Thierry Grenade

Blowout of Carotid Venous Patch Angioplasty

Two cases of vein patch blowout were observed five and seven days after carotid bifurcation endarterectomy with patch angioplasty. Both patients died in spite of emergency reoperation. One patient developed respiratory failure with subsequent fatal cardiac arrest seven days after reoperation; the other died of extensive hemispheric infarction on the fifth postoperative day. At reoperation both ruptures were found to be located in the middle of the patch whereas the suture lines were intact. Both patients were hypertensive. In the first case, an accessory saphenous vein retrieved from the calf had been the only venous material available for the patch, while the other patient had varicose veins in the contralateral leg. Pathology revealed central transmural tissue necrosis in one of the disrupted patches. A review of the literature regarding morphologic alterations of free vein grafts placed within the arterial circulation as well as hemodynamics in patched arterial segments may provide additional insight as to the inherent benefits and risks of vein patch angioplasty after carotid endarterectomy. When considering vein patch angioplasty, particular attention should be directed to the gross aspect of the vein to be used as well as to any antecedent history of phlebitis.

Usefulness of Thromboendarterectomy in Association with Coronary Artery Bypass Grafting

Thromboendarterectomy is sometimes performed in association with coronary artery bypass graft surgery (CABG). Right coronary arteries and severely narrowed coronary arteries mainly undergo thromboendarterectomy, but perioperative acute myocardial infarctions (AMI) are possible complications. One hundred seventy-six consecutive patients with rest and stress thallium-201 scintigraphy and angiography were studied before and after surgery. To compare patients with and without thromboendarterectomy, 48 patients who had undergone thromboendarterectomy and whose characteristics matched closely those of patients who had not were selected. Twenty patients had previous AMI before CABG in each group. Analysis accounted for the severity of vessel lesion (complete or incomplete) and for the patency of the graft and of the native coronary artery. In these 96 patients, graft patency was lower than in the overall group and similar among patients with and without thromboendarterectomy among the 56 patients without previous AMI. In patients with previous AMI and thromboendarterectomy, however, reperfusion was achieved more often through the native vessel than through the graft. New AMI or residual ischemia occurred in 32% of the areas undergoing thromboendarterectomy and in only 5% of the standard grafts (p less than 0.001). Best results were obtained in patients with incomplete occlusion after AMI. Patients without previous AMI had worse results. Thus, thromboendarterectomy can yield 64 to 75% good results in selected subgroups when CABG is otherwise impossible, but should be avoided in mildly or moderately stenotic arteries perfusing noninfarcted myocardium.

La tomodensitométrie cardiaque dans la mise au point préopératoire d’une anomalie congénitale d’une artère coronaire

We report the case of a 81-year-old man presenting with stable exercise angina pectoris. The stress test is positive and the coronaro-angiographic evaluation demonstrates a coronary fistula between the left anterior descending (LAD) artery and the pulmonary artery trunk. The mid LAD presents a significant lesion after the origin of the fistula. A cardiac computed tomography is used before surgical treatment. Coronary artery fistulas are unusual congenital or acquired coronary artery abnormalities in which blood is shunt into a cardiac chamber, great vessel or other structure. Low-pressure structure is the most common site of drainage of the coronary fistula. The clinical presentation of coronary fistulas is mainly dependent on the severity of the left-to-right shunt. Various cardiac imaging modalities are used for diagnosis and anatomical exploration before surgical or percutaneous intervention if the closure of the fistula is indicated.