Volume 14 Number 2 August 1991

conditions, we feel that using a cutoff point of 45 cm/sec for peak systolic velociity is too strict. Benjamin B. Chang, M D Robert P. Leather, M D Dhiraj M. Shah, .MD

Vascular Surgery Section Albany Medical College

Carotid patch angioplasty: immediate and long-term results To the Editors:

We read with interest the recent article by Rosenthal et al.1 concerning the results of the carotid patch angioplasty. They concluded that there are no statistical differences between polytetrafluoroethylene, Dacron, saphenous vein, and nonpatched endarterectomy. Nevertheless, we can see in their study that the vein patch gives the best results with 1% restenosis and 0% Iate ipsilateral stroke. If this had been a random study based on a larger number of patients there would probably be a significant difference in favor of the vein patch, that has already been pointed out in other studies. 2 We are still convinced of the superiority of the biologic patched carotid angioplasty, especially when the internal carotid artery is small and when the patient is a woman. In those situations it may be better to use a nonnarrowing patch than an enlarging patch. Complications such as dilations and ruptures have been reported with the use of oversized saphenous vein patches. 3 Therefore we propose a new technique using apicce taken from the superior thyroid artery,4 which is the first descending branch of the external carotid artery. We have always succeeded in removing at least a 2 cm × 4 mm piece of an arterial tissue. Satisfactory preliminary results were obtaihed in our first 58 cases with neither stroke nor restenosis in the following year. Also, this inexpensive autologous biologic material has several advantages. It is an arterial structure, therefore compatible within the sutured artery. It is obtained in situ, which is very important for the surgeons who practice this surgery, as we do, with the patient under local-regional anesthesia. Finally, it spares the venous system of the patients with arteriosclerosis. The advantages of this technique must encourage its acceptance by vascular surgeons and allow the development of the carotid patch angioplasty.

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REFERENCES

1. Rosenthal D, Archie JP, Rinaldi RG, et al. Carotid patch angioplasty: immediate and long-term results. I VASCSURG 1990;12:326-33. 2. Lord RSA, Barstha TR, Story DL, et al. Comparison of saphenous vein patch, polFmtrafluoroethylenepatch, and direct arterotomy closure after carotid endarterectomy. Part I. Perioparativc results. ~ VASCSURG 1989;9:521-9. 3. Hertzer NR, Beven EG, O'Hara PJ, et al. A prospective study of results for 801 patients and 917 operations. Arm Surg 1987;206:628-35. 4. Obadia IF, Brenot R, Bed~er F, et al. "Non narrowing" patch from the superior thyroid artery in surgery of the carotid arterys. La Presse Med 1990;19:1150-1. Reply To the Editors:

Obadia et al. have presented an interesting idea of using superior thyroid artery for patch angioplasty when carotid endarterectomy is performed under local-regional anesthesia. Their initial results with 58 operations during the year are excellent: no postoperative strokes and no evidence of early recurrent stenoses. Our study demonstrated that postoperative neurologic complications and late ipsilateral stroke, regardless of method of arterial closure, were not statistically different. Recurrent carotid stenosis, however, in general, is a "late" phenomenon, and this was reemphasized by our study, as recurrent stenosis in all patient groups occurred late (i.e., 24 to 60 months after operation). We await, and encourage, long-term foUow-up on these patients operated on by Dr. Obadia's group for assessment of recurrent carotid stenosis. Although patch angioplasty in our study was not statistically superior to primary closure in preventing recurrent stenosis, it appears to be appropriate in habitual smokers and patients with small internal carotid arteries, most of whom are women. Until a large rnulticenter randomized trial answers the question of which is the most appropriate means to close the carotid artery after endarterectomy, a technically perfect operation appears to be the surest means of reducing the incidence of perioperative stroke, late ipsilateral stroke, and recurrent stenosis. David Rosenthal, M_D

Atlanta Vascular Specialists, PC Suite 412 Baptist Professional Bldg. 315 Boulevard N.E. Atlanta, GA 30312

f. E Obadia R. Brenot M. H. Raoux M. David

An unusual symptom o f subclavian artery aneurysm: hemoptysis

Service de Chirurgie Cardio-vasculaire et Angiologie H6pital du Bocage 21000 Dijon, France

We report a recent interesting case of a 62-year-old man with chronic hemoptysis, vcho had a left subclavian artery

To the Editors:

244

Journal of VASCULAR SURGERY

Letters to the Editors

Fig. 1. A, Chest radiograph on admission. B, Drip infusion CT scan. C, Bolus injection CT scan after first operation (approximately same level slice as that of Fig. 1, B). D, Selective angiography of the left subclavian artery.

aneurysm (SAA) with a fistula to the lung parenchyma. He was successfully treated by operation. Only four cases of SAA complicated with hemoptysis have been reported in the English literature. ~-~ CASE REPORT This patient without history of chest trauma had suffered from hemotysis for a few months before the present admission. In another hospital he was diagnosed as having a left Pancoast tumor because of a huge mass in the left upper field found on chest radiography and drip infusion CT scan (Figs. 1,A andB) and transferred to our hospital for operation. Although no malignant cells were found by any examination, he underwent thoracotomy for the purpose of accurate diagnosis and eventual resection of the Pancoast tumor. However, since a fist-sized pulsating mass densely adherent to the upper lobe of the lung was found, the exploratory thoracotomy was terminated for further evaluation of the aneurysm. Thereafter a bolus injection CT scan, and selective subclavian arteriography revealed a saccular aneurysm of the left subclavian artery (Figs. 1, C and D) and reoperation was performed. After

cross-clamping the origin of the !eft subclavian artery, the aneurysmal sac was incised. No reflux bleeding from the subclavian artery was observed. The organized thrombus in the aneurysm was examined and revealed coagulasenegative staphylococci. By use of an expanded polytetrafluoroethylene graft, a subdavian-axillary artery bypass graft was placed. His postoperative course was uneventful, and he was discharged from the hospital on the thirtieth postoperative day with disappearance of hemoptysis. Although histologic examination of the aneurysmal wall did not clarify the origin of the aneurysm, it showed communication between the aneurysm and pulmonary parenchyma. The key to diagnosis and successful treatment is a high index of suspicion followed by prompt operation. Three of the live cases including ours had a history of hemoptysis lasting longer than 1 week without any definite diagnosis. Occult hemoptysis with an abnormal mass appearing in routine chest radiography, especially if it is paramediastinal one, requires immediate further examination, such as bolus injection CT scanning 4 or angiography. In case of aneurysm, surgical treatment should be aggressively carried out

Volume 14 Number 2 August 1991

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Fig. 2. Histologic evidence of arteriopulmonary fistula. A, Aneurysm; arrow, fusion region of aneurysm into the lung. (Hematoxylin-eosin stain; original magnification >