Open Surgical Bypass Research Articles

Outcome of the FUSION vascular graft for above-knee femoropopliteal bypass

Although endovascular procedures have become popular for the treatment of patients with femoropopliteal occlusive disease, open surgical bypass is still required in a significant proportion of patients. Saphenous vein is the conduit of choice, but prosthetic bypass grafts are often necessary. The Peripheral Bypass Grafting: Prospective Evaluation of FUSION Vascular Graft for Above Knee Targets (PERFECTION) trial was performed to assess the clinical outcome of the FUSION vascular graft (Maquet Cardiovascular, Wayne, NJ), a novel bilayer prosthetic graft with an external expanded polytetrafluoroethylene inner layer and an outer knit polyester layer. Eligible study patients included those requiring prosthetic femoral-to-above-knee popliteal bypass for claudication, rest pain, or localized tissue loss without wet gangrene. During a 30-month period ending in March 2012, 117 patients were enrolled in the PERFECTION trial and underwent bypass with FUSION vascular grafts at 10 European investigational sites. Patients were followed up with duplex ultrasound imaging and ankle-brachial indices performed at 30 days, 6 months, and 12 months. The primary efficacy end point was 12-month primary patency of the study graft, assessable in 102 patients. Safety end points included all-cause mortality, major adverse events, amputation, and graft reinterventions. The 67 male (57.3%) and 50 female (42.7%) patients averaged 67.8 ± 8.9 years in age and were implanted with 6-mm (25 [21.4%]), 7-mm (26 [22.2%]), or 8-mm (66 [56.4%]) FUSION grafts. The 30-day primary graft patency was 95.3%, with five graft occlusions in the perioperative period. The 12-month primary rate was 85.6%, and the secondary patency rate was 93.2%. Ankle-brachial indices increased from a mean of 0.53 ± 0.20 preoperatively to 0.97 ± 0.16 at 30 days and 0.91 ± 0.22 at 12 months. There were no major amputations through 12 months of follow-up, 15 patients (12.8%) had graft reinterventions, one patient (0.9%) developed a graft infection, and five patients (4.3%) died of unrelated causes. The findings of the prospective, multicenter PERFECTION study confirm clinical utility of the FUSION vascular graft through 12 months of follow-up. Patency rates equal or exceed those reported with other nonbioactive vascular grafts. These observations suggest that the FUSION graft is a useful alterative to standard expanded polytetrafluoroethylene grafts and should be considered as an option in patients requiring prosthetic femoral-to-above-knee popliteal arterial reconstruction.

Endo First Is Not Appropriate in Some Patients with Critical Limb Ischemia because “Bridges Are Burned”

The aims of this study were to determine the effect of failed prior endovascular treatment (EV) on early and midterm outcomes of subsequent lower extremity open surgical (OS) bypass. Patients undergoing infrainguinal bypass for critical limb ischemia (CLI) from January 2008 to December 2011 were retrospectively reviewed. The results after first-line bypass and bypass after failure of EV treatment were compared. A total of 213 patients (65.25% men; average age, 73.30 years) underwent bypass. OS patients were then divided into 2 groups: group 1 consisted of 138 patients who underwent primary OS for CLI without prior EV (control group) and group 2 consisted of 75 patients who had OS after a failed attempt at elective EV for peripheral vascular disease. Of the 213 bypass performed, 34% had a prior infrainguinal failed EV. The primary study end points were early and 1-year major amputations and graft occlusion. The secondary outcomes included early and 1-year mortality and the level of distal revascularization. Secondary patency and limb salvage rates were significantly better in group 1 up to 1 year (99% vs. 86%; P < 0.001 at 1 month and 95% vs. 76%, P < 0.05 at 12 months, respectively). Previous failed EV should be predictive of poor outcome in patients undergoing distal OS for CLI.

Defining risks and predicting adverse events after lower extremity bypass for critical limb ischemia.

Successful treatment of patients with critical limb ischemia (CLI), hinges on the adequacy of revascularization. However, CLI is associated with a severe burden of systemic atherosclerosis, and patients often suffer from multiple cardiovascular comorbidities. Therefore, CLI patients in general represent a cohort at increased risk for procedural complications and adverse events. Although endovascular therapy represents a minimally invasive alternative to open surgical bypass, the durability of surgical reconstruction is superior, and it remains the “gold standard” approach to revascularization in CLI. Therefore, selection of the optimal treatment modality for individual patients requires careful consideration of the procedural risks and likelihood of adverse events associated with surgery. Individualized decision-making with regard to revascularization strategy requires a comprehensive understanding of the likelihood of adverse outcomes after major surgery. Here we review the risks of surgical bypass in patients with CLI, with particular emphasis on the identification of preoperative variables that predict poor outcome.

Palliation of biliary and duodenal obstruction in patients with unresectable pancreatic cancer: Endoscopy or surgery?

Patients with unresectable pancreatic adenocarcinoma often develop biliary and/or duodenal obstruction during the course of their disease. Jaundice, pruritis, nausea and vomiting impact negatively on the quality of life and chemotherapy must often be withheld until these symptoms are resolved. In the past, an open surgical palliative bypass was proposed, but the development of endoprosthetic stents has changed the management of these patients. The success rate for placement of duodenal and biliary stents is greater than 90% with low morbidity. Classical surgical bypass surgery includes biliary-digestive and gastro-jejunal anastomoses. Many studies have compared endoscopic and surgical treatment, and there is a clear advantage to endoscopic treatment in terms of quality of life and cost.

Critical appraisal of surgical revascularization for critical limb ischemia

Peripheral artery disease is growing in global prevalence and is estimated to afflict between 8 and 12 million Americans. Its most severe form, critical limb ischemia (CLI), is associated with high rates of limb loss, morbidity, and mortality. Revascularization is the cornerstone of limb preservation in CLI, and has traditionally been accomplished with open surgical bypass. Advances in catheter-based technologies, coupled with their broad dissemination among specialists, have led to major shifts in practice patterns in CLI. There is scant high-quality evidence to guide surgical decision making in this arena, and market forces have exerted profound influences. Despite this, available data suggest that the expected outcomes for both endovascular and open surgery in CLI are strongly dependent on definable patient factors such as anatomic distribution of disease, vein quality, and comorbidities. Optimal patient selection is paramount for maximizing benefit with each technique. This review summarizes some of the existing data and suggests a selective approach to revascularization in CLI, which continues to rely on vein bypass surgery as a primary option in appropriately selected patients.

The future of cardiac surgery: find opportunity in change!†

Many cardiac surgeons are worried about their current position and importance, and even more about how they will evolve in the coming years. The development of endovascular techniques is considerably changing patient care and will most probably continue to expand as patients express their preference for less-invasive interventions. As a result, cardiac surgery has already dramatically changed, as reflected by the dramatic reduction in open surgical bypass cases. Change is happening, but change will not necessarily imply a negative future. In fact, it is quite the opposite. Cardiac surgeons are ready and willing to Find Opportunity in Change. Change is nothing new to cardiac surgery. Since its inception, cardiac surgery has faced resistance and required adaptation. It took a lot of pioneers, a lot of leadership and inspiration, for cardiac surgery to become what it is today, a critical part of patient care. For several decades, cardiac surgeons have actually been able to adapt to new technologies, to embrace innovation and drive change. Times are different, but the direction is the same: the ability to change will continue to determine cardiac surgery’s future.

Commentary on ‘Autonomy following Revascularization in 80-Year-old Patients with Critical Limb Ischaemia’

The long-term outlook for patients with critical limb ischaemia (CLI) is poor and half will be dead within 5 years of diagnosis. What is more, it has been suggested that even those who have been revascularized show little postoperative improvement in mobility or autonomy. Lejay et al. sought to assess patient-reported functional outcomes after infra-inguinal revascularization for CLI and clarify whether octogenarian patients achieve greater autonomy after open surgical bypass (OS) or endovascular surgery (ES). These ‘softer’ patient-reported outcomes are increasingly accepted as useful indicators of treatment efficacy as they offer important information on how successful treatment has been from the patient’s perspective e unlike ‘harder’ clinical endpoints such as primary patency and amputation, which often have little correlation with clinical benefit. In this study, the authors conclude that only the subgroup of patients considered to be ‘partially dependent’ prior to intervention (based on Parker score) are likely to derive significant benefit from revascularization. Though this conclusion should perhaps be viewed with some caution since the Parker score has undergone only rudimentary validation in this patient group, broadly similar findings have been reported elsewhere.1 The authors also report significantly better functional recovery after ES than after OS. This is perhaps surprising, since the only large randomized-controlled trial to have compared outcome of ES versus OS for patients with severe limb ischaemia (BASIL) failed to demonstrate any difference between groups in terms of quality of life (QoL).2 Though the results

Comparison of initial hemodynamic response after endovascular therapy and open surgical bypass in patients with diabetes mellitus and critical limb ischemia

While endovascular (ENDO) therapy has increasingly become the initial intervention of choice to treat lower extremity peripheral arterial disease, reported outcomes for ENDO in patients with critical limb ischemia (CLI) and diabetes have been reported to be inferior compared to open bypass surgery (OPEN). Objective data assessing the hemodynamic success of ENDO compared to the established benchmark of OPEN are sparse. We therefore evaluated and compared early hemodynamic outcomes of ENDO and OPEN in patients with diabetes with CLI at a single academic center. We studied 85 consecutive patients with diabetes and CLI who underwent 109 interventions, either ENDO (n = 78) or OPEN (n = 31). The mean patient age was 69 years; 62% were men. All patients presented with either rest pain and/or ulcer/gangrene. Per protocol, all were assessed using ankle brachial index (ABI) and toe pressure (TP) determinations before and early postintervention. Both ENDO (ΔABI = 0.36 ± 0.24, P < .0001; ΔTP = 35.6 ± 24.1, P < .0001) and OPEN (ΔABI = 0.39 ± 0.17, P < .0001; ΔTP = 34.3 ± 24.0, P < .0001) resulted in significant hemodynamic improvement. There was no statistically significant initial difference between the two types of intervention (ABI, P = .6; TP, P = .6). These data suggest that with appropriate patient selection, each intervention is similarly efficacious in initially improving hemodynamics. If the intermediate or long-term results of ENDO for CLI in people with diabetes are inferior, the problem is not one of initial hemodynamic response, but more likely due to differing patient characteristics or durability of the intervention.

Abstract 45: Higher Reintervention Rate But Similar Amputation-free Survival With Endovascular Procedures For Peripheral Arterial Disease Compared To Bypass Surgery

Background: Over the last decade, the number of endovascular procedures for peripheral arterial disease (PAD) has surpassed the number of open surgical bypass procedures. Yet, the effectiveness of endovascular procedures in comparison to open procedures is not fully understood. The aim of this study was to compare the outcomes of open and endovascular procedures for PAD in a population-based study. Methods: We used the Patient Discharge Data (PDD) from California’s Office of Statewide Health Planning and Development (OSHPD) to identify all patients &gt;35 years of age who underwent a lower extremity arterial intervention from 2005 to 2009. OSHPD has been recording ambulatory surgery data since 2005. The PDD is linked to the death database. A look back period of five years was used to exclude patients with prior lower extremity endovascular or open procedures. Cox proportional hazards regression was used to compare amputation-free survival and logistic regression was used to compare 12-month reintervention rate between the endovascular and open groups adjusting for age, gender, race/ethnicity, insurance status, severity of illness, and comorbidities. Results: Between 2005 and 2009, 41,507 individuals underwent lower extremity arterial interventions. 25,635 (61.7%) underwent endovascular procedures and 15,872 underwent open procedures. There were 17,942 women (43.2%) and 23,565 men. 4,094 (25.8%) of the patients in the open group and 8,593 (33.5%) of patients in the endovascular group underwent reintervention for PAD. The 12-month reintervention rate was significantly associated with endovascular procedures ( p &lt;0.001). The odds ratio for 12-month reintervention was 1.38 in the endovascular group (95% CI 1.32-1.45) compared to the open group. However, there was no difference in the amputation-free survival following endovascular procedures compared to open procedures ( p =0.154); the hazard ratio was 1.07 in the endovascular group (95%CI 0.97-1.15) compared to the open group. Conclusions: Nearly a third of all patients who undergo a lower extremity arterial revascularization procedure require reintervention within the first year. Our results demonstrate that although endovascular procedures are more likely than open procedures to require reintervention, the amputation-free survival is not improved with endovascular procedures. Cost analysis of multiple reinterventions can be beneficial in understanding the cost-effectiveness of endovascular procedures. Further research is also needed to understand patient characteristics that distinguish patients who benefit more from endovascular procedure for PAD.

Abstract 28: Racial Disparities In Outcomes Of Endovascular Procedures For Peripheral Arterial Disease: An Evaluation Of California Hospitals, 2005-2009

Background: Endovascular procedures are being increasingly performed for peripheral arterial disease (PAD), exceeding the number of open surgical bypass procedures. Previously, it had been demonstrated that there is a disparity in access to and outcomes of PAD treatment based on race/ethnicity. Blacks have been shown to be more likely to undergo amputation and less likely to undergo revascularization procedures for limb salvage compared to whites. The aim of this study was to determine if there is disparity in the outcomes of endovascular PAD procedures based on race/ethnicity in this contemporary population-based study. Methods: We used the Patient Discharge Data (PDD) from California's Office of Statewide Health Planning and Development (OSHPD) to identify all patients &gt;35 years of age who underwent a lower extremity arterial intervention from 2005 to 2009. OSHPD has been recording ambulatory surgery data since 2005. A look back period of five years was used to exclude patients with prior lower extremity endovascular or open bypass procedures. Cox proportional hazards regression was used to compare amputation-free survival and logistic regression was used to compare 12-month reintervention rate among the racial groups adjusting for age, gender, insurance status, severity of illness, and comorbidities. Results: Between 2005 and 2009, 41,507 individuals underwent lower extremity arterial interventions; 25,635 (61.7%) underwent endovascular procedures. There were 11,389 women (44.2%) and 14,246 men. This cohort included 17,433 (68%) non-Hispanic (NH) whites, 4,417 (17.3%) Hispanics, 1,979 (7.7%) blacks, 1,163 (4.5%) Asian/Native Hawaiians, and 643 (2.5%) others. The Hazard ratio for amputation or death was 1.69 in Hispanics (95%CI 1.50-1.89) and 1.65 in blacks (95%CI 1.42-1.92) compared to NH whites ( p &lt;0.001). The 12-month reintervention rate was significantly associated with race/ethnicity ( p =0.001). The odds ratio for 12-month reintervention was 1.18 in Hispanics (95% CI 1.06-1.31) and 1.08 in blacks (95%CI 0.95-1.22) compared to NH whites following endovascular procedures. Conclusions: Our study demonstrates that Hispanics and blacks have worse amputation-free survival than NH whites following endovascular PAD procedures in this contemporary state-wide database. However, Hispanics and blacks were more likely than NH whites to undergo reintervention. Further research is needed to understand if the higher reintervention rate is secondary to more severe illness and/or poor access to proper follow-up care and cardiovascular risk factor modifications.

Spontaneous axillary artery aneurysm: a case report and review of the literature

Degenerative arterial aneurysms can occur in any vascular territory. However, they are exceedingly rare in the axillary artery. Complications of axillary artery aneurysms may result in acute vascular insufficiency and neurological deficits. Prompt treatment should be employed in the management of this condition. We report a case of an atraumatic degenerative axillary artery aneurysm that was treated with transaxillary open surgical bypass.

Prior failed ipsilateral percutaneous endovascular intervention in patients with critical limb ischemia predicts poor outcome after lower extremity bypass

Although open surgical bypass remains the standard revascularization strategy for patients with critical limb ischemia (CLI), many centers now perform peripheral endovascular intervention (PVI) as the first-line treatment for these patients. We sought to determine the effect of a prior ipsilateral PVI (iPVI) on the outcome of subsequent lower extremity bypass (LEB) in patients with CLI. A retrospective cohort analysis of all patients undergoing infrainguinal LEB between 2003 and 2009 within hospitals comprising the Vascular Study Group of New England (VSGNE) was performed. Primary study endpoints were major amputation and graft occlusion at 1 year postoperatively. Secondary outcomes included in-hospital major adverse events (MAE), 1-year mortality, and composite 1-year major adverse limb events (MALE). Event rates were determined using life table analyses and comparisons were performed using the log-rank test. Multivariate predictors were determined using a Cox proportional hazards model with multilevel hierarchical adjustment. Of 1880 LEBs performed, 32% (n = 603) had a prior infrainguinal revascularization procedure (iPVI, 7%; ipsilateral bypass, 15%; contralateral PVI, 3%; contralateral bypass, 17%). Patients with prior iPVI, compared with those without a prior iPVI, were more likely to be women (32 vs 41%; P = .04), less likely to have tissue loss (52% vs 63%; P = .02), more likely to require arm vein conduit (16% vs 5%; P = .001), and more likely to be on statin (71% vs 54%; P = .01) and beta blocker therapy (92% vs 81%; P = .01) at the time of their bypass procedure. Other demographic factors were similar between these groups. Prior PVI or bypass did not alter 30-day MAE and 1-year mortality after the index bypass. In contrast, 1-year major amputation and 1-year graft occlusion rates were significantly higher in patients who had prior iPVI than those without (31% vs 20%; P = .046 and 28% vs 18%; P = .009), similar to patients who had a prior ipsilateral bypass (1 year major amputation, 29% vs 20%; P = .022; 1 year graft occlusion, 33% vs 18%; P = .001). Independent multivariate predictors of higher 1-year amputation and graft occlusion rates were prior iPVI, prior ipsilateral bypass, dialysis dependence, prosthetic conduit and distal (tibial and pedal) bypass target. Prior iPVI is highly predictive for poor outcome in patients undergoing LEB for CLI with higher 1-year amputation and graft occlusion rates than those without prior revascularization, similar to prior ipsilateral bypass These findings provide information, which may help with the complex decisions surrounding revascularization options in patients with CLI.

Intraoperative Use of Cell Saver on Patients Undergoing Open Abdominal Aortic Aneurysm Surgical Repair: A Greek Hospital Experience

Perioperative use of a cell saver device can serve as a cost-beneficial alternative to the transfusion method, especially in countries where the cost of a single unit of blood is high. The purpose of this study, conducted in a Greek hospital, was to calculate the cost benefit of using a cell saver device to salvage intraoperative blood during open surgical abdominal aortic aneurysm repair or open aortofemoral bypass for occlusive disease. This retrospective study measured the amounts of salvaged blood and reinfused blood encountered during the procedure and then calculated the cost benefit of cell saver use. With the cost of a unit of blood purchased in Greece about €450 ($585), the blood units salvaged and reinfused were calculated at a mean cost benefit of €754 ($980) per case.

PVSS8. Comparison of Early Hemodynamics after Endovascular Therapy and Open Surgical Bypass in Patients with Diabetes and Critical Limb Ischemia: Does mode of revascularization matter?

PVSS8. Comparison of Early Hemodynamics after Endovascular Therapy and Open Surgical Bypass in Patients with Diabetes and Critical Limb Ischemia: Does mode of revascularization matter?

Iatrogenic Vertebral Artery Pseudoaneurysm Due to Central Venous Catheterization

Central venous lines have become an integral part of patient care, but they are not without complications. Vertebral artery pseudoaneurysm formation is one of the rarer complications of central line placement. Presented is a rare case of two pseudoaneurysms of the vertebral and subclavian artery after an attempted internal jugular vein catheterization. These were successfully treated with open surgical repair and bypass. Open surgical repair remains the gold standard of treatment. Endovascular repair of vertebral artery pseudoaneurysms has been described with promising outcomes, but long-term results are lacking. Ultimately, the best treatment of these iatrogenic injuries should start with prevention. Well-documented techniques to minimize mechanical complications, including inadvertent arterial puncture, should be practiced and taught in training programs to avoid the potentially devastating consequences.

Ureteroarterial Fistula Treatment With Open Surgery Versus Endovascular Management: Long-Term Outcomes

Ureteroarterial fistulas can be treated with open vascular or percutaneous arterial stent placement. We compared the long-term outcomes of each treatment. A single center, retrospective review of ureteroarterial fistulas (1996 to 2008) was performed. We identified 20 ureteroarterial fistulas in 19 patients. All patients had undergone extirpative surgery with pelvic radiation in 74% and long-term ureteral stents in 84%. At a mean followup of 15.5 months (range 1 to 99) survival was 53%. Of the 70% (14 of 20) treated with percutaneous endovascular iliac artery stenting or embolization, 2 patients later required open vascular graft and 12 were treated with long-term ureteral stenting. Of the 30% (6 of 20) of patients treated with open surgical repair or bypass 2 required bypass revision and/or thrombectomy, and 4 had concomitant ureteral ligation or nephrectomy. Despite undergoing anticoagulation 10 patients (53%) experienced lower extremity morbidity including ulceration, ischemia and amputation. In each treatment group 2 patients had recurrent hemorrhage requiring a secondary procedure, leading to death in 2 for an overall 10% acute mortality rate. Overall noncause specific mortality of ureteroarterial fistulas was 47% and 10% to 20% was related to the fistula or treatment complications. Endovascular stenting is increasingly used in lieu of open techniques due to the high operative risk and comorbidities in patients with ureteroarterial fistulas. This retrospective review fails to identify a clear advantage for endovascular or open vascular surgical management. Thus, endovascular stenting is preferred in most cases. Regardless of therapy, patients are at risk for recurrent bleeding, lower extremity complications and stent/graft complications. The use of antibiotics and long-term anticoagulant therapy appear prudent but not proved.

Early and long-term comparison of endovascular treatment of iliac artery occlusions and stenosis

This study evaluated early and long-term results of endovascular treatment of iliac artery occlusions and compared these outcomes with those in patients treated for stenotic lesions. During a 10-year period ending in January 2010, 223 endovascular procedures to treat aortoiliac occlusive disease (PAD) were performed. All patients were prospectively enrolled in a dedicated database. The intervention was performed for iliac occlusion in 109 patients (group 1) and for iliac stenosis in 114 (group 2). Early results were analyzed and compared by χ² and Fisher exact tests. Follow-up consisted of clinical examination and duplex scanning at discharge, ≤ 3 months, at 6 and 12 months, and yearly thereafter. Follow-up results were analyzed with Kaplan-Meier curves and compared with the log-rank test. The two groups had similar risk factors for atherosclerosis and comorbidities. Critical limb ischemia was more common in group 1 (20.5%) than in group 2 (8.5%; P = .01). Intraoperative technical details were similar, except for a higher percentage of brachial and contralateral femoral access and more frequent use of nitinol stents in group 1. Two immediate technical failures occurred, one in both groups, requiring immediate conversion to surgical bypass. Four intraoperative iliac ruptures occurred, two in each group; all were successfully treated with covered stents. An additional 10 immediate complications occurred (8 in group 1; 2 in group 2), one of which required conversion to open surgical bypass. The cumulative rate of perioperative complications was 9% in group 1 and 3.5% in group 2 (P = .08). Primary patency at 30 days was 97.3% and 98.7%, respectively. Mean duration of follow-up was 28.4 months; 203 patients (91%) had a regular postoperative follow-up visit. At 60 months, primary patency in group 1 vs group 2 was 82.4% vs 77.7% (P = .9), assisted primary patency was 90.6% vs 85.5% (P = .4), and estimated secondary patency was 93.1% vs 92.8% (P = .3). The cumulative rate of reintervention during follow-up (excluding reinterventions performed in the perioperative period) was 2.5% in group 1 and 12.5% in group 2 at 60 months (P = .09). Univariate analysis in group 1 failed to find any of the examined risk factors significantly affected long-term primary patency rates. In our experience, endovascular treatment of iliac occlusions provides excellent early and long-term results, similar to those obtained in the treatment of stenotic lesions.

Early and Midterm Results of Hybrid Endovascular Repair for Thoracic Aortic Disease

Background: A hybrid procedure using an open surgical extra-anatomic bypass of aortic arch vessels and thoracic endovascular aortic repair (TEVAR) is less invasive than open surgery, and provides a suitable proximal landing zone. Here we report our experience with a hybrid TEVAR procedure at a single center. Material and Method: We retrospectively reviewed consecutive patients with thoracic aortic disease who received a hybrid TEVAR procedure between August 2008 and January 2010. Patients’ data were prospectively collected and mean follow-up was 10.8±5.5 months (range 3~20). Result: Nine patients (7 males and 2 females) with a mean age of 63.8±15.8 years (range 38~84) underwent a hybrid procedure. Five patients had an arch or a proximal descending aortic aneurysm, two had a dissecting aneurysm of the descending aorta, and two had an aneurysm of the ascending arch and descending aorta. Mean expected mortality calculated by logistic EuroSCORE was 21%. Six patients underwent debranching and rerouting from ascending aorta to arch vessels, 2 had carotid-carotid bypass grafting, and 1 underwent carotid-axillary bypass grafting. Mean operation time was 221.4±84.0 min (range 94~364). Deployment success of endovascular stent grafting was 100% with no endoleak on completion angiography. There was no mortality, and a small embolism in the branch of the right opthalmic artery in one patient. During follow-up, one intervention was required for the endoleak. Actuarial survival at 20 months was 100%. Conclusion: Early and mid-term results are encouraging and suggest that hybrid TEVAR procedures are less invasive and safer and represent an effective technique for treating thoracic aortic disease.

A Case of Downhill Esophageal Varices: A Rare Cause of Upper Gastrointestinal Bleeding

Purpose: Downhill varices are varices of the upper esophagus. This is a rare complication of superior vena cava (SVC) obstruction and may be caused by tumor, thrombus, or complicated central venous catheter (CVC). These varices are usually subclinical and discovered incidentally in patients undergoing endoscopy for other reasons, but may bleed profusely as well. Here we present a case of downhill varices and compare and contrast to features of uphill varices. A 67 year old man with history of hypertension and end stage renal disease on hemodialysis status post multiple failed grafts and CVC insertions was referred to the GI clinic for 2 weeks of epigastric pain. He had no hematemesis, melena, or hematochezia. He took aspirin daily but denied NSAID use. Patient had a 40 pack year smoking history and abused alcohol in the past. Physical exam revealed distended neck and upper chest wall veins. Labs showed normocytic anemia, normal liver function tests, and elevated creatinine. EGD showed a white based ulcer and duodenitis in the bulb and mild gastritis. Distal esophagus was normal and without varices. However, two columns of non bleeding varices were noted in the proximal esophagus. A chest CT showed thrombosis of the SVC, right subclavian, and right proximal internal jugular veins with extensive collateralisation. Patient underwent percutaneous transluminal angioplasty with stent placement. The etiology of downhill varices includes upper mediastinal tumors, most commonly lung, thyroid, and metastases. Other causes are mediastinal fibrosis, venulitis, surgical ligation of the SVC, and complicated CVC placement. Diagnostic evaluation may include direct venography, CT angiography, or magnetic resonance venography. Management consists of treating the underlying condition, relieving the outflow obstruction, and endoscopic variceal band ligation. Percutaneous transluminal angioplasty with or without stenting or open surgical bypass may be used to restore outflow. Downhill varices rarely (7.6%) bleed as opposed to the uphill (lower) varices. This is likely due to complicating coagulopathy and reflux disease that affects patients with uphill varices and liver failure. Findings of downhill esophageal varices on EGD should prompt further investigation for the SVC obstruction. Conversely, in patients with known SVC obstruction, downhill esophageal varices should be in the differential diagnosis of the upper GI bleeding.

Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) and the (hoped for) dawn of evidence-based treatment for advanced limb ischemia

The Bypass versus Angioplasty in Severe Ischemia of the Leg (BASIL) trial is the only randomized controlled trial (RCT) to date comparing open surgical bypass with endovascular therapy for severe limb ischemia (SLI). In their initial 2005 publication, the BASIL investigators reported that the main clinical outcomes (overall survival and amputation-free survival) were no different at 2 years after randomization to angioplasty-first or bypass-first revascularization strategies. However, beyond 2 years there appeared to be a benefit for open bypass surgery, providing impetus for an extension study. The final analysis of the long-term outcomes from BASIL is now presented in a set of articles that are reviewed in this commentary. The benefit of initial randomization to open surgery for patients surviving > or =2 years (70% of the BASIL cohort) was confirmed. When outcomes were analyzed by treatment received, patients who had received prosthetic bypass grafts (25% of the surgical arm) fared much more poorly than those treated with a vein bypass. Patients who underwent surgical bypass after an initial failed angioplasty also fared significantly worse than those who were treated initially with bypass surgery. Health-related quality of life measures and costs were not significantly different overall. There are many controversies surrounding the BASIL trial and its interpretation, which are reviewed herein. These include the choice of study population, end points examined, and the nature of procedures performed. The BASIL trial confirms the primacy of open surgical bypass with vein for most patients with SLI and raises questions about the sequelae of failed endovascular interventions. Further multicenter trials are needed to address the large gap in evidence for treatment selection in this patient population.