (electrocardiography, echocardiography, duplex ultrasonography) evaluations. RESULTS From January 2005 to March 2013, 10 patients with CSSS were treated; 7 had stable and 3 unstable angina. Of the 10 patients, 8 had left SA stenosis (6 ostial to the origin and 2 in the middle segment), 1 had proximal occlusion of the left SA, and 1 had stenosis in the innominate artery (proximally to a right internal thoracic artery). Arterial access was at the brachial artery through surgical exposure (n=6), or radial artery percutaneously (n=3). In 1 case of proximal occlusion of the left SA, simultaneous femoral and percutaneous radial access was necessary. Predilatation of the stenotic lesion was performed in 6. Balloon expandable stents were used in 7 patients with proximal ostial stenosis or occlusion and self-expandable stents in 2 with nonostial lesions. In 1 other patient with proximal heavy calcified stenosis, cutting-balloon predilatation was performed, resulting in dissection of the SA and occlusion of the ITA graft; blood flow was restored in the left upper arm and myocardium by adjunctive dilatation of the SA and endovascular coronary revascularization. No patients developed angina during the follow-up period (15±7 months). CONCLUSIONS A tailored endovascular approach can be used to treat CSSS. However, the occurrence of potentially lethal complications is possible and needs prompt correction.

Impact of acute cerebral ischemic lesions and their volume on the revascularization outcome of symptomatic carotid stenosis

Background: The influence of acute cerebral ischemic lesions (CILs) on the revascularization outcome of symptomatic carotid stenosis has been scarcely investigated in the literature. This study evaluated the effect of CILs and their volume on the results of carotid revascularization in symptomatic patients. Methods: All patients with symptomatic carotid artery stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) between 2005 and 2014 were considered. CILs ipsilateral to the stenosis were identified in the preoperative cerebral computed tomography. The volume was quantified in mm3 and correlated with 30‐day rates of stroke and stroke/death by χ2, multivariate analysis, Pearson correlation, and receiver operating characteristic curves. Results: A total of 489 symptomatic patients were treated by CEA (327 [67%]) or CAS (162 [33%]), 186 (38%) ≤2 weeks and 303 (62%) >2 weeks from symptom onset. CEA and CAS patients had statistically similar rates of stroke (3.3% vs 5.5%; P = .27) and stroke/death (3.8% vs 5.9%; P = .22). CILs were identified in 251 patients (53%) and were associated with similar stroke and stroke/death rate compared with patients without CIL (12 [4.8%] vs 8 [3.5%], P = .46; and 14 [5.6%] vs 8 [3.5%]; P = .26, respectively). The median CIL volume was 1000 mm3 (interquartile range [IQR], 7000 mm3). Patients with postoperative stroke and stroke/death had a significantly higher preoperative CIL volume of 5100 mm3 (IQR, 31,000 mm3) vs 1000 mm3 (IQR, 7000 mm3; P = .01) and 4500 mm3 (IQR, 17,450 mm3) vs 1000 mm3 (IQR, 7000 mm3; P = .03), respectively. The receiver operating characteristic curve analysis showed a volume of 4000 mm3 was predictive of postoperative stroke with 75% sensitivity and 63% specificity. A CIL volume ≥4000 mm3 was an independent risk factor for postoperative stroke, with a stroke rate of 9.3% (n = 9) vs 1.9% (n = 3) for a CIL volume of <4000 mm3 (odds ratio, 4.6; 95% confidence interval, 1.1‐19.1; P = .03). Conclusions: CIL volume in symptomatic carotid stenosis seems to influence the 30‐day outcome independently from the timing of carotid revascularization. A CIL volume of ≥4000 mm3 could be considered a significant predictor for postoperative stroke after carotid revascularization.

PC026 Impact of Previous Open Aortic Repair on the Outcome of Thoracoabdominal Fenestrated and Branched Endografts

case of distal type I endoleak and device migration (>10 mm) of a right iliac leg component was noted during longer-term follow-up. No other limb-related endoleak, migration, component separation, or stent fracture was reported during a mean follow-up of 10.8 6 5.6 months. Conclusions: Results from this postmarket registry under routine clinical care demonstrate infrequent limb occlusions and limb-related reintervention, supporting the excellent performance of the Spiral-Z leg graft.