Native Artery Occlusion Research Articles

Mid-term Outcomes of Image-Guided Surgical Thromboembolectomy and Routine Intraoperative Angiography for Native Vessel Acute Lower-Limb-Threatening Ischemia.

Standard balloon-catheter thromboembolectomy (TE) is an established effective treatment for acute lower-limb ischemia (ALI) with recognized limitations when there is an underlying arterial lesion or thromboembolism of the infrapopliteal arteries. The aim of this study was to evaluate the efficacy and safety of image-guided surgical TE combined with routine intraoperative completion angiography in the treatment of ALI patients. Between September 2020 and August 2022, this prospective study included all consecutive adult patients presenting to a tertiary center with unilateral ALI of Rutherford class II due to thromboembolic occlusion of native arteries who underwent image-guided surgical TE and routine completion intraoperative angiography. Adjunctive endovascular techniques (hybrid revascularization) including plain balloon angioplasty (PTA)±stenting or on-table lysis were used if underlying arterial lesions or residual thrombosis were detected on the intraoperative angiography, respectively. The primary outcome measures included technical success and 30-day major amputation rate. Perioperative complications, 1-year primary and secondary patency, limb salvage, mortality, and amputation-free survival rates were endorsed as secondary outcome measures. Image-guided surgical thrombectomy was done for 109 ALI patients (109 limbs), provisionally diagnosed as embolic (57 patients, 52.3%) or thrombotic (52 patients, 47.7%) arterial occlusion. Thromboembolectomy without adjunctive endovascular treatment was done in 38 patients (34.86%), whereas 71 patients (65.14%) required adjunctive PTA±stenting of underlying arterial lesions (60, 55.05%) or on-table lysis±PTA of residual thrombosis (11, 10.09%). The overall technical success rate was 92.66%. At 30 days, amputation and mortality rates were 3.67% and 5.5%, respectively. None of the patients had thrombectomy-induced arterial injuries. One-year follow-up data were available for 81 patients (74.3%). The Kaplan-Meier estimate of the 12-month primary and secondary patency, limb salvage, and amputation-free survival rates was 76.5%±0.04, 91.5%±0.03, 90.6±0.03, and 91.4±0.03%, respectively. Image-guided TE combined with routine intraoperative angiography is a safe and effective technique for surgical TE in acute lower-limb ischemia patients with the advantage of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. The present study has confirmed the safety and effectiveness of image-guided thromboembolectomy combined with routine use of intraoperative angiography during surgical treatment of acute lower limb ischemia in terms of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. This technique also facilitates selective passage of Fogarty balloon catheter into infrapopliteal arteries from the femoral approach which is traditionally done by exploration of the popliteal trifurcation or tibial arteries under regional or general anesthesia. Using this technique can guide the operating surgeon for adequate balloon manipulation and inflation to avoid iatrogenic vessel injury.

Interventions in Left Internal Mammary Artery

Left internal mammary artery (LIMA) grafts are the preferred arterial grafts as they are more durable. LIMA grafts can develop stenosis most commonly at the distal anastomotic site and less frequently involve the ostium or body of LIMA. They may occur in the immediate post-operative period due to technical faults or occur several years later. LIMA graft interventions are more challenging because of its long and tortuous course and frequently tend to develop spasm and dissection. It might be the only method of revascularization in some patients and needs to be undertaken on and off. LIMA grafts have been used for retrograde revascularization of chronic total occlusion of native coronary arteries.

Outcomes of patients with acute type A aortic dissection and concomitant lower extremity malperfusion

ObjectiveThe occurrence of acute lower limb ischemia (ALLI) is a serious risk within the context of aortic dissection repair. The aim of the present study was to examine the outcomes of patients with acute type A aortic dissection (ATAD) and concomitant lower extremity malperfusion. MethodsWe performed a retrospective medical record review at our tertiary referral center of patients who underwent ATAD repair from January 2002 to June 2018. We used univariate and multivariate analyses to compare the outcomes of patients with and without lower extremity malperfusion. The primary outcomes were 30-day and 1-year mortality. ResultsA total of 378 patients underwent ATAD repair during the study period. Their mean age was 57 years, 68% were men, and 51% were White. A total of 62 patients (16%) presented with concomitant ALLI, including 35 (9%) who presented with isolated ALLI and 27 (7%) who presented with ALLI and concomitant malperfusion of at least one other organ. Of the 62 patients with ALLI, 46 underwent only proximal aortic repair. Of the 378 patients, 6 died within the first 24 hours, and their limb perfusion was not assessed. Among the 40 patients who underwent isolated proximal repair and survived >24 hours, 34 (85%) had resolution of their ALLI. Of the 16 patients who underwent concomitant lower extremity peripheral vascular procedures, 10 had bypass procedures and 1 died within 24 hours due to refractory coagulopathy and hypotension. All six patients with adequate follow-up imaging studies had asymptomatic occlusion of the bypass graft with recanalization of the occluded native arteries. Patients who presented with any organ malperfusion had increased 30-day (odds ratio, 1.8; P = .04) and 1-year (odds ratio, 1.8; P = .04) mortality and decreased overall survival (P < .01). For the patients with isolated ALLI, no significant differences were found in 30-day or 1-year mortality or overall survival (P = .57). ConclusionsProximal repair of ATAD resolves most cases of associated ALLI, and isolated ALLI does not affect short- or long-term survival. All patients with follow-up in our study who underwent extra-anatomic bypass developed asymptomatic graft occlusion, which could be attributed to competitive flow from the remodeled native arterial system. We believe that rapid and aggressive restoration of flow to the lower extremity is the best method to treat ALLI malperfusion syndrome. Close monitoring for the development of compartment syndrome is recommended.

A Comparison of Outcomes Based on Vessel Type (Native Artery vs. Bypass Graft) and Artery Location (Below-Knee Artery vs. Non-Below-Knee Artery) Using a Combination of Multiple Endovascular Techniques for Acute Lower Limb Ischemia

To evaluate outcomes of endovascular treatment (EVT) using a combination of multiple endovascular techniques for acute lower limb ischemia (ALLI) and to compare outcomes based on vessel type and artery location. A total of 95 consecutive patients with ALLI (mean age, 72.0 years; 65 males; 104 lower limbs) who received emergency EVT using a combination of multiple endovascular techniques including thrombolysis, aspiration thrombectomy, stenting, and balloon angioplasty with or without surgical thromboembolectomy, between January 2005 and December 2017 were included. Vessel type was classified into native artery occlusion (native occlusion) and bypass graft occlusion (graft occlusion), including prosthetic and vein graft. Additionally, native arteries were categorized into below-knee occlusion and non-below-knee occlusion. Technical success, perioperative death (POD), ALLI-related death, amputation, amputation-free survival (AFS), and complications were compared according to vessel type (native occlusion vs. graft occlusion) and artery location (below-knee occlusion vs. non-below-knee occlusion). Of all patients with ALLI, 16.8% underwent a single endovascular technique, whereas 83.2% underwent a combination of multiple endovascular techniques. The technicalsuccess, POD, and ALLI-related death rates in the total number of patients were 94.7%, 11.6%, and 4.2%, respectively. A total of 67 patients (75 limbs) and 28 patients (29 limbs) were classified as having native occlusion and graft occlusion (prosthetic, 24 limbs; vein, 5 limbs), respectively. No significant differences in technical success (native occlusion: 92.5% vs. graft occlusion: 100%), POD (14.9% vs. 3.6%), and ALLI-related death (6.0% vs. 0%) were noted between native occlusion and graft occlusion. However, the 30-day AFS rate of native occlusion was significantly lower than that of graft occlusion (75.2% vs. 96.3%, P=0.01). The amputation rate (P=0.03) and AFS rate (P=0.03) of below-knee occlusion were significantly worse for below-knee occlusion patients than for non-below-knee occlusion patients. EVT using multiple endovascular techniques for ALLI is effective and safe. A combination of multiple endovascular techniques is crucial for successful treatment. However, native occlusion may have a lower AFS rate than graft occlusion, and below-knee occlusion may have a higher risk of amputation than non-below-knee occlusion.

Acute coronary syndrome due to native coronary occlusion proximal to a patent bypass graft: a case report.

BackgroundPrimary percutaneous coronary intervention (PCI) for acute coronary syndrome has significantly contributed to improvements in overall outcomes. However, clinical challenges exist when performing urgent PCI for patients with a history of coronary artery bypass grafting (CABG).Case summaryAn 83-year-old man with a history of CABG presented with an inferior ST-elevation myocardial infarction (STEMI). Emergent coronary angiography showed an occlusion of the right coronary artery that had been previously grafted with the right gastroepiploic artery. Primary PCI for the native coronary artery was performed on the assumption that the bypass graft had been occluded. We were unable to attain angiographic antegrade flow after balloon angioplasty, and intravascular ultrasound revealed a ruptured plaque with a thrombus proximally and a patent bypass graft with complete recanalization distally. These findings suggested that the plaque rupture with resultant thrombus formation proximal to the anastomosis eventually overlay the patent bypass graft. Subsequent stent implantation covering only the culprit site with a residual stenosis proximal to the anastomosis was performed, resulting in good patency of both the native coronary artery and bypass graft for more than 3 years.DiscussionThis is the first documented case of a patient with STEMI due to proximal native coronary artery occlusion with a thrombus overlying a patent bypass graft. Intravascular ultrasound was helpful to recognize the distal patency and guide optimal stent implantation. This case illustrates the complexity of treating a patient with a history of CABG and the importance of a multifaceted approach in such an urgent situation.

Determinants of amputation and mortality following thromboembolectomy in native acute lower limb arterial occlusions, the influence of early intervention: A retrospective cohort study

Aim: In acute arterial occlusion, there is a sudden blockage of blood flow to the extremity, threatening its viability. Early/emergency intervention is required to eliminate the risk of amputation, but some of these cases receive a delayed diagnosis. The aim of this study is to evaluate the influence of surgical timing on the incidence of amputation and other factors affecting the risk of extremity loss. Methods: A total of 154 patients who underwent thromboembolectomy were analyzed. The patients were categorized into three groups, as follows: Group 1 included patients with symptoms present for less than 12 hours, Group 2 comprised those with symptoms present for more than 12 hours but less than one week, and Group 3 included patients with symptoms present for more than one week. The groups were evaluated in terms of amputation and mortality. Results: The incidence of amputation was significantly lower in Group 1 compared to the other two groups (P<0.05), and similar between Groups 2 and 3. In-hospital mortality did not significantly differ between the groups. When categorical and continuous variables were evaluated, a significant relationship was found between the risk of amputation and increasing age, female gender, diabetes, and iliac occlusion (P<0.05). The risk of in-hospital mortality was higher in females and in cases with cardiac arrhythmia (P<0.05). Conclusion: Early surgical embolectomy is more successful in limb salvage. The risk of amputation is increased in diabetics, females, the elderly, and in proximal arterial occlusion.

PC024. Lower Limb Malperfusion in Acute Type A Dissection

Acute type A aortic dissection (ATAD) presenting with acute limb ischemia (ALI) has been identified as a predictor of in-hospital mortality. This study examines the outcome of patients presenting with ATAD with ALI. A prospectively collected database was queried for all cases of ATAD repaired between 2002 and 2018 at a tertiary referral center. Patients presenting with ALI were identified. Comparisons between groups with and without lower extremity ALI were made. For continuous variables, univariate two-group comparisons were performed. For categorical variables, univariate two-group comparisons are performed. Statistical significance is set at P < .05. During this period, 378 patients (average age, 56.9 years) underwent ATAD repair. Of these, 62 patients (16.4%) presented with ALI; 35 patients (9.2%) presented with isolated ALI, whereas 27 (7.1%) had concomitant malperfusion in at least one other organ system. Of the 62 patients presenting with ALI, 46 (74.2%) underwent proximal aortic repair alone; 16 (25.8%) also underwent lower extremity vascular intervention (Fig). In the latter part of the study, perfusion of the ischemic limb was accomplished during repair of the ATAD through a side perfusion cannula directly from the bypass circuit (10 patients). There were six amputations (9.7%) performed in the ALI group, two of which had peripheral vascular repairs. Fasciotomies were performed on 18 patients; of these, 5 had concomitant peripheral vascular repairs. Of the 55 patients with ALI surviving past 24 hours, 34 (61%) had resolution of their lower limb ischemia with proximal repair only. The 30-day survival was decreased in patients who presented with any organ malperfusion (P = .012). However, in patients with isolated ALI, there was no significant difference in 30-day mortality (11.4%) compared with the group with no malperfusion (15.7%; P = .5). Sixteen patients underwent peripheral vascular procedures for their limb ischemia, including 10 patients who underwent bypass procedures (7 femoral-femoral, 1 axillary-femoral-femoral, and 2 axillary-femoral), with 1 patient dying within 24 hours. All six patients with adequate follow-up imaging demonstrated asymptomatic occlusion of the bypass graft. In this group, computed tomography angiography showed recanalization of the occluded native arteries. Proximal repair of ATAD resolves most associated ALI. Isolated ALI did not increase 30-day mortality. All patients with follow-up who underwent extra-anatomic bypass developed asymptomatic graft occlusion. This was attributed to competitive flow from the remodeled native arterial system.

Catheter-directed thrombolysis in thrombotic acute lower limb ischemia: challenges and management

Background The aim of this study to assess the result of catheter directed thrombolysis (CDT) in acute thrombotic lower limb ischemia with special emphasis on the technique and challenges. Methods It is a prospective study that was held in vascular surgery department, Cairo University from March 2016 to March 2018. Twenty four patients with ALI were recruited with infra-inguinal acute native arterial occlusions less than 14 days. Inclusions criteria were age is less than 75 years, ALI categories I, IIa Rutherford classification. Exclusion criteria were; acute embolic ischemia, ALI category IIb or III Rutherford classification, occluded bypass graft, contraindication of thrombolytic therapy and Patients older than 75 years. Result Twenty four consecutive patients (19 males and 5 females) were included in the study with mean Age 63.5 years. Out of 24 CDTs performed, 20 patients (83.3%) required additional procedures, 15 percutaneous intervention (12 balloon dilatations and 6 stentings for superficial femoral artery (SFA), and 3 cases of aspiration thrombectomy) and 3 open procedures (3 cases of popliteal thromboemolectomy) and 2 hybrid cases of CFA thromboendarterectomy and angioplasty for femeropoliteal segment). Five bleeding complications were reported in the study group with 4 clinically non- major bleeding complications, all were managed conservatively. Major bleeding from groin required surgical intervention in only one case. A total of 4 (16.6%) major amputations were done during the follow-up period, the amputation-free survival was 87.5%, 83.3%, and 83.3 at one, three, and six months post-procedurally. No mortalities in the study patients during 6 months of follow up. Conclusion Thrombolytic therapy remains an effective and valuable option for treatment of ALI. About 25% of patients still required an open procedure post thrombolytic therapy. So; proper patients selection is needed to detect patient who will benefit from primary surgery rather than thrombolysis.

Acute Limb Ischemia Secondary to Native Artery Occlusion: Results of a Contemporary Case Series.

The treatment of acute limb ischemia (ALI) has barely changed over the last years. However, the progressive implementation of anticoagulants, antiplatelet agents or statins within the population might have modified the profile and prognosis of patients suffering an ALI. The aim of this study was to evaluate the current results of the management of ALI secondary to a native artery occlusion. Retrospective study of 220 consecutive patients (mean age 78years; 49% male) was conducted between 2007 and 2015. ALI secondary to trauma or grafts/stents occlusions were excluded. Statistical analysis was performed with logistic regression. A total of 141 cases (64.1%) were attributed to embolism and 79 (35.9%) to acute arterial thrombosis. Peripheral neuro-ischemic impairment occurred in 135 patients (61.4%), being severe in 42 (19.1%). ALI treatment included anticoagulation (n=27; 12.3%), regional fibrinolysis (n=2; 1%), embolectomy/thrombectomy (n=129; 58.6%), angioplasty/stenting (n=8; 3.6%), bypass (n=47; 21.3%) or direct major limb amputation (n=7; 3.2%). Limb salvage and survival rates at 30/90days were 95%/95% and 82.3%/74.1%, respectively. Independent risk factors for major amputation were diabetes, severe neuro-ischemic impairment, acute arterial thrombosis and treatment delay >1day after vascular consultation. In addition, age, chronic peripheral arterial disease, any neuro-ischemic impairment and a hospitalization for any other reason simultaneous to the ALI were independently associated with mortality. Regardless of excellent limb salvage rates, patients currently suffering from an ALI are, when compared to previous studies, older than before and with an increased rate of mortality. Risk factors do not appear to be modifiable once the ALI appears so prevention strategies should be aimed to avoid the episode.

Recanalization of native superficial femoral artery chronic total occlusion after failed femoropopliteal bypass in patients with critical limb ischemia.

This study aimed to examine the outcomes of endovascular recanalization for native superficial femoral artery (SFA) chronic total occlusion (CTO) in patients with critical limb ischemia (CLI) after femoropopliteal bypass failure with limited surgical revascularization options. Endovascular recanalization of native artery occlusions has been recently used as a new alternative for threatened limbs after bypass graft occlusion. The feasibility and efficacy has not been widely reported. We retrospectively analyzed 45 consecutive patients (45 limbs) undergoing endovascular recanalization of native SFA occlusion following failed femoropopliteal bypass between June 2010 and December 2016. All limbs had Transatlantic Inter-Society Consensus class C (26.7%, 12/45) or D (73.3%, 33/45) lesions with a mean lesion length of 29.8 cm. The technical success rate was 95.6% (43/45 limbs). The ABI showed a significant increase from 0.3 ± 0.1 pre-procedure to 0.7 ± 0.1 post-procedure (P < 0.01). Two early (<30 days) below-knee amputations due to acute thrombotic ischemia occurred during perioperative period and resulted in one death due to myocardial infarction. The mean follow-up was 42.7 months (1-62 months). Two patients were lost to follow up. The primary patency rates at 12 and 36 months were 54% and 51%, respectively. Secondary patency rates at 12 and 36 months were 78% and 61%, respectively. Limb salvage rate was 95% and amputation-free survival rate was 88% at both 12 and 36 months. Recanalization of native SFA CTO due to failed femoropopliteal bypass offers a feasible and safe alternative to surgical reconstruction with acceptable limb salvage.

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.

Cardiac Ischemic Complications Following Cardiac Surgery - Angiographic Findings and Predictors of In-hospital Mortality

Objective: To describe findings and predictors of in-hospital mortality in patients requiring repeated coronary angiogram for cardiac ischemic complications following heart surgery. Methods: Between January 2005 and January 2015, out of 10,759 (3.1%) 336 patients underwent postoperative coronary angiogram because clinical signs of cardiac ischemia occurred. Operative procedures included CABG in 294 patients, 84 valve and 14 aortic procedures. A logistic regression analysis was performed to identify significant risk factors for in-hospital mortality. Results: Graft failure including distal anastomotic stenosis, kinking or graft thrombosis was found in 121 angiograms (36%). A new native coronary artery occlusion was found in 96 patients (28.6%). A combination of graft-related and non-graft-related occlusions occurred in 36 patients (10.7%), while 83 patients (24.7%) had normal postoperative graft-related angiograms. Revision CABG and percutaneous coronary intervention was performed in 56 (16.7%) and 120 (35.7%) patients respectively. In hospital mortality was 15.8% (53 patients). After multivariate adjustment emergency admission (p< 0.0001; OR 5.3), absence of preoperative sinus rhythm (p = 0.006; OR 3.2), female sex (p = 0.007; OR 2.7), aortic valve surgery (p = 0.01; OR 2.8), aortic surgery (0.01; OR 2.8), history of decompensation (p = 0.02; OR 2.9) and surgery duration (p = 0.04; OR 1.004) turned out to be independent predictors of in hospital mortality. Conclusion: Postoperative ischemic heart complications with the need of re-coronary angiogram generally results in a notably bad outcome in terms of mortality. Patients with abovementioned risk factors for mortality deserve particular care and expertise to avoid ischemic complications.

Results of Emergency Postoperative Re-Angiography After Cardiac Surgery Procedures

The purpose of this study was to evaluate the diagnostic and therapeutic role of emergency coronary angiography (ECA) in the setting of acute ischemic or hemodynamic instability after cardiac surgery. Between January 2005 and September 2014 we prospectively collected data from a consecutive cohort of 5,275 patients who underwent cardiac surgery. Patients who underwent ECA due to new ST-segment changes on electrocardiogram (ECG), ventricular arrhythmias, cardiac arrest or hemodynamic collapse, new changes in regional wall motion, or any other relevant suspect of myocardial ischemia during postoperative intensive care unit stay were included. Forty patients (0.7% of the overall population) were enrolled. Nineteen patients (47.5%) received isolated coronary surgery, 21 (52.5%) underwent valve or aortic or combined operations. The most common indications to ECA were new ECG or echo signs of acute ischemia (62.5%). The mean time from primary operation to ECA was 51 hours (27 minutes to 9 days). Graft failure was found in 17 cases (42.5%), native coronary artery occlusion in 7 (20%), and coronary spasm in 5 (12.5%). No pathologic alterations were found in 7 cases (17.5%). Three patients (7.5%) underwent reoperation (group 1), 15 (37.5%) underwent percutaneous interventions (PCI) (group 2), and 22 (55%) were managed conservatively (group 3). In-hospital mortality was 100% in group 1, 6% in group 2, and 0% in group 3; 93% of the patients who underwent PCI had complete resolution of the ischemic or hemodynamic problems. No complications related to angiography occurred. Kaplan-Meier survival curves differed significantly according to the post-angiography management. At multivariate analysis combined surgery and the strategy of treatment were independent predictors of long-term mortality. Emergency coronary angiography is safe and allows diagnosis and resolution of the instability in the great majority of cases. An ECA should be the first-line measure in case of acute ischemic or hemodynamic instability after cardiac surgery.

LONG TERM FOLLOW UP OF CORONARY BYPASS PATIENTS WITH PRE-OPERATIVE AND NEW POST-OPERATIVE CHRONIC TOTAL OCCLUSIONS

Chronic total occlusions (CTOs) of native coronary arteries are a frequent finding among patients with multi-vessel coronary artery disease who are being referred for surgical revascularization with coronary artery bypass grafting (CABG). We have recently demonstrated that among patients 1 year post CABG, at least 1 new native coronary artery CTO was found in 43.6% patients. We aimed to assess the long term clinical significance of native coronary artery CTO identified at baseline and at 1 year post CABG. Study included all patients who underwent 1-year follow-up angiography as part of the multi-centre Radial Artery Patency Study (RAPS). A total of 388 patients, with a mean age of 60±9 years were followed for a median of 7.3 +/- 2.9 years. Adverse events were 39 (10%) deaths, 6 (1.5%) non-fatal myocardial infarctions and 19 (4.9%) underwent PCI. CTO of at least one native coronary artery vessel in the baseline pre-operative coronary angiogram was demonstrated in 240 (61.9%) of patients. The composite endpoint of death from any cause, non-fatal myocardial infarction and repeat coronary revascularization, was significantly increased in patients with at least one pre-operative CTO than in patients without a pre-operative CTO (20% vs 11% respectively, p=0.048). At least 1 new complete native coronary artery occlusion at 1 year post surgery occurred in 169 (43.6%) of patients. The composite endpoint of death from any cause, non-fatal myocardial infarction and repeat coronary revascularization, occurred significantly more often in patients who developed a new CTO at 1 year post CABG compared to those who did not (21.3% and 12.8%, respectively, p=0.028). Among patients undergoing CABG, pre-operative CTOs as well as new CTOs that develop 1 year following surgery are associated with adverse long term clinical outcomes.

Endovascular Recanalization of Native Chronic Total Occlusions in Patients with Failed Lower-Extremity Bypass Grafts

PurposeTo investigate the feasibility, safety, and outcome of endovascular recanalization of native chronic total occlusions (CTOs) in patients with failed lower-extremity bypass grafts. Materials and MethodsRetrospective review of 19 limbs in 18 patients with failed lower-extremity bypass grafts that underwent recanalization of native arterial occlusions between February 2009 and April 2013 was performed. Nine of the limbs presented with acute ischemia and 10 presented with chronic ischemia, including eight with critical limb ischemia and two with disabling claudication. ResultsThe mean patency of the failed bypass grafts (63% venous) was 27 months. All limbs had Transatlantic Inter-Society Consensus class D lesions involving the native circulation. Technical success of the endovascular recanalization procedure was achieved in all but one limb (95%). The mean ankle brachial indices before and after treatment were 0.34 and 0.73, respectively. There were no major complications or emergency amputations. Mean patient follow-up was 64 weeks, and two patients were lost to follow-up. Primary patency rates at 3, 6, and 12 months were 87%, 48%, and 16%, respectively. Successful secondary procedures were performed in seven patients, with secondary patency rates at 3, 6, and 12 months of 88%, 73%, and 44%, respectively. Limb salvage rates at 12 and 24 months were 94% and 65%, and amputation-free survival rates at 12 and 24 months were 87% and 60%, respectively. ConclusionsEndovascular recanalization of native CTOs in patients with failed lower-extremity bypass grafts is technically feasible and safe and results in acceptable limb salvage.

Native Coronary Artery Patency After Coronary Artery Bypass Surgery

The aim of the study was to determine native coronary artery patency 1 year after coronary artery bypass grafting and to identify clinical and angiographic predictors for the development of a chronic total occlusion (CTO). In contrast to the large body of information regarding graft patency, data regarding atherosclerosis progression and vessel patency in surgically bypassed native coronary arteries arelessclear. Of the 440 patients who underwent 1-year follow-up angiography as part of the multicenter RAPS (Radial Artery Patency Study), included in our study were 388 patients (88%) for whom angiograms were available for review. Angiograms were reviewed for native coronary artery patency in an independent blinded manner. On the pre-operative angiogram, CTO of at least 1 native coronary vessel was demonstrated in240 patients (61.9%) having 305 occluded vessels. At 1 year after coronary artery bypass grafting, atleast 1 new native coronary artery CTO occurred in 169 patients (43.6%). In 7.5% of patients, the native artery and the graft supplying that territory were both occluded. A new CTO was almost 5 times more likely to occur in coronary vessels with a pre-operative proximal stenosis >90% compared with vessels with proximal stenosis <90% (45.5% vs. 9.5%, respectively, p < 0.001). Patients with a new CTO had significantly more baseline Canadian Cardiovascular Society class 4 angina compared with patients without a new CTO. A new CTO was less likely to occur in the left anterior descending artery (18.4%), supplied by the left internal thoracic artery. When comparing radial artery and saphenous veingrafts, neither the type of graft nor graft patency had any association with native coronary artery occlusion. CTO of surgically bypassed coronary arteries 1 year after coronary artery bypass grafting is extremely common.

Outcome after thrombolysis for occluded endoprosthesis, bypasses and native arteries in patients with lower limb ischemia

IntroductionTo report contemporary outcomes, and evaluate differences after thrombolysis for occluded endoprosthesis, bypasses and native artery occlusion in patients with lower limb ischemia. MethodsPatients undergoing local intra-arterial thrombolysis for lower limb ischemia between 2001 and 2010 were identified in the prospective database for endovascular intervention, and analysis was performed retrospectively. ResultsThere was an increase in thrombolysis for occluded endoprosthesis and a decrease in thrombolysis for occluded bypasses during the study period (p=0.001). The technical success rate for thrombolysis in occluded endoprosthesis, bypasses and native artery occlusion was 91%, 89% and 73%, respectively. The overall major amputation rate, mortality rate and amputation-free survival rate at 1year was 19%, 14% and 73%, respectively, without differences between groups. The major amputation rate at long-term was highest, 45%, for patients with occluded synthetic bypass grafts. Female gender (HR 1.7; 95% CI 1.1–2.7), ischemic heart disease (HR 1.8; 95% CI 1.1–2.8), anemia at admission (HR 1.9; 95% CI 1.2–3.0), foot ulcer (HR 4.4; 95% CI 2.4–8.0), motor deficit at admission (HR 2.5; 95% CI 1.4–4.3), occluded synthetic bypass graft (HR 3.3; 95% CI 1.9–5.7) and failure of thrombolysis (HR 4.8; 95% CI 2.9–7.7) were independently associated with an increased long-term risk of major amputation. ConclusionsThrombolysis for occluded endoprosthesis, bypasses and native artery occlusion was effective. Female gender, ischemic heart disease, anemia, foot ulcer, motor deficit, occluded synthetic bypass graft and failure of thrombolysis were independently associated with an increased risk of major amputation.

Evaluation of coronary artery bypass grafts patency using CT angiography: a reports of multi-center study

Objective To investigate the diagnostic value of computed tomography angiography (CTA) for assessing patency of coronary artery bypass grafts (CABG) using conventional coronary artery angiography (CAG) as the reference standard.Methods This study was a multicenter study in China.A total of 83 participants had been enrolled,including 63 male patients (75.9％),age of (64 ± 9) years (44-84 years).The inclusion criteria were patients who had been performed both CAG and CTA within 3 months.Thirty of them had been scanned by 64 multidetector row spiral CT,and 53 of them had been scanned by dual source CT scanner.Two groups of radiologists evaluated CAG and CTA datasets blindly,and the results of CTA for assessing both stenosis (≥50％) and occlusion of CABGs were compared with the CAG results.Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic efficacy of CTA.Results Among 83 cases,the median follow-up time after CABG surgery was 58.6 (1.0-227.1) months.A total of 240 CABG vessels were analyzed,including 80 arterial grafts and 160 venous grafts.The patent grafts to left anterior descending were 93 (78.8％,93/118),to left circumflex were 34 grafts (58.6％,34/58),and to the right coronary artery were 35 grafts (54.7％,35/64),derived a total patency of 67.5％ (162/240).In comparison to CAG results,the sensitivity and specificity of CTA for detecting CABG stenosis (≥50％) were 88.6％ (93/105) and 94.1％ (127/135),area under ROC curve was 0.917.For detecting CABG occlusion,the sensitivity and specificity were 97.4％ (76/78)and 96.9％ (157/162),area under ROC curve was 0.972.For the detection of native coronary artery stenosis and occlusion,the areas under ROC curves were 0.889 and 0.836,respectively.Conclusions CTA is a tool with high diagnostic sensitivity and specificity to evaluate stenosis and occlusion of CABG.The diagnostic efficacy is higher than the evaluation of native coronary arteries. Key words: Coronary artery disease; Coronary revascularization; Tomography,X-ray computed; Coronary angiography

Alternative treatment approach to late graft occlusion of femoropopliteal artery: subintimal tracking and stenting to occluded native artery via transpedal pathway.

There are various options for the treatment of occluded femoropopliteal (fem-pop) bypass graft. Although surgical revision is the gold standard, it is also associated with higher rates of complications such as nerve injury, wound and graft infection, and bleeding. In this case report we present the case of fem-pop in graft occlusion in which percutaneous angioplasty and stenting was performed to the occluded native fem-pop artery via transpedal pathway. With this case we tried to emphasise that percutaneous intervention to the native artery could be an alternative to surgical treatment.

EKOS™ ultrasound – accelerated catheter – directed thrombolysis for acutely occluded femoro-popliteal graft

Acute limb ischemia due to bypass thrombotic occlusion may occur in patients with poor collateral circulation. It constitutes a medical emergency with increased morbidity, mortality and risk for limb amputation. Although the management of acute limb ischemia due to native artery occlusion is well studied, the optimal approach of acute bypass graft failure resulting in acute limb ischemia is uncertain. We present a case of acute limb ischemia in a patient with femoro-femoral and femoro-popliteal graft who presented with acute limb ischemia due to acute thrombotic occlusion of his femoro-popliteal graft. The patient was successfully managed with ultrasound-enhanced catheter-directed thrombolysis using the EkoSonic® endovascular system with excellent clinical and angiographic results. To our knowledge this is the first published report of the use of the EkoSonic® system for this indication.