Geroulakos, George

Griffin, Maura B.

Kakkos, Stavros K.

Kyriacou, Efthyvoulos C.

Nicolaides, Andrew N.

Sabetai, Michael M.

Tegos, Thomas J.

Elsevier - Publisher Connector 

Author Disclosures: D. J. Bertges: Nothing to disclose;
J. L. Cronenwett: Nothing to disclose; R. R. De Mar-
tino: Nothing to disclose; J. Eldrup-Jorgensen: Nothing
to disclose; P. P. Goodney: Nothing to disclose; B. W.
Nolan: Nothing to disclose; A. Schanzer: Nothing to
disclose; J. B. Wallaert: Nothing to disclose.
VS7.
Video Presentation
Complex Carotid Reconstruction: Left Subclavian to
Carotid Bypass with Branched Grafts to the Left Ver-
tebral and Carotid Arteries
Jacob Quick, Colleen S. Hupp, Rumi Faizer. University of
Missouri, Columbia, MO
Background: Background: Complex cerebrovascular
lesions require careful operative planning.We present a case
of a 59 year-old male with a history of recent transient
ischemic attack and right subclavian steal symptoms. Ca-
rotid duplex and CT angiography showed an aberrant left
vertebral artery with critical origin stenosis, left common
carotid artery (CCA) critical origin stenosis, and an oc-
cluded innominate artery extending to the right CCA bulb.
This presented multiple therapeutic options including an-
tegrade or retrograde endovascular stenting of the left
CCA, with or without femoral to axillary bypass on the
right to protect cerebral perfusion. We chose an alternate
strategy made available by the normal left subclavian: a left
subclavian to right carotid bypass, with branched grafts to
the left CCA and left vertebral. No complications occurred.
Follow up angiography demonstrated full-patency of the
grafts and the patient has been without symptoms for
greater than one year.
Technical Description:Technical Description:We be-
gin with an outline of the anatomy and the options. We
then present the operation, first with a left transverse supra-
clavicular incision through which the phrenic nerve is pre-
served and the left CCA, subclavian, and vertebral arteries
are circumferentially controlled. Next, through a separate
incision we expose and control the right carotid vessels. We
then create a retroesophageal tunnel through which we
pass a ringed 6 mm graft between the two incisions. Two
short 6 mm branches are then sewn into place on the left
side of the graft. These are occluded with hemoclips and
we proceed with the left subclavian and right carotid
anastamoses. Once antegrade right carotid flow is insti-
tuted, we then perform anastomoses of the graft
branches to the left CCA and vertebral arteries, without
interrupting flow to the right carotid. The hemoclips are
then removed to restore flow through the left CCA and
vertebral arteries. Pulsatile flow is confirmed and the
wounds are closed.
Author Disclosures: R. Faizer: Nothing to disclose; C. S.
Hupp: Nothing to disclose; J. Quick: Nothing to disclose.
SS27.
The Risk of Carotid Artery Stenting Compared with
Carotid Endarterectomy Is Greatest in Patients Treated
within Seven Days of Symptoms
Barbara Rantner1, Georg Goebel2, Leo Bonati3, Gustav
Fraedrich1. 1Department of Vascular Surgery, Innsbruck
Medical University, Innsbruck, Austria; 2Department of
Medical Statistics, Informatics and Health Economics,
Innsbruck Medical University, Innsbruck, Austria; 3De-
partment of Neurology and Stroke Unit, University Hos-
pital Basel, Basel, Switzerland
Objectives: Among patients with symptomatic carotid
stenosis, carotid artery stenting (CAS) is associated with a
higher risk of peri-procedural stroke or death than carotid
endarterectomy (CEA). Uncertainty remains whether the
balance of risks changes with time since the most recent
ischemic event.
Methods: We investigated the association of time
since the qualifying event (0-7 days, 8-14 days, and 14
days after the qualifying event) with the risk of stroke or
death within 30 days after CAS or CEA in a pooled
analysis of data from individual patients randomised in
the Endarterectomy vs Angioplasty in patients with
Symptomatic Severe Carotid Stenosis trial (EVA-3S), the
Stent-Protected Angioplasty versus Carotid Endarterec-
tomy trial (SPACE), and the International Carotid
Stenting Study (ICSS).
Results: Timing information was available for 2839
patients. In the first 30 days after intervention, any stroke or
death occurred significantly more often in the CAS group
(110 [7.7%] of 1434) compared to the CEA group (54
[3.8%] of 1405, crude risk ratio 2.0 [95% CI 1.5-2.7]. The
timing of the intervention modified the treatment benefit:
early treated CEA patients.
Conclusions:The increase in risk of CAS comparedwith
CEA appears greatest in patients treated within 7 days of
symptoms. This effect is also apparent independent of age.
Author Disclosures: L. Bonati: Nothing to disclose; G.
Fraedrich: Nothing to disclose; G. Goebel: Nothing to
disclose; B. Rantner: Nothing to disclose.
SS28.
The Size of Juxtaluminal Black Area in Ultrasonic
Images of Asymptomatic Carotid Plaques Predicts the
Occurrence of Stroke
Stavros K. Kakkos, Maura B. Griffin, Andrew N. Nico-
laides, Efthyvoulos C. Kyriacou, Michael M. Sabetai,
Thomas J. Tegos, George Geroulakos. Imperial College,
London, London, United Kingdom
Objectives: It has been suggested that a juxtaluminal
black (hypoechoic) area (JBA) in ultrasonic images of
asymptomatic carotid artery plaques is associated with a
lipid core close to the lumen or a thrombus on the plaque
surface. The aim of our study was to test the hypothesis that
JOURNAL OF VASCULAR SURGERY
June Supplement 201284S Abstracts
the presence and size of JBA predicts future ipsilateral
ischemic stroke.
Methods: JBAwas defined as an area of pixels with gray
scale value 25 adjacent to the lumen without a visible
echogenic cap, after image normalization. The size of a JBA
was measured in the carotid plaque images of 1121 patients
with asymptomatic carotid stenosis 50-99% in relation to
the bulb (ACSRS study), followed-up for up to 8 years.
Results: JBA had a linear association with future stroke
rate. The area under the ROC curve was 0.816. Using
Kaplan Meier curves, the mean annual stroke rate was 0.4%
in 706 patients with JBA 4 mm2; it was 1.4% in 171
patients with JBA 4-8 mm2, 3.2% in 46 patients with JBA
8-10 mm2 and 5% in 198 patients with JBA 10 mm2 (P
.001). In a Cox model with ipsilateral ischemic events
(AF, TIA or stroke) as the dependent variable, JBA (4,
4-8,8) was still significant after adjusting for other plaque
features known to be associated with increased risk (steno-
sis, GSM, presence of discrete white areas without acoustic
shadowing (DWA) indicating neovascularization, plaque
area and history of contralateral TIA or stroke. Plaque area
and gray scale median (GSM) were not significant. Using
the significant variables (stenosis, DWA, JBA and history of
contralateral TIA or stroke), this model predicted the an-
nual risk of stroke (range 0.5-10.0%). The average annual
stroke risk was 1% in 734 patients, 1-1.9% in 94, 2-3.9%
in 134, 4-5.9% in 125 and 6-10% in 34.
Conclusions: The size of JBA is linearly related to the
risk of stroke and can be used in risk stratification models.
These findings need to be confirmed in future prospective
studies or in the medical arm of randomized controlled
studies in the presence of optimal medical therapy.
Author Disclosures: G. Geroulakos: Nothing to disclose;
M. B. Griffin: Nothing to disclose; S. K. Kakkos: Noth-
ing to disclose; E. C. Kyriacou: Nothing to disclose; A. N.
Nicolaides: Nothing to disclose; M. M. Sabetai: Nothing
to disclose; T. J. Tegos: Nothing to disclose.
SS29.
The Hemodynamic Impact of Balloon Angioplasty in
Multiple Sclerosis Patients with Chronic Cerebrospinal
Venous Insufficiency
Manish Mehta, R. Clement Darling, Sean P. Roddy, Paul
B. Kreienberg, John B. Taggert, Kathleen J. Ozsvath, Jorge
Rey, Dhiraj M. Shah. The Institute for Vascular Health and
Disease, Albany Medical College/Albany Medical Center
Hospital, Albany, NY
Objectives: Recently an association has been made
between Multiple Sclerosis (MS) and Chronic Cerebrospi-
nal Venous Insufficiency (CCSVI) characterized by stenosis
and reflux of the principal extracranial venous drainage
including the Internal Jugular veins (IJV) and the Azygous
veins (AZV). This is the first angiographic study to quanti-
tatively analyze the impact of percutaneous balloon angio-
plasty (PTA) on flow dynamics across these lesions.
Methods: 50 IJV formMS patients with CCSVI and 12
IJV from healthy volunteers underwent detailed angiographic
evaluation. Technical components of all venogramswere stan-
dardized. Quantitative analysis included the contrast time of
flight (TOF) from the mid IJV to the superior vena cava, and
the primary venous emptying time (PVET), quantified as
50% of venous emptying, from the IJV. The TOF and
PVET were recorded in patients with CCSVI prior and sub-
sequent to balloon angioplasty, as well in normal healthy
subjects. All data was prospectively collected, and statistical
analysis was performed using two-tailed Student’s test.
Results: Of the 50 CCSVI-MS patients with IJV ste-
nosis 70% and reflux underwent balloon angioplasty,
technical success defined as20% residual IJV stenosis was
achieved in 78% (44/50). The Table describes the pre and
post angioplasty TOF and PVET in patients with CCSVI,
as well as in healthy non-MS patients without any treat-
ment. CCSVI patients were noted to have a significant
improvement in both the TOF and PVET following bal-
loon angioplasty that paralleled healthy non-MS subjects.
Conclusions: Results of this prospective pilot study
suggest an association between MS and CCSVI, which
results in abnormally elevated TOF and PEVT through the
IJV. Furthermore, balloon angioplasty these lesions im-
proves the hemodynamic parameters that are comparable
to healthy non-MS patients.
Table.
MS patients with CCSVI
Healthy
Non-MS
Pre-
angioplasty
Post-
angioplasty
No
treatment
TOF PVET TOF PEVT TOF PEVT P value
Mean time (sec.) 5.28 12.45 2.45 6.44 2.33 6.10 .001
St. dev. 2.52 10.0 0.79 2.05 0.42 0.58
Author Disclosures: R. Darling: Nothing to disclose;
P. B. Kreienberg: Nothing to disclose; M. Mehta: Noth-
ing to disclose; K. J. Ozsvath: Nothing to disclose; J. Rey:
Nothing to disclose; S. P. Roddy: Nothing to disclose;
D. M. Shah: Nothing to disclose; J. B. Taggert: Nothing
to disclose.
R1: Rapid Paced Paper Session I
RR1.
Safety of Carotid Stenting (CAS) Is Based on the
Center Experience More than on the Individual Perfor-
mance
Gianbattista Parlani1, Paola De Rango1, Fabio Verzini1,
Enrico Cieri1, Gioele Simonte1, Piergiorgio Cao2. 1Vascu-
lar and Endovascular Surgery; University of Perugia, Peru-
gia, Italy; 2Vascular Surgery, Hospital S. Camillo Forlanini,
Rome, Italy
JOURNAL OF VASCULAR SURGERY
Volume 55, Number 1S Abstracts 85S


SS28. The Size of Juxtaluminal Black Area in Ultrasonic Images of Asymptomatic Carotid Plaques Predicts the Occurrence of Stroke 

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SS28. The Size of Juxtaluminal Black Area in Ultrasonic Images of Asymptomatic Carotid Plaques Predicts the Occurrence of Stroke

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