Abstract DGG

myotomy


Materials and methods:
Contrast enhanced Computed Tomography (CT) revealed a giant aneurysm of the proximal and middle left subclavian artery with a maximum diameter of 5.5cm. Due to the proximal extent of the aneurysm open surgical repair would have required a re-re sternotomy approach which was considered technically very high risk.
Likewise complete endovascular exclosure was deemed uncertain due to the large size and proximal extent of the aneurysm without an adequate proximal landing zone.
We opted therefore for an alternative indirect hybrid approach combining a thoracic aortic stent graft (TEVAR) covering the aortic origin left subclavian artery and left carotid-subclavian bypass as well as transposition of the left vertebral artery into the left common carotid artery for aneurysm exclusion.
First a 28x40mm Relay Pro aortic stent graft (Terumo Aortic, UK) was implanted in the distal aortic arch for proximal closure of the aneurysm. Next the left common carotid as well as the left vertebral artery were exposed via a left cervical incision and transposition of the left vertebral artery into the left common carotid artery was performed, facilitating save ligation of the proximal left vertebral artery arising from the aneurysm. Finally the distal left subclavian artery was exposed via a separate infraclavicular incision. A 8 mm Dacron prosthesis was anastomosed in an end-to-end fashion to the distal subclavian artery creating a carotid-subclavian bypass. The distal end of the mid left subclavian artery was ligated thereby completing aneurysm exclusion.

Results:
The patient had an uneventful postoperative course and was discharged at post-operative day six. A control CT prior hospital discharge showed sufficient exclosure of the subclavian aneurysm and  Popliteal artery entrapment syndrome (PAES) is an important differential diagnosis in young patients with intermittent claudication and without atherosclerotic risk factors. The aim of this systematic review was to put a light on the revascularization techniques to treat PAES and report the patency and reintervention rates in this patients' group.

Materials and methods:
Multiple databases; Pubmed, Embase, Web of Science, Scopus and were searched for studies, case series, prospective trials, retrospective studies and randomized controlled trials. Case reports or series, prospective and retrospective studies reporting treatment of poplitea artery entrapment syndrome in any age-group reporting surgical treatment and atleast one follow-up after discharge were included. Book chapters, Books, Conference papers, Review articles and studies not providing any follow-up data, studies not available in English and studies with only abstracts were identified and excluded from the review. Studies reporting treatment of PAES with only Botulinum toxin injection were excluded.

Results:
A total of 41 studies matched the criteria. Age of patients ranged from 7-67 years. Symptoms ranged from claudication to rest pain and lesions. Duration of symptoms ranged from 1-2100 months. Typ 2 PAES was most commonly reported. Posterior approach was the preferred. Operative techniques were myotomy with or without revascularization, which was carried out with bypass or local endarterectomy and patch reconstruction of the artery. Follow-up range was 1-207 months. The 1- year, 3-Y and 5-Y patency rates ranged from 84.6-100%, 74.6-100% and 74.6-100% respectively.
Secondary patency at 2-Y was 100%. Less than 20% patients require redo surgery within 5 years. All patients undergoing local TEA and patch reconstruction without myotomy failed during the follow-up period. Failed bypass resulted in amputation in a few.