Composite Graft Research Articles

AMI-PONT PROSPECTIVE RANDOMIZED CLINICAL TRIAL FOR ANTEROLATERAL TERRITORY CORONARY ARTERY BYPASS GRAFTING STRATEGIES

AMI-PONT PROSPECTIVE RANDOMIZED CLINICAL TRIAL FOR ANTEROLATERAL TERRITORY CORONARY ARTERY BYPASS GRAFTING STRATEGIES

BioBentall procedure and autological materials in aortic root surgery

The BioBentall procedure has many options, but the optimal approach is still not determined. Alternative options for aortic root surgery include Ross procedure and modification of the Bentall – De Bono procedure using autologous pericardium leaflets. This literature review showed topical issues of surgical technique and the results of various modifications of the BioBentall operation, as well as methods of the aortic root repair using autologous materials. The search strategy included the analysis of international (PubMed, Scopus, Embase) and Russian’s databases (Russian Science Citation Index). The BioBentall procedure demonstrates satisfactory early and long-term results comparable to both the classic Bentall – De Bono procedure and valve-sparing techniques. Composite grafts containing frameless bioprostheses seem to be more promising and durable in comparison with stent-grafts, however, given the minimal amount of publications directly comparing these techniques, further study of this hypothesis is necessary. Total xenopericardial conduits have demonstrated higher rates of degradation and are currently not recommended for use, as demonstrated in most foreign studies. Modified Ross procedure shows excellent hemodynamic outcomes in the long-term follow-up, however, the literature data regarding its applicability in a cohort of patients with proximal aortic aneurysms are limited. The combination of the Bentall – De Bono procedure and autopericardial neocuspidization seems to be a promising and cost-effective method, however, this approach requires a clinical assessment, which results have not been yet published. Received 26 February 2022. Revised 20 April 2022. Accepted 21 April 2022. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Contribution of the authorsConception and study design: R.N. Komarov, A.M. IsmailbaevDrafting the article: A.N. Dzyundzya, A.O. Danachev, O.O. Ognev, M.V. LencovetsCritical revision of the article: S.V. CherniavskiiFinal approval of the version to be published: R.N. Komarov, A.M. Ismailbaev, S.V. Cherniavskii, A.N. Dzyundzya, A.O. Danachev, O.O. Ognev, M.V. Lencovets

The strategy of composite grafting with BMP2-Loaded calcium phosphate cements and autogenous bone for alveolar cleft reconstruction.

Purpose: To remedy the drawbacks of traditional autogenous bone harvesting in alveolar bone grafting (ABG), a novel strategy of composite grafting with BMP2-loaded calcium phosphate cements (BMP2-CPC) and autogenous bone harvested by minimally invasive technique was developed and evaluated for its bone-repairing efficacy. Materials and methods: A chart review was conducted for 19 patients with unilateral alveolar clefts who underwent secondary ABG from 2017 to 2020. Of the enrolled patients, 9 patients underwent grafting with autogenous bone harvested by traditional trap door technique (group I), and 10 patients underwent grafting with the composite graft comprising BMP2-CPC and autogenous bone harvested by minimally invasive technique at a ratio of 1:1 by volume (group II). The clinical performance of the composite graft was comprehensively evaluated in terms of clinical, radiographic and histological perspectives. Results: The present results demonstrated that the composite graft exhibited satisfactory bone-repairing efficacy comparable to that of the autogenous bone graft on the premise of lower amount of harvested bone. The post-surgical resorption of bone volume and vertical height of grafted area was significantly slower in group II. The favourable resorption performance of BMP2-CPC contributed to preserving the post-surgical bony contour reconstructed with the composite graft. Conclusion: The composite graft comprising BMP2-CPC and autogenous bone harvested by minimally invasive technique was demonstrated to be an eligible alternative for application in ABG, especially for its improved resorption performance in preserving post-surgical bony contour.

Effect of the combination of composite skin grafting and recombinant human basic fibroblast growth factor on plastic surgery for extensive sc ars after burns

Purpose: To investigate the effect of combined use of composite skin grafting and recombinant human basic fibroblast growth factor (rh-bFGF) on plastic surgery for extensive burn scars, and its influence on wound healing and inflammatory responses in patients.
 Methods: Hospital records of 120 patients who underwent extensive scar plastic surgery after burns in Hanchuan People’s Hospital from February 2019 to February 2020 were retrospectively analyzed. The patients were equally assigned to study group (STG) and control group (COG), based on the order of admission. All patients received composite skin grafting surgery and post-surgery topical silver sulphadiazine cream regularly, while those in study group (STG) received additional treatment with rh-bFGF spray on the wound surfaces. Scar scores, degree of wound healing, populations of fibrocytes and capillaries, levels of vascular endothelial growth factor (VEGF) and transforming growth factor-β1 (TGF-β1), and activities of lactate dehydrogenase (LDH) and succinate dehydrogenase (SDH) were evaluated.
 Results: Patients in STG had significantly better scar scores, shorter mean wound healing time, higher mean degree of wound healing, higher scores on inflammatory reactions near the wounds, and higher populations of fibrocytes and capillaries, when compared with patients in COG group (p < 0.001). After surgery, there were lower levels of VEGF and TGF-β1, and lower levels of activities of LDH and SDH in STG than in COG group (p < 0.001).
 Conclusion: Rh-bFGF accelerates the proliferation of wound tissue, improves local microcirculation, regulates inflammatory response, and enhances wound healing in burn scar patients when used in combination with composite skin grafting. Therefore, Rh-bFGF has a potential for enhanced management of burn scars.

Long-Term Outcomes of Cardiovascular Operations in Children With Connective Tissue Disorders

Connective tissue disorders can be associated with significant cardiovascular morbidity needing cardiac surgery during childhood. In this retrospective study, we used the Pediatric Cardiac Care Consortium, a multicenter United States-based registry of pediatric cardiac interventions, to describe the long-term outcomes of patients who underwent their first surgery for connective tissue-related cardiovascular conditions aged <21 years. Between 1982 and 2003, a total of 103 patients were enrolled who underwent cardiac surgery for a connective tissue-related cardiovascular disorder, including 3 severe infantile cases operated on within the first year of life. Most patients underwent aortic site surgery (n = 85) as a composite graft (n = 50), valve-sparing (n = 33), or other aortic surgery (n = 2). The remaining patients underwent atrioventricular valve surgery (mitral 17, tricuspid 1). Of the 99 patients surviving to discharge, 80 (including the 3 infantile) had adequate identifiers for tracking long-term outcomes through 2019 through linkage with the National Death Index and the Organ Procurement. Over a median period of 19.5 years (interquartile range 16.0 to 23.1), 29 deaths and 1 transplant occurred in the noninfantile group, whereas all 3 infantile patients died before the age of 4 years. The postdischarge survival for the noninfantile group was 92.2%, 68.2%, and 56.7% at 10, 20, and 25 years, respectively. Cardiovascular-related pathology contributed to all deaths in the infantile and 89% (n = 27) of deaths for the noninfantile cases after hospital discharge. The significant late attrition from cardiovascular causes emphasizes the need for close monitoring and ongoing management in this population.

343.3: Outcomes of Primary Simultaneous Pancreas-Kidney Transplants by Induction Agent in the United States

Background: Induction immunosuppression choice for simultaneous pancreas-kidney (SPK) transplants varies widely in the United States. We examined the association between induction agents and outcomes of SPK recipients discharged on tacrolimus and mycophenolate. Methods: We used the Scientific Registry of Transplant Recipients to examine all primary SPK transplants between 2000 and 2020, excluding crossmatch positive recipients and those with other induction regimens. We grouped recipients according to induction regimen used into three groups: anti-thymocyte globulin (n=5678), alemtuzumab (n=1199) and IL-2 RA (1593). Delayed graft function, acute kidney and pancreas rejection rates were compared by type of induction. We analyzed the ten-year recipient and composite (kidney and pancreas) grafts survival using Kaplan-Meier survival function. Cox proportion hazard models were utilized to examine the association between induction type and the ten-year recipient and grafts survival. Models were adjusted for recipient age, sex, ethnicity, HLA-MM, diabetes type, dialysis dependency, cold ischemia time, local vs imported organs, PRA, steroid maintenance and PDRI. Results: Delayed graft function rate was observed in less than 6.5% of the recipients and did not differ between groups P=0.68. One-year kidney rejection rates were observed in 8.9% of the anti-thymocyte group, 9.5% of the IL-2RA group and 13% in the alemtuzumab group (p<0.001). Similarly, one-year pancreas rejection rates were observed in 9.5% of the anti-thymocyte group, 12.4% of the IL-2RA group and 14.1% in the alemtuzumab group (p<0.001). In the univariable analysis, induction type was not associated with recipient (log-rank p=0.11) or grafts survival (log-rank p=0.36). In the multivariable model for the composite grafts survival, alemtuzumab use was associated with 22% increased kidney or pancreas graft loss compared to anti-thymocyte globulin (LLCI, aHR, ULCI) (1.05, 1.22, 1.42), while IL-2RA use was not a predictor of worse grafts survival. Induction type didn’t influence recipient survival in the adjusted model. Conclusion: r-ATG use was associated with the lowest kidney and pancreas rejection rates. Compared to r-ATG, alemtuzumab but not IL-2RA was associated with worse long-term death-censored SPK grafts outcome. Our analysis supports the US national popularity of r-ATG induction in primary SPK recipients.

Simultaneous Alveolar Ridge Augmentation and Periodontal Regenerative Therapy Leveraging Recombinant Human Platelet-Derived Growth Factor-BB (rhPDGF-BB): A Case Report

Severe alveolar ridge deficiencies in concomitance with periodontal attachment loss can represent a serious clinical challenge in the context of implant therapy. The present case report describes the management of a complex defect in the esthetic zone via ridge augmentation and periodontal regenerative therapy using a biologic material. A systemically healthy 55-year-old man diagnosed with peri-implantitis around an implant in the maxillary left central incisor position and with severe bone loss on the mesial aspect of the maxillary left lateral incisor underwent several surgical interventions to achieve simultaneous vertical ridge augmentation and periodontal regeneration. These interventions included implant removal, bone augmentation using a composite bone graft (autogenous bone + xenograft particles), and a bioactive protein (recombinant human platelet-derived growth factor), soft tissue augmentation using connective tissue grafts, and peri-implant keratinized mucosa width augmentation via a labial gingival graft strip and a xenogeneic collagen matrix. Substantial gains in vertical bone and clinical attachment were achieved, which allowed for delayed implant placement and subsequent completion of tooth replacement therapy with an implant-supported prosthesis. The present case report demonstrates how simultaneous vertical ridge augmentation and periodontal regeneration can be achieved to manage a challenging clinical situation. Key factors to consider in this type of scenario are proximal bone level, tooth mobility, surgical flap design and management, biomaterial selection, and proper treatment sequencing.

Saving a large volume of soft tissue by using an untailored composite graft after total degloving amputation of the hand: a case report

Total degloving amputations present surgeons with unique challenges to preserve function and prevent amputation of the digits. Obviously, the replantation of avulsed skin is the best option; however, there are situations in which vascular networks are severely contused, making it difficult to restore the circulation, due to the crushing mechanism of injury. As an alternative, defatted or meshed skin grafts from the avulsed skin have been proposed. However, those options have not been proven to guarantee viable digits. Moreover, the application of thinned skin grafts usually results in cosmetically and functionally unsatisfactory outcomes due to the lack of sufficient tissue volume. We present a case in which we successfully saved a large volume of the amputated stump with minimal digit amputation by performing a composite graft of the untailored (i.e., without defatting or meshing) avulsed skin on a totally degloved hand.

Endoscopic Fascia-Cartilage Composite Grafting in Chronic Suppurative Otitis Media

Objective: To evaluate perforation of an air-bone gap closure success using fascia-cartilage composite graft in endoscopic Trans canal tympanoplasty.&#x0D; Study Design: Randomized Control Trial (Clinical Trials.gov Identifier: NCT04945811)&#x0D; Place and Duration of Study: ENT Department Combined Military Hospital, Quetta Pakistan, from Apr 2020 to May 2021&#x0D; Methodology: One hundred and thirty-three cases of chronic Suppurative otitis media fulfilling the selection criteria were operated upon, and an endoscopic fascia-cartilage composite graft was used. A successful outcome in terms of perforation closure and air-bone gap closure was evaluated in all patients.&#x0D; Results: In the 138 patients operated, complete fascia-cartilage composite graft uptake was achieved in 129 (93.5%) patients. Nine (6.5%) patients had graft failure. The pre-operative mean air-bone gap was 36.49 ± 4.61 decibels, and the postoperative mean air-bone gap was 12.57 ± 5.09 decibels. This improvement was found to be significant, with the p-value &lt; 0.001.&#x0D; Conclusion: Endoscopic per-meatal fascia-cartilage composite grafting has a high graft uptake and air-bone gap closure percentage in chronic Suppurative otitis media cases.

Endoscopic closure of tympanic membrane anterior perforation using a strip-type chondroperichondrial graft.

Myringoplasty is a surgical procedure to reconstruct tympanic perforation. However, repair of anterior perforations is still challenging. To analyze the anatomical and hearing outcomes of myringoplasty with a new technique of chondroperichondrial graft via endoscopy, 23 adult patients were retrospectively analyzed. All patients had anterior perforations of tympanic membranes that were repaired with a composite strip-type cartilage-perichondrium graft through a total endoscopic transcanal approach. The anatomical graft success rate at postoperative 1 month was 86.96% (20/23) and reached 100% at the 6- and 12-month follow-up. Compared to the preoperative air conduction threshold (44.7 ± 13.56 dB) and air-bone gap (ABG) (22.35 ± 6.54 dB), the postoperative air conduction threshold and ABG decreased to 33.52 ± 10.88 dB and 12.52 ± 3.94 dB, respectively (P < .0001). Twenty-two (95.65%) patients had an ABG below 20 dB postoperatively. The mean ABG improvement in our cohort was 9.83 ± 5.00 dB. The functional graft success rate was 95.65% (22/23). The convenience, reliability, time, and labor savings accrued from the approach described here make it a good choice for repair of anterior perforation of tympanic membrane.

Electrospun PCL/collagen hybrid nanofibrous tubular graft based on post-network bond processing for vascular substitute.

Inhibiting thrombus formation and intimal hyperplasia is essential for orthotopic tissue-engineered vascular grafts. The matching mechanical properties of autologous blood vessels and inhibition of platelet aggregation are considered as two points to improve the success rate of transplantation. The poly(ε-caprolactone)/collagen/heparin composite vascular graft (PCLHC) with three-dimensional network structure were constructed by electrospinning, which can mimic natural vascular biomechanics and enhance the viability of cells viability in vitro. The hybrid collagen matrix network nanofibers formed by electrospinning exhibited uniform and smooth morphology. The results of mechanical experiments showed that PCLHC had similar mechanical properties to natural blood vessels. And the addition of heparin enhanced the anticoagulation of PCLHC. Simultaneous three-component hybrid nanofibers showed a potentially reliable ability to promote the proliferation of human umbilical vein endothelial cells (HUVECs). In summary, all the results showed that the three-dimensional network structure of PCLHC presented the potential to heal injured vessels.

Bony Cartilaginous Graft in Unilateral Cleft Lip Rhinoplasty.

Cleft rhinoplasty is a challenging form of nasal correction of both esthetic and functional deformities. The septal cartilage in many Asian patients are not sufficient and weak. Does a combination of the septal cartilage and the bony septum have both esthetic and functional benefits to secondary unilateral cleft rhinoplasty? Thirty patients with a unilateral cleft lip palate underwent open rhinoplasty from October 2018 to January 2021. After preserving a 10mm L-strut, the posterior cartilaginous and bony septum were harvested as an integrative unit. The osteocartilaginous graft was used as a caudal septal extension graft and an extended spreader graft. Correcting the asymmetry of the tip and tip projection followed. The intraoperative harvested composite graft was analyzed. Acoustic rhinometry and the 3-dimensional anthropometric measurements of the external nose were assessed before and after surgery. The osteocartilaginous unit was much larger than the cartilaginous part of this unit. The mean nasal tip height and the nasolabial angle increased significantly after surgery. The measurement of cross-sectional areas and volumes by acoustic rhinometry revealed that septorhinoplasty provided a significant increase in the function of both nasal cavities. This septal bony cartilaginous graft is effective for cleft lip nasal deformity when correcting the deviated septum, creating a supporting frame to correct the nasal tip asymmetry, improving function.

Partial Lateral Eyebrow Defect Reconstruction Using the Contralateral Orbicularis Oculi Muscle Pedicled Skin Island Flap: A Case Report

The reconstruction of scarring eyebrow defects is a challenging task for plastic surgeons as the eyebrow is an important cosmetic landmark of the face. Various methods are used for eyebrow reconstruction; free hair follicle transplantation, scalp composite graft, local flap transposition, and hair-bearing island scalp flap have been widely reported in the past and are applied according to the size and position of the eyebrow defect. For partial eyebrow defects, the best option is the use of local flaps from the remaining ipsilateral eyebrow, which have characteristics highly similar to those of the recipient site. Herein, we present a case in which an orbicularis oculi muscle pedicled flap from the contralateral eyebrow was used as a donor site with good results.

Use of Composite Acellular Dermal Matrix-Ultrathin Split-Thickness Skin in Hand Hot-Crush Injuries: A One-Step Grafting Procedure.

Background Hot-crush injuries to the hands can be devastating, and early debridement and coverage with skin autograft remains the golden standard of wound treatment. However, this type of treatment is not feasible or unlikely to succeed due to limited donor sites and wound characteristics of hot-crush injuries on hands. Thus, the composite grafting of acellular dermal matrix (ADM) and split-thickness skin graft (STSG) as a novel alternative method has been attempted. In this series, the results are presented to demonstrate the feasibility and effectiveness of the use of one-stage procedure for early reconstruction in hand hot-crush injuries. Methods All consecutive patients with hand hot-crush injuries, who underwent one-stage procedure of ADM and ultrathin STSG for soft tissue coverage at our institution from December 2018 to November 2019, were retrospectively analyzed. Wound dressings were opened on 7 days after operation to examine graft survival and complications. Patients were followed up for at least 9 months to evaluate their hand profiles. Results Samples of 14 patients with a total of 23 wounds were involved in the study. Thirteen of the 23 third–fourth-degree wounds had varying degrees of tendon exposure. On 7 days postoperation, the composite grafts survived in 12 patients with minimal focal graft losses and liquefaction and necrosis in 2 patients, which achieved successful healing following new coverage of ultrathin STSG. All the wounds healed with hospital stays ranging from 9 days to 32 days (median: 24.5 days). At the final follow-up (from 9 months to 20 months), all patients achieved excellent or good total active motion grade and good scar quality (Vancouver scar scale scored 1–3) with no revision surgery. Conclusions One-stage composite grafting of ADM and ultrathin STSG is a reliable alternative for early reconstruction in hand hot-crush injuries, which delivers good functional outcomes and a good cosmetic appearance.

499 A novel preclinical model for translating an induced pluripotent stem cell therapy for the treatment of skin diseases

Induced pluripotent stem cells (iPSCs) hold promise for treating recessive dystrophic epidermolysis bullosa (RDEB). An iPSC-based therapy for RDEB involves multiple steps such as reprogramming, gene correction, iPSC differentiation, and transplantation of genetically corrected iPSC-derived skin cells onto patients. Strong evidence supports the use of epidermal sheets or composite skin grafts as final therapeutic products for the transplantation of genetically corrected iPSC-derived skin cells. However, the generation of epidermal sheets or composite grafts is a lengthy and consequently expensive process.

Treatment of Infected Nonunions With Bone Defects Using Autologous Bone Graft and Absorbable Antibiotic-Loaded Calcium Sulfate-Hydroxyapatite Paste.

Revision surgery in the presence of infection carries high risks. We describe our results using a new technique to treat these challenging problems. We treated infected nonunions with cavitary voids with adjuvant antibiotic loaded calcium sulfate-hydroxyapatite paste composite and autologous bone graft (ABG) layer technique coupled with stable fixation. Thirty consecutive patients who underwent revision foot and ankle surgery for an infected nonunion were prospectively studied. Following multidisciplinary team workup, surgical debridement and biopsies were undertaken. Bone voids were measured and classified according to containment and size. ABG was mixed and layered with an adjuvant antibiotic-loaded calcium sulfate-hydroxyapatite paste followed by surgical reconstruction including arthrodesis and fixation. Empirical and pathogen-specific antibiotics were instituted until intraoperative sample-specific antibiotics were identified and used. Patients were prospectively followed up for a minimum of 1 year. The male-female ratio was 16:14, mean age was 51.3 years, and 23.3% smoked at definitive surgery. Void volume was <1 cm3 (n=9), 1-2 cm3 (n = 13), and >2 cm3 (n=8). No patients either were lost to follow-up or had a further infective episode at a mean of 38.3 months; 86.7% united with fusion on imaging. Four patients had radiographic evidence of nonunion; 3 were asymptomatic and 1 required revision surgery (void >2 cm3). Independent ambulation was achieved at an average of 12 weeks, at 1 year mean American Orthopaedic Foot & Ankle Society score was 77.7 (SD 9.59), and the Manchester-Oxford Foot Questionnaire reached an effect size >0.5 in all domains at 1 year following surgery. The union rate was independent of smoking status and vitamin D deficiency (P = .94). Layered autologous bone grafting with adjuvant antibiotic-loaded calcium sulfate-hydroxyapatite paste has been shown to be effective and safe in revision arthrodesis, with low comorbidities in void gaps without infection recurrence.

Characterization of a cotton-wool like composite bone graft material

Bone graft materials are applied in patients to augment bone defects and enable the insertion of an implant in its ideal position. However, the currently available augmentation materials do not meet the requirements of being completely resorbed and replaced by new bone within 3 to 6 months. A novel electrospun cotton-wool like material (Bonewool®, Zurich Biomaterials LLC, Zurich, Switzerland) consisting of biodegradable poly(lactic-co-glycolic) acid (PLGA) fibers with incorporated amorphous ß-tricalcium phosphate (ß-TCP) nanoparticles has been compared to a frequently used bovine derived hydroxyapatite (Bio-Oss®, Geistlich Pharma, Wolhusen, Switzerland) in vitro. The material composition was determined and the degradation behavior (calcium release and pH in different solutions) as well as bioactivity has been measured. Degradation behavior of PLGA/ß-TCP was generally more progressive than for Bio-Oss®, indicating that this material is potentially completely resorbable.Graphical abstract

Development of Injectable Calcium Sulfate and Self-Setting Calcium Phosphate Composite Bone Graft Materials for Minimally Invasive Surgery.

The demand of bone grafting is increasing as the population ages worldwide. Although bone graft materials have been extensively developed over the decades, only a few injectable bone grafts are clinically available and none of them can be extruded from 18G needles. To overcome the existing treatment limitations, the aim of this study is to develop ideal injectable implants from biomaterials for minimally invasive surgery. An injectable composite bone graft containing calcium sulfate hemihydrate, tetracalcium phosphate, and anhydrous calcium hydrogen phosphate (CSH/CaP paste) was prepared with different CSH/CaP ratios and different concentrations of additives. The setting time, injectability, mechanical properties, and biocompatibility were evaluated. The developed injectable CSH/CaP paste (CSH/CaP 1:1 supplemented with 6% citric acid and 2% HPMC) presented good handling properties, great biocompatibility, and adequate mechanical strength. Furthermore, the paste was demonstrated to be extruded from a syringe equipped with 18G needles and exerted a great potential for minimally invasive surgery. The developed injectable implants with tissue repairing potentials will provide an ideal therapeutic strategy for minimally invasive surgery to apply in the treatment of maxillofacial defects, certain indications in the spine, inferior turbinate for empty nose syndrome (ENS), or reconstructive rhinoplasty.

The treatment of an Allen type III fingertip injury with a composite graft: A case report and review of the literature

Fingertip injuries are frequently seen and there are many treatment options. Small defects with limited exposure of the bone can be treated conservatively with healing by secondary nature. Good results can be achieved with standard dressings or a semi-occlusive dressing. With larger defects, surgical treatment is needed. Local advancement flaps can be used when there is sufficient local tissue. If this is not present, a pedicle flap or tissue transfer is needed. The non-microsurgical refixation of the amputated part as a composite graft yields excellent results in children. It is, however, not frequently used in adults, due to the less favourable results. In this case report, an Allen type III fingertip amputation was successfully treated by non-microsurgical re-fixation of the amputated fingertip. At final follow up, 18 months after injury, there was a satisfactory aesthetic and functional result. Although smaller in size, the fingertip resembled the other fingers with normal nail growth. Sensibility had recovered moderately and cold intolerance was present. However, the patient was very satisfied with the result and did not experience any limitations during daily activities.In conclusion, the use of a composite graft in Allen type III fingertip injuries is a viable option in selected cases.

Composite Grafts as an Alternative Conduit to Prosthetic Grafts in Below Knee Femoro-popliteal Bypass in Patients of Chronic Lower Limb Ischemia

Composite Grafts as an Alternative Conduit to Prosthetic Grafts in Below Knee Femoro-popliteal Bypass in Patients of Chronic Lower Limb Ischemia