Shin-Seok Yang

Surgical bypass vs endovascular treatment for patients with supra-aortic arterial occlusive disease due to Takayasu arteritis.

OBJECTIVE This study compared treatment outcomes of patients with supra-aortic arterial (SAA) occlusive disease due to Takayasu arteritis (TA) treated with bypass surgery or endovascular treatment. METHODS All patients diagnosed with TA from September 1994 to November 2010 were identified using the hospital database. This retrospective study included 21 TA patients who underwent endovascular or surgical intervention due to SAA lesions and four patients who were referred from other hospitals after endovascular treatment of SAA lesions. Fifteen arterial lesions in 10 patients were treated with an endovascular technique, and 24 arteries in 15 patients were reconstructed using bypass surgery. We performed endovascular intervention for short (<5 cm) stenotic lesions and bypass surgery for longer occlusive lesions. After surgical or endovascular intervention, anti-inflammatory medication (steroids, methotrexate, or azathioprine, or both) was given to 12 patients (48%) with evidence of disease activity for a mean of 4.4 ± 4.5 months (median, 2.6; range, 1-15 months). We reviewed and compared demographic and clinical features, lesion characteristics, indications for treatment, and treatment results between the bypass surgery and endovascular treatment groups. To evaluate the treatment results, we assessed the patency of reconstructed arteries, recurrent symptoms, and complications associated with treatment. RESULTS During the 194-month study period, 9.6% of TA patients with SAA lesions required bypass surgery or endovascular treatment. The typical indication for treatment was brain ischemic symptoms. Two patients were neurologically asymptomatic but had cervical artery occlusion in conjunction with an aortic arch aneurysm or symptomatic aortic regurgitation. During a mean follow-up of 39.4 ± 44.4 months (median, 23.2; range, 0.5-178 months), restenosis (>50%) or occlusion of the reconstructed arteries was observed in eight of 15 arteries (53.3%) in the endovascular treatment group vs three of 24 (12.5%) in the bypass surgery group (P = .01; Fisher exact test). More serious complications, such as intracerebral hemorrhage (n = 2) due to cerebral hyperperfusion syndrome or cardiac tamponade developed in the surgical bypass group. No operative deaths occurred in either group. CONCLUSIONS Surgical or endovascular interventions were required in one of 10 TA patients with SAA occlusive lesions. Arteries reconstructed after surgical bypass had superior patency to those reconstructed by endovascular treatment. However, bypass surgery was more likely than endovascular treatment to be accompanied by serious early postoperative complications.

Impact of contralateral carotid or vertebral artery occlusion in patients undergoing carotid endarterectomy or carotid artery stenting.

OBJECTIVE To determine the impact of contralateral carotid occlusion (CCO) and/or vertebral artery occlusion (VAO) on the development of early postoperative neurologic complications after carotid endarterectomy (CEA) or carotid artery stenting (CAS). METHODS A retrospective analysis was conducted using a database of patients who underwent CEA (n = 698) or CAS (n = 455) at a single institution. Excluded were 44 CEAs synchronously performed with coronary artery bypass grafting and 76 CASs performed without an embolic protective device (n = 69) or that resulted in technical failures (n = 7). All CEAs were the conventional type and performed under general anesthesia, and carotid shunts were routinely used. Patients were categorized into three groups according to patency of the contralateral carotid and vertebral arteries: Group I (no CCO or VAO); Group II (CCO with or without VAO); Group III (with VAO but no CCO). CCO or VAO were diagnosed with two or more carotid imaging studies including duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, or conventional carotid angiography. Patient groups were compared with demographics, preoperative symptomatic status, and frequencies of early (<30 days) symptomatic neurologic complications (ESNCs) including transient ischemic attack and stroke. Postprocedural stroke alone was separately compared. Univariate (χ(2) or Fishers exact test) and multivariate analysis (multiple logistic regression) were conducted to determine predictors of ESNC or postprocedural stroke. RESULTS ESNCs and postprocedural stroke developed significantly more often with CAS compared with CEA (ESNC, 2.6% vs 8.1%; P < .001; stroke, 1.3% vs 6.8%; P < .001). In group II, the frequency of ESNCs was higher (6.8% vs 1.8%; P = .044), but the frequency of postprocedural stroke was not significantly higher (2.3% vs 0.9%; P = .405) in the CEA group. By multivariate analysis, the presenting symptom of stroke (odds ratio, 3.612; 95% confidence interval, 1.288-10.130; P = .015) and group II (odds ratio, 7.242; 95% confidence interval, 1.727-30.374; P = .007) were independent risk factors of ESNC following CEA but not CAS. When we analyzed the risk factor for postprocedural stroke alone, the presenting symptom of stroke was the only risk factor, while presence of CCO or VAO was not. CONCLUSIONS CAS was followed by a significantly higher frequency of ESNC and postprocedural stroke compared with CEA. By subgroup analysis, CCO was a risk factor for ESNC but not for postprocedural stroke alone in patients undergoing CEA. Unilateral or bilateral VAO was not associated with a higher rate of ESNC or stroke in CEA or CAS.

Open surgical decompression of celiac axis compression by division of the median arcuate ligament.

Median arcuate ligament syndrome is a rare cause of abdominal pain which results from compression of the celiac artery (CA) or rarely, the superior mesenteric artery by a ligament formed by the right and left crura of the diaphragm. We report a case of open surgical decompression of the CA by division of the median arcuate ligament for a 37-year-old female patient who had suffered from chronic postprandial epigastric pain and severe weight loss. We described clinical features, characteristic angiographic findings and details of the surgical procedure for the patient with this rare vascular problem.

Comparisons between prosthetic vascular graft and saphenous vein graft in femoro-popliteal bypass.

Purpose Infrainguinalfemoropopliteal bypass (IFPB) is recommended to peripheral arterial disease (PAD) with a long occlusion of the superficial femoral artery (SFA). The aims of our study were to determine the patency of graft materials, and identify the risk factors of graft failure. Methods From January 1995 to April 2011, we had performed 380 IFPBs in 351 patients, including 302 femoro-above the knee (AK) bypasses and 78 femoro-below the knee (BK) bypasses. We compare age, sex, severity of ischemia between polytetra-uoroethylene (PTFE) graft and saphenous vein (SV) graft, and evaluate patency rate rates of the two groups. Results The primary patency rates at 5 years for SV (n = 76 limbs) and PTFE grafts (n = 226 limbs) in AK were 85.2% and 64.5% (log rank = 0.03), and the secondary patency rates at 5 years for SV and PTFE grafts in AK were 88.2% and 79.0% (log rank = 0.13). The primary patency rates at 5 years for SV (n = 50 limbs) and PTFE grafts (n = 28 limbs) in BK were 63.2% and 40.0% (log rank = 0.08), and the secondary patency rates at 5 years for SV and PTFE grafts in BK were 71.6% and 55.5% (log rank = 0.18). Conclusion There was no statistical significant difference in secondary patency rates between SV and PTFE in IFPB. PTFE grafts as SV grafts can be a good alternative bypass material in IFPB instead of SV grafts.

Renal and abdominal visceral complications after open aortic surgery requiring supra-renal aortic cross clamping

Purpose The aim of this study was to assess renal or abdominal visceral complications after open aortic surgery (OAS) requiring supra-renal aortic cross clamping (SRACC). Methods We retrospectively reviewed the medical records of 66 patients who underwent SRACC. Among them, 17 followed supra-celiac aortic cross clamping (SCACC) procedure, 42 supra-renal, and 7 inter-renal aorta. Postoperative renal, hepatic or pancreatic complications were investigated by reviewing levels of serum creatinine and hepatic and pancreatic enzymes. Preoperative clinical and operative variables were analyzed to determine risk factors for postoperative renal insufficiency (PORI). Results Indications for SRACC were 25 juxta-renal aortic occlusion and 41 aortic aneurysms (24 juxta-renal, 12 supra-renal and 5 type IV thoraco-abdominal). The mean duration of renal ischemic time (RIT) was 30.1 ± 22.2 minutes (range, 3 to 120 minutes). PORI developed in 21% of patients, including four patients requiring hemodialysis (HD). However, chronic HD was required for only one patient (1.5%) who had preoperative renal insufficiency. RIT ≥ 25 minutes and SCACC were significant risk factors for PORI development by univariate analysis, but not by multivariate analysis. Serum pancreatic and hepatic enzyme was elevated in 41% and 53% of the 17 patients who underwent SCACC, respectively. Conclusion Though postoperative renal or abdominal visceral complications developed often after SRACC, we found that most of those complications resolved spontaneously unless there was preexisting renal disease or the aortic clamping time was exceptionally long.

Successful management of pulmonary and inferior vena cava tumor embolism from renal cell carcinoma.

Pulmonary tumor embolism can be a cause of respiratory failure in patients with cancer even though it occurs rarely. We describe a 56-year-old man who underwent a pulmonary tumor embolectomy using cardiopulmonary bypass on beating heart combined with inferior vena cava embolectomy and right radical nephrectomy. Aggressive surgical treatment in this severe case is necessary not only to reduce the fatal outcome of pulmonary embolism in the short run, but also to improve the oncological prognosis in the long term.

Treatment of failing vein grafts in patients who underwent lower extremity arterial bypass

Purpose We attempted to determine risk factors for the development of failing vein graft and optimal treatment in patients with infrainguinal vein grafts. Methods We retrospectively reviewed a database of patients who underwent infrainguinal bypass using autogenous vein grafts due to chronic atherosclerotic arterial occlusive disease of lower extremity (LE) at a single institute between September 2003 and December 2011. After reviewing demographic, clinical, and angiographic features of the patients with failing grafts, we analyzed those variables to determine risk factors for the development of failing grafts. To determine an optimal treatment for the failing vein grafts, we compared results of open surgical repair (OSR), endovascular treatment (EVT) and conservative treatment. Results Two hundred and fifty-eight LE arterial bypasses using autogenous vein grafts in 242 patients were included in this study. During the follow-up period of 39 ± 25 months (range, 1 to 89 months), we found 166 (64%) patent grafts with no restenosis, 41 (15.9%) failing grafts, 39 (15.1%) graft occlusions, and 12 (4.7%) grafts lost in follow-up. In risk factor analysis for the development of a failing graft, no independent risk factors were identified. After 50 treatments of the 41 failing grafts (24 OSR, 18 EVT, 8 conservative management), graft occlusion was significantly more common in conservative treatment group and severe (>75%) restenosis was significantly more common following EVT than OSR (P = 0.001). Reintervention-free graft patency was also superior in the OSR group to that of the EVT group (87% vs. 42%, P = 0.015). Conclusion OSR of failing grafts has better outcomes than EVT or conservative management in treating failing grafts.

Three-Grade Classification of Photoplethysmography for Evaluating the Effects of Treatment in Raynaud Phenomenon

We assessed the utility of a 3-grade classification of photoplethysmography (PPG) with cold water provocation test in Raynaud phenomenon (RP). A total of 35 patients with RP and 38 healthy volunteers were recruited. In healthy volunteers, PPG was measured twice at intervals of 30 minutes for evaluating reproducibility of test. Percentage variation of the PPG amplitude in post- versus precold provocation was expressed on a 3-grade scale at 1, 3, and 5 minutes (reflection index: RI) in patients with RP. The improvement pattern of the PPG (IPPPG) was evaluated by summing the score differences from RI1 min to RI3 min and RI5 min. After a therapeutic period of 8 weeks with nifedipine, the decreases in posttherapeutic RI3 min and RI5 min were statistically significant (P < .05). Subgroup analysis of IPPPG showed statistical significance in patients with negative fluorescent antinuclear antibody (P < .05). The analysis of cold-provoked PPG waves demonstrated and quantified improvements in peripheral arterial circulation in RP.

Ten year outcomes after bypass surgery in aortoiliac occlusive disease.

Purpose Most outcome studies of bypass surgery are limited to five years of follow-up. However, as human life expectancy has increased, analyses of more long-term outcomes are needed. The aim of this study is to evaluate 10-year outcomes of anatomical bypasses in aortoiliac occlusive disease. Methods From 1996 to 2009, 92 patients (82 males and 10 females) underwent aortic anatomical bypasses to treat aortoiliac occlusive disease at Samsung Medical Center. The patients were reviewed retrospectively. Kaplan-Meier survival analyses were performed using PASW ver. 18.0 (IBM Co). Results A total of 72 patients (78.3%) underwent aorto-femoral bypasses (uni- or bi-femoral), 15 patients (16.3%) underwent aorto-iliac bypasses (uni- or bi-iliac), and 5 patients (5.4%) underwent aorto-iliac and aorto-femoral bypasses. The overall primary patency rates of the 92 patients were 86.2% over 5 years and 77.6% over 10 years. The 10-year limb salvage rate and overall survival rate were 97.7% and 91.7%, respectively. Conclusion The overall patency rates of bypass graft and limb salvage rates decreased as time passed. The analysis of results after bypass surgery to treat arterial occlusive disease will be needed to extend for 10 years of follow-up.