Prosthetic Graft Research Articles

Anaesthesia Management of A Patient with Airway Obstruction Caused by Prosthetic Vascular Graft Invasion into the Tracheal Lumen.

Primary intratracheal masses causing luminal obstruction are relatively rare, posing a challenge for anaesthesiologists in airway management. This case report describes a distinctive airway management approach in a 71-year-old female patient with an aorta-carotid artery bypass graft that significantly obstructed the trachea. The patient presented with worsening shortness of breath, and a thoracic computed tomography scan revealed a 19.2 mm×9.9 mm×19.3 contrast-enhancing mass penetrating the right anterolateral tracheal wall, resulting in 80% occlusion of the tracheal lumen. Awake fiberoptic bronchoscopy (FOB)-guided nasotracheal intubation was performed following topical upper airway anaesthesia, with the patient positioned at a 30º head-up angle and slight right-up tilt to minimize discomfort. A 6.0 mm ID cuffed endotracheal tube was successfully placed under fiberoptic guidance distal to the intratracheal vascular graft but proximal to the carina. Intratracheal masses can lead to severe tracheal obstruction followed by progressive airway obstruction, which can be life-threatening when effective ventilation cannot be established after the induction of general anaesthesia. We recommend the use of awake FOB-guided intubation in such cases. Additionally, contingency plans should be prepared and meticulously prepared in the event of intubation or ventilation failure.

Surgical treatment of infective endocarditis: some experiences at the Heart Institute, Ho Chi Minh City

Objective: To determine the factors associated with in-hospital mortality and the appropriate timing of operation in patients with infective endocarditis undergoing cardiac surgery. Methods: Cross-sectional study in patients admitted to the Heart Institute from 01/01/2021 to 31/12/2023 who had a diagnosis of infective endocarditis and had undergone cardiac surgery within the same hospital admission. Results: 128 patients (87 men, age: 44,8 ± 15,8 years) were enrolled. Streptococcus (37,5%) and Enterococcus (12,5%) were the most frequent pathogen agents. Aortic valve replacement and mitral valve replacement or repair were the main procedures. In-hospital mortality was 6.3%. The factors associated with in-hospital mortality included the presence of a prosthetic valve or pulmonary artery graft, abscess and/or fistula, and severe heart failure necessitating urgent operation. Preoperative duration of antibiotic therapy >21 days vs ≤21 days, and >14 days vs ≤14 days had no influence on in-hospital mortality. There was no infective endocarditis relapse. While waiting for cardiac surgery, the cumulative incidence of embolic events rose markedly beginning from the 3rd week after antibiotic therapy initiation. Conclusions: Factors associated with in-hospital mortality should be taken into account in the preoperative risk assessment. Patients with infective endocarditis who have indication for cardiac surgery and favorable response to antibiotic therapy should be operated after 2 weeks of antibiotic treatment.

Transprosthetic Fenestration With Electrified Wires. Experimental Evaluation of Three Multifilament Endografts.

In situ fenestration of aortic endografts is an alternative endovascular technique for treatment of complex aortic aneurysms. While this technique has been carried out also to pass stent-grafts in individual cases, its feasibility and safety using different stent-grafts needs to be evaluated. In a saline bath at water temperature of 37°C, a 0.018" Astato 30 guidewire was advanced through 3 different stent-grafts (RelayPro, Zenith and Endurant II) by applying external current of 180 W via an electrosurgery pencil. Puncture efficacy and quality of the fenestration after ballooning with a 6 mm percutaneous transluminal angioplasty (PTA) catheter were assessed. Then, balloon-expandable covered stents were deployed in the fenestrations and evaluated for stenosis, using microscopy and radiography. Crossing of the electrified guidewire was instantaneous in the Zenith (n:10) and RelayPro (n:10) groups but not in 3 of 10 punctures in the Endurant group (p<.05). The fenestration area created after PTA was significantly larger in the RelayPro (5.3 mm2 ± 1.8, interquartile range [IQR] 1.6) and Zenith group (6.7 mm2 ± 0.7, IQR 0.5) compared to Endurant (2.3 mm2 ± 0.4, IQR 0.5, p<.001). Fraying was observed in all groups while graft shredding was found in 8 cases after PTA of the Zenith and Endurant endografts and in 5 of the RelayPro group, but the difference was not significant. Vertical tearing was detected after RelayPro (2 out of 10) and Zenith (6 out of 10) fenestrations, no damage was found in the Endurant group (p<.01). Residual stenosis at the level of the fenestration after implantation of a 6 × 79 mm VBX stent had to be corrected in all Endurant cases with a high-pressure PTA catheter. No stenosis was found in the RelayPro and Zenith groups before and after flaring. The "electrified wire" technique is a feasible tool that can be used to perform in situ fenestration by perforation of the endograft fabric. Based on this experimental evaluation the "ideal graft" for this technique could not be identified. Long-term fatigue tests and comparison with other fenestration techniques are required. In situ endograft fenestration can be a useful technique in emergent aortic repair. Recently, the electrified wire technique has been proposed as alternative option to laser, radiofrequency and needle-based techniques. In comparison to these methods, the use of electrified wires can be performed without modifications of routine equipment. Additionally, the material costs can be substantially reduced. However, the effectiveness of this approach for fenestration of different prosthetic grafts is unknown. Based on our experimental studies, the electrified wire technique is feasible but the Endurant endograft requires more attempts, and the placement of a bridging stent should be completed with high-pressure balloons.

A systematic review and meta-analysis of outcomes associated with development of surgical site infection after lower-limb revascularization surgery.

Although surgical site infection (SSI) is a commonly used quality metric after lower-limb revascularization surgery, outcomes associated with development of this complication are poorly characterized. We conducted a systematic review and meta-analysis of studies reporting associations between development of an SSI after these procedures and clinical outcomes and healthcare resource use. We searched MEDLINE, Embase, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 4th, 2023) for studies examining adjusted associations between development of an SSI after lower-limb revascularization surgery and clinical outcomes and healthcare resource use. Two investigators independently screened abstracts and full-text citations, extracted data, and assessed risk of bias. Data were pooled using random-effects models. Heterogeneity was assessed using I2 statistics. GRADE was used to assess estimate certainty. Among 6671 citations identified, we included 11 studies (n = 61,628 total patients) that reported adjusted-associations between development of an SSI and 13 different outcomes. Developing an SSI was associated with an increased adjusted-risk of hospital readmission (pooled adjusted-risk ratio (aRR) = 3.55; 95% CI (confidence interval) = 1.40-8.97; n = 4 studies; n = 13,532 patients; I2 = 99.0%; moderate certainty), bypass graft thrombosis within 30-days (pooled aRR = 2.09; 95% CI = 1.41-3.09; n = 2 studies; n = 23,240 patients; I2 = 51.1%; low certainty), reoperation (pooled aRR = 2.69; 95% CI = 2.67-2.72; n = 2 studies; n = 23,240 patients; I2 = 0.0%; moderate certainty), bleeding requiring a transfusion or secondary procedure (aRR = 1.40; 95% CI = 1.26-1.55; n = 1 study; n = 10,910 patients; low certainty), myocardial infarction or stroke (aRR = 1.21; 95% CI = 1.02-1.43; n = 1 study; n = 10,910 patients; low certainty), and major (i.e., above-ankle) amputation (pooled aRR = 1.93; 95% CI = 1.26-2.95; n = 4 studies; n = 32,859 patients; I2 = 83.0; low certainty). Development of an SSI >30-days after the index operation (aRR = 2.20; 95% CI = 1.16-4.17; n = 3 studies; n = 21,949 patients; low certainty) and prosthetic graft infection (aRR = 6.72; 95% CI = 3.21-12.70; n = 1 study; n = 272 patients; low certainty) were both associated with an increased adjusted-risk of major amputation. Prosthetic graft infection was also associated with an increased adjusted-risk of mortality >30-days after the index procedure (aRR = 6.40; 95% CI = 3.32-12.36; n = 1 study; n = 272 patients; low certainty). This systematic review and meta-analysis suggests that development of an SSI after lower-limb revascularization surgery significantly increases patient morbidity and healthcare resource use. SSI is therefore a valuable quality metric after these surgeries. However, current estimates are based on heterogenous, low-to-moderate certainty evidence and should be confirmed by large, multicenter, cohort studies.

Outcomes of Prosthetic and Biological Grafts Compared to Arm Vein Grafts in Patients with Chronic Limb Threatening Ischemia

ObjectivesThe optimal conduit for infrainguinal bypass (IIB) is single segment great saphenous vein (GSV). Unfortunately, GSV is not always available in patients with chronic limb threatening ischemia (CLTI). Other graft choices include arm vein grafts (AV), prosthetic grafts (PG) or biologic grafts (BG). Current data regarding the durability and limb salvage rates of those options is scarce, hence we aimed to investigate the impact of alternative graft types on post-operative and long-term outcomes on IIB in patients with CLTI. MethodsThe Vascular Quality Initiative (VQI) database was queried for patients undergoing IIB from January 2003 to April 2024. Patients were stratified into three groups: arm vein (cephalic, basilic), prosthetic grafts [Dacron, polytetrafluoroethylene (PTFE)], and biologic grafts (cadaveric, homograft, or xenograft). Saphenous vein grafts (greater and lesser saphenous) were excluded. Multivariate logistic regression analyzed postoperative outcomes: 30-day mortality, major adverse cardiovascular events (MACE), graft occlusion, prolonged length of stay >7days (PLOS), packed red blood cell (pRBC) transfusion >2 units, and infection. Cox Regression was used to report one-year outcomes: mortality, major amputation (above-ankle), and major adverse limb events (MALE defined as major amputation, thrombectomy or reintervention). ResultsA total of 9165 IIB procedures have been analyzed: AV 417 (4.55%); PG 7520 (82.05%); BG 1228 (13.40%). Compared to AV, patients receiving PG had higher odds of infection (aOR 2.89, p=0.045) and higher hazard of one-year mortality (aHR 1.51, p=0.035). On the other hand, patients receiving BG had higher risk of graft occlusion (aOR 4.55, p=0.040) and infection (aOR 2.78, p=0.046) as well higher hazard of one-year mortality (aHR 1.53, p=0.040), amputation (aHR 1.72, p=0.019) and amputation or death (aHR 1.52, p=0.005) compared to AV. After stratifying by bypass configuration, AV had the highest overall survival and amputation-free survival among the three alternative conduits in below-knee popliteal and tibial bypass targets. ConclusionsIn this large multi-institutional study investigating alternative conduits to GSV, AV are found to be the most resistant to infections and are associated with the best overall survival and limb salvage outcomes compared to PG and BG particularly in below-knee distal targets. In cases where no GSV is available, AV and PG are acceptable alternatives with comparable one-year amputation-free survival and MALE-free survival rates. On the other hand, BG are associated with higher risk of graft occlusion and lower freedom from major amputation and death compared to AV.

Effectiveness of autologous interposition saphenous graft in the creation of proximal arteriovenous fistula: Our initial experience

Abstract: For the individuals with end-stage renal disease, maintenance hemodialysis is a common treatment. When we compare to dialysis catheters or prosthetic grafts, arteriovenous fistula (AVF) is associated with a greater maturation period but a smaller incidence of infections, central venous stenosis, hospitalizations, and mortality. Fistulas mature by a dynamic process which is known as venous arterialization, where the breakdown of elastin and release of nitric oxide promote the functional and structural remodeling of the venous wall, permitting the expansion of venous outflow. Veins made them exposed to the arterial environment at the time of venous grafts and AVFs creation. Successful adaptation of the vein to the arterial flow is the most demanding part for long-term success, identified by venous dilation followed by wall thickening. Arteriovenous fistulas (AVF) and grafts (AV graft) are the commonest form of vascular access used for maintenance of hemodialysis. In general AVF is superior than AV graft in terms of its durability, patency, complication rate and overall survival of patients. But when the calibre of the vein is not satisfactory or length is not adequate to make tension free anastomosis, interposition graft is used. Most commonly used bridging material is polytetrafluoroethylene (PTFE) polymer. In this case, we used an interposition graft of the saphenous vein for making dialysis access on a 38 year old male patient having renal insufficiency and evaluated its efficacy in maintaining flow.

Spliced-Vein Conduit Offers Better Patency and Limb Salvage Than Prosthetic Graft for Femoral-Tibial Bypasses in Critical Limb-Threatening Ischemia

BackgroundSingle-segment great saphenous vein (ssGSV) is the gold standard conduit for femoral-tibial bypasses in patients with critical limb-threatening ischemia (CLTI). In the absence of a good single-segment saphenous vein, alternative options are prosthetic grafts or spliced-vein conduits. Although spliced-vein conduits may provide better long-term patency/limb salvage, prosthetic grafts are more often the chosen conduit due to shorter operative and presumably better immediate postoperative outcomes; nevertheless, there is little data supporting this practice. In this study, we compared 30-day outcomes between spliced-vein and prosthetic conduits in CLTI bypass using a national registry. MethodsCLTI patients who underwent lower extremity bypass using spliced vein (SpV) or prosthetic conduits only were selected from National Surgical Quality Improvement Program (NSQIP) targeted database. A 1:5 propensity-score matching was conducted between SpV and prosthetic groups to address preoperative differences. Thirty-day outcomes, including primary patency, reintervention, major amputation, mortality, major morbidity, transfusion, and wound complications, were compared between the two groups. ResultsThere were 886 patients who underwent femoral-tibial bypass without ssGSV (104 SpV and 782 prosthetic grafts). All SpV patients were propensity-score matched to 445 prosthetic patients. SpV exhibited significantly better 30-day primary patency than prosthetic (87.5% vs 74.38%, P = 0.004). SpV was associated with significantly longer operative time (346 min vs 222 min, P < .001) and higher transfusion (43.3% vs 27.87%, P =0.003), but those did not translate into higher 30-day mortality or major systemic complications. There was no difference in wound complications or 30-day limb loss. ConclusionSpliced-vein conduit affords significantly better 30-day primary patency than prosthetic grafts without increased mortality and morbidities. Therefore, despite greater procedural complexity and longer operative time, spliced-vein conduit should be considered when available. Future prospective studies are needed to investigate the long-term outcomes of these two conduits.

Rifampin in device-related infections: Assessing the modern evidence.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Rifampin is commonly used to treat device-related infections (DRIs) due to its activity against biofilms, despite a history of limited clinical evidence to support its use. Evidence published since 2011 regarding rifampin use for DRIs is reviewed to describe the contemporary findings and ongoing considerations for rifampin use in these infections. A literature review was performed by searching PubMed and Google Scholar to identify relevant studies evaluating systemic rifampin use for the treatment of DRIs published from 2011 to 2023. References of identified studies were also screened for additional pertinent studies. Sixty-eight studies were identified, and 48 met the inclusion criteria. Rifampin efficacy was evaluated as both a primary outcome for cardiac device infections (n = 3) and prosthetic joint infections (n = 21) and as a nonprimary outcome (n = 24). Overall, the studies were primarily retrospective (n = 36) and small, with sample sizes ranging from 14 to 842 patients, and varied greatly with respect to prosthesis site, surgical intervention, pathogen, infection time frame, and antibiotic combination and duration. Efficacy outcome results varied greatly, with statistically significant evidence for the efficacy of rifampin combination in DRIs limited to a single study of prosthetic vascular graft infections and 13 studies of prosthetic joint infections. The modern literature provides conflicting results regarding the benefit and lack of benefit with rifampin combination therapy in DRIs. Additional, robust research is imperative to solidify the ongoing role of rifampin in DRIs.

The rise of the machines: are robots the future of renal artery aneurysm repair? A systematic review.

Renal artery aneurysms (RAAs) are a rare vascular condition. Robot-assisted surgery offers a minimally invasive approach for RAA repair, potentially improving surgical outcomes. This review investigates the current evidence on the effectiveness and limitations of this technique. A systematic search following PRISMA guidelines identified relevant studies across five electronic databases. Studies investigating the use of robot-assisted surgery for RAA repair were included. The review identified 11 studies encompassing a total of 23 patients. Procedures included aneurysmectomy, end-to-end anastomosis, prosthetic graft repair, and even coil embolization. All surgeries were successful, with only minor complications reported in four cases. Robot-assisted RAA repair shows promise as a minimally invasive approach with encouraging preliminary outcomes. However, the limited data come from small studies. Future advancements in robotic technology hold the potential to optimize this approach for improved patient care.

768. ENDOSCOPIC MANAGEMENT OF COMPLEX THORACIC AORTA ANEURYSMAL SAC AND ENDOGRAFT INFECTION ASSOCIATED WITH AORTOESOPHAGEAL FISTULA

Abstract Background Aortoesophageal fistula (AEF) is a rare but life-threatening condition. Secondary AEF is a complex pathology occurring after thoracic aorta surgery with prosthetic graft, with an incidence of 1.6%. However, this is likely to rise with the increasing number of thoracic endovascular aortic repair (TEVAR) being performed. Management of secondary AEF is more challenging due to presence of adhesions in the pleural space, co-existing endograft infection and poor physiology of this group of patients. Definitive surgery carries high mortality rate and not all patients are suitable candidates. We review a case of secondary AEF with thoracic endograft infection managed non-operatively. Methods Our patient is a 70 years old man with a background of Stanford type A aortic dissection managed with ascending aorta and hemi-arch replacement with Dacron graft. Six years later, he had frozen elephant trunk reconstruction due to aneurysmal dilatation. Three months later, he underwent TEVAR for descending thoracic aorta aneurysm. Post-operation, he was diagnosed with Flavonifractor plautii bactaeremia secondary to infected aneurysmal sac and aortic stent graft and was initiated on antimicrobial therapy. During this time patient also developed recurrent episodes of haemoptysis. Bronchoscopy excluded an aortobronchial fistula and Oesophago-gastro-duodenoscopy (OGD) confirmed AEF at 25 cm from incisors. Results After discussion with a multidisciplinary team and patient, endoscopic management was chosen over surgery. Initial endoscopic closure of AEF with over-the-scope-clip appeared satisfactory but repeat OGD showed recurrence of new AEF which was partially closed with clips. Repeat imaging showed worsening mediastinal infection with larger gas-containing cavity. OGD was repeated with contrast demonstrating fistulous connection between the oesophagus and aneurysmal sac. A 7-French 4 cm double pigtail (DPT) stent was deployed into the sac under fluoroscopy to allow for trans-oesophageal drainage. Repeat imaging showed improvement in infection (Figure 1). Patient underwent endoscopic exchange of DPT stent 2 months after the initial insertion. Conclusion Definitive surgery for secondary AEF includes drainage of infection, explantation of infected endograft and aortic and oesophageal reconstruction. Oesophagectomy is preferred over primary repair of oesophageal defect. Not all patients will be suitable candidates for radical surgery and a non-operative approach may be required. Our patient likely has dense pleural and mediastinal adhesions from previous surgeries and thus, repeat surgery will be more challenging with increased risk of complications. However, if his mediastinal infection fails to resolve despite a period of DPT stent drainage, definitive surgery involving McKeown minimally invasive oesophagectomy with substernal gastric pull up would be required. Figure 1: Image A shows a large cavity with air and coalescent locules (arrow) prior to insertion of DPT stent. Image B shows a collapsed cavity (arrow) after DPT stent insertion.

Validation of arteriovenous access stage (AVAS) classification: a prospective, international multicentre study.

The arteriovenous access stage (AVAS) classification provides evaluation of upper extremity vessels for vascular access (VA) suitability. It divides patients into classes within three main groups: suitable for native fistula (AVAS1) or prosthetic graft (AVAS2), and patients not suitable for conventional native or prosthetic VA (AVAS3). We validated this system on a prospective dataset. A prospective, international observational study (NCT04796558) involved 11 centres from 8 countries. Patient recruitment was from March 2021 to January 2024. Demographic data, risk factors, vessels parameters, VA types, AVAS class and early VA failure were collected. Percentage agreement was used to assess predictive ability of AVAS (comparison of AVAS and created VA) and consistency of AVAS assessment between evaluators. Pearson's Chi-squared test was used for comparison of early failure rate of conventional (predicted by AVAS) and unconventional (not predicted by AVAS) VA. From 1034 enrolled patients, 935 had arteriovenous fistula or graft, 99 patients did not undergo VA creation due opting for alternative renal replacement therapies, experiencing health complications, death or non-compliance. AVAS1 had 91.2%, AVAS2 7.2% and AVAS3 1.6% of patients. Agreement between evaluators was 89%. The most frequently created VAs were radial-cephalic (46%) and brachial-cephalic (27%) fistulae. The accuracy of AVAS versus created access was 79%. In comparison, VA predicted by clinicians versus created access was 62.1%. Inaccuracy of AVAS prediction was more common with higher AVAS classes, and the most common reason for inaccuracy was creation of distal VA despite less favourable anatomy (17%). Patients with unconventional VA had higher early failure rate than patients with conventional VA (20% vs 9.3%, respectively, P=.002). AVAS is effective in predicting VA creation, but overall accuracy is reduced at higher AVAS classes when the complexity of decision-making increases and proximal vessels require preservation. When AVAS was followed by clinicians, early failure was significantly decreased.

Outcome of upper limb arteriovenous prosthetic graft versus lower limb arteriovenous access for hemodialysis in patients with exhausted vascular accesses

Outcome of upper limb arteriovenous prosthetic graft versus lower limb arteriovenous access for hemodialysis in patients with exhausted vascular accesses

Leiomyosarcoma of Inferior Vena Cava: Resection and Reconstruction

Primary leiomyosarcomas of the inferior vena cava (IVC) are rare tumors with complex anatomical relationships. Surgical resection remains the primary approach for management, with selective use of preoperative radiation and chemotherapy. Given the propensity for local invasion of these tumors, radical resection of surrounding structures is often required. Herein we describe the presentation, work-up, operative management, and outcomes of these lesions through the case of a patient with a tumor involving the middle segment of the IVC. Given the extent of involvement, IVC resection with en bloc right nephrectomy, right adrenalectomy, and partial left renal vein resection was performed with vascular reconstruction using a prosthetic graft. With appropriate preoperative planning and a well-coordinated multidisciplinary approach, aggressive surgical resection can be safely performed and patients can benefit from favorable long-term survival.

Long-Term Outcomes of Vein Adjuncts in Distal Infrainguinal Bypass

IntroductionAutologous vein is recommended for infrainguinal bypass due to improved freedom from occlusion compared to prosthetic graft. In patients without adequate vein, vein adjunct at the distal anastomosis has been suggested to improve patency in small studies. This study aimed to determine if performance of a distal vein adjunct was associated with improved freedom from occlusion in below knee popliteal and tibial bypasses compared to prosthetic bypass alone. MethodsA retrospective review of the Vascular Quality Initiative Infrainguinal Bypass database was conducted. Patients undergoing prosthetic-only and prosthetic with vein adjunct were compared. Inclusion criteria included age >18 years, and bypass to below knee popliteal or tibial vessels. Exclusion criteria included autologous vein conduits and prior interventions. Groups were further divided into below knee popliteal and tibial subgroups. ResultsA cohort of 3,939 patients underwent bypass to the below knee popliteal artery, with 287 (7.3%) receiving vein adjunct. More patients were male (68.8 vs 57.8%, p<.001) and had higher rates of CHF (21.1 vs 16.0%, p=.040) within the below knee popliteal group. Two-year bypass occlusion was decreased in patients receiving vein adjuncts (11.6 vs 17.1%, p=.004). A cohort of 2,378 patients underwent tibial bypass, with 473 (19.9%) receiving vein adjunct. Within the tibial group, patients were similar in age, BMI, race, comorbidities, and indications. Bypass occlusion (24.8 vs. 17.6%, p=.005) and amputation (20.5 vs. 15.9%, p=.048) rates at two years were worse for patients who did not receive a distal vein adjuncts to tibial arteries. ConclusionDistal vein adjuncts are associated with improved freedom from occlusion, amputation, MALEs, and overall survival when compared to bypasses performed with prosthetic graft alone for tibial bypasses within the VQI. Vein adjunct was not associated with improved freedom from occlusion in below knee popliteal bypasses. Consideration should be given to utilization of a distal vein adjunct to improve prosthetic bypass longevity and limb salvage for patients requiring tibial bypasses.

Retrospective evaluation of three types of expanded polytetrafluoroethylene grafts for upper limb vascular access

Currently, three expanded polytetrafluoroethylene (ePTFE) prosthetic graft types are most commonly used for patients with end-stage kidney disease (ESKD) who require long-term vascular access for hemodialysis. However, studies comparing the three ePTFE grafts are limited. This study compared the clinical efficacy and postoperative complications of three ePTFE prosthetic graft types used for upper limb arteriovenous graft (AVG) surgery among patients with ESKD. Patients with ESKD requiring upper limb AVG surgery admitted to our center between January 2016 and September 2019 were enrolled. Overall, 282 patients who completed the 2-year follow-up were included and classified into the following three groups according to the ePTFE graft type: the GPVG group with the PROPATEN® graft, the GAVG group with the straight-type GORE® ACUSEAL, and the BVVG group with the VENAFLO® II. The patency rate and incidence of access-related complications were analyzed and compared between groups. The patients were followed up postoperatively, and data were collected at 6, 12, 18, and 24 months postoperatively. Respective to these follow-up time points, in the GPVG group, the primary patency rates were 74.29%, 65.71%, 51.43%, and 42.86%; the assisted primary patency rates were 85.71%, 74.29%, 60.00%, and 48.57%; and the secondary patency rates were 85.71%, 80.00%, 71.43%, and 60.00%. In the GAVG group, the primary patency rates were 73.03%, 53.93%, 59.42%, and 38.20%; the assisted primary patency rates were 83.15%, 68.54%, 59.55%, and 53.93%; and the secondary patency rates were 85.39%, 77.53%, 68.54%, and 62.92%, respectively. In the BVVG group, the primary patency rates were 67.24%, 53.45%, 41.38%, and 29.31%; the assisted primary patency rates were 84.48%, 67.24%, 55.17%, and 44.83%; and the secondary patency rates were 86.21%, 81.03%, 68.97%, and 60.34%, respectively. The differences in patency rates across the three grafts were not statistically significant. Overall, 18, 4, and 12 patients in the GPVG, GAVG, and BVVG groups, respectively, experienced seroma. Among the three grafts, GORE® ACUSEAL had the shortest anastomosis hemostatic time. The first cannulation times for the three grafts were GPVG at 16 (±8.2), GAVG at 4 (±4.9), and BVVG at 18 (±12.7) days. No significant difference was found in the postoperative swelling rate between the GPVG group and the other two groups. Furthermore, no statistically significant differences were found across the three graft types regarding postoperative vascular access stenosis and thrombosis, ischemic steal syndrome, pseudoaneurysm, or infection. In conclusion, no statistically significant differences in the postoperative primary, assisted primary, or secondary graft patency rates were observed among the three groups. A shorter anastomosis hemostatic time, first cannulation time, and seroma occurrence were observed with the ACUSEAL® graft than with its counterparts. The incidence of upper extremity swelling postoperatively was greater with the PROPATEN® graft than with the other grafts. No statistically significant differences were observed among the three grafts regarding the remaining complications.

460 Exploring Optimal Antithrombotic Strategies for Acute Limb Ischaemia: A Comprehensive Review

Abstract Aim Antithrombotic therapy is an integral part of acute limb ischaemia (ALI) management. This study aimed to systematically review the up-to-date evidence available in antithrombotic management of ALI. Method A systematic search (PubMed, OVID, Embase, and Google Scholar) identifying Randomised Control Trials (RCT) and observational studies following PRISMA guidelines was conducted, to report on outcomes of ALI using different antithrombotic agents. Results 6262 studies were originally screened, after removal of duplicates 10 studies were left that fully matched our criteria. No RCT was found comparing antithrombotic agents’ efficacy. Pre-intervention anticoagulation was associated with a risk reduction of amputation and improved secondary patency in ALI treated with prosthetic bypass grafts. Regarding intra-arterial thrombolysis, a continuous heparin infusion showed no advantage. Low weight molecular heparin should be considered as an alternative to unfractionated heparin in ALI patients after arterial embolectomy. Low dose Rivaroxaban and aspirin are associated with decreased major adverse cardiovascular events and amputation incidence following revascularisation, when compared to aspirin and placebo in ALI. Ticagrelor was not superior to clopidogrel with similar bleeding rates. Conclusions The evidence base is inconclusive to determine a standardised guidance. ALI presentation and aetiology might be the best current guide on the antithrombotic regime choice.

Percutaneous Pharmacological Thrombolysis as an Effective Primary Mode of Management of Thrombosed Prosthetic Arterio-Venous Grafts

Abstract Background Thrombosis of prosthetic arterio-venous graft (PAVG) is the most common cause of failure of using this access for haemodialysis (HD) in end stage kidney disease (ESKD) patients. Many different open surgical and vascular techniques were described to restore the function of thrombosed PAVG. Objectives We wanted to assess the feasibility and patency rates following the continuous thrombolysis infusion using tissue Plasminogen Activator (tPA) followed by angiogram and angioplasty of stenotic segment(s) in thrombosed PAVG. Methods We performed retrospective analysis of prospectively collected data from patients who had a thrombosed AVG from January 2020 to January 2022. Thrombolysis took place maximum 7 days after thrombosis was diagnosed. We have excluded patients who were referred to us more than a week after thrombosis occurred and patients with relative or absolute contraindication for thrombolysis and/or anticoagulation. Results During the two years of the study, there were 58 patients referred to our centre with thrombosed PAVG. We have excluded 28 patients who didn’t fulfill inclusion criteria. We have performed PAVG continuous thrombolysis infusion using tPA till we have achieved reopening of the thrombosed PAVG followed by angiography and angioplasty. All patients had venous anastomosis stenosis while 17 patients had stenosis in the graft and only 5 had a stenosis at the arterial anastomosis. During the period of follow up primary patency was achieved in 80% of our patients while our primary assisted patency was 86.67% Conclusions Endovascular tPA thrombolysis for early thrombosis of prosthetic AVAs is feasible, safe, and is associated with an excellent technical success and very good 12 months patency rate.

Prosthetic Graft Migration in Living Donor Liver Transplantation: A Case for Conservative Management?

Abstract A 61-year-old male underwent living donor liver transplantation (LDLT) for decompensated chronic liver disease with hepatocellular carcinoma. The right lobe from the live donor was used as the graft. During implantation, the drainage of the anterior sector of the right lobe graft was through a reconstructed middle hepatic vein using a prosthetic polytetrafluoroethylene (PTFE) graft. Routine follow-up at 6 weeks showed a thrombosed PTFE graft with no clinical, radiological, or biochemical deterioration of the allograft. He was therefore managed conservatively. A routine computed tomography scan at 2 years demonstrated that the PTFE graft had eroded into the duodenum. Given the total absence of symptoms and the risk of complications associated with removing the graft, we decided against any surgical or endoscopic intervention. After a further 3 year period of follow-up, the patient continues to remain well. Enteric erosion of a prosthetic graft following LDLT can be managed without intervention, although long-term consequences are unknown.

Contemporary Experience of the Neo-Aortoiliac System (NAIS) Procedure: A Case Series with Review of the Literature

Aortic graft infection (AGI) is a life-threatening complication that can result in death, amputation, sepsis, aorto-enteric fistula, and pseudoaneurysm formation. After explantation of the infected graft, options for reconstruction include extra-anatomic bypass or in-line reconstruction using antibiotic-coated prosthetic graft, cryopreserved allograft, or a neo-aortoiliac system (NAIS) using autogenous femoral veins. While the NAIS procedure has shown promising results, there is relatively limited clinical experience due the magnitude and morbidity of the surgery. In this study, we reviewed our single-center experience using the NAIS procedure and performed a systematic review of the contemporary literature more than the past decade. A retrospective review was performed on all patients undergoing NAIS reconstruction with autogenous femoral vein conduits at a single institution from 2010 to 2022. Pubmed, Embase, and Cochrane Library databases were queried for studies published from 2012 to 2022 to identify those reporting on outcomes of patients undergoing the NAIS procedure. Outcome variables included early and late mortality, major complications including amputation, graft or conduit related complications, re-infection, and re-intervention. Additional variables collected include patient demographics, operative technique, and follow up. There were 14 patients included in our case series with 30-day mortality of 21%. At a mean follow up of 22months, complication rate was 64.3%, re-intervention rate was 14.3%, re-infection rate was 7.1%, and amputation rate was 7.1%. On review of the literature, 12 studies ultimately met criteria to be included in analysis with a combined total of 368 patients. Pooled averages included 30-day mortality of 9.0%, re-intervention rate of 20.5%, re-infection rate of 5.6%, and amputation rate of 6.5%. The NAIS procedure for management of AGI is a formidable procedure with significant early mortality and morbidity. This treatment should be considered in the context of other revascularization options for management of an AGI.

The Role of the Omniflow II Biosynthetic Graft in Postoperative Wound Problems After Lower Limb Revascularization: A Single Center Prospective Registry

To investigate the role of the Omniflow II prosthesis in the prevention of vascular graft infection (VGI) in patients with peripheral arterial disease and to report on short-and mid-term graft-related morbidity. Patients were included in prospective registry between October 2019 and March 2023. The primary endpoint was to report infection-related problems, operation-related wound problems, and short- and mid-term graft-related morbidity. Secondary endpoint was to report the bypass patency rates and limb salvage rates. A total of 146 Omniflow II grafts were implanted in 125 patients. Sixty-seven patients (45.9%) received a femoral interposition graft, and 77 patients (52.7%) underwent ipsilateral bypass surgery (femoropopliteal or femorocrural). Forty-one patients (28.1%) underwent crural bypass surgery. Seventy-six patients (52.1%) had previous vascular operation in the groin. The mean follow-up time was 352days (range 0-1108days). 3.4% of the patients suffered a wound infection limited to the dermis, and in 8.2%, the subcutaneous tissue was involved. Five early VGI (3.4%) and one late VGI (0.7%) occurred. One year primary patency rate of above-the-knee bypass was significantly better compared to the bypass below the knee (74.5%±0.131 versus 54%±0.126 (P=0.049)). This difference was not significantly different when below-the-knee bypass surgery was compared with crural bypass surgery (54%±0.126 versus 23.8%±0.080 (P=0.098)). The performance of the Omniflow II prosthesis in the preventive setting is highly influenced by the anatomic location of the distal anastomosis. No influence on the incidence of postoperative wound problems could be observed. The rate of Omniflow II VGI in a high-risk population is similar to reported outcomes in other prosthetic grafts.