Prosthetic Graft Material Research Articles

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.

Ascending aorta graft pseudoaneurysm and aortobronchial fistula caused by a fractured sternal wire: a case report

BackgroundPseudoaneurysm of ascending aorta is a rare but serious complication of cardiovascular surgeries and it infrequently occurs in the normal prosthetic graft materials. We share our experience with an unusual case of ascending aorta Dacron graft pseudoaneurysm caused by a fractured sternal wire.Case presentationA 34-year-old man, known case of Marfan syndrome, with history of two prior aortic surgeries for aneurysm of ascending aorta, arch and thoracoabdominal aorta, presented with hemoptysis. The hemoptysis originated from an aortobronchial fistula secondary to a huge ascending aorta Dacron graft pseudoaneurysm. The graft erosion and subsequent pseudoaneurysm was caused by a fractured sternal wire. Surgical repair of the pseudoaneurysm was performed successfully and a Gore-tex patch was placed behind the sternum over the graft to prevent further direct contact of the wire and the graft.ConclusionSternal wires can damage the adjacent vascular grafts and lead to fatal complications such as pseudoaneurysm formation. Thus, preventive measures such as using sternal bands and placing a covering layer between the sternal wires and aortic grafts are recommended in patients with dilated or replaced ascending aorta.

A case report of a perigraft inflammatory reaction to a Viabahn stent-graft: diagnosis with MRI and treatment with steroids

BackgroundPerigraft inflammatory reactions to prosthetic graft materials in vascular surgery have been reported; however, to our knowledge, this is the first report of a perigraft inflammatory reaction to a Viabahn stent-graft used in a superficial femoral artery occlusion lesion.Case presentationA 76-year-old man with right leg claudication was diagnosed with a right superficial femoral artery occlusion via contrast-enhanced computed tomography. Endovascular treatment included intravascular ultrasound for passing through the true lumen. A 25-cm Viabahn stent-graft (diameter 5 mm) was implanted. The patient developed pain and local swelling of the right thigh 5 days after endovascular treatment. Blood analysis revealed elevated inflammatory marker levels. Magnetic resonance imaging revealed extensive soft-tissue edema and a high perivascular T2 signal around the right superficial femoral artery. Clinical symptoms resolved within 7 days after initiating steroid therapy, which was gradually decreased and halted after 3 weeks. Follow-up magnetic resonance imaging demonstrated substantially reduced inflammation over the following months.ConclusionsPerigraft inflammatory reaction to a Viabahn stent-graft implant can be immediately diagnosed via magnetic resonance imaging and treated with steroids to reduce the possibility of stent-graft occlusion.

Autologous Bifurcated Carotid Artery Reconstruction: Technique and 2 Year Follow Up

Carotid bifurcation resection with subsequent reconstruction is performed infrequently. While internal carotid artery (ICA) revascularisation is regarded as mandatory, the external carotid artery (ECA) is severed in most instances. Indications for and results of an autologous bifurcated carotid artery reconstruction are discussed. This was a single centre retrospective analysis of a consecutive series of patients treated at an academic vascular surgery centre. From December 2006 to August 2015, 47 patients underwent reconstruction of the carotid artery using an autologous bifurcated interposition graft (36 men; median age 68.3 years [range 41–87 years]; 33 asymptomatic [70%]). The indication for reconstruction was recurrent carotid stenosis unfavorable for endovascular treatment/redo patch plasty (n = 29; symptomatic: n = 12), carotid aneurysm (n = 10), neck tumour with vascular involvement (n = 7), and trauma (n = 1). Groups were not different with regard to vascular risk factors. Non-reversed valve depleted saphenous/accessory saphenous vein from the groin was used in 44 (94%), and reversed valve depleted cubital vein bifurcation graft in three patients (6%). Median ICA cross clamp time was 17 min (range 8–30 min). Five patients suffered from intra-operative ischaemic neurological deficits (11%), of which all were temporary except one. One tumour patient died on post-operative day 1 due to bleeding. Median follow up was 28.3 months (range 0.1–97.4 months). Tumour erosion required graft ligation in one patient 7 months after reconstruction. Five significant stenoses of the ICA (11%), nine (19%) stenoses of the ECA, and two (4%) common carotid artery stenoses, with four (8%) re-redo interventions, were observed. Thirteen patients (28%) died after a median follow up of 6.7 months (range 1.7–56.7 months), all unrelated to the vascular procedure. Autologous bifurcated carotid artery interposition graft avoids the use of prosthetic graft material, the ECA remains patent in 80%, and it provides mid-term results comparable with other redo carotid artery procedures. Therefore, this procedure should be reserved for symptomatic patients with no other revascularisation option.

Application of a Cryogel-Coated Prosthetic Vascular Graft Material for Delivery of Targeted Gene Therapies in a Rabbit Model

Application of a Cryogel-Coated Prosthetic Vascular Graft Material for Delivery of Targeted Gene Therapies in a Rabbit Model

Autologous Bifurcated Carotid Artery Reconstruction: Technique and 2 Year Follow Up

Carotid bifurcation resection with subsequent reconstruction is performed infrequently. While internal carotid artery (ICA) revascularisation is regarded as mandatory, the external carotid artery (ECA) is severed in most instances. Indications for and results of an autologous bifurcated carotid artery reconstruction are discussed. This was a single centre retrospective analysis of a consecutive series of patients treated at an academic vascular surgery centre. From December 2006 to August 2015, 47 patients underwent reconstruction of the carotid artery using an autologous bifurcated interposition graft (36 men; median age 68.3 years [range 41-87 years]; 33 asymptomatic [70%]). The indication for reconstruction was recurrent carotid stenosis unfavorable for endovascular treatment/redo patch plasty (n=29; symptomatic: n=12), carotid aneurysm (n=10), neck tumour with vascular involvement (n=7), and trauma (n=1). Groups were not different with regard to vascular risk factors. Non-reversed valve depleted saphenous/accessory saphenous vein from the groin was used in 44 (94%), and reversed valve depleted cubital vein bifurcation graft in three patients (6%). Median ICA cross clamp time was 17min (range 8-30min). Five patients suffered from intra-operative ischaemic neurological deficits (11%), of which all were temporary except one. One tumour patient died on post-operative day 1 due to bleeding. Median follow up was 28.3 months (range 0.1-97.4 months). Tumour erosion required graft ligation in one patient 7 months after reconstruction. Five significant stenoses of the ICA (11%), nine (19%) stenoses of the ECA, and two (4%) common carotid artery stenoses, with four (8%) re-redo interventions, were observed. Thirteen patients (28%) died after a median follow up of 6.7 months (range 1.7-56.7 months), all unrelated to the vascular procedure. Autologous bifurcated carotid artery interposition graft avoids the use of prosthetic graft material, the ECA remains patent in 80%, and it provides mid-term results comparable with other redo carotid artery procedures. Therefore, this procedure should be reserved for symptomatic patients with no other revascularisation option.

PC224. Application of a Cryogel-Coated Prosthetic Vascular Graft Material for Delivery of Targeted Gene Therapies in a Rabbit Model

PC224. Application of a Cryogel-Coated Prosthetic Vascular Graft Material for Delivery of Targeted Gene Therapies in a Rabbit Model

Abstract 132: Application of a Cryogel-Coated Prosthetic Vascular Graft Material for Delivery of Targeted Gene Therapies in a Rabbit Model

Objectives: Long-term success of prosthetic grafts (PG) in peripheral arterial disease is limited by development of anastomotic neointimal hyperplasia. We have constructed a bioactive prosthetic graft material (BPGM) capable of delivering biologic agents in vitro, and evaluate our BPGM in vivo with a rabbit carotid interposition bypass model. Methods: We synthesized our BPGM by cryopolymerization of RGD with methacrylated alginate and heparin, coating 1.5cm by 2mm electrospun PET (ePET) grafts, and dipcoating in fluorescent siRNA for 3 hours. Three rabbits received bare ePET and 3 received cryogel-coated ePET for a carotid interposition bypass (Figure 1). After 24 hours, bypass patency was assessed, and cell toxicity of the proximal anastomosis, mid-graft, and distal anastomosis examined with H&E staining. Confocal microscopy was used to visualize fluorescence, correlating with ability to deliver siRNA in vivo. Results: Graft patency was equal between groups, with no increased cell toxicity in rabbits receiving cryogel-coated ePET. Confocal microscopy demonstrated no difference in retained fluorescence between rabbits receiving cryogel-coated or bare ePET, and no increased transfection of cells at 24 hours (Figure 2). Conclusion: Creation of the optimal PG demands a material that is biocompatible, responsive, and nonthrombogenic. We have constructed a modified PG capable of in vitro delivery of targeted gene therapies, with comparable patency and biocompatibility in our large animal model. Additional optimization to achieve predictable and sustained release is needed to validate this as an effective and practical method to deliver biologic agents in vivo.

Tissue expander-stimulated lengthening of arteries for the treatment of midaortic syndrome in children

BackgroundMidaortic syndrome (MAS) is a rare condition characterized by stenosis of the abdominal aorta. Patients with disease refractory to medical management will usually require either endovascular therapy or surgery with use of prosthetic graft material for bypass or patch angioplasty. We report our early experience with a novel approach using a tissue expander (TE) to lengthen the normal native arteries in children with MAS, allowing primary aortic repair without the need for prosthetic graft material. MethodsWe conducted a retrospective review of patients with MAS undergoing the TE-stimulated lengthening of arteries (TESLA) procedure at our institution from 2010 to 2014. Data are presented as mean (range). ResultsFive patients aged 4.8 years (3-8 years) underwent the TESLA procedure. Stages of this procedure include the following: stage I, insertion of retroaortic TE; stage II, serial TE injections; and stage III, final repair with excision of aortic stenosis and primary end-to-end aortic anastomosis. Stage II was completed in 4 months (1-9 months) with 12 (7-20) TE injections. Goal lengthening was achieved in all patients. Stage III could not be completed in one patient because of extreme aortic inflammation, which precluded safe excision of the aortic stenosis and required use of a prosthetic bypass graft. The other four patients completed stage III with two (one to three) additional vessels also requiring reconstruction (renal or mesenteric arteries). At 3.2 years (1-6 years) of follow-up, all patients are doing well. ConclusionsThe TESLA procedure allows surgical correction of MAS without the need for prosthetic grafts in young children who are still growing.

Cryopreserved Human Allografts for the Reconstruction of Aortic and Peripheral Prosthetic Graft Infection.

Background: This study aimed to present cases with cryopreserved human allografts (CHAs) for vascular reconstruction in both aortic and peripheral infected prosthetic grafts.Materials and Methods: This is a single center, observational descriptive study with retrospective analysis. In all cases, the infected prosthetic graft material was completely removed. At discharge, patients were administered anticoagulants. Follow-up examinations included clinical visits, echo-color-Doppler ultrasounds, or computed tomography angiography within 30 days and at 3, 6, and 12 months after the treatment, and then twice per year.Results: We treated 21 patients (90% men, n=19) with the mean age of 71±12 years and mean interval between the initial operation and replacement with CHA of 30 months [range, 1–216; interquartile range (IQR), 2–36]. In-hospital mortality was 14% (n=3); no CHA-related complication led to death. Limb salvage was 100%. No patient was lost at the median follow-up of 14 months (range, 2–61; IQR, 6–39). No rupture, aneurysmal degeneration, or re-infection occurred. Estimated freedom from CHA-related adverse events (95% confidence interval, 43–63) was 95% at 3 years.Conclusion: In our experience, CHAs are a viable option for prosthetic graft infections and provide satisfactory clinical results and favorable stability because of a very low rate of CHA-related adverse events during follow-up.

Treatment and outcomes of aortic endograft infection

This study examined the medical and surgical management and outcomes of patients with aortic endograft infection after abdominal endovascular aortic repair (EVAR) or thoracic endovascular aortic repair (TEVAR). Patients diagnosed with infected aortic endografts after EVAR/TEVAR between January 1, 2004, and January 1, 2014, were reviewed using a standardized, multi-institutional database. Demographic, comorbidity, medical management, surgical, and outcomes data were included. An aortic endograft infection was diagnosed in 206 patients (EVAR, n = 180; TEVAR, n = 26) at a mean 22 months after implant. Clinical findings at presentation included pain (66%), fever/chills (66%), and aortic fistula (27%). Ultimately, 197 patients underwent surgical management after a mean of 153 days. In situ aortic replacement was performed in 186 patients (90%) using cryopreserved allograft in 54, neoaortoiliac system in 21, prosthetic in 111 (83% soaked in antibiotic), and 11 patients underwent axillary-(bi)femoral bypass. Graft cultures were primarily polymicrobial (35%) and gram-positive (22%). Mean hospital length of stay was 23 days, with perioperative 30-day morbidity of 35% and mortality of 11%. Of the nine patients managed only medically, four of five TEVAR patients died after mean of 56 days and two of four EVAR patients died; both deaths were graft-related (mean follow-up, 4 months). Nineteen replacement grafts were explanted after a mean of 540 days and were most commonly associated with prosthetic graft material not soaked in antibiotic and extra-anatomic bypass. Mean follow-up was 21 months, with life-table survival of 70%, 65%, 61%, 56%, and 51% at 1, 2, 3, 4, and 5 years, respectively. Aortic endograft infection can be eradicated by excision and in situ or extra-anatomic replacement but is often associated with early postoperative morbidity and mortality and occasionally with a need for late removal for reinfection. Prosthetic graft replacement after explanation is associated with higher reinfection and graft-related complications and decreased survival compared with autogenous reconstruction.

Gene silencing in human aortic smooth muscle cells induced by PEI–siRNA complexes released from dip-coated electrospun poly(ethylene terephthalate) grafts

An excessive tissue response to prosthetic arterial graft material leads to intimal hyperplasia (IH), the leading cause of late graft failure. Seroma and abnormal capsule formation may also occur after prosthetic material implantation. The matricellular protein Thrombospondin-2 (TSP-2) has shown to be upregulated in response to biomaterial implantation. This study evaluates the uptake and release of small interfering RNA (siRNA) from unmodified and surface functionalized electrospun PET graft materials. ePET graft materials were synthesized using electrospinning technology. Subsets of the ePET materials were then chemically modified to create surface functional groups. Unmodified and surface-modified ePET grafts were dip-coated in siRNAs alone or siRNAs complexed with transfection reagents polyethyleneimine (PEI) or Lipofectamine RNAiMax. Further, control and TSP-2 siRNA–PEI complex treated ePET samples were placed onto a confluent layer of human aortic smooth muscle cells (AoSMCs).Complexation of all siRNAs with PEI led to a significant increase in adsorption to unmodified ePET. TSP-2 siRNA-PEI released from unmodified-ePET silenced TSP-2 in AoSMC. Regardless of the siRNA–PEI complex evaluated, AoSMC migrated into the ePET. siRNA–PEI complexes delivered to AoSMC from dip-coated ePET can result in gene knockdown. This methodology for siRNA delivery may improve the tissue response to vascular and other prosthetics.

Abstract 254: TSP-2 siRNA Coating of Prosthetic Arterial Graft Material to Reduce Intimal Hyperplasia in a Rat Model

Introduction Intimal hyperplasia represents a complex pathologic vascular response to injury. Our group previously revealed that TSP-2 was associated with this response, and demonstrated that intraluminal delivery of TSP-2 siRNA can suppress the intimal hyperplastic response in an animal model. Furthermore, we have shown that siRNA can be incorporated into prosthetic graft material using a dip-coating technique. We sought to determine whether this method could be employed for siRNA delivery in order to attenuate the response to arterial injury, and to reduce neointima formation in an in vivo model. Methods Carotid artery endothelial cell denudation was performed on male Wistar rats using a 2 Fr Fogarty balloon catheter. ePET graft material was dip-coated in several siRNA solutions (i.e. saline, TSP-2 siRNA, PEI-complexed TSP-2 siRNA) for 50 minutes. The graft was cut longitudinally, and then wrapped circumferentially around the denuded carotid artery. Arterial segments were then isolated at 21 days. TSP-2 gene expression was measured by qRT-PCR, and intimal hyperplasia was assessed by quantitative morphometry. Results Balloon denudation increased TSP-2 gene expression by 10-fold, when compared to non-denuded arteries after 21 days (p = .01). Fluorophore-conjugated siRNA confirmed transmural delivery following denudation. When compared to saline treated animals, TSP-2 siRNA reduced TSP-2 mRNA expression by 70% (p = .001). The addition of the transfection reagent PEI to TSP-2 siRNA treated grafts, however, did not significantly augment gene silencing. Morphometric analysis of arterial cross sections demonstrated significantly less neointima formation–as measured by intima-media (I/M) total area ratio–among grafts dip-coated with unmodified and PEI-treated TSP-2 siRNA (I/M: 0.2 and 0.4, respectively) compared to saline grafts (I/M: 1.0, p < .001). Conclusions In the rat carotid artery balloon injury model, dip-coating of prosthetic graft material with subsequent perivascular delivery of TSP-2 siRNA is an effective method to achieve transmural transfection and consistent gene silencing, while significantly suppressing the intimal hyperplastic response following arterial injury.

Prophylactic Muscle Flaps in Vascular Surgery

High-risk patients undergoing vascular procedures through inguinal incisions experience significant benefit from undergoing prophylactic muscle flaps. The authors present a risk assessment tool, an evidence-based algorithm for using prophylactic muscle flaps, and a comprehensive cost analysis. Data derived from the authors' previously performed retrospective cohort study of patients undergoing open vascular groin surgery were used to construct an evidence-based risk assessment tool. A multivariate regression analysis identified significant, independent predictors of complications, which were used to construct a scoring system. An institutional cost analysis and preoperative assessment algorithm were derived based on patient risk stratification and statistical analyses. Sixty-eight prophylactic flaps in 53 patients were compared with 195 open femoral access procedures without flaps in 178 patients. Multivariate regression demonstrated that obesity, smoking, reoperation, and prosthetic graft reconstruction are significant predictors of complications. A weighted risk factor score (0 to 7) was devised: obesity, for a value of 1; smoking, 2; reoperation for open groin surgery, 2; and prosthetic graft material, 2. Patients with higher scores had significantly more complications, infections, and more frequently required secondary salvage flap procedures. Using study data, the authors constructed an algorithm to guide preoperative groin assessment and use of prophylactic muscle flaps. The authors provide an assessment tool, called the Penn Groin Assessment Scale, that accurately predicts groin complications. They also describe a simple algorithm to assess for prophylactic muscle coverage. Their results suggest that patients with two or more risk factors will benefit from prophylactic muscle flaps. Risk, II.

PS122. Negative Pressure Wound Therapy on Exposed Prosthetic Vascular Grafts in the Groin

This study assessed the outcome of vacuum-assisted closure (VAC) as primary therapy for exposed prosthetic vascular grafts in the groin (Szylagi III). The study included all consecutive patients with Szylagi III groin infections and exposed prosthetic graft material from 2009 to 2011. After initial wound debridement, VAC was applied using a two-layer combination, consisting of polyvinyl-alcohol and polyurethane sponges. Continuous negative pressure was set on a maximum of 50 mm Hg. All patients received complementary antibiotic therapy. The primary end point was defined as complete wound closure. Secondary end points comprised bleeding complications, amputation, and death. The study evaluated 15 patients with 17 Szylagi III groin infections. Mean total length of VAC therapy was 43 days (range, 14-76 days). Mean time until complete healing was 51 days (range, 24-82). Mean length of VAC therapy in the hospital was 21 days (range, 5-61 days). Eleven patients received continued VAC treatment at home for a mean length of 22 days (range, 5-69 days). Complete healing was achieved in 14 groins (82%). Three failures due to persisting infection, persisting necrosis, and a pseudomonas infection were noted. No bleeding complications, amputations, or late reinfections occurred. Median follow-up was 380 days (range, 56-939 days). Despite therapy failure, all 17 grafts were preserved. VAC therapy on an exposed prosthetic vascular graft in the groin is safe and feasible when applying a combination of polyvinyl alcohol and polyurethane foam dressing and 50 mm Hg of continuous negative pressure, resulting in midterm graft preservation.

Negative pressure wound therapy on exposed prosthetic vascular grafts in the groin

This study assessed the outcome of vacuum-assisted closure (VAC) as primary therapy for exposed prosthetic vascular grafts in the groin (Szilagyi III). The study included all consecutive patients with Szilagyi III groin infections and exposed prosthetic graft material from 2009 to 2011. After initial wound debridement, VAC was applied using a two-layer combination, consisting of polyvinyl alcohol and polyurethane sponges. Continuous negative pressure was set on a maximum of 50 mm Hg. All patients received complementary antibiotic therapy. The primary end point was defined as complete wound closure. Secondary end points comprised bleeding complications, amputation, and death. The study evaluated 15 patients with 17 Szilagyi III groin infections. Mean total length of VAC therapy was 43 days (range, 14-76 days). Mean time until complete healing was 51 days (range, 24-82 days). Mean length of VAC therapy in the hospital was 21 days (range, 5-61 days). Eleven patients received continued VAC treatment at home for a mean length of 22 days (range, 5-69 days). Complete healing was achieved in 14 groins (82%). Three failures due to persisting infection, persisting necrosis, and a pseudomonas infection were noted. No bleeding complications, amputations, or late reinfections occurred. Median follow-up was 380 days (range, 56-939 days). Despite therapy failure, all 17 grafts were preserved. VAC therapy on an exposed prosthetic vascular graft in the groin is safe and feasible when applying a combination of polyvinyl alcohol and polyurethane foam dressing and 50 mm Hg of continuous negative pressure, resulting in midterm graft preservation.

An Experience of Arteriovenous Fistulas Created for Hemodialysis in the Largest Health Center in Eastern Turkey

Background: The aim of the study was to evaluated the primary and secondary (after reoperation) patency rates and some effect factors in fistula patency for hemodialysis patients. Material and methods: Over a 10-year period, 1529 arteriovenous fistulas (AVFs) were fashioned in 1003 (611 males, 392 females; median age range 7–72) patients using the native vascular tissue and prosthetic graft material. We also evaluated the effects of various factors in fistula patency and primary and secondary patency rates in AVF patients. Results: The primary patencies of fistulas in this series were 72%, 64%, 51%, 41%, and 26%, and secondary patencies were 79%, 70%, 56%, 46%, and 33% at 6 months, 1, 2, 4, and 6 years, respectively. There was no statistically significant difference between the primary and secondary patencies (p = 0.082) in the 6-year follow-up. Factors affecting the patency of fistulas were diabetes mellitus (p < 0.005), hypertension (p < 0.005), and smoking habits (p < 0.005). Conclusion: Even if shown to be not statistically significant, successful surgical revision after fistula occlusion improves secondary patency with potential benefits in terms of patient morbidity. Besides, the AVF patency was shortened in chronic renal-insufficiency patients with diabetes mellitus, hypertension, and smoking habits.

Small Interfering RNA Coating of Prosthetic Arterial Graft Materials

Small Interfering RNA Coating of Prosthetic Arterial Graft Materials

Remote Endarterectomy Versus Supragenicular Bypass Surgery for Long Occlusions of the Superficial Femoral Artery: Medium-Term Results of a Randomized Controlled Trial (The REVAS Trial)

To investigate the optimal surgical treatment, remote superficial femoral artery endarterectomy (RSFAE) or supragenicular bypass, for Transatlantic Inter-Society Consensus (TASC) C and D lesions of the superficial femoral artery. Medium-term results will be presented. The study randomized 116 patients, 61 to RSFAE and 55 to supragenicular bypass surgery. Indications for surgery were claudication in 77, rest pain in 21, or tissue loss in 18. Primary patency after 3 years of follow-up was 47% for RSFAE and 60% for bypass (p = 0.107), assisted primary patency was 63 and 69% (p = 0.406), and secondary patency was 69 and 73% (p = 0.541), respectively. For venous (n = 25) and prosthetic grafts (n = 30) at 3-year follow-up, primary patency was 65% and 56 versus 47% for RSFAE (p = 0.143), assisted primary patency was 84% and 56 versus 63% for RSFAE (p = 0.052), and secondary patency was 89% and 59 versus 69% for RSFAE (p = 0.046), respectively. Limb salvage was 97% after RSFAE and 95% after bypass surgery (p = 0.564). RSFAE is a minimally invasive option for surgical repair of TASC C and D superficial femoral artery obstructions, with assisted primary and secondary patency rates comparable with bypass surgery. Venous bypass grafting is superior to both RSFAE and polytetrafluoroethylene grafting, but only 45% of patients had a sufficient saphenous vein available. If the saphenous vein is not applicable, RSFAE should be considered because it is less invasive and prosthetic graft material can be avoided.

Repair of Aortic Coarctation in an Adult by Direct Aortoplasty

Various techniques have been proposed for surgical correction of aortic coarctation in adults. We describe direct aortoplasty repair in a 28-year-old woman with native coarctation. Four-year follow-up with magnetic resonance angiography confirmed a good result. This is a safe and effective technique that provides enlargement of the aortic lumen by avoiding extensive anastomotic suture lines or interposition of prosthetic graft material.