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Little research has been done on the current cut-off international normalized ratio (INR) value of 1.5 for patients undergoing surgery. The objectives of this study are to assess the association between INR and postoperative major bleeding and mortality in patients undergoing surgery and to identify an ideal pre-operative INR for surgical patients. We analyzed data from the American College of Surgeons’ National Surgical Quality Improvement Program database between 2008 and 2011 (636,231 patients). The primary outcomes were major bleeding and mortality at 30 days postoperatively. Multivariate logistic regression analyses were carried out to assess these associations. Compared to an INR of

Endovascular abdominal aortic aneurysm repair (EVAR) with the Cook Zenith or Zenith Flex Endograft is performed for symptomatic or asymptomatic aortic aneurysm greater than 5.5 cm in men and 5 cm in women with suitable anatomy.

Proximalization of the arterial inflow is performed to address ischemic steal syndrome secondary to a functioning hemodialysis arteriovenous fistula. This procedure allows for preservation of the fistula without having to ligate the native artery at the fistula side as done in the DRIL procedure. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Asymptomatic popliteal artery aneurysm greater than 2 cm in diameter in the presence of suitable anatomy. Symptomatic popliteal artery aneurysm in the presence of suitable anatomy.

Innominate/common carotid artery angioplasty stenting using hybrid open technique is performed for combined innominate or common carotid artery disease in the presence of a hostile arch and limited peripheral access. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Asymptomatic splenic artery aneurysm in a child-bearing age female patient. Asymptomatic splenic artery aneurysm and planned liver transplantation. Asymptomatic splenic artery aneurysm greater than 2 cm. Asymptomatic splenic artery false aneurysm and chronic pancreatitis. Symptomatic splenic artery aneurysm.

Bypasses to infrapopliteal vessels with prosthetic grafts are rarely used. When no other alternative is available and in the absence of an autogenous conduit, such bypasses may be performed as a last resort for limb salvage. Adjunctive procedures have been designed to address poor patency of infrapopliteal prosthetic bypasses, such as the construction of a venous cuff or the creation of an arteriovenous fistula at the distal anastomosis. One procedure combines both a vein cuff and an arteriovenous fistula at the distal anastomosis. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

1. Mark the area of stenosis preoperatively under duplex guidance. 2. Perform a longitudinal skin incision over the bypass. 3. Identify the bypass and dissect a segment proximal to the area of stenosis. 4. Expose the target artery distal to the stenotic area. 5. Confirm the site of stenosis by Doppler ultrasound. 6. Harvest an appropriate segment of vein. 7. Anticoagulate. 8. Proximal and distal control.

Transmetatarsal foot amputation is performed to treat forefoot infections or gangrene in patients with blood supply adequate for healing the foot. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

The management of penetrating neck injuries remains most challenging and may vary depending on the zone involved and the patient stability. Maintaining the airways and breathing followed by control of bleeding are essential. Foley balloon tamponade of bleeding neck wounds can prevent exsanguination if external pressure was not adequate to control the bleeding. In stable patients with injury to zones 1 and 3, evaluation with CT angiography, trachea-bronchoscopy, and upper endoscopy are essential steps in the management. This can also be applied to stable patients with zone 2 injury, although routine exploration is also an acceptable approach, depending on the local resources available. Identified carotid injuries are best repaired except in the comatose, unstable patient where ligation may be the only alternative.

Ligation of popliteal aneurysm along with femoropopliteal/tibial reversed vein bypass is performed to treat popliteal aneurysms greater than 1.5–2.0 cm in diameter. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Granulating wound following forefoot amputation or other leg wounds can be covered by split-thickness skin graft once an adequate granulation bed is available. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Severe lower extremity trauma is an unfortunate, but not uncommon, result of armed conflict. Frequently, the decision is made to amputate rather than salvage the limb, especially when the process can be performed quickly and is not very technically challenging. The most commonly performed amputations in the battlefield are transtibial amputations. Battlefield-related amputations pose a challenge as they are more prone to postoperative complications ranging from mild infections and simple wound dehiscence to more serious complications of mucomycosis and complete flap necrosis. The process of rehabilitation of the amputee is not only limited to surgical care. The prosthetist has a huge role in fashioning the most suitable prosthesis. Finally, psychological support is critical to aid in the reintegration of the amputee into society.

1. Expose the target peroneal vessel. 2. Expose the greater saphenous vein (GSV). 3. Expose the inflow femoral vessels. 4. Transect the GSV at the saphenofemoral junction. 5. Excise the saphenofemoral valve under direct vision. 6. Construct the proximal anastomosis. 7. Incise the valves. 8. Identify and ligate arteriovenous (AV) fistulae. 9. Construct the distal anastomosis. 10. Completion angiogram. 11. Recheck for hemostasis. 12. Wound closure. 13. Pulses re-evaluation.

1. 10-cm oblique skin incision mid-distance between the costal margin and the anterior superior iliac crest. 2. Division of the external, internal oblique muscles and the transversalis abdominal fascia. 3. Dissection in the retroperitoneum with mobilization of the peritoneal contents medially. 4. Exposure and control of the common, internal, and external iliac arteries.

Tunneled cuffed catheters are inserted in patients with chronic renal failure expected to need dialysis for more than 2–3 weeks. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Femoroposterior tibial bypass with reversed greater saphenous vein is performed for critical limb ischemia, often after failed endovascular options. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

A bioheat model for the elderly was developed focusing on blood flow circulatory changes that influence their thermal response in warm and cold environments to predict skin and core temperatures for different segments of the body especially the fingers. The young adult model of Karaki et al. (Int J Therm Sci 67:41-51, 2013) was modified by incorporation of the physiological thermoregulatory and vasomotor changes based on literature observations of physiological changes in the elderly compared to young adults such as lower metabolism and vasoconstriction diminished ability, skin blood flow and its minimum and maximum values, the sweating values, skin fat thickness, as well as the change in threshold parameter related to core or skin temperatures which triggers thermoregulatory action for sweating, maximum dilatation, and maximum constriction. The developed model was validated with published experimental data for elderly exposure to transient and steady hot and cold environments. Predicted finger skin temperature, mean skin temperature, and core temperature were in agreement with published experimental data at a maximum error less than 0.5 °C in the mean skin temperature. The elderly bioheat model showed an increase in finger skin temperature and a decrease in core temperature in cold exposure while it showed a decrease in finger skin temperature and an increase in core temperature in hot exposure.

The use of totally implantable venous devices (TIVAD) has changed the care and quality of life for cancer patients, these devices allow chemotherapy administration, and blood sampling without the need for repeated venipuncture. These ports are used mainly when IV access is needed only intermittently over a long period of time. We are presenting a brief overview on TIVADs, with focus on the mid and long-term complications associated with these devices with their management.

Infrarenal abdominal aortic aneurysm (AAA) replacement was performed in 97 patients aged 79 or greater over a 14-year period. Sixty-eight patients had intact aneurysms and 29 had ruptured aneurysms. In the intact aneurysm group, the 30-day mortality rate from 1980 to 1986 was 11.5% and decreased to 2.3% from 1987 to 1994. In the ruptured aneurysm group, the 30-day mortality rate was 73% in the earlier period from 1980 to 1986 and 43% in the later period from 1987 to 1994. In the intact aneurysm group, the median hospital stay was 11 days for the transabdominal approach and 8 days with a retroperitoneal approach. In the ruptured aneurysm group, the median hospital stay was 26 days. The occurrence of a ruptured AAA in a patient over 79 years of age is still associated with a high mortality rate, despite the many advances in aneurysm surgery during the past few decades. Hence, in appropriately selected elderly patients, infrarenal aortic aneurysm replacement should be performed electively as the perioperative mortality is low and late survival is similar to that of agematched controls. Age alone should not be a contraindication for infrarenal aortic aneurysm replacement.

Based on current knowledge, it appears that atherosclerosis is a multifactorial disease. There are differences in the effects of atherosclerotic risk factors between the various vascular beds. More than one risk factor is found in the majority of the patients and, often there is atherosclerotic involvement of several vascular territories. In order to prevent or retard atherosclerotic complications and improve patient survival, it is prudent that all the major modifiable risk factors should be corrected in patients with cardiovascular, cerebrovascular, and peripheral vascular disease.

Purpose: Describe a hybrid approach to simplify management of complex aortoiliac occlusive disease (AIOD) extending into the common femoral artery (CFA). Methods: Retrospective review of 56 patients who underwent hybrid management of AIOD extending into CFA between January 2003 and February 2007. Two distinct hybrid approaches were compared: Inline (iliac stenting continuous with an open CFA reconstruction, 38 limbs in 37 patients) and tandem (noncontiguous stenting of an upstream iliac segment, 20 limbs in 19 patients). The median follow-up duration was 15 ± 12 months in the inline group and 24 ± 12 months in the tandem group. Results: Technical success was achieved in all but 1 procedure. Clinical and hemodynamic responses to the interventions and limb loss rates were comparable in both groups. Survival table analysis showed no significant difference between inline and tandem reconstructions. Conclusions: Inline stenting represents a lesser invasive revascularization choice in complex AIOD with contiguous involvement of the CFA.

Background Simultaneous bilateral total knee arthroplasty (SBTKA) may offer certain benefits; however, its overall safety is still disputed. This study aimed at comparing the risk of thromboembolism and bleeding in patients who underwent SBTKA vs unilateral total knee arthroplasty (TKA). Methods The American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2015 was used to investigate the short-term postoperative complications and their risk factors following SBTKA as compared to unilateral TKA. Demographics, comorbidities, and 30-day outcomes were analyzed. Complications with an increased incidence following SBTKA were stratified to identify subgroups of patients at high risk. Results A total of 155,022 patients were identified, of which 150,581 underwent unilateral TKA and 4441 underwent SBTKA. The SBTKA group was found to be at a higher risk of venous thromboembolism (VTE), bleeding, and composite morbidity. Stratification analysis revealed that SBTKA subgroups at higher risk of VTE include patients of black or Asian origin, obese patients, and those who underwent anesthesia other than general or spinal/epidural. SBTKA subgroups at higher risk of bleeding include patients older than 85 years, those with race other than white, underweight and obese patients, and patients who underwent anesthesia other than spinal/epidural. Although none of the subgroups were protected from bleeding, patients who underwent spinal/epidural anesthesia had a lower risk of bleeding compared to other types of anesthesia. Conclusion SBTKA confers an increased risk of postoperative VTE, bleeding, and composite morbidity at 30 days, with no increase in mortality.

Purpose: To report experience with aggressive recanalization approaches in chronic total arterial occlusion (CTO). Methods: Chronic total arterial occlusion recanalization was attempted on 112 limbs in 99 consecutive patients between January 1999 and December 2006. Results: There were 63 iliac arteries, 45 femoropopliteal arteries, and 4 occluded stents. Mean occlusion length was 8.7 ± 4.7 cm. Conventional recanalization was attempted first and was successful in 71 limbs (70%). Probing with the guidewire’s stiff end was attempted in 33 of the 41 procedures where conventional techniques failed and was successful in 18 (54%), improving the overall procedural success rate to 80%. For the remaining 15 limbs, home-made directional sharp needle recanalization was attempted in 11 and was successful in 9 (82%), further improving the overall recanalization success to 88%. Procedural complications were self-limited or managed nonoperatively. Conclusions: Aggressive recanalization techniques in CTO following failure of traditional means are safe and can substantially improve procedural success rates.

Our objective of the study was to address the question: "What is the efficacy of a deep venous thrombosis (DVT) and pulmonary embolus prophylaxis protocol after total knee arthroplasty (TKA) in which low-risk patients had only aspirin and mechanical devices for prophylaxis?" A multimodal approach to DVT prophylaxis using aspirin as the primary mode of chemoprophylaxis was successful in preventing DVT-related morbidity and mortality in 312 consecutive TKAs performed in low-risk patients. There were no DVT-related deaths and no deaths in general at 90 days of follow-up coupled with a low rate of readmission for thromboembolic events and no readmissions or reoperations from bleeding in this group. This low-morbidity, low-cost prophylaxis should be considered an appropriate protocol for low-risk patients undergoing TKA. Of all TKAs performed during the time period of the study, 73% qualified for the low-risk group.

Evaluamos la seguridad del clampaje aortico suprarrenal en los pacientes con aneurisma aortico abdominal (AAA) tratados mediante sustitucion aortica abierta revisando de forma retrospectiva todos aquellos sometidos a una correccion del AAA programada en un hospital universitario desde el ano 1993 hasta el 2003. Revisamos las historias clinicas de 249 pacientes y los dividimos en 3 grupos segun la localizacion del clampaje durante la sustitucion aortica: grupo 1, clampaje infrarrenal (n = 185); grupo 2, clampaje suprarrenal (n = 52); y grupo 3, clampaje supraceliaco (n = 12). Se compararon los grupos 1 y 2 con respecto a los factores de riesgo, los sucesos intraoperatorios, y los sucesos postoperatorios. Se realizo el analisis estadistico utilizando el test de la suma de los rangos de Wilcoxon, el test chi-cuadrado, y el test exacto de Fisher. Los factores de riesgo fueron comparables en los grupos 1 y 2 a excepcion del peso, que fue mas elevado en el grupo 1. La diuresis intraoperatoria, los episodios de hipotension, y el uso de protectores renales fueron comparables en ambos grupos. La duracion de la cirugia, la perdida de sangre, y el uso de fluidos endovenosos fueron significativamente mas altos en el grupo 2, en cambio el tiempo total de clampaje aortico fue mas alto en el grupo 1. Los sucesos postoperatorios fueron comparables exceptuando los niveles plasmaticos postoperatorios maximos de creatinina, la duracion de la estancia en cuidados intensivos, y la estancia hospitalaria, que fueron mas elevados en el grupo 2; sin embargo, la concentracion de creatinina al alta hospitalaria fue comparable sin que existiese una diferencia significativa. El clampaje suprarrenal es un metodo seguro de control aortico durante la cirugia abierta de sustitucion de AAA. La seleccion del lugar del clampaje debe individualizarse en funcion de la anatomia intraoperatoria. El clampaje supraceliaco no es necesariamente el metodo preferible de control aortico cuando la localizacion infrarrenal no es adecuada para el control aortico.

Nous avons evalue la surete du clampage de l'aorte supra-renale chez les malades ayant un anevrysme de l'aorte abdominale (AAA) traite par remplacement aortique chirurgical en etudiant retrospectivement tous les malades ayant eu le remplacement electif d'un AAA dans un hopital universitaire entre 1993 et 2003. Nous avons etudie 249 dossiers de malades et les avons divises en trois groupes suivant la localisation du clampage au cours du remplacement aortique : groupe I clampage sous-renal (n = 185); groupe II clampage supra-renal (n = 52); et groupe III clampage supra-cœliaque (n = 12). Les groupes I et II ont ete compares en ce qui concerne les facteurs de risque et les evenements per et post-operatoires. L'analyse statistique a ete faite en utilisant un test de Wilcoxon, un test du χ2 et un test exact de Fisher. Les facteurs de risque etaient comparables dans les groupes I et II sauf le poids, plus eleve dans le groupe I. La diurese per-operatoire, des episodes d'hypotension arterielle et l'utilisation de drogues nephro-protectrices etaient comparables dans les deux groupes. La duree de l'intervention, les pertes sanguines et l'utilisation de fluides intra-veineux etaient toutes significativement plus elevees dans le groupe II, alors que la duree totale du clampage aortique etait plus importante dans le groupe I. Les evenements post-operatoires etaient comparables sauf le pic de creatininemie post-operatoire, la duree de sejour en unite de soins intensifs et la duree de sejour post-operatoire, qui etaient plus importants dans le groupe II. Cependant, la creatininemie lors de la sortie etait comparable, sans difference significative. Le clampage supra-renal est une methode sure de controle aortique au cours de la chirurgie conventionnelle des AAA. La selection du site de clampage doit etre individualisee suivant l'anatomie per-operatoire. Le clampage supra-cœliaque n'est pas necessairement la methode preferable de controle aortique lorsqu'un clampage sous-renal n'est pas possible.

Evaluamos la permeabilidad a largo plazo de la reconstruccion mediante kissing stent de la bifurcacion aortoiliaca e identificamos las variables que pueden afectarla. Revisamos de forma retrospectiva nuestra experiencia en los procedimientos de reconstruccion mediante stent de la bifurcacion aortoiliaca desde enero de 1998 hasta junio de 2005. Se evaluo el impacto de las variables demograficas, los factores de riesgo vascular, la localizacion de la enfermedad y sus caracteristicas, el material del stent y su diseno, y la configuracion del stent en la permeabilidad mediante analisis de uni y multivariante. En particular, evaluamos el efecto de la discordancia geometrica entre el segmento que sobresale del stent y la luz aortica distal. Sesenta y seis pacientes fueron sometidos a una reconstruccion con stent aortoiliaco. Las indicaciones fueron: enfermedad iliaca proximal o de la bifurcacion en 52 pacientes y enfermedad ostial unilateral que requirio proteccion contralateral en 14. Cuarenta extremidades de 19 pacientes presentaron enfermedad limitada (TASC A y B); 78 extremidades de 47 pacientes tenian afectacion extensa/difusa (TASC C y D). Treinta y siete extremidades de 28 pacientes presentaron una oclusion completa (bilateral en 9 pacientes). Se utilizaron stents autoexpansibles en 56 intervenciones y stents expansibles con balon en 10. La configuracion cruzada se utilizo en 43 intervenciones, mientras que la confluyente se utilizo en 23. El exito tecnico se logro en 62 pacientes (94%), con 4 fracasos debido a la imposibilidad de atravesar una extremidad con una oclusion cronica. En 3 de estos pacientes se coloco un stent aortomonoiliaco con un bypass protesico femorofemoral cruzado, y en el cuarto se decidio no realizar intervenciones adicionales. La media del seguimiento combinado fue de 37 ± 27 meses (intervalo 0-102). Se produjeron reestenosis hemodinamicamente significativas en 9 pacientes (14%). El tratamiento de las reestenosis fue endovascular en 8 y tuvo exito en todos ellos (dilatacion con balon en 4, nueva colocacion de stent en 3, trombolisis y colocacion de stent en 1) y quirurgico en un paciente que presento oclusion aortica y se le practico un injerto aortobifemoral. El analisis de la tabla de supervivencia mostro indices de permeabilidad primaria y asistida a los 4 anos del 81 y el 94%, respectivamente. La tasa de mortalidad durante el seguimiento fue del 19%, por causas cardiacas en 8, causas pulmonares en 3, y neoplasias malignas en 5. El analisis univariantes mostro que la discordancia radial (espacio muerto de la luz aortica alrededor del segmento que sobresale de los stent), el sexo femenino, la oclusion previa, y la estenosis residual fueron factores predictivos de reestenosis. El analisis de regresion logistica multivariante mostro que la discordancia radial fue el unico determinante significativo de reestenosis, aunque la potencia estadistica del modelo se vio limitada por el bajo numero de eventos. La reconstruccion mediante stent de la bifurcacion aortoiliaca en la patologia oclusiva es eficaz y duradera, incluso ante enfermedad aortoiliaca compleja y oclusiones de segmentos largos. La mayoria de las reestenosis son susceptibles de tratamiento endovascular, con una permeabilidad asistida a largo plazo excelente. Las variables geometricas relacionadas con la anatomia aortica individual y el patron de la enfermedad (dependiente del paciente) y la configuracion del stent (dependiente del cirujano) podrian influir en la permeabilidad a largo plazo.

La aterectomia periferica con dispositivo SilverHawk ha suscitado un interes generalizado. En este estudio, evaluamos nuestra permeabilidad a medio plazo tras aterectomia del sector infrainguinal. Diecinueve pacientes consecutivos fueron sometidos a 23 aterectomias separadas en 20 extremidades desde marzo de 2005 hasta junio de 2006 (11 hombres, edad 66 ± 14 anos). Las lesiones primarias consistieron en aterosclerosis (n = 18) y estenosis de injertos venosos (n = 2). Tres intervenciones adicionales fueron repeticiones de aterectomias para lesiones reestenosicas. La clasificacion TASC de las lesiones primarias fue A en 3, B en 9, y C en 8. La media del numero de lesiones tratadas por extremidad fue de 2 (intervalo 1-4). La estenosis de los vasos originarios mas distales se localizo en la arteria femoral superficial en 12, en la arteria poplitea en 6, y en la arteria crural en 2. La aterectomia se realizo con exito en 18 intervenciones primarias y en las 3 aterectomias repetidas. En 5 intervenciones se utilizo la dilatacion mediante balon “touch-up”. Entre las complicaciones observadas cabe destacar un hematoma inguinal, y dos perforaciones, que se trataron mediante la colocacion de un stent en una y un bypass protesico en la otra. El indice preoperatorio tobillo-brazo y el volumen del pulso transmetatarsiano registrados fueron 0,51 ± 0,16 y 3,3 ± 0,8, respectivamente, los cuales mejoraron al cabo de 1 mes a 0,80 ± 0,16 y 2,4 ± 0,4 (p

There has been widespread initial enthusiasm for peripheral atherectomy using the SilverHawk device. We sought to evaluate our midterm patency following infrainguinal atherectomy. Nineteen consecutive patients underwent 23 separate atherectomy procedures on 20 limbs from March 2005 through June 2006 (11 males, age 66 +/- 14 years). The primary lesions were atherosclerotic (n = 18) and vein graft stenoses (n = 2). Three additional procedures were redo atherectomies for restenotic lesions. The TASC classification of the primary lesions was A in 3, B in 9, and C in 8. The median number of treated lesions per limb was 2 (range 1-4). The location of the most distal native vessel stenosis was the superficial femoral artery in 12, popliteal artery in six, and crural artery in two. Atherectomy was successful in 18 primary procedures and all three repeat atherectomy procedures. Touch-up balloon dilatation was used in five procedures. Complications included one groin hematoma and two perforations, treated with stenting in one and bypass grafting in one. Preoperative ankle-brachial index and transmetatarsal pulse volume recording were 0.51 +/- 0.16 and 3.3 +/- 0.8, respectively, which at 1-month improved to 0.80 +/- 0.16 and 2.4 +/- 0.4 (p0.001). Only two vessels remained patent at 12 months. Recurrence developed in 16 of the successful primary procedures, including both vein graft lesions and all three repeat atherectomy procedures. The mode of recurrence was restenosis in 14 and occlusion/thrombosis in five. Secondary interventions included balloon angioplasty/thrombolysis in two, stenting in three, redo atherectomy in three, vein bypass grafting in five, and observation alone in one. Major limb amputation was required in five patients. Primary patency rates per treated limb at 3, 6, and 12 months were 38%, 10%, and 10%. The corresponding assisted patency rates were 50%, 23%, and 10%. Our experience suggests a very poor midterm patency of excisonal atherectomy using the SilverHawk device, although a 74% limb salvage rate was maintained through secondary interventions. Liberal use of this technology is associated with high cost and frequent requirement of reintervention.

Nous avons evalue la permeabilite a long terme de la reconstruction par stents en kissing de la bifurcation aortique et avons identifie les variables qui peuvent l'influencer. Nous avons retrospectivement revu notre experience des procedures de reconstruction par stents de la bifurcation aortique realisees de janvier 1998 a juin 2005. L'impact des variables demographiques, des facteurs de risque vasculaires, du siege et des caracteristiques de la maladie, du materiel et de la conception des stents, et de la configuration du stenting sur la permeabilite des stents a ete evalue en analyse multivariee et univariee. En particulier, nous avons evalue l'effet de la disparite geometrique entre la partie saillante des stents et la lumiere aortique distale. Soixante-six patients ont eu une reconstruction aortobi-iliaque par stents. Les indications etaient des lesions de la bifurcation ou bilaterales des iliaques proximales chez 52 patients et une atteinte ostiale unilaterale exigeant une protection controlaterale chez 14 patients. Des lesions limitees (TASC A et B) etaient presentes au niveau de 40 membres chez 19 patients ; des lesions etendues/diffuses (TASC C et D) etait presentes au niveau de 78 membres chez 47 patients. Des occlusions completes etaient presentes au niveau de 37 membres chez 28 patients (bilaterales chez neuf patients). Des stents auto-expansibles ont ete employes dans 56 procedures et des stents expansibles par ballonnet dans 10. Un croisement a ete realise dans 43 procedures, alors qu'une configuration en abouchement etait employee dans 23 procedures. Un succes technique a ete obtenu chez 62 patients (94%), les quatre echecs etant dus a l'incapacite de franchir une occlusion chronique. Trois de ces patients ont eu un stenting aortouni-iliaque et un pontage femoro-femoral croise, l'autre refusant une autre intervention. Le suivi combine median etait de 37 ± 27 mois (extremes 0-102). Une restenose hemodynamiquement significative est survenue chez neuf patients (14%). Le traitement des restenoses a ete endovasculaire chez huit patients et toujours reussi (dilatation par ballonnet dans quatre cas, restenting dans trois, thrombolyse et stenting dans un cas) et chirurgical chez un patient qui a developpe une occlusion aortique et a eu un pontage aortobifemoral. L'analyse de table de survie a montre des taux primaires et assistes de permeabilite a 4 ans respectivement de 81% et de 94%. Dix-neuf deces sont survenus au cours du suivi (cause cardiaque huit fois, cause pulmonaire trois fois, cancer cinq fois). L'analyse univariee a montre que la disparite de diametre (espace mort de lumiere aortique autour du segment saillant des stents), le sexe feminin, une occlusion anterieure, et une stenose residuelle etaient les facteurs predictifs significatifs de restenose. L'analyse en regression logistique multivariee a montre que la disparite de diametre etait la seule cause determinante significative de restenose, bien que la puissance statistique du modele ait ete limitee par le petit nombre des restenoses. La reconstruction par stents de la bifurcation aorto-iliaque pour lesions occlusives est efficace et durable, meme en cas de lesions aorto-iliaques complexes et d'occlusions longues. La plupart des restenoses sont accessibles au traitement endovasculaire, avec une excellente permeabilite assistee a long terme. Les variables geometriques liees a l'anatomie aortique individuelle et le type de lesions (patient-dependants) et la configuration du stenting (operateur-dependante) peuvent avoir un impact sur la permeabilite a long terme.

Kissing stent reconstruction of the aortoiliac bifurcation is a widely used technique for the management of aortoiliac occlusive disease involving the aortic bifurcation or proximal common iliac arteries. New advances in delivery systems and stent design have enabled better anatomic results with kissing stenting. Long-term patency is generally excellent, although several factors may adversely affect patency and should be taken into account when devising the stenting configuration and selecting the device to be used. Geometric variables related to individual aortic anatomy and disease pattern (patient dependent) and stenting configuration (operator dependent) may have an impact on long-term patency. Kissing stent aortoiliac reconstruction is effective and durable, even with complex aortoiliac disease and long-segment occlusions. In our experience, TASC (TransAtlantic Inter-Society Consensus) C and D class disease is not necessarily a contraindication to aortoiliac stent reconstruction, especially in poor operative risk patients. Most restenoses are amenable to endovascular treatment, with excellent long-term assisted patency.

The arteriovenous graft (AVG) is most often used in hemodialysis patients when an autogenous fistula is not feasible. The optimal location (forearm or upper arm) and configuration (loop or straight) of AVGs are not known. To evaluate relationships of AVG location and configuration with patency, we conducted a secondary analysis using data from a randomized, placebo-controlled trial of dipyridamole plus aspirin for newly placed AVG.Participants of the Dialysis Access Consortium (DAC) Graft Study with newly placed upper extremity prosthetic grafts involving the brachial artery were studied. Multivariable analyses adjusting for trial treatment group, center, gender, race, body mass index, diabetes, current treatment with chronic dialysis, and prior arteriovenous vascular access or central venous catheter were performed to compare outcomes of forearm (fAVG) and upper arm (uAVG) grafts, including loss of primary unassisted patency (LPUP) and cumulative primary graft failure (CGF). Subgroup analyses of graft configuration and outflow vein used were also conducted.A total of 508 of the 649 participants (78%) enrolled in the trial had an upper extremity brachial artery graft placed, 255 with fAVG and 253 with uAVG. Participants with fAVG were less often male (33% vs 43%; P = .03), African American (62% vs 78%; P .001), and receiving dialysis at the time of surgery (62% vs 80%; P .001). Participants with fAVG had a higher mean body mass index (33 vs 29; P .001). The LPUP (fAVG 70% vs uAVG 78%; P = .07) and CGF (33% vs 36%; P = .91) were similar between fAVG and uAVG at 1-year follow-up. In multivariable analysis, AVG location (uAVG vs fAVG) was not associated with LPUP (hazard ratio, 1.21; 95% confidence interval, 0.90-1.63; P = .20) or CGF (hazard ratio, 1.36; 95% confidence interval, 0.94-1.97; P = .10). LPUP did not differ significantly between fAVG and uAVG among subgroups based on AVG configuration (P = 1.00) or outflow vein used (P = .16).Patency was comparable between fAVG and uAVG despite the larger caliber veins often encountered in the upper arm in carefully selected patients. Our findings support the traditional view that, in order to preserve a maximal number of access sites, the forearm location should be considered first before resorting to an upper arm graft.