Femoropopliteal Bypass Grafts Research Articles

Assessment of primary patency for femoropopliteal graft entrapment within the sartorius muscle

PurposeBlind tunneling of subfascial femoropopliteal bypass grafts may result in inadvertent graft passage through the sartorius. The purpose of this study was to determine whether intramuscular passage of femoropopliteal bypass grafts affects primary patency.MethodsPatients undergoing femoropopliteal bypass at a Veterans Administration hospital and associated university medical center over a recent 13-year period who also had postoperative cross-sectional imaging adequate to determine graft location were examined. Five-year primary patency of grafts circumferentially enveloped by the muscle was compared with that of both extramuscular subfascial grafts and subcutaneous grafts.Results370 femoropopliteal grafts were identified, among which 258 (70%) were subfascial. Vein grafts comprised 51% of the subfascial grafts, and 53% were inserted above the knee. Available postoperative imaging in 110 subfascial grafts demonstrated 74 (67%) to lie completely within the muscle at some point. Among imaged subfascial grafts, primary patency at five years for intramuscular grafts was not significantly worse than extramuscular grafts (P = 0.31). This remained true whether grafts were vein (P = 0.39) or prosthetic (P = 0.31) and whether grafts inserted to the above-knee (P = 0.43) or below-knee (P = 0.21) popliteal artery. Multivariable Cox regression revealed a significant relationship between use of vein grafts (P = 0.013), active smoking (P = 0.01), and hypertension (P = 0.041) and primary patency, but not intramuscular graft location (P = 0.31).ConclusionThis study failed to demonstrate significantly inferior primary patency among subfascial femoropopliteal grafts tunneled intramuscularly. Larger studies may be required to adequately detect any differences in patency by muscular entrapment, especially among subgroups.

Endovascular Transvenous versus Open Femoropopliteal Bypass.

Background and Objectives: Lower extremity arterial disease is one of the most prevalent manifestations of atherosclerosis. The results from numerous studies regarding the best revascularization method of an occluded superficial femoral artery have been conflicting. The aim of this study was to compare the patency of transvenous endovascular with open femoropopliteal bypass, both with vein and prosthetic grafts. To our knowledge, a direct patency comparison between transvenous endovascular and open femoropopliteal bypass has not been published. This could help elucidate which method is preferable and in which cases. Materials and Methods: Patients with complex TASC-C and D SFA lesions were offered endovascular transvenous or open bypass. A total of 384 consecutive patients with PAD requiring surgical treatment were evaluated for inclusion in this study. Three-year follow-up data were collected for 52 endovascular procedures, 80 prosthetic grafts, and 44 venous bypass surgeries. Bypass patency was investigated by Duplex US every 6 months. Kaplan-Meier plots were used to analyze primary, primary-assisted, and secondary patency for endovascular transvenous, autovenous, and prosthetic bypasses. Results: Primary, primary-assisted, and secondary patency in venous group at 3 years was 70.5%, 77.3%, and 77.3%, respectively. In the endovascular transvenous group, primary, primary-assisted, and secondary patency at 3 years was 46.2%, 69.2%, and 76.9%, respectively. The lowest patency rates at 3 years were noted in the prosthetic graft group with 22.5% primary, 26.6% primary-assisted, and 28.2% secondary patency. Conclusions: The saphenous vein is the best graft to perform in above-the-knee femoropopliteal bypass. Transvenous endovascular bypass is a viable option with comparable primary-assisted and secondary patency. Primary patency is substantially lower for endovascular transvenous compared to venous bypass. Patients treated with endovascular transvenous bypass will require a significant number of secondary procedures to provide optimal patency. Prosthetic grafts should only be used if no other option for bypass is available.

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.

Long-term results of revascularization of the lower extremities in patients with critical ischemia and diabetes mellitus with localization of the occlusive-stenotic process in the femoral artery

Aim: to determine the most preferable tactics of surgical treatment of patients with critical ischemia of the lower extremities of atherosclerotic genesis and diabetes mellitus based on a comparison of the results of revascularizing interventions. Methods: The study involved 82 patients who were treated in the department of vascular surgery due to critical ischemia of the lower extremities as a result of atherosclerotic occlusive-stenotic lesion of the femoral arterial segment against the background of diabetes mellitus. After the diagnostic stage and preoperative preparation, the patients were divided into two groups depending on the nature of the intervention performed: endovasal revascularization or femoropopliteal autovenous bypass grafting above the knee joint gap. In the postoperative period, dynamic observation of patients was continued with a predominant assessment of the clinical status. Results: Clinically, circulatory decompensation requiring repeated intervention or amputation was observed in 9 (30 %) patients from the first group and in 13 (25 %) patients from the second. High amputation was performed in 2 (6.6 %) study participants from the endovasal revascularization group and 3 (5.7 %) from the open surgery group. Over the entire observation period, 2 (6.7 %) and 4 (7.8 %) patients died in the groups under consideration, respectively. No statistically significant differences were obtained for any of the studied parameters, however, repeated interventions were significantly more frequently performed in patients undergoing endovascular revascularization. Conclusion: When analyzing the advantages and disadvantages of endovascular and open surgery in patients with diabetes mellitus and critical ischemia, the first should be preferred due to the possibility of repeated repetition throughout the patients life. Particular attention should be paid to conservative therapy and assessment of clinical status in the late postoperative period.

Ultrasonographic Appearance of the Lower Extremity Arteries After Femoropopliteal Bypass Surgery

Objective: The aim of this study was to assess the ultrasonographic appearance of the lower extremity arteries, after a femoropopliteal bypass surgery. Materials and Methods: Ninety patients, with atherosclerotic peripheral artery disease, underwent either autologous vein (30 subjects) or synthetic femoropopliteal bypass grafting, using an end-to-side (30 subjects) or end-to-end anastomotic technique. The outcomes were compared to 30 volunteers, who were recruited to serve as healthy controls. A lower extremity duplex ultrasonogram (DUS) was performed 1 year after treatment. The healthy volunteers underwent DUS at the point of being included in the study. Results: In healthy volunteers, the angle between the profunda femoris artery (deep femoral artery, PFA) and common femoral artery (CFA) did not exceed 30° of angulation. The diameter of the CFA, in the bifurcation area, was 9.8 ± 1.5 mm. The bypass patency rates, CFA diameter, PFA angle, and neointimal hyperplasia rates differed between the groups as presented. Conclusion: The results that were obtained may indicate the importance of bypass graft surveillance, using DUS, with precise analysis of the topography and geometry of the lower extremity arteries and vascular conduits, during the perioperative period. In addition, in this cohort, femoropopliteal bypass procedures were associated with an increase in the angle of the PFA from 30° to 80° of angulation. An increase in the diameter of the CFA in the area of the proximal anastomosis from 9.8 to 15.1 mm was also noted. In these patients, the saphenous vein bypasses were associated with minimal changes of the vascular geometry and better patency rates.

Influence of crural vessel run-off on short- and mid-term outcomes following femoro-popliteal bypass grafting.

To determine the influence that the number of patent crural run-off vessels has on short- and mid-term outcomes following femoro-popliteal bypass. All patients undergoing index femoro-popliteal bypass grafting between 2013 and 19 at our unit were included. Preoperative imaging was used to stratify patients into cohorts with either one or ≥2 patent run-off vessels. Primary outcomes measures included bypass patency and limb salvage rates at one and 3years post-operatively. Survival analysis was performed using Kaplan-Meier curves and Logrank test. 147 bypasses performed on 143 patients were included. 24 patients had one-vessel run-off and 123 had ≥2 vessels patent. Patients with one-vessel run-off had a higher proportion of emergency admissions (54% vs 41%) and diabetes (42% vs 31%). 31% of patients underwent diagnostic angiogram imaging in addition to having duplex ultrasound and/or computed tomography angiography. There were no significant differences in primary, primary-assisted or secondary patency rates between the cohorts at 12 or 36 months. Limb salvage rates were significantly higher amongst those with ≥2 vessel run-off at 12 (86% vs 71%, p = 0.03) and 36 (85% vs 71%, p = 0.04) months. For those with occluded grafts, a higher proportion of patients with ≥2 vessel run-off subsequently had an attempt at redo bypass grafting. Femoro-popliteal bypass is a reasonable treatment option for patients with one-vessel run-off. However, whilst patency rates are comparable, clinicians should be aware of the lower successful limb salvage rates for patients with one patent vessel (especially those presenting with tissue loss).

Results of redo endovascular surgery in patients with occlusion of autovenous femoropopliteal bypass grafts

Results of redo endovascular surgery in patients with occlusion of autovenous femoropopliteal bypass grafts

A Case Series Analysis of Major Vascular Revascularization.

PurposeAtherosclerosis is a generalized disorder and can begin to develop in the abdominal aorta by the second decade of life. The nature of these lesions in coronaries and aorta is atheromatous and less sclerotic when compared to peripheral arteries. A broad spectrum of presentations and different types of lesions demand a personalized approach for the best outcome. This study is a case series analysis of major vascular revascularization. We aim to study various revascularization surgeries and underline the wide range of vascular lesions to which it is applied.MethodsThis is a study based on accrual patient records of all major vascular revascularization surgical/interventional procedures conducted at a tertiary care center for one year.ResultsA total of 110 patients were operated on for vascular diseases. Among these, 86 (78.81%) were men, and 24 (21.81%) were women. The femoropopliteal segment (n=47) was most commonly involved, followed by the common carotid artery (n=20). Atherosclerosis was the main cause of vascular occlusion (81.8%), followed by aneurysm of the aorta (14.5%) and coarctation of the aorta (2.7%). Smoking (62.2%) accounted to be the leading risk factor, followed by hypertension, diabetes, and hyperlipidemia. The majority of patients had a good outcome (92.7%). Minor complications (7.3%) include seroma formation and wound infection, which were managed conservatively. The repair was performed by autologous vein graft in 30% of patients and by synthetic polytetrafluoroethylene (PTFE) graft in 70% of patients. Carotid artery stenting was the most common endovascular procedure performed (n=5). Femoropopliteal bypass grafting was the most common procedure, followed by carotid endarterectomy (n=20) and aortofemoral bypass (n=14).ConclusionThe application of novel techniques such as cavo-atrial shunt in Budd-Chiari syndrome calls attention to the broadened scope of vascular surgery, and the modification of the conventional method of the carotid endarterectomy underscores the evolution of vascular revascularization. Our study thus highlighted that a wide spectrum of vascular lesions ranging from carotid artery stenosis to extensive below-knee disease, either atherosclerotic or aneurysmal, can be successfully treated with surgical revascularization techniques.

Impact of anticoagulation/antiplatelet therapy on femoropopliteal bypass graft outcomes

BackgroundAnticoagulant and antiplatelet (AC/AP) medications have been reported to improve bypass graft patency, however, the optimal AC/AP strategy remains unclear in the heterogenous peripheral artery disease population. MethodsA multi-institutional retrospective review utilizing the Research Patient Data Registry database from 1995 to 2020 was performed for all patients who underwent femoropopliteal bypass procedures. Electronic medical records were used to obtain demographic information, comorbidities, smoking status, operative details (bypass target), postoperative AC/AP medications, postoperative complications, and long-term outcomes and were reviewed for the cohort. Cox proportional hazards model was used to determine independent risk factors for major adverse limb events (MALE) after bypass. MALE was defined as reintervention for patency or major amputation of index limb (above- or below-knee amputation). ResultsA total of 1421 patients underwent femoropopliteal bypass between 1995 and 2020 throughout five institutions included in this study. Complete data were available for 1292 of the 1421 patients (90.9%). The indications for bypass included intermittent claudication (21.4%), rest pain (30.3%), tissue loss (33.5%), and nonatherosclerotic disease (14.8%). Distal bypass targets comprised above-knee (38.6%) and below-knee (61.4%) popliteal arteries. Patients were divided into six groups based on postoperative AC/AP use including none (n = 57 [4.4%]), monoantiplatelet therapy (n = 587 [45.4%]), dual AP therapy (n = 214 [16.6%]), AC alone (n = 73 [5.7%]), AC + monoantiplatelet therapy (n = 319 [24.7%]), and AC + dual AP therapy (n = 42 [3.3%]). Postoperative bleeding complications were low for both hematoma (3.7%) and pseudoaneurysm (0.7%). There was no difference in bleeding complications across AC/AP groups (hematoma, P = .61; pseudoaneurysm, P = .31). After adjusting for patient factors, below-knee bypass target (hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.04-1.52; P = .019) and bypass for tissue loss (HR, 1.40; 95% CI, 1.04-1.88; P = .028) were independent predictors for MALE. Great saphenous vein conduit trended toward protection for MALE, compared with prosthetic grafts (HR, 0.84; 95% CI, 0.70-1.01; P = .06). No AC/AP regimen was associated with of MALE, even stratifying by above-knee and below-knee bypass cohorts. The median follow-up period was 2 years. ConclusionsAmong patients undergoing femoropopliteal bypass grafting, no combination of AC or AP medications was associated with improved graft patency; however, a below-knee target and tissue loss were associated with adverse limb events. AC and AP regimen may be individualized after bypass with regard to other concomitant medical comorbidities.

Endovasküler Yöntemlerle Tedavi Ettiğimiz Akut Alt Ekstremite Emboli Deneyimlerimiz

Objectives: The study aims to retrospectively evaluate the 1-year results of endovascular treatment with rheolytic thrombectomy(TR) or catheter-directed thrombolytic(CDT) infusion therapy in acute femoro-popliteal bypass graft occlusion.&#x0D; Methods: The patients who had a history of femoro-popliteal by-pass operation and during their follow-up diagnosed with ipsilateral acute limb ischemia between 2016 and 2018 were included. The total of 13 patients were included and they were divided into two groups according to their treatment methods (RT, n=8 vs CDT, n=5).&#x0D; Results: There was no statistically significant difference between the two groups in terms of demographic data and Rutherford embolism classification. Reolitic thrombectomy and catheter-directed thromolytic infusion primary patency values were 87.5% and 80% for 6 months, 75% and 60% for 12 months, respectively. Secondary patency values were found to be 100% in both groups for 6 months, and 87.5% and 80% for 12 months, respectively. There was no significant difference between the two groups in terms of primer and sekonder patency.&#x0D; Conclusion:Endovascular therapy can be preferred in the treatment of acute femoro-popliteal by-pass graft occlusion in selected patient groups due to its less invasiveness, early mobilization, and low mortality and morbidity rates compared to surgery,

Different methods of femoropopliteal bypass grafting with autologous vein: propensity score matching analysis

To analyze immediate and long-term results of various methods of femoropopliteal bypass grafting with autologous vein using propensity score matching. A retrospective single-center open study included 464 patients who underwent femoropopliteal bypass grafting with an autologous vein between January 10, 2016 and December 25, 2019 at the Research Institute - Ochapovsky Regional Clinical Hospital No. 1. The following types of autovenous conduits were used: n=266 - reversed autologous vein (group 1); n=59 - in situ autologous vein (group 2); n=73 - upper limb autologous vein (group 3); n=66 - ex situ autologous vein (group 4). The long-term period was 16.6±10.3 months. We used propensity score matching analysis because patients were not comparable for some indicators. Groups 2-4 included small samples of patients, and their number was reduced to less than 10. This did not allow us to draw reliable conclusions about treatment outcomes. In this situation, we decided to allocate two groups: group 1 - ex situ femoropopliteal bypass grafting; group 2 - other variants of femoropopliteal bypass grafting with autologous vein. Propensity score matching allocated 299 people in group 1 and 46 patients in group 2. There were significant differences in early postoperative incidence of autologous vein thrombosis (group 1: n=3 (6.5%), group 2: n=79 (26.4%), p=0.003; OR= 0.19; 95% CI 0.05-0.64) and postoperative wound suppuration (group 1: n=2 (4.3%), group 2: n=52 (17.4%); p=0.02; OR=0.21; 95% CI 0.05-0.91). In long-term postoperative period, significant differences were obtained in the incidence of limb amputation (group 1: n=6 (13%), group 2: n=85 (28.4%); p=0.02; OR=0.37; 95% CI 0.15-0.92) and myocardial infarction (group 1: n=1 (2.2%), group 2: n=43 (14.4%); p=0.02; OR 0.13; 95% CI 0.01-0.98). Femoropopliteal bypass grafting ex situ is characterized by lower incidence of graft thrombosis, amputations of the limb, mild decrease in the incidence of infectious complications and all adverse cardiovascular events in early and late postoperative period compared to conventional surgery (reversed autologous vein, in situ autologous vein, upper limb autologous vein).

Changes in deep femoral artery topography during open revascularization of the lower limbs

To study topographic changes of femoral triangle arteries during open revascularization of the lower limbs. A retrospective study included 30 men aged 59.6±3 years with atherosclerotic femoropopliteal occlusion and chronic lower limb ischemia IIb-III stage according to the Pokrovsky-Fontaine classification. All patients underwent open reconstructive interventions. Ten patients underwent above-knee femoropopliteal replacement with a synthetic prosthesis, 10 patients - above-knee femoropopliteal bypass with a synthetic prosthesis, 7 patients - above-knee femoropopliteal bypass with autologous vein, 3 patients - below-knee femoropopliteal bypass with autologous vein. Control group consisted of 30 healthy mean aged 60±2 years. Ultrasound was carried out using the Esaote My Lab Alfa scanner (3-12 MHz linear transducer and 3-5 MHz convex transducer). In healthy volunteers, deep femoral artery always arose from common femoral artery under the angle ≤30° in all cases (20° - 93.3% of cases, 30° - 6.7% of cases). In patients with previous surgical treatment, angle of deep femoral artery varied from 35 to 80°. After femoropopliteal bypass grafting with autologous vein, angle of deep femoral artery varied from 35 to 45° (35° - 8 patients, 40° - 1 patient, 45° - 1 patient). After femoropopliteal bypass grafting with a synthetic prosthesis, angle of deep femoral artery increased up to 40-50° (40° - 2 patients, 50° - 8 patients). In case of previous femoropopliteal replacement with a synthetic prosthesis, angle of deep femoral artery increased up to 70-80° (70° - 7 patients, 75° - 2 patients, 80° - 1 patient). Normally, angle of deep femoral artery does not exceed 30°. Open reconstructive surgery on femoropopliteal arteries increases this value from 30° to 80°. Minimal changes are observed after femoropopliteal bypass grafting with autologous vein.

Early outcomes of novel Temren atherectomy device combined with drug-coated balloon angioplasty for treatment of femoropopliteal lesions.

In this study, perioperative properties and early outcomes of patients who underwent combined Temren rotational atherectomy (RA) and drug-coated balloon (DCB) angioplasty treatment for complex femoropopliteal lesions in a single center were reported. Between June 2019 and February 2020, 40 patients who underwent combined Temren RA and DCB treatment due to critical lower limb ischemia or claudication-limiting daily living activities were retrospectively evaluated. The mean age of patients was 73.2 ± 7.8 years and the majority of the patients were male (65%). Of the patients, 17 had critical limb ischemia and 23 had lifestyle-limiting claudication. Pathologies were total occlusion in 33 limbs and critical stenosis in seven limbs. Nine patients previously underwent endovascular intervention or surgery. The mean total occlusion length was 140.9 ± 100.9 (range, 20-360) mm in patients with chronic total occlusion. There was an additional iliac artery pathology in 5 and below the knee pathology in 8 patients. Rotational atherectomy was possible in all cases. Flow-limiting dissection was seen in six patients (15%). Provisional stent was performed to these patients. Following Temren RA, all patients underwent DCB. Adequate vascular lumen (less than 30% stenosis) was provided in all patients and the symptoms regressed. No distal embolization was encountered. Access site complications (17.5%) were small hematoma in four patients, ecchymosis in two patients, and pseudoaneurysm of the femoral artery in one patient. The mean follow-up was 13.55 ± 4.2 (range, 1-18) months. Re-occlusion was seen in three patients (7.5%) (n = 2 at 2months and n = 1 at 4months). Of these patients, two had required open revascularization via femoropopliteal bypass graft with common, superficial femoral, and popliteal artery endarterectomy and one had required femoro-posterior tibial artery bypass. Four minor toe amputations (10%) were performed to reach complete wound healing in the critical limb ischemia patients. A below-knee amputation was performed in a 94-year-old patient with long segment stenosis at the end of a 1-month follow-up period. There was no mortality after follow-ups. The Kaplan-Meier estimator estimated the rate of freedom from target lesion revascularization (TLR) which was 92.3%. The decrease in the Rutherford levels after the procedure was found to be statistically significant in 36 patients (p < 0.001). The increase in the ankle-brachial index after the procedure was found to be statistically significant in 36 patients (p < 0.001). Combined use of Temren RA with adjunctive DCB is safe and effective method with high rates of primary patency and freedom from TLR and low rates of complication in the treatment of femoropopliteal lesions.

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.

Effect of occult malignancy on femoropopliteal bypass graft thrombosis

ObjectiveThe presence of cancer increases arterial thromboembolic events, specifically myocardial infarction and stroke, before a formal diagnosis of cancer. To the best of our knowledge, this increase in thrombotic risk has not been studied in patients with lower extremity bypass grafts. In the present study, we aimed to determine the effect of occult cancer on femoropopliteal bypass patency. MethodsA retrospective review of femoropopliteal bypass procedures completed from 2001 to 2018 was performed. International Classification of Diseases, 9th and 10th revision, codes corresponding to breast, lung, prostate, colorectal, skin, brain, and hematologic cancer were used to identify patients who had had occult cancer. Occult cancer was defined as cancer diagnosed within ≤1 year after the bypass procedure. The demographics, comorbidities, bypass configuration and conduit, 1-month, 3-month, 6-month, and 1-year occlusion rates, major adverse limb events, and mortality rates were analyzed. Statistical analysis included t tests, χ2 tests, and Cox regression analysis. ResultsA total of 621 procedures in 517 patients met the inclusion criteria. Of the 621 procedures, 36 (5.8%) were classified as procedures in patients with occult cancer. The patients with occult cancer had had higher occlusion rates at 3 months (27.8% vs 8.0%; P < .001), 6 months (30.5% vs 15.1%; P < .01), and 1 year (44.4% vs 19.8%; P < .001). In Cox regression analysis for bypass thrombosis at 1 year, the only significant predictors were occult cancer (hazard ratio [HR], 2.03; P = .01), below-the-knee distal target (HR, 1.88; P < .01), and a compromised conduit (HR, 2.14; P < .001). ConclusionsWe found an increase in bypass graft thrombosis rates in patients who had undergone femoropopliteal bypass who had had occult cancer. Thrombosis of the graft within 1 year postoperatively might be a sign of occult cancer.

Vascular Graft Infections: a Decade’s Clinical Experience in Indian Population

Vascular graft infection with its morbidity and mortality has tormented the world of vascular reconstruction overlong. India despite carrying a sizable burden of patients requiring vascular reconstruction has minimal research on the subject. We attempted to chronicle clinical profiles, symptom variability, risk factors, prophylactic measures, and various therapeutic options extended to patients with vascular graft infection, in this medical record-based case series analysis, of a decade (years 2010–2020), of patients presenting with vascular graft infections. Statistical comparison was done with chi-square and Fisher’s exact probability test. A total of 70 patients presented with vascular graft infection, 92.9% men and 7.1% women (mean age of 58 SD 11.8 years). Diabetes and coronary artery disease were the commonest comorbid conditions (24.7% each). The most common site of infection was the groin, and femoropopliteal bypass graft was the most infected segment (48.5%). The average time interval from index surgery to presentation with infection was 308 days. Early graft infection was seen in 60% patients, with extra-cavitary graft infections manifesting earlier than others. Local symptoms with discharging sinuses and cellulitis were common clinical presentations. Staphylococcus aureus was the commonest organism isolated (31.4%). A total of 58.5% patients underwent graft explantation and 40% were managed conservatively. Incidence of infection in patients who underwent immediate post-operative re-intervention was statistically significant when compared with Bunt’s classification (P value < 0.05). The distribution of incidence of post-operative infection differed significantly across various sites and the type of graft material used (P value < 0.05). Prosthetic vascular grafts provide unparalleled benefit to a patient in maintenance of life and limb. Our Indian experience of a decade when summed up reflects that extra-cavitary graft infections express early and anatomical predisposition of the groin makes femoropopliteal segment the worst affected in VGI. Remote infections and re-interventions are hidden caveats of VGI. Apt to say that “Aegrescit medendo”—“the cure is worse than the disease”—holds good for vascular graft infections.

Results of loop endarterectomy and femoropopliteal bypass grafting in TASC C and D lesions

The aim of our investigation was to analyse the results of treatment of patients with atherosclerotic lesions of the femoropopliteal segment by means of femoropopliteal bypass grafting or loop endarterectomy within the framework of a single-centre retrospective study. The study included a total of 177 patients who were divided into two groups. Group One was composed of 108 patients subjected to loop endarterectomy from the arteries of the femoropopliteal segment, and Group Two comprised 69 patients who endured femoropopliteal bypass surgery using a synthetic graft. Thoroughly analysed were the clinical, demographic, anatomical and perioperative data, as well as intra- and perioperative complications, followed by assessment of primary and secondary patency, with no statistically significant differences in these parameters revealed. Secondary patency was somewhat better in the group of loop endarterectomy. Also determined and examined were specific complications such as insufficient extraction of the plaque, perforation of the artery with the loop, thinning of the wall, detachment of the calcified plaque. This is followed by discussing variants of correction of similar events. In the group of loop endarterectomy, there were no severe complications, such as myocardial infarction, stroke, amputation in the early postoperative period. Loop endarterectomy is an acceptable alternative to femoropopliteal bypass grafting with a synthetic prosthesis. Taking into account all specific complications, it is possible to achieve minimization of unsuccessful outcomes.

Advantages of profundoplasty in patients with lower limb critical ischaemia in redo operations

Our study was aimed at determining advantages of profundoplasty in patients with critical ischaemia of lower limbs in repeat arterial reconstructions. It included a total of 56 patients subjected to redo operations for thrombosis of a femoropopliteal bypass graft. Of these, 29 underwent profundoplasty (group I) and 27 repeat femoropopliteal bypass grafting (group II). Critical ischaemia was relieved in the early postoperative period in 28 (97%) and 24 (89%) patients of group I and II, respectively. The 3-year patency rate after profundoplasty amounted to 100% and after femoropopliteal bypass grafting to 47% (p<0.05). The lower-limb amputation rates over the 3-year period of follow up amounted to 3 (10%) and 11 (41%), p<0.05, respectively. Over the 3-year period of follow up, there was no statistically significant difference in the values of the ankle-brachial index (p>0.05).

Prosthetic repair of the aorta with a cadaveric homograft for infection of bifurcated synthetic vascular prosthesis

Infection of arterial vascular grafts is a rare but utterly severe complication in vascular surgery. Therapeutic policy in patients with graft infection has not been standardized, to be determined individually. One of the variants of surgical treatment is considered to be repeat aortic repair using a cadaveric graft. Presented in the article is a clinical case report concerning a 60-year-old male patient previously subjected to aortofemoral bifurcation bypass grafting with stage IV ischaemia of lower limbs according to the Pokrovsky-Fontaine classification. In the early postoperative period the events of critical ischaemia were not arrested. Due to the presence of a block of the femoropopliteal segment, as the second stage 3 days after the primary operation, the patient underwent autovenous femoropopliteal bypass grafting with a reversed autovein above the knee-joint fissure. The clinical course of critical ischaemia of the limb was relieved. During subsequent 8 months of follow up his state remained stable. Eight months after the primary operation he developed purulent discharge from the postoperative scar on the left femur. In the setting of the Purulent Surgery Department, the patient was emergently subjected to opening and drainage of the abscess of the postoperative scar. On the bottom of the wound there was a freely lying branch of a synthetic vascular prosthesis. Computed tomography revealed infection of the entire synthetic prosthesis and aneurysms of distal anastomoses. Given extremely high risk for the development of arrosive haemorrhage, a decision was made on operative treatment - repeat prosthetic repair of the abdominal aorta with a cadaveric allograft. At the Vascular Department of the Clinic of Faculty Surgery, laparotomy was performed, with removal of the infected graft, followed by debridement of the retroperitoneal space and repeat aortofemoral bifurcation prosthetic repair of the abdominal aorta with a cadaveric allograft. The wound healed with first intention. There was no evidence of infectious process relapse. The patient was discharged on postoperative day 15 in a satisfactory condition. The duration of follow up amounted to 6 months. The control examination showed that the pain-free walking distance was 500 m. Doppler ultrasonography demonstrated that the graft was functioning, with no signs of either anastomotic aneurysms or suppuration of the retroperitoneal space.

Alternative femoral endarterectomies: technical aspects and short-term results.

Femoral endarterectomies are often performed by means of longitudinal arteriotomies with patching. Autologous and synthetic patches can be used. Synthetic patches in the groin may expose patients to infection. We present two alternative techniques for the treatment of femoral atherosclerotic lesions. The alternative endarterectomies (AE) included eversion (EE) and semi-closed endarterectomies (SCE). An EE with an oblique transection of a femoral bifurcation (FB) was used for lesions extending to the FB. The artery was reconstructed in an end-to-end manner. An SCE with a bovine pericardium patch (BPP) was used for lesions extending further. An arteriotomy was made from the superficial femoral artery just past the level of the profunda femoris opening (PFO). The plaque was cut proximally to the PFO, dissected circularly with a Swedish-type dissector, and then removed with Crile forceps. The distally remaining plaque was endarterectomized in a conventional manner. The arteriotomy was closed with a BPP. A total of 21 AEs were performed, 8 of which were accomplished in a hybrid setting. There were no periprocedural complications. One distal embolization after a balloon dilatation was registered during the early postoperative period. The median follow-up was 3 months. There were no deep wound infections, pseudoaneurysms, amputations, or deaths. A total of 20/21 patients reported complete symptom relief, with one requiring an additional femoro-popliteal bypass grafting owing to poor outflow. The primary patency rate of the endarterectomized segments was 100%. Alternative methods of local endarterectomy can extend the available range of procedures for patients suffering from chronic lower-limb ischemia. According to our results, these endarterectomy techniques are safe and could be taken into consideration, as they provide some advantages over conventional methods.