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Background and Objectives: Lower extremity arterial disease is one of the most prevalent manifestations of atherosclerosis. The results from numerous studies regarding the best revascularization method of an occluded superficial femoral artery have been conflicting. The aim of this study was to compare the patency of transvenous endovascular with open femoropopliteal bypass, both with vein and prosthetic grafts. To our knowledge, a direct patency comparison between transvenous endovascular and open femoropopliteal bypass has not been published. This could help elucidate which method is preferable and in which cases. Materials and Methods: Patients with complex TASC-C and D SFA lesions were offered endovascular transvenous or open bypass. A total of 384 consecutive patients with PAD requiring surgical treatment were evaluated for inclusion in this study. Three-year follow-up data were collected for 52 endovascular procedures, 80 prosthetic grafts, and 44 venous bypass surgeries. Bypass patency was investigated by Duplex US every 6 months. Kaplan–Meier plots were used to analyze primary, primary-assisted, and secondary patency for endovascular transvenous, autovenous, and prosthetic bypasses. Results: Primary, primary-assisted, and secondary patency in venous group at 3 years was 70.5%, 77.3%, and 77.3%, respectively. In the endovascular transvenous group, primary, primary-assisted, and secondary patency at 3 years was 46.2%, 69.2%, and 76.9%, respectively. The lowest patency rates at 3 years were noted in the prosthetic graft group with 22.5% primary, 26.6% primary-assisted, and 28.2% secondary patency. Conclusions: The saphenous vein is the best graft to perform in above-the-knee femoropopliteal bypass. Transvenous endovascular bypass is a viable option with comparable primary-assisted and secondary patency. Primary patency is substantially lower for endovascular transvenous compared to venous bypass. Patients treated with endovascular transvenous bypass will require a significant number of secondary procedures to provide optimal patency. Prosthetic grafts should only be used if no other option for bypass is available. [ABSTRACT FROM AUTHOR]

Vascular graft/endograft infection (VGEI) is a constant in cardiovascular surgery with published rates between 1 and 5%. Every graft type and anatomical location is a potential target for infectious complications. These patients are sick patients with high frailty burden. Management of VGEI entails a multidisciplinary and multimodality approach. Here we review some aspects of the problem of VGEI including prevention, diagnosis, and surgical therapy with focus on recent developments in the field. [ABSTRACT FROM AUTHOR]

Background and Objectives: Lower extremity arterial disease is one of the most prevalent manifestations of atherosclerosis. The results from numerous studies regarding the best revascularization method of an occluded superficial femoral artery have been conflicting. The aim of this study was to compare the patency of transvenous endovascular with open femoropopliteal bypass, both with vein and prosthetic grafts. To our knowledge, a direct patency comparison between transvenous endovascular and open femoropopliteal bypass has not been published. This could help elucidate which method is preferable and in which cases. Materials and Methods: Patients with complex TASC-C and D SFA lesions were offered endovascular transvenous or open bypass. A total of 384 consecutive patients with PAD requiring surgical treatment were evaluated for inclusion in this study. Three-year follow-up data were collected for 52 endovascular procedures, 80 prosthetic grafts, and 44 venous bypass surgeries. Bypass patency was investigated by Duplex US every 6 months. Kaplan–Meier plots were used to analyze primary, primary-assisted, and secondary patency for endovascular transvenous, autovenous, and prosthetic bypasses. Results: Primary, primary-assisted, and secondary patency in venous group at 3 years was 70.5%, 77.3%, and 77.3%, respectively. In the endovascular transvenous group, primary, primary-assisted, and secondary patency at 3 years was 46.2%, 69.2%, and 76.9%, respectively. The lowest patency rates at 3 years were noted in the prosthetic graft group with 22.5% primary, 26.6% primary-assisted, and 28.2% secondary patency. Conclusions: The saphenous vein is the best graft to perform in above-the-knee femoropopliteal bypass. Transvenous endovascular bypass is a viable option with comparable primary-assisted and secondary patency. Primary patency is substantially lower for endovascular transvenous compared to venous bypass. Patients treated with endovascular transvenous bypass will require a significant number of secondary procedures to provide optimal patency. Prosthetic grafts should only be used if no other option for bypass is available.

We encountered two fusiform abdominal aortic aneurysm cases with delayed AFX endograft (Endologix Inc) migration >4 years after placement. These cases showed shortening and slight angulation of the main body in the anteroposterior direction. We speculate that the potential mechanism relates to the AFX portion that is easily shortened at the bifurcation of its stent structure. This portion might contribute to delayed migration after slight angulation of the main body. Preoperative three-dimensional computed tomography should be performed from the anteroposterior and lateral views. Although the AFX is useful for narrow bifurcations, one should consider the patient's anatomy before deciding to use an AFX endograft.

Aim: Complex atherosclerotic femoro-popliteal lesions have traditionally been treated with bypass surgery. A prosthetic graft is used to save the vein graft for more distal revascularisations or when a vein graft is unavailable. The endovascular approach has gained popularity and is offered as a first-line strategy for complex lesions. This study aimed to evaluate whether endovascular procedures can be used as a first-line treatment strategy for complex native femoro-popliteal lesions over open surgery with prosthetic bypass in patients with peripheral arterial disease (PAD). Methods: This single-centre retrospective observational study was conducted between 2013 and 2021; it included patients with symptomatic PAD who required limb revascularisation at the femoro-popliteal segment and who had complex lesions. The primary endpoints analysed were technical success, primary patency, freedom from clinically driven target lesion revascularisation (cdTLR), freedom from major adverse limb and cardiovascular events (MALE and MACE, respectively), freedom from limb loss, and survival. The secondary endpoints were length of in-hospital stay, and duration and costs of the procedure. Results: We identified 185 limbs among 174 suitable candidates for comparison, wherein 105 were treated with an endovascular procedure and 80 with a femoro-popliteal prosthetic bypass. Most patients in both groups presented with chronic limb-threatening ischaemia, and >90% of them had an American Society of Anesthesiologists (ASA) physical status classification of >3. The endovascular group had more octogenarians (p = 0.02) and patients with coronary disease (p = 0.004). The median follow-up was 30 months. The technical failure rate for endovascular procedures was 4.7%, versus 0% in the open group (p = 0.047). Freedom from MACE was similar in both groups. The endovascular group showed superior primary patency (p < 0.0001), cdTLR (p < 0.0001), MALE (p < 0.0001), and freedom from limb loss (p = 0.0018) at 24 and 48 months. Further analysis performed for the open above-the-knee sub-group showed that the aforementioned endpoints were similar between the groups at 12 months and were better in the endovascular group at 24 and 48 months. Procedural time and in-hospital stay were longer in the open group than in the endovascular group (p < 0.0001 and p < 0.001, respectively). The procedural cost in the endovascular group was 10-fold lower than that in the prosthetic bypass group. Conclusions: Endovascular procedures are safe for treating complex femoro-popliteal lesions in patients at a high risk for surgery and show better outcomes at 24 months than prosthetic bypasses do. The latter may be considered as an alternative should endovascular treatment fail. [ABSTRACT FROM AUTHOR]

Background: Behçet's disease (BD) is a rare form of systemic vasculitis that affects small to large vessels. It is characterized by mucocutaneous, pulmonary, cardiovascular, gastrointestinal, and neurological manifestations. Large vessel involvement may occur in a third of cases. Veins are usually more affected than arteries. Furthermore aneurysms are the most frequent arterial complication. Case presentation: A 41-year-old man presented with multiple arterial aneurysms. He had previous medical history of a right popliteal aneurysm treated with a reversed femoro-popliteal venous bypass, long-term steroids and immunosuppressive treatment. On admission, diagnostic computed tomography angiography revealed multiple aneurysms, including an 87 mm aneurysm of the femoro-popliteal bypass and an abdominal aortic and left common iliac artery aneurysm. He received an intensification of medical treatment with methylprednisolone and infliximab intravenous infusion. Aorto iliac artery aneurysms were treated by infrarenal bifurcated stent graft implantation. The aneurysm of the venous femoro-popliteal bypass was treated by explantation and prosthetic repair. One month later, he presented with acute right limb ischemia related to occlusion of the right limb of the stent graft despite anticoagulation which was treated by mechanical thrombectomy. Conclusions: Vascular BD can worsen the vascular outcome after surgery. Except in an urgent context, BD must be controlled before surgery. This case report illustrates the importance of combined medical and surgical management, with first BD activity control with corticosteroids and immunosuppressive treatment, then surgical or endovascular treatment. [ABSTRACT FROM AUTHOR]

Long-term follow-up data comparing surgical and endovascular revascularization of femoropopliteal lesions is rarely reported. This study presents 4-year results of revascularization for long femoropopliteal lesions (Trans-Atlantic Inter-Society Consensus Types C and D) with vein bypass (VBP), polytetrafluorethylene bypass (PTFE), and endovascular intervention with a nitinol stent (NS). Data from a randomized-controlled trial on VBP and NS was compared with a retrospective patient cohort using PTFE with the same inclusion and exclusion criteria. Primary, primary assisted, and secondary patency, as well as changes in Rutherford categories and limb salvage rates, are reported. Between 2016 and 2020, 332 femoropopliteal lesions underwent revascularization. The lesion lengths and basic patient characteristics were similar between the groups. 49% of the patients presented with chronic limb threatening ischemia at the time of revascularization. During the four-year follow-up, primary patency was comparable for all three groups. Primary assisted and secondary patency were significantly higher after VBP, while PTFE and NS had similar results. Clinical improvement was also significantly superior after VBP. After four years of follow-up, patency rates as well as the clinical outcome clearly favor VBP. If no vein is available, NS is as effective as PTFE bypass with regard to patency and clinical outcome. [ABSTRACT FROM AUTHOR]

Common femoral artery (CFA) aneurysms are rare with an unknown exact incidence and often found in elderly males with chronic diseases. Early recommendations are to repair aneurysms with a maximum diameter of ≥2.5cm. We present the case of a 37-year-old male with a right CFA aneurysm. Open surgical repair (OSR) consisting of aneurysmectomy and reconstruction of the femoral artery with a bifurcated prosthetic graft was applied. Our study details this case and thoroughly reviews on the treatment of femoral artery aneurysms in the literature. OSR and vascular reconstruction with interposition prosthetic graft were durable and associated with favorable outcomes.

Surgical bypass is the gold standard treatment in patients affected by chronic limb-threatening ischemia in advanced GLASS stages, according to the Global Vascular Guidelines. For patients in whom an autologous graft is not available, a prosthesis could be used with the adjunct of a distal arteriovenous fistula interposition. The aim of this study was to examine the long-term results of below-the-knee surgical revascularization using a prosthesis with the distal adjunct mentioned above. From 2010 to 2020, we performed 159 lower limb below-the-knee surgical revascularizations using a prosthesis with the creation of an arteriovenous fistula interposition on the distal anastomosis. The GLASS stage was 3 in 100% of patients. The primary patency rates were as follows: 86.7% at 1 year, 57.2% at 3 years, and 12.6% at 5 years. The graft thrombosis rates were 17.4% at 1 year, 42.1% at 3 years, and 64.5% at 5 years. The amputation-free survival rates were 79% at 1 year, 76% at 3 years, and 64% at 5 years. PTFE prosthetic bypass for below-the-knee arteries using an arteriovenous fistula interposition is a good solution in patients without an autologous conduit. This technique offers reasonable graft patency and limb salvage rates. [ABSTRACT FROM AUTHOR]

In recent years, endovascular therapy (EVT) has come to play an important role in the revascularization of the femoropopliteal artery region; however, the number of cases that cannot be treated with EVT is increasing, and the importance of bypass surgery has been reaffirmed. We will provide an overview of the revascularization of the femoropopliteal artery region in accordance with the JCS/JSVS 2022 Guideline on the Management of Peripheral Arterial Disease. (This is a translation of Jpn J Vasc Surg 2024; 33: 57-59)., (@ 2024 The Editorial Committee of Annals of Vascular Diseases.)

Objectives: To present early and midterm results of our patients treated using gracilis muscle flap for prosthetic vascular graft (PVG) infections located the femoral region. Materials and Methods: Eight patients admitted to our clinic between January 2012 and August 2016 and treated using gracilis muscle flap owing to PVG infection in the femoral region were included in the current study. Contents of hospital files of the patients with PVG infection were thoroughly evaluated and recorded. Additionally, routine biochemical tests, Doppler ultrasonography, computed tomography; angiography wound site and blood culture results pertaining to the patients were also evaluated in detail. Results: In the present study, we treated 8 patients (5 males and 3 females) using gracilis muscle flap. Their average age was 58±8.9 (39-67) years. All the patients showed graft infections spreading to the subcutaneous tissues (Szilagyi grade III). While the prosthetic grafts used in 6 patients were Polytetrafluoroethylene (PTFE), they were Dacron in 2 patients. Moreover, 6 infections occurred in the early period while 2 infections occurred in the late period. The pathogens causing graft infections were identified to be staphylococcus aureus in 3 patients, staphylococcus epidermidis in 1 patient and polymicrobial in 4 patients. Furthermore, while graft occlusion was noted in one of the patients, a 2 cm opening was noticed distal to the skin incision in another patient. There was no loss of limb and mortality in any of the patients we presented here and they were fully recovered. Conclusion: The present results indicate that gracilis muscle fiber reconstruction in PVG infections is an effective and feasible alternative in order to covering the area exposed to infection and rescuing prosthetic graft material. [ABSTRACT FROM AUTHOR]

Surgical bypass is the gold standard treatment in patients affected by chronic limb-threatening ischemia in advanced GLASS stages, according to the Global Vascular Guidelines. For patients in whom an autologous graft is not available, a prosthesis could be used with the adjunct of a distal arteriovenous fistula interposition. The aim of this study was to examine the long-term results of below-the-knee surgical revascularization using a prosthesis with the distal adjunct mentioned above. From 2010 to 2020, we performed 159 lower limb below-the-knee surgical revascularizations using a prosthesis with the creation of an arteriovenous fistula interposition on the distal anastomosis. The GLASS stage was 3 in 100% of patients. The primary patency rates were as follows: 86.7% at 1 year, 57.2% at 3 years, and 12.6% at 5 years. The graft thrombosis rates were 17.4% at 1 year, 42.1% at 3 years, and 64.5% at 5 years. The amputation-free survival rates were 79% at 1 year, 76% at 3 years, and 64% at 5 years. PTFE prosthetic bypass for below-the-knee arteries using an arteriovenous fistula interposition is a good solution in patients without an autologous conduit. This technique offers reasonable graft patency and limb salvage rates.

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Among patients with ascending thoracic aortic aneurysms, prosthetic graft replacement yields major benefits but risk for recurrent aortic events persists for which mechanism is poorly understood. This pilot study employed cardiac magnetic resonance to test the impact of proximal prosthetic grafts on downstream aortic flow and vascular biomechanics. METHODS Cardiac magnetic resonance imaging was prospectively performed in patients with thoracic aortic aneurysms undergoing surgical (Dacron) prosthetic graft implantation. Imaging included time resolved (4-dimensional) phase velocity encoded cardiac magnetic resonance for flow quantification and cine-cardiac magnetic resonance for aortic wall distensibility/strain. RESULTS Twenty-nine patients with thoracic aortic aneurysms undergoing proximal aortic graft replacement were studied; cardiac magnetic resonance was performed pre- [12 (4, 21) days] and postoperatively [6.4 (6.2, 7.2) months]. Postoperatively, flow velocity and wall shear stress increased in the arch and descending aorta (P  < 0.05); increases were greatest in hereditary aneurysm patients. Global circumferential strain correlated with wall shear stress (r  = 0.60–0.72, P  < 0.001); strain increased postoperatively in the native descending and thoraco-abdominal aorta (P  < 0.001). Graft-induced changes in biomechanical properties of the distal native ascending aorta were associated with post-surgical changes in descending aortic wall shear stress, as evidenced by correlations (r = −0.39–0.52; P  ≤ 0.05) between graft-induced reduction of ascending aortic distensibility and increased distal native aortic wall shear stress following grafting. CONCLUSIONS Prosthetic graft replacement of the ascending aorta increases downstream aortic wall shear stress and strain. Postoperative increments in descending aortic wall shear stress correlate with reduced ascending aortic distensibility, suggesting that grafts provide a nidus for high energy flow and adverse distal aortic remodelling. [ABSTRACT FROM AUTHOR]

BackgroundDue to an increasing life expectancy, more and more patients experience the failure of peripheral arterial revascularization. This study aims to investigate patients treated for the failure of infra-inguinal bypass grafts, and to investigate the interaction of different bypass materials [great saphenous vein (GSV) and polytetrafluoroethylene (PTFE)] and the further outcome.MethodsRetrospective single-center analysis of consecutive patients treated for acute or chronic occlusion of infra-inguinal bypasses at a university hospital was conducted. Hospitalizations from 1st January 2010 through 31st December 2019 were included. Perioperative parameters from the index operation including graft material (prosthetic vs. autologous) were assessed. After bypass occlusion, the grade of ischemia, as well as the distal landing zone of the redo bypass compared with the primary bypass was investigated.ResultsIn this study, 158 (65% men and 35% women with a m mean age of 70.5 years) eligible patients were included (57% vein and 42% prosthetic bypass grafts). After graft occlusion, 47% of the patients presented with symptoms of acute limb-threatening ischemia, 53% with symptoms of chronic leg ischemia. The rate of acute limb-threatening ischemia was significantly higher when prosthetic graft material was used during the index operation (p =0.016). Additionally, in case of reoperation, the landing zone of the redo bypass was significantly more distally located after occlusion of prosthetic bypass graft (p = 0.014)ConclusionOcclusions of prosthetic bypass grafts were associated with significantly higher rates of acute symptoms compared with vein grafts. Additionally, a shift to a more distal landing zone was recognized after the failure of a prosthetic bypass graft during the redo bypass operation.

Background : Homologous vein allografts are adequate for reconstruction of the middle hepatic vein (MHV) in living-donor liver transplantation (LDLT). However, supply is a matter of concern. To replace homologous vein allografts, polytetrafluoroethylene (PTFE) grafts were used. This study aimed to assess the long-term patency rates and complications of PTFE grafts used for MHV reconstruction of LDLT in a high-volume liver transplantation center. Methods : We analyzed the patency rates of PTFE-interposed MHV in 100 LDLT recipients and reviewed complications including PTFE graft migration. Results : The mean age was 53.5±5.4 years and male to female ratio was 73:27. Primary diagnoses were hepatitis B virus infection (n=71) and other (n=28). Mean model for endstage liver disease score was 16.2±8.3. V5 reconstruction was performed as either single anastomosis (n=85) or double anastomoses (n=14). No V5 reconstruction was required in one patient. V8 reconstruction was performed as single anastomosis, double anastomoses, and no reconstruction in 75, 0, and 25 patients, respectively. During a mean follow-up of 6 years, three recipients required early MHV stenting within 2 weeks. After 3 months, there were no episodes of congestion-associated infarct, regardless of MHV patency. Patency rates of PTFE-interposed MHV were 54.0%, 37.0%, and 37.0% at 1, 3, and 5 years, respectively. Unwanted PTFE graft migration occurred in two recipients, and the actual incidence was 2% at 5 years. Conclusions: PTFE grafts combined with small-artery patches demonstrated acceptably high short- and long-term patency rates. Since the risk of unwanted migration of PTFE graft is not negligibly low, lifelong surveillance is necessary to detect unexpected rare complications.

A 71-year-old man who received a total arch replacement with a knitted Dacron® graft presented aneurysmal sac re-expansion due to leakage at the distal anastomotic site of the graft. He did not tolerate the stress of general anesthesia due to severe pulmonary function impairment. Therefore, thoracic endovascular aortic repair (TEVAR) in zone 3 was performed under epidural anesthesia. Contrast-enhanced computed tomography (CT) revealed another leakage into the aneurysmal sac in zone 1 after performing TEVAR. Because open surgical repair and debranching TEVAR were contraindicated, transcatheter arterial embolization was performed with careful consideration of his comorbidities. Follow-up contrast-enhanced CT performed 2 weeks after embolization indicated no opacification of the aneurysmal sac, and noncontrast-enhanced CT a year after embolization showed no dilatation of the aneurysmal sac. [ABSTRACT FROM AUTHOR]

The improvement of dialysis therapy and clinical support has increased the life expectancy of patients with end stage renal disease (ESRD) over the last years. However, in Brazil, the renal transplant rate cannot follow this growth. This fact, in association with the unavailability of adequate healthcare services in the country, substantially enlarges the use of dual lumen catheters and, consequently, access-related complications. The result is a high rate of patients with access failure, which brings a challenge: how to maintain dialysis in this group? This case report describes a non-conventional surgical approach to create a definite access using abdominal vessels, in an end stage vascular access patient., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Successful hemodialysis (HD) treatment depends on well-functioning arteriovenous access. Thrombosis and stenosis are the main causes of access failure. The current report describes the successful establishment of an arteriovenous graft for HD using a previously placed stent graft in an HD patient who developed multiple episodes of access stenosis and thrombosis., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study evaluated the effect of diabetes on outcomes of autogenous fistulas and prosthetic grafts for hemodialysis access in a large population-based cohort of patients. A retrospective cohort study was conducted of all patients who initiated hemodialysis in the United States Renal Database System (2007-2014). The χ 2 test, Student t -test, Kaplan-Meier analysis, log-rank test, and multivariable logistic and Cox regression analyses were employed to evaluate maturation, interventions, patency, infection, and mortality. The study of 381,622 patients comprised 303,307 (79.5%) autogenous fistulas and 78,315 (20.5%) prosthetic grafts placed in 231,134 (60.6%) diabetic patients and 150,488 (39.4%) nondiabetic patients. There was decrease in maturation for diabetics compared to nondiabetics who received autogenous fistulas (adjusted hazard ratio [aHR], 0.86; 95% confidence interval [CI], 0.83-0.88; P <.001) and prosthetic grafts (aHR, 0.88; 95% CI, 0.83-0.93; P <.001). Comparing diabetics vs nondiabetics, primary patency at 5 years was 19.4% vs 23.5% (P <.001) for autogenous fistulas and 9.1% vs 11.2% (P <.001) for prosthetic grafts. Primary assisted patency at 5 years was 35.2% vs 38.7% (P <.001) for autogenous fistulas and 17.2% vs 19.2% (P =.015) for prosthetic grafts. Secondary patency at 5 years was 44.8% vs 48.6% (P <.001) for autogenous fistulas and 34.1% vs 36.8% (P =.002) for prosthetic grafts. There was 5% decrease in primary patency (aHR, 0.95; 95% CI, 0.94-0.96; P <.001) for diabetics compared to nondiabetics who received autogenous fistulas. There was no difference in primary assisted and secondary patency for autogenous fistulas as well as primary, primary assisted, and secondary patency for prosthetic grafts in comparing diabetic to nondiabetic patients. There was also no significant difference in severe prosthetic graft infection between the groups (aHR, 0.99; 95% CI, 0.92-1.08; P =.90). There was a 19% increase in patient mortality for diabetic relative to nondiabetic autogenous fistula recipients (aHR, 1.19; 95% CI, 1.17-1.20; P <.001) and 12% increase for prosthetic graft recipients (aHR, 1.12; 95% CI, 1.10-1.15; P <.001). In this population-based cohort of hemodialysis patients, diabetes mellitus was associated with a decrease in patient survival, access maturation, and primary fistula patency. In contrast, there was no association between diabetes and prosthetic graft patency and severe prosthetic graft infection warranting excision. [ABSTRACT FROM AUTHOR]

Objective: Inguinal vascular graft infections are high-risk events that cannot be controlled medically but require surgical intervention. This study reviewed the long-term clinical outcomes of obturator bypass using a ringed polytetrafluoroethylene graft for inguinal graft infection.Methods: A total of eight consecutive patients who underwent obturator bypass using a ringed polytetrafluoroethylene graft for inguinal prosthetic graft infection at a single medical center between January 2006 and October 2017 were retrospectively analyzed. The demographics, clinical characteristics, surgical procedure, and clinical outcomes were evaluated.Results: There was no perioperative death; however, there were three operative complications. On the 1st and 9th postoperative day, two patients underwent hematoma evacuation in the pelvic cavity, and the other patient underwent suture reinforcement for partial dehiscence of the distal anastomosis on the 49th postoperative day. The median length of hospital stay was 14.5 (range, 7-29) days. Only one graft occlusion was observed at postoperative month 40; however, there were no ischemic symptoms. There were no limb amputations and postoperative deaths during the long-term follow-up period. There were no infections of the previous residual and obturator bypass grafts and inguinal infection during the follow-up period of 49 (range, 7-154) months.Conclusion: Obturator bypass for inguinal graft infection is feasible and durable with excellent long-term outcomes. However, perioperative bleeding should be taken into consideration. [ABSTRACT FROM AUTHOR]

Bypass graft preservation with wound sterilization using serial antibiotic bead exchange has been described in patients presenting with deep wound infections after extremity bypass. The long-term benefits of this approach remain poorly understood. We examined whether graft preservation and wound sterilization with antibiotic beads affect amputation rates and patient survival. Patients who underwent operations for aortoiliac or infrainguinal aneurysmal or occlusive arterial disease were retrospectively analyzed. The Infection group included those with patent vascular grafts who developed Szilagyi class II or III deep wound infections within 90 days of index reconstruction and had no evidence of anastomotic or arterial bleeding. All patients in the infection group were managed with graft preservation using serial antibiotic bead exchange every 3 to 5 days until wound cultures became negative. This group was compared with a contemporary group of controls who underwent similar interventions but did not develop wound infections postoperatively. The primary outcome was amputation-free survival, defined as survival without major amputation. Secondary outcomes included major amputations and the occurrence of anastomotic pseudoaneurysms necessitating repair. Inverse propensity score weighting was used for risk adjustment between the groups. Over an 8-year period, we treated 701 patients (infection, 68; controls, 633). Compared with controls, patients in the infection group had a higher body mass index (mean, 28.5 vs 26.3, P =.002) and more prosthetic conduits placed during the index reconstruction. Amputation-free survival for the infection vs the control group was 78 vs 76% at 2 years, 61 vs 66% at 4 years, and 51 vs 57% at 6 years postoperatively (log-rank test, P =.516). Freedom from major amputation for the infection vs the control group was 82 vs 86% at 2 years, 80 vs 82% at 4 years, and 80 vs 76% at 6 years postoperatively (log-rank test, P =.568). In the risk-adjusted model, the presence of treated infection did not affect amputation-free survival (hazard ratio, 0.82; P =.440) or major amputation (hazard ratio, 1.02; P =.949). Anastomotic pseudoaneurysms occurred only in the Infection group (4.4%; P =.001), and were treated with interposition grafts without complications. Bypass graft preservation with wound sterilization using serial antibiotic bead exchange is associated with excellent limb salvage and survival rates, similar to those of noninfected wounds. With the use of this preservation strategy, close follow-up for timely detection of anastomotic pseudoaneurysms is recommended. [ABSTRACT FROM AUTHOR]

Purpose: To describe a multi-center preliminary experience of treating prosthetic above knee femoropopliteal (AKFP) bypass occlusion by placing a Viabahn stent graft inside the occluded prosthetic bypass graft.Materials and Methods: Retrospective analysis of consecutive 14 patients (mean age 73.2 ± 10.2, 78.6% male) receiving Viabahn stent graft inside the occluded prosthetic bypass graft for the treatment of prosthetic AKFP bypass occlusion in the collaborating hospitals from November 2016 to June 2019 was performed.Results: Technical success was achieved in all patients. Mean lesion length was 34.0 ± 3.5 cm, concomitant thrombectomy or thrombus aspiration was performed in 11 patients (78.6%), and average of 1.57 ± 0.65 Viabahn stent grafts were used. Mean ankle-brachial index improved from 0.24 ± 0.23 to 0.98 ± 0.14 after the treatment. All patients had preoperative ischemic symptoms with 9 patients (64.3%) having Rutherford class > 4 symptoms; however, all preoperative symptoms resolved after the treatment. During the mean follow-up of 450.9 ± 234.7 days, there were two target lesion revascularizations, leading to a primary patency rate of 92.9% and a secondary patency of 100.0% at 1 year.Conclusion: Placing a Viabahn stent graft inside the occluded prosthetic bypass graft for the treatment of prosthetic AKFP bypass occlusion appears to be effective from our preliminary experience. Even though sample size is limited in our study, it may be considered as a potential treatment option before surgical reintervention. [ABSTRACT FROM AUTHOR]

This study introduces a novel technique for supra-inguinal arterial reconstructions with cryopreserved femoral vein and caval allografts with a low re-infection rate and an acceptable graft re-intervention rate on early mid term analysis. Patients treated from February 2012 to March 2018 with cryopreserved venous allograft reconstructions owing to infection in the supra-inguinal area were reviewed retrospectively. The primary end points were re-infection and the treatment related mortality rate. Secondary end points were 30 and 90 day and overall mortality and graft re-intervention rate. Of the 23 patients treated with cryopreserved venous allografts for infection in aorto-iliac area, 21 (91%) patients underwent reconstruction with cryopreserved femoral veins and two (9%) with vena cava. Indications for treatment were aortic graft infections (n = 12 [52%]), mycotic aneurysms (n = 5 [22%]), femorofemoral prosthetic infections (n = 3 [13%]), anastomotic pseudo-aneurysms (n = 2 [9%]), and aortic thrombosis with intestinal spillage (n = 1 [4%]). In hospital and 90 day mortality were 9% (n = 2); overall treatment related mortality during the median follow up of 15 months was 13% (n = 3). During the follow up, two allografts were re-operated on owing to anastomotic dilatation and one because of re-infection, resulting in a re-intervention rate of 13% (n = 3). None of the grafts was lost and there were no amputations. At the end of follow up 17 patients (74%) were alive. Kaplan–Meier estimation for survival was 76% (95% confidence interval [CI] 57%–95%) at one year and 70% (95% CI 49%–91%) at two years. Cryopreserved venous allografts appear to be an infection resistant and reasonably safe reconstruction material in the aorto-iliac axis based upon the early mid term analysis from a single centre experience. Further research is needed to compare their performance with other biological reconstruction material. [ABSTRACT FROM AUTHOR]

Resection of the inferior vena cava (IVC) for malignancy is a technically demanding procedure. We present a series of six cases of resection of the IVC for retroperitoneal sarcomas, four of which were primary caval tumors. We outline the technical difficulties faced in these complex procedures and discuss the oncological outcomes of these rare tumors. We performed a retrospective review of six patients operated for retroperitoneal masses involving the inferior vena cava between April 2015 and July 2016 at our tertiary care institute. Six patients underwent resection of the IVC, three of which required a multivisceral resection. An artificial prosthesis was used to reconstruct the IVC in three patients, whereas two patients underwent primary repair of the vein wall. One patient did not require any reconstruction. Margins were microscopically positive in two out of six patients. All patients received radiotherapy, either in the neo-adjuvant or adjuvant setting. Two patients developed local recurrences with a median follow-up of 24.5 months. Resection of the IVC for extirpation of retroperitoneal sarcomas is a technically complex and difficult procedure. The availability of a multidisciplinary team of surgeons and state-of-the-art intensive care support is essential for good outcomes. [ABSTRACT FROM AUTHOR]