Graft Patency Research Articles

Bypass Patency and Amputation-Free Survival after Popliteal Aneurysm Exclusion Significantly Depends on Patient Age and Medical Complications: A Detailed Dual-Center Analysis of 395 Consecutive Elective and Emergency Procedures.

Background/Objectives: A popliteal artery aneurysm (PAA) is traditionally treated by an open PAA repair (OPAR) with a popliteo-popliteal venous graft interposition. Although excellent outcomes have been reported in elective cases, the results are much worse in cases of emergency presentation or with the necessity of adjunct procedures. This study aimed to identify the risk factors that might decrease amputation-free survival (efficacy endpoint) and lower graft patency (technical endpoint). Patients and Methods: A dual-center retrospective analysis was performed from 2000 to 2021 covering all consecutive PAA repairs stratified for elective vs. emergency repair, considering the patient (i.e., age and comorbidities), PAA (i.e., diameter and tibial runoff vessels), and procedural characteristics (i.e., procedure time, material, and bypass configuration). Descriptive, univariate, and multivariate statistics were used. Results: In 316 patients (69.8 ± 10.5 years), 395 PAAs (mean diameter 31.9 ± 12.9 mm) were operated, 67 as an emergency procedure (6× rupture; 93.8% severe acute limb ischemia). The majority had OPAR (366 procedures). Emergency patients had worse pre- and postoperative tibial runoff, longer procedure times, and more complex reconstructions harboring a variety of adjunct procedures as well as more medical and surgical complications (all p < 0.001). Overall, the in-hospital major amputation rate and mortality rate were 3.6% and 0.8%, respectively. The median follow-up was 49 months. Five-year primary and secondary patency rates were 80% and 94.7%. Patency for venous grafts outperformed alloplastic and composite reconstructions (p < 0.001), but prolonged the average procedure time by 51.4 (24.3-78.6) min (p < 0.001). Amputation-free survival was significantly better after elective procedures (p < 0.001), but only during the early (in-hospital) phase. An increase in patient age and any medical complications were significant negative predictors, regardless of the aneurysm size. Conclusions: A popliteo-popliteal vein interposition remains the gold standard for treatment despite a probably longer procedure time for both elective and emergency PAA repairs. To determine the most effective treatment strategies for older and probably frailer patients, factors such as the aneurysm size and the patient's overall condition should be considered.

Alternative vein bypass in octogenarians with chronic limb-threatening ischaemia.

Octogenarians are regarded as one of the frailest patient groups among the chronic limb-threatening ischaemia population with high perioperative morbidity and mortality rates. As a result, alternative vein bypass surgery in the absence of sufficient great saphenous vein is often not considered as a potential treatment option. The aim of this study was to compare the results of octogenarians undergoing alternative vein bypass surgery due to chronic limb-threatening ischaemia to younger patients. A single-centre retrospective analysis of patients undergoing bypass surgery for chronic limb-threatening ischaemia with alternative autologous vein grafts between 1997 and 2018 was performed. Patients aged over 80 years were compared with those under 80 years. Graft patency rates were assessed and a risk factor analysis for limb loss was performed. In total, 592 patients underwent bypass surgery during the study interval. Twenty-one per cent (n = 126) of patients were 80 years or older. At 4 years, primary, primary-assisted and secondary patency as well as limb salvage rates were not significantly different between the two groups (46% versus 50%, 60% versus 66%, 69% versus 72%, 72% versus 77%, for octogenarians versus non-octogenarians respectively). Major amputations were performed in 27 (21%) octogenarians and 91 (20%) non-octogenarians (P = 0.190). No higher 30-day and long-term mortality rates nor morbidity rates were detected in the octogenarian group with a median follow-up time of 27 (interquartile range 12-56) months. Minor amputation, the reason for alternative vein grafts, as well as the profunda femoris artery as proximal origin of the bypass were risk factors for limb loss in the postoperative course. Alternative vein bypass surgery in octogenarians with chronic limb-threatening ischaemia is safe and effective in terms of patency rates, limb salvage and survival compared with younger patients in the absence of sufficient great saphenous vein. Age alone should not be a deterrent from performing bypass surgery.

Rationale and design of a single-center randomized trial to compare the graft patency between the radial artery and the no-touch saphenous vein in coronary artery bypass grafting surgery (GRAFT-CAB Study)

Previous studies suggested only the radial artery and the No-touch (NT) technique were effective in reducing graft occlusion after coronary artery bypass grafting (CABG) surgery. However, there is no randomized trial comparing these 2 graft conduits. The optimum second conduit for CABG remains undetermined. This study is a prospective, single-center randomized clinical trial, aiming to compare the graft patency between the radial artery and the NT vein graft. All patients undergoing isolated CABG with left internal mammary artery (LIMA) plus at least 2 additional grafts will be considered eligible. About 774 cases (516 in the radial artery group and 258 in the NT vein group) will be enrolled in over 1 to 2 years. Participants will be randomized and allocated to two bypass strategies: the LIMA plus 1 radial artery and 1 conventional vein graft, or the LIMA plus 2 NT vein grafts. The primary outcome is graft occlusion at 1 year after CABG evaluated by CT angiography. The secondary outcomes include graft occlusion at 3 and 5 years and major adverse cardiac or cerebrovascular events at 1, 3, and 5 years follow-ups. This study will define whether or not the NT vein has a lower graft occlusion rate than the radial artery in short and mid-term follow-ups, and provide new evidence for the second conduit choice in CABG surgery. ClinicalTrials.gov NCT06014047. Registered on October 15th, 2023.

Pre-Coronary Artery Bypass Grafting Computed Tomography-Based Fractional Flow Reserve Predicts Graft Failure: Implications for Planning Invasive Treatment of Coronary Artery Disease.

The aim of the study is to evaluate whether a pre-coronary artery bypass grafting (CABG) coronary computed tomography-based fractional flow reserve (FFR-CT) result at the site of a future anastomosis would predict the graft failure in patients undergoing CABG. In 43 patients who had coronary computed tomography angiography (CCTA) prior to the CABG, follow-up CCTA were acquired >12 months post-CABG procedure. The FFR-CT values were simulated on the basis of the pre-CABG CCTA. Based on follow-up CCTA, the anastomosis sites and the graft patency were determined. The graft failure was defined as either its stenosis >50% or occlusion. Ninety eight (44 saphenous, 54 left or right internal mammary artery) grafts were assessed. Eighteen grafts from 16 patients were dysfunctional on follow-up CCTA. The FFR-CT values at the location of future anastomosis were higher in dysfunctional than in normal grafts (0.77 [0.71-0.81] vs 0.60 [0.56-0.66], respectively, P = 0.0007). Pre-CABG FFR-CT (hazard ratio = 1.1; 95% CI: 1.012-1.1, P = 0.0230), and bypass graft to right coronary artery (hazard ratio = 3.7; 95% CI: 1.4-9.3 vs left anterior descending artery) were independent predictors of graft dysfunction during follow-up. The optimal threshold of FFR-CT to predict graft failure was >0.68 (sensitivity 88.9% (95% CI: 65.3-98.6), specificity 63.7% (95% CI: 52.2-74.2), positive predictive value 35.6% (95% CI: 28.3%-43.5%), negative predictive value 96.2% (95% CI: 87.2%-99.0%)). Pre-CABG functional FFR-CT predicts future coronary bypass graft failure. This shows utility of FFR-CT for guiding coronary revascularization and also suggests significance of physiological assessment prior to CABG.

Abstract 1143: Unraveling Histological Dynamics In Deep Venous Arterialization For Chronic Limb-threatening Ischemia

Introduction: Deep venous arterialization (DVA) is emerging as a promising alternative for no-option CLTI) but its pathophysiology remains incompletely understood. Research question: What histologic changes occur in the limb after DVA to allow tissue oxygenation? Study aim: To uncover histological alterations induced by DVA and provide a framework for future experimental models to explore early radiologic and histologic markers of successful DVA. Methods: We report the case of a 53-year-old female who underwent a percutaneous DVA for CLTI using a covered stent (Fig.1). The intervention was successful with evidence of improved blood flow to the foot, but the patient presented worsening infection leading to a below-knee amputation 4 weeks later. A high-resolution 7T MRI was used to scan the amputated limb, and the blood vessels were harvested for histology analysis. Results: The MRI confirmed the patency of the DVA stent graft (Fig. 2A) and plantar loop while histology demonstrated evidence of valvular disruption and eccentric neointimal hyperplasia (NIH) in the vein that underwent intervention (Fig 2B). There was also evidence of NIH and increased smooth muscle cells in the media of the paired vein that did not undergo intervention, resulting in greater thickness compared to the media of the anterior tibial vein at the same level (Fig 2C). Conclusion: Our case reveals some of the changes induced by DVA and demonstrates a possible role of the untouched paired vein in facilitating arterialized flow to the foot. This offers a framework for experimental studies to further investigate these histological alterations and their role in prognosticating DVA outcomes.

Directions for promoting patency of arterial grafts.

Directions for promoting patency of arterial grafts.

Selecting conduits for coronary artery bypass grafting: caution regarding the right internal mammary artery

This narrative review summarizes the angiographic and clinical outcome results of the most common coronary artery bypass grafting (CABG) conduits. The left internal mammary artery is the preferred first conduit to bypass the left anterior descending artery due to superior long-term survival and graft patency. Recent studies suggest the radial artery may be the preferred second conduit for the circumflex or right coronary artery territories, challenging the belief that the right internal mammary artery is the best choice. Despite their historical high failure rates, saphenous vein grafts continue to be widely used as secondary conduits. Several recent studies report suboptimal rates of right internal mammary artery graft failure, with clinical outcomes comparable to or worse than saphenous veins. The suboptimal rates of RIMA graft failure may be attributed to several factors such as improvements in vein graft failure rates, the use of in situ and non-left anterior descending artery grafting configurations, and skeletonized harvesting techniques. While observational studies favor multiple over single arterial grafting, randomized studies are needed for confirmation. The ongoing Randomized comparison of the clinical Outcome of single vs. Multiple Arterial grafts (ROMA) trial aims to determine if multiple arterial grafting reduces major adverse cardiovascular events and mortality and how secondary conduit selection influences these outcomes. Greater adoption of arterial grafting strategies is likely to come from high-quality evidence of benefit and safety from ongoing and future large pragmatic trials.

Influence of graft anastomosis and graft morphology on long-term patency of the saphenous vein after aortocoronary bypass.

Several factors are involved in the preservation of graft function after surgical myocardial revascularization. This follow-up study aimed to evaluate the effects of vein graft anastomosis and graft morphology on long-term graft patency a minimum of 10 years after aortocoronary bypass grafting.Setting and Cohorts. This was a sub-analysis of a study that enrolled patients after isolated bypass surgery at the University Hospital Ostrava in order to evaluate the long-term graft patency of the saphenous vein after endoscopic harvest, a minimum of 10 years after aortocoronary bypass grafting. Fifty angiograms, with a total of 90 grafts, after isolated myocardial revascularization were visualized using coronary computed tomography angiography, with 50% luminal stenosis or greater considered significant. The overall graft patency rate was 72.3%. The differences in occlusion rates between sequential and individual grafts were not statistically significant (P=0.156). All y-grafts were totally occluded. Graft and target artery diameters had a statistically significant influence on patency (P=1.000 and 0.381, respectively). Longer graft length and higher calcium scores were associated with statistically significant graft occlusion (P=0.033 and 0.005, respectively). Sequential grafts can be constructed safely, especially when the goal is complete myocardial revascularization.

The impact of perivascular tissue preservation on 5-year patency of saphenous vein composite grafts.

This retrospective study was conducted to evaluate the impact of saphenous vein (SV) harvesting with versus without perivascular tissue on the 5-year angiographic patency in coronary artery bypass grafting. Among the 944 patients who received coronary artery bypass grafting between 2010 and 2015, 579 patients who received off-pump coronary artery bypass grafting using 1 SV as a Y-composite graft based on the in situ left internal thoracic artery were enrolled. SV harvesting was performed using no-touch technique without perivascular tissue (the NoPVT group) in 342 patients and with perivascular tissue (the PVT group) in 237 patients. Follow-up duration was 84.0 months (interquartile range 66.5-105.4). Propensity score matching was performed, and long-term clinical outcomes and angiographic patency were compared. The average number of distal anastomoses per patient was comparable between the groups, although more SV grafts were anastomosed to left anterior descending territory in the PVT group than in the NoPVT group. Overall survival and cumulative incidence of cardiac death were comparable between the groups, whereas cumulative incidence of target vessel revascularization (1.3% vs 4.3% at 5 year, P = 0.009) and that of major adverse cardiac events (7.3% vs 9.9% at 5 year, P = 0.035) were lower in the PVT group than in the NoPVT group. One-year and 5-year angiographic patency rates of the SV grafts were higher in the PVT group than in the NoPVT group [97.0% vs 91.7% (P = 0.004) and 96.3% vs 89.9% (P = 0.007), respectively]. SV grafts harvested using no-touch technique with perivascular tissue further improved the 5-year patency of SV composite grafts compared with those without perivascular tissue.

The efficacy of minimally invasive coronary artery bypass grafting (mics cabg) for patients with coronary artery diseases and diabetes: a single center retrospective study

Backgroundconventional coronary artery bypass grafting (CCABG) tends to cause severe complications in patients with comorbid Coronary Artery Diseases (CAD) and diabetes. On the other hand, the Minimally Invasive Cardiac Surgery Coronary Artery Bypass Grafting (MICS CABG) via transthoracic incision is associated with rapid recovery and reduced complications. Adding to the limited literature, this study compares CCABG and MICS CABG in terms of efficacy and safety.MethodsHerein, 104 CCABG and MICS CABG cases (52 cases each) were included. The patients were recruited from the Minimally Invasive Cardiac Surgery Center, Anzhen Hospital, between January 2017 and December 2021 and were selected based on the Propensity Score Matching (PSM) model. The key outcomes included All-cause Death, Myocardial Infarction (MI), Cerebrovascular Events, revascularization, Adverse Wound Healing Events and one-year patency of the graft by coronary CTA.ResultsCompared to CCABG, MICS CABG had longer surgical durations [4.25 (1.50) h vs.4.00 (1.13) h, P = 0.028], but showed a reduced intraoperative blood loss [600.00 (400.00) mL vs.700.00 (300.00) mL, P = 0.032] and a lower secondary incision debridement and suturing rate (5.8% vs.19.2%, P = 0.038). In follow up, no statistically significant differences were found between the two groups in the cumulative Major Adverse Cardiovascular and Cerebrovascular Events (MACCEs) incidence (7.7% vs. 5.9%), all-cause mortality (0 vs. 0), MI incidence (1.9% vs. 2.0%), cerebral apoplexy incidence (5.8% vs. 3.9%), and repeated revascularization incidence (0 vs. 0) (P > 0.05). Additionally, coronary CTA results revealed that the two groups’ one-year graft patency (94.2% vs. 90.2%, P = 0.761) showed no statistically significant difference.ConclusionIn patients with comorbid CAD and diabetes, MICS CABG and CCABG had comparable revascularization performances. Moreover, MICS CABG can effectively reduce, if not prevent, poor clinical outcomes/complications, including incision healing, sternal infection and prolonged length of stay in diabetes patients.

Optimizing Internal Mammary Artery Harvest and Preparation

The left internal mammary artery (LIMA) graft plays a pivotal role in coronary artery bypass surgery, offering unparalleled efficacy in revascularization. This review paper delves into the multifaceted considerations surrounding LIMA utilization, aiming to provide a comprehensive understanding of optimal approaches. The study encompasses the alleviation of spasm, selection of graft harvesting techniques, identification of ideal vasodilators, and exploration of optimal delivery methods. Through an analysis of extensive research spanning the past three decades, this review elucidates critical insights for cardiac surgeons and researchers alike. The review emphasizes the ubiquity of severe spasms in harvested LIMA and examines interventions to mitigate this challenge. Studies highlighting the efficacy of papaverine administration through various routes underscore the need for tailored approaches based on clinical context. The debate between skeletonized and pedicled LIMA harvests is explored, revealing the advantages and complexities associated with each technique. Findings suggest that while skeletonized grafts offer enhanced flow, the decision remains multifaceted due to potential complications. Addressing the quest for the ideal vasodilator, the review juxtaposes papaverine and sodium nitroprusside, presenting both as viable options. Despite ongoing discussions, the cost-effectiveness and accessibility of papaverine have positioned it as the favored choice among clinicians. Optimal delivery methods emerge as a crucial factor in graft success, with perivascular injection showing promise in promoting sustained and improved flow rates. The clinical implications of these findings are substantial. By integrating the evidence presented, cardiac surgeons can make informed decisions, maximizing graft patency and patient outcomes. Further, research avenues are identified, encompassing refined delivery techniques, comprehensive comparisons of vasodilators, and long-term clinical outcome evaluations. In conclusion, this review underscores the intricate considerations essential for successful LIMA utilization. By addressing spasms, selecting graft techniques, choosing vasodilators, and refining delivery methods, practitioners can tailor their strategies to the individual patient, enhancing the efficacy of coronary revascularization.

Treatment of Aorto-iliac and Infrainguinal Vascular Infections with a Prefabricated Bovine Pericardial Graft

The use of biological grafts provides acceptable mid- and long-term results in native or prosthetic vascular infections. Several reports describe the successful use of bovine pericardium in case of vascular infections, mainly as a large patch to be sutured as a tubular graft. Recently, a novel prefabricated bovine pericardium graft (Biointegral Surgical No-React® Inc, Mississauga, ON, Canada) has been introduced in clinical practice with promising results. In this study, we report our preliminary experience utilizing Biointegral Surgical graft in case of native and or prosthetic aorto-iliac and infrainguinal infection. We retrospectively analyzed data from 20 patients with native or prosthetic aorto-iliac and infrainguinal infection who underwent in situ reconstruction (ISR) with a Biointegral Surgical No-React bovine pericardium prosthesis between October 2020 and February 2023 at the Vascular Surgery Unit of the Fondazione Policlinico Universitario Gemelli - IRCCS in Rome, Italy. All patients followed a standardized protocol including postoperative anticoagulation and long-term intravenous antibiotics. The indication for surgery was: mycotic aortic aneurysm in 4 patients (20%), graft infection after abdominal aortic repair in 11 patients (55%), peripheral graft infection in 5 patients (25%). Complete excision of the infected aorta or prosthetic graft, surgical debridement and ISR were performed in all patients. Hospital mortality rate was 5% (n=1) and graft-related mortality of 0%. During follow-up (median 13months, range 6-34months), reinfection was 5.2% and primary graft patency 94.7%. The use of prefabricated bovine pericardial grafts represents a promising option for the treatment of native and prosthetic aorto-iliac and infrainguinal infections. The application of this biological graft with a standardized postoperative protocol has been associated with a satisfactory patency and reinfection rate without increased bleeding complications.

Glycemic Variability as a Predictor of Graft Failure Following Infrainguinal Bypass for Peripheral Arterial Disease: A Retrospective Cohort Study

BackgroundGlycaemic variability (GV), measured as the change in visit-to-visit glycated haemoglobin (HbA1c), increases the risk of multiple adverse outcomes. However, the impact of GV on graft patency following infra-inguinal bypass (IIB) is unknown. A retrospective cohort study was undertaken to assess the impact of GV on graft patency. MethodA 3-year single centre retrospective case notes analysis of all people undergoing IIB between 2017-2019. Rutherford stage, graft conduit, level of bypass, procedure details, baseline demographics, co-morbidities, and GV were assessed. Time to re-intervention, ipsilateral amputation or death were recorded to determine primary patency (PP). Results106 IIB outcomes were analysed: mean (±SD) age 68.0(9.2) years; 69(65.1%) male, 37(33.9%), 75(70.8%) had DM; 46(43.4.%) underwent elective procedures.GV>9.1% was associated with significantly lower median PP than GV<9.1%, 198 [97-753.5] vs. 713 [166.5-1044.5] days (p = 0.045).On univariate analysis, GV >9.1% vs <9.1% was significantly associated with PP (HR 1.85 [CI 1.091-3.136], p = 0.022). Bypass level was also a univariate predictor, with below knee bypasses (HR 2.31 [CI 1.164-4.564], p = 0.017), and tibial (HR 2.00 [CI 1.022-3.090], p <0.043) having lower PP than above knee bypasses. On multivariate adjustment, GV >9.1% and level of bypass remained independent predictors of primary patency, HR 1.96 (95% CI:1.12-3.42, p=0.018) and HR 2.54 (95%CI:1.24-5.22, p=0.011) respectively. ConclusionsGV is an independent predictor of primary patency following infra-inguinal bypass, thus optimising GV should be a therapeutic target.

Distal Adjuncts for High-Risk Lower Extremity Bypasses

This review will discuss the use of distal adjuncts for improving graft patency in high-risk lower extremity bypasses. Factors that contribute to the increased risk of failure in high-risk lower extremity bypasses, such as the use of nonautogenous conduits, the creation of bypasses to very distal arterial targets, and bypasses in patients with significant tibial arterial disease, will be discussed. The use of surgical techniques such as creating venous cuffs, venous patches, and arteriovenous fistulas have been shown to improve the patency of high-risk bypasses. Despite the increased risk of failure, the use of surgical adjuncts such as cuffs, patches, and arteriovenous fistulas can improve the patency rates of high-risk lower extremity bypasses.

No-touch saphenous vein: current understanding of the conduit 'less handled'.

The no-touch technique is an established method to harvest the saphenous vein (NT-SV), which is the most commonly used conduit in coronary artery bypass grafting. Herein, we summarize the foundational evidence, as well as highlight recent innovations and ongoing clinical trials involving NT-SV. Through preservation of perivascular tissue for atraumatic handling and omission of manual distension, the NT-SV maintains endothelial nitrous oxide synthase levels and experiences less vascular smooth muscle cell activation, which translates to slower progression of atherosclerosis and less size mismatch of the graft and target vessel. These biomolecular advantages allow NT-SV to provide superior graft patency compared to conventional skeletonized saphenous vein and approximating that of the radial artery. Nonetheless, the clinical benefits of NT-SV for mortality and reduction in major adverse cardiac and cerebrovascular events are insufficiently studied in the long-term. The drawback of NT-SV is the short-term harvest site complications, which may potentially be addressed by the advent of endoscopic no-touch technique. NT-SV is a promising conduit, and its role will be further clarified in upcoming clinical trials and as follow-up lengthens. However, conduit selection and harvest technique should ultimately be personalized to the individual patient.

Effect of gait speed on clinical outcomes after crural and pedal bypass in patients with chronic limb-threatening ischemia.

Many factors affect long-term outcomes after open bypass in patients with chronic limb-threatening ischemia (CLTI). Ambulatory status has been suggested to be associated with clinical outcomes, but there is limited knowledge on the effect of gait speed on outcomes. The purpose of this study is to evaluate the effect of gait speed assessed in a 6-min walk test (6MWT) on outcomes after crural and pedal bypass in patients with CLTI. A retrospective analysis was performed in patients with CLTI who underwent a 6MWT at 1month after crural and pedal bypass at a single center from 2014 to 2021. Comparisons were made between those with high gait speed (HG group, 6-min walk distance (6MWD) > 288m) and those with low gait speed (LG group, 6MWD ≤288m). The primary endpoint was survival, and the secondary endpoints were graft patency, limb salvage, wound healing, major adverse cardiovascular events (MACEs), and hospital outcomes. Of 104 patients with CLTI who underwent a 6MWT after crural and pedal bypass, 46 (44%) and 58 (56%) were placed in the HG and LG groups, respectively. The LG group was older (p < .001), had more female subjects (p = .006), and had a higher prevalence of cerebrovascular disease (p = .042) and tissue loss (p = .007). The median follow-up was 36 (22-57) months. The HG group had significantly higher 3-year primary patency (65% vs 42%, p = .013), 3-year secondary patency (87% vs 66%, p = .018), 3-year overall survival (89% vs 58%, p < .001), and 3-year freedom from MACE (79% vs 67%, p = .039). The 3-year limb salvage and 12-month wound healing rates did not differ between the groups. Gait speed in patients with CLTI after crural and pedal bypass was associated with survival, freedom from MACE, and graft patency but not with limb salvage and wound healing. A detailed study of walking ability in these patients may be needed in the future.

Randomized comparison of HARVesting the Left Internal Thoracic Artery in a skeletonized versus pedicled technique: the HARVITA trial-study protocol.

Latest research has indicated a potential adverse effect on graft patency rates and clinical outcomes with skeletonizing the left internal thoracic artery. We aim to provide a prospective, randomized, multicentre trial to compare skeletonized versus pedicled harvesting technique of left internal thoracic artery concerning graft patency rates and patient survival. A total of 1350 patients will be randomized to either skeletonized or pedicled harvesting technique and undergo surgical revascularization. Follow-up will be performed at 30 days, 1 year, 2 years and 5 years after surgery. The primary outcome will be death or left internal thoracic artery graft occlusion in coronary computed tomography angiography or invasive angiography within 2 years (+/- 3 months) after surgery. The secondary outcome will be major adverse cardiac events (composite outcome of all-cause death, myocardial infarction and repeated revascularization) within 1 year, 2 years and 5 years after surgery. The primary end point will be compared in the modified intention-to-treat population between the two treatment groups using Kaplan-Meier graphs, together with log-rank testing. Hereby, we present the study protocol of the first adequately powered prospective, randomized, multicentre trial which compares skeletonized and pedicled harvesting technique of left internal thoracic artery regarding graft patency rates and patient survival.

Selective assisted intravascular lithotripsy for complex aorto-iliac calcific lesions.

Intravascular lithotripsy has proven to be safe, less invasive, and effective for coronary and peripheral arteries, and the indication has been extended to the aortic district but there is still little evidence in the literature as only a few cases have been described so far. We report a case of intravascular lithotripsy of the infrarenal aorta due to coral reef, chronic occlusion using a single Shockwave M5 + balloon, followed by a covered stent deployment. The aortic bifurcation and common iliac arteries presented hemodynamic calcific lesions, which were prepared singularly with lithotripsy before aorto-iliac covered stenting in kissing configuration. The aortic length from which arises the inferior mesenteric and lumbar arteries was left uncovered preserving their patency. In this case, a single shockwave balloon was sufficient to treat successfully and safely the aortic occlusion by heavy calcific lesions. At 1 and 6 months follow-up, the patient had no clinical symptoms, and the ultrasound assessment showed a triphasic waveform at the common femoral arteries bilaterally and confirmed the patency of the stent grafts. Selective assisted lithotripsy of heavy aortic and iliac vessels is possible, but definitive outcomes have yet to be supported by the literature.

Influence of Preoperative COVID-19 Vaccination on Outcomes After Coronary Artery Bypass Grafting-A Propensity Score-Matched Analysis.

Reports of intravascular thrombosis and cardiac complications have raised concerns about the safety of COVID-19 vaccinations, particularly in patients with high cardiovascular risk. Herein, we aimed to analyze the impact of preoperative COVID-19 vaccination on outcomes after coronary artery bypass grafting (CABG). Among 520 patients who underwent isolated CABG from 2020 to 2022, 481 patients (mean±SD age: 67±11 years, 86 women) whose COVID-19 vaccination status could be confirmed were included. A total of 249 patients who had not received any COVID-19 vaccine before CABG (never vaccinated group) and 214 patients who had completed primary vaccination (fully vaccinated group) were subjected to 1:1 propensity score matching, and 156 pairs of patients were matched. There was no significant difference in early mortality between the 2 groups after matching. After matching, overall survival (P=0.930) and major adverse cardiovascular and cerebrovascular event-free survival (P=0.636) did not differ between the 2 groups. One-year graft patency also did not differ significantly between the 2 groups; all patent grafts in 85/104 patients (82%) and 62/73 patients (85%) in the never vaccinated and fully vaccinated groups, respectively (P=0.685). Subgroup analysis showed equivalent overall and major adverse cardiovascular and cerebrovascular event-free survival among AstraZeneca and Pfizer vaccine recipients and between those with ≤30 days versus >30 days from vaccination to CABG. Despite the very high cardiovascular risk for patients undergoing CABG, COVID-19 vaccination did not affect major outcomes after CABG. Therefore, there is no reason for patients with coronary artery disease requiring CABG to avoid preoperative COVID-19 vaccination.

O104: The “At-Risk” Infrainguinal Bypass Graft: benefit of Duplex Ultrasound Surveillance and Institutional costs of failure

Abstract Introduction The “Achilles heel” of infrainguinal surgical revascularisation (IISR) is that of restenosis. Duplex Ultrasound Surveillance (DUS) is undertaken to identify restenosis to permit intervention to maintain graft patency. We report the impact of DUS on outcomes focusing on patient- and treatment-associated costs. Methods Consecutive patients undergoing IISR at our Institution were assessed (January 2017 - December 2020). Data on DUS (1-, 6- and 12-month scans) were collated. Primary outcomes were mortality and major limb amputations (MLA) at 2-years post IISR. Grafts were defined “at-risk” if radiological evidence of significant graft stenosis or occlusion, with or without symptoms, was identified. Post IISR graft-specific Institutional costs for all patients were quantified. Results 254 patients had IISR in the observed period (196 men, median age 70yrs). Of those, 194 (76%) entered DUS, and 109 (43%) completed it. In patients who completed DUS (vs incomplete vs none), mortality was 6.4%, (vs 26.5% vs 38% respectively; p &amp;lt;0.001) and MLA rates were 6.4% (vs 12% vs 30%, p=0.174 and p&amp;lt;0.001 respectively). Managing at-risk grafts led to additional 384 cross-sectional imaging requests, 284 outpatient reviews, 933 hospital admission days and 233 open and endovascular reinterventions with a total additional NHS cost of £ 1.348.518 in 2 years. Per-patient costs were £216 (per patient, per month) for the complete DUS group vs £348 in no DUS group. Conclusion The ongoing management of IISR is associated with significant costs. Enrolment in and completion of a DUS programme is associated with improved patient outcomes and a reduction in costs.