Graft-related Complications Research Articles

Use of Autologous Costal Cartilage Combined with Expanded Polytetrafluoroethylene in Asian Rhinoplasty

ABSTRACT Background The corresponding author's experience and recent methods employed in autologous costal cartilage grafts combined with expanded polytetrafluoroethylene (ePTFE) in Asian rhinoplasty were presented in this study. Objectives The purpose of this study was to assess the outcomes of rhinoplasty performed on patients using autogenous costal cartilage grafts combined with an ePTFE implant. Methods Seventy-five rhinoplasty cases with autologous costal cartilage grafts and an ePTFE implant were retrospectively reviewed. Graft types, complications associated with the graft itself or graft harvesting, surgical outcomes, and patient satisfaction were assessed. Results The mean follow-up time post-operation was 13.5 months. A total of 42/75 patients underwent revision surgeries. Graft-related complications were found in 8% of cases, including two warped graft and four infection cases. Three individuals with infections had mild graft resorption. One patient with an infection removed the implant. Graft exposure, mobility, and substantial resorption were not recorded. A total of two cases underwent revision procedures for infection and perforation, respectively. Chest incision lengths for graft harvesting averaged 2.1 cm. No pneumothorax or significant donor-site pain was found. Donor-site scars were negligible, although two cases had hypertrophic chest scars. In general, functional and esthetic outcomes were mostly satisfactory among the assessed patients. Conclusions Rhinoplasty using autologous rib cartilage provides adequate support and sufficient cartilage amounts for correcting nasal contouring. Meanwhile, ePTFE alone for nasal dorsum augmentation safely achieves satisfactory outcomes. Rib cartilage rhinoplasty performed by an experienced surgeon yields excellent, long-lasting results with minimal risk; however, the potential for infection should be considered following revision surgery.

Surgical technique of robot-assisted laparoscopic sacrocolpopexy

: Comparing to the laparoscopic approach, robotic surgery provides many advantages, facilitating the operating process, improving results and making it more comfortable for the surgeon. Sacrocolpopexy (SCP) is the most beneficial technique for apical prolapse, despite its complexity, so the robot’s assistance could make it more convenient. Steps of SCP are the following: (I) peritoneal opening with further mobilization of the longitudinal presacral ligament, mm. pubococcygeus, perineal body, posterior and anterior vaginal walls. Subtotal hysterectomy should be done if the uterus is present. (II) Fixation of the posterior part of the mesh to mm. levator ani, perineal body, the posterior vaginal wall, and vaginal cuff or cervix. Fixation anterior part of the mesh to the anterior vaginal wall and vaginal cuff or cervix. (III) Fixation of the mesh to the longitudinal presacral ligament in the area of promontorium. (IV) Peritoneal closure and vaginal packing. From January 2013 to December 2019, 181 patients underwent RA SCP in our department. Long-term assessment (more than 1 year) was made in 74 patients. There weren’t found graft-related complications requiring additional surgery. Seventy (94.6%) of patients claimed excellent and good subjective results showing improvement in scoring using pelvic organ prolapse questionnaires. Sixty-one (82.4%) showed good and excellent anatomical results showing an absence of prolapse or stage I prolapse recurrence. However, 13 (17.6%) patients showed recurrent II–III stage of cystocele. RA SCP is the operation of choice in sexually active women with apical prolapse. Robotic surgery has advantages comparing laparoscopic approach in obese patients, women with dense or strong intraabdominal adhesions, recurrent pelvic organ prolapse after laparoscopic or vaginal mesh repair.

Laparoscopic Left Lateral Monosegmentectomy in Pediatric Living Donor Liver Transplantation Using Real-Time ICG Fluorescence In Situ Reduction

BackgroundNowadays, laparoscopic left lateral sectionectomy has been acknowledged as a standard practice in pediatric living donor liver transplantation (PLDLT).1, 2 We here report the first case of laparoscopic left lateral monosegmentectomy (L-LLM) in PLDLT using real-time ICG fluorescence in situ reduction in China. MethodA 35-year-old father volunteered for living donation to his daughter who diagnosed with liver cirrhosis and portal hypertension after Kasai operation due to biliary atresia. Preoperative liver function was normal. Liver dynamic CT showed a left lateral graft volume of 387.5cm3 with a graft to recipient weight ratio (GRWR) of 4.45%. Ratio of the maximum thickness of the left lateral segment to the anteroposterior diameter of the recipient’s abdominal cavity was 1.09. The estimated segment II volume was 245.3cm3 and GRWR was 2.82%. L-LLM was scheduled.3 No anatomic variation was seen. ResultsThe transection was divided into two stages. Stage I: Separating the left lateral section along the right side of sickle ligament. Stage II: Anatomic in situ reduction of segment III by using real-time ICG fluorescence. The left bile duct was transected above the bifurcation by ICG fluorescence cholangiography. The total operation time was 200 min without transfusion. The final graft weight was 225.2g with GRWR of 2.59%. The donor was discharged uneventfully on postoperative day 4, while the graft function recovered to normal in recipient without any graft-related complication. ConclusionL-LLM with in situ reduction is feasible in PLDLT by using real-time ICG fluorescence in experienced transplant center.

Wrist Arthrodesis and Osteoarticular Reconstruction in Giant Cell Tumor of the Distal Radius

The aim of this multi-institutional retrospective study was to compare osteoarticular graft reconstruction (OA) and wrist arthrodesis (WA) after distal radius resection for giant cell tumor. Sixty-seven patients affected by giant cell tumor of the distal radius underwent resection and reconstruction with OA (47 patients) or WA (20 patients). The mean age was 40 years (range, 13-74 years). Grafts included fresh-frozen allograft or nonvascularized fibular autograft. Complications requiring surgical revision were recorded. Clinical outcome was assessed with the Musculoskeletal Tumour Society Score (MSTS) and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Fifteen patients developed a local recurrence after a median of 12 months (range, 6-137 months). Sixteen patients required revision surgery for complications. Of these, 10 were graft-related complications (7 in the OA group and 3 in the WA group). Among OA, 2 patients with painful instabilities and 4 with severe arthritis required conversion into WA after a mean of 26 months (range, 13-38 months) At a median follow-up of 105 months (range, 12-395 months), similar functional outcome (MSTS and DASH score) was observed between OA and WA. Our results did not show any advantage of OA or WA over the other technique. A patient-by-patient decision should be taken both regarding the type of reconstruction (OA or WA) and the type of graft (allograft or autograft). The reconstructive choice should also consider the patient's functional expectations. Therapeutic IV.

Two sisters with myoclonus and ataxia

A 26-year-old woman (patient 1 on the family tree—figure 1) gave a 6-year history of dysarthria, occasional jerks and progressive gait unsteadiness with frequent falls, and had become bedridden. On...

Overall outcome after endovascular aneurysm repair with a first-generation stent graft (Vanguard): A 20-year single-center experience

ObjectiveThe problems with first-generation stent grafts for endovascular aneurysm repair are well known, but their long-term outcome remains to be established. The purpose of the study was to characterize the outcome of patients treated for abdominal aortic aneurysm (AAA) with a first-generation stent graft, Vanguard (Boston Scientific, Natick, Mass), in a single academic center with a follow-up of up to 20 years. MethodsThere were 48 AAA patients electively treated with a Vanguard stent graft between February 1997 and November 1999. The patients were monitored annually until the end of 2018. The outcomes were overall survival and the number of graft-related complications and reinterventions. ResultsThe mean age was 70 years (range, 54-85 years), and the mean follow-up was 107 months (range, 6-262 months). All stent grafts were successfully implanted, but 90% of the patients encountered graft-related complications during follow-up. The most common complications were endoleaks (type I, 27%; type II, 29%; type III, 31%), stent fracture (46%), graft thrombosis (31%), and migration (40%). A total of 40 (83%) patients required a secondary procedure during long-term follow-up. The endovascular method for treating the complication was successful in 73 (87%) of 84 cases. There were no primary conversions, but 10 patients (21%) required a late conversion. In five cases, the complications required relining with a newer device. There were four AAA ruptures (8.3%), two of them fatal. The cumulative overall survival rates were 94%, 69%, 33%, 15%, and 13% at 1 year, 5 years, 10 years, 15 years, and 20 years, respectively. ConclusionsThe use of the Vanguard, a first-generation stent graft, was associated with multiple graft-related complications. However, these complications could mainly be treated by endovascular means. The Vanguard stent graft is a good example of how new technology can cause unpredictable problems that can magnify the workload and endanger the patient's well-being even decades after the initial procedure.

Clinical experience with the use of a spherical bioactive glass putty for cervical and lumbar interbody fusion.

A retrospective clinical case series study was conducted to evaluate the use of a novel, spherical bioactive glass bone graft (BioSphere Putty) as a graft material for cervical and lumbar interbody fusion. Data was collected from a single surgeon using BioSphere Putty along with standardized hardware in anterior cervical decompression and fusion (ACDF), transforaminal lumbar interbody fusion (TLIF), and anterior lumbar interbody fusion (ALIF) surgical procedures. BioSphere Putty was used in combination with cancellous allograft (ACDF and ALIF) or in combination with autograft (TLIF). Clinical outcomes were assessed at 1- and 2-year using radiographic imaging and the visual analog pain scale (VAS). VAS scores at the 1- and 2-year follow-up periods were statistically compared to pre-operative scoring. Successful clinical outcomes were determined by a combination of the presence of a complete radiographic fusion and a decrease in VAS at 1-year and 1- and 2-year follow-up periods. The retrospective review of the patient data identified 248 cases that had either 1- or 1- & 2-year follow-up. This consisted of 115 ACDF procedures and 133 lumbar fusion procedures. Lumbar fusion cases were further sub-grouped with 103 patients undergoing TLIF procedures and 30 patients undergoing ALIF procedures. The global results for the series as a whole showed clinical outcomes comparative to other advanced biologic bone grafts. Radiographically all patients demonstrated fusion (100% fusion rate) and there were no clinical adverse events, infections, or graft-related complications in any of the patients in the series. One-year VAS scores were consistent with historical norms and demonstrated significant decreases in pre-operative pain for both ACDF patients (78% decrease) and lumbar patients (66% decrease TLIF/ALIF) (t test, P<0.05). By 2 years, VAS scores continued to drop with significant decreases for the ACDF patients (96%), TLIF patients (82%), and ALIF patients (80%) (t test, P<0.05). VAS scores were also assessed for each individual patient. The data showed a VAS score decrease from pre-operative levels in 93% of the ACDF patients and 89% of the lumbar patients. Combined with the 100% radiographic fusion rate in all patients, this resulted in a in a clinical success rate of 93% for the ACDF patients and 89% for the lumbar patients. The results of this clinical case series demonstrated that BioSphere Putty is a clinically effective and versatile synthetic bone graft material in the spine.

Rate and risk factors for wound complications after internal hemipelvectomy

Although internal hemipelvectomy is associated with a high incidence of morbidity, especially wound complications, few studies have examined rates of wound complications in these patients or have identified factors associated with the consequences. The present study aimed to: 1) determine the rate of wound and other complications requiring surgery after internal hemipelvectomy; and 2) identify factors that affect the rate of wound complications and can be used to stratify patients by risk of wound complications. The medical records of 123 patients undergoing internal hemipelvectomy were retrospectively reviewed, with a focus on both overall complications and wound complications. Logistic regression analyses were performed to examine the association between host, tumour, and surgical factors and rates of postoperative wound complications. The overall rate of postoperative complications requiring surgery was 49.6%. Wound complications were observed in 34.1% of patients, hardware-related complications in 13.2%, graft-related complications in 9.1%, and local recurrence in 5.7%. On multivariate analysis, extrapelvic tumour extension (odds ratio (OR) 23.28; 95% confidence interval (CI), 1.97 to 274.67; p = 0.012), both intra- and extrapelvic tumour extension (OR 46.48; 95% CI, 3.50 to 617.77; p = 0.004), blood transfusion ≥ 20 units (OR 50.28; 95% CI, 1.63 to 1550.32; p = 0.025), vascular sacrifice of the internal iliac artery (OR 64.56; 95% CI, 6.33 to 658.43; p < 0.001), and use of a structural allograft (OR, 6.57; 95% CI, 1.70 to 25.34; p = 0.001) were significantly associated with postoperative wound complications. Internal hemipelvectomy is associated with high rates of morbidity, especially wound complications. Several host, tumour, and surgical variables are associated with wound complications. The ability to stratify patients by risk of wound complications can help refine surgical and wound-healing planning and may lead to better outcomes in patients undergoing internal hemipelvectomy. Cite this article: Bone Joint J 2020;102-B(3):280-284.

The Medial Subcoronoid Process Region as a Novel Source of Bone Grafts in Orthognathic Surgery and Genioplasty.

Since 2012, the authors have adopted the medial subcoronoid process bone interpositional grafting in OGS and genioplasty procedures. The purpose of this study was to present the technical details and clinical outcomes of this alternative bone interpositional grafting for LeFort I and chin osteotomies. Consecutive patients (n = 50) who underwent single-splint bimaxillary OGS with or without genioplasty and received medial subcoronoid bone interpositional grafting were included. Standardized facial and intraoral photographs at early and late postoperative periods (12.2 ± 3.3 and 44.8 ± 8.4 months postsurgery, respectively) were blindly rated to assess facial symmetry, chin, and occlusion status based on qualitative rating scales. Complication and reoperation rates were also reviewed. The medial subcoronoid bone interpositional grafts were adopted to stabilize different LeFort I maxillary movement types or lengthening/advancing genioplasty (36 and 14 patients, respectively). Overall, the early facial symmetry, chin, and occlusion status were maintained at late evolutions. None of the patients had donor-site or bone graft-related complications (i.e., bad split, undesired mandible fracture, infection, fibrous union, nonunion, and/or permanent neurosensory deficit) or revisionary surgery during follow-up. The medial subcoronoid process bone grafting was a feasible alternative for bone interpositional defects of LeFort I and chin osteotomies with no significant morbidity and avoiding secondary donor sites.

Anterior Versus Posterior Decompression for Degenerative Thoracic Spine Diseases: A Comparison of Complications.

Study Design:Retrospective database.Objectives:Although posterior decompression is the most common approach for surgical treatment of degenerative thoracic spine disease, anterior approach is gaining interest due to its advantage in disc visualization. The objective of this study was to compare the intra- and postoperative medical complication rates between anterior and posterior decompression for degenerative thoracic spine pathologies.Methods:A national US insurance database was queried for patients with degenerative diagnoses who had undergone anterior or posterior thoracic decompression. Incidence of intra- and postoperative complications were evaluated on the day of surgery and within 1 and 3 months. Two subgroups were matched based on age, gender, and comorbidity. The association of decompression approach and complications was assessed using logistic regression.Results:A total of 1459 patients were included, consisting of 1004 patients in posterior and 455 patients in anterior group. Respiratory complications were the most common complications on the day of surgery (8.57%) and within 30 days (17.75%). Matched analysis showed that anterior approach was associated with organ failure, gastrointestinal, and device-/implant-/graft-related complications in all follow-up periods; and with cardiovascular, deep venous thrombosis/pulmonary embolism, and respiratory complications in at least 1 follow-up period. Among respiratory complications, anterior decompression was significantly associated with noninfectious etiologies on the day of surgery (odds ratio [OR] = 1.72), within 30 days (OR = 2.05), and within 90 days (OR = 1.92).Conclusions:Anterior approach was associated with increased rates of several complications. High rates of respiratory complications necessitate comprehensive preoperative risk stratification to identify those who may benefit more from posterior approach.

Robotic assisted extravascular stent placement for nutcracker phenomenon of the left renal vein: a case series.

Nutcracker phenomenon of the left renal vein is a rare anatomic anomaly that can present with chronic flank/pelvic pain, pelvic congestion, and hematuria. Conventional treatment options (superior mesenteric artery transposition, endovascular stent placement, auto-transplantation) involve substantial risk, morbidity, or the need for chronic anti-coagulation. We now report our institution's robotic experience with extravascular left renal vein stent placement. A retrospective, single surgeon series from December 2016 to May 2019 was reviewed. After positioning and port placement (three robotic ports, one assistant), the left renal vein was exposed and dissected free circumferentially down to the inferior vena cava insertion. The distance between the renal vein ostium and adrenal vein was measured and a 1cm-diameter ringed polytetrafluoroethylene vascular stent of this length placed. The stent edges were secured to itself with 3-0 polyglactin sutures. Demographics, surgical, and functional outcomes were collected. Six patients with mean age of 45 ± 6years and body mass index of 20.3 ± 3.3g underwent the procedure. Mean operative time was 143 ± 20min. Estimated blood loss was minimal. Mean graft length utilized was 2.25 ± 0.3cm. Median day of discharge was 1.5days (range 1-3). No high-grade complications occurred. All patients received immediate pain relief and 50% also saw other symptomatic improvements. Robotic assisted extravascular left renal vein stent placement appears safe and effective in a small cohort with short follow-up. Further long-term follow-up for pain relief and graft-related complications are needed.

Impact of Aortic Tortuosity on Displacement Forces in Descending Thoracic Aortic Aneurysms

As elastin fibres in the aorta deteriorate with age, the descending thoracic aorta (DTA) becomes longer and more tortuous. In patients with DTA aneurysms, this increased tortuosity may result in a hostile haemodynamic environment for thoracic endovascular aortic repair (TEVAR). The objective of this study was to analyse how increased tortuosity affects haemodynamic displacement forces (DFs) in different segments of the DTA in patients with DTA aneurysms (DTAAs). Thirty patients with DTAAs were selected to form three equal groups based on the maximum tortuosity of their DTA: low < 30°, moderate 30°-60°, and high > 60°. Computational fluid dynamics simulations were performed to calculate DFs in all patients. Image based segmentations were carried out to create patient specific models of the aortic geometry. When physiological simulation results were obtained, the haemodynamic DFs on the aortic wall were calculated in four segments of the DTA (zones 4A - D). To enable comparison of DFs in different segments, the DF was normalised by the aortic wall surface area, the equivalent surface traction (EST). The mean age was 73 years, with 67% male. In zone 4C, where most tortuosity occurs, the EST in patients with high tortuosity was more than three times higher, than those with low tortuosity (low, 743N/m2; moderate, 956N/m2; high, 2294N/m2; p=.004). These differences could be attributed to the higher sideways components of the DF vectors, which were more than two times greater in patients with high tortuosity than in patients with low or moderate tortuosity (low, 5.01N; moderate, 5.50N; high, 13.21N; p=.009). High tortuosity results in increased displacement forces in the distal segments of the DTA. These forces should be taken into account when planning for TEVAR, as potentially they increase the risk of stent graft related complications, such as migration and endoleak.

Graft-related complications after open surgery of abdominal aortic aneurysm – An 8-year follow-up study

Introduction: Open surgery repair (OSR) is generally considered as a single definitive procedure and requires minimal postoperative follow-up once immediate survival is established. There are many studies which focus on endovascular aneurysm repair reintervention, only few contemporary studies report graft-related reinterventions after open repair. The present study describes the incidence of graft-related complications following OSR for abdominal aortic aneurysm (AAA) and its management. This study also analyse the factors which can preoperatively predict the occurrence of graft related complications, so that necessary steps can be taken to prevent such complications. Materials and Methods: This is a single-center prospective analysis of 165 patients who underwent elective open repair for AAA over a period of 8 years from January 2008 to December 2016. Demographics, preoperative, perioperative, and postoperative data were recorded in a structured data collection sheet after reviewing patient records and institutional electronic medical records after obtaining clearance from the Institutional Ethics Committee. Results: The overall incidence of graft-related complications in our study was 6.6%. The most common graft-related complication in our study is iliac graft limb occlusion 3.6% followed by graft infection of 1.5% and anastomotic pseudo aneurysm of 1.5%. The graft-related reintervention rate is 5.1% and graft-related mortality is 1.5% in 8-year follow-up. The risk factors for graft-related complications are preoperative uncontrolled DM, aorto-iliac aneurysms, use of bifurcated graft, and postoperative wound infection. Conclusions: This study showed that aggressive control of DM preoperatively and anastomosing distal Y-limb of graft to femoral artery rather than external iliac artery may decrease the complications. The majority of graft-related complications occurred 2 years after surgery. Hence, we suggest that those patients with above risk factors should be put on a short-interval surveillance program.

Tortuosity of the Descending Thoracic Aorta in Patients with Aneurysm and Type B Dissection.

Tortuosity in the descending thoracic aorta (DTA) comes with aging and increases the risk of endoleaks after TEVAR. With this report, we would like to define and classify tortuosity in the DTA of patients with thoracic aortic disease. Retrospective case-control study of two hundred seven patients, comparing sixty-nine controls without aortic disease (CG), to sixty-nine patients with descending thoracic aortic aneurysm (AG) and sixty-nine patients with type B aortic dissection (DG). 3Mensio Vascular software was used to analyze CTA scans and collect the following measurements; tortuosity index, curvature ratio and the maximum tortuosity of the DTA. The DTA was divided into four equal zones. The maximum tortuosity was divided into three groups: low (<30°), moderate (30°-60°) and high tortuosity (>60°). Compared to the CG, tortuosity was more pronounced in the DG, and even more in the AG, evidenced by the tortuosity index (1.11 vs. 1.20 vs. 1.31; p < 0.001), curvature ratio (1.00 vs. 1.01 vs. 1.03; p < 0.001), maximum tortuosity in degrees (28.17 vs. 33.29 vs. 43.83; p < 0.001) and group of tortuosity (p < 0.001). The maximum tortuosity was further distal for the DG and AG, evidenced by the zone of maximum tortuosity (4A vs. 4B vs. 4B; p < 0.001). This study shows that tortuosity in the DTA is more prominent in diseased aortas, especially in aneurysmal disease. This phenomenon needs to be taken into account during planning of TEVAR to prevent stent graft-related complications and to obtain positive long-term outcome.

Analysis of Failure-mechanisms of Cryopreserved Vascular Allografts in Peripheral Reconstructions

Introduction: Cryopreserved vascular allografts represent a well known option in the treatment of vascular infections. Moreover several groups also suggested their use in case of patients with no suitable veins requiring an infragenicular bypass. The aim of the present study was to evaluate the failure mechanisms of cryopreserved allografts in peripheral reconstructions in a cohort of patients treated at a single Institution. Methods: We retrospectivly analized a prospectively collected database comprising all patients undergoing a peripheral reconstruction with cryopreserved arterial or venous allografts between August 2010 and January 2019. The composite result of graft failure (occlusion + degeneration + any graft-related complication) was calculated as a primary endpoint. In case of reintervention hystological analysis of a segment of allograft was performed. Results: A total of 20 patients [mean age 66.1 +/- 10.3 yy, M 66% (12/18)] underwent 25 vascular in-situ reconstruction with cryopreserved arterial or venous allografts. Indication for treatment was infection of a previous prosthetic graft in 12 cases, critical limb ischemia in 8, allograft degeneration in 3 and mycotic pseudoaneurym in 2. Type of reconstruction are reassumed in table I Table I. Type o.... In 17 cases an arterial allograft was used (11 single segment, 6 multiple segments) and in 8 cases a vein allograft (6 single segment, 2 multiple segments). At 30 days there were 3 deaths (1 myocardial infarction, 1 rupture of thoracic aortic aneurysm, 1 anastomotyc disrupture) with 2 additional deaths during follow up (1 drug overdose, 1 intestinal ischemia). Mean follow-up was 31 months (min 1 - max 81) with no patients lost to follow up. Overall graft failure occurred in 7 cases (28%) (3 aneurysmal degenerations, 2 occlusions, 2 anastomotyc disrupture) with reintervention with allograft performed in 4 cases. There was no statistical difference in the incidence of the composite endpoint between venous and arterial grafts [OR 0.71 (0.098 - 5.2), p 1], between patients with infection and without infection [OR 1.8 (0.26 - 12), p 0.66] and between single and multiple segments grafts [OR 2.8 (0.42 - 2.9), p 0.34], although occlusions occurred only in veins (2/8, 25%) and aneurismal degeneration only in arterial allografts (3/17, 17%). Hystological analysis was available for 5 allografts: 2 anastomotyc disruptures showing wall necrosis due to infection, 3 aneurysmal degenerations showing a chronic flogistic pattern suggestive of immune-mediated rejection. Kaplan-Meier estimates showed an overal 26% of freedom from graft failure at 60 months, with no difference between patients with and without infection and venous and arterial allografts (Logrank test p: 019 and 0.26 respectively). Conclusion: In our series the failure rate of allografts was not low, although their use was limited to very high risk situations. Accurate follow up is mandatory as the risk of aneurysmal degeneration is not negligible with arterial allografts, although they seem to offer a better patency rate compared to veins. Immune-mediated rejection plays a role in aneurysmal degeneration while uncontrollable infection greatly hinders the early postoperative outcome.Table IType of peripheral reconstruction with allografts and type of allografts usedType of ReconstructionN (%)Type of allografts (N)Composite axillo-femoral bypass1 (4%)Single Arterial (1)Femoral tibial bypass4 (16%)Multiple Arterial (2) Single Venous (1) Multiple Venous (1)Femoral femoral crossover bypass2 (8%)Single Arterial (2)Below knee femoral popliteal bypass5 (20%)Single Arterial (1) Multiple Arterial (3) Single Venous (1)Above knee femoral popliteal bypass2 (8%)Single Arterial (1) Single Venous (1)Iliac femoral bypass3 (12%)Single Arterial (2) Multiple Arterial (1)Femoral truncal bypass2 (8%)Single Venous (1) Multiple Venous (1)Common femoral reconstruction4 (16%)Single Arterial (3) Single Venous (1)Bypass of a dilated segment of a previous allograft2 (8%)Single Arterial (2) Open table in a new tab Disclosure: Nothing to disclose

Sixteen-Year Survival after Endovascular Abdominal Aortic Aneurysm Repair with the Zenith Stent Graft

Introduction - Although endovascular aneurysm repair (EVAR) is in widespread use, truly long-term data is still lacking. This study characterizes our sixteen year experience of EVAR using the Zenith stent graft in a single academic center. Methods - Between 2000 and 2010, 282 patients with abdominal aortic aneurysm (AAA) underwent elective EVAR using the Zenith stent graft (Cook Inc. Bloomington, Ind). Patients were annually monitored thereafter. Primary outcomes were overall and AAA-rupture free survival. Secondary outcomes were survival from graft-related complications and re-interventions. Results - Mean age was 75 years (range, 49- 92 years) and mean aneurysm diameter 61mm (range, 40-110mm) at the time of the initial treatment. The mean follow-up was 79 months (range, 0-201 months). The overall survival was 93%, 61%, 25% and 9% at 1, 5, 10 and 16 years. Even for those ≥80 years, the survival was 46% at 5 years. Five AAA ruptures occurred during the follow-up, four of which were fatal. Consequently, cumulative AAA-rupture free survival was 100%, 99%, 97% and 97% at 1, 5, 10 and 16 years. Freedom from any stent graft related complications was 68%, 58%, 54%, 52%, and from graft-related re-interventions 95%, 80%, 73%, 70% at 1, 5, 10 and 16 years, respectively. Only five (1.8%) late conversions to open repair were required during the follow-up. Aneurysm sac shrinkage ≥5mm was seen in 60% of the cases with the mean decrease of 18.5mm in maximum diameter. Conclusion - Fatal AAA rupture after EVAR is a rare phenomenon and patients eventually die from natural causes. Even octo-and nonagenarians seem to tolerate the procedure well as almost half of the patients are still alive at five years. The number of graft-related complications is relatively high, but according to our findings, they don’t always require re-intervention and can safely be followed. New complications keep appearing years after the initial procedure thus suggesting the life-long surveillance as mandatory.

Doppler ultrasound values after liver transplantation in children and their association with graft outcomes: a protocol for a systematic review and meta-analysis

IntroductionLiver graft and patient survival in children have improved substantially over the years; nevertheless, graft-related complications persist as the most important risk factor for mortality and graft loss. Doppler ultrasound...

Immediate Access Arteriovenous Grafts Decrease Catheter Days and Complications

Introduction - Immediate-access arteriovenous grafts (IAAVG) can be used as peripheral access or in combination with outflow through the Hemodialysis Reliable Outflow (HeRO) graft. This study compares IAAVG to standard arteriovenous grafts (SAVG) as well as describing IAAVG use with HeRO outflow. Methods - All patients who underwent placement of AV graft from 1/2014 - 4/2016 at two large tertiary referral centers were retrospectively identified in the electronic medical record and through the Vascular Quality initiative (VQI). Patients were divided into three groups based on the type of graft implanted (SAVG and IAAVG) and a third group of HeRO/IAAVG. Patient comorbidities, graft configuration, operative characteristics and subsequent follow-up were collected and analyzed with respect to primary patency, primary assisted patency, and secondary patency. Additional outcomes included graft-related complications, time to first canulation, time to tunneled catheter removal, catheter-related complications and overall survival. Patency was defined per Society for Vascular Surgery recommended reporting standards and was determined from the time of the index procedure. Chi-square, Kaplan-Meier and Cox regression analysis were used with the p-value set as significant at <0.05 Results - 254 grafts were identified; 148 SAVG, 62 IAAVG, 44 combined IAAVG-HeRO. Patient characteristics were similar between groups, except for more pre-operative central venous occlusions in the IAAVG vs SAVG (16.3% vs 6.8%, p<0.04) and these vs IAAVG/HeRO (100%, P<.001) . Of the IAAVG group, 50 were Acuseal (Gore) and 12 were Flixene (Atrium). IAAVG/HeR0 patients all used Acuseal. Standard AVG were all ePTFE (Gore Medical). Overall primary, primary assisted, and secondary patency at 6 months were 35.9%, 43.6%, and 51.3% respectively for IAAVG/HeRO. Primary patency at 1 year (SAVG: 39.4%, IAAVG: 56.7%, p=0.4), and secondary patency (SAVG: 50.7%, IAAVG: 52.1%, p=0.73) showed no significant differences. Similarly, there were no significant differences in primary (SAVG: 29.0%, IAAVG: 43.7%, p=0.4) or secondary patency (SAVG: 42.3%, IAAVG: 46.3%, p=0.73) at 18 months. Regression analysis did not show any association to the type of graft; however, IAAVG patients required fewer additional procedures to maintain patency (mean number of procedures 0.99 SAVG vs. 0.61 IAAVG, p=0.025). There was no difference in steal syndrome (SAVG: 6.8%, IAAVG: 8.1%, p=0.74).) or graft infection (19.0% SAVG vs. 12.0% IAAVG, p=0.276). 75% of all grafts were successfully canulated, with shorter median time to first canulation in the IAAVG group (6 days IQR 1-19) compared to the SAVG group (31 days, IQR 26-47) (p<0.01). For IAAVG/HeRO) patients, 95% of grafts were successfully canulated with mean time to canulation of 13.0±51.6 days. 53% of IAAVG/HeRO patients left the OR with this graft as their only access. This group had 100% canulation success at < 24 hours. 65.75% of all pre-existing catheters were removed, with a shorter median time until catheter removal in the IAAVG cohort at 34 days (IQR 22-50) versus 49 days (IQR 39-67) in the SAVG group (p<0.01). Catheter-related complications occurred less frequently in the IAAVG group (16.4% vs. 2.9%, p<0.045). Conclusion - IAAVGs allow earlier canulation and tunneled catheter removal, thereby significantly decreasing catheter-related complications. Patency and infection rates were similar between SAVG and IAAVG, but with fewer secondary procedures performed in IAAVG.

Safety of Patient Stratification Based on Initial Imaging Follow-up After Endovascular Aneurysm Repair (EVAR)

Introduction: Most patients undergo uneventful long-term follow-up after EVAR. Therefore, unmodified surveillance protocols may be ineffective. Recently, modified follow-up protocol was suggested by the European Society for Vascular Surgery (ESVS). One feature of this protocol is that for patients without any detectable complication at one month or at one year, the next scheduled follow-up could be carried out at five years. In this study, we analysed the safety of this protocol retrospectively by evaluating the fate of the patients if they had been followed according to the introduced protocol. Methods: Between 2005 and 2013, 346 patients were treated electively for abdominal aortic aneurysm (AAA) in an academic center. Indication for treatment was an AAA ≥5.5cm in men and ≥5.0cm in women or growth (≥5mm) during the previous six months. Patients were treated with three different stent grafts: Zenith by Cook, Excluder by Gore and Endurant by Medtronic. All patients were annually followed according to prearranged program including CTA at 1 and 24 moths and CDUS annually. Available control images until the end of 2018 were retrospectively analysed for the study. Results: The mean follow-up was 68 months (range, 0- 153 months) and overall survival was 93.4%, 84.1%, 65.0%, 21.4% at 1, 2, 5 and 10 years. 30-day mortality was 1.2% (n=4). Imaging data for those surviving the first 30 days was available for 98.8% (n=338) subjects. At one-month control exam 82.0% (n=277) patients had no detectable endoleak. Of those patients 11.1% (n=31) developed re-intervention requiring graft-related complication during the next five years (Figure 2, 1). Among these incidents were four RAAAs. Among those with an endoleak type 2 at one month (n=56), six had sac shrinkage at one year CDUS and therefore the next surveillance control would have been at five years. Four out of these six patients developed re-intervention requiring graft-related complication between 1 and 5 years, including one RAAA (Figure 2, 2). Complications requiring treatment that would have been missed by following the suggested protocol included: endoleak type 1A (n=9), endoleak type 1B (n=7), endoleak type II (n=19), thrombosis (n=4), and RAAA (n=5). In general 22.0% (n=76) of the patients had re-intervention requiring complication and 80.0% (n=61) of them were treated during the first five years after EVAR. The sensitivity and specificity of one month CTA to detect potential significant complications during the first five years were 47.5% (95% CI 32.3-60.9%) and 88.2% (95% CI 83.8-91.7%) respectively. Conclusion: According to our study, most re-intervention requiring complications after EVAR occur in early postoperative years. Further, in our cohort the sensitivity of one month CTA to detect potential significant complications during the first five years is low, 47.5 %. Therefore, surveillance should be more frequent during the early years after EVAR and patient-modified surveillance should probably be considered later in the course of follow-up.Figure 2Retrospectively analysed 346 EVAR patients placed in recommended algorithm during first five years of follow-up.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disclosure: Nothing to disclose

Influence of Thoracic Endovascular Repair on Aortic Morphology in Patients Treated for Blunt Traumatic Aortic Injuries: Long-term Outcomes in a Multicenter Study

Introduction - To evaluate long-term outcomes and aortic remodeling in patients treated with thoracic endovascular aneurism repair (TEVAR) for blunt traumatic aortic injuries (BTAI). Methods - From 2004 to 2017 a cohort of 52 patients with BTAI were treated at four Italian trauma centers (Modena, Reggio Emilia, Pisa, Bolzano). This is an observational retrospective multicenter study, measurements and data were reviewed by a single center (Modena) that performed the analysis. The primary endpoint was to evaluate proximal and distal aortic neck remodeling during follow up. Secondary endpoint includes evaluation of each graft-related complication or caused by reiterate radiation exposure. The study protocol required CTA scans within 3 months and at 1, 6 and 10 postoperative years. From 2004 to 2017 a cohort of 52 patients with BTAI were treated at four Italian trauma centers (Modena, Reggio Emilia, Pisa, Bolzano). This is an observational retrospective multicenter study. Primary endpoint was to evaluate proximal and distal aortic neck remodeling during follow up. Secondary endpoint includes evaluation of each graft-related complication or caused by reiterate radiation exposure. The study protocol required CTA scans within 3 months and at 1, 6 and 10 postoperative years. Results - Median age was 46 years [range 20-86], mean oversizing of TEVAR was 19.5% ± 9.7% [range 5%>35%]. At 30-days 47 (90.4%) patients were alive and took part at the study. During a median follow-up of 86 ± 79 months (range, 1-160 months) late survival was 95,7% (n=45/47), no spinal cord ischemia (SCI), endoleak, migration, device rupture and malignancies were recorded and one re-intervention (TEVAR) was performed for a late intramural hematoma on third post-operative month. Freedom from aortic remodeling was 86.5% (SE 4.7%), 53.8% (SE 6.9%) and 51.9% (SE 6.9%) at 1, 6 and 10 years respectively. A significant correlation between time to intervention (proximal and distal: P< .001), age (proximal P< .001; distal P= .002), distal and proximal neck increasing was found. A significant correlation between sealing in zone 2 and increasing in both proximal (P= .027) and distal (P= .042) diameter was found, on the other hand subclavian revascularization seems to have not affected this outcome. A correlation between oversizing and proximal neck diameter remodeling (P=.05) was found to be 3.4% at each 10% oversizing increase. Median age was 46 years [range 20-86], mean oversizing was 19.5% ± 9.7% [range 5%>35%]. At 30-days 47 (90.4%) patients were alive and took part at the study. During a median follow-up of 86 ± 79 months (range, 1-160) late survival was 95,7% (n=45/47), no spinal cord ischemia, endoleak, migration, device rupture and malignancies were recorded and one re-intervention was performed for a late intramural hematoma. Freedom from aortic remodeling was 86.5% (SE 4.7%), 53.8% (SE 6.9%) and 51.9% (SE 6.9%) at 1, 6 and 10 years respectively. A significant correlation between time to intervention, age, distal and proximal neck increasing was found. Correlation between sealing in zone 2 and increasing in both proximal (P= .027) and distal (P= .042) diameter was found. A correlation between oversizing and proximal neck diameter remodeling (P=.05) was found to be 3.4% at each 10% oversizing increase. Conclusion - TEVAR has confirmed to be safe over years but aortic remodeling and oversizing are likely related. We reported a correlation between oversizing and remodeling without an increase of adverse events over time.