Outcomes following unilateral axillofemoral bypass versus crossover femorofemoral bypass in chronic limb-threatening ischemia patients.

One Year Outcomes of Endovascular Aneurysm Repair with the Alto Stent Graft in the Hellenic Alto Registry.

Severe arterial calcification is a challenging limitation in endovascular procedures leading to worsesuccess rates and outcomes. Conventional balloon angioplasty may provide limited luminal gain, calling for adjunctive strategies of plaque modification, such as intravascular lithotripsy (IVL). The aim of this study is to describe our institutional experience with IVL in the treatment of peripheral artery disease (PAD). A prospectively maintained database from a tertiary academic medical centre was retrospectively enquired from October 2021 to September 2024. The study included all patients who underwent IVL (Shockwave Medical, Inc., California, USA) for vessel preparation during endovascular treatment of PAD. 19 patients were included (79% male, median age 76 years) with a median follow-up period of 6 and total of 35 months. Most common risk factors were hypertension (90%), diabetes (68%), dislipidemia (63%) and ischaemic heart disease (63%). Clinical presentation was mostly chronic limb-threatening ischemia (Fontaine grade IV in 74% and Fontaine grade III in 10%). The target lesion undergoing IVL was most often femoropopliteal (68%). Intraprocedural lesion crossing was almost equally subintimal and intraluminal (53% vs. 47%) and definitive treatment was mostly performed with stenting (79%). Additionally, 3 patients (16%) underwent a hybrid procedure with femoral endarterectomy (11%) or femoro-femoral bypass (5%). There were no identified procedural complications. Major adverse limb events (MALE) included no reinterventions and 1 major amputation (5%), and the all-cause mortality rate was 16%. Regarding the 14 patients in Fontaine grade IV, the wound healing rate was 57%. IVL is a safe and effective adjunctive in vessel preparation during endovascular revascularisation procedures, particularly in the femoropopliteal sector. Procedure and/or device-related complications, MALE and mortality are infrequent. Further research is needed concerning aortoiliac and infrapopliteal sectors and comparison with other supplementary treatment alternatives.

Mycotic Aneurysm Following Renal Transplantation: A Rare Complication Linked To Contaminated Preservation Fluid- A Case Report.

The study aim was to determine our results of minimally invasive technique without aortic cross clamping for mitral valve surgery after previous cardiac surgery. We performed 24 consecutive mitral valve surgeries between January 2015 and December 2018 in patients with a history of previous cardiac surgery. The procedure was performed using video-assisted right minithoracotomy, femoro-femoral bypass, a temperature of 26 °C, and cardiopulmonary bypass without aortic cross-clamping. Mitral valve replacement was performed in 12 (50%) of these patients, and mitral valve repair was performed in the same number (50%). The mean ejection fraction was 46.08±6.52% and the mean age was 61.52±11.48 years. Eighteen patients (75%) had previous coronary artery bypass graft surgery, and six patients (25%) had previous mitral valve surgery. In terms of postoperative complication frequencies that patients have experienced, one of the patients (4.1%) had postoperative low cardiac output syndrome. Two patients (8.3%) had renal failure; 2 patients (8.3%) had pneumonia, and stroke was seen in one patient (4.1%) postoperatively, whereas 2 patients (8.3%) had reoperation for bleeding. The mean postoperative packed red blood cell transfusion requirement at 48 hours was 1.00±1.10 units. The mean length of hospital stay was 10.54±4.37 days. Minimally invasive port access procedure via right thoracotomy may be a safe and effective option in selected patients who need mitral surgery and have a history of prior sternotomy.

Abstract Background Cannulation site selection for the surgical treatment of acute type A aortic dissection remains controversial. Several cannulation sites –from femoral to axillary vessels– have been proposed, but each one is associated to the risk of adverse complications. However, in some cases none of them could be an available option due to the dissection extension. Transapical cannulation is a simple maneuver that could restore antegrade blood flow during cardiopulmonary bypass, but only few series have been described in literature. Our aim is to investigate about the safety and efficacy of this procedure. Methods Between 2000 and 2024, n=355 patients underwent surgical repair of acute type A dissection at our center. Among them, transapical cannulation was performed in n=10 cases. Transapical cannulation was selected as the initial cannulation site in all patients due to unavailability of other places. The main surgical procedures were ascending aorta replacement with open distal technique (n=7), followed by total– (n=2) and partial–arch replacement (n=1). Two cases required an additional bioprosthetic aortic valve replacement. Hypothermic circulatory arrest with antegrade cerebral perfusion was performed in all cases at a mean temperature of 22.5 ± 2 °C, with additional retrograde perfusion in 6 of them. Median cross–clamp and circulatory arrest times were 68 [44,86] and 42 [28,73] minutes, respectively. Results 30–day mortality rate was 40% (n=4) and 2 patients died during follow–up at 4 and 6 years, respectively. Three patients had strokes (30%) and four developed postoperative acute kidney disease. Transapical cannulation was successful in all the subjects. One patient showed leg ischemia requiring femoro–femoral bypass. Nobody developed visceral organ malperfusion. The main dissection tear was found in the ascending aorta, aortic arch and root in n=6, n=3 and n=1 patients, respectively. Conclusions Despite high mortality rate, transapical cannulation could be a safe and effective bailout option for the repair of acute type A aortic dissection when none other cannulation site is available. Nevertheless, this cannulation method cannot completely reduce the risk of intraoperative malperfusion, especially when large tears are found in ascending aorta, so careful intraoperative monitoring is required.

Rupture of a Non-Infected, Non-Anastomotic False Aneurysm in a Patient with Prior Femorofemoral Bypass

A quinquagenarian underwent zone 2 arch repair for acute type A dissection followed by endovascular repair utilizing a branch endoprosthesis and covered stents. He developed a fever and positive blood culture results 3 weeks after the thoracic endovascular repair. A preoperative left carotid to subclavian artery bypass was performed. First stage: A right axillary artery was re-cannulated. The innominate vein was divided to facilitate the exposure. At a bladder temperature of 20℃, selective antegrade cerebral perfusion was established. A bifurcated graft was anastomosed to the left common carotid artery and the innominate artery. The endografts, including a branch endograft, were removed. A classical elephant trunk graft was inserted into the descending aorta and the left subclavian artery was ligated. The elephant trunk was pulled out and a proximal anastomosis was performed. Finally, the bifurcated graft was anastomosed to the elephant trunk. The innominate vein was repaired. Delayed closure with the pectoralis major muscle flap was performed. Second stage: A descending aortic repair was performed using a partial femoro-femoral bypass. The distal aortic arch was clamped, including the residual endograft and the elephant trunk. Covered endografts were removed. An open distal anastomosis was performed above the celiac axis utilizing a Dacron graft followed by the proximal elephant trunk-to-graft anastomosis. After completion of the repair, residual covered endografts were removed completely.

下肢末梢動脈疾患治療において腸骨動脈領域では血管内治療が第一選択となりつつあるが，非解剖学的血行再建である大腿–大腿動脈間交叉バイパスは低侵襲で開存率も良好で跛行症例だけでなく包括的高度慢性下肢虚血症例においても有用な場面が存在する。当院のデータから下肢末梢動脈疾患治療における大腿–大腿動脈間交叉バイパスの意義を示す。

BackgroundThe aim of this study is to report the early outcomes of valvular heart surgeries performed via the right thoracotomy approach. While thoracotomy with femoro-femoral bypass is an established method for minimally invasive open-heart surgeries, thoracotomy with conventional cannulation is still being explored. In our center, we conducted 958 valvular heart surgery cases using the right anterolateral thoracotomy approach with central cannulation and data were analyzed.MethodsThis is a retrospective observational study based on prospectively collected data from patients who underwent valvular heart surgery at our center spanning from April 2013 to April 2023. The data encompass demographics, procedures, operative techniques, post-operative morbidity, mortality, and a 1-month follow-up.ResultsOur study revealed no procedure-related mortality. No patient required conversion to median sternotomy. Smooth cannulation and satisfactory exposure were achieved in all patients. The study encompassed a wide age range, from 14 to 68 years, with 618 female patients (64.5%) and 340 male patients (35.5%). The average cross-clamp time ranged from 38 to 90 min, the duration of cardio-pulmonary bypass ranged from 45 to 105 min, post-operative extubation ranged from 3 to 8 h, the average drain volume ranged from 100 to 350 ml, and the incision size ranged from 5 to 7 cm.ConclusionsOur data demonstrate that conventional cannulation via the right antero-lateral thoracotomy approach for valvular heart disease is a viable alternative to reduce the side effects associated with sternotomy and femoral cannulation. This procedure is safe, reproducible, and provides the same level of treatment quality.

Highlights: 1. While GSV has its advantage as a conduit of choice, in certain cases it might not be a suitable option for the patient depending on how complex the case is. 2. This article discusses the usage of ASV as alternative vein conduit and it shows an interesting result. - Background: PAD can be treated with either endovascular intervention and open surgery. Great saphenous vein (GSV) is the most commonly used vein conduit for infrainguinal vascular bypass. Case Summary: 38-years old man presented with intermittent claudication for 2 months and diabetic foot ulcer on his left cruris. Left pedal artery pulse was absent with ABI of <0.4. Angiography showed a chronic total occlusion of left superficial femoral artery (SFA). Upon intraoperative, an aneurysmatic GSV and a good accessory saphenous vein (ASV) were found through the same incision. Thus, ASV was chosen as the vein conduit. Postoperative period of 3 days was steady. Two months follow up revealed his ability to walk normally, good pulse and perfusion, and no deterioration on his ulcer. Discussion: GSV performed better than prosthetic conduits with a 5-year patency rate of 80%, thus it becomes the conduit of choice in 2024 ESVS guideline. However, the GSV was found inadequate, and the prosthetic graft was unavailable, in this case. ASV was decided to be more suitable to be used as an alternative vein conduit. In the absence of adequate GSV, alternative autologous vein can be used and even perform better than prosthetic conduits.

Type III endoleak is a severe complication after endovascular aneurysm repair (EVAR) and can result in aneurysm rupture. In the presence of common (CIA) and internal iliac artery (IIA) aneurysm the preservation of at least one IIA is mandatory to avoid pelvic ischemia. A 88-year old man wit EVAR extending to the right external iliac artery presented with a type III endoleak from disconnection between the main body and the contralateral limb. He also had an aneurysm of the left CIA, with subsequent loss of left limb fixation, and an aneurysm of the left IIA, the only one maintaining pelvic flow. A hybrid procedure was performed including placement of an aorto-uni-iliac graft, crossover femoro-femoral bypass and placement of an external to the aneurysmal IIA reverse U stent - graft. Post-operative CT scan demonstrated complete sealing of the endoleak with preservation of pelvic flow through the IIA.

Spontaneous exteriorization of a prosthetic vascular graft is a rare complication of vascular repair. It is even rarer when there is no evidence of an infective cause. We aim to highlight this unusual complication of vascular graft and to review the literature. We report a case of a middle-aged man who was managed for total occlusion of the left external iliac artery with a non-anatomic femorofemoral graft using Poly-Tetra-Flour-Ethylene (PTFE). Five years later, he presented with exposure to the graft without obvious signs of wound infection which is a rare complication of vascular repair. The graft was test-clamped and subsequently excised when no sign of limb ischemia was noted. The wound was refreshed and closed primarily. He is still on follow-up and has no symptoms or signs of limb ischemia. Exposure of femorofemoral bypass graft can occur due to skin erosion when the graft is in contact with the dermis. Good tunelisation and avoiding angulation of prosthesis are advised to avoid this complication.

Limb ischaemia is a clinically relevant complication of venoarterial extracorporeal membrane oxygenation (VA ECMO) with femoral artery cannulation. No selective distal perfusion or other advanced techniques were used in the past to maintain adequate distal limb perfusion. A more recent trend is the shift from the reactive or emergency management to the pro-active or prophylactic placement of a distal perfusion cannula to avoid or reduce limb ischaemia-related complications. Multiple alternative cannulation techniques to the distal perfusion cannula have been developed to maintain distal limb perfusion, including end-to-side grafting, external or endovascular femoro-femoral bypass, retrograde limb perfusion (e.g., via the posterior tibial, dorsalis pedis or anterior tibial artery), and, more recently, use of a bidirectional cannula. Venous congestion has also been recognized as a potential contributing factor to limb ischaemia development and specific techniques have been described with facilitated venous drainage or bilateral cannulation being the most recent, to reduce or avoid venous stasis as a contributor to impaired limb perfusion. Advances in monitoring techniques, such as near-infrared spectroscopy and duplex ultrasound analysis, have been applied to improve decision-making regarding both the monitoring and management of limb ischaemia. This narrative review describes the evolution of techniques used for distal limb perfusion during peripheral VA ECMO.

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

Mid-term Outcomes of Open Thoracoabdominal Aortic Aneurysm Repair Following Thoracic Endovascular Aortic Repair

Transfemoral access has been established as the gold standard approach for the majority of patients undergoing transcatheter aortic valve implantation (TAVI). However, in cases with anatomical difficulties or severely diffused peripheral arterial disease, alternative vascular access may be considered such as the transaxillary approach. We present the case of a 92-year-old gentleman with exertional dyspnea due to severe symptomatic aortic stenosis and a history of peripheral femoro-femoral bypass surgery, coronary arterial bypass surgery and a permanent dual-chamber left-side implanted pacemaker. Due to the high surgical risk and the severe anatomical difficulties, the method of TAVI using the left axillary approach was opted. A 14-F vascular sheath was inserted with surgical cutdown and with fluoroscopic guidance while small injections of contrast confirmed the non-occlusive position and the patency of the left internal mammary artery (LIMA) graft. A stiff guidewire was used to cross the heavily calcified aortic valve and subsequently was placed into the left ventricle. Balloon aortic valvuloplasty was performed followed by a successful TAVI with no significant aortic regurgitation or paravalvular leak. The patient recuperated uneventfully and was discharged after 72 h. Axillary access for TAVI is a feasible option for high-risk patients with extended peripheral arteriopathy. To our knowledge this is the first case report describing the implantation of a newer type of intra-annular self-expanding valve platform in a nonagenarian patient with severe comorbidities and such a remarkable history of multiple previous interventions in the selected access site. Meticulous upfront strategy planning and efficient collaboration between specialties is of outmost importance in hybrid procedures for favorable clinical outcomes, especially in cases with challenging anatomies.

PurposeThis study aimed to report the results of femorofemoral bypass (FFB) using a great saphenous vein (GSV) graft as an alternative to polytetrafluoroethylene (PTFE) grafts.Materials and MethodsFrom January 2012 to December 2021, 168 patients who underwent FFB (PTFE, 143; GSV, 25) were included. The patients’ demographic features and surgical intervention results were retrospectively reviewed.ResultsThere were no intergroup differences in patients’ demographic features. In GSV vs. PTFE grafts, the superficial femoral artery provided statistically significant inflow and outflow (P<0.001 for both), and redo bypass was more common (P=0.021). The mean follow-up duration was 24.7±2.3 months. The primary patency rates at 3 and 5 years were 84% and 74% for PTFE grafts and 82% and 70% for GSV grafts, respectively. There was no significant intergroup difference in primary patency (P=0.661) or clinically driven target lesion revascularization (CD-TLR)-free survival (P=0.758). Clinical characteristics, disease details, and procedures were analyzed as risk factors for graft occlusion. Multivariate analysis revealed that none of the factors was associated with an increased risk of FFB graft occlusion.ConclusionFFB using PTFE or GSV grafts is a useful method with an approximately 70% 5-year primary patency rate. The GSV and PTFE grafts showed no difference in primary patency or CD-TLR–free survival during follow-up; however, FFB using GSV may be an option in selective situations.

Low-Profile Altura Endograft System for Endovascular Abdominal Aorta Aneurysm Repair. Preliminary Results in Elective and Emergent Situations

Background: Infected prosthetic arterial grafts at the Scarpa triangle is a serious complication in vascular surgery with high failure results. Extra-anatomic bypass is one of solution in literature, but there is no research in Vietnam yet. This report will share some experiences of Viet Duc hospital.[1] Subjects and methods: 03 patients with infected prosthetic arterial grafts at the Scarpa triangle after lower extremity vascular surgery were treated by femoral artery ligation, perineal femorofemoral bypass or obturator foramen bypass for lower extremity revascularization, on-site wound care. Result: Primary patency rate is 100% after surgery, inguinal incision can be well healed. Re-examination after 6 months without any signs of infection or limb ischemia, the inguinal incision was completely healed. Conclusion: Extra-anatomical bypass is an effective method for revascularization of the lower extremities in the case of infected prosthetic arterial grafts.