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Calcification of the lower extremities arteries is an unfavorable factor for vascular surgery. Extensive lesions of the femoral segment are an indication for femoropopliteal bypass surgery. Calcification of the femoral arteries complicates the construction of a proximal anastomosis because it precludes clamping the arteries. In addition to technical difficulties in the construction of an anastomosis, significant calcification increases the risks of bleeding and embolic complications and the duration of surgery. In cases of total calcification of the femoral and iliac arteries, balloon occlusion during the construction of an anastomosis makes it possible to occlude the arteries without clamping, which reduces the risks of perioperative complications. We report a case of femoropopliteal bypass surgery in a patient with total calcification of the iliofemoral segment and occlusion of the superficial femoral artery.

Objectives: Open lower extremity revascularization is controversial among octogenarians; however, the indications for surgical bypass are higher in the elderly population. The aim of the study was to compare postoperative outcomes between octogenarians and non-octogenarians following femoropopliteal bypass surgery. Methods: Our regional, multi-institutional database was queried for femoropopliteal bypass procedures performed between 1995 and 2020. Electronic medical records were individually reviewed for operative and postoperative data. Univariable and multivariable logistic regression were utilized to determine predictors of postoperative outcomes. Results: Among 1315 patients who underwent femoropopliteal bypass, 234 (17.8%) were octogenarians. Octogenarians more frequently underwent bypass for lower extremity tissue loss (48.7% vs 30.2%), whereas claudication was more common among non-octogenarians (24.0% vs 9.8%) (p <.001). Below-knee bypass target (72.2% vs 59.3%) and prosthetic conduit utilization (58.5% vs 43.7%) were more frequent in octogenarians (p <.001 each). Overall hospital length of stay was longer among patients > 80 years (median 6 days [interquartile range [IQR] 4–9] vs 5 days [IQR 4–8], p =.017). The overall 30-day (5.6% vs 1.5%) and one-year mortality rates (25.6% vs 7.9%) were higher among octogenarians (p <.001 each). On multivariable analysis, age greater than 80 years was found to be an independent risk factor for postoperative mortality (OR 3.79 [1.75–8.20], p =.0007) Conclusions: Octogenarians undergoing bypass femoropopliteal bypass surgery have considerably worse postoperative outcomes, compared with non-octogenarians. These data may help inform elderly patients prior to undergoing open lower extremity revascularization. [ABSTRACT FROM AUTHOR]

Bypass graft failure and major amputation are among the worst complications after femoropopliteal bypass surgery. In this large multicenter analysis, we examined our incidence and risk factors for failure-to-salvage (FTS) following either bypass surgery or bypass graft failure. A regional multicenter database was retrospectively queried for all femoropopliteal bypass procedures performed between 2002 and 2021. Re-do bypasses were excluded. The primary outcome was FTS, defined as major ipsilateral limb amputation within 90 d following index bypass surgery or bypass graft failure. Bypass graft failure was defined as critical stenosis or occlusion of the bypass graft requiring reintervention. Graft rescue was defined as bypass graft failure without subsequent major ipsilateral limb amputation within 90 d. Multivariable logistic regression analysis was utilized to identify factors associated with bypass graft failure and FTS. Over the study period, 1315 femoropopliteal bypass procedures were performed across five hospitals. There were 25 major amputations within 90 d of initial bypass. Bypass graft failure was diagnosed in an additional 503 (38.3%) patients. Mean time to graft failure was 619 d. On multivariable analysis, bypass for tissue loss (adjusted odds ratio [aOR] 1.38 [95% confidence interval (CI) 1.03-1.83], P = 0.03) was associated with graft failure. Of patients with graft failure, 33 had major amputation, leading to an overall FTS incidence of 4.4% (n = 58) over a mean follow-up period of 3.4 y. Patient demographics, medical comorbidities, and bypass conduits were similar between the FTS and graft rescue groups (n = NS each). The FTS group more frequently underwent bypass for tissue loss (51.7% versus 29.8%, P = 0.002), and an infrageniculate bypass target was more frequently utilized in FTS compared to graft rescue patients (81.0% versus 60.4%, P = 0.002). Anticoagulation (34.5% in FTS versus 37.7% in rescue) and dual antiplatelet therapy (15.5% versus 22.1%, respectively) were similar between groups (P = NS each). On multivariable analysis, factors associated with FTS included infrageniculate target (aOR 2.42 [95% CI 1.22-4.08], P = 0.01), black race (aOR 2.47 [95% CI 1.04-5.84], P = 0.04), and bypass for tissue loss (aOR 4.75 [95% CI 1.41-16.0], P = 0.01). Anticoagulation and dual antiplatelet therapy were not associated with loss of graft patency or FTS. Failure-to-salvage after femoropopliteal bypass surgery is associated with nonmodifiable factors, and may represent progression of underlying disease. These data may help inform vascular surgeons in counseling patients with failing bypass grafts. Further investigation of care delivery factors improving likelihood of graft salvage may be warranted. [ABSTRACT FROM AUTHOR]

The persistent sciatic artery (PSA) normally regresses during embryonic development; however, it can persist in some cases with an estimated frequency of 0.03 %. This rare case of PSA involved a 76-year-old woman with a history of right femoral fracture surgery, who experienced recurrent hematomas between her right buttock and thigh. Contrast-enhanced computed tomography revealed a complete, right-sided PSA, necessitating two-staged surgical intervention. Right femoropopliteal artery bypass surgery and popliteal artery banding were performed, followed by coil embolization of the PSA. A postoperative examination confirmed that the graft was receiving adequate perfusion without any PSA perfusion. Consequently, the patient was discharged without complications on the 14th postoperative day. Treatment of the persistent sciatic artery is contingent upon the individual's situation. Thoughtful consideration must be taken when deciding on surgical technique, in order to ensure minimal surgical invasiveness and optimal long-term outcomes.

Objective: To study immediate and long-term results of the tibioperoneal trunk repair (plastic reconstruction or prosthetic repair) during femoropopliteal bypass.Materials and methods: In our retrospective cohort study we analyzed surgical treatment results of 109 patients with lower extremities atherosclerosis who were treated in the Vascular Surgery Unit of Interregional Clinical Diagnostic Center (Kazan, Russian Federation) from 2018 to 2020. 26 (23.8%) patients were hospitalized for stage IB-IIA acute arterial insufficiency with atherothrombosis, and 83 (76.1%) patients were admitted with critical limb ischemia (CLI) as a result of advanced atherosclerosis. Among the CLI patients, 43 (39.4%) of them had stage III chronic arterial insufficiency, and 40 (36.7%) patients had stage IV chronic arterial insufficiency. The study selection criteria included extensive femoral and popliteal arteries disease and significant stenosis or occlusion of the tibioperoneal trunk. TASC II type C lesions were detected in 2 (1.8%) patients, while 107 (98.2%) patients were diagnosed with TASC II type D lesions. Based on the GLASS classification, all 109 (100%) patients had FP grade 3-4 femoropopliteal lesions with concomitant IP grade 1-4 tibial lesion. The main group included 24 (22%) patients who underwent femoropopliteal bypass with plastic or prosthetic repair of the tibioperoneal trunk using an original technique. The control group included 85 (78%) patients who underwent bypass surgery without the tibioperoneal trunk repair. Isolated femorotibial bypass was performed in 7 (8.2%) patients, and 78 (91.7%) patients underwent femoropopliteal bypass with a reversed autogenous vein.Results: We followed up patients for 2 years after surgery. Immediate technical success was 97.24% (106/109). Graft thrombosis was reported in 3 cases. No difference between the groups was observed. Long-term graft patency was significantly higher in the main group (P = .044) and significantly associated with age (RR = 0.96; 95% CI of 0.92 to 1.00, P = .03), type 2 diabetes mellitus (RR = 2.10; 95% CI of 1.10 to 4.10, P = .03), and history of the tibioperoneal trunk repair (RR = 0.43; 95% CI of 0.18 to 1.00, P = .06). Variables associated with patency in the univariate regression at a significance level P ≤ .1 were included in a multivariate model that demonstrated the combined effect of predictors on the outcome.Conclusions: Femoropopliteal bypass with the tibioperoneal trunk repair improves treatment results in patients with extensive peripheral artery disease and immediately threatened limbs or a threat to a limb within 2 years.

Persistent sciatic arteries are rare congenital abnormalities, with an incidence between.01-.6%. Whilst most patients with the pathology are asymptomatic during their younger years, up to 48% of patients will suffer aneurysmal degeneration of the persistent sciatic artery and present with claudication or lower limb ischaemia (from distal embolisation of mural thrombus). Due to the rare nature of persistent sciatic artery aneurysms, optimal management of the pathology is yet to be determined. Both endovascular and open techniques have been described in the management of this pathology, however hybrid management approaches are reported infrequently. The authors present a case of a persistent sciatic artery aneurysm successfully treated in a 69-year-old male utilising a hybrid approach with a femoropopliteal bypass (below knee), Amplatzer plug occlusion of the aneurysm and subsequent resection of the aneurysm. [ABSTRACT FROM AUTHOR]

Outcomes after femoropopliteal bypass for intermittent claudication (IC) remain unclear in the endovascular era. A multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures performed between 1995 and 2020. Demographics, operative details, and outcomes were documented. A statistical analysis included Kaplan–Meier curves and Cox proportional hazards ratios (HR). A total of 282 patients underwent femoropopliteal bypass surgery for IC. Median age was 68 y (interquartile range, 61-73 y). Bypass conduits included great saphenous vein (GSV) (48.2%), prosthetic grafts (48.9%), and non-GSV autogenous grafts (2.8%). Distal bypass target was above-knee in 62.1% and below-knee in 37.9% of patients. The most common postoperative complications were wound infections (14.2%) followed by unplanned 30-d hospital readmissions (12.4%). Mortality rates were low at 0.4% (30 d) and 3.2% (1 y). Five-year primary patency rates trended highest for claudicants undergoing above-knee bypass with GSV conduit (log-rank P = 0.065). Five-year amputation-free survival rates were highest using GSV conduit regardless of distal bypass target (log-rank P = 0.017). On a multivariable analysis, age (HR 1.02 [1.00-1.04], P = 0.023) and active smoking (HR 1.48 [1.06-2.06], P = 0.021) were identified as risk factors for diminished primary graft patency. Risk factors for amputation-free survival included age (HR 1.03 [1.01-1.05], P < 0.001) and GSV conduit type (HR 0.65 [0.46-0.90], P = 0.011). Femoropopliteal bypass among claudicants is associated with high rates of wound infection and hospital readmission. Active smoking portends worse outcomes in this population. These data may inform clinical decision-making regarding surgical intervention for claudication in the endovascular era. [ABSTRACT FROM AUTHOR]

Objectives: In this study, we aimed to compare the outcomes of endovascular treatment (ET) and femoropopliteal artery bypass (FPB) in patients with Trans-Atlantic Inter-Society Consensus (TASC) II type C femoropopliteal lesions. Patients and methods: A total of 149 patients with symptomatic TASC II type C femoropopliteal lesions who underwent invasive treatment between January 2012 and January 2017 were retrospectively analyzed. The patients were divided into two groups as the ET group (n=46; 34 males, 12 females; mean age: 64.3±10.3 years) and the FPB group (n=103; 82 males, 21 females; mean age: 62.9±8.2 years). Primary and secondary patency rates at 6, 12, and 24 months were evaluated. Results: The primary success rates for ET and FPB were 100%. Primary patency at 6, 12, and 24 months were 93.5%, 89.0%, 69.5%, respectively for ET and 86.4%, 81.5%, 72.8%, respectively for FPB (p>0.05). Secondary patency rates at 6, 12, and 24 months were 97.8%, 93.5%, %84.8, respectively for ET and 96.1%, 90.3%, 79.6%, respectively for FPB group (p=0.41). The length of hospital stay was significantly longer in the FPB group (p [Turk J Vasc Surg 2022; 31(1.000): 25-32]

Aim. To analyze the long-term outcomes of a novel method of femoropopliteal bypass (FPB) surgery.Material and methods. This retrospective, open-label, comparative study for the period from October 1, 2016 to December 25, 2019 at the Research Institute of the S. V. Ochapovsky Regional Clinical Hospital №1 (Krasnodar Krai) included 473 patient who underwent FBP. Depending on the type of graft, 5 groups were formed: group 1 (n=266) — reversed vein (great saphenous vein (GSV)); group 2 (n=59) — autologous vein graft (GSV) prepared in situ; group 3 (n=66) — autologous vein graft (GSV) prepared ex situ; group 4 (n=9) — synthetic graft (Jotec, Germany); group 5 (n=73) — upper limb veins. In all cases, Multislice computed tomography angiography revealed an extended (25 cm or more) Trans-Atlantic Inter-Society Consensus (TASC II) class D occlusion of the superficial femoral artery. The longterm follow-up period was 16,6±10,3 months. The technical result of novel FPB technique was achieved using proposed type of an autologous vein graft preparation, in which, after GSV isolation, ex situ valvulotomy was performed, followed by the non-reversed subfascial orthotopic graft passage along the neurovascular bundle by tunneling (Sheath Tunneler Set; Peripheral Vascular, USA) soft tissues. The GSV ex situ was prepared as follows: the GSV was isolated from the saphenofemoral fistula in the distal direction to the required length and removed from the wound. Further, valvulotomy was performed through the proximal end of GSV. Then the valvulotome was removed and a metal cannula was inserted. Through it, a saline solution at indoor temperature with unfractionated heparin was injected into the GSV lumen, simulating blood flow, and the quality of the performed valvulotomy was assessed.Results. In the inhospital postoperative period, all complications developed in groups 1, 2, 3 and 5. However, no significant intergroup statistical differences were found. In the long-term follow-up, there were no significant intergroup differences in the prevalence of deaths (group 1: 4,6%; group 2: 1,7%; group 3: 4,6%; group 4: 0%; group 5: 2,8%; p=0,78), myocardial infarction (group 1: 1,9%; group 2: 0%; group 3: 1,5%; group 4: 0%; group 5: 0%; p=0,62), ischemic stroke (group 1: 0,8%; group 2: 1,7%; group 3: 1,5%; group 4: 0%; group 5: 0%; p=0,8) and shunt thrombosis (group 1: 14,5%; group 2: 19,3%; group 3: 18,5%; group 4: 44,4%; group 5: 19,7%; p=0,16). However, the highest number of limb amputations (group 1: 4,2%; group 2: 5,3%; group 3: 9,2%; group 4: 22,2%; group 5: 1,4%; p=0,03) and the highest rate of composite endpoint (sum of all complications) (group 1: 26,0%; group 2: 28,1%; group 3: 35,4%; group 4: 66,7%; group 5: 23 ,9%; p=0,05) were observed in patients with synthetic prosthesis.Conclusion. FPB with the autologous vein graft ex situ is characterized by a comparable inhospital and long-term outcomes with BPS using the reversed autologous vein and autologous vein in situ. Thus, this surgical technique may become one of the preferable operations for patients with extended occlusion of the superficial femoral artery.

In this multi-institutional series, we aimed to determine the incidence, risk factors, and long-term outcomes of graft infection in patients post-femoropopliteal bypass. A multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures from 1995 through 2020. Cumulative incidence function estimated the long-term rate of bypass graft infection (BGI), and the Fine-Gray model was used to determine independent risk factors for BGI to account for death as a competing risk. Over the 25-year period, 1315 femoral popliteal bypasses were identified with a median follow-up of 2.89 years (interquartile range, 0.75-6.55 years). BGI was diagnosed in 34 patients (2.6%). BGI occurred between 9 days and 11.2 years postoperatively, with a median of 109 days. Estimated 1- and 5-year incidence of BGI was 2.1% (95% confidence interval [CI], 1.4%-3.1%) and 2.8% (95% CI, 1.9%-3.9%), respectively. Medical comorbidities, indications for bypass, and popliteal bypass targets (above- vs below-knee) were similar between patients with BGI and all patients (P = not significant for each). Patients with BGI were more frequently complicated by postoperative hematoma (14.7% vs 3.7%), superficial wound infection (38.2% vs 19.2%), lymphocele/lymphorrhea (8.8% vs 2.1%), and 30-day readmission rates (47.1% vs 21.3%) (P <.05 for each). Most commonly isolated pathogens were Staphylococcus aureus (n = 19; 55.9%) and polymicrobial cultures (n = 5; 14.7%). Reoperation for BGI involved incision and drainage (n = 7; 20.6%), graft excision without reconstruction (n = 12; 35.3%), graft excision with in-line reconstruction (n = 11; 32.4%), and graft excision with extra-anatomic reconstruction (n = 2; 5.9%). Nine patients with BGI (26.5%) ultimately required major amputation. Prosthetic bypass (subdistribution hazard ratio [SHR], 3.73; 95% CI, 1.64-8.51; P =.002), postoperative hematoma (SHR, 3.44; 95% CI, 1.23-9.61; P =.018), and 30-day readmission (SHR, 2.75; 95% CI, 1.27-5.44; P =.010) were independently associated with BGI. One-year amputation-free survival was 50% (95% CI, 31.9%-65.7%) after BGI. BGI is a rare complication of femoral-popliteal bypass with significant morbidity. Graft infection is associated with the use of prosthetic grafts, postoperative hematoma, and unplanned hospital readmission. Mitigation of these risk factors may decrease the risk of this dreaded complication. [ABSTRACT FROM AUTHOR]

Introduction: Concurrent stenting of complex iliac lesions during infrainguinal bypasses can increase the complexity of a case and impact outcomes. Objective: Our aim was to evaluate the effect of inflow stenting of TASC-II C, D iliac lesions on femoropopliteal bypass patency. Methods: A retrospective observational cohort study of patients who underwent femoropopliteal bypass with TASC-II C, D iliac artery stenting (hybrid group) or without inflow lesions (non-hybrid group) was conducted. After propensity score matching, 120 patients were included in the non-hybrid group and 60 patients in the hybrid one. The median follow-up was 432 (193; 1313) days in the hybrid group and 472 (196; 1376) days in the non-hybrid group (p = 0.94). Results: No significant differences were found between the groups in 30-day morbidity and serious adverse events. At 3 years, primary and secondary bypass patency for the hybrid group and non-hybrid group were 62.2% versus 59.9% (p = 0.36) and 63.7% versus 64.3% (p = 0.077), respectively. The primary patency of the iliac stents in patients of the hybrid group was 95% at 3 years. The estimated hazard ratio for primary patency for hybrid versus non-hybrid was 0.77, with 90% CI: 0.50–1.21; the noninferiority upper bound being 1.31, which corresponds to a 10% additive noninferiority margin for probabilities. The 3 years of freedom from amputation in patients with chronic limb-threatening ischemia was 94.1% and 75.0% in the hybrid and non-hybrid groups, respectively (p = 0.09). Conclusion: The outcomes of the femoropopliteal bypass in hybrid surgery supplemented with stenting of TASC-II C, D iliac lesions was similar to femoropopliteal bypass with intact inflow arteries. [ABSTRACT FROM AUTHOR]

A 61-year-old man presented with chronic limb threatening ischemia due to reocclusion of a femoropopliteal (FP) bypass using a saphenous vein graft (SVG). After performing endovascular intervention using plain angioplasty and drug-coated balloon and drug-eluting stent implantation of the proximal anastomosis of FP bypass, refractory early reocclusion occurred during the perioperative period. Thus, we decided to alternatively place a stent-graft in the occluded FP bypass. After the SVG had been dilated using a high-pressure balloon, a stent-graft was successfully placed. This alternative therapy using a stent-graft prevented SVG FP bypass reocclusion, and the patient's ulcers had completely healed within 1 month.

Objectives: In this study, we aimed to compare the outcomes of endovascular treatment (ET) and femoropopliteal artery bypass (FPB) in patients with Trans-Atlantic Inter-Society Consensus (TASC) II type C femoropopliteal lesions. Patients and methods: A total of 149 patients with symptomatic TASC II type C femoropopliteal lesions who underwent invasive treatment between January 2012 and January 2017 were retrospectively analyzed. The patients were divided into two groups as the ET group (n=46; 34 males, 12 females; mean age: 64.3±10.3 years) and the FPB group (n=103; 82 males, 21 females; mean age: 62.9±8.2 years). Primary and secondary patency rates at 6, 12, and 24 months were evaluated. Results: The primary success rates for ET and FPB were 100%. Primary patency at 6, 12, and 24 months were 93.5%, 89.0%, 69.5%, respectively for ET and 86.4%, 81.5%, 72.8%, respectively for FPB (p>0.05). Secondary patency rates at 6, 12, and 24 months were 97.8%, 93.5%, %84.8, respectively for ET and 96.1%, 90.3%, 79.6%, respectively for FPB group (p=0.41). The length of hospital stay was significantly longer in the FPB group (p<0.001). The cost of treatment was significantly higher in the FBP group (p=0.02). Conclusion: In TASC II type C patients, ET is a safe therapeutic option with lower in-hospital stay and treatment expenses and similar primary and secondary patency rates to FPB. [ABSTRACT FROM AUTHOR]

Background: Incisional complications of groin after inflow or infrainguinal bypasses with prosthetic conduits can result in major morbidities that require reoperation, infected graft removal, and limb loss. Muscle flaps are typically performed to treat groin wound complications, but they are also done prophylactically at the time of index procedures in certain high-risk-for-poor-healing patients to mitigate anticipated groin wound complications. We used a nationwide multi-institutional database to investigate outcomes of prophylactic muscle flaps in high-risk patients who underwent prosthetic bypasses involving femoral anastomosis., Methods: We utilized ACS-NSQIP database 2005-2021 to identify all elective inflow and infrainguinal bypasses that involve femoral anastomoses. Only high-risk patients for poor incisional healing who underwent prosthetic conduit bypasses were selected. A 1:3 propensity-matching was performed to obtain two comparable studied groups between those with (FLAP) and without prophylactic muscle flaps (NOFLAP) based on demographics and comorbidities. 30-day postoperative outcomes were compared., Results: Among 35,011 NOFLAP, 990 of them were propensity-matched to 330 FLAP. There was no significant difference in 30-day mortality, MACE, pulmonary, or renal complications. FLAP was associated with higher bleeding requiring transfusion, longer operative time, and longer hospital stay. FLAP also had higher overall wound complications (15.2% vs. 10.6%; p = 0.03), especially deep incisional infection (4.9% vs. 2.4%; p = 0.04)., Conclusion: Prophylactic muscle flap for prosthetic bypasses involving femoral anastomosis in high-risk-for-poor-healing patients does not appear to mitigate 30-day wound complications. Caution should be exercised with this practice and more long-term data should be obtained to determine whether prophylactic flaps decrease the incidence of graft infection., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Vein cuff anastomosis is beneficial in cases in which a prosthetic graft is anastomosed to a small and thickened peripheral artery. Various types of vein cuff are currently in use, although their design is insufficient when a size discrepancy exists between the two vessels and the angle of anastomosis requires adjustment. We report a case of a patient who underwent below-knee femoropopliteal bypass using a new design of vein cuff (boat-form vein cuff) that increases the ease of cuff creation and enables surgeons to adjust the anastomotic size and angle.

Objectives: Lower extremity peripheral artery disease is a common and important type of systemic atherosclerosis. The purpose of this study is to compare safety and effectiveness of balloon angioplasty, primary stenting and femoropopliteal bypass to treat total superficial femoral artery (SFA) lesions. Methods: 181 consecutive limbs from 149 patients who underwent endovascularly or surgically infrainguinal interventions between June 2013 and June 2017 were included in this retrospective study. Seventy-four legs (40.2%) underwent femoropopliteal bypass surgery, 58 legs (31.5%) were treated with balloon angioplasty, and nitinol stents were used in 49 (23.9%) legs. Results: A total of 149 patients were treated; surgically 56 patients and endovascularly 45 + 40 patients. The mean follow-up time was 24 months (range 4–56 months). The patency rates were 86.7% in the angioplasty group, 82.5% in the stent group, and 94.6% in the bypass group at the end of 24 months (P = 0.159). The rate of reintervention was three patients in the bypass group, six patients in the angioplasty group, and seven patients in the stent group (P = 0.159). The mean reintervention time in bypass was 52.075 months, 43.467 months in balloon angioplasty, and 44.075 months in stent group. Conclusions: There was no significant difference between groups in terms of reintervention and patency rates.

Objective: Periprosthetic seroma is a rare complication of femoropopliteal bypass grafting. Periprosthetic seroma can be defined as the collection of non-infected serous fluid around a prosthetic arterial graft. There is a dearth of literature on how to manage periprosthetic seroma occurrence after femoropopliteal bypass especially in patients whose symptoms do not improve with typical conservative measures.Method/Results: This report highlights the case of a 70-year-old patient who had a femoropopliteal bypass using a 6 mm Propaten graft for peripheral arterial disease. The patient subsequently presented with leg edema. Leg ultrasound and computed tomography arteriogram showed a periprosthetic seroma with a patent graft. Patient was initially managed conservatively and semi-conservatively and ultimately with aggressive therapy utilizing exploration and surgical resection of the seroma capsule.Conclusion: Only surgical resection of the seroma capsule produced definitive resolution of the seroma and symptoms. Thigh exploration and surgical resection can be considered as part of the management modalities of periprosthetic seroma occurring after femoropopliteal bypass especially in patients who do not respond to typical conservative measures such as elevation, compression stockings, and diuretics. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of heparin-bonded endoprosthesis compared with femoropopliteal bypass on key hospital resources and revenues up to 1-year follow-up., Design: A 2-arm scenario resource consumption data analysis was modeled based on a multicentre prospective randomized controlled trial., Setting: Six centers in the Netherlands., Participants: A total of 100 patients were assigned to 2 arms (50 each arm). The first arm evaluated endovascular treatment using the heparin-bonded Viabahn endoprosthesis and the second the femoropopliteal bypass. Resource consumption rates were compared between arms., Primary and Secondary Outcomes Measures: Resource consumption rates, including hospital stay for bypass procedure, operating room time, type of anesthesia, number of used (endo)grafts, use of different types of bed locations (vascular ward, medium or intensive care), readmission for wound infections, and reinterventions over a period of 12 months., Results: Endovascular repair used fewer hospital resources, with an overall difference of €149.983. Hospital stay was 118 days less (261 vs 379), including 21 fewer days in medium/intensive care (5 vs 26) and 50 fewer operating room hours (100 vs 150). Fewer patients required general anesthesia (31 vs 39), and there were less surgical site infections (3 vs 12). In the surgical bypass group, there were 18 fewer days of hospital stay related to reinterventions (80 vs 62), and the cost of the devices was €309.996, cheaper. The total monetary difference was € 160.013, in favor of the femoropopliteal bypass (€3.200, per patient)., Conclusions: Endovascular repair of the superficial femoral artery reduces the use of valuable hospital resources. Its major limitation is the cost of the devices, which should be balanced against the reduction in peri-procedural morbidity and faster recovery. In the context of shortage of hospital beds, it offers capacity benefits, allowing for the treatment of more patients overall. These benefits may outweigh the fewer reinterventions in the surgical bypass group., Registration: The SuperB Trial was registered in clinicaltrials.gov; NCT-ID: NCT01220245., Clinical Impact: Modeling is a useful technique to predict the impact of treatment modalities on hospital resources and revenue. This study uses real-world data from the SuperB Trial to compare two treatment strategies of superficial femoral artery disease, reflecting actual clinical practice and patient outcomes. The analysis focused on direct costs associated with hospital resources and device usage without considering indirect costs or long-term cost-effectiveness. The analysis showed that endovascular repair reduces the use of valuable hospital resources. Its major limitation is device costs, which should be balanced against the reduction in peri-procedural morbidity and faster recovery. In the context of shortage of hospital beds, it offers capacity benefits, allowing for the treatment of more patients overall., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: M.M.P.J.R. is consultant for W.L. Gore & Associates. K.I. is employee of W.L. Gore & Associates, and C.J.Z. has received research grants and speaker fees from W.L. Gore & Associates. L.A.v.W. received speaker fees from W.L. Gore & Associates.

Objective: This study aims to compare the 5-year outcomes of endoluminal bypass (EB) using heparin-bonded self-expanding covered stents versus bypass surgery for extensive femoropopliteal disease, including technical and clinical outcomes and health status., Background: The surgical femoropopliteal bypass was the gold standard to treat peripheral arterial disease (PAD) for decades; however, endovascular treatment modalities are now recommended for most femoropopliteal lesions. One-year data of a randomized controlled trial comparing EB with surgical bypass (SB) have shown a faster recovery, less morbidity, and comparable patency rates between the two techniques. To date, long-term randomized controlled data regarding both techniques are lacking., Methods: Five-year results of a multicenter randomized controlled trial comparing EB with SB in patients with femoropopliteal artery disease were evaluated based on intention-to-treat and per-protocol analyses., Results: At 5-year follow-up, primary, primary-assisted, and secondary patency rates were 36.2%, 52.4%, and 68.1% for EB and 49.4%, 72.2%, and 77.8% for SB, respectively (p=0.608). Freedom from target lesion revascularization (fTLR) was 34.1% for EB and 57.6% for SB (p=0.365). In both groups, the ankle-brachial index, Rutherford classification, and walking distance significantly improved compared with baseline without differences between groups at follow-up. Freedom from major amputation rate was 92.6% in the EB group and 96.2% in the SB group (p=0.361). The 36-Item Short-Form Health Survey showed no significant differences between groups., Conclusion: Treatment of extensive femoropopliteal disease with self-expanding covered stents provides comparable clinical-related and health-related questionnaire outcomes when compared with SB through 5 years of follow-up. However, the EB is related to a higher number of reinterventions., Clinical Impact: This present study is the first to report five-year outcomes comparing an endoluminal (EB) using heparin-bonded self-expanding covered stents with surgical bypass (SB) for long and complex femoropopliteal disease. Although the advantages of treatment with EB are mostly seen in the early period after treatment, the outcomes support the use of EB for this indication and seems to be a valid and safe alternative for bypass surgery. Future trials comparing various endovascular strategies may provide further guidance for the development of an evidence-based treatment algorithm., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: This is an investigator-sponsored study supported in part by W.L. Gore and Associates. Dr Reijnen IS consulting for W.L. Gore and Associates. Dr van Walraven has received speakers fees from W.L. Gore and Associates. Dr Zeebregts recieved research grants from W.L.gore and Associates. All other authors have reported that they have no relationships relevant to the contents of the paper to disclose.

To compare outcomes in patients with chronic limb threatening ischaemia (CLTI) due to femoropopliteal (FP), with or without infrapopliteal (IP), disease who underwent FP (vein or synthetic) open surgical bypass (OSB), or plain balloon angioplasty (PBA), with or without bare metal stenting (BMS), in the Bypass versus Angioplasty in Severe Ischaemia of the Limb (BASIL-1) trial. Data were extracted from BASIL-1 case record forms. Outcomes reported include immediate technical success, freedom from major adverse limb events (FF-MALE) and further re-intervention (FF-R), amputation free survival (AFS), overall survival (OS), and limb salvage (LS). Patients underwent primary OSB (n = 128; 89 vein, 39 synthetic) or primary PBA (n = 183; six had BMS). Mean follow up was 46.2 and 43.6 months respectively. Patients were well matched at baseline except that PBA ± BMS patients were significantly more likely to be current smokers. There was no difference in overall or IP (runoff) Bollinger angiogram scores between groups. Immediate technical success was significantly higher for OSB (98% vs. 81%; p <.001). OSB was associated with a longer mean index hospital admission (p =.001), but there was no difference in hospital days at 12 months. FF-MALE (hazard ratio [HR] 1.51; p =.04) and FF-R (HR 1.68; p =.02) but not AFS (HR 1.18; p =.4), OS (HR 1.14; p =.5), and LS (HR 1.09; p =.8) were significantly better after OSB. Although AFS, OS, and LS were similar in the two groups, OSB was associated with significantly fewer MALE and re-interventions. So, while PBA ± BMS may be a less resource intensive (expensive) and morbid option in the short term, this appears unlikely to be the case in the longer term. Present data add further weight to the argument that, where possible, patients presenting with CLTI due to FP disease should be offered OSB as their primary revascularisation procedure. [ABSTRACT FROM AUTHOR]

Bypass surgery (BS) remains the gold standard revascularization strategy in patients with chronic limb-threatening ischemia (CLTI) owing to infrainguinal disease. The Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL)-1 trial showed that, in patients with CLTI who survived for 2 years or more, BS resulted in better clinical outcomes. Despite this finding, there has been an increasing trend toward an endovascular-first approach to infrainguinal CLTI. Our aim was to investigate whether changes in practice have impacted the clinical outcomes of BS in our unit 10 years after BASIL-1. Data for patients who underwent femoropopliteal (FP) BS in BASIL-1 (1999-2004) were retrieved from trial case record forms. The comparator contemporary series (CS) comprised all patients undergoing FP BS for CLTI in our unit between 2009 and 2014. Demographic and clinical outcome data on patients in the CS were collected from the prospectively collected hospital electronic notes. Anatomic patterns of disease in the BASIL-1 and CS cohorts were scored using the Bollinger and GLASS criteria. Statistical analysis was performed in SAS v9.4. There were 128 patients from BASIL-1 and 50 patients in the CS. Baseline age, gender, affected limb, and diabetes prevalence were similar, as were days spent in hospital out to 12 months and length of follow-up. BASIL-1 patients were more likely to be current smokers (P =.000) and had a higher creatinine (P =.04). The 30-day morbidity and mortality were higher in BASIL-1 (45.3% vs 22%; P =.004). There was no significant difference between BASIL-1 and CS with regard to run-off Bollinger (37.7 vs 32.1; P =.167) and IP GLASS (0 vs 0; P =.390) scores, with both groups having a median of two runoff vessels. Amputation-free survival (62% vs 28%; hazard ratio [HR], 1.86; 95% confidence interval [CI], 1.18-2.93; P =.007), limb salvage (85% vs 69%; HR, 2.31; 95% CI, 1.14-4.68; P =.02), overall survival (69% vs 35%; HR, 1.66; 95% CI, 1.00-2.74; P =.05) and major adverse limb events (67% vs 47%; HR, 1.93; 95% CI, 1.15-3.22; P =.01) were all significantly better in BASIL-1. Although 30-day mortality and morbidity were significantly lower, all of the examined longer term clinical outcomes after FP BS were significantly worse in the CS group a decade on from BASIL-1. Further research in the form of prospective cohort studies and randomized controlled trials is urgently required to determine if the CS data reported herein are generalizable to current vascular surgical practice and, if so, to determine the reasons for these unexpected outcomes. [ABSTRACT FROM AUTHOR]

Objective: This population-based retrospective cohort study investigates long-term results of femoropopliteal bypass and femoropopliteal endovascular intervention (PTA) in patients with critical ischemia, with focus on limb salvage and amputation-free survival. Methods: All patients who underwent femoropopliteal bypass or femoropopliteal PTA for critical ischemia without other simultaneous intervention between 1999 and 2013 were included. Stratification was according to treatment modality and symptoms, rest pain, or ischemic ulcer/gangrene. We assessed technical success, 30-day complications, length of stay, recurrent interventions, limb salvage, survival, and amputation-free survival in all patients. Results: We identified 292 operations in 264 patients, 140 bypass and 152 PTA. In 32 PTA cases, the patients were explicitly deemed unfit for bypass surgery. This group had significantly inferior technical success and limb salvage (P = .00). In other patients, technical success was 96% for bypass and 93% for PTA, while limb salvage after 5 years was 78% for bypass and 81% for PTA. Reoperation for local complications was performed in 16% after bypass and 2% after PTA (P = .00). Mean length of stay was 8 days after bypass and 1.9 days after PTA (P = .00). Conclusions: Long-term follow-up showed similar technical success and good limb salvage for both PTA and bypass patients in this clinical cohort. Patients who were unfit for bypass surgery had significantly inferior technical success and limb salvage. PTA was associated with shorter hospital stay and fewer reoperations for local complications. The findings support a PTA first strategy in all cases where technical success is likely. [ABSTRACT FROM AUTHOR]

The geometry of the distal anastomosis of a femoropopliteal bypass influences local hemodynamics and formation of intimal hyperplasia. We hypothesized that the distal anastomosis of an above-knee femoropopliteal bypass undergoes remodeling that results in displacement of the original course of the popliteal artery and change in the anastomosis angle. We identified 43 CT angiography examination with proximal femoropopliteal bypass and either a preserved contralateral popliteal artery or previous CTA before construction of the bypass for comparison. In these examinations, we measured the displacement distance and angle at the level of the distal anastomosis and compared these measurements with clinical and imaging data. The displacement distance was 8.8±4.9 mm (P<0.0001) and the displacement angle was -1° (IQR=44°). The angle between the inflow and outflow artery was 153±16° (P<0.0001). There was a negative association between the displacement angle and the angle between the bypass and the outflow artery (r=-0.318, P=0.037). Patients with reversed venous grafts had a greater displacement of the anastomosis (14.7±3.0 mm) than patients with prosthetic grafts (8.0±4.5 mm, P=0.0011). We conclude that construction of a distal anastomosis of proximal femoropopliteal bypass results in displacement of the original course of the popliteal artery towards the bypass and this effect is more pronounced in reversed venous grafts. [ABSTRACT FROM AUTHOR]

Backround. Intermittent claudication is a classic symptom of peripheral arterial disease. It is mainly treated conservatively but if this fails, a form of revascularization is indicated. The revascularization in chronic occlusion of femoropopliteal region is currently performed by two basic methods: the standard method of surgical bypass and the newer miniinvasive alternative represented by the endovascular method. The treatment of patients with solely claudication and long occlusion of femoropopliteal region remains controversial. The aim of this minireview was to determine whether surgical bypass is still the best method of choice in a time of endovascular techniques. Methods: A MEDLINE search for original and review articles using key terms, intermittent claudication and long femoropopliteal oclusion. Results and Conclusion: No ideal treatment for long occlusions of the femoropopliteal segment has been established to date. It is clear that the role of endovascular techniques in the treatment of SFA occlusions is increasing. It remains that, lower risk patients with claudication should be examined to assess the quality of veins suitable for revascularization and bypass should be selected as the first method of choice.

Objectives: This study aimed to examine the outcomes of endovascular recanalization for native superficial femoral artery (SFA) chronic total occlusion (CTO) in patients with critical limb ischemia (CLI) after femoropopliteal bypass failure with limited surgical revascularization options.Background: Endovascular recanalization of native artery occlusions has been recently used as a new alternative for threatened limbs after bypass graft occlusion. The feasibility and efficacy has not been widely reported.Methods: We retrospectively analyzed 45 consecutive patients (45 limbs) undergoing endovascular recanalization of native SFA occlusion following failed femoropopliteal bypass between June 2010 and December 2016.Results: All limbs had Transatlantic Inter-Society Consensus class C (26.7%, 12/45) or D (73.3%, 33/45) lesions with a mean lesion length of 29.8 cm. The technical success rate was 95.6% (43/45 limbs). The ABI showed a significant increase from 0.3 ± 0.1 pre-procedure to 0.7 ± 0.1 post-procedure (P < 0.01). Two early (<30 days) below-knee amputations due to acute thrombotic ischemia occurred during perioperative period and resulted in one death due to myocardial infarction. The mean follow-up was 42.7 months (1-62 months). Two patients were lost to follow up. The primary patency rates at 12 and 36 months were 54% and 51%, respectively. Secondary patency rates at 12 and 36 months were 78% and 61%, respectively. Limb salvage rate was 95% and amputation-free survival rate was 88% at both 12 and 36 months.Conclusion: Recanalization of native SFA CTO due to failed femoropopliteal bypass offers a feasible and safe alternative to surgical reconstruction with acceptable limb salvage. [ABSTRACT FROM AUTHOR]

Introduction. Acute lower limb ischemia results from thrombosis or embolization of diseased native artery or previously implanted bypass graft. When this occurs, several options are available to restore blood flow: catheter-directed thrombolysis, mechanical thrombectomy or open surgery. Fundamental reasons to apply percutaneous interventions are avoiding open procedures in high risk patients, and avoiding difficult dissection through scar tissue. Case Outline. A 67-year-old male was admitted at our Institution for critical limb ischemia. After performed angiography the diagnosis of occluded femoropopliteal graft was established. Occlusion was resolved by catheter-directed thrombolysis with plasmin. Culprit lesions were treated by angioplasty. Conclusion. Our patient underwent a successful thrombolysis of occluded femoropopliteal graft with locally-delivered human plasmin.

Introdução: Os autores elaboraram um estudo retrospectivo de todos os casos clínicos admitidos no seu Serviço com o diagnóstico de aneurisma poplíteo ao longo de 5 anos. Material e Métodos: Para atingir esse objectivo, procederam à consulta dos processos hospitalares de todos os doentes admitidos com o diagnóstico de aneurisma poplíteo entre 01 de Janeiro de 2004 e 31 de Dezembro de 2008. Resultados: De um total de 61 doentes, 37 (60,7%) apresentavam aneurismas bilaterais. Desses 61 doentes, 58 eram do sexo masculino e 3 do feminino, sendo a média de idades de 66,9 ± 11,6 anos. 36,1% dos doentes apresentavam também aneurismas noutras localizações. Os aneurismas eram, na sua maioria, assintomáticos. Quando sintomáticos, a forma de apresentação mais frequente foi a isquémia aguda por trombose do aneurisma. Dentro da totalidade dos aneurismas poplíteos (n=98), 37 foram operados electivamente, 29 de urgência e 32 não foram operados. As intervenções cirúrgicas de eleição foram a exclusão do aneurisma através de bypass femoro-poplíteo distal com veia safena interna (n=48) ou com prótese (n=16). As taxas de patência primária aos 30 dias foram de 98% com o uso de veia e de 68,8% com prótese, tendo motivado 3 amputações supracondilianas. Conclusões: Os aneurismas poplíteos são mais prevalentes no sexo masculino, frequentemente bilaterais, e existe uma forte relação entre estes e aneurismas noutras localizações/megadistrofia arterial generalizada. O tratamento cirúrgico ideal é o realizado electivamente com material autólogo, sendo as taxas de patência com o recurso a material protésico bastante inferiores.Introduction: The authors performed a 5-year retrospective study of all the case reports admitted in their Department with the diagnosis of popliteal aneurysm. Material and Methods: To achieve that purpose, the clinical files of all the patients admitted with the diagnosis of popliteal aneurysm between January 1st 2004 and December 31st 2008 were reviewed. Results: From a total of 61 patients, 37 (60,7%) had bilateral aneurysms. Of those 61 patients, 58 were males and 3 were females. The mean age was 66,9 ± 11,6 years. 36,1% of the patients had also aneurysms in other locations. The majority of the aneurysms were asymptomatic. When symptomatic, the most frequent presentation was acute ischemia caused by thrombosis of the aneurysm. Of all the popliteal aneurysms (n=98), 37 were repaired electively, 29 urgently and 32 were not repaired. The most used surgical interventions were the exclusion of the aneurysm by distal femoropopliteal bypass with greater saphenous vein (n=48) or with prosthesis (n=16). Primary patency rates at 30 days were of 98% with vein and of 68,8% with prosthesis, which caused 3 transfemoral amputations. Conclusions: Popliteal aneurysms are more prevalent in males, frequently bilateral and there is a strong connection between them and aneurysms in other locations/arteriomegaly. The ideal surgical treatment is the elective repair with autologous material, being the patency rates with prosthesis inferior to the ones with vein.

Anticoagulant and antiplatelet (AC/AP) medications have been reported to improve bypass graft patency, however, the optimal AC/AP strategy remains unclear in the heterogenous peripheral artery disease population. A multi-institutional retrospective review utilizing the Research Patient Data Registry database from 1995 to 2020 was performed for all patients who underwent femoropopliteal bypass procedures. Electronic medical records were used to obtain demographic information, comorbidities, smoking status, operative details (bypass target), postoperative AC/AP medications, postoperative complications, and long-term outcomes and were reviewed for the cohort. Cox proportional hazards model was used to determine independent risk factors for major adverse limb events (MALE) after bypass. MALE was defined as reintervention for patency or major amputation of index limb (above- or below-knee amputation). A total of 1421 patients underwent femoropopliteal bypass between 1995 and 2020 throughout five institutions included in this study. Complete data were available for 1292 of the 1421 patients (90.9%). The indications for bypass included intermittent claudication (21.4%), rest pain (30.3%), tissue loss (33.5%), and nonatherosclerotic disease (14.8%). Distal bypass targets comprised above-knee (38.6%) and below-knee (61.4%) popliteal arteries. Patients were divided into six groups based on postoperative AC/AP use including none (n = 57 [4.4%]), monoantiplatelet therapy (n = 587 [45.4%]), dual AP therapy (n = 214 [16.6%]), AC alone (n = 73 [5.7%]), AC + monoantiplatelet therapy (n = 319 [24.7%]), and AC + dual AP therapy (n = 42 [3.3%]). Postoperative bleeding complications were low for both hematoma (3.7%) and pseudoaneurysm (0.7%). There was no difference in bleeding complications across AC/AP groups (hematoma, P =.61; pseudoaneurysm, P =.31). After adjusting for patient factors, below-knee bypass target (hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.04-1.52; P =.019) and bypass for tissue loss (HR, 1.40; 95% CI, 1.04-1.88; P =.028) were independent predictors for MALE. Great saphenous vein conduit trended toward protection for MALE, compared with prosthetic grafts (HR, 0.84; 95% CI, 0.70-1.01; P =.06). No AC/AP regimen was associated with of MALE, even stratifying by above-knee and below-knee bypass cohorts. The median follow-up period was 2 years. Among patients undergoing femoropopliteal bypass grafting, no combination of AC or AP medications was associated with improved graft patency; however, a below-knee target and tissue loss were associated with adverse limb events. AC and AP regimen may be individualized after bypass with regard to other concomitant medical comorbidities. [ABSTRACT FROM AUTHOR]

Backround. Intermittent claudication is a classic symptom of peripheral arterial disease. It is mainly treated conservatively but if this fails, a form of revascularization is indicated. The revascularization in chronic occlusion of femoropopliteal region is currently performed by two basic methods: the standard method of surgical bypass and the newer miniinvasive alternative represented by the endovascular method. The treatment of patients with solely claudication and long occlusion of femoropopliteal region remains controversial. The aim of this minireview was to determine whether surgical bypass is still the best method of choice in a time of endovascular techniques. Methods. A MEDLINE search for original and review articles using key terms, intermittent claudication and long femoropopliteal oclusion. Results and Conclusion. No ideal treatment for long occlusions of the femoropopliteal segment has been established to date. It is clear that the role of endovascular techniques in the treatment of SFA occlusions is increasing. It remains that, lower risk patients with claudication should be examined to assess the quality of veins suitable for revascularization and bypass should be selected as the first method of choice. [ABSTRACT FROM AUTHOR]

Peripheral vascular disease commonly affects the arteries supplying the leg and is mostly caused by atherosclerosis. Restriction of blood flow due to arterial stenosis or occlusion often leads patients to complain of muscle pain on walking (intermittent claudication). Any further reduction in blood flow causes ischemic pain at rest, affecting by consequence the extremity. Ulceration and gangrene may then supervene and can result in loss of the limb if not treated. We present the case of a 55 year old male, C.I., with tissue necrosis of the right calf, aching pain at rest in the distal foot and disabling claudication (stage IV Fontaine PAOD).The patient's history reveals that he is a former smoker undergoing anticoagulation and vasodilation treatment. He also suffered severe spinal cord injury leading to paraplegia in 2008, a laryngeal neoplasm surgery in 2013 and a PTA with stent placement in the proximal right CIA. [ABSTRACT FROM AUTHOR]

Acute and subacute ischemia of the legs in acute and subacute femoropopliteal bypass occlusion is a dramatic situation that endangers the survival of the limbs, depending on the severity of the ischemia. Different therapy options like percutaneous mechanical thrombectomy procedures, which include rotational thrombectomy, have become available in recent years in addition to local lysis and surgical thrombectomy. Rotational thrombectomy with the Straub Rotarex System as an endovascular therapy option has demonstrated promising results leading to amputation-free survival in multiple studies. We recently provided data of 22 patients with acute femoropopliteal bypass occlusion where we examined the feasibility of the Rotarex System in this indication. A technical success rate of 82 % was demonstrated. During a follow-up period of 6 months, no reinterventions in these patients had to be performed. We now provide patency rates in 21 patients of our study group after a follow-up period of 12 months. The average ABI after 12 months was 0.80 ± 0.1. One patient showed a hemodynamic restenosis in a Nitinolstent distal to the femoropopliteal bypass which was implanted in the index procedure. No reocclusion of the femoropopliteal bypasses occurred in all patients. [ABSTRACT FROM AUTHOR]

Redo femoropopliteal bypass surgery is associated with increased morbidity and related to a poorer outcome than primary procedures. Endografts might provide an alternative, avoiding dissection of a previously operated groin. Patients treated with a polytetrafluoroethylene-covered stents for superficial femoral artery occlusive disease between February 2009 and September 2011 were prospectively gathered. Demographics, clinical status, procedural aspects, and follow-up were retrieved. Seventy-four patients were included of which 5 (7%) were treated before with a femoropopliteal bypass. Indication for intervention was Rutherford category 3 in all patients and the median ankle–brachial index (ABI) was 0.68. Technical success was achieved in all cases. The postoperative course was uneventful in all and the ABI increased to 0.95. After a follow-up period of 18 months, 4 of 5 endografts remained patent. The use of endografts after failed femoropopliteal bypass surgery is feasible and safe and could be used to avoid or minimize a difficult and hazardous dissection of a previously operated area. [ABSTRACT FROM PUBLISHER]

Acute and subacute ischemia of the legs in acute and subacute femoropopliteal bypass occlusion is a dramatic situation that endangers the survival of the limbs, depending on the severity of the ischemia. Different therapy options like percutaneous mechanical thrombectomy procedures, which include rotational thrombectomy, have become available in recent years, in addition to local lysis and surgical thrombectomy. Surgical thrombectomy using the Fogarty catheter technique, in particular, shows an increased incidence of perioperative complications but only small technical success rates in randomized trials. On the other hand, local lysis is associated with increased costs due to resource-consuming measures, such as intensive monitoring and repeat angiographies, in addition to bleeding complications. In the past, further development of the Straub Rotarex® system as an endovascular therapy option has demonstrated good success leading to amputation-free survival in multiple studies. At the same time, a low rate of complications with use has been documented. Most examinations have been conducted in the thigh. To date, there are little investigational data on its use in acutely and subacutely occluded femoropopliteal bypasses. In this paper, the current study-based significance of the Rotarex system for this indication is analyzed based on the existing literature and the authors' own experiences with 22 patients. [ABSTRACT FROM AUTHOR]

Patency of femoropopliteal vein bypass above the knee has been estimated between 69% and 77% at 5 years. This article reports a case of a patent femoropopliteal vein bypass 45 years after implantation without any reintervention. The morphologic alterations observed after 45 years at this vein bypass graft are additionally discussed. [ABSTRACT FROM AUTHOR]

Critical limb ischaemia is a result of occlusive arterial disease in the infrainquinal segment and is a major indication for arterial revascularization, which implies a femoropopliteal bypass procedure or an interventional procedure - stent grafting of the occluded segment. Although indications for both techniques are clearly deemed, there are still controversies. Thus, the aim of this study was to determine short-term results in patients treated with these two treatment modalities. In the period between 2002 and 2008 a total of 70 patients with occlusive arterial diseases of the low extremity were analysed. In 50 out of 70 patients a femoropopliteal bypass was made. Of these, in 30 (60%) patients PTFE material was used and in 20 (40%) patients an autologous saphenous vein graft was used. The other group comprised 20 patients who underwent stenting. In patients treated with surgical revascularization, the major indication for surgery was occlusive arterial disease in: stage II - in 10 patients (20%), stage III - in 5 patients (10%), stage IV - in 25 patients (50%) and the remaining 10 patients (20%) had subacute ischaemia. Arteriography showed three crural patent tributaries in 18% of the patients, two patent crural tributaries in 40% of the patients and one crural patent tributary in 32% of the patients. There were no significant differences concerning indications and arteriographic findings between the two subgroups. The follow-up period lasted for 6 months and the patency rate was 85% (17) for venous bypass, 11 (64.6%) - short-segment lesions (< 4 cm) and 6 (35.3%) longer segment lesions (> 4 cm) versus 76.5% (23) for PTFE graft (p < 0.05), of which 13 (56.5%) were short-segment (<4 cm) and 10 (43.5%) longer segment lesions (> 4 cm). The following results were obtained for the second group of patients: initially successful stems in 85%; failure in 15% or 2 patients; technical failure in 1 patient or 5%. After 6 months the patency rate was 75% (15), of which 11 patients (73.2%) had short-segment occlusions (< 4 cm) whereas 4 patients (26,8%) had lesions > 4 cm. The baseline value of the lower limb index (ABI - ankle-brachial index) was significantly increased in both groups, from 0.41 to 0.91 in the group with surgical revascularization and from 0.47 to 0.88 in the second group treated with stenting. The same trend was observed after six months. This study demonstrated a small but significant difference (85% vs 75%, p < 0.05) in favour of the autologous saphenous vein, which should be a preferred graft material in all cases for reconstruction of the femoropopliteal segment. When compared to the overall patency rate of PTFE grafts after 6 months there was no significant difference in patency in the group treated with stem grafting (76.5% vs 75%). However, stenting is a method of choice in the treatment of short-segment occlusions - smaller than 4 cm with good early run off (73.2% vs 64.6%, p > 0.05 p = ns). It is obvious that the results are identical to those in treatment with an autologous great saphenous vein, but in comparison with PTFE the results imply stent usage (73.2% vs 56.5%, p < 0.005). Prosthesis (PTFE) is a graft material of choice when the great saphenous vein is used, damaged or calcified and when the occlusion is longer than 4 cm and is not suitable for stent grafting (43.5% vs 26.6%, p < 0.001). [ABSTRACT FROM AUTHOR]

Abstract: Objective: Tetrapolar whole-body (hand-foot) bioelectrical impedance (Z-body) is used in body composition analysis assuming homogeneous soft tissue hydration. Limbs and trunk contribute to Z-body by 90% and 10%, respectively. We determined the effect on Z-body of an edema localized in one leg. Methods: Resistance (R) and reactance (Xc) components of Z vector were measured at 50 kHz (BIA-101, RJL Systems, Akern, Italy) in 20 adult male patients without edema, before and 3 d after a femoropopliteal bypass that induced pitting edema in the leg. Z-body was measured from hand to foot on the right and left sides. Z from the leg (Z-leg) was measured from the pair of electrodes on the foot and the other pair on the trochanter. Data were analyzed with the vector bioelectric impedance analysis (Vector BIA) method (Piccoli''s RXc graph with 95% confidence ellipses). Results: Before surgery, the positions of the mean Z-body and Z-leg vectors from either side of the body were not significantly different (overlapping 95% confidence ellipses). After surgery, the mean Z-leg and Z-body vectors from the side without edema did not change position in the RXc plane with respect to the presurgery position. In contrast, the mean Z-leg and Z-body vectors of the body side with edema significantly (P < 0.05) shortened according to the Vector BIA patterns of fluid accumulation. Conclusion: Z-body in the side of the body without edema is not sensitive to the edema localized in the leg on the opposite side and therefore can be used in the assessment of body composition in patients with edema in one leg. [Copyright &y& Elsevier]

Abstract: Objective: Despite many clinical studies, there is still uncertainty as to whether venous material is superior to prosthetic materials for femoropopliteal reconstruction proximal to the knee joint. A prospectively randomized clinical trial was designed to evaluate the effectiveness of reversed saphenous vein in comparison with that of collagen impregnated woven polyester prosthesis in above-knee arterial reconstruction. Methods: In a 3-year period, 103 above-knee femoropopliteal bypass graft operations were performed and followed in 85 patients (52 male, 33 female). The indication for operation was severe claudication in 74 cases, rest pain in 7 cases, and ulceration in 4 cases. For the bypass graft, a reversed saphenous vein was used in each of 51 cases, and a collagen impregnated woven polyester prosthesis was used in each of 52 cases. Preoperative risk factors were diabetes (24%), a history of myocardial infarction (23%), and current status with respect to smoking (74%). There was no hospital mortality; 5% of patients had minor postoperative complications. Results: After 2 years of follow-up, the primary patency was 81% for saphenous vein and 67% for collagen impregnated woven polyester prosthesis (P =0.065); the secondary patency was 81% for saphenous vein and 77% for collagen impregnated woven polyester prosthesis (P =0.298). During this follow-up period of 2 years, we found no statistically significant difference in primary and secondary patency between saphenous vein and collagen impregnated woven polyester prosthesis. We found no predictive factor for the occlusion of either bypass graft. Conclusion: The use of collagen impregnated woven polyester prosthesis above the knee is a reasonable alternative in femoropopliteal bypass grafting that is associated with acceptable short-term patency rates. [Copyright &y& Elsevier]

A case is presented of a patient with a false aneurysm at the distal anastomosis of the femoropopliteal bypass who received a peripheral stent-graft to repair vascular defects. Current knowledge on the etiology, pathomechanisms of development, and treatment of such complications is also presented. Finally, the potential use of minimally invasive procedures in the treatment of late complications following reconstructive surgery is discussed. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the feasibility and efficacy of a specific aortomonoiliac endograft and the durability of the femorofemoral bypass for treatment of abdominal aortic aneurysm (AAA). Methods: From 2002 to 2004, 39 high-risk (ASA III/IV) patients (36 men; median age 74 years, range 63-84) with AAA (n = 33) or AAA and common iliac artery aneurysm (n = 6) were treated with an EndoFit aortomonoiliac endograft and femorofemoral crossover bypass. The contralateral iliac axis was obstructed with an endoluminal occluder. Patients were followed with contrast-enhanced computed tomography at 1, 6, 12, and 24 months. Results: EndoFit AMI stent-grafts were implanted successfully in all patients. Perioperative mortality was zero. Endoleak occurred in 3 (7.7%) cases. A proximal type I endoleak was identified at 1 month and was treated with a proximal cuff. Two type II endoleaks are under surveillance because the aneurysm sac shows no enlargement. Thrombosis of the femorofemoral graft occurred in 1 case during the immediate postoperative period due to insufficient inflow from a residual stenosis of the endograft (primary patency 97.5%). The deficit was treated successfully (secondary patency 100%). Two (5.1%) tunnel hematomas were treated conventionally. Median follow-up was 14 months (range 6-30). All patients are alive. None of the aneurysms has ruptured or been converted to an open procedure. Graft migration, serious infection, paraplegia, distal embolization, or any other serious complication has not been observed. Conclusions: In high surgical risk patients with complex iliac anatomy, aortomonoiliac endograft with femorofemoral crossover bypass is feasible and efficacious. Moreover, the midterm patency of the extra-anatomic bypass appears quite satisfactory. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To compare end-to-side (ETS) and end-to-end (ETE) distal anastomoses for femoropopliteal bypasses. Design: Prospective, randomized, multicenter trial. Methods: Patients from 14 centers were randomized to either ETS or ETE distal anastomosis, with stratification according to center and four categories: venous and prosthetic above knee bypass, and venous and prosthetic below knee bypass. Follow-up, with history, physical examination, ankle-brachial pressure index and duplex scan was performed at 3 months, 6 months and every 6 months thereafter until 36 months postoperatively. Results: A total of 328 femoropopliteal bypass operations were performed in 274 patients. Due to anatomical considerations at the time of surgery, 15 procedures (4.6%) were excluded from further analysis. Patient characteristics, cardiovascular risk factors, Rutherford classification and number of open run-off vessels were similar for both groups. Primary patency was 75 vs 74%, 65 vs 66% and 63 vs 55% for ETE vs ETS after 1, 2 and 3 years, respectively, (p=0.26). During follow up major amputations were necessary in 20 ETE bypasses and in nine ETS bypasses (p=0.028). Conclusion: ETE distal anastomosis in femoropopliteal bypasses does not improve patency compared to ETS anastomosis. Major amputations, after failure of the bypass, were required more frequently for ETE distal anastomoses. [Copyright &y& Elsevier]

We present a 59-year-old woman who underwent femoropopliteal bypass to relieve claudication caused by superficial femoral artery occlusion. We performed endoscopic saphenous vein harvest and used minimal access approaches to the anastomoses to reduce the risk of post-operative wound complications and speed recovery. The technique of the minimal access operation is described and we discuss the pertinent literature outlining results of endoscopic saphenous vein harvest used for infrainguinal bypass procedures. With the improvement in technology, reduction in wound complication rates, and decrease in overall expense, we predict that minimal access approaches for infrainguinal bypass procedures will regain popularity among vascular surgeons. [ABSTRACT FROM AUTHOR]

Late-stage occlusions of peripheral synthetic bypass grafts are frequently due to intimal hyperplasia and/or thrombosis at the distal anastomosis, resulting in unacceptably high failure rates. It has been widely established that hemodynamic and blood particle interactions with the vascular surface as well as surgical injury and compliance mismatch are inciting mechanisms capable of eliciting various cellular level responses associated with distal anastomotic intimal hyperplasia (IH) formation. Primary geometric factors influencing anastomotic hemodynamics include the graft-to-artery diameter ratio and graft-hood shape, which are determined by the graft caliber and initial graft-end cut selected by the vascular surgeon. In this study, the particle-hemodynamic effects of graft-end cuts (straight, curved, and S-shaped) and graft-to-artery diameter ratios (2:1 vs. 1.5:1) have been numerically assessed in four common unexpanded anastomotic configurations with respect to vortical flow patterns, wall shear stress based parameters, and platelet interactions with the vascular surface. Sites of significant platelet–wall interactions have been identified by a novel near-wall residence time (NWRT) model, which includes shear stress based factors for platelet activation and endothelial cell expression of anti-thrombogenic compounds. Of the configurations evaluated, straight and curved graft-end cuts with a graft-to-artery diameter ratio of 1.5:1 were found to reduce the particle-hemodynamic potential for IH development at locations critical to flow delivery. Nevertheless, the potential for significant IH occurrence via platelet and/or endothelial response pathways was highly evident in all conventional anastomoses considered, such that a decisively superior configuration was not determined. These results illustrate the need for alternative anastomotic designs with the intent of reducing critical hemodynamic wall parameters and mitigating regions of significant particle–wall interactions. [Copyright &y& Elsevier]

Objective: To analyze immediate and long-term results of various methods of femoropopliteal bypass grafting with autologous vein using propensity score matching., Material and Methods: A retrospective single-center open study included 464 patients who underwent femoropopliteal bypass grafting with an autologous vein between January 10, 2016 and December 25, 2019 at the Research Institute - Ochapovsky Regional Clinical Hospital No. 1. The following types of autovenous conduits were used: n =266 - reversed autologous vein (group 1); n =59 - in situ autologous vein (group 2); n =73 - upper limb autologous vein (group 3); n =66 - ex situ autologous vein (group 4). The long-term period was 16.6±10.3 months., Results: We used propensity score matching analysis because patients were not comparable for some indicators. Groups 2-4 included small samples of patients, and their number was reduced to less than 10. This did not allow us to draw reliable conclusions about treatment outcomes. In this situation, we decided to allocate two groups: group 1 - ex situ femoropopliteal bypass grafting; group 2 - other variants of femoropopliteal bypass grafting with autologous vein. Propensity score matching allocated 299 people in group 1 and 46 patients in group 2. There were significant differences in early postoperative incidence of autologous vein thrombosis (group 1: n =3 (6.5%), group 2: n =79 (26.4%), p =0.003; OR= 0.19; 95% CI 0.05-0.64) and postoperative wound suppuration (group 1: n =2 (4.3%), group 2: n =52 (17.4%); p =0.02; OR=0.21; 95% CI 0.05-0.91). In long-term postoperative period, significant differences were obtained in the incidence of limb amputation (group 1: n =6 (13%), group 2: n =85 (28.4%); p =0.02; OR=0.37; 95% CI 0.15-0.92) and myocardial infarction (group 1: n =1 (2.2%), group 2: n =43 (14.4%); p =0.02; OR 0.13; 95% CI 0.01-0.98)., Conclusion: Femoropopliteal bypass grafting ex situ is characterized by lower incidence of graft thrombosis, amputations of the limb, mild decrease in the incidence of infectious complications and all adverse cardiovascular events in early and late postoperative period compared to conventional surgery (reversed autologous vein, in situ autologous vein, upper limb autologous vein).

Factors responsible for edema formation in a patient who had femoropopliteal bypass and its inhibitory effect on healing were examined in this study. Femoropopliteal bypass was performed with autogenous saphenous graft in a 50-year-old male diabetic patient with superficial femoral arterial occlusion of right leg. Antithrombin III defficiency was detected in the patient in whom wound healing was delayed and grade 2-3 edema formation occurred in the operated leg. We think that detailed preoperative evaluation and meticulous surgical care could help in the prevention of this complication. [ABSTRACT FROM AUTHOR]

An above-knee femoropopliteal bypass graft constructed of great saphenous vein became dilated in 2 patients 12 and 25 years after surgery. Both patients had several concomitant disorders. The dilations were treated by insertion of an expanded polytetrafluoroethylenecovered nitinol endoprosthesis. There were no major procedural complications. One minor endoleak that developed immediately after endograft placement resolved within 6 weeks. The leg swelling subsided, and the endoprostheses have remained patent for 18 and 24 months, respectively. To our knowledge, these were the first cases in which an endoprosthesis was used to treat dilation of a venous bypass graft. [ABSTRACT FROM AUTHOR]

To analyze the prevalence and predictors of prosthetic vascular graft infection (PVGI) in a multicenter registry. This registry-based, multicenter study retrospectively evaluated PVGI that developed after infrainguinal revascularization performed with a heparin-bonded expanded polytetrafluoroethylene graft that was used in 1400 interventions between 2002 and 2016. A prosthetic graft with infection was defined as direct involvement of the graft with positive bacterial cultures of graft or perigraft material, intraoperative gross purulence or failure of graft incorporation, or exposed graft in an infected wound. Critical limb ischemia (CLI) was the main indication for bypass (n = 915 [65%]). The median duration of follow-up was 29 months (range, 1-168 months; interquartile range, 12-60 months). A total of 33 heparin-bonded expanded polytetrafluoroethylene grafts (2.3%) became infected; the median time to occurrence was 5 months (range, 1-54 months; interquartile range; 2.00-13.25 months). Freedom from PVGI at 1 year was 98% (standard error, 0.4; 95% confidence interval [CI], 97.2-98.9), and 97% (standard error, 0.6; 95% CI, 95.6-98.0) at 5 years. The multivariate model identified CLI (P =.042; hazard ratio, 0.39; 95% CI, 0.164-0.969) to be independently associated with PVGI. In-hospital mortality of PVGI treatment was 12% (n = 4/33). Freedom from major amputation was significantly different between patients with PVGI and those who did not experience this complication (at 1 year, 67.0% vs 88.5%; Log-rank χ 2 = 22.5; P =.001). In our "real-world" multicenter experience the prevalence of PVGI after infrainguinal femoropopliteal bypasses was relatively low at 2.3%, but still associated with significant mortality and limb loss. CLI was the only significant predictor of PVGI. This conclusion is reasonable; however, more comprehensive data are required to confirm these findings, because the presence of ischemic ulcers or gangrene was not predictive of PVGI. [ABSTRACT FROM AUTHOR]