Secondary Patency Research Articles

Comparison of Lower and Upper Extremity Arteriovenous Graft: A Retrospective Clinical Analysis with 5-Year Follow-Up

For patients in whom an upper extremity (UE) vascular access cannot be established, the lower extremity (LE) arteriovenous graft (AVG) could be selected. However, the application of LE AVG is limited owing to its high infection rate, uncertain patency time, and technical difficulties. This study aimed to compare the long-term patency rates and the incidence of vascular access complications of AVG in the LE and UE to provide a reference for the applications of AVG, especially in the LEs. This was a retrospective analysis of patients who successfully underwent LE or UE AVG placement from March 2016 to October 2021. Patient characteristics were collected and compared using parameter or nonparameter tests according to data type. Postoperative patency was evaluated using Kaplan-Meier test. Postoperative complication incidence density and intergroup comparison were estimated using the Poisson distribution. Twenty-two patients with LE AVG and 120 patients with UE AVG were included. The 1-year primary patency rate was 67.4% (±11.0% standard error [SE]) in the LE group and 30.1% (±4.5% SE) in the UE group (P=0.031). The assisted primary patency rate at postoperative months 12, 24, and 36 was respectively 78.6% (±9.6% SE), 65.5% (±14.4% SE), and 49.1% (±17.8% SE) in the LE group and 63.3% (±4.6% SE), 47.5% (±5.4% SE), and 30.4% (±6.1% SE) in the UE group (P=0.137). The secondary patency rate at postoperative months 12, 24, and 36 remains 95.5% (±4.4% SE) in the LE group and 89.3% (±2.9% SE), 83.7% (±3.9% SE), and 73.0% (±6.2% SE), respectively, in the UE group (P=0.200). Postoperative complications included stenosis, occlusion/thrombosis, infection, steal syndrome, pseudoaneurysm, severe postoperative serum swelling, and AVG exposure. The total incidence rates of postoperative complications were 0.87 (95% confidence interval [CI] 0.59-1.23) versus 1.61 (95% CI 1.45-1.79) (P=0.001) cases/person-year, the incidence rates of stenosis were 0.45 (95% CI 0.26-0.73) versus 0.92 (95% CI 0.80-1.06) (P=0.005) cases/person-year and the incidence rates of occlusion/thrombosis were 0.34 (95% CI 0.17-0.59) versus 0.62 (95% CI 0.52-0.74) cases/person-year in the LE group compared to those in the UE group (P=0.041). LE AVG had higher primary patency rate and lower postoperative complication incidence than UE AVG. With the development of interventional technology, both LE AVG and UE AVG exhibited high secondary patency rates. LE AVG can be a reliable and long-term alternative for appropriately selected patients with unusable UE vessels.

Clinical Outcomes of Common Femoral Thromboendarterectomy with Bovine Pericardium Patch Angioplasty

The purpose of the study is to evaluate the efficacy of thromboendarterectomy (TEA) for common femoral occlusive disease using bovine pericardium patch angioplasty. The subjects were patients who underwent TEA for common femoral occlusive disease with bovine pericardium patch angioplasty from October 2020 to August 2021. The study had a prospective, multicenter, and observational design. The primary endpoint was primary patency (freedom from restenosis). The secondary endpoints were secondary patency, amputation-free survival (AFS), postoperative wound complication, hospital death within 30 days, and major adverse cardiovascular events (MACE) within 30 days. Forty-seven TEA procedures with a bovine patch were performed in 42 patients (34 males; median age, 78 years; diabetes mellitus, 57%; end-stage renal disease with hemodialysis, 19%). Clinical presentations were intermittent claudication (68%) and critical limb-threatening ischemia (CLTI) (32%). Sixteen (34%) limbs underwent TEA alone and 31 (66%) underwent a combined procedure. Surgical site infection (SSI) occurred in 4 limbs (9%) and lymphatic fistulas in 3 limbs (6%). One limb with SSI required surgical debridement 19 days after the procedure, and one limb (2%) without postoperative wound complications required additional treatment due to acute bleeding. Hospital death within 30 days occurred in one case due to panperitonitis. There were no MACE within 30 days. Claudication was improved in all cases. Postoperative ABI of 0.92 [0.72-1.00] was significantly higher than the preoperative value (P < 0.001). The median follow-up period was 10 months [9-13 months]. One limb (2%) required additional endovascular therapy due to stenosis at the endarterectomy site at 5 months postoperatively. Primary and secondary patencies were 98% and 100% at 12 months, respectively, and the AFS rate was 90% at 12 months. Common femoral TEA with bovine pericardium patch angioplasty has satisfactory clinical outcomes.

Long Term Follow Up, Causes for Re-intervention, and Consequences for Surveillance After Stenting for Proximal Deep Vein Obstruction

Venous stenting is performed increasingly for acute deep vein thrombosis (DVT) and post-thrombotic syndrome (PTS) with good short term patency results, but long term data are scarce. The purpose of this study was to evaluate long term outcome of stenting for acute DVT and PTS and to study causes of re-intervention. All patients stented for acute DVT and PTS between May 2006 and November 2021 were included retrospectively in this single centre cohort study. Patency was studied by duplex ultrasound (DUS) or computed tomography. The primary endpoint was stent patency. Re-intervention free survival was calculated using Kaplan-Meier methods. Secondary endpoints were causes of re-intervention, using the Pouncey classification system (2022). Binary logistic regression was used to calculate odds ratios for predictors of re-intervention. A total of 114 patients were included, with 129 limbs involved (acute DVT n= 53; 41%), PTS n= 76; 59%). Median follow up was 2.3 years (interquartile range [IQR] 2.3) for acute DVT and 5.2 years (IQR 7.1) for PTS. Primary patency, secondary patency, and permanent occlusion were 73.5%, 98.1%, and 1.9% for acute DVT, and 63.2%, 92.1%, and 7.9% for PTS limbs. Overall, 41 limbs underwent at least one re-intervention: 14 in the acute DVT group and 27 for PTS. Most re-interventions (82.9%) were performed within the first year after stenting. Missed inflow, insufficient flow, and thrombosis despite anticoagulation were the most common causes of re-intervention. The strongest predictor for re-intervention for PTS was inflow disease (odds ratio 3.57, 95% confidence interval 1.26 - 10.13, p= .017). Long term patency of deep venous stenting is good. Re-interventions are typically performed in the first year and are potentially preventable by improving the procedure and patient selection. Since secondary patency rates are excellent, selected patients may be considered for discharge from long term surveillance.

Heparin-Bonded Expanded Polytetrafluoroethylene Is a Solution for Infrapopliteal Revascularization in the Absence of an Adequate Autologous Vein Graft

To analyze the outcomes of heparin-bonded expanded polytetrafluoroethylene (HePTFE) graft as an alternative conduit in infrapopliteal revascularization of chronic limb-threatening ischemia (CLTI) in the absence of an autologous vein conduit. A single-center retrospective analysis of patients with CLTI submitted to infrapopliteal bypasses with autologous vein graft (VEIN group) or HePTFE graft (HePTFE group) was implemented. Primary end points were freedom from CLTI at 12months and recurrence of CLTI at 3years. Secondary end points included freedom from major amputation, amputation-free survival (AFS), survival, and primary (PP) and secondary patency (SP) rates at 3years of follow-up. A total of 348 limbs submitted to infrapopliteal bypasses, 214 with venous graft and 134 with HePTFE graft, were followed-up for a median of 25months. Most patients of the HePTFE group were male (69%), with a median age of 76years (interquartile range [IQR] 15). Fifty-nine percent of the limbs of the HePTFE group had Wound grade ≥2, being 46% of them infected. Eighty-eight percent were GLASS stage III. Freedom from CLTI was not significantly different between HePTFE and VEIN groups (75% vs. 84%, adjusted hazard ratio [aHR] 0.88, confidence interval [CI] 0.66-1.18, P=0.401). Recurrence of CLTI was higher in the HePTFE group (42% vs.18% at 3years; aHR 2.82, CI 1.59-5.00, P<0.001). The VEIN group achieved higher rates of freedom from major amputation (87% vs.69% at 3years; aHR 2.21, CI 1.31-3.75, P=0.003) and AFS (59% vs. 37% at 3years; aHR 1.39, CI 1.02-1.88, P=0.036), but no significance in survival (aHR 1.10, CI 0.72-1.66, P=0.667). Patency rates were inferior in the HePTFE group, with 2-year PP and SP rates of 52% vs. 74%, and 76% vs. 90%, respectively (PP: aHR 1.70, CI 1.11-2.59, P=0.014; SP: aHR 2.51, CI 1.42-4.42, P=0.001). Infrapopliteal bypass with autologous vein graft is the gold standard to treat CLTI limbs. HePTFE graft should be regarded as an alternative for complex infrapopliteal revascularization when lacking an autologous vein conduct.

150-OR: Mean HbA1c and Glycaemic Variability Are Associated with Adverse Outcomes following Infrainguinal Bypass for Peripheral Arterial Disease (PAD)—A Retrospective Cohort Study

Introduction: Glycemic variability (GV) is associated with increased risk of several adverse outcomes in people with diabetes (DM). However, on the impact of GV on graft patency following infra-inguinal bypass (IIB) for peripheral arterial disease (PAD) is unknown. Methods: A 3-year single centre retrospective case notes analysis of those undergoing IIB 2017-2019. HbA1c values for 5 years pre-procedure (minimum of 3) were used to calculate a mean (±SD) HbA1c (MH) and GV. Time to re-intervention, ipsilateral amputation or death were recorded to determine primary (PP) and secondary patency (SP). Results: 193 IIB outcomes were analysed: mean (±SD) age 68.9 (9.2) years; 135 (69.9%) male. 156 (80.8%) had pre-operative HbA1c for analysis and 88 (45.6%) had DM; 87 (45.1%) were current smokers; 107 (55.4%) underwent emergency procedures. Those without diabetes were more likely to smoke (P=0.011), but those with DM had higher Rutherford stage (p&amp;lt;0.01), underwent more distal bypasses (p&amp;lt;0.01) and more emergency procedures (p=0.04). Those with DM had longer mean [IQR] hospital stays 9 [5-21] vs 7 [4-15] days (p=0.017), lower PP 335 [184-542] vs 883 [436-1437] days (p=0.04) and lower SP 751 [387-1108] vs 1079 [895-1593] days (p=0.037). Both MH and GV were associated with amputation free survival time (r=-0.232, p=0.004 and r=-0.243, p=0.011 respectively). A GV&amp;gt;9.1% was associated with significantly lower PP than GV&amp;lt;9.1%, 198[105-377] vs 713 [313-1287] days (p=0.02). On multivariate adjustment, GV &amp;gt;9.1% and level of bypass remained independent predictors of primary patency, HR 1.96 (95% CI:1.12-3.42, p=0.018) and HR 2.54 (95%CI:1.24-5.22, p=0.038) respectively. Conclusions: We have shown a significant relationship between MH and GV and risk of adverse outcomes in people undergoing IIB. Lowering glycemic variability should be an additional therapeutic target together with lowering mean HbA1c. Disclosure K.Dhatariya: Other Relationship; Novo Nordisk, AstraZeneca, Boehringer-Ingelheim, Eli Lilly and Company. P.C.Bennett: None. D.J.Farndon: None.

Efficacy and safety of iliofemoral bypass using arm veins as an alternative conduit for chronic limb-threatening ischemia

ObjectiveThe use of basilic vein in iliofemoral revascularizations was previously described in the literature as an autologous option for the treatment of vascular prosthesis infection and as a primary conduit in patients at high risk of infectious surgical complications. However, the publications available include several different indications and are limited to case reports. Therefore, the aim of this study was to evaluate the outcomes of the use of arm veins as a safe and effective autologous alternative for iliofemoral reconstruction in patients with chronic limb-threatening ischemia (CLTI) and at high risk of prosthesis infection. MethodsWe performed a multicenter, retrospective cohort study with 53 consecutive iliofemoral bypasses using arm veins as an alternative conduit. The procedures were performed between November 2013 and November 2021, exclusively for patients with CLTI classified as TASC aortoiliac C or D with increased risk of postoperative surgical infection. Demographic, clinical variables, and outcomes were collected from a prospective database. Main endpoints were amputation-free survival (AFS) and major adverse cardiovascular events. Secondary endpoints included primary and secondary patencies and overall survival. Cox regression analysis was used to identify the predictors of AFS. Postoperative surgical complications and 30-day mortality were also assessed. ResultsThe mean age was 64.2 ± 8.4 years, with a predominance of male gender. The median follow-up period was 615 days. All patients had CLTI, with a predominance of tissue loss (n = 51; 96.2%) and a median ankle-brachial index of 0.28. The basilic vein was utilized in most procedures (69.8%). Thirty-day major adverse cardiovascular events occurred in five cases (9.4%), and the 30-day mortality rate was 3.8%. The AFS, primary patency, secondary patency, and overall survival in 720 days were 71%, 72%, 89%, and 75%, respectively. Cox regression analysis revealed no association between the variables analyzed for AFS. There was no graft late infection nor pseudoaneurysmal degeneration. ConclusionsIliofemoral bypass using arm veins as an autologous conduit proved to be an effective and safe procedure with low incidence of postoperative cardiovascular complications and high rates of AFS in patients with CLTI. Also, this suggests that arm veins can be an interesting and suitable autologous alternative conduit for iliofemoral reconstructions, especially in cases in which a prosthesis should be avoided or when it is not available.

#5918 ENDOVASCULAR CREATION OF AN ARTERIOVENOUS FISTULA (ENDOAVF) FOR HEMODIALYSIS ACCESS: A RETROSPECTIVE MONOCENTRIC EXPERIENCE

Abstract Background and Aims Functioning vascular access is an essential element for life-saving hemodialysis therapy. Surgical creation of a radiocephalic arteriovenous fistula (AVF) is the gold standard of vascular access for hemodialysis. However an endovascular approach to arteriovenous fistula creation (endoAVF) has increasingly gained acceptance over the last years as an alternative to the conventional surgical method. It offers a minimally invasive method for the formation of arteriovenous shunts and allows the creation of fistulas with minimal vessel trauma. There are currently two technologies available for this purpose, the Ellipsys Vascular Access System (Medtronic, Avenu Medical, San Juan Capistrano, Calif) and the Wavelinq endoAVF System (BD Medical, Franklin Lakes, NJ). At our centre (Careggi University Hospital, Florence), we developed an integrated service, based on a multidisciplinary approach between Interventional Radiology and Interventional Nephrology for percutaneous arteriovenous fistulas utilizing both Ellipsys and Wavelinq. We describe our experience with a case series of 39 patients, showing feasibility and outcome of this treatment option. Method Between December 2020 and January 2023 we created an endoAVF in 39 patients. Patients were suitable for the procedure after a pre-therapeutic ultrasound vascular mapping showed adequate brachial, radial and ulnar vessels and no ipsilateral central venous stenosis. After procedure, we performed a regular clinical and ultrasound monitoring. Therefore, we collected data regarding patient characteristics, initial technical success rate, number of access lost and number of endoAVF meeting primary and secondary patency. Results Of the total of 39 patients treated with endoAVF, 29 (74.3%) were male, with a mean age of 60.1 ± 33.9 years. The Wavelinq procedure was performed in 32 patients (82.0%) and the Ellipsys procedure in 7 patients (17.9%). Initial technical success was achieved in 38 (97.4%) cases, while in 1 case we had a primary failure of the fistula (Figure 1). Among these 38 patients, 4 (10.5%) were lost to follow-up because of death from other causes (3 patients) and because of kidney transplantation (1 patient), while 2 other patients (5.2%) have not required hemodialysys yet. Of the remaining 32 patients, we had 2 fistulas lost because of complications and a cumulative functional patency of 93.7% (30 fistulas), with a primary patency rate of 76% (23 fistulas). Conclusion The endoAVF appears to be feasible and safe for the creation of arteriovenous fistula suitable for hemodialysis access. Our data show an high functional cumulative patency of the endoAVF and a good primary patency, reducing the necessity of further interventions. Furthermore, in the prevalent hemodialysis population, the minimally invasive endovascular arteriovenous fistula procedure should help improving long wait times for vascular access creation. Further studies with more patients and multicentric data are needed to assess long-term outcomes.

#4923 ARTERIOVENOUS FISTULAS AS HEMODIALYSIS ACCESS IN A PEDIATRIC POPULATION – IS YOUNGER AGE A REASON TO MAINTAIN CENTRAL VENOUS CATHETER?

Abstract Background and Aims In the pediatric population, transplantation remains the first-line therapy in patients with end-stage renal disease (ESRD). However, it is not always possible, increasing the need for other kidney replacement therapy (KRT) modalities, and hemodialysis (HD) has been growing as a modality choice in recent years. To provide quality HD treatment, efficient vascular access is mandatory, and the arteriovenous fistula (AVF) is advocated as the best long-term access option. However, its creation is technically challenging, and its development and maintenance are some of the most difficult elements in the pediatric population. In this study, we describe our experience in the utilization of AVFs in children and adolescents on HD. Method We conducted a retrospective study including all the AVFs performed in our center on underage patients between January 2006 and December 2022. We reviewed the medical records, collected data on demographic variables, AVF characteristics, blood test results, and clinical outcomes. Statistical analysis was performed using SPSS software. Results Forty-three AVFs were performed in 32 pediatric patients. The median age at first AVF construction was 13.5 years (min 4.8; max 17.9). The most frequent etiology of ESRD was congenital anomalies of kidney and urinary tract (n = 20, 62.5%) and most patients (n = 24, 75.0%) were already receiving KRT. Median follow-up time was 16.4 months (min 1; max 98.4) and, at the end of the follow-up period, most patients (n = 22, 68.8%) were transplanted. The mortality rate was 6.3% (n = 2). In what concerns to the location of the AVF, radiocephalic was the first choice in 46.9% of the cases (n = 15), accounting for 34.9% of the total AVFs. Brachiocephalic location was used in 34.4% (n = 11) of first fistulas and 6 subsequent accesses, accounting for 39.5% of the total AVFs. The brachiobasilic location was chosen in 18.8% (n = 6) of the first AVFs and 25.6% of the total AVFs. Primary AVF failure occurred in 26.6% (n = 11) cases and, in 4 of these (36.4%), it was possible to successfully use the same location for a second AVF. We observed no statistical association between primary AVF failure dysfunction and gender, age at the construction of the first fistula, AVF location, or dialysis vintage. Platelet-lymphocyte (PLR) and neutrophil-lymphocyte (NLR) ratios also did not differ between groups. Primary and secondary patency rates at one year were, respectively, 62.5% and 93.8%. With respect to total AVF complications, we observed: thrombosis (27.9%), stenosis (18.6%), distal ischemia induced by vascular access (4.7%), and high flow/aneurismatic dilations (18.6%). The presence of complications was statistically related to age (p = 0.046), with more events in older patients at the time of AVF construction. There was no statistical difference between complications’ occurrence and AVF type, sex, gender, PLR, and NLR. Conclusion The utilization of AVF for HD has been growingly recognized as a safe and efficient alternative for the performance of KRT in pediatric patients. Although larger studies are needed, we demonstrate positive results in its usage in a pediatric population, with high primary and secondary patency rates. These outcomes were independent of the AVF location. We also advocate AVF usage in younger patients, as complications were associated with older age. PLR and NLR, which are emerging biomarkers for systemic inflammation, were not associated with AVF dysfunction, aligning with the results of other studies in pediatrics.

#3408 A META-ANALYSIS OF VASCULAR ACCESS OUTCOMES IN HEMODIALYSIS PATIENTS OVER 75 YEARS OF AGE

Abstract Background and Aims The age of patients with end-stage renal disease is constantly growing, but evidence for the best vascular access for hemodialysis is scarce and controversial for elderly. A meta-analysis was performed in hemodialysis patients over 75 years old to compare the outcomes of different vascular access procedures in the sub-group of elderly ESRD patients ≥ 75 years of age. Method A literature search was performed using the electronic databases MEDLINE and SCOPUS up to October 2021. Twelve eligible articles fulfilled the inclusion criteria and were finally selected in the meta-analysis (Table). Three of these studies including ESRD patients &amp;gt;70 years of age were exceptionally included as the mean age was well above 75 years. First step analysis was focused on studies that reported the primary patency rates of autologous vs. prosthetic vascular accesses (5 studies). Second step analysis was focused on articles comparing the results of primary and secondary patency rates of distal (forearm) vs. proximal (upper arm) fistulas in elderly patients (8 studies). All these studies were retrospective cohort studies, none was randomized controlled trial. Results Regarding the first step analysis, primary failure rate at 24 months was in favor of AVFs (OR: 0.56, 95% CI: 0.38-0.83, p = 0.003, Fig. 1). Although several studies have shown that AVG patency is not affected by age, this meta-analysis showed patency benefit of AVF in this subgroup of elderly patients ≥75 years of age. In a second step, the 12-month primary failure rate was by far in favor of proximal AVFs (OR: 2.14, 95% CI: 1.53-2.97; p&amp;lt;.00001, Fig. 2). The 12-month secondary patency rate of the forearm AVFs was also inferior compared to the proximal AVF (OR: 1.76, 95% CI: 1.12-2.78; p&amp;lt;.01, Fig. 3) These findings favor the use of proximal AVFs as first choice access in this subgroup of elderly patients, especially when they are late referrals or have low life expectancy. Conclusion The question of the right access in elderly ESRD patients does not have an easy answer. The present study shows that patients ≥75 years old should not be excluded from creation of an autologous access, with proximal AVFs having better patency rates.

Outcomes of Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Procedure for the Treatment of Extensive Aortoiliac Occlusive Disease Using the BeGraft Balloon-Expandable Covered Stent: A Multicenter Observational Study.

The covered endovascular reconstruction of the aortic bifurcation (CERAB) technique offers an alternative for Trans-Atlantic Inter-Society Consensus (TASC) C/D lesions involving the aortic bifurcation. The study aims to evaluate the outcomes of the CERAB technique for extensive aortoiliac occlusive disease (AIOD) using the BeGraft balloon-expandable covered stent (BECS). This is a physician-initiated, multicenter, retrospective, observational study. Between June 2017 and June 2021, all consecutive patients who underwent the CERAB procedure using the BeGraft stent (Bentley InnoMed, Hechingen, Germany) in 3 clinics were enrolled. Patients' demographics, lesion characteristics, and procedural results were collected and retrospectively analyzed. Follow-up was done at 1, 6, and 12 months and then annually with clinical examination, ankle-brachial index (ABI), and duplex ultrasound. The primary endpoint was the patency at 12 months. Secondary endpoints included procedural-related complications, secondary patency, freedom from target lesion revascularization (TLR), and clinical improvement. In all, 120 patients (64 men) with a median age of 65 years (range: 34-84 years) were analyzed. Most patients had extensive AIOD classified as TASC II C (n=32; 26.7%) or TASC II D (n=81; 67.5%). The median duration of the procedure was 120 minutes (interquartile range [IQR]: 80-180 minutes). All 454 BeGraft stents (137 aortic and 317 peripheral) were successfully delivered and deployed. The overall procedural complication rate was 14 (11.7%). The median hospital length of stay was 5 days (IQR: 3-6 days). All patients improved clinically, and the ABI increased significantly (p<0.05). The median follow-up was 19 months (range: 6-56 months). The primary patency rate, secondary patency rate, and freedom from TLR at 12 months were 94.5%, 97.3%, and 93.5%, respectively. The CERAB procedure with BeGraft BECSs has a high technical success rate, favorable patency outcomes, and low morbidity, even in relatively ill patients with extensive AIOD. Prospective randomized studies on the CERAB technique are definitely recommended. This study evaluates the outcomes of BeGraft stents used during the covered endovascular reconstruction of the aortic bifurcation (CERAB) procedure. To date, several balloon-expandable covered stents have been used for this technique with satisfactory results. This study showed the safety and excellent patency of the CERAB technique in extensive AIOD using BeGraft balloon-expandable covered stents.

Multicenter trans-Atlantic experience with fenestrated-branched endovascular aortic repair of chronic post-dissection thoracoabdominal aortic aneurysms

ObjectiveThis multicenter international study aimed to describe outcomes of fenestrated-branched endovascular aortic repairs (FB-EVAR) in a cohort of patients treated for chronic post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs). MethodsWe reviewed the clinical data of all consecutive patients treated by FB-EVAR for repair of extent I to III PD-TAAAs in 16 centers from the United States and Europe (2008-2021). Data were extracted from institutional prospectively maintained databases and electronic patient records. All patients received off-the-shelf or patient-specific manufactured fenestrated-branched stent grafts. Endpoints were any cause mortality and major adverse events at 30 days, technical success, target artery (TA) patency, freedom from TA instability, minor (endovascular with <12 Fr sheath) and major (open or ≥12 Fr sheath) secondary interventions, patient survival, and freedom from aortic-related mortality (ARM). ResultsA total of 246 patients (76% male; median age, 67 years [interquartile range, 61-73 years]) were treated for extent I (7%), extent II (55%), and extent III (35%) PD-TAAAs by FB-EVAR. The median aneurysm diameter was 65 mm (interquartile range, 59-73 mm). Eighteen patients (7%) were octogenarians, 212 (86%) were American Society of Anesthesiologists class ≥3, and 21 (9%) presented with contained ruptured or symptomatic aneurysms. There were 917 renal-mesenteric vessels targeted by 581 fenestrations (63%) and 336 directional branches (37%), with a mean of 3.7 vessels per patient. Technical success was 96%. Mortality and rate of major adverse events at 30 days was 3% and 28%, including disabling complications such as new onset dialysis in 1%, major stroke in 1%, and permanent paraplegia in 2%. Mean follow-up was 24 months. Kaplan-Meier (KM) estimated patient survival at 3 and 5 years was 79% ± 6% and 65% ± 10%. KM estimated freedom from ARM was 95% ± 3% and 93% ± 5% at the same intervals. Unplanned secondary interventions were needed in 94 patients (38%), including minor procedures in 64 (25%) and major procedures in 30 (12%). There was one conversion to open surgical repair (<1%). KM estimated freedom from any secondary intervention was 44% ± 9% at 5 years. KM estimated primary and secondary TA patency were 93% ± 2% and 96% ± 1% at 5 years, respectively. ConclusionsFB-EVAR for chronic PD-TAAAs was associated with high technical success and a low rate of mortality (3%) and disabling complications at 30 days. Although the procedure is effective in the prevention of ARM, patient survival was low at 5 years (65%), likely due to the significant comorbidities in this cohort of patients. Freedom from secondary interventions at 5 years was 44%, although most procedures were minor. The significant rate of reinterventions highlights the need for continued patient surveillance.

Patency of arteriovenous fistulas and grafts for dialysis access: An analysis using the Korean National Health Insurance Service database from 2008 to 2019.

Arteriovenous (AV) access practice and its outcomes vary internationally. To provide a better understanding of the patterns and outcomes of AV access creation, we investigated the patency and risk factors of arteriovenous fistulas (AVFs) and grafts (AVGs) as initial AV access in the Korean adult population using data from the last 10 years. The National Health Insurance Service database was queried retrospectively to identify patients undergoing hemodialysis with AVFs and AVGs as well as their clinical characteristics and outcomes from 2008 to 2019. AV access patency and its associated risk factors were evaluated. During the study period, 64,179 AVFs and 21,857 AVGs were placed. The mean patient age was 62.6 ± 13.6 years (21.5% were ⩾75 years old), and 39.3% patients were women. More than half of the patients underwent AV access creation at tertiary care hospitals. At 1 year, the primary, primary assisted, and secondary patency rates were 62.2%, 80.7%, and 94.2% for AVFs, and 46.0%, 68.4%, and 86.8% for AVGs, respectively. AVG, older age, female sex, diabetes, and creation at general hospitals (vs tertiary hospitals) were associated with decreased patency outcomes (all, p < 0.05). This study using national data showed that three quarters of patients with AV access had AVF and AVF showed superior performance to AVG and identified several patient and center factors related to AV access patency in Korea.

Is the Mid-Term Patency Rate of Small-Diameter Viabahn Stent-Grafts in Peripheral Artery Disease Related to Their Length? A Systematic Review.

Small-diameter endografts can be used for the treatment of the peripheral vascular disease, but the patency rate during the follow-up is still under debate. With this review, we aimed at analyzing the mid-term patency of small-diameter Viabahn stent-grafts and investigating the relationship between patency and the length of the graft. We performed a review of articles published until September 2020 and reporting use of ≤7-mm-diameter Viabahn stent-grafts in diseased peripheral arteries. Data on study type, demographic, lesion length, stent-graft diameter, length, and patency (1-year, 3-year, 5-year primary patency, primary-assisted patency, and secondary patency), follow-up, endoleak, and re-intervention rates were extracted and analyzed. A statistical test was applied to identify a correlation between stent-graft length and patency. 16 retrospective and 7 prospective studies reported the outcome of 1613 patients (mean age: 69.6±33.7 years). There was considerable heterogeneity in reporting standards among studies. The diameter of Viabahn stent-grafts ranged 5 to 7mm and the average length was 23.6±12.4cm. Heparin-bonded grafts were used in 46.4% of cases. Mean follow-up time was 26.4±17.6 months. The 1- and 5-year primary patency rate was 75.7% (95% CI, 73.6%-77.8%) and 46.8% (95% CI, 41.0%-52.6%), respectively. The 1- and 5-year primary-assisted patency rate was 80.9% (95% CI, 73.9%-87.8%) and 60.9% (95% CI, 46.4-75.5%), respectively. The 1- and 5-year second-assisted patency was 90.4% (95% CI, 87.4%-93.3%) and 73.7% (95% CI, 64.7%-82.8%), respectively. No correlation between the stent-graft length and patency was found. Small-diameter Viabahn stent-graft implantation represents a safe treatment for patients with peripheral artery disease, and the mid-term patency rate seems not be affected by the length of the graft. The use of small diameter stent-grafts for peripheral vascular disease is an established technique but the patency rate is still under debate. With this review we have investigated the relationship between the mid-term patency and the diameter of the stent-grafts. Afterv having analysed data from 23 published studies including 1613 patients we can conclude that the treatment of the peripheral artery disease with small diameter stent-grafts is safe and the mid-term patency rate seems not be affected by the lenght of the grafts.

Outcomes of Omniflow® II prosthesis used for revascularization in the femoral tract both in infected and non-infected setting.

Evidence regarding the outcomes of Omniflow® II prosthesis in peripheral arterial revascularization at different anatomical sites and for different indications is scarce. Therefore, the aim of this study was to evaluate the outcomes of the Omniflow® II used at various positions within the femoral tract both in infected and non-infected setting. Patients who underwent reconstructive lower leg vascular surgery with implantation of an Omniflow® II from 2014 until 2021 at five medical centers were retrospectively included (N.=142). Patients were subdivided into the following categories: femoro-femoral crossover (N.=19), femoral interposition (N.=18), femoro-popliteal (above-the-knee [N.=25; AK] or below-the-knee [N.=47; BK]), and femoro-crural bypass grafts (N.=33). Primary outcome was primary patency and secondary outcomes included primary assisted patency, secondary patency, major amputation, vascular graft infection, and mortality. Outcomes were compared according to different subgroups and the surgical setting (infected versus non-infected). The median follow-up was 35.0 (17.5-54.3) months. Three years primary patency of 58% was observed for femoro-femoral crossover bypass, 75% for femoral interposition graft, 44% for femoro-popliteal above-the-knee bypass, 42% for femoro-popliteal below-the-knee bypass, and 27% in the femoro-crural position (P=0.006). Freedom from major amputation at three years were 84% for femoro-femoral crossover bypass, 88% for femoral interposition bypass, 90% for femoro-popliteal AK bypass, 83% for femoro-popliteal BK bypass, and 50% for femoro-crural bypass (P<0.001). This study demonstrates the safety and feasibility of the use of Omniflow® II for femoro-femoral crossover-, femoral interposition-, and femoro-popliteal (AK and BK) bypass. Omniflow® II seems to be less suitable for femoro-crural bypass with a significantly lower patency compared to other positions.

Use of Omniflow® II Biosynthetic Graft for the Treatment of Vascular Graft and Endograft Infections

Vascular graft/endograft infection is a rare but life-threatening complication of cardiovascular surgery and remains a surgical challenge. Several different graft materials are available for the treatment of vascular graft/endograft infection, each having its own advantages and disadvantages. Biosynthetic vascular grafts have shown low reinfection rates and could be a potential second best after autologous veins in the treatment of vascular graft/endograft infection. Therefore, the aim of our study was to evaluate the efficacy and morbidity of Omniflow® II for the treatment of vascular graft/endograft infection. A multicenter retrospective cohort study was performed to evaluate the use of Omniflow® II in the abdominal and peripheral region to treat vascular graft/endograft infection between January 2014 and December 2021. Primary outcome was recurrent vascular graft infection. Secondary outcomes included primary patency, primary assisted patency, secondary patency, all-cause mortality, and major amputation. Fifty-two patients were included with a median follow-up duration of 26.5 (10.8-54.8) months. Nine (17%) grafts were implanted in intracavitary position and 43 (83%) in peripheral position. Most grafts were used as femoral interposition (n=12, 23%), femoro-femoral crossover (n=10, 19%), femoro-popliteal (n=8, 15%), and aorto-bifemoral (n=8, 15%) graft. Fifteen (29%) grafts were implanted extra-anatomically and 37 (71%) in situ. Eight patients (15%) presented with reinfection during follow-up, most of these patients received an aorto-bifemoral graft (n=3, 38%). Intracavitary vascular grafting had a 33% (n=3) reinfection rate and peripheral grafting 12% (n=5; p=0.025). The estimated primary patencies at 1, 2, and 3 years were 75%, 72%, and 72% for peripherally located grafts and 58% (at all timepoints) for intracavitary grafts (p=0.815). Secondary patencies at 1, 2, and 3 years were 77% (at all timepoints) for peripherally located prostheses and 75% (at all timepoints) for intracavitary prostheses (p=0.731). A significantly higher mortality during follow-up was observed in patients who received a intracavitary graft compared to patients with a peripheral graft (p=0.003). This study highlights the efficacy and safety of the Omniflow® II biosynthetic prosthesis for the treatment of vascular graft/endograft infection, in absence of suitable venous material, with acceptable reinfection, patency, and freedom of amputation prevalences, especially in replacing peripheral vascular graft/endograft infection. However, a control group with either venous reconstruction or another alternative graft is needed to make firmer conclusions.

Contemporary Minimally Invasive Surgery for TASC-D Aorto-Iliac Lesions: Analysis of Outcomes and Risk Factors for Primary and Secondary Patency

For complex extensive TASC-II D lesions, the standard of care remains conventional surgery. Nevertheless, guidelines tend to broaden endovascular surgery indications in expert centers for patients at high surgical risk with TASC-II D lesions. Due to the increasing use of endovascular surgery in this setting, we planned to evaluate the patency rate of this approach. We conducted a retrospective study in a tertiray center. All patients treated for symptomatic peripheral arterial disease (PAD) with classified D lesions according to the TASC-II classification and requiring management of the aortoiliac bifurcation were retrospectively included between January 1, 2007 and December 31, 2017. The type of surgical approach was classified as a pure percutaneous approach or hybrid surgery. The main objective was to describe long-term patency results. The secondary objectives were to identify risk factors for loss of patency and long-term complications. The primary outcomes were primary patency, primary assisted patency and secondary patency at 5 years of follow-up. 136 patients were included. For the overall population, the primary, primary assisted and secondary patency proportions at 5 years were: 71.6% (95% CI 63.2% -81%), 82.1% (95% CI 74.9% - 89.3%), 96.3% (95% CI 92-100%), respectively. For primary patency, there was a significant difference in favor of the covered stent group at 36 months (p <0.01) and 60 months (p = 0.037). In a multivariate model, only CS and age were associated with a better primary patency (HR 0.36, CI95% [0.15 - 0.83], p=0.0193 and a HR 0.07, 95%CI [0.05-0.09], p=0.005, respectively). The overall rate of perioperative complications was 11%. We report that endovascular and hydrid surgery are safe and effective in the management of TASC-D complex aortoiliac lesions in mid to long-term follow-up. Short- and long-term complications were all considered as minor.

Long-term Results of a Heparin-bonded Expanded Polytetrafluoroethylene Grafts for Above-the-knee Femoropopliteal Bypasses: A Japanese Prospective Multicenter Registry

Propaten (WL Gore & Associates, Flagstaff, AZ) is a bioactive heparin-bonded expanded polytetrafluoroethylene graft widely used for bypass surgery; however, its long-term results are yet to be established. In this study, we evaluated the long-term results of Propaten for above-the-knee femoropopliteal bypasses (AKFPB) using a Japanese prospective multicenter registry. In this prospective single-arm multicenter registry, 120 limbs (113 patients) underwent AKFPB for superficial femoral artery (SFA) lesion in 20 Japanese institutions between July 2014 and October 2017. We evaluated the long-term results by estimating primary patency (PP), secondary patency (SP), freedom from target lesion revascularization (TLR), and freedom from death at 6 years using the Kaplan-Meier method. Factors associated with the risk for the loss of PP were investigated using the Cox proportional hazards regression model. Baseline characteristics of 120 limbs are summarized in Table. Mean lesion length was 26.2 ± 5.7 cm, chronic limb-threatening ischemia was present in 45 limbs (37.5%), and only 35 limbs (29.2%) had all three runoff vessels patent. Technical success was achieved in all cases, and 49 limbs (40.8%) had concomitant additional procedure, mainly endovascular treatment (EVT), and cuffed distal anastomosis was employed in 93 limbs (77.5%). There were eight perioperative complications (6.7%), however, mean ankle brachial index (ABI) improved from 0.45 ± 0.27 to 0.96 ± 0.14, and improvement in Rutherford classification (RC) was achieved in 98 limbs (81.7%) at 30 days. Clinical improvement was sustained at the latest follow-up as mean ABI was 0.87 ± 0.23, and improvement in RC was achieved in 105 limbs (87.5%). PP, freedom from TLR, SP, and freedom from death at 6 years were 66.1% ± 4.9%, 72.4% ± 4.5%, 85.6% ± 3.6%, and 62.9% ± 4.8%, respectively (Fig 1). As for the factors associated with the risk for the loss of PP, prior coronary disease (unadjusted hazard ratio [HR], 2.57; 95% confidence interval [CI], 1.09-4.36; P = .006), hemodialysis (unadjusted HR, 2.62; 95% CI, 1.19-5.57; P = .02), three runoff vessels patent (unadjusted HR, 0.48; 95% CI, 0.22-1.06; P = .07), and cuffed distal anastomosis (unadjusted HR, 0.51; 95% CI, 0.25-1.07; P = .08) were selected for the multivariate analysis from the result of univariate analysis; however, only prior coronary disease remained significant (adjusted HR, 2.18; 95% CI, 1.09-4.36; P = .03). Long-term sustained clinical improvement and acceptable SP was achieved for AKFPB using Propaten. When good venous conduit is unavailable, AKFPB using Propaten is a reasonable revascularization option for complex SFA lesions, especially when EVT is inappropriate.TablePatients’ demographics and characteristicsVariableN = 120 limbsAge, years72.7 ± 8.1Male sex81 (67.5%)Body mass index, kg/m222.5 ± 3.8Rutherford classification 230 (25.0%) 345 (37.5%) 413 (10.8%) 531 (25.8%) 61 (0.8%)Ankle brachial index0.45 ± 0.27Number of runoff vessels 01 (0.8) 143 (35.8) 241 (34.2) 335 (29.2)TASC II classifications A0 (0.0) B6 (5.0) C20 (16.7) D94 (78.3)Lesion length, cm26.2 ± 5.7Outflow popliteal artery diameter, mm4.9 ± 1.1Key comorbidities and medical history Smoking, current31 (25.8%) Smoking, former67 (55.8%) Prior superficial femoral artery treatment32 (26.7%) Arterial hypertension91 (75.8%) Diabetes mellitus63 (52.5%) Dyslipidemia57 (47.5%) Chronic kidney disease (eGFR <60 mL/min)69 (57.5%) Hemodialysis17 (14.2%) Prior coronary disease38 (31.7%) Prior cerebrovascular disease24 (20.8%) Serum albumin <3.0 g/dL24 (20.8%)eGFR, Estimated glomular filtration rate.Categorical variables are presented as number (%), and continuous variables are presented as mean ± standard deviation. Open table in a new tab

8mm Conduit Outperforms 6mm Conduit in Extra-anatomic Bypass

Extra-anatomic bypass is an important tool in relieving supra-inguinal occlusive disease. These bypasses are frequently conducted with prosthetic material, commonly available in 6-mm and 8-mm sizes. Previous studies have demonstrated infra-inguinal bypass has improved patency when graft size is 6 mm or greater. This study aimed to examine outcomes of 6-mm vs 8-mm prosthetic graft use in extra-anatomic bypasses. A retrospective analysis of the Vascular Quality Initiative supra-inguinal database (2010-2022) was conducted. Patients undergoing either axillary-femoral or femoral-femoral prosthetic bypass with available conduit size data were included. Primary endpoints included graft patency and major adverse limb events (MALE). A logistic regression analysis was performed of demographic and operative variables to determine if any factors contributed to the selection of graft size. Then, multivariable Cox regression analysis was conducted in groups based on prosthetic diameter (6 mm vs 8 mm), controlling for these factors. Seven mm was excluded from formal regression analysis due to small sample size but included in survival curves to demonstrate the stepwise impact of graft size. A total of 6463 patients were included for analysis; 2355 axillary-femoral bypasses and 4128 femoral-femoral bypasses. Of these, 1071 patients underwent bypass with 6-mm graft, and 5392 patients underwent bypass with 8-mm graft. Significant predictors (P < .05) of 8-mm graft use in both types of extra-anatomic bypass included male gender, body mass index (BMI) of 25-35 kg/m2, and common femoral as distal target when compared to profunda, superficial femoral artery, and other distal vessels. The most significant predictor (P < .001) of improved primary patency in both types of extra-anatomic bypass examined was larger conduit diameter (8 mm vs 6 mm axillary-femoral hazard ratio [HR], 0.5; femoral-femoral HR, 0.66). Cox regression curves by graft size were generated for both axillary-femoral and femoral-femoral bypasses (Figs 1 and 2), which demonstrated significantly higher primary patency in patients with 8-mm bypasses over time. Improved performance in 8-mm graft compared with 6-mm graft was additionally demonstrated in primary-assisted patency, secondary patency, and MALE regression curves with P < .001 for both axillary-femoral and femoral-femoral bypasses. In this retrospective analysis of extra-anatomic bypasses, 8-mm grafts had significantly improved patency rates and fewer MALE when compared with 6-mm grafts over time. Male sex and body mass index were associated with larger diameter bypass use; after controlling for these preoperative factors, 8-mm grafts still outperformed 6-mm grafts. Vascular surgeons should be cognizant of the potential implications in limb salvage when selecting prosthetic graft for extra-anatomic bypass.Fig 2Primary patency of axillary-femoral bypass over time by graft size.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

EXPERIENCE OF HYBRID SURGICAL TREATMENT FOR MULTILEVEL OCCLUSIVE-STENOTIC ARTERIAL LESIONS IN LOWER EXTREMITIES

Peripheral artery disease affects approximately 20% of individuals over the age of 70 and is particularly prevalent among smokers and diabetics. The increasing global prevalence of metabolic syndrome, diabetes, and smoking suggests a further rise in its occurrence. The treatment of this disease incurs significant economic costs, which are projected to continue growing. This disease is associated with high rates of disability, morbidity, and mortality. Without revascularization, 20 to 40% of patients face limb loss, and over 20% die within six months. Conservative therapies are often ineffective, leading to the surgical methods. In cases of critical limb ischemia, revascularization is performed to improve blood flow distal to stenotic or occlusive lesions. Open surgery remains the standard of care, demonstrating good limb preservation and long-term outcomes. The success of bypass procedures depends on multiple factors. The use of endovascular techniques is rapidly increasing, supported by substantial long-term data. While endovascular surgery reduces perioperative complications, choosing the appropriate instrumentation and assessing associated costs remain contentious. Method selection depends on several factors. For certain patients where open surgery is technically challenging or impractical, endovascular surgery provides a viable solution for revascularization. In such cases, revascularization of all arterial lesion levels using a combination of methods is indicated to restore limb blood supply. Isolated revascularization of a single anatomical level is often insufficient and rarely leads to the healing of trophic changes. Hybrid surgery, involving a combination of techniques during a single intervention, is a common approach. This type of surgical procedure includes endovascular correction of the iliac segment with femoral endarterectomy and/or infrainguinal bypass. Another common option is an "above knee bypass" with tibial balloon angioplasty. Surgical treatment using hybrid procedures demonstrates high technical success, good primary and secondary patency rates, limb preservation, and economic efficiency. In this article, we present two clinical cases of hybrid surgical lower extremity revascularization performed at the Department of Vascular Surgery of the M.V. Sklifosovsky Poltava Regional Clinical Hospital. These cases involve patients with stage IV peripheral artery disease (Fontaine classification) caused by an atherosclerotic process. Computed tomography with angiography and digital subtraction angiography were employed as two distinct methods for studying the vascular bed in routine patient management. The method selection was based on angiosomal targets and the suspected vascular lesions initially diagnosed. The objective of this study is to analyze the effectiveness of various hybrid surgical treatment methods for patients with critical limb ischemia resulting from multilevel occlusive-stenotic arterial lesions.

Surgical Treatment for Popliteal Artery Entrapment Syndrome in Japan: a Retrospective, Multicentre Study Using a National Clinical Registry

Surgical treatment is an established method for popliteal artery entrapment syndrome (PAES), which, however, mainly derives from single centre experiences where PAES cases are centralised and treated periodically. This study evaluated clinical outcomes of surgical treatment for PAES in a clinical setting where PAES cases were not centralised. Multicentre, retrospective cohort study using a national clinical registry. From a Japanese nationwide clinical registry, data for patients who underwent surgical treatment for PAES between 2013 and 2018, including 58 limbs from 41 institutes, were retrieved and evaluated. Patency was analysed using Kaplan-Meier curves. The mean patient age was 36 ± 19 years, 78% were male, and the incidence of PAES was 0.24 limbs/centre/year, reflecting a clinical setting where PAES cases are not centralised. The most frequent arterial symptom was intermittent claudication (90%). Computed tomography was performed in 57 limbs (98%) for the diagnosis, however active manoeuvres such as dorsiflexion and plantarflexion during the examination was performed in only 13 limbs (22%), and occlusion of the popliteal artery was present in 38 limbs (66%) at diagnosis. Regarding surgical treatment, myotomy alone was performed in only seven limbs (12%), and other limbs were revascularised. Mean follow up was 26 ± 20 months, and surgical treatment was effective as it relieved symptoms in > 96% of limbs, with five year primary and secondary patency of the surgical treatment for PAES of 72% and 93%, respectively. Results of surgical treatment were acceptable even in a clinical setting where PAES cases were not centralised. However, a low incidence of active manoeuvres performed during the examination and a high incidence of occlusion at diagnosis suggests there may be delayed or underdiagnosis of PAES in Japan, and increased awareness for PAES is warranted.