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To investigate the occurrence of limb graft occlusion (LGO) and intra-prosthetic thrombus (IPT) formation in Zenith Alpha and Endurant II stent graft limbs. A single centre retrospective study was conducted on patients treated with the Zenith Alpha and Endurant II stent grafts between 2017 and 2019. All post-operative computed tomography angiography images were re-investigated for thrombus formation. Demographic, aneurysm, and stent graft data were collected and compared. LGO was defined as complete occlusion or significant stenosis (≥ 50% lumen diameter reduction). Logistic regression on pro-thrombotic risk factors was conducted. Freedom from LGO and overall limb IPT were compared using Kaplan–Meier analyses. Seventy-eight Zenith Alpha and eighty-six Endurant II patients were studied. The median follow up was 33 (IQR 25, 44) months for Zenith Alpha patients and 36 (IQR 22, 46) months for Endurant II patients (p =.53). LGO was seen in 15% (n = 12) of Zenith Alpha patients and 5% (n = 4) of Endurant II patients (p =.032), and freedom from LGO was significantly higher among Endurant II patients (p =.024). The Zenith Alpha stent graft was an independent risk factor for LGO (OR 3.9, 95% CI 1.1 – 13.4; p =.032). Among Zenith Alpha patients, limb flare compression within the main body gate was over represented in LGO patients (p =.011). There was no difference in freedom from overall limb IPT between the stent graft systems. For Endurant II limbs, IPT was significantly less common in the integrated ipsilateral limbs (without ETLW/ETEW stent graft limbs) (p =.044). Main endograft body IPT was correlated with overall limb IPT (p =.035). LGO was significantly more common among Zenith Alpha than Endurant II patients. Zenith Alpha limbs was an independent risk factor for LGO. There was no difference between stent grafts in overall limb IPT formation. [ABSTRACT FROM AUTHOR]

Introduction: Simultaneous pancreas‐kidney transplantation (SPK) is an option for patients with type 1 diabetes (T1D) and kidney failure but can be associated with a high complication rate. Here we describe our 10‐year experience since the launch of the SPK program. Methods: This retrospective study included consecutive patients with T1D receiving SPK from March 14, 2010 to March 14, 2020 at Helsinki University Hospital. Portocaval anastomosis (i.e., systemic venous drainage) and enteric exocrine drainage were used. A specific team was trained for both pancreas retrieval and transplantation, postoperative care was standardized to include somatostatin analogues, antimicrobial treatment, and preoperatively initiated chemothrombopropylaxis. During program maturation donor criteria were expanded and logistical processes improved to minimize cold ischemia time. Clinical data were collected from a nationwide transplantation registry and patient records. Results: A total of 166 SPKs were performed (median 2 per year in the first 3 years, 17.5 per year for the following 4 years, and 23 per year for the past 3 years). Seven patients (4.1%) died with a functioning graft with a median 43 months follow‐up. One‐year pancreas graft survival was 97.0%, 3‐year pancreas graft survival was 96.1% and 5‐year was 96.1%. Mean HbA1c was 36 mmol/mol (SD 5.57) and creatinine was 107 μmol/L (SD 34.69) at 1‐year after transplantation. All kidney grafts were functioning at the end of follow‐up. Complications required re‐laparotomy in 39 (23%) patients, mostly due to a pancreas graft related problem (N = 28). No pancreas or kidney graft failure from thrombosis occurred. Conclusion: A planned, step‐wise development of an SPK program offers a safe and effective treatment for patients with T1D and kidney failure. [ABSTRACT FROM AUTHOR]

Heparin-induced thrombocytopenia (HIT) after cardiac surgery is a clinical condition associated with increased incidence of thromboembolic events and mortality. HIT without thrombocytopenia is a rare clinical entity poorly reported in the literature, especially after cardiac surgery. In this case report, we present the case of a post aortocoronary bypass grafting patient who presented with HIT in the absence of thrombocytopenia. [ABSTRACT FROM AUTHOR]

Introduction Vascular complications are severe complications of pediatric kidney transplantation (KT). We aimed to investigate whether a complex bench surgery (BS) affects the outcomes. Methods All pediatric KT performed at the University Hospital of Padua from 2015 to 2019 were analyzed, comparing those in which a standard BS was possible to those that necessitated a complex BS. The rates of vascular complications, patients' outcome, and graft survival were compared in the two groups. Results Eighty KTs were performed in 78 patients with a median age of 11 years (interquartile range [IQR] 4.3–14) and a median body weight of 24 kg (IQR 13–37). Thirty-nine donor kidneys (49%) needed a complex BS due to anomalies of renal veins in 12 (31%) and renal arteries in 16 (41%). The remaining 11 grafts (28%) underwent an elongation of the vein. There was no difference in the rate of primary graft non function (p = 0.97), delayed graft function (p = 0.72), and overall survival (p = 0.27). The rates of vascular complications, bleedings, and venous graft thrombosis were similar (p = 0.51, p = 0.59, p = 0.78, respectively). No arterial thrombosis or stenosis was reported. Conclusion Complex BS did not compromise survival of the graft and did not put the allograft at risk of vascular complications, such as bleedings or thrombosis. [ABSTRACT FROM AUTHOR]

Coronary artery bypass grafting (CABG) is the most frequently performed cardiac surgery worldwide. The reported incidence of graft failure ranges between 10% and 50%, depending upon the type of conduit used. Thrombosis is the predominant mechanism of early graft failure, occurring in both arterial and vein grafts. Significant advances have been made in the field of antithrombotic therapy since the introduction of aspirin, which is regarded as the cornerstone of antithrombotic therapy for prevention of graft thrombosis. Convincing evidence now exists that dual antiplatelet therapy (DAPT), consisting of aspirin and a potent oral P2Y12 inhibitor, effectively reduces the incidence of graft failure. However, this is achieved at the expense of an increase in clinically important bleeding, underscoring the importance of balancing thrombotic risk and bleeding risk when considering antithrombotic therapy after CABG. In contrast, anticoagulant therapy has proved ineffective at reducing the occurrence of graft thrombosis, pointing to platelet aggregation as the key driver of graft thrombosis. We provide a comprehensive review of current practice for prevention of graft thrombosis and discuss potential future concepts for antithrombotic therapy including P2Y12 inhibitor monotherapy and short-term DAPT.

Background Peripheral artery disease is endemic in our globally aging population, with >200 million affected worldwide. Graft/stent thrombosis after revascularization is common and frequently results in amputation, major adverse cardiovascular events, and cardiovascular mortality. Optimizing medications to decrease thrombosis is of paramount importance; however, limited guidance exists on how to use and monitor antithrombotic therapy in this heterogeneous population. Thromboelastography with platelet mapping (TEG‐PM) provides comprehensive coagulation metrics and may be integral to the next stage of patient‐centered thrombophrophylaxis. This prospective study aimed to determine if TEG‐PM could predict subacute graft/stent thrombosis following lower extremity revascularization, and if objective cut point values could be established to identify those high‐risk patients. Methods and Results We conducted a single‐center prospective observational study of patients undergoing lower extremity revascularization. Patients were followed up for the composite end point postoperative graft/stent thrombosis at 1 year. TEG‐PM analysis of the time point before thrombosis in the event group was compared with the last postoperative visit in the nonevent group. Cox proportional hazards analysis examined the association of TEG‐PM metrics to thrombosis. Cut point analysis explored the predictive capacity of TEG‐PM metrics for those at high risk. A total of 162 patients were analyzed, of whom 30 (18.5%) experienced graft/stent thrombosis. Patients with thrombosis had significantly greater platelet aggregation (79.7±15.7 versus 58.5±26.4) and lower platelet inhibition (20.7±15.6% versus 41.1±26.6%) (all P70.8% platelet aggregation and/or 70.8% platelet aggregation and

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

Summary: Small‐donor kidneys (≤20 kg donor weight, SDK) are preferably transplanted en bloc in adults. Concerns about thrombotic complications or hyperfiltration hinder their use in children, particularly as single grafts. Low centre experience and donor‐to‐recipient size are rated critical regarding outcomes. We evaluated SDK transplantation (SDTx) in paediatric recipients at a specialized transplant centre. Between 2008 and 2018, SDTx was performed in 40 children (mean age 5.4 ± 1.4 years, single grafts n = 38, donor weight ≤10 kg: n = 10). Perioperative complications were rare (n = 3), mainly thromboses despite immediate heparinization and resulted in graft loss in one patient. Overall, early and long‐term GFR were excellent (76 ± 21 and 100 ± 11 ml/min/1.73 m2, first month and year 5, respectively). Three patients presented with delayed graft function. Graft volume increased significantly (69 ± 38 vs. 111 ± 33 ml within 5 years; P < 0.0001). Patients showed catch‐up growth to normal range (SDS for height −2.06 ± 1.6 to −1.60 ± 1.5). Stratification by recipient age and donor weight revealed superior results in young recipients (≤3 years) and ≤10 kg donors, respectively. Outcome of single SDK grafts was excellent. Gain of GFR and graft volume was even higher in patients with very small donor or recipient size, regardless of a reduced donor‐to‐recipient weight ratio. Therefore, SDTx should be considered favouring small paediatric recipients. [ABSTRACT FROM AUTHOR]

Limb graft occlusion (LGO) is a serious complication after endovascular aneurysm repair (EVAR) and while device development enables treatment of increasingly complex aortic anatomy, little is known about how endograft type affects the risk of occlusion. This observational study aimed to explore the incidence of LGO after EVAR for three major endograft systems. All patients with standard EVAR as the primary intervention for infrarenal abdominal aortic aneurysm (AAA), between January 2012 and December 2018, at five Swedish vascular surgery centres, were included in this multicentre retrospective cohort study. LGO was defined as a total limb occlusion regardless of symptoms, or a treated significant stenosis. A nested case control (NCC) design with incidence density sampling of 1:3 was used for analysis of potential per-operative and morphological risk factors. Conditional logistic regression was used to estimate multivariable odds ratios (OR) with 95% confidence intervals (CI) A total of 924 patients were included. The majority were male (84%), the mean age was 76 years (± 7.5 SD), and median AAA diameter was 59 mm (IQR 55, 67). Patients were treated with Zenith Alpha (n = 315, ZISL limbs), Excluder (n = 152, PLC/PXC limbs), and Endurant (n = 457, ETLW/ ETEW limbs). During median follow up of 37 months (IQR 21, 62), 55 occlusions occurred (5.9%); 39 with Zenith Alpha (12.4%), one with Excluder (0.7%), and 15 with Endurant (3.3%). In the NCC analysis, the Zenith Alpha device (OR 5.31, 95% CI 1.97 – 14.3), external iliac artery (EIA) landing (OR 5.91, 95% CI 1.30 – 26.7), and EIA diameter < 10 mm (OR 4.99, 95% CI 1.46 – 16.9) were associated with an increased risk of LGO. Endograft device type is an independent risk factor for LGO after EVAR. Specifically, the Zenith Alpha demonstrated an increased risk of LGO compared with the Endurant and Excluder devices. In addition, a narrow EIA and landing zone in EIA are also risk factors for LGO. [ABSTRACT FROM AUTHOR]

Perioperative graft failure is an important cause of myocardial ischemia following coronary artery bypass grafting. Early diagnosis of graft thrombosis is of paramount importance for limiting the sequelae of postoperative myocardial infarction (PMI). We present a case of PMI following off-pump coronary artery bypass grafting resulting from saphenous venous graft thrombosis.

Allograft renal vein thrombosis is a rare vascular catastrophe which occurs usually in the first few weeks following renal transplantation. The occurrence of allograft rupture due to venous thrombosis compounds the situation and often it leads to allograft nephrectomy. We present a case of renal allograft rupture resulting from allograft renal vein thrombosis which was successfully salvaged. We describe the clinical presentation and Doppler imaging findings of allograft vein thrombosis and surgical therapy undertaken in the patient.

Background: Antiphospholipid syndrome (APS) is characterized by thrombosis and/or pregnancy morbidity with presence of anti-phospholipid antibodies (aPL). The APS classification criteria only consider the aPL of IgG/IgM isotype, however testing of aPL of IgA isotype is recommended when APS is suspected and consensus aPL are negative. IgA anti-βeta-2 glycoprotein-I (B2GP1) has been clearly related with occurrence of thrombotic events. Antibodies anti-B2GP1 of IgG/M isotypes recognize an epitope in Domain 1 (R39-G43), the epitopes that recognize IgA anti-B2GP1 antibodies are not well-identified.Aim: To determine the zones of B2GP1 recognized by antibodies of IgA isotype from patients with APS symptomatology and positive for IgA anti-B2GP1.Methods: IgA antibodies to Domain-1(D1) and Domain-4/5(D4/5) of B2GP1 (ELISA) and epitope mapping on oligopeptide arrays of B2GP1 were evaluated in sera from a group of 93 patients with at least one thrombotic and with isolated positivity for IgA anti-B2GP1 antibodies (negative for other aPL).Results: A total of 47 patients (50.5%) were positive for anti-D4/5 and 23(25%) were positive for anti-D1. When peptide arrays were analyzed, three zones of B2GP1 reactivity were identified for more than 50% of patients. The center of these zones corresponds to amino acids 140(D3), 204(D4), and 264(D5). The peptides recognized on D3 and D4 contain amino acid sequences sharing high homology with proteins of microorganism that were previously related with a possible APS infectious etiology. In the three-dimensional structure of B2GP1, the three peptides, as the R39-G43 epitope, are located on the right side of the molecule (L-shape). The left side (J-shape) does not bind the antibodies.Conclusions: Patients with thrombotic APS clinical-criteria, and isolated IgA anti-B2GP1 positivity appear to preferentially bind, not to the D1 or D4/5 domains of B2GP1, but rather to three sites in D3, D4, and D5. The sites on D3 and D4 were previously described as the target identified by human monoclonal antibodies derived from patients that were capable of inducing APS in animal models. The localization of these epitopes opens a new route to explore to increase understanding of the patholophysiology of the APS and to propose new alternatives and therapeutic targets.

Arteriovenous graft for hemodialysis vascular access is a widely used technique with many advantages. However, it has crucial complications with graft thrombosis and infection. We recently experienced an unusual case of arteriovenous graft complication involving graft thrombosis related to fistula formation between the graft and the natural vein with infection. We diagnosed this condition using Doppler ultrasound and computed tomography angiography. Successful surgical treatment including partial graft excision and creation of a secondary arteriovenous fistula using an inadvertently dilated cephalic vein was performed. The dialysis unit staff should keep this condition in mind and try to prevent this complication.

BackgroundGraft thrombosis is a devastating complication after renal transplantation. We recently described the association of anti-beta-2-glycoprotein-I (IgA-ab2GP1) antibodies with early graft loss mainly caused by thrombosis in a monocenter study.MethodsMulticenter prospective observational cohort study.Setting and participantsSeven hundred forty patients from five hospitals of the Spanish Forum Renal Group transplanted from 2000 to 2002 were prospectively followed-up for 10 years.OutcomesEarly graft loss and graft loss by thrombosis.MeasurementsThe presence of IgA anti-B2GP1 antibodies in pretransplant serum was examined using the same methodology in all the patients.ResultsAt transplantation, 288 patients were positive for IgA-B2GP1 (39%, Group-1) and the remaining were negative (Group-2). Graft loss at 6 months was higher in Group-1 (12.5 vs. 4.2% p

Background: Graft thrombosis is a devastating complication after renal transplantation. We recently described the association of anti-beta-2-glycoprotein-I (IgA-ab2GP1) antibodies with early graft loss mainly caused by thrombosis in a monocenter study. Methods: Multicenter prospective observational cohort study. Setting and participants: Seven hundred forty patients from five hospitals of the Spanish Forum Renal Group transplanted from 2000 to 2002 were prospectively followed-up for 10 years. Outcomes: Early graft loss and graft loss by thrombosis. Measurements: The presence of IgA anti-B2GP1 antibodies in pretransplant serum was examined using the same methodology in all the patients. Results: At transplantation, 288 patients were positive for IgA-B2GP1 (39%, Group-1) and the remaining were negative (Group-2). Graft loss at 6 months was higher in Group-1 (12.5 vs. 4.2% p < 0.001), vessel thrombosis being the most frequent cause of early graft loss, especially in Group-1 (6.9 vs. 0.4% p < 0.001). IgA-aB2GP1 was the most important independent risk factor for graft thrombosis (hazard ratio: 13.83; 95% CI: 3.17-60.27, p < 0.001). Furthermore, the, presence of IgA-aB2GP1 was associated with early graft loss and delayed graft function. At 10 years, survival figures were also lower in Group-1: graft survival was lower compared with Group-2 (60.4 vs. 76.8%, p < 0.001). Mortality was significantly higher in Group-1 (19.8 vs. 12.2%, p = 0.005). Limitations: Patients were obtained during a 3-year period (1 January 2000-31 December 2002) and kidneys were only transplanted from brain-dead donors. Nowadays, the patients are older and the percentage of sensitized and retransplants is high. Conclusion: In a prospective observational multicenter study, we were able to corroborate that pretransplant presence of IgA-aB2GP1 was the main risk factor for graft thrombosis and early graft loss. Therefore, a prospective study is needed to evaluate the efficacy and safety of prophylactic anticoagulation to avoid this severe complication. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the incidence, management methods and follow-up results of arterial embolism during percutaneous thrombectomy of hemodialysis grafts.Materials and Methods: After Institutional Review Board approval, the radiologic database of our department for percutaneous thrombectomy procedure in hemodialysis access was retrospectively reviewed. Between 1998 and June 2014, 2975 percutaneous thrombectomy procedures using thromboaspiration technique were performed in 1524 patients with thrombosed hemodialysis grafts. After thrombectomy, angioplasty was performed for significant stenoses. The incidence of arterial embolism was analyzed according to the location/shape of the arteriovenous graft. Percutaneous management methods of arterial embolism and long-term follow-up results by fistulography were also evaluated.Results: Arterial embolism was documented by angiography in 117 cases (3.9%). Of these, three were symptomatic and subsided after embolectomy. The incidence was significantly correlated with the location/shape of the graft (p = 0.001). Arterial emboli were retrieved using occlusion balloon/Fogarty balloon (n = 58), guiding catheter-assisted aspiration (n = 36), sheath-assisted aspiration (n = 2) and back-bleeding technique (n = 3). Others were observed without intervention (n = 17) or surgically removed (n = 1). Arterial emboli were completely retrieved in 86 cases and partially retrieved in 13 cases. Ulnar artery rupture occurred in one case due to over-inflation of the occlusion balloon. Follow-up fistulography performed in 60 patients among whom 99 percutaneous embolectomies were done revealed arterial stenosis/occlusion in 7 and residual emboli in one patient. In observed patients without intervention, follow-up documented complete resolution of the emboli without arterial stenosis in 9 patients.Conclusion: Radiologically perceivable arterial embolism is uncommon during percutaneous thrombectomy of thrombosed dialysis grafts. The majority of the emboli can be retrieved by percutaneous techniques, but may induce arterial damage in some patients. Clinical observation can be another option for patients without ischemic symptoms. [ABSTRACT FROM AUTHOR]

Allograft renal vein thrombosis is a rare vascular catastrophe which occurs usually in the first few weeks following renal transplantation. The occurrence of allograft rupture due to venous thrombosis compounds the situation and often it leads to allograft nephrectomy. We present a case of renal allograft rupture resulting from allograft renal vein thrombosis which was successfully salvaged. We describe the clinical presentation and Doppler imaging findings of allograft vein thrombosis and surgical therapy undertaken in the patient. [ABSTRACT FROM AUTHOR]

Coronary artery bypass grafting (CABG) is the most frequently performed cardiac surgery worldwide. The reported incidence of graft failure ranges between 10% and 50%, depending upon the type of conduit used. Thrombosis is the predominant mechanism of early graft failure, occurring in both arterial and vein grafts. Significant advances have been made in the field of antithrombotic therapy since the introduction of aspirin, which is regarded as the cornerstone of antithrombotic therapy for prevention of graft thrombosis. Convincing evidence now exists that dual antiplatelet therapy (DAPT), consisting of aspirin and a potent oral P2Y 12 inhibitor, effectively reduces the incidence of graft failure. However, this is achieved at the expense of an increase in clinically important bleeding, underscoring the importance of balancing thrombotic risk and bleeding risk when considering antithrombotic therapy after CABG. In contrast, anticoagulant therapy has proved ineffective at reducing the occurrence of graft thrombosis, pointing to platelet aggregation as the key driver of graft thrombosis. We provide a comprehensive review of current practice for prevention of graft thrombosis and discuss potential future concepts for antithrombotic therapy including P2Y 12 inhibitor monotherapy and short-term DAPT., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Harik, Perezgrovas-Olaria, Soletti, Dimagli, Alzghari, An, Cancelli, Gaudino and Sandner.)

Thoracic endovascular aortic repair (TEVAR) explantation remains a challenge due to endovascular graft ingrowth into the aortic wall with time. Surgical access into the aortic arch can be difficult either via sternotomy or thoracotomy, and proximal barbs become engaged firmly into the aortic wall. Explantation often requires extensive thoracic aortic resection, sometimes from the distal aortic arch to the abdominal aorta, followed by reconstruction, risking injury to surrounding neurovascular structures and even death. In cases of blunt thoracic aortic injury, the original injury is often healed, and failed TEVAR could theoretically be removed when thrombotic complications occur. We present a novel technique to facilitate TEVAR recapture with limited distal thoracic aorta replacement.

Arteriovenous graft for hemodialysis vascular access is a widely used technique with many advantages. However, it has crucial complications with graft thrombosis and infection. We recently experienced an unusual case of arteriovenous graft complication involving graft thrombosis related to fistula formation between the graft and the natural vein with infection. We diagnosed this condition using Doppler ultrasound and computed tomography angiography. Successful surgical treatment including partial graft excision and creation of a secondary arteriovenous fistula using an inadvertently dilated cephalic vein was performed. The dialysis unit staff should keep this condition in mind and try to prevent this complication. [ABSTRACT FROM AUTHOR]

Background Peripheral artery disease is endemic in our globally aging population, with >200 million affected worldwide. Graft/stent thrombosis after revascularization is common and frequently results in amputation, major adverse cardiovascular events, and cardiovascular mortality. Optimizing medications to decrease thrombosis is of paramount importance; however, limited guidance exists on how to use and monitor antithrombotic therapy in this heterogeneous population. Thromboelastography with platelet mapping (TEG-PM) provides comprehensive coagulation metrics and may be integral to the next stage of patient-centered thrombophrophylaxis. This prospective study aimed to determine if TEG-PM could predict subacute graft/stent thrombosis following lower extremity revascularization, and if objective cut point values could be established to identify those high-risk patients. Methods and Results We conducted a single-center prospective observational study of patients undergoing lower extremity revascularization. Patients were followed up for the composite end point postoperative graft/stent thrombosis at 1 year. TEG-PM analysis of the time point before thrombosis in the event group was compared with the last postoperative visit in the nonevent group. Cox proportional hazards analysis examined the association of TEG-PM metrics to thrombosis. Cut point analysis explored the predictive capacity of TEG-PM metrics for those at high risk. A total of 162 patients were analyzed, of whom 30 (18.5%) experienced graft/stent thrombosis. Patients with thrombosis had significantly greater platelet aggregation (79.7±15.7 versus 58.5±26.4) and lower platelet inhibition (20.7±15.6% versus 41.1±26.6%) (all P <0.01). Cox proportional hazards analysis revealed that for every 1% increase in platelet aggregation, the hazard of experiencing an event during the study period increased by 5% (hazard ratio, 1.05 [95% CI, 1.02-1.07]; P <0.01). An optimal cut point of >70.8% platelet aggregation and/or <29.2% platelet inhibition identifies those at high risk of thrombosis with 87% sensitivity and 70% to 71% specificity. Conclusions Among patients undergoing lower extremity revascularization, increased platelet reactivity was predictive of subacute postoperative graft/stent thrombosis. On the basis of the cut points of >70.8% platelet aggregation and <29.2% platelet inhibition, consideration of an alternative or augmented antithrombotic regimen for high-risk patients may decrease the risk of postoperative thrombotic events.

Purpose: To compare the midterm results in patients treated with the Endurant stent-graft according to device-specific instructions for use (IFU) vs. those treated in an off-label (OL) situation. Methods: Between November 2007 and March 2010, 177 patients (161 men; mean age 73.7 years) with abdominal aortic aneurysm were treated with the Endurant stent-graft at 2 European centers. Patients operated on according to the IFU (121, 68.4%) were compared with those who underwent endovascular aneurysm repair in OL circumstances (56, 31.6%) to evaluate estimated 5-year survival, freedom from any device-related reinterventions, freedom from graft thrombosis, and freedom from type I endoleak. Univariate and multivariate analyses were performed to identify independent predictors of poor outcomes in the OL group. Results: Mean follow-up was 31.2 months (range 1-65). At 5 years, there were no differences in terms of survival (67.9% IFU vs. 54.1% OL, p=0.3), freedom from any device-related reintervention (91.2% IFU vs. 92.4% OL, p=0.8), or freedom from graft thrombosis (97.5% IFU vs. 92.7% OL, p=0.3). Estimated 5-year freedom from type I endoleak was significantly better in the IFU group than in OL (100% vs. 96.2%, respectively; p=0.03). In the OL group, multivariate analysis showed that female sex and coronary artery disease were independent predictors of poor survival. Conclusion: Off-label use of the Endurant stent-graft was associated with a greater but acceptable risk of type I endoleak. Otherwise, there was no difference between the IFU and off-label groups as regards survival, graft thrombosis, or reintervention. [ABSTRACT FROM AUTHOR]