Transthoracic repair of innominate and common carotid artery disease: Immediate and long-term outcome for 100 consecutive surgical reconstructions

AbstractPurpose: This is a review of 100 consecutive supraaortic trunk reconstructions (SAT) performed over 16 years. Methods: There were eight innominate endarterectomies and 92 bypass procedures based on the thoracic aorta (n = 86) or proximal innominate artery (n = 6) in 98 patients 24 to 79 years of age. Indications included cerebrovascular ischemia in 83 and upper extremity ischemia in four. Thirteen patients were asymptomatic. An innominate lesion was bypassed in 78 cases. The left common carotid and left subclavian arteries required reconstruction in 38 and nine patients, respectively. Multiple trunks were reconstructed by direct bypass grafting in 35. Approach was via median sternotomy in 92, partial sternotomy in six, and left thoracotomy in two. Seven patients underwent concomitant cardiac surgery. Results: Eight deaths and eight nonfatal strokes occurred, for a combined stroke/death rate of 16%. The operative mortality rate was 6% for SAT and 29% for SAT/cardiac operations. Perioperative complications included two asymptomatic graft occlusions, three nonfatal myocardial infarctions, seven significant pulmonary complications, three sternal wound infections, and one recurrent laryngeal nerve injury. Follow-up ranged from 1 to 184 months (mean, 51 ± 4.8 months). Eight patients were lost to follow-up. Twenty-one late deaths occurred. Two SATs required late revision. The cumulative primary patency rates at 5 and 10 years were 94% ± 3% and 88% ± 6%, respectively. The stroke-free survival rates at 5 and 10 years were 87% ± 4% and 81% ± 7%, respectively. Patients who survived beyond 30 days had a median stroke-free life expectancy of 10 years, 7 months (SE, 6%). Conclusions: Direct reconstruction of complex symptomatic SAT lesions can be performed with acceptable death/stroke rates and with long-term patient benefit. Asymptomatic lesions in patients who have significant concomitant conditions should be managed with a less-morbid cervical or endovascular approach, even if long-term outcome of the latter is inferior. (J Vasc Surg 1998;27:34-42.

Long-term sac behavior after endovascular abdominal aortic aneurysm repair with the Excluder low-permeability endoprosthesis

PurposeSac regression is a surrogate marker for clinical success in endovascular aneurysm repair (EVAR) and has been shown to be device-specific. The low porosity Excluder endograft (Excluder low-permeability endoprosthesis [ELPE]; W. L. Gore & Associates Inc, Flagstaff, Ariz) introduced in 2004 was reported in early follow-up to be associated with sac regression rates similar to other endografts, unlike the original Excluder which suffered from sac growth secondary to fluid accumulation in the sac. The purpose of this study was to determine whether this behavior is durable in mid-term to long-term follow-up.MethodsBetween July 2004 and December 2007, 301 patients underwent EVAR of an abdominal aortic aneurysm (AAA) with the ELPE at two institutions. Baseline sac size was measured by computed tomography (CT) scan at 1 month after repair. Follow-up beyond 1 year was either with a CT or ultrasound scan. Changes in sac size ≥5 mm from baseline were determined to be significant. Endoleak history was assessed with respect to sac behavior using χ2 and logistic regression analysis.ResultsTwo hundred sixteen patients (mean age 73.6 years and 76% men) had at least 1-year follow-up imaging available for analysis. Mean follow-up was 2.6 years (range, 1-5 years). The average minor-axis diameter was 52 mm at baseline. The proportion of patients with sac regression was similar during the study period: 58%, 66%, 60%, 59%, and 63% at 1 to 5 years, respectively. The proportion of patients with sac growth increased over time to 14.8% at 4-year follow-up. The probability of freedom from sac growth at 4 years was 82.4%. Eighty patients (37.7%) had an endoleak detected at some time during follow-up with 29.6% (16 of 54) residual endoleak rate at 4 years; 13 of the residual 16 endoleaks were type II. All patients with sac growth had endoleaks at some time during the study compared with only 18% of patients with sac regression (P < .0001).ConclusionA sustained sac regression after AAA exclusion with ELPE is noted up to 5-year follow-up. Sac enlargement was observed only in the setting of a current or previous endoleak, with no cases of suspected hygroma formation noted

Use of dairies by postreproductive flocks of European starlings

Knowledge of the behavior and movement patterns of European starlings (Sturnus vulgaris L.) is important to wildlife managers that seek to resolve conflicts at livestock facilities. We captured and radio tagged 10 starlings at each of 5 dairies in northeastern Ohio. From September 19 to October 31, 2007, we obtained sufficient data from 40 birds to study their behavior and movements. The birds visited the dairies where they were initially captured (home sites) on 85% of the days, spending 58% of each day at the dairies. Onsite arrival and departure times were 2.5 h after sunrise and 3.1 h before sunset. Daily visits by radio-tagged cohorts from the other dairies were greatest for the 2 most proximate dairies (1.3 km apart), with number of visits between this pairing \u3e7× that of the 9 other pairings combined (4.1–6.5 km apart). Two birds used their home sites intermittently as roosts, arriving 3.8 h before sunset and departing 0.2 h after sunrise. In addition to using home-site roosts, these birds also used a distant roost (22 km) that was used by 36 of the 40 birds. The efficacy of starling management programs, especially lethal management, depends on degree of site fidelity, use of other facilities, and roosting behavior. For example, starlings that use dairies as roosting sites may require a different management strategy than required at dairies used as daytime sites because of differences in arrival and departure behavior. Our research will help resource managers evaluate current management strategies already in place and change them, if needed, to fit the behavior profile of starlings using dairies and other types of livestock facilities