Endovascular Techniques Research Articles

Ultrasound-Guided vs Non-Ultrasound-Guided Angio-Seal Vascular Hemosasis After Endovascular Treatment for Peripheral Artery Disease: An Observational Study.

Ultrasound visualization of vascular closure devices during endovascular access closure leads to a significant decrease in overall and major post interventional access site complications. This non-invasive and often readily available imaging technique could therefore lead to an important decrease in morbidity and subsequent overall health care costs when added to the standard intervention protocol. With the increasing use of endovascular techniques to treat peripheral artery disease, the addition of ultrasound-techniques in closure of endovascular access sites could potentially have a large clinical impact, both on patient outcomes as well as financial outcomes.

A Novel Combined Microsurgical and Endovascular Approach for Type II Endoleak Embolization Through Direct Puncture of a Lumbar Segmental Artery: A Technical Case Instruction

BACKGROUND AND IMPORTANCE: Despite the advances in endovascular aortic repair techniques, type II endoleaks with aneurysm sac expansion remain frequent and challenging problems. CLINICAL PRESENTATION: An elderly gentleman underwent a combined microsurgical and endovascular procedure to address a type 2 endoleak and the growth of a recurrent abdominal aortic aneurysm caused by direct puncture of a lumbar segmental artery. The patient tolerated the procedure well and was discharged without complications. Follow-up imaging revealed no further endoleak and a smaller aneurysm size. CONCLUSION: This unique case presents a novel multidisciplinary surgical strategy for treating complex, recurrent aortic aneurysms with type II endoleaks. The approach is tailored to the individual patient and has shown effectiveness. Long-term follow-up data will be crucial for assessing the efficacy and durability of this approach.

Endovascular Treatment of Spetzler-Martin Grade III Arteriovenous Malformations: A Single-Center 12 years' Experience Stratified by the Spetzler-Martin Modified Scale.

Limited evidence exists for endovascular first-line treatment of Spetzler-Martin (SM) grade III brain arteriovenous malformations (AVMs). In this article, we sought to evaluate advanced endovascular techniques for treating SM III AVMs across different sizes, eloquence, and patterns of venous drainage. Data from AVMs SM III treated between January 2010 and January 2022 were collected: size (S), eloquence (E), drainage (V), angioarchitecture features (arterial and venous aneurysms, venous drainage, and venous stenosis), treatment strategy (single arterial, double arterial, venous, both arterial and venous, and transvenous endovascular embolization with selective temporary flow arrest [TFATVE]), neoadjuvant treatment, and number of previous embolization sessions. AVMs were classified according to the modified SM grade as follows: small (S1V1E1/III-), medium/deep (S2V1E0/III), medium/eloquent (S2V0E1/III+), and large (S3V0E0). Treatment complications (hemorrhagic and ischemic), clinical discharge and 6-month outcomes (modified Rankin Scale 0-2, mRS), and angiographic occlusion rates were recorded. A total of 91 AVMs (62.6% ruptured, 72.5% S1V1E1, 7% S2V1E0, 19.7% S2V0E1, and 0% S3V0E0) in 91 patients (mean age 37 ± 15.8 years) were included. Treatment techniques included single arterial approach (28.6%), double arterial technique (30.8%), single venous strategy (9.9%), TFATVE (10.9%), and arterial and venous combined (19.8%). The angiographic occlusion rate was 91.2% (90.9% S1V1E1, 100% S2V1E0, and 88.9% S2V0E1) for all techniques, and 100% for the transvenous technique, isolated or combined with transarterial embolization. Minor complication (mRS 0-2), major complication (mRS >2), and mortality rate were 16.5%, 2.2%, and 3.4%, respectively. Overall, treatment morbimortality (mRS >2) was 3% (2/66) for S1V1E1, 0% for S2V1E0, and 16.7% (3/18) for S2V0E1. Although morbidity is non-negligible , endovascular treatment of SM grade III lesions with advanced techniques offers up to 100% rates of cure, which is of high interest, especially for ruptured deep-seated eloquent AVMs with high reruptured rates, and less amenable to microsurgery techniques.

Endovascular Management of Aortic Rupture Secondary to Thoracolumbar Spine Fracture From a Domestic Fall: A Case Report and Clinical Challenges.

Instances of aortic lesions combined with thoracolumbar spine fractures have been rarely described, primarily occurring in high-speed motor vehicle collisions and falls from heights. We present a unique case of a 71-year-old woman with a thoracic aortic rupture caused by a thoracolumbar spine fracture during an accidental domestic fall. She experienced an injury at the level of the celiac trunk on the posterior aspect of the aorta. Hemorrhagic shock and profound hemodynamic instability prompted the swift initiation of a percutaneous endovascular approach, involving the use of REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) followed by the parallel graft technique in a sandwich configuration. Subsequently, thoracolumbar spinal fixation was carefully scheduled and performed 20 days after achieving clinical stabilization. This case underscores the importance of a multidisciplinary approach in managing complex aortic and spinal injuries. The combined use of REBOA and the sandwich graft technique can be life-saving in managing acute thoracic aortic injuries, allowing for the staged stabilization and repair of associated spinal fractures. This case highlights a novel approach to managing a rare thoracic aortic rupture caused by an accidental domestic fall. The application of REBOA for immediate hemodynamic stabilization, combined with the use of a sandwich graft configuration, underscores the adaptability of advanced endovascular techniques in complex, life-threatening situations. These interventions demonstrate the importance of tailoring treatment strategies to individual patient needs, especially in cases involving atypical mechanisms of injury. The findings emphasize the value of early multidisciplinary collaboration and dynamic procedural planning, paving the way for improved outcomes and the refinement of clinical protocols in the management of similar trauma cases.

Evaluation of coiling endovascular technique on treatment of middle cerebral artery cerebral aneurysms in different blood hematocrits: A numerical study

Intracranial aneurysms are localized dilatations of the cerebral arteries that carry a risk of rupture and subsequent subarachnoid hemorrhage, a life-threatening condition. Middle cerebral artery (MCA) aneurysms are a common type of intracranial aneurysm, and endovascular treatment using coils or flow diverters is a common intervention approach. Understanding the hemodynamics, or blood flow patterns, within MCA aneurysms and how they are affected by endovascular treatment is crucial for improving patient outcomes. This numerical study investigates the hemodynamics of blood flow within MCA aneurysms before and after endovascular treatment. Patient-specific geometric models of MCA aneurysms were reconstructed from medical imaging data. Simulations using computational fluid dynamics were conducted to examine flow characteristics, wall shear stress, and additional hemodynamic factors within the aneurysms. The study assessed and contrasted the impact of coil embolization and flow diverter placement on the hemodynamics inside the aneurysms. The findings offer a deeper understanding of the intricate flow dynamics within MCA aneurysms and illustrate the ways in which endovascular treatments can modify these dynamics.

Vein of Galen Aneurysmal Malformations: Updates on Technical Aspects and Functional Outcomes Post-Endovascular Treatment—A Systematic Review and Meta-Analysis

Background and Objectives: Vein of Galen aneurysmal malformations (VGAMs) represent the most common vascular malformations of the brain at the pediatric age. Comprehension of its angioarchitecture and clinical features may influence their treatment options and functional outcomes. The aim of this review is to give an update of the anatomical and technical aspects of the management of VGAMs after endovascular treatment. Materials and Methods: We conducted a systematic review of original articles published between 1 January 2014 and 1 February 2024 in Pubmed, Web of Science (WOS), and Scopus databases following PRISMA guidelines. Variables such as age, sex, angioarchitecture of the malformation, clinical presentation, embolization technique, rate of occlusion, post-procedural complications, follow-up time, and mortality were collected. Random-effect meta-analysis of proportions was performed. Results: Fifteen studies on a total of 400 patients with VGAMs were collected. A total of 65.1% was male. The age at diagnosis was 12% prenatal, 35.5% neonates, 34.1% infants, 15.1% children, and 3.3% adults. Clinical presentation included 31.4% increased head size, 25.7% congestive heart failure, 12.9% neurological deficits, 10% seizures, 9.3% prominence of facial veins, and 8.9% developmental delay. A total of 339 patients underwent endovascular treatment (84.8%) with an average of 2.1 procedures per patient. The embolization technique was defined by transarterial access and glue material. Radiological occlusion was complete in 62.3% of the patients. The most frequent periprocedural incidents included hemorrhagic events (28.4%), embolization material migration (25.7%), and death (22%). The functional outcome was good in 68% of the surviving patients. The average follow-up time was 43.18 months. High heterogeneity was found in all outcomes but mortality rate. Conclusions: The angioarchitecture of VGAMs is significantly important when planning endovascular treatment and may have an influence on functional outcomes. More research into endovascular techniques and the risks of periprocedural complications must be performed. Indeed, a homogeneous protocol for the assessment of surviving VGAM patients during follow-up is necessary.

Open Microsurgical Versus Endovascular Management of Unruptured and Ruptured Brain Aneurysms.

Open microsurgical and endovascular techniques are the 2 primary strategies for treating intracranial aneurysms. Microsurgical clipping and adjuvant technical maneuvers are well-established techniques with a track record for high occlusion rates and durable repairs. Endovascular, endosaccular, and extrasaccular therapies are associated with lower peri-procedural morbidity but with generally higher rates of retreatment. We discuss key clinical and anatomic considerations in treatment decision-making and compare the risks and benefits of microsurgical vs endovascular treatment within each context.

Hemodynamic evaluation of endovascular techniques of stenting and coiling for the treatment of internal carotid artery aneurysm: a computational study

The selection optimum endovascular method for the treatment of different cerebral aneurysms has been the main challenge for surgeons. In the present article, the computational technique is used for the hemodynamic evaluation of two main endovascular techniques of stent and coiling for the reduction of the hemorrhage risk of ICA aneurysms. Comprehensive analyses of the blood flow are performed to detect potential regions with high risk at critical stages of the cardiac cycle. Two coiling porosity conditions and stent deformation have been investigated via computational study to reveal the main change related to hemodynamics when these techniques are implemented. The hemodynamic results of this study show that the endovascular technique is more efficient in small aneurysms rather than giant ones. Meanwhile, the stent treatment of the giant saccular aneurysm is effective when the parent vessel of this type of aneurysm is fully aligned and limited blood flow enters the sac area.

Hybrid Aortic Arch Replacement with Frozen Elephant Trunk (FET) Technique: Surgical Considerations, Pearls, and Pitfalls.

The involvement of the aortic arch in thoracic aortic aneurysms (TAA), or acute aortic dissections (AAD), represents a challenging clinical entity, mandating a meticulous surgical plan, tailored to each individual case. The advent of endovascular techniques and the introduction of modern arch protheses have led to the implementation of the frozen elephant trunk (FET) technique. This one-step hybrid operation consists of a total aortic arch replacement combined with an antegrade delivery of a stent-graft for the descending aorta, which acts as a proximal landing zone facilitating a potential distal endovascular reintervention. In this manner, this technique addresses acute and chronic arch disease with an acceptable morbidity and mortality. Several FET prosthetic devices are available on the global market and have exhibited favourable outcomes, although with some disadvantages in complex cases; similarly, the hybrid procedure described in this review has also been associated with complications, such as coagulopathy and neurological and graft-related events. The purpose of this review is to thus provide key insights into successful hybrid aortic arch replacements and to discuss useful tips and relevant considerations regarding its use.

Programmed cell death-related ABI1 is a critical mediator of abdominal aortic aneurysm

Abdominal aortic aneurysm (AAA) is a life-threatening condition characterized by localized dilation of the abdominal aorta, posing a significant risk of rupture and fatal hemorrhage. While surgical and endovascular repair techniques have advanced, the underlying mechanisms driving AAA development remain unclear, hindering the development of effective preventive and therapeutic strategies. Using bioinformatics analysis of publicly available data sets, the study identified a strong correlation between cell death (CD) score and different types of programmed cell death scores in AAA samples. WGCNA analysis revealed a module enriched in genes related to proteasome-mediated protein degradation, nuclear envelope, and endocytosis, significantly correlated with CD score. Further analysis identified ABI1 as a dominant feature gene, highlighting its potential role in AAA pathogenesis. In vitro validation using an Angiotensin II-induced AAA model in human aortic smooth muscle cells demonstrated that siRNA-mediated knockdown of ABI1 significantly reduced cell apoptosis, migration, and the expression of pro-apoptotic proteins, confirming ABI1's crucial role in promoting CD and AAA progression. The findings suggest that ABI1 may represent a promising therapeutic target for the prevention and treatment of AAA. Further research is warranted to fully understand the role of ABI1 in AAA and to develop targeted therapies based on this promising target.

Sonography-Guided Endovascular Retrieval of Fractured Angiocatheter in Brachial Artery: A Case Report.

The insertion of an angiocatheter into a peripheral artery for continuous hemodynamic monitoring is a widely employed clinical practice. Fracture of a angiocatheter retained in an artery, though infrequent, presents a challenge in clinical management, particularly in critically ill patients. Surgical exploration for retrieval is generally required, as fluoroscopy-guided endovascular methods are precluded due to the radiolucency of catheters. This case report demonstrates the successful retrieval of a fractured catheter from the brachial artery of an 85-year-old critically ill patient through the utilization of endovascular techniques guided by sonography. Key considerations include selecting an appropriate snare system diameter and ensuring real-time sonographic visualization to prevent displacement of the fractured segment. This case illustrates the feasibility and safety of sonography-guided endovascular retrieval as an alternative to surgical intervention for fractured angiocatheters. The proposed strategy demonstrates its applicability in similar clinical scenarios.

Endovascular removal of a symptomatic intracranial foreign body via contact aspiration: illustrative case.

With the growing utilization of general endovascular techniques, iatrogenic endovascular foreign bodies have become more prevalent. Contact aspiration has proven to be a valuable technique in treating ischemic strokes by removing the intraluminal thrombus causing cerebral perfusion deficits and neurological symptoms. The authors present a case of the removal of a foreign body from the vasculature via contact aspiration, which had embolized in a delayed fashion after aortic valve replacement. A 54-year-old male developed intermittent left-sided weakness 8 days after aortic valve replacement. A head computed tomography scan showed a metallic foreign body within the origin of the M2 superior division of the middle cerebral artery suspected to be a migrated Cor-Knot fastener. During angiography, the foreign body was repositioned and removed via contact aspiration. Postprocedurally, magnetic resonance imaging scans showed a small area of diffusion restriction in the right basal ganglia. The patient was neurologically intact and was discharged on postprocedure day 2 without further neurological sequelae. Contact aspiration is a safe and effective technique to remove foreign bodies from the intracranial circulation; however, it requires a quality interface between the aspiration catheter and the foreign body throughout the aspiration process. https://thejns.org/doi/10.3171/CASE24376.

Different endovascular solutions for short, wide and conic shaped neck

Hostile neck anatomy is the most important issue in prediction of outcomes of endovascular procedures. Surgeon modified fenestrated stent graft (SMFSG) may be an effective and available solution in proper patients by changing the proximal sealing of EVAR to the abdominal visceral aorta. Here we present two frail, comorbid, symptomatic infrarenal abdominal aortic aneurysm (iAAA) cases with reverse tapered wide necks treated with different endovascular techniques.

Enhancing understanding of stent-induced deformation in MCA aneurysms: a hemodynamic study

This article provides a comprehensive hemodynamic assessment of two endovascular techniques for treating cerebral aneurysms. Through finite volume simulations of pulsatile blood flow in saccular aneurysms, we evaluated hemodynamic factors under two coiling conditions with varying porosities and deformation stages to determine the most effective treatment for each case. Our analysis shows that stent and coiling treatments are more effective for aneurysms with smaller sac volumes. In particular, stent placement is found to be more effective than coiling for managing saccular aneurysms. The results indicate that stent-induced deformation effectively redirects the main blood flow, significantly lowering the risk of aneurysm rupture near the ostium. Obtained results emphasize the role of deformation and porosity in controlling wall shear stress, which is essential for understanding aneurysm progression and potential rupture risk.

INTRACRANIAL ARTERIAL LOOP WITH A COMPLEX PARTIALLY THROMBOSED LARGE ANEURYSM ON THE POSTERIOR CIRCULATION: WHAT TO DO NEXT?

Introduction Managing intracranial aneurysms in the posterior circulation is particularly challenging due to anatomical complexities and the high risk of rupture. The presence of a large, partially thrombosed aneurysm adds another layer of difficulty. This report details the case of a 66-year-old female patient presenting with a symptomatic intracranial arterial loop and a large, partially thrombosed aneurysm in the posterior circulation, successfully treated through microsurgical clipping. Material and Methods A 66-year-old female with a history of intermittent headaches, vertigo, and diplopia underwent neuroimaging, including computed tomography angiography (CTA) and magnetic resonance imaging (MRI). Imaging revealed a large aneurysm in the posterior circulation, with partial thrombosis and an associated intracranial arterial loop. The patient was scheduled for a craniotomy to perform microsurgical clipping of the aneurysm. Two titanium aneurysm clips were applied to achieve complete occlusion. Results Intraoperative findings confirmed the large, partially thrombosed aneurysm arising from the basilar artery, with a complex arterial loop intricately intertwined with the aneurysm and adjacent neurovascular structures. The first clip was placed to secure the primary inflow, and the second clip provided additional reinforcement. Postoperative imaging demonstrated successful clipping with no residual aneurysm filling. The patient had an uneventful recovery with no immediate postoperative complications. Clinically, the patient reported significant improvement in symptoms, with a complete resolution of headaches and vertigo. Conclusions This case highlights the challenges and considerations in managing large, partially thrombosed aneurysms in the posterior circulation, particularly in the presence of an intracranial arterial loop. Successful management requires precise microsurgical technique and careful intraoperative decision-making. Further research is needed to optimize treatment strategies, potentially incorporating adjunctive endovascular techniques to enhance surgical outcomes.

Multidisciplinary Approach to Direct Segmental Artery Revascularization to Prevent Spinal Cord Ischemia Associated With Endovascular Thoracoabdominal Aortic Repair.

Despite advances in complex endovascular aortic repair techniques, spinal cord ischemia (SCI) remains a devastating complication following endovascular thoracoabdominal aortic repairs. Novel strategies to preserve key intercostal/lumbar arteries have been described. We report our early results of patients who underwent direct intercostal/lumbar artery revascularization using endovascular incorporation of fenestrations/branches or extra-anatomic approaches for fenestrated-branched endovascular aortic repairs (FBEVARs). A retrospective review of consecutive patients who underwent FBEVAR with intercostal/lumbar artery revascularization from 2018 to 2022 was performed. Patient characteristics, intraoperative details, and outcomes including SCI and branch occlusions were evaluated. Among 317 patients who underwent FBEVAR during the study period, 12 patients were included. Aortic pathologies consisted of degenerative aneurysms (33%), postdissection aneurysms (33%), extensive penetrating aortic ulcers with intramural hematoma (25%), and visceral patch pseudoaneurysm (8%). Full thoracoabdominal coverage was required in 8 patients and supraceliac coverage >10 cm was required in 4. Nine patients received endovascular incorporation, including directional branches (5/9), unstented fenestrations (2/9), and stented fenestration (2/9). Three patients received extra-anatomic subcutaneous femoral-to-radicular artery bypass using a composite graft of polytetrafluoroethylene (PTFE) and venous conduit. Our institutional SCI prevention protocol, consisting of prophylactic cerebral spinal fluid drain (CSFD) for high-risk patients, hemodynamic augmentation, and oxygen supplementation, was followed. Prophylactic CSFD was placed in 9 patients. One patient had unsuccessful drain placement attempts. The other 2 patients had previous unsuccessful attempts at CSFD placement. Median number of target vessels for FBEVAR was 4 with fluoroscopy time 66±31 minutes, contrast usage 109±51 ml. There were no in-hospital mortalities. Tarlov grade II SCI (ASIA grade D) were seen in 2 patients (1 endovascular and 1 extra-anatomic bypass), which resolved before discharge. At mean follow-up of 472±447 days, 3 patients had thrombosed intercostal/lumbar branches (1 extra-anatomic bypass and 2 endovascular branches) with no new SCI symptoms. In patients at high risk for SCI undergoing FBEVAR, direct revascularization of an intercostal or lumbar artery is feasible using endovascular or extra-anatomic bypass approach. Further studies are planned to identify key contributing segmental arteries and optimization of revascularization strategies. This study demonstrates the feasibility of Endovascular and extra-anatomic bypass to preserve segmental artery flow, aimed at reducing the risk of spinal cord ischemia during endovascular thoracoabdominal aortic repairs.

Predictors of In-hospital and Short-term Outcomes of Thoracic Endovascular Aortic Repair for Aortic Aneurysm and Aortic Syndrome: A Single-Center Experience

BACKGROUND: Endovascular technique has replaced open repair as primary treatment for different aortic disease indications and was associated with low perioperative mortality and acceptable short-, mid-, and long-term survival. Locally, thoracic endovascular aortic repair (TEVAR) was not widely practiced until year 2017. This study aims to determine the predictors of in-hospital and short-term outcomes of patients who underwent TEVAR for aortic aneurysm and aortic syndrome in a single center and how it compares with local and international data. METHODS: This study is a retrospective analysis of 52 adult patients who underwent TEVAR for the treatment of aortic aneurysm and aortic syndrome. Demographic and clinical data, diagnostic imaging, and procedural details were obtained via inpatient charts at the medical records section and hospital system database archiving. Outcomes at 30 days and 1 year postprocedure were obtained through telephone follow-up after attaining verbal consent. Gathered data were analyzed as to association of different variables with or without the presence of complications. Outcomes reported included in-hospital mortality rate, presence of major adverse events (MAEs), 30-day and 1-year survival rates, and rate of freedom from reintervention. RESULTS: The overall in-hospital mortality was 7.69% (n = 4/52), and complication rate was 32% (n = 20/52), with a survival rate of 92.31% and 87.76% at 30 days and 1 year, respectively. The rates of overall freedom from reintervention were 83.33% and 100% at 30 days and 1 year, respectively. The independent predictors for in-hospital mortality and development of MAEs were increasing weight (odds ratio [OR], 1.0588; 95% confidence interval [CI], 1.003–1.208), preexisting chronic kidney disease (OR, 10.33; 95% CI, 1.1069–96.462), and TEVAR with debranching done as a single procedure (OR, 3.6667; 95% CI, 1.1154–12.054), whereas an estimated glomerular filtration rate of 49.05 ± 19.25 (OR, 0.9402; 95% CI, 0.9019–0.9801) and TEVAR with debranching done as a staged procedure (OR, 0.1624; 95% CI, 0.0321–0.8225) statistically decrease the risk for development of in-hospital mortality and MAEs (P = 0.001 and P = 0.028, respectively). CONCLUSIONS: In this single-center study, indications for TEVAR were fusiform and saccular aneurysm, high-risk intramural hematoma and penetrating aortic ulcer, complicated acute type B dissection, chronic complicated type B dissection with high-risk feature, and aortic rupture. The outcome of this study shows comparable results with other international studies with an acceptable in-hospital mortality rate, complication rate, short-term survival rate, and rate freedom from reintervention at 30 days and 1 year. Increasing weight, preexisting chronic kidney disease, and TEVAR with debranching done as a single setting are independent predictors for developing in-hospital mortality and MAEs, whereas a normal estimated glomerular filtration rate and TEVAR with debranching done as a staged procedure decrease the risk; hence, careful planning and scheduling of procedure among elective and amenable cases could further reduce complication rates of future TEVAR procedures.

"Picket fence" an alternative clipping technique for wide necked and large aneurysms: technical nuances in a case series.

Complex aneurysms are a therapeutic challenge in contemporary neurosurgery. Several microsurgical and endovascular techniques have been proposed for their treatment. The picket fence clipping technique uses fenestrated clips, that are stacked not to reconstruct the neck of the aneurysm, but to create a duct to normalize the cerebral flow by reconstructing the dome. We present four illustrative cases using the picket fence clipping technique. The aneurysms considered were of different locations (ICA, MCA, AComA), of large or giant size with wide necks, in which clipping attempt with a conventional technique was not possible, so that the use of non-conventional clipping techniques had to be applied with favorable results. In our experience we found this technique useful in large and giant, wide-necked aneurysms by reconstructing the parent vessel according to the concept of the ideal closure line in these previously unreported locations, thereby restoring normal cerebral circulation. The use of non-conventional techniques for clipping complex aneurysms can be used alone or in combination for adequate treatment, preserving cerebral circulation without compromising adequate exclusion of the aneurysm. The Picket fence technique is a feasible clipping technique that can be used as a less morbid option in large and giant aneurysms with wide necks.

Amputation-Free Survival, WIfI Stage, and GLASS Classifications in Distal Crural or Pedal Bypass for Chronic Limb-Threatening Ischemia.

Background: Chronic limb-threatening ischemia (CLTI) is a severe condition with high risks of amputation and mortality, especially in patients with distal crural or pedal artery disease. Despite advances in endovascular techniques, bypass surgery remains crucial for patients with CLTI. This study aimed to investigate amputation-free survival, Wound, Ischemia, and foot Infection (WIfI) staging, and Global Limb Anatomic Staging System (GLASS) classifications in patients undergoing distal crural or pedal bypass for CLTI. Methods: This retrospective study analyzed all patients who underwent distal crural or pedal bypass for CLTI in a tertiary vascular centre from January 2010 to December 2019. The data were collected from hospital records and preoperative imaging. WIfI stages and GLASS classifications were determined for each patient, and the primary endpoint was amputation-free survival. Secondary outcomes included bypass patency, 30-day morbidity, and mortality. Results: We identified 31 bypasses performed on 29 patients with a median age of 67 years (79% male). Preoperatively, 94% of limbs were staged GLASS III and 55% were classified WIfI stage 4. Failed endovascular revascularization preceded bypass surgery in 65% of the cases. Thirty-day mortality was 3% (n = 1) and 30-day major amputation rate was 10%. Primary patency was 87%, and secondary patency was 94% at 30 days. Median duration of follow-up for survival was 59 months with a mean follow-up index (FUI) of 0.99 ± 0.05, and for major amputation and bypass patency 54 months (mean FUI 0.9 ± 0.19 and 0.85 ± 0.28, respectively). At one year, amputation-free survival was 58%, decreasing to 45% at two years, 39% at three years, and 32% at five years. Most major amputations occurred in WIfI stage 4 patients, but 53% of WIfI stage 4 and 80% of WIfI stage 3 patients were alive without major amputation after one year. Conclusions: Distal crural and pedal bypasses are essential for limb salvage in high-risk CLTI patients, particularly those with failed prior revascularization. However, the procedure is associated with limited long-term amputation-free survival. WIfI and GLASS classifications are useful for stratifying risk and guiding treatment, but outcomes suggest the need for individualized care strategies. Further research into perioperative management and alternative interventions is warranted to improve long-term outcomes in this population.

Study protocol for a French multicenter randomized controlled trial evaluating the medicoeconomic impact of Surgical vs Endovascular Arteriovenous Access Creation for Hemodialysis in End-stage Renal Disease (ENDO-FAV)

BackgroundVascular access is indispensable for performing hemodialysis in patients with end-stage renal disease. The Kidney Disease Outcome Quality Initiative and the French Health Authority advocate for native arteriovenous fistulas (AVFs) as a primary option owing to their association with lower morbidity, mortality, and enhanced quality of life. However, a significant proportion of AVFs fail to mature, and many require multiple re-interventions, increasing overall costs. To address these issues, endovascular techniques for AVF creation have been developed. These methods use energy-based technologies, avoiding vessel dissection and preserving perivascular tissues. Initial results are promising, but these devices are expensive, and the technical act of creating an endovenous fistula is not recorded in the coding of the common classification of medical procedures and, as such, cannot be reimbursed by health insurance in France. Although international studies suggest their effectiveness, no French studies have yet replicated or confirmed these findings in the local context, which would help to support a reimbursement request from health insurance. MethodsThis protocol represents the first French medicoeconomic study to compare the two available endovascular AVF creation devices (Ellipsys and WaveLinQ) with traditional open surgery. This multicenter, comparative clinical trial will randomize patients into two parallel groups: (1) endovascular AVF creation using either the WaveLinQ or Ellipsys device, and (2) surgical proximal AVF creation (brachiocephalic/brachiobasilic). Randomization will be balanced and stratified by center and dialysis timing. Follow-up assessments will occur at 1 week and 1, 3, 6, 12, and 18 months. The primary objective is to evaluate the cost effectiveness of endovascular AVF creation compared with open surgery from the perspective of the French health care system. The primary end point is the cost-utility ratio (cost per quality-adjusted life year gained) of endovascular AVF vs open surgery. Utility is assessed using the EQ-5D-5 L questionnaire, with costs derived from micro-costing and the National Health Data System. Secondary outcomes include health economics with total costs at 18 and 36 months, success rate of vascular access creation, AVF maturation and functionality, recirculation rates, early and late access failures, cannulation success, primary and secondary patency, reintervention rates, and adverse events. Based on a cost-utility threshold of €30,000 per quality-adjusted life year, cost difference estimates, and standard deviations from previous studies, anticipated sample size is 126 patients per group (endovascular and surgical), totaling 252 patients with approximately 142 patients for the Ellipsys device and 110 patients for WaveLinQ, based on the capacity of 7 centers using Ellipsys and 4 centers using WaveLinQ. ConclusionsThis multicenter randomized controlled trial will provide contemporary data on the clinical outcomes and prognoses for endovascular AVF techniques, potentially establishing endovascular methods as a viable and cost-effective alternative to traditional surgical AVF creation.