Saphenous Bypass Research Articles

Thrombose veineuse profonde et faux anévrisme poplité révélant une exostose fémorale chez une enfant

Recent unprovoked and symptomatic thrombosis of the left popliteal vein was diagnosed in a 9-year-old girl. Treatment with low-molecular-weight heparin was initiated in association with vitamin K antagonist (INR 2.5), and compressive stockings. Two and a half months later, the ultrasound examination revealed a false aneurysm of the left distal superficial femoral artery. Knee X-rays showed a distal femoral exostosis. MRI clarified the relationship between the false aneurysm and the exostosis. Bone scintigraphy eliminated multiple exostoses. Resection of the false aneurysm associated with end-to-end femoro-popliteal saphenous bypass and exostosectomy in the same operative time were performed. On histopathological examination there was no sign of malignant transformation. Vascular complications of exostoses are infrequent and the association with deep venous thrombosis and false aneurysm is exceptional. This case report illustrates the contribution of knee X-rays to unravel this unusual clinical presentation.

Posttraumatic popliteal pseudoaneurysm caused by a femoral osteochondroma

We report an exceptional case of a 12-year-old-boy with a pseudoaneurysm of the popliteal artery caused by an osteochondroma on the lower femoral metaphysic after a hyperextension trauma. On account of the absence of the most constant findings, the pulsation of a soft tissue mass and elevated inflammation blood parameters, we preoperatively assumed an infected haematoma. This patient was successfully operated upon with resection of the osteochondroma and saphenous vein femoropopliteal bypass. Owing to the severity of potential vascular complication, preventive resection of osteochondromas in the course of an artery and the need for a vascular surgeon on stand-by should be discussed.

Incidência e preditores de revascularização da lesão-alvo no seguimento clínico de longo prazo: análise crítica do Registro DESIRE

INTRODUÇÃO: Reportamos a incidência e preditores de nova revascularização da lesão-alvo (RLA) numa coorte de pacientes do mundo real tratados com stents farmacológicos (SF) MÉTODO: Entre maio de 2002 e fevereiro de 2010, 3.320 pacientes de único centro foram submetidos a intervenção percutânea (ICP), eletiva ou de urgência, com implante de 5.320 SF (Cypher, 83%; Taxus, 9%; Xience V/Promus, 3%; Endeavor, 4%; BioMatrix, 1%). O seguimento clínico de até oito anos (mediana, 3,4 anos) foi completo em 98% do grupo e 129 pacientes (3,88%) foram submetidos a RLA RESULTADOS: Entre os pacientes com RLA, 33% tinham diabetes, 10% eram portadores de insuficiência renal e 61%, de doença em múltiplos vasos. A artéria descendente anterior foi o vaso mais frequentemente tratado (33%), e 72,3% das lesões eram de alta complexidade (tipo B2/C). Nesse grupo, foram implantados 214 SF em 191 lesões e 45% dos pacientes receberam múltiplos stents. Na análise univariada, os preditores de RLA foram: diabetes melito [razão de risco (RR) 1,88, intervalo de confiança (IC) de 95% 1,08-3,27; P = 0,025), uso do stent Taxus (RR 1,73, IC 95% 1,20-2,50; P = 0,003), lesão ostial (RR 1,82, IC 95% 1,1-2,98; P = 0,018), ponte de safena (RR 2,36; IC 95% 1,55-3,50; p = 0,0001), e lesões reestenóticas (RR 1,95, IC 95% 1,17-3,24; P = 0,009). Após análise multivariada, permaneceram como preditores independentes: diabetes melito, uso do stent Taxus e tratamento de lesões em pontes de safena (RR 1,64, IC 95% 1,14-2,35; P = 0,008) CONCLUSÃO: No registro DESIRE, a RLA em pacientes complexos tratados com SF foi baixa, e o diabetes melito, o tratamento de lesões em ponte de safena e o uso de SF Taxus foram os únicos preditores de RLA no acompanhamento clínico de até oito anos.

Use of Cryopreserved Arterial Homografts for the Treatment of Stent Infections and Pseudoaneurysms: Regarding “Renal Artery Stent Infection and Pseudoaneurysm Management”

Stout and Glickman 1 Stout C.L. Glickman M.H. Renal artery stent infection and pseudoaneurysm management. Ann Vasc Surg. 2009; https://doi.org/10.1016/j.avsg.2009.06.018 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar reported a case of a 56-year-old black female with a renal artery stent infection and a pseudoaneurysm just distal to stent, 8 months postoperatively. The blood cultures during the first postoperative course evidenced methicillin-resistant Staphylococcus aureus, and the bloodstream infection was treated with initial intravenous vancomycin and a 6-month course of oral dicloxacillin due to the continued fevers. At the time of representation, the authors treated the vascular infection through an explantation of the renal artery stent and a wide debridement of the infected tissue and the pseudoaneurysm. Thereafter, a renal artery to hepatic artery saphenous bypass was fashioned. Microbiological investigation of the intraoperative specimens showed no microorganisms.

Achados de imagem da revascularização do miocárdio pela tomografia computadorizada por múltiplos detectores: onde estão os enxertos? Ensaio iconográfico

A angiotomografia por multidetectores de coronárias constitui um método preciso para avaliação dos enxertos venosos e arteriais pós-revascularização coronariana e vem substituindo em parte o cateterismo, o qual é um método invasivo e de maior custo. Este ensaio iconográfico tem como objetivo a demonstração anatômica dos enxertos mais comumente utilizados, como diferenciar enxertos venosos e arteriais e como localizá-los. Os exames foram realizados em aparelhos de tomografia computadorizada multislice de 64 fileiras de detectores, com apneia, frequência cardíaca controlada e protocolos adequados com posterior reconstruções MPR, MIP e 3D, de acordo com o eletrocardiograma. A localização dos enxertos e anastomoses em tomografias computadorizadas direcionadas para as artérias coronárias e para o tórax pode dificultar a análise do exame pelo radiologista não familiarizado, sendo que o conhecimento das técnicas cirúrgicas utilizadas e dos possíveis trajetos das pontes de safena e enxertos arteriais ajuda na análise de ambos os exames, evitando também erros diagnósticos.

Covered Perforated Aortocoronary Saphenous Vein Graft Aneurysm

We report a case of a 75-year-old man suffering from a covered perforated aneurysm of a saphenous bypass graft to the right coronary artery (RCA) constructed 22 years ago. Additional complete revascularization had been performed in 2001. A thoracic computed tomography scan for evaluation of fever of unknown origin had revealed a huge hematoma in front of the right heart. Coronary angiography showed open bypasses but an irregular-shaped aneurysm of the venous graft to the RCA right before the distal anastomosis. Occurrence of a new right-sided pleural effusion led to the emergent operation since rupture of the aneurysm and drainage into the pleura was likely. A massive precordial hematoma was found and the existence of the perforated aneurysm could be confirmed. After institution of cardiopulmonary bypass the graft was resected. Since the patient had a functioning bypass to the RIVP, there was no need for additional revascularization. The patient underwent an uneventful postoperative course.

DES in saphenous bypass grafts: A treatment in vain?

DES in saphenous bypass grafts: A treatment in vain?

Saphenous vein bypass stenoses, early diagnosis with color coded Doppler sonography

In a prospective study 54 patients with 62 saphenous vein arterial bypass grafts were examined by colour-coded Doppler sonography and angiography. Five cases of graft occlusion were diagnosed by colour-coded Doppler sonography and confirmed by angiography. In comparison with angiography, colour-coded Doppler sonography showed a sensitivity of 92% and a specificity of 100% in the detection of focal graft stenosis. Only two stenoses in the region of the distal anastomosis could not be detected by colour-coded Doppler sonography. In 28 cases a marked dilatation of the proximal anastomosis was found corresponding to the surgically used patch angioplasty. Within this dilated bypass segment, turbulence and flow reversal zones were demonstrated, which might be predisposing factors for graft stenosis. Colour-coded Doppler sonography can accurately detect saphenous vein arterial bypass graft stenoses and should be routinely used in postoperative screening.

Common hepatic artery as an inflow site for off-pump coronary artery bypass grafting

We used the common hepatic artery (CHA) as an inflow site for a saphenous vein graft bypass to the right coronary system during off-pump coronary artery bypass grafting. The CHA is a suitable inflow vessel to provide sufficient blood flow and a short-distance bypass in case both the ascending aorta and the gastroepiploic artery are considered inadequate.

Pseudoaneurysm of a saphenous bypass treated with covered endograft in the ascending aorta

Aneurysms and pseudoaneurysms complicating aorta–coronary bypasses with the saphenous vein are a rare but possibly underestimated complication. Riahi and associates1 reported the first case in 1975. We report the first case of a saphenous bypass pseudoaneurysm treated with a homemade endograft in the ascending aorta.

Giant fusiform aneurysm in an adolescent with PHACES syndrome treated with a high-flow external carotid artery–M3bypass

The acronym PHACES describes a rare neurocutaneous syndrome that comprises posterior fossa malformations, facial hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, eye abnormalities, and sternal defects. Facial hemangiomas constitute the hallmark of this disorder. Giant intracranial aneurysms have not been previously reported in the literature as manifestations of PHACES syndrome and can present difficult therapeutic challenges. The authors describe a unique case of a 13-year-old adolescent boy with an incomplete phenotypic expression of PHACES syndrome who harbored diffuse cerebral angiodysplasia and a giant fusiform internal carotid artery (ICA) aneurysm extending from the distal cavernous segment to the supraclinoid segment. The aneurysm was successfully treated with a high-flow saphenous vein graft bypass from the external carotid artery to the distal middle cerebral artery followed by proximal ICA occlusion. This case represents a unique vascular manifestation of PHACES syndrome that required a complex management strategy. The authors review the literature on this rare disorder and emphasize the importance of considering the diagnosis of PHACES syndrome in child with a facial hemangioma.

The role of vein grafts in coronary surgery

BACKGROUND: Coronary artery bypass grafting (CABG) is a cornerstone of invasive treatment of coronary artery disease. Despite the frequent use of arterial conduits saphenous veins remain important grafts (SVG). METHODS: Review of literature on SVG. RESULTS: SVG are surgically attractive to handle (e.g. to serve for plaque bridging arteriotomies, anastomoses to vascular prostheses). However vein graft disease limits the longevity of SVG, which results in occlusion rates of 40–50% after 10 years. The injury of vein grafts starts with surgical harvesting and exposure to a varying ischemic time. After arterialisation the (thin walled) vein is exposed to systemic blood pressures. Hence surgical handling using a no-touch technique is the first step towards preserving the integrity of the vein graft. Postoperative care of CABG patients is highly important, too. Postoperative therapy with aspirin and statin is standard. In addition, blood pressure and diabetes have to be closely controlled. CONCLUSIONS: Intraoperative surgical handling and postoperative patient care are important factors that influence the outcome of saphenous vein graft bypass operations.

Transvenous Embolization of a Spontaneous Femoral AVF 5 Years After an Incomplete Treatment with Arterial Stent-Grafts

A 66-year-old man with complex left femoral arterio-venous fistula (AVF) was first diagnosed after a deep venous thrombosis incident approximately 5 years ago. Partial treatment was performed by means of endografts along the superficial femoral artery, which remained patent for 5 years. The patient had been doing well until a couple of months ago when he developed severe venous stasis and ulcers of the left cruris, due to a high-flow nonhealing complex AVF with additional iliac vein occlusion. Therefore; the definitive treatment was performed by a unique endovascular technique combined with surgical venous bypass (femoro-femoral crossover saphenous bypass, the Palma operation). A novel percutaneous transvenous technique for occlusion of a complex high-flow AVF is reported with a review of the literature. The case is unique with spontaneous AVF, transvenous embolization with detachable coils and ONYX, and the hybrid treatment technique as well as the long-term patency of superficial femoral artery stent-grafts.

Tumors of the Jugular Foramen—Diagnosis and Management

Objective: With the advent of modern neurosurgical techniques and multidisciplinary “skull base groups,” surgery has become the treatment of choice for jugular foramen lesions. Tumors with large intracranial extension represent, however, a considerable challenge to the skull base surgeon. With the availability of new diagnostic procedures these tumors have been more precisely studied and questions arise of whether, when, and how these lesions should be treated. Data from 110 consecutive patients, surgically treated in the past 18 years, were retrospectively analyzed to identify surgical outcomes. Methods: Between 1987 and 2006, 110 patients with jugular foramen tumors presenting with intracranial-intradural extension were operated upon at the Neurological Institute of Curitiba and State University of Campinas, Brazil. A multidisciplinary craniocervical approach was the standard method of treatment. The same surgical technique was used to resect all tumors. Preoperative embolization was performed in cases of paragangliomas and well-vascularized meningiomas. Saphenous graft bypass was carried out in 2 patients before removal of the lesions due to infiltration of the ICA. A new muscle-fascia flap was developed by our group and was used to cover the surgical defect. When necessary, the facial nerve was reconstructed with nerve grafts (great auricular nerve) or XII/VII anastomosis. Results: Paragangliomas were the most frequent lesions, followed by schwannomas and meningiomas. There were 62 paragangliomas, 18 schwannomas, and 11 meningiomas. The most common signs and symptoms were hearing loss and dysfunction of cranial nerves IX, X, and XI. Complete tumor removal was achieved in 89% of benign tumors and 80% of paragangliomas. Lower cranial nerves deficit was the most frequent complication (10 patients, 9.4%); it was transient in 4 cases. Facial and cochlear nerve paralysis occurred in 8 patients (7.5%). The function of facial nerve recovered spontaneously in 3. CSF leak was observed in 4 patients (3.7%). Four patients (3.7%) died after surgery. Conclusion: Radical removal of benign jugular foramen tumors is the treatment of choice and may be curative. Single-stage removal of complex cases of jugular foramen tumors may be performed safely with acceptable morbidity. Postoperative lower cranial nerves deficit is the most serious surgical complication. The possible causes of complications in these large tumors and the strategies used to avoid them will be presented.

Push and park: uma opção técnica no tratamento do ateroembolismo agudo dos membros inferiores

A aterotrombose é uma doença multissistêmica associada a elevada morbidade e mortalidade. A manipulação das artérias com fios-guia ou cateteres pode gerar trauma mecânico, com conseqüente deslocamento de material ateromatoso da parede vascular. Um paciente de 82 anos, no qual uma ponte fêmoro-poplítea distal com veia safena in situ havia sido realizada por nós há 10 anos, apresentou dor, palidez, hipotermia, diminuição da sensibilidade e força do pé direito 6 horas após coronariografia com acesso pela artéria femoral direita (classe 2b de Rutherford). Arteriografia diagnóstica evidenciou perviedade do enxerto, com múltiplas irregularidades em seu terço distal, compatíveis com material ateroembólico, além de pobreza extrema de circulação distal. Optamos pela revascularização do membro inferior direito em caráter de urgência, associando técnicas convencionais a métodos endovasculares. Empregando a técnica de push and park, cruzamos a lesão ateroembólica com fio-guia e tratamos todo o eixo arterial acometido com manobras de angioplastia. O paciente apresentou boa evolução, boa perfusão distal, adequado enchimento capilar, eliminação da dor e melhora acentuada imediata do déficit motor e sensitivo.

Correlation of preoperative ankle-brachial index and pulse volume recording with impaired saphenous vein incisional wound healing post coronary artery bypass surgery

Patients undergoing coronary artery bypass surgery have vascular disease and, subsequently, the risk for impaired healing of their saphenous vein graft site. The purpose of this study was to identify the correlation of the preoperative ankle-brachial index (ABI) and pulse volume recording (PVR) with impaired saphenous vein incisional wound healing post coronary artery bypass grafting. A prospective, correlational research design was used to study 271 male and female adults undergoing coronary artery bypass surgery in which the saphenous vein was used for grafting. Arterial insufficiency was assessed preoperatively using patient history, physical examination, ABI, and PVR. Wound status was assessed postoperatively using the validated ASEPSIS tool for inpatients. A modified ASEPSIS tool, the Wound Healing Self Score, was used for telephone follow-up post discharge. Abnormal ABI and PVR measurements were positively correlated with impaired saphenous vein incisional wound healing (r = 0.72, P < .0001). Both tests also independently predicted impaired healing. Incisional infection correlated with impaired healing (P < .0001). Other clinical variables, including diabetes, hypertension, venous disease, and alcohol and cigarette use, were not found to be statistically significant independent predictors of impaired healing. Routine histories and physical examinations alone are insufficient in predicting risk for impaired saphenous vein incisional wound healing. The addition of noninvasive screening for the presence of arterial insufficiency before coronary artery bypass grafting using ABI and PVR tests is one method of predicting the likelihood of impaired healing.

CT Angiography of Peripheral Arterial Bypass Grafts: Accuracy and Time-Effectiveness of Quantitative Image Analysis with an Automated Software Tool

Qualitative analysis of computed tomography (CT) angiography data often is limited by intra- and interobserver variability. The purpose of this study was to evaluate the time-effectiveness and accuracy of a quantitative CT angiography data analysis using automated software in comparison with qualitative axial and coronal CT image reading in patients with peripheral bypass grafts. Twenty-eight patients with 33 saphenous bypass grafts underwent 4-channel (n = 21) and 16-channel (n = 7) CT angiography. Two readers evaluated in consensus the CT data qualitatively on axial and coronal reconstructions and with the software regarding the presence of graft stenoses, aneurysmal changes, and arteriovenous fistulas. The time for data analysis was taken and the accuracy was compared with the results from digital subtraction angiography (DSA). No significant difference was present between data analysis time using axial and coronal CT images (4.9 +/- 1.5 minutes) and when using the software tool (5.5 +/- 1.4 minutes). Good (kappa = 0.652) to excellent (kappa = 1.000) intermodality agreement was present between qualitative and quantitative CT analysis regarding graft-related abnormalities. Sensitivity and specificity for diagnosing stenoses, aneurysms, and fistula did not differ significantly (P > .025) between qualitative CT image reading and the automated software tool. CT angiography analysis of peripheral bypass grafts using an automated software tool is similar regarding time-effectiveness and accuracy when compared with qualitative CT data analysis on axial and coronal images. It may assist in determining the significance of an abnormality and can yield objective morphometric data of vessel calibers.

Treatment of a large coronary saphenous bypass graft aneurysm by implantation of covered stents

Treatment of a large coronary saphenous bypass graft aneurysm by implantation of covered stents

Giant aneurysm of an aortocoronary saphenous bypass graft

Fig. 1. (A and B) Conventional X-ray images of an 81-year-old man (A: posterior-anter mediastinal mass (arrows). (C and D) CTangiography (C: cross-sectional image; D: mu exceptional aneurysmally enlargement of up to 8 cm in diameter and embedded fr consistent with the diagnosis of a giant partially thrombotic aneurysm of an aortocoron wall thinning presumably from a previous myocardial infarction.

Prospective Randomized Study on Reversed Saphenous Vein Infrapopliteal Bypass to Treat Limb-Threatening Ischemia: Common Femoral Artery Versus Superficial Femoral or Popliteal and Tibial Arteries as Inflow

Prospective Randomized Study on Reversed Saphenous Vein Infrapopliteal Bypass to Treat Limb-Threatening Ischemia: Common Femoral Artery Versus Superficial Femoral or Popliteal and Tibial Arteries as Inflow