Autogenous Vein Research Articles

REMOVED: Liver autotransplantation and retrohepatic vena cava reconstruction for alveolar echinococcosis

Alveolar echinococcosis (AE) is characterized by a slow-growing infiltrative neoplasm that is often unresectable by traditional methods because of strong adhesions and invasion to adjacent structures. We present our experience with liver autotransplantation and retrohepatic inferior vena cava (RHIVC) reconstruction using autogenous veins in patients with this end-stage parasitic disease. Twelve patients with hepatic AE and extensive RHIVC, hepatic vein, and/or hilar invasion underwent exvivo liver resection and RHIVC reconstruction using autogenous veins followed by autotransplantation in the West China Hospital of Sichuan University from 2013 to2016. The mean weight of the harvested liver graft was 537g (range: 390-900g), the mean anhepatic time was 216min (range, 120-310min), and the mean operation time was 13.6h (range, 10.5-19.5h). The main postoperative complication was bile leakage. The mean postoperative hospital stay was 16.4d (range, 10.0-37.0d), and the median follow-up time was 15.5mo (range, 1.0-32.0 mo). All patients were alive at the latest follow-up. The vascular patency rate was 100%, and no residual disease, recurrence, or metastasis was detected. To our knowledge, liver autotransplantation and RHIVC reconstruction using autogenous veins are rarely performed for patients with end-stage hepatic AE. This technique requires no organ donor, allogeneic, or artificial vessel implantation, postoperative immunosuppressive therapy, or long-term postoperative anticoagulant treatment. These benefits may make the treatment of select end-stage hepatic AE patients more affordable and effective.

A solution to the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur: Bridging with vein transplantation

PurposeThe present study aimed to evaluate the feasibility and clinical efficacy of bridging vein transplantation to deal with the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur. MethodsTwelve patients (aged 15–58 years) with infected bone defects of the femur (between 6.0 and 18.0cm) were recruited in this study. Vacuum sealing drainage were applied after extensive debridement of the infected bone defects and irrigated with 0.9% sodium chloride solution for 1–2 weeks. After the drainage was clear and the focal infections were controlled, the free vascularized fibula was harvested for reconstructing the femoral bone defects. The vascularized fibula was grafted and fixated appropriately at the recipient site. The autogenous great saphenous vein was harvested, one end was anastomosed and bridged the vascular pedicles of the fibular grafts, and the other end anastomosed the artery and/or the vein in the recipient healthy site. ResultsMean length of vein transplantation with vascularized fibular graft was 10.2 cm (range 7–15cm). All patients had good radiological healing without recorded nonunion or malunion. No patient developed deep infection or implant failure. Primary bone healing was achieved in 10 patients; however, 2 grafted fibular formed pseudarthrosis with the recipient femoral and then healed after a secondary surgery. One patient suffered from graft stress fracture after bone healing and healed after external fixation. After the mean follow-up of 30 months (9–72 months), according to the Enneking scoring system, clinical outcomes were excellent in 7 patients, good in 4 and fair in one. The functional recovery rate of the lesion limb was 89.4%. ConclusionsFree vascularized fibular graft with vein transplantation bridged vascular pedicle can effectively repair the infected bone, improve blood supply to the bone defect site, and help control infection. It is a feasible and effective treatment for infected bone defects of the femur with poor soft tissue conditions, or blood supply vessel shortage.

A multicenter experience with infected abdominal aortic endograft explantation

ObjectiveEndovascular aneurysm repair (EVAR) is widely used with excellent results, but its infectious complications can be devastating. In this paper, we report a multicenter experience with infected EVAR, symptoms, and options for explantation and their outcome. MethodsWe have reviewed all consecutive endograft explants for infection at 11 French university centers following EVAR, defined as index EVAR, from 1998 to 2015. Diagnosis of infected aortic endograft was made on the basis of clinical findings, cultures, imaging studies, and intraoperative findings. ResultsThirty-three patients with an infected aortic endograft were identified. In this group, at index EVAR, six patients (18%) presented with a groin or psoas infection and six patients (18%) presented with a general infection, including catheter-related infection (n = 3), prostatitis (n = 1), cholecystitis (n = 1), and pneumonia (n = 1). After index EVAR, eight patients underwent successful inferior mesenteric artery embolization for a type II endoleak within 6 months of index EVAR and one patient received an additional stent for a type Ib endoleak 1 week after index EVAR. Median time between the first clinical signs of infection and endograft explantation was 30 days (range, 1 day to 2.2 years). The most common presenting characteristics were pain and fever in 21 patients (64%) and fever alone in 8 patients (24%). Suprarenal fixation was present in 20 of 33 endografts (60%). All patients underwent endograft explantation, with bowel resection in 12 patients (36%) presenting with an endograft-enteric fistula. Methods of reconstruction were graft placement in situ in 30 patients and extra-anatomic bypass in 3 patients. In situ conduits were aortic cryopreserved allografts in 23, polyester silver graft in 5, and autogenous femoral vein in 2. Microbiology specimens obtained from the endograft and the aneurysm were positive in 24 patients (74%). Gram-positive organisms were the most commonly found in 18 patients (55%). Early mortality (30 days or in the hospital) was 39% (n = 13) in relation to graft blowout (n = 3), multiple organ failure (n = 6), colon necrosis (n = 3), and peripheral embolism (n = 1). At 1 year, the rates of patient survival, graft-related complications, and reinfection were 44%, 10%, and 5%, respectively. ConclusionsAbdominal aortic endograft explantation for infection is high risk and associated with graft-enteric fistula in one-third of the cases. Larger multicenter studies are needed to better understand the risk factors and to improve preventive measures at index EVAR and during follow-up.

Effect of coronary-caval shunt combined with partial pericardial devascularisation on oesophageal and gastric variceal bleeding caused by portal hypertension.

To investigate the effect of coronary-caval shunt combined with partial pericardial devascularisation on oesophageal and gastric variceal bleeding caused by portal hypertension. Between January 2005 and January 2015, coronary-caval shunt operations combined with partial pericardial devascularisation were performed electively on 15 cirrhotic patients with portal hypertension. All of these patients had a history of oesophageal and gastric variceal bleeding. The clinical and follow-up data of these patients were reviewed retrospectively. Another 15 patients receiving non-surgical treatments in a similar follow-up period were used as controls to compare the preventive effects of different treatment strategies on rebleeding. All of the 15 surgical procedures were performed successfully, and no severe complications occurred. Among these, autogenous splenic veins were used as bridge vessels in 6 cases, whereas the coronary vein and inferior vena cava were anastomosed directly in 9 cases. All surgical patients were followed up from 5 months to 10 years with an average of 63 months; 2 patients died due to liver failure induced by reactivation of hepatitis B virus and oesophageal/gastric variceal rebleeding, respectively. The rebleeding rates for surgical and non-surgical patients were 6.7% and 66.7% (p < 0.05), respectively, whereas the 5-year survival rates for the two groups were 85.7% and 33.3% (p < 0.05), respectively. Patients with oesophageal and gastric variceal bleeding caused by portal hypertension may benefit from a coronary-caval shunt combined with partial pericardial devascularisation due to decreased coronary vein pressure, unaffected hepatic blood inflow, and reduced incidence of rebleeding.

Cryopreserved Saphenous Vein: Last-Ditch Conduit for Limb Salvage?

In patients lacking autogenous vein suitable for infrainguinal bypass, cryopreserved saphenous vein (CSV) allograft (CryoLife Inc, Kennesaw, Ga) may be an acceptable alternative. However, long-term follow-up is lacking. The purpose of this study was to examine outcomes of CSV conduit for infrainguinal revascularization. Between February 2008 and August 2015, 72 patients underwent infrainguinal bypass grafts in 75 limbs using CSV. All patients were treated by a multidisciplinary limb preservation team and lacked suitable arm or leg vein. Demographic data and patient outcomes were retrospectively collected using electronic medical records. The mean age of our cohort was 70 ± 14 years, and 37 of 72 (51%) were male; 47 of 72 (65%) were white, 39 of 72 (54%) had coronary artery disease, 29 of 72 (40%) had diabetes, 57 of 72 (79%) had hypertension, and 52 of 72 (72%) were former or current smokers. Median follow-up was 304 days (interquartile range, 130-1051 days). Indications for the index operation included claudication (2%), rest pain (25%), tissue loss (53%), and prosthetic graft infection (17%); 62 of 75 (83%) bypasses were performed for critical limb ischemia, and 46 of 75 (61%) were revision operations. Distal targets included superficial femoral artery/popliteal (39%), tibial (54%), and pedal (7%). All grafts had a minimum diameter of 3 mm. At 30 days, 57 of 66 grafts (86%) were patent; 9 were lost to early follow-up. The only significant risk factor associated with 30-day failure was ABO mismatch (3 of 7 patients [43%] compared with 6 of 59 [10%]; P = .046). Estimated primary patency was worse in the tibial/pedal group (27%) compared with those bypasses to the superficial femoral artery/popliteal target (46%) (Fig). There were 20 (27%) major amputations, and all grafts in these limbs had occluded at the time of amputation. Of the 32 limbs with ischemic tissue loss that had long-term follow-up, 16 of 32 (50%) went on to graft occlusion, 9 of 32 (28%) had a major amputation, and 23 of 32 (72%) had complete healing of the index wound. The use of CSV for infrainguinal revascularization should be discouraged in patients with disabling claudication or rest pain. However, with an aggressive multidisciplinary approach including vigilant wound care and lack of autologous options, CSV may yield acceptable limb salvage. Avoiding ABO mismatch may improve 30-day graft patency.

Simulation of Anastomosis in Coronary Artery Bypass Surgery.

Developing cardiac surgical skills and experience takes years of practice. Cardiac trainees need to develop technical proficiency in order to enhance quality of care and patient safety. Simulation-based models are common resources for teaching procedural skills in both undergraduate and postgraduate medical education. Suitable and accessible educational platforms can play a progressively important role in the training process for young surgeons in the area of cardiac surgery. Coronary artery bypass graft (CABG) surgery consists of a wide range of pathologic anatomies and surgical techniques. In this paper we introduce a novel, synthetic, biomimetic platform that allows for the realistic practice of the CABG surgery. The prototype uses a polyvinyl alcohol hydrogel which has been designed to mimic the geometric properties of vasculature. The proposed models look and feel like human tissue and possess somewhat consistent mechanical properties. In this study, we apply the platform to simulate a case of autogenous saphenous vein bypass grafting of a patient. An autogenous saphenous vein graft is placed from the aorta to the left anterior descending coronary artery. The standard procedures of the coronary artery bypass surgery were successfully simulated. Using the proposed technology, other complicated surgeries such as end to end, side to end, and sequential anastomoses can be simulated such that these models lend themselves very well to various types of anastomoses.

Brachial artery repair using the basilic vein as a reliable conduit in a 3-year-old child

A supracondylar fracture of the humerus is the most common upper extremity fracture in children with concurrent neurovascular complications. However, bypass grafting in the management of a pediatric open elbow dislocation with an arterial injury has rarely been reported in the literature. Hence, an adequate conduit for a vessel graft interposition remains questionable when a primary anastomosis is limited in an arterial reconstruction. The purpose of this study is to present a brachial artery reconstruction in a 3-year-old patient with an open supracondylar fracture of the humerus. In the clinical and surgical examination of the patient, an open wound in the left antecubital fossa presented with accompanying brachial artery injury. To repair the artery, a reverse end-to-end anastomosis was conducted using basilic vein graft from the ipsilateral arm under general anesthesia. The patient had palpable radial pulses in the postoperative clinical examination and was discharged without complications. The great saphenous vein (GSV) has proven to be the most common and the best conduit for arterial reconstruction of the upper extremity in the adult patients. However, the GSV graft is known to have the propensity for becoming aneurysmal in pediatric patients. Some studies have demonstrated the basilic vein as a suitable conduit in pediatric patients, in that it has durable patency, fewer branches, size compatibility for anastomosis, and proximity to the brachial artery. Our case confirms the safety of using this autogenous vein from within the zone of injury for arterial reconstruction, after a supracondylar humeral fracture. The management of pediatric elbow fractures accompanying vascular injuries can be technically demanding due to relatively small, delicate structures and concurrent neurovascular network. Nonetheless, a vascular injury should be treated with high level of suspicion and immediate intervention to avoid any limb ischemia or loss. In situations where the brachial artery is compromised and needs repair with a bypass, the basilic vein should be considered as a conduit for its greater accessibility and long-term patency.

Acute limb-threatening ischemia following rupture of a brachial A-V fistula pseudoaneurysm

We present a case of acute limb-threatening ischemia following contained rupture of a pseudoaneurysm at brachial arterio-venous fistula site. The rapid progression of the clinical ischemia with impending external rupture of the pseudoaneurysm made the presentation unique. Emergent salvage surgery was performed with autogenous saphenous vein reconstruction of the brachial artery. We believe that emergent surgery with autogenous reconstruction of the artery would give the best results considering the strong probability of infection as the etiology.

Autogenous Vein Wrapping versus In Situ Decompression for Management of Secondary Cubital Tunnel Syndrome after Surgical Fixation of Elbow Fractures: Short-Term Functional and Neurophysiological Outcome.

The aim of this study was to compare the functional and neurophysiological outcome of in situ decompression versus in situ decompression augmented with autogenous vein wrapping in management of secondary cubital tunnel syndrome at the elbow following fixation of elbow fractures. A prospective comparative randomized study was performed on 29 patients who were divided into two groups: group I (in situ decompression) and group II (in situ decompression augmented with autogenous vein wrapping). We measured the patients' demographics, subjective reports of symptoms, and objective evaluation of the functional and neurophysiological outcomes of both groups. Group II patients achieved statistically better results in both neurophysiological scoring and clinical sensory rating but not in all other parameters. Autogenous vein wrapping for secondary cubital tunnel syndrome after elbow fracture fixation only provides a better sensory outcome. Level II, therapeutic prospective comparative study.

The experimental study on osteogenic potential of goat adipose derived stromal cells induced by PRP with rhBMP-2

Objective To evaluate the feasibilty of modified osteogenic culturing of goat adipose derived stromal cells (ADSCs). Methods From March, 2013 to September, 2014, platelet-rich plasma (PRP) was made from goat autogenous vein blood, and abodimoneal fat was aspirated, following aspetic procedure, primary and series passage of ADSCs was established. Osteoinduced ADSCs was carried out according to following group: combinative osteo-induction group (PRP+rhBMP-2+ADSCs) , growth factor group (rhBMP-2+ADSCs) , conventional inductive group (dexamathasone+ascorbic acid + ADSCs) and noninductive group (blank group). Converted microscope was used to observe cellular pattern, cell activity, osteocalcin and collagen type I level were detected at 1, 3, 5, 7, 9, 13, 17, 21 days. Red Alazarin and Von Kossa staining were also assayed at different interval. Results Under observation of converted microscopy, remarkable cell proliferation with abundant ECM was noticed in combinative osteoinduction group, compared with other groups, level of cell activity, osteocalcin, collagen type I [ (0.82 ± 2.19) AU, (79.82 ± 1.36) U/L at, (78.51 ± 4.32) μg/ml at]were significantly higher than other groups (P < 0.05) , and remarkable ALP expression and calcifed nodules were also seen. Conclusion PRP can enhance the inductive effect of rhBMP-2, and combinative osteoinduction procedure acts as a satisfactory culturing method. Key words: Platelet-rich plasma; Adipose derived stromal cells; Osteoinduction; Recombinant human morphogenetic protein-2

Society for Vascular Surgery limb stage and patient risk correlate with outcomes in an amputation prevention program

Clinical decision making and accurate outcomes comparisons in advanced limb ischemia require improved staging systems. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System (Wound extent, Ischemia, and foot Infection [WIfI]) was designed to stratify limb outcomes based on three major factors-wound extent, ischemia, and foot infection. The Project or Ex-Vivo vein graft Engineering via Transfection III (PREVENT) III (PIII) risk score was developed to stratify patients by expected amputation-free survival (AFS) after surgical revascularization. This study was designed to prospectively assess limb and patient-based staging for predicting outcomes of hospitalized patients in an amputation prevention program. This study undertook a retrospective analysis of prospectively gathered registry data of consecutive patients with limb-threatening conditions admitted to a fully integrated vascular/podiatry service over a 16-month period. Upon admission, limb risk was stratified using the WIfI system and patient risk was categorized using PIII classification. Patients were assessed for perioperative and postdischarge outcomes, and their relationship to staging at admission was analyzed. There were 174 threatened limbs (143 hospitalized patients) stratified by WIfI stage (1%-12%, 2%-28%, 3%-24%, 4%-28%, 5%-3%, unstaged-5%) and PIII risk (34% low, 49% moderate, and 17% high risk). Diabetes and end-stage renal disease were associated with WIfI stage (P= .006 and P= .018) and PIII risk (P= .003 and P< .001). Perioperative (30-day) events included 3% mortality, 8% major adverse cardiovascular events and 2.4% major amputation. There were 119 limbs (71%) that underwent revascularization, including 108 infrainguinal reconstructions (endovascular or open revascularization). Rate of revascularization increased with WIfI stage (P< .001), concomitant with the number of podiatric procedures, minor amputations, and initial hospital duration of stay (all P< .001). Increased WIfI stage was associated with major adverse limb events (P= .018), reduced limb salvage (P= .037), and decreased AFS (P= .048). In contrast, PIII risk category was associated with mortality (P< .001) and AFS (P< .001). Among infrainguinal reconstruction procedures, there was a similar distribution of endovascular (46%) and surgical (54%) interventions. Freedom from major adverse limb events was best for autogenous vein bypass (P= .025), and surgical revascularization was associated with improved limb salvage among the most severely threatened limbs (WIfI stage 4: 95% limb salvage for open bypass vs 68% limb salvage for endovascular; P= .026). Among patients hospitalized with limb-threatening conditions and treated by a multidisciplinary amputation prevention team, PIII risk correlates with mortality whereas WIfI stage strongly predicts initial hospital duration of stay, and key mid-term limb outcomes. Surgical revascularization performed best in the limbs at greatest risk (WIfI stage 4), and autogenous vein bypass was the preferred conduit for open bypass. These data support the use of WIfI and PIII as complementary staging tools in the management of chronic limb-threatening ischemia.

Surgical techniques for hemostasis in penetrating trauma to femoral artery

Objectives: To analyse the efficacy of various operative procedures and factors affecting the outcome especially the effect of limb ischemia time in penetrating trauma to the femoral artery. Study Design: Prospective. Setting: Study was conducted at West Surgical Ward, Mayo Hospital Lahore. Duration: August 2001 to July 2004. Materials and Methods: All the patients &gt;12 years of age referred from periphery as well as directly admitted with penetrating trauma to the femoral vessels alone or associated with other organ injuries having hard/soft physical signs of an arterial injury were included in the study. Results: 39(97.5%) patients were male, age ranged from 14-53 years with the mean limb ischemia time of 7.8 hours in the series. 35(87.5%) patients sustained firearm injuries. Superficial femoral artery was injured in 23(57.5%) followed by vein in 12(30%) and major vessels were found intact in 4(10%) patients. Lateral arteriorrhaphy was performed in 4(10%) &amp; venorrhaphy in 3(7.5%) patients with 100 % succ ess rate, resection and primary anastomosis in 18(45%) patients with pseudo aneurysm formation in 1(2.5%) patient. Reverse great saphenous vein graft was interposed in 9(22.5%) patients with graft failure rate of 5% (2 patients). Femoral vein was ligated in 12(30%) patients with development of deep vein thrombosis in 2(5%) patients. There were 3(7.5%) deaths. No synthetic graft was used in the series. Conclusion: Exsanguination, prolonged injury duration, associated organ injuries and extensive soft tissue and skin damage of the extremities were the major factors responsible for increased morbidity particularly limb loss and mortality. Proximity of injury to the femoral vessels was a poor predictor of an arterial injury in the study. Arteriorrhaphy and primary end-to-end anastomosis are the main stays for an arterial injury repair, next comes the use of autogenous vein graft, in our setup. Moreover ligation of femoral vein is not associated with leg amputation.

Recurrent Cubital Tunnel Syndrome: A Critical Analysis Review.

Most patients (>90%) will have continued or recurrent symptoms after primary cubital tunnel release. Those patients with severe preoperative findings are at a higher risk of failure. Failed primary surgery may be due to diagnostic, technical, or biologic factors. Revision surgical interventions can provide relief, but there is no consensus on what is the optimal technique. The options for revision surgery include simple neurolysis, neurolysis with subcutaneous transposition, and neurolysis with submuscular transposition. Autogenous (vein) and non-autogenous nerve wraps may be placed around the nerve to prevent cicatrix reformation.

Management of Critical Limb Ischemia

Critical limb ischemia (CLI) is a clinical syndrome of ischemic pain at rest or tissue loss, such as nonhealing ulcers or gangrene, related to peripheral artery disease. CLI has a high short-term risk of limb loss and cardiovascular events. Noninvasive or invasive angiography help determine the feasibility and approach to arterial revascularization. An endovascular-first approach is often advocated based on a lower procedural risk; however, specific patterns of disease may be best treated by open surgical revascularization. Balloon angioplasty and stenting form the backbone of endovascular techniques, with drug-eluting stents and drug-coated balloons offering low rates of repeat revascularization. Combined antegrade and retrograde approaches can increase success in long total occlusions. Below the knee, angiosome-directed angioplasty may lead to greater wound healing, but failing this, any straight-line flow into the foot is pursued. Hybrid surgical techniques such as iliac stenting and common femoral endarterectomy are commonly used to reduce operative risk. Lower extremity bypass grafting is most successful with a good quality, long, single-segment autogenous vein of at least 3.5-mm diameter. Minor amputations are often required for tissue loss as a part of the treatment strategy. Major amputations (at or above the ankle) limit functional independence, and their prevention is a key goal of CLI therapy. Medical therapy after revascularization targets risk factors for atherosclerosis and assesses wound healing and new or recurrent flow-limiting disease. The ongoing National Institutes of Health-sponsored Best Endovascular Versus Best Surgical Therapy in Patients With Critical Limb Ischemia (BEST-CLI) study is a randomized trial of the contemporary endovascular versus open surgical techniques in patients with CLI.

Polytetrafluoroethylene Patch Closure at Venous Anastomotic Site: A Novel Technique for Arteriovenous Graft Salvage

Introduction: The use of prosthetic arterio-venous grafts (avgs) is necessary in patients where all autogenous vein options are exhausted. This study asseses the results of PTFE patch plasty at the venous end of the access anastomosis. Materials and Methods: This is a prospective observational single centre study in a tertiary care centre for all patients with prosthetic AV graft venous anastomotic site stenosis between 2012 and 2015. Results: There were 40 patients in the study period. Presenting symptoms were primarily inadequate dialysis from AV Graft due to thrombosed graft within 14 days duration. The average age was 58.2 years and 70% were male. They underwent thrombectomy and PTFE patch closure at the venous anastomotic site due to AV graft thrombosis in upper extremity. 38.4% patients had both hypertension, Type II DM while 38.4% patients suffered from triad of hypertension, Type II DM and Hyperlipidemia. Criteria of success was based on immediate post operative bruit and next day heparin free hemodialysis from AV Graft. 37 patients who underwent the procedure had primary patency rate of 91.89% at 3 months and 59.45% at 6 months. Mean follow-up time was 8 months with average hospital stay of 3 days without post-operative complications. Conclusion: Treatment of AVG thrombosis should be performed urgently. There is no standard approach for AV graft thrombosis and surgical management must be individualized for each case. As the commonest cause of graft occlusion is at the venous anastomotic site, hence AV graft thrombectomy with eptfe patch closure can achieve better result compared to thrombectomy with primary closure or stent placement.

IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes.

Recommendations Examine a patient with diabetes annually for the presence of peripheral artery disease (PAD); this should include, at a minimum, taking a history and palpating foot pulses. (GRADE strength of recommendation: strong; quality of evidence: low) Evaluate a patient with diabetes and a foot ulcer for the presence of PAD. Determine, as part of this examination, ankle or pedal Doppler arterial waveforms; measure both ankle systolic pressure and systolic ankle brachial index (ABI). (strong; low) We recommend the use of bedside non‐invasive tests to exclude PAD. No single modality has been shown to be optimal. Measuring ABI (with &lt;0.9 considered abnormal) is useful for the detection of PAD. Tests that largely exclude PAD are the presence of ABI 0.9–1.3, toe brachial index ≥0.75 and the presence of triphasic pedal Doppler arterial waveforms. (strong; low) In patients with a foot ulcer in diabetes and PAD, no specific symptoms or signs of PAD reliably predict healing of the ulcer. However, one of the following simple bedside tests should be used to inform the patient and healthcare professional about the healing potential of the ulcer. Any of the following findings increases the pre‐test probability of healing by at least 25%: a skin perfusion pressure ≥40 mmHg, a toe pressure ≥30 mmHg or a transcutaneous oxygen pressure (TcPO2) ≥25 mmHg. (strong; moderate) Consider urgent vascular imaging and revascularisation in patients with a foot ulcer in diabetes where the toe pressure is &lt;30 mmHg or the TcPO2 &lt;25 mmHg. (strong; low) Consider vascular imaging and revascularisation in all patients with a foot ulcer in diabetes and PAD, irrespective of the results of bedside tests, when the ulcer does not improve within 6 weeks despite optimal management. (strong; low) Diabetic microangiopathy should not be considered to be the cause of poor wound healing in patients with a foot ulcer. (strong; low) In patients with a non‐healing ulcer with either an ankle pressure &lt;50 mmHg or ABI &lt;0.5, consider urgent vascular imaging and revascularisation. (strong; moderate) Colour Doppler ultrasound, computed tomography angiography, magnetic resonance angiography or intra‐arterial digital subtraction angiography can each be used to obtain anatomical information when revascularisation is being considered. The entire lower extremity arterial circulation should be evaluated, with detailed visualisation of below‐the‐knee and pedal arteries. (strong; low) The aim of revascularisation is to restore direct flow to at least one of the foot arteries, preferably the artery that supplies the anatomical region of the wound, with the aim of achieving a minimum skin perfusion pressure ≥40 mmHg, a toe pressure ≥30 mmHg or a TcPO2 ≥25 mmHg. (strong; low) A centre treating patients with a foot ulcer in diabetes should have the expertise in and rapid access to facilities necessary to diagnose and treat PAD; both endovascular techniques and bypass surgery should be available. (strong; low) There is inadequate evidence to establish which revascularisation technique is superior, and decisions should be made in a multidisciplinary team on a number of individual factors, such as morphological distribution of PAD, availability of autogenous vein, patient co‐morbidities and local expertise. (strong; low) After a revascularisation procedure for a foot ulcer in diabetes, the patient should be treated by a multidisciplinary team as part of a comprehensive care plan. (strong; low) Patients with signs of PAD and a foot infection are at particularly high risk for major limb amputation and require emergency treatment. (strong; moderate) Avoid revascularisation in patients in whom, from the patient perspective, the risk–benefit ratio for the probability of success is unfavourable. (strong; low) All patients with diabetes and an ischaemic foot ulcer should receive aggressive cardiovascular risk management including support for cessation of smoking, treatment of hypertension and prescription of a statin as well as low‐dose aspirin or clopidogrel. (strong; low)

Contemporary Outcomes for Open Infrainguinal Bypass in the Endovascular Era

The role of infrainguinal bypasses in this era of increasing endovascular interventions remains the subject of significant debate. In this study, we evaluate contemporary long-term outcomes of lower-extremity open revascularization for peripheral arterial disease (PAD). We evaluated all patients who underwent infrainguinal bypass with autogenous vein conduits for claudication or critical limb ischemia in our institution between January 1st, 2007 and July 31st, 2014. Kaplan-Meier and Cox regression analyses were used to evaluate graft failure and identify its predictors. Outcomes were defined per the Society for Vascular Surgery standards. There were 428 autogenous vein grafts (femoro-popliteal: 32%, femoro-tibial: 39%, popliteo-tibial: 27%, and tibio-tibial: 2%) placed in 368 patients (mean age of 67 ± 11.4 years). Most patients were male (59%), white (73%), and presented with critical limb ischemia (81%). Sixty-five cases (15%) were redo bypasses. Arm veins and spliced vein conduits were used in 15% and 14% of cases, respectively. Primary patency at 1, 3, and 5 years was 66%, 59%, and 55%, respectively. Primary-assisted patency was 78%, 69%, and 64% at 1, 3, and 5 years, respectively. Secondary patency was 88%, 84%, and 82% at 1, 3, and 5 years, respectively. Patency was higher for grafts harvested from the lower versus upper extremities and for proximal versus distal bypass (all P < 0.05). Limb salvage rate was 88% after a mean follow-up of 2 ± 1.8 years. Significant predictors of graft failure were younger age, diabetes mellitus, and hyperlipidemia (all P < 0.05). In this contemporary cohort of patients, we have demonstrated that infrainguinal bypass for lower-extremity revascularization has good long-term outcomes in patients with symptomatic PAD. Patency and limb salvage rates are optimized with careful selection of autogenous conduits, close monitoring of high-risk groups and management of comorbidities.

Variant meso-Rex bypass with transposition of abdominal autogenous vein for the management of idiopathic extrahepatic portal vein obstruction: a retrospective observational study.

BackgroundThe aim of this study was to evaluate whether variant meso-Rex bypass with transposition of abdominal autogenous vein can be used as an alternative treatment modality for selected patients with symptomatic extrahepatic portal vein obstruction.MethodsThis was a retrospective review of six consecutive patients who received this alternative procedure for the treatment of symptomatic portal hypertension secondary to idiopathic extrahepatic portal vein obstruction. Their clinical characteristics, operative procedures and outcomes were analyzed retrospectively.ResultsThe procedure was attempted in six patients, and all had a patent shunt established by intraoperative portography at the end of the procedure; the coronary vein was used in four patients and the inferior mesenteric vein was used in two. During the median period of 23.5 months (range 10–30 months), follow-up was uneventful except one patient; reduced portal hypertension and no new episodes of gastrointestinal bleeding were observed in all patients, with the exception of one patient with shunt stenosis and recurrent varix bleeding who had to undergo endovascular treatment to restore portal vein blood flow. Technical and clinical success was achieved in all patients.ConclusionsThis procedure could be used safely and effectively to treat selected patients with portal hypertension secondary to extrahepatic portal vein obstruction.

The correlation between computed tomography and duplex evaluation of autogenous vein bypass grafts and their relationship to failure

Duplex ultrasound (DUS) imaging for vein bypass graft (VBG) surveillance is confounded by technical and physiologic factors that reduce the sensitivity for detecting impending graft failure. In contrast, three-dimensional computed tomography angiography (CTA) offers high-fidelity anatomic characterization of VBGs, but its utility in detecting at risk grafts is unknown. The current study analyzed the correlation between DUS and CTA for detection of vein graft stenosis and evaluated the relationship of the observed abnormalities to VBG failure. Consecutive lower extremity VBG patients underwent surveillance with concurrent DUS imaging and CTA at 1 week and at 1, 6, and 12 months postoperatively. A standardized algorithm was used for CT reconstruction and extraction of the lumen geometries at 1-mm intervals. At each interval, CT-derived cross-sectional areas were coregistered and correlated to DUS peak systolic velocities (PSVs) within six predesignated anatomic zones and then analyzed for outcome association. Vein graft failure was defined as pathologic change within a given anatomic zone resulting in thrombosis, amputation, or reintervention within the 6-month period after the observed time point. The study recruited 54 patients, and 10 (18%) experienced failure ≤18 months of implantation. The expected inverse relationship between cross-sectional area and PSV was only weakly correlated (Spearman rank coefficient = -0.19). Moderate elevations in the PSV ratio (PSVr; 2-3.5) were frequently transient, with 14 of 18 grafts (78%) demonstrating ratio reduction on subsequent imaging. A PSVr ≥3.5 was associated with a 67% failure rate. CT stenosis <50% was highly correlated with success (0 failures); however, high-grade (>80%) CT stenosis was more likely to succeed than to fail (25%). Significant discordance between CT and DUS was found in 18 patients. Although 14 of these patients had CT stenosis >70% with a PSVr <3.5, subsequent failure occurred in only two. Conversely, graft failure occurred in three of four patients with CT stenosis <70% but PSVr >3.5. Focused analysis of these patients using computational fluid dynamic modeling demonstrated that vein side branches, local tortuosity, regional diameter variations, and venovenostomies were the drivers of these discrepancies. This analysis demonstrated that a PSVr ≥3.5 is strongly correlated with VBG failure, whereas the natural history of moderately elevated PSVr (2-3.5) is largely clinically benign. Although minimum stenosis on the CT scan was highly predictive of success, high-grade CT stenosis was infrequently associated with failure. The interaction of anatomic features with the local flow dynamics was identified as the primary confounder for a direct correlation between CT and DUS imaging.

The Significance of Neuregulin-1/ErbB Expression in Autogenous Vein Grafts in a Diabetic Rat Model.

Diabetes mellitus (DM) is an important risk factor for increased vein graft failure after bypass surgery. The neuregulin-1 (NRG-1)/ErbB signaling system plays a critical role in neointimal formation after vascular injury as well as the proliferation and migration of mitogen-induced vascular smooth muscle cells; however, changes in NRG-1/ErbB signaling leading to vein grafts attrition in DM remain largely unexplored. Therefore, the aim of this study was to investigate changes in NRG-1/ErbB signaling in vein grafts in diabetic rats. To do this, a rat model of DM was established by streptozotocin injection followed by engraftment of autologous jugular veins to carotid arteries to induce intimal hyperplasia. After vein graft harvest, a pathohistological examination was performed; changes in NRG-1 and ErbB expression were also assessed. NRG-1 and ErbB expression localized to endothelial cells and vascular smooth muscle cells, which is consistent with the arterialization of vein grafts. NRG-1, ErbB2, and ErbB4 expression significantly decreased in vein grafts over time. Our findings show that NRG-1/ErbB signaling is impaired in vein grafts of diabetic rats, suggesting an important role for this pathway in the pathogenesis of intimal hyperplastic lesions in vein grafts of patients with DM.