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Superiority of the left brachial artery to the femoral approach in percutaneous transluminal angioplasty
Session 1
0800-1130
Monday,September 11,1995
Endovascular Techniques Room B-1 1.1
Endovascular Femoral-Popliteal Bypass: Animal Studies S.S. AHN, B. CONCEPCION, V.A. REGER, T.L. KAIURA, S.D. NELSON, G.E. MORRIS, D. DEA TON and R. BOCK, Log Angeles, California, USA The endovascular femoral-popliteal bypass procedure is the semi-closed placement of a PTFE Gore-Tex graft in the femoral-popliteal position through a single groin incision. We tested this technique in 11 dogs between December 1993 and October 1994. We performed the procedure unilaterally in the first 6 dogs, and both conventional and endovascular femoralpopliteal bypass procedures bilaterally in 5 dogs. We successfully placed the grafts in all 16 limbs. Completion angiograms revealed defects in 4 endovascular femoral-popliteal bypass grafts: a longitudinal narrowing near the distal end of the graft due to a size mismatch in 3 limbs, and a small intimal flap at the distal end in one. Estimated blood loss and operative time ranged from 400 to 1000 ml (mean 694 ml) and 1.5-4.5 h (mean 2.6 h), respectively, for the endovascular femoralpopliteal procedures; and 150 to 800 ml (mean 358 ml) and 1.0--2.75 h (mean 1.79 h) for the conventional procedures. The mean patency rates were 35 days (range 1-98 days) for the endovascular femoral-popliteal bypass, and 52 days (4-98 days) for the conventional bypass. Although our results from the endovascular bypass procedure were generally worse than from the conventional bypass, we were able to improve significantly the outcome of the last 3/4 endovascular femoralpopliteal bypass procedures, whose mean patency rate was 85 days (range 64-98 days), mean estimated blood loss 517 ml (range 400-750 mm), and mean operative time 1.7 h (range 1.5-2 h); in contrast to the first four endovascular femoralpopliteal bypass procedures whose mean patency rate was 5 days (range 1-9 days), mean estimated blood loss 825 ml (range 600-1000 ml), and mean operative time 3.5 h (range 2.5-4.5 h). We conclude that endovascular femoral-popliteal bypass is feasible but has a steep learning curve for success. Human trials are currently in progress. Further refinement of the techniques may be needed to improve the durability and efficacy of this procedure. 1.2 Superiority of the Left Brachial Artery to the Femoral
Approach in Percutaneous Transluminal Angioplasty S. TANABE, E. SANO, M. WOO, T. MAESHIRO, H. MATSUNAGA, M. OHTSUKA, Y. AWANE, H. KIYAMA, N. OHSHIMA, M. YOKOYAMA, T. IMAZEKI and T. YAMADA, Tokyo and Saitama, Japan We consider that the brachial approach for percutaneous transluminal angioplasty (PTA) has advantages over a femoral approach. Over the last three years we performed PTA via the left brachial artery in 12 cases. We punctured and introduced a 5-French sheath catheter into the left brachial artery. A
CARDIOVASCULAR SURGERY SEPTEMBER 1995
ultrathin balloon dilatation catheter 120 cm long can be inserted through this sheath if the diameter of the balloon is 7 mm or less. No major complications of PTA were encountered and the results were excellent. PTA normalized the blood pressure and plasma renin activity in two patients with renovascular hypertension. A 71-year-old male with a stenotic SMA who had had two previous surgical anastomotic failures was cured by PTA. There were nine patients with arteriosclerosis obliterans (ASO) in which three bilateral and six unilateral iliacofemorai arteries were involved. PTA was successful in eight, the exception being a 74-year-old male patient in whom we failed to pass the balloon catheter through the stenotic left iliofemoral region. This was due to a tortuous left subclavian artery and aorta in this patient. The 5-French catheter was too soft to reach into the femoral artery across such a long and tortuous route. Usually the splanchnic arteries branch off the aorta at an obtuse angle and it is easy to introduce a catheter into these arteries down the aorta and to hold the balloon catheter in the right position. The catheter is long enough to treat the distal superficial femoral artery. We can dilate bilateral iliofemoral lesions in a single PTA. The patient can walk immediately after PTA whilst the punctured artery is compressed. Compression of the puncture site may reduce blood flow in the angioplastied artery in a retrograde PTA by the femoral approach. In summary, the left brachial artery is a site of choice for PTA catheter insertion.
1.3
Endoluminal Balloon Occlusion Technique for Arterial Blowout from Cervical Arteries Y. SAKAKIBARA, K. KURAMOTO, T. JIKUYA, Y. TERADA, N. ATSUMI and T. MITSUI, Ibaraki, Japan Head and neck surgeons have recently adopted a more aggressive surgical approach to advanced cervical cancers. High incidences of local recurrence and the presence of gross infection may in some cases lead to the rupture of cervical arteries. Although urgent surgical treatment is required in these situations, high incidences of neurological deficit and mortality have been reported as serious problems in these cascs. We recently introduced an endoluminal balloon occlusion technique in three cases of sudden blowout of cervical arteries. In addition to the control of hemorrhage by a balloon occlusion catheter (5 Fr, balloon size: 8-10 mm) injected through the femoral artery, intra-cranial cross filling could be examined angiographically by the injection of contrast medium from a separate catheter placed in the opposite carotid artery. The level of consciousness could be directly confirmed with unilateral carotid occlusion. With the aid of this technique, ruptured cervical arteries have been successfully repaired without excessive blood loss or serious thought to neurological complication. Coverage by a myocutaneous flap has been routinely employed in these cases. The advantages of this technique can be summarized as
1
0800-1130
Monday,September 11,1995
Endovascular Techniques Room B-1 1.1
Endovascular Femoral-Popliteal Bypass: Animal Studies S.S. AHN, B. CONCEPCION, V.A. REGER, T.L. KAIURA, S.D. NELSON, G.E. MORRIS, D. DEA TON and R. BOCK, Log Angeles, California, USA The endovascular femoral-popliteal bypass procedure is the semi-closed placement of a PTFE Gore-Tex graft in the femoral-popliteal position through a single groin incision. We tested this technique in 11 dogs between December 1993 and October 1994. We performed the procedure unilaterally in the first 6 dogs, and both conventional and endovascular femoralpopliteal bypass procedures bilaterally in 5 dogs. We successfully placed the grafts in all 16 limbs. Completion angiograms revealed defects in 4 endovascular femoral-popliteal bypass grafts: a longitudinal narrowing near the distal end of the graft due to a size mismatch in 3 limbs, and a small intimal flap at the distal end in one. Estimated blood loss and operative time ranged from 400 to 1000 ml (mean 694 ml) and 1.5-4.5 h (mean 2.6 h), respectively, for the endovascular femoralpopliteal procedures; and 150 to 800 ml (mean 358 ml) and 1.0--2.75 h (mean 1.79 h) for the conventional procedures. The mean patency rates were 35 days (range 1-98 days) for the endovascular femoral-popliteal bypass, and 52 days (4-98 days) for the conventional bypass. Although our results from the endovascular bypass procedure were generally worse than from the conventional bypass, we were able to improve significantly the outcome of the last 3/4 endovascular femoralpopliteal bypass procedures, whose mean patency rate was 85 days (range 64-98 days), mean estimated blood loss 517 ml (range 400-750 mm), and mean operative time 1.7 h (range 1.5-2 h); in contrast to the first four endovascular femoralpopliteal bypass procedures whose mean patency rate was 5 days (range 1-9 days), mean estimated blood loss 825 ml (range 600-1000 ml), and mean operative time 3.5 h (range 2.5-4.5 h). We conclude that endovascular femoral-popliteal bypass is feasible but has a steep learning curve for success. Human trials are currently in progress. Further refinement of the techniques may be needed to improve the durability and efficacy of this procedure. 1.2 Superiority of the Left Brachial Artery to the Femoral
Approach in Percutaneous Transluminal Angioplasty S. TANABE, E. SANO, M. WOO, T. MAESHIRO, H. MATSUNAGA, M. OHTSUKA, Y. AWANE, H. KIYAMA, N. OHSHIMA, M. YOKOYAMA, T. IMAZEKI and T. YAMADA, Tokyo and Saitama, Japan We consider that the brachial approach for percutaneous transluminal angioplasty (PTA) has advantages over a femoral approach. Over the last three years we performed PTA via the left brachial artery in 12 cases. We punctured and introduced a 5-French sheath catheter into the left brachial artery. A
CARDIOVASCULAR SURGERY SEPTEMBER 1995
ultrathin balloon dilatation catheter 120 cm long can be inserted through this sheath if the diameter of the balloon is 7 mm or less. No major complications of PTA were encountered and the results were excellent. PTA normalized the blood pressure and plasma renin activity in two patients with renovascular hypertension. A 71-year-old male with a stenotic SMA who had had two previous surgical anastomotic failures was cured by PTA. There were nine patients with arteriosclerosis obliterans (ASO) in which three bilateral and six unilateral iliacofemorai arteries were involved. PTA was successful in eight, the exception being a 74-year-old male patient in whom we failed to pass the balloon catheter through the stenotic left iliofemoral region. This was due to a tortuous left subclavian artery and aorta in this patient. The 5-French catheter was too soft to reach into the femoral artery across such a long and tortuous route. Usually the splanchnic arteries branch off the aorta at an obtuse angle and it is easy to introduce a catheter into these arteries down the aorta and to hold the balloon catheter in the right position. The catheter is long enough to treat the distal superficial femoral artery. We can dilate bilateral iliofemoral lesions in a single PTA. The patient can walk immediately after PTA whilst the punctured artery is compressed. Compression of the puncture site may reduce blood flow in the angioplastied artery in a retrograde PTA by the femoral approach. In summary, the left brachial artery is a site of choice for PTA catheter insertion.
1.3
Endoluminal Balloon Occlusion Technique for Arterial Blowout from Cervical Arteries Y. SAKAKIBARA, K. KURAMOTO, T. JIKUYA, Y. TERADA, N. ATSUMI and T. MITSUI, Ibaraki, Japan Head and neck surgeons have recently adopted a more aggressive surgical approach to advanced cervical cancers. High incidences of local recurrence and the presence of gross infection may in some cases lead to the rupture of cervical arteries. Although urgent surgical treatment is required in these situations, high incidences of neurological deficit and mortality have been reported as serious problems in these cascs. We recently introduced an endoluminal balloon occlusion technique in three cases of sudden blowout of cervical arteries. In addition to the control of hemorrhage by a balloon occlusion catheter (5 Fr, balloon size: 8-10 mm) injected through the femoral artery, intra-cranial cross filling could be examined angiographically by the injection of contrast medium from a separate catheter placed in the opposite carotid artery. The level of consciousness could be directly confirmed with unilateral carotid occlusion. With the aid of this technique, ruptured cervical arteries have been successfully repaired without excessive blood loss or serious thought to neurological complication. Coverage by a myocutaneous flap has been routinely employed in these cases. The advantages of this technique can be summarized as
1