Disease pattern in cranial and large-vessel giant cell arteritis. (1/157)

OBJECTIVE: To identify variables that distinguish large-vessel giant cell arteritis (GCA) with subclavian/axillary/brachial artery involvement from cranial GCA. METHODS: Seventy-four case patients with subclavian/axillary GCA diagnosed by angiography and 74 control patients with temporal artery biopsy-proven GCA without large vessel involvement matched for the date of first diagnosis were identified. Pertinent initial symptoms, time delay until diagnosis, and clinical symptoms, as well as clinical and laboratory findings at the time of diagnosis, were recorded by retrospective chart review. Expression of cytokine messenger RNA in temporal artery tissue from patients with large-vessel and cranial GCA was determined by semiquantitative polymerase chain reaction analysis. Distribution of disease-associated HLA-DRB1 alleles in patients with aortic arch syndrome and cranial GCA was assessed. RESULTS: The clinical presentation distinguished patients with large-vessel GCA from those with classic cranial GCA. Upper extremity vascular insufficiency dominated the clinical presentation of patients with large-vessel GCA, whereas symptoms related to impaired cranial blood flow were infrequent. Temporal artery biopsy findings were negative in 42% of patients with large-vessel GCA. Polymyalgia rheumatica occurred with similar frequency in both patient groups. Large-vessel GCA was associated with higher concentrations of interleukin-2 gene transcripts in arterial tissue and overrepresentation of the HLA-DRB1*0404 allele, indicating differences in pathogenetic mechanisms. CONCLUSION: GCA is not a single entity but includes several variants of disease. Large-vessel GCA produces a distinct spectrum of clinical manifestations and often occurs without involvement of the cranial arteries. Large-vessel GCA requires a different approach to the diagnosis and probably also to treatment.  (+info)

Improved results with conventional management of infrarenal aortic infection. (2/157)

PURPOSE: Interest in alternative methods, such as autogenous vein grafts and aortic allografts, for the management of infrarenal aortic infection (IRAI) has been stimulated by the historically disappointing results with conventional surgical management. Recently, there have been dramatic improvements in the results of axillofemoral bypass grafting (AXFB) followed by excision of the IRAI that have gone relatively unrecognized. The purpose of this report is the presentation of modern-day results in the treatment of IRAI with conventional surgical methods. METHODS: From January 1, 1983, through June 30, 1998, patients with IRAI underwent treatment with AXFB and complete excision of the IRAI. The patients were followed for survival, limb salvage, and AXFB graft patency. The results were tabulated with life-table methods. RESULTS: During the 15-year study period, 60 patients (51 men, nine women; mean age, 68 years) underwent treatment for IRAI (50 graft infections, including 16 graft-enteric fistulae, and 10 primary aortic infections). The mean follow-up period was 41 months. The perioperative mortality rate was 13% (12% for graft infection, and 20% for primary infection). The overall 2-year and 5-year survival rates were 67% and 47%, respectively. The limb salvage rates at 2 and 5 years were 93% and 82%, respectively. The 5-year primary AXFB graft patency rate was 73%. CONCLUSION: These results show an improvement with the conventional management of IRAI equal or superior to those results reported with alternative methods, including femoral vein grafts or aortic allografts. These results should be regarded as the modern standard with which alternative therapies can be compared.  (+info)

Unilateral antegrade cerebral perfusion through the right axillary artery provides uniform flow distribution to both hemispheres of the brain: A magnetic resonance and histopathological study in pigs. (3/157)

BACKGROUND: Bilateral antegrade cerebral perfusion (ACP) has decreased in popularity over the past decade because of its complexity and the risk of cerebral embolism. We used magnetic resonance (MR) perfusion imaging to assess flow distribution in both hemispheres of the brain during unilateral ACP through the right carotid artery via a cannula placed in the right axillary artery in conjunction with hypothermic circulatory arrest. METHODS AND RESULTS: Twelve pigs were randomly exposed to 120 minutes of either bilateral ACP through both carotid arteries (n=6) or unilateral ACP through the right axillary artery (n=6) at pressures of 60 to 65 mm Hg at 15 degrees C, followed by 60 minutes of cardiopulmonary bypass at 37 degrees C. MR perfusion images were acquired every 30 minutes before, during, and after ACP. The brain was perfusion fixed for histopathology. During initial normothermic cardiopulmonary bypass, MR perfusion imaging showed a uniform distribution of flow in the brain. In both the bilateral and unilateral ACP groups, the same pattern was maintained, with an increase in regional cerebral blood volume during ACP and reperfusion. The changes in regional cerebral blood volume and mean transit time were similar in both hemispheres during and after unilateral ACP. No difference was observed between the 2 groups. Histopathology showed normal morphology in all regions of the brain in both groups. CONCLUSIONS: Both bilateral ACP and unilateral ACP provide uniform blood distribution to both hemispheres of the brain and preserve normal morphology of the neurons after prolonged hypothermic circulatory arrest.  (+info)

Comparative evaluation of externally supported Dacron and polytetrafluoroethylene prosthetic bypasses for femorofemoral and axillofemoral arterial reconstructions. Veterans Affairs Cooperative Study #141. (4/157)

PURPOSE: Currently, the choice of a vascular prosthesis for an extra-anatomic arterial bypass graft is left to the surgeon's preference because well-designed comparative evaluations have not been performed. The Department of Veterans Affairs Cooperative Study 141 was organized to identify whether there is improved patency with different prosthetic grafts for patients with femorofemoral or axillofemoral bypass grafts. METHODS: Between June 1983 and June 1988, patients at 20 Veterans Affairs Medical Centers who had aortoiliac occlusive disease but were not considered suitable candidates for aortic bypass surgery were randomized to receive either an externally supported polytetrafluoroethylene or Dacron bypass graft for an extra anatomic bypass. Doppler-derived ankle brachial indices (ABIs) were determined before the operation and serially after the operation. Patients were seen in follow-up every 3 months for the first year and every 6 months thereafter. All patients were instructed to take 650 mg of aspirin each day for the duration of the study. A bypass graft was considered to be patent if the Doppler-derived postoperative ABI remained significantly improved (0.15 units above the preoperative value), and additional clinical information (such as subsequent ABIs, angiograms, or operations) did not contradict these observations. RESULTS: Three hundred forty patients with femorofemoral bypass grafts and 79 patients with axillofemoral or axillofemorofemoral bypass grafts were randomized. The indication for the bypass operation was limb salvage in 72% of the patients. The assisted primary patency rate for a Dacron bypass grafting was 79% at 1 year, 63% at 3 years, and 50% at 5 years; for polytetrafluoroethylene bypass grafting, the patency was 77% at 1 year, 62% at 3 years, and 47% at 5 years. CONCLUSION: The overall results of this prospective randomized study suggest that the current choices of prosthetic bypass grafting have similar long-term patency in patients who undergo femorofemoral or axillofemoral vascular reconstruction.  (+info)

Axillary-to-carotid artery bypass grafting for symptomatic severe common carotid artery occlusive disease. (5/157)

PURPOSE: Revascularization of the internal or external carotid arteries is occasionally indicated for symptomatic atherosclerotic common carotid artery occlusion or long-segment high-grade stenosis beginning at its origin. I report the outcome of axillary artery-based bypass grafts to the distal common, internal, or external carotid arteries. METHODS: Between 1981 and 1997, 29 axillary-to-carotid bypass grafting procedures were performed on 28 patients, 15 men and 13 women, with a mean age of 68 years. Indications were transient ischemia in nine patients, amaurosis fugax in four patients, completed stroke in six patients, and nonlateralizing global ischemia in nine patients. Twenty-three common carotid arteries were totally occluded, and six had long-segment stenosis of 90% or greater beginning at the origin. Saphenous vein grafts were used in 25 procedures, and synthetic grafts were used in four. Grafts were placed to 13 internal, eight distal common, and eight external carotid arteries. RESULTS: There were no perioperative deaths; one stroke occurred (3.4%). No lymphatic or peripheral nerve complications occurred. In a 1- to 11-year follow-up period (mean, 4.5 years), there were no graft occlusions, one restenosis of 50% or greater, and two restenoses of 70% or greater. The 1-year stenosis-free rate for 50% or greater stenosis was 93%, and the 5- and 10-year rates were 87%. No late ipsilateral strokes occurred. The 5- and 10-year survival rates were 64% and 28%, respectively. Coronary artery disease was the major cause of late mortality. CONCLUSION: Axillary-to-carotid bypass grafting for severe symptomatic common carotid occlusive disease is safe, well tolerated, durable, and effective in stroke prevention. There is a high late mortality rate because of coronary artery disease in patients with severe proximal common carotid occlusive disease.  (+info)

The long-term outcome after axillo-axillary bypass grafting for proximal subclavian artery disease. (6/157)

OBJECTIVES: to investigate the outcome of patients undergoing axillo-axillary bypass grafting for symptomatic subclavian artery stenoses or occlusions. DESIGN: retrospective case-note review and prospective review of patients available for follow-up. PATIENTS AND METHODS: sixteen patients had axillo-axillary grafts in a 17-year period. Ten patients were available for review and assessed clinically, by measurement of arm blood pressures, and by duplex scanning of their grafts. RESULTS: one patient died and three grafts occluded within 30 days of operation. Nine out of 10 grafts scanned were patent, with three further grafts clinically patent at death. Overall secondary patency was 75% at a combined median follow-up of 56 months (range 12-204 months). Recurrent symptoms occurred in two patients, one with an occluded graft and one with a patent graft. CONCLUSION: axillo-axillary bypass grafts give good long-term symptom-free results.  (+info)

Atypical aortic coarctation with resistant hypertension treated with axilloiliac artery bypass. (7/157)

A 68-year-old woman was found to have atypical coarctation of the aorta, accompanied by systolic hypertension of the upper extremities despite administration of five types of antihypertensive drugs. Since the systolic hypertension was resistant to the conventional antihypertensive therapy, axilloiliac artery bypass grafting with a subcutaneous tunnel was performed to alleviate the pressure gradient. Systolic blood pressure was successfully reduced and hypertension was controlled after surgery.  (+info)

Endovascular treatment of penetrating thoracic outlet arterial injuries. (8/157)

OBJECTIVES: to establish the feasibility of stent-graft treatment of penetrating thoracic outlet arterial injuries. DESIGN: prospective study. MATERIALS AND METHODS: forty-one patients with penetrating injuries to the carotid, subclavian and proximal axillary arteries admitted between August 1998 and May 1999 were studied. Patients requiring urgent surgical exploration for active bleeding (n=26) were excluded. Remaining patients underwent arteriography to assess suitability for stent-graft placement. After successful stent-graft treatment clinical and sonographic follow-up were done at 1 month and thereafter 3-monthly. RESULTS: of the 15 patients considered, 10 patients qualified for stent-graft treatment (seven male, three female, mean age 27 years). The vessels involved were subclavian artery (seven), carotid artery (two) and axillary artery (one). Seven had arteriovenous fistulae and three, pseudoaneurysms. Stent-graft treatment was successful in all 10 patients with no procedure-related complications. On mean follow-up of 7 months no complications were encountered. CONCLUSION: endovascular treatment shows promise as a treatment modality for thoracic outlet arterial injuries. Long-term follow-up is required for comparison to the results of standard surgical repair.  (+info)