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Background and Aims In chronic ischaemic heart failure, revascularisation strategies control symptoms but are less effective in improving left ventricular ejection fraction (LVEF). The aim of this trial is to investigate the safety of cardiac shockwave therapy (SWT) as a novel treatment option and its efficacy in increasing cardiac function by inducing angiogenesis and regeneration in hibernating myocardium. Methods In this single-blind, parallel-group, sham-controlled trial (cardiac shockwave therapy for ischemic heart failure, CAST-HF; NCT03859466) patients with LVEF ≤40% requiring surgical revascularisation were enrolled. Patients were randomly assigned to undergo direct cardiac SWT or sham treatment in addition to coronary bypass surgery. The primary efficacy endpoint was the improvement in LVEF measured by cardiac magnetic resonance imaging from baseline to 360 days. Results Overall, 63 patients were randomized, out of which 30 patients of the SWT group and 28 patients of the Sham group attained 1-year follow-up of the primary endpoint. Greater improvement in LVEF was observed in the SWT group (Δ from baseline to 360 days: SWT 11.3%, SD 8.8; Sham 6.3%, SD 7.4, P =.0146). Secondary endpoints included the 6-minute walking test, where patients randomized in the SWT group showed a greater Δ from baseline to 360 days (127.5 m, SD 110.6) than patients in the Sham group (43.6 m, SD 172.1) (P =.028) and Minnesota Living with Heart Failure Questionnaire score on day 360, which was 11.0 points (SD 19.1) for the SWT group and 17.3 points (SD 15.1) for the Sham group (P =.15). Two patients in the treatment group died for non-device-related reasons. Conclusions In conclusion, the CAST-HF trial indicates that direct cardiac SWT, in addition to coronary bypass surgery improves LVEF and physical capacity in patients with ischaemic heart failure. [ABSTRACT FROM AUTHOR]

Aim: The aim of our study is to determine the amputation rates in patients with acute limb ischemia (ALI) who were monitored for one year and to identify the factors influencing these rates, as well as to examine the effects of popliteal artery aneurysm (PAA) on acute limb ischemia. Material and Methods: Between January 2022 and January 2023, a retrospective analysis was conducted on 103 patients who presented to our clinic with ALI. Among patients, 59.2% (n=61) were not amputated and classified as Group-1. Group-2 comprised 40.8% of the patients (n=42) all of whom required amputation in the follow-up period. Cases of ALI attributable to atrial fibrillation and trauma were excluded from the study. Both groups were compared in terms of amputation rates in the follow-up period and demographic characteristics. All patients were Rutherford Stage IIa and IIb. Unsalvageable Rutherford Stage3 patients were also excluded. All patients who underwent amputation had exclusively undergone embolectomy; no amputations were observed in patients with PAA (p=0.01). Results: The average age of the patients was 70.01±12.56 years (min 31-max 89). Seventy-five patients were male (72.8%), while twenty-eight patients were female (27.2%). The etiology of ALI was identified as thromboembolic events secondary to atherosclerotic peripheral artery disease (APAD) in 92 patients (89.3%), and as PAA in 11 patients (10.7%). Sixty-six (64.7%) patients underwent solely embolectomy, nine (8.7%) patients received combined embolectomy with thrombolytic therapy and twenty-eight patients (27.4%) patients underwent surgical revascularization. In the first year follow-up, 42 (41.2%) patients had undergone amputation. All patients who underwent amputation had exclusively undergone embolectomy; no amputations were observed in patients with PAA (p=0.01). Conclusion: Blinded embolectomy may be the first line surgical treatment for ALI but it has higher amputation rates in 1-year follow-up. While PAA is considered one of the rare causes of ALI, it should be kept in mind as one of the etiological factors in patients presenting with ALI. With appropriate treatment, amputation rates are significantly lower in patients with PAA. [ABSTRACT FROM AUTHOR]

Moyamoya disease (MMD) is a chronic, occlusive cerebrovasculopathy typified by progressive steno-occlusive disease of the intracranial internal carotid arteries (ICAs) and their proximal branches. Moyamoya syndrome (MMS) categorizes patients with characteristic MMD plus associated conditions. As such, the most usual presentations are those that occur with cerebral ischemia, specifically transient ischemic attack, acute ischemic stroke, and seizures. Hemorrhagic stroke, headaches, and migraines can also occur secondary to the compensatory growth of fragile collateral vessels propagated by chronic cerebral ischemia. While the pathophysiology of MMD is unknown, there remain numerous clinical associations including radiation therapy to the brain, inherited genetic syndromes, hematologic disorders, and autoimmune conditions. We describe the case of a 31-year-old woman who presented with recurrent ischemic cerebral infarcts secondary to rapidly progressive, bilateral MMD despite undergoing early unilateral surgical revascularization with direct arterial bypass. She had numerous metabolic conditions and rapidly decompensated, ultimately passing away despite intensive and aggressive interventions. The present case highlights that progression of moyamoya disease to bilateral involvement can occur very rapidly, within a mere 6 weeks, a phenomenon which has not been documented in the literature to our knowledge.

IntroductionAt our institution, we perform off-pump coronary artery bypass (OPCAB) as a standard procedure. Moreover, patients with favorable coronary anatomy and condition are selected for minimally invasive cardiac surgery (MICS)-OPCAB. We retrospectively compared early outcomes, focusing on safety, between MICS-OPCAB and conventional off-pump techniques for multivessel coronary artery bypass grafting (CABG).MethodsFrom August 2017 to September 2022, 1,220 patients underwent multivessel coronary artery grafting at our institution. They were divided into the MICS-OPCAB group (MICS group = 163 patients) and the conventional OPCAB group (MS group = 1057 patients). Propensity score matching (1 : 1 ratio) was applied to the MICS-OPCAB and MS groups (149 patients per group) based on 23 preoperative clinical characteristics.ResultsAfter matching, there were no significant differences in preoperative characteristics between the groups. The MICS group had a lower total graft number (2.3 ± 0.6 vs. 2.9 ± 0.8, p

Background: Numerous studies have examined the therapeutic effects of mitral valve repair during revascularization on moderate ischemic mitral regurgitation (IMR), as well as the incremental benefit of subvalvular repair alongside an annuloplasty ring. However, the impact of depressed left ventricular (LV) function on the surgical outcome of patients with moderate IMR has been rarely investigated. The aims of this single-center, retrospective, observational study were firstly to evaluate short- and medium-term outcomes in this patient group after undergoing mitral valve repair during revascularization, and secondly to assess the impact of depressed LV function on surgical outcomes. Methods: A total of 272 eligible patients who had moderate IMR and underwent concomitant mitral valve repair and revascularization from January 2010 to December 2017 were included in the study. These patients were categorized into different groups based on their ejection fraction (EF) levels: an EF <40% group (n = 90) and an EF ≥40% group (n = 182). The median time course of follow-up was 42 months and the shortest follow-up time was 30 months. This study compared in-hospital outcomes (major postoperative morbidity and surgical mortality) as well as midterm outcomes (moderate or more mitral regurgitation, all-cause mortality, and reoperation) of the two groups before and after propensity score (PS) matching (1:1). Results: No significant difference was observed in surgical mortality between groups (8.9% vs. 3.3%, p = 0.076). More patients in the EF <40% group developed low cardiac output (8.9% vs. 2.7%, p = 0.034) and prolonged ventilation (13.3% vs. 5.5%, p = 0.026) compared to the EF ≥40% group. Propensity score (PS) matching successfully established 82 patient pairs in a 1:1 ratio. No significance was discovered between the matched cohorts in terms of major postoperative morbidity and surgical mortality, except for prolonged ventilation. Conditional mixed-effects logistic regression analysis revealed that EF <40% had an independent impact on prolonged ventilation (odds ratio (OR) = 2.814, 95% CI 1.321– 6.151, p = 0.031), but was not an independent risk factor for surgical mortality (OR = 2.967, 95% CI 0.712–7.245, p = 0.138) or other major postoperative morbidity. Furthermore, the two groups showed similar cumulative survival before (log-rank p = 0.278) and after (stratified log-rank p = 0.832) PS matching. Cox regression analysis suggested that EF <40% was not related to mortality compared with EF ≥40% (PS-adjusted hazard ratio (HR) = 1.151, 95% CI 0.763–1.952, p = 0.281). Conclusions: Patients with moderate IMR and EF <40% shared similar midterm outcomes and surgical mortality to patients with moderate IMR and EF ≥40%, but received prolonged ventilation more often. Depressed LV function may be not associated with surgical or midterm mortality. [ABSTRACT FROM AUTHOR]

Objective: The aim was to analyze the risk of progression to chronic limb-threatening ischemia (CLTI), amputation and subsequent interventions after revascularization versus noninvasive therapy in patients with intermittent claudication (IC). Background: Conflicting evidence exists regarding adverse limb outcomes after each treatment strategy. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. MEDLINE, Web of Science, and Google Scholar were searched aided by a health sciences librarian through August 16, 2022. Randomized control trials (RCTs) comparing invasive (endovascular or surgical revascularization) and noninvasive treatment (exercise and/or medical treatment) were included. PROSPERO registration was completed (CRD42022352831). Results: A total of 9 RCTs comprising 1477 patients (invasive, 765 patients; noninvasive, 712 patients) were eligible. During a mean of 3.6-year follow-up, progression to CLTI after invasive [5 (2–8) per 1000 person-years] and noninvasive treatment [6 (3–10) per 1000 person-years] were not statistically different [rate ratio (RR): 0.77; 95% CI, 0.35–1.69; P =0.51, I 2=0%]. Incidence of amputation (RR: 1.69; 95% CI, 0.54–5.26; P =0.36, I 2=0%) and all-cause mortality (hazard ratio: 1.26; 95% CI, 0.91–1.74; P =0.16, I 2=0%) also did not differ between the groups. However, the invasive treatment group underwent significantly more revascularizations (RR: 4.15; 95% CI, 2.80–6.16; P <0.00001, I 2=83%). The results were not changed by fixed effect or random-effects models, nor by sensitivity analysis. Conclusions: Although there is equivalent risk of progression to CLTI, major amputation and all-cause mortality compared with noninvasive treatment, invasive treatment for patients with IC led to significantly more revascularization procedures and should be used selectively in patients with major lifestyle limitation. Guideline recommendation of noninvasive treatment for first-line IC therapy is supported. Long-term outcomes after invasive versus non-invasive treatment for patients with IC. CLTI=chronic limb threatening ischemia; NS=not significant; RR=rate ratio * per 1000 person-year [ABSTRACT FROM AUTHOR]

High mortality from cardiovascular diseases (CVD) requires improved approaches to the treatment of this socially significant pathology. Wide implementation of surgical myocardial revascularization makes it possible to improve significantly both life quality and expectancy in patients with coronary heart disease. The aim of this work was to analyze the literature on the impact of preoperative, operative and postoperative factors on the long-term prognosis after coronary artery bypass grafting (CABG). The review refers to both recent and earlier informative works. The target groups for this article are therapists, cardiologists, rehabilitologists, who work with patients in the short and long term after CABG. Data of Russian and foreign literature show that the long-term prognosis after CABG is largely determined by preoperative factors, in particular – age, set of cardiovascular risk factors (RF) and comorbidity, specifically – severity of coronary and systemic atherosclerosis, incident cardiovascular complications, structural and functional state of the heart. In the aggregate these factors reflect the cumulative effect and further potential of actual cardiovascular RFs, affect longterm risk of adverse events, and determine the therapeutic targets of secondary prevention. Priority of arterial conduits and completeness of revascularization are the main operative factors that determine the course of the long-term period after CABG. Among the postoperative factors, the efficiency of secondary CVD prevention is of paramount importance, in particular – achievement of target RF levels, compensation of cardiac and extracardiac pathology, adherence to the long-term medical therapy, known to improve outcomes based on specific comorbidity. Efficiency of secondary CVD prevention largely depends on patient's health attitudes, the key influence on which beyond attending physician can be provided by participation in rehabilitation programs, teaching patients the meaning and essentials of lifestyle modification and cardiovascular RFs’ control.

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]

During the acute phase of myocardial infarction, the culprit artery must be revascularized quickly with angioplasty. Surgery then completes the procedure in a second stage. If emergency surgery is performed, the resulting death rate is high; 15–20% of patients are operated on within the first 48 h after the myocardial infarction. The timing of surgical revascularization and the patient's preoperative state influence the mortality rate. We aimed to evaluate the impact of surgery delay on morbimortality. Between 2007 and 2017, a retrospective monocentric study was conducted including 477 haemodynamically stable patients after myocardial infarction who underwent an urgent coronary bypass. Three groups were described, depending on the timing of the surgery: during the first 4 days (Group 1, n = 111, 23%), 5 to 10 days (Group 2, n = 242, 51%) and after 11 days (Group 3, n = 124, 26%). The overall thirty-day mortality was 7.1% (n = 34). The death rate was significantly higher in Group 1 (n = 16; 14% vs. n = 10; 4.0% vs. n = 8; 6%, p < 0.01). The mortality risk factors identified were age (OR: 1.08; CI 95%: 1.04–1.12; p < 0.001), peripheral arteriopathy (OR: 3.31; CI 95%: 1.16–9.43; p = 0.024), preoperative renal failure (OR: 6.39; CI 95%: 2.49–15.6; p < 0.001) and preoperative ischemic recurrence (OR: 3.47; CI 95%: 1.59–7.48; p < 0.01). Ninety-two patients presented with preoperative ischemic recurrence (19%), with no difference between the groups. The optimal timing for the surgical revascularization of MI seems to be after Day 4 in stable patients. However, timing is not the only factor influencing the death rate: the patient's health condition and disease severity must be considered in the individual management strategy. [ABSTRACT FROM AUTHOR]

Background: Hepatic artery–related complications (HARC) after live donor liver transplantation (LDLT) is associated with high morbidity and mortality rate. Methods: Prospectively maintained data from July 2011 to September 2020 was analyzed for etiology, detection, management, and outcome of HARC. Results: Six hundred fifty-seven LDLT (adult 572/pediatrics 85) were performed during the study period. Twenty-one (3.2%) patient developed HARC; 16 (2.4%) hepatic artery thrombosis (HAT) and 5 (0.76%) non-thrombotic hepatic artery complication (NTHAC). Ninety percent (19/21) HARC were asymptomatic and detected on protocol Doppler. Median time to detection was day 4 (range − 1 to 35), which included 18 early (within 7 days) vs 3 late incidents. Only one pediatric patient had HAT. Seven patients underwent surgical revascularization, 11 had endovascular intervention and 3 with attenuated flow required only systemic anticoagulation. All NTHAC survived without any sequelae. Revascularization was successful in 81% (13/16) with HAT. Biliary complications were seen in 5 (23.8%); four were managed successfully. Overall mortality was 14.8% (3/21). The 1-year and 5-year survival were similar to those who did not develop HARC (80.9% vs 84.2%, p = 0.27 and 71.4% vs 75.19%, p = 0.36 respectively) but biliary complications were significantly higher (23.8% vs 14.2%, p = 0.03). On multivariate analysis, clockwise technique of arterial reconstruction was associated with decreased risk of HAT (1.7% vs 4.1% (p value − 0.003)). Conclusion: Technical refinement, early detection, and revascularization can achieve good outcome in patients with HARC after LDLT. [ABSTRACT FROM AUTHOR]

Objective: To analyze trends and differences of endovascular, surgical and hybrid revascularization approaches and the impact of comorbidity on characteristics, costs, and outcome of in-patients with peripheral artery disease (PAD) of the lower extremity. Methods: Analyzing data provided by the Research Data Center of the German Federal Statistical Office, we included all hospitalizations due to PAD Fontaine IIb (Rutherford 2–3) or higher in Germany between 2009–2011 and 2016–2018. According to the individually performed procedures encoded by the Operation and Procedure Classification System, we divided hospitalizations by revascularization procedures into sole endovascular, sole surgical, hybrid, two-step and no revascularization. Patient's comorbidity was assessed using the linear van Walraven comorbidity score (vWs). Results: 1,067,671 hospitalizations (mean age 71.3 ± 11.1 years; 60.1% male) were analyzed. Between 2009–2011 and 2016–2018, reimbursement costs rose by 28.0% from €2.72 billion (€5,350/case) to €3.49 billion (€6,238/case). The share of hospitalizations with any revascularization increased by 8.9% (67.7–73.7%) driven by an increase in two-step (+ 63.3%), hybrid (+ 58.2%) and sole endovascular revascularizations (+ 32.6%), while sole surgical approaches declined (− 18.2%). Hospitalizations of more comorbid patients (vWs ≥ 20) rose by 46.8% (21,444–31,478 cases), showed an overproportionate increase in costs of 124.6% (+ €1,750/case) and were associated with more individual procedures (+ 90.6%). Conclusions: In-patient treatment of PAD patients shows increasing numbers of hybrid and sole endovascular revascularizations and more patients with higher comorbidity, while sole surgical interventions and in-hospital mortality decrease. Consequently, associated costs are surging especially in more comorbid patients due to an increasing number of performed procedures and escalation of therapy. [ABSTRACT FROM AUTHOR]

The aim. To analyze the features of the perioperative period in high-risk cardiac surgery patients with coronary artery disease (CAD) and thyroid disease. Materials and methods. Retrospective analysis of data of 354 high-risk patients with CAD who were operated and discharged from the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine from 2009 to 2019. All the patients underwent standard clinical and laboratory tests, ECG, echocardiography, coronary angiography and surgical myocardial revascularization with correction of concomitant cardiac pathology. Ultrasound screening of thyroid disease and thyroid hormone levels was not performed in all patients, however, patients with severe symptoms were referred for follow-up. Results. Thyroid disease was diagnosed in 37 (10.4%) patients, of whom 11 (3.1%) had hypothyroidism and were receiving hormone replacement therapy, and 1 (0.28%) had hyperthyroidism on tyrosol therapy. Ultrasound signs of thyroiditis were detected in 7 (1.9%) patients, nodular goiter in 29 (8.1%), and retrosternal goiter in 1 (0.28%) patient. Depending on the cardiac surgical pathology, the prevalence of hypothyroidism did not differ in patients with uncomplicated and complicated forms of CAD (7 [3.6%] and 4 [2.5%] patients, respectively, p = 0.5498). Patients with hypothyroidism received hormone replacement therapy with levothyroxine in a dosage prescribed by an endocrinologist. The day before the surgery, thyroid-stimulating hormone control was performed to confirm the achievement of compensation. When comparing the course of the operative period in compensated hypothyroidism and clinical euthyroidism, no significant differences were found, and the postoperative period didn’t differ in the occurrence of atrial fibrillation (p = 0.0801), hydrothorax (p = 0.5280), but a decrease in the estimated glomerular filtration rate at discharge was found in patients with hypothyroidism (59.5 ± 16.8 vs. 71.3 ± 19.6 ml/min/1.73 m2, p = 0.0493). Conclusions. Timely detection of thyroid dysfunction allows to compensate the condition and avoid postoperative complications. Analysis of the perioperative period in patients with hypothyroidism showed no effect of compensated hypothyroidism on the operative and postoperative periods in high-risk patients with CAD. Decreased glomerular filtration rate after surgery in patients with hypothyroidism requires further study and adherence to the strategy of nephroprotection in polymorbid patients.

ObjectivesCerebral infarction is the major complication of revascularization surgery in patients with moyamoya disease (MMD), and we analyzed the possible causes of cerebral infarction after revascularization surgery for MMD.MethodsMMD patients who were admitted and underwent surgical revascularization at Shanghai Huashan Hospital from January 2019 to December 2021 were retrospectively analyzed.ResultsA total of 815 patients and 890 revascularization surgeries (677 first revascularization surgeries and 213 second revascularization surgeries) were included in this study; 453 (50.9%) were performed on the left side and 437 (49.1%) on the right side, with 779 (87.5%) combined procedures and 111 (12.5%) indirect bypasses included. The mean patient age at the time of these procedures was 44.6 ± 11.7 years (range 6–72 years). Postoperative cerebral infarctions were observed in 46 (5.17%) surgeries, among which 31 occurred after left hemisphere revascularization surgeries, with an incidence of 6.84%, and 15 occurred after right hemisphere revascularization surgeries, with an incidence of 3.43%. Of these, 30 (65.2%) occurred in the operated hemispheres, 2 (4.3%) in the contralateral hemisphere and 13 (28.3%) in the bilateral hemisphere. There were 11 cases of massive infarction (23.9%). The incidence of postoperative infarction in patients undergoing the first revascularization was 6% (41/677) and 2.3% (5/213) in the second revascularization surgeries. Initial presentation as infarction (P < 0.001), initial presentation as hemorrhage (P < 0.001), hypertension (P = 0.018), diabetes (P = 0.006), 1st or 2nd surgery and surgical side (P = 0.007) were found to be related to postoperative cerebral infarction. Initial presentation as infarction (OR = 2.934, 95% CI 1.453–5.928, P = 0.003), initial presentation as hemorrhage (OR = 0.149, 95% CI 0.035–0.641, P = 0.011), and 1st or 2nd surgery and surgical side (OR = 1.66, 95% CI 1.106–2.491, P = 0.014) were independently associated with cerebral infarction after revascularization surgeries.ConclusionsIn patients with MMD undergoing surgical revascularization, initial presentation as infarction and first revascularization surgery performed on the left hemisphere are independent risk factors for postoperative cerebral infarction, whereas initial presentation as hemorrhage is a protective factor.

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Moyamoya disease (MMD) is a chronic, occlusive cerebrovasculopathy typified by progressive steno-occlusive disease of the intracranial internal carotid arteries (ICAs) and their proximal branches. Moyamoya syndrome (MMS) categorizes patients with characteristic MMD plus associated conditions. As such, the most usual presentations are those that occur with cerebral ischemia, specifically transient ischemic attack, acute ischemic stroke, and seizures. Hemorrhagic stroke, headaches, and migraines can also occur secondary to the compensatory growth of fragile collateral vessels propagated by chronic cerebral ischemia. While the pathophysiology of MMD is unknown, there remain numerous clinical associations including radiation therapy to the brain, inherited genetic syndromes, hematologic disorders, and autoimmune conditions. We describe the case of a 31-year-old woman who presented with recurrent ischemic cerebral infarcts secondary to rapidly progressive, bilateral MMD despite undergoing early unilateral surgical revascularization with direct arterial bypass. She had numerous metabolic conditions and rapidly decompensated, ultimately passing away despite intensive and aggressive interventions. The present case highlights that progression of moyamoya disease to bilateral involvement can occur very rapidly, within a mere 6 weeks, a phenomenon which has not been documented in the literature to our knowledge., 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., (© 2024 Leach III, Margam, Gustin, Gustin, Jajeh, Chavis, Walker and Bentley.)

Introduction: Critical limb-threatening ischemia (CLTI) is a severe manifestation of peripheral artery disease (PAD) that can lead to limb amputation and significantly reduce quality of life. In addition to guideline-directed medical therapy (GDMT), endovascular therapy and surgical revascularization are the two revascularization options for CLTI. In recent years, there has been an ongoing debate about the best approach for CLTI patients. The purpose of this meta-analysis is to examine the current evidence and compare the clinical outcomes of endovascular therapy and surgical revascularization for CLTI., Methods: We conducted a systematic search of electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) for studies comparing the outcomes of endovascular therapy versus surgery in patients with CLTI. The primary outcomes were major adverse limb events (MALE) and major adverse cardiovascular events (MACE), while secondary outcomes included risk of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure, and length of hospital stay. Pooled data was analyzed using the fixed-effect model or the random-effect model in Review Manager 5.3. The Newcastle-Ottawa Scale and Cochrane risk of bias assessment tool were used to assess the bias of included studies., Results: A total of 16 studies (47,609 patients) were included in this meta-analysis. The overall effect favors surgery over endovascular intervention in terms of MALE [odds ratio (OR) 1.13, 95% CI (1.01-1.28), P = 0.04]. Endovascular therapy is associated with lower MACE rates compared to surgery [OR 0.62, 95% CI (0.51-0.76), P < 0.00001]. Furthermore, the risk of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure as well as the length of hospital stay was lower for endovascular intervention. Finally, there was no statistically significant difference in 30-day mortality between the two groups [OR 0.94, 95% CI 0.79-1.12, P = 0.52; Fig. 3i], and the pooled studies were homogeneous [P = 0.39; I2 = 5%]., Conclusion: Surgery may be the preferred treatment option for CLTI patients, as it is associated with a lower risk of MALE than endovascular therapy. However, endovascular therapy may be associated with a lower risk of MACE and lower rates of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure, and shorter hospital stays. There was no statistically significant difference in 30-day mortality between the two groups. Ultimately, the decision to use endovascular therapy or surgery as the primary treatment strategy should be based on a multi-disciplinary team approach with careful consideration of patient characteristics and anatomy., Competing Interests: Declaration of competing interest None., (Copyright © 2023. Published by Elsevier Inc.)

Abstract Background Despite several studies comparing off- and on-pump coronary artery bypass grafting (CABG), the effectiveness and outcomes of off-pump CABG still remain uncertain. Methods In this registry-based study, we assessed 8163 patients who underwent isolated CABG between 2014 and 2016. Propensity score matching (PSM), inverse probability of weighting (IPW) and covariate adjustment were performed to correct for and minimize selection bias. Results The overall mean age of the patients was 62 years, and 25.7% were women. Patients who underwent off-pump CABG had shorter length of hospitalization (p

Whether surgical revascularization can prevent recurrent hemorrhage in hemorrhagic moyamoya disease (HMD) patients remains a matter of debate. This study mainly aims at the comparison of treatment effect between surgical revascularization and conservative treatment of adult HMD patients. We retrospectively enrolled 322 adult HMD patients, including 133 in revascularization group and 189 in conservative group. The revascularization group included patients who underwent combined (n = 97) or indirect revascularization alone (n = 36). Ninety-two and forty-one patients underwent unilateral and bilateral revascularization respectively. The modified Rankin scale (mRS) was used to assess the functional status. The comparison was made based on initial treatment paradigm among two categories: (1) revascularization vs. conservative, (2) unilateral vs. bilateral revascularization. The rebleeding rate was significantly lower in revascularization group than that in conservative group (14.3% vs. 27.0%, P = 0.007). As for the functional outcomes, the average mRS was significantly better in revascularization group (1.7 ± 1.5) than that in conservative group (2.8 ± 1.9) (P < 0.001). The death rate in revascularization group was 8.3% (11/133), comparing to 20.1% (38/189) in conservative group (P = 0.004). While comparing between unilateral and bilateral revascularization within the revascularization group, the result demonstrated lower annual rebleeding rate in bilateral group (0.5%/side-year) than that in unilateral group (3.3%/side-year) (P = 0.001). This study proved the better treatment efficacy of surgical revascularization than that of conservative treatment in HMD patients, regarding both in rebleeding rate and mortality rate. Furthermore, bilateral revascularization seems more effective in preventing rebleeding than unilateral revascularization. [ABSTRACT FROM AUTHOR]

BackgroundA number of small studies have suggested that outcomes following endovascular (ENDO) therapy are comparable to those following surgical (SURG) revascularization for patients presenting with acute limb ischemia (ALI). We sought to compare mortality, limb amputation and recurrent ischemia across both revascularization strategies.MethodsA comprehensive database search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases from January 1990 through January 2016 was performed to identify studies of ENDO versus SURG for ALI. Two independent reviewers selected studies and extracted the data. Random-effects meta-analysis was used to pool results across studies. Heterogeneity of treatment effect among trials was assessed using the I2 statistics. The primary endpoints were mortality and limb amputation at 1 month, 6 and 12 months. Secondary endpoint was recurrent ischemia at one year.ResultsA total of 1,773 patients were included from six studies (five randomized prospective and one observational retrospective) comparing ENDO and SURG in the setting of ALI. The mean age was 67 years and 65% of patients were male. There were no differences in mortality between the two groups at 1 month [risk ratio (RR) for ENDO vs. SURG is 0.70; 95% confidence interval (CI), 0.33 to 1.50], 6 months (RR 1.12; CI, 0.78 to 1.61) or 12 months (RR 0.74; CI, 0.29 to 1.85). Similarly, there was no significant difference in amputation rates between ENDO and SURG at 1 month (RR 0.75; CI, 0.40 to 1.42), 6 months (RR 0.87; CI, 0.52 to 1.48) or 12 months (RR 0.81; CI, 0.55 to 1.18). When looking into secondary outcomes, recurrent ischemia was not different between the two groups (RR 1.12; CI, 0.75 to 1.67).ConclusionsIn patients presenting with ALI (

The aim. To analyze the influence of obesity on the perioperative course in high-risk patients with coronary artery disease (CAD) in cardiac surgery. Material and methods. Retrospective analysis of 354 randomly selected high-risk patients with CAD (ES II > 5%) who underwent surgical intervention and were discharged from the Institute in the period from 2009 to 2019. All the patients underwent routine clinical tests, ECG, echocardiography, coronary angiography and surgical revascularization of the myocardium with correction of concomitant cardiac pathology. Among the patients of the experimental group, 194 (54.8%) had CAD, 132 (37.2%) had postinfarction left ventricular aneurysm, 12 (3.3%) suffered from ischemic mitral regurgitation, 16 (4.5%) patients had CAD and aortic valve disease. Results. Among high-risk patients with CAD, 287 (81.07%) had BMI > 25 kg/m2. Carbohydrate metabolism disorders were found in 208 (72.4%) overweight patients. Type 2 diabetes mellitus (DM) was diagnosed in 78 (27.1%) patients, glucose intolerance was found in 130 (45.2%) cases. Risk stratification according to the ES II scale showed maximum risk (9.8%) in patients with normal body weight and the lowest risk (5.23%) in those with grade III obesity: however, the scale does not take into account anthropometric data. With the increase in body weight, the average number of grafts decreased (3.1 at a BMI of 25-35 kg/m2, 2.6 at a BMI > 40 kg/m2) and the use of internal thoracic arteries increased: 53.7% in patients with normal weight, 66.6% in those with grade III obesity. The level of blood transfusions was the highest (55.2%) in patients with normal weight, and in those with grade III obesity no blood transfusions were performed. Postoperative atrial fibrillation occurred in 14 (20.8%) patients with BMI up to 25 kg/m2, in 30 (28.03%) with BMI 30-29.9 kg/m2 and in 8 (34.7%) patients with grade II obesity. Regardless of body weight, there was a trend towards increase in glucose levels on the first postoperative day with subnormalization until discharge. Acute kidney injury was detected in 3 (4.4%) patients with normal weight, 3 (1.94%) overweight patients, 3 (2.8%) patients with grade I obesity and 1 (33.3%) patient with morbid obesity. Conclusions. Timely preventive measures can help to avoid serious complications even in high-risk patients with obesity. Despite the fact that overweight patients have more severe perioperative period, experience of our Institute allows to operate and treat high-risk patients successfully regardless of their body weight.

Kawasaki disease (KD) is a systemic inflammatory condition occurring predominantly in children. Coronary artery bypass grafting (CABG) is performed in the presence of inflammation and aneurysms of the coronary arteries. The objectives of our study were to assess which CABG strategy provides better graft patency and early and long-term outcomes.

Introduction: Buerger's disease, also known as thromboangiitis obliterans (TAO), is vasculitis of small- and medium-sized arteries and veins, which may involve both upper and lower extremities. It is strongly related to smoking and fairly common in the Indian subcontinent. Diagnosis is based on history, clinical examination, and angiography. The single most important modality of treatment is smoking cessation. As only few patients have suitable anatomy for surgical revascularization, the aim of this study is to evaluate the feasibility and outcome of surgical revascularization in TAO patients of North India. Methods: This is a prospective observational study involving 50 patients of TAO diagnosed by modified Shionoya criteria who underwent surgical revascularization. Computed tomographic angiography was done in all patients to see their suitability for surgical revascularization. Graft patency at 6 months postsurgery, pre- and post-operative ankle–brachial pressure index (ABPI), and visual analog scale (VAS) score for pain were calculated and compared. Results: All patients were male bidi smokers, with a mean age of 29.8 ± 9.5 years. Intermittent claudication was present in 42%, rest pain in 58%, and ulcer in 40%. Most common area of blockage was tibioperoneal trunk (62%) and tibial arteries (52%). The most frequent bypass procedure was popliteotibial done in 32 (64%) patients, followed by femoropopliteal bypass in 8 (16%) patients. Majority of our patients were symptom free at 6 months postsurgery. The mean VAS score for pain at the time of presentation was 6.08 ± 1.77, which decreased to 1.62 ± 1.23 at the end of 6 months. The mean preoperative ABPI was 0.45 ± 0.12 which improved to 0.73 ± 0.09 at 6 months postsurgery. A total of 46 (92%) limbs were salvaged while overall our graft patency rate was 70% at 6 months. Conclusion: We conclude that surgical revascularization is feasible in properly selected patients of TAO with acceptable results.

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.

During the acute phase of myocardial infarction, the culprit artery must be revascularized quickly with angioplasty. Surgery then completes the procedure in a second stage. If emergency surgery is performed, the resulting death rate is high; 15–20% of patients are operated on within the first 48 h after the myocardial infarction. The timing of surgical revascularization and the patient’s preoperative state influence the mortality rate. We aimed to evaluate the impact of surgery delay on morbimortality. Between 2007 and 2017, a retrospective monocentric study was conducted including 477 haemodynamically stable patients after myocardial infarction who underwent an urgent coronary bypass. Three groups were described, depending on the timing of the surgery: during the first 4 days (Group 1, n = 111, 23%), 5 to 10 days (Group 2, n = 242, 51%) and after 11 days (Group 3, n = 124, 26%). The overall thirty-day mortality was 7.1% (n = 34). The death rate was significantly higher in Group 1 (n = 16; 14% vs. n = 10; 4.0% vs. n = 8; 6%, p < 0.01). The mortality risk factors identified were age (OR: 1.08; CI 95%: 1.04–1.12; p < 0.001), peripheral arteriopathy (OR: 3.31; CI 95%: 1.16–9.43; p = 0.024), preoperative renal failure (OR: 6.39; CI 95%: 2.49–15.6; p < 0.001) and preoperative ischemic recurrence (OR: 3.47; CI 95%: 1.59–7.48; p < 0.01). Ninety-two patients presented with preoperative ischemic recurrence (19%), with no difference between the groups. The optimal timing for the surgical revascularization of MI seems to be after Day 4 in stable patients. However, timing is not the only factor influencing the death rate: the patient’s health condition and disease severity must be considered in the individual management strategy.

This case describes a 72-year-old woman with a history of chronic kidney disease stage III presented with bilateral renal artery stenosis with a progressively atrophied right kidney. At the time of surgery, the atrophied kidney was nonfunctional. Therefore, the patient underwent unilateral renal artery revascularization via the inferior mesenteric artery as an inflow. A 7-year follow-up revealed improvement in the kidney function and stabilization of blood pressure, which was controlled with less number of antihypertensive medications. In brief, open surgical correction of the renal artery stenosis using the inferior mesenteric artery as an inflow source can retrieve renal function in selected hypertensive patients with ischemic nephropathy.

Introduction: At our institution, we perform off-pump coronary artery bypass (OPCAB) as a standard procedure. Moreover, patients with favorable coronary anatomy and condition are selected for minimally invasive cardiac surgery (MICS)-OPCAB. We retrospectively compared early outcomes, focusing on safety, between MICS-OPCAB and conventional off-pump techniques for multivessel coronary artery bypass grafting (CABG)., Methods: From August 2017 to September 2022, 1,220 patients underwent multivessel coronary artery grafting at our institution. They were divided into the MICS-OPCAB group (MICS group = 163 patients) and the conventional OPCAB group (MS group = 1057 patients). Propensity score matching (1 : 1 ratio) was applied to the MICS-OPCAB and MS groups (149 patients per group) based on 23 preoperative clinical characteristics., Results: After matching, there were no significant differences in preoperative characteristics between the groups. The MICS group had a lower total graft number (2.3 ± 0.6 vs. 2.9 ± 0.8, p  < 0.001) and fewer distal anastomoses (2.7 ± 0.8 vs. 3.2 ± 0.9, p  < 0.001). There were no significant differences in hospital stay, intensive care unit stay, postoperative complications, and 30-day mortality. The MICS group had less drain output (MICS 350 ml [250-500], MS 450 ml [300-550]; p  = 0.013). Kaplan-Meier analysis revealed no significant differences in postoperative MACCE (major adverse cardiac or cerebrovascular events)-free and survival rates between the groups (MACCE-free rate p  = 0.945, survival rate p  = 0.374)., Conclusion: With proper patient selection, MICS-OPCAB can provide good short to mid-term results, similar to those of conventional OPCAB., 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., (© 2024 Ushioda, Hirofuji, Yoongtong, Sakboon, Cheewinmethasiri, Lokeskrawee, Patumanond, Lawanaskol, Kamiya and Arayawudhikul.)

Objectives: Many factors affect long-term outcomes after open bypass in patients with chronic limb-threatening ischemia (CLTI). Ambulatory status has been suggested to be associated with clinical outcomes, but there is limited knowledge on the effect of gait speed on outcomes. The purpose of this study is to evaluate the effect of gait speed assessed in a 6-min walk test (6MWT) on outcomes after crural and pedal bypass in patients with CLTI., Methods: A retrospective analysis was performed in patients with CLTI who underwent a 6MWT at 1 month after crural and pedal bypass at a single center from 2014 to 2021. Comparisons were made between those with high gait speed (HG group, 6-min walk distance (6MWD) > 288 m) and those with low gait speed (LG group, 6MWD ≤288 m). The primary endpoint was survival, and the secondary endpoints were graft patency, limb salvage, wound healing, major adverse cardiovascular events (MACEs), and hospital outcomes., Results: Of 104 patients with CLTI who underwent a 6MWT after crural and pedal bypass, 46 (44%) and 58 (56%) were placed in the HG and LG groups, respectively. The LG group was older ( p < .001), had more female subjects ( p = .006), and had a higher prevalence of cerebrovascular disease ( p = .042) and tissue loss ( p = .007). The median follow-up was 36 (22-57) months. The HG group had significantly higher 3-year primary patency (65% vs 42%, p = .013), 3-year secondary patency (87% vs 66%, p = .018), 3-year overall survival (89% vs 58%, p < .001), and 3-year freedom from MACE (79% vs 67%, p = .039). The 3-year limb salvage and 12-month wound healing rates did not differ between the groups., Conclusions: Gait speed in patients with CLTI after crural and pedal bypass was associated with survival, freedom from MACE, and graft patency but not with limb salvage and wound healing. A detailed study of walking ability in these patients may be needed in the future., 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.

Background: Despite several studies comparing off- and on-pump coronary artery bypass grafting (CABG), the effectiveness and outcomes of off-pump CABG still remain uncertain.Methods: In this registry-based study, we assessed 8163 patients who underwent isolated CABG between 2014 and 2016. Propensity score matching (PSM), inverse probability of weighting (IPW) and covariate adjustment were performed to correct for and minimize selection bias.Results: The overall mean age of the patients was 62 years, and 25.7% were women. Patients who underwent off-pump CABG had shorter length of hospitalization (p < 0.001), intubation time (p = 0.003) and length of ICU admission (p < 0.001). Off-pump CABG was associated with higher risk of 30-days mortality (OR: 1.7; 95% CI 1.09-2.65; p = 0.019) in unadjusted analysis. After covariate adjustment and matching (PSM and IPW), this difference was not statistically significant. After an average of 36.1 months follow-up, risk of MACCE and all-cause mortality didn't have significant differences in both surgical methods by adjusting with IPW (HR: 1.03; 95% CI 0.87-1.24; p = 0.714; HR: 0.91; 95% CI 0.73-1.14; p = 578, respectively).Conclusion: Off-pump and on-pump techniques have similar 30-day mortality (adjusted, PSM and IPW). Off-pump surgery is probably more cost-effective in short term; however, mid-term survival and MACCE trends in both surgical methods are comparable. [ABSTRACT FROM AUTHOR]

Background: Significant geographical variations exist in amputation rates and utilization of diagnostic and therapeutic vascular procedures before lower extremity amputations in the United States. The purpose of this study was to evaluate the rates of diagnostic and therapeutic vascular procedures in the year prior to amputation in a contemporary population and correlate with pathological findings of the amputation specimens. Methods: A retrospective analysis was conducted of non-traumatic amputations from 2011 to 2017 at a rural community hospital. We reviewed the proportion of patients undergoing diagnostic (ankle brachial index with duplex ultrasound, computerized tomography angiogram and invasive angiogram) and therapeutic (endovascular and surgical revascularization) vascular procedures in the year prior to amputation. Prevalence of tissue viability and osteomyelitis were evaluated in all amputated specimens and atherosclerotic vascular disease (ASVD) was evaluated in major amputations. We also analyzed primary amputation rates among different subgroups. Results: 698 patients were included with 248 (36%) major amputations and 450 (64%) minor amputations. Any diagnostic procedure was performed in 59% of the major amputations and 49% of the minor amputations (P = 0.01). Any therapeutic revascularization procedure was performed in 34% of the major amputations and 28% of the minor amputations (P = 0.08). The pathology of major amputation specimens revealed severe ASVD in 57% and mild-moderate ASVD in 27% of specimens. Tissue viability was significantly higher in major amputations (90% vs 30%, P = 0.04) and osteomyelitis was significantly higher in minor amputations (50% vs 14%, P = 0.03). Primary amputations were performed in 66% of major amputations, 72% of minor amputations, 81% with mild to moderate ASVD and 54% with severe ASVD. Conclusion: Diagnostic and therapeutic vascular procedures appear under-utilized for patients undergoing lower extremity amputations at a rural community hospital. ASVD rates and tissue viability imply that revascularization could be of significant benefit to avoid major amputation. [ABSTRACT FROM AUTHOR]

Background: When superficial temporal artery-middle cerebral artery bypass is combined with indirect methods (e.g., revascularization surgery) to treat Moyamoya disease (MMD), antiplatelet treatment can impact bypass patency, infarction, or hemorrhage complications. Recently, heparin has been proposed as an anticoagulant treatment against white thrombus at the anastomosis site. The study aims to evaluate the effect of aspirin on the perioperative outcomes and investigate the results of heparin treatment for white thrombus. Methods: This retrospective study included 74 procedures of combined revascularization surgery for MMD patients who either received or did not receive aspirin. Perioperative outcomes were compared between the two groups. In addition, the effects of heparin treatment for white thrombus were evaluated. Results: The rate of white thrombus at the anastomosis site was significantly higher in the non-aspirin medication group (univariate: p = 0.032, multivariate: p = 0.044) and, accordingly, initial bypass patency was lower in the non-aspirin medication group (p = 0.049). Of the 17 patients with white thrombus development, five received heparin injections, and all white thrombi disappeared; however, there was one case of epidural hematoma and another of subdural hematoma. The risk of hemorrhagic complications was significantly higher in the surgical procedures that received heparin injections (p = 0.021). Conclusions: In MMD patients who received combined revascularization surgery, aspirin medication lowered the occurrence of white thrombus. Heparin injections help to treat white thrombus but can enhance the risk of hemorrhagic complications. [ABSTRACT FROM AUTHOR]

Introduction. Moya-moya disease is a progressive disease resulting in bilateral stenotic occlusion of the cerebral arteries. In recent years, there has been an increase in the number of studies focused on moya-moya disease. Unfortunately, there are no data on moya-moya disease therapy in Kazakhstan. Low awareness, in turn, leads to a delay in establishing an accurate diagnosis for patients with moya-moya disease. Methods. The study included 25 patients diagnosed with moya-moya disease who were treated at the National Center for Neurosurgery for the period from 2013 to 2020. The study is retrospective and descriptive. The analysis included the following patient characteristics: gender, age at the time of diagnosis, number of surgical interventions, clinical manifestations of the disease, treatment performed and its results. The dynamics was assessed using the Rankin and Bartel scales. Results. The primary manifestations of the disease are characterized by ischemic stroke (36%), hemorrhagic stroke (28%), headache (20%), TIA (8%) and seizures (8%). 13 patients underwent surgical treatment on the vessels on one side, the remaining 12 patients underwent surgery on both sides, depending on the side and severity of the clinical manifestations of the affected arteries. According to the Rankin scale, in the year of the operation, there are 16% of patients without disabilities. In 2020, they became 43.5%. On the Bartel scale, there is an identical positive trend. In the year of surgery, there were 48% independent patients, and in 2020 the number increased sharply, the figure reached 78.3%. Conclusion. According to our series of observations, the main clinical manifestation in 36% was ischemic strokes. Other manifestations are less common. There is a clear positive dynamics after surgical revascularization of patients. The performed surgical treatment made it possible to prevent the development of disease progression and the appearance of repeated clinical manifestations of cerebrovascular insufficiency. [ABSTRACT FROM AUTHOR]

The present study aimed to clarify the current status, therapeutic strategy, and 1-year outcome in acute limb ischemia (ALI) patients in Japan. The EnDOvascular treatment (Edo) registry database includes 324 patients from 10 institutes who were registered between November 2011 and October 2013. A total of 70 ALI patients (mean age 74.0 years) from the Edo registry database were enrolled in this study. Of the 70 included patients, 72.9% were male and 35.7% had embolism. Of patients, 38.6%, 42.9%, and 18.6% underwent EVT, surgery, and hybrid thrombectomy, respectively, in primary revascularization strategy. Limb ischemia was categorized into four classes at initial evaluation: SVS/ISCVS class I (n = 13, 18.6%), SVS/ISCVS class IIa (n = 36, 51.4%), SVS/ISCVS class IIb (n = 21, 30%), and SVS/ISCVS class III (n = 0, 0%). Three patients with SVS/ISCVS class IIb limb ischemia developed myonephropathic metabolic syndrome. No catheter-directed thrombolysis was employed as a primary revascularization strategy. The 1-year rates of all-cause death, major amputation, and a composite of perioperative death or major adverse limb event were 28.6%, 5.7%, and 40.0%, respectively. Lower age, male sex, dyslipidemia, high estimated glomerular filtration rate, high albumin level, and low C-reactive protein level were independent positive predictors of all-cause death. In this registry, SVS/ISCVS class IIa ALI was predominant. Approximately 40% of primary revascularization strategy was surgery and EVT, followed by hybrid therapy. All-cause death and major amputation rates at 1 year were less than 30% and 6%, respectively. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate temporal trends in the frequency of revascularization and associated outcomes in patients with diabetes mellitus and critical limb ischemia (CLI). Little is known about outcomes following revascularization for CLI in patients with diabetes mellitus. Temporal trends in hospitalization for CLI among patients with diabetes were determined using the 2002–2015 National Inpatient Sample database. Propensity score matching was used to compare patients who underwent revascularization with those who did not and, separately, to compare those who underwent endovascular versus surgical revascularization. The main study outcome was in-hospital mortality. The analysis included 1,222,324 hospitalizations. The number of hospitalizations for CLI among patients with diabetes increased over time (p trend < 0.001). There was an increase in the use of lower extremity revascularization, paralleled by a decline in in-hospital mortality during the study period. In the matched cohort, patients who were revascularized had lower in-hospital mortality (odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.63 to 0.72) and major amputation (OR: 0.25; 95% CI: 0.24 to 0.27) compared with those who were treated medically. Compared with endovascular revascularization, those who underwent surgical revascularization had higher rates of in-hospital mortality (OR: 1.18; 95% CI: 1.04 to 1.35) but lower rates of major amputation (OR: 0.75; 95% CI: 0.70 to 0.81). Major bleeding, blood transfusion, post-operative infection, respiratory complications, discharges to nursing facility, and longer length of hospital stay were also more common among those who underwent surgery. In this national analysis of patients with DM and CLI, we demonstrated an increase in hospitalization for CLI among patients with diabetes in the United States. Although in-hospital mortality decreased over time regardless of the treatment strategy used, this outcome occurred less frequently among those who underwent revascularization than not. Compared with surgical revascularization, endovascular revascularization was associated with lower in-hospital mortality but higher rates of major amputation. [Display omitted] [ABSTRACT FROM AUTHOR]

Objective: Moyamoya disease (MMD) is a vasculopathy of the internal carotid arteries with ischemic and hemorrhagic sequelae. Surgical revascularization confers upfront peri-procedural risk and costs in exchange for long-term protective benefit against hemorrhagic disease. The authors present a cost-effectiveness analysis (CEA) of surgical versus non-surgical management of MMD. Methods: A Markov Model was used to simulate a 41-year-old suffering a transient ischemic attack (TIA) secondary to MMD and now faced with operative versus nonoperative treatment options. Health utilities, costs, and outcome probabilities were obtained from the CEA registry and the published literature. The primary outcome was incremental cost-effectiveness ratio which compared the quality adjusted life years (QALYs) and costs of surgical and nonsurgical treatments. Base-case, one-way sensitivity, two-way sensitivity, and probabilistic sensitivity analyses were performed with a willingness to pay threshold of $50,000. Results: The base case model yielded 3.81 QALYs with a cost of $99,500 for surgery, and 3.76 QALYs with a cost of $106,500 for nonsurgical management. One-way sensitivity analysis demonstrated the greatest sensitivity in assumptions to cost of surgery and cost of admission for hemorrhagic stroke, and probabilities of stroke with no surgery, stroke after surgery, poor surgical outcome, and death after surgery. Probabilistic sensitivity analyses demonstrated that surgical revascularization was the cost-effective strategy in over 87.4% of simulations. Conclusions: Considering both direct and indirect costs and the postoperative QALY, surgery is considerably more cost-effective than non-surgical management for adults with MMD. [ABSTRACT FROM AUTHOR]

Background: There are no reports describing the surgical procedure for moyamoya disease (MMD) patients with severe cerebral ischemia in the territory of the posterior cerebral artery (PCA) at initial presentation. In this study, therefore, we describe their clinical and radiological features and clinical results of one-stage revascularization surgery for both anterior and posterior circulation. Methods: This study included 6 MMD patients who had severe cerebral ischemia in the PCA territory and underwent one-stage revascularization surgery for both anterior and posterior circulation. Of these, one patient underwent it on both sides. Their clinical and radiological data were precisely analyzed. Compared with usual procedure, craniotomy was extended towards the temporo-parietal area more widely. The parietal branch of superficial temporal artery (STA) was anastomosed to the angular or posterior temporal artery, while the frontal branch was anastomosed to the frontal branch of MCA. Ultimate indirect bypass was added. Their clinical and radiological outcomes were evaluated. Results: Their neurological symptoms included visual and speech disturbance as well as numbness of the extremities. Cerebral infarct was distributed in the posterior temporal, parietal, and/or occipital lobe. Cerebral hemodynamics and metabolism were also impaired in the same regions. These findings were completely different from those in MMD patients without PCA lesion. Postoperative course was uneventful, and none of them recurred stroke during a mean follow-up period of 10.5 years. Surgical collaterals widely provided blood flow to the entire hemispheres, including the occipital lobe. Cerebral hemodynamics and metabolism markedly improved after surgery. Conclusion: One-stage revascularization surgery for both anterior and posterior circulation is feasible and effective to prevent future stroke in MMD patients with severe cerebral ischemia in the PCA territory at initial presentation. [ABSTRACT FROM AUTHOR]

Talar osteochondral lesions (OCLs) lead to progressive stages of talar destruction. Core decompression with cancellous bone grafting (CBG) is a common treatment for Berndt and Harty stages II and III. However, in a subset of patients, talar revascularization may fail. Surgical angiogenesis using vascularized medial femoral condyle (MFC) autografts may improve on these outcomes. These 2 treatment strategies were directly compared via a prospective preliminary randomized trial including 20 participants with talar core decompression followed by either cancellous (CBG group, n = 10) or vascularized MFC (MFC group, n = 10) bone grafting. Outcome analysis was performed with visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Lower Extremity Functional Scale (LEFS), and contrast-enhanced magnetic resonance imaging (MRI) scans. At 12 months of follow-up, the mean VAS score was reduced from 6.6 ± 2.5 preoperatively to 4 ± 1.9 in the CBG group and from 5.2 ± 2.9 preoperatively to 1 ± 1.1 in the MFC group (p <.001). The LEFS improved from 53.4 ± 13.1 to 62.6 ± 16.2 CBG and from 53 ± 9.3 to 72.4 ± 7.4 MFC (p =.114). AOFAS improved from 71 ± 12.1 to 84.1 ± 12.5 in CBG and from 70.5 ± 7.4 to 95.1 ± 4.8 in MFC (p =.019). The MRI scans in the CBG group demonstrated 9 partial malperfusions and 1 hypervascularized bone graft, whereas the MFC group had 8 well-vascularized grafts incorporated into the talus and 1 partial malperfusion. Vascularized MFC autografts provide superior pain relief along with improvement of physical function in patients with talar OCL stage II and III compared with CBG. To confirm these promising results, further multicenter randomized controlled trials are required. [ABSTRACT FROM AUTHOR]

Purpose: To discuss and share the experience of treatment of traumatic innominate arterial injury.Methods: A retrospective analysis was performed on patients with innominate arterial injuries admitted from January 2016 to July 2018 at the department of vascular surgery, Beijing Jishuitan Hospital, China. All the arterial injuries were confirmed by arteriography. Clinical data including mechanism of injury, type of injury, demographics, concomitant injuries, time interval from trauma to blood flow reconstruction, and operation methods were collected. Follow-up program included outpatient visit and duplex-ultrasonography. SPSS version 23.0 was adopted for data analysis. Categorical variables are presented as number and/or frequency and continuous variables as mean ± standard deviation.Result: Altogether 7 patients were included and 6 (85.7%) were male. The mean age of patients was (29.43 ± 7.98) years, range 19-43 years. Six patients had isolated innominate arterial injuries and the rest 1 combined innominate arterial and vein injuries. The injury causes were road accidents in 3 patients, stab wound in 2, gunshot wound in 1, and crush injury in 1. All the 7 patients presented hemorrhagic shock at admission, which was timely and effectively corrected. No perioperative death or technical complications occurred. Intimal injury (n = 2) and partial transaction (n = 2) of the innominate artery were treated with covered stents. Two patients with complete transection of artery received vascular reconstruction by artificial grafts. One patient with partial transaction received balloon dilation and open surgical repair (hybrid operation). The mean time interval from trauma to blood flow reconstruction was (4.27 ± 0.18) h, range 4.0-4.5 h; while the operation time was (48.57 ± 19.94) min, range 25-75 min. Cerebral infarction occurred in one patient with brain injury due to anticoagulation contraindication. The average follow-up was (13.29 ± 5.65) months, range 6-24 months. No severe stenosis, occlusion, and thrombosis of covered stents or artificial vessels were found by color Doppler ultrasound.Conclusion: Urgent control of hemorrhage and restoration of blood supply are critical for the treatment of traumatic innominate arterial injury. Endovascular therapy is a feasible and effective method with short operation time and less trauma. [ABSTRACT FROM AUTHOR]

Background: The optimal timing of surgical revascularization for patients presenting with ST-segment elevation myocardial infarction (STEMI) and impaired left ventricular function is not well established. This study aimed to examine the timing of surgical revascularization after STEMI in patients with ischemic heart disease and left ventricular dysfunction (LVD) by comparing early and late results. Methods: From January 2003 to December 2013, there were 2276 patients undergoing isolated coronary artery bypass grafting (CABG) in our institution. Two hundred and sixty-four (223 male, 41 females) patients with a history of STEMI and LVD were divided into early revascularization (ER, 3 months) groups according to the time interval from STEMI to CABG. Mortality and complication rates were compared among the groups by Fisher's exact test. Cox regression analyses were performed to examine the effect of the time interval of surgery on long-term survival. Results: No significant differences in 30-day mortality, long-term survival, freedom from all-cause death, and rehospitalization for heart failure existed among the groups (P > 0.05). More patients in the ER group (12.90%) had low cardiac output syndrome than those in the MR (2.89%) and LR (3.05%) groups (P = 0.035). The mean follow-up times were 46.72 ± 30.65, 48.70 ± 32.74, and 43.75 ± 32.43 months, respectively (P = 0.716). Cox regression analyses showed a severe preoperative condition (odds ratio = 7.13, 95% confidence interval 2.05–24.74, P = 0.002) rather than the time interval of CABG (P > 0.05) after myocardial infarction was a risk factor of long-term survival. Conclusions: Surgical revascularization for patients with STEMI and LVD can be performed at different times after STEMI with comparable operative mortality and long-term survival. However, ER (