Good Patency Research Articles

A Retrospective Analysis of Treatment Outcomes of 40 Incidental Cavernous Carotid Aneurysms

The management of cavernous carotid aneurysms (CCAs) poses a significant dilemma to the treating surgeon. Asymptomatic CCAs usually are managed conservatively with clinical and radiologic follow-up. Large size, intradural extension, sphenoid bone erosion, and increasing size on follow-up are usual indications for treating asymptomatic CCAs. However, there are no clear-cut guidelines in literature. We share our experience of 40 asymptomatic CCAs treated by endovascular and surgical methods. All the asymptomatic CCAs treated between January 2014 and December 2018 were analyzed retrospectively. Patient demographics, aneurysm characteristics, postprocedural complications, and clinical and radiologic follow-up data were obtained from records. Outcome was evaluated in terms of aneurysm obliteration and maintained cerebral perfusion, postoperative complications, recurrence, and clinically significant complications during follow-up. Endovascular coiling, balloon-assisted coiling, and stent-assisted coiling were performed in 27 (75%), 5 (13.9%), and 4 (11.1%), respectively. Raymond-Roy occlusion classification grade I occlusion was achieved in 88.9% of cases. No immediate or delayed complications were noted. Coil compaction was seen in 4 (11.1%) patients. In the surgery group, all patient underwent high-flow bypass with radial artery graft. Aneurysm exclusion with good graft patency was achieved in all 4 cases without any permanent morbidity or mortality. The current study demonstrates excellent outcomes of asymptomatic CCAs after treatment. In view of the technical advancements of both surgical and endovascular methods, consideration for treatment should be given to asymptomatic CCAs. Each aneurysm should be individually assessed by experts for choosing the best endovascular or surgical treatment option.

Randomized Comparative study between Reversed and Insitu Great Saphenous Vein Grafts in Infrapopliteal Revascularization

Background: Foot ulcer is a disabling complication and not uncommon among patients with DM, the predictive factors for diabetic foot ulcer development were peripheral neuropathy, duration of diabetes, poor glycemic control, and peripheral vascular disease which was a major significant risk factor. Aim of the study: to determine whether Reversed or Insitu Great Saphenous Vein Grafts is the optimum In Infrapopliteal Revascularization. Patients and Methods: diabetic patients referred to Vascular Surgery department of Al-Azhar University Hospitals and Nasr City Hospital were included if they had foot lesions such as ulcers, gangrene or tissue necrosis and had no palpable pedal pulses. End points were healed, healing, non healing or amputation. Fifty diabetic foot patients were included. Results: twenty-four patients reached the end point of adequate healing or complete healing, whereas twenty-six patients had nonhealing lesions. The Ankle Peak Systolic Velocity (APSV) was significantly higher in patients with Reversed Great Saphenous Vein Grafts compared with patients with Insitu Great Saphenous Vein Grafts: 57.8cm/s (±12.72) versus 24.9 cm/s (±9.55), p < 0.001. At a cutoff point of 40 cm/s, the APSV showed sensitivity of 90.91%, specificity of 100%, positive predictive value of 100%, negative predictive value of 92.3%, with diagnostic accuracy of 97.4% in predicting healing of diabetic foot lesions. There was a significant difference between the APSV before and after revascularization: 23.4 cm/s (±6.5) versus 58.8 cm/s (±12.3), p < 0.001. Conclusion: both reversed and insitu great saphenous vein grafts have good patency in infrapopliteal revascularization.

IFT05. Outcomes of Basilic Vein Transposition: Challenges in an Indian Setting

Basilic vein transposition (BVT) is performed after other native access options are exhausted. Based on the numbers that we perform and vein maturation, we would expect good patency. The objective of this study was to understand the patency of BVT in our practice and the adequacy of surveillance. This was a retrospective study. All patients who underwent BVT between January 2015 and December 2016 were included. Patients who did not attend follow-up clinic were contacted by telephone. Data regarding patient demographics, previous vascular access, dialysis status, postoperative complications and patency (primary, primary assisted and secondary patency rates) at one year and two-year intervals were collected. There were 126 BVTs performed in 125 patients. Mean age of patients was 53 years (range, 16-82 years) and 78 patients (62.4%) were male. All patients had multiple failed native arterial fistulas before BVT. Two patients were in predialysis status and the others were on dialysis using tunneled central lines. BVT was performed as single-stage procedure in all patients. Three patients (2.4%) died and one patient underwent renal transplant within the first 30 days. Only 18% of the patients attended the scheduled follow-up visits. Of 122 procedures, 115 (94.3%) resulted in a mature fistula. At the 1-year follow-up, 38 patients were lost, 19 patients were dead, and 4 patients had renal transplant. At 1 year there were 65 (52%) eligible patients for analysis, of which 8 patients had ligation of the transposed basilic vein for pseudoaneurysm/bleeding complications and the primary patency was 49.2%, primary-assisted patency 56.9%, and secondary patency was 66.1%. At 2 years an additional 10 patients died and 3 patients had renal transplant. At 2 years there were 52 eligible patients (41%) for analysis, out of which the primary patency was 38.5%, primary-assisted patency was 42.3%, and secondary patency was 59.6%. Surveillance was inadequate because patients were being dialyzed at other centers and in other cities. Dialysis technicians and nurses often failed to recognize failing fistulas. BVT can be performed safely with good maturation in majority of the patients. However, inadequate surveillance and maintenance of fistulas can result in reduced 1- year and 2-year patency rates. A patient-centered approach with communication and education of patients, dialysis technicians, nephrologists and vascular surgeons could improve the patency rates.

Distal Edge Stenosis After Stent Placement for Isolated Superior Mesenteric Artery Dissection: Mechanisms and Risk Factor Analysis.

To analyze factors potentially associated with the occurrence of distal edge stenosis after stent placement for isolated superior mesenteric artery dissection (ISMAD). Cases of consecutive patients who were diagnosed with spontaneous ISMAD between February 2010 and July 2018 were retrospectively identified. Of the 123 cases identified, 45 patients (42 men; three women) underwent endovascular stent placement and were included in the study. Univariate and multivariate analyses were used to assess factors potentially associated with distal edge stenosis. The technical success rate among study patients was 100%. During 26.7 ± 17.3months of follow-up, CT angiography demonstrated good distal edge patency in 25 patients (55.6%) and evidence of distal edge stenosis in 20 patients (44.4%). In univariate analysis, stent length (odds radio [OR] 1.03; 95% confidence interval [CI] 1.01, 1.06; P = .02), stent-to-vessel (S/V) diameter ratio (OR 2.27; 95% CI 1.35, 3.82; P < .01), and angulation at the distal edge (OR 1.05; 95% CI 1.00, 1.10; P =.03) were significantly associated with distal edge stenosis; only S/V diameter ratio (OR 3.36; 95% CI 1.41,7.99; P < .01) and angulation at the distal edge (OR 1.12; 95% CI 1.01, 1.23; P =.03) retained this significance in multivariate analysis. Distal edge stenosis after stent placement for ISMAD is common. S/V diameter ratio and angulation at the distal edge are independent risk factors for distal edge stenosis in patients with ISMAD who undergo stent placement.

A 2-mm Cutoff Value Is Reasonable and Feasible for Vascular Reconstruction in a Kidney Allograft With Multiple Arteries

BackgroundMultiple renal arteries are found in approximately 20% of living donor kidneys. We have been using an accessory artery cutoff diameter of 2 mm on preoperative computed tomography angiography to determine whether to sacrifice or reconstruct the artery. In this study, we assessed the validity and feasibility of this cutoff value. MethodsLiving related kidney recipients from 2005 to 2013 were enrolled in this retrospective study. The diameter of the accessory artery and adverse events were evaluated. The lost parenchymal volume (%) due to vascular obstruction or branch ligation was calculated by computed tomography volumetry. ResultsAmong 128 kidney transplants, 30 donor kidneys had multiple arteries. Accessory arteries were reconstructed in 18 cases and intentionally ligated in 12 cases (mean diameter of accessory arteries, 3.10 [SD, 0.75] mm and 1.81 [SD, 0.28] mm, respectively). The mean estimated glomerular filtration rate at 1 or 12 months after transplant was not significantly different between the groups. Among reconstructed cases, 14 cases (77.8%) had good patency in the reconstructed arteries whereas the other 4 had vascular complications. The percentage of lost parenchymal volume due to ligation or occlusion of the reconstructed artery (calculated in 16 cases) was predictable with the following formula: lost volume (%) = 9.09 × diameter (mm) − 10.5 (P= .03, rs= 0.533 by Spearman rank correlation coefficient). This formula indicated that ligation of a 2-mm accessory artery leads to 7.68% loss of the renal parenchyma. ConclusionsReconstruction using a cutoff diameter of 2 mm is worth attempting in terms of the success rate and graft function. Sacrifice of a 2-mm accessory artery leads to parenchymal loss of <8%.

Treatment of pediatric vascular injuries: the experience of a single non-pediatric referral center.

Pediatric peripheral vascular trauma carries significant risk of complications including limb loss and long-term invalidity. Mechanisms and types of morphological lesions are very diverse. The objectives of this study are to present the experience of a single vascular center in the surgical approach to pediatric vascular injuries, and to analyze the main challenges related to this clinical entity. Over a period of 25 years, 17 pediatric peripheral vascular injuries were treated in our institution. Patient's age ranged between one day (newborn) and 15 years (mean: 10.7 years). There were five injuries of upper and 12 injuries of the lower extremity. Preoperative diagnosis was established by clinical examination (N.=4), ultrasonography (N.=1) and angiography (N.=12). Blunt trauma mainly caused arterial thrombosis while penetrating trauma caused arterial laceration or complete transection. Five patients had associated orthopedic injuries (29,4%). There were two posttraumatic pseudoaneurysms and two arterio-venous fistulas. There was no perioperative mortality. Vascular reconstructions included arterial suture (N.=4), thrombectomy + patch angioplasty (N.=1), termino-terminal anastomosis (N.=3), venous anatomic bypass (N.=6), PTFE graft reconstruction (N.=2), and venous extra-anatomic reconstruction (N.=1). Two patients had associated venous injury demanding both arterial and venous reconstruction. In the only case of war trauma treatment ended with limb loss. Other reconstructions presented good early and long-term patency. Pediatric vascular injuries are extremely challenging issues. Treatment includes broad spectrum of different types of vascular reconstructions. It should be performed by vascular surgeon trained in open vascular treatment or pediatric surgeon with significant experience in vascular surgery.

Femoral Vein Transposition Arteriovenous Fistula is a Feasible Option in "Selected" Patients as Hemodialysis Access.

Introduction: Lower extremity hemodialysis access is offered to the patients who have severe central venous stenosis. Femoral vein transposition arteriovenous fistula (FV tAVF) is an alternative to lower leg arteriovenous prosthetic grafts. Its safety and patency is under observation.Materials and Methods: This is a retrospective review of patients who had FV tAVF between January 2011 and March 2016. Preoperative clinical findings, intraoperative findings, postoperative complications, and patency of the AVF were noted and analyzed.Results: There were 7 patients who underwent FV tAVF during this study period. Most patients were female (6 : 1), with mean age of 45.2 years (range, 33–55 years). All patients were hypertensive. Mean body mass index was 26.1 kg/m2. Patient had on average previous 6 dialysis accesses. Most patients had preoperative venograms (6/7). Mean interval between initiation of dialysis and creation of the arteriovenous fistula was 1.08 years. All procedures were done under general anesthesia. Four patients required extension of FV with either the small segment of polytetrafluorethylene or vein graft. Two patients had early postoperative complications. One patient developed hematoma, whereas other had wound dehiscence. All the accesses were utilized for dialysis after a mean interval of 6 weeks. All patients had a patent fistula on average follow-up of 2 years.Conclusion: Appropriate patient selection for FV tAVF can provide good patency with low incidence of complications. This can be considered for good risk individuals undergoing their first lower extremity access.

Insurance and Flow-Alteration Superficial Temporal Artery to Middle Cerebral Artery (STA-MCA) Bypass in Management of Complex Anterior Intracranial Circulation Aneurysms in Postendovascular Era

Optimal management of complex anterior circulation aneurysms is an enigmatic challenge because of frequent involvement of major vessel bifurcation, choroidal vessels, and lenticulostriate/thalamostriate perforators. Cerebral ischemia associated with prolonged clipping time is a major concern pertinent to their surgical management, especially in patients with poor cross-flow. To circumvent this hurdle, single/double-barrel low-flow superficial temporal artery (STA) to middle cerebral artery (M3/M4-MCA) can be performed, which can maintain distal cerebral perfusion while facilitating safe clip reconstruction of complex MCA and supraclinoidal internal carotid artery (ICA) aneurysms involving ICA bifurcation or supraclinoidal ICA aneurysms with poor cross-circulation-insurance bypass, as well as supplement/alter blood flow after MCA aneurysm trapping-flow-alteration bypass. A retrospective chart review of consecutive neurosurgical patients operated over 2 years at this center was performed. Patients with complex MCA and ICA aneurysms who were treated with STA-MCA bypass were included. The clinical profile, pre- and postoperative images, intraoperative imaging, and patient outcomes were recorded. Surgical reconstruction of aneurysm was the treatment of choice due to involvement of choroidal/thalamostriate perforators, MCA/ICA bifurcation, complex aneurysm morphology, or dissecting/thrombosed nature of aneurysm. STA-MCA low-flow bypass was performed using M3/M4 segment of MCA as the recipient in anticipation ofprolonged temporary clipping time on M1-MCA, supraclinoidal ICA aneurysms with suspected ICA terminus involvement, or need for possible trapping of fusiform MCA aneurysm. The saccular/fusiform part of aneurysm was clip reconstructed and the partially thrombosed dissecting segment was opened for thrombectomy and trapped using proximal and distal clips after good patency of bypass was confirmed. The distal MCA flow was restored adequately and confirmed intraoperatively using indocyanine green angiography and micro-Doppler ultrasonography. MCA (n= 4) and supraclinoid-ICA (n= 1) aneurysms were managed successfully using this strategy, which involved 6 STA-MCA bypass procedures (insurance and flow-alteration bypass, 3 each). Postoperative check angiograms demonstrated patent bypass in all 5 patients. Four patients had favorable outcome (modified Rankin Scale score 0/1); one had recovering hemiparesis and aphasia (modified Rankin Scale score 4). This series highlights the surgical strategy and safety for successfully managing complex MCA and ICA aneurysms using low-flow STA-MCA revascularization procedures.

Partial aneurysmectomy for treatment of autologous hemodialysis fistula aneurysm is safe and effective

ObjectiveThe purpose of this study was to evaluate the outcome and the factors associated with stenosis after treatment using partial aneurysmectomy for aneurysm in autologous arteriovenous fistulas. MethodsThis retrospective cohort study was conducted from July 2007 to June 2016 and included patients with complicated aneurysms in upper extremity autologous arteriovenous fistulas were treated by partial aneurysmectomy. Vascular ultrasound examination was performed every 6 months after the surgery. ResultsForty-one patients (median age, 37 years; 70.7% males) were included. Of the patients, 95.1% had a radial-cephalic fistula in the forearm and nearly 88% had 1 or 2 aneurysms in arteriovenous fistulas that had been created for 10 to 84 months. Technical success of partial aneurysmectomy was achieved in all patients. The access diameter (44.0 ± 5.1 mm vs 10.4 ± 1.8 mm; P < .01) and brachial artery blood flow (1618.2 ± 277.0 mL/min vs 772.1 ± 127.4 mL/min; P < .01) were significantly decreased after the surgery. The median follow-up time was 27 months (range, 12-43 months). The primary patency rates at 6 and 12 months were 100% and 95%, respectively. Loss of patency was due to stenosis of the remodeled fistulas, which occurred in seven patients (17%). Multivariate COX regression analysis revealed that diabetes (hazard ratio, 114.28; 95% confidence interval, 2.85-4583.94; P = .01) was a risk factor for the impaired primary patency rates. A larger postprocedure residual diameter trended to favor fistula patency (hazard ratio, 0.46; P = .07). Stenosis was successfully treated with percutaneous transluminal angioplasty. ConclusionsPartial aneurysmectomy is an effective and safe method for treating aneurysm of upper extremity autologous arteriovenous fistulas, leading to good 12-month primary patency and no aneurysm recurrence. Using a larger catheter to size the revised fistula during aneurysmectomy may increase access patency.

One-Year Results of Iliocaval Stenting

The aim of the study was to assess results of interventions for iliocaval obstruction or compression in patient with acute and chronic venous disease. Patients with chronic venous insufficiency (CVI) C3-C6 (Clinical, Etiology, Anatomy, Pathology - classification of venous insufficiency) and acute deep venous thrombosis were assessed by ultrasound scan, computed tomography, venography, and/or intravascular ultrasound, and if an obstruction in their iliocaval or iliofemoral segments were confirmed, they underwent venoplasty and stenting. Acute deep venous thrombosis cases were treated with pharmacomechanical and/or catheter-directed thrombolysis and residual obstruction was then stented. One hundred eighteen consecutive limbs were treated between October 2011 and December 2017. Thirty-two limbs had an active ulcer (27%), 27 limbs had healed ulcer or advanced skin changes (23%), 39 limbs had swelling with or without other symptoms of CVI (33%), 15 limbs had acute symptomatic deep venous thrombosis (13%), and the residual 5 iliac vein cases were causing pelvic congestion syndrome (4%). Patency rates of the stents in acute cases were 84.6%, 76.9%, 76.9%, and in chronic cases (combined thrombotic and nonthrombotic) 93.1%, 91%, and 89.9% in 3, 6, and 12months, respectively. A relief of symptoms was achieved in 81.5 % of limbs at some stage during the first 12months (most of them within the first 3months), although at the end of this period only 59.3% remained free of symptoms. There was no limb loss and no mortality within 30days from the intervention. Iliocaval and iliofemoral venoplasty and stenting in both acute and chronic obstruction cases can be performed safely with good patency rates and reasonable improvement of symptoms of CVI.

Long-term patency and clinical outcome of the transjugular intrahepatic portosystemic shunt using the expanded polytetrafluoroethylene stent-graft.

BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) creation is an established treatment option to management the complications of portal hypertension. Recent data on the long-term outcomes of TIPS are scarce.Materials and methodsIn this single-institution retrospective study, 495 patients underwent TIPS with the Fluency stent-grafts between December 2011 and June 2015 were evaluated. The cumulative rates of TIPS dysfunction, hepatic encephalopathy (HE), survival, and variceal rebleeding were determined using the Kaplan–Meier method. Cox regression analysis was used to assess the parameters on TIPS patency, occurrence of HE and all-cause mortality.ResultsTechnical success was 98.2%. TIPS-related complications occurred in 67 patients (13.5%) during the index hospital stay. TIPS creation resulted in an immediate decrease in mean portosystemic pressure gradient from 23.4 ± 7.1 mmHg to 7.6 ± 3.5 mmHg. The median follow-up period was 649 days. Primary TIPS patency rates were 93%, and 75.9% at 1 and 3 years, respectively. Previous splenectomy was associated with a higher risk of TPS dysfunction. The cumulative survival rates were 93.4% and 77.2% at 1 and 3 years, respectively. The 1- and 3-year probability of remaining free of variceal bleeding rates were 94.2% and 71.4%, respectively.ConclusionsThis retrospective single-center experience with TIPS using the Fluency stent-grafts demonstrates good long-term patency and favorable good clinical results. Previous splenectomy strongly predicts shunt dysfunction.

Outcomes of Left Renal Vein Stenting in Patients with Nutcracker Syndrome

Nutcracker syndrome (NCS) is a rare condition that can present with hematuria, flank pain, pelvic varicosities, or chronic pelvic congestion related to left renal vein (LRV) compression. Open surgery, specifically LRV transposition, has been the mainstay of treatment, but during the past few years, LRV stenting has emerged as a valid alternative without sufficient evidence to support it. This study aimed to assess outcomes of renal vein stenting in the treatment of NCS. A retrospective chart review of patients with NCS who underwent LRV stenting between 2010 and 2018 was performed. End points were perioperative adverse outcomes, symptom relief, and stent patency. Symptom resolution was classified as complete, partial, and none on the basis of the interpretation of medical records on clinical follow-up. Standard descriptive statistics and survival analysis were used. Seventeen patients (16 female; mean age, 35.8 ± 14.6 years; mean body mass index, 21.3 ± 4.1 kg/m2) diagnosed with NCS and treated with LRV stenting were identified. Five of these had a prior LRV transposition that had failed within a mean of 7.0 ± 4.9 months. Ten patients had coexisting pelvic congestion syndrome treated with gonadal vein embolization. The most frequent sign and symptom were hematuria (9/17 patients) and flank pain (14/17 patients), respectively. All patients received self-expanding stents (mean diameter, 12.7 ± 1.6 mm), the smaller ones typically placed in the previously transposed LRVs. No perioperative complications occurred. Eight patients were discharged on the same day; the remaining stayed longer for pain control (mean hospital stay, 1.0 ± 1.3 days). At an average follow-up of 33 ± 25 months, 13 (76.5%) patients had symptom relief (9 complete, 4 partial). Three of the four patients whose symptoms persisted had previous LRV transposition surgery. Five of nine patients who presented with hematuria had it resolved. Three patients underwent a reintervention. Two of these had successful balloon venoplasty for restenosis. The third patient had persistent debilitating pain despite a patent stent and eventually underwent renal auto transplantation with no symptom relief. Two-year primary and primary assisted patencies were 81.8% and 90%, respectively. No stent migration occurred. Endovascular treatment with renal vein stenting is safe and effective, providing good midterm patency rates and symptom relief. Minimally invasive approaches may have a potential role in the treatment of NCS. Larger series and longer follow-up are needed to better assess its comparative performance against LRV transposition.

Left-Sided Complete Revascularization With Bilateral Internal Thoracic Arteries in Patients With Diabetes

Reports are few on the long-term patency of bilateral internal thoracic artery (BITA) grafts in patients with diabetes. We evaluated the relationship between the long-term patency of BITAs and the clinical outcomes in diabetes. We retrospectively identified 569 patients (321 with diabetes, 248 without diabetes) who underwent isolated BITA grafting for left-sided complete revascularization at our institution from 2000 to 2015. The primary end point was the incidence of major adverse cardiovascular events comprising death, re-revascularization, and myocardial infarction. The secondary end point was the patency of the BITAs. No differences were found in the major adverse cardiovascular event rate (10-year: diabetic group, 33.7%; nondiabetic group, 22.3%; p= 0.15) or overall mortality rate (24.0% versus 12.2%, p= 0.066) between the patients with and without diabetes. The incidence of cardiac death (3.3% versus 1.8%, p= 0.80) or re-revascularization and myocardial infarction (11.4% versus 11.8%, p= 0.67) was similar between the groups. The patency of free internal thoracic artery (ITA) grafts to the left circumflex artery was associated with greater patency in patients with diabetes than in patients without diabetes (4 years: 99.3% versus 95.5%, p= 0.049); the patency of other ITA grafts did not differ between the groups. All-cause death, re-revascularization, and myocardial infarction showed no differences between patients with and without diabetes who underwent left-sided revascularization with the BITAs. Although diabetes did not affect the patency of the ITA, free ITA grafts to the left circumflex artery showed good long-term patency in patients with diabetes.

The long-term patency of a gastroepiploic artery bypass graft deployed in a semiskeletonized fashion: predictors of patency.

Whether or not using the gastroepiploic artery (GEA) is associated with improved outcomes of coronary artery bypass grafting (CABG) remains unclear. Previous research has shown that the short-term function of the GEA was strongly associated with the degree of native vessel stenosis. We assessed the association between long-term GEA patency and the degree of stenosis of the coronary artery. We retrospectively examined 517 patients who underwent CABG with an in situ semiskeletonized GEA from January 2000 to January 2015. In this cohort, 282 (54.5%) patients underwent distant radiological evaluations for >1 year post-surgery (range 1-18 years after surgery). Quantitative coronary angiography was used to measure the degree of stenosis of the native coronary artery. Preoperative angiographic parameters include the minimal lumen diameter (MLD) and the percentage of target vessel stenosis. A multivariable stepwise Cox proportional hazards regression analysis was used to identify predictors of angiographic occlusion. The cumulative patency rate of the GEA was 79.3% at 10 years. A multivariable analysis showed that an MLD (hazard ratio 4.43, 95% confidence interval 3.25-6.82; P < 0.001) was an independent risk factor of GEA occlusion. A time-dependent receiver operating characteristic (ROC) curve analysis identified that an MLD >1 mm was set as the cut-off value for graft occlusion. Patients with an MLD <1 mm had a 10-year patency rate of 89.8%. The long-term patency of the semiskeletonized GEA was acceptable. The target vessel MLD obtained using quantitative coronary angiography was a strong predictor of patency. Good long-term patency can be expected for an MLD <1 mm.

Percutaneous Antegrade and Retrograde Endovascular approach to Symptomatic High-Grade Subclavian Artery Stenosis: Technique and Follow-Up.

Background and Purpose:Angioplasty and stenting of the subclavian artery have been reported with high technical and clinical success rates, low complication rates, and good midterm patency rates. Different antegrade or retrograde endovascular catheter-based approaches are used. Nowadays, endovascular therapy has taken over open surgical techniques in subclavian artery disease. The purpose of this study was to determine safety, efficacy, and midterm clinical and radiological outcome of the endovascular treatment with special focus on the different technical approaches in subclavian artery disease.Materials and Methods:Between 2014 and 2017, 11 patients (10 men, 1 woman) with symptomatic high-grade stenosis (90%–100%) of the subclavian artery were treated with endovascular treatment. Their mean age was 51.3 years (range, 32-61 years). Mean angiographic and clinical follow-up was 22.5 months (range, 5-44 months). Clinical follow-up was performed at hospital discharge and routine follow-up was performed at 1, 3, 12 months, and 6 monthly thereafter. In all 11 patients, a percutaneous approach was used successfully. In eight patients, the lesions were accessed retrogradely through a brachial artery puncture.Results:Acute success rate was 100%. There were no significant peri-procedure complications. At the latest clinical follow-up (mean of 22.5 months), all patients showed a good outcome with a restenosis rate of 18.2% including a patient with Takayasu arteritis.Conclusion:Percutaneous antegrade and retrograde stenting of high-grade subclavian artery stenosis is a viable less invasive alternative to open bypass surgery with good midterm clinical results and patency rates.

Pentobarbital-induced sleep upregulates the survival p-FADD/FADD ratio in mouse brain cortex

The aim was to evaluate the outcomes of endovascular treatment with bare stents alone versus stent assisted coiling in isolated mesenteric artery dissection (IMAD) aneurysms.Patients with an IMAD aneurysm who underwent endovascular stenting between February 2010 and February 2017 at one of three institutions were included in this study. Data regarding technical success, procedure time, symptom resolution, complications, changes in IMAD aneurysm, and stent patency were recorded.A total of 38 patients (35 men) were included, 27 treated with bare stents alone and 11 treated with stent assisted coiling. Technical success was achieved in 100% of patients treated with bare stents and in 81.8% of those treated with stent assisted coiling (p = 0.078). The mean procedure times were 62.6 ± 5.3 min for treatment with bare stents and 116.4 ± 8.4 min for stent assisted coiling (p < 0.001). A total of 23 patients had persistent symptoms before stenting; all symptoms were resolved within 3.0 ± 0.7 days. No procedure related major complications occurred. Over 30.2 ± 18.1 months of follow up, complete resolution of the IMAD aneurysm was achieved in all patients; good stent patency and in stent re-stenosis were achieved in 65.8% and 34.2% patients, respectively. There were no occlusions of the stented arteries.Bare stents alone and stent assisted coiling have high technical success rates and demonstrate good intermediate patency in patients with an IMAD aneurysm. Bare stents alone may serve as an alternative to stent assisted coiling for the management of IMAD aneurysm

Femoropopliteal bypass for chronic lower limb ischemia: A prospective cohort study and single center cases series

BackgroundPeripheral occlusive arterial disease (POAD) is a steadily increasing global epidemic. Femoropopliteal bypass (FPB) is the traditional therapeutic option whenever endovascular treatments failed or not indicated. We present our experience in lower limb revascularization. Patients and methodsProspective observational cohort single center study included 158 patients with intermittent claudication (IC) or critical limb ischemia (CLI). The patients were placed in 7 Rutherford categories & their angiographic findings were graded according to Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) criteria. The ipsilateral great saphenous vein was used for revascularization. Resultsmale patients were 113 (71.5%); female were 45 (28.5%). Age ranged from 39 to 77 years, with a mean of 60.7 ± 7.8 years. About 79.1% of patients were in the 6th & 7th decades. Only 26 patients (16.5%) had severe IC & 83.5% had CLI. Almost all patients with Rutherford category 3–6 had an ankle brachial index (ABI) less than 0.70. Most Femoropopliteal lesions (n = 115, 72.8%)near half infrapopliteal lesions (n = 74, 46.8%) were of TASC II B & C types. Majority of patients received a vein graft. Distally, 100 grafts (66.7%) were sutured below the knees whereas the remainder were either behind (n = 31) or above the knees (n = 8). The follow up ranged from 1 month to 11 years. One & 5 year patency rates of vein grafts were 88.7% & 70.2% respectively. ConclusionsFPB using saphenous graft yield a very good graft patency, low rates of amputation, morbidity and mortality. Long-term patency is excellent.

Brachio- Axillary Translocation Fistula with Reverse Saphenous Venous Graft: a New Hope for the Patients of End stage Renal Disease

Native arterio-venous fistula (AVF) are the preferred mode of repeated vascular access for the chronic renal failure patients surviving on hemodialysis because of their easy accessibility, good long term patency, low complication rate and cost-effectiveness. Creation of a fistula between the radial or brachial artery and a suitable adjacent vein is the most commonly practiced option. However the major upper arm veins of the CKD patients are often found thrombosed, cord like and not suitable for AV anastomosis. A 48 years old male patient of chronic kidney disease with a permanent catheter placed in the right subclavian vein was referred to create an AV fistula. On exploration none of the upper limb veins was found suitable for fistula formation. The proximal part of the left GSV was harvested from patient’s left upper thigh and was used to make a connection between left brachial artery at cubital fossa and the left axillary vein. To avoid over flooding of the limb vasculature, partial banding of the left axillary vein was done distal to this anastomosis. When all options in both upper limbs are exhausted, autologous great saphenous grafts may be a very useful tool for the surgeons in creating upper limb AV fistulas in difficult situations&#x0D; Bangladesh Heart Journal 2018; 33(2) : 134-137

Meta-analysis of Individual Patient Data After Kissing Stent Treatment for Aortoiliac Occlusive Disease

Purpose: To evaluate short- and long-term technical and clinical outcomes after kissing stent treatment of aortoiliac occlusive disease (AIOD) based on an individual participant data (IPD) meta-analysis. Materials and Methods: A search of the Scopus database identified 156 articles on KS treatment of AIOD; of these 22 met the inclusion criteria. Authors of 19 articles with contact information were approached to join an IPD consortium. Eight author groups responded and 5 provided anonymized data for merging into an IPD database. The number of included procedures was equal before and after 2005. The primary study outcome was the cumulative patency at 24 months. Secondary outcomes were patency at up to 60 months, complications, and changes in Rutherford category and ankle-brachial index. The predictive value of stent protrusion length, pre-/postdilation, stent type, and patient demographics on primary patency were examined with Cox proportional hazard modeling; outcomes are reported as the hazard ratio (HR). The Kaplan-Meier method was employed to estimate patency rates. Results: In total, 605 (40.9%) of 1480 patients presented in the literature were included in the IPD analysis. The indication for intervention was intermittent claudication in 84.2% and critical limb ischemia in 15.8%. Lesions were classified as TransAtlantic Inter-Society Consensus (TASC) A or B in 52.8% and TASC C and D in 47.2%. The overall primary patency estimate was 81% at 24 months. Primary patency significantly increased after 2005 (p=0.005). Cox regression analysis revealed only age as a significant predictor of sustained primary patency (HR 0.60, p<0.005). Any previous endovascular intervention (HR 2.52, p=0.02) was the main predictor for loss of secondary patency; history of cardiovascular disease (HR 0.27, p=0.04) was the main predictor of sustained secondary patency. Conclusion: The kissing stent technique has a good safety profile and acceptable patency rates up to 2 years, even in TASC C and D lesions, supporting an endovascular-first approach for AIOD.

Infrainguinal inflow assessment and endovenous stent placement in iliofemoral post-thrombotic obstructions

PurposeTo assess the technical success, patency, and clinical outcome, following assessment of inflow and infrainguinal endovenous stent placement in patients with iliofemoral post-thrombotic obstruction with infrainguinal involvement.MethodsA retrospective analysis of 39 patients with iliofemoral post-thrombotic venous obstruction accepted for infrainguinal stent placement in the period November 2009–December 2016. The clinical status was categorized according to the Clinical Etiological Anatomical Pathophysiological (CEAP) classification and symptom severity was assessed using Venous Clinical Severity Score (VCSS). The inflow was categorized as “good”, “fair”, or “poor” depending on vein caliber and extent of post-thrombotic changes in the inflow vessel(s). Stent patency was assessed by duplex ultrasound. Median follow-up was 44 months (range 2–90 months).ResultsStent placement was successful in all 39 patients. Primary patency after 24 months was 78%. Thirty of 39 patients (77%) had open stents at final follow-up. Re-interventions were performed in four patients and included catheter-directed thrombolysis (CDT) in all and adjunctive stenting in two. Twenty-eight of 39 patients (72%) reported a sustained clinical improvement. Patients with “good” inflow had better patency compared to those with “fair”/“poor” (p = 0.01). One patient experienced acute contralateral iliofemoral thrombosis; this segment was successfully treated with CDT and stenting. No other complications required intervention.ConclusionInfrainguinal endovenous stent placement was a feasible and safe treatment with good patency and clinical results, and should be considered in patients with substantial symptoms from post-thrombotic obstructions with infrainguinal involvement. Stents with good inflow have better patency and inflow assessment is essential in deciding the optimal stent landing zone.