Primary Bypass Research Articles

External Scaffold for Venous Graft to Treat Chronic Limb-Threatening Ischemia: Results of the FRAME Vascular Support.

Background: The surgical treatment of chronic limb-threatening ischemia and optimal conduit choice are extensively debated. The presence of suboptimal autologous material, such as varicosities or venous aneurysms, might impair long-term outcomes. Therefore, kink-resistant external supports have been advocated in the recent literature to improve the conduit quality and outcomes. This study analyzes the FRAME external support in venous ectasic grafts in patients with chronic limb-threatening ischemia. Methods: From September 2017 to September 2023, a total of sixteen patients underwent CLTI surgery with FRAME external support for venous grafts. The inclusion criteria for FRAME applications were varicose or ectasic autologous material with a diameter ≥ 4.5 and ≤ 8 mm in an isolated segment or in the entire vein and a higher risk of bypass extrinsic compression (e.g., extra-anatomical venous bypass course). Results: Technical success and intraoperative patency were achieved in all cases. At 30 days, the limb salvage and survival rates were 100%. The primary bypass patency was 93.7% due to an early graft occlusion. No graft infection was registered. In one case, dehiscence of the surgical wound was treated by surgical debridement and antibiotic therapy. Minor amputation was required in four patients. Over a median follow-up of 32 months, two occlusions were observed; one was treated with reoperation and the other with major amputation. The primary patency was 68.7% and the assisted primary patency was 75%. Limb salvage rates observed during the entire follow-up period were 87.5%. No graft infections or dilatation of the reinforced veins were registered. Conclusions: For patients with CLTI undergoing infrainguinal bypass, satisfactory results in terms of patency and limb salvage rates were achieved using the autologous venous material, even if ectasic or varicose, with the vascular external support FRAME.

The natural history of chronic limb-threatening ischemia after technical failure of endovascular intervention

ObjectivesThe treatment for chronic limb-threatening ischemia (CLTI) has changed dramatically in the last few decades with a shift toward an endovascular-first approach and aggressive revascularization to achieve limb salvage. As the size of the CLTI population and intervention rates increase, patients will continue to experience technical failure (TF). Here, we describe the natural history of patients after TF of endovascular intervention for CLTI. MethodsWe conducted a retrospective cohort study of patients with CLTI who attempted endovascular intervention or bypass at our multidisciplinary limb salvage center from 2013 to 2019. Patient characteristics were collected according to the Society for Vascular Surgery’s reporting standards. Primary outcomes included survival, limb salvage, wound healing, and revascularization patency. Product-limit Kaplan-Meier estimated survival functions for these outcomes, and between-group comparisons were made using Mantel-Cox log-rank nonparametric tests. ResultsWe identified 242 limbs from 220 unique patients who underwent primary bypass (n = 30) or attempted endovascular intervention (n = 212) at our limb salvage center. Endovascular intervention was a TF in 31 (14.6%) limbs. After TF, 13 limbs underwent secondary bypass and 18 limbs were managed medically. Patients who experienced TF tended to be older (P < .001), male (P = .003), current tobacco users (P = .014), have longer lesions (P = .001), and have chronic total occlusions of target arteries (P < .001) as compared with those who experienced technical success. Furthermore, the TF group had worse limb salvage (P = .047) and slower wound healing (P = .028), but their survival was not different. Survival, limb salvage, and wound healing were not different in patients who received secondary bypass or medical management after TF. The secondary bypass group was older (P = .012) and had a lower prevalence of tibial disease (P = .049) than the primary bypass group and trended toward decreased survival, limb salvage, and wound healing (P = .059, P = .083, and P = .051, respectively). ConclusionsIncreased age, male sex, current tobacco use, longer arterial lesions, and occluded target arteries are associated with TF of endovascular intervention. Limb salvage and wound healing are relatively poor after TF of endovascular intervention, but survival appears comparable with patients who experience technical success. Secondary bypass may not always rescue patients after TF, though our sample size limits statistical power. Interestingly, patients who received a secondary bypass after TF trended toward decreased survival, limb salvage, and wound healing compared with primary bypass.

Whether exercises and testosterone replacement therapy support a treatment for cardiovascular and atherosclerotic patients with iliac artery stenosis and low total testosterone and high-density lipoprotein cholesterol after endovascular procedure?

Serum levels of testosterone (ST) and high-density lipoprotein (HDL) are generally associated with atherosclerosis in male patients over 50 years with critic iliac stenosis (TASC II A and B) and cardiovascular disease with significant changes in HDL and low-density lipoprotein (LDL). In addition to the standard therapy, combined medicamentous therapy and adequate model of exercise are also important factors as medicines can improve HDL levels and primary bypass and endovascular potency impacting positively on improvement of ST or it can be the following testosterone replacement therapy (TRT) comprising cardiovascular disease prevention and vascular treatment as adjunct therapy options after endovascular and vascular surgical procedures. The aim of the study is to identify the association between HDL and ST after surgical and endovascular intervention on the iliac segment (TASCII A and B), as well as cardiovascular risk factors with modified medium activity (MET) &lt;6 with short interval increase over &gt;6 (MET), with total duration of 30–60 minutes. It also attempts to remodel a patient behavioral pattern, optimize ST levels and link them to outcomes and patency of vascular procedures on the iliac segment. Materials and methods. 108 selected male patients with cardiovascular disease combined with metabolic syndrome and critical iliac artery stenosis (TASC II A and B) were examined during 2014–2018, 4 years after invasive and minimal invasive treatment (54 patients were treated with surgical Dacron reconstruction and 54 patients – with endovascular treatment on short segment of critical iliac artery stenosis (TASC II A and B). Results. In the total population, no difference was observed in changes of constraint-induced movement therapy between the standard exercise group and the control one after 4 years from baseline. However, there was no significant interaction between the effect of exercise trainings and primary bypass potency within 4 years. Conclusions. Primary effects of endovascular procedure and Dacron bypass revascularization raise the risk of elevated testosterone levels after 4 years of group training but does not provide adequate answers to questions as to whether higher levels of ST have any major influence on primary bypass potency preventing further progression of cardiovascular disease and general symptomatic and asymptomatic atherosclerosis. However, exercise and TRT can be potential adjunctive therapeutic options for a future supporting postsurgical and endovascular illiac treatment in cardiovascular patients with low testosterone levels.

A Format Compliant Framework for HEVC Selective Encryption After Encoding

The security protection of Ultra-High-Definition (UHD) video is facing grand challenges due to changeable application scenarios. The video business is highly dependent on the video format structure, which makes the format compliance of the encryption algorithm essential. Existing HEVC Selective Encryption (SE) algorithms are difficult to encrypt with format compliance while independent from the encoding, which limits their practical application. In order to realize the format compliant encryption on encoded bitstream, this paper first proposes a non-diffusion rule by analyzing the coding format specification of High Efficiency Video Coding (HEVC). Following the non-diffusion rule, a Bit Flipping (BF) method and a Bit Insertion-Deletion (BID) method are proposed based on the lower bound mapping of the bypass syntax element bit coding interval. Then, considering the various binarization methods and the correlation between syntax elements when decoding, this paper proposes the Validity Principle (VP) and Independence Principle (IP) of format compliant encryption. Focusing on the binary bits of the primary bypass elements in HEVC, the encryptability of them is analyzed in detail, and the corresponding format compliant encryption schemes based on BF, BID methods are constructed. Based on the above, a Format Compliance Encryption (FCE) framework after encoding is formulated. The flexibility, security, and adaptability of the framework are analyzed. Finally, through experiments from the aspects of format compliance, encryption speed, and perception effect, the proposed methods, schemes, and framework are format compliance while ensuring the basic performance and security requirements.

Connection of Low Serum Testosterone Levels in Cardiovascular Disease in Metabolic Syndrome Patients with Diagnosis of Critic Iliac Artery Stenosis (TASC II A and B) and Can Exercise Improve those Levels and Primary Potency of Revascularization after Surgical and Endovascular Treatment? (Pilot Study)

Introduction: Low concentration of free testosterone and low serum testosterone levels are associated in males patients with metabolic syndrome and cardiovascular disease and in some cases in connection with critic iliac stenosis and also in most cases with lack of physical activity. Exercise can be also important factor to improve primary bypass and endovascular potency and general health benefits after surigal and endovascular treatment in patients with critical ishemia over 75% of lumen obstruction of short liiac artery segment have positive impact on improvemt of generely Testosterone Levels. Subjects and Methods: 72 selected Patients with Cardiovascular Disease with Metabolic Syndrome and Critic Iliac Artery Stenosis (TASC II A and B) were observed in period 3 years between ferbruary 2015 and ferbruary 2018. In focus was 1 year potency after invasive and minimalinvasive tertmant (45 patients treated with surgical dacron reconstruction and 25 patients with endovascular tretmant of short segment critical iliac artery stenosis (TASC II A and B). Results: In the total population no difference in changes of CIMT from baseline was observed between the standard exercise group and controls. However, there was no significant interaction between the effect of exercise training and primary bypass potency during 1 year. Conclusion: Primary potency of Endovascular procedure and Dacron bypass revascularization after 1 year in exercise training group significantly rise of testosterone levels higher but still not therapy adequate. With potential optimization testosterone therapy levels we can answer of the question. Is any major influence on primary bypass potency and are higher levels of free testosterone are preventing further progressing of cardiovascular disease and generel symptomatic and asymptomatic atherosclerosis?

Femorodistal bypasses using venous “cuffs”

Background/Aim. Although distal venous patch and cuff techniques are recommended to improve the patency of by-pass in the lower extremities, the advantage of these techniques remains unproven. Autovenous bypass graft remains the method of choice, but when there is no possibility of using the great saphenous vein, the venous cuff method may have an advantage. The aim of this study was to evaluate the results of femorodistal bypass procedures with a venous cuff in critical lower extremity ischemia. Methods. The study described the results of femorodistal bypass procedures after a follow-up period of 6 to 24 months. We followed 28 patients with distal composite anastomosis of femorodistal arterial reconstruction. Indications for surgical treatment were set on the basis of the clinical exam and morphological criteria based on multidetector computed tomographic angiography. Three types of distal graft-arterial anastomoses were applied: Miller?s cuff, Taylor?s patch, and St. Mary?s vein boot anastomosis. Results. After 6 months of surgery, all bypasses were passable; after one year, 2 (7%) patients had graft occlusion and above-knee amputation, and 8 (28%) patients died; after 24 months, 18 (64%) patients had primary bypass patency. Conclusion. Femorodistal bypass procedures using a synthetic graft and venous cuff have good long-term results. The optimal anastomosis type is St. Mary?s boot. A longer follow-up period and comparison with the autovenous bypass are necessary for a more detailed assessment of the final conclusion.

Ten-year experience of infrainguinal bypass with endoscopic vein harvest.

There is conflicting data comparing minimally invasive vein harvest (MIVH) using endoscopic technique and open vein harvest (OVH) in terms of bypass patency, wound infection incidence, and patient morbidity. Our institution has performed MIVH since 2003 for peripheral bypass procedures with a consistent team of specialized endoscopic vein harvesters. This study reviewed the major outcomes of MIVH infrainguinal bypass at our institution given a predominant cohort of critical limb ischemia. We performed a 10-year, retrospective, single-institution review from January 2005 to December 2014, identifying all patients undergoing MIVH for obstructive infrainguinal disease. Primary outcomes were primary patency, operative time, intraoperative complications, surgical site infection (SSI), and freedom from amputation. A total of 289 patients (70% male) underwent MIVH infrainguinal bypass at an average age of 68 ± 12years old, an obesity prevalence of 28%, and with critical limb ischemia in 81% of the patient cohort (20% rest pain, 61% tissue loss/gangrene). Ninety-four percent of patients had no intraoperative complications, 2.5% had adverse cardiac or technical complications, and 4.2% of patients required transfusion. Average operative time was 4.2h. Femoral-popliteal TASC classification C and D constituted 80% of our patient cohort. At the last follow-up, toe pressures had increased from 30 ± 30 to 62 ± 40mmHg (p < 0.0001). Primary bypass patency in the first 30days was 95%. SSI incidence requiring surgical treatment was only 6%. Our median length of stay was 4.0days, with median intravenous narcotic use of 1day. In addition, 77% of patients returned to their baseline mobility at first follow-up (median 19days), and 83% of patients had freedom from amputation at last follow-up (median 820days). In a center with experience in MIVH and a consistent group of experienced endoscopic vein harvesters, MIVH bypass has excellent patency, low surgical site infection, short length of stay, and prompt return to baseline mobility.

S1112 Endoscopic Management of Esophageal Perforations and Leaks: A Multi-Center Study

Introduction: Endoscopic advancements in stenting and tissue plication have proven to be viable alternatives to surgical management of esophageal perforations and are increasingly being used in clinical practice. We aim to assess the efficacy and outcome of different endoscopic treatment modalities in patients with esophageal perforations. Methods: We performed a retrospective analysis of patients with esophageal perforations from an endoscopic database since 2007. Patients with esophageal fistula, stricture, or stenosis were excluded. Patients were categorized into four treatment groups: primary closure (endoscopic suturing), primary bypass (stenting), combination (suturing defect and stenting), and conservative therapy (NPO, trans-nasal feeding tubes). Baseline demographics, patient characteristics, and treatment modality outcomes were collected. Predictors of success were identified using logistic regression. Results: 95 patients (mean age 64 ±15, 67% male) with esophageal perforations were included. The most common etiology was iatrogenic after dilatations or endoscopic myotomy (40%). 64% of perforations were in the distal esophagus. Regardless of strategy employed, 49% of patients had successful endoscopic repair of perforation. Only 7 patients required subsequent operative intervention. The combination approach achieved the greatest clinical success (66%), defined as no need for surgical intervention, when compared to the other modalities (primary bypass 35%, closure 57%, and conservative 25%, p=0.05). Patients with concomitant systemic inflammatory response syndrome had greater clinical success if they were treated with combination approach compared to primary bypass approach (18% vs. 64%, p=0.01). If the perforation was greater than or equal to 20mm, combination therapy had greater clinical success compared to primary bypass approach (0% vs. 50%, p=0.04). Early stent migration was associated with greater need for rescue surgery (p=0.02). (Table) Conclusion: Esophageal perforations can be managed effectively with endoscopic therapy. Larger, prospective trials are needed to clarify ideal individualized endoscopic strategies. Patients with systemic inflammatory response and/or perforation ≥20 mm are managed most effectively with combination therapy. Table 1. - Demographics, Presentation and Outcomes by Treatment Group Variables (%) All (n=95) Primary bypass (n=43) Primary closure (n=12) Combination(n=29) Conservative(n=11) Demographics All Primary bypass (n=43) Primary closure (n=12) Combination (n=29) Conservative (n=11) p-value Age (± SD) 63 ±14 66 ±13 61 ±13 61 ±15 64 ±15 0.23 Sex (Male) 64(67) 16(70) 10 (83) 19(65) 7(63) 0.61 History of EC 14 (16) 6(26) 1(8.3) 3(10) 2(18) 0.31 History of Radiotherapy 15 (19) 6(26) 0(0) 4(14) 2(18) 0.245 Diabetes 14(15) 2(9) 7 (43) 3(10) 2(18) 0.686 Hypertension 48(51) 12(52) 7(58) 13(45) 5(46) 0.927 Sleep apnea 16(17) 5(22) 2(17) 5(17) 0(0) 0.45 Site of Perforation Proximal 4(9.3) 0 2(6.9) 6(54.5) Middle 7(6.3) 3(25.0) 7(24.1) 0 Distal 29 (67.4) 8(66.7) 20(69.0) 5(45.5) Etiology of perforation SpontaneousIatrogenicFood impactionAnastomotic leakEsophageal cancer Boerhaave syndrome 7(16.3)22(51.2)2(4.7) 4(9.3) 2(4.7)6(14.0) 1(8.3)9(75.0)1(8.3) 0 01(8.3) 021(72.4)2(6.9) 3(10.3) 01(3.4) 2 (18.2)7(63.6)1(9.1) 0 01(9.1) Symptoms at time of diagnosis DysphagiaChest painAbdominal painFeverOther 10(23.3)11(25.6)1(2.3) 4(9.3)10(23.3) 1(8.3)4(33.3)0 1(8.3)2(16.7) 4(13.8)4(13.8)1(3.4) 5(17.2)8(27.6) 4(36.4)1(9.1)1(9.1) 02(18.2) Outcomes by Treatment Group Pittsburgh Perforation Severity Score (n=47) 3.17 ±2.1 3.59 ±2.2 2.5±2.0 2.72±1.8 3.45±2.25 0.225 Operative intervention required 7(5.7) 2(4.7) 1(8.3) 3(10.3) 1(9.1) 0.95 Mortality 9(7.4) 4(9.3) 0 3(10.3) 2(18.2) 0.652 SIRS 44(36.1) 19(44.2) 4(33.3) 16 (55.2) 5(45.5) 0.635 Stent migration 11 10(23.3) 0 2(6.9) 0 0.182 LOS* (days) 16±15 19 ±15 11±10 18±19 7.9±7.0 0.123 LOF* (months) 4.6±4.1 4.25±1.5 6±8.8 3.5±2.1 9.3±6.4 0.07 *LOS – Length Of Stay In The Hospital; LOF - Time From Diagnosis To Last-Follow Up; SIRS - Systemic Inflammatory Response Syndrome)

The Natural History of Chronic Limb-Threatening Ischemia After Technical Failure of Endovascular Intervention

We sought to explore the natural history of patients with chronic limb-threatening ischemia who had technical failure of endovascular interventions at a multidisciplinary limb salvage center. Data from 2013 to 2019 on all patients who had attempts at limb salvage at our center, including comorbidities categorized per Society of Vascular Surgery reporting standards and clinical outcomes including mortality, limb salvage, wound healing, and patency, were collected retrospectively. The t and χ2 tests assessed the differences between groups and product-limit Kaplan-Meier estimated survival functions. A total of 212 limbs underwent attempted endovascular intervention and 30 underwent primary bypass. Of the 212 attempted endovascular interventions, 181 were successful, for a technical failure rate of 14.6%. The technical failure group was older, more likely to be male, and more likely to be current smokers compared with the technical success group. No differences in ethnicity, diabetes, hypertension, renal status, hyperlipidemia, cardiac or pulmonary status, Wound, Ischemia, foot Infection score, or level of disease were found. Mean survival in the technical success and failure groups was 58 and 42 months, respectively (P = .087). Mean time to major amputation was longer in the technical success group compared with the technical failure group, 58 vs 45 months, respectively (P = .047) (Fig 1). Mean time to wound healing was shorter in the technical success group compared with the technical failure group, 25 vs 38 months, respectively (P = .028). Of the 31 technical failures, 18 underwent medical management and 13 underwent secondary bypass. Compared with the primary bypass group, the secondary bypass group was older and less likely to have tibial disease. There were no significant differences in sex, ethnicity, diabetes mellitus, smoking, hypertension, renal status, hyperlipidemia, cardiac status, pulmonary status, or Wound, Ischemia, foot Infection score. The secondary bypass group trended toward decreased survival, limb salvage, and wound healing compared with the primary bypass group (P = .059, .083, .051) (Fig 2). Not surprisingly, survival, limb salvage, and wound healing are relatively poor after technical failure of endovascular intervention, even when bypass is performed afterward. Furthermore, secondary bypass after technical failure of endovascular intervention trended toward decreased survival, limb salvage, and wound healing compared with primary bypass.Fig 2Kaplan-Meier curve depicting limb salvage in the primary bypass vs secondary bypass groups.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Outcomes and Fate of the Distal Landing Zone Compared Between Prosthetic and Autologous Grafts After Infra-Inguinal Graft Occlusions.

BackgroundDue to an increasing life expectancy, more and more patients experience the failure of peripheral arterial revascularization. This study aims to investigate patients treated for the failure of infra-inguinal bypass grafts, and to investigate the interaction of different bypass materials [great saphenous vein (GSV) and polytetrafluoroethylene (PTFE)] and the further outcome.MethodsRetrospective single-center analysis of consecutive patients treated for acute or chronic occlusion of infra-inguinal bypasses at a university hospital was conducted. Hospitalizations from 1st January 2010 through 31st December 2019 were included. Perioperative parameters from the index operation including graft material (prosthetic vs. autologous) were assessed. After bypass occlusion, the grade of ischemia, as well as the distal landing zone of the redo bypass compared with the primary bypass was investigated.ResultsIn this study, 158 (65% men and 35% women with a m mean age of 70.5 years) eligible patients were included (57% vein and 42% prosthetic bypass grafts). After graft occlusion, 47% of the patients presented with symptoms of acute limb-threatening ischemia, 53% with symptoms of chronic leg ischemia. The rate of acute limb-threatening ischemia was significantly higher when prosthetic graft material was used during the index operation (p =0.016). Additionally, in case of reoperation, the landing zone of the redo bypass was significantly more distally located after occlusion of prosthetic bypass graft (p = 0.014)ConclusionOcclusions of prosthetic bypass grafts were associated with significantly higher rates of acute symptoms compared with vein grafts. Additionally, a shift to a more distal landing zone was recognized after the failure of a prosthetic bypass graft during the redo bypass operation.

Insufficient weight loss after banded vs. non-banded primary gastric bypass surgery: insights from an observational 5year follow-up study.

While Roux-en-Y gastric bypass (RYGB) is effective in achieving weight loss and improving obesity-related co-morbidities, insufficient weight loss in the long-term can occur. The goal was to assess whether banded vs. non-banded RYGB reduces the risk of insufficient weight loss at 5-year follow-up. This is a retrospective single-center cohort study from Switzerland. We assessed the 5-year metabolic trajectories in terms of body weight, body mass index, glucose control, lipid profile and blood pressure of two surgical cohorts undergoing identical RYGB procedures with or without banding using a uniform 6.5cm silastic Fobi band. Insufficient weight loss was defined as < 50% excess weight loss (EWL) at 5years. A total of 55 patients receiving banded (Fobi) and 55 patients receiving non-banded (non-Fobi) RYGB were included in the analysis. 5-year follow-up was 91% for both groups. Percentage of EWL at 5years was 78.11 ± 26.1% and 73.5 ± 27%.3 for the Fobi vs. non-Fobi group (p = 0.368), respectively. Insufficient weight loss (defined as < 50%EWL) at 5years or last follow-up was significantly higher in the non-Fobi group compared to the Fobi group (19/55 vs. 9/55, respectively, OR = 2.639 (95% CI 1.066, 6.531), p = 0.036). Surrogate markers for cardiometabolic outcomes consistently improved over time, without differences between the groups. During the follow-up period, Fobi-removal was necessary in nine patients (16.3%). Banded-RYGB lowered the odds of insufficient weight loss at 5years follow-up by approximately 62%. Further research is needed to explore the effect of restriction on eating behaviour and neuroendocrine responses after RYGB.

Endovascular recanalization of chronic total occlusions of the native superficial femoral artery after failed femoropopliteal bypass in patients with critical limb ischemia

BackgroundFemoropopliteal bypass occlusions are a significant issue in patients with critical limb ischemia and chronic total occlusion of the native superficial femoral artery, which challenges vascular surgeons and interventional radiologists. Performing a secondary femoropopliteal bypass is still considered the standard of care, although it is associated with a higher complication rate and lower patency rate in comparison with primary bypass. Over the past few years, angioplasty has been commonly used, with the development in endovascular technologies, to treat chronic total occlusions of the native superficial femoral artery, with a good technical success rate and clinical prognosis. The purpose of the study is to assess the outcome of endovascular recanalization of chronic total occlusions of the native superficial femoral artery, in patients unfit for surgery with critical limb ischemia after failed femoropopliteal bypass.ResultsA total of 54 patients were treated. 77.8 % of the conduits were PTFE grafts; the remainder were single-segment great saphenous veins. The most common clinical presentation was rest pain. Technical success was achieved in 51 (94.4 %) of 54 limbs. Angiographically, 77.8 % of the lesions were TASC II category D, while 22.2 % were TASC II category C. The average length of the native SFA lesions was 26.8 cm. Clinical success, with improved Rutherford classification staging, followed each case of technical success. The median follow-up value was 5.75 years (IQR, 1.5–7). By Kaplan-Meier survival analysis, primary patency rates were 61 % (± 0.07 SE) at 1 year and 46 % (± 0.07 SE) at 5 years. Secondary patency rates were 93 % (± 0.04 SE) at 1 year and 61 % (± 0.07 SE) at 5 years. Limb salvage rates were 94 % (± 0.03 SE) at 1 year and 88 % (± 0.05 SE) at 5 years.ConclusionsThe endovascular recanalization of chronic total occlusions (CTO) of the native superficial femoral artery (SFA) after a failed femoropopliteal bypass is a safe and effective therapeutic option in patients unfit for surgery with critical limb ischemia.

The effect of the stented iliac lesions TASC-II C, D on the femoropopliteal bypass patency: Propensity score-matched observational study.

Concurrent stenting of complex iliac lesions during infrainguinal bypasses can increase the complexity of a case and impact outcomes. Our aim was to evaluate the effect of inflow stenting of TASC-II C, D iliac lesions on femoropopliteal bypass patency. A retrospective observational cohort study of patients who underwent femoropopliteal bypass with TASC-II C, D iliac artery stenting (hybrid group) or without inflow lesions (non-hybrid group) was conducted. After propensity score matching, 120 patients were included in the non-hybrid group and 60 patients in the hybrid one. The median follow-up was 432 (193; 1313) days in the hybrid group and 472 (196; 1376) days in the non-hybrid group (p = 0.94). No significant differences were found between the groups in 30-day morbidity and serious adverse events. At 3 years, primary and secondary bypass patency for the hybrid group and non-hybrid group were 62.2% versus 59.9% (p = 0.36) and 63.7% versus 64.3% (p = 0.077), respectively. The primary patency of the iliac stents in patients of the hybrid group was 95% at 3 years. The estimated hazard ratio for primary patency for hybrid versus non-hybrid was 0.77, with 90% CI: 0.50-1.21; the noninferiority upper bound being 1.31, which corresponds to a 10% additive noninferiority margin for probabilities. The 3 years of freedom from amputation in patients with chronic limb-threatening ischemia was 94.1% and 75.0% in the hybrid and non-hybrid groups, respectively (p = 0.09). The outcomes of the femoropopliteal bypass in hybrid surgery supplemented with stenting of TASC-II C, D iliac lesions was similar to femoropopliteal bypass with intact inflow arteries.

Effect of ischemia–reperfusion on outcomes after open mesenteric bypass for chronic mesenteric ischemia

ObjectiveSignificant physiologic perturbations can occur in patients with chronic mesenteric ischemia (CMI) undergoing open mesenteric bypass (OMB). These events have frequently been attributed to ischemia–reperfusion events and have been directly implicated in the occurrence of multiple organ dysfunction (MOD). Scoring systems (MOD score [MODS] and sequential organ failure assessment [SOFA]) have been derived within the critical care field to provide a composite metric for these pathophysiologic changes. The purpose of the present study was to describe the early pathophysiologic changes that occur after OMB for CMI and determine whether these are predictive of the outcomes. MethodsPatients with CMI who had undergone elective OMB from 2002 to 2018 at a single institution were reviewed. Changes in the hemodynamic, pulmonary, hepatic, renal, and hematologic parameters in the first 96 hours postoperatively were analyzed. The MODSs and SOFA scores were calculated. Cox regression was used to determine the association of the MODSs and SOFA scores with the outcomes. ResultsThe use of OMB was analyzed for 72 patients (age, 66 ± 11 years; 68% women; body mass index, 23.8 ± 6 kg/m2; 48 ± 34-lb weight loss in 59%). Previous mesenteric stent placement or bypass had been performed in 39% [stenting in 21; bypass in 8; (one patient had both)]. An antegrade configuration (93%) was most common (retrograde configuration, 7%), with revascularization of the superior mesenteric artery/celiac vessels in 85% (superior mesenteric artery only in 15%). Postoperative pathophysiologic and metabolic changes were common, and the mean MODSs and SOFA scores were 3.6 ± 2.4 (range, 1-10) and 4.0 ± 2.7 (range, 1-13), respectively. The median length of stay was 14 days (interquartile range, 9-21). The 30-day mortality was 4% (n = 3) and in-hospital morbidity was 53% (n = 38; gastrointestinal, 25%; infectious, 22%; cardiac, 18%; pulmonary, 18%; renal, 11%). The clinical follow-up period was 16 ± 20 months. The MODSs and SOFA scores correlated linearly with overall mortality (MODS: odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.7; P < .01; SOFA score: OR, 1.4; 95% CI, 1.2-1.7; P < .01 per unit), with a score of ≥5 the inflection point most predictive of mortality (MODS: OR, 3.9; 95% CI, 1.6-9.9; P ≤ .01; SOFA score: OR, 2.8; 95% CI, 1.2-6.6; P = .02). The 1- and 3-year primary bypass patency and freedom from reintervention was 91% ± 5% and 83% ± 7%, respectively, with no association with the MODSs or SOFA scores. The 1- and 3-year survival was 86% ± 4% and 71% ± 6% with significantly worse outcomes for patients with higher MODSs and/or SOFA scores. ConclusionsMost CMI patients undergoing OMB will experience significant metabolic derangements resulting from sequelae of the ischemia–reperfusion phenomenon postoperatively. These can be objectively assessed in the early postoperative period using simply applied scoring systems to reliably predict the early and long-term outcomes. A derivation of the MODS and/or SOFA score after OMB for CMI can identify the most vulnerable patients at the greatest risk of mortality.

Intraoperative conversion and complications in robotic assisted primary and redo gastric bypass surgery.

The rise of robotic assisted surgery in the treatment of morbidly obese patients has enlarged the armamentarium for surgeons involved in bariatric surgery. This in particular is of great advantage not only in primary cases, but also in patients undergoing revisional procedures following preceding upper GI surgery. In the following, our experience with intraoperative conversions and complications in revisional robotic surgery using the Da Vinci robotic system will be reported and compared to primary robotic bypass surgery and the literature. In a 36-month period, a total of 157 minimally invasive bariatric procedures (48 robotic assisted, 109 laparoscopic) were performed. Out of 43 patients receiving a gastric bypass 32 (74%) were performed robotically. Out of these 20 (62.5%) had previous operations (RRBP): one hiatal mesh repair, one open Mason operation, eight gastric band, nine gastric sleeve, one sleeve with fundoplication. The Da Vinci Xi was used for all surgeries. 3/20 (15%) RRBP were converted to open laparotomy because of a huge left liver lobe (1), extreme adhesions (1) and short mesentery (1) (p = 0.631 vs 1/12 RBP). One out of these had to be reoperated for an insufficiency of the gastroenterostomy. 3/17 (23%) patients (RRBP) without conversion had complications: hemorrhage (1), insufficiency of biliodigestive anastomosis (1), insufficiency of gastroenterostomy (1). There was no mortality and length of hospital stay was 3.5days in uncomplicated cases and 12.3days in complicated cases (p < 0.05). This preliminary experience suggests, that robotic revisional surgery can be performed safely even in complicated cases. Conversion to laparoscopic or open surgery may be required when adverse anatomical conditions are present. However, the incidence of complications was not increased when conversion was performed. In this series, the incidence of complications was not greater in case of revisional surgery.

Long-Term Patency and Final Structure After Superficial Temporal Artery–Middle Cerebral Artery Bypass Surgery: A Retrospective Study

To investigate long-term bypass patency and final structure for patients who underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass. This study retrospectively evaluated 20 patients who underwent STA-MCA bypass and had 2-year follow-up with cerebral angiography. Patients were divided into internal carotid artery occlusion (n= 11) and MCA occlusion or stenosis (n= 9) groups, and diagnosis was either arteriosclerotic (n= 14) or nonarteriosclerotic (n= 6) disease. Final bypass formation was examined with cerebral angiography at 2 years postoperatively. Diameters of the STA, middle meningeal artery (MMA), and deep temporal artery (DTA) were measured at preoperative angiography and at 2-year follow-up. No significant differences in STA, MMA, and DTA diameters were reported between the internal carotid artery versus MCA group. For patients with arteriosclerotic disease, thicker STA diameters were noted on preoperative angiography. For patients with nonarteriosclerotic disease, MMA and DTA dilatation was noted on 2-year follow-up imaging. For patients with arteriosclerotic disease, all direct bypasses were patent at 2 years. For patients with nonarteriosclerotic disease, remarkable angiogenesis was demonstrated. Long-term patency of a direct bypass may be correlated with arteriosclerotic or nonarteriosclerotic etiology. An indirect bypass route may develop in patients with nonarteriosclerotic disease; therefore, it is important to create a foundation for an indirect bypass with MMA and DTA preservation during craniotomy. In 2 patients with nonarteriosclerotic disease, STA remained the primary bypass foundation; however, the technique resembled novel angiogenesis after encephaloduroarteriosynangiosis and not direct STA-MCA bypass. Therefore, final bypass structure might be affected by disease etiology.

Indocyanine green videoangiography for recipient vessel stratification in superficial temporal artery-middle cerebral artery bypass surgery.

In superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery, recipient vessel properties are likely one of the main reasons for bypass failure. In daily practice, most surgeons select the recipient with the largest diameter. However, selection of the ideal recipient remains debatable because there are no objective selection criteria if multiple potential recipients exist. Here, the authors assessed the benefit of using indocyanine green videoangiography (ICG-VA) to optimize recipient vessel selection in patients undergoing STA-MCA bypass surgery for hemodynamic compromise. All patients who had undergone STA-MCA bypass procedures with pre- and postanastomosis ICG-VA between 2010 and 2019 were eligible for inclusion in this study. The primary bypass surgeon was blinded to the preanastomosis ICG-VA. Preanastomosis white-light and ICG-VA images were compared to determine the identifiability of potential recipient vessels and pathological flow patterns. After completion of the anastomosis, a second (postanastomosis) ICG-VA image was used to analyze the flow increase within the chosen recipient based on the vessel diameter, initial recipient blood flow, initial sequence of appearance on ICG-VA, initial blood flow direction within the recipient, and orientation of the bypass graft. ICG-VA, FLOW 800, and intraoperative white-light images, as well as demographic, clinical, and radiographic patient data, were retrospectively analyzed by a clinician who was not directly involved in the patients' care. Sixty patients underwent 65 STA-MCA bypass procedures with pre- and postanastomosis ICG-VA. The ICG-VA permitted identification of a significantly higher number of potential recipient vessels (median 4, range 1-9) than the white-light images (median 2, range 1-5; p < 0.001), with detection of pathological flow patterns in 20% of all procedures. No association was found between the diameter and blood flow within potential recipients (Spearman r = 0.07, p = 0.69). After bypass grafting, the highest flow increase was noted in recipients with an initially low flow (p < 0.01), a late appearance (p < 0.01), and an initially retrograde flow direction (p = 0.02). Interestingly, flow increase was not significantly influenced by the recipient diameter (p = 0.09) or graft orientation (p = 0.44). ICG-VA facilitates identification of potential recipient vessels and detection of pathological flow patterns. Recipients with an initially low flow, a late appearance, and a retrograde flow seem to bear the highest potential for flow increase, possibly due to a higher hemodynamic need for revascularization.

Significance of Prior Endovascular Intervention on Contemporary Outcomes of Open Mesenteric Revascularization

Endovascular treatment has emerged as the primary modality of revascularization in patients with chronic mesenteric ischemia (CMI). The purpose of this study was to determine whether patients undergoing open mesenteric revascularization in the setting of failed prior endovascular intervention had worse outcomes compared to those without prior endovascular intervention. A single-center retrospective review of patients with CMI treated with open mesenteric bypass from 2000 to 2019 was conducted. Demographic, comorbidities, perioperative variables, and outcomes were collected. Patients were categorized into those with prior endovascular intervention and those without. Categorical factors were compared with Pearson χ2 tests or Fisher exact tests, and the life-table method for survival analysis was used to estimate event rates at predefined time frame. From 2000 to 2019, there were 236 patients who underwent open mesenteric bypasses, of which 92 were performed for CMI. Antegrade aortomesenteric bypasses constituted 95% (87/92) of cases. Total of 145 vessels were revascularized: celiac artery (33 vessels), hepatic artery (25 vessels), and superior mesenteric artery (87 vessels). Seventy-six percent (70/92) of patients had undergone a prior endovascular intervention, which subsequently failed. In 91% (84/92) of patients, one or more visceral vessel was chronically occluded on imaging prior to bypass procedure. Patients with prior endovascular intervention were older (64 ± 15 years vs 54 ± 11 years; P = .006). Demographics and comorbidities were otherwise similar between the groups. Primary patency for celiac artery bypass was 93% and 89% at 1 and 3 years, respectively. Primary patency for superior mesenteric artery bypass was 92% and 84% at 1 and 3 years, respectively. There was no statistically significant difference in primary bypass patency rates of those with or without prior endovascular intervention (P > .05). Patients with prior endovascular intervention had a higher all-cause mortality trend at 30 days, 1 year, and 3 years (5.8% vs 0%; 13.7% vs 5.4%; and 30% vs 5.4%; P = .1); however, this did not reach statistical significance. Open mesenteric bypass remains a durable revascularization procedure in patients with CMI. Failed endovascular intervention does not significantly impact open mesenteric revascularization outcomes; however, it likely signifies an overall higher atherosclerotic disease burden.

Protamine sulfate use during tibial bypass does not appear to increase thrombotic events or affect short-term graft patency.

While the use of protamine sulfate as a heparin reversal agent has been extensively reviewed in patients undergoing carotid endarterectomy and coronary artery bypass grafting, there is a lack of literature on protamine's effects on lower extremity bypasses. The purpose of this study was to determine the risk of protamine sulfate dosing after tibial bypass on thrombotic or bleeding events, including early bypass failure. We performed a retrospective review of our institutional database for patients undergoing primary distal peripheral bypass from January 2009 through December 2015 (contralateral bypass was considered to be a new primary bypass). Primary endpoints include composite thrombotic events (myocardial infarction, stroke, amputation at 30days and patency less than 30days) and composite bleeding events (bleeding or transfusion). A total of 152 tibial or peroneal bypasses in 136 patients with critical limb ischemia were identified. Of these, 78 (57.4%) patients received protamine sulfate intraoperatively and 58 (42.6%) did not. There were no differences in composite thrombotic or hemorrhagic outcomes. Protamine use had no effect on the rates of perioperative MI (9.0% versus 3.5%, p = 0.20), stroke (1.3% versus 1.7%, p = 0.83), or perioperative mortality (5.1% versus 3.5%, p = 0.64). There was no significant difference in composite post-operative bleeding events (20.7% versus 14.1%, p = 0.31) or composite thrombotic events (17.2% versus 18.0%, p = 0.91). Patients who received protamine undergoing bypass with non-autogenous conduit had significantly higher-recorded median operative blood loss (250mL versus 150mL, p = 0.0097) and median procedure lengths (265min versus 201min, p = 0.0229). No difference in 30-day amputation-free survival was noted (91.0% versus 91.4%, p = 0.94). Follow-up Kaplan-Meier estimation did not demonstrate a difference in 30-day patency (91.7% versus 88.5%, p = 0.52). Heparin reversal with protamine sulfate after tibial or peroneal bypass grafting is not associated with higher cardiovascular morbidity, bypass thrombosis, amputation, or mortality. Additionally, there was no statistically significant difference in post-operative bleeding or thrombosis complications for patients who did not receive protamine, although the findings are suggestive of a potential difference in a more adequately powered study. Our results suggest that protamine sulfate is safe for intraoperative use without increased risk of thrombotic complications or early tibial bypass graft failure.

A Case Series of Double Bypass Technique Used for the Treatment of Internal Carotid Blood Blister-like Aneurysms in Patients in Poor Initial Neurological Condition at the Early Stage of Subarachnoid Hemorrhage.

Optimal surgical treatment of blood-blister aneurysms (BBA) remains controversial. Some surgeons prefer clipping reconstruction while others favor primary bypass with trapping. To analyze of benefit of double bypass technique to surgical outcomes in patients with ruptured BBA in poor initial neurological condition (PINC). Retrospective analysis of clinical, radiological, and surgical data in 9 patients treated between January 2009 and December 2015. Intraoperative middle cerebral artery blood pressure (MCABP) measurement was used for selection of bypass procedure. Seven patients presented with World Federation of Neurosurgical Societies (WFNS) subarachnoid hemorrhage (SAH) score 4 or 5. No pulse pressure in the MCA after internal carotid artery (ICA) clamping was found in 3 patients, although their ACoA or PCoA were well visualized on preoperative angiograms. By contrast, only a minimal drop in MCABP following ICA clamping was detected in two cases, although their collaterals were slim/nonvisualized on imaging. Although angiographic vasospasms were not observed in our patients, two of them experienced cerebral infarction, attributable more to the mass effect and postoperative ICA thrombosis than to SAH-induced vasospasm. There were 2 premature intraoperative ruptures, but no perioperative mortality, aneurysm recurrence, or rebleeding. Five patients with WFNS SAH score 4 or 5 achieved favorable outcomes. Early double bypass technique guided by MCABP measurement and combined with trapping (or rarely clipping) seems to be a safe method with excellent long-term outcomes in patients in PINC. This study may thus contribute to the debate on the optimal treatment strategy for BBA.