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IP109. Clinical Significance of Reversal of Flow in the Vertebral Artery Identified on Cerebrovascular Duplex Ultrasound
JOURNAL OF VASCULAR SURGERY June Supplement 2016
90S Abstracts
Methods: Between 2002 and 2012, 607 patients underwent elective carotid endarterectomy in a vascular tertiary referral center, of which, 428 (70.51%) had Dacron patch closure. Results: Only eight patients returned with late Dacron patch reaction after a mean of 4.1 6 2.1 SD years (range, 18 months-7 years). Seven of eight patients underwent surgical reintervention, with one patient refusing surgical management. One patient had an interposition vein bypass. Three had vein patch repair. One required internal carotid artery (ICA) ligation, and two underwent débridement, with sternomastoid and omohyoid muscle covering of the patch. Stroke-free survival was 85.7% at 3 years, in the patients that underwent surgery. The patient who refused surgery developed a stroke, while the patient who required ligation of the ICA, developed a massive infarct and died. All patients showed evidence of foreign body reaction in pathologic examination with no pathological organism cultured from swabs or tissue harvested during surgery. Conclusions: Late inflammatory reaction from Dacron patch is a serious complication despite absence of infection. Careful clinical surveillance should be carried out after carotid reconstruction. Infection should be excluded first. Reconstruction with vein is recommended. Ligation alone was associated with stroke. Débridement with sternomastoid and omohyoid muscle covering of the patch may be a good alternation to extensive surgical treatment in high risk patients after exclusion of infection. Author Disclosures: M. Alawy: Nothing to disclose; N. Hynes: Nothing to disclose; S. Sultan: Nothing to disclose; W. Tawfick: Nothing to disclose. IP109. Clinical Significance of Reversal of Flow in the Vertebral Artery Identified on Cerebrovascular Duplex Ultrasound Aleksandra Policha, MD1, Melissa Baldwin, MD1, Sheila N. Blumberg, MD, MS2, Caron B. Rockman, MD1, Glenn Jacobowitz, MD1, Mark Adelman, MD1, Thomas Maldonado, MD1. 1New York University Langone Medical Center, New York, NY; 2New York University Langone Medical Center, Brooklyn, NY Objectives: Reversal of flow in the vertebral artery is a common finding on cerebrovascular duplex ultrasound. The clinical significance and natural history of patients presenting with this finding, however, is poorly understood. Methods: A retrospective review was performed of all cerebrovascular duplex studies performed at our institution between January 2010 and January 2016. Individuals with reversal of flow in one or both vertebral arteries were included in the analysis. A total of 74 patients were thus included in our study. Results: Half of all study patients were male. Mean age at the time of the first ultrasound demonstrating vertebral flow reversal was 71 years (range, 27-92 years). The demographics of the patients were as follows: 83% had hypertension, 57% had hyperlipidemia, 30% were diabetic, 70% were current/former smokers, 40% had PAD, 50% had CAD, and 21% had a history of TIA/
CVA. Indications for the ultrasound were as follows: 44% screening/asymptomatic, 7% anterior circulation symptoms, 21% posterior circulation symptoms, 29% follow-up studies after cerebrovascular intervention, and 6% isolated upper extremity symptoms. At the time of the initial ultrasound, 21 patients (28%) had evidence of a prior unilateral/bilateral carotid intervention (CEA/CAS), 21 patients had evidence of moderate CAS (50%-79%) in at least one carotid artery, and 12 patients (16%) had evidence of severe CAS (>80%) in at least one carotid artery. The mean duration of followup was 28 6 22 months. Follow-up data were available for 63 patients (85%), including the 15 patients who presented with posterior circulation symptoms. Of these 15 patients, five underwent PTA/stenting of the SCA with resolution of symptoms. Three patients were awaiting SCA stenting, including one patient who presented symptomatic after occlusion of a previously placed SCA stent. Three patients underwent CEA with resultant improvement in posterior circulation symptoms. Finally, two patients were lost to follow-up, one patient was deemed too high risk for intervention, and one patient was found to have an alternate etiology for symptoms. The remaining 59 patients continued to be asymptomatic during the follow-up period. One patient progressed to vertebral artery occlusion, and six patients had progression of their CAS during this interval. Conclusions: Symptomatic reversal of flow in the vertebral artery responds well to intervention, including SCA stenting and carotid intervention (CEA/CAS) in patients with anterior circulation symptoms. The majority of patients with this finding are asymptomatic at the time of presentation. Although progression of vertebral artery disease is rare, these patients should be monitored for progression of CAS with surveillance ultrasonography. Author Disclosures: M. Adelman: Nothing to disclose; M. Baldwin: Nothing to disclose; S. N. Blumberg: Nothing to disclose; G. Jacobowitz: Nothing to disclose; T. Maldonado: Nothing to disclose; A. Policha: Nothing to disclose; C. B. Rockman: Nothing to disclose. IP111. A Parallel Observational Comparative Study of Cervical Carotid Artery Stenting Approach vs Groin Approach vs Carotid Endarterectomy in High-Risk Patients: A 12 Years’ Experience Sherif Sultan, MD, MB1, Wael Tawfick, MD2, Niamh Hynes, MD2. 1Department of Vascular Surgery and Endovascular Surgery, Galway University Hospital, Galway, Ireland; 2Western Vascular Institute, Galway, Ireland Objectives: Studies advocate approach technique in CAST may be pivotal in reducing perioperative stroke. Aims: To compare CEA to transfemoral carotid artery (F-CAST) and transcervical carotid artery (C-CAST) regarding clinical success in high-risk patients, efficacy in decreasing morbidity and mortality. Composite primary end points included stroke, MI, and death. Secondary end points included patency and reintervention rates.
90S Abstracts
Methods: Between 2002 and 2012, 607 patients underwent elective carotid endarterectomy in a vascular tertiary referral center, of which, 428 (70.51%) had Dacron patch closure. Results: Only eight patients returned with late Dacron patch reaction after a mean of 4.1 6 2.1 SD years (range, 18 months-7 years). Seven of eight patients underwent surgical reintervention, with one patient refusing surgical management. One patient had an interposition vein bypass. Three had vein patch repair. One required internal carotid artery (ICA) ligation, and two underwent débridement, with sternomastoid and omohyoid muscle covering of the patch. Stroke-free survival was 85.7% at 3 years, in the patients that underwent surgery. The patient who refused surgery developed a stroke, while the patient who required ligation of the ICA, developed a massive infarct and died. All patients showed evidence of foreign body reaction in pathologic examination with no pathological organism cultured from swabs or tissue harvested during surgery. Conclusions: Late inflammatory reaction from Dacron patch is a serious complication despite absence of infection. Careful clinical surveillance should be carried out after carotid reconstruction. Infection should be excluded first. Reconstruction with vein is recommended. Ligation alone was associated with stroke. Débridement with sternomastoid and omohyoid muscle covering of the patch may be a good alternation to extensive surgical treatment in high risk patients after exclusion of infection. Author Disclosures: M. Alawy: Nothing to disclose; N. Hynes: Nothing to disclose; S. Sultan: Nothing to disclose; W. Tawfick: Nothing to disclose. IP109. Clinical Significance of Reversal of Flow in the Vertebral Artery Identified on Cerebrovascular Duplex Ultrasound Aleksandra Policha, MD1, Melissa Baldwin, MD1, Sheila N. Blumberg, MD, MS2, Caron B. Rockman, MD1, Glenn Jacobowitz, MD1, Mark Adelman, MD1, Thomas Maldonado, MD1. 1New York University Langone Medical Center, New York, NY; 2New York University Langone Medical Center, Brooklyn, NY Objectives: Reversal of flow in the vertebral artery is a common finding on cerebrovascular duplex ultrasound. The clinical significance and natural history of patients presenting with this finding, however, is poorly understood. Methods: A retrospective review was performed of all cerebrovascular duplex studies performed at our institution between January 2010 and January 2016. Individuals with reversal of flow in one or both vertebral arteries were included in the analysis. A total of 74 patients were thus included in our study. Results: Half of all study patients were male. Mean age at the time of the first ultrasound demonstrating vertebral flow reversal was 71 years (range, 27-92 years). The demographics of the patients were as follows: 83% had hypertension, 57% had hyperlipidemia, 30% were diabetic, 70% were current/former smokers, 40% had PAD, 50% had CAD, and 21% had a history of TIA/
CVA. Indications for the ultrasound were as follows: 44% screening/asymptomatic, 7% anterior circulation symptoms, 21% posterior circulation symptoms, 29% follow-up studies after cerebrovascular intervention, and 6% isolated upper extremity symptoms. At the time of the initial ultrasound, 21 patients (28%) had evidence of a prior unilateral/bilateral carotid intervention (CEA/CAS), 21 patients had evidence of moderate CAS (50%-79%) in at least one carotid artery, and 12 patients (16%) had evidence of severe CAS (>80%) in at least one carotid artery. The mean duration of followup was 28 6 22 months. Follow-up data were available for 63 patients (85%), including the 15 patients who presented with posterior circulation symptoms. Of these 15 patients, five underwent PTA/stenting of the SCA with resolution of symptoms. Three patients were awaiting SCA stenting, including one patient who presented symptomatic after occlusion of a previously placed SCA stent. Three patients underwent CEA with resultant improvement in posterior circulation symptoms. Finally, two patients were lost to follow-up, one patient was deemed too high risk for intervention, and one patient was found to have an alternate etiology for symptoms. The remaining 59 patients continued to be asymptomatic during the follow-up period. One patient progressed to vertebral artery occlusion, and six patients had progression of their CAS during this interval. Conclusions: Symptomatic reversal of flow in the vertebral artery responds well to intervention, including SCA stenting and carotid intervention (CEA/CAS) in patients with anterior circulation symptoms. The majority of patients with this finding are asymptomatic at the time of presentation. Although progression of vertebral artery disease is rare, these patients should be monitored for progression of CAS with surveillance ultrasonography. Author Disclosures: M. Adelman: Nothing to disclose; M. Baldwin: Nothing to disclose; S. N. Blumberg: Nothing to disclose; G. Jacobowitz: Nothing to disclose; T. Maldonado: Nothing to disclose; A. Policha: Nothing to disclose; C. B. Rockman: Nothing to disclose. IP111. A Parallel Observational Comparative Study of Cervical Carotid Artery Stenting Approach vs Groin Approach vs Carotid Endarterectomy in High-Risk Patients: A 12 Years’ Experience Sherif Sultan, MD, MB1, Wael Tawfick, MD2, Niamh Hynes, MD2. 1Department of Vascular Surgery and Endovascular Surgery, Galway University Hospital, Galway, Ireland; 2Western Vascular Institute, Galway, Ireland Objectives: Studies advocate approach technique in CAST may be pivotal in reducing perioperative stroke. Aims: To compare CEA to transfemoral carotid artery (F-CAST) and transcervical carotid artery (C-CAST) regarding clinical success in high-risk patients, efficacy in decreasing morbidity and mortality. Composite primary end points included stroke, MI, and death. Secondary end points included patency and reintervention rates.