Extra-anatomic Bypass Research Articles

Late pseudo-aneurysms after coarctation repair with extra-anatomic ascending-descending aortic bypass surgery

Abstract Background Extra-anatomic ascending-descending aortic bypass operations are an alternative to difficult aortic arch reconstruction in patients with complex aortic coarctation. Reported short-term results are favorable, however, data on long-term outcomes are sparse. The aim of our study was to report long-term outcomes in affected adult patients. Methods We identified all adults with extra-anatomic ascending-descending aortic bypass surgeries followed at our center. Outcomes were assessed by chart review with a specific focus on formation of late pseudo-aneurysms and requirement for redo surgery. Results We identified a total of 12 adults (67% males) with previous ascending-descending aortic bypass surgery. These patients account for 12/171 (7%) of adults with aortic coarctation followed at our center. 10/12 patients (83%) had undergone coarctation repair by different repair techniques before ascending-descending aortic bypass surgeries. Median age at ascending-descending aortic bypass surgery was 17 years (range: 7-42 years). Prosthetic conduit sizes ranged from 12-22mm. In long-term follow-up, 11/12 patients (92%) required antihypertensive medication (median 2 antihypertensive drugs, 50% ≥ 3 drugs). A total of 5/12 patients (42%) required redo-surgery for formation of pseudo-aneurysms (figure 1) at graft anastomoses (4 proximal anastomosis at ascending aorta, 1 distal anastomosis to descending aorta) at a median age of 47.6 years (28.2-65.0 years) and a median of 22.1 years (range: 14.7-24.6 years) after the initial extra-anatomic ascending-descending aortic bypass operation (figure 2). Two of these patients required redo-operations / interventions for recurrent pseudo-aneurysms at 26 and 33 months after the redo-operations. Conclusions Although reported short- and medium-term outcomes after ascending-descending aortic bypass surgery for complex aortic coarctation are favorable, our data suggest a high rate of pseudo-aneurysm formation late (>10 years) after surgery. Our data highlight the need for careful long-term (life-long!) follow-up of these patients at specialized centers.

Mid-term morphological change of Kommerell’s diverticulum after hybrid thoracic endovascular aortic repair

ObjectivesKommerell’s diverticulum (KD) is associated with a high incidence of right-sided aortic arch (RAA). Hybrid thoracic endovascular aortic repair (TEVAR) is an effective and less invasive alternative to open repair. However, the long-term results regarding KD diameter regression or symptom improvement remain inadequately described. MethodsNine patients underwent TEVAR for KD associated with RAA between January 2016 and September 2023 at our university hospital and affiliated institutions.A hybrid procedure was performed to exclude KD by blocking the proximal blood flow with TEVAR and distal blood flow with embolization of the aberrant subclavian artery. Simultaneously, extra-anatomical bypass surgery was performed to revascularize the covered supra-arch vessels. ResultsThe patients' mean age was 65.2 years, and six patients were men. Two patients presented with dysphagia, whereas the rest were asymptomatic. The mean diameter and distance to the opposite aortic wall of KD were 32.1 mm and 56.2 mm, respectively. For revascularization of the covered supra-arch vessels, six and two patients underwent total debranching with sternotomy and extra-thoracic bypass (bilateral common carotid artery–axial artery bypass), respectively. The 30-day and in-hospital mortality rates were 0%, with no instances of cerebral infarction or spinal cord ischemia. The mean follow-up period was 3.2 years. The survival and avoidance rates of aortic events were 100% at 1 and 3 years. Follow-up computed tomography scans showed no endoleaks; however, one (11.1%) type 2 endoleak from the aberrant left subclavian artery occurred 1 week postoperatively, necessitating additional coiling. Seven patients were followed up for more than 1 year, with five experiencing reductions of more than 3 mm in KD diameter, distance to the opposite aortic wall, or both. ConclusionAlthough further follow-up and investigations are needed, TEVAR may be a safe and effective surgical treatment for KD associated with RAA.

Utility of covered stents as a bypass for the treatment of central venous occlusion: a case report

BackgroundCentral venous occlusion (CVO) is difficult to treat with percutaneous transluminal angioplasty because the guidewire cannot pass through the occluded segments. In this study, we devised a new method for establishing an extra-anatomic bypass between the right subclavian vein and the superior vena cava via a covered stent to treat whole-segment occlusion of the right brachiocephalic vein (BCV) with calcification.Case presentationWe present the case of a 58-year-old female patient who complained of right arm swelling present for 1.5 years. Twelve years prior, the patient began hemodialysis because chronic glomerulonephritis had progressed to end-stage renal disease. During the first 3 years, a right internal jugular vein (IJV)-tunneled cuffed catheter was used as the dialysis access, and the catheter was replaced once. A left arteriovenous fistula (AVF) was subsequently established. Owing to occlusion of the left AVF, a new fistula was established on the right upper extremity 1.5 years prior to this visit. Angiography of the right upper extremity revealed complete occlusion of the right BCV and IJV with calcification. Because of the failure to pass the guidewire across the lesion, we established an extra-anatomic bypass between the right subclavian vein and the superior vena cava with a covered stent. Angiography confirmed the patency of whole vascular access system. After 3 months of follow-up, the patient’s AVF function and the bypass patency were satisfactory.ConclusionsAs a new alternative for the treatment of long, angled CVO with or without calcification, a covered stent can be used to establish an extravascular bypass between central veins.

Impact of operative approach and patient frailty on outcomes for aorto-iliac occlusive disease with critical limb threatening ischemia.

Multiple treatment modalities exist for the management of aorto-iliac occlusive disease (AIOD) including endovascular (endo), extra-anatomic bypass (EAB), and anatomic bypass (AB). The goal of this study was to examine the impact of revascularization strategy and patient frailty on outcomes for AIOD in patients with critical limb threatening ischemia (CLTI). Patients undergoing revascularization for CLTI and AIOD were identified from the NSQIP database over 5years. Demographics, procedural characteristics, and outcomes were recorded. Modified frailty index (mFI-5) was calculated for each patient. Patients were compared based on the type of procedure and frailty (mFi>0.6). From 2017 to 2021, 1777 patients underwent revascularization for CLTI from AIOD. Patients were majority male (56%) with a mean age of 68. A total of 1346 patients (76%) underwent an open operation of which 669 were EAB. When endo (431 patients) was compared with open repair, endo was associated with a higher incidence of tissue loss at presentation (42% vs 33%, p < 0.001), lower rates of bleeding (6.5% vs 15.5%, p < 0.001), fewer MI/stroke (1.6% vs 4.6%, p = 0.004), and fewer wound complications (2.6% vs 11.2%, p < 0.001). There was no difference in re-intervention, amputation, or death based on frailty. For frail patients (184 patients), type of repair did not impact re-intervention, major amputation, or mortality, though there was increased MI/stroke with EAB and increased wound complications with AB/EAB. AIOD revascularization strategies for patients with CLTI have similar 30-day re-intervention, major amputation, and mortality rates. Endovascular repair has less surgical wound complications and is better suited for frail patients.

Contemporary Experience of the Neo-Aortoiliac System (NAIS) Procedure: A Case Series with Review of the Literature

Aortic graft infection (AGI) is a life-threatening complication that can result in death, amputation, sepsis, aorto-enteric fistula, and pseudoaneurysm formation. After explantation of the infected graft, options for reconstruction include extra-anatomic bypass or in-line reconstruction using antibiotic-coated prosthetic graft, cryopreserved allograft, or a neo-aortoiliac system (NAIS) using autogenous femoral veins. While the NAIS procedure has shown promising results, there is relatively limited clinical experience due the magnitude and morbidity of the surgery. In this study, we reviewed our single-center experience using the NAIS procedure and performed a systematic review of the contemporary literature more than the past decade. A retrospective review was performed on all patients undergoing NAIS reconstruction with autogenous femoral vein conduits at a single institution from 2010 to 2022. Pubmed, Embase, and Cochrane Library databases were queried for studies published from 2012 to 2022 to identify those reporting on outcomes of patients undergoing the NAIS procedure. Outcome variables included early and late mortality, major complications including amputation, graft or conduit related complications, re-infection, and re-intervention. Additional variables collected include patient demographics, operative technique, and follow up. There were 14 patients included in our case series with 30-day mortality of 21%. At a mean follow up of 22months, complication rate was 64.3%, re-intervention rate was 14.3%, re-infection rate was 7.1%, and amputation rate was 7.1%. On review of the literature, 12 studies ultimately met criteria to be included in analysis with a combined total of 368 patients. Pooled averages included 30-day mortality of 9.0%, re-intervention rate of 20.5%, re-infection rate of 5.6%, and amputation rate of 6.5%. The NAIS procedure for management of AGI is a formidable procedure with significant early mortality and morbidity. This treatment should be considered in the context of other revascularization options for management of an AGI.

Vascularsurgical Long-term Outcome - Comparison of Orthotopic and Extraanatomic Reconstructions in Unilateral Occlusions of Iliac Artery over 10 Years

In PAOD, several vascular regions are usually affected, the pelvic axis in 35% of cases. Interventional-radiological/endovascular or hybrid interventions have been established for recanalization, so that bypass procedures are increasingly taking a back seat, but are not losing their importance.To study unilateral iliac artery occlusions (inclusion criterion) that were repaired either by implantation of an orthotopic or extraanatomic bypass (oBP/eaBP).Over a defined period of time, the rate of open vessel, complications (frequency, type, severity) to characterize morbidity and mortality as well as the extent of clinical improvement after BP implantation were analyzed in a clinical-systematic, single-center observational study (for vascular surgical quality assurance and contribution to vascular medical-clinical health care research). The study method was not explicitly based on the STROBE criteria, but essentially corresponds to them.Over 10 years, 122 PAOD patients (50% in stage IIb-stage III and IV equally distributed; mean age: 63 [range, 44-87] years; majority ASA III) were included with the same number of reconstructions: 71 patients received an eaBP ("crossover"), 51 patients an iliacofemoral (orthotopic - oBP) bypass (neither significant difference regarding frequency nor number of risk factors per patient).The oBP is not superior to eaBP with regard to the analysis parameters of openness, complication rate and mortality. Furthermore, extraanatomic revascularization does not have to be reserved for polymorbid patients only.

Secondary aorto-enteric fistula after aortic aneurysm repair

Overview: Secondary Aorto-enteric fistula (sAEF) is a serious complication after open abdominal aortic aneurysm (AAA) repair, diagnosis and treatment are the sacraments for a vascular surgeons. Objectives: Describe the patient’s characteristics and treatment results of a series of clinical cases diagnosed with Secondary Aorto-enteric Fistula after surgery to open abdominal aortic aneurysm repair.. Methods: A clinical case series. Results: Report on 3 clinical cases of Secondary Aorto-enteric Fistula admitted to the hospital due to gastrointestinal bleeding, underwent surgery to completely remove the graft infection, restore the intestinal fistula, perform extra-anatomic bypass (axillary-bifemoral), the results showed one patient died early postoperatively due to multiple organ failure, two patients had stable postoperative progress and were discharged. Conclusions: Secondary Aorto-enteric Fistula is a rare complication, diagnosis and treatment are often very difficult, early surgery to remove the graft, performing extra-anatomic bypass is an effective method, helping to reduce the mortality rate.

The anatomic repair of recurrent aortic arch obstruction in children and adolescents

ObjectiveSurgery for recurrent aortic arch obstruction is highly challenging and publications are rare. The aim of this retrospective, single-center study was to evaluate mortality, complications, and reintervention rate after an anatomic repair. MethodsBetween 1999 and 2022, in total 946 operations on the aortic arch were performed at the Children's Heart Center Linz. In 39 cases, the indication was a recurrent or residual aortic arch obstruction or coarctation in a patient aged 18 years or younger. This is our study cohort. The aorta was reconstructed by a direct anastomosis/autograft in 20 patients, patch in 17 patients, and interposition graft in 2 adolescents. In 32 procedures, cardiopulmonary bypass with whole body perfusion was employed, in 4, antegrade cerebral perfusion was employed, in 2, a left heart bypass was employed, and in 1 no cardiopulmonary bypass was used. ResultsMedian (Q1, Q3) age at operation was 253 days (100, 2198 days), weight 7.5 kg (4.5, 17.8 kg). Median cardiopulmonary bypass time was 177 minutes (115, 219 minutes), crossclamp time 73 minutes (49, 102 minutes). Three infants died during the hospital stay: 1 with Williams syndrome, 1 with hypoplastic left heart syndrome, and 1 with heterotaxia. There was no death due to an arch complication. The main complications were 1 neurologic injury after postoperative resuscitation (Williams syndrome) and 1 permanent recurrent laryngeal nerve paralysis. During the follow-up period of median 8.1 years (2.6, 12 years) 1 re-reintervention on the aortic arch was necessary. ConclusionsSophisticated reoperations on the aortic arch could be performed safely. In children, the growth potential of all segments of the aorta could be sustainably preserved by avoiding interposition or extra-anatomic bypass grafts.

External Scaffold for Venous Graft to Treat Chronic Limb-Threatening Ischemia: Results of the FRAME Vascular Support.

Background: The surgical treatment of chronic limb-threatening ischemia and optimal conduit choice are extensively debated. The presence of suboptimal autologous material, such as varicosities or venous aneurysms, might impair long-term outcomes. Therefore, kink-resistant external supports have been advocated in the recent literature to improve the conduit quality and outcomes. This study analyzes the FRAME external support in venous ectasic grafts in patients with chronic limb-threatening ischemia. Methods: From September 2017 to September 2023, a total of sixteen patients underwent CLTI surgery with FRAME external support for venous grafts. The inclusion criteria for FRAME applications were varicose or ectasic autologous material with a diameter ≥ 4.5 and ≤ 8 mm in an isolated segment or in the entire vein and a higher risk of bypass extrinsic compression (e.g., extra-anatomical venous bypass course). Results: Technical success and intraoperative patency were achieved in all cases. At 30 days, the limb salvage and survival rates were 100%. The primary bypass patency was 93.7% due to an early graft occlusion. No graft infection was registered. In one case, dehiscence of the surgical wound was treated by surgical debridement and antibiotic therapy. Minor amputation was required in four patients. Over a median follow-up of 32 months, two occlusions were observed; one was treated with reoperation and the other with major amputation. The primary patency was 68.7% and the assisted primary patency was 75%. Limb salvage rates observed during the entire follow-up period were 87.5%. No graft infections or dilatation of the reinforced veins were registered. Conclusions: For patients with CLTI undergoing infrainguinal bypass, satisfactory results in terms of patency and limb salvage rates were achieved using the autologous venous material, even if ectasic or varicose, with the vascular external support FRAME.

Extra-anatomic bypass procedures for severe aortoiliac occlusive disease-A cohort study.

Extra-anatomic bypass (ExAB) grafting has been questioned due its inferior durability compared to anatomic bypass for aortoiliac occlusive disease (AIOD). This study aims to present early and late outcomes of patients treated with ExAB as well as to evaluate potential prognostic factors. This is a retrospective cohort study presenting a series of patients treated with ExAB for AIOD. All patients were treated between 2005 and 2022 within the Vascular Surgery Unit of a University Surgery Clinic. Both early (30-day) and late outcomes were evaluated. Univariate and multivariate analyses were conducted for potential predictors. Kaplan-Meier curve was produced for long-term patency. A total of 41 patients were treated (85.3% males; mean age: 76.3 ± 4.2years). Indication for treatment included severe claudication or critical limb ischemia (Rutherford stages III-VI). The following procedures were recorded: Femorofemoral bypass (FFB; n = 21) and axillofemoral bypass (AxFB; n = 20). All procedures were conducted using synthetic grafts with external rings. Early outcomes included no death, no myocardial infarction, no major bleeding, no graft infection, and no major amputation. Regarding late outcomes, 14.6% patients were lost after the first month. For the rest of patients (n = 35), five-year primary patency was 88.6%, primary-assisted patency was 94.3%, and secondary patency was also 94.3%. Limb salvage was 100% within follow-up. Endarterectomy at the distal anastomosis was the only independent predictor associated with worse patency in the long-term (OR = 5.356; 95% CI (1.012-185.562); p = .041). FFB and AxFB is a safe and durable strategy for treating patients with severe AIOD where no other option is feasible. Regarding predictors, only endarterectomy at the distal anastomosis site was associated with an increased risk for graft failure.

Extra-anatomical bypass operation in patients with unilateral graft limb occlusion after endovascular aneurysm repair for abdominal aortic aneurysm.

Extra-anatomical bypass operation in patients with unilateral graft limb occlusion after endovascular aneurysm repair for abdominal aortic aneurysm.

An early single-center experience with the Relay double inner-branch arch endograft.

Open surgery remains the gold standard technique for the treatment of aortic arch pathologies, although endovascular techniques offer a new opportunity for patients deemed unfit for open repair. This paper assesses the early outcomes of patients treated with a double inner-branched arch endograft in a single, tertiary-care institution. All consecutive cases of elective endovascular arch repair from 2016 to 2022 were included in a prospective database. All procedures were performed using the custom-made Relay® (Terumo Aortic-Bolton Medical Inc., Sunrise, FL, USA) double inner-branched endograft; an extra-anatomical bypass was associated in all cases to preserve the patency of supra-aortic trunks. Comorbidities, periprocedural data, immediate results and follow-up complications were analyzed. Twelve patients were treated during the study period [mean age 74±7 years, 100% male, 58% American Society of Anesthesiologists (ASA) risk ≥3]. Treated conditions included aneurysms (n=9), one pseudoaneurysm, one aortic ulcer and a type IA endoleak. The technical success rate was 100%. Early complications included respiratory insufficiency (n=3; 25%), stroke (n=1; 8.3%), acute coronary syndrome needing coronary stenting (n=1; 8.3%), and one perioperative death (n=1; 8.3%) secondary to an intracranial bleeding after coronary stenting. One patient required early reintervention due to retroperitoneal iliac access bleeding (n=1; 8.3%). During a median follow-up of 15.5 (range, 0-44) months, four patients suffered neurological events (two of them of cardioembolic origin), one reintervention was needed (subclavian anastomosis pseudoaneurysm), and a type IB endoleak was diagnosed. Overall mortality was of 17% (n=2), with an 83% overall survival at 2 years. The aortic-related death-free survival was 100%. Endovascular treatment of aortic arch pathology is feasible and shows promising early mortality and stroke rates in high-risk candidates. The main short and midterm goal should be minimizing neurological complications. A longer follow-up is mandatory to determine the effectiveness of the technique and to detect device related complications.

Axilofemoral bypass in aortoiliac diseases: a case report

Introduction: In patients presenting with severe comorbid conditions and infra-renal aortic occlusion, an extra-anatomic bypass stands as one of the viable revascularization options for limb preservation. Axillofemoral bypass offers a valuable alternative in cases involving hostile abdominal environments or infectious aortic aneurysms. To our knowledge, this is the first report from Indonesia of a case of Aortoiliac Occlusive Disease (AIOD). This case report presents a 39-year-old female patient with complaints of left leg pain persisting for the past seven months. Case Description: A 39-year-old female patient sought care at our hospital, reporting left leg pain persisting for the past seven months. The pain worsened during physical activity and subsided during rest. She had a history of hypertension for the last eight years but no diabetes or smoking history. The previous hospital had diagnosed her with peripheral arterial disease, prescribing cilostazol and rivaroxaban, which provided only temporary relief. A computed tomography (CT) angiogram revealed occlusion of the abdominal aorta at the level of L2, extending to the left common iliac and right iliac arteries. We elected to perform an axilla-femoral bypass using a polytetrafluoroethylene (PTFE) graft, which yielded satisfactory results. The patient's progress was monitored for three months postoperatively. This report details the case of a female patient with aortoiliac occlusive disease. Given the absence of insurance coverage for endovascular treatment at our facility, we opted for an axilla-femoral bypass using a PTFE graft, which produced satisfactory outcomes during a three-month follow-up period. Conclusion: The axillofemoral bypass procedure is fairly safe and easy, especially in patients with a high risk of direct aortofemoral bypass and difficult anatomy. The number of collateral vessels in our patients based on CT scans and endovascular procedures that have not been supported by insurance in our hospital makes us choose the axillofemoral bypass option is the action we decided.

Nonspecific Presentation of an Infected Aorto-Iliac Artery Stent Following Endovascular Revision and Stent Insertion.

Over the last few decades, the use of covered stent grafts became increasingly popular; as it plays a pivotal role in the management of various atherosclerotic diseases that are rising in both incidence and prevalence. Subsequently, vascular stent infections, although rare, are becoming a well-recognized complication with possibly devastating consequences, owing to the difficulties associated with its diagnosis and treatment. This has prompted significant interest in the condition regarding its pathophysiology, modifiable and non-modifiable risk factors, diagnostic and therapeutic approaches, and the possible implementation of prophylactic measures. We herein present a case of a patient with an infected aortoiliac stent 4weeks after endovascular revision with atherectomy and additional stent insertion. The patient initially developed nonspecific symptoms and later developed a life-threatening hemorrhage, which was urgently controlled using a percutaneously inserted covered stent at the infected site. Definitive treatment using extraanatomical bypass implantation and an explantation of the infected stents was performed with excellent clinical response.

Abstract 13814: Combined Omental and Bilateral Pectoralis Major Flaps for Treatment of Thoracic Aortic Graft Infections

Introduction: Aortic graft infections have historically been managed through graft removal and replacement. However, coverage with vascularized tissue flaps may provide an effective alternative, particularly in patients who are not able to undergo extended extra-anatomic bypass procedures. Hypothesis: Here we describe our experience treating thoracic aortic graft infections with combined omental and bilateral pectoralis major myocutaneous (PMM) advancement flaps. Methods: All patients undergoing sternal wound treatment with PMM flaps by the senior author (JAA) at a high-volume cardiac surgery center from 1996-2023 were reviewed. Patients with evidence of aortic graft infection were included. Results: Complete data were available for 598 patients, 11 of whom had combined PMM and omental flaps mobilized for aortic graft infections. ASA score was &gt;4 in 9/11 (81.9%). At the index cardiac surgery, 11/11 (100%) underwent aortic root repair/replacement, and 9/11 (81.9%) also underwent aortic valve repair/replacement. Indications in this group for flap surgery included culture-positive infection (8/11; 72.7%), dehiscence (5/11; 45.5%), drainage (7/11; 63.6%), and inability to close the sternotomy incision due to hemodynamic instability (5/11; 45.5%). During chest exploration, 7/11 (63.6%) underwent complete removal of the infected graft, compared to 4/11 (36.4%) who underwent graft-preserving washout and debridement. Immediate flap closure was performed in 4/11 (36.4%). Intraoperative mediastinal cultures were positive in 3/11 (27.3%). Post-operative complications included dehiscence (1/11; 9.1%), seroma (2/11; 18.2%), hematoma (1/11, 9.1%), abdominal hernia (1/11; 9.1%), and recurrent infection (1/11; 9.1%). One (9.1%) patient died within 30 days of sternal reconstruction from mitral valve failure and a tachyarrhythmia. None have undergone reoperation for flap-related complications, while one patient underwent elective resection due to aesthetic complaints. Conclusions: Low postoperative morbidity and mortality indicate that combined omental and pectoralis major flaps are a safe and effective treatment for aortic graft infections.

Surgical bypass to the left subclavian artery: an extra-anatomical transpleural approach

A distal anastomosis in zone 3 is technically demanding during the frozen elephant trunk procedure. Proximalization of the distal anastomosis to zone 2 with subsequent revascularization of the left subclavian artery is an attractive alternative. This video tutorial describes the technique of an extra-anatomical bypass from the aortic prosthesis to the infraclavicular left subclavian (axillary) artery in arch replacement with the distal aortic graft anastomosis in zone 2.

Aortic Arch Debranching and Thoracic Endovascular Aortic Repair (TEVAR) for Type B Aortic Dissection

Since its introduction, thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of type B aortic dissections (TBADs). However, the proximal aspect of the aortic pathology treated may infringe on the origin of the left subclavian artery or even more proximally. Hence, to ensure durable outcomes, the origin of these vessels needs to be covered, but an extra-anatomical bypass is required to perfuse vital branches, known as aortic arch debranching. This series aims to describe and delineate the disparities of aortic arch debranching during TEVAR for TBAD. A retrospective review and analysis of a multicenter international database was conducted to identify patients with TBAD treated with TEVAR between 2005 and 2021. Data analyzed included patient demographics, disease characteristics, operative characteristics, and postoperative outcomes with follow-up on mortality and reintervention. All statistical analyses were carried out using IBM SPSS 26. Patient survival was calculated using a Kaplan-Meier survival analysis, and a P value of less than 0.05 was considered statistically significant. A total of 58 patients were included in the analysis, of which 27 (46.6%) presented with complicated disease and 31 were uncomplicated, of which 10 (17.2%) were classed as high risk and 21 (36.2%) low risk. Zone 2 was the most common proximal landing zone for the stent graft. Left subclavian artery bypass was performed selectively (26%), with 1 stroke occurring, likely due to embolic reasons. A further 6 underwent more proximal aortic debranching before TEVAR (10%) and was a significant risk factor for mortality and the number of stents deployed. The overall rates of reintervention and mortality were 17.2% (n=10) and 29.3% (n=17). Aortic arch debranching and TEVAR for TBAD is associated with significant mortality. Future developments to treat aortic arch pathology could incorporate branched graft devices, eliminating the need for debranching, improving stroke rates, and reducing future reinterventions.

The place of regional anesthesia in vascular surgery: literature review and personal experience

Background. Vascular surgery is a high-risk procedure, and most interventions carry a greater than 5% risk of an acute cardiac event. Direct reconstruction of aorto-iliac-femoral segment is associated with a 2.8% perioperative mortality, whereas extra-anatomic bypass has an 8.8% mortality. Arteriosclerosis obliterans is a growing public health concern affecting 8.5 million people in the United States and 200 million people worldwide. Main goals of preoperative assessment of vascular patients are risk stratification and its potential reduction by safe methods of anesthesia. Aim: to compare regional anesthesia during carotid endarterectomy, abdominal aortic aneurysm resection and repair, repair of the lower limb vessels and lower extremity amputation based on the data of the world literature and the choice of safe methods of anesthesia. Materials and methods. The materials are modern world literature, Scopus, Web of Science, MedLine, the Cochrane databases and the latest scientific research. Using the comparative method of analysis, the world literature data were compared with the experience of using regional methods of analgesia at the Kyiv Regional Clinical Hospital. Conclusions. Given the data presented in the article, it can be considered that regional anesthesia is the optimal method for use as monoanesthesia or in combination with general anesthesia in vascular surgery. The use of these methods of anesthesia by an experienced anesthesiologist can decrease length of stay in the hospital and improve the disease course in this rather complex patient population. The decision to use regional techniques should be made by the patient, surgeon, and anesthesiologist after an individualized discussion of the risk-benefit profile for each patient and type of surgery.

CT Arterioportography for Complex Portomesenteric Venous Interventions

AbstractAuthors report the use of computed tomography arterioportography (CTAP) in the diagnosis and endovascular treatment of portomesenteric venous occlusion. Three patients (2 male and 1 female; median age: 51 years) with an extrahepatic portal or mesenteric venous occlusion and variceal bleeding were included in this institutional review boards-approved retrospective study. CTAP was performed with an angiographic catheter positioned in the proximal superior mesenteric artery, and CT was obtained during the venous phase following the intra-arterial injection of contrast material. CTAP provided excellent opacification and delineation of portomesenteric veins, including occlusion length, intravascular webs, venous collaterals, and bleeding varices. This enabled preoperative planning for complex recanalization or extra-anatomic bypass to treat extrahepatic portal and mesenteric venous obstruction. There were no complications related to CTAP.

Extra-anatomical left common carotid and subclavian artery bypass followed by aortic arch replacement with frozen elephant trunk

BackgroundTotal arch replacement (TAR) using a frozen elephant trunk (FET) allows for simultaneous treatment of the aortic arch and descending aortic pathology via median sternotomy. In addition, an extra-anatomical bypass performed between the left common carotid artery (CCA) and subclavian artery (SCA) prior to TAR allowed further proximalisation of the FET prosthesis, facilitated distal anastomosis of the TAR and spared the demanding left subclavian artery (LSA) anastomosis in the deep thorax. We investigated the efficacy of this debranching-first technique, followed by TAR using a frozen elephant trunk, as a two-stage operation for extensive thoracic aortic aneurysms in high-risk patients.MethodsForty-nine consecutive patients with diffuse degenerative aneurysms from the aortic arch to the descending aorta or chronic aortic dissection who underwent left common carotid to subclavian artery bypass followed by TAR using a frozen elephant trunk and subsequent thoracic endovascular aortic repair between 2016 and 2021 were analysed. The baseline characteristics and clinical outcomes were assessed. The estimated overall survival, 5-year aortic event-free survival, and aortic reintervention rates were analysed.ResultsThe average European System for Cardiac Operative Risk Evaluation (EuroSCORE II) was 4.7 ± 2.5. The operative mortality rate was 4.1%, with no paraplegia events. The estimated 5-year overall survival, cumulative aortic-related mortality rates were 76.8% and 2%, respectively. The estimated 5-year overall cumulative aortic reintervention rate, including the intended intervention, was 31.3%. The estimated 5-year cumulative rate of non-intended reintervention was 4.5%.ConclusionsThe assessed technique enables a less technically demanding surgery with reasonable outcomes. The estimated 5-year aortic event-free survival and reintervention rates were acceptable, suggesting that multiple stages of alternative open and endovascular interventions, such as this technique, may reduce the morbidity and mortality rates of high-risk patients with diffuse thoracic aortic aneurysm.UMIN-CTR (University hospital Medical Information Network-Clinical Trial Registry)https://center6.umin.ac.jp/cgi-open-bin/ctr_e/index.cgiClinical registration number: UMIN000051531