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Background: Autologous vein is recommended for infrainguinal bypass due to improved freedom from occlusion compared to prosthetic graft. In patients without adequate vein, a vein adjunct at the distal anastomosis has been suggested to improve patency in small studies. This study aimed to determine if performance of a distal vein adjunct was associated with improved freedom from occlusion in below-knee popliteal and tibial bypasses compared to prosthetic bypass alone., Methods: A retrospective review of the Vascular Quality Initiative Infrainguinal Bypass database was conducted. Patients undergoing prosthetic-only and prosthetic with vein adjuncts were compared. Inclusion criteria included age ≥18 years, and bypass to below-knee popliteal or tibial vessels. Exclusion criteria included autologous vein conduits and prior interventions. Groups were further divided into below-knee popliteal and tibial subgroups., Results: A cohort of 3,939 patients underwent bypass to the below-knee popliteal artery, with 287 (7.3%) receiving vein adjuncts. More patients were male (68.8 vs. 57.8%, P < 0.001) and had higher rates of congestive heart failure (21.1 vs. 16.0%, P = 0.040) within the below-knee popliteal group. Two-year bypass occlusion was decreased in patients receiving vein adjuncts (11.6 vs. 17.1%, P = 0.004). A cohort of 2,378 patients underwent tibial bypass, with 473 (19.9%) receiving vein adjuncts. Within the tibial group, patients were similar in age, body mass index, race, comorbidities, and indications. Bypass occlusion (24.8 vs. 17.6%, P = 0.005) and amputation (20.5 vs. 15.9%, P = 0.048) rates at 2 years were worse for patients who did not receive a distal vein adjunct to tibial arteries., Conclusions: Distal vein adjuncts are associated with improved freedom from occlusion, amputation, major adverse limb events, and overall survival when compared to bypasses performed with prosthetic graft alone for tibial bypasses within the Vascular Quality Initiative. A vein adjunct was not associated with improved freedom from occlusion in below-knee popliteal bypasses. Consideration should be given to utilization of a distal vein adjunct to improve prosthetic bypass longevity and limb salvage for patients requiring tibial bypasses., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Occlusion after infra-inguinal bypass surgery for peripheral artery disease is a major complication with potentially devastating consequences. In this descriptive analysis, we sought to describe the natural history and explore factors associated with long-term major amputation-free survival following occlusion of a first-time infra-inguinal bypass., Methods: Using a prospective database from a tertiary care vascular center, we conducted a retrospective cohort study of all patients with peripheral artery disease who underwent a first-time infra-inguinal bypass and subsequently suffered a graft occlusion (1997-2021). The primary outcome was longitudinal rate of major amputation-free survival after bypass occlusion. Cox proportional hazard models were used to generate hazard ratios (HRs) and 95% confidence intervals (CIs) to explore predictors of outcomes., Results: Of the 1318 first-time infra-inguinal bypass surgeries performed over the study period, 255 bypasses occluded and were included in our analysis. Mean age was 66.7 (12.6) years, 40.4% were female, and indication for index bypass was chronic limb threatening ischemia (CLTI) in 89.8% (n = 229). 48.2% (n = 123) of index bypass conduits used great saphenous vein, 29.0% (n = 74) prosthetic graft, and 22.8% (n = 58) an alternative conduit. Median (interquartile range) time to bypass occlusion was 6.8 (2.3-19.0) months, and patients were followed for median of 4.3 (1.7-8.1) years after bypass occlusion. Following occlusion, 38.04% underwent no revascularization, 32.94% graft salvage procedure, 25.1% new bypass, and 3.92% native artery recanalization. Major amputation-free survival following occlusion was 56.9% (50.6%-62.8%) at 1 y, 37.1% (31%-43.3%) at 5 y, and 17.2% (11.9%-23.2%) at 10 y. In multivariable analysis, factors associated with lower amputation-free survival were older age, female sex, advanced cardiorenal comorbidities, CLTI at index procedure, CLTI at time of occlusion, and distal index bypass outflow. Initial treatment after occlusion with both a new surgical bypass (HR 0.44, CI: 0.29-0.67) or a graft salvage procedure (HR 0.56, CI: 0.38-0.82) showed improved amputation-free survival. One-year rate of major amputation or death were 59.8% (50.0%-69.6%) for those who underwent no revascularization, 37.9% (28.7%-49.0%) for graft salvage, and 26.7% (17.6%-39.5%) for new bypass., Conclusions: Long-term major amputation-free survival is low after occlusion of a first-time infra-inguinal bypass. While several nonmodifiable risk factors were associated with lower amputation-free survival, treatment after graft occlusion with either a new bypass or a graft salvage procedure may improve longitudinal outcomes., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The optimal timing and modality of surveillance after endovascular intervention for peripheral arterial disease is controversial, and no randomized trial to assess the value of peripheral endovascular intervention has ever been performed. The aim of this systematic review was to examine the practice of surveillance after peripheral endovascular intervention in randomized trials., Methods: We used the Medline, Embase, Cochrane Library, and WHO trial registry databases in this systematic review of the literature to capture surveillance strategies used in randomized trials comparing endovascular interventions. Surveillance protocols were assessed for completeness, modalities used, duration, and intensity., Results: Ninety-six different surveillance protocols were reported in 103 trials comparing endovascular interventions. Protocol specification was incomplete in 32% of trials. The majority of trials used multiple surveillance modalities (mean of 3.46 modalities), most commonly clinical examination (96%), ankle-brachial index (80%), duplex ultrasound examination (75%), and digital subtraction angiography (51%). Trials involving infrapopliteal lesions used more angiographic surveillance than trials with femoropopliteal lesions (P = .006). The median number of surveillance visits in the first 12 months after intervention was three and the mean surveillance duration was 21 months. Trials treating infrapopliteal vessels had a higher surveillance intensity compared with those treating femoropopliteal lesions in the first 12 months after endovascular intervention (mean 5 vs 3 surveillance visits; P = .017). Trials with drug-eluting devices had longer surveillance duration compared with those without (mean 26 vs 19 months; P = .020)., Conclusions: There is a high level of variation in the modality, duration, and intensity of surveillance protocols used in randomized trials comparing different types of peripheral endovascular arterial intervention. Further research is required to determine the value and impact of postprocedural surveillance on patient outcomes., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Patients with peripheral arterial disease (PAD) are predisposed to postprocedure adverse limb events (ALE). Previous single-center studies investigating the relationship between baseline C-reactive protein (CRP) levels and postprocedure ALE have reported inconsistent results. Therefore, we performed a systematic review and meta-analysis of reported data to determine the association between CRP levels and the occurrence of postprocedure ALE in patients with PAD., Methods: Studies investigating the association between the CRP levels and postprocedure ALE (ie, target vessel revascularization, amputation, restenosis, disease progression, composite endpoint of any of these ALE) were identified in the Medline, EMBASE, and Cochrane databases. Meta-analyses of the reported hazard ratios (HRs) were conducted using an inverse variance-weighted random effects model. Subgroup analyses were performed to determine the differences in outcomes between open surgery and endovascular treatment. Pooled estimates are reported as HRs to compare higher and lower CRP levels and odds ratio or relative risk per unit increase in log e CRP (natural logarithm C-reactive protein)., Results: A total of eight studies involving 1460 participants were included in our meta-analysis. Patients with higher baseline CRP levels had a greater risk of ALE (HR, 1.09; 95% confidence interval, 1.00-1.18; P = .04) compared with those with lower baseline CRP levels. The pooled estimate of odds ratio and relative risk for ALE was 2.25 (95% confidence interval, 1.49-3.41; P < .01) per unit increase in log e CRP. Subgroup analyses found no significant differences in the pooled estimates in studies of open surgery vs endovascular treatment., Conclusions: Our results have demonstrated that high baseline CRP levels are predictive of ALE in patients with PAD after lower limb revascularization., (Copyright © 2021. Published by Elsevier Inc.)

Introduction: The proportion of patients with comorbid atrial fibrillation (AF) and peripheral artery disease (PAD) has increased in this era. This study aimed to assess the relationship between AF and totally occlusive in-stent restenosis (ISR) in femoropopliteal (FP) lesions., Methods: In this study, 363 patients (461 stents) who underwent endovascular therapy with de novo stent implantation in our hospital between April 2007 and December 2016 were retrospectively evaluated. The patients were divided into two groups according to the AF status (AF group, 61 patients; sinus group, 302 patients). The primary endpoint was the incidence of totally occlusive ISR within 3 years. The secondary endpoint was the incidence of acute limb ischemia (ALI) due to FP stent occlusion., Results: Baseline characteristics were similar, except for higher age and a lower prevalence of dyslipidemia in the AF group. The incidence of a totally occlusive ISR was higher in the AF group than in the sinus group (29.5% vs. 14.6%, p =0.004). A multiple Cox regression model suggested that presence of AF (hazard ratio, 2.10) and CTO lesion (hazard ratio, 1.97) which were the independent predictors of a totally occlusive ISR within 3 years. The incidence of ALI was significantly higher in the AF group than in the sinus group (3.9% vs. 0%, p =0.0001). In the AF group, the introduction of an anticoagulant did not prevent the occurrence of totally occlusive ISR ( p =0.71) for ALI ( p =0.79)., Conclusions: AF is independently associated with totally occlusive ISR of FP stents; however, anticoagulant use does not prevent stent occlusion., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Yohsuke Honda et al.)

Saphenous vein grafts (SVG) patency is limited by intimal hyperplasia (IH) caused by endothelial dysfunction. This study aimed to explore the effect of placental growth factor (PlGF) on the endothelial function of SVG. In rat models of external jugular vein-carotid artery graft treated with PlGF or saline hydrogel, PlGF inhibited vein graft IH (day 28: 12.0 ± 1.9 vs. 61.7 ± 13.1 μm, P < 0.001), promoted microvessel proliferation (day 14: 33.3% 3+ vs. 50.0% 2+, P = 0.03), and increased nitric oxide (NO) production (P < 0.05 on days 1/3/5) and NO synthase (NOS) expression by immunohistochemistry. In human umbilical vein endothelial cells (HUVECs) cultured under hypoxia and treated or not with PlGF, PlGF restored the survival (50 ng/ml PlGF, 48 h: 91.7 ± 0.6% vs. 84.9 ± 0.5%, P < 0.01), migration (by Matrigel assay), and tube formation ability (junctions, tubules, and tubule total length; all P < 0.01) of HUVECs after hypoxia. PlGF increased NO production through increased eNOS expression (P < 0.05), without changes in iNOS expression. The mRNA expression of eNOS decreased after the addition of the PI3K inhibitor LY294002 (P < 0.05). PlGF promoted the protein expression of eNOS by up-regulating AKT, and the AKT and eNOS protein levels were decreased after adding LY294002 (all P < 0.05). In conclusion, PlGF is a candidate for the inhibition of IH in SVG after coronary artery bypass graft. The effects of PlGF are mediated by the upregulation of the eNOS mRNA and protein through the PI3K/AKT signaling pathway. PlGF promotes the secretion of NO by endothelial cells and thereby reduces the occurrence and development of IH., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: Groin complications following vascular reconstruction, extensive trauma, or severe radiation induced scarring may complicate future revascularisation procedures of the lower limb. Although several techniques have been described, only few cases of trans-iliac bypass grafting have been published. The aim of this study was to perform a review of the literature on trans-ilac bypass grafting and add the authors' experience., Methods: A single centre retrospective data analysis and a literature review of all trans-iliac bypass procedures was performed. Data on indication, patency, limb salvage, and survival were collected. Study endpoints were patency, limb salvage, and patient survival., Results: Eight trans-iliac wing bypass grafting procedures were performed in our institution between 2003 and 2018, which represents the largest single centre series. Twenty-three procedures were reported in the literature between 1989 and 2018. Prior to the bypass procedure in the eight patients, six had local infection and two irradiation of the groin. The indication for operation was ischaemia in six cases, bleeding in one case, and infection in another case. The external iliac artery was most often used for the proximal (6 cases) and the superficial femoral artery for distal anastomosis (6 cases). Great saphenous vein was the most commonly used graft material (6 cases). The median follow up was five years with three bypass occlusions after 1, 2, and 8 months, followed by two successful thrombectomy procedures. There were no major amputations and only one death after five months, which was not procedure related., Conclusions: Trans-iliac bypass grafting is a viable alternative extra-anatomic bypass technique in patients with vascular groin complications. Patency as well as limb salvage and survival are good and may be comparable to those reported for autologous in situ repair and obturator canal bypass grafting., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Dialysis-associated steal syndrome remains a difficult clinical scenario for vascular access surgeons. The ideal treatment would improve blood flow to the hand without compromising the fistula; however, most treatment options rarely allow for both. The study describes an innovative technique used in clinical practice over a 17-year period for the treatment of dialysis-associated steal syndrome. The procedure and long-term results are discussed., Methods: 27 patients with dialysis-associated steal syndrome were recruited over 17 years at two large UK University Teaching Hospitals and treated with the extension technique. All patients included were assessed for resolution of their symptoms, patency of the fistula and adequacy of needling., Results: 27 patients were admitted with dialysis-associated steal syndrome and underwent surgery using the extension technique. Complete symptom resolution was seen in 26 of the 27 patients (96%), with improvements in pain, sensori-motor disturbance and temperature. All 26 patients had a patent fistula at 6-months' follow-up. At 12 months, 3 of 27 (11.1%) developed fistula thrombosis which could not be salvaged and 2 of 27 (7.4%) developed thrombosis successfully salvaged by fistulaplasty., Conclusion: Our study shows that the Extension Technique is an effective treatment method for dialysis-associated steal syndrome and results have demonstrated a high level of fistula patency and a low rate of complications. It has several advantages when compared with other established treatment methods and has the versatility to be used as a method for dialysis-associated steal syndrome prevention in high-risk groups as well as treatment.

Introduction: Takayasu arteritis (TA) is a chronic and nonspecific inflammatory disease mainly affecting the aorta and its major branches, resulting in the stenosis or occlusion of target arteries. Approximately 50% to 60% of patients with TA likely have renal artery stenosis (RAS), which results in refractory hypertension (HTN) and renal dysfunction. Aortorenal bypass with saphenous vein graft (SVG) is the classical procedure to relieve patients' symptoms. Graft restenosis is the most common complication during long-term follow-up. However, aortorenal vein graft aneurysm (AVGA) is uncommonly reported, and symptomatic or ruptured AVGA that needs reoperation is even rarer. Long-term follow-up results after AVGA reoperation also remain scare. Here, we introduced the long-term result of a symptomatic AVGA under the reoperation of polytetrafluoroethylene (PTFE) graft replacement and provided a literature review of AVGA reoperation after surgical bypass for RAS., Clinical Finding: An 18-year-old male complained about mild to severe right lumbar pain for 5 days. He underwent right aortorenal bypass with SVG for TA-induced right renal artery stenosis to relieve refractory HTN and renal dysfunction 2 years ago. However, this patient did not proceed with a follow-up after the procedure. Physical examination showed normal vital signs, and an obvious percussion tenderness over the right kidney region was detected. The updated computed tomography angiography (CTA) revealed a right AVGA with a maximum diameter of 26 mm. No restenosis of the proximal and distal anastomoses was detected., Diagnosis: The patient was diagnosed to have right aortorenal vein graft aneurysm at the risk of rupture and Takayasu arteritis., Interventions: The AVGA was resected with a 6 mm PTFE graft replacement. An end-to-side proximal anastomosis to the orifice of the original anastomosis on the abdominal aorta and an end-to-end distal anastomosis to the distal normal renal artery were made., Outcomes: The patient had an uneventful postoperative clinical course and was discharged from the hospital 5 days after the operation. The 4-year updated CTA revealed no restenosis or aneurysmal degeneration of the prosthetic graft., Conclusion: Symptomatic AVGA that needs reoperation is rare. Prosthetic graft replacement is an effective way to eliminate the risk of potential rupture. A 4-year satisfactory result indicative of a prosthetic graft can be the first choice for aortorenal bypass in RAS without active biological inflammation.

Background: Vein graft stenosis is a critical complication of lower-limb bypass surgery. For vein graft stenosis, balloon angioplasty has been performed instead of surgical revision in recent years. We therefore investigated the effectiveness of the balloon angioplasty for vein graft stenosis., Methods and Result: We conducted a retrospective analysis of prospectively collected data for 115 vein graft stenoses performed via balloon angioplasty from August 2011 to January 2018. The rate of freedom from reintervention after balloon angioplasty was 54.3%, 44.4%, and 38.0% at 1, 2, and 3 years, respectively. The rate of freedom from graft occlusion after balloon angioplasty was 79.9%, 71.9%, and 61.3% at 1, 2, and 3 years, respectively. Predictors of freedom from graft occlusion after balloon angioplasty by a multivariate analysis were a single treated lesion (hazard ratio [HR]: 0.38; 95% confidence interval [CI]: 0.17-0.85; P = 0.0189), balloon angioplasty within 90 days after bypass surgery (HR: 3.59; 95% CI: 1.56-8.07; P = 0.0033), and using a cutting balloon (HR: 0.42; 95% CI: 0.17-0.97; P = 0.0426)., Conclusions: The freedom from graft occlusion rate after balloon angioplasty remained relatively high. Furthermore, better results can be expected in single treated lesions and cases of balloon angioplasty occurring 90 days after bypass surgery or in which a cutting balloon was used. Balloon angioplasty for lower-limb bypass graft stenosis was shown to be a useful treatment., (Copyright © 2019. Published by Elsevier Inc.)

Objective: The objective of this study was to assess the technical and short- and long-term clinical outcomes of catheter-directed thrombolysis (CDT) with urokinase for occluded infrainguinal bypass grafts. In addition, factors associated with technical success and amputation-free survival were assessed., Methods: A retrospective analysis of a cohort of patients treated with catheter-directed urokinase-based thrombolysis for occluded infrainguinal bypass grafts was conducted between January 2000 and December 2015. Demographics, procedural data, and short- and long-term outcome data, including patency rates of the bypasses, limb salvage, and overall survival, were collected. Statistical models for clustered data were applied to assess predictive factors., Results: In 177 patients, 251 CDTs were performed on 204 bypasses. In 209 procedures (83.3%), the occluded bypass was reopened; clinical disappearance of ischemic symptoms occurred after 157 procedures (62.6%). Premature cessation of thrombolysis occurred in 33 procedures (13.2%), and periprocedural and postprocedural complications were noted in 91 patients (36.3%). Factors associated with long-term limb salvage are fewer vascular interventions before CDT (P = .0003), higher number of patent outflow vessels before start of CDT (P < .0001), and higher number of patent outflow vessels after CDT (P < .0001). The 1- and 5-year patency rates of bypasses after successful CDT were 64.6% and 48.9%; amputation-free survival after 1 year, 5 years, and 7 years was 81.5%, 71.3%, and 70.5%, respectively., Conclusions: Clinical success after CDT was observed in 62% of procedures with an associated complication rate of 36%. Patent outflow vessels before and after CDT are factors associated with long-term limb salvage. Amputation-free survival after 5 years is 71.3%., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The effect of superficial femoral artery (SFA) occlusion on long-term patency of aortofemoral bypasses (AFBs) for aortoiliac occlusive disease (AIOD) was examined., Methods: The AIOD database was reviewed to identify risk factors for AFB failure. The status of the SFA at AFB procedure was categorised as patent; diseased treated (DT), if the SFA occlusion was intervened on concomitant to AFB; or diseased untreated (DU), if the SFA was occluded but not revascularised. Censoring hierarchies for primary patency and patent graft survival time were constructed. Data were analysed by contingency table, Kaplan-Meier, and Cox regression analysis., Results: Between 2004 and 2015, 122 AFB (9 unifemoral, 113 bifemoral) for AIOD were performed. Seventy-five (61%) were female and the mean age was 60 ± 10 years. At the time of AFB, 50 (41%) had occluded SFAs (DT/DU). Of these, 15 had concomitant SFA revascularisation (i.e., DT) at the time of AFB. Patients with occluded SFAs had greater history of prior aortoiliac/infrainguinal procedures (aortoiliac 54% vs. 22%, infrainguinal 58% vs. 25%, both p < 0.001), Trans-Atlantic Inter-Society Consensus II classification of femoropopliteal type D lesions (78 vs. 10%, p < 0.001), Rutherford 4-6 categories (80% vs. 57%, p = 0.011), and longer hospital stay (median 11 vs. 7 days, p < 0.004). SFA status did not affect 30 day mortality (overall 9%); however, sub-analysis showed DT had significantly higher mortality than DU (p < 0.03). Over a median follow up of 7.7 (IQR 4.3-11.4) years, primary patency at one and five years was 98.3% and 91.2% in patients with patent SFAs, 87.9% and 82.7% in DU, and 72.7% and 43.6% in DT (p < 0.001), respectively. On multivariable analysis, low baseline glomerular filtration rate (HR 1.01, p = 0.022), DT (HR 3.7, p = 0.020), Rutherford 4-6 (HR 9.1, p = 0.048), and occluded SFA (HR 3.9, p = 0.009) adversely affected primary patency of AFBs. Long-term mortality was not different between the SFA status groups (p = 0.279)., Conclusion: Baseline SFA occlusion predicted a fourfold increased hazard of primary AFB failure. Concomitant SFA revascularisation did not improve AFB durability and was associated with increased in hospital mortality., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Poly (propylene carbonate, PPC) is a new member of the aliphatic polyester family. An outstanding feature of PPC is that it produces mainly water and carbon dioxide when degraded in vivo, causing minimal side effects. This unique property together with excellent biocompatibility and biodegradability makes PPC a promising material for drug delivery. In this study, we explored the effect of the sirolimus (an inhibitor of cell growth)-eluting PPC mesh on graft stenosis and its possible mechanisms in a rat arteriovenous grafting model. The PPC mesh was prepared by electrospinning. A jugular vein to abdominal aortic autograft transplantation model was established in rats. The graft was then treated by wrapping with the drug mesh or the drug-free mesh or left untreated. Four weeks posttransplantation, neointima was measured with hematoxylin and eosin staining, matrix metalloproteinase-2 (MMP-2), and MMP-9, and proliferating cell nuclear antigen (PCNA) in the grafts were assayed by Western blotting and immunohistochemistry, respectively. In vitro rat aortic adventitial fibroblast cell (RAAFC) migration was assessed using the Boyden chamber assay, and phospho-mammalian target of rapamycin (mTOR) levels in RAAFCs were determined by Western blotting. Animals with the drug mesh had an intimal area index of 4.87% ± 0.98%, significantly lower than that of the blank group (14.21% ± 2.56%) or the PPC group (15.03% ± 2.35%, both P < .05). The sirolimus mesh markedly suppressed MMP-2 and MMP-9 expression, decreased PCNA-positive cell numbers, inhibited RAAFC migration, and reduced phospho-mTOR levels. Our data suggest that the sirolimus-eluting PPC mesh might be potentially applied for the management of grafting stenosis.

Background: The optimal time for flap anastomosis to an arteriovenous loop remains controversial. Whether perforator flaps and axially vascularized muscle or fasciocutaneous flaps lead to comparable outcomes in conjunction with arteriovenous loops has not been investigated., Methods: Medical records from 103 patients undergoing arteriovenous loop reconstruction (76 one-stage and 27 two-stage) between 2007 and 2017 were reviewed. Postoperative outcomes were compared between one- and two-stage arteriovenous loop reconstructions and different types of free flaps., Results: Rates of flap thrombosis, major wound complications, and flap failure did not differ significantly between one- and two-stage arteriovenous loop reconstructions (14.47 percent versus 11.11 percent, p = 1.00; 30.26 percent versus 25.93 percent, p = 0.67; and 10.53 percent versus 7.41 percent, p = 1.00). For two-stage arteriovenous loop reconstructions, the time interval between arteriovenous loop placement and flap anastomosis was a predictor for thrombotic events (OR, 1.31; p < 0.05). Anterolateral thigh flaps in conjunction with arteriovenous loops showed higher failure rates (33.33 percent) compared with all other flaps (6.59 percent) (p < 0.05) and combined latissimus dorsi and parascapular flaps (0 percent) (p < 0.05). Thrombosis rates were higher in anterolateral thigh flaps (33.33 percent) compared with all other flaps (10.99 percent; p = 0.056), and combined latissimus dorsi and parascapular flaps (0 percent; p < 0.05)., Conclusions: Two-stage arteriovenous loop reconstructions do not lead to increased postoperative complications compared to one-stage arteriovenous loop reconstructions and may be favorable in complicated cases because of shorter operative times. To avoid an increased thrombosis risk, flap anastomosis should not be delayed beyond 10 days in two-stage arteriovenous loop reconstructions. Anterolateral thigh flaps are less suitable for arteriovenous loop reconstructions because of higher complication rates., Clinical Question/level of Evidence: Therapeutic, III.

Background: Stenosis is a known complication in bypass vein grafts for peripheral arterial disease. The aim of this study was to evaluate the effect of drug-coated balloons (DCBs) in the treatment of vein graft stenoses. DCBs may prevent restenosis in arterial lesions. One small prospective and larger retrospective and registry studies have failed to show benefit from DCBs in vein grafts. Prospective data are scarce., Methods: Sixty patients treated for primary or recurrent stenosis in venous bypass grafts were randomized to DCB (n = 30) or standard balloon angioplasty (BA) (n = 30). Follow-up was 1 year. The primary outcome measure was target lesion revascularization (TLR). Secondary outcome measures were assisted primary patency and secondary patency and graft occlusion., Results: Fifty-seven patients were analyzed. Three patients were excluded due to primary technical failure (2 DCB, 1 BA). Overall TLR rate was 34.5% and 46.4% in the DCB and BA groups, respectively (P = 0.33). Five (8.8%) grafts occluded during follow-up (1 DCB, 4 BA). Assisted primary patency was 93.1% (DCB) versus 85.7% (BA) (P = 0.362) and secondary patency was 100% (DCB) versus 89.3% (BA) (P = 0.076). Subgroup analysis showed a significant benefit from DCB in the treatment of primary stenosis (TLR rate 15.0% vs. 18.9%, P = 0.03)., Conclusion: There was no significant benefit from DCBs for treatment of vein graft stenosis compared to BA, although a trend in favor of DCBs could be seen., Trial Registration: ClinicalTrials.govNCT03023098., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Sequential grafting may be an effective way to maximize the benefits of the left internal mammary artery (LIMA) conduit. Despite increasing clinical application, the strategy of sequential LIMA grafting has not been proven its superiority. This single-center retrospective study aimed to evaluate the in-hospital and mid-term outcomes of sequential grafting of in situ skeletonized LIMA to the left coronary system.According to the use of sequential or separate LIMA grafting, 1505 eligible patients were assigned to a sequential group (n = 230) and a control group (n = 1275). According to sequential LIMA graft configurations, patients with sequential LIMA grafting were divided into a DOM subgroup (n = 113) and a DLAD subgroup (n = 117). The clinical outcomes and LIMA graft patency were investigated and compared.Sequential LIMA grafting compared with separate LIMA grafting was not an independent predictor either of in-hospital adverse events or follow-up survival free from repeat revascularization during the follow-up period of 32.4 ± 8.5 months. Sequential LIMA grafting had similar LIMA graft patency with separate LIMA grafting (99.5% of 1st sequential sites and 97.7% of 2nd sites versus 98.2% of LIMA-LAD grafts) at 32.3 ± 8.5 months after coronary artery bypass grafting (CABG) surgery. Additionally, the two subgroups received similar mid-term clinical outcomes and graft patency of LIMA segments.Sequential grafting of in situ skeletonized LIMA to the left coronary system resulted in excellent clinical outcomes and graft patency. The two sequential LIMA graft configurations received similar clinical outcomes and graft patency.

Analysed herein is the experience of the first eight ultrasonographic studies of peripheral arteries with dynamic contrast enhancement using sulphur hexafluoride («SonoVue») carried out in patients after previously performed femoropopliteal bypass grafting with a synthetic prosthesis (in seven cases the distal anastomosis of the bypass graft was located below the fissure of the knee joint and in one case - above the fissure of the knee joint). Contrast-enhanced ultrasonography was performed averagely 12.5±4.0 months after the operation, according to the technique recommended by the manufacturer of the contrast agent. It was demonstrated that control ultrasonic scanning of lower-limb arteries using contrast enhancement in the remote period after bypass operations proved more informative in relation to detection of stenoses of the distal anastomosis of the femoropopliteal bypass graft, trifurcation of the popliteal artery and near-ostium segments of tibial arteries than a study with no contrast medium.

Presented herein are the results of a prospective cohort study of clinical efficacy of medicamentous treatment and operations of shunting to the third segment (V3) of the vertebral artery in patients with vertebrobasilar insufficiency (VBI). The study included a total of 60 patients with pronounced clinical manifestations of VBI and concomitant lesions of the V1 and V2 segments of the vertebral arteries. The patients were found to have no significant involvement of the carotid bifurcation. At the first stage, all patients during 12 months were receiving a course of optimal medicamentous therapy. Clinical improvement was observed in only 3 (5%) patients, and they were not subjected to surgery. The remaining 57 patients with no improvement after the course of conservative therapy underwent a second-stage treatment consisting in shunting to the third (V3) segment of the vertebral artery. Of these, 5 patients underwent arterial bypass grafting and 52 patients endured autovenous shunting. In the early postoperative period one patient developed thrombosis of the autovenous shunt. This patient died of repeat stroke into the trunk of the brain. In 56 patients the shunts were patent. Clinical improvement was observed in all 56 patients during 3-month follow-up. By month 12, all 5 patients with autoarterial shunts developed shunt thrombosis and were found to have a return of the clinical course of VBI, with no events of either acute impairment of cerebral circulation or transitory ischaemic attacks. We managed to mitigate the clinical course of VBI in 51 (85%) patients with autovenous shunts, with this effect persisting for 12 months and more after the operation. The differences between the results of medicamentous and surgical treatment were statistically significant (p≤0.01). During 3 years of follow up the achieved improvement persisted in 88.7% of the surgically treated patients and during 7 years in 78.3% of patients, with the 3- and 7-year shunt patency rate amounting to 90.2 and 88.2%, respectively.

Objective: Duplex ultrasound (DUS) surveillance of infrainguinal vein bypass grafts is widely practiced, but the evidence of its effectiveness compared with other methods of surveillance remains unclear., Methods: Following an a priori protocol developed by the guidelines committee from the Society for Vascular Surgery, this systematic review and meta-analysis included randomized and nonrandomized comparative studies that enrolled patients who underwent infrainguinal arterial reconstruction and received DUS surveillance for follow-up compared with any other method of surveillance. The search included MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature, and Scopus through November 2016. Outcomes of interest included all-cause mortality, limb viability, and graft patency reports. Meta-analysis was performed using the random-effects model., Results: We included 15 studies. Compared with ankle-brachial index and clinical examination, DUS surveillance was not associated with a significant change in primary, secondary, or assisted primary patency or mortality. DUS surveillance was associated with a nonstatistically significant reduction in amputation rate (odds ratio, 0.70 [95% confidence interval, 0.23-2.13]). The quality of evidence was low because of imprecision (small number of events and wide confidence intervals) and high risk of bias in the primary literature., Conclusions: A recommendation for routine DUS surveillance of infrainguinal vein grafts remains dependent on low-quality evidence. Considering that DUS offers the opportunity of early intervention and because of its noninvasive nature and low cost, vascular surgeons may incorporate DUS as they individualize the follow-up of lower extremity vein grafts., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Endovascular treatment of a significant stenosis in an infrainguinal autologous bypass prevents bypass occlusion and improves bypass patency. Drug-eluting balloons (DEBs) have been proven to possess antirestenotic features in the treatment of femoropopliteal stenoses and occlusions. This study evaluated the effects of DEB angioplasty vs uncoated balloon (UCB) angioplasty to rescue infrainguinal autologous bypass grafts at risk (BAR)., Methods: The study included all consecutive patients treated endovascularly for BAR from December 1, 2012, to July 31, 2015. As of April 1, 2014, the primary treatment of BAR was changed from UCBs to DEBs. Patients treated with DEBs were prospectively recorded in a database and retrospectively analyzed. Patients treated with UCBs were retrospectively collected from a historical cohort with a similar inclusion period length as the DEB cohort. The follow-up scheme did not differ between the two groups. The primary end point was the combined end point of freedom from recurrent stenosis or bypass occlusion. Secondary end points were primary assisted patency, secondary patency, technical success, major amputation, and mortality., Results: Twenty-one patients were treated in the DEB group and 18 were treated in the UCB group. The two groups were evenly distributed in demographics, bypass, treatment, and lesion characteristics. No statistically significant differences were found in the combined end point of freedom from recurrent stenosis and the occlusion rate after 1 year between the UCB group (77.8%) and the DEB group (80.0%; P = .76). After 1 year, the primary assisted patency rate was 88.2% in the UCB group vs 95.2% in the DEB group (P = .47), and the secondary patency rate was 94.1% in the UCB group vs 95.2% in the DEB group (P = .91). During follow-up, restenosis developed in four patients (22.2%) in the UCB group and in four patients (19.0%) in the DEB group (P = .80). One bypass (5.6%) in the UCB group and one bypass (4.8%) in the DEB group occluded during follow-up (P = .884)., Conclusions: DEBs and UCBs perform equally in the treatment of significant stenosis in infrainguinal autologous bypasses with regard to freedom from restenosis or bypass occlusion, primary assisted patency, and secondary patency at 1 year. We suggest using a less expensive UCB in the treatment of BAR., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

A 59-year-old man with critical claudication underwent left femoro-anterior bypass grafting, which was uneventful. The graft was tunneled medially across the knee, then anterior to the tibia. His symptoms recurred 1 year later and he was found to have critical stenosis of the vein graft just proximal to the anterior tibial arterial anastomosis. This was treated with scaffolded balloon angioplasty and implantation of a coronary, zotarolimus-eluting balloon-expandable stent, which was also uneventful. However, his claudication again recurred 1 year later. Diagnostic angiography revealed crush, deformation and restenosis of the balloon-expandable stent requiring surgical revision of the bypass graft.

A girl aged 11 years and 3 months with occlusion of the inferior vena cava had experienced two renal transplant graft failures since birth. The third renal transplant from a live donor was carried out. Preoperative evaluation showed that the arteries from the right common to the right external iliac artery were absent, and the ilio-caval vein was occluded below the level of the renal vein. The donor's renal artery was anastomosed to the aorta. The donor's ovarian and large saphenous veins were used to extend the transplant renal vein to the recipient's patent inferior vena cava. The present report concludes that the extension of a short donor renal vein using other donor veins is a viable therapeutic option for pediatric patients with vascular occlusions., (© 2017 The Japanese Urological Association.)

Background: Duplex ultrasound (DU)-based graft surveillance remains controversial. The aim of this study was to assess the ability of a recently proposed decision tree in identifying high-risk grafts which would benefit from DU-based surveillance., Materials and Methods: Consecutive patients undergoing infrainguinal vein graft bypass from January 2008 to December 2015 were identified from the National Vascular registry and enrolled in a duplex surveillance program. An early postoperative DU was performed at a median of 6 weeks (range: 4-9 weeks). Grafts were classified into high risk or low risk based on the findings of the earliest postoperative scan and 4 established risk factors for graft failure (diabetes, smoking, infragenicular distal anastomosis, and revision bypass surgery) using a classification and regression tree (CRT). The accuracy of the CRT model was evaluated using area under receiver operator characteristic (AROC) curve., Results: About 278 vein graft bypasses were performed; 29 grafts had occluded by the first surveillance visit; 249 vein grafts were entered into surveillance. Sixty-four (23%) developed critical stenosis. Overall 30-month primary patency, primary-assisted patency, and secondary patency rates were 71.2%, 77.2%, and 80.1%, respectively. AROC for prediction of graft stenosis or occlusion was 83% (95% confidence interval [CI]: 78-87%). The sensitivity and specificity of the CRT model for prediction of graft stenosis or occlusion were 95% (95% CI: 88-98%) and 52.2% (95% CI: 45-60%)., Conclusions: A prediction model based on commonly recorded clinical variables and early postoperative DU scan is accurate at identifying grafts which are at high risk of failure. These high-risk grafts may benefit from DU-based surveillance., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The importance of antithrombotic therapy following reconstructive operations on arteries below the inguinal ligament is beyond question. The pharmaceutical market offers a wide variety of antiaggregant and anticoagulant agents, with many studies (including randomised and multicenter ones) performed worldwide on the problem of choosing optimal antithrombotic therapy in the postoperative period after arterial reconstructions. Nevertheless, the problem of selecting adequate antithrombotic therapy after shunting operations remains undetermined. Presented in the article is a review of foreign studies on the problem concerned. This is followed by discussing the results of many large international studies, including such trials as the BOA and CASPAR. Based on the findings obtained in these studies, Cochrane reviews, European and American guidelines, the authors express their opinion on the algorithms of choosing an appropriate variant of antithrombotic therapy during the postoperative period in patients after arterial reconstructions below the inguinal ligament.

The authors provide a detailed description of the step-by-step technique of performing the operation of shunting to the V3 segment of the vertebral artery in patients with clinical manifestations of vertebrobasilar insufficiency (VBI). Reported are surgical outcomes in a total of 57 patients with VBI. Of these, 5 patients underwent arterial bypass grafting and 52 patients endured autovenous shunting. One patient developed shunt thrombosis in the early postoperative period and, unfortunately, died, with the remaining 51 shunts being patent. At 3 years of follow up, shunt thrombosis occurred in four (80%) patients with the arterial bypass and only in one (1.7%) of the 52 autovein-treated patients. The total duration of postoperative follow up amounted to 10 years. Long-term freedom from VBI clinical manifestations was achieved in 88.7 % of patients after 3 years and in 78.3% after 7 years, with the 3- and 7-year patency rate of the autovenous shunts amounting to 98.1 and 96.2%, respectively.

Drug-eluting stent (DES) and bare metal stent (BMS) are effective treatments for preventing vascular disease, but whether using DES is associated with positive clinical outcomes compared with BMS in patients with saphenous vein graft disease (SVGD) has not been established. Three electronic databases including PubMed, EmBase, and the Cochrane Central Register of Controlled Trials were searched to identify potentially includible studies. We did a random-effects meta-analysis of randomized controlled trials (RCTs) to obtain summary effect estimates for the clinical outcomes with the use of relative risk calculated from the raw data of individual trial. Among 812 patients from 4 RCTs, DES was associated with lower risk of short-term major cardiovascular events (MACEs) when compared with BMS, whereas no significant effect on the risk of long-term MACEs. Furthermore, there was no significant difference between DES and BMS for short-term myocardial infarction (MI) and long-term MI. Similarly, DES was not associated with risk of short- and long-term mortality risk as compared with BMS. In addition, DES has no significant effect on the risk of cardiac death and stent thrombosis. Finally, DES therapy significantly reduced the risk of TLR, TVF, and TVR. SVGD patients received DES can minimize the risk of short-term MACEs, TLR, TVF, and TVR when compared with BMS. However, it does not effect on the incidence of long-term MACEs, MI, mortality, cardiac death, and stent thrombosis., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Pressure guidewire pullback recording can differentiate between functional focal and diffuse disease types in coronary artery disease. The aim of this study was to compare the outcome of coronary artery bypass graft (CABG) patency between patients with functional focal versus diffuse disease types in recipient coronary arteries., Methods and Results: We investigated 89 patients who underwent pressure guidewire pullback in the left anterior descending (LAD) artery before CABG using internal mammary artery (IMA). Based on the pressure guidewire pullback data, the LAD lesions were classified into functional focal disease (abrupt pressure step-up; n=58) or functional diffuse disease (gradual pressure increase; n=31). Follow-up computed tomography (CT) angiography was conducted within 1year after CABG to assess the bypass graft patency. Pre CABG, LAD angiographic percent diameter stenosis (57±10% vs. 54±12%, p=0.228) and fractional flow reserve (FFR) (0.68±0.07 vs. 0.69±0.07, p=0.244) were not different between the functional focal and diffuse disease groups. The CABG procedure characteristics were similarly comparable between the two groups. In the follow-up CT angiography after CABG, occlusion or string sign of the IMA graft to LAD was more frequently observed in the functional diffuse disease group than in the functional focal disease group (26% vs. 7%, p=0.021)., Conclusion: In CABG, functional diffuse disease in the recipient coronary artery was associated with an increased risk of the graft failure in comparison with functional focal disease., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Purpose: The present study aimed to explore the regulating effect of Toll-like receptor 4 (TLR4) on intimal hyperplasia in rat vein grafts., Methods: Rat models of external jugular vein carotid artery bypass grafting were established. Afterward, TLR4 small interfering RNA (siRNA) recombinant plasmids were constructed, which were transfected into rat vein graft bypass to study the effect of TLR4 silencing on intimal hyperplasia and to explore the underlying mechanisms. Real-time polymerase chain reaction and Western blot were used to detect the expression levels of TLR4 and inflammatory factors in TLR4 siRNA-transfected vein graft bypass. The intimal thickness was evaluated using hematoxylin-eosin staining., Results: Compared with the scramble siRNA group, the intimal thickness of vein grafting was decreased significantly, while the inflammatory factors including interleukin (IL) 1β, IL-6, and tumor necrosis factor α in grafted vein were dramatically downregulated in the TLR4 siRNA group., Conclusion: These results showed that local silencing of TLR4 in the vein grafts could inhibit intimal hyperplasia by downregulating the expression of inflammatory factors in the vein grafts, suggesting that TLR4 can be used as a new target for therapy of vascular intimal hyperplasia., (© The Author(s) 2016.)

Objective: Graft angioplasty combines the durability and ability of surgical bypasses to treat long arterial occlusions with the minimally invasive nature of endovascular procedures. The purpose of this study was to evaluate the efficacy of single and repeated graft angioplasty in revising failing infrainguinal vein bypass grafts and to determine predictors of medium- and long-term freedom from revision after graft angioplasty., Method: This was a retrospective analysis from a prospectively maintained database. Consecutive endovascular revisions of graft-threatening lesions identified by duplex ultrasound surveillance were reviewed from 2003 to 2010. Patients were followed up until death, major amputation, or the end of follow-up, with the data last updated on January 1, 2013., Results: 178 graft angioplasty procedures performed in 114 bypass grafts in 103 limbs from 98 patients were studied. At 5 years, freedom from revision was 22.6%, graft survival was 45.8%, amputation-free survival was 57.9%, and patient survival was 64.9%. Analysis of repeated angioplasties found no evidence that effectiveness diminishes significantly with the number of previous angioplasties performed (p=.892). Higher Rutherford Grade of ischemia and longer time interval from index surgery to first angioplasty were significant positive predictors of medium- and long-term patency., Conclusion: Percutaneous transluminal angioplasty of infrainguinal vein grafts is safe and effective in the treatment of failing grafts identified by duplex surveillance. Graft angioplasties do not lose effectiveness when repeated and have shown cumulative benefit in prolonging graft survival. Treatment of claudicants and time interval from graft implantation of more than 6 months at the time of first angioplasty are positive predictors of at least medium-term patency after graft angioplasty., (Copyright © 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Approximately 30% of autogenous vein grafts develop luminal narrowing and fail because of intimal hyperplasia or negative remodeling. We previously found that vein graft cells from patients who later develop stenosis proliferate more in vitro in response to growth factors than cells from patients who maintain patent grafts. To discover novel determinants of vein graft outcome, we have analyzed gene expression profiles of these cells using a systems biology approach to cluster the genes into modules by their coexpression patterns and to correlate the results with growth data from our prior study and with new studies of migration and matrix remodeling., Methods: RNA from 4-hour serum- or platelet-derived growth factor (PDGF)-BB-stimulated human saphenous vein cells obtained from the outer vein wall (20 cell lines) was used for microarray analysis of gene expression, followed by weighted gene coexpression network analysis. Cell migration in microchemotaxis chambers in response to PDGF-BB and cell-mediated collagen gel contraction in response to serum were also determined. Gene function was determined using short-interfering RNA to inhibit gene expression before subjecting cells to growth or collagen gel contraction assays. These cells were derived from samples of the vein grafts obtained at surgery, and the long-term fate of these bypass grafts was known., Results: Neither migration nor cell-mediated collagen gel contraction showed a correlation with graft outcome. Although 1188 and 1340 genes were differentially expressed in response to treatment with serum and PDGF, respectively, no single gene was differentially expressed in cells isolated from patients whose grafts stenosed compared with those that remained patent. Network analysis revealed four unique groups of genes, which we term modules, associated with PDGF responses, and 20 unique modules associated with serum responses. The "yellow" and "skyblue" modules, from PDGF and serum analyses, respectively, correlated with later graft stenosis (P = .005 and P = .02, respectively). In response to PDGF, yellow was also associated with increased cell growth. For serum, skyblue was also associated with inhibition of collagen gel contraction. The hub genes for yellow and skyblue (ie, the gene most connected to other genes in the module), scavenger receptor class A member 5 (SCARA5) and suprabasin (SBSN), respectively, were tested for effects on proliferation and collagen contraction. Knockdown of SCARA5 increased proliferation by 29.9% ± 7.8% (P < .01), whereas knockdown of SBSN had no effect. Knockdown of SBSN increased collagen gel contraction by 24.2% ± 8.6% (P < .05), whereas knockdown of SCARA5 had no effect., Conclusions: Using weighted gene coexpression network analysis of cultured vein graft cell gene expression, we have discovered two small gene modules, which comprise 42 genes, that are associated with vein graft failure. Further experiments are needed to delineate the venous cells that express these genes in vivo and the roles these genes play in vein graft healing, starting with the module hub genes SCARA5 and SBSN, which have been shown to have modest effects on cell proliferation or collagen gel contraction., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Clinical Vignette: Despite being the most common antithrombotic strategy in trials comparing venous with prosthetic grafts, the use of vitamin K antagonists (VKAs) to improve the outcome of venous bypass remains the subject of debate. In this systematic review, evidence supporting the use of VKAs for improving venous patency following infrainguinal venous bypass is provided., Clinical Question: A 67 year old man with lifestyle limiting claudication underwent a successful infrainguinal venous bypass. Can VKAs help preserve patency after venous bypass surgery?, Methods: A systematic review of electronic databases, including MEDLINE and Embase, was conducted. Only randomized controlled studies comparing VKAs with aspirin (ASA) were included. The main outcome was bypass patency., Results: Four studies using different intensities of anticoagulation ± ASA were identified. All but one showed a benefit of VKAs over ASA with respect to primary patency. However, this benefit was also accompanied by an increased risk of bleeding. The Dutch Bypass Oral Anticoagulants, or ASA, study was the largest included and showed that VKAs (without concomitant ASA) were superior to ASA alone for the prevention of graft occlusion (hazard ratio 0.69, 95% confidence interval 0.54-0.88)., Conclusion: Current evidence suggests that VKAs are superior to ASA for the prevention of infrainguinal autologous venous graft thrombosis., (Copyright © 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: To describe the patency of percutaneous transluminal angioplasty (PTA) of autologous infrainguinal bypasses at risk., Methods: This was a retrospective single-center cohort study of consecutive patients who underwent primary PTA of an infrainguinal autologous bypass at risk from January 2009 to December 2013. Duplex ultrasound surveillance was performed for at least 1 year after PTA. The primary study end point was the number of secondary interventions. Secondary end points were freedom from recurrent stenosis or bypass occlusion and the patency of the infrainguinal autologous bypass at 1 year after primary PTA., Results: A total of 69 infrainguinal bypasses at risk in 69 patients were identified and treated with PTA. Technical success was achieved in 91%. The median follow-up was 17 months (range, 1-58 months). During follow-up, 30 bypasses (43%) remained free of significant stenosis or bypass occlusion, 29 bypasses (42%) developed recurrent stenosis, and 10 bypasses (14%) occluded. Rates of primary assisted, and secondary patency at 1 year were 84%, and 86%. Five (7%) major amputations were performed, all after bypass occlusion., Conclusions: Secondary interventions after PTA of a bypass at risk are common. However, repeated secondary interventions of autologous infrainguinal bypasses at risk result in patency rates of more than 80% at 1 year., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Lower extremity bypass grafts that develop stenoses are commonly treated with either open surgical or endovascular revision. Vein graft stenoses with unfavorable lesions (multiple lesions, lesions >2 cm in length, lesions in grafts <3 months old, lesions in grafts <3 mm in diameter) fare worse than those with favorable lesions when treated with endovascular therapy. However, it is not known if unfavorable lesions fare better with surgical revision than with endovascular treatment or than favorable lesions treated with surgery., Methods: We performed a retrospective review of 175 vein graft revisions performed at a single institution from 2000 to 2010. Characteristics of lesions treated with surgical and endovascular revision were identified. Cox proportional hazard models were used to identify predictors of revision failure (restenosis >75%, revision, or amputation)., Results: Ninety-one failing vein grafts (52%) were treated with surgical revision and 84 with endovascular treatment (48%), with a median follow-up of 30 months. Favorable lesions fared better than unfavorable lesions after endovascular treatment, with 12-month freedom from failure of 59% vs 34% (P < .01), but not after surgical revision (66% vs 62%; P = .90). Unfavorable lesions had better freedom from failure after surgery than endovascular treatment (62% vs 34%; P < .01), and results in favorable lesions were similar (66% vs 59%; P = .57)., Conclusions: For the treatment of failing vein grafts, endovascular therapy appears adequate for favorable lesions and surgical revision is more durable for unfavorable lesions., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Analysed in the article are the results of the Ross procedure in patients presenting with dilatation of the ascending portion of the aorta. A combination of aortic valve defects with dilatation of the ascending aorta of more than 45 mm supposes simultaneous prosthetic repair of the aortic valve and ascending aorta. The most common surgical procedure remains the Bentall-DeBono operation whose main disadvantage is associated with implantation of a mechanical prosthesis and the necessity of lifelong anticoagulant therapy. An alternative method is the Ross procedure demonstrating low risk of thromboembolic complications and freedom from anticoagulant therapy. Over the period from 2002 to April 2015, specialists of the Novosibirsk Scientific Research Institute of Circulatory Pathology named after Academician E.N. Meshalkin carried out a total of 162 Ross procedures in patients presenting with accompanying dilatation of the ascending aorta (more than 45 mm). The mean diameter of the aorta at the level of Valsalva sinuses amounted to 45.6±8.6 mm, with that of the ascending aortic portion equalling 53.4±7.8 mm. The technique of total replacement of the aortic root was used in all cases. When the aneurysm extended to distal portions of the ascending aorta, additionally performed were the following procedures: in 24 patients--reduction aortoplasty, in 6 patients--replacement of the resected aorta with an insert from xenopericardium, and in 2 patients with a vascular graft. The average duration of follow up amounted to 40.1±21.6 months. Ten patients were subjected to repeat operations for autograft dysfunction. There were no reoperations on the ascending portion of the aorta. The regression analysis revealed that predictors of the development of autograft dysfunction were the baseline dilatation of the fibrous ring (FR) of the aortic valve of more than 27 mm (p=0.04) and uncorrected arterial hypertension in the postoperative period (p=0.03). In the group of patients with the FR less than 27 mm there were no cases of allograft dysfunction. The results of the study suggest that the Ross procedure is a safe and effective method in patients with accompanying dilatation of the ascending aorta. Risk factors for autograft dysfunction are dilatation of the FR of the aortic valve exceeding 27 mm and arterial hypertension in the postoperative period.

The present study was aimed at analyzing the remote results of the operation of cross-over autovenous bypass at terms varying from 2 to 28 years in a total of 68 patients presenting with unilateral post-thrombotic occlusive lesions of iliac veins and in 12 patients operated on for obstruction of the femoral vein (saphenopopliteal bypass grafting). The obtained findings showed that a decisive factor of successful cross-over bypass grafting was a sufficient diameter of the autovenous transplant (not less than 7-8 mm). It was determined that in 70.6% of patients the cross-over bypass grafts become dilated with time and thus provide adequate outflow of blood from the affected extremity. Studies of the phlebodynamics in the diseased limb under the conditions of an open and cross-clamped shunt demonstrated that in 72% of patients the main function on carrying out venous return is performed by a cross-over shunt. Some shunts (20.7%) undergo pathological transformation in the form of deforming ectasias and cicatricial stenosis, which in many cases deteriorates the conditions of the outflow of blood and requires secondary surgical correction of the shunts. These operations were successfully performed in patients in the remote terms. Patency of the grafts at 15 years of follow up amounted to 79.6%. There was significant improvement of the outcomes of the bypassing operation observed in application of distal arteriovenous fistulas. A permanent clinical effect was achieved in 74.4% of patients with the functioning shunts. Patency of the saphenopopliteal shunts within the follow-up terms up to 12 years amounted to 91.7%. The remote results showed their reliable function and improvement of the regional phlebodynamics. It was determined that the shunts could function for a long time, not undergoing pathological ectasia. Forty-eight patients during dynamic follow up were subjected to operations on superficial and perforant veins with predominant application of minimally invasive technologies.

Aim: to improve treatment of patients with severe atherosclerotic lesion of lower extremities arteries followed by critical ischemia by optimization of femoropopliteal bypass surgery., Material and Methods: Treament and survey of 60 patients with severe atherosclerotic lesion of femoropopliteotibial segment and critical lower limb ischemia were analyzed. Patients were divided into 2 groups depending on technique of femoropopliteal bypass. Conventional in situ autovenous technique was used in group 1. In the second group we used original method of free autovenous graft with destructed valves., Results: Technique of free autovenous graft with destructed valves decreases incidence of early postoperative complications by 13.3%, remote thrombosis of graft by 13.3%. Also it increases physical and mental components of health by 7.9% and 3.1% respectively., Conclusion: Use of free autovenous graft with destructed valves is reasonable and improves results of treatment.

The article presents an analysis of complex examination and treatment of 60 patients with critical ischemia of the lower extremities due to atherosclerotic lesions of femoral-poplitealtibia segment. Typical traditional autovenous bypass of reverse big saphena was performed for the first (control) group of patients. The operation, which used an original technology by free autovenous transplant with collapsed valves without vein reverse, was completed for the second (experimental) group of patients. An application of original treatment technology allowed an increase of blood flow volume in the extremity in 1,5 times, an arterial blood flow - in 1,6 times, rate of microcirculation - in 1,3 times. An early postoperative complications were decreased on 23,4%, the late shunt thrombosis - on 40%. Long-term shunt passability was improved in 2,6 times and physical component of health - on 10,6%, psychological - on 4,3%. The shunt functioned in 36,7% of the first group and in 83,3% patients of the second group after two years since operation. The extremity was saved in 60% of the first group and 90% patients of the second group.

Objective: Infrapopliteal bypass is an established and effective method for limb salvage in patients with critical limb ischemia. Secondary interventions maybe required to maintain graft patency. The aim of this study was to look at the frequency and outcomes of such interventions., Methods: Consecutive patients undergoing bypasses onto the infrapopliteal vessels for critical limb ischemia (Rutherford 4-6) at a single institution were analyzed between 2009 and 2013. The primary end points were graft patency, amputation-free survival (AFS), and freedom from reintervention at 12 months by Kaplan-Meier analysis., Results: A total of 114 infrapopliteal bypasses were performed in 102 patients. Distal anastomosis was on to the anterior tibial (n = 31), posterior tibial (n = 27), peroneal (n = 24), tibioperoneal trunk (n = 23), or dorsalis pedis artery (n = 9). Primary patency, assisted primary patency, and secondary patency was 57%, 76%, and 82%, respectively, at 12 months and 44%, 70%, and 80%, respectively, at 36 months. AFS was 80% at 12 months and 65% at 36 months. Endovascular salvage interventions were performed on 58 grafts (51%) including angioplasty of inflow/proximal anastomosis (33%), outflow/distal anastomosis (46%), and graft stenosis (20%), with a further 12 grafts (11%) undergoing thrombolysis for occlusion. Surgical salvage interventions included jump grafts (n = 7), revision of anastomotic stenosis (n = 3), and thrombectomy (n = 2). AFS was similar in salvaged threatened and acutely occluded grafts compared with nonthreatened grafts (P = .064) and better in grafts requiring reintervention later (>6 months from bypass) compared with those requiring early reintervention (<6 months; P = .047)., Conclusions: Secondary interventions in threatened distal bypass grafts are successful at maintaining graft patency and AFS when compared with nonthreatened grafts, and are associated with a low morbidity rate., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

We describe an extremely rare case of a pregnant woman who had a successful delivery despite developing bypass graft occlusion after right external iliac bypass surgery. External and common iliac artery bypass surgery is often performed when arteriosclerosis obliterans or thromboangiitis obliterans result in iliac artery occlusion or when revascularization is required because of iliac artery injury. Because arteriosclerosis obliterans and thromboangiitis obliterans rarely develop in young women or girls, most physicians have little experience with graft occlusion after iliac artery bypass surgery. Here we describe and discuss the published work pertaining to this extremely rare case., (© 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.)

Unlabelled: In vivo experiments were carried out to study functioning of vascular grafts manufactured by means of electrospinning from solutions of polycaprolactone (PCL) and hexafluoroisopropanol (HFIP), PCL with 10% gelatine and a low-permeability inner layer (LPIL) 10 μm thick and PCL with 10% gelatine and LPIL (10 μm) wherein as polymeric base instead of PCL copolymer of lactic and hydroxyacetic acids (polylactide-co-glycolide, PLGA) was used. The grafts were implanted into the infrarenal portion of the aorta to 45 rats, 15 rats for each type of the graft. Patency of artificial vessels was assessed by means of magnetic resonance tomography and diagnostic ultrasound Dopplerography at 2, 4 and 20 weeks (5 animals for each time point). The state of the graft and surrounding tissues was analysed by means of intraoperative assessment, survey microscopy and survey fluorescent microscopy., Conclusion: The obtained findings demonstrated that vascular grafts made by electrospinning technique with a low-permeability inner layer are less prone to formation of the neointima and stenosing as compared with grafts having no such layer.

After the creation of an autogenous lower extremity bypass graft, the vein must undergo a series of dynamic structural changes to stabilize the arterial hemodynamic forces. These changes, which are commonly referred to as remodeling, include an inflammatory response, the development of a neointima, matrix turnover, and cellular proliferation and apoptosis. The sum total of these processes results in dramatic alterations in the physical and biomechanical attributes of the arterialized vein. The most clinically obvious and easily measured of these is lumen remodeling of the graft. However, although somewhat less precise, wall thickness, matrix composition, and endothelial changes can be measured in vivo within the healing vein graft. Recent translational work has demonstrated the clinical relevance of remodeling as it relates to vein graft patency and the systemic factors influencing it. By correlating histologic and molecular changes in the vein, insights into potential therapeutic strategies to prevent bypass failure and areas for future investigation are explored., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Even in the setting of duplex ultrasound (DUS) surveillance, a significant number of lower extremity vein bypass grafts (LEVBGs) become occluded as a first event. We sought to identify factors that may contribute to these primary occlusions., Methods: This was a retrospective analysis of the Project of Ex Vivo Graft Engineering via Transfection III (PREVENT III) multicenter randomized clinical trial, in which 1404 patients with critical limb ischemia (CLI) underwent LEVBG with 1-year follow-up. Subjects were to undergo DUS at regular intervals (1, 3, 6, and 12 months), with reintervention based on prespecified DUS criteria. Patients who had nontechnical graft occlusion as the initial graft-related event were identified, and multivariate analysis was used to determine factors associated with primary graft occlusion., Results: Primary vein graft occlusion occurred in 200 subjects and accounted for 36% of all primary patency events and 64% of all graft occlusions in the trial. Primary occlusion events were evenly distributed throughout the first postoperative year. Rates of recurrent CLI, loss of secondary patency, and major amputation in those with primary occlusion were 55%, 79%, and 22% respectively as compared to 18%, 10%, and 10% for subjects without primary occlusion (P < .001). On multivariate analysis, African-American race (subdistribution hazard ratio [SHR], 1.50; 95% confidence interval [CI], 1.06-2.12), a graft diameter <3 mm (SHR, 2.31; 95% CI, 1.33-4.01), and nonadherence with ultrasound surveillance (SHR, 1.58; 95% CI, 1.10-2.27) were independently associated with primary graft occlusion. Of the 123 subjects who received their last scheduled surveillance DUS prior to a primary occlusion event, 39 had a critical ultrasound abnormality identified but failed to undergo graft revision, while 84 had no critical ultrasound abnormality identified. Among these 84 subjects, female gender (SHR, 1.65; 95% CI, 1.07-2.54), and graft diameter <3 mm (SHR, 2.12; 95% CI, 1.03-4.37) were independent factors associated with unheralded graft occlusion., Conclusions: Among patients undergoing LEVBG for CLI, almost half of primary patency events are occlusions even in the setting of a DUS surveillance protocol. African Americans, patients with smaller-diameter grafts, and those who are nonadherent with surveillance ultrasound are at increased risk. Failure to intervene on critical findings, and lack of sensitivity of DUS threshold criteria to predict thrombosis, are also important contributors. These findings suggest that prevention of vein graft thrombosis requires further improvements in risk stratification, surveillance, and the timing of reinterventions., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Aim: Atherosclerosis with its cardiovascular events including cardiac and peripheral ischemia represents the main cause of death in the developed countries. Although interventional treatments like percutaneous transluminal angioplasty or stents are increasingly applied for the treatment of peripheral arterial disease, they are not always technically applicable or durable and bypass surgery is needed. Compared to synthetic grafts, vein grafts show a better patency especially when used for the lower leg as well as a lower risk for infection compared to synthetic grafts. Still the long-term patency rates are unsatisfactory due to accelerated intimal hyperplasia, a thickening of the vessel wall. The aim of this study was to elucidate, if the implantation of embryonic stem cells into vein grafts can reduce the development of intimal hyperplasia in a mouse in vivo model., Methods: In this study we implanted LacZ-tagged (ROSA26) murine embryonic stem cells into decellularized vein grafts. Control groups were: 1) untreated veins; 2) decellularized veins; 3) decellularized veins with gel and plastic film; and 4) decellularized veins with smooth muscle cells in gel surrounded by plastic film. Six weeks after insertion into the carotid artery of mice, the grafts were excised and analyzed immunohistochemically, morphologically, and by x-gal staining and compared to the control groups. The Mann-Whitney U test was used to compare groups. Statistical significance was indicated by a value of P<0.05., Results: Decellularized veins with implanted stem cells showed significantly less intimal thickening compared to all control groups (intimal hyperplasia vs. luminal circumference mean±SD 7.3±3.5 µm, median 8 µm). The control groups: 1) untreated veins (60.3±25.5 µm, median 58.5 µm); 2) decellularized veins (53.9±22.4 µm, median 48.4 µm); 3) decellularized veins with gel and plastic film (70.6±22.4 µm, median 72.6 µm); and 4) decellularized veins with smooth muscle cells in gel surrounded by plastic film (73.5±18.1 µm, median 73.6 µm) all showed the same high degree of intimal hyperplasia., Conclusion: This study demonstrates that embryonic stem cells have a therapeutic competence to favourably modulate intimal hyperplasia in vivo.