Cumulative Patency Rate Research Articles

Impact of the Result of Continued Thrombolysis After Stenting Following Pharmacomechanical Thrombectomy for Iliofemoral Deep Vein Thrombosis-A Retrospective Study.

ObjectiveThe aim of this study is to compare the procedure and treatment outcomes of using either direct stenting alone following pharmacomechanical thrombectomy or continued catheter-directed thrombolysis after stenting for treatment of acute left iliofemoral deep vein thrombosis while clot removal degree achieved grade III.MethodsFrom March 2018 to May 2019, 82 patients who underwent iliac venous stenting for treatment of acute left iliofemoral deep vein thrombosis with iliac vein stenosis after pharmacomechanical thrombectomy therapy using the AngioJet system while Clot removal degree achieved grade III were divided into two groups: Direct stenting alone group (n = 39) and continued catheter-directed thrombolysis after stenting group (n = 43). Comparisons were made regarding the treatment outcomes, stent patency rate, and Villalta scale between these two groups.ResultsNo serious perioperative complications occurred. The mean urokinase dose and hospitalization time in the stenting alone group and continued catheter-directed thrombolysis after the stenting group were 0.30 million U versus 1.76 ± 0.54 million U and 4.85 ± 0.93 days versus 6.33 ± 1.02 days, (P < .001). In the first 30 days after the operation, there were 3 recurrent episodes of deep vein thrombosis in the stenting alone group (P = 0.064). Each patient has completed at least one year of follow-up, the mean follow-up was 15.95 ± 3.44 months. Overall cumulative stent patency rates were 87.2% in stenting alone group and 97.7% in continued catheter-directed thrombolysis after stenting group at 12months (P = 0.037). The Villalta scores at 12 months had a significant difference between the two groups. The mean Villalta scores in the stenting alone group and continued catheter-directed thrombolysis after the stenting group were 4.44 ± 1.63 and 1.63 ± 1.29, respectively (P < 0.001).ConclusionWhen the clot removal degree of pharmacomechanical thrombectomy thrombectomy reaches grade III, both stenting alone and continued catheter-directed thrombolysis after stenting are effective treatment modalities. For young patients with low bleeding risk, continued catheter-directed thrombolysis after stenting has a better patency rate and a lower 1-year post-thrombotic syndrome risk and does not increase major bleeding events. However, it may increase the time and costs of hospitalization accordingly.

Significance of Distal Runoff Score as a Key Influencer on Clinical Outcomes after Endovascular Interventions for Superficial Femoral Artery Disease

Endovascular therapy (EVT) is being adopted by many surgeons as a suitable first choice in the treatment of most femoropopliteal disease when clinically indicated. However, there are multiple factors affecting the outcome of EVT including the anatomy of lesions and distal runoff status. The evidence of runoff effect on the outcome of superficial femoral artery (SFA) interventions is still scarce and not well studied in the current literature. The aim of this study was to investigate the effect of runoff score on the outcomes of SFA endovascular interventions. Retrospective analysis was carried out on prospectively collected data on patients who underwent SFA endovascular intervention for critical limb ischemia (CLI) in a single tertiary center. Patients with Rutherford categories 4, 5, and 6 who did not have any previous vascular interventions were included in the study. The modified SVS runoff score was used after calculating scores from popliteal and all tibial vessels. Runoff was stratified into good (score <5), compromised (score 5-10), and poor (score >10). Amputation-free survival, patency rates, and overall survival were compared between all groups at 5 years. Between 2011 and 2018, 254 procedures were performed in 220 patients. Technical success was >92%; 66 patients required SFA stents, and 55 had concomitant tibial angioplasty. There was no significant difference between good, compromised, or poor runoff groups regarding complication rates, with 3.5% overall perioperative mortality (5 cases in the compromised group and 4 in the poor runoff group). A runoff score of <5 was associated with significantly marked clinical improvement (P<0.001). Patency rates were significantly worse in the compromised and poor runoff groups, with 5-year cumulative primary patency rates of 80%, 50%, and 22% in the good, compromised, and poor runoff groups, respectively (P<0.001). Amputation-free survival worsened as the runoff got poorer with 98%, 91%, and 78% in the good, compromised, and poor runoff groups, respectively, at 5 years (P<0.001). SFA stenting and concomitant tibial angioplasty led to slight improvement in patency rates in the poor runoff group. Poor runoff with a score of >10 was associated with significantly reduced amputation-free survival and patency rates at 5 years in patients undergoing SFA endovascular intervention for CLI. Patients with a runoff score of <5 showed marked clinical improvement postoperatively when compared with patients with a runoff score of ≥5.

Self-Expandable Nitinol Stents for the Treatment of Nonmalignant Deep Venous Obstruction

Angioplasty with stent placement is a therapeutic option for patients with acute thrombotic, postthrombotic, and nonthrombotic obstruction of the iliofemoral veins or inferior vena cava. Previous studies of steel-alloy stents described variable patency rate across indications. The prospective Swiss Venous Stent Registry includes patients treated with self-expandable nitinol stents for deep venous obstruction. Routine follow-up visits include serial duplex ultrasound for stent patency assessment. The primary outcome was primary stent patency. The secondary outcome was venous thromboembolisms. We studied the rate of stent occlusion and potentially contributing factors. We included 379 patients: 160 with acute thrombotic, 193 with postthrombotic, and 26 with nonthrombotic deep vein obstruction. The mean age was 46±18 years; 55% were women. The cumulative 3-year primary patency rate was 80.5% (95% CI, 73.0%-88.0%) for acute thrombotic, 59.2% (95% CI, 50.4%-68.0%) for postthrombotic, and 100% for nonthrombotic obstruction (log-rank, P<0.0001). Annualized rates of stent occlusion or venous thromboembolism were 7.8 (acute thrombotic), 15.0 (postthrombotic), and 0 (nonthrombotic) events/100 patient-years. In a multivariable Cox regression model, postthrombotic femoral veins at baseline (hazard ratio, 2.64 [95% CI, 1.53-4.56]) and the number of stents (hazard ratio, 1.22 [95% CI, 1.06-1.40]) were associated with stent occlusion after conditioning for age, sex, and clinically relevant factors. The rate of stent occlusion (patency loss) and venous thromboembolism varies substantially across indications, also with dedicated venous nitinol stents. Patients with postthrombotic femoral veins and those who received multiple stents were characterized by the highest risk. Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT02433054.

Long-Term Outcomes of Endovascular Interventions in More than 500 patients with Budd–Chiari Syndrome

PurposeTo assess and compare the long-term outcomes of various endovascular interventions in patients with Budd-Chiari syndrome (BCS). Materials and MethodsIn this single-center retrospective study, 510 consecutive patients with BCS who had undergone a total of 618 endovascular procedures from January 2001 to December 2019 were included. Details of the type of endovascular intervention, technical success, clinical success, patency rate, complications, and survival outcomes were analyzed. ResultsThe overall technical success rate was 96% (593 of 618 procedures; 500 in treatment-naïve patients and 93 repeat interventions for recurrent disease). Endovascular procedures included recanalization procedures (angioplasty and stent placement) in 355 patients (71%) and transjugular intrahepatic portosystemic shunt (TIPS) creation in 145 (29%). Major postprocedure complications occurred in 14 patients (2.8%). Vascular/stent restenosis occurred in 95 patients (19%), and successful repeat intervention was performed in 82 of those 95 (86.3%). An additional 11 of these 82 (13.4%) underwent a third intervention for restenosis. In the recanalization and TIPS groups, the 1- and 5-y cumulative patency rates were 87% and 74% and 95% and 68%, respectively. The 1- and 5-y survival rates were 96% and 89% and 90% and 76%, respectively. ConclusionsEndovascular interventions for BCS are feasible and safe in the majority of patients, with excellent short- and long-term patency and survival rates.

Effect of thrombophilia on clinical outcomes of chronic post-thrombotic patients after iliofemoral stenting with nitinol venous stents

ObjectiveThrombophilia is a prothrombotic condition that increases the risk of venous thromboembolism. It is unclear whether the presence of thrombophilia alters the clinical outcomes after deep venous stenting. The aim of the present study was to examine the relationship between thrombophilia and outcomes after stenting for post-thrombotic syndrome. MethodsConsecutive patients (2012-2017) receiving a nitinol venous stent for chronic post-thrombotic venous occlusive disease with a minimum of 18 months of follow-up in one center using the same anticoagulation protocol were included. The clinical history and thrombophilia testing results were reviewed. The outcomes were stent patency, which was assessed using duplex ultrasonography at 24 hours, 2 and 6 weeks, 3 months, 6 months, and annually thereafter; and reinterventions, which were performed when the stent diameter was <50% or occluded. ResultsOf the 136 patients who had undergone intervention, 55 (40%) had had a provoked deep vein thrombosis (DVT) and 81 (60%) had had an unprovoked DVT and had therefore undergone thrombophilia testing. Of the 81 patients, 38 (47%) had had either inherited (n = 19; 50%) or acquired (n = 19; 50%) thrombophilia. Of the 136 patients who had undergone stenting, 68 had required reintervention (50%) during follow-up to maintain stent patency. Of the 55 patients with a provoked DVT, 29 (53%) had required reintervention. Of the 81 patients with an unprovoked DVT, 39 (48%) had required reintervention (P = .420). Of the 38 patients with unprovoked DVT and thrombophilia, 17 (45%) had required reintervention. Of the 43 patients with unprovoked DVT and no thrombophilia, 22 (51%) had required reintervention (P = .766). The cumulative patency rate was 80% for patients with provoked DVT and 88% for those with unprovoked DVT (P = .193). The presence of thrombophilia was not associated with patency loss (92% cumulative patency for patients with thrombophilia and 84% for patients without thrombophilia; P = .307). ConclusionsUsing our anticoagulation protocol, patients with and without thrombophilia had similar clinical outcomes after deep venous stenting and should not be excluded from iliofemoral venous stenting. We found no significant differences in outcomes in conjunction with appropriate postoperative anticoagulation therapy.

Surgical treatment of total subclavian artery occlusion: a single center experience of 67 cases

Objective: To examine the outcomes of surgical repair for patients with total subclavian artery occlusion. Methods: A retrospective analysis was performed on 67 patients with subclavian artery occlusion disease admitted at Ward 1 of Aortic and Vascular Surgery Center, Fuwai Hospital from January 2016 to July 2019. The age was, and There were 51 male patients and 16 females with an age of (61.7±8.2) years (range: 37 to 79 years). The t-test, Mann-Whitney U-test, χ(2) test, and Fisher's exact test were used to analyze the factors related to the technique success. The Kaplan-Meier curve was used to calculate the cumulative patency rate and plot the corresponding survival curves, and the Log-rank test was used for comparison. The length from the subclavian artery ostial to the occlusion area was used as a variable to plot the receiver operating characteristic curve, and the optimal cut-off value was determined by the Youden index. Results: Eighteen patients received open surgery. Forty-nine patients with subclavian artery occlusion accepted endovascular repair, of which 38 patients succeeded (31 cases on left side and 3 cases on right side). Fifteen patients failed with endovascular therapy, of which 10 cases received elective surgery and 5 cases received conservative therapy. The success rate of endovascular repair was 69.4%(34/49). Among them, the success rate of left subclavian artery occlusion was 81.6%(31/38), while the right side was 3/11. Patients with the length from the subclavian artery ostial to the occlusion area ≥6 mm were more likely to get success (23/34 vs. 4/15, χ(2)=5.506, P=0.019). In the endo-group, one patient had hemorrhage in the left chest. In the open-group, one patient had lymphatic leakage. Follow-up period ranged from 3 to 46 months with a median of 22 months. The patency of endovascular repair group and the open surgery group was 92.6% and 90.8% at 12-month, while 82.9% and 84.3% at 24-month, respectively. The cumulative patency rates of smoking patients and non-smoking patients after endovascular treatment were 70.2% vs. 100% (P=0.048) at 24-month. No independent prognosis factors were identified through the Cox proportional risk model which significantly affected postoperative patency rates for patients with subclavian artery occlusion. Conclusions: Part of patients with subclavian artery occlusion can be treated by endovascular therapy. The success rate of left subclavian artery occlusions is higher than right sides. The length from the subclavian artery ostial to the occlusion area affected the success rate of repair.

Deep venous stenting in chronic iliac venous obstructive lesions: a single-center experience

Introduction Endovascular management for patients with chronic outflow lesions has been considered as an optimal alternative option for symptom control, as conservative compression therapy may fail later. The study aimed to determine the clinical outcomes and to evaluate the quality of life (QoL) improvement after recanalization and deep venous stenting in patients with postthrombotic syndrome and nonthrombotic iliac vein lesion in whom conventional treatment had failed. Patients and methods This study was conducted prospectively on 40 patients with chronic deep venous diseases (nonthrombotic iliac vein lesion or postthrombotic syndrome) and who presented to Vascular Surgery Department, Faculty of Medicine, Assiut, Egypt from July 2016 to September 2019. Results A total of 40 patients with 50 limbs (21 males; median age, 45.2 years, with range, 18–75 years) were included, and all had successful recanalization and stent deployment. A complete history and physical examination were performed for all included patients as well as assessment of daily activity improvements after endovenous procedures during postoperative follow-up visits at 2 weeks, 1.5, 3, 6, and 12 months. Deep venous recanalization with deployment of stents was medically successful in all 50 limbs with overall high patency (primary, assisted secondary, and secondary patency rates of 76, 88, and 92%, respectively). A statistically significant improvement in QoL scores (VEINESQOL/Sym scores) was observed in all patients as compared with the baseline at 2, 6, and 12 months after stenting (64.4, 69.2, and 73.4, respectively, P Conclusions Our results confirm the significant effect of stenting on QoL of patients with chronic symptomatic iliofemoral venous obstructive lesions with high cumulative patency rate, making it a viable treatment option.

Analysis of influencing factors of shunt dysfunction after transjugular intrahepatic portosystemic shunt in liver cirrhosis accompanied with portal vein thrombosis

Objective: To investigate the efficacy of shunt after transjugular intrahepatic portosystemic shunt (TIPS) in liver cirrhosis accompanied with portal vein thrombosis (PVT). Methods: Forty-four cases with liver cirrhosis accompanied with PVT who underwent TIPS treatment from January 2015 to May 2018 were retrospectively analyzed. Clinical baseline data of the patients were collected. Portal vein pressure gradient (PVPG) before and after the surgery was recorded. Shunt patency was observed at 3, 6, 12, 18 and 24 months after the surgery. The influencing factors were determined by univariate and multivariate analysis. Results: Transjugular intrahepatic portosystemic shunt was successfully established in all 44 cases. The postoperative PVPG was lower than preoperative (P < 0.01). The shunt patency rate after TIPS in PVT was 18.2% (n = 8). The cumulative shunt patency rates at 3, 6, 12, 18, and 24 months after surgery were 95.5%, 90.7%, 90.7%, 86.8% and 74.4%, respectively. Univariate analysis showed that diabetes history, platelet level and prothrombin time-international normalized ratio were associated with postoperative shunt dysfunction. Multivariate analysis showed that diabetes history (P = 0.007, OR = 28.606) was an independent risk factor for postoperative shunt dysfunction. Conclusion: TIPS is a safe and feasible procedure, which can effectively reduce the portal pressure in liver cirrhosis accompanied with PVT. Diabetic patients have a higher risk of postoperative shunt dysfunction. Therefore, clinical intervention should be strengthened for high-risk patients.

The short-term outcome of residual thrombus of the lower extremity after pharmacomechanical catheter-directed thrombolysis for deep vein thrombosis.

BackgroundThis study aimed to assess the short-term effect of residual thrombus of the lower extremity after pharmacomechanical catheter-directed thrombolysis (PCDT) on the incidence of post-thrombotic syndrome (PTS) and iliofemoral vein patency rate in patients who underwent PCDT.MethodsThere were 94 continuous patients with severe deep vein thrombosis (DVT) of the lower extremities admitted to our hospital between March 2016 and June 2018; 73 cases receiving PCDT and verified with iliac vein compression syndrome (IVCS) were assigned into two groups. Thirty-nine patients without thrombus of the popliteal and infrapopliteal veins were assigned to the proximal DVT group. The remaining 34 cases were placed in the extensive DVT group. The thrombus scores, including venous registry index (VRI) score, Marder score, and Society for Vascular Surgery (SVS) score before and after PCDT, the primary two years’ cumulative rate of iliofemoral patency, and the rate of PTS, and complications were analyzed retrospectively.ResultsUltimately, 27 patients in the proximal DVT group and 26 cases in the extensive DVT group completed the study. The two groups had no significant differences in terms of basic characteristics, complication and the rate of PTS (P>0.05). However, there were significant differences in terms of postoperative mean thrombus score and the mean degree of thrombosis removal score by Marder and SVS scores, residual thrombus by lower thrombosis classification (LET) and the two years’ cumulative iliofemoral vein patency rate (P<0.05). And the logistic regression analysis demonstrated the residual thrombus of LET class II [odds ratio (OR), 4.619, 95% confidence interval (CI), 1.090–19.567, P=0.038] was an independent risk factor for iliofemoral vein occlusion.ConclusionsThe residual thrombus of LET class II is an independent risk factor for iliofemoral vein occlusion. It is very important to keep the patency of the popliteal vein when deciding to use a stent to maintain iliofemoral vein patency. Furthermore, the anterior tibial vein approach and crisscross technique may be two important alternative methods that can be used to address the thrombus of popliteal vein for patients with extensive DVT.

Our arteriovenous fistula experiences with grafts in hemodialysis patients

Aim: In patients whose life is dependent on hemodialysis, the most suitable vascular access routes are arteriovenous fistulas made with native vessels. However, in patients whose natural vessels are depleted, or not suitable, arteriovenous fistulas can be opened with artificial grafts. Our aim is to examine arteriovenous fistulas opened with synthetic grafts in hemodialysis patients who do not have native vascular access in the upper extremity and share our results.Methods: Patients who underwent opening of an arteriovenous fistula with a synthetic graft to the upper extremities in Adıyaman University Faculty of Medicine, Cardiovascular Surgery Clinic between December 2012 and December 2018 were examined in this retrospective cohort study. They were screened for age, gender, end-stage renal failure etiology, complications in vascular access site, postoperative follow-up, and duration of use. Primary and secondary patency rates were determined.Results: It was determined that synthetic grafts were used in 33 (15 males, 18 females) out of 436 arteriovenous fistulas (AVF) opened to 372 patients. The mean age was 59.2 (17) years. Left radiocephalic (RC) straight graft fistula was opened in 2 patients, left brachiocephalic (BC) straight graft fistula was opened in 12, left BC distal loop AVF in 13, right BC distal loop AVF in 1, left brachioaxillary (BA) distal loop AVF in 3 and right BA distal loop was used to open an AVF in 2 patients. Primary cumulative patency rates were as follows: 72% in the 3rd month, 65% in the 6th month, 42.24% in the 12th month. The secondary patency rates were 33.9% in the 60th month, 12% in the 60th month, 96.96% in the 12th and 24th months, 90.28% in the 36th and 48th months, 59.12% in the 60th month and 43.11% in the 72nd month.Conclusion: In chronic renal failure patients who do not have a natural vascular access routes or whose natural routes have been exhausted, AVFs that are opened to the upper extremities with a synthetic graft are suitable vascular access routes for long-term dialysis.

Treatment of bypass failure in patients with chronic limb threatening ischemia - open surgery vs. percutaneous mechanical thrombectomy.

Background: Lower limb bypass occlusion in patients with chronic limb threating ischemia remains a challenge. We can choose between different treatment options: open surgery, local thrombolysis, thrombectomy/atherectomy devices. In this pilot study, we compare clinical outcomes and treatment costs between open surgery (OS) and percutaneous mechanical thrombectomy (pMTH). Patients and methods: This pilot study represents a retrospective analysis of hospital data of 48 occluded bypasses admitted from 2013 to 2018. Only patients presenting with severe ischemia and recrudescence of symptoms (Rutherford 4-6) were included in the current analysis. Two cohorts of patients were analysed: patients who underwent OS and patients that underwent pMTH. Primary clinical outcomes were one-year cumulative patency and limb salvage rates. Total cost was calculated as a sum of intra- and post-operative costs. To weigh clinical benefits against the economic consequences of OS versus pMTH a cost-effectiveness framework was adopted. Results: We analysed a series of 48 occluded bypasses 17 treated with open surgery and 31 with pMTH. Procedural success was 100% in both groups. When comparing one-year death rates (p-value=.22) and re-occlusion rates (p-value=.43), no statistically significant differences were observed between the two cohorts. Mean patency duration in the surgery cohort was significantly shorter (p-value<.05). Primary patency (OS 41.2% vs. pMTH 48.4%) and limb salvage rate (OS 88.2% vs. pMTH 90.3%) at one year are similar in both groups. The total cost of surgery was substantially higher (OS 10,159€ vs. pMTH 8,401€) Conclusions: This pilot study, although limited to 48 occluded bypasses, demonstrates that endovascular treatment with pMTH is less invasive, less time consuming and less expensive, and produces greater health benefits than traditional OS.

Therapeutic effect of portal vein stenting for portal vein stenosis after upper-abdominal surgery

BackgroundThe therapeutic effect of portal vein (PV) stenting for PV stenosis following nontransplant hepato-pancreato-biliary (HPB) surgery has not been fully investigated. MethodsChanges in portal venous pressure (PVP) gradient before and after stenting, complications, symptomatic improvement, and stent patency were evaluated. ResultsWe identified 14 consecutive patients undergoing PV stenting for malignant (n = 8) and benign (n = 6) PV stenosis. Signs of PV stenosis were composed of refractory ascites in 6 patients, varices with hemorrhagic tendencies in 5, and abnormal liver function in 5. The median PVP gradient after PV stenting was 3.0 cm H2O (range, 1.5–3.0), which was significantly smaller than that before PV stenting (median, 15 cm H2O [range, 2.5–25]; P < 0.01). Thirteen out of 14 (93%) achieved clinical success with symptomatic improvement, except one patient with sustained refractory ascites because of peritoneal seeding. During the median follow-up time of 7.3 months (range, 1.0–87), stent occlusion occurred in two patients (14%) because of intrastent tumor growth. The 1-year cumulative stent patency rate was 76% in the entire cohort. ConclusionsBased on durable effect on patency, we deemed PV stenting for PV stenosis after HPB surgery to be safe and beneficial for improving symptoms.

Long-term outcomes of interventional treatment for Budd-Chiari syndrome with chronic accessory hepatic vein obstruction.

Interventional treatment is the main therapy for Budd-Chiari syndrome (BCS) with hepatic vein obstruction. The aim of this study was to investigate the long-term outcomes of endovascular management for BCS with chronic accessory hepatic vein (AHV) obstruction. In total, 68 patients with primary BCS who underwent AHV dilation with or without stenting from January 2008 to December 2018 were included in this retrospective study. The technical success rate and complications were recorded. Cumulative patency rates were estimated by the Kaplan-Meier curves and compared using the log-rank test. Technical success was achieved in all 68 patients, and AHV patency was confirmed by postoperative angiography. Fifty-two patients underwent balloon dilation alone and 16 underwent adjunctive stent implantation. During a mean follow-up period of 60.2 ± 30.5 months, AHV reocclusion occurred in 14 patients in the balloon group and four patients in the stent group (χ2 = 0.034, P = 0.855). The overall cumulative 1-, 3-, 5-, and 7-year primary and secondary AHV patency rates were 90.6, 76.6, 72.0, and 68.2% and 98.4, 91.4, 89.2, and 89.2%, respectively. The cumulative 1-, 3-, 5-, and 7-year primary patency rates of the AHV were 89.8, 73.8, 71.2, and 71.2% in the balloon group and 93.3, 86.2, 75.4, and 60.3% in the stent group, respectively. There was no statistically significant difference between the two groups (P = 0.934). Interventional treatment of BCS with chronic AHV obstruction has good long-term outcomes. Both balloon dilation alone and adjunctive stent implantation can be used for AHV recanalization.

Short interposition with a small-diameter prosthetic graft for flow reduction of a high-flow arteriovenous fistula

ObjectiveThe objective of this study was to evaluate the outcome of a short interposition using a small-diameter prosthetic graft as a flow-limiting procedure to manage symptomatic high-flow arteriovenous fistula (AVF). MethodsA retrospective review of medical records on a case series was conducted. From June 2004 to April 2017, there were 25 patients with clinical symptoms of high output cardiac failure and progressive dilation of aneurysmal fistula vein due to high-flow AVF (≥1.5 L/min) who underwent short interposition with a 5-mm prosthetic graft at Saitama Medical Center. The primary outcome was the relief of clinical symptoms; other outcome measures included technical success, surgical complications, patency of vascular access, and postoperative changes in local and systemic hemodynamics as assessed by Doppler ultrasound. ResultsTwenty-five patients underwent short interposition for cardiac indications (n = 16) and aneurysmal dilation (n = 9). The technical success rate was 100%. The clinical symptoms were relieved in 24 patients (96.0%). Mean reduction in access blood flow was 52.4%. Cumulative primary unassisted patency rates (± standard error) at 1 year, 2 years, and 3 years were 76.2% ± 9.3%, 70.4% ± 10.3%, and 58.1% ± 11.6%, respectively. Secondary patency rates (± standard error) at 1 year, 2 years, and 3 years were 81.8% ± 8.2%, 71.5% ± 9.9%, and 71.5% ± 9.9%, respectively. Complications included access occlusion due to late thrombosis (n = 5 [21.7%]) and graft infection (n = 1 [4.3%]) in the median follow-up period of 3.9 years. ConclusionsShort interposition with a prosthetic graft is a simple, effective, and durable treatment option for end-stage renal disease patients with cardiac symptoms and progressive dilation of the fistula vein due to high-flow AVF, offering clinical symptom resolution while preserving the autologous behavior of the initial access.

Modified Brachio-basilic/brachial Arteriovenous Fistula Creation with Short-segment Elevation Preserving the Axilla

Brachio-basilic/brachial transposition arteriovenous fistula has emerged as one of the autologous arteriovenous fistula options. However, there have not been many reports on the outcomes of basilic or brachial elevation of arteriovenous fistula compared with those of conventional transposition. We evaluated the efficacy of modified brachio-basilic and brachio-brachial arteriovenous fistula creation with short-segment elevation preserving the axillary area. From March 2016 to August 2018, medical records of the patients who underwent short-segment elevation of brachio-basilic or brachio-brachial arteriovenous fistula in the upper arm (sBAE or sBRE) were reviewed retrospectively. Of the 51 patients, 37 underwent sBAE and 14 underwent sBRE. Maturation failure occurred in two patients (3.92%), who underwent sBAE. Stenosis was the most common complication, which developed in 13 patients (25.5%), and there was no significant difference between the sBAE and the sBRE. In the 51 patients, cumulative primary patency rates at 6 and 12months were 88.3% and 69.1%, respectively. Assisted primary patency rates at 6 and 12months were 97.8% and 90.7%, respectively. Secondary patency rates at 6 and 12months were both 100%. There were no significant differences between the sBAE and the sBRE in 1-year primary patency (79.1% vs. 46.7%; P=0.20), assisted primary patency (91.6% vs. 88.1%; P=0.36), and secondary patency rates (100% vs. 100%). Brachio-basilic/brachial arteriovenous fistula with short-segment elevation preserving the axilla showed excellent 1-year patency rate, easier cannulation, and other future advantages, and therefore, is a logical modification of conventional transposition of arteriovenous fistula.

Outcomes of the Gore Excluder abdominal aortic aneurysm leg endoprosthesis for treatment of central vein stenosis or occlusion in patients with chronic hemodialysis

ObjectiveCentral venous occlusive disease is a critical complication in long-term hemodialysis patients with arteriovenous (AV) dialysis circuits. The purpose of this retrospective, single-arm cohort study was to evaluate the effectiveness of an abdominal aortic aneurysm (AAA) contralateral leg endoprosthesis to treat symptomatic central venous occlusive diseases in patients with chronic hemodialysis. MethodsA prospective cohort study included 60 patients on hemodialysis presenting with central venous stenosis or occlusion, who were treated with a Gore Excluder AAA contralateral leg stent graft between December 2013 and July 2018. Follow-up angiography was obtained at 3, 6, and 12 months. The outcomes and duration of primary circuit and target site patency were measured from the time of the stent graft implantation to the first reintervention for AV circuit dysfunction and target site restenosis. Secondary patency was calculated from stent graft implantation to the point when AV access was no longer attainable. ResultsCircuit primary patency rate was 54.9% at 1 year of Gore Excluder AAA contralateral leg or iliac extender stent grafts, implanted in 60 hemodialysis patients with central vein occlusive disease. Cumulative target site primary patency rate was 88.3% at 1 year. Secondary patency rate was 95% during follow-up. Patients with concomitant lesions had a significantly higher risk of circuit primary patency dysfunction. ConclusionsTreatment of central vein obstructions in hemodialysis patients with stent grafts has been appealing owing to the tapered shape with a larger diameter and the availability of various lengths.

Long-term outcomes of axillary to carotid bypass for symptomatic patients with chronic common carotid artery occlusion

ObjectiveRelatively little is known about the natural history of atherosclerotic common carotid artery occlusion and optimal treatment of these patients is still unclear. The aim of this retrospective study was to evaluate the immediate- and long-term outcomes of axillary to carotid bypass with polytetrafluoroethylene graft for symptomatic patients with chronic common carotid artery occlusion. MethodsFrom March 2001 to December 2017, 58 symptomatic patients (41 men; mean age 64.7 years) with chronic common carotid artery occlusion underwent axillary to carotid bypass at one academic hospital. The clinical data of this patient cohort were retrospectively analyzed. The cumulative graft patency, overall survival, freedom from symptoms, and freedom from ipsilateral stroke were calculated with Kaplan-Meier method. ResultsThirty-three patients presented with transient ischemic attack and 25 patients presented with minor stroke. At 30 days after bypass, the overall perioperative complication rate was 3.4% (2/58). Mild injuries of brachial plexus occurred in one (1.7%) patient and myocardial infarction occurred in one (1.7%) patient. No perioperative stroke or death occurred. The median follow-up was 51 months (range, 12-203) for this series. The cumulative graft patency rates at 1, 3, 5, and 10 years were 100%, 100%, 94%, and 83%, respectively. The cumulative freedom from symptoms rates at 1, 3, 5, and 10 years were 100%, 100%, 94%, and 75%, respectively. The cumulative freedom from ipsilateral stroke rates at 1, 3, 5, and 10 years were 100%, 100%, 94%, and 82%, respectively. The overall survival rates at 1, 3, 5, and 10 years were 98%, 89%, 81%, and 67%, respectively. ConclusionsAxillary to carotid bypass with polytetrafluoroethylene graft is safe and durable for symptomatic patients with chronic common carotid artery occlusion. The results of this study should be confirmed with a larger, randomized controlled trial in future.

Association of Concomitant Disease in The Profunda and Femoro-Popliteal Veins to Cumulative Patency and Re-intervention Rates Following Ilio-femoral Venous Stenting of Limbs with Postthrombotic Occlusion

Association of Concomitant Disease in The Profunda and Femoro-Popliteal Veins to Cumulative Patency and Re-intervention Rates Following Ilio-femoral Venous Stenting of Limbs with Postthrombotic Occlusion

Two-year cumulative patency of endovascular arteriovenous fistula.

Background and objectives:The recent advent of a device to create a proximal radial artery arteriovenous fistula using an endovascular approach to create the anastomosis represents a significant advance in dialysis access creation. This endovascular arteriovenous fistula offers the beneficial attributes of the proximal radial artery arteriovenous fistula while adding the advantages of avoiding a surgical procedure. The endovascular arteriovenous fistula can be created safely, functions well, has excellent patency, and has a high degree of patient satisfaction. The purpose of this study is to report the 2-year cumulative patency rate for a large multicenter cohort of endovascular arteriovenous fistula cases.Design:An endovascular arteriovenous fistula was created in 105 patients using either local or regional anesthesia and conscious sedation. Patient data were obtained from each program’s electronic health record system. Data collection was truncated at 2 years postprocedure and used to calculate cumulative patency. Post-access creation patient satisfaction was assessed.Results:A physiologically mature arteriovenous fistula (blood flow ⩾500 mL/min and a target vein internal diameter ⩾4 mm) was obtained in 98%. A clinically functional arteriovenous fistula (supporting two-needle dialysis according to the patient’s dialysis prescription) was demonstrated in 95%. Access failure resulting in the loss of access occurred in eight cases during the study period. The cumulative patency rate at 6, 12, 18, and 24 months was 97.1%, 93.9%, 93.9%, and 92.7%, respectively. The post-procedure patient evaluation emphasized a high level of patient satisfaction.Conclusion:The proximal radial artery arteriovenous fistula created using an endovascular approach for the anastomosis is associated with excellent 2-year cumulative patency and is associated with a high level of patient satisfaction.

Current state of vascular access in Singapore.

This article described the current state of vascular access management for patients with end-stage renal disease in Singapore. Over the past 10 years, there has been a change in the demographics of end-stage renal disease patients. Aging population and the increase in prevalence of diabetes mellitus has led to the acceleration of chronic kidney disease and increase in incidence and prevalence of end-stage renal disease. Vascular access care has, therefore, been more complicated, with the physical, psychological, and social challenges that occur with increased frequency in elderly patients and patients with multiple co-morbidities. Arteriovenous fistula and arteriovenous graft are created by vascular surgeons, while maintenance of patency of vascular access through endovascular intervention has been a shared responsibility between surgeons, interventional radiologists, and interventional nephrologists. Pre-emptive access creation among end-stage renal disease patients has been low, with up to 80% of new end-stage renal disease patients being commenced on hemodialysis via a dialysis catheter. Access creation is exclusively performed by a dedicated vascular surgeon with arteriovenous fistula success rate up to 78%. The primary and cumulative patency rates of arteriovenous fistula and arteriovenous graft were consistent with the results from many international centers. Vascular access surveillance is not universally practiced in all dialysis centers due to its controversies, in addition to the cost and the limited availability of equipment for surveillance. Timely permanent access placement, with reduced dependence on dialysis catheters, and improved vascular access surveillance are the main areas for potential intervention to improve vascular access management.