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This study aimed to detect the predictors of vein graft disease (VGD) progression between 1 week and 1 year after surgery and to evaluate the impact of secondary prevention medications.A total of 218 consecutive patients underwent surgical coronary revascularization were evaluated by coronary computed tomography angiography both at 1-week and 1-year follow-up. Logistic regression analyses were performed to investigate the predictors of VGD progression. A risk score (0-4) was set up to evaluate implementation result of secondary prevention measures according to 1-year follow-up result. Association between VGD progression and the risk score was assessed.VGD progression occurred in 11.3% of saphenous vein grafts (SVG) and 22.1% of patients. At the patient level, poor vein graft (odds ratio [OR] = 4.25), noncontrolled hyperlipidemia (OR = 3.01), and diabetes mellitus (DM) (OR = 2.96) were predictors, while diameter of SVG (mm, OR = 0.35) was protective factor. At the graft level, DM (OR = 3.52), noncontrolled hyperlipidemia (OR = 2.33), and peripheral artery disease (PAD) (OR = 2.20) were predictors, while number of SVGs (OR = 0.63), diameter of SVG (mm, OR = 0.39), and mean graft flow25 ml/min (OR = 0.35) were protective factors. VGD progression was significantly associated with the risk score at both the patient (OR = 1.52) and the graft level (OR = 1.38).Poor vein graft, noncontrolled hyperlipidemia and DM were predictors of VGD progression between 1 week and 1 year after surgery at the patient level, while larger SVG diameter was a protective factor. DM, PAD and noncontrolled hyperlipidemia were predictors at the graft level, while a number of SVGs, larger SVG diameter, and mean graft flow25 ml/min were protective factors. Implementation failure of secondary prevention medications was associated with VGD progression from as early as 1 year after surgery.

Background: Vein mapping using duplex ultrasound (DUS) is a routine in selecting optimal autologous bypass grafts (aBG) but is time consuming and operator-dependent. Tomographic three-dimensional (3D) ultrasound (tUS), using free-hand electromagnetic tracking, allows cardiac and vascular surgeons to view 3D images of the entire length of the potential bypass graft. This study compares tUS with DUS in the evaluation of potential autologous grafts for coronary and lower limb bypass. Methods: Both DUS and tUS imaging of 434 potential autologous grafts (364 long, 22 short saphenous veins, and 48 radial artery) immediately before bypass surgery were compared. The time in minutes to evaluate each aBG was recorded. Surgeons scored the quality of the aBG at operation. A score of 5 was in complete agreement with preoperative imaging with scores of 4 considered “good”. Results: Most operating surgeons (113, 57%) preferred interpreting the tUS images and felt that this technology could replace DUS completely. The choice of aBG would have been changed as a result of tUS images in 64 (32%) cases. DUS imaging took a mean (+/-sd) of 08:26 ± 04:44 minutes compared with only 01:00 ± 00:25 minutes for tUS (P < 0.001). However, processing the tUS images, which is currently done manually by the vascular scientist, took significantly longer at 19:31 ± 12:41 minutes compared with 09:03 ± 09:12 minutes for reporting DUS (P < 0.001). Conclusions: Surgeons preferred to see tUS images of the potential aBG themselves rather than relying on DUS reports. tUS images were significantly quicker than DUS to acquire but needed more processing time.

We aimed to compare the clinical outcomes of pre-emptive angioplasty versus post-thrombotic percutaneous endovascular restoration of dysfunctional arteriovenous fistula (AVF).This retrospective study reviewed the data from 80 patients who underwent 114 endovascular interventions for a malfunctioning AVF from July 2016 to August 2019. Stenotic AVFs were treated with pre-emptive angioplasty. Thrombosed AVFs were treated with percutaneous pharmacomechanical fibrinolysis with urokinase used only during the operation or continuously infused. The differences in patency rates were evaluated using the Kaplan-Meier method. In addition, univariate and multivariate regression Cox models were used to determine influential factors on the postintervention primary patency.Post-thrombotic interventions and pre-emptive angioplasty yielded statistically similar rates in clinical success (100 vs. 100%), anatomic success (94 vs. 89%; P = 0.52), complication (4 vs. 11%; P = 0.29), as well as postintervention primary, assisted primary and secondary patency (P = 0.80; 0.57; 0.57). The use of pre-emptive angioplasty was associated with reduced total cost (¥25,108 vs. ¥30,833, P 0.001). The patients who used urokinase only during the operation prolonged both the primary and assisted primary patency (P = 0.02; 0.002), while those with continuous infusion of urokinase had worst patency rates and high costs (¥39,275 vs. ¥25,108 vs. ¥27,140, P 0.001). Compared with the other locations, dysfunction in the anastomotic or juxta-anastomotic segment (HR = 0.41, P = 0.001) was associated with prolonged postintervention primary patency.No clinical outcome differences were found between the post-thrombotic percutaneous endovascular interventions and pre-emptive angioplasty. However, pre-emptive angioplasty decreased access expenditure.

To assess the feasibility and outcomes of an approach utilizing transbasilic access for balloon-assisted maturation (BAM) of brachiocephalic arteriovenous fistulas (BCAVFs).This retrospective analysis comprised 28 patients (mean age, 63 years ± 10.8) who underwent endovascular treatment of their immature BCAVFs via a basilic approach from December 2016 to December 2018. The mean age of the BCAVFs was 3.3 months ± 1.4 at the time of BAM. Other demographic data, vascular access characteristics, procedural data, technical and clinical success rates, and adverse events were also evaluated.All patients had inflow juxta-anastomotic stenoses, with 4 patients (14%) having concomitant outflow tract stenoses and 1 patient (4%) having a short-segment occlusion at the stenotic juxta-anastomotic segment. Technical success was achieved in 27 patients (96%). The mean diameter of the largest balloon used was 5.7 mm ± 0.6. Clinical success was achieved in 22 patients (79%), with 6 patients (21%) requiring a subsequent additional intervention before successful cannulation. No perioperative adverse events were observed.The retrograde basilic approach is feasible, safe, and effective for BAM of BCAVFs.

Percutaneous transluminal angioplasty (PTA) is an effective treatment for autogenous arteriovenous hemodialysis access (AAVA) stenosis; however, it causes pain in most cases. Therefore, safe and effective anesthesia for PTA is required.We introduced a method of ultrasound-guided cradle-like infiltration anesthesia (UCIA) to administer analgesia during PTA. Using ultrasound guidance, 1% lidocaine was injected into the bilateral and inferior perivascular spaces of the stenosis to form a cradle-like region. In this study, 100 consecutive patients were divided into two groups, and the analgesic effect of UCIA was evaluated using a numerical rating scale with non-ultrasound-guided infiltration anesthesia as a control. Meanwhile, we compared the effect of PTA between the two groups with the postoperative internal diameter of the stenosis.The numerical rating scale score was 4.6 ± 1.9 and 2.0 ± 1.6 (P0.001) in UCIA group and non-ultrasound-guided infiltration anesthesia group, respectively. The postoperative internal diameter of stenosis was 3.9 ± 0.6 mm and 4.1 ± 0.7 mm (P = 0.113); the postoperative AAVA flow volume was 627 ± 176 mL/min and 644 ± 145 mL/min (P = 0.600).This study preliminarily showed that UCIA is effective and safe for the analgesia of AAVA PTA.

American Indians (AI) or Alaska Natives, or in combination with another race, comprised 6.8 million individuals in 2010 and the population is expected to exceed 10 million in the current census. Diabetes is more common in AIs than in other races in the United States and is responsible for 69% of new onset end stage renal disease in AI patients. The incidence of obesity is also higher among AIs. As both diabetes and obesity make creating a successful autogenous vascular access more challenging, we reviewed our experience creating arteriovenous fistulas in AI patients.Our vascular access database was reviewed for consecutive new AI patients undergoing creation of a hemodialysis vascular access during a 10-year period. Each patient underwent ultrasound vessel mapping by the operating surgeon in addition to history and physical examination. The goal for initial cannulation was 4-6 weeks after access creation. Minimal AVF flow volume for cannulation was 500 mL/min with an outflow vein diameter of 6 mm.235 consecutive new AI patients were identified. All patients had an autogenous access constructed. The median age was 56 years (range, 15-89 years). Diabetes was present in 85% and 42% were female. Obesity was noted in 27% of the patients and 37% had previous vascular access operations. Primary patency at 12 and 24 months was 62% and 46%, respectively. Cumulative patency at 12 and 24 months was 96% and 94%, respectively. Female gender and previous access operations were associated with lower primary (P = 0.002 and 0.02, respectively) and cumulative patency (P = 0.01 and 0.04, respectively). Obesity was associated with lower cumulative access patency (P = 0.02). Overall, 74% of the access operations used the radial or ulnar artery for AVF inflow. Distal radial artery inflow AVFs were associated with longer patient survival (P = 0.01) and individuals with proximal radial inflow had longer survival when compared to brachial artery AVFs. Previous access operations were associated with shorter patient survival (P = 0.04).Safe and functional arteriovenous fistulas can be created for American Indians despite a higher prevalence of vascular access risk factors such as diabetes and obesity.

To evaluate the outcome of endovascular treatment after surgical treatment for cephalic arch stenosis (CAS) in the brachiocephalic fistula (BCF) and to analyze the factors influencing patency.We conducted a retrospective review of patients undergoing cephalic vein transposition (CVT) or graft interposition (GIP) for CAS from January 1, 2017, to December 31, 2019. A total of 73 patients with restenosis were included in this study. Patients were classified into cephalic transposition (BCF-CVT) (n = 49) and graft interposition (BCF-GIP) (n = 24) groups. We calculated the postintervention primary and secondary patency of endovascular treatment by using the Kaplan-Meier analysis and analyzed variables associated with loss of postintervention patency.Six-month and 12-month postintervention primary patency rates of endovascular treatment for restenosis were 56.7% and 15.6% and secondary patency rates were 89.7% and 72.1%, respectively. In the BCF-CVT group, 6-month and 12-month postintervention primary patency was 56.8% and 17.6% and secondary patency was 93.3% and 79.4%, respectively. In the BCF-GIP group, 6-month and 12-month postintervention primary patency was 56.5% and 8.7% and secondary patency was 85.7% and 56.3%, respectively. There was no significant difference in postintervention primary patency between the two groups (P = .79). However, the BCF-CVT group demonstrated higher postintervention secondary patency (P = .034). The BCF-GIP group had a higher number of stenosis sites (P .01). There was no significant predictor of reduced postintervention primary patency. The only adverse variable of postintervention secondary patency was BCF-GIP (hazard ratio, 3.14; 95% CI, 1.06-9.34; P .05).Endovascular treatment is still the acceptable option for stenosis occurring after surgical treatment for CAS. CVT provides higher postintervention secondary patency than GIP.

Arteriovenous fistula (AVF) aneurysms are a chronic complication which can be disfiguring, painful, and can rupture. Here, we compare the outcomes between three different methods of AVF aneurysm repair.One-way ANOVA, Chi-square, and Fisher Exact analyses were used to compare demographics. Multivariate logistic regression compared outcomes. Kaplan-Meier estimate illustrated long-term fistula patency.There were no differences between demographics in the aneurysmorrhaphy, end-to-end anastomosis, and synthetic graft groups. The odds of patients who received graft repair losing primary patency within one year compared to the aneurysmorrhaphy group was 3.5 (p = 0.025). Graft repair patients were 6.7 times more likely to develop an infection compared to aneurysmorrhaphy (p = 0.014). Synthetic grafts also exhibited accelerated rates of complete access loss compared to autogenous methods (p = 0.034).Graft repair of AVF aneurysms results in higher rates of infection and decreased primary and ultimate patency compared to autogenous repair techniques. Therefore, synthetic grafts should be avoided whenever possible.

To analyze the results of endovascular treatment of venous anastomotic stenosis (VAS) in humero-axillary arteriovenous grafts (HAG), comparing outcomes between patent and thrombosed HAG.A retrospective cohort study was made of endovascular treated patients because of a VAS in a HAG between January 2009 and December 2019. Group A: Thrombosed HAG secondary to a VAS. Group B: Patent HAG with a VAS detected during follow-up. Technical success was defined as residual stenosis after treatment30%, and clinical success as satisfactory immediate dialysis after surgery. After ET a biannual clinical and ultrasound follow-up was performed.Survival analysis was performed for time-to-event data to assess patency.Group A: 55 patients. Group B: 22. There were no significative differences in demographic and anatomical factors between groups. Technical and clinical success were 100% in Group B and 94.5% and 91% respectively in Group A. Primary patency at 1, 6 and 12 months was: Group A: 81.8%, 22.4% and 15.7% respectively. Group B: 100%, 85.9%, 76.4% (p0.001). Secondary patency at 1, 6 and 12 months was: Group A: 85.2%, 45.8% and 31.3% respectively. Group B 100%, 95.3%, 95.2% (p0.001). Use of non-covered stents was associated with an increased risk of occlusion (HR 2.669 95% CI 1.146-6.216, p=0.010).A higher patency of EV performed on a patent HAG is expected. It is therefore advisable to develop surveillance programs that are capable to detect VAS before its occlusion.

Data on the efficacy of non-reversed and reversed great saphenous vein bypass (NRGSV and RGSV) techniques are lacking. The aim of the study was to compare the outcomes of patients undergoing open infrainguinal revascularisation using NRGSV and RGSV from a multi-institutional database.The Vascular Quality Initiative database was queried for patients undergoing infrainguinal bypasses using NRGSV and RGSV for symptomatic occlusive disease from January 2003 to February 2021. The primary outcome measures included primary and secondary patency at discharge and one year. Secondary outcomes were re-interventions at discharge and one year. Cox proportional hazards models were used to evaluate the impact of graft configuration on outcomes of interest.Of 7 123 patients, 4 662 and 2 461 patients underwent RGSV and NRGSV, respectively. At one year, the rates of primary patency (78% vs. 78%; p = .83), secondary patency (90% vs. 89%; p = .26), and re-intervention (16% vs. 16%; p = .95) were similar between the RGSV and NRGSV cohorts, respectively. Subgroup analysis based on outflow bypass target and indication for revascularisation did not show differences in primary and secondary outcomes between the two groups. Multivariable analysis confirmed that RGSV (NRGSV as the reference) configuration was not independently associated with increased risk of primary patency loss (hazard ratio [HR] 1.01; 95% confidence interval [CI] 0.91 - 1.13; p = .80), secondary patency loss (HR 0.94; 95% CI 0.81 - 1.10; p = .44), and re-intervention (HR 1.03; 95% CI 0.91 - 1.16; p = .67) at follow up.The study shows that RGSV and NRGSV grafting techniques have comparable peri-operative and one year primary and secondary patency and re-intervention rates. This effect persisted when stratified by outflow targets and indication for revascularisation. Therefore, optimal selection of vein grafting technique should be guided by the patient's anatomy, vein conduit availability, and surgeon's experience.

Objectives : Spiral saphenous vein grafts (SSVG) or paneled vein grafts (PVG) can be used when the diameter of the autologous great saphenous vein does not match the vessel that needs to be repaired. This study aimed to present early results of complex vascular reconstruction with SSVGs and PVGs in the lower extremities. Methods : From May 2019 through January 2021, six SSVGs and three PVGs were used for vascular reconstruction in nine patients. Patient data were collected retrospectively, including age, gender, cause of vascular pathology, target vessels, concomitant injury, surgical method, additional surgical methods, and hemodynamic status. The Kaplan-Meier method was used to calculate the rate of freedom from reintervention. Results : Among these patients, seven had trauma, one had graft infection, and one had vascular reconstruction after tumor excision. The mean duration of follow-up was 6 ± 6.6 months (range 1–19 months). The rate of freedom from reintervention for any reason was 77.8% at 1 year. Two patients underwent amputation after vascular reconstruction with patent vascular reconstructions. One of the two amputations was performed because of infection, and the other was due to ischemia >24 hours. The success rate of reconstruction was 100%, and the primary patency rate was 100%. The rate of limb salvage was 77.8%. There was no death, bleeding, embolism, skin ulcers, graft-related complication, or aneurysmal dilation during follow-up. Conclusions : SSVG and PVG were associated with low infection rates and satisfactory short-term patency rates. These two grafts may be good choices when there is a diameter mismatch in vascular reconstructions.

The role of ticagrelor with or without aspirin after coronary artery bypass graft surgery remains unclear.To compare the risks of vein graft failure and bleeding associated with ticagrelor dual antiplatelet therapy (DAPT) or ticagrelor monotherapy vs aspirin among patients undergoing coronary artery bypass graft surgery.MEDLINE, Embase, and Cochrane Library databases from inception to June 1, 2022, without language restriction.Randomized clinical trials (RCTs) comparing the effects of ticagrelor DAPT or ticagrelor monotherapy vs aspirin on saphenous vein graft failure.Individual patient data provided by each trial were synthesized into a combined data set for independent analysis. Multilevel logistic regression models were used.The primary analysis assessed the incidence of saphenous vein graft failure per graft (primary outcome) in RCTs comparing ticagrelor DAPT with aspirin. Secondary outcomes were saphenous vein graft failure per patient and Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding events. A supplementary analysis included RCTs comparing ticagrelor monotherapy with aspirin.A total of 4 RCTs were included in the meta-analysis, involving 1316 patients and 1668 saphenous vein grafts. Of the 871 patients in the primary analysis, 435 received ticagrelor DAPT (median age, 67 years [IQR, 60-72 years]; 65 women [14.9%]; 370 men [85.1%]) and 436 received aspirin (median age, 66 years [IQR, 61-73 years]; 63 women [14.5%]; 373 men [85.5%]). Ticagrelor DAPT was associated with a significantly lower incidence of saphenous vein graft failure (11.2%) per graft than was aspirin (20%; difference, -8.7% [95% CI, -13.5% to -3.9%]; OR, 0.51 [95% CI, 0.35 to 0.74]; P .001) and was associated with a significantly lower incidence of saphenous vein graft failure per patient (13.2% vs 23.0%, difference, -9.7% [95% CI, -14.9% to -4.4%]; OR, 0.51 [95% CI, 0.35 to 0.74]; P .001). Ticagrelor DAPT (22.1%) was associated with a significantly higher incidence of BARC type 2, 3, or 5 bleeding events than was aspirin (8.7%; difference, 13.3% [95% CI, 8.6% to 18.0%]; OR, 2.98 [95% CI, 1.99 to 4.47]; P .001), but not BARC type 3 or 5 bleeding events (1.8% vs 1.8%, difference, 0% [95% CI, -1.8% to 1.8%]; OR, 1.00 [95% CI, 0.37 to 2.69]; P = .99). Compared with aspirin, ticagrelor monotherapy was not significantly associated with saphenous vein graft failure (19.3% vs 21.7%, difference, -2.6% [95% CI, -9.1% to 3.9%]; OR, 0.86 [95% CI, 0.58 to 1.27]; P = .44) or BARC type 2, 3, or 5 bleeding events (8.9% vs 7.3%, difference, 1.7% [95% CI, -2.8% to 6.1%]; OR, 1.25 [95% CI, 0.69 to 2.29]; P = .46).Among patients undergoing coronary artery bypass graft surgery, adding ticagrelor to aspirin was associated with a significantly decreased risk of vein graft failure. However, this was accompanied by a significantly increased risk of clinically important bleeding.

Objective: To highlight safety and efficacy of sine wave technique (SWT) in superficializing deep arterio venous fistula (AVF) and managing infiltrations and other complications. Methods: It is a single centre observational study done from Jul 2017 to July 2020. All successive cases of deep AVFs, aneurysm / pseudoaneurysms of AVFs and AVF requiring open venoplasty were managed with SWT. Data was collected prospectively and analyzed. SWT is based on random pattern skin flaps. Using ultrasound, a line is marked on either side of centre line (AVF) at a distance of approximately 1.5 - 2 cm. A sine wave is drawn starting from either of the lines to the other with multiple crests and troughs. The base of flap should be double the height of the flap, that is, about 3-4 cm. Skin is incised and flaps are raised at level of AVF. Excess fat is removed. A sliver of unhealthy skin can be sacrificed if required. Flaps are sutured back to restore sine wave continuity. Results: SWT was used in a total of eleven patients. Median age was 58 years (range 10 - 67 years). Eight were females and three males. One was radio-cephalic and rest were brachio-cephalic AVFs. Eight AVFs were deep with median depth of 10.25mm (range 8-13mm), median body mass index of 25.5 kg/m2 (range 23.9- 26.5kg/m2), median vein diameter of 7 mm (range 6-8 mm), and median flow rate of 1137.5ml/min (range 650- 1380 ml/min). Out of eight, four AVFs presented with infiltration. In other three, SWT was used for exposing AVF to treat underlying pathology (one case each of aneurysm, pseudoaneurysm & stenosis). Ten cases were done under local or regional anaesthesia and one under general anaesthesia. There was no peri-operative mortality or loss of AVF. Transient limb oedema developed in one case. Median time to cannulate was 20 days (range 13 - 28 days). Median follow up was 13 months (range 6 - 31months). Cumulative patency at 18 months was 90% (95% CI 47.3% - 98.53%) and 45 % (95% CI 9.9% - 87.1%) at 24months and at the end of the study. Conclusion: SWT is safe and effective in superficialization of deep / difficult to cannulate AVF as well a good approach to treat complications like infiltration. Post procedure cannulation time is reasonably short.

Mega-fistulae are generalized aneurysmal dilations of a high flow (1500-4000 mL/min) autogenous arteriovenous (AV) access which may result in hemorrhage and/or high-output cardiac failure. Current treatments include ligation, ligation with prosthetic jump graft, and imbrication; however, these may not be suitable for advanced disease, or may result in loss of functioning access, poor cosmesis, or recurrence. We describe our early experience with a technique of complete mega-fistula resection and replacement with an early use prosthetic graft that both maintains existing AV access and eliminates the need for long-term catheter (LTC) placement; including lessons learned.A single-center, retrospective review of medical records was conducted from March 2018-February 2021. Outcomes were technical success, LTC use, time to cannulation, and complications. Mega-fistulae were completely resected from the proximal to distal aneurysmal segment, including all pseudoaneurysms, followed by tunneling a prosthetic graft (Propaten later converted to Acuseal; W.L. Gore Assoc.) with an end-to-end anastomosis to the remaining arterial and venous ends of the previous AV access.We had 100% immediate technical success (n=12). Pre-operative long-term catheters were placed in all eight Propaten patients; one was already placed in an Acuseal patient. Average time to cannulation was six weeks with Propaten and 4.5 days with Acuseal. At 30 days, three Propaten patients developed complications including one instance of skin necrosis, one seroma, and one hematoma. Two Acuseal patients developed complications including one central venous occlusion (CVO) and one graft infection. Of the six patients with long-term follow-up, five continue to use their access, however, two required thrombectomies and central venous angioplasties. One patient required a new contralateral access due to CVO.Complete mega-fistula resection and replacement with Acuseal graft maintains existing AV access and may eliminate the need for long-term catheter placement. Our early experience with this technique is encouraging, but further follow-up is required to determine the durability of this approach.

Aims: The study aimed to review the use of synthetic grafts (SGs) and autologous vein grafts (AVGs) in visceral arterial reconstruction (VAR) in chronic visceral ischaemia. Methods: Systematic review methodology was employed. Results: Six studies were included (218 patients and 281 vessels). Two studies had data about AVG only, 3 had data about SG only and 1 had both AVG and SG data. Three studies reported outcomes for AVG (117 patients and 132 vessels revascularized). One-year primary patency was 87% (95% CI 71%, 97%). Graft thrombosis rate was 6% (95% CI 0%, 16%). Pooled stenosis rate at one-year was 11% (95% CI 1%, 28%). The 30-day (n = 96), one-year (n = 72) and 5-year mortality (n = 30) were 0%, 0% and 12%, respectively. Four studies reported outcomes for SGs (106 patients and 147 vessels). The pooled primary patency at one year was 100% (95% CI 99%, 100%). Pooled primary 5-year patency rate was 88% (95% CI 69%, 100%). There was no graft infection in 2 of the 3 studies. Overall pooled percentage of graft thrombosis and stenosis at one year was 0%. Jimenez et al. (2002) reported one graft thrombosis at 20 months and graft stenosis in 2 patients at 46 and 49 months. Illuminati et al (2017) reported graft thrombosis in 2/24 patients at 22 and 52 months. Thirty days, one-year and 5-year mortality was 1% (95% CI 0%, 6), 7% (95% CI 0%, 20%) and 39% (95% CI 11%), respectively. Conclusion: Patency was better with SG compared with AVG. Mortality was higher in the SG group. Graft dilatation does occur with vein grafts, but in this review no intervention was found necessary. Poorly designed studies, incomplete reporting and absence of morbidity and mortality indices preclude emphatic conclusions.

Background To investigate the long-term outcomes of femoropopliteal bypass surgery in patients with chronic limb-threatening ischemia (CLTI) and TransAtlantic Inter-Society Consensus II (TASC II), type D (TASC D) femoropopliteal disease. Methods A retrospective analysis was performed for all consecutive patients undergoing above-knee (AK) femoropopliteal bypass surgery at an academic vascular centre between January 2007 and March 2019. Patients with claudication (IC) and patients with CLTI were included. Patency rates and freedom from major adverse limb events (MALE) after 5 years were analysed. Results In total, 432 femoropopliteal grafts were performed. Indications for surgery were claudication and CLTI in 232 (53.7%) and 200 (46.3%) patients, respectively. Graft material was autologous vein in 186 patients (43.1%), polytetrafluoroethylene (PTFE) in 128 patients (29.6%), and heparin-bonded expanded polytetrafluoroethylene (HePTFE) in 118 patients (27.3%). At the 5-year follow-up, the primary patency rate was 58.1% and 58.3% in patients with CLTI and claudication, respectively. Secondary patency rates were 74.1% and 68.6%, respectively. Freedom from MALE was 64.5% and 61.9%, respectively. Analyses of graft material in the CLTI group showed that, at 5 years, autologous vein grafts had better long-term patency rates than PTFE and HePTFE grafts. At 5 years, the primary and secondary patency rate for autologous vein grafts were 63.2% (P= 0.324) and 83.2% (P = 0.020), respectively. Freedom from MALE was 72.0% with the use of autologous vein grafts, 47.9% using PTFE and, 52.9% using HePTFE, respectively (P= 0.021). Conclusions Our study shows that femoropopliteal bypass surgery in patients with TASC D lesions is safe and effective in the long term. Autologous vein grafts remain the first choice for patients with CLTI, also for bypasses in AK position. However, prosthetic grafts in AK the position are an acceptable alternative for revascularisation when the saphenous vein is not available.

Background Luminal narrowing, suspected secondary to thrombus, occurs within stent grafts at an unclear incidence after thoracic endovascular aortic repair (TEVAR). The significance of this phenomenon has not been determined, nor have the risk factors for development of intragraft luminal narrowing. Small graft diameter is hypothesized to be a risk factor for the development of ingraft stenosis. Methods A retrospective analysis was performed of a multicenter healthcare system including all patients who underwent TEVAR between July 2011 and July 2019 with at least 1 year of subsequently available surveillance contrast-enhanced computed tomography imaging. Standard demographic, preoperative, intraoperative, and postoperative variables were collected. Measurements were obtained via direct off-line images from computed tomography scans. Patent intragraft diameters were compared with baseline and interval change values were normalized to time to follow-up. The primary outcome measure was annual rate of intragraft luminal narrowing. Results There were 208 patients who met the inclusion criteria (94 women, 114 men) with a median follow-up of 822 days. The mean annual rate of percent intragraft diameter reduction was 10.5 ± 7.7% for women and 7.6 ± 5.6% for men (P = .0026). Multivariate analysis demonstrated female gender (P = .0283), preoperative diagnosis of hypertension (P = .0449), and need for coverage of the left subclavian artery (P = .0328) were all significant predictors of intragraft luminal narrowing. Small aortic diameters were not found to be associated independently with ingraft luminal narrowing nor was the concomitant use of antiplatelet or anticoagulation medications. Significant amounts of ingraft luminal narrowing, defined as a greater than 20% intragraft diameter decrease, were associated with an increased need for any reintervention, including for malperfusion, endoleak, and symptomatic aneurysm (P = .0249). Kaplan-Meier estimates demonstrated a significant gender-associated difference in high rates of intragraft luminal narrowing (P = .00189). Conclusions In this analysis, female gender is shown to be a significant nonmodifiable risk factor for intragraft luminal narrowing after TEVAR. The development of this phenomenon is not benign; as such, these findings were associated with an increased need for reintervention. This finding may be attributable to differences in aortic compliance or gender-associated differences in coagulation pathways and merits further investigation. Surveillance after thoracic stent grafting must account for patient-specific variations in complication risk.

Saphenous vein graft (SVG) is the most commonly used conduits in coronary artery bypass grafting (CABG), but the disadvantage of SVG is its tendency for progressive failure. We hypothesized that therapeutic-dose warfarin (international normalized ratio [INR]1.6) plus aspirin improve SVG patency. This study aimed to evaluate the factors contributing to SVG patency.Since 2010-2020, 199 patients who underwent isolated CABG using SVG were divided into two groups according to their INR values in the first year: group T (INR1.6) and group L (INR1.6).Group T had 162 SVGs (105 patients) and group L had 151 SVGs (94 patients). The 1-, 4-, and 7-year SVG patency rates were higher in group T than in group L (99%, 96%, and 92% vs. 93%, 86%, and 79%, respectively; p = 0.00378). The 1-, 4-, and 7-year freedom from repeat-revascularization was higher in group T than in group L (100%, 100%, and 99% vs. 98%, 95%, and 87%, respectively; p = 0.0264). Multivariate analysis showed that therapeutic-dose warfarin (p = 0.00204) and target vessel diameter (p0.0001) were independent risk factors of SVG occlusion.Therapeutic-dose warfarin (INR1.6) plus aspirin after CABG improved the long-term patency of SVG and decreased repeat-revascularization rate.

OBJECTIVE: Despite a shared degenerative vascular phenotype, Marfan syndrome (MFS), Loeys-Dietz syndrome (LDS), and other genetically distinct connective tissue diseases (CTDs) have unique extravascular pathologies that impact the outcomes of aortic replacement. The aim of our study was to investigate the association of CTD genotype with postoperative outcomes and branch patency following open thoracoabdominal aortic replacement in a large institutional cohort. METHODS: All patients undergoing open branched thoracoabdominal aortic replacement at a single academic center from 2006 to 2020 were included and classified as CTD or non-CTD based on the presence of genotypic documentation. Outcomes were compared using analysis of variance and χ(2) testing for continuous and discrete variables, respectively. Kaplan-Meier curves were utilized to examine patency of graft branches over time. RESULTS: Overall, 172 patients were included, with a mean follow-up of 30.5 ± 34.9 months. CTD was present in 45 patients (26%); specifically, 32 had MFS, five had LDS, and eight had another CTD. Patients with CTDs had more extent II thoracoabdominal aneurysms (40% vs 15%), more reconstructed branches (3.5 vs 1.8), more frequently reconstructed visceral branches (86.7% vs 22.7%), and higher intraoperative blood loss (13.3 vs 6.8 L; all P < .05) compared with non-CTD patients. Patients with MFS were more frequently systemically anticoagulated preoperatively (50% vs 5%) and demonstrated higher rates of postoperative deep vein thrombosis/pulmonary embolism compared with non-CTD patients (9% vs 2%; both P < .05). Five-year renal branch patency was decreased among all patients compared with visceral branches (87.3% vs 95.6%; P = .05), but there were no individual branch patency differences between patients with and without CTDs (P = .086). Overall branch patency at 1 and 5 years was significantly higher in patients with MFS than in non-CTD patients (98.9% vs 89.1% at 5 years); there were no significant patency differences between non-CTD patients and any other CTD subgroup, mostly due to early patency loss. CONCLUSIONS: Open thoracoabdominal reconstruction in patients with CTD is technically challenging and associated with increased transfusion and postoperative thromboembolic events when compared with non-CTD patients. Technical outcomes of the procedure are excellent and are differentially associated with genotype, with patients with MFS experiencing significantly improved branch patency over both non-CTD patients and patients with other CTDs, a finding which has multifactorial drivers.

Antiplatelet therapy prevents saphenous vein graft (SVG) occlusion and improves outcomes after coronary artery bypass graft surgery (CABG). However, the optimal postoperative antiplatelet regimen remains unclear. The goal of the Ticagrelor Antiplatelet Therapy to Reduce Graft Events and Thrombosis (TARGET) trial was to assess whether early postoperative ticagrelor reduces SVG occlusion compared to conventional aspirin therapy.In this multi-center double-blind randomized trial, 250 patients who had CABG with SVG were randomized to receive either aspirin 81 mg twice daily or ticagrelor 90 mg twice daily. The primary outcome was SVG occlusion at 1 year.Altogether, 123 patients were randomized to aspirin and 127 received ticagrelor. One-year graft assessment was performed in 202 patients (80.8%), examining 588 grafts, yielding an overall graft occlusion rate of 10.9%. The primary outcome, SVG occlusion at 1 year, did not significantly differ between the two groups (17.4% vs. 13.2%, aspirin vs. ticagrelor, p = .30). The incidence of vein grafts with any disease (stenosis or occlusion) did not significantly differ between the groups (21.5% vs. 22.3%, aspirin vs. ticagrelor, p = .90), and the number of patients with vein graft disease did not significantly differ between the groups (29.4% vs. 28.0%, aspirin vs. ticagrelor, p = .88). Freedom from major adverse cardiovascular events at 1 year was similar between the groups (p = .60).Compared to conventional aspirin therapy, ticagrelor did not significantly reduce vein graft occlusion 1 year after CABG. Further study will assess the impact of ticagrelor on 2-year graft patency for this cohort.

Vascular access is required for hemodialysis treatment. An effect of activated protein C resistance on access thrombosis rates has not yet been investigated. The aim of this study is to determine whether an activated protein C resistance is correlated with the patency of polytetrafluoroethylene arteriovenous grafts.The primary endpoint was the impact of activated protein C resistance; secondary endpoints were the influence of Factor V Leiden thrombophilia, homocysteine, ß2-glycoprotein antibodies, and other laboratory values on the assisted primary patency.Forty-three grafts in 43 patients were included. The overall mean assisted primary patency was 18.4 months (±3.16 SE). Activated protein C resistance (p = 0.01) and ß2-glycoprotein antibodies (p = 0.018) had a significant influence on the assisted primary patency. The assisted primary patency for patients with low (4) activated protein C resistance was 9.3 months compared to 24.8 of those with a high (≥4) activated protein C resistance. Patients with low (≤2.6) ß2-glycoprotein antibodies presented an assisted primary patency of 31.8 months whereas those with high (2.6) ß2-glycoprotein antibodies showed 9.3 months. In all patients with a pathologic activated protein C resistance, a heterozygous or homozygous Factor V Leiden thrombophilia was detected.This study identified low activated protein C resistance and high ß2-glycoprotein antibodies as risk factors for thrombosis in polytetrafluoroethylene arteriovenous grafts. A prospective study is needed to clarify if oral anticoagulation should be administered to all patients with a pathologic activated protein C resistance blood value and/or factor V Leiden mutation.

Objective Nonfasting serum triglyceride (TG) level is attracting more and more attention as an atherosclerosis-promoting factor. However, no study has investigated the relationships between nonfasting TG levels and carotid restenosis after carotid endarterectomy (CEA) or carotid artery stenting (CAS). This study was conducted to investigate if nonfasting TG levels can be used to assess a risk for carotid restenosis after CEA or CAS. Methods This was a single-center retrospective study. We reviewed 201 consecutive primary carotid artery revascularization procedures (39 CEAs and 162 CASs), which were performed from 2008 to 2018 for 179 patients (163 men and 16 women) with atherosclerotic carotid stenosis, and were followed up for at least 1 year. Clinical variables including nonfasting lipid profiles and findings of magnetic resonance plaque imaging were compared between groups with and without postprocedural carotid restenosis (≥50% stenosis on ultrasonography). Results During a mean follow-up period of 1413 days, 24 of 201 carotid stenosis procedures (11.9%) suffered restenosis after successful revascularization procedures. Multivariate analyses demonstrated that nonfasting TG level was the only independent risk factor of postprocedural restenosis. The receiver operating characteristic curve analyses revealed that a cutoff value of nonfasting TG to discriminate postprocedural carotid restenosis was 127.5 mg/dL, which was much lower than the upper limit of normal. Conclusions This study showed that nonfasting TG level may be a useful marker to predict carotid restenosis after CEA or CAS, and could be a new therapeutic target to prevent carotid restenosis after revascularization procedures.