Graft Occlusion Rate Research Articles

Sarcopenia in Patients Undergoing Lower Limb Bypass Surgery is Associated with Higher Mortality and Major Amputation Rates

BackgroundSarcopenia is adversely associated with survival in several diseases. Vasculopathy is often associated with multimorbidity and consequent deconditioning with poor long-term outcomes. This study examined the impact of sarcopenia on clinical outcome in patients with and without critical limb-threatening ischaemia who underwent infrainguinal bypass surgery. MethodsAll patients undergoing infra-inguinal surgical revascularisation in 2016–2018 were retrospectively reviewed. Sarcopenia was defined as a skeletal muscle area at the L3 vertebral level (defined as L3 muscle area < 114cm2 for men or <89.8cm2 for women) on CT angiography. The primary outcome was overall survival by analysed by time to event analysis. Secondary outcomes included ipsilateral major lower-limb amputation, length of hospital stay, myocardial infarction and surgical-site infection. ResultsA total of 116 patients with a mean age of 66.9 years were included, with a mean follow-up of 21 months. 14 (12%) of patients were sarcopenic; there were more patients with diabetes (40% vs 7%) in the sarcopenic group, p=0.018. Age, gender, Rutherford grade at presentation, other co-morbidities, other laboratory tests, conduit material and Rutherford grade at presentation were similar in those with and without sarcopenia and were statistically insignificant upon testing.Overall survival was worse for sarcopenic patients (Log Rank P=0.001) and Hazard Ratio for death 5.8; 95%CI 1.8–19.1; P=0.001. Major lower-limb amputation occurred more frequently in patients with sarcopenia (7/14 [50%] vs 23/102 [23%]; P=0.046). There was no difference in other secondary outcomes including rates of graft occlusion, myocardial infarction, surgical site infection and length of stay.Adding SMA measurement to a multivariate generalised linear model including age, sex, diabetes, and haemoglobin improved the AUROC from 0.75–0.85. ConclusionIn this cohort of patients undergoing vascular surgery, sarcopenia defined using L3 muscle area was significantly associated with overall mortality and major lower-limb amputation.

Angiographic Patency of Coronary Artery Bypass Conduits: A Network Meta-Analysis of Randomized Trials.

BackgroundSeveral randomized trials have compared the patency of coronary artery bypass conduits. All of the published studies, however, have performed pairwise comparisons and a comprehensive evaluation of the patency rates of all conduits has yet to be published. We set out to investigate the angiographic patency rates of all conduits used in coronary bypass surgery by performing a network meta‐analysis of the current available randomized evidence.Methods and ResultsA systematic literature search was conducted for randomized controlled trials comparing the angiographic patency rate of the conventionally harvested saphenous vein, the no‐touch saphenous vein, the radial artery (RA), the right internal thoracic artery, or the gastroepiploic artery. The primary outcome was graft occlusion. A total of 4160 studies were retrieved of which 14 were included with 3651 grafts analyzed. The weighted mean angiographic follow‐up was 5.1 years. Compared with the conventionally harvested saphenous vein, both the RA (incidence rate ratio [IRR] 0.54; 95% CI, 0.35–0.82) and the no‐touch saphenous vein (IRR 0.55; 95% CI, 0.39–0.78) were associated with lower graft occlusion. The RA ranked as the best conduit (rank score for RA 0.87 versus 0.85 for no‐touch saphenous vein, 0.23 for right internal thoracic artery, 0.29 for gastroepiploic artery, and 0.25 for the conventionally harvested saphenous vein).ConclusionsCompared with the conventionally harvested saphenous vein, only the RA and no‐touch saphenous vein grafts are associated with significantly lower graft occlusion rates. The RA ranks as the best conduit.RegistrationURL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42020164492.

Relation between functional coronary artery stenosis and graft occlusion after coronary artery bypass grafting

ObjectivesThis study was conducted to evaluate graft patency rates during the 5 years after coronary artery bypass grafting according to the functional significance of the coronary artery stenosis, as determined by myocardial single-photon-emission computed tomography. MethodsTwo hundred ninety-five patients who underwent coronary artery bypass grafting using Y-composite grafts based on the in situ left internal thoracic artery, and in whom preoperative stress/rest myocardial single-photon-emission computed tomography and 1-year angiographies were available were enrolled. Seven hundred sixty-nine and 262 distal anastomoses were constructed to ischemic and nonischemic areas, respectively. One-year and 5-year angiographic occlusion rates were evaluated in all and 80.3% of study patients, respectively. Factors associated with graft occlusion were evaluated using generalized linear mixed-effects models. ResultsOverall 1- and 5-year graft occlusion rates were 4.3% (44 of 1031 distal anastomoses) and 5.5% (45 out of 820), respectively. The occlusion rates of grafts bypassed to vessels with functionally significant and insignificant stenosis were 2.7% (21 out of 769) and 8.8% (23 out of 262) at 1 year and were 4.0% (25 out of 618) and 9.9% (20 out of 202) at 5 years, respectively. Graft occlusion during the 5 years after coronary artery bypass grafting was associated with the functional significance of coronary artery stenosis (odds ratio, 0.50; 95% confidence interval, 0.28-0.92). The odds ratio of the graft occlusion according to functional ischemia was lower and significant in grafts to arteries with intermediate stenosis (stenosis ≥70% but <90%; odds ratio, 0.34; 95% confidence interval, 0.13-0.93) whereas it was higher and insignificant in grafts to arteries with severe stenosis (≥90% stenosis; odds ratio, 0.76; 95% confidence interval, 0.33-1.72). ConclusionsGraft occlusion during the 5 years after coronary artery bypass grafting was associated with the functional significance of coronary artery stenosis, particularly when the stenosis degree was not severe.

Right gastroepiploic artery versus right internal thoracic artery composite grafts: 10-year patency and long-term outcomes

ObjectivesWe compared the 10-year graft occlusion rates and long-term clinical outcomes of right gastroepiploic artery (RGEA) composite grafts with those of right internal thoracic artery (RITA) composite grafts. MethodsFrom 2000 to 2008, 548 patients had undergone total arterial revascularization for multivessel coronary artery disease using the RGEA (RGEA group; n = 389) or RITA (RITA group; n = 159) as a second-limb Y-composite graft based on the in situ left ITA. A propensity score-matched analysis was used to match the RGEA group (n = 152) with the RITA group (n = 152). The 10-year angiographic occlusion rates and long-term clinical outcomes were compared. The follow-up data were complete for all 304 patients (100%) with a median follow-up of 143.7 months. ResultsThe early clinical outcomes were similar between the matched groups. The overall graft occlusion rate was 9.5% at 10 years in the matched group patients (matched RGEA and RITA groups, 10.3% and 8.4%, respectively; P = .639). The 10-year occlusion rates of the second-limb conduits showed no differences between the matched RGEA and RITA groups (14.1% and 10.2%, respectively; P = .487). No statistically significant differences were found at 15 years postoperatively in the overall survival (52.9% vs 49.4%; P = .470), cardiac mortality-free survival (92.1% vs 90.9%; P = .560), freedom from target vessel revascularization (83.0% vs 91.4%; P = .230), freedom from reintervention (68.8% vs 76.2%; P = .731), or freedom from major adverse cardiac and cerebrovascular events (56.4% vs 64.6%; P = .364) rates between the matched groups. ConclusionsTotal arterial revascularization using RGEA composite grafts showed comparable results to those using RITA composite grafts in terms of the 10-year occlusion rates and long-term clinical outcomes.

Outcomes of Endovascular Aneurysm Repair Using the Anaconda Stent-Graft

Purpose: To report outcomes of elective endovascular aneurysm repair (EVAR) using the Anaconda stent-graft in a tertiary vascular center. Materials and Methods: A retrospective study was conducted of 271 patients (mean age 71.5 years; 260 men) who underwent elective EVAR for abdominal aortic aneurysm using the Anaconda stent-graft from January 2006 to January 2017. Median aneurysm diameter was 58 mm (range 50–90). All patients were anatomically suitable for EVAR according to the 2003 version of the instructions for use. Follow-up included computed tomography angiography at 1, 6, and 12 months and yearly thereafter for the first 4 years and then every 2 years. Primary outcomes included technical success and 30-day aneurysm-related mortality and complications; secondary outcomes were overall and aneurysm-related mortality and aneurysm-related morbidity in follow-up. Results: The Anaconda stent-graft was implanted successfully in all patients. Primary and secondary technical success rates were 99.6% and 100%, respectively. Three patients (1.1%) died within 30 days of causes unrelated to the aneurysm, while 15 patients (5.5%) suffered perioperative complications. Median follow-up was 72 months (range 14–141). The overall type I endoleak rate was 4.7% (11 proximal, 2 distal). Late aneurysm-related complications were observed in 48 patients (17.3%); aneurysm-related mortality was 1.4% (n=4). Non-aneurysm-related mortality was 21.0% (n=57). Freedom from reintervention was 95.2% at 1 year, 98% at 2 years, and 90% at 6 years. There was no significant difference in the overall limb graft occlusion rate between the second- and third-generation devices. Conclusion: Results in our cohort study demonstrate that the Anaconda stent-graft has satisfactory early and late results with low aneurysm-related mortality.

Systematic Review and Meta: Analysis of Aortic Graft Infections following Abdominal Aortic Aneurysm Repair.

Introduction. Aortic graft infection (AGI) is a rare complication following AAA repair and is associated with high morbidity and mortality. Management is variable, and there are no evidence-based guidelines. The aim of this study was to systematically review and analyse management options for AGI. Methods Data was collected between July and August 2018. A full HDAS search was conducted on the following databases: MEDLINE, EMBASE, CINAHL, and PUBMED. Meta-analysis was conducted using RevMan 5 software. Results 1,365 patient outcomes were assessed (10 cohort studies and 12 comparative studies). The most common treatment was in situ replacement of the graft (ISR) followed by extra-anatomical replacement (EAR). Various grafts were used for ISR, such as fresh/cryopreserved allograft, venous graft, and prosthetic grafts. No graft material was shown to be superior. Axillobifemoral graft was the commonest type of EAR used. In the majority of cohort studies, ISR was the main treatment for AGI. There was no significant difference in the overall mortality rate (ISR n = 70/176 vs. EAR n = 70/176 vs. EAR P = 0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group (n = 70/176 vs. EAR n = 70/176 vs. EAR P = 0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group (n = 70/176 vs. EAR n = 70/176 vs. EAR P = 0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group (Discussion. In situ replacement is the preferred method of treatment as it had lower rates of occlusion. Further strong evidence is required, such as a multicentre trial to establish a management pathway for the condition.

Late outcomes of different hypogastric stent grafts in aortoiliac endografting with iliac branch device: Results from the pELVIS Registry

ObjectiveThe objective of this study was to evaluate long-term results of self-expanding vs balloon-expandable hypogastric stent grafts in conjunction with iliac branch devices (IBDs) for aortoiliac aneurysm repair in a multicenter experience (pErformance of iLiac branch deVIces for aneurysmS involving the iliac bifurcation [pELVIS] Registry). MethodsAll patients electively treated for aortoiliac aneurysm with the Cook IBD (Cook Medical, Bloomington, Ind) in nine European centers were reviewed. Clinical and imaging data were prospectively collected in each center, and a multicenter database was created and interrogated. The primary outcome was the primary patency of the IBDs. For the purpose of this investigation, three subgroups were identified: patients receiving a hypogastric balloon-expandable stent graft (BESg); those with a self-expanding stent graft (SESg); and those with any stent graft plus relining with a bare-metal stent (RESg). ResultsBetween 2005 and 2017, there were 691 patients who underwent 747 elective endovascular repairs of aortoiliac aneurysms (n = 518 [75.0%]) or isolated iliac aneurysms (n = 173 [25.0%]) with Cook IBDs (n = 56 bilateral) in nine European centers. Mean age was 72 years (range, 41-93 years); 658 (95.2%) patients were male. In 364 patients (52.7%), BESg was used; in 127 (18.4%), SESg; and in 200 (28.9%), RESg. At 30 days, there were 3 (0.4%) perioperative deaths, 3 (0.4%) technical failures, 7 (1.0%) graft thromboses, 30 (4.3%) reinterventions, and 1 (0.1%) conversion to open repair. After a mean follow-up of 32 months (range, 0-128 months), 28 (3.7%) IBD occlusions and 17 (2.3%) IBD-related endoleaks occurred. In 10 patients, iliac diameter increased >5 mm (1.4%). Overall primary patency was 99.2% at 1 month, 97.9% at 12 months, and 95.1% at 72 months. Primary patency was not significantly different in the BESg vs SESg or RESg cohorts (P = .4). During follow-up, there were 126 (18.2%) reinterventions, 93 (13.5%) of which were IBD related, including 11 (1.6%) conversions. Overall, freedom from reintervention and conversion was 90.4% at 12 months and 71.0% at 72 months. IBD-related reinterventions during follow-up in the three cohorts were not significantly different (P = .3) Overall survival was 71.3% at 72 months without differences between the subgroups. At multivariate analysis, aneurysmal hypogastric artery (P < .001; Exp [B] = 4.44) and bilateral treatment (P = .02; Exp [B] = 1.87) were associated with an increase in late failure. ConclusionsIn this wide real-world experience, long-term results of endovascular treatment of aortoiliac aneurysms with the IBD are favorable, with a low rate of late graft occlusion and aneurysm-related death. No significant differences in clinical outcomes were observed in patients receiving hypogastric BESg vs SESg or endovascular relining.

Endograft Device type is a Significant Risk Factor for Limb Graft Occlusion After Endovascular Aortic Repair of Infrarenal Abdominal Aortic Aneurysm

Introduction: Limb graft occlusion (LGO) is an uncommon yet serious complication after EndoVascular Aortic Repair (EVAR). It is reportedly influenced by several patient-specific anatomical variables. In a rapidly developing field of new vascular devices and an overall tendency toward endovascular treatment of complex aortic cases, minimising complications becomes increasingly important. Albeit worldwide clinical usage, there is still a lack of long-term follow-up data for many “second generation” endograft types. Our objective was to identify factors associated with LGO after EVAR. Methods: Between 2013-2018, all patients undergoing standard EVAR for infrarenal aortic aneurysms at two high-volume Vascular referral centers were included in this study. Cases treated with fenestrated or branched endografts were excluded. Patients were identified through a national registry for Vascular Surgery and all pertinent data was retrospectively collected from patient electronic medical records. LGO was defined as a symptomatic total limb occlusion requiring intervention. Results: Mean age at primary intervention for the 639 patients included was 75.3 years and 85.5% were men. Three graft manufacturers were predominantly used; Medtronic Endurant (n=274), Cook Zenith (n=243) and Gore Excluder (n=122). All grafts were bifurcated and the majority were deployed in an elective setting (77.5%). Median follow-up time for respective groups was 52, 21 and 25 months. A total of 29 patients presented with LGO (4.5%); 8 patients treated with Medtronic (2.9%), 19 with Cook (7.8%) and 2 with Gore (1.6%). Cox proportional hazard regression models were used to estimate multivariable hazard ratios (HR) with 95% confidence intervals (95% CI) of LGO during follow up. The multivariable HR of LGO was increased more than 6-fold in the Cook Zenith group, compared with Medtronic Endurant (HR, 6.14; 95% CI, 2.29 - 16.44), and Gore (HR 7.10; 95% CI, 1.55 - 32.57) respectively. There was no significant difference in rate of LGO when comparing Gore with Medtronic (HR, 0.87; 95% CI, 0.18-4.26). The observed point estimates in univariable models did not differ from those observed after adjustment for potential confounders in multivariable models. We observed no difference in rate of all cause mortality between the three groups. Conclusion: In this study, endograft device type was identified as an independent risk factor for LGO after EVAR. Specifically, limbs in the Cook Zenith endografts were observed to occlude at a 6 times higher rate compared with the Medtronic Endurant or Gore Excluder devices. [Rate of Limb Graft Occlusion] Disclosure: Nothing to disclose

Efficacy of Balloon Angioplasty for Infrainguinal Vein Graft Stenosis

Vein graft stenosis is a critical complication of lower-limb bypass surgery. For vein graft stenosis, balloon angioplasty has been performed instead of surgical revision in recent years. We therefore investigated the effectiveness of the balloon angioplasty for vein graft stenosis. We conducted a retrospective analysis of prospectively collected data for 115 vein graft stenoses performed via balloon angioplasty from August 2011 to January 2018. The rate of freedom from reintervention after balloon angioplasty was 54.3%, 44.4%, and 38.0% at 1, 2, and 3years, respectively. The rate of freedom from graft occlusion after balloon angioplasty was 79.9%, 71.9%, and 61.3% at 1, 2, and 3years, respectively. Predictors of freedom from graft occlusion after balloon angioplasty by a multivariate analysis were a single treated lesion (hazard ratio [HR]: 0.38; 95% confidence interval [CI]: 0.17-0.85; P=0.0189), balloon angioplasty within 90days after bypass surgery (HR: 3.59; 95% CI: 1.56-8.07; P=0.0033), and using a cutting balloon (HR: 0.42; 95% CI: 0.17-0.97; P=0.0426). The freedom from graft occlusion rate after balloon angioplasty remained relatively high. Furthermore, better results can be expected in single treated lesions and cases of balloon angioplasty occurring 90days after bypass surgery or in which a cutting balloon was used. Balloon angioplasty for lower-limb bypass graft stenosis was shown to be a useful treatment.

Cryopreserved Allografts for Treatment of Chronic Limb-Threatening Ischemia in Patients Without Autologous Saphenous Veins

Revascularization is the best alternative to reduce symptoms and to improve the limb salvage rate in patients with chronic limb-threatening ischemia (CLI). Alternative grafts as synthetic prostheses and allografts must be considered for patients without a suitable autologous graft. Our aim was to evaluate outcomes of cryopreserved allografts used as a vascular conduit for bypass surgery in the infrainguinal territory. A retrospective analysis (January 1995 to January 2014) of the Registry of vascular and valvular allografts transplant in the autonomous community of Catalonia, Spain was performed for identifying patients with CLI who required infrainguinal bypass with cryopreserved arterial allografts. Statistical analysis was performed using SPSS, ver. 20, for Mac (Chicago). A total of 149 patients with CLI (mean age of 70.1years) were analyzed. One hundred two patients (68.5%) had a grade IV lesion (Fontaine classification). In the overall follow-up, 24.8% of patients required a reintervention. Overall graft occlusion, infection, and dilation rate were 52.3%, 6%, and 5.4% respectively. Overall 30-day mortality was 0.7%. Five-year primary patency rate and limb salvage rate were 38.6% and 50.2%, respectively. Survival rate at 5years was 54.2%. Major adverse limb event (MALE)-free rate was 21.5% at 5years. Revascularization to a distal target vessel was an independent positive predictive risk factor for a lower limb salvage rate and lower primary patency rate. Dyslipidemia was related to a lower limb salvage rate and represents a risk factor involved in MALEs. Although arterial allografts seem to represent a suboptimal alternative, some selected patients could beneficiate from them. Five-year results are disappointing, and more studies are required to know other predictive factors for better selection of patients.

Infrainguinal Bypass Following Failed Endovascular Intervention Compared With Primary Bypass: A Systematic Review and Meta-Analysis

Patients with infrainguinal peripheral arterial disease often undergo multiple revascularisation procedures. Although many centres have adopted an endovascular first approach, some are reluctant to do so for fear of compromising the outcomes of any subsequent bypasses. All studies that compared the outcomes of primary infrainguinal bypass with bypass after failed endovascular intervention were analysed. A systematic review was conducted of MEDLINE, EMBASE, and CENTRAL databases for studies comparing outcomes of primary infrainguinal bypass with bypass after failed endovascular intervention for peripheral arterial disease. Abstracts and full text studies were screened independently by two reviewers with data abstraction done in duplicate. Dichotomous outcome measures were reported using the OR and 95% CI, and pooled using random effects models. Abstracts were screened (2,528), with 50 selected for full text review. Of these, 15 studies involving 11,886 patients met the inclusion criteria. Pooling the results of studies comparing primary bypass with bypass after failed endovascular intervention showed no significant difference in 30 day mortality (OR 1.00; 95% CI 0.65–1.54), or 30 day amputation rates (OR 1.26; 95% CI 0.95–1.65). Interestingly, one year amputation free survival was higher in the patients who had primary bypass (OR 1.30; 95% CI 1.10–1.52) compared with patients who had bypass after failed endovascular therapy. There was also worse one year primary patency (OR 1.65; 95% CI 1.04–2.62) for patients with prior failed endovascular intervention. The review demonstrated a trend towards higher rates of early graft occlusion (OR 4.54; 95% CI 0.97–21.28). Meta-analysis of the existing literature comparing primary bypass with bypass following failed endovascular intervention shows worse one year amputation free survival and worse primary patency in those patients who undergo bypass after failed endovascular intervention. There is also a trend towards higher rates of early graft occlusion, although these results were not statistically significant. These conclusions are limited by observational study design, inconsistent patient selection, and significant heterogeneity between studies.

NESVS10. Outcomes of Lower Extremity Bypass After Failed Endovascular or Open Revascularization Are Inferior to Bypasses Without Prior Intervention

Outcomes of lower extremity bypass (LEB) after failed lower extremity interventions have almost exclusively been studied in the short term, and the role of changes in runoff remains unclear. The goal of this study was to assess long-term outcomes of LEB after failed endovascular (peripheral vascular intervention [PVI]) or open (bypass graft [BPG]) revascularization and to determine the effect of PVI on distal bypass targets. Patients who underwent infrainguinal LEB for critical limb ischemia between 2010 and 2017 at our institution were included. Patients were stratified into three cohorts based on prior intervention: PVI, BPG, and none. Primary end points were major amputation, graft patency, and amputation-free survival (AFS). Univariate analysis was performed, and predictors of AFS were determined. In 148 patients, 160 procedures were stratified by previous intervention: 74 (46%) PVI, 25 (16%) BPG, and 61 (38%) none. Most patients were male (71%) and diabetic (56%). BPG patients were more likely to have compromised conduit (80%; P = .03), whereas PVI patients were more likely to be diabetic (68%; P = .01); 75% of LEB patients had a below-the-knee distal target, and there were no differences in above-knee vs below-knee targets between the cohorts (P = .15). There were no differences in 30-day complications. Overall major ipsilateral amputation rate was 14%. The none cohort had higher overall freedom from amputation (P = .045). The BPG cohort had decreased rates of primary patency (P = .03) and higher rates of graft occlusion (P = .03). The none cohort had better survival at 1 year and 2 years (85% and 79%). There was no difference in long-term AFS (5 years, 46%; P = .228). End-stage renal disease and conduit were negative predictors of AFS (P < .01). The number of prior PVIs did not affect 30-day or long-term outcomes. After PVI, 41 (55%) had either a runoff or distal target change at LEB. Patients who undergo LEB without prior intervention have better graft patency and amputation outcomes, but the demonstrated benefit for AFS is short-lived. More than half of patients who underwent PVI before LEB had either runoff or distal target change, which may be a contributor to the differences seen in graft patency and amputation outcomes.

Study Design of the Graft Patency After FFR-Guided Versus Angiography-Guided CABG Trial (GRAFFITI).

NCT01810224.

Saphenous vein versus right internal thoracic artery as a Y-composite graft: Five-year angiographic and clinical results of a randomized trial

ObjectivesWe compared the 5-year graft occlusion rates and midterm clinical outcomes of saphenous vein composite grafts with those of right internal thoracic artery composite grafts in patients who were enrolled in the SAphenous VEin versus Right Internal Thoracic Artery as a Y-Composite Graft trial. MethodsOf 224 eligible patients with multivessel coronary artery disease who were randomized to undergo off-pump revascularization using the saphenous vein (saphenous vein group, n = 112) or right internal thoracic artery (right internal thoracic artery group, n = 112) as Y-composite grafts based on the in situ left internal thoracic artery from September 2008 to October 2011, 219 patients (saphenous vein group, n = 109; right internal thoracic artery group, n = 110) entered the analysis. A third limb conduit to lengthen the graft limb for complete revascularization was used in 47 patients (saphenous vein group vs right internal thoracic artery group, 8 vs 39). Postoperative 5-year (61.7 ± 5.2 months) angiograms were performed in 186 patients (84.9%; saphenous vein group = 95; right internal thoracic artery group = 91). Follow-up was complete in 97.7% (214/219) of patients with a median follow-up of 80.7 months. ResultsThe overall graft occlusion rate was 3.6% at 5 years (3.5% in the saphenous vein group vs 3.7% in the right internal thoracic artery group, P = .910). The 5-year occlusion rate of the second limb conduits in the saphenous vein group was 4.3% and was noninferior to that of the right internal thoracic artery group (2.4%) within the 95% 2-sided confidence interval of −1.4% to 5.2% (P < .001 for noninferiority). No statistically significant differences were found in the overall survival (P = .439) and the freedom from major adverse cardiac and cerebrovascular event rates (P = .354) at 5 and 8 years between the 2 groups. ConclusionsThe saphenous vein composite grafts were noninferior to the right internal thoracic artery composite grafts in terms of 5-year graft occlusion rates and midterm clinical outcomes.

Differential Impact of Serial Measurement of Nonplatelet Thromboxane Generation on Long-Term Outcome After Cardiac Surgery.

BackgroundSystemic thromboxane generation, not suppressible by standard aspirin therapy and likely arising from nonplatelet sources, increases the risk of atherothrombosis and death in patients with cardiovascular disease. In the RIGOR (Reduction in Graft Occlusion Rates) study, greater nonplatelet thromboxane generation occurred early compared with late after coronary artery bypass graft surgery, although only the latter correlated with graft failure. We hypothesize that a similar differential association exists between nonplatelet thromboxane generation and long‐term clinical outcome.Methods and ResultsFive‐year outcome data were analyzed for 290 RIGOR subjects taking aspirin with suppressed platelet thromboxane generation. Multivariable modeling was performed to define the relative predictive value of the urine thromboxane metabolite, 11‐dehydrothromboxane B2 (11‐dhTXB2), measured 3 days versus 6 months after surgery on the composite end point of death, myocardial infarction, revascularization or stroke, and death alone. 11‐dhTXB2 measured 3 days after surgery did not independently predict outcome, whereas 11‐dhTXB2 >450 pg/mg creatinine measured 6 months after surgery predicted the composite end point (adjusted hazard ratio, 1.79; P=0.02) and death (adjusted hazard ratio, 2.90; P=0.01) at 5 years compared with lower values. Additional modeling revealed 11‐dhTXB2 measured early after surgery associated with several markers of inflammation, in contrast to 11‐dhTXB2 measured 6 months later, which highly associated with oxidative stress.ConclusionsLong‐term nonplatelet thromboxane generation after coronary artery bypass graft surgery is a novel risk factor for 5‐year adverse outcome, including death. In contrast, nonplatelet thromboxane generation in the early postoperative period appears to be driven predominantly by inflammation and did not independently predict long‐term clinical outcome.

Similar Patency and Limb Salvage Rates in Comparing Primary Bypass with Bypass Following Failed Endovascular Intervention for Lower Limb Arterial Occlusive Disease

Patients with infrainguinal peripheral arterial disease often undergo multiple revascularization procedures. Although many centers have adopted an endovascular-first approach, some are reluctant for fear of damaging outflow and compromising the outcomes of any subsequent bypasses. A systematic review was conducted of MEDLINE, Embase, and CENTRAL databases for studies that compared outcomes of primary infrainguinal bypass with bypass after failed endovascular intervention for peripheral arterial disease. Abstracts and full-text studies were screened independently by two reviewers with data abstraction done in duplicate. Dichotomous outcome measures were reported using the odds ratio (OR) and 95% confidence interval (CI) and pooled using random-effects models. Study quality was assessed using the Newcastle Ottawa Scale. There were 2112 abstracts screened, with 43 selected for full-text review. Of these, 13 studies involving 7325 patients met the inclusion criteria. Pooling the results of studies comparing primary bypass with bypass after failed endovascular intervention showed no significant difference in primary patency (OR, 1.37; 95% CI, 0.61-3.08; Fig 1) or ipsilateral limb salvage at 1 year (OR, 1.37; 95% CI, 0.57-3.28). Similarly, 30-day amputation rates (OR, 1.75; 95% CI, 0.55-5.59), 30-day mortality (OR, 1.04; 95% CI, 0.67-1.61), and 1-year secondary patency (OR, 0.94; 95% CI, 0.47-1.88) were similar between groups. There was a trend toward higher rates of early graft occlusion (OR, 4.24; 95% CI, 0.81-22.09) and worse 3-year amputation-free survival (OR, 1.52; 95% CI, 0.94-2.45) for patients who failed to respond to endovascular intervention, but this was nonsignificant (Fig 2). Meta-analysis of the existing literature comparing primary bypass with bypass following endovascular intervention shows no significant difference in patency or limb salvage. The existing published data are limited by observational study design, inconsistent patient selection, and significant heterogeneity yet suggest that bypass following failed endovascular intervention does not conclusively result in inferior outcomes.Fig 2Forrest plot comparing the pooled odds ratio (OR [95% confidence interval (CI)] for (A) early graft occlusion (within 30 days; OR >1 indicates higher rates of graft occlusion in the bypass after failed endovascular intervention group) and (B) amputation-free survival at 3 years (OR >1 indicates higher amputation-free survival in the primary bypass group).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Midterm outcomes and evolution of gutter area after endovascular aneurysm repair with the chimney graft procedure

ObjectiveThe objective of this study was to describe our experience with endovascular aneurysm repair (EVAR) with the use of chimney grafts for branch vessel preservation. MethodsPatients treated with a chimney graft procedure between October 2009 and May 2015 were included for analysis. Patients who were not considered eligible for open surgical repair or for conventional, branched, or fenestrated endovascular repair were selected. A standardized operating procedure with left brachial or axillary artery cutdown access for the chimney grafts and bilateral femoral artery cutdown access for the aortic main device was used. Outcomes were noted according to the Society for Vascular Surgery reporting standards. In addition, evolution of gutter area over time was determined. Estimated rates of survival, freedom from aneurysm growth, and clinical success at 24 months of follow-up were calculated. ResultsThirty-three patients (mean age, 77.6 ± 6.8 years; 87.9% male) with a mean preoperative maximum aneurysm diameter of 71.7 ± 13.5 mm were included. A total of 54 of an intended 54 chimney grafts were deployed. Primary technical success and 30-day secondary clinical success rates were 87.9% and 84.8%, respectively. The early mortality rate was 6.1% (n = 2). The early type IA endoleak rate was 6.1% (n = 2), and the chimney graft occlusion rate was 6.1% (n = 2). Median follow-up duration was 26 months (interquartile range, 14.8-37.3 months). The estimated 2-year actuarial survival rate was 78.1% (standard error, ±7.4%). Late complications included type IA endoleak (n = 1), chimney graft occlusion (n = 2), type II endoleak with aneurysm growth (n = 4), and distal stent graft limb kinking and occlusion (n = 1). Late reinterventions included coil or glue embolization (n = 3), distal limb extension (n = 2), open endoleak ligation (n = 2), Palmaz stent placement (n = 1), repeated EVAR (n = 1), and femorofemoral bypass graft (n = 1). At 2 years, the estimated secondary clinical success and freedom from aneurysm growth rates were 80.5% (±7.2%) and 84.4% (±7.2%). Gutter size showed a small but significant decrease over time at the level of the proximal markers and at 10 mm distal from the markers. ConclusionsMidterm results show that a standardized procedure for EVAR using chimney grafts for branch vessel preservation is an acceptable option for high-risk patients with large, complex aneurysms who are unfit for open repair and who have been excluded from fenestrated EVAR. Gutter size decreases over time, but the rate of branch vessel loss and reinterventions demonstrate that this approach should remain reserved for those who are at truly prohibitive risk for open or fenestrated stent graft repair.

A Meta-Analysis of Outcomes After In Situ Reconstructions for Aortic Graft Infection.

To confirm the advantage of in situ reconstruction (ISR) over extra-anatomic reconstruction (EAR) for aortic graft infection and determine the most appropriate conduit including autogenous veins, cryopreserved allografts, and synthetic prosthesis (standard, rifampicin of silver polyesters). A meta-analysis was conducted with rate of mortality, graft occlusion, amputation, and reinfection. A meta-regression was performed with 4 factors: patients' age, presence of prosthetic-duodenal fistula (PDF), virulent organisms, or nonvirulent organisms. In situ reconstruction over EAR seems to favor all events. For the 5 conduits used for ISR, according to operative mortality, age of the patients looks to have a positive correlation only for silver polyester and no conduit present any advantage in the presence of PDF. Reinfection seems to be not significantly different for the 5 conduits, and only autogenous veins appear to have a positive correlation with infecting organisms. In situ reconstruction may be considered as first-line treatment. Our results suggest that silver polyesters appear to be most appropriate for older patients, and in order to limit reinfection, autogenous veins are probably the most suitable conduit.

Coronary Artery Bypass Surgery in Diffuse Advanced Coronary Artery Disease: 1-Year Clinical and Angiographic Results

Proper treatment of patients with diffuse, severe coronary artery disease (CAD) is a challenge due to its complexity. Thus, data on the outcomes after coronary artery bypass graft (CABG) in this population is scarce. In this study, we aimed to determine the impact of CABG on the clinical and functional status, as well as graft patency in those individuals. Patients with severe and diffuse CAD who underwent incomplete CABG due to complex anatomy or extensive distal coronary involvement were evaluated preoperatively and 1 year after surgery. Postoperative coronary angiography was performed to evaluate graft patency. Graft occlusion was defined as the complete absence of opacification of the target vessel. Stratified analysis of graft occlusion was performed by graft type and territories, defined as left anterior descending artery (LAD), the left circumflex branch, and the right coronary artery territories; the latter two, grouped, were further classified as non-LAD territory. A total of 57 patients were included, in whom 131 grafts were placed. There was a significant improvement in Canadian Cardiovascular Society angina symptom severity (Z = -6.1; p < 0.001) and maximum oxygen uptake (p < 0.001), with a corresponding decrease in the use of long-acting nitrates (p < 0.001). The overall graft occlusion rate was 19.1%, with no significant difference between LAD and non-LAD territories (p = 0.08). However, a significantly lower occlusion rate was noted for the internal mammary artery (IMA) grafts when compared with saphenous vein grafts (p = 0.01), though this difference was only significant in the LAD territory (p = 0.04). Overall, the use of venous graft was the only predictor occlusion at 1 year (odds ratio: 4.03; p = 0.016). In patients with diffuse CAD, incomplete CABG surgery resulted in a significant clinical improvement, with acceptable graft occlusion rates at 1 year, particularly for IMA grafts to the LAD territory.

Postoperative Heparin-Mediated Extracorporeal Low-Density Lipoprotein Fibrinogen Precipitation Aphaeresis Prevents Early Graft Occlusion after Coronary Artery Bypass Grafting.

Background Early graft occlusion due to thromboembolic events is a well-known complication after coronary artery bypass grafting (CABG). Fibrinogen, the coagulation factor I, is a glycoprotein that is transformed by thrombin into fibrin. It plays a major role in thrombus formation and is highly elevated after CABG. Our aim was to determine if postoperative lowering of fibrinogen levels by H.E.L.P. (heparin-mediated extracorporeal low-density lipoprotein [LDL] fibrinogen precipitation) aphaeresis could reduce the rate of early graft occlusion in patients with hypercholesterolemia undergoing CABG. Methods Between December 2004 and September 2009, 36 male patients with hypercholesterolemia (mean LDL cholesterol 128 ± 12 mg/dL), mean age 58 ± 9 years, underwent CABG. Mean preoperative fibrinogen level was 387 ± 17 mg/dL. H.E.L.P. aphaeresis was postoperatively performed when fibrinogen levels exceeded 350 mg/dL on day 1 and 250 mg/dL every consecutive day up to day 8. Pre- and postaphaeresis blood samples were obtained and plasma fibrinogen level reduction was calculated. Early graft occlusion was evaluated by means of coronary angiography or multislice computed tomography before discharge. Results A total of 128 distal anastomoses were performed in 36 patients (mean 3.6/patient). Postoperatively, 191 H.E.L.P. aphaeresis sessions were performed (mean 5.3/patient). Fibrinogen levels were lowered from 391 ± 10 mg/dL (preaphaeresis) to 171 ± 5 mg/dL (postaphaeresis; p < 0.001). Coronary angiography (multislice computed tomography in 7 patients) revealed graft patency in 125 of 128 grafts (98% patency) with three occluded venous grafts to target vessels of 1.5 mm. H.E.L.P. aphaeresis-related complications were limited to hypotensive episodes in two patients and bacteremia in one patient. Conclusions H.E.L.P. apheresis offers an easy, save, and efficient method to decrease fibrinogen postoperatively in patients having CABG. Showing excellent graft patency rates in comparison to the literature, this method is a promising tool to reduce early graft occlusion after CABG.