Femorofemoral Bypass Research Articles

Can concomitant above-knee femoropopliteal bypass with artificial graft affect the outcome of femorofemoral bypass with artificial graft?

Few have studied the effect of concomitant femoropopliteal (FEM-POP) bypass surgery on the outcome of femorofemoral (FEM-FEM) bypass in patients with peripheral arterial disease (PAD). This study was aimed to analyze the risk relationship of concomitant FEM-POP bypass on the patency of FEM-FEM bypass. From March 2009 to April 2020, a total of 27 patients who underwent FEM-FEM bypass surgery using polytetrafluoroethylene grafts were retrospectively analyzed according to concomitant FEM-POP bypass surgery. The mean follow-up duration was 38.20 ± 34.56months. The overall primary patency of the FEM-FEM bypass grafts in all 27 patients was 83.7, 78.5, and 72.0 at one, two, and 3years, respectively. The overall limb salvage rate was 100, 94.1, and 86.9 at one, two, 3years, respectively. Among them, ten patients underwent FEM-FEM bypass only (group 1). The other 17 patients needed a concomitant FEM-POP bypass and these patients were classified into three groups (group 2, ipsilateral FEM-POP, n = 5; group 3, crossover FEM-POP, n = 6; and group 4, bilateral FEM-POP, n = 6) The comparison of the primary patency of group 1 with the concomitant FEM-POP groups (sum of groups 2, 3, and 4, that is, group 5, n = 17) revealed a statistically significant improved patency for FEM-FEM bypasses not requiring concomitant infra-inguinal bypass (p = .036). Among the concomitant FEM-POP groups, group 2 had the lowest primary patency of the FEM-FEM bypass significantly (p = 0.07). The limb salvage rate of group 4 was significantly low. A concomitant FEM-POP bypass influenced the outcome of FEM-FEM bypass surgery. In conclusion, compromised infra-inguinal runoff at either extremity requiring concomitant FEM-POP bypass significantly worsens long-term FEM-FEM bypass patency. In addition, a concomitant bilateral FEM-POP bypass is a risk factor affecting the limb salvage rate in FEM-FEM bypass.

Open Seldinger-guided peripheral femoro-femoral cannulation technique for totally endoscopic cardiac surgery

BackgroundThe cannulation technique used in totally endoscopic cardiac surgery has a significant impact on the overall prognosis of patients. However, there are no large cohort studies to discuss it. Here we report on our research of using open Seldinger-guided technique to establish femoro-femoral cardiopulmonary bypass during totally endoscopic cardiac surgery and evaluate its safety and efficacy.MethodsThe institutional database from 2017 to 2020 was retrospectively reviewed to find cases in which totally endoscopic cardiac surgery was performed. We identified 214 consecutive patients who underwent totally endoscopic cardiac surgery with peripheral femoro-femoral cannulation. All patients underwent femoral artery cannulation. Of these, 201 were cannulated in the femoral vein and 13 were cannulated in the femoral vein combined with internal jugular cannulation. The technique involves surgically exposing the femoral vessel, setting up purse-string over the vessels and then inserting a guidewire into the femoral vessel without a vascular incision, followed by exchange of the guidewire with a cannula.ResultsSurgery indications included mitral valve disease in 82.71% (177/214), atrial septal defect in 11.68% (25/214) and tricuspid regurgitation in the remaining 5.61% (12/214). Hospital survival was 98.60% (211/214). There were no cases of stroke and postoperative limb ischaemia. No femoral vessel injuries or wound infections was observed. No late pseudoaneurysms were evident.ConclusionThe open Seldinger-guided femoro-femoral cannulation technique is effective and safe. We highly recommend this technique, given its safety, simplicity and speed under direct vision. The limited manipulation of the vessels under direct vision minimizes the risk of local complications.

Totally endoscopic surgical resection for a blood cyst originated from mitral valve: a case report

BackgroundIntracardiac blood cysts are very rare primary cardiac tumors. Blood cysts originated from the mitral valve represent a minority of cases, and previous cases have been mainly treated with conventional surgery through median sternotomy. When the tumor involves heart valves and histopathological diagnosis remains unknown preoperatively, minimally invasive surgical resection of an intracardiac tumor can be challenging, especially through an endoscopic approach. We herein present the first case of successful surgical resection for a rare mitral valve originated blood cyst in a minimally invasive, totally thoracoscopic approach.Case presentationAn apparently healthy 38-year-old male presented to his local hospital with six months history of palpitation and exertional dyspnea. Transthoracic echocardiography showed a mobile round cystic mass inside the left ventricle, attached to the anterolateral papillary muscle and chordae tendineae of the mitral valve. The local doctor diagnosed an intracardiac tumor and suggested a surgical resection through median sternotomy. However, the patient refused to have a sternotomy. He was then referred to us seeking minimally invasive surgery. We assessed the location, appearance and relationship to nearby structures of the tumor with echocardiography, and made a diagnosis of a suspected primary cystic intracardiac tumor. Since we had enough experience of totally endoscopic mitral surgery, our surgical plan was to resect the tumor in the aid of thoracoscopy, and manage the possible deformation and dysfunction of the cardiac structure if necessary. Using femoro-femoral cannulation and cardiopulmonary bypass, we successfully resected the tumor through a thoracoscopic approach in a closed chest, and well preserved the subvalvular structure and valvular function. Postoperative recovery was quick and uneventful. Pathologic diagnosis confirmed a simple blood cyst.ConclusionsSurgical resection is warranted for symptomatic cases of intracardiac blood cysts. With prudent preoperative diagnosis and comprehensive surgical plan, we believe the thoracoscopic approach is a safe, curative and viable alternative for complete resection of cardiac valvular tumors.

Temporary extracorporeal femoro-femoral crossover bypass to treat critical limb ischemia due to occlusive femoral transaortic microaxial left ventricular assist device – a novel technique and case series

Abstract Objective The Impella transaortic microaxial left ventricular assist device (MLVAD) bears the risk of severe ipsilateral limb ischemia due to it´s percutaneous insertion through the common femoral artery (CFA). As long as the MLVAD is required for cardio-circulatory support, treatment options are limited. Therefore, we developed a temporary extracorporeal femoro-femoral crossover bypass to restore and maintain perfusion of the affected leg. Methods From October 2018, we treated all patients with severe limb ischemia due to the MLAVD with a femoro-femoral crossover bypass. For comparison, a consecutive cohort of patients undergoing placement of the MLAVD between January 2011 and July 2019 was identified. For those patients who experienced limb ischemia after Impella placement, data on age, gender, BMI and diabetes, underlying cardiac condition, duration of Impella pump in place, limb complications, limb salvage procedure, need for additional surgical procedure on the affected limb (e.g. fasciotomy) were recorded. The primary outcome is the feasibility and safety of our percutaneously established extracorporeal femoro-femoral crossover bypass. As secondary outcomes, we report overall 30 day mortality and limb salvage rates. Results Between January 2011 and July 2019, 25 of 245 (10.3%) patients developed a severe ipsilateral limb ischemia following the MLVAD placement. Until October 2018, 20 patients were treated conventionally (C-cohort) and since October 2018, five (consecutive) patients have been treated by an extracorporeal femoro-femoral cross over bypass (BP-Cohort). Following the BP-procedure, an immediate improvement of the perfusion was seen in all patients. The bypass remained in place during a median of 5 days. Limb salvage was documented in 100% of our patients and 30 days mortality was 60% in both groups. Conclusion This is the first case series reporting on this novel technique. We demonstrated that the percutaneous creation of an extracorporeal femoro-femoral crossover bypass is feasible, safe and effective and should therefore be promoted in the future.

Do Not Delay Removing the Infected Graft!

A 66 year old male presented with dyspepsia. He had been treated by aortobifemoral bypass for aorto-iliac occlusions three years previously. Several thrombectomy procedures and a femorofemoral bypass were required because of symptomatic occlusion of the prosthetic left limb. Computed tomography angiography noted inflammatory tissue with air bubbles (arrow) between the proximal jejunum and the graft (secondary aorto-enteric fistula) (A). Exploratory laparotomy showed that the infected aortic graft was surrounded by the gut wall (B). Infected abdominal vascular grafts should be removed as soon as possible if the patient’s condition permits.Image 1

Increased collateral flow by rescue femorofemoral bypass dissolved residual thrombus in implanted iliofemoral artery stents: a case report

BackgroundFailed aortofemoral and femoropopliteal bypass grafts in the lower extremity artery usually result in acute limb ischemia. Endovascular treatment and surgical revascularization have been reported for limb salvage.Case presentationA 72-year-old Japanese man was admitted with acute limb ischemia due to failed aortofemoral and femoropopliteal bypass grafts. Endovascular treatment with balloon angioplasty, thrombectomy, and stent implantation in the long chronic total occlusion from the right common iliac artery to the superficial femoral artery did not result in efficient flow due to thrombus transfer from a failed aortofemoral bypass graft. However, a rescue femorofemoral bypass (the left femoral to the right deep femoral artery) improved his symptoms, and implanted in-stent flow was gradually recovered. Lower extremity angiography performed 5 months later confirmed the patency of the iliofemoral in-stent flow. However, the femorofemoral bypass graft was unfortunately occluded due to the progression of left external iliac artery stenosis. The patency of the iliofemoral in-stent flow was confirmed at 1 year by ultrasonography.ConclusionsImprovement of the deep femoral artery flow plays an important role in the treatment of acute limb ischemia due to failed aortofemoral and femoropopliteal bypass grafts. Thus, increased collateral circulation to the periphery through the deep femoral artery dissolved the remaining in-stent thrombus in the iliofemoral artery.

Endovascular Surgery or Both: A Case Report of Hybrid Procedure in a Patient with Abdominal Aortic Aneurysm and Tasc D Aortoiliac Occlusive Disease

Hybrid procedure, a combination of endovascular and open surgical approach, has emerged as the first-line treatment for patients with severe aortoiliac diseases because of its effectiveness. We report a hybrid procedure in a 72 year old man with an Abdominal Aortic Aneurysm (AAA) and Trans-Atlantic Inter-Society Consensus (TASC) D aortoiliac occlusive disease. After two failed attempts using the intraluminal technique (retrograde and antegrade), we successfully performed an endovascular approach with subintimal and Subintimal Arterial Flossing Antegrade-retrograde Intervention (SAFARI) technique with the help of roadmap technology. The vascular surgeon completed the procedure by creating femorofemoral bypass using a Great Saphenous Vein (GSV) graft. The graft was patent and there were no complications at 1 week, 1 month and 6 months follow-up.

Microbial evolution of vascular graft infections in a tertiary hospital based on positive graft cultures

BackgroundVascular graft infections are a serious complication in vascular surgery. Correct antibiotic therapy targeted to the most likely infecting species is essential to treat these patients, although the bacterial epidemiology and pathogenesis are still not completely understood. We analyzed the behavior of vascular graft infections and the microbiologic patterns of resistance. MethodsA 10-year (2008-2018), single-center, retrospective cohort study was performed of all patients admitted with vascular graft infection identified by positive direct graft cultures. An extensive microbiologic study was performed to analyze the bacterial strains, antibiotic resistance and sensitivity, and prevalence stratified by the year. ResultsA total of 72 vascular graft infections with positive graft cultures occurring in 65 patients were found. Their mean age was 67 ± 9.6 years, and 85% were men. Infection-related mortality was 11%. Of the 65 patients, 14 had undergone aortobifemoral bypass, 13 axillofemoral bypass, 5 femorofemoral bypass, 27 femoropopliteal bypass, and 4 femoral endarterectomy with synthetic patch angioplasty. The median interval from the index procedure to infection was longer for intracavitary than for extracavitary grafts (P = .011). Of the 72 infections, 48 were monomicrobial and 24 were polymicrobial. Gram-negative bacteria were predominantly identified in intracavitary graft infections (54%). In contrast, gram-positive bacteria were most frequent in the extracavitary graft group (58%). Multidrug-resistant bacterial species occurred more frequently in early graft infections (P = .002). Throughout the study duration, an overall decrease in gram-positive infections and an increase in gram-negative infections was observed, especially in extensively drug-resistant strains. A similar progression was found in all nosocomial infections. ConclusionsThe present study has shown that vascular graft infection microbiology changed in accordance with graft location and interval to infection from revascularization surgery and had also evolved over the study period with patterns similar to those for all nosocomial infections. This highlights the importance of studying the specific microbiology of each healthcare center and its relationship to vascular graft infections to achieve the best treatment possible.

Treatment of trophic ulcers of the lower extremities

Background. In 50 % of cases trophic ulcers (TU) are caused by chronic venous insufficiency, in 10 % – by arterial insufficiency, in 5 % – by disorders of nerve trophic. Treatment of ischemic TU includes conservative and surgical tactics, wound dressings, pain management, use of hydrogel dressings, antibacterial therapy, measures to improve blood circulation.
 Objective. To describe the treatment of TU of the lower extremities.
 Materials and methods. Analysis of literature data on this issue.
 Results and discussion. The pathogenesis of chronic venous ulcers includes persistent venous hypertension and microcirculation disorders. Varicose veins, postthrombotic disease and congenital vascular malformations are the main causes of such ulcers. In postthrombotic disease affecting the veins of the lower extremities in patients with severe symptoms, surgery (femoro-femoral or femoro-caval bypass), percutaneous endovascular recanalization (stenting, balloon angioplasty), combined surgical-endovenous desobliteration, transposition of the segmentary vein valves and relocation of autoveins may be considered. After the operations on veins, surgical interventions for TU are performed. Antibiotic therapy (Leflocin, “Yuria-Pharm”, 500 mg intravenously once before surgery), topical antiseptic Dekasan (“Yuria-Pharm”) and skin disinfectant Gorosten (“Yuria-Pharm”) are used to accompany interventions for postthrombotic disease. Vasodilation disorders, which are one of the links in the TU pathogenesis, are the result of endothelial dysfunction and nitric oxide (NO) deficiency. To eliminate these factors, L-arginine (Tivortin, “Yuria-Pharm”) is used. Tivortin catalyzes the synthesis of NO in endothelial cells, reduces the activation and adhesion of leukocytes and platelets to the vascular endothelium, prevents the formation and progression of atherosclerotic plaques. In the treatment of lower extremity ischemia and TU, it is advisable to use the infusion therapy scheme “TRIO”: Reosorbilact 400 ml + Latren 400 ml + Tivortin 100 ml (“Yuria-Pharm”).
 Conclusions. 1. Minimally invasive methods are effective and minimally traumatic option of TU treatment, which should actively displace open methods. 2. Conservative TU treatment includes the microcirculation improvement, the use of antiseptics, strengthening of the vascular wall, antibacterial and rheological support.

Novel bypass risk predictive tool is superior to the 5-Factor Modified Frailty Index in predicting postoperative outcomes

ObjectiveThis study aimed to develop risk predictive models of 30-day mortality, morbidity, and major adverse limb events (MALE) after bypass surgery for aortoiliac occlusive disease (AIOD) and to compare their performances with a 5-Factor Frailty Index. MethodsThe American College of Surgeons National Surgical Quality Improvement Program 2012-2017 Procedure Targeted Aortoiliac (Open) Participant Use Data Files were queried to identify all patients who had elective bypass for AIOD: femorofemoral bypass, aortofemoral bypass, and axillofemoral bypass (AXB). Outcomes assessed included mortality, major morbidity, and MALE within 30 days postoperatively. Major morbidity was defined as pneumonia, unplanned intubation, ventilator support for >48 hours, progressive or acute renal failure, cerebrovascular accident, cardiac arrest, or myocardial infarction. Demographics, comorbidities, procedure type, and laboratory values were considered for inclusion in the risk predictive models. Logistic regression models for mortality, major morbidity and MALE were developed. The discriminative ability of these models (C-indices) were compared with that of the 5-Factor Modified Frailty Index (mFI-5): a general frailty tool determined from diabetes, functional status, history of chronic obstructive pulmonary disease, history of congestive heart failure, and hypertension. Calculators were derived using the most significant variables for each of the three risk predictive models. ResultsA total of 2612 cases (mean age 65.0, 60% male) were identified, of which 1149 (44.0%) were femorofemoral bypass, 1138 (43.6%) were aortofemoral bypass, and 325 (12.4%) were axillofemoral bypass. Overall, the rates of mortality, major morbidity, and MALE were 2.0%, 8.5%, and 4.9%, respectively. Twenty preoperative risk factors were considered for incorporation in the risk tools. Apart from procedure type, age was the most statistically significant predictor of both mortality and morbidity. Preoperative anemia and critical limb ischemia were the most significant predictors of MALE. All three constructed models demonstrated significantly better discriminative ability (P < .001) on the outcomes of interest as compared with the mFI-5. ConclusionsOur models outperformed the mFI-5 in predicting 30-day mortality, major morbidity, and adverse limb events in patients with AIOD undergoing elective bypass surgery. Calculators were created using the most statistically significant variables to help calculate individual patient's postoperative risks and allow for better informed consent and risk-adjusted comparison of provider outcomes.

The Efficacy of a Protocol of Iliac Artery and Limb Treatment During EVAR in Minimising Early and Late Iliac Occlusion

Iliac limb occlusion (ILO) is a complication of endovascular aortic repair (EVAR) and requires re-intervention in most cases. Attention to any intra-operative defect of iliac limbs and arteries may prevent ILO. The study aimed to analyse the long term effect of an intra-operative protocol of iliac limb treatment during EVAR on ILO. Patients treated from 2012 to 2017 for abdominal aortic aneurysm (AAA) with standard EVAR were collected prospectively. Pre-operative computed tomography angiography anatomical characteristics were evaluated. The protocol for intra-operative iliac limb management was: a. pre-EVAR angioplasty of common/external iliac artery stenosis; b. precise contralateral iliac limb deployment at the same level of the flow divider; c. iliac limb kissing ballooning with high pressure non-compliant balloons; d. iliac limb stenting for residual tortuosity/kink and adjunctive external iliac stenting for residual stenosis/dissection after EVAR. ILO was evaluated at 30 days and at follow up, which was performed by duplex ultrasonography before discharge, at three, six, and 12 months and yearly thereafter. Kaplan-Meier and Cox linear regression were used. Four hundred and forty-two patients and 884 iliac limbs were included in the study. Severe iliac tortuosity and calcification were present in 15% (132/884) and 8% (70/884), respectively. External iliac angioplasty and stenting of iliac limb were performed in 2% (18/884) and 9.5% (84/884) of limbs. The thirty day mortality was 1.6%, with no ILO. At a mean follow up of 33±12 months, ILO occurred in 7/884 (0.8%) limbs of six patients. Five ILO were treated by endovascular relining, two surgically: one by femorofemoral bypass and one by surgical explant. On univariable analysis, sac shrinkage was significantly associated with ILO (HR 1, 95% CI 0.8-2.5, p=.043). A protocol of aggressive iliac limb treatment in EVAR leads to a very low rate of late ILO. The role of sac shrinkage in ILO should be investigated further.

Repair of ventricular septal defect through anterolateral thoracotomy with central cannulation: our experience.

BackgroundAt present thoracotomy with femoro-femoral bypass is an established approach for minimally invasive open heart surgeries, but thoracotomy with conventional cannulation is yet to be established. We performed 54 cases of ventricular septal defect (VSD) closure via anterolateral thoracotomy approach with central cannulation. Here we are describing our results and experience of VSD closure via anterolateral thoracotomy approach.Aim and objectiveThe aim of our study was to evaluate early outcomes of VSD repair via anterolateral thoracotomy with central cannulation.MethodsThis is a retrospective, observational, descriptive type of study. Fifty four patients (31 males, 23 females) underwent VSD repair from November 2016 to November 2018 via anterolateral thoracotomy with age ranges from 3 to 22 years (mean age 10.57 + 8.88 years). Mean body weight was 22.29 + 13.44 kg (range 10 to 48 kg). The VSD was perimembranous in 47 patients, subpulmonic in 2, muscular in 2, and inlet in 3 patients.ResultsThere was no operative or late mortality. The mean incision length was 7.16 ± 02.08 cm (range, 5 cm to 9 cm). Average duration of cardiopulmonary bypass (CPB) was 61.72 ± 14.20 min (range, 48–78 min), and aortic cross-clamp time was 38.51 ± 13.08 min (range, 26–56 min). The average postoperative intensive care unit (ICU) stay was 1.83 ± 1.32 days (range, 1–3 days), and hospital stay was 4.92 ± 1.82 days (range, 4–7 days).ConclusionAnterolateral thoracotomy with conventional central cannulation can be a safe alternative to median sternotomy with superior cosmetic results for the repair of VSDs.

Gastrointestinal bleeding due to a primary aortoenteric fistula.

We present the case of a 80 years-old male patient who underwent a CT angiogram due to hematemesis and hypovolemic shock. An upper gastrointestinal endoscopy revealed a large clot that closed the antrum and abundant red blood in the pyloric-antrum region. Sclerosis was performed blindly and the bleeding origin was not identified and the success of the sclerosis could not be evaluated. A primary aorta-duodenal fistula was observed by CT angiography, which was treated with an endograft and femoro-femoral bypass. The patient was discharged 14 days after admission.

Endovascular aneurysm repair with aorto-uni-iliac device: Review of indications and outcomes with a case report of the deployment in a low-lying dominant accessory renal artery

We present a patient requiring aorto-uni-iliac (AUI) endovascular aneurysm repair with a review of indications and outcomes of this procedure. A 72-year-old male presented at Jain Institute of Vascular Sciences due to infrarenal saccular abdominal aortic aneurysm with a maximum diameter of 4.5 cm. A low-lying, the dominant left accessory renal artery with inadequate length from the origin of the left accessory renal artery to aortic bifurcation (50 mm) precluded the deployment of a bifurcated device (since the length of the aorta from the origin of the left accessory renal artery to aortic bifurcation was inadequate for the contralateral limb to open). Hence, AUI stent-graft deployment, with occlusion of the contralateral common iliac artery and crossover femorofemoral bypass was performed.

In the Current Era of Endovascular Surgery, What is the Role of Axillofemoral Bypass?

Introduction - Nowadays, axillofemoral bypass (AxFB) is viewed as an end-of-line solution for lower limb revascularization, owing to its classically described poor long-term patency and recent advances in endovascular surgery. There is a marked difference in patient profiles in published series of AxFB, reflecting changing procedures indications. The objective of this study is to determine the contemporary profile of patients treated with AxFB and their outcome. Methods - Patients who underwent AxFB surgery in a tertiary hospital from April 2011 to December 2017 were identified. Surgical indication, primary patency, major amputation and death rates were recorded. Patients were grouped in:-Bypass configuration: axillouni vs axillobifemoral;-Previous vascular surgery status: first revascularization procedure vs reintervention;-Primary vascular disease: aortoiliac occlusive disease vs aneurysmal disease,-Emergency character of procedure: urgent (initiated less than 24hours from patient presentation) vs planned (more than 24hours from patient presentation). Groups were compared using Kaplan-Meier survival analysis. Results - 56 patients were included. 44 (78,6%) underwent axillobifemoral bypass; remaining patients underwent axillounifemoral bypass. Median age was 68,18±9,59 years; 94,6% were male. The most prevalent cardiovascular risk factors were HTA (77%) and history of smoking (76%). Primary vascular disease was aneurysmal in 14 patients (25%). The remaining group had aortoiliac occlusive disease. AxFB was an urgent procedure in 11 patients (19,6%). In 30 patients (53,6%), AxFB was the first revascularization performed. Indications for procedure on this group were aorto-iliac occlusive disease (25; 83,3%) and AA thrombosis (5; 16,7%). In patients previously submitted to revascularization (26; 46,4%), the most common previous procedures were aortobifemoral bypass (12; 46,2%), femoro-femoral bypass (12; 46,2%) and EVAR (9; 34,6%). Indications for AxFB on this group were: prosthesis thrombosis (17; 65,4%), secondary aorto-enteric fistulae (7; 26,9%) and prosthesis infection (2; 7,7%). Global primary patency of AxFB was 91,5±4,1% at 1 month, 74,8±7,6% at 1 year, and 56,1±12,8% at 5 years (Fig.1). Group survival analysis showed superior primary patency in aneurysmal disease group (p=0,063), and after urgent procedures (p=0,113). Previous vascular surgery and bypass configuration did not affect long-term primary patency. No patient with aneurysmal disease required major amputation during follow-up. In primary occlusive disease group, 83,4±5,7% patients were free-of-amputation at 1 month, 77,2±6,8% at 1 year and 5 years. Amputation rates were similar regardless previous vascular surgery status, bypass configuration and urgency character of procedure. Median time of survival was 5,1±1,1years. Patients who underwent AxFB had a survival rate of 76,8±5,6% at 1 month, 64,7±6,6% at 1 year, and 50,0±7,8% at 5 years. Survival rates were similar regardless bypass configuration and primary vascular disease. However, patients whose AxFB was a vascular reintervention or an urgent procedure had significant worse long-term survival (p=0,042 and p=0,017, respectively). Conclusion - Axillofemoral bypass, although being an increasingly uncommon procedure, still allows acceptable rates of patency and limb salvage. As patients with aortoiliac disease usually have multiple comorbidities and a short life-expectancy, axillofemoral bypass is attractive owing to its less invasive character.

Redo Mitral Valve Replacement using a St. Jude Medical Mechanical Prosthesis in a Patient with Thrombosed Mitral Prosthesis: A Video Presentation

AbstractWe performed explantation of a chronically thrombosed St. Jude Medical mechanical mitral prosthesis with failed thrombolysis and re-replacement of the mitral valve using another St. Jude Medical mechanical mitral prosthesis. The technical details of explantation and re-implantation without causing injury to the cardiac chambers, great vessels, and atrioventricular groove and the importance of elective femoro-femoral bypass prior to sternotomy has been described.

In Situ Fenestration to Convert an Aorto-Uni-Iliac Into a Bifurcated Endograft

Introduction - Narrow distal aorta and severely calcified aorto-iliac occlusive disease (AOID) represent conditions at risk of failure during endovascular aortic repairs. In such situations, an aorto-uni-iliac repair associated with a crossover femoro-femoral bypass (CFFB) may be preferable. We here present the results of an in situ fenestration (ISF) technique that allows conversion of an aorto-uni-iliac endograft (AUIE) into a bifurcated repair. Methods - Between January 2014 and January 2017, 163 patients underwent standard EVAR in our department. Among them, 20 patients (12%) underwent ISF of AUIE. All were considered at high surgical risk. After AUIE deployment, ISF was performed through the contralateral common iliac artery with a transjugular intrahepatic access set. The fabric hole was enlarged with a cutting balloon, and kissing iliac covered stents were positioned to convert the AUIE into a bifurcated repair. Data was collected prospectively. Results are presented as median with range. Results - The series included 13 males (65%) and 7 females (35%), aged 77 year-old (range, 37-88). Distal aortic diameter was 13 mm (range, 9-17). CFFB was felt at risk for complication in all cases for various reasons (radiation therapy, corticosteroids, small external iliac arteries, calcified femoral arteries, obesity). Indication for ISF was (1) an abdominal aortic aneurysm (AAA) with a narrow distal aorta (<14mm), (2) bilateral severely calcified AOID and (3) ruptured AAA in 10 (50%), 8 (40%) and 2 (10%) patients, respectively. The punctured graft was made of Dacron in 14 cases (70%) and a PTFE in 6 cases (30%). Technical success was 90%. The two failures were patients who had prior iliac ligation. Fluoroscopy time was 28 minutes (range, 15-46) and 90 cc (range, 70-140) of contrast product were necessary. There was no death or systemic complication, especially no postoperative bleeding. Hospitalization duration was 6 days (2-14). With a follow-up of 12 months (range, 1-20), all repairs were patent on last CT-scan. No endoleak was observed at the ISF site. Conclusion - This technique represents another application of ISF. Although it remains an off-label technique, it provides a bifurcated repair in cases where it is usually considered at risk. ISF use in other aortic sites, such as the visceral aorta, remains to be evaluated.

One-stage hybrid management of patients with critical limb ischemia due to complex multilevel arterial occlusions

Aim To evaluate the safety and efficacy of one-stage hybrid revascularization modality in patients with complex multifocal arterial occlusive lesions. Patients and methods A prospective study design was established. Included patients were those admitted to the Vascular and Endovascular Surgery Department between November 2015 and November 2016 and presenting with Rutherford stages 5 and 6 critical limb ischemia due to multilevel arterial occlusion involving common femoral artery and one or both of inflow (iliac) and outflow arteries (superficial femoral and leg arteries) with nonsignificant aortic lesions and underwent a one-stage hybrid revascularization procedure aiming limb salvage. Common femoral artery endarterectomy was a fixed step in all cases. For inflow lesions; plain balloon angioplasty with bare metal stenting was first attempted then a femoro-femoral bypass if failed the endovascular approach. For outflow lesions, plain balloon angioplasty with selective stenting was tried in all cases and to stop if failed provided the presence of sufficient profunda flow. The study end points were 1-year primary patency, secondary patency, limb salvage, and complication rates. Results This study included 30 patients (30 limbs), with a mean age of 65±10.28 years. Technical success was achieved in 46 (95.8%) of 48 performed procedures and hemodynamic or clinical success in all patients (100%). Twelve-month primary and secondary patency rates were 67 and 80%, respectively. One-year limb salvage rate was 93.3%. Postoperative complications were reported in four (13.3%) cases. Conclusion One-stage hybrid procedures may be considered a safe and effective modality in the treatment of patients with critical limb ischemia due to multilevel complex arterial occlusions.

Limb occlusion following endovascular aortic repair

Limb occlusion following endovascular aortic repair (EVAR) is one of the most common complications requiring secondary interventions and is associated with a relevant morbidity and mortality. This review article describes the risk factors for limb occlusion, highlights strategies for prevention and provides a treatment algorithm involving current open and endovascular modalities. A selective literature search for risk factors and treatment modalities of limb occlusion after EVAR was carried out. A total of five risk factors for limb occlusion after EVAR were identified: (1) iliac angulations >60°/high iliac tortuosity (odds ratio, OR 5.76), (2) severe iliac calcification (OR 5.8), (3) excessive oversizing >15% (OR 5.54), (4) graft placement in the external iliac artery (EIA) with (5) EIA diameter <10 mm. While there are multiple treatment modalities (e.g. open, endovascular and hybrid procedures) for treating limb occlusion after EVAR, recommendations concerning treatment selection are diverse. Even in the endovascular era, open surgical repair with an iliacofemoral or femorofemoral crossover bypass is frequently used. Reocclusion still occurs in up to 30% of cases after initially successful treatment with endovascular and/or hybrid repair. Patients with tortuous iliac arteries, significant iliac vessel calcification that require endograft limb placement in small diameter EIAs have the highest risk for limb occlusion. During planning and implantation a special focus should be on strategies to prevent this complication. The suggested treatment algorithm represents a practical tool in clinical decision-making processes concerning treatment of limb occlusion.

Suitability of EVAR with Hostile Neck

AbstractBackground: Endovascular treatment of abdominal aortic aneurysms (EVAR) is now considered first line of treatment for abdominal aortic aneurysm (AAA) mainly due to the lower morbidity and mortality, hostile neck is a major obstacle in treating such patients, however many endovascular methods are available to overcome such obstacle, EVAR out of IFU is considered one of the lines of management. Further evaluation is needed.Aim of Study: Aim of this study was to evaluate the effectiveness of endovascular treatment of AAA with hostile neck anatomy, with commenting on the perioperative compli-cations, mortality and morbidity.Material and Methods: This study was done retrospectively over a period of 18 months including 10 patients who had endovascular treatment of abdominal aortic aneurysms with hostile neck anatomy.Results: 10 patients were included in this study primary technical success was achieved in 90% of cases while the last case needed aortic cuff as an adjunctive procedure. One case required re-intervention within 30 days post-operative due to limb graft occlusion, managed by femoro-femoral bypass. At one year follow up mortality was 10%.Conclusion: EVAR for AAA patients with HNA is feasible; patients with single feature of HNA showed the best outcome, while patients with more than one feature required the usage of adjunctive techniques for proximal sealing and were more liable to develop post-operative complications.