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We performed a systematic review of the literature to establish whether revascularisation of the left subclavian territory is necessary when this artery is covered by a stent. We retrieved data from 99 studies incorporating 4906 patients. Incidences of left-arm ischaemia (0.0% vs 9.2%, p=0.002) and stroke (4.7% vs 7.2%, p<0.001) were significantly less following revascularisation, although mortality (10.5% vs 3.4%, p=0.032) and endoleak incidence (25.8% vs 12.6%, p=0.008) were increased. No significant differences in spinal-cord ischaemia were seen. Revascularisation may reduce downstream ischaemic complications but can cause significant risk. Indications must be carefully considered on an individual patient basis., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: Free-floating thrombus (FFT) of the carotid artery is a rare condition of currently unknown etiology. Less than 150 cases have been described in the published world literature to date., Design and Setting: We present 6 consecutive cases of carotid FFT, identified prospectively from 5000 carotid duplex scans over a 34-month period in a single tertiary center for vascular surgery., Results: All 6 cases involved the left carotid bifurcation in neurologically symptomatic individuals. In 5 of the 6 cases, FFT occurred in the absence of a significantly stenosing atheromatous plaque and was not associated with an elevation in velocity on duplex. The patients were all treated with surgical thromboendarterectomy, with good result., Conclusions: Duplex imaging can underestimate the degree of stenosis. Free-floating thrombus presents a challenge in diagnosis due to its rapidly evolving nature. The management of FFT by acute thromboendarterectomy appears to be safe and effective in limiting further focal neurological sequelae.

Background: Despite the publication of recent guidelines for management of the left subclavian artery (LSA) during endovascular stenting procedures of the thoracic aorta, specific management for those presenting with dissection remains unclear. This systematic review attempts to address this issue., Methods: Systematic assessment of the published data on thoracic aorta dissection was performed identifying 46 studies, which incorporated 1,275 patients. Primary outcomes included the prevalence of left arm ischemia, stroke, spinal cord ischemia, endoleak, stent migration, and mortality. Outcomes were compared between patients with and without LSA coverage and revascularization incorporating factors such as the number of stents used, length of aorta covered, urgency of intervention, and type of dissection (acute or chronic). Statistical pooling techniques, χ(2) tests, and Fisher's exact testing were used for group comparisons., Results: As compared with other outcomes, LSA coverage without revascularization in the presence of aortic dissection is much more likely to be complicated by left arm ischemia (prevalence increased from 0.0% to 4.0% [p = 0.021]), stroke (prevalence increased from 1.4% to 9.0% [p = 0.009]), and endoleak (prevalence increased from 4.0% to 29.3% [p = 0.001]). However, revascularization was not shown to reverse these effects. Longer aortic coverage (≥ 150 mm) was associated with an increased prevalence of spinal cord ischemia (from 1.3% to 12.5% [p = 0.011]) and mortality (from 1.3% to 15.6% [p = 0.003])., Conclusion: In patients undergoing endovascular stenting for thoracic aortic dissection, in cases where LSA coverage is necessary, revascularization should be considered before the procedure to avoid complications such as left arm ischemia, stroke, and endoleak, and where feasible, an appropriate preoperative assessment should be carried out., (Copyright © 2010. Published by Elsevier Inc.)

Prosthetic aortic valve dysfunction presenting as aortic regurgitation is a complication of mechanical valve replacement. We describe a case of late valve dysfunction caused by an annular suture of excessive length obstructing the closure mechanism of a bileaflet prosthetic valve.We present this rare cause of valve dysfunction in an 80-year-old male patient who presented with haemolysis and dyspnoea. At the time of operation it was found that a long vertically positioned annular valve suture was interfering with the normal closure mechanism of one of the prosthetic leaflets causing eccentric regurgitation jets. These findings were misdiagnosed as paravalvular leaks on the preoperative transoesophageal echo. No paravalvular leak was identified intraoperatively. After removal of the responsible suture normal prosthetic valve function was restored.Whilst early aortic valve dysfunction caused by suture material has previously been reported, this is the first report of suture material causing late dysfunction.