Saphenous Vein Bypass Research Articles

Pediatric Popliteal Artery Pseudo-Aneurysm: A Case Report and Literature Review

<h3>Introduction/Objectives</h3> Osteochondroma is the most common benign, skeletal tumor occurring in 1% of the population and is most prevalent in males.¹ Rarely, they can be associated with vascular complications, in the lower extremity most commonly affecting the popliteal artery.² We describe a case of a young male who presented with right knee pain and a history significant forprevious removal of bilateral tibial osteochondromas that were symptomatic. He was found to have a large popliteal pseudo-aneurysm associated with a posterior right distal femur osteochondroma. <h3>Case Report</h3> A 16-year-old male with a past medical history of multiple hereditary exostoses was seenas an outpatient due to sudden right knee pain and tightness over his popliteal fossa that started occurring over the last several days. Three years prior he underwent removal of bilateral medial proximal tibial osteochondromas that were symptomatic. He was found to have a large popliteal pseudo-aneurysm on CT measuring 3.5 × 5.6 × 6.6cm with thrombus visualized with the aneurysm (Fig. 1Figure 1CT image demonstrating a large popliteal artery pseudo-aneurysm in association with an osteochondroma spike. Orlando Health, Department of General Surgery, Orlando, FloridaFigure 1). An arterial duplex was also obtained (Fig. 2Figure 2Proximal, mid, and distal representations of popliteal pseudo-aneurysm on arterialduplex. Orlando Health, Department of General Surgery, Orlando, FloridaFigure 2). There was no evidence of neurological compromise and distal pulses were palpable. In the operating room, the right thigh greater saphenous vein was harvested endoscopically with the patient in the supine position. Concerned about our ability to obtain proximal control from the prone position, our attention was turned to the above-knee popliteal fossa and proximal control of the popliteal artery was obtained. The patient was then placed in the prone position. We created a "Lazy S" incision and deepened the incision over the popliteal fossa. We dissected over the large pseudo-aneurysm, continuing our dissection distally until normal popliteal artery was encountered, obtaining distal control. Although the pseudo-aneurysmextended approximately 20cm, the diseased portion of the artery was only approximately 0.5cm (Fig. 3Figure 30.5cm segment of diseased portion of popliteal artery, anterior surface (left) andposterior surface (right). Video link below.Figure 3). We were able to separate the underlying pseudo-aneurysm from the normalized artery and again ensured proximal and distal control. We entered the sac and encountered a large amount of clot, this was evacuated (Fig. 4Figure 4Clot evacuated from pseudo-aneurysm sac.Figure 4). We then began to resect the pseudo-aneurysm wall distally, this allowed us to encounter the spike coming off of the osteochondroma which was essentially a sharp, pointed segment (Fig. 5Figure 5Osteochondroma spike.Figure 5). At this point the orthopedist took over resecting thissegment, we then resected the diseased portion of the artery and performed our repair of the popliteal artery with reversed greater saphenous vein in an end-end fashion (Fig. 6Figure 6Repair of popliteal artery with greater saphenous vein.Figure 6). The patient was discharged the following day with strongly palpable pulses and no in-hospital complications. Unfortunately, the patient was lost to follow up. <h3>Discussion</h3> Osteochondromas develop from skeletal elements that have undergone endochondral ossification and can occur at any time of the human skeletal growth phase. They are ‘protected' by a soft hyaline cartilaginous cap that is identical to the epiphyseal plate and undergoes ossification following cessation of growth.³ They are often solitary (90% of cases) although when multiple represent a hereditary autosomal dominant condition as in our patient's case. Thepopliteal artery is particularly susceptible to pseudo-aneurysmal changes as it is fixed between Hunter's canal superiorly and popliteus muscle inferiorly, preventing displacement from any underlying lesion. There have been multiple studies suggesting that following the cessation of growth, the cartilaginous cap undergoes ossification resulting in a sharp bone spur. As the vesselbecomes tethered, the resulting constant compression and pulsatile friction against the ‘non- protected' osteochondroma causes continuous injury to the vessel wall, resulting in pseudo- aneurysm formation.^4-6 Early surgical repair is mandatory, conservative management has been shown to increasethe risk of secondary complications including venous thrombosis, and distal emboli.^7-9 Posterior and medial surgical approaches have both been described, venous patch angioplasty, vein/prosthetic bypass and ligation. We adopted a posterior approach to the lesion, utilizing a greater saphenous vein bypass. <h3>Conclusion</h3> Popliteal pseudo-aneurysms are the most common vascular sequela of femur osteochondromas due to the superior and inferior fixation of the vessel. Post-operative imaging investigations should be considered due to multiple osteochondromas occurring in about 10% ofpatients as evidenced in our case.

Cervical to Petrous Carotid Artery High-Flow Bypass for Carotid Artery Pseudoaneurysm Through Zygomatic Approach: 2-Dimensional Operative Video

Pseudoaneurysms of the cervical internal carotid artery may generate grave risk from catastrophic rupture, thromboembolic stroke, or mass effect. They have many causes, including malignancy, infection, and iatrogenic and most commonly blunt or penetrating trauma.1 These aneurysms require treatment to eliminate their risk. Treatment options include trapping, with or without revascularization, or endovascular stenting. Trapping without revascularization requires evaluation of the cerebral collateral under a physiological challenge, which is usually done with a balloon occlusion test, which is not applicable in this lesion.2 Occluding the carotid without revascularization carries the risk of delayed ischemia and aneurysm formation.3,4 Carotid stenting has been applied in the treatment of these lesions5,6; however, the extent of the lesion in our patient from the carotid bifurcation to the petrous carotid makes endovascular treatment challenging. We present a patient with a delayed post-traumatic pseudoaneurysm of the carotid artery that extended from the bifurcation to the petrous carotid who was treated with trapping and high-flow saphenous vein bypass from the proximal cervical internal carotid to the petrous carotid. Adequate exposure of the petrous carotid to perform anastomosis requires a thorough knowledge of the anatomy and surgical nuances, which we demonstrate here through a zygomatic approach.7 The patient consented to the procedure and publication of imaging. Image at 2:28 from Al-Mefty O, Operative Atlas of Meningiomas, © LWW, 1997, with permission.

Long-Term Outcomes of Popliteal Artery Aneurysms Treated by Ligation and in Situ Saphenous Vein Bypass

The modality of elective repair (open or endovascular) of popliteal artery aneurysms (PAAs) is still debated. No strict evidence exists regarding the best surgical technique for open repair. The aim of our study was to report a 20-year experience with ligation and in situ saphenous vein bypass for the elective treatment of PAAs.

Safety and effectiveness of high flow extracranial to intracranial saphenous vein bypass grafting in the treatment of complex intracranial aneurysms: a single-centre long-term retrospective study

BackgroundTo summarize the safety and effectiveness of high flow extracranial to intracranial saphenous vein bypass grafting in the treatment of complex intracranial aneurysms.MethodsThe data of complex intracranial aneurysms patients for high flow extracranial to intracranial saphenous vein bypass grafting from January 2008 to January 2020 were retrospectively collected and analyzed. Eighty-two patients (31 men and 51 women) with 89 aneurysms underwent 82 saphenous vein bypass grafts followed by immediate parent vessel occlusion. The aneurysm was located at the internal carotid artery, middle cerebral artery, and basilar artery in 75, 11, and 3 cases, respectively.ResultsThe patency rate of bypass grafting was 100, 100, 96.3 and 92.4% on intraoperation, on the first postoperative day, at discharge and 6 months follow-up, respectively. At discharge and 6 months follow-up, 3 and 6 patients had graft occlusions. The main postoperative complications were transient hemiparesis and hemianopsia. 3 patients died due to bypass complications and poor physical condition.ConclusionsHigh flow extracranial to intracranial saphenous vein bypass grafting is safe and effective in the treatment of complex intracranial aneurysms and the saphenous vein can meet the requirements of brain blood supply. A high rate of graft patency and adequate cerebral blood flow can be achieved.HighlightsA single-centre long-term retrospective study was conducted to assess the safety and effectiveness of high flow EC-IC saphenous vein bypass grafting in the treatment of complex intracranial aneurysms. The data of 82 patients from January 2008 to January 2020 were retrospectively collected and analysed.We found the patency rate of bypass grafting was 100, 100, 96.3 and 92.4% on intraoperation, on the first postoperative day, at discharge and 6 months follow-up, respectively. At discharge and 6 months follow-up, 3 and 6 patients had graft occlusions.Finally, we conclude that high flow extracranial to intracranial saphenous vein bypass grafting is safe and effective in the treatment of complex intracranial aneurysms and the selected blood supply vessels can meet the requirements of blood supply.As far as we know, this study is one of the maximum number of cases in the treatment of complex intracranial aneurysms with saphenous vein bypass.

Successful limb salvage beyond the golden time following blunt traumatic open complete transection of the femoral artery and vein in a patient with cardiac arrest: a case report

BackgroundOpen complete transection of the femoral artery and vein following blunt trauma is extremely rare. Furthermore, even if the patient has been successfully resuscitated, it is sometimes difficult in most patients to preserve the injured limb, especially after damage control resuscitation. We report a case of open complete transection of the femoral artery and vein secondary to high-energy blunt trauma and a successful limb preservation treatment strategy.Case presentationA 57-year-old Asian man was transferred to hospital after having fallen from the 15th floor of a condominium. The patient was in cardiac arrest at the scene, but was successfully resuscitated by emergency medical services staff. On arrival, the patient’s hemodynamics were completely collapsed with active external bleeding from the thigh, so we immediately started resuscitation including activation of massive transfusion protocol and temporarily ligated the transected proximal superficial femoral artery, deep femoral artery just distal after branching lateral femoral circumflex artery and the superficial femoral vein. Following radiological findings showing a potential pelvic fracture with active bleeding, we also performed retroperitoneal packing in the resuscitation room and moved the patient to the angiography room for transcatheter arterial embolization. The patient’s consciousness was preserved and perfusion of the injured limb was barely maintained after his hemodynamics were adequately stabilized. As we detected weak perfusion of the lower limb via a potential collateral flow from the lateral femoral circumflex artery branches from deep femoral artery by pulse doppler of the dorsal pedis artery, we decided to reconstruct superficial femoral artery and vein at 24 h after injury using great saphenous vein bypass grafts. The patient was transferred to a rehabilitation hospital with good neurological and limb outcome after hospitalization for 52 days.ConclusionWe successfully preserved the patient’s lower limb after cardiac arrest and complete transection of the femoral artery and vein and achieved a good neurological outcome. Even if a femoral artery needs to be ligated temporarily, careful observation and assessment should be performed so as not to lose the chance to salvage the limb even during damage control resuscitation.

True radial artery aneurysm in a patient with somatic mosaicism for a mutation in platelet-derived growth factor receptor β gene

We have presented the case of a right radial artery aneurysm (RAA) in a 27-year-old man with cerebral and coronary artery aneurysms and features of Parkes-Weber syndrome (port-wine stains and right upper extremity arteriovenous malformation and overgrowth). The RAA was repaired with an interposition great saphenous vein bypass graft. Analysis of the intracranial artery aneurysm and affected skin demonstrated a somatic mutation in the platelet-derived growth factor receptor-β gene. Mosaicism was present in the RAA but not in the great saphenous vein. Somatic mosaicism should be considered as a possible etiology for peripheral aneurysms in patients for whom standard genetic test results are unrevealing.

Contemporary outcomes of in-situ saphenous vein bypass in the endovascular era: update on LIMBSAVE registry

article: Contemporary outcomes of in-situ saphenous vein bypass in the endovascular era: update on LIMBSAVE registry - Italian Journal of Vascular and Endovascular Surgery 2020 September;27(3):103-4 - Minerva Medica - Journals

18F-sodium fluoride coronary uptake in patients with coronary artery bypass grafts

Abstract 18F-Sodium fluoride (18F-NaF) positron emission tomography (PET) provides an assessment of active calcification (microcalcification) across a wide range of cardiovascular conditions including coronary artery disease, carotid and penile atherosclerosis, aortic and mitral valve disease, and abdominal aortic aneurysms. To date the significance of 18F-NaF uptake in patients with coronary artery bypass grafts (CABG) is unknown. We aimed to characterize 18F-NaF activity in CABG patients. We performed 18F-NaF PET (30-min long single bed position acquisition 1h after a 250mB injection of 18F-NaF) and coronary CT angiography in patients with multivessel coronary artery disease and followed them for fatal or non-fatal myocardial infarction over 42 [31,49] months. On motion-corrected datasets we quantified the whole-vessel coronary 18F-NaF PET uptake (the coronary microcalcification activity (CMA)) by measuring the activity of voxels above the background (right atrium activity) + 2 * standard deviations threshold. All study subjects underwent a comprehensive baseline clinical assessment including evaluation of their cardiovascular risk factor profile with the SMART [Secondary Manifestations of Arterial Disease] risk score calculated, and the coronary calcium burden assessed with calcium scoring (CCS). Among 293 study participants (65±9 years; 84% male), 48 (16%) had a history of CABG. Although the majority 124/128 (97%) of coronary bypass grafts showed no uptake, 4 saphenous vein grafts presented with a CMA&amp;gt;0 (range: 2.5–11.5, Figure). While a similar proportion of patients with and without prior CABG showed increased coronary 18F-NaF uptake (CMA&amp;gt;0) (58.3% versus 71.4%, p=0.11) overall prior-CABG subjects had higher CMA (2.0 [0.3, 6.6] versus 0.6 [0, 2.7], p=0.001) and CCS (1135 [631, 2120] versus 225 [59, 542], p&amp;lt;0.001), respectively. In line with the differences in the calcification activity and the coronary calcium burden, the SMART risk scores were higher in CABG patients (23 [17, 28] versus 17 [12, 24], p=0.01), and these patients were also older (68±8 versus 64±8, p=0.01). Despite the aforementioned differences the incidence of myocardial infarction 5/48 (9%) versus 15/245 (6%) and MACE 6/48 (12%) versus 34/245 (14%) during follow-up between subjects with and without prior CABG was similar (p=0.44 and p=0.80, respectively). CABG patients have a higher coronary microcalcification activity on 18F-NaF PET than multivessel coronary artery disease patients without prior CABG. Despite evidence of higher 18F-NaF uptake there is no difference in outcome between these two groups. Figure 1. 18F-NaF uptake in CABG patients. (A) 63-year old male with prominent uptake in stented saphenous vein bypass grafts and native coronary arteries who experienced a non-fatal non ST elevation myocardial infarction during follow-up. (B) 70-year old male with evident uptake in native coronary arteries and only little 18F-NaF activity within coronary bypasses. Funding Acknowledgement Type of funding source: Other. Main funding source(s): National Heart, Lung, and Blood Institute/National Institute of Health (NHLBI/NIH), British Heart Foundation

Preliminary six-month outcomes of LIMBSAVE (treatment of critical Limb IscheMia with infragenicular Bypass adopting in situ SAphenous VEin technique) registry.

Guidelines recommend open bypass surgery for long occlusions of infrainguinal arteries. In situ saphenous vein bypass is a standardized technique. The aim of this study was to report preliminary six-month outcomes of a national, multicenter, observational, prospective registry based on the examination of treatment of critical Limb IscheMia with infragenicular Bypass adopting the in situ SAphenous VEin technique (LIMBSAVE). From January 2018 until October 2019, 428 patients from 41 centers were enrolled in the LIMBSAVE registry. Data were prospectively collected in a dedicated database, including demographics, preoperative risk factors, clinical and diagnostic preoperative assessments, intraoperative measures (including safety and effectiveness of the valvulotome during the surgical procedures), and 30-day follow-up data. Furthermore, estimated six-month outcomes according to Kaplan-Meier curves in terms of primary patency, primary assisted patency, secondary patency, and limb salvage were evaluated. Patients were predominantly male (n = 332, 77.6%) with a mean age of 73.3 years (range 39-95). Technical success, defined as bypass pulse after use of the valvulotome, was obtained in all cases. The proximal anastomosis could be reached by the valvulotome in all cases. The mean number of valvulotome uses was 2.5 (range 1-5). No vein perforation was reported. In nine cases (2.1%), a vein lesion with intramural hemorrhage occurred. The mean length of hospital stay was 11.1 days (range 1-60). At 30-day follow-up, the overall bypass patency rate was 97.4%, and the rate of open or endo reinterventions for failing bypass was 5.4%. At six-month follow-up, the estimated primary patency, primary assisted patency, secondary patency, and limb salvage were 78.1%, 86.2%, 92.1%, and 94.7%, respectively. Preliminary intraprocedural outcomes of the LIMBSAVE registry show that the in situ technique with the valvulotome is safe and effective in disrupting valves and obtaining pulsatility in the saphenous vein. The complication rate related to the use of the valvulotome is low. The six-month preliminary outcomes in terms of overall patency and limb salvage are promising. Further examinations and continuous follow-up are needed to evaluate long-term outcomes.

Surgical Treatment of True Superior Mesenteric Artery Aneurysms

Superior mesenteric artery aneurysms (SMAAs) are a rare clinical problem that can be associated with significant morbidity and mortality. The optimal surgical approach for both mycotic and degenerative SMAAs remains poorly defined. The study was designed to review our institutional experience and develop a treatment algorithm. A single-institution, retrospective review was performed to document presentation, treatment, and outcomes of patients undergoing surgical repair of SMAAs from 2003 to 2020. The primary end-point was 30-day mortality, and secondary end-points included complications, patency, freedom from reinfection, freedom from reintervention, and survival. Eighteen patients (mean age: 46±16yrs; 50% male; mean diameter 2.4±2.0cm) underwent treatment of mycotic (50%) or degenerative (50%) SMAAs. Abdominal pain (66%) was the most common presenting symptom, and the diagnosis was confirmed with CT arteriography. Endocarditis secondary to intravenous drug abuse was responsible for most (88%) of the mycotic SMAAs, with a majority (66%) having positive cultures and Streptococcus being the most common organism. The majority (61%) of patients underwent urgent or emergent repair with aneurysmectomy and interposition saphenous vein bypass being the most common treatment of mycotic SMAAs while aneurysmectomy and prosthetic bypass were used most frequently for degenerative aneurysms. The operative mortality rate was 6% with a major complication rate of 17% (n=3 patients: respiratory failure/reintubation-1, pulmonary embolism-1, necrotizing pancreatitis/graft disruption and death-1). The single death occurred in a patient with a degenerative aneurysm that developed postoperative pancreatitis and multiple organ dysfunction. The mean clinical follow-up time was 25±48 (95% CI 1-48) months. The estimated primary patency, freedom from reinfection, and freedom from reintervention were 93±7 %, 94±5%, and 94±5%, respectively, at 1year. The overall mean survival was 55±51 (95% CI 30-80) months with an estimated survival at 3years of 77±10%. SMAAs associated with both degenerative and mycotic etiologies can be treated using a variety of surgical approaches with acceptable morbidity and mortality. Mycotic SMAAs should likely be repaired, regardless of size, while the indications for asymptomatic, degenerative aneurysms remain to be defined by further natural history studies.

Vaping Induced Pathological Changes in the Lung: A Case Report Study

Introduction: The angiosome concept was first described in 1987, defining an angiosome as an area of tissue comprising skin, subcutaneous tissue, fascia, muscle and bone supplied by a specific artery and drained by a specific vein. We report a case of a patient who was successfully complex revascularized by open surgery and endovascular techniques based on angiosome concept. Case presentation: A 73-years-old male patient with critical limb ischemia and type 2 diabetes, presented increasing resting pain in the lower right limb during the last 3 months, followed by necrosis of distal phalanx of I and II toes, wet interdigital necrosis of toes I-II on the right leg, with absence of distal pulses on both limbs. Direct flow into affected angiosome was successfully achieved with right proximal femoral-popliteal saphenous vein bypass and ATA balloon dilatation angioplasty. Conclusion: The vascular patient with critical ischemia associated to diabetes currently requires a complex treatment including open surgery, endovascular technique and negative pressure therapy to save the lower limbs. The angiosome concept is useful during both open and endovascular tibial revascularisation.

Complex Lower Limb Revascularization Based on Angiosomes Concept: A Case Report

Introduction: The angiosome concept was first described in 1987, defining an angiosome as an area of tissue comprising skin, subcutaneous tissue, fascia, muscle and bone supplied by a specific artery and drained by a specific vein. We report a case of a patient who was successfully complex revascularized by open surgery and endovascular techniques based on angiosome concept. Case presentation: A 73-years-old male patient with critical limb ischemia and type 2 diabetes, presented increasing resting pain in the lower right limb during the last 3 months, followed by necrosis of distal phalanx of I and II toes, wet interdigital necrosis of toes I-II on the right leg, with absence of distal pulses on both limbs. Direct flow into affected angiosome was successfully achieved with right proximal femoral-popliteal saphenous vein bypass and ATA balloon dilatation angioplasty. Conclusion: The vascular patient with critical ischemia associated to diabetes currently requires a complex treatment including open surgery, endovascular technique and negative pressure therapy to save the lower limbs. The angiosome concept is useful during both open and endovascular tibial revascularisation.

Peripheral Arterial Injuries in Children: An Audit at a University Hospital in Developing Country.

Objectives: To review the prevalence, pattern, management, outcome, and predictive factors for limb loss of pediatric peripheral arterial injuries (PAIs) at a university hospital in Pakistan.Methods: Medical records of children (age <18 years) managed for PAIs at the university hospital between Jan 2008 and Dec 2018 were reviewed for demographic data; mechanism, type, and severity of injury; management; and outcome.Results: During the study period, of the 1718 children managed for trauma, 75 (67 males and 8 females) had PAI secondary to glass cut (33.3%), gunshot (28.0%), and road traffic accidents (24.0%). Forty-nine patients (65.3%) presented to the emergency room within 6 h of injury. Brachial (28.0%), superficial femoral (20.0%), and radial (20.0%) arteries were the frequently injured vessels. At presentation, the mean revised trauma score and Mangled Extremity Severity Score (MESS) were 3.86±0.55 and 3.4±1.92, respectively. Sixty-eight patients (90.66%) underwent vascular procedures: interposition saphenous vein bypass graft or PTFE graft in 38.7% and primary repair in 29.3%. Limb salvage was achieved in 92.65% of the patients. Late presentation (>6 h) was a risk factor for limb loss (p=0.014).Conclusion: Of the 23 children who presented with trauma, 1 had major PAI. Early presentation (<6 h) and appropriate vascular interventions can salvage limbs in most of the patients.

Symptomatic superficial femoral artery pseudoaneurysm due to late stent fracture.

Late formation of pseudoaneurysm related to stent fracture is rarely described in the literature. We describe a case of spontaneous 8-cm femoral superficial artery pseudoaneurysm rupture that had developed from fracture of a stent implanted 3 years previously. Surgical repair was performed with fractured stent removal and reverse saphenous vein bypass.

Long-term results of polytetrafluoroethylene versus saphenous vein repair of degenerative carotid artery aneurysm

ObjectiveTo compare the results of polytetrafluoroethylene (PTFE) and great saphenous vein (GSV) bypass after resection of a degenerative aneurysm of the carotid artery. MethodsFrom January 1994 to November 2017, 37 patients (27 men) with a mean age of 58 years (range, 39-82 years) with a degenerative aneurysm of the carotid artery (median diameter, 28 mm; range, 19-42 mm), underwent resection of the aneurysm followed by a bypass with either a GSV (n = 10) or a PTFE prosthesis (n = 27). Although 31 patients were asymptomatic, 6 patients were symptomatic: transient ischemic attack (n = 4), minor stroke (n = 1), and compression of the hypoglossal nerve (n = 1). The preoperative workup included duplex ultrasound examination of the arteries to the head, and angiography or computed tomography angiography. All patients were operated under general anesthesia and six were intubated through the nose. Sixteen patients were monitored through transcutaneous oximetry. No shunt was used in this series. In 10 patients receiving a PTFE graft, the external carotid artery was implanted in the prosthesis. Mean follow-up was 16.9 ± 2 years (95% confidence interval, 14.5-19.3 years). Primary end points were the 30-day combined stroke/death rate, graft infection, late graft patency, and late stroke-free survival. Secondary end points were cranial nerve injury and length of postoperative hospital stay. ResultsPostoperative mortality was nil in both groups. One postoperative stroke was observed in the PTFE group, whereas none occurred in the GSV group (P = .84). No graft infection was observed in either group. At 10 years, survival in the GSV group was 80 ± 12%, and survival in the PTFE group was 76 ± 8% (log-rank [Mantel-Cox], P = .85). In the GSV group, graft patency at 7 and 10 years was 85 ± 13%. In the PTFE group B, graft patency was 100% (log-rank [Mantel-Cox], P = .12). No late stroke was observed. Two transient cranial nerve injuries were observed in the GSV group (20%) and two in the PTFE group (8%) (P = .97). Length of hospital stay was comparable in both groups (GSV group, 6 days; PTFE group, 5 days; P = .12). ConclusionsThis study suggests that, after resection of a degenerative aneurysm of the carotid artery, bypass with a PTFE prosthesis gives comparable results to those obtained with the GSV. We recommend sparing the GSV and instead using a PTFE prosthesis in patients with a degenerative aneurysm of the carotid artery.

The Role of Routine Ultrasound Surveillance after In Situ Infrainguinal Peripheral Vein Bypass for Critical Limb-Threatening Ischemia

To evaluate systematic duplex ultrasound (DUS) surveillance of patients treated with in situ great saphenous vein bypass (ISSVB) due to critical limb-threatening ischemia (CLTI) we performed a retrospective analysis of prospectively entered registry data. Single-center study including consecutive patients undergoing elective ISSVB surgery due to CLTI between 2011 and 2015. Postoperative graft surveillance program included clinical examination, ankle-brachial indices (ABIs), and DUS at 6weeks and 3 and 12months. All DUS scans were performed by trained nurse sonographers. Patient data were extracted from the Danish Vascular Registry, electronic medical records and Picture Archiving and Communication System (PACS). Primary outcomes were reintervention rate, patency, and survival. In total, 363 consecutive and treatment-naive CLTI patients were revascularized with ISSVB and included in the study. Of those, 310 patients had minimum one follow-up visit and in total 1,199 DUS examinations. During the study period, 84 (23%) patients received 125 graft preserving reinterventions of which 20 were indicated solely on routine DUS without concurrent ischemic symptoms and/or significant (>15%) decrease in ABI. Hence, to find one asymptomatic graft stenosis requiring reintervention, we needed to scan 60 patients. After 1, 2, and 3years, assisted primary patency was (Kaplan-Meier estimate) 79.4% (95% CI: 74.4, 83.5), 76.3% (95% CI: 70.7, 81.0), and 73.6% (95% CI: 66.9, 79.2), respectively. Survival rates were 82.6% (95% CI: 78.1, 86.3), 64.2% (95% CI: 57.8, 69.9) and 47.7% (95% CI: 40.6, 54.4) at 1, 2, and 3years, respectively. In this study, one in four patients received a graft preserving intervention, but very few were driven by routine DUS and most graft lesions were detected on clinical findings. These findings suggest that development of a more individualized surveillance program differentiating between high- and low-risk infrainguinal bypass patients may increase cost-effectiveness.

Saphenous Vein Vasa Vasorum as a Potential Target for Perivascular Fat-Derived Factors.

Perivascular adipose tissue (PVAT) is a source of factors affecting vasomotor tone with the potential to play a role in the performance of saphenous vein (SV) bypass grafts. As these factors have been described as having constrictor or relaxant effects, they may be considered either beneficial or detrimental. The close proximity of PVAT to the adventitia provides an environment whereby adipose tissue-derived factors may affect the vasa vasorum, a microvascular network providing the vessel wall with oxygen and nutrients. Since medial ischaemia promotes aspects of graft occlusion the involvement of the PVAT/vasa vasorum axis in vein graft patency should be considered.

Percutaneous occlusion of large aneurysmal right coronary artery saphenous vein bypass graft.

Percutaneous occlusion of large aneurysmal right coronary artery saphenous vein bypass graft.

Novel technique of vein harvesting for reversed saphenous vein bypass graft

Novel technique of vein harvesting for reversed saphenous vein bypass graft

Ultrasound Surveillance of Insitu Bypass Grafts - is it Worth the Effort?

Introduction: In surgical fit patients with critical limb ischaemia (CLI) a great saphenous vein bypass is the recommended treatment for long occlusions of the infra-popliteal segment ADDIN EN.CITE ADDIN EN.CITE.DATA 1. Development of vein graft stenosis and bypass failure is observed in as much as 40% within the first 12 months2 and duplex ultrasound (DUS) surveillance has been broadly implemented with the aim to increase patency. ADDIN EN.CITE ADDIN EN.CITE.DATA Nevertheless, the evidence supporting this many DUS examinations are conflicting. ADDIN EN.CITE ADDIN EN.CITE.DATA 2, 3 Most cohorts in the literature are heterogeneous and report on a variety of autogenous vein conduits (insitu vein, reversed vein, arm vein and spliced vein) and indications (claudication or CLI) making generalizability difficult.3 The aim of this study was to describe patency of insitu saphenous vein bypass (ISSVB) in critical limb ischaemia and to analyse the added value of systematic DUS surveillance of in situ saphenous vein bypass. Methods: Single centre study including all patients undergoing ISSVB surgery due to CLI between 2011 and 2015. Postoperative graft surveillance program were offered to all patients, including clinical examination, ABI and DUS at 6 weeks, 3 and 12 months. The study was based on prospective entered data from the Danish Vascular Registry and primary endpoints were re-intervention rate and patency. To avoid idealization of the survival plots we decided to include occlusion, amputation and death as endpoints in both plots and use reintervention as the only variable in the Kaplan Meyer estimates. Results: In total 392 consecutive and treatment naive CLI-patients were revascularized with ISSVB and included in the study. Of those, 326 patients had minimum one follow up visit resulting in 1267 DUS examinations. During the study period, 95 (24%) patients received 143 reinterventions to avoid graft failure, 76 patients (80%) with percutaneous transluminal angioplasty (PTA) and 19 patients (20%) with surgical revision. Only 18 patients (20 reinterventions) were revised solely based on DUS findings (significant stenosis) without simultaneous ischemic symptoms or significant (>15%) decrease in ankle brachial index. Hence, to find one asymptomatic graft stenosis requiring reintervention one need to scan 65 patients (1267:20=65). Occlusion- and amputation-free survival (OAS) after 1, 2 and 3 years was 59.7% (95%-CI: 54.6-64.5), 45.3% (39.6-50.9) and 32.3% (26.4-38.4), respectively (figure 1). Reintervention-, occlusion-, and amputation-free survival (ROAS) after 1, 2 and 3 years was 47.6% (42.5-52.6), 33.5% (28.1-38.9) and 21.1% (16.0-26.7). Conclusion: The KM-plots showed a significant difference between ROAS and OAS until 2½ years postoperatively, indicating a modest (approximately 10%) effect of reintervention on graft stenosis. In this study, every fourth of ISSVB patients received a graft-preserving intervention but very few were driven by routine DUS as most graft lesions were recognised on symptoms and clinical findings. This finding suggests that development of more individualised surveillance programs differentiating between high and low risk patients may be more cost effective. Disclosure: Nothing to disclose