Femoral Bypass Research Articles

80-Year-Old Man With Vision Loss

An 80-year-old man presented to the emergency department with a 1-week history of progressive, transient, monocular vision loss, binocular diplopia, transient headache, and lightheadedness. Clinical comorbidities included obesity, hypertension, hyperlipidemia, former tobacco smoking, and femoral popliteal artery bypass surgery. He also had bilateral cataract surgery the month before presentation, which occurred without complications. Upon presentation, the patient’s medications included aspirin 325 mg daily (prescribed after bypass surgery), hydrochlorothiazide 25 mg daily, lansoprazole 15 mg daily, losartan 25 mg twice daily, metoprolol tartrate 100 mg twice daily, and simvastatin 80 mg daily. CORRECT ANSWERS: 1. b. 2. d. 3. a. 4. d. 5. e.

Outcomes of Omniflow® II prosthesis used for revascularization in the femoral tract both in infected and non-infected setting.

Evidence regarding the outcomes of Omniflow® II prosthesis in peripheral arterial revascularization at different anatomical sites and for different indications is scarce. Therefore, the aim of this study was to evaluate the outcomes of the Omniflow® II used at various positions within the femoral tract both in infected and non-infected setting. Patients who underwent reconstructive lower leg vascular surgery with implantation of an Omniflow® II from 2014 until 2021 at five medical centers were retrospectively included (N.=142). Patients were subdivided into the following categories: femoro-femoral crossover (N.=19), femoral interposition (N.=18), femoro-popliteal (above-the-knee [N.=25; AK] or below-the-knee [N.=47; BK]), and femoro-crural bypass grafts (N.=33). Primary outcome was primary patency and secondary outcomes included primary assisted patency, secondary patency, major amputation, vascular graft infection, and mortality. Outcomes were compared according to different subgroups and the surgical setting (infected versus non-infected). The median follow-up was 35.0 (17.5-54.3) months. Three years primary patency of 58% was observed for femoro-femoral crossover bypass, 75% for femoral interposition graft, 44% for femoro-popliteal above-the-knee bypass, 42% for femoro-popliteal below-the-knee bypass, and 27% in the femoro-crural position (P=0.006). Freedom from major amputation at three years were 84% for femoro-femoral crossover bypass, 88% for femoral interposition bypass, 90% for femoro-popliteal AK bypass, 83% for femoro-popliteal BK bypass, and 50% for femoro-crural bypass (P<0.001). This study demonstrates the safety and feasibility of the use of Omniflow® II for femoro-femoral crossover-, femoral interposition-, and femoro-popliteal (AK and BK) bypass. Omniflow® II seems to be less suitable for femoro-crural bypass with a significantly lower patency compared to other positions.

Right axillopopliteal artery bypass using a combined transiliac and lateral popliteal approach for groin infection and lymph fistula.

Wound infection in the groin is a serious complication after vascular bypass surgery. The combined treatment of critical limb ischemia and recurrent infection presents challenges for vascular surgery(1Lounes Y. Ozdemir B. Alric P. Canaud L. Trans-iliac Bypass for Critical Limb Ischaemia with Groin Necrosis: A Case Report.EJVES Short Reports. 2019; 42: 31-33https://doi.org/10.1016/j.ejvssr.2019.01.002Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 2Multon S. Jayet J. Javerliat I. Coscas R. Coggia M. Aortic–tibial transiliac wing extra-anatomic bypass with distal fistula for treatment of an infected deep femoral pseudoaneurysm.J Vasc Surg Cases, Innov Tech. 2022; 8: 201https://doi.org/10.1016/j.jvscit.2022.02.008Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 3Engin C, Posacioglu H, Ayik F, Apaydin A . Management of vascular infection in the groin. Texas Hear Inst J (2005) 32:529–534.Google Scholar). In this case, we successfully managed the wound infection in the groin after axillofemoral artery bypass grafting, using a combination of trans-iliac bypass and lateral popliteal approach(4Enzmann F.K. Nierlich P. Eder S. Aspalter M. Dabernig W. Aschacher T. et al.Trans-Iliac Bypass Grafting for Vascular Groin Complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935https://doi.org/10.1016/j.ejvs.2018.11.003Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 5Benzing C. Fellmer P. Lateral Approach to the Distal Femoral Artery in Femoro-Anterior-Tibial Bypass Surgery.Eur J Vasc Endovasc Surg. 2016; 52: 267https://doi.org/10.1016/j.ejvs.2016.04.024Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar). A 74-year-old man, having Buerger's disease and arteriosclerosis obliterans, presented with extensive lymphatic fistula and necrosis of the groin (Fig.1) after right axillary artery to the right deep femoral artery bypass, which had been patented for last five years after the several revascularizations of iliac arteries and femoral arteries. Due to the several open surgeries, such as aorto-right external iliac artery bypass, aorto-left popliteal artery bypass, cholecystectomy and resection of gastric cancer, we chose right axillopopliteal artery bypass grafting, through the iliac wing. The skin incision was made along the iliac crest and the external oblique muscle fascia was separated to reach the pelvis, and a longitudinal incision was made anterosuperior to the greater trochanter to create a gluteal pathway to bypass the infected groin. 10-mm hole was made by shaving the bone about 4 cm from the iliac crest, and the graft was passed through the hole. (Fig 2). A lateral popliteal approach was selected for revascularization owing to extensive groin and medial thigh infective wounds. After that the extensive lymphatic fistula and necrosis were controlled with using negative pressure wound therapy.Figure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) The postoperative course was uneventful, and contrast-enhanced computed tomography confirmed proper arrangement of the graft, without bending (Fig 3 and Fig 4). He was discharged from the hospital on the 14th postoperative day. The computed tomography which was taken one year later showed the patency of this graft. The combination of trans - iliac bypass and lateral popliteal approach was shown to be effective in this case of extensive groin and medial compartment infection, and can potentially be applied in similar future cases.Figure 4View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Percutaneous access of an intraoperatively recanalized mid-superficial femoral artery for distal lower limb revascularization.

A 61-year-old male patient presented with rest pain and ulceration in his left leg 1 week after a hybrid procedure with bilateral external iliac stenting, common femoral artery thromboendarterectomy, and left-sided femoral popliteal bypass with an in situ saphenous vein. The bypass had been stented intraoperatively but had again become occluded directly after surgery. In the present report, we demonstrate the usefulness of direct percutaneous access to the mid-superficial femoral artery that had been intraoperatively recanalized via brachial artery access during the same procedure. This innovative combination of approaches allows for proximal and distal lower limb revascularization with stenting when avoidance of femoral artery access is considered appropriate.

P298 TRANS–AXILLARY ACCESS AS AN ALTERNATIVE ROUTE IN TRANSCATHETER AORTIC VALVE IMPLANTATION

Abstract Background Transcatheter aortic valve replacement (TAVR) is the main procedure for treating severe aortic stenosis in patients considered at high surgical risk. Generally, this procedure is performed through percutaneous femoral arterial access. The presence of anatomical variants or peripheral atherosclerotic pathology sometimes necessitates the use of alternative vascular accesses, including access through the axillary artery. Data from a meta–analysis involving 1793 patients who underwent TAVR through trans axillary or transapical access showed a statistically significant reduction in 30–day mortality in the former group. We wait for future randomized trials to confirm the consistency of these data. Clinical case 71–year–old man, smoker, hypertensive and dyslipidaemic. In 2018, he underwent bilateral aorta–iliac–femoral bypass surgery for severe lower limb arteriopathy. Due to the onset of angina and dyspnea at rest, he went to the ER where a diagnosis of NSTEMI was made. On echocardiogram, there was evidence of severe high–gradient aortic stenosis while coronary angiography showed 80% RCA stenosis in the middle tract. Because of the high surgical risk (EUROSCORE II: 12%) and the evidence of bilateral femoral artery occlusion on CT–angiography, the Heart Team concluded to perform TAVR through percutaneous left trans–axillary access with concomitant percutaneous coronary revascularization. Obtained the backup access on the left radial artery, PTCA+DES was performed on RCA through the right radial access with subsequent placement of a pigtail catheter in the non–coronary sinus of Valsalva. Once the temporary pacemaker had been placed through the right femoral vein, an angio–guided puncture of the left axillary artery was performed with placement of the 14 Fr introducer for implantation of the Medtronic Evolut R 26 mm aortic biological prosthesis. Post–procedure ultrasound examination showed a residual mean aortic valve gradient of 17 mmHg with evidence of a small periprosthetic leak. Seven days after the procedure, the patient was discharged, asymptomatic and in good hemodynamic compensation without vascular complications. Conclusions Trans–axillary arterial access should be considered a viable alternative to transfemoral access for the performance of TAVR.

Long-term outcomes after minimal right lateral thoracotomy for the resection of cardiac tumors

ObjectivesCardiac tumors are a rare and heterogeneous entity, with a cumulative incidence of up to 0.02%. This study aimed to investigate one of the largest patient cohorts for long-term outcomes after minimally-invasive cardiac surgery using right-anterior thoracotomy and femoral cardiopulmonary bypass (CPB) cannulation. MethodsBetween 2009 and 2021, patients who underwent minimally-invasive cardiac tumor removal at our department were included. The diagnosis was confirmed postoperatively by (immune-) histopathological analysis. Preoperative baseline characteristics, intraoperative data, and long-term survival were analyzed. ResultsBetween 2009 and 2021, 183 consecutive patients underwent surgery for a cardiac tumor at our department. Of these, n = 74 (40%) were operated on using a minimally-invasive approach. The majority, n = 73 (98.6%), had a benign cardiac tumor, and 1 (1.4%) had a malignant cardiac tumor. The mean age was 60 ± 14 years, and n = 45 (61%) of patients were female. The largest group of tumors was myxoma (n = 62; 84%). Tumors were predominantly located in the left atrium in 89% (n = 66). CPB-time was 97 ± 36min and aortic cross-clamp time 43 ± 24 min s. The mean hospital stay was 9.7 ± 4.5 days. The perioperative mortality was 0%, and all-cause mortality after ten years was 4.1%. ConclusionMinimally-invasive tumor excision is feasible and safe, predominantly in benign cardiac tumors, even in combination with concurrent procedures. Patients who require cardiac tumor removal should be evaluated for minimally-invasive cardiac surgery at a specialized center, as it is highly effective and associated with good long-term survival.

Open Surgical Insertion of TandemHeart Device for Left Ventricular Unloading.

TandemHeart (Cardiac Assist Inc., Pittsburgh, PA) is a valuable mechanical circulatory support (MCS) device that provides left atrial to femoral artery bypass and directly unloads the left ventricle. The device is inserted under fluoroscopic guidance in the cardiac catheterization laboratory without requiring invasive surgical exposure. However, this device is unique because it directly unloads the oxygenated blood from the left atrium and may be needed for postoperative support in patients undergoing various open cardiac surgeries. In this article, we provide a detailed description of the open surgical insertion of a TandemHeart device.

Fresh arterial allograft as a replacement for an infected common femoral prosthetic graft and recurrent false aneurysm.

Replacing an infected vascular prosthetic conduit with an allograft is a possible solution of this complication given the low recurrence of infection. It is most commonly utilized for cases where the use of autologous tissue is not an option. We present the case of a 70-year-old patient who had undergone repeated vascular reconstructions in the right lower limb. He was admitted to our department due to a progressively growing mass in the right groin and subsequently placed on the waiting list for a fresh allograft. The patient had the infected false aneurysm and prosthetic material of the femoral bifurcation replaced with an arterial allograft. The previous femoral popliteal autovenous bypass graft was reimplanted into the allograft. There were signs of sepsis during the operation; however, the blood culture was negative. Cultures from neither the wound nor the drain revealed the presence of any bacteria. The patient was discharged on the seventh post-operative day with prophylactic antibiotics. An early followup confirmed that there were no signs of recurrent infection and that the reconstruction remained patent. Seven and half months after the surgery, the femoral popliteal bypass graft became occluded and a conservative approach was chosen. A small thrombosed false aneurysm of the graft was revealed two years after the surgery due to transient non-compliance of the patient to immunosuppression therapy. It was treated conservatively. Two and a half years after the surgery, the allograft still remains open and the limb is preserved.

Two methods of aerobic and combined training on biomechanics of Vessels in patients after bilateral femoral artery coronary grafting

Background: Cardiovascular disease is one of the most common causes of death in the world and its prevalence increases with age. For the purpose of cardiac rehabilitation after heart disease, performing exercise training causes functional and structural adaptations in patient’s cardiovascular system and consequently reduces mortality from related diseases. Therefore, the aim of this study was to investigate the effect of two methods of aerobic and combined exercise training biomechanics of blood in middle-aged patients after bilateral femoral artery coronary bypass grafting surgery. Materials and Methods: In this semi-experimental study with a pre-post test design, 68 middle-aged men (mean age 56.19± 1.26 years) were studied after bilateral femoral artery coronary bypass grafting surgery. Subjects were randomly and availably divided into 3 groups: aerobic (n =20) and combined (aerobic + resistance) (n =20) exercise training, and control groups (n =28). Subjects in the intervention groups performed 8 weeks of training/3 sessions per week. Each training session in aerobic and combined groups was considered for 40 minutes with the intensity of 70-85% heart rate reserved, and 60 minutes with the intensity of 40-80% one repetition maximum for each patient, respectively. In order to analyze the data, Leven, MANOVA and Bonferroni statistical tests were used at the significance level of P≤0.05. Results: The results of one-way MANOVA test showed that the levels of functional capacity, ejection fraction and maximal oxygen consumption were increased significantly after aerobic and combined exercise training compared to control group (p <0.05). However, Bonferroni post hoc test showed no significant differences between functional capacity, ejection fraction and maximal oxygen consumption post-test levels in aerobic and combined exercise training groups (p> 0.05). Conclusion: the findings of this study show that both aerobic and combined exercise training can improve the heart functional variables in middle-aged patients after bilateral femoral artery coronary bypass grafting surgery, and this improvement levels appears to be independent of the types of training.

External Iliac–Superficial Femoral Artery Bypass Surgery for Intractable Common Femoral Artery Infection

External Iliac–Superficial Femoral Artery Bypass Surgery for Intractable Common Femoral Artery Infection

Fenestrated/branched endovascular aortic repair using unilateral femoral access in patients with iliac occlusive disease

ObjectiveFenestrated/branched endovascular aortic repair (F/BEVAR) in patients with occluded iliac arteries is challenging owing to limited access for branch vessel catheterization and increased risk for leg and spinal ischemic complications. The aim of this study was to analyze technical strategies and outcomes of F/BEVAR in patients with unilateral iliofemoral occlusive disease. MethodsWe performed a retrospective review of all consecutive patients treated by F/BEVAR in two institutions (2003-2021). Patients with unilateral iliofemoral occlusive disease were included in the analysis. All patients had one patent iliac artery that was used for advancement of the fenestrated-branch component. Preloaded catheter/guidewire systems or steerable sheaths were used as adjuncts to facilitate catheterization. Primary endpoints were technical success, mortality, major adverse events (stroke, spinal cord injury, dialysis or decrease in the glomerular filtration rate of more than 50%, bowel ischemia, myocardial infarction, or respiratory failure), primary iliac patency, and freedom from reinterventions. ResultsThere were 959 patients treated with F/BEVAR. Of these, 15 patients (1.56%; mean age, 74 years; 80% male) had occluded iliac arteries and 1 patent iliofemoral access and were treated for a thoracoabdominal aortic aneurysm (n = 8) or juxtarenal abdominal aortic aneurysm (n = 7). Brachial access was used in 14 of the 15 patients and preloaded systems in 7 of the 15 patients (47%). The remaining 53% had staggered deployment of stent grafts. There were seven physician-modified endovascular grafts, seven custom-made devices, and one off-the-shelf device used. Thirteen patients (87%) had distal seal using aortouni-iliac stent grafts and two (13%) had distal seal in the infrarenal aorta. Concomitant femoral crossover bypass (FCB) was performed in two patients and six patients had a prior FCB. Technical success was 100%. There were no intraoperative complications or early lower extremity ischemic complications, and all FCB were preserved. There was one mortality (7%) within 30 days owing to retrograde type A dissection. Major adverse events occurred in 20% of patients. The median follow-up was 12 months (range, 0-85 months). Two patients (13%) required three reinterventions. One patient required proximal stent graft extension for an acute type B dissection (3 months) and another required iliac extension for type Ib endoleak of an aortouni-iliac graft (21 months) and thrombolysis of that extension (50 months). At last follow-up, all patients had primary graft patency except one with secondary graft patency without new claudication. One patient had a single renal artery stent occlusion at follow-up with no r-intervention. The overall survival rate was 60%, without aortic-related deaths. ConclusionsAlthough challenging, F/BEVAR with unilateral femoral/brachial approach is feasible in patients with occluded iliac limbs, with an important rate of ischemic complications, but satisfactory outcomes.

Abstract 12256: Symptomatic Supratherapeutic International Normalized Ratio on Rivaroxaban: A Case Report and a Systematic Review

Rivaroxaban is a direct oral anticoagulant that works by inhibiting factor Xa. Direct anticoagulants have largely replaced direct vitamin K inhibitors (VKAs) due to the increased risk of major hemorrhages and the need for regular monitoring and dose adjustments. However, there have been multiple reports of elevated international normalized ratio (INR) and incidents of bleeding in patients on rivaroxaban, which brings into question the potential need for monitoring. The purpose of this review is to differentiate the patients that may benefit from regular monitoring and to propose future directions for implementation of monitoring. Here we report a case of an INR of 4.8 in a patient who presented with a gastrointestinal bleed and a drop of five gm/dL in hemoglobin four days after starting rivaroxaban following right femoral popliteal bypass graft stenting. The patient had no liver or kidney abnormalities and was not taking any medication or consuming any foods that could introduce any significant drug interaction. Additionally, we conducted a systematic review of similar reports in the literature with the goal of identifying the factors that could influence rivaroxaban’s levels in the blood or its influence on the INR. We reviewed PubMed using keywords including; “rivaroxaban”, “anti-Xa”, “DOAC”, “elevated”, “INR”, “bleeding”, “hemorrhage”, “pharmacology”, and “pharmacokinetics”. The literature revealed reports of INRs up to 5.2. Reviewing the pharmacokinetics of rivaroxaban indicated possibly higher drug levels in Caucasians, patients with a low body mass index (BMI), and patients with polymorphisms in the genes coding for CYP3A4, CYP2J2, or p-glycoprotein, assuming no renal or liver disease and no significant drug-drug or drug-food interactions. INR can be falsely normal if the thromboplastin reagent used to monitor the INR on warfarin is not sensitive to the changes in INR due to rivaroxaban. We suggest finding a thromboplastin reagent that is sensitive to INR changes with rivaroxaban, which could yield clinically relevant INRs on rivaroxaban allowing for accurate monitoring. We then suggest conducting studies to evaluate the cost effectiveness of regular monitoring in at-risk patients.

PSAT018 Management of Pheochromocytoma in the Setting of a Patient with Multiple Vasculopathies

Abstract A 66-year-old male with history of Type 2 diabetes and adrenal incidentaloma presented to the hospital with significant left lower limb edema and was found to have severe peripheral vascular disease. CT surgery was consulted and performed an angiogram as well as an angioplasty; however, the patient had severe stenosis and stenting was not possible. Femoral popliteal bypass was planned. Due to the patient's acute kidney injury from renovacular hypertension, preoperative evaluation included a MRI abdomen w/wo contrast which showed a 1.4 cm right adrenal nodule with early contrast enhancement which appeared fairly avid and uniform. This nodule had been previously noted by CT scan three years prior. Previous outpatient labs showed elevated metanephrines of 543 pg/mL, which determined the adrenal nodule to be consistent with a pheochromocytoma. Subsequently, femoral popliteal bypass was postponed and the patient was started on an alpha blocker, doxazosin. Urology was consulted and right laproscopic adrenalectomy was planned. Preoperatively, patient developed chest pain due to ventricular tachycardia and NSTEMI was diagnosed by EKG. Patient then underwent a LHC which revealed severe left main 3 vessel coronary artery disease, postponing planned adrenalectomy. CABG was performed with pericardiectomy. After initial recovery, patient was discharged to in-patient rehabilitation, indefinitely delaying definitive pheochromocytoma therapy. Reference Jacques W. M. Lenders, Quan-Yang Duh, Graeme Eisenhofer, Anne-Paule Gimenez-Roqueplo, Stefan K. G. Grebe, Mohammad Hassan Murad, Mitsuhide Naruse, Karel Pacak, William F. Young, Jr, Pheochromocytoma and Paraganglioma: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology &amp; Metabolism, Volume 99, Issue 6, 1 June 2014, Pages 1915–1942, https://doi.org/10.1210/jc.2014-1498 Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Single-Center Experience of Treating Chronic Limb-Threatening Ischemia of Lower Limbs Combined with Diabetes

To summarize our hospital's single-center experience of and reflections on the treatment of chronic limb-threatening ischemia (CLTI) of lower limbs combined with diabetes in the past 5 years. We retrospectively analyzed cases of lower limb CLTI combined with diabetes diagnosed at our hospital from March 2017 to June 2021. The baseline data, surgical information, and follow-up results of the patients were collected. The primary outcome indicator was the patency rate of lower limb target artery within 1 year post-op, and the secondary indicators were the reoperation rate within 1 year post-op and the amputation rate within 1 year post-op. A total of 89 patients with lower limb CLTI combined with diabetes were included in the study. A total of 85 patients underwent percutaneous transluminal angioplasty and the operation of 7 patients ended in failure, with the operation success rate reaching 91.76% (78/85). Three patients underwent femoral popliteal artery bypass grafting with artificial blood vessels and one patient underwent iliac femoral artery bypass grafting with artificial blood vessels, with the success rate of the operations reachign 100% (4/4). Among 78 patients who successfully underwent percutaneous transluminal angioplasty, the median follow-up time was 33 months (13, 64). Two patients died within one year after operation, with the post-op one-year survival rate being 97.44% (76/78). The post-op 1-year reoperation rate was 19.23% (15/78), the 1-year target vascular patency rate (deaths not included) was 85.53% (65/76), and the 1-year amputation rate was 3.85% (3/78). Among the patients who underwent bypass surgery, the follow-up period was 13-48 months. No thrombosis in or re-occlusion of the artificial blood vessels were observed during the follow-up period, and the artificial blood vessels remained unoccluded. Transluminal angioplasty has a relatively ideal rate of postoperative vascular patency. In addition, it is a minimally invasive procedure involving low perioperative risks and is performed under local anesthesia. Therefore, it can be used as the preferred treatment for patients with CLTI. On the other hand, bypass surgery has good long-term patency rate, but it involves higher perioperative risks and the procedure is more invasive. Therefore, bypass surgery can be used as an alternative when transluminal angioplasty ends in failure.

Prevention of Spinal Cord Injury during Thoracoabdominal Aortic Aneurysms Repair: What the Anaesthesiologist Should Know.

Thoraco-abdominal aortic repair is a high-risk surgery for both mortality and morbidity. A major complication is paraplegia-paralysis due to spinal cord injury. Modern thoracic and abdominal aortic aneurysm repair techniques involve multiple strategies to reduce the risk of spinal cord ischemia during and after surgery. These include both surgical and anaesthesiologic approaches to optimize spinal cord perfusion by staging the procedure, guaranteeing perfusion of the distal aorta through various techniques (left atrium–left femoral artery by-pass) by pharmacological and monitoring interventions or by maximizing oxygen delivery and inducing spinal cord hypothermia. Lumbar CSF drainage alone or in combination with other techniques remains one of the most used and effective strategies. This narrative review overviews the current techniques to prevent or avoid spinal cord injury during thoracoabdominal aortic aneurysms repair.

Experience of Patient-Specific CFD Simulation of Blood Flow in Proximal Anastomosis for Femoral-Popliteal Bypass

Femoral artery bypass surgery needs postoperative monitoring due to the high complication risks after bypass. Numerical simulation is an effective tool to help solve this task. This work presents the experience of patient-specific CFD simulation of blood flow in proximal anastomosis for femoral-popliteal bypass, including patient follow-up after bypass surgery. Six cases of proximal anastomosis of femoral-popliteal bypass 3–30 months after surgery were studied. A repeated study was performed for four patients to monitor geometric and hemodynamic changes. The blood flow structure variety in proximal anastomoses and the blood flow dynamics during the cardiac cycle are described in detail using CFD simulation. Special attention is paid to time-average wall shear stresses (TAWSS) and oscillatory shear index (OSI) distributions. Low and oscillatory wall shear stresses were registered in the graft downstream from the suture, especially in case of low inlet flow. It was shown that the postoperative geometry changes led to significant hemodynamic changes; thereby, neointima has grown in areas with initially low and oscillatory wall shear stresses.

Retropubic Femoral–Femoral Bypasses have Superior Outcomes Compared to Grafts Tunneled Subcutaneously

A femoral–femoral bypass is often used to revascularize lower extremities or as an adjunct to endovascular aneurysm repair. We hypothesized that grafts tunneled retropubically in the space of Retzius would be more resistant to infection because of the deeper tunnel and have better long-term patency owing to a linear course with less propensity for kinking compared with subcutaneously tunneled grafts.

Acute Limb Arterial Ischemia Following Iliac Vein Stenting in the Setting of a Frozen Pelvis.

The authors report on a young patient with previous radiation to her pelvis who presented with acute limb ischemia following iliac vein stenting believed to be secondary to extrinsic iliac artery compression in the setting of a frozen pelvis. She underwent revascularization and a trans-femoral amputation, ultimately needing a femoral to femoral artery crossover bypass in order to achieve amputation stump healing. This case describes a potential arterial complication of venous stenting in a previously irradiated field.

Spontaneous Resolution of Lower Extremity Hypoperfusion in Type B Aortic Dissection: A Case Report

Lower extremity hypoperfusion occurs in 5.7-30% of Stanford type B aortic dissection cases. A 53-year-old male patient presented with type B aortic dissection. His left femoral pulse was not palpable. The proximal left common iliac artery was nearly occluded in computed tomography angiography. There was no extremitythreatening rest pain, but there was intermittent claudication at 100 meters. Cross femoral bypass was planned for the patient under elective conditions. After two months, the left femoral pulse was palpable, and the patient no longer had intermittent claudication. In this study, we report that lower extremity hypoperfusion, which developed after acute type B aortic dissection resolved without open and endovascular surgery.

A comparative study between osteosynthesis by proximal femoral nail (PFN) and Coxafemoral bypass with bipolar hemiarthroplasty Incomminuted inter- trochanteric fractures of femur in elderly patients

This study was done to compare osteosynthesis by Proximal Femoral Nail And coxa femoral bypass by Bipolar Hemiarthroplasty in Comminuted/ Unstable Inter- Trochanteric Fractures of Femur in Elderly patients. The study was Interventional, prospective study. The study was conducted at department of Orthopaedics at tertiary care centre. Sample size 60. Fractures included in this study were restricted to comminuted and unstable inter-trochanteric fractures. Evans classification type 3,4,5. patients were divided in 2 groups- Group A which was Operated by Proximal femoral nail (PFN) and Group B which was Operated by Bipolar Hemiarthroplasty.Pre-operative workup was done followed by Operation and post operatively physiotherapy was given. Follow up was taken at regular intervals. At each follow up Harris hip score was evaluated. The study concludes that, Coxa femoral bypass by bipolar hemiarthroplasty is a better option than proximal femoral nail in the treatment of unstable IT fractures in the elderly.