Bypass Occlusion Research Articles

Superficial Temporal Artery to Middle Cerebral Artery Bypass and Endovascular Parent Artery Occlusion in the Treatment of Giant Intracranial Aneurysms

The authors are reporting on a study drawn from unpublished dissertation done by the corresponding author when he completed his neurosurgical training in Paris, France in 2004, few years before the advent of flow diverters. The study was a retrospective review of giant intracranial aneurysms treated by superficial temporal artery to middle cerebral artery bypass combined with endovascular occlusion of the parent artery. From 1990 to 2003, 29 consecutive cases of giant cerebral aneurysms, not suitable to selective treatment were managed in that way. Twenty-one medical records had enough data to allow objective evaluation. Sixteen female and five male patients bearing 21 giant aneurysms were involved. Their mean age was 46 years. The aneurysm was revealed by mass effect in 13 cases and subarachnoid hemorrhage in one case. On admission 19 patients presented with unruptured aneurysms and two have sustained a subarachnoid hemorrhage. The balloon occlusion test before the bypass operation was not tolerated in 18 patients. The treatment was completed in 19 patients and 17 of them had parent artery occlusion with latex detachable balloons. The only death of the series occurred before the endovascular treatment. The mean follow-up period was 30 months. After completion of the treatment, 16 (84%) patients had no symptom. Aneurysm recanalization or rupture was not observed after the parent artery occlusion. With the combination of superficial temporal artery to middle cerebral artery bypass + endovascular parent artery occlusion, 90% of giant intracranial aneurysms untreatable selectively were permanently excluded with a good outcome in 95%.

Valve surgery in combination with cryoablation in the treatment of atrial fibrillation.

Objective:To investigate the effectiveness and safety of valve surgery in combination with cryoablation in the treatment of atrial fibrillation.Methods:Fifty patients who needed to undergo valve surgery because of heart valve disease and sixty-five patients who needed to undergo valve surgery in combination with cryoablation were selected as the research subjects. The perioperative technical characteristics, postoperative curative effect and complications were compared between the two different treatment modalities in our hospital between October 2013 and November 2015.Results:No significant differences were observed between the two groups in valve surgery mode, valve type and postoperative length of hospital stay (P>0.05), but the duration of extracorporeal bypass and aorta occlusion of the observation group was longer than that of the control group (P<0.05). The 3-month, 6-month and one-year atrial fibrillation cardioversion rates of patients in the observation group were superior to those of the control group, and the differences were notable (P<0.05). The improvement of left atrial diameter of the observation group was also superior to that of the control group (P<0.05). The incidence of postoperative complications of the two groups had no significant difference (P>0.05).Conclusion:Valve surgery in combination with cryoablation has favorable short-term clinical effect in the treatment of heart valve disease in combination with atrial fibrillation, which is worth promotion.

Treatment of Recurrent Intracranial Aneurysms After Neck Clipping: Novel Classification Scheme and Management Strategies.

BACKGROUNDRecurrent aneurysms after initial clipping have been discussed as an important issue in the surgical management of aneurysm.OBJECTIVETo report our experience with recurrent cerebral aneurysms after neck clipping and to discuss classification and recommended management.METHODSAneurysm treatments from a single institution over a 20-year period were retrospectively reviewed. Twenty-three recurrent aneurysms in 23 patients were managed during the study period. Recurrent aneurysms were classified using the concepts of closure line and closure plane, as follows. Type 1: neck situated in an almost different site from the previous clip. Type 2: existing closure plane and reconstructive closure plane are almost the same. Type 3: existing closure plane and reconstructive closure plane cross (type 3a); in rare cases, the existing closure line is sufficiently distant from the neck (type 3b). Type 4: no reconstructive closure line is identifiable.RESULTSNine patients presented with subarachnoid hemorrhage at recurrence. The mean interval to recurrence was 15.0 years. Management comprised clipping with elective subsequent old-clip removal (n = 7), clipping with preceding old-clip removal (n = 2), bypass occlusion (n = 1), coating (n = 1), combined surgery (n = 1), endovascular surgery (n = 4), and observation (n = 3). Therapeutic intervention was not indicated in 4 patients. Types 3a and 4 required more complex surgical procedures or coil embolization. Procedural complications were observed in 2 patients.CONCLUSIONA small but definite propensity toward recurrence after neck clipping exists, and most recurrent aneurysms require some form of retreatment. The novel classification scheme may provide conceptual clarity and therapeutic guidance for decision making.

Total aortic arch replacement using frozen elephant trunk technique with J Graft Open Stent Graft for distal aortic arch aneurysm.

The J Graft Open Stent Graft, the first commercialized stent graft in Japan, has been available since February 2014, and we have used this new device as a frozen elephant trunk technique for distal aortic arch aneurysm. Here, we present our surgical method and result with this new device. Between October 2014 and October 2016, 30 patients (26 males, mean age 74.3 ± 9.7 years) underwent total aortic arch replacement using the frozen elephant trunk technique with the J Graft Open Stent Graft for distal aortic arch aneurysm. The follow-up period was 10 months. In-hospital mortality and 30-day mortality were 0%. Stroke occurred in three cases (10%), paraplegia in one case (3.3%), respiratory complication in two cases (6.7%), and renal failure in two cases (6.7%). During the follow-up period, there was no aorta- related death, and two patients needed an aortic operation (re-hemiarch replacement for pseudoaneurysm of proximal anastomotic site; axilloaxillary bypass for occlusion of the left subclavian artery), and two patients needed catheter embolization for type II endoleak for reopening of the left subclavian artery. Our short-term surgical results were acceptable. This new device is useful for distal aortic arch aneurysms.

Risk factors for unplanned readmission and stump complications after major lower extremity amputation

ObjectiveThe unplanned 30-day readmission rate is a marker of quality of patient care across many disciplines. Data regarding risk factors for unplanned readmission after major lower extremity amputation (LEA) are limited. We evaluated predictors of readmission at our institution after major LEA. MethodsWe conducted a retrospective review of all patients undergoing above-knee amputation (AKA) or below-knee amputation (BKA) between November 2009 and November 2014. Patient demographic variables were collected. Predictors of unplanned 30-day readmission and stump complications were determined by multivariable logistic regression. ResultsA total of 811 patients were identified (AKA, 325; BKA, 486). Of these, 739 patients were included in the final analysis after excluding 30-day decedents without readmission. The overall 30-day readmission rate was 28.8% (AKA 27.9%; BKA 29.4%; P = .730). Stump complications accounted for 28.6% of readmissions (16.5% of AKA; 35.8% of BKA; P = .004). Other common diagnoses included nonsurgical site infection (33.8%), exacerbation of congestive heart failure (7.0%), and diabetes-related complications (6.1%). Surgical intervention was performed on 61% of stump complications (35.9% of AKA readmitted with stump complications; 68.7% of BKA readmitted with stump complications). BKA stump complications were converted to AKAs in 34.1% of cases (3.2% of the total BKA). None of the AKA stump complications required a higher level of amputation (ie, hip disarticulation). Independent predictors of all 30-day readmission included coronary artery disease and end-stage renal disease. American Society of Anesthesiologists class 3 as compared with class 4 was protective. Independent predictors of 30-day readmission for stump complications included rest pain and BKA. Patients who underwent BKA, rest pain as an indication for amputation, and having an occluded bypass graft were predictors of having a stump complication requiring surgery. ConclusionsThe 30-day readmission rate after major LEA is high, with wound infections accounting for a significant proportion of these readmissions. There was no difference in readmission rates based on level of amputation. Those undergoing BKA were more likely to present with stump complications requiring a surgical intervention, and often a higher level of amputation. Identification of high-risk patients may play a role in reducing postoperative readmissions and stump complications.

Rationale for graft selection in patients with complex internal carotid artery aneurysms treated with extracranial to intracranial high-flow bypass and therapeutic internal carotid artery occlusion.

OBJECTIVE After internal carotid artery (ICA) sacrifice without revascularization for complex aneurysms, ischemic complications can occur. In addition, hemodynamic alterations in the circle of Willis create conditions conducive to the formation of de novo aneurysms or the enlargement of existing untreated aneurysms. Therefore, the revascularization technique remains indispensable. Because vessel sizes and the development of collateral circulation are different in each patient, the ideal graft size to prevent low flow-related ischemic complications (LRICs) in external carotid artery (ECA)-middle cerebral artery (MCA) bypass with therapeutic ICA occlusion (ICAO) has not been well established. Authors of this study hypothesized that the adequate graft size could be calculated from the size of the sacrificed ICA and the values of MCA pressure (MCAP) and undertook an investigation in patients with complex ICA aneurysms treated with ECA-graft-MCA bypass and therapeutic ICAO. METHODS In the period between July 2006 and January 2016, 80 patients with complex ICA aneurysms were treated with ECA-MCA bypass and therapeutic ICAO. Preoperative balloon test occlusion (BTO) was performed, and the BTO pressure ratio was defined as the mean stump pressure/mean preocclusion pressure. Low flow-related ischemic complications were defined as new postoperative neurological deficits and ipsilateral cerebral blood flow reduction. Initial MCAP (iMCAP), MCAP after clamping the ICA (cMCAP), and MCAP after releasing the graft (gMCAP) were intraoperatively monitored. The MCAP ratio was defined as gMCAP/iMCAP. Based on the Hagen-Poiseuille law, the expected MCAP ratio ([expected gMCAP]/iMCAP) was hypothesized as follows: (1 - cMCAP/iMCAP)(graft radius/ICA radius)2 + (cMCAP/iMCAP). Correlations between the BTO pressure ratio and cMCAP/iMCAP, and between the actual and expected MCAP ratios, were evaluated. Risk factors for LRICs were also evaluated. RESULTS The mean BTO pressure ratio was significantly correlated with the mean cMCAP/iMCAP (r = 0.68, p < 0.0001). The actual MCAP ratio correlated with the expected MCAP ratio (r = 0.43, p < 0.0001). If the expected MCAP ratio was set up using the BTO pressure ratio instead of cMCAP/iMCAP (BTO-expected MCAP ratio), the mean BTO-expected MCAP ratio significantly correlated with the expected MCAP ratio (r = 0.95, p < 0.0001). During a median follow-up period of 26.1 months, LRICs were observed in 9 patients (11%). An actual MCAP ratio < 0.80 (p = 0.003), expected MCAP ratio < 0.80 (p = 0.001), and (M2 radius/graft radius)2 < 0.49 (p = 0.002) were related to LRICs according to the Cox proportional-hazards model. CONCLUSIONS Data in the present study indicated that it was important to use an adequate graft to achieve a sufficient MCAP ratio in order to avoid LRICs and that the adequate graft size could be evaluated based on a formula in patients with complex ICA aneurysms treated with ICAO.

IP089. Options for Preservation of Pelvic Circulation During Endovascular Aortic Aneurysm Repair

Maintenance of pelvic circulation reduces risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of aortoiliac aneurysmal disease. We evaluated the use of four techniques for preservation of flow to hypogastric arteries. All patients undergoing endovascular aneurysm repair requiring extension into the external iliac artery (and therefore management of the hypogastric artery) at a single institution were reviewed from 2006 to 2016. Choice of preservation vs embolization and preservation technique was at surgeon discretion. Four techniques were used in the series: external-to-internal iliac artery endovascular bypass (EIA-IIA), iliac branch endograft (IBD), kissing iliac stents extended from the gate of a bifurcated endograft (parallel grafts), and double bifurcated main-body graft use. Surveillance included duplex ultrasound imaging 1 month and 6 months postoperatively and annually thereafter for patients who required cross-femoral bypass (with the EIA-IIA bypass). For the remainder of patients, surveillance computed tomography scan (with selective contrast usage) was done 1 month postoperatively and annually thereafter. Thirty-two patients (mean age, 70 years; 97% male) were treated, preserving 36 hypogastric arteries. Most were treated for primary disease (n = 20), and the remainder was secondary interventions following open repair (n = 4) or endovascular repair (n = 8). Thirty patients had bilateral common iliac aneurysms, one had bilateral hypogastric aneurysms, and the remaining 18 had unilateral common iliac aneurysms. There was no preference for laterality (right, n = 20; left, n = 16). Proximal extension requiring snorkel/fenestration was present in seven patients. Seventeen aneurysms were treated with EIA-IIA bypass, 2 by IBD, 4 with double-bifurcated endografts, and 13 with parallel grafts. Technical success was 100%, with mean operative time 182 minutes and 71 mL contrast usage (range, 30-275 mL). Median length of stay was 3 days (range, 1-13 days). Over a mean follow-up of 22 months, there were no aortic-related mortalities, one EIA-IIA bypass occlusion (asymptomatic), and one reintervention (for type II endoleak). There were no additional endoleaks and no sac growth. The incidence of bowel ischemia, buttock claudication, and paralysis was zero in the series. While it is not yet clear which patients warrant preservation vs embolization, multiple techniques exist for preservation of pelvic circulation during endovascular repair. All four techniques presented appear to offer acceptable success and patency rates, and the optimal technique for each patient is largely a factor of preoperative selection based on anatomy and surgeon experience.

IP043. Hypogastric Preservation Using Retrograde Endovascular Bypass

Maintenance of pelvic circulation reduces risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of extensive aortoiliac aneurysmal disease. We evaluated the mid to late follow-up of patients treated using one preservation technique, the endovascular external-to internal iliac artery (EIA-IIA) bypass. All patients undergoing retrograde EIA-IIA endovascular bypass were retrospectively reviewed from 2006 to 2016. Anatomic inclusion criteria were common iliac artery aneurysms with or without concomitant aortic aneurysm limiting distal landing zone for endovascular repair and an iliac bifurcation angle >45°. Procedures were performed using aortouniiliac (AUI) endografts extended to one EIA, cross femoral artery bypass, and retrograde placement of covered stent grafts into the contralateral IIA. For patients with prior open repair, AUI placement was not required. Surveillance included duplex ultrasound imaging 1 month and 6 months postoperatively, and annually thereafter with computed tomography CT scan (with selective contrast usage) 1 month postoperatively and annually thereafter. Seventeen patients (mean age, 70 years; 93% male) were treated over the period. Most were treated for primary disease (n = 11), while the remainder underwent secondary interventions following open repair (n = 4) or endovascular repair (n = 2). Nine patients had bilateral common iliac aneurysms, one had bilateral IIA aneurysms, and the remainder had unilateral iliac aneurysmal degeneration with occluded or severely diseased ipsilateral hypogastric arteries. There was no preference for laterality (right iliac, n = 8; left iliac, n = 9). Retrograde bypasses were performed using Fluency (n = 1), Viabahn (n = 13), or Gore Excluder (n = 3) grafts. Hypogastric embolization with AUI extension to the EIA was required in six patients. Proximal extension requiring snorkel/fenestration was present in five patients. Technical success was 100%, with a mean operative time of 168 minutes (range, 50-300 minutes), and 71 mL contrast usage (range, 30-115 mL). Mean preoperative iliac artery aneurysm size was 4.0 cm with iliac bifurcation angle 71° (range, 51°-102°). Median length of stay was 3 days (range, 1-13 days). Over a mean follow-up of 25.7 months, there were no aortic related deaths, one EIA-IIA bypass occlusion (asymptomatic), and one reintervention (for type II endoleak). There were no additional endoleaks and no sac growth. The incidence of bowel ischemia, paralysis, and bowel/bladder dysfunction was zero in the series. Retrograde endovascular EIA-IIA bypass provides a low risk, high patency option for preservation of a single hypogastric artery with resultant maintenance of pelvic circulation.

Iliac Artery Stenting Combined with Ipsilateral Open Femoro-Popliteal Revascularization and Its Effect on Bypass Patency

In cases of multilevel obstructive atherosclerotic disease, hybrid procedures of concomitant iliac artery stenting and femoro-popliteal bypass (IS-FPB) may represent a valid approach, but results are still unclear. The aim was to evaluate early and long-term outcomes of concurrent IS-FPB. This retrospective study included 75 patients (76 limbs) treated with concomitant IS-FPB between January 2010 and June 2016. All patients were prospectively enrolled in a dedicated database. Long-term patency and limb salvage rates were reported using Kaplan-Meier curves. Clinical presentation, lesion sites and extension, distal runoff, type of stent, and bypass were evaluated for their association with patency using univariate and multivariate analysis. Mean age was 72.2±9.4years; the Society for Vascular Surgery comorbidity score was 1.14±0.61. A covered stent (CS) was implanted in 41 (54%) iliac arteries and a bare-metal stent in 35 (46%); a polytetrafluoroethylene graft was used for bypass in 44 limbs (58%) while 32 limbs (42%) had great saphenous vein bypass. Technical success was 99%; the 30-day cumulative surgical complications rate was 6%, mortality 2%, and morbidity 1%. At 42months, primary patency of the entire ilio-femoral axis was 65.2% (95% confidence interval [CI], 53-86%). This finding was primarily related to femoro-popliteal bypass occlusion (primary patency, 69.5%), rather than iliac stent loss of patency (primary patency, 94.6%). Secondary patency was 77.6% and limb salvage 89.9%. Univariate analysis demonstrated that Rutherford category 5/6 was a negative predictor of FPB patency (P=0.04), whereas common femoral artery endarterectomy (P=0.03) and the use of a CS (P=0.02) were positive predictors. Multivariate analysis finally indicated that the use of CS to treat iliac obstructive disease was an independent predictor of patency (hazard ratio, 0.15; 95% CI, 0.03-0.64; P=0.01). Concurrent IS-FPB has acceptable early and long-term results. Even if further studies are needed, the use of a CS for the iliac obstruction seem to provide better outcomes in the hybrid treatment of these cases of multilevel disease.

Drug-eluting balloons and uncoated balloons perform equally to rescue infrainguinal autologous bypasses at risk

ObjectiveEndovascular treatment of a significant stenosis in an infrainguinal autologous bypass prevents bypass occlusion and improves bypass patency. Drug-eluting balloons (DEBs) have been proven to possess antirestenotic features in the treatment of femoropopliteal stenoses and occlusions. This study evaluated the effects of DEB angioplasty vs uncoated balloon (UCB) angioplasty to rescue infrainguinal autologous bypass grafts at risk (BAR). MethodsThe study included all consecutive patients treated endovascularly for BAR from December 1, 2012, to July 31, 2015. As of April 1, 2014, the primary treatment of BAR was changed from UCBs to DEBs. Patients treated with DEBs were prospectively recorded in a database and retrospectively analyzed. Patients treated with UCBs were retrospectively collected from a historical cohort with a similar inclusion period length as the DEB cohort. The follow-up scheme did not differ between the two groups. The primary end point was the combined end point of freedom from recurrent stenosis or bypass occlusion. Secondary end points were primary assisted patency, secondary patency, technical success, major amputation, and mortality. ResultsTwenty-one patients were treated in the DEB group and 18 were treated in the UCB group. The two groups were evenly distributed in demographics, bypass, treatment, and lesion characteristics. No statistically significant differences were found in the combined end point of freedom from recurrent stenosis and the occlusion rate after 1 year between the UCB group (77.8%) and the DEB group (80.0%; P = .76). After 1 year, the primary assisted patency rate was 88.2% in the UCB group vs 95.2% in the DEB group (P = .47), and the secondary patency rate was 94.1% in the UCB group vs 95.2% in the DEB group (P = .91). During follow-up, restenosis developed in four patients (22.2%) in the UCB group and in four patients (19.0%) in the DEB group (P = .80). One bypass (5.6%) in the UCB group and one bypass (4.8%) in the DEB group occluded during follow-up (P = .884). ConclusionsDEBs and UCBs perform equally in the treatment of significant stenosis in infrainguinal autologous bypasses with regard to freedom from restenosis or bypass occlusion, primary assisted patency, and secondary patency at 1 year. We suggest using a less expensive UCB in the treatment of BAR.

Metabolomic profiling in patients undergoing Off-Pump or On-Pump coronary artery bypass surgery

BackgroundCoronary artery bypass surgery can be performed without (Off-Pump) or with cardiopulmonary bypass (On-Pump). Extracorporeal circulation and cardioplegic arrest may cause alterations in the plasma metabolome. We assessed metabolomic changes in patients undergoing On-Pump or Off-Pump coronary artery bypass surgery.MethodsWe assessed five analyte classes (41 acylcarnitines, 14 amino acids, 92 glycerophospholipids, 15 sphingolipids, sugars, lactate) using a mass-spectrometry-based kit (Biocrates AbsoluteIDQ® p150) in paired arterial and coronary sinus blood obtained from 10 consecutive On-Pump and 10 Off-Pump patients. Cardioplegia for On-Pump was warm blood Calafiore. On-Pump outcomes were corrected for hemodilution through crystalloid priming.ResultsDemographic data were equal in both groups with normal ejection fraction, renal and liver function. Patients received 2.25 ± 0.64 bypass grafts. All postoperative courses were uneventful. Of 164 measured metabolites, only 13 (7.9%) were altered by cardiopulmonary bypass. We found more long-chain acylcarnitines Off-Pump and more short-chain acylcarnitines On-Pump. Glycerophospholipids showed lower concentrations On-Pump and arginine (as the only different amino acid) Off-Pump. Interestingly, plasma arginine (nitric oxide precursor) concentration at the end of surgery correlated inversely with postoperative vasopressor need (r = −0.7; p < 0.001). Assessing arterial/venous differences revealed phosphatidylcholine-production and acylcarnitine-consumption. These findings were unaffected by cardiopulmonary bypass, cardioplegia or temporary vessel occlusion during Off-Pump surgery.ConclusionsCardiopulmonary bypass and warm blood cardioplegia cause only minor changes to the metabolomic profile of patients undergoing coronary artery bypass surgery. The observed changes affected mainly acylcarnitines. In addition, there appears to be a relationship between arginine and vasopressor need after bypass surgery.

バイパス（外腸骨～腋窩）閉塞26年後に吻合部動脈瘤を生じた高安動脈炎の1例

バイパス（外腸骨～腋窩）閉塞26年後に吻合部動脈瘤を生じた高安動脈炎の1例

頭蓋内血行再建を安全確実に行うための原則と工夫

Introduction: Although improvements in endovascular treatment have decreased the frequency of bypass surgery, cerebral vascular reconstructions are still important. Many critical points are required to achieve a reliable bypass patency. We describe our experience and techniques for bypass surgery, especially focusing on the superficial temporal artery to middle cerebral artery (STA-MCA) bypass.Materials and methods: Over a period of 5 years, STA-MCA bypass was performed for 42 patients with atherosclerotic internal carotid artery or middle cerebral artery occlusion, or hemodynamic ischemia; 35 patients with moyamoya disease; and 97 patients with complex cerebral aneurysms. Mean occlusion time, bypass patency, hyperperfusion, ischemic complication, and postoperative delayed wound healing were assessed.Results: Within 42 ischemic cases, the mean occlusion time of the STA-MCA procedure was 20 minutes 16 seconds. No ischemic complications due to temporal occlusion occurred. Acute bypass occlusion (occlusion within 2 weeks after operation) occurred in 1 case of STA-MCA for moyamoya disease and 1 case of STA-MCA bypass for a patient with ischemic occlusion. Perioperative ischemic stroke was observed in 4 patients with ischemic occlusion and 1 patient with moyamoya disease.Conclusion: To perform a safe and reliable vascular reconstruction, off-the-job training, a bloodless operative field, selection of an appropriate donor and recipient artery, use of the “fish mouth” method for trimming the donor artery, and an intima-to-intima everting suture are necessary.

Biosynthetic Grafts To Replace Infected Prosthetic Vascular Bypasses: A Single-Center Experience.

There are only a few options to replace infected infrainguinal synthetic vascular grafts in the absence of suitable autologous veins. To use a biosynthetic vascular graft (Omniflow®II) might be a valuable alternative. We retrospectively analyzed the clinical course of 29 patients who underwent replacement of an infected infrainguinal vascular prosthesis (Szilagyi 3) by an Omniflow®II graft. Because of the lack of suitable autologous veins, 15 above-knee femoro-popliteal, 5 below-knee femoro-popliteal, and 9 femoro-tibial bypasses were replaced with biosynthetic grafts. There were no in-hospital deaths, reinfections, or major amputations. The survival rate was 92% at one year and 87% at two years. During follow-up (median 24 months; range 5-66 months), no reinfections occurred. However, nine patients presented with bypass occlusions (primary patency 67.6% at one year and 61.5% at two years; secondary patency 85.3% at one year and 69% at two years). The limb salvage rate was 89% at one year and 83% at two years. Biosynthetic bypass grafts might be valuable to replace infected prosthetic grafts in the absence of a suitable vein. They have excellent re-infection resistance. Limb salvage, morbidity, and the mortality rate are similar to those obtained with autologous vein grafts in infected fields.

The Treatment of Post-Thrombotic Syndrome.

Post-thrombotic syndrome (PTS) arises in 20-50% of patients who have sustained a deep vein thrombosis and markedly impairs their quality of life. This review is based on pertinent publications retrieved by a selective literature search in PubMed and the Cochrane Library, and on the guidelines of the German Societies of Phlebology and Vascular Surgery (Deutsche Gesellschaft für Phlebologie, Deutsche Gesellschaft für Gefässchirurgie). The treatment options are conservative treatment with compression and patient exercises, endovascular recanalization with stent angioplasty, and open bypass surgery of the iliac obstructions. The endovascular techniques yield patency rates of 73 to 100%, with thrombotic stent occlusion and hematoma as potential complications. The open operations have only been documented in studies with small case numbers (3 to 85 cases per study, patency rates 58 to 100%). The complications of these invasive procedures can include thrombotic bypass occlusion, hematoma, and wound infection. There have been randomized trials of conservative treatment, but not of surgical treatment. The American Heart Association, in its guidelines, gives the same weak recommendation for all surgical methods (IIb). All conservative options should be exhausted as the first line of treatment. If PTS symptoms persist and markedly impair the patient's quality of life, the possible indication for surgery should be considered. As PTS hardly ever leads to death or limb loss, its treatment should be as uninvasive as possible. Endovascular recanalization is an attractive option in this respect. A conclusive evaluation of the role of endovascular procedures in PTS must await randomized trials of this form of treatment and of the optimal stent configuration.

Patterns in the Management of Acute Limb Ischemia: A VESS Survey

Treatment strategies for acute limb ischemia (ALI) are abundant with few established guidelines. We sought to determine nationwide ALI treatment patterns in the modernera. Anonymous electronic surveys examining the management of ALI involving native vessel and bypass occlusion were sent to all members of the Vascular and Endovascular Surgery Society (n=738). Treatment options included catheter-directed lysis (CDL) or pharmacomechanical (PMT) thrombolysis and open surgery. CDL management strategies were evaluated for lytic and heparin dosing, fibrinogen monitoring, and treatment duration. Influence of Rutherford category (RC), time from training, practice type, hospital size, region, and protocol use was assessed. Data were analyzed by univariate contingency tables and multinomial regression analysis. A total of 117 (response rate of 16%) surveys were completed. The most common management strategy RC 2a ischemia in all conduit occlusions was endovascular (prosthetic graft, 96 [82%] respondents; vein graft 96 [82%] respondents; native artery occlusion 79 [68%] respondents), while those with RC 3 ischemia were more commonly treated with open techniques (prosthetic graft, 96 [83%]; vein graft 94 [81%]; native artery occlusion 94 [80%]). Of those respondents using endovascular therapy, CDL was most commonly used in RC 2a patients, while PMT was most commonly used in RC 3 patients. Multivariate analysis identified prosthetic and vein graft occlusion were more likely to be treated via endovascular approach (odds ratio, 2.45 and 2.78, respectively; P<0.001), while those with RC 2b (odds ratio, 0.19; P<0.001), RC 3 (odds ratio, 0.01; P<0.001), or in centers without a hybrid operating room (odds ratio, 0.49; P=0.017) were more likely to be treated by openapproach. Tissue plasminogen activator (TPA) dosing during catheter directed therapywas usually 1mg/hr (77%) with variable concentrations and duration of the initial treatment of 8-24 hr (78%). Most respondents indicated having developed their own protocols and patterns of treatment varied but were influenced by training and practice environment variables. Management strategies vary widely in ALI. Some effects of provider training and individual protocol development were observed, and TPA protocols were influenced by increased institutional responsibility for thrombolysis. Further efforts are needed to develop consensus guidelines for ALI management.

Management of endo-graft infection following endovascular repair of abdominal aortic aneurysm

To summarize our experience in the management of stent-graft infection after endo-vascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA). Data of patients who were diagnosed as endo-graft infection following EVAR and admitted in our center between January 2000 and December 2015 were reviewed. Clinical records including causes of infection, medical history, re-operative procedures, and prognostic data were analysed. A total of 10 male patients, aged 45-72 years (averaged 62.5 years), were enrolled. Two patients received previous EVAR in our center, accounting for 0.23% of all the 885 EVAR procedures we conducted during the same period. The symptoms related to stent infection, including recurrent fever (100%) and persistent back pain (40%), occured 0 to 27 months (averaged 6.9 months) after EVAR procedure. Eight patients were found to have apparent causes (80%), including 1 case with upper respiratory infection and sepsis, 4 cases with aorto-enteric fistula (AEF) and 3 cases with inflammatory AAA. Except one DNR, other 9 patients received re-operation, including 1 procedure of open debridement and drainage, 1 procedure of endo-graft excision and bilateral axillary-femoral bypass, 7 procedures of endograft excision and axillary-bifemoral bypass. During the follow-up period(2-60 months, averaged 24.1 months), 1 patient was lost, 1 patient died from aortic stump rupture (12.5%) and other 7 patients survived. Bypass occlusion was observed in 1 patient (12.5%) without severe limb ischemia. AEF and inflammatory AAA are two leading causes of endo-graft infection following EVAR in our patients. Graft excision and axillofemoral bypass is an acceptable management for this life-threatening morbidity.

Is It Worthwhile Treating Occluded Cold Stored Venous Allografts by Thrombolysis?

Thrombolysis has been reported to be suboptimal in occluded vein grafts and cryopreserved allografts, and there are no data on the efficacy of thrombolysis in occluded cold stored venous allografts. The aim was to evaluate early outcomes, secondary patency and limb salvage rates of thrombolysed cold stored venous allograft bypasses and to compare the outcomes with thrombolysis of autologous bypasses. This was a single center study of consecutive patients with acute and non-acute limb ischemia between September 1, 2000, and January 1, 2014, with occlusion of cold stored venous allografts, and between January 1, 2012, and January 1, 2014, with occlusion of autologous bypass who received intra-arterial thrombolytic therapy. Sixty-one patients with occlusion of an infrainguinal bypass using a cold stored venous allograft (n=35) or an autologous bypass (n=26) underwent percutaneous intra-arterial thrombolytic therapy. The median duration of thrombolysis was 20h (IQR 18-24) with no difference between the groups (p=.14). The median follow up was 18.5 months (IQR 11.0-52.0). Secondary patency rates of thrombolysed bypass at 6 and 12 months were 44±9% and 32±9% in patients with a venous allograft bypass and 46±10% and 22±8% with an autologous bypass, with no difference between groups (p=.40). Limb salvage rates at 1, 6, and 12 months after thrombolysis in the venous allograft group were 83±7%, 72±8% and 63±9%, and in the autologous group 91±6%, 76±9%, and 65±13%, with no difference between groups (p=.69). Long-term results of thrombolysis of venous allograft bypasses are similar to those of autologous bypasses. Occluded cold stored venous allograft can be successfully re-opened in most cases with a favorable effect on limb salvage.

A Ruptured Vertebral Artery Dissecting Aneurysm Involving the Anterior Spinal Artery:A Case Report

A 50-year-old woman presented with a subarachnoid hemorrhage caused by a ruptured vertebral artery dissecting aneurysm(VADA)involving the anterior spinal artery(ASA). The ASA branched at the proximal component of the dissecting aneurysm. The rupture point was presumed to be the distal region of the dissecting aneurysm. We performed coil embolization of the distal part only in order to prevent rebleeding and preserve the ASA. The patient showed no neurological deficits. Six months after the procedure, an angiogram demonstrated occlusion of a distal portion of the right vertebral artery. However, the ASA was still patent. No rebleeding occurred, and the patient has remained neurologically symptom-free for 3 years from the treatment. ASA-involved VADAs are extremely rare. Treatment strategy is difficult because there are no options for bypass surgery and occlusion of the ASA may lead to quadriplegia unless there is collateral flow to the ASA. Although the outcome of the patient was good with partial coil embolization in this case, the treatment strategy should be carefully considered for ASA-involved VADAs.

クリッピング困難な内頚動脈瘤に対するバイパス併用手術

The treatment of complex internal carotid artery (ICA) aneurysms is still a controversial issue. This study aimed to evaluate the safety and efficacy of a surgical strategy using the bypass procedure in such patients. We retrospectively reviewed the clinical and radiological records of 50 consecutive patients with 52 complex ICA aneurysms who underwent bypass surgery. In this study, we divided the ICA into 3 segments based on the origin of the ophthalmic artery (OpthA) and posterior communicating artery (PComA). All patients with an aneurysm located in the portion proximal to the OpthA (segment 1) were treated with bypass and proximal ICA occlusion, and only 1 patient (5.2%) experienced an ischemic complication. Among patients with an aneurysm located between the OpthA and PComA (segment 2), 14 were treated with bypass and trapping, and 10 were treated with clipping under bypass. Among these, 3 (12.5%) had an ischemic complication and 1 (4.2%) had a hemorrhagic complication. Among patients with an aneurysm located distal to the PComA (segment 3), clipping under temporary bypass was performed in 2, clipping with bypass and proximal occlusion in 4, trapping in 2, and bypass and proximal occlusion in 1. However, 4 of 9 (44.4%) patients had an ischemic complication. Finally, 41 of 50 (82.0%) patients showed a favorable outcome (modified Rankin scale 0-2) in this series. In conclusion, the results of our surgical strategy using a bypass procedure were acceptable; however, ischemic complications were a persistent problem in aneurysms located distal to the PComA.