Bypass Grafting Research Articles

Matrix-Binding, N-Cadherin-Targeting Chimeric Peptide Inhibits Intimal Thickening but Not Endothelial Repair in Balloon-Injured Carotid Arteries.

Treatment of occluded vessels can involve angioplasty, stenting, and bypass grafting, which can be limited by restenosis and thrombosis. Drug-eluting stents attenuate restenosis, but the current drugs used are cytotoxic, causing smooth muscle cell (SMC) and endothelial cell (EC) death that may lead to late thrombosis. N-cadherin is a junctional protein expressed by SMCs, which promotes directional SMC migration contributing to restenosis. We propose that engaging N-cadherin with mimetic peptides can act as a cell type-selective therapeutic strategy to inhibit polarization and directional migration of SMCs without negatively impacting ECs. We designed a novel N-cadherin-targeting chimeric peptide with a histidine-alanine-valine cadherin-binding motif, combined with a fibronectin-binding motif from Staphylococcus aureus. This peptide was tested in SMC and EC culture assays of migration, viability, and apoptosis. Rat carotid arteries were balloon injured and treated with the N-cadherin peptide. Treating scratch-wounded SMCs with the N-cadherin-targeting peptide inhibited migration and reduced polarization of wound-edge cells. The peptide colocalized with fibronectin. Importantly, EC junction, permeability, or migration was not impacted by peptide treatment in vitro. We also demonstrated that the chimeric peptide persisted for 24 hours after transient delivery in the balloon-injured rat carotid artery. Treatment with the N-cadherin-targeting chimeric peptide reduced intimal thickening in balloon-injured rat carotid arteries at 1 and 2 weeks after injury. Reendothelialization of injured vessels after 2 weeks was unimpaired by peptide treatment. These studies show that an N-cadherin-binding and fibronectin-binding chimeric peptide is effective in inhibiting SMC migration in vitro and in vivo and limiting neointimal hyperplasia after balloon angioplasty without affecting EC repair. These results establish the potential of an advantageous SMC-selective strategy for antirestenosis therapy.

Impact of cilostazol on prevention of late failure of autologous vein grafts.

The effectiveness of postoperative medication for the prevention of late graft failure is controversial. We conducted the present study to investigate whether cilostazol improved the mid-term outcomes after infrainguinal autologous vein bypass for chronic limb-threatening ischemia (CLTI). From April 1994 to March 2022, we performed 590 de novo infrainguinal bypass procedures using autologous vein grafts (AVGs) in three hospitals. The bypass grafts were classified according to the postoperative prescription of cilostazol. The loss of graft patency and major adverse limb events (MALEs) were set as endpoints. Patients who died within 30days and grafts that lost primary patency within 30days after surgery were excluded. Data up to 3years were analyzed. The cumulative primary patency (PP), assisted primary patency (AP), secondary patency (SP), and freedom from MALE (ffMALE) rates were calculated by the Kaplan-Meier method and compared between the cilostazol group and the non-cilostazol group. After a propensity score matching, same statistical analyses were performed. In addition, a Cox proportional hazards regression analysis that included preoperative factors, intraoperative factors, and postoperative medications was performed to identify whether cilostazol is an independent predictor for the outcomes. A total of 523 AVGs met inclusion criteria. Kaplan-Meier curves showed that the cilostazol group was superior to the non-cilostazol group in all outcomes, while the cilostazol group was superior to the non-cilostazol group in AP and SP after a propensity score matching. A multivariable analysis showed that non-use of cilostazol was identified as an independent predictor for loss of AP, SP, and ffMALE. Cilostazol improved the mid-term outcomes after infrainguinal autologous vein bypass.

Is Dissection and Preservation of Adherent Popliteal Vessels From a Posterior Soft Tissue Mass Associated With a Higher Proportion of Local Recurrence in Patients With a Distal Femoral Osteosarcoma?

Is Dissection and Preservation of Adherent Popliteal Vessels From a Posterior Soft Tissue Mass Associated With a Higher Proportion of Local Recurrence in Patients With a Distal Femoral Osteosarcoma?

Duplex ultrasound for surveillance of lower limb revascularisation.

Duplex ultrasound for surveillance of lower limb revascularisation.

Bypass Grafting and Coil Embolization for Impending Rupture of Celiac Artery Aneurysm in a Patient with Neurofibromatosis Type 1 (NF1)

Bypass Grafting and Coil Embolization for Impending Rupture of Celiac Artery Aneurysm in a Patient with Neurofibromatosis Type 1 (NF1)

The comparison of the short and mid-term results of endovascular interventions and bypass graft surgery in the treatment of patients with intermittent claudication complaints because of isolated femoropopliteal artery disease.

Intermittent Claudication (IC) is exercise pain seen in lower extremity arterial diseases. If it is left untreated, it may be the initial sign of a process leading to amputation. In the present study, the purpose was to compare the postoperative early and mid-term results of the patients who were treated with endovascular methods and those who underwent bypass graft surgery in the treatment due to IC complaints because of isolated Femoropopliteal Arterial Disease. Postoperative first-month, sixth-month, and 12th-month follow-up results, procedure requirements, and demographic characteristics of the 153 patients who underwent femoropopliteal bypass because of isolated Femoropopliteal Arterial Disease and 294 patients who underwent endovascular intervention in our hospital between January 2015 and May 2020 were compared in the study. It was found in demographic characteristics that endovascular intervention was performed more frequently in smokers and graft bypass surgery was performed more frequently in hyperlipidemic patients, and the results were found to be statistically significant. High amputation rates were detected at statistically significant levels in diabetic and hypertriglycemic patients and 1-year primary patency rates were found to be higher in patients who underwent graft bypass surgery. No differences were detected between the two methods in terms of mortality. Interventional treatment modalities must be considered for patients with isolated Femoropopliteal Arterial Disease whose symptoms persist despite exercise and the best medical treatment. We think that Bypass Graft Surgery has more positive results than endovascular interventions when short and medium-term amputation, repetitive intervention needs, and changes in quality of life are compared in patients who receive the same medical treatment.

Predicting Surgical Coronary Disease Prior to Invasive Coronary Angiography to Inform Selective Avoidance of Radial Artery Access and Preserve it for Use as a Bypass Graft

Predicting Surgical Coronary Disease Prior to Invasive Coronary Angiography to Inform Selective Avoidance of Radial Artery Access and Preserve it for Use as a Bypass Graft

Is central repair with coronary artery bypass grafting enough for multi-organ malperfusion in acute type A aortic dissection with coronary malperfusion?

ObjectivesAcute type A aortic dissection with coronary malperfusion syndrome is rare but associated with high mortality. Multi-organ malperfusion is an independent predictor of acute type A aortic dissection. Coronary malperfusion requires treatment, but it is not feasible to treat all malperfusions. The adequacy of “central repair and coronary artery bypass grafting” for patients with coronary and other organ malperfusion is unknown. MethodsOf the 299 patients who underwent surgery between 2008 and 2018, 21 patients with coronary malperfusion, who received cental repair with coronary artery graft bypass, were analyzed retrospectively. They were divided; into Group M (n = 13, coronary and other organ malperfusion) and Group O (n = 8, coronary malperfusion only). The patient background, surgical content, details of malperfusion, surgical mortality and morbidity, and long-term outcome were compared. ResultsThere was no difference in operation time (205 ± 30 vs. 266 ± 88, p = 0.49), but the time from arrival to circulatory arrest tended to be shorter in Group M (81 vs. 134, p = 0.05). Among Group M, cerebral malperfusion was the most common at 92%. Two of the three cases with mesenteric malperfusion died. The mortality of Group M and Group O was 13% and 15% (P = 0.85), respectively. There was no difference in long-term mortality (p = 0.62). ConclusionsCentral repair and coronary artery bypass grafting is a sufficiently acceptable treatment for patients with acute type A aortic dissection and multi-organ malperfusion, including coronary malperfusion.

Intraoperative Hemodynamics of Parasylvian Cortical Arteries for Predicting Postoperative Symptomatic Cerebral Hyperperfusion after Direct Revascularization in Patients with Moyamoya Disease: A Preliminary Study.

Objective. The search for methods by which to predict the risks of cerebral hyperperfusion syn-drome (CHS) in adults with moyamoya disease (MMD), including those utilizing new biomarkers, still deserves further research. The objective of this study was to investigate the association between the hemodynamics of parasylvian cortical arteries (PSCAs) and postoperative CHS. Methods. A consecutive number of adults with MMD who had undergone direct bypass between September 2020 and December 2022 were recruited. Intraoperative microvascular doppler ultrasonography (MDU) was performed to evaluate the hemodynamics of PSCAs. The intraoperative flow direction, mean value of velocity (MVV) of recipient artery (RA) and bypass graft were recorded. According to flow direction after bypass, RA was divided into entering sylvian (RA.ES) and leaving sylvian (RA.LS) subtypes. Univariate, multivariate, and ROC analyses of the risk factors for postoperative CHS were performed. Results. A total of 16 (15.09%) cases in 106 consecutive hemispheres (101 patients) sat-isfied the postoperative CHS criteria. According to univariate analysis, advanced Suzuki stage, MVV of RA before bypass, and fold increase of MVV in RA.ES after bypass were significantly associated with postoperative CHS (p < 0.05). Multivariate analysis indicated that left-operated hemisphere (OR (95%CI), 4.58 (1.05-19.97), p = 0.043), advanced Suzuki stage (OR (95%CI), 5.47 (1.99-15.05), p = 0.017), and fold increase of MVV in RA.ES (OR (95%CI), 1.17 (1.06-1.30), p = 0.003) were statistically significantly associated with the occurrence of CHS. The cut-off value of fold increase of MVV in RA.ES was 2.7-fold (p < 0.05). Conclusions. Left-operated hemisphere, advanced Suzuki stage, and postoperative fold increase of MVV in RA.ES were potential risk factors for postoperative CHS. Intraoperative MDU was useful for evaluating hemodynamics and predicting CHS.

Successful treatment with urgent revascularization and parent artery occlusion for a ruptured intratumoral aneurysm following prior meningioma surgery: illustrative case.

An intratumoral aneurysm encased within the associated intracranial tumor is rare, and hemorrhage caused by its rupture is even more rare. While urgent and adequate surgical treatment is important, the treatment can be difficult given the limited understanding of this rare condition. A 69-year-old man who had undergone meningioma surgery 30 years prior presented with a disturbance in consciousness. Magnetic resonance imaging revealed massive intracerebral and subarachnoid hemorrhage. A round, partially calcified mass, which was diagnosed as recurrent meningioma, was also observed. Subsequent cerebral angiography revealed that the source of the hemorrhage was an intratumoral aneurysm in the dorsal internal carotid artery (ICA) encased within the recurrent meningioma. Urgent surgical ICA trapping and high-flow graft bypass were conducted. The postoperative course was uneventful, and he was referred to another hospital for rehabilitation. This is the first case report of a ruptured intratumoral aneurysm being treated with urgent combined revascularization and parent artery trapping surgery. This surgical approach may be a feasible treatment option for such a challenging condition. Additionally, this case highlights the importance of diligent long-term follow-up after skull-base surgery, as minor intraoperative vascular wall injury may trigger the development and rupture of an intracerebral aneurysm.

Penetrating Vascular Injuries of the Lower Limbs after Stab Wounds: Predictive Factors of Limb Loss and Mortality.

Penetrating vascular injuries (PVIs) of the lower limbs due to stab wounds are associated with high mortality and limb loss rates. We analyzed the outcomes of a series of patients who underwent surgical treatment of these lesions, assessing the presence of any factor associated with limb loss and mortality; (2) Methods: Data of patients admitted from 01/2008 to 12/2018 were retrospectively analyzed. Primary outcomes were the limb loss and the mortality rate at 30 days postoperatively. Univariate and multivariate analyses were performed as appropriate. p values < 0.05 were considered significant; (3) Results: Data of 67 male patients were analyzed. Two died (3%) and three (4.5%) had a lower limb amputation after failed revascularization. In the univariate analysis, the clinical presentation significantly affected the risk of postoperative mortality and limb loss. The location of the lesion at the superficial femoral artery (OR 4.32, p = 0.001) or at the popliteal artery (OR 4.89, p = 0.0015) also increased the risk. In the multivariate analysis, the need for a vein graft bypass was the only significant predictor of limb loss and mortality (OR 4.58, p < 0.0001); (4) Conclusions: PVIs of lower limbs due to stab wounds were lethal in 3% of cases and lead to a secondary major amputation in 4.5% more cases. The need for a vein bypass grafting was the strongest predictor of postoperative limb loss and mortality.

Treatment of Long Femoropopliteal Occlusive Lesions With Self-expanding Interwoven Nitinol Stent: 24 Month Outcomes of the STELLA-SUPERA-SIBERIA Register Trial.

The efficacy and safety of the Supera stent in superficial femoral artery (SFA) have been reported mostly in shorter lesions with relatively low proportion of occlusions. There are little data on the effectiveness of the Supera stent in long lesions. The aim of this study was to assess the clinical safety and efficiency of the Supera stent in the treatment of long femoropopliteal occlusive lesions (Trans-Atlantic Inter-Society Consensus [TASC] C/D) in patients with symptomatic peripheral artery disease. The STELLA-SUPERA-SIBERIA is a prospective, single-center, single-arm study. Patients with symptomatic (Rutherford stages 3-6) de novo and TASC C/D occlusive lesions of the femoropopliteal segment were treated with Supera stent. The primary endpoint was the 12 month rate of primary sustained clinical improvement (upward shift on the Rutherford classification to a one level without the need for repeated target lesion revascularization (TLR) in surviving patients without the need for unplanned amputation). Secondary endpoints were the 24 month of primary sustained clinical improvement, MALE, limb salvage, the primary patency, the secondary patency, 24 month MACE. Follow-up included clinical examination, duplex scan, and biplane x-ray up to 24 months. Between April 2019 and January 2020, 52 symptomatic patients with 55 long femoropopliteal occlusive lesions (52.7% TASC D lesions and 47.3% TASC C lesions) were treated. The mean target lesion length was 205±72 mm. All patients had total occlusions. The mean lesion length of the implanted Supera stents was 198±82 mm. At 12 and 24 months, the primary sustained clinical improvement rate was 80.2% and 63.6%, respectively. The Rutherford category assessment was significantly improved at 24 months compared with baseline (p=0.02). The primary patency rate at 12 and 24 months was 78.1% and 60.0%, respectively. At 12 and 24 months, freedom from TLR was 83.5% and 81.8%, respectively. There were no stent fractures at 24 months. Supera Stent implantation for TASC C/D femoropopliteal lesions revascularization appears to be a safe and efficient implant given the complexity of the treated lesions. Head-to-head studies are mandatory to establish Supera Stent as an alternative tool to open surgery for long femoropopliteal lesions. Our study indicated, that using self-expanding interwoven nitinol stent for TASC C/D femoropopliteal lesions revascularization appears to be a safe and efficient implant given the complexity of the treated lesions. Although bypass grafting is recommended for prolonged femoropopliteal lesions, open surgery is more traumatic and is associated with greater risks than endovascular procedures. Our findings suggest that the use of interwoven nitinol stents can overcome the disadvantages of traditional stents in such cases, which may help to improve patients' outcomes and reduce the risk of adverse events.

Two-step arterial reconstruction technique for en bloc resection of a large retroperitoneal liposarcoma involving the common iliac artery.

Retroperitoneal liposarcoma (RPLS) is a rare but challenging neoplasm, which is frequently associated with iliac vessel invasion. We describe how we used a two-step arterial reconstruction technique to perform en bloc resection of a large RPLS involving the iliac arteries in three patients. A temporal long in situ graft bypass was established using a prosthetic vascular graft during dissection of the tumor. This bypass provided an unobscured surgical field, while maintaining blood flow in the lower limb during the operation. After removal of the tumor and washing out the abdominal cavity, the new prosthetic vascular graft of a suitable length was placed. No graft-related complications, including vascular graft infection or graft occlusion, occurred during the follow-up period. This novel technique appears to provide a safe and effective way to remove large RPLSs involving the retroperitoneal major vessels.

Comparison of graft bypass surgery and endovascular ınterventional techniques ın ıliofemoral and above knee femoropopliteal arterial occlusion

ÖZ&#x0D; Amaç: Periferik damar hastalığı önemli morbidite ve mortalite ile ilişkilidir. Bu çalışmada iliofemoral ve diz üstü femoropopliteal arter tıkanıklığında cerrahi baypas greftleme ile endovasküler stentleme arasında bir karşılaştırma yaparak her bir tedavi yönteminin avantaj ve dezavantajlarını ortaya çıkarmaya çalıştık.&#x0D; Yöntemler: Ocak 2015 ile Aralık 2020 arasında 60 hasta bu çalışmaya dahil edildi. Hastalar tedavi yöntemlerine göre iki gruba ayrıldı. Grup I 33 hastadan oluşuyordu ve cerrahi baypas greftleme ile ameliyat edildi, grup II ise endovasküler girişim ile 27 hastadan oluşuyordu. Hastaların morbiditeleri, görüntüleme yöntemleri, tıkanıklığın lokalizasyonu, greft tipi ve endovasküler işlem, damar açıklığı, hastanede kalış süresi, kan transfüzyonu, revizyon ve komplikasyonlar değerlendirildi ve analiz edildi.&#x0D; Bulgular: Grup I'de femoral arter tıkanıklığı (%72.7) çoğunluktayken, Grup II'de iliak arter (%66.7) idi. Grup I'de 3, Grup II'de balon uygulanan 14 hasta vardı. Vasküler açıklık açısından Grup I'de 10 (%45,5) hastada greftler, Grup II'de ise 12 (%54,5) hastada stent tıkandı. Grup I'de on beş hastaya, Grup II'de altı hastaya kan transfüzyonu yapıldı.&#x0D; Sonuç Grup I'de greft açıklık oranı daha yüksek, cerrahi tedavinin yeniden revaskülarizasyon oranı endovasküler tedaviye göre daha düşüktü. En yüksek greft açıklık oranı, safen venlerden sonra Dakron greftlerde görüldü. Grup I hastalara Grup II hastalarından daha fazla kan transfüzyonu yapıldı ve hastanede kalış süreleri uzatıldı.

Computed tomographic angiography in coronary artery disease.

Coronary computed tomographic angiography (CCTA) is becoming the first-line investigation for establishing the presence of coronary artery disease and, with fractional flow reserve (FFRCT), its haemodynamic significance. In patients without significant epicardial obstruction, its role is either to rule out atherosclerosis or to detect subclinical plaque that should be monitored for plaque progression/regression following prevention therapy and provide risk classification. Ischaemic non-obstructive coronary arteries are also expected to be assessed by non-invasive imaging, including CCTA. In patients with significant epicardial obstruction, CCTA can assist in planning revascularisation by determining the disease complexity, vessel size, lesion length and tissue composition of the atherosclerotic plaque, as well as the best fluoroscopic viewing angle; it may also help in selecting adjunctive percutaneous devices (e.g., rotational atherectomy) and in determining the best landing zone for stents or bypass grafts.

Common peroneal neuroma in continuity with complete foot drop secondary to a bullet fragment injury

Background. Common peroneal nerve (CPN) injuries are generally common but they are uncommon due to gunshot injuries and are associated with poor motor outcomes. Managing neuroma-in-continuity is still challenging because there are currently no accepted standards for deciding on the most effective course of treatment or estimating the time needed for repair. Treatment options for a neuroma-in-continuity include neurolysis, neuroma resection with interposition, end-to-side nerve grafting, and bypass grafting. Case presentation. A 40-year-old man presented with findings of complete right foot drop due to an 8-month-old firearm injury to his right distal thigh. Following baseline investigations, imaging, and anaesthesia fitness, he underwent surgical exploration under general anaesthesia. A neuroma-in-continuity was found in the CPN, resected, and an end-to-end nerve repair was performed. Along with the neuroma-in-continuity, a bullet fragment was also removed. The neurological status remained unchanged postoperatively. Conclusion. Regardless of the cause of the lesion, patients should be urged to seek surgical therapy if there is no spontaneous recovery within four months after the CPN injury. Sharp injuries and knee dislocations have a better chance of recovery than crush injuries and gunshot wounds.

Abstract Number ‐ 221: Lower Thoracic Spinal Dural Arteriovenous Fistula Presenting With Progressive Paraplegia: A Case Report

Introduction We present a 72‐year‐old male with osteoarthritis, lumbar stenosis, coronary artery disease with a 4‐vessel bypass graft in February 2020, hypertension, hyperlipidemia, and obesity who presented with subacute progressive lower extremity weakness. He began having lower back pain following his cardiac surgery in February 2020. He was evaluated by a rehabilitation doctor in September 2020 who diagnosed him with lumbar radiculopathy and treated him with one round of steroid injections that helped a bit. Six months later he returned for follow‐up with the aid of a wheelchair which he started using in the last two weeks due to progressive lower extremity weakness. He was sent to the ED for neurologic evaluation. He denied radicular pain, saddle anesthesia, and urinary or bowel incontinence. Methods On neurologic exam, he had 2/5 bilateral hip flexion strength, 4/5 bilateral distal lower extremity strength, intact sensation to all modalities, and diffuse bilateral hyporeflexia (1+) with flexor plantar responses. An MRI brain was unremarkable. An MRI cervical, thoracic and lumbar spine with contrast showed extensive confluent cord edema with enhancement from T9 to the conus medullaris. He was started on high‐dose IV methylprednisolone for concern of transverse myelitis. Serum metabolic, hematologic, autoimmune, and infectious workup were negative. Due to a lack of improvement, his spinal imaging was reviewed with neuroradiology who recognized previously unidentified posterior T2 flow voids in the subarachnoid space at T1. A spinal angiogram for suspicion of a spinal dural arteriovenous fistula (dAVF) was subsequently scheduled. Results Angiography confirmed a type I spinal dAVF which was treated with posterior laminectomy and surgical ligation. The patient’s lower extremity strength improved and he was discharged to acute rehab. At his 1‐month neurology follow‐up appointment, he was ambulating with minimal assistance from a cane with near full lower extremity strength. Conclusions With an initial presentation of subacute progressive lower extremity weakness and imaging findings concerning for longitudinally extensive transverse myelitis, our initial suspicion was highest for an underlying autoimmune or infectious disease. However, this case teaches us to not presume all transverse myelitis or enhancing spinal cord lesions must be from an inflammatory, neoplastic, or infectious condition. A wide differential for this presentation including spinal dAVF is necessary as this is one of the most commonly missed neurovascular diagnoses. T2 flow voids are highly suggestive of this condition, but a spinal angiogram is the gold standard for diagnosis.

Self-Made Bovine Pericardial Tube Grafts for the Treatment of Abdominal Aortic Infections

Aortic infections are an uncommon but life-threatening disease. The material of choice for aortic reconstruction is still a matter of debate. The aim of this study is to examine the short and mid-term outcomes in the treatment of abdominal aortic infections using self-made bovine pericardium tube grafts. This retrospective, single-center study collected all patients who underwent in situ abdominal aortic reconstruction using self-made bovine pericardial tube grafts between February 2020 and December 2021 in a tertiary care center. Patient comorbidities, symptoms, radiological, bacteriological and peri-operative findings, as well as postoperative outcomes were analyzed. Bovine pericardial aortic tube grafts were used in 11 patients (10 male, median age 68.7 years). Two patients presented a native aortic infection and nine had graft infections (four bypass grafts, four endografts and a plurioperated patient who had undergone both endovascular and open procedures). There were two emergent surgeries due to infectious aneurysm ruptures. All patients were symptomatic and the most frequent clinical finding was lumbar or abdominal pain (36%), followed by wound infection (27%) and fever (18%). Seven bifurcated and four straight pericardial tube grafts were needed. Purulent drainage was obtained around the previous graft or in the aneurysmal sac in 7 cases; intraoperative cultures were positive in 6 cases (Gram + bacteria). Two patients died in the immediate postoperative period (perioperative mortality 18%; urgent procedures 50%; scheduled procedures 11%). One patient had a major complication due to bilateral SARS-CoV2 pneumonia. There was one single reintervention to control hemostasis due to bleeding non-graft-related. The median follow-up was 14.1 months (3-24 months). Our preliminary experience in the treatment of abdominal aortic infections by in situ reconstrucción with self-made bovine pericardial tube grafts shows promising results. These should be confirmed in the long term.

Antithrombotic monotherapy for stable coronary artery disease and atrial fibrillation patients with and without prior coronary artery revascularization: Insights from the AFIRE trial

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Japan Cardiovascular Research Foundation under a contract with Bayer Yakuhin Background The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial demonstrated that rivaroxaban monotherapy was noninferior to combination therapy with rivaroxaban plus a single antiplatelet therapy regarding efficacy and superior for safety endpoints in patients with atrial fibrillation and stable coronary artery disease including patients not requiring revascularization [prior percutaneous coronary intervention (PCI) or bypass grafting (CABG)]. Purpose The aim of this post-hoc subgroup analysis was to investigate the efficacy and safety of rivaroxaban monotherapy compared to combination therapy in patients with and without prior revascularization. Methods Among 2,215 patients included in the modified intention-to-treat analysis in the AFIRE trial, 1445 patients (65.2%) had undergone previous PCI alone, and 252 (11.4%) had undergone previous CABG. The remaining 518 patients (23.4%) was categorized as a group without prior revascularization and then compared with a group with prior revascularization (PCI or CABG). The primary efficacy end point was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, or death from any cause. The primary safety end point was major bleeding, according to the criteria of the International Society on Thrombosis and Hemostasis. Results In 1697 patients with prior revascularization, efficacy and safety endpoints of rivaroxaban monotherapy were superior to combination therapy (efficacy: HR 0.62, 95%CI 0.45-0.85, p=0.003; safety: HR 0.62, 95%CI 0.39-0.98, p=0.040), whereas there were no significant differences in efficacy and safety endpoints among 518 patients without prior revascularization (efficacy: HR 1.19, 95%CI 0.67-2.11, p=0.553; safety: HR 0.47, 95%CI 0.18-1.26, p=0.125). There was a borderline interaction of efficacy endpoint (P for interaction=0.055) by randomized treatment assignment (Figure 1 and Figure 2). Compared with combination therapy, the safety benefit of rivaroxaban monotherapy on any bleeding was significant in patients without prior revascularization (HR 0.59, 95%CI 0.38-0.93, p=0.022). Conclusions In patients with prior PCI or CABG, rivaroxaban monotherapy resulted in more favorable safety and efficacy outcomes than combination therapy. There was a borderline interaction for primary efficacy outcome between prior revascularization and anti-thrombotic therapy.

An Observational Study on Clinical Profile and Management of Transatlantic Intersociety Consensus II C and D Aortoiliac and Femoropopliteal Occlusive Diseases: Role of Hybrid Procedures in Hybrid Operation Theater

Objective: Peripheral arterial disease is a powerful predictor of the loss of limb and even loss of life. Endovascular treatment (ET) and hybrid procedures are gradually replacing open procedures. The purpose of this study is to evaluate the management outcome of transatlantic intersociety consensus (TASC) C and D aortoiliac (AI) and femoropopliteal (FP) disease by various methods. Materials and Methods: Prospective observational study was done at Army Hospital (Research and Referral) Delhi Cantt from June 2015 to January 2017. Patients with TASC C and D AI and FP lesions were included. Patients were treated with either open, endovascular or hybrid technique and followed at 1, 3, and 6 months. Results: A total of 110 (36 AI and 74 FP) patients were included. 96.3% were smokers. Seventeen were TASC C and 93 were TASC D lesions. Fourteen out of 17 TASC C lesions could be managed by endovascular, two by hybrid and only one required open reconstruction. Whereas 58 out of 93 TASC D lesions needed to be opened, 15 were endovascular, and the rest 20 cases were managed by hybrid procedures. One had an iliac artery rupture managed with bypass graft. We have seven mortalities two within 30 days and five from 30 days to 1-year primary and secondary patency for ET was 72.4% and 80%, for open surgery was 76.2% and 93% and for hybrid procedure was 60% and 77.7%. Conclusions: Hybrid therapy simplifies and allows the one-step treatment with complex peripheral multifocal steno-obstructive vascular disease with high technical success rate and excellent long-term patency in few patients.