We can conclude, with the power limitation of the study, that PAA treatment can be safely performed by using either OR or ET. ET has several advantages, such as quicker recovery and shorter hospital stay.

No abstract

Anastomotic connections between the developing internal carotid and basilar arterial system exist in early fetal life. Rarely, these carotid-basilar anastomoses will persist into adult life unilaterally or, rarely, bilaterally. 1 A 78-year-old woman was admitted to the Vascular Surgery Division of Padua University (VSDPU). For 30 days, she had experienced focal (transischemic attacks with right-sided paresis-5 episodes) and nonfocal (syncope and multiple attacks of vertigo) cerebral symptoms. Digital subtraction angiography (DSA) confirmed a duplex scanning result showing a 85% stenosis of left carotid bifurcation and revealed a persistent proatlantal intersegmental artery (PIA), arising 2 cm from the origin of left internal carotid artery (ICA). The plaque was ulcerated and extended into the external carotid artery, ICA, and the PIA origin. The first and second tracts (V 1, V 2 ) of the left vertebral artery were not visualized. The left ICA had a 60% intracranial stenosis (A [Cover]).There was a 40% right carotid bifurcation stenosis with a 50% intracranial tandem stenotic lesion. The right vertebral artery was hypoplasic without intracranial connection with the basilar artery. Most of the cerebral posterior territory was supplied by the left PIA. Very poor connections were visualized between carotid and posterior territory circulation.The patient underwent left carotid endarterectomy according to a previously described VSDPU technique 2 (general anesthesia, continuous electroencephalogram monitoring, heparinization, routine delayed shunting, and polytetrafluoroethylene patching). Surgery planning took into account not only intraoperative routine shunt perfusion of the ICA but also the necessity of perfusion of the PIA due to the demonstration of incomplete circle of Willis. After left laterocervical incision and exposure of the common carotid artery, external carotid artery, ICA, and PIA with the no-touch technique, vessel clamping was followed by longitudinal arteriotomy. Two intraluminal balloon shunts (Pruitt-Inahara model 2000-49; LeMaitre Vascular, Inc, Burlington, Mass) were used after plaque removal. The first shunt was inserted distally into the ICA, and proximally into the common carotid artery. The second shunt was inserted distally into the PIA, and proximally into the common carotid artery. Proximal ends of both shunts were placed in contiguity inside the common carotid artery; balloons were partially inflated with a vessel loop encircling the artery to help with hemostasis (B). Ischemia time was 4 minutes for the carotid territory and 5 minutes for the posterior territory. Electroencephalogram frequency and amplitude decreased significantly after clamping and returned to normal after insertion of the shunts.Cerebrovascular symptoms disappeared after surgery and the patient had no problems during 12 months of follow-up. Patency of the ICA and PIA was assessed by duplex scanning and documented by DSA (C).This report differs from an unpublished case, also successfully operated in 1982 by the senior a...

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• Complex anatomy of the aortic arch is not rare • Endovascular carotid artery stenting (CAS) is more difficult when the anatomy is complex • A new dedicated guiding catheter may help CAS when the arch anatomy is complex • The new dedicated guiding catheter may be less risky in complex arches.