Extra-anatomic Bypass Research Articles

Outcome of Radical Surgical Treatment of Abdominal Aortic Graft and Endograft Infections Comparing Extra-anatomic Bypass with In Situ Reconstruction: A Nationwide Multicentre Study

Abdominal aortic graft and endograft infection (AGI) is primarily treated by resection of the infected graft and restoration of distal perfusion through extra-anatomic bypass (EAB) or in situ reconstruction/repair (ISR). The aim of this study was to compare these surgical strategies in a nationwide multicentre retrospective cohort study.

Improved perioperative mortality after secondary aortoenteric fistula repair and lessons learned from a 20-year experience

Secondary aortoenteric fistulas (SAEFs) are rare but represent one of the most challenging and devastating problems for vascular surgeons. Several issues surrounding SAEF treatment remain unresolved, including optimal surgical reconstruction and conduit choice. We performed an audit of our experience with SAEFs and highlight aspects of care that have affected outcomes over time with the intent to identify factors associated with best outcomes. We performed a single center, retrospective review of all consecutive SAEF repairs (1999-2019), defined as presence of a false communication between an enteric structure and pre-existing aortic graft. The primary endpoint was 30-day mortality. Secondary endpoints included incidence of complications and overall survival. Time-dependent outcome comparison was performed. Cox proportional hazards modeling and life-table analysis estimated risk and freedom from endpoints. A total of 57 patients (63% male; n= 36) presented with SAEF (median age, 69years; interquartile range [IQR], 61-74years). Median follow-up time was 10months (interquartile range, 3-21months. The most common presenting symptoms were gastrointestinal bleeding (60%; n= 34) and abdominal pain (56%; n= 3 2). For the overall cohort, 30% (n= 17) underwent extra-anatomic bypass with aortic ligation, 30% (n= 17) rifampin-soaked Dacron graft, 26% (n= 15) femoral vein (eg, neoaortoiliac system), and 14% (n= 8) cryopreserved aortic allograft. The enteric communication involved the duodenum in 85% (n= 48), and a double-layer hand-sewn primary repair was most commonly employed (61%; n= 35). Thirty-day mortality was 35% (n= 20) with no significant difference between 90days (39%; n= 22) and 180days (42%; n= 24). Morbidity was 70% (n= 40), with gastrointestinal (30%; n= 17; leak [9%]), pulmonary (25%; n= 14), and renal (21%) complications being most common. Incidence of reoperation for any vascular and/or gastrointestinal-related complication was 56% (n= 32). One-year and 3-year survival was 54%± 6% and 48%± 8%, respectively. Over time, 30- and 90-day mortality improved (odds ratio, 0.1; 95% confidence interval, 0.4-0.5; P= .002) despite no change in patient factors, operative strategy, conduit choice, or morbidity rate. Prehospital history of gastrointestinal bleeding was associated with worse survival (hazard ratio, 2.0; 95% confidence interval, 1.0-3.9; P= .06); however, reconstruction strategy (in-situ vs extra-anatomic bypass), postoperative gastrointestinal and/or vascular complication, omental flap use, and preoperative endovascular aneurysm repair history were not associated with outcome. In conclusion, we observed improved short-term mortality despite no significant change in patient presentation or postoperative complications. This highlights increasing institutional experience in selecting the optimal surgical strategy and improved ability to rescue patients experiencing adverse postoperative events. An individualized approach to reconstruction and conduit choice can lead to best outcomes after SAEF management when patients are treated at a high-volume aortic surgery center.

Brucella aortitis managed with debridement, extra-anatomical bypass, and long-term antimicrobial therapy.

This report aims to review the management and outcomes of Brucella-associated mycotic aortic aneurysms. This is a retrospective chart review at a tertiary-level healthcare system. IRB approval was waived per policy. We describe a case of Brucella aortitis acquired from habitual contact with wild hogs. Clinical presentation included lower back pain and elevated white blood cell count. Diagnosis was confirmed with imaging showing an infrarenal abdominal aortic aneurysm and serology revealing elevated Brucella antibodies titers. The patient was initially managed with endovascular aortic repair and combined oral and intravenous antibiotics therapy. He then underwent explanation and extra-anatomical bypass due to symptomatic periaortic infection and interval development of type I endoleak. The patient was asymptomatic after his final operation at 24months of follow-up and remained on suppressive oral antibiotic therapy. An aortic aneurysm secondary to Brucella is a rare entity. A detailed history of long-term exposure to animals may be a clue to obtain serologic testing. Operative debridement and re-establishing of reliable blood flow combined with long-term antibiotic suppression are the mainstay of treatment.

Role of Extra-anatomic Ascending to Descending Bypass in Complex Thoracic Aortic Pathology.

Complex pathology of the distal arch and proximal descending thoracic aorta is usually approached by stent endografting or in situ graft replacement. Oftentimes, these options are not feasible due to unfavorable anatomy, multiple previous procedures, active infection, or presence of concomitant cardiac disease. Thoracic aortic extra-anatomic bypass, as part of an open surgical strategy, is a useful and often the only curative option left for the treatment in these patients. Herein, we describe two cases that illustrate the utility of extra-anatomic thoracic aortic bypass for complex aortic disease.

Progression in clinical application of cryopreserved vascular allografts in the treatment of abdominal aortic graft infection

Once an abdominal aortic graft infection occurs,it is often catastrophic associated without high morbidity and mortality.Standard surgical treatment includes removing infected grafts,arteries,and surrounding tissues,and revascularization of blood supply to organs and limbs. Extra-anatomical vascular bypass and in-situ reconstruction are the main surgical treatment methods,and many factors affect the prognosis of surgical treatment. So far,there are a variety of vascular grafts used to restore revascularization in clinical practice,mainly including rifampicin or silver-coated artificial blood vessels,autologous veins,cryopreserved allogeneic blood vessels,or bovine pericardium and other biological materials. There is no consensus on the selection of the best vascular graft. In recent years,clinical application studies have confirmed that the results of cryopreserved allogeneic blood vessels for the treatment of graft infectious diseases are acceptable,but the complications related to grafts should not be ignored. This article reviews the clinical application progress of cryopreserved allogeneic blood vessels for the treatment of abdominal aortic graft infection.

C28. Chronic Limb Threatening Ischemia in Patient With Aortoiliac Occlusive Disease (Leriche Syndrome) and Pulmonary Hypertension

Abstract Background Chronic limb-threatening ischemia (CLTI) is a manifestation of peripheral arterial disease (PAD) which is characterized by stenosis or occlusion of peripheral arteries causing impaired perfusion to the extremities, especially during rest and chronic progresses, which are associated with decreased quality of life and increased morbidity and mortality. Case Description A 51-year-old man complained of wound on both legs and pain during light activity. Risk factor is smoking for 30 years. History of primary pulmonary hypertension since 30 years. Physical examination revealed decreased pulsation from femoral artery to dorsalis pedis arteries in both leg. Echocardiography with RA and RV dilatation, D-shaped LV during systolic, mild TR and normal LV systolic function. Dupplex ultrasound and MSCT scan pulmonary-abdominal angiography shows thrombus in the abdominal aorta causing occlusion of blood flow distally. There is a comorbid pulmonary hypertension which causes right heart failure with symptoms of dyspnea. This patient is at high risk of undergoing revascularization surgery, so that in severe comorbid conditions an extraanatomical bypass with axillobifemoral bypass graft is considered. Discussion Atherosclerosis that occurs in the abdominal aorta, iliac artery, and femoropopliteal artery is called aortoiliac occlusive disease (AIOD). This condition when symptomatic is known as Leriche syndrome with a triad of symptoms of claudication, impotence, and reduced or no palpable pulsation of the femoral artery. Medical management include antiplatelet, statin, analgetic, and therapy according to risk factors. The main purpose is revascularization by surgery or endovascular which aims to improve blood flow to the distal artery.

C28. Chronic Limb Threatening Ischemia in Patient With Aortoiliac Occlusive Disease (Leriche Syndrome) and Pulmonary Hypertension

Abstract Background Chronic limb-threatening ischemia (CLTI) is a manifestation of peripheral arterial disease (PAD) which is characterized by stenosis or occlusion of peripheral arteries causing impaired perfusion to the extremities, especially during rest and chronic progresses, which are associated with decreased quality of life and increased morbidity and mortality. Case Description A 51-year-old man complained of wound on both legs and pain during light activity. Risk factor is smoking for 30 years. History of primary pulmonary hypertension since 30 years. Physical examination revealed decreased pulsation from femoral artery to dorsalis pedis arteries in both leg. Echocardiography with RA and RV dilatation, D-shaped LV during systolic, mild TR and normal LV systolic function. Dupplex ultrasound and MSCT scan pulmonary-abdominal angiography shows thrombus in the abdominal aorta causing occlusion of blood flow distally. There is a comorbid pulmonary hypertension which causes right heart failure with symptoms of dyspnea. This patient is at high risk of undergoing revascularization surgery, so that in severe comorbid conditions an extraanatomical bypass with axillobifemoral bypass graft is considered. Discussion Atherosclerosis that occurs in the abdominal aorta, iliac artery, and femoropopliteal artery is called aortoiliac occlusive disease (AIOD). This condition when symptomatic is known as Leriche syndrome with a triad of symptoms of claudication, impotence, and reduced or no palpable pulsation of the femoral artery. Medical management include antiplatelet, statin, analgetic, and therapy according to risk factors. The main purpose is revascularization by surgery or endovascular which aims to improve blood flow to the distal artery.

Abstract 12320: Long-Term Outcomes of Open and Endovascular Management of Adult Aortic Coarctation

Objective: To compare outcomes of endovascular vs. surgical management of adult aortic coarctation (CoA). Methods: We performed a retrospective study of patients who underwent surgical vs. endovascular intervention for CoA during adulthood (age>16 years) at a single institution. Results: We identified 137 adult patients with coarctation of the aorta seen between 1975 - 2019. 18/137 (13%) required no intervention for their coarctation. While 23/137 (40%) had surgical procedures and 34/137 (60%) had endovascular procedures. Surgical procedures included extra-anatomic bypass (13/23), resection of coarctation segment with interposition graft (4/23), distal hemi-arch replacement (1/23) and total arch replacement (1/23). Endovascular interventions included balloon angioplasty alone in 2/34 patients and stenting in 32/34 patients. Median age at intervention was 38 years (IQR: 30-47) in the surgical group and 36 (30-47) in the endovascular group. Patient follow up time ranged from 0-45 years with a mean follow-up of 12 years as calculated from the first intervention for CoA during adulthood. Overall survival was 96% in the surgical group and 100% in the endovascular group. There was one post-operative transient ischemic attack in the surgical group and no post-procedural complications in the endovascular group. In a Kaplan Meier analysis of freedom from re-intervention during an overall follow-up period of 45 years, surgical intervention for CoA during adulthood was superior to endovascular treatment (p=0.008). Conclusions: Although long-term survival is similar, surgical intervention for adult CoA offers superior freedom from re-intervention than endovascular treatment (p=0.008).

Editor's Choice – Outcome of Radical Surgical Treatment of Abdominal Aortic Graft and Endograft Infections Comparing Extra-anatomic Bypass with In Situ Reconstruction: A Nationwide Multicentre Study

Abdominal aortic graft and endograft infection (AGI) is primarily treated by resection of the infected graft and restoration of distal perfusion through extra-anatomic bypass (EAB) or in situ reconstruction/repair (ISR). The aim of this study was to compare these surgical strategies in a nationwide multicentre retrospective cohort study. The Swedish Vascular Registry (Swedvasc) was used to identify surgically treated abdominal AGIs in Sweden between January 1995 and May 2017. The primary aim was to compare short and long term survival, as well as complications for EAB and ISR. Some 126 radically surgically treated AGI patients were identified - 102 graft infections and 24 endograft infections - treated by EAB: 71 and ISR: 55 (23 neo-aorto-iliac systems, NAISs). No differences in early 30 day (EAB 81.7% vs. ISR 76.4%, p= .46), or long term five year survival (48.2% vs. 49.9%, p= .87) were identified. There was no survival difference comparing NAIS to other ISR strategies. The frequency of recurrent graft infection during follow up was similar: EAB 20.3% vs. ISR 17.0% (p= .56). Survival and re-infection rates of the new conduit did not differ between NAIS and other ISR strategies. Age ≥ 75 years (odds ratio [OR] 4.0, confidence interval [CI] 1.1 - 14.8), coronary artery disease (OR 4.2, CI 1.2 - 15.1) and post-operative circulatory complications (OR 5.2, CI 1.2 - 22.5) were associated with early death. Prolonged antimicrobial therapy (> 3 months) was associated with reduced long term mortality (HR 0.3, CI 0.1 - 0.9). In this nationwide multicentre study comparing outcomes of radically treated AGI, no differences in survival or re-infection rate could be identified comparing EAB and ISR.

Procedure-Associated Costs and Mid-Term Outcomes of Endovascular Zone 0 and Zone 1 Aortic Arch Repair

Thoracic endovascular aortic repair (TEVAR) of proximal aortic arch pathology provides a less-invasive treatment option for high-risk patients ineligible for open arch reconstruction. However, the fiscal impact of these techniques remains unclear. Therefore, our objective was to characterize the mid-term outcomes after Zone 0 and Zone 1 TEVAR and describe the associated technical costs, revenues, and net margins at a single tertiary medical center. We examined all patients who underwent TEVAR between April 2011 and August 2019 via retrospective chart review. Patients were categorized by proximal endograft extent to identify Zone 0 or Zone 1 repairs. Procedural characteristics and outcomes were described. Technical costs, revenues, and margins were obtained from the hospital finance department. We identified 10 patients (6 Zone 0, 4 Zone 1) who were denied open arch reconstruction. Patients were predominantly female (n=8; 80%) and the mean age was 72.8 ± 5.5 years. TEVAR was performed in 5 asymptomatic patients, urgently in 3 symptomatic patients, and emergently in 2 ruptured patients. TEVAR plus extra-anatomic bypass was performed in 4 patients. Another 4 patients also received parallel stent-grafting while 1 patient received a branched thoracic endograft and yet another an in-situ laser fenestration followed by branch stent grafting. Within the 30-day postoperative period, 1 patient experienced stroke and 1 patient died. Bypass and branch vessel patency were 100% through the duration of follow-up (mean 19.3 months). Mean total technical cost associated with all procedures or repair stages was $105,164 ± $59,338 while mean net technical margin was -$25,055 ± $18,746. The net technical margin was negative for 9 patients. Endovascular repair of the proximal aortic arch is associated with good mid-term outcomes in patients considered too high-risk for open repair. However, reimbursement does not adequately cover treatment cost, with net technical margins being negative in nearly all cases. To remain financially sustainable, efforts should be made to both optimize aortic arch TEVAR delivery as well as advocate for reimbursement commensurate with associated costs.

Endovascular Treatment of Acquired Atheromatous Postsubclavian Aortic Coarctation

Coral reef aorta is a rare calcifying obstructive disease that involves the thoracoabdominal aorta. Similar presentations in the postsubclavian aorta may result in acquired atheromatous aortic coarctation leading to systemic hypertension and heart failure. The associated calcification makes surgical anatomic or extraanatomic bypass and thromboendarterectomy challenging. Extensive circumferential calcification often precludes endovascular intervention. We present the case of a 25-year-old man with an acquired atheromatous coarctation of the postsubclavian aorta who underwent successful endovascular treatment with use of a balloon-expandable covered stent.

Extra-Anatomical Iliopopliteal Bypass

Introduction: Pseudoaneurysm of the femoral artery or an infected graft in the femoral region is a very serious disease with devastating complication. The aim of this study is to describe a novel technique for its management in the form of an extra-anatomic bypass between external iliac artery (EIA) and the popliteal/distal superficial femoral artery (SFA). Methods: This is a single-center retrospective study and includes eight consecutive patients with infection of previous femoral grafts and large femoral pseudoaneurysms, in which extra-anatomic bypass between EIA and popliteal or distal SFA was done. Results: The mean age of patients in the study was 43 years. There was one 30-day postoperative mortality (12.5%) due to sepsis. The patency rate in rest of the seven patients at the end of 3 months was 100% with no major complications. Conclusion: Our technique of extra-anatomic bypass from external iliac to femoral or popliteal artery, just medial to anterior superior iliac spine beneath the inguinal ligament in the subcutaneous plane is a simple and quick approach with no major neurological or bleeding risk.

Extra- Anatomical Bypass Applications Still as an Alternative in Progressive Aortoiliac Occlusive Disease Manegement

Aims: Extra-anatomical bypass (EAB) is still an important alternative treatment method in patients with aortoiliac occlusive disease (AIOD). Settings and Design: In this study, we assessed the results of EAB procedures, over a 22-year period, based on 30-day morbidity and mortality, 1st month, 1st, 3rd, and 5th year patient survival, primary patency, and limb salvage rates. Subjects and Methods: A retrospective review and analyze was performed on a single-center database of consecutive 46 patients who underwent femorofemoral or axillofemoral bypass grafting procedures from 1998 to 2020. All patients were called to followed up and were performed clinical examination and color duplex ultrasound (CDUS) evaluation for determination of graft patency. The surviving patients were followed-up for 5 years. Statistical Analysis Used: Five-year survival, graft patency, and limb salvage rates were calculated by the Kaplan–Meier method. Results: The 46 subjects included 25 (54.3%) femoral and 21 (45.7%) axillary bypass applications. The mean age was 64.2 ± 12.8 years (28–82) and 36 were male (78.3%). Critical limb ischemia was the most accounted indication for EAB surgery (25/54.4%). The cumulative mortality rate was 34.8% at 5 years' period. The graft patency and limb salvage rates for femoral and axillary applications were 59.2% versus 57.4% and 86.4% versus 80% at 5 years, respectively. Conclusions: Femorofemoral and axillofemoral bypasses are suitable for patients with AIOD requiring revascularization for relief of symptoms or limb salvage, who are not candidates for endovascular therapy or who are at high risk for direct anatomical revascularization.

Re-discovering an Old Standard: Ilio-Femoral Bypass, with Adjunctive Procedures, for Primary orSecondary Iliac Artery Occlusion

<h3>Introduction and Objective</h3> Endovascular techniques constitute first-line treatment for iliac artery occlusions and enjoy outstanding primary and long-term durability. Some iliac occlusions are not amenable to endovascular repair because of calcification, chronic occlusion, and failed stents. Twenty-eight patients with unilateral iliac occlusion who were not candidates for or failed endovascular repair underwent ilio-femoral bypass. Extra-anatomical bypass was avoided because of previous contralateral procedures or risk to the contralateral extremity. This abstract reviews one surgeon's experience with ilio-femoral bypasses from December, 2014 to November, 2020. <h3>Case Report</h3> Twenty-eight (28) patients, 74% males, with an average patient age of 63.8 years and unilateral iliac occlusion, underwent ilio-femoral bypass. 88% were smokers, 38% were diabetics, and 30% had severe heart disease. Two patients had severe kidney disease requiring dialysis. Twenty-four patients underwent previous attempts at revascularization: 14 received iliac stents and 4 patients had failed aorto bifemoral or axillo/ilio femoral bypasses. There were 6 previous open interventions involving the femoral arteries. Two patients sustained rupture while undergoing endovascular procedures and required emergent bypasses. Indications for intervention were rest pain in 11, tissue loss in 8, and disabling claudication in 5. There were 3 urgent interventions: two required immediate intervention following rupture of an iliac artery angioplasty, and a third occurred during insertion of a thoracic stent. One procedure was performed fora 2-year-old infected iliac bypass with impending rupture. All operations were performed under general anesthesia. Proximal retro-peritoneal exposure of the iliac arteries was obtained via a curvilinear incision in the ipsilateral lower quadrant. Twenty-four (24) patients received a Dacron conduit, 2 PTFE, 1 bovine, and 1 femoral vein. Thirty-five (35) adjuvant procedures were done in conjunction with the bypass. In 14 cases (54%,) retrograde endarterectomy/thrombectomy/stent extraction was performed. Eleven patients (35%) required a femoral endarterectomy/thrombectomy. Angiography was used selectively if inflow was deemed inadequate. Six (6) intraoperative angiograms were needed with 2 patients requiring proximal stent insertions. Two patients received simultaneous femoral to distal bypasses done for tissue loss. <h3>Results</h3> Procedures were technically successful in 100% of patients. All bypasses were patent at the time of their loss to follow-up or death. Patients were followed for an average of 22.3 months. No secondary interventions were required. There was 1 groin infection that required excision of the graft; one above knee amputation was required for an infected knee prothesis. There was one groin hematoma. Two patients died within thirty days (8%), one from SIRS (multi-organ system failure following recent myocardial infarction) and one patient died of a coagulopathy following rupture of a calcified common iliac artery during angioplasty. There were no amputations due to vascular disease. 100% patency in this series was enhanced by adjunctive procedures. Ilio-femoral bypasses done to symptomatic elderly patient with occluded superficial femoral arteries frequently enjoyed relief of rest- pain without the morbidity of distal incisions. This group required endarterectomy of the common and deep femoral arteries. No hernias, local nerve injuries, lymphorrhea, damage to ureters, or major infections occurred. One groin infection was a catabolic, nursing home patient with an infected, ischemic, above knee residual limb. He required excision of the exposed graft. Patients tolerate the retroperitoneal approach usually without paralytic ileus and prompt restoration of bowel function. Respiratory insufficiency is also minimal since a major body cavity is not entered. The majority of patients were extubated before transfer to the post-operative acute care unit. <h3>Discussion</h3> Historically, ilio-femoral bypass is considered a durable operation with a cumulative patency of 92% 3- year patency and exhibit superior patency when compared to extra-anatomical bypasses that demonstrate a 73% 3-year patency. The operation has been largely supplanted by endovascular procedures which are equally durable and less invasive. There is a subset of patients in whom angioplasty/stents are not possible or who have failed endovascular intervention and require in flow procedures. In this series, ilio femoral bypass was only performed in 5 patients (19%) with claudication.The remaining patients had critical limb ischemia and required intervention for limb preservation. Ilio-femoral bypass with adjunctive procedures provided acceptable short term and mid-term results in complicated patients, 85% of whom had previously undergone ipsilateral vascular intervention.

Total autogenous revascularization of an innominate artery occlusive disease

Total autogenous revascularization of an innominate artery occlusive disease

Alternative Approaches to the Abdominal Aorta: Outcomes of the Right Retroperitoneal Approach for Aortic Surgery

The left retroperitoneal (LRP) approach to the aorta is a well-established technique for aortic exposure. The right retroperitoneal (RRP) approach to the aorta has been performed less often, and the outcomes remain unknown. The purpose of our study was to evaluate the outcomes of RRP aortic procedures and to determine whether it is a viable strategy to preserve the LRP space for future procedures. We performed a retrospective review of a prospectively maintained computerized database with a query for all retroperitoneal aortic procedures. The patients' medical records were reviewed and data collected. The demographics, indications, intraoperative details, and outcomes were tabulated. We found 6076 retroperitoneal approaches for aortic procedures that had been performed between 1984 and 2020. Of these, 225 had used the RRP approach. Of the 225 patients, 153 were men (68%), and the median age was 65.2 years (range, 26-88). The comorbidities included hypercholesterolemia (n = 98; 15.6%), hypertension (n = 38; 16.9%), coronary artery disease (n = 25; 11.1%), current tobacco use (n = 98; 43.6%), diabetes (n = 32; 14.2%), and renal failure (n = 5; 2.2%). The indications for intervention included aneurysm (n = 112; 49.8%), occlusive disease (n = 100; 44.4%), and other (n = 13; 5.8%). The intraoperative blood loss was 967.1 mL (range, 50-8000 mL). Perioperative complications occurred in 43 patients (19.1%), with a total of 50 complications. These included cardiac events (n = 5), cerebrovascular events (n = 3), multiorgan failure (n = 8), renal failure (n = 4), pulmonary events (n = 3), bleeding (n = 7), colon ischemia (n = 6), hematoma (n = 1), infection (n = 2), limb loss (n = 3), and graft occlusion or stenosis (n = 5). Four patients died perioperatively (1.8%). Of the 225 patients treated with a RRP approach, 31 required 66 subsequent procedures. These procedures included 29 cases of extra-anatomic bypass, 19 cases of thrombectomy or embolectomy, 10 cases of bypass revision, 5 cases of infected graft excision, and 3 cases of aneurysm revision. Of the 225 patients in the RRP group, 8 had eventually undergone a LRP approach for aortic reconstruction and had also required 26 subsequent procedures. Of the RRP group, 14 had undergone a prior LRP approach and had required 12 subsequent procedures. The RRP approach to the aorta is a useful technique in the setting of prior surgery, anatomic abnormality, or infection that complicates the use of other approaches. The outcomes were similar to those with other more standard approaches. The RRP aortic approach has the added benefit of preserving the left retroperitoneum for future inflow procedures.

Treatment Comparisons in Management of Localized Groin Wound Prosthetic Graft Infection

We sought to determine whether conventional extra-anatomic bypass and graft removal vs aggressive attempts at graft preservation would result in better survival and limb salvage for patients with localized groin wound infections of prosthetic grafts.

Pleural Approach to Aberrant Right Subclavian Artery in Aortic Surgery.

An aberrant right subclavian artery usually arises from the aortic arch just distal to the left subclavian artery and crosses behind the esophagus on its way to the right axillary artery. Several reconstructive techniques of this artery in aortic surgery have been reported but mostly resulted in troublesome procedures. Here, we describe an alternative strategy presenting the occlusion of the aberrant right subclavian artery through the right pleural approach followed via extraanatomical axillary artery bypass. This surgical approach might be a simple and safe option for the aberrant right subclavian artery.

Mid- and long-term outcomes of extra-anatomic bypass procedures

Mid- and long-term outcomes of extra-anatomic bypass procedures

Comparison of Open Repair vs. the One-Stage Hybrid Extra-Anatomic Technique for Distal Aortic Arch Disease Treatment: Mid-term Outcomes With a Risk-Adjusted Analysis.

Objective: This study aims to compare the short- and mid-term outcomes of the stented elephant trunk (SET) procedure combined with supra-arch branch reconstruction and one-stage hybrid arch repair combined thoracic endovascular aortic repair (TEVAR) with extra-anatomic bypass in the management of distal arch disease.Methods: From January 2009 to January 2019, 97 patients underwent one-stage hybrid arch repair combined with TEVAR with extra-anatomic bypass (HAR group), and 206 patients underwent the SET procedure with supra-arch branch reconstruction (SET group). We used inverse-probability-of treatment weighting (IPTW) to adjust baseline differences.Results: Before IPTW adjustment, there was no significant difference in operative mortality between the two groups (5.2 vs. 1.0%, P = 0.064). The incidences of stroke, spinal cord injury (SCI), acute kidney injury (AKI), and endoleak also showed no significant differences (4.1 vs. 0.5%, P = 0.066; 2.1 vs. 1.5%, P = 1.000; 0 vs. 1.0%, P = 0.831; 6.2 vs. 1.9%, P = 0.113, respectively). After IPTW adjustment, the incidences of stroke, SCI, and AKI showed no significant differences between the two groups (1.8 vs. 1.1%, P = 0.138; 0.8 vs. 1.6%, P = 0.448; and 0 vs. 0.7%, P = 0.148, respectively). However, the HAR group tended to have higher operative mortality and incidence of endoleak than the SET group (12.4 vs. 1.3%, P = 0.01; 9.9 vs. 1.8%, P = 0.031, respectively). In the multivariate analysis, open repair decreased the risks of endoleak (odds ratio [OR], 0.171, 95% CI, 0.060–0.401; P < 0.001) and operative mortality (OR, 0.093, 95% CI, 0.027–0.238; P < 0.001). The overall survival and event-free survival of the HAR group were significantly lower than those of the SET group (P < 0.001).Conclusion: One-stage hybrid arch repair combined TEVAR with extra-anatomic bypass and the SET procedure with supra-arch branch reconstruction both provided good postoperative treatment outcomes for distal arch disease. However, hybrid arch repair increased the risks of endoleak and operative mortality. The SET procedure provided better mid-term survival than hybrid arch repair without increasing operative mortality. Carefully selecting the indications for the procedure, while receiving close long-term follow-up, may improve the survival rate of patients undergoing hybrid arch repair.