Introduction Flow-limiting lesions or embolic phenomena can produce vertebrobasilar ischemia. This study aims to differentiate the pathophysiology of vertebral ischemia and examine contemporary ...outcomes after distal vertebral reconstruction. Methods Between February 2005 and November 2011, 41 consecutive distal vertebral artery (VA) reconstructions were performed in 34 patients, including bypass to the third portion of the VA (V3) at the C1-2 level (n = 24) or the C0-1 level (n = 7); transposition of the external carotid artery or its occipital branch onto V3 (n = 6); transposition of V3 onto the internal carotid artery (n = 3); and bypass from the ipsilateral subclavian artery to V3 (n = 1). Six patients required a concomitant carotid intervention, and nine patients required a partial resection of the C1 transverse process. Symptoms, present in 91% of patients, were attributed to a flow-limiting lesion in 16 (52%), to embolization in nine (29%), and to a mixed etiology in six (19%). Results Intraoperatively, five patients required graft revision or conversion of a transposition to a bypass, and two patients required vertebral ligation. Median blood loss was 260 mL. Median hospital length of stay was 1 day. Postoperatively, one patient (2%) required re-exploration for bleeding, a stroke occurred in one patient (2%), and cranial nerve injury occurred in three patients (7%). There were no perioperative deaths. Survival analysis showed that primary patency at 1, 2, and 5 years, respectively, was 74%, 74%, and 54%. Secondary patency was 80% at 1 year and remained so through the end of follow-up at 80 months. A statistically significant difference in patency was noted favoring arterial transposition over vertebral bypass of 100%, 100%, and 83% at 1, 2, and 5 years, respectively, vs 65%, 65%, and 39% ( P = .018). Considering successful redo bypass grafting for late failure, 97% of patients demonstrated preserved patency at their last follow-up. There were two late deaths of unknown etiology and no late strokes. Conclusions Distal VA reconstruction for flow-limiting or embolic lesions provides excellent stroke protection and symptomatic relief with acceptable perioperative risk in selected patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective The use of fenestrated and branched stent graft technology for paravisceral abdominal aortic aneurysms (PAAA) is on the rise; however, its application is limited in the United States to ...only a few selected centers. Most PAAAs are currently repaired using an open approach. The objective of this study was to determine which patients are at highest risk with open PAAA repair and might benefit most from endovascular repair using fenestrated or branched stent grafts. Methods This was a retrospective cohort study using data from American College of Surgeons National Surgical Quality Improvement Program (NSQIP) hospitals. We identified 598 patients (27.5% women) who underwent elective open PAAA repair from the 2007 to 2009 NSQIP, a prospective database maintained at >250 centers. The main outcome measure was 30-day postoperative mortality. Results The median patient age was 73 years. The 30-day major morbidity rate was 30.1%, and the mortality rate was 4.5%. Major complications included reintubation (10.0%), sepsis (10.7%), return to operating room (9.2%), new dialysis requirement (5.9%), cardiac arrest or myocardial infarction (4.5%), and stroke (1.2%). Multivariate analyses identified four predictors of postoperative mortality after open PAAA repair: peripheral arterial disease (PAD) requiring revascularization or amputation, chronic obstructive pulmonary disease (COPD), anesthesia time, and female sex. PAD and COPD were present in only 5.2% and 20.4% of patients but were associated with a 16.1% and 9.0% mortality rate, respectively. The mortality rate in women was 7.3% vs 3.5% for men ( P = .045). Conclusions PAD, COPD, and female sex are major risk factors for postoperative mortality after open PAAA repair. Fenestrated or branched stent graft repair may be a more valuable alternative to open repair for patients with one or more of these characteristics who have suitable access vessels.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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