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the treatment outcomes of advanced atherosclerotic occlusive disease involving the aortic arch vessels and extracranial (ICA) carotid artery Outcome Analysis Early and late clinical procedural outcomes Stroke Cardiac-related morbidity Death Open versus Endovascular repair Duplex U/S to confirm repair site patency and presence of residual stenosis Need for secondary intervention Serial testing at 6-month intervals to monitor for atherosclerotic disease progression Z,$ Z' Z  ZL Z  ZW Zp4,' L  W  ` !;,|$JXp0"O P(  W   pe0e0e?Title 11Z$^  :2___PPT9  Q Study Design: ,    0e0e?,Content Placeholder 2Z$v RJ___PPT9,$ 12 year retrospective, chart review study 31 patients 16 men, 15 women Mean age: 69 yr Symptoms - Signs Neurologic (stroke, TIA, amarosis fugax) Upper extremity claudication Abnormal vascular finding on physical examination Decision for Surgery  all patients had CEA Symptomatic ICA stenosis(8); asymptomatic >70% ICA (23) Upper Extremity Claudication (10) High-grade CCA or distal 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H@B 0 s *1#"@PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!drs/downrev.xmlDAk1BCBom*[l ^zXf,L$uW}C<̛޷X 'qq nV۾ BD:&g ZލksIME2ᐣcK*CuvtbL'sʧ,J ~6V8^t_n˽ϳ]?|J= HCZA*\}K &%0?PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!drs/downrev.xmlPKZH@B 0 s *1#"@PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!drs/downrev.xmlDAk1BCBom*[l ^zXf,L$uW}C<̛޷X 'qq nV۾ BD:&g ZލksIME2ᐣcK*CuvtbL'sʧ,J ~6V8^t_n˽ϳ]?|J= HCZA*\}K &%0?PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!drs/downrev.xmlPKZ, H, @B 0 s *1#"@PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!drs/downrev.xmlDAk1BCBom*[l ^zXf,L$uW}C<̛޷X 'qq nV۾ BD:&g ZލksIME2ᐣcK*CuvtbL'sʧ,J ~6V8^t_n˽ϳ]?|J= HCZA*\}K &%0?PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!drs/downrev.xmlPKZ~ H~ @B 0 s *1#"@PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!drs/downrev.xmlDAk1BCBom*[l ^zXf,L$uW}C<̛޷X 'qq nV۾ BD:&g ZލksIME2ᐣcK*CuvtbL'sʧ,J ~6V8^t_n˽ϳ]?|J= HCZA*\}K &%0?PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!drs/downrev.xmlPKZZ @B 0 s *1#"@PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!drs/downrev.xmlDAk1BCBom*[l ^zXf,L$uW}C<̛޷X 'qq nV۾ BD:&g ZލksIME2ᐣcK*CuvtbL'sʧ,J ~6V8^t_n˽ϳ]?|J= HCZA*\}K &%0?PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!drs/downrev.xmlPKHH @B 0 s *1#"@PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!drs/downrev.xmlDAk1BCBom*[l ^zXf,L$uW}C<̛޷X 'qq nV۾ BD:&g ZލksIME2ᐣcK*CuvtbL'sʧ,J ~6V8^t_n˽ϳ]?|J= HCZA*\}K &%0?PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!drs/downrev.xmlPKZH@B 0 s *1#"@PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!drs/downrev.xmlDAk1BCBom*[l ^zXf,L$uW}C<̛޷X 'qq nV۾ BD:&g ZލksIME2ᐣcK*CuvtbL'sʧ,J ~6V8^t_n˽ϳ]?|J= HCZA*\}K &%0?PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!drs/downrev.xmlPKZ H  !;,|$JXp0y___PPT10Y+D=' = @B +"O  0--4(  4*  Txz 4C (Table 33" >j PK!^[Content_Types].xmlAN0EH] tA*ٓj2<&i˂E,-ZQy*@2:k}*da< us}UmYdCJAk6N8Af=UYi)!"-^@t+ S6ƕoQ9JBLVM\sUysnJ7U|Il2\PU&<.~[m'E;Vx PK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!sg.drs/e2oDoc.xmlZ[o8~_iip-Z Uֱ#P=v hdA3}"M\>;No?fDFT">/4,)}'mkA"SnV$ ¶5Q*l7!nDH8< `q1$"\aV,v`ʭG ف?g߶*m`T?­߅O  ї *:ţhqR" :%FrTm,VܬWmn:ۺJ,iSu *%Q/M=`TVIiNpKlQgWP-y;_jRW4 S+TzvpW/ N}W}"2MUQR__+eR$lwzRͱ!W6DmnT8Si{C[{/t.|:ID&\ 0˜sۂTpˈv$%&Tx$`F]$Fd#oʰM-Ց>\F"E7}p%~NV܂[/b{]yhc9 {Z08:\CM pz (NǝEJĽ4B`Sftke0k[h- 9-&lgC9LuITAkXJ +*1hdxjY *+C&]Qnl&pPÜ%bZɆArL<2θwtT. ;o .)M8 N K0$JE̦ahB]MRv:2©IDĿ \~6 g9Y~_\a5>.*`3LfG"O'MG#Q8Ne^1֩WDUsPI p}z 3ȵ "4rt'Tߘ:PK`H #>zj~/yą;C.pBΥZ!w)40AW਋P~J^D4wn(C} ^D3@ILbpm%ЗX9Gd(0"5ā5UE;pzT<&Ώ֏Ư@>cY"j{U9-D סNB@@_38tP2YKl&U\,OP>ҡjpYuFYfDпD|>o ZnW +PK-!^[Content_Types].xmlPK-!8! ,_rels/.relsPK-!sg.+drs/e2oDoc.xmlPK-!ܕodrs/downrev.xmlPKa Txz` 4 s *`"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!&<#drs/downrev.xmlDAO@&͘x14J˿go{@7<ĥ W ~6)5IvDM}^_@X.޷___PPT9  @Indications for Brachiocephalic Revascularization: Open vs. Endo4A @GG@@- 4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!Fdrs/downrev.xmlDMK1!El[֦ bA-.fn&koyۊ=8p3R g4O!"lϦXᐡ:.25Y #tbLWxܶV;iPcG5ͯпo0_y\ " yYTQK!χoC$$d rPK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!Fdrs/downrev.xmlPK N! NF>___PPT9  Subclavian Artery0 EE@' 4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!'VGdrs/downrev.xmlD]K@E e_nT-(bc@|ݍ;k{>;w83_8z [8JA|uZ`$l2T萅JD!t\d#y!F_Ipʛ$j豦b5ϒ?sU|X=43ߎO<^hRnor Dh rPK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!'VGdrs/downrev.xmlPK ! N NF>___PPT9   Open Surgical.  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NF>___PPT9  20 EE@  4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!mgdrs/downrev.xmlDAK1!f6-AM7ddv =7; rT n(X~<]܂ Yc(trz2R=iHFdؔRX[rG')`pɫ {zT VƼT_߯`fKφ; oidS֡sM%/PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!mgdrs/downrev.xmlPK  xNF>___PPT9  00 EE@3  4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK![drs/downrev.xmlDN0EH5H B !A*$}nO{&M X޹sufY1PgquˍDLgRp K폼a!KT`RK)cma8w{C#uc;+^:l9/PݭXuiV}}Bs]nA$`3jd}uڅV0& K6͖ PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-![drs/downrev.xmlPK ! NF>___PPT9  Subclavian Artery Aneurysm. 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Z NF>___PPT9  Innominate Artery0 EE@ 4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!7Ρdrs/downrev.xmlDMK1!ElVVMUDA,Xoff& =wx^|8cw qtõbz"DdcRpsz^ak rT`br)Cib8uccඕY -6 vlo~EQ|ُ.rTjx4Y_yFkɤz;|"%&KPK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!7Ρdrs/downrev.xmlPK ! q Z B:2___PPT9  Z E @ 4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!7Ρdrs/downrev.xmlDMK1!ElVVMUDA,Xoff& =wx^|8cw qtõbz"DdcRpsz^ak rT`br)Cib8uccඕY -6 vlo~EQ|ُ.rTjx4Y_yFkɤz;|"%&KPK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!7Ρdrs/downrev.xmlPK  qxZ B:2___PPT9  Z E @< 4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!>drs/downrev.xmlDAK1aͪ6-"CRm&n&$m Oe{q,vCF\;հP}drs/downrev.xmlPK Z ! NF>___PPT9  "Cerebral Embolization with >70% DR.# "EE"@ 4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!mgdrs/downrev.xmlDAK1!f6-AM7ddv =7; rT n(X~<]܂ Yc(trz2R=iHFdؔRX[rG')`pɫ {zT VƼT_߯`fKφ; oidS֡sM%/PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!mgdrs/downrev.xmlPK ! Z  NF>___PPT9  00 EE@ 4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!U@drs/downrev.xmlDAO1&fLɬԬBLt HL ۡ]w.mp7^t8pwGvW_ow b"%8tr}5R[aK`RKXGgRA tpCQ<C=կvs5|-0{xH+ dWQKM%PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!U@drs/downrev.xmlPK  Z x NF>___PPT9  20 EE@7 4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!2#drs/downrev.xmlDMK1!DM V.$k&vЃy-Fۉnp=U ȕ޴Pl@pDg4a1??anVtXZ$541\6d'1PKpHpn֥{zjܯxg;d___PPT9  Proximal Common Carotid Art0 EE@ 4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!7Ρdrs/downrev.xmlDMK1!ElVVMUDA,Xoff& =wx^|8cw qtõbz"DdcRpsz^ak rT`br)Cib8uccඕY -6 vlo~EQ|ُ.rTjx4Y_yFkɤz;|"%&KPK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!7Ρdrs/downrev.xmlPK !  B:2___PPT9  Z E @ 4 s * "PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!7Ρdrs/downrev.xmlDMK1!ElVVMUDA,Xoff& =wx^|8cw qtõbz"DdcRpsz^ak rT`br)Cib8uccඕY -6 vlo~EQ|ُ.rTjx4Y_yFkɤz;|"%&KPK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!7Ρdrs/downrev.xmlPK   x B:2___PPT9  Z E @3 4 s *@"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!gdrs/downrev.xmlDAK1!ElVZ֦ERZ ަifMb7  aT n(XߏAĄL Na6`tX%#2c lJ})e-9#nÔc0R|"ѐƋ/5 ɮ:mC%fK?PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!gdrs/downrev.xmlPK  ! NF>___PPT9  Embolization with >70% DR. EE@  4 s *`"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!U@drs/downrev.xmlDAO1&fLɬԬBLt HL ۡ]w.mp7^t8pwGvW_ow b"%8tr}5R[aK`RKXGgRA tpCQ<C=կvs5|-0{xH+ dWQKM%PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!U@drs/downrev.xmlPK !  NF>___PPT9  20 EE@ !4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!Py[drs/downrev.xmlDAK@!n`%v[ BE6NwdgݵMK -FgGu,qCF8ղzx,Ddcp N\qu  `b !Bcb8u;-)m/YXl9-PӭPvۏ,ׇFq Y1^k7U_^PLvy[Uc/d,APK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!Py[drs/downrev.xmlPK   x NF>___PPT9  10 EE@2 "4 s *"PK![Content_Types].xml|N0 HC+jS8 @:Q۸ ??\o<7p]V޷O(I'6E=, ){Ō4>I)q7UuDހǏ)}nL"Mᴸ&g0eSA)΄2';2 WYu7{ɯΒzŘqFrj9K*(]mOlPK!Z,[ _rels/.relslj0 ``t_Pƈ[>,dgzjǎ?I'f#®Pb-\/Ƿ0Z]nLnp__3.iJV KQBiDžrL,Vʌ/7р4`ANar+m;E/'3U Aںv83/PK!cz>drs/downrev.xmlDMk1ECxj]ej+ؑB~Pp&mّB4 x^l7`1zGa2܍t\%2蔺Xk#SAqE-4v4T7?+ VU}UCPFX>ݞ?fM_kyA-lλ`cpdl |PK-![Content_Types].xmlPK-!Z,[ _rels/.relsPK-!cz>drs/downrev.xmlPK  ! NF>___PPT9  Asymptomatic with >75% DR. 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hematomas No CEA-related adverse events (stroke, CN injury) Mean LOS: 3.5 days Symptoms of vertobrobasilar insufficiency or arm claudication improved or resolvedV $   $   ` !;,|$JXp0"$O  @(  @_ @  p0e0e?Title 1Z$^  :2___PPT9  YResults: Surveillance , 5 @  I0e0e?,Content Placeholder 2 vn___PPT9PH All patients had Duplex testing at 30 days 100% patency all repairs without evidence of stenosis (<50% DR) 28 pts--Enrollment to present day (16-44mos): 24 pts remain asymptomatic with patent nonstenotic repairs on duplex 3 pts report new symptoms: Amarosis s/p CEA/CCA-SCA bypass Dizziness s/p CEA/CCA-SCA bypass Dizziness s/p CEA/IA stent angioplasty Treatment: Medical therapy and observation 1 pt asymptomatic, high-grade >70% stenosis in distal CCA/SCA bypass - Rx with angioplasty at 8 & 24 mo. , @ . `  j  ,@.` j  ` @ dG/8cRight Brace 3#"]@QPK!Zf[Content_Types].xmlMO &2WR=cJ`F0iK`#̼vLw 9uSq:w`G ^i ½KI)c/ $oVjTMRc|}042ҥCƔM̏P~*ka/8^DkHbL8e i"K\XN\6rco4y@_;oPK!1_a _rels/.relsj0 ѽqCNo^K [ILcX&m߾0XFo;>0xM e`|X}đ I`߽N4aG2$RKIZ)4(M9`ctB{m:f@`3n|O,ܗr޾jxR0T ,0@}WBLǬ5vPK!ѯdrs/shapexml.xmlU_o0`ujCR*= Aǁ lنA?v MԖpɝݿmFZh,y~LU?=ޟ]s<`J,N:~;0:0%_zo,sb)[pH$]m ^"3V:<*C 733AeMUKZ6g# B<(# !ob[۶sO?(t]mWA(ڑ{U*z&A?zA`0 c&bᢒMx6c(2PTRH1}fD1_DyUYUrwG[7Jpe/@˺¿x21F~Nx))ۑv9SRے oC/ϗWh&kKN}I4 jCEJNjA0D*Y?|L]Фd/a#,P|I6td Y2Y T/ gFS;b$S۽?jjN;_Ss>n# S<(i%Vi&J1\ӌ_\ $l۬hEaEV '[Pͳ_ ;POu = oj1qd{{.cZk:9f5-jLNBp] ٍޥ=PK!bΒdrs/downrev.xmlDOO1&~x.A\)71!$<>݆mi ,z73Yo[qw kj_1il#g0^_M0tܤZ04)ujb{;,&:ᶕY6;*/Wg|dߊBۛ~ "QeT?B+x+?5DA㧌9PK-!Zf[Content_Types].xmlPK-!1_a /_rels/.relsPK-!ѯ*drs/shapexml.xmlPK-!bΒAdrs/downrev.xmlPKF 8 B:2___PPT9  T A  ) @ J ?TextBox 5 b B:2___PPT9  e <50% stenosis    !;,|$JXp0"fO D(  DS D  p0e0e?Title 1DZ$^  :2___PPT9  M Conclusions   S D  0e0e?,Content Placeholder 2Z$^ :2___PPT9  +Single-stage intervention was safe and durable Our limited experience supports the application of combined CEA with transluminal stent-angioplasty of surgically inaccessible proximal or distal lesions with >50% DR Endovascular procedure can be accomplished via open, retrograde, or percutaneous common femoral artery Technical precision confirmed by ultrasound (duplex, intravascular) imaging may contribute to low re-intervention rate (1 of 31 patients).    @` !;,|$JXp0"0O H(  HT H  p 0e0e?Title 1DZ$^  :2___PPT9  N Conclusions:    H  @0e0e?,Content Placeholder 2Z$ vn___PPT9PH Overall Clinical Outcomes Excellent Small series of patients Risk factor modification program Statin Antihypertensive medications Antiplatelet agents Annual duplex surveillance Assess for restenosis Evaluate patients with recurrent symptoms$  ! 8  @ $!8 @ @` !;,|$JXp0"O QIL1(  LQ L  p0e0e?Title 1DZ$^  :2___PPT9  K Thank You    L # TEEAZ??,bPicture of TGH Exterior Dusk February 2008-1Content Placeholder 5Picture of TGH Exterior Dusk February 2008-1.jpgZ$  !;,|$JXp0"g 'T(  T T c 0e0eP?4Slide Image Placeholder 1   l T # 0e0eP?(Notes Placeholder 2 0R  :2___PPT9  N   [ T l`?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPM  X(  X X c 0e0eP?4Slide Image Placeholder 1    X # `0e0eP?(Notes Placeholder 2 0R  :2___PPT9  For over a century, clinicians have sought to better define the stroke risk of atherosclerotic disease of the aortic arch and extracranial carotid artery. Contemporary evaluation of patients with known or suspected extracranial carotid artery occlusive disease typically involves duplex ultrasound testing and/or CT angiography, the latter able to identify severe ICA stenosis as well as concomitant atherosclerotic disease of the aortic arch great vessels such as the innominate, subclavian, common carotid, and vertebral. Advances in endovascular techniques provide a less invasive option to treat orificial/proximal disease of aortic arch great vessels or surgical inaccesible disease of the distal ICA. A patient-specific plan based on clinical presentation and disease location is required to repair combined severe ICA stenosis and arch vessel occlusive disease; ideally by means of a single procedure utilizing open and/or hybrid techinques. In previous studies such as by AbuRahma, who compared the outcome of 51 surgical and 121 endovascular procedures for subclavian artery occlusive disease and concluded both procedures were safe and effective.   [ X l?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPMW @\(  \ \ c 0e0eP?4Slide Image Placeholder 1   \ \ #  0e0eP?(Notes Placeholder 2 0R  :2___PPT9  > Since information on the durability of concomitant aortic arch and carotid interventions is sparse, we conducted a retrospective outcome analysis of patients who underwent interventions to treat tandem atherosclerotic lesions involving the extra-cranial carotid bifurcation and another aortic arch branch vessel. Early and late clinical procedural outcomes were analyzed for differences between open versus endovascular repair, and the need for secondary intervention for restenosis.   [ \ l?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPMf &``(  ` ` c 0e0eP?4Slide Image Placeholder 1   k ` # 0e0eP?(Notes Placeholder 2 0R  :2___PPT9  MThe medical charts and vascular laboratory studies of 31 patients treated for multifocal athersclerotic occlusive disease involving the internal carotid artery and proximal aortic arch vessels by the combination of open and endovascular techniques were reviewed from 1998-2010. The cohort included 16 men and 15 women with a mean age at time of intervention of 69 years. Patients who exhibited neurologic symptoms and signs, complaints of upper extremity claudication, or any abnormal vascular finding on physical examination prompted further diagnostic testing. The decision to perform concomitant carotid endarterectomy and another brachiocephalic or extracranial artery repair was based on lesion being associated with known or potential symptoms including neurologic events, vertebrobasilar insufficiency, subclavian steal syndrome or arterial aneurysm, upper extremity claudication, and high-grade stenosis of the common carotid artery or internal carotid artery remote from carotid endarterectomy repair.   [ ` l?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPM d(  d d c 0e0eP?4Slide Image Placeholder 1    d #  !0e0eP?(Notes Placeholder 2 0R  :2___PPT9  Assessment of aortic arch great vessels was performed by either CTA or digital subtraction arteriography. Occlusive lesions producing greater than 70% diameter reduction were considered for repair. Duplex ultrasound testing was also performed to confirm ICA stenosis severity using our published criteria for ICA disease classification, and to verify that hemodynamic changes associated with proximal innominate, common carotid, or vertebral artery stenosis were present based on velocity spectra waveform abnormalities. All elective patients were prescribed the best medical therapy including control of hypertension and diabetes, statin drugs, antiplatelet therapy, and recommendations for smoking cessation. All patients were taking aspirin and 8 were on plavix, after intervention all patients were on plavix and aspirin for at least 4 weeks before returning to their preprocedural regimens.   [ d l#?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPM ho(  h h c 0e0eP?4Slide Image Placeholder 1    h # 0e0eP?(Notes Placeholder 2 0R  :2___PPT9  `Shown in this schematic is the anatomic distribution of treated carotid and aortic arch lesions.a a a [ h l`?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPM5    l (  l l c 0e0eP?4Slide Image Placeholder 1   : l # @0e0eP?(Notes Placeholder 2 0R  :2___PPT9  Carotid endarterectomy and patch angioplasty was performed under general anesthesia typically prior to proceeding with open or endovascular reconstruction of the comon carotid, subclavian, or vertebral artery. Selective internal shunting was used based on EEG or cerebral oximetry changes during common carotid occlusion, with intraoperative duplex scan to confirm technical success of repair. All patients received antiplatelet therapy prior to and following the procedure, with systemic heparin administered during the case. Stent-angioplasty procedures were completed in the operative suite with portable fluoroscopy, with stent selection, sizing, and technique based on surgeon preferences. Retrograde distal common carotid sheath access and stenting was used to treat both innoninate artery and 6 of the common carotid artery lesions, with adjunct femoral sheath access to enhance accuracy of stent placement in the majority. Femoral access was utilized in the rest of the interventions. For the 3 cases involving the distal internal carotid artery, filter protection devices were used after closing the endarterectomy site with two stents being placed from femoral sheath access and the other from cervical sheath access. Digital subtraction angiography, duplex ultrasound, and intravascular ultrasound were used perioperatively to evaluate the technical success of stent deployement. Technical success is defined as residual diameter stent stenosis less than 30%.   [ l l`?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPM p(  p p c 0e0eP?4Slide Image Placeholder 1    p # @0e0eP?(Notes Placeholder 2 0R  :2___PPT9  Here you can see our results. When looking at patients, there were no differences in terms of gender or age of open versus endovascularly treated patients, but more symptomatic patients underwent open repair, with a p value of 0.001. The majority of the patients who underwent combined procedures were symptomatic, 23 of the 31 pts or 74%. Only 8 patients were asymptomatic, and all of these were treated endovascularly.   [ p l`?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPM t(  t t c 0e0eP?4Slide Image Placeholder 1    t # @0e0eP?(Notes Placeholder 2 0R  :2___PPT9  There were no differences in the medical comorbidities of patients treated with endarterectomy and concomitant open or endovascular procedures.   [ t l`?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPM   x}(  x x c 0e0eP?4Slide Image Placeholder 1    x # @0e0eP?(Notes Placeholder 2 0R  :2___PPT9  lAs mentioned previously, the indication for the majority of carotid endarterectomy was asymptomatic disease.m m m [ x l`?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPMn  .&@|(  | | c 0e0eP?4Slide Image Placeholder 1   s | # 0e0eP?(Notes Placeholder 2 0R  :2___PPT9  UAnd here you can see the indications for brachiocephalic revascularization. Of note, all subclavian artery interventions were treated by open surgical bypass. The majority of subclavian artery interventions were for upper extremity claudication, while the majority of the common carotid artery interventions were for asymptomatic disease with greater than 75% diameter reduction, and these were treated by endovascular stent-angioplasty, as were innominate artery and distal internal carotid artery lesions.   [ | l?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPM  `|(    c 0e0eP?4Slide Image Placeholder 1     # 0e0eP?(Notes Placeholder 2 0R  :2___PPT9  kConcurrent carotid endarterectomy and single arch vessel revascularizations included 2 vertebral artery transpositions to the common carotid artery, 14 common carotid artery to subclavian artery bypasses with saphenous vein or PTFE, and one common carotid artery to axillary artery bypass. Only one procedure was performed urgently, repair of a contained subclavian aneurysm rupture along with high-grade ipsilateral internal carotid artery stenosis. Endovascular therapy included 14 stent-angioplasty procedures of the innominate artery, proximal common carotid artery, and distal internal carotid artery lesions. l l l [  l?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPMl  ,$ (    c 0e0eP?4Slide Image Placeholder 1   q    0e0eP?(Notes Placeholder 2 0R  :2___PPT9  YThe mean followup period was 42 months, but all patients completed at least one year of clinical and duplex ultrasound assessment, with three patients lost to surveillance at 3, 5 and 8 years respectively secondary to relocation. 2 patients developed arterial access site hematomas that were observed. Using a single-stage revascularization procedure, all patients had repair of tandem lesions involving the brachiocephalic and extracranial internal carotid artery without the occurrence of a stroke, myocardial infarction, or death within 30 days. No cranial nerve injuries, cervical hematomas, or surgical site infections occurred. All pts with symptoms of vertebrobasilar insufficiency or arm claudication improved or completely resolved. * /YYY [  l@?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPM  F>&(    c 0e0eP?4Slide Image Placeholder 1     # 0e0eP?(Notes Placeholder 2 0R  :2___PPT9  mAll patients as mentioned previously were enrolled in strict duplex surveillance. At 30 days all repairs were 100% patent. Of the 28 pts left in surveillance to present day, 24 or 86% remain asymptomatic with patent nonstenotic repairs on duplex. 3 patients reported new symptoms, and on arterial imaging were found to have patent nonstenotic repairs and thus were treated with medical therapy and observation. One patient, although asymptomatic, was identified on duplex ultrasound testing to have a high-grade >70% stenosis in the distal anastomosis of a carotid-subclavian saphenous vein bypass at 8 months. The lesion was successfully treated with balloon angioplasty, recurred 24 months later, and was retreated with balloon angioplasty with a good technical result to this day.    [  l?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPM     (    c 0e0eP?4Slide Image Placeholder 1     # 0e0eP?(Notes Placeholder 2 0R  :2___PPT9  Our experience with combined carotid endarterectomy and arch vessel repair for complex extracranial athersclerotic occlusive disease suggest that a single-stage intervention is safe and durable, as documented by the absence of stroke morbidity, no severe procedural complications, and a low incidence of secondary reinterventions. Our study correlates multiple reports that show the safety and efficacy of stent-angioplsty for orificial arch vessel atherosclerotic disease involving the innominate, common carotid, and subclavian arteries. Our limited experience supports the application of combined carotid endarterectomy with transluminal stent-angioplasty of surgically inaccessible proximal or distal lesions with >50% diameter reduction. The endovascular procedure can be accomplished via open, retrograde, or percutaneous common femoral artery approach. Attention to procedural technical precision accomplished by ultrasound duplex or intravascular imaging is a key component to achieving low stroke-related morbidity with concurrent therapy. We recommend intraoperative duplex imaging of the CEA site and use of intravascular ultrasound imaging as an adjunct to digital subtraction angiography to confirm technical success. Implementation of similar quality control measures has been shown to favorably alter procedural conduct and may be a critical component for the large degree of early and late outcome success seen in this group.   [  l?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPM xpX(    c 0e0eP?4Slide Image Placeholder 1     # 0e0eP?(Notes Placeholder 2 0R  :2___PPT9  GAlthough our clinical series is small, the outcome in this cohort having combined arch vessel and ICA procedures is excellent. The implementation of contemporary atherosclerotic risk factor modification program including antihypertensive medications, statins, and antiplatelet agents may also contribute to the low incidence of repair site failure. We would also recommend that the addition of annual duplex surveillance seems effective in monitoring these reconstructions for the development of restenosis, as well as verifying patent anastomoses in the face of recurrent symptoms.H H H [  l?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPM ~v^(    c 0e0eP?4Slide Image Placeholder 1     # 0e0eP?(Notes Placeholder 2 0R  :2___PPT9  MI thank you for your attention, and would be happy to entertain any questionsN N N [  l?6Slide Number Placeholder 3_ K:2___PPT9  l* C    I}OPMr`";,A2HNV3]Ÿ^ΕhYȸ(i% }  +$)&Oh+'0< px( @L t   tOutcome of Combined Carotid-Great Vessel Interventions for Complex Extracranial Atherosclerotic Occlusive DiseaseKelley Hodgkiss-Harlow Breeze.thmxRich Mariner18 Microsoft Macintosh PowerPoint@v@@n@X Gg  pp  pA 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   On-screen Show (4:3)UCSD , ArialNews Gothic MT Wingdings 2ＭＳ ＰゴシックCalibriTimes New RomanBreeze 1_BreezerOutcome of Combined Carotid-Great Vessel Interventions for Complex Extracranial Atherosclerotic Occlusive Disease-Combined Carotid-Great Vessel Interventions Purpose:Study Design:Patient EvaluationSlide 6Methods: Surgical TechniqueDemographics: Open vs. EndoComorbidities: Open vs. EndoCEA Indications Slide 11(Type of Cervical Vascular InterventionsResults: Clinical OutcomeResults: Surveillance Conclusions Conclusions: Thank You  Fonts UsedTheme Slide Titles$_U* Rich MarinerRich Mariner  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXY[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      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