Primary Patency Research Articles

AVG delamination: a cause of early cannulation arteriovenous graft dysfunction in hemodialysis patients

Background A series of cases have reported graft delamination as a rare complication of early-cannulation arteriovenous graft (ecAVG). The unique multilayer structure of ecAVGs contributes to the property of cannulation as early as hours after implantation, but on other hand it takes the risk of graft delamination. However, the underlying mechanism and management of graft delamination as well as its effects on the long-term patency of ecAVGs have not been systemically analyzed. Methodsz A retrospective study was conducted in a cohort of patients who required an ecAVG for hemodialysis (HD) access in our center between April 2017 and December 2021. The characteristics of graft delamination and the outcomes of its different treatments were analyzed. Results A total of 144 ecAVGs were established in 141 end-stage renal disease (ESRD) patients, including 124 (86.1%) Acuseal grafts and 20 (13.9%) Flixene grafts. During follow-up 24.5(11.5, 45.8) months, 11 (7.6%) subjects had graft infection with an incidence of 0.03 patient-year. Thirteen (9.0%) subjects had graft delamination at 9.3(5.0,12.4) months after ecAVG implantation, with an incidence of 0.04 per patient-year. ecAVG delamination was observed in both Acuseal grafts (0.037 per patient-year) and Flixene grafts (0.055 per patient-year). Thrombosis or venous hypertension was the most common complaints. Seven delamination was observed at 1.3 (0.1, 4.2) months after an endovascular procedure. The primary patency, primary assistant patency and secondary patency in delamination group were significantly lower than that in non-delamination group (p < 0.05). Post-procedure primary patency of group A (percutaneous transluminal angioplasty, PTA), group B (stenting) and group C (partial graft replacement, PGR) were 1.3 (0.45,4.22) months, 5.3 (3.05,6.85) months and 8.45 (4.78,14.53) months respectively (p = 0.029). Conclusions Graft delamination was not a rare complication of ecAVGs in this cohort. It significantly reduced the long-term patency of AVGs. PGR might be a more effective therapeutic way than endovascular treatments.

Amputation-Free Survival, WIfI Stage, and GLASS Classifications in Distal Crural or Pedal Bypass for Chronic Limb-Threatening Ischemia

Background: Chronic limb-threatening ischemia (CLTI) is a severe condition with high risks of amputation and mortality, especially in patients with distal crural or pedal artery disease. Despite advances in endovascular techniques, bypass surgery remains crucial for patients with CLTI. This study aimed to investigate amputation-free survival, Wound, Ischemia, and foot Infection (WIfI) staging, and Global Limb Anatomic Staging System (GLASS) classifications in patients undergoing distal crural or pedal bypass for CLTI. Methods: This retrospective study analyzed all patients who underwent distal crural or pedal bypass for CLTI in a tertiary vascular centre from January 2010 to December 2019. The data were collected from hospital records and preoperative imaging. WIfI stages and GLASS classifications were determined for each patient, and the primary endpoint was amputation-free survival. Secondary outcomes included bypass patency, 30-day morbidity, and mortality. Results: We identified 31 bypasses performed on 29 patients with a median age of 67 years (79% male). Preoperatively, 94% of limbs were staged GLASS III and 55% were classified WIfI stage 4. Failed endovascular revascularization preceded bypass surgery in 65% of the cases. Thirty-day mortality was 3% (n = 1) and 30-day major amputation rate was 10%. Primary patency was 87%, and secondary patency was 94% at 30 days. Median duration of follow-up for survival was 59 months with a mean follow-up index (FUI) of 0.99 ± 0.05, and for major amputation and bypass patency 54 months (mean FUI 0.9 ± 0.19 and 0.85 ± 0.28, respectively). At one year, amputation-free survival was 58%, decreasing to 45% at two years, 39% at three years, and 32% at five years. Most major amputations occurred in WIfI stage 4 patients, but 53% of WIfI stage 4 and 80% of WIfI stage 3 patients were alive without major amputation after one year. Conclusions: Distal crural and pedal bypasses are essential for limb salvage in high-risk CLTI patients, particularly those with failed prior revascularization. However, the procedure is associated with limited long-term amputation-free survival. WIfI and GLASS classifications are useful for stratifying risk and guiding treatment, but outcomes suggest the need for individualized care strategies. Further research into perioperative management and alternative interventions is warranted to improve long-term outcomes in this population.

5-years patency results of Zilver PTX on the femoro-popliteal arterial segment: A Northern Sydney experience.

The burden of peripheral arterial disease is increasing. Treatment of femoro-popliteal lesions remains challenging despite novel endovascular devices. Drug-eluting stents suppress post-treatment inflammation and reducing neo-intimal hyperplasia to reduce in-stent restenosis. A multi-centre retrospective 5-years longitudinal study was undertaken to evaluate freedom from clinically driven target limb revascularisation (FF CD-TLR) and patency of Zilver PTX stents in treating symptomatic femoro-popliteal stenotic lesions. Kaplan-Meier survival curves were used to demonstrate FF CD-TLR, primary, primary assisted and secondary patency. There were 148 patients and 183 lesions treated with a mean age of 80.3years and 52% males. The all-cause 5-years mortality was 25%. FF CD-TLR yearly patencies to 5years were 81%, 67%, 62%, 57% and 52%, respectively, with significantly poorer outcomes for in-stent restenosis, longer stent lengths and lesions at the femoro-popliteal junction. Primary patencies were 63%, 47%, 40%, 34% and 24%, assisted primary patencies were 90%, 75%, 68%, 59% and 48% and secondary patencies were 96%, 94%, 94%, 92% and 92%. Major adverse limb events were 5% at 1-year and cumulative at 5-years was 16%. The clinical outcomes in this study population are comparable to recent publications with smaller cohorts. Our study confirms Zilver PTX has very good primary patency over 5years with no discernible effect on all-cause mortality in an elderly cohort with particularly long treated lesions. Our results are similar to those seen in younger patients with shorter lesions. Nonetheless, longer lesions required more reinterventions to maintain patency. Zilver PTX is a safe and durable drug-eluting stent when utilised in the management of femoro-popliteal stenotic lesions with good long-term patency and limited need for re-intervention.

Long-term results of carotid body tumours surgery and predictive analytics on metastatic disease and recurrence.

The determination of clinico-surgical predictors of carotid body tumour (CBT) metastasizing and/or recurrence. Patients with CBT but without a history of its previous treatment who had received inpatient medical aid at a tertiary surgical centre during the period 2011-2021 were retrospectively reviewed to obtain baseline data. Primary endpoints of the study were CBT metastasizing and/or local recurrence after radical surgery (composite endpoint) and overall survival. Secondary endpoint of the study was primary patency of carotid arteries that had been repaired/reconstructed as a result of CBT removal. Suspected predictors of CBT metastasizing/recurrence were young age of CBT onset, positive family history, multifocal paraganglioma, Shamblin type III CBT, carotid bifurcation and/or internal carotid artery (ICA) reconstruction as a result of CBT excision. To detect CBT metastasizing/recurrence, prospective imaging-based whole-body screening was suggested to patients. Fifty-three patients met the eligibility criteria. The overall survival rate was 100% at a median follow-up time of 68 months (interquartile range [IQR] 27‒104.5 months). The primary patency of repaired carotid arteries (n = 9) was 88.9% at a median follow-up time of 99 months (IQR 15.5‒116.5 months). Thirty-nine patients underwent the prospective whole-body screening. Eight (20.5%) patients were diagnosed with metastatic disease (n = 6) or local recurrence (n = 2). Patients with CBT metastasizing/recurrence were younger at age of CBT onset (p = .011), more frequently had Shamblin type III CBT (p = .004) and the necessity for carotid artery repair/reconstruction (p = .041) than patients without metastasizing/recurrence. These two groups were similar in terms of gender (p = .682), the prevalence of multifocal paraganglioma (p = .167) and positive family history (p = .180). Only the belonging of a CBT to Shamblin type III was defined as a statistically significant predictor of CBT metastasizing/recurrence in both univariable and multivariable binary logistic regression analyses (odds ratio 30; 95% confidence interval: 2.649-339.739; p = .006 and odds ratio 75.409; 95% confidence interval: 1.082-5254.557; p = .046, respectively). Multifocal paraganglioma as a predictor exhibited a strong tendency towards statistical significance (p = .09 and p = .072, respectively). Other suspected predictors didn't reach the level of statistical significance either in univariable (p = .151 for positive family history) or in multivariable (p = .211 for age of CBT onset; p = .734 for carotid artery reconstruction/repair) binary logistic regression analyses. Shamblin type III CBT has high potential for metastasizing and recurrence. Patients with Shamblin type III CBT and/or multifocal paraganglioma should be considered for genetic testing as well as preoperative whole-body radiological imaging and long-term postoperative whole-body imaging-based follow-up.

Paclitaxel- or sirolimus-coated balloons used for ArterioVEnous fistulas-2 (PAVE-2): study protocol for a randomised controlled trial to determine the efficacy of paclitaxel- or sirolimus-coated balloons in arteriovenous fistulas used for haemodialysis

BackgroundIn view of the conflicting results from previous studies, the benefit of paclitaxel-coated balloons for arteriovenous fistulas is uncertain and equipoise remains. Although an industry-led trial testing the efficacy of sirolimus-coated balloons in AVFs is in progress, the benefit of sirolimus-coated balloons for arteriovenous fistulas is currently unknown. The purpose of this trial is to compare the efficacy of additional paclitaxel-coated or sirolimus-coated balloons on outcomes after a plain balloon fistuloplasty to preserve the patency of arteriovenous fistulae used for haemodialysis.MethodsThe study design is a multicentre randomised controlled trial. Following a successful plain balloon fistuloplasty, participants will be randomised to further treatment with a paclitaxel-coated balloon, a sirolimus-coated balloon, or an uncoated control balloon. We will recruit 642 patients, each with one or two treatment segments, over a 3-year period. Patients will remain in the trial and be followed up for 1 year. The primary endpoint is time to loss of treatment segment primary patency. Cox-proportional hazards models will be used to estimate hazard ratios for the time to loss of treatment segment primary patency for each treatment group relative to the control group. Analysis of the primary endpoint will be based on treatment segments rather than participants and a shared frailty will be estimated to account for the clustering of treatment segments within patients. Secondary endpoints are time to loss of primary patency at any treatment segment; time to end of access circuit primary patency; time to AVF abandonment; number of radiological or surgical interventions; adverse events; intima-media thickness and degree of stenosis at 3 months on ultrasound; and patient quality of life assessed by EQ-5D-5L and VASQoL.DiscussionThe three-armed design in this proposal will provide an answer on the efficacy of both paclitaxel- and sirolimus-coated balloons in the same trial. This trial is likely to provide a clear answer regarding the efficacy of drug-coated balloons for arteriovenous fistulas.Trial registrationISRCTN ISRCTN40182296. Registered on 4 August 2023.

Reported outcomes in studies of intermittent claudication - first step toward a core outcome set: systematic review.

This review aimed to compile an exhaustive list of all outcome measures and identify different characteristics of the outcomes reported in studies of intermittent claudication as the first step in developing a core outcome set for intermittent claudication. Medline and Embase were searched for all studies including individuals with intermittent claudication and reporting ≥1 outcome from January 2015 to August 2024. Abstract, full text screening and data extraction were performed by two investigators independently. All reported outcome measures were extracted verbatim and categorized by Dodd's domains (Core Outcome Measures in Effectiveness Trials registration: COMIC Study, 1590; https://www.comet-initiative.org/Studies/Details/1590). 4985 studies were screened and 408 were included. A total of 541 unique outcomes across 25 Dodd's domains were identified. Ankle-brachial pressure index was the most frequently reported outcome. Among the 541 unique outcomes, 386 outcomes were only reported once. Only 38.9% of the studies exclusively included patients with intermittent claudication. Patient-reported outcomes were reported in 36.2% of studies. There were wide variations in the definition of commonly used outcome measures (for example, major adverse limb event and primary patency) across different studies. There is substantial heterogeneity in reported outcomes in studies of intermittent claudication. Most reported outcomes are clinical/physiology oriented rather than patient centred. Development of a core outcome set for intermittent claudication is vital to improve and standardize reporting in future research.

Safety and efficacy of low-dose versus high-dose paclitaxel-coated balloons in patients with femoropopliteal lesions: an updated and meta-analysis

Abstract Introduction Drug-coated balloons (DCBs) have reduced restenosis and reintervention of femoropopliteal lesions compared to uncoated percutaneous transluminal angioplasty (PTA). However, limited data are available on different dosages of the DCBs. Purpose We aimed to give a comprehensive analysis in this regard and update the current evidence. Methods We searched Scopus, Cochrane, PubMed, and WOS from inception till February 2024 to include all randomized controlled trials (RCTs) that addressed different dosages of DCBs in femoropopliteal lesions. The primary endpoint was all-cause death, primary patency, and amputation at six months, while the secondary outcomes were all-cause death, primary patency, and amputation at 12 months. Dichotomous data were pooled using Odds Ratio (OR) and 95% Confidence Interval (CI) in a random-effect model. Results A total of 21 studies, including 4081 patients in the analysis. Low-dose DCB was associated with high rates of primary patency compared to the standard dose at both 6 and 12 months of follow-up with the following values (OR: 2.46, 95% CI: 1.48 to 4.08, and 1.93, 95% CI: 1.5 to 2.49, receptively). Also, low-dose DCB reduced the incidence of clinically driven target lesion revascularization (CD-TLR) compared to the standard dose at 12 months (OR: 0.45, 95% CI: 0.31 to 0.65). Regarding high-dose DCB, higher primary patency rates were observed when compared to standard doses at 6 and 12 months (OR: 1.89, 95% CI: 1.19 to 2.99, and 5.47, 95% CI: 4.31 to 6.95, respectively). Moreover, high-dose DCB reduced the incidence of CD-TLR at 6 and 12 months of follow-up (OR: 0.33, 95% CI: 0.18 to 0.63, and 0.63, 95% CI: 0.48 to 0.84, respectively). Conclusion Low-dose DCBs were associated with higher primary patency without significant differences in all-cause mortality or amputation. On the other hand, high-dose DCBs were associated with a higher incidence of amputation without significant differences in other studied outcomes.Low dose Paclitaxel coated balloon vs CoHigh dose Paclitaxel coated balloon vs C

Impact of the lower extremity arterial calcification score on clinical outcomes after drug-coated balloon angioplasty for de novo femoropopliteal artery disease

Abstract Background Severe calcification, assessed using the peripheral artery calcification scoring system (PACCS), is associated with poor clinical outcomes after endovascular treatment (EVT) for de novo femoropopliteal lesions. However, the PACCS classification is a qualitative assessment performed in the angiographic room, and there are no established indicators for the quantitative assessment of calcification prior to treatment. Purpose We aimed to investigate the impact of the lower extremity arterial calcification score (LEACS) calculated using non-contrast lower limb computed tomography on clinical outcomes after drug-coated balloon angioplasty for de novo femoropopliteal artery disease. Methods We retrospectively analyzed the clinical outcomes of 141 consecutive patients treated at our center for de novo femoropopliteal artery disease using a drug-coated balloon between April 2018 and December 2022. Patients who did not undergo lower limb computed tomography before EVT were excluded from the analyses. LEACS was determined based on the method used to calculate the Agatston score for the coronary arteries. Each patient’s score consisted of a sum of calcification scores from ostium of superficial artery to the popliteal artery at the knee joint of treated limb. The primary and secondary outcomes measured were primary patency and clinically-driven target vessel revascularization (CD-TVR) at 1 year. Cox proportional hazards analysis was used to explore independent predictors of clinical outcomes. The study population was divided into higher and lower LEACS groups based on the cut-off value (1750), which best discriminated patency, and the outcomes were compared between the two groups. Results In the higher and lower LEACS groups, the mean age was 75.1 ± 9.1 years and 75.5 ± 11.0 years (p = 0.87) and the mean lesion length was 170.3±102.8 mm and 157.7±112.1 mm (p = 0.64), respectively. The higher LEACS group showed significantly lower 1-year patency than the lower LEACS group (53.5% vs. 84.3%, log-rank, p = 0.041). In addition, freedom from 1-year CD-TVR was significantly lower in the higher LEACS group than in the lower LEACS group (66.8% vs. 93.7%, p = 0.047). The Cox proportional hazard analysis showed that the higher LEACS group was an independent predictor of 1-year restenosis (odds ratio: 2.80, 95% confidence interval: 1.24–8.84, p=0.037), along with a small (&amp;lt; 5 mm) reference vessel diameter (odds ratio: 3.55, 95% confidence interval: 1.44–9.53, p=0.028). Conclusion Higher LEACS scores were independently associated with clinical outcomes after drug-coated balloon angioplasty for de novo femoropopliteal artery disease. Non-contrast lower limb computed tomography is an acceptable and feasible option for predicting the outcomes in patients with de novo femoropopliteal artery disease prior to treatment.

Mid-Term Outcomes of the Iliac Branch Endoprosthesis with Standardized Combinations of Bridging Stent-Grafts for Endovascular Treatment of Aortoiliac Disease with or Without Co-existing Hypogastric Aneurysms (The HYPROTECT Study).

To evaluate retrospectively the 2-year outcomes of the Gore Excluder Iliac Branch Endoprosthesis (IBE) in patients with and without coexisting hypogastric artery (HA) aneurysms in a large contemporary multicentric European experience using dedicated bridging devices. The study included all consecutive patients treated at participating institutions with the Gore Excluder IBE device who received a covered stent (i.e., stent-graft) from the same manufacturer. Technical success was defined as deployment of endografts with complete exclusion of the aneurysm(s), patency of target vessels, and absence of type 1 and 3 endoleak. Assessment of follow-up outcomes included freedom from HA branch instability defined as the composite cumulative endpoint of any HA branch-related complication. A total of 437 patients were included for analysis from 22 European vascular surgery centers. Patients were categorized into two subgroups: subgroup A (n = 269) if they did not have concomitant hypogastric aneurysms, otherwise they were categorized into subgroup B (n = 168). Finally, 78 (18%) had bilateral IBE with a total of 515 IBE included in the study. Balloon expandable stents were deployed in 19 (6.3%) subgroup A patients compared with 46 (21.7%,) in subgroup B, p < .001. The two-year estimate for freedom of HA branch instability was significantly higher for patients in group A as compared with patients in group B (94% vs. 90%, p = .045). At univariate regression, the number of stent-grafts used was associated with higher risk of iliac branch instability (p = .021), while in multivariate regression for the use of more than 2 bridging stent-grafts the risk of instability increased by 2.35 times. This large contemporary European multicentric experience with the use of the Gore Excluder IBE in patients with or without associated HA aneurysms shows satisfactory mid-term outcomes when the device is used in conjunction with both self-expandable and balloon-expanding stent-grafts from the same manufacturer. Although primary patency of the iliac branch was as high as 90%, caution and strict follow-up must be exercised when multiple bridging stent-grafts are used over longer distances.

Midterm results of endovascular treatment of ateriovenous fistula stenosis at Dong Nai General Hospital

Introduction: AVF stenosis is a common complication, leading to impaired dialysis function, increased risk of occlusion and increased mortality. Endovascular intervention treatment of AVF stenosis is an important technique in the management of dialysis patients, particularly at local hospitals. Methods: This is a retrospective study performed at Dong Nai general hospital from 2022-2024. Results: The success rate of endovascular intervention to treat AVF stenosis at Dong Nai General Hospital is 91%, 3-month primary patency was 93.1% and 6-month primary patency was 86.2%. Drug-coated balloons (DCB) shows superior effectiveness compared to conventional balloons (PBA) with a lower restenosis rate. Conclusion: Endovascular intervention to treat AVF stenosis at Dong Nai General Hospital has good short term and midterm results. Drug-eluting balloons have a statistically significantly lower mid-term restenosis rate than conventional balloons. Implementing this technique at provincial hospitals helps reduce the burden on central hospitals and reduce medical costs for chronic kidney failure patients requiring hemodialysis.

Optimizing venous anastomosis for forearm loop arteriovenous grafts: A comparative analysis of elbow veins and upper arm basilic veins in end-stage kidney disease patients.

Optimizing vascular access for hemodialysis in end-stage kidney disease is crucial. While arteriovenous fistulas (AVFs) are preferred for better patency and fewer complications, many patients require alternatives options like arteriovenous grafts (AVGs) due to anatomical constraints. This study compares outcomes between elbow and upper arm (UA) basilic veins for forearm loop AVGs, highlighting the potential benefits of the UA basilic vein to improve patency and feasibility in patients with poor elbow veins through retrospective analysis. This retrospective study analyzed 59 limbs of patients who underwent forearm loop AVG formation from January 2018 to June 2022. Elbow veins (basilic, median cubital, brachial) and UA basilic veins were evaluated for suitability using duplex ultrasonography. AVG decisions were based on patient age, health, and vein diameter (⩾2.3 mm). Statistical analyses compared baseline characteristics and evaluated primary and secondary patency rates at 12 and 18 months using Pearson's chi-square, Student's t-test, Kaplan-Meier survival analysis, and the Log-rank test. Thirty-six patients had elbow anastomosis, while 23 had UA anastomosis for forearm loop AVG. The elbow group had a higher male proportion (72.7% vs 34.7% in UA, p = 0.005) and larger elbow vein diameters (2.52 ± 0.19 mm vs 2.16 ± 0.21 mm in UA, p < 0.001). Primary patency rates at 12 months were 72.7% for elbow and 56.2% for UA; at 18 months, 59.4% and 25.5%, respectively (p = 0.376). Secondary patency rates at 12 months were 75.7% for elbow and 62.2% for UA; at 18 months, 67.8% and 33.9%, respectively (p = 0.238). The primary and secondary patency rates of forearm loop AVG with UA basilic vein anastomosis were not inferior to those with elbow veins anastomosis. UA basilic vein can be a feasible alternative for creating forearm loop AVG when elbow veins are not suitable.

Effect of preoperative heart failure on arteriovenous access patency and prognosis in patients on hemodialysis.

The risk of arteriovenous (AV) access failure is associated with hemodynamic factors, clinical factors, or technical issues. Although several studies have shown the detrimental effects of AV access on heart function, few studies have assessed whether heart function affects AV access patency. We investigated the impact of cardiac function on AV access patency. Additionally, we evaluated the influence of heart failure (HF) on the prognosis of patients on dialysis. Patients who underwent dialysis and had echocardiographic reports between 2011 and 2013 were retrospectively included. Left ventricular ejection fraction (LVEF) was used to measure cardiac function. Data on demographics, clinical features, and technical factors associated with AV access surgery were collected. Univariate and multivariate analyses were performed to evaluate the risk factors for AV access patency loss and the prognosis of patients on dialysis. During the study period, 395 patients initiated on dialysis underwent echocardiography. In multivariate analysis, older age (hazard ratio (HR) 1.02 (1-1.03), p = 0.028), smoking (HR 2.05 (1.19-3.53), p = 0.01), lower LVEF (HR 0.98 (0.97-1), p = 0.015), and graft use (HR 2.29 (1.47-3.58), p = 0.001) were significant risk factors for primary patency loss. Regarding secondary patency loss, lower LVEF (HR 0.98 (0.96-1), p = 0.035) was the sole risk factor. In multivariate analysis, risk factors for cardiac events (acute coronary syndrome and aggravation of HF) in patients on dialysis were age (HR 1.06 (1.04-1.09), p = 0.001), diabetes (HR 2.46 (1.31-4.63), p = 0.005), pre-existing coronary artery disease (HR 2.84 (1.57-5.14), p = 0.001), and HF (HR 1.93 (1.05-3.56), p = 0.036). Decreased cardiac function adversely affects the primary and secondary patency of AV access, but its impact is limited. Additionally, HF is associated with future cardiac events in dialysis patients. However, HF is not independently associated with patient survival.

Mid-Term Results of Popliteal-Pedal Inframalleolar Vein Bypasses in Chronic Limb-Threatening Ischemia Patients After Previous Failed Tibial Endovascular Recanalization

Inframalleolar bypass still preserves its role in the modern endovascular era. Aim of this study was to evaluate the mid-term outcomes of "short" inframalleolar vein bypasses in patients with chronic limb-threatening ischemia (CLTI) after previous failed tibial endovascular recanalization. Between January 2015 and December 2021 107 CLTI patients in 3 Italian Departments of Vascular Surgery underwent "short" inframalleolar vein bypass after failed tibial endovascular recanalization. Early (30-day) and 3-year outcomes were evaluated in terms of survival, primary patency, primary assisted patency, secondary patency, and amputation-free survival. Univariate analysis of the perioperative factors affecting outcomes were performed by means of log-rank test. Associations of procedure variables were sought based on a multivariate Cox regression analysis. Distal anastomosis (inframalleolar) was mostly performed on dorsal pedis (64, 59.8%). At 30 days bypass occlusion was recorded in 5 cases (4.6%). Mean follow-up period was 20.5 ± 17.9 months. Estimated 3-year overall survival was 66.7%. Three-year estimates of primary patency, primary assisted patency, secondary patency, and amputation-free survival were 68.5%, 70.1%, 70.2%, and 76.7%, respectively. Multivariate analysis showed a negative association of insulin treatment with primary patency (HR 4.3, p = .04), primary assisted patency (HR 5.1, p = .02), and secondary patency (HR 5.1, p = .02). Negative association of long-term corticosteroid use was also found with primary patency (HR 7.8, p = .005), primary assisted patency (HR 8.7, p = .003), secondary patency (HR 8.7, p = .003), and amputation-free survival (HR 3.9, p = .05). "Short" vein bypasses to the foot arteries in CLTI patients yielded good mid-term overall patency, and limb salvage rates after a failed tibial endovascular recanalization. Insulin dependent diabetes mellitus, and long-term corticosteroid use seemed to affect the outcomes.

The Feasibility of Thrombolysis Followed with Ultrasound-Guided Percutaneous Transluminal Balloon Angioplasty in Acutely and Sub-Acutely Thrombosed Arteriovenous Fistulas.

Prompt resolution of arteriovenous fistula (AVF) thrombosis is essential to minimize the need for temporary dialysis catheters. Identifying the ideal timing for the management of thrombosed arteriovenous fistula (AVF) is an area that has not been thoroughly explored. Herein, we examined a local infusion of urokinase for thrombolysis followed by ultrasound-guided percutaneous transluminal balloon angioplasty (PTA) in acute and subacute AVF thromboses. This retrospective cohort research assessed thrombosed AVF in patients referred to the Second Xiangya Hospital. We included patients who underwent local thrombolysis followed by ultrasound-guided PTA treatment between January 1, 2018, and January 1, 2020. Results. We enrolled the records of 86 patients into the present study, including 44 patients with acute AVF thrombosis (group 1: thrombus age, < 72 hours) and 42 patients with subacute AVF thrombosis (group2: thrombus age, 72 hours to seven days). The thrombolytic success rate was 79.5% in group 1 and 42.9% in group 2 (P < .001). All patients underwent ultrasound-guided PTA to dissolve any residual thrombi regardless of thrombolytic success. Technical success after PTA procedures was achieved in 93.2% of patients in group 1 and 88.1% in group 2 (P = .417). Primary patency at six months was comparable between the two groups (67.5% vs. 64.8%, P = .564). We observed that thrombolytic effect does not affect PTA success rate, and six-month patency rate. Direct local infusion of urokinase to the affected area followed by ultrasound-guided PTA constitutes a minimally invasive and effective method for salvaging thrombosed AVF in contrast to abandoning the occluded fistula.

Hemodialysis vascular access in the elderly: Promising results from a tertiary center

BackgroundHemodialysis patients, particularly the elderly, present challenges for vascular access (VA) creation due to age-related vascular changes and comorbidities. This study aimed to characterize outcomes related to VA in elderly patients (≥75 years) and compare them with younger patients, focusing on primary failure, maturation failure, and patency rates. MethodsThis retrospective study included patients evaluated in VA consultations between January 2019 and December 2021; patients were evaluated through physical examination and Color Doppler Ultrasound to determine the suitability of vessels for VA construction. Demographic data, proposed and created VA types were assessed. The primary outcomes were the evaluation and comparison of primary failure and maturation failure of VA in the elderly (O) and younger (Y) groups. Secondary outcomes included the assessment of primary patency and primary assisted patency at 6, 12, and 24 months in both groups. ResultsAmong 167 patients, 36 were elderly. There were no significant differences in proposed and created VA types between the Y and O groups and radial-cephalic AVFs were the most commonly constructed VA in both groups.Primary and maturation failure rates were similar (Y group: 17.3% and 5.6%; O group: 9.7% and 10.7%, respectively). Primary patency and primary assisted patency rates did not significantly differ between groups at 6, 12, and 24 months. ConclusionThe impact of age on the feasibility of VA should not be exaggerated. Preoperative assessment and a tailored approach enable successful autologous access creation in elderly patients, resulting in outcomes comparable to those of younger patients.

Comparison of Early Outcomes in Patients Who Underwent Common Femoral Thromboendarterectomy with Vein versus Bovine Pericardial Patches

The treatment outcomesof vein and bovine pericardial patches in thromboendarterectomy (TEA) for common femoral artery (CFA) lesions in patients with peripheral arterial disease (PAD) remain unclear. The purpose of this study was to evaluate the efficacy and safety of the bovine pericardial patch by comparing it with vein patch angioplasty. This was a multicenter retrospective study. We reviewed the data of patients who underwent TEA with patch angioplasty (vein versus bovine pericardial patch angioplasty) for PAD between January 2018 and December 2022. Indication for revascularization is PAD patients with claudication symptoms to rest pain and foot ulcers that interfere with daily life, with lesions in the CFA region. The primary endpoint was 2-year patency. The secondary endpoints were postoperative wound complications, including patch rupture, and safety of remote-phase puncture of the patch area after patch angioplasty. Within the observation period, TEA was performed on 157 limbs in 136 patients using vein patches, and on 86 limbs in 79 patients using bovine pericardial patches. The number of claudication/rest pain/tissue loss was 110/13/34 cases in the vein patch group and 57/14/15 cases in the bovine pericardial patch group, respectively. No significant differences were observed in patient characteristics. No significant between group differences were observed in operative time, blood loss, or percentage of patients who underwent concomitant revascularization during the procedure. The 2-year primary patency rates of the vein and bovine pericardial patch were 95.6% and 92.8%, respectively (P= .49). The rate of surgical site infection (SSI) in this study was 2.5% in the vein patch group and 5.8% in the bovine pericardial patch group, respectively (P=.29). Rupture of the patch occurred in 4 (2.5%) and 4 (4.7%) patients in the vein and bovine pericardial patch groups, respectively (P= .46), and the percentage of cases requiring revision of the patch site was 7 (4.5%) and 5 (5.8%) in the vein and bovine pericardial patch groups, respectively (P= .76). Postoperatively, 23 patients in the vein and 13 patients in the bovine pericardial patch groups underwent patch puncture during the remote period. The median follow-up duration from the date of the surgery to the date of the puncture was 544 days and 374 days in the vein and bovine pericardial patch groups, respectively. No patch-related complications were observed during remote stage puncture. Compared with vein patches, TEA with bovine pericardial patches had acceptable outcomes in terms of patency and postoperative complications.

Custom-Made Device (CMD) for the Repair of Thoraco-Abdominal Aneurysm (TAA): Mid-Long Term Outcomes from a Single Southeast Asian Centre Experience in Singapore.

Introduction: Given the high risk of peri-operative morbidity and mortality associated with open repair, endovascular repair for thoraco-abdominal aneurysms is increasingly performed. This study aims to describe mid to long-term results for patients who were treated with COOK Custom-Made Endograft Device at a single Southeast Asian tertiary centre. Methods: Mid to long-term results of patients treated from 2012 to 2022 were retrospectively reviewed. Indications for treatment were aortic diameter > 5.5 cm, enlargement > 5 mm in 6 months or high-risk morphology. Clinical, operative, early to late complications and reintervention details were captured. The endpoints were technical success, primary patency and primary assisted patency. Results: Electronic medical records of 29 consecutive patients (64.4 ± 1.6 years old; 26/29 males 89.6%) were reviewed. 24/29 (83%) were hypertensive, and 20/29 (69%) were smokers. The mean diameter was 5.5 cm, and the majority were treated for Crawford type IV (19/29, 65.5%). Endograft deployment was 100%. Catheterisation of fenestration was successful in 109/116 (94%). 30-day mortality and morbidity were observed in 12/29 (41%), for which access site complications were most common. No significant haemorrhage or graft explant was recorded. The mean follow-up period was 32.4 months (range 1-108 months). Primary patency was 92.9% (95% CI: 83.8-100.0) at 6 months and decreased to 77.7% (95% CI: 63.4-95.2) at 24 months. Sac shrinkage or stability was noted in 17/29 (58.6%). Re-intervention was performed in 9/29 (31%) for limb occlusion (2/9, 22.2%), renal artery stent occlusion (1/9, 11.1%) and endoleaks (6/9, 66.6%). Assisted patency was maintained at 100% for 12 months before decreasing to 66.7% (95% CI: 37.9-100.0) at 24 months. Conclusions: The study reports the first mid-long-term result in this region, though limited by the sample size. Re-intervention at 30% suggests that disease and procedures remain challenging, emphasising the need to assimilate lessons and experience at high-volume centres.

Treatment with a self-expanding endoprosthesis in patients with stenosis or occlusion at the arteriovenous graft: 6-Month outcomes of a post-marketing surveillance study.

To assess 6-month safety and efficacy of a self-expanding stent graft placement to treat stenotic or thrombosed synthetic arteriovenous access graft at the venous anastomoses. This prospective, multicenter, post-market surveillance study assessed the GORE® VIABAHN® Endoprosthesis (stent graft) in Japanese patients with stenotic or thrombosed vascular access grafts. Key efficacy and safety outcomes were primary patency (PP) and secondary patency (SP) of the target lesion and the vascular access circuit, repeat interventions, technical and clinical success, incidence of adverse and serious adverse events, and device deficiencies through 6 months. The 103 enrolled patients (mean age 71.8 years; 57.3% female) had stent grafts placed in the venous anastomosis of arteriovenous access grafts (on-label). The majority of lesions were stenotic (77.1%) and located in the upper arm (91.4%). Mean lesion length was 42.9 ± 23.6 mm and diameter was 6.7 ± 1.9 mm; 28 patients (27.2%) had elephant trunk placements. Technical and clinical success rates were 100%. At 6 months, Kaplan-Meier estimates of target lesion and circuit PP were 75.1% (95% CI: 65.2, 82.6) and 66.8% (95% CI: 56.4, 75.3), and SP rates were 93.8% (95% CI: 86.7, 97.2) and 93.8% (95% CI: 86.7, 97.2), respectively. Mean cumulative number of reinterventions (0.36; 95% CI: 0.20, 0.51) and incidence of device- or procedure-related adverse events were low (⩽3%). No device deficiencies were reported. The 6-month outcomes of the self-expanding stent graft to treat thrombosed venous anastomoses of synthetic hemodialysis vascular access grafts with stenosis demonstrated safety and effectiveness.

Features associated with arteriovenous fistula patency. A meta-analysis.

It is unclear if cannulation-associated variables such as timing of first cannulation, access creation method, cannulation technique, or needle type are associated with the outcomes of arteriovenous fistulas. We conducted a meta-analysis to investigate such potential associations with 1-year primary patency. Twenty-eight publications with titles that included "arteriovenous fistula," "patency," "cannulation," "metric," "first cannulation," "hemodialysis," "complication," "vascular," "nursing," and "puncture" were retrieved and reviewed. The 1-year primary patency rates ranged from 0.32 to 0.93. Primary patency rates were significantly lower in patients in whom initial cannulation was done less than 1.5 months after fistula creation compared to fistulas first cannulated more than 1.5 months after anastomosis (odds ratio [OR] = 0.41, 95% confidence interval [CI]: 0.32-0.52). The effect of cannulation timing on primary patency rate was attenuated when plastic cannulas were used during the first two to three puncture weeks compared to metal needles (OR = 0.62 vs. 0.34; p = 0.032). Fistulas in the upper arm did not have a higher 1-year primary patency compared to those in the forearm (OR = 1.05, 95% CI: 0.93-1.19). Primary patency of upper arm arteriovenous fistulas was higher in reports from the Americas or Europe compared to reports from Asia. Buttonhole cannulation was not associated with higher patency rates at 1 year compared to rope-ladder cannulation (OR = 1.14, 95% CI: 0.75-1.71). Early cannulation was associated with reduced 1-year arteriovenous fistula patency. This association was reduced when plastic cannulas were used during the initial 2-3 weeks.

Hybrid Stent Graft Technique in Bridging Hostile Renal Arteries in Thoraco-abdominal Branched Endografting

Patency of target arteries is crucial for fenestrated and branched endovascular aortic repair (F/B-EVAR) in thoracoabdominal aortic aneurysms (TAAAs). Occlusions more frequently occur in renal arteries (RAs) than in coeliac and superior mesenteric arteries, especially in patients with hostile anatomy treated by BEVAR. This study aimed to report RA outcomes using a hybrid bridging stent graft technique with distal self expandable (SE) combined with proximal balloon expandable (BE) stent graft during BEVAR with hostile RA anatomies. Clinical data from consecutive patients treated for TAAA by F/B-EVAR in three aortic centres (two in the USA, one in Europe) from 2016 to 2022 were prospectively collected. Renal artery orientation was defined as hostile in case of upward (type B) or downward + upward (type D) orientation. Hostile RAs accommodated by BEVAR and combination of SE + BE stent grafts were retrospectively evaluated. Intra-operative RA related complications, technical success, and branch occlusions were assessed as early outcomes. Primary and secondary RA patency, freedom from RA related re-interventions, and freedom from RA instability were assessed during follow up. Of 584 TAAAs managed by F/B-EVAR, 83 patients (14.2%) had 125 hostile RAs (type B, 45.6%; type D, 54.4%) managed by BEVAR with hybrid SE + BE stent grafts. Intra-operative complications occurred in three RAs (2.4%), including two dissections and one disconnection, all successfully managed with additional stent. Technical success was achieved in all cases, with no RA occlusions at 30 days. The median follow up was 21 (interquartile range 4, 38) months. Estimated three year RA primary patency was 97 ± 2%. Re-interventions were performed in five RAs (4.0%), including two RA branch embolisations for bleeding, two catheter thrombectomies with stent relining (bilateral occlusion in one patient), and one revision of type Ic endoleak. Freedom from RA related re-interventions and RA instability was 95 ± 2% and 91 ± 3% at three years, respectively. Renal artery secondary patency was 99 ± 1% at three years. In hostile RA anatomies, a combination of distal SE and proximal BE stent grafts as bridging stenting in BEVAR is safe and effective, with low rates of occlusion, re-interventions, and branch instability at midterm follow up.