Open Surgical Bypass Research Articles

Female patients have fewer limb amputations compared to male patients in the BEST-CLI trial

ObjectiveFemale patients are less likely to be diagnosed with and treated for peripheral artery disease. When treated, there are also reported sex disparities in short- and long-term outcomes. We designed this study to compare outcomes after open and endovascular revascularization in the Best Endovascular vs best Surgical Therapy in patients with Critical Limb Ischemia (BEST-CLI) trial between females and males, and to examine outcomes of each revascularization type in an all-female cohort. MethodsIn a secondary analysis of cohorts 1 and 2 of the BEST-CLI Trial, patients with chronic limb-threatening ischemia (CLTI) undergoing open surgical bypass (with or without adequate conduit) and endovascular therapy were stratified by sex. In addition, in a female-only cohort, we evaluated differences in outcomes between treatment arm (combined all bypasses from cohorts 1 and 2 and compared with all endovascular treatment in cohorts 1 and 2). Outcomes included major amputation, reintervention, major adverse limb event (MALE, a composite of major amputation and reintervention), all-cause death, and composite outcome of MALE or all-cause death. Univariable and adjusted Cox regressions were used to assess outcome between males and females. Similar methods were used to assess differences in outcomes between treatment arm in females. ResultsAmong 1830 patients, females were significantly underrepresented, comprising only 28% (n = 519) of the BEST-CLI cohort. Overall, the characteristics of females enrolled in the trial had some differences compared with males: females were more likely to have rest pain alone (72% vs 60%; P < .0001) and when presenting with an ischemic wound, were less likely to have a wound infection (38% vs 47%; P = .01). Females were less likely to have an adequate single-segment greater saphenous vein (SSGSV) available (82% vs 89%; P = .01). Controlled for baseline clinical factors, at 1 year, females had significantly lower rates of major limb amputation compared with males (hazard ratio [HR], 0.70; P = .023), which drove better amputation- and MALE-free survival rates. All-cause death at 1 year was not statistically different between sexes (11.8% vs 11.2%; P = .286). In the all-female cohort, results paralleled the overall trial; open surgical bypass (with any conduit) had significantly better outcomes compared with endovascular therapy. Specifically, among females undergoing endovascular therapy, the rate of major reintervention was particularly high compared with females undergoing open surgical bypass (24.8% vs 10.5%; P < .001). ConclusionsDespite being underrepresented in BEST-CLI, the primary results of the trial, namely, improved MALE-free survival with open surgical bypass with SSGSV, were mirrored in the all-female subset. Female patients enrolled in BEST-CLI had better amputation-free survival at 1 year compared with male patients. These findings suggest that in treating female patients with CLTI considered appropriate for both open and endovascular revascularization, surgical bypass with optimal conduit is the preferred treatment option and can potentially ameliorate poor limb preservation outcomes associated with sex.

Safety and efficacy of drug-eluting stents versus heparin-bonded stents in treatment of femoropopliteal peripheral artery disease: study protocol for a multicentre, prospective randomised controlled trial in China (ELITE trial)

IntroductionEndovascular therapy has emerged as a prominent strategy for managing femoropopliteal peripheral artery disease, offering acceptable safety and efficacy compared with open surgical bypass. Both paclitaxel-eluting stents and heparin-bonded covered...

The Impact of Revascularization Strategy on Clinical Failure, Hemodynamic Failure and Chronic Limb Threatening Ischemia Symptoms in the BEST-CLI Trial

ObjectivesSustained clinical and hemodynamic benefit following revascularization for chronic limb-threatening ischemia (CLTI) is needed to resolve symptoms and prevent limb loss. We sought to compare rates of clinical and hemodynamic failure as well as resolution of initial and prevention of recurrent CLTI following endovascular (ENDO) vs bypass (OPEN) revascularization in the BEST-CLI trial. MethodsAs planned secondary analyses of the BEST-CLI trial, we examined the rates of A) clinical failure (a composite of all-cause death, above-ankle amputation, major reintervention, and degradation of WIfI stage); B) hemodynamic failure (a composite of above-ankle amputation, major and minor reintervention to maintain index limb patency, failure to initially increase or a subsequent decrease in ankle brachial index of 0.15 or toe brachial index of 0.10, and radiographic evidence of treatment stenosis or occlusion); C) time to resolution of presenting CLTI symptoms; and D) incidence of recurrent CLTI. Time-to-event analyses were by intention-to-treat assignment in both trial cohorts (cohort 1: suitable single segment great saphenous vein [SSGSV], N=1434; cohort 2: lacking suitable SSGSV, N= 396) and multivariate stratified Cox regression models were created. ResultsIn cohort 1, there was a significant difference in time to clinical failure (log-rank p<0.001), hemodynamic failure (log-rank p<0.001), and resolution of presenting symptoms (log-rank p=0.009) in favor of OPEN. In cohort 2, there was a significantly lower rate of hemodynamic failure (log-rank p=0.006) favoring OPEN, and no significant difference in time to clinical failure or resolution of presenting symptoms. Multivariate analysis revealed that assignment to OPEN was associated with significantly lower risk of clinical and hemodynamic failure in both cohorts, and a significantly higher likelihood of resolving initial and preventing recurrent CLTI symptoms in cohort 1, including after adjustment for key baseline patient covariates (end stage renal disease (ESRD), prior revascularization, smoking, diabetes, age>80, WIfI stage, tissue loss, infrapopliteal disease). Factors independently associated with clinical failure included age>80 in cohort 1 and ESRD across both cohorts. ESRD was associated with hemodynamic failure in cohort 1. Factors associated with slower resolution of presenting symptoms included diabetes in cohort 1 and WIfI stage in cohort 2. ConclusionsDurable clinical and hemodynamic benefit following revascularization for CLTI is important to avoid persistent and recurrent CLTI, reinterventions and limb loss. When compared with ENDO, initial treatment with OPEN surgical bypass, particularly with available saphenous vein, is associated with improved clinical and hemodynamic outcomes and enhanced resolution of CLTI symptoms.

Midterm Outcomes and Predictors of Failure of Lower Extremity Bypass to Para-Malleolar and Pedal Targets

ObjectivesThe frequency of distal lower extremity bypass (LEB) for infra-popliteal critical limb threatening ischemia (IP-CLTI) has significantly decreased. Our goal was to analyze the contemporary outcomes and factors associated with failure of LEB to para-malleolar and pedal targets. MethodsWe queried the VQI infra-inguinal database from 2003-2021 to identify LEB to para-malleolar or pedal/plantar targets. Primary outcomes were graft patency, major adverse limb events [vascular re-intervention, above ankle amputation] (MALE), and amputation-free survival at 2 years. Standard statistical methods were utilized. ResultsWe identified 2331 LEB procedures (1265 anterior tibial at ankle/dorsalis pedis, 783 posterior tibial at ankle, 283 tarsal/plantar). The prevalence of LEB bypasses to distal targets has significantly decreased from 13.37% of all LEB procedures in 2003 to 3.51% in 2021 (p<0.001). The majority of cases presented with tissue loss (81.25. Common post-operative complications included major adverse cardiac events (8.9%) and surgical site infections (3.6%). Major amputations occurred in 16.8% of patients at 1 year. Post-operative mortality at 1 year was 10%.On unadjusted Kaplan-Meier survival analysis at 2 years, primary patency was 50.56%±3.6%, MALE was 63.49%±3.27%, and amputation-free survival was 71.71%±0.98%. In adjusted analyses [adjusted for comorbidities, indication, conduit type, urgency, prior vascular interventions, graft inflow vessel (femoral/popliteal), concomitant inflow procedures, surgeon and center volume] conduits other than GSV (p<0.001) were associated with loss of primary patency and increased MALE. High center volume (>5 procedures/year) was associated with improved primary patency (p=0.015), and lower MALE (p=0.021) at 2 years. ConclusionsDespite decreased utilization, open surgical bypass to distal targets at the ankle remains a viable option for treatment of IP-CLTI with acceptable patency and amputation-free survival rates at 2 years. Bypasses to distal targets should be performed at high volume centers to optimize graft patency and limb salvage and minimize re-interventions.

Presentation and management of true aneurysms of the pancreaticoduodenal arcade with concomitant celiac artery stenosis using the endovascular approach

True aneurysms of the pancreaticoduodenal artery (PDA) arcade are rare but require intervention due to the high risk of rupture. Historically, these aneurysms have been managed with open surgical methods. In this study, we describe a contemporary series of aneurysms treated using a modern approach that includes endovascular and hybrid techniques. All the patients with aneurysms of the PDA arcade in an institutional database were identified between 2008 and 2022. Patients with history of pancreatic resection were excluded. Data on demographics, presenting symptoms, imaging findings, operative approach, and outcomes were collected and reviewed. There were nine patients diagnosed with a PDA aneurysm, and all nine underwent endovascular intervention. Most were men (n = 5; 55.6%) and White (n = 7; 77.8%) and had American Society of Anesthesiologists class II or III. The median aneurysm size was 21 mm (range, 6-42 mm), and five (55.5%) were symptomatic. Of the five symptomatic cases, two presented with rupture and were treated urgently. The median time to intervention for the nonurgent cases was 30 days. All but one patient had concomitant celiac artery stenosis and two of the eight cases (25%) were due to extrinsic compression from median arcuate ligament syndrome. Both patients underwent median arcuate ligament syndrome release before endovascular intervention. Another patient required open surgical bypass before endovascular repair from the supraceliac aorta to hepatic artery using a Dacron graft to maintain hepatic perfusion. Among the eight patients with celiac axis stenosis, five (62.5%) required celiac stent placement within the same operation. Coil embolization of the aneurysm was used for all except for two patients (n = 7 of 9; 77.8%), with one patient receiving embolic plugs and another receiving an 8 × 38-mm balloon-expandable covered stent for aneurysm exclusion. The median operating room time was 134 minutes. All repairs were technically successful without any intraoperative or postoperative complications. The mean follow-up was 30 months. There was no morbidity, mortality, or unplanned secondary reinterventions within 6 months after aneurysm repair. Stent patency and aneurysm size remained stable at 2 years of follow-up. True pancreaticoduodenal artery arcade aneurysms can be safely and effectively treated using endovascular and hybrid techniques. Because many of these aneurysms have concomitant celiac artery stenosis, the use of endovascular technology allows for simultaneous treatment of both the aneurysm and the stenosis with exceptional results.

Optional management of failed endovascular intervention for infrainguinal arterial occlusive disease

Introduction Endovascular treatment is increasingly chosen as the first option for treating infrainguinal peripheral arterial disease. Although open surgical bypass provides the most durable option for limb salvage, it has substantial morbidity and mortality. Aim The aim of the study is to determine the causes of failure of endovascular intervention and treatment modalities of failed endovascular intervention and results of each modality. Patients and methods A prospective case series study that addresses the outcomes of managing 40 patients with chronic limb ischemia due to femoropopliteal disease treated by endovascular intervention, and the intervention was failed. Causes of failure within 30 days were analyzed. Results We had 13 (27.5%) females and 27 (72.5%) males; their age ranged from 45 to 77 years with a mean of 62.20±7.44. Presentation with rest pain: three (7.5%) patients, minor tissue loss: 18 (45%) patients, major tissue loss: 19 (47.5%) patients the length of lesion was between 5 and 10 cm in three (7.5%) patients and more than 10 cm in 37 (92.5%) patients. Runoff in anterior tibial artery: 23 (57.5%) patients, posterior tibial artery: 19 (47.5%) patients, and peroneal artery: 15 (37.5%) patients. We had no complications in 26 (65%) patients, failure to pass in 12 (30%) patients, and distal embolization in two (5%) patients as intraprocedural complications. During the 30-day follow-up: Acute stent thrombosis in 7 (17.5%) cases, flow-limiting dissection in 8 (20%) cases, residual stenosis in 3 (7.5%) cases, acute thrombosis in 2 (5%) cases, missed iliac lesions in 2 (5%) cases, post-procedural distal arterial tree embolization in 2 (5%) cases, and clinical failure was the cause in 2 (5%) cases. The management was: Redo endovascular in 18 (45%) patients, surgical bypass in 14 (35%) patients, primary amputation in six (15%) patients, and medical treatment in two (5%) patients. After 6 months follow-up limb salvage was in 57.5% of the cases with transmetatarsal amputation in 69.6% of them and major amputation was in 42.5% of the cases Conclusion Failed endovascular intervention procedures within 30 days were associated mainly with long lesions. So, surgical bypass appeared to be superior to endovascular intervention for long lesions. Improvements in endovascular equipment and angioplasty technique might ultimately improve the outcome results and decrease the failure rate of endovascular interventions

Open Surgical Therapy for Peripheral Artery Disease.

The surgical management of symptomatic peripheral artery disease (PAD) has changed in the last few decades. Improvement in endovascular technology has resulted in more complex lesion once reserved for open surgery being addressed in an endovascular fashion. Even with these advances, there are lesions and patients that are better managed with an open surgical procedure. The aim of this review is to describe the most commonly performed open surgical procedures for PAD. The recently published Best Endovascular versus Best Surgical Therapy (BEST-CLI) trial was an international, prospective, randomized controlled trial that aimed to investigate which revascularization (endovascular vs. surgical bypass) approach was superior for limb salvage. The evidence supports an open surgical bypass as an initial approach. The advancements made in the surgical management of PAD have provided options for patients who were once deemed poor surgical candidates. The goal continues to be utilization of the best available tools to address patient disease. In this current era, it is important to be familiar with the open surgical therapies.

Outcomes of Surgical Revascularization in Trans-Atlantic Society Consensus (TASC II) Type C &amp; D Aortoiliac Occlusive Disease

Introduction: Aortoiliac occlusive disease is a disabling illness. This study was conducted on the patients of Trans-Atlantic Society Consensus (TASC II) type C &amp; D aortoiliac occlusive disease. Open surgical revascularization in the form of aortofemoral and aorto-bifemoral bypass grafting was done and the demography of patients of AIOD, the efficacy and outcomes of open surgical bypass in the patients of TASC II, type C &amp; D aortoiliac occlusive disease was studied. Methods: in this study, total of 52 patients were revascularized and were observed for various parameters thoroughly throughout the course of diagnosis, preoperative, intra-operative and postoperative phase and until 6 months of follow-up. The demographics, clinical characteristics of the patients, co-morbid conditions, type of aorto-iliac occlusive disease (AIOD), the surgical procedure conducted and the outcomes of surgery in terms of limb salvageability, healing of ulcer, relief of claudication and graft patency were observed. Results: 50 (96.16%) out of 52 patients were males, with a mean age of presentation 55.01 + 8.58 years. 47 (90.38%) were smokers, 43 (82.69%) had hypertension, 17 (32.69%) had diabetes, 11 (21.15%) had CAD, 12 (23.07%) had COPD, 22 (42.30%) had type C and 30 (57.69%) patients had type D disease. Aorto-bifemoral bypass grafting was done in 42 (80.76%) . Mean duration of ICU stay was 1.9 days, 6 (11.53%) patients expired postoperatively. The graft patency and limb salvageability were 100% and 96.15% respectively during 1st, 3rd and 6th months of follow-up with complete healing of ulcers in 21 (91.30%) patients by the end of 6 months. Conclusion: Surgical revascularization is an important, high yielding, life changing intervention which serves as a boon for the patients with extensive or advanced aortoiliac disease. The surgery has excellent outcomes in terms of graft patency as well as limb salvageability.

MT12 Comparison of Hospital Case Characteristics of Popliteal Artery Aneurysm Repair with ePTFE Covered Stent Grafts with a Heparin Bioactive Surface and Open Surgical Bypass: Highlights from the 2021 Hospital Dataset in Germany

MT12 Comparison of Hospital Case Characteristics of Popliteal Artery Aneurysm Repair with ePTFE Covered Stent Grafts with a Heparin Bioactive Surface and Open Surgical Bypass: Highlights from the 2021 Hospital Dataset in Germany

Open reconstruction of severe superior vena cava syndrome with right internal jugular-Superior vena cava bypass using femoral vein.

Current treatment of chronic benign superior vena cava syndrome (SVCS) is endovascular with angioplasty/stenting1Rizvi A.Z. Kalra M. Bjarnason H. Bower T.C. Schleck C. Gloviczki P. Benign superior vena cava syndrome: Stenting is now the first line of treatment.J Vasc Surg. 2008; 47: 372-380Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar,2Wilson L.D. Detterbeck F.C. Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes.N Engl J Med. 2007; 356: 1862-1869Crossref PubMed Scopus (355) Google Scholar. Open surgical bypass is typically considered for patients who fail endovascular therapy3Picquet J. Blin V. Dussaussoy C. Jousset Y. Papon X. Enon B. Surgical reconstruction of the superior vena cava system: Indications and results.Surgery. 2009; 145: 93-99Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar,4Kalra M. Sen I. Gloviczki P. Endovenous and Operative Treatment of Superior Vena Cava Syndrome.Surg Clin North Am. 2018; 98: 321-335Abstract Full Text Full Text PDF Scopus (20) Google Scholar. This report illustrates the surgical treatment of symptomatic SVCS. The patient consented to the publication. A 31-year-old male patient presented with recurrent edema and dilated veins of the upper extremities, head, neck, and chest, with concomitant severe headache. His history was significant for previous left lower extremity osteomyelitis six years before, being treated with antibiotics through a left upper extremity peripherally inserted central catheter (PICC). Symptoms of SVCS developed three years later. He was treated with bilateral subclavian and innominate vein stenting extending into the superior vena cava (SVC). Despite oral anticoagulation since the first intervention, the patient had multiple in-stent reocclusions and seven reinterventions with only temporary symptom improvement. Physical examination evidenced facial edema, plethoric facies, and dilated veins in the chest and abdomen. Computed tomography venogram (CTV) demonstrated occlusion of all stents. The right internal jugular vein (RIJV) was patent at the upper-neck level, close to the carotid bifurcation and the SVC was also patent caudally to the azygos vein. A left upper extremity and central venogram were performed and attempts were made to cross the occluded stents, without success. The patient then agreed to proceed with an open reconstruction. A RIJV to SVC bypass was performed using the patient´s right femoral vein, which had 8 mm in diameter, via a median sternotomy and a right neck incision (01:39). The suitable diameter of the vein-graft relies upon the main vessels’ diameter and patient´s anatomy, although a minimum dimeter of 6 mm is generally accepted. After the SVC anastomosis, a Valsalva maneuver was performed, and the clamp was opened with the patient in Trendelenburg position to minimize the risk of air embolism. At the two-year follow-up, a patent bypass was demonstrated with symptoms resolution. Annual follow-up with duplex ultrasound will be pursued. Open surgical treatment of SVC syndrome is associated with long-term symptoms relief and is an excellent option for patients who fail endovascular treatment. The femoral vein-graft was an excellent conduit with a good size-match to the RIJV, durable results and symptoms resolution. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3OTBmNTRkMDM4ODYxZjBkNTkxYTBlMWZlNDc5OGU3NyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg3NTk5NzY2fQ.cmFN_OFbjDH4lOiwl1zKkjrgnyVQ2yXQnj_hVfumqU1CX0DvODIdqDnFjP8WKhsd08e_hL8cEQf62356emnlqTr0YQ3Taf7QzqEzXDSXdshLabCLWCJSBJImuFBTwhSNEbChKp9VtQEQaGgQFyoxmim8ywtDZOp91FbZKEyqSzPRGpQZ1TaQTnYdofXOPWy6HWHwpA7L72nUSdtDa6DKZAo-7fV2qqKuAhpR-b2_-TYFZ5QDsM4894KbXMoSfpiuH1MyYN3E2RcS1dja_5IiR_wUucRBjC65wTnhE2xRmiUL_0CZXxMNdfGKpq8bBaTg1GNl69QgdXWvXJkmViQ8Mw Download .mp4 (86.14 MB) Help with .mp4 files

The Impact of Revascularization Strategy on Clinical Failure, Hemodynamic Failure, and Chronic Limb-Threatening Ischemia Symptoms in the BEST-CLI Trial

Sustained clinical and hemodynamic benefit following revascularization for chronic limb-threatening ischemia (CLTI) is needed to resolve symptoms and prevent limb loss. We sought to compare rates of clinical and hemodynamic failure as well as resolution of initial and prevention of recurrent CLTI following endovascular vs bypass (OPEN) revascularization in the BEST-CLI trial. As planned secondary analyses of the BEST-CLI trial, we examined the rates of (A) clinical failure (a composite of all cause death, above ankle amputation, major reintervention, and degradation of WIfI stage); (B) hemodynamic failure (a composite of above ankle amputation, major and minor reintervention to maintain index limb patency, failure to initially increase or a subsequent decrease in ankle-brachial index of 0.15 or toe-brachial index of 0.10, and radiographic evidence of treatment stenosis or occlusion); (C) time to resolution of presenting CLTI symptoms; and (D) incidence of recurrent CLTI. Time-to-event analyses were by intention-to-treat assignment in both trial cohorts (cohort 1: suitable single segment great saphenous vein, n = 1434; cohort 2: lacking suitable single segment great saphenous vein, n = 396) and multivariate stratified Cox regression models were created. In cohort 1, there was a significant difference in time to clinical failure (Figure; log-rank P < .001), hemodynamic failure (log-rank P < .001), and resolution of presenting symptoms (log-rank P = .009) in favor of OPEN. In cohort 2, there was a significantly lower rate of hemodynamic failure (log-rank P = .006) favoring OPEN, and no significant difference in time to clinical failure or resolution of presenting symptoms. Multivariate analysis revealed that assignment to OPEN was associated with significantly lower risk of clinical and hemodynamic failure in both cohorts, and a significantly higher likelihood of resolving initial and preventing recurrent CLTI symptoms in cohort 1 (Table), including after adjustment for key baseline patient covariates (end stage renal disease [ESRD], prior revascularization, smoking, diabetes, age >80, WIfI stage, tissue loss, infrapopliteal disease). Factors independently associated with clinical failure included age >80 in cohort 1 and ESRD across both cohorts. ESRD was associated with hemodynamic failure in cohort 1. Factors associated with slower resolution of presenting symptoms included diabetes in cohort 1 and WIfI stage in cohort 2. Durable clinical and hemodynamic benefit following revascularization for CLTI is important to avoid persistent and recurrent CLTI, reinterventions and limb loss. Initial treatment with open surgical bypass, particularly with available saphenous vein, is associated with improved clinical and hemodynamic outcomes and enhanced resolution of CLTI symptoms.TableIncidence of clinical failure, hemodynamic failure, resolution of initial chronic limb-threatening ischemia (CLTI), and development of recurrent CLTIParameterCohort 1Cohort 2Open, n = 603, No. (%w event)Endovascular, n = 617, No. (%w event)Hazard ratio (95% confidence interval)P valueOpen, n = 171, No. (%w event)Endovascular, n = 173, No. (%w event)Hazard ratio (95% confidence interval)P valueClinical failure303 (50.25)419 (67.91)0.65 (0.56-0.76)<.00181 (47.37)104 (60.12)0.67 (0.50-0.90).009Hemodynamic failure377 (62.52)464 (75.20)0.71 (0.62-0.82)<.001112 (65.50)130 (75.14)0.65 (0.50-0.84).001Initial CLTI resolution514 (85.24)514 (83.31)1.22 (1.08-1.38).002142 (83.04)140 (80.92)1.08 (0.84-1.38).54Recurrent CLTI253 (0.15)a323 (0.18)a0.81b (0.68-0.95).0176 (0.23)a83 (0.23)a0.91b (0.67-1.25).57a Person-years of follow-up incidence rate.bIncidence rate ratio. Open table in a new tab

Smartphone-Based Infrared Thermography as an Option for Evaluating the Treatment Effect of Revascularization Procedure in Patients With Peripheral Arterial Disease, a Prospective Study

Infrared imaging has been used to assess peripheral perfusion; however, large, heavy, and prohibitively expensive cameras have precluded its adoption for widespread clinical applications. With advent of more affordable and portable infrared cameras in recent years, they have become more accessible for clinical use. In this study, we aim to introduce the use of smart phone based thermal camera using thermal ankle-brachial index (TABI) to assess the perfusion in peripheral arterial disease (PAD)-affected lower extremities both preintervention and postintervention and simultaneously comparing with ABI. To our knowledge, this is the first study in the Indian scenario. We included 52 patients with 67 lower limbs with PAD requiring revascularization who presented to our institute between July 2020 and December 2021 in the study. Revascularization procedures included endovascular or open surgical bypass. ABI was measured in affected lower limb using Handheld Doppler device before revascularization, after revascularization at discharge and at 1-month follow-up after revascularization. Thermal images of upper and lower limbs were obtained using FLIR ONE PRO (a smartphone-based infrared thermal camera) at the time of measuring ABI. TABI was calculated by dividing maximum lower limb temperature by maximum upper limb temperature. ABI and TABI were compared for correlation using Pearson analysis. After revascularization, there was statistically significant improvement in ABI, 0.38 ± 0.20, t(66) = 15.1; P < .001, and TABI, 0.09 ± 0.053, t(66)=14.2; P < .001, at discharge when compared with before intervention (Table). Before intervention, positive correlation was found between ABI and Lower limb temperature (r = 0.973; P < .001) and ABI and TABI (r = 0.810; P < .001). After intervention at discharge, positive correlation was found between ABI and Lower limb temperature (r = 0.682; P < .001) and ABI and TABI (r = 0.662; P < .001). At the 1-month follow-up after intervention, positive correlation was found between ABI and Lower limb temperature (r = 0.874; P < .001) and ABI and TABI (r = 0.663; P < .001). Smart phone-based thermal imaging can be used to assess perfusion status in PAD in clinical settings as non-invasive, portable, cost effective and reproducible alternative to ABI. It has shown improvement in perfusion status corresponding to standard Doppler ABI.TableShowing descriptive analysis of revascularized lower limbsBefore interventionAfter intervention at dischargeAt the 1-month follow-upABITABILower extremity temperature (℉)Ambient temperature (℉)ABITABILower extremity temperature (℉)Ambient temperature (℉)ABITABILower extremity temperature (℉)Ambient temperature (℉)Mean.28.8382.786.4.67.9392.986.8.68.9492.987.7Median.27.8382.988.4.67.9592.688.4.67.9692.688.2Std deviation.21.044.219.40.22.065.779.54.17.055.348.64Minimum.00.7574.864.0.00.7879.560.8.00.7878.664.2Maximum.83.9796.6101.41.11.02103.6102.31.11.02103.1102.3Range.83.2221.837.41.1.2424.141.51.1.2424.538.1Interquartile range.28.045.37.90.21.1010.137.35.19.099.456.67TABI, Thermal ankle-brachial index. Open table in a new tab

Lower Extremity Staged Revascularization (LESR) as a new innovative concept for lower extremity salvage in acute popliteal artery injuries: a hypothesis

Popliteal artery injury following knee dislocation is associated with significant morbidity and high amputation rates. The complex and multi-disciplinary input required to manage this injury effectively can take time to arrange, prolonging the time to revascularization. Furthermore, open surgical bypass or interposition graft can be technically challenging in the acute setting, further prolonging ischemic time.Temporary intravascular shunts can be used to temporarily restore flow but require surgical exposure which takes time. Endovascular techniques can decrease the time to revascularization; however, endovascular popliteal stent-grafting is controversial because the biomechanical forces relating to flexion and extension of the knee may increase the risk of stent thrombosis. An ideal operation would result in rapid revascularization, eventually leading to a definitive and durable surgical solution.We hypothesize that a staged approach combing extracorporeal shunting, temporary endovascular covered stent placement, external fixation of bony injury, and definitive open repair provides for a superior approach to popliteal artery injury than current standard of care. We term this approach lower extremity staged revascularization (LESR) and the aim is to minimize the known factors contributing to poor outcomes after traumatic popliteal artery injury.

Outcomes Following Spliced Vein Graft and Composite Graft as Conduit for Infrainguinal Bypass

Background: Peripheral arterial disease is a significant health care burden globally. Treatment options for limb salvage include open surgical bypass or endovascular revascularization. One of the vital prerequisite for successful infrainguinal bypass is the availability of good conduit. Not all patients have good quality great saphenous vein of adequate length to facilitate bypass. In these scenarios, splicing of available autologous veins and synthetic graft with vein cuff are alternate options. Aim: To compare the outcomes of infrainguinal bypass done for patients with chronic limb threatening ischemia in two groups In Group I, non spliced GSV was the conduit used. In Group II, either spliced vein graft or synthetic graft with vein cuff was used. Materials and Methods: This is a retrospective study done in a tertiary care centre over a period of 40 months. Ipsilateral Great Saphenous Vein (GSV) was our preferred conduit. In the absence of good calibre GSV, splicing of available autologous veins were done. Only when autologous veins were not available synthetic graft was used with distal vein cuff. Results: A total of 52 patients have undergone bypass during the study period of which 15 patients (28.8%) did not have good calibre GSV. Splicing of autologous veins were done for 10 patients (19.2 %) and synthetic graft with vein cuff was used for 5 patients (9.6%). One year graft patency in group I was 81% and in group II was 66.6%. Limbs were salvaged in 86% of patients in either groups. The mortality rate was 8.1% and 6.6% in groups I &amp; II respectively. Conclusion: When good caliber GSV is not available, splicing of available autologous veins provide comparable patency and should be preferred over synthetic graft. Synthetic graft provides acceptable limb salvage rate when used with an adjunctive procedure like vein cuff for tibial bypasses and should be used when autologous veins are not available or when the patient carries a high risk for major surgery.

Giant 11- x 22-cm Bilobed Popliteal Artery Aneurysm 12 Years Following Initial Exclusion and Bypass

Popliteal artery aneurysms (PAAs) comprise 85% of all peripheral arterial aneurysms. Secondary interventions are needed in 33% to 63% of open surgical or endovascular repairs within the first 2 years after treatment. Until now, the largest reported PAA following open surgical exclusion and bypass was 9.5 cm. We present a case of an 11- x 22-cm PAA 12 years after initial treatment for an aneurysm diameter of 3.1 cm.

Surgical Management for Refractory Raynaud’s Phenomena: A Rare Presentation of Upper Extremity Limb Ischemia

The purpose of this study was to highlight the elusiveness of vasculitis and that surgical intervention maybe possible when vaso-occlusive disorder results in limb ischemia. We propose that end-stage vasculitis that results in limb ischemia and gangrene with evidence of vascular occlusion has open surgical bypass options for achieving limb salvage.

Distal Bypass Versus Infrageniculate Endovascular Intervention for Chronic Limb-Threatening Ischemia.

Chronic limb-threatening ischemia (CLTI) carries a high risk of amputation and warrants urgent intervention. CLTI involving the infrageniculate vessels, in particular, carries a considerably higher risk of major limb amputation. Open surgical bypass is the historical gold standard for the treatment of tibial arterial disease; however, endovascular therapy provides an attractive alternative in this high-risk patient population. In this article, we review the existing literature regarding distal bypass and infrageniculate endovascular intervention in patients with CLTI.

Open Repair for Juxta-Renal Aortic Occlusion in High-Risk Patients

Background: Juxtarenal aortic occlusion (JRAO) is an infrequent form of aortic occlusion, resulting from a proximal progression of a distal aortic thrombus. The occlusion at or above the level of renal arteries may present with features of renal failure or intestinal ischemia along with increased severity of pelvic and limb ischemia. Surgical treatment of JRAO is complex and usually involves suprarenal clamping and poses a significant morbidity and mortality risk. Nevertheless, the current literature supports superiority of surgical bypass with excellent long-term outcomes and remains the preferred modality in JRAO. We reviewed the results of open surgical bypass in JRAOs, done at our center over a 5-year period. Materials and Methods: A retrospective analysis of 35 patients who underwent JRAO over the past 5 years was performed. Demographic data, comorbidities, clinical presentation, and surgical results were analyzed. Results: Of the 35 patients who underwent open surgical bypass, 34 were male, and one was female. The median age of the cohort was 56 years. All the patients had either disabling claudication, rest pain or tissue loss at presentation. The notable comorbid conditions were hypertension (91%), diabetes (51%), coronary artery disease (71%), and chronic obstructive pulmonary disease (37%). Direct aortic reconstruction was done in all cases, seven patients with critical limb ischemia underwent sequential infra-inguinal bypass, additional mesenteric bypass was done in one patient, renal artery revascularisation was done in three patients in the form of endarterectomy for two patients and aortorenal bypass in one patient. There was no perioperative mortality, and a 93% cumulative graft patency rate was noted. Conclusion: Open surgical reconstruction is a safe method for JRAO even in patients with comorbidities and offers excellent perioperative and long-term results.

Ilio-mesenteric bypass for chronic mesenteric ischaemia where prior endovascular treatment has failed: a case series

Background: Symptomatic chronic mesenteric ischaemia is a rare but debilitating disease, and its diagnosis is often delayed by the time taken to rule out underlying malignancy or other abdominal pathology. Once diagnosed, definitive revascularisation should not be delayed to avoid future bowel infarction. There is no consensus on the best treatment option, but most centres use angioplasty as the first choice, leaving open surgery for those who are unsuitable for or failed endovascular treatment. Failure of endovascular treatment does not seem to preclude open surgical bypass. Methods: This series includes four patients who presented with symptomatic chronic mesenteric ischaemia in whom endovascular treatment failed and who were then managed successfully with ilio-mesenteric bypass, with average follow-up of 4 years. Results: The average age of the patients was 57 years; three of the four patients were female. Two patients had initial successful angioplasty but required bypass later for recurrent symptoms. In the other two cases the endovascular approach failed immediately, with one developing acute ischaemia requiring bowel resection followed by mesenteric bypass. Conclusion: Mesenteric bypass for symptomatic chronic mesenteric ischaemia is feasible after failed angioplasty. Immediate or delayed failure of endovascular treatment does not seem to preclude future surgery.

Open Surgery: Still the Gold Standard for Juxtarenal Aortic Occlusion Even in High Risk Patients

Purpose: Juxtarenal aortic occlusion (JRAO) is an infrequent form of aortic occlusion, resulting from a proximal progression of a distal aortic thrombus. Surgical treatment of JRAO is complex, usually involves suprarenal clamping, and poses a significant morbidity and mortality risk. Nevertheless, the current literature supports superiority of surgical bypass with excellent long term outcomes and remains the preferred modality in JRAO. We reviewed the results of open surgical bypass in juxtarenal aortic occlusions, done at our centre over a five year period.