Superior Patency Research Articles

Iodine-125 Seeds Combined With Biliary Stent Placement Versus Stent Placement Alone For Unresectable Malignant Biliary Obstruction: A Meta-Analysis Of Randomized Controlled Trials.

Background and Aims: Malignant biliary obstruction is always caused by tumors which are unresectable so that palliative stent placement is conducted for drainage of bile duct tree. Recently, irradiation stent with 125I seeds has been used to improve the stent patency and survival time of patients. We conducted this meta-analysis to evaluate the therapeutic efficacy and safety of biliary stent placement with 125I seeds compared with stent placement alone in patients with malignant biliary obstruction.Methods: We searched Pubmed, Web of Science, ClinicalTrials.gov, Cochrane Library, Embase and CNKI databases for all relevant studies up to 1 May 2020. Patient survival, stent patency, and adverse events were the primary outcome measured. Also, Review Manager 5.3 and Stata/SE15.0 were used to perform the analysis.Results: Eleven randomized controlled trials with a total of 767 patients were included for meta-analysis. Stent combined with 125I seeds showed lower risk of stent occlusion at 3 month (Odds Ratios(OR) = 0.15; 95%CI: 0.05-0.49, P =0.002), 6 month (OR = 0.18; 95%CI: 0.08-0.44, P = 0.0001), 9 month (OR = 0.10; 95%CI: 0.05-0.20, P < 0.00001) and 1 year (OR = 0.15; 95%CI: 0.07-0.31, P < 0.00001) and better mean survival (MD = 125days; 95% CI 91-159 days; P < 0.00001) compared with stent placement alone. Also, reconstructed Kaplan-Meier data demonstrated improved survival in patients treated with stent plus 125I seeds (hazard ratio(HR)= 1.886; 95% CI: 1.609 to 2.210; P < 0.0001) Moreover, our analysis did not show significant difference between the two groups about the risk of adverse events including abdominal pain, hemobilia, pancreatitis, cholangitis and cholecystitis.Conclusion: 125I seeds combined with stent demonstrated superior stent patency and improved survival time compared to stent alone with acceptable complications.

Inferiority of arteriovenous grafts, in comparison to autogenous fistulas, is underestimated by standard survival measures alone.

It has been argued that a prosthetic arteriovenous graft (AVG) is a reasonable alternative to an arteriovenous fistula (AVF) for dialysis. We aimed to compare the patency rates and requirements for the intervention of newly formed AVF and AVG. A retrospective analysis was undertaken of AVF and AVG formed between 1 January 2013 and 31 December 2015 at two tertiary referral centres and followed up until 31 December 2017. Outcome measures included successful use for dialysis, patency rates and the number of interventions required to maintain dialysis access per patient-year (PPY). Four hundred and seventy AVF and 92 AVG were constructed. Of 470 AVF, 324 (68.9%) were used compared to 80 of 92 (87%) AVG. One year assisted primary patency of AVF was 75% (confidence interval 71-79%) compared to 47% (confidence interval 36-57%) for AVG. Secondary patency rates for AVF at 1, 2 and 3 years were 77%, 71% and 69%, respectively. At the same time points, secondary patency rates for AVG were 77%, 60% and 46%, respectively (log rank P = 0.034). AVG required 2.4 times the number of interventions PPY than AVF. Surgical thrombectomy of AVG was at a rate of 0.49 PPY compared with 0.042 PPY for AVF. AVG have a substantially higher rate of thrombosis than AVF, evident from early in the life of the graft. AVF demonstrate superior patency rates to AVG throughout the life of the access, with far fewer interventions PPY than grafts.

Superior Short-term Patency of Stents Over Balloons in Infrapopliteal Artery Disease

Cardiogenic shock remains the leading cause of in-hospital death in acute myocardial infarction (AMI). Because of temporary changes in management of cardiogenic shock with widespread implementation of early revascularization along with increasing attention to the use of mechanical circulatory devices, complete and longitudinal data are important in this subject. The objective of this study was to examine temporal trends of first-time hospitalization, management, and short-term mortality for patients with AMI-related cardiogenic shock (AMICS).Using nationwide medical registries, we identified patients hospitalized with first-time AMI and cardiogenic shock from January 1, 2005, through December 31, 2017. We calculated annual incidence proportions of AMICS. Thirty-day mortality was estimated with use of Kaplan-Meier estimator comparing AMICS and AMI-only patients. Multivariable Cox regression models were used to assess mortality rate ratios.We included 101,834 AMI patients of whom 7,040 (7%) had AMICS. The median age was 72 (interquartile range: 62-80) for AMICS and 69 (interquartile range: 58-79) for AMI-only patients. The gender composition was similar between AMICS and AMI-only patients (male: 64% vs 63%). The annual incidence proportion of AMICS decreased slightly over time (2005: 7.0% vs 2017: 6.1%, P for trend < .0001). In AMICS, use of coronary angiography increased between 2005 and 2017 from 48% to 71%, as did use of left ventricular assist device (1% vs 10%) and norepinephrine (30% to 70%). In contrast, use of intra-aortic balloon pump (14% vs 1%) and dopamine (34% vs 20%) decreased. Thirty-day mortality for AMICS patients was 60% (95% CI: 59-61) and substantially higher than the 8% (95% CI: 7.8-8.2) for AMI-only patients (mortality rate ratio: 11.4, 95% CI: 10.9-11.8). Over time, the mortality decreased after AMICS (2005: 68% to 2017: 57%, P for temporal change in adjusted analysis < .0001).We observed a slight decrease in AMICS hospitalization over time with changing practice patterns. Thirty-day mortality was markedly higher for patients with AMICS compared with AMI only, yet our results suggest improved 30-day survival over time after AMICS.

OPERATIVE TECHNIQUES AND APPROACHES IN COMPLETE ARTERIAL REVASCULARIZATION IN MULTIVESSEL CORONARY ARTERY DISEASE. Review

Relevance. Multi arterial bypass surgery comprises nearly 10% of the overall operations for ischemic heart disease. Multiple studies proved the superiority of arterial grafts for multivessel coronary artery disease. Nevertheless, the vast majority of conduits utilized for multiple bypasses are saphenous vein grafts. With the increasing popularity of radial artery utilization, the gastroepiploic artery remains a faded option. So more studies should be conducted for evaluation of the benefits from the gastroepiploic artery in the setting of multi-arterial revascularization.&#x0D; Objective. Presentation of approaches and operative techniques for complete arterial revascularization in patients with multivessel coronary artery disease.&#x0D; Methods. Analytical review of literature on keywords in international scientometric databases Pub Med, Scopus, Web of Science. Search depth 12 years: from 2007 to 2018.&#x0D; Results. The current paper presents operative techniques and approaches to complete arterial revascularization in patients with multivessel coronary artery disease. The internal mammary artery remains the “gold standard” for the left anterior descending artery anastomosis site. Multiple arterial grafting is superior in terms of overall and cardiac survival. Emerging evidence of radial artery high term patency suggests the use of this arterial graft. Bilateral internal artery utilization provides long-term survival. Supplemental radial artery grafting to bilateral internal mammary provides complete arterial revascularization and can be safely used in routine cardiac surgery practice. Gastroepiploic artery proved superior patency rates, compared to saphenous vein grafts. Right coronary artery territory is an ideal anastomotic site for gastroepiploic artery grafting. The inferior epigastric artery may be used in addition to other arterial grafts as free graft or as y- or t-graft in the setting of multivessel coronary atherosclerotic lesions.&#x0D; Conclusion. Complete arterial revascularization provides symptomatic relief from coronary artery disease provides superior patency rates and lowers the incidence of major adverse cardiac events.

Contemporary Treatment of Popliteal Artery Aneurysms in 14 Countries: A Vascunet Report

Popliteal artery aneurysm (PAA) is the second most common arterial aneurysm. Vascunet is an international collaboration of vascular registries. The aim was to study treatment and outcomes. This was a retrospective analysis of prospectively registered population based data. Fourteen countries contributed data (Australia, Denmark, Finland, France, Hungary, Iceland, Italy, Malta, New Zealand, Norway, Portugal, Serbia, Sweden, and Switzerland). During 2012-2018, data from 10764 PAA repairs were included. Mean values with between countries ranges in parenthesis are given. The incidence was 10.4 cases/million inhabitants/year (2.4-19.3). The mean age was 71.3 years (66.8-75.3). Most patients, 93.3%, were men and 40.0% were active smokers. The operations were elective in 73.2% (60.0%-85.7%). The mean pre-operative PAA diameter was 32.1 mm (27.3-38.3 mm). Open surgery dominated in both elective (79.5%) and acute (83.2%) cases. A medial surgical approach was used in 77.7%, and posterior in 22.3%. Vein grafts were used in 63.8%. Of the emergency procedures, 91% (n = 2 169, 20.2% of all) were for acute thrombosis and 9% for rupture (n = 236, 2.2% of all). Thrombosis patients had larger aneurysms, mean diameter 35.5 mm, and 46.3% were active smokers. Early amputation and death were higher after acute presentation than after elective surgery (5.0% vs. 0.7%; 1.9% vs. 0.5%). This pattern remained one year after surgery (8.5% vs. 1.0%; 6.1% vs. 1.4%). Elective open compared with endovascular surgery had similar one year amputation rates (1.2% vs. 0.2%; p = .095) but superior patency (84.0% vs. 78.4%; p = .005). Veins had higher patency and lower amputation rates, at one year compared with synthetic grafts (86.8% vs. 72.3%; 1.8% vs. 5.2%; both p < .001). The posterior open approach had a lower amputation rate (0.0% vs. 1.6%, p = .009) than the medial approach. Patients presenting with acute ischaemia had high risk of amputation. The frequent use of endovascular repair and prosthetic grafts should be reconsidered based on these results.

Comparison of Outcomes of Percutaneous Arteriovenous Fistulae Creation by Ellipsys and WavelinQ Devices

PurposeThe purpose of this study was to compare the clinical outcomes of Ellipsys with those of WavelinQ-4F percutaneous arteriovenous fistulae (pAVF) devices in a single center by a single operator. Materials and MethodsA retrospective review was conducted in 100 patients who underwent pAVFs procedures (65 Ellipsys and 35 WavelinQ patients) and created between December 2017 and December 2019. A total of 69% were male and 37% were diabetic. Median age was 64.1 years (range: 28–86), and median body mass index was 27.2 (range: 15–45.1) kg/m2. A procedure sequence algorithm was followed for selecting all vascular accesses created. ResultsEllipsys outcomes were compared to WavelinQ outcomes. Technical success was 100% versus 97%, respectively, and median procedure times were 14 versus 63 minutes, respectively (P < .001), with 183 (1–487) versus 185 (0–760) days follow-up, respectively. Maturation at 4 weeks was 68.3% versus 54.3%, respectively, and median times to cannulation were 60 (1–164) versus 90 (1–180) days, respectively. Successful pAVF dialysis was established in 31 of 39 patients (79.5%) versus 14 of 24 patients (58%), respectively (P = .071), dialysis patients with access-related adverse events observed in 4 individuals (1 Ellipsys versus 3 WavelinQ). Six patients (5 versus 1) with matured outflow from previous AVFs underwent first-day cannulations. Interventions were performed in 27.7% (33 Ellipsys) and 26.5% (15 WavelinQ) patients, and the number of interventions per patient-years was 0.96 versus 0.46, respectively. pAVF failure was seen in 15.4% versus 37.1% patients, respectively (P = .0137). Secondary patency at 12 months was significantly higher among patients who had an Ellipsys procedure (82%) than among those who underwent the WavelinQ procedure (60%). ConclusionspAVFs were created with high technical success and low complications with both devices. Ellipsys pAVFs demonstrated significantly shorter procedure times without a need for radiation exposure and with superior secondary patency.

A Novel Technique to Increase the Maturation Rate of Arteriovenous Fistulae

Given the superior patency of arteriovenous (AV) fistulae and the decreased risk of infection compared with AV grafts, the Kidney Disease Outcomes Quality Initiative guidelines recommend the Fistula First approach. Unfortunately, approximately 18% to 53% of all AV fistulae fail to mature. Our objective is to describe a single-center experience with a novel technique using bovine pericardial patch angioplasty to increase the rate of AV fistula maturation.

Randomised clinical study of the impact of routine preoperative Doppler ultrasound for the outcome of autologous arteriovenous fistulas for haemodialysis.

Background:Arteriovenous fistulas are the gold standard of vascular accesses in haemodialysis; however, they have a considerable primary failure rate. This study evaluated the comparative reliability of routine preoperative Doppler ultrasound with an isolated physical examination of autologous arteriovenous fistulas within the Single Health System of Brazil and analysed the potential clinical benefit, improvement in primary failure rates and its economic impact.Methods:A non-blind randomised clinical study group of patients undergoing a vessel mapping with preoperative Doppler ultrasound (ultrasound group) and a control group who had undergone only a physical examination (clinical group) before the vascular procedures was performed. The role of the arteriovenous fistula in dialysis and possible alterations was evaluated in both the groups and followed up for 6 months.Results:Of the initial 248 eligible patients, there was a randomisation of 230 patients, 228 of whom were submitted for surgery, 114 in each group. In the clinical group, a significantly higher rate of primary failure was recorded, with 13.6% versus 4.4% in the ultrasound group (p = 0.002). The Kaplan–Meier curve with log-rank analysis showed a significantly higher primary patency in the ultrasound group (p = 0.042). Regarding the cost-effectiveness of the use of Doppler ultrasound, there was no increase in the final cost compared to the physical examination (US$1.28/fistula day × US$1.29/fistula day).Conclusion:It was concluded that Doppler ultrasound contributed to the reduction of primary failure, leading to a significantly superior primary patency of arteriovenous fistulas, and no increase in the final cost. This justifies its routine preoperative use in the Single Health System. Registration number RBR-474xhn (http://www.ensaiosclinicos.gov.br).

MP19-04 MANAGEMENT OF INTRACTABLE BLADDER NECK STRICTURES FOLLOWING RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I (MP19)1 Apr 2020MP19-04 MANAGEMENT OF INTRACTABLE BLADDER NECK STRICTURES FOLLOWING RADICAL PROSTATECTOMY Arjun Nathan*, Giorgio Mazzon, Nicola Pavan, Ruben De Groote, Ashwin Sridhar, and Senthil Nathan Arjun Nathan*Arjun Nathan* More articles by this author , Giorgio MazzonGiorgio Mazzon More articles by this author , Nicola PavanNicola Pavan More articles by this author , Ruben De GrooteRuben De Groote More articles by this author , Ashwin SridharAshwin Sridhar More articles by this author , and Senthil NathanSenthil Nathan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000852.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The incidence of Vesicourethral Anastomotic Stenosis (VUAS) post radical prostatectomy varies from 1% to 26%. Current treatment can be challenging and include a variety of different procedures. These range from endoscopic dilations to bladder neck reconstruction to urinary diversion. We investigated a 2-stage endoscopic treatment, using the thermo-expandable Memokath®045 bladder neck stent to manage patients with VUAS post radical prostatectomy. To retrospectively review 30 patients who underwent a Memokath®045 stent insertion for VUAS with a minimum of 12 months follow-up. METHODS: All patients had two previous attempts at endoscopic dilatation with or without incision and a trial of clean intermittent catheterisation. During the stage 1, the bladder neck stricture is dilated to diameter of 30Fr, the stricture length is measured, and a catheter is left in-situ. One to two weeks later, post haemostasis and healing, an appropriately sized Memokath®045 stent is inserted. The stent is then removed 1-year post-op. RESULTS: Our series of patients had a median age of 62 (54-72). Most patients (26) had a robot assisted radical prostatectomy (RARP) or salvage procedure. The mean interval time between prostatectomy and Memokath®045 stent insertion was 13 months. The mean follow-up time was 3.6 years with all patients having a minimum of 12 months follow-up. Results showed improvement in IPSS scores, IPSS quality of life scores, Qmax and PVR after the Memokath®045 stent was removed compared to pre-operation. With a minimum 12 months post stent removal, 93% of patients were fully continent, whilst 7% of patients were socially continent. 2 (7%) patients had their stents removed and not replaced due to re-stricturing and stone formation. However, no urinary tract infections, stricture recurrence or urinary retention was observed in the rest of the cohort (93%). CONCLUSIONS: Overall, the Memokath®045 stent was successful in treating 93% of our patients with VUAS. Our series had minimal complications that were managed with conservative measures and in 3 patients’ re-operation was needed. In conclusion, the Memokath®045 stent is less invasive than other techniques such as bladder neck reconstruction and urinary diversion and provides superior patency results. Therefore, this management option should be considered in the management of VUAS. Source of Funding: N/A © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e299-e299 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arjun Nathan* More articles by this author Giorgio Mazzon More articles by this author Nicola Pavan More articles by this author Ruben De Groote More articles by this author Ashwin Sridhar More articles by this author Senthil Nathan More articles by this author Expand All Advertisement PDF downloadLoading ...

Patency of conduits in patients who received internal mammary artery, radial artery and saphenous vein grafts

BackgroundWhere each patient has all three conduits of internal mammary artery (IMA), saphenous vein graft (SVG) and radial artery (RA), most confounders affecting comparison between conduits can be mitigated. Additionally, since SVG progressively fails over time, restricting patient angiography to the late period only can mitigate against early SVG patency that may have occluded in the late period.MethodsResearch protocol driven conventional angiography was performed for patients with at least one of each conduit of IMA, RA and SVG and a minimum of 7 years postoperative. The primary analysis was perfect patency and secondary analysis was overall patency including angiographic evidence of conduit lumen irregularity from conduit atheroma. Multivariable generalized linear mixed model (GLMM) was used. Patency excluded occluded or “string sign” conduits. Perfect patency was present in patent grafts if there was no lumen irregularity.ResultsFifty patients underwent coronary angiography at overall duration postoperative 13.1 ± 2.9, and age 74.3 ± 7.0 years. Of 196 anastomoses, IMA 62, RA 77 and SVG 57. Most IMA were to the left anterior descending territory and most RA and SVG were to the circumflex and right coronary territories. Perfect patency RA 92.2% was not different to IMA 96.8%, P = 0.309; and both were significantly better than SVG 17.5%, P < 0.001. Patency RA 93.5% was also not different to IMA 96.8%, P = 0.169, and both arterial conduits were significantly higher than SVG 82.5%, P = 0.029. Grafting according to coronary territory was not significant for perfect patency, P = 0.997 and patency P = 0.289. Coronary stenosis predicted perfect patency for RA only, P = 0.030 and for patency, RA, P = 0.007, and SVG, P = 0.032.When both arterial conduits were combined, perfect patency, P < 0.001, and patency, P = 0.017, were superior to SVG.ConclusionsAll but one patent internal mammary artery or radial artery grafts had perfect patency and had superior perfect patency and overall patency compared to saphenous vein grafts.

Split-bolus CTA for mesenteric ischemia with a single scan opacifying arterial and mesenteric venous systems.

To evaluate the diagnostic accuracy of split-bolus single-scan computed tomography angiography (CTA) protocol for evaluation of acute mesenteric ischemia and alternate diagnoses. In this IRB-approved, HIPAA-compliant retrospective study, consecutive patients from 21 October 2016 to 6 May 2018 evaluated for mesenteric ischemia with split-bolus CTA (a single scan in concurrent arterial and portal venous phase) in a single tertiary academic institution were included. Intravenous contrast was administered on weight-based basis. Quantitative and qualitative assessments of superior mesenteric artery (SMA) and superior mesenteric vein (SMV) attenuation and patency were performed by two independent reviewers. CT imaging findings were correlated with clinical reference outcomes. One hundred fifty-four patients (age 66.3 ± 14.1years, BMI 27.3 ± 6, 86 (56%) female) were included. CTA studies were performed with a volumetric CT dose index of 15.9 ± 5.5mSv and dose length product of 1042.9 ± 389.4mGycm. Average intravenous contrast volume administered was 164.3 ± 12.1cc. SMA attenuation was 263.6 ± 92.4HU, SMV was 190 ± 50.2HU. Qualitative assessment of SMA and SMV showed good opacification in all patients. 17/154 (11%) patients were diagnosed on CT with mesenteric ischemia; in 6/154 (4%), CTA studies were indeterminate; in 131/154 (85%), CTA confidently ruled out mesenteric ischemia. Alternate diagnoses were made in 38/154 (25%) patients. Using composite clinical outcomes as a reference standard, sensitivity of split-bolus CTA protocol for diagnosis of mesenteric ischemia is 100% (95% CI 79-100%), and specificity is 99% (95% CI 96-100%). Split-bolus CTA has high sensitivity and specificity for diagnosis of acute mesenteric ischemia. • Split-bolus CTA protocol for mesenteric ischemia has great diagnostic accuracy with lower radiation exposure and fewer images to interpret compared with standard multiphasic CTA.

Differential efficacy between stenting and plain balloon angioplasty for femoropopliteal disease with or without total occlusion.

Background/AimsWhether the presence of chronic total occlusion (CTO) affects patency after stenting in femoropopliteal lesions is unknown. We determined the effects of plain balloon angioplasty (POBA) in comparison with those of stenting on patency for femoropopliteal CTO and stenosis (non-CTO).MethodsWe analyzed data from the Korean Vascular Intervention Society Endovascular Therapy in Lower-Limb Artery Diseases Registry, a multicenter cohort of patients with lower extremity peripheral arterial disease. Data from 1,329 patients and 1558 limbs treated with endovascular intervention for at least one femoropopliteal lesion were evaluated.ResultsAmong the 1,558 limbs, 345, 432, 275, and 506 were in the non-CTO-POBA, non-CTO-stent, CTO-POBA, and CTO-stent groups, respectively. During follow-up, loss of clinical primary patency, a composite of freedom from restenosis or clinically driven target lesion revascularization, occurred in 65 (18.8%), 68 (15.7%), 62 (22.5%), and 113 limbs (22.3%) in the non-CTO-POBA, non-CTO-stent, CTO-POBA, and CTO-stent groups, respectively. The patients in the non-CTO-stent group showed a significantly better clinical primary patency than those in the no-CTO-POBA group, whereas those in the CTO-stent and CTO-POBA groups showed no significant differences. After inverse probability of treatment weighting to balance the differences among covariates between the non-CTO-stent and non-CTO-POBA groups, the non-CTO-stent group still showed superior clinical primary patency as compared with the non-CTO-POBA group.ConclusionsIn the patients with femoropopliteal stenosis without CTO, stenting resulted in better clinical outcomes than balloon angioplasty. The presence of CTO in the femoropopliteal lesion should be considered when selecting a suitable device for performing endovascular procedures.

Bioresorbable silk grafts for small diameter vascular tissue engineering applications: In vitro and in vivo functional analysis

The success of tissue-engineered vascular graft (TEVG) predominantly relies on the selection of a suitable biomaterial and graft design. Natural biopolymer silk has shown great promise for various tissue-engineering applications. This study is the first to investigate Indian endemic non-mulberry silk (Antheraea assama-AA) – which inherits naturally superior mechanical and biological traits (e.g., RGD motifs) compared to Bombyx mori-BM silk, for TEVG applications. We designed bi-layered biomimetic small diameter AA-BM silk TEVGs adopting a new fabrication methodology. The inner layer showed ideally sized (~40 µm) pores with interconnectivity to allow cellular infiltration, and an outer dense electrospun layer that confers mechanical resilience. Biodegradation of silk TEVGs into amino acids as resorbable byproducts corroborates their in vivo remodeling ability. Following our previous reports, we surgically implanted human adipose tissue-derived stromal vascular fraction (SVF) seeded silk TEVGs in Lewis rats as abdominal aortic interposition grafts for 8 weeks. Adequate suture retention strength (0.45 ± 0.1 N) without any blood seepage post-implantation substantiate the grafts’ viability. AA silk-based TEVGs showed superior animal survival and graft patency compared to BM silk TEVGs. Histological analysis revealed neo-tissue formation, host cell infiltration and graft remodeling in terms of extracellular matrix turnover. Altogether, this study demonstrates promising aspects of AA silk TEVGs for vascular tissue engineering applications. Statement of significanceClinical ‘off the shelf’ implementation of tissue-engineered vascular grafts (TEVGs) remains a challenge. Achieving optimal blood vessel regeneration requires the use of bioresorbable materials having suitable degradation rates while producing minimal or no toxic byproducts. Host cell recruitment and preventing acute thrombosis are other pre-requisites for successful graft remodeling. In this study, for the first time we explored the use of naturally derived Indian endemic non-mulberry Antheraea assama silk in combination with Bombyx mori silk for TEVG applications by adopting a new biomimetic approach. Our bi-layered silk TEVGs were optimally porous, mechanically resilient and biodegradable. In vivo implantation in rat aorta showed long-term patency and graft remodeling by host cell infiltration and extracellular matrix deposition corroborating their clinical feasibility.

Total arterial myocardial revascularization in octogenarians.

According to the current ESC/EACTS Myocardial Revascularization Guidelines, the left internal mammary artery (LIMA) should always be implanted to graft the left anterior descending (LAD) artery, but an additional arterial graft should be considered in appropriate patients undergoing coronary artery bypass grafting (CABG) [1]. In spite of inconclusive 10-year results from the Arterial Revascularization Trial (ART) [2], observational studies underline the superior patency of arterial grafts [3]. Nevertheless, based on the data published by the Society of Thoracic Surgeons (STS), bilateral internal mammary grafts are implanted in as few as 5% of CABG cases, and the use of the radial artery (RA) has declined by approximately 33% within the last decade [4]. Grafting the LIMA to the LAD is considered a gold standard in surgical revascularization. With the use of LIMA, both short and long term survival are improved in all age groups, including octogenarians [5, 6]. However, comorbidities and limited life expectancy may potentially abolish the survival benefit from arterial revascularization in older patients. Data on arterial revascularization in octogenarians are sparse, and arterial revascularization trials omitted this age group, as the mean age of patients enrolled in the two most prominent trials (ART and RADIAL) was below 70 years old [2, 7].

Game changers in vascular and endovascular surgery

Game changers in vascular and endovascular surgery

In the Current Era of Endovascular Surgery, What is the Role of Axillofemoral Bypass?

Introduction - Nowadays, axillofemoral bypass (AxFB) is viewed as an end-of-line solution for lower limb revascularization, owing to its classically described poor long-term patency and recent advances in endovascular surgery. There is a marked difference in patient profiles in published series of AxFB, reflecting changing procedures indications. The objective of this study is to determine the contemporary profile of patients treated with AxFB and their outcome. Methods - Patients who underwent AxFB surgery in a tertiary hospital from April 2011 to December 2017 were identified. Surgical indication, primary patency, major amputation and death rates were recorded. Patients were grouped in:-Bypass configuration: axillouni vs axillobifemoral;-Previous vascular surgery status: first revascularization procedure vs reintervention;-Primary vascular disease: aortoiliac occlusive disease vs aneurysmal disease,-Emergency character of procedure: urgent (initiated less than 24hours from patient presentation) vs planned (more than 24hours from patient presentation). Groups were compared using Kaplan-Meier survival analysis. Results - 56 patients were included. 44 (78,6%) underwent axillobifemoral bypass; remaining patients underwent axillounifemoral bypass. Median age was 68,18±9,59 years; 94,6% were male. The most prevalent cardiovascular risk factors were HTA (77%) and history of smoking (76%). Primary vascular disease was aneurysmal in 14 patients (25%). The remaining group had aortoiliac occlusive disease. AxFB was an urgent procedure in 11 patients (19,6%). In 30 patients (53,6%), AxFB was the first revascularization performed. Indications for procedure on this group were aorto-iliac occlusive disease (25; 83,3%) and AA thrombosis (5; 16,7%). In patients previously submitted to revascularization (26; 46,4%), the most common previous procedures were aortobifemoral bypass (12; 46,2%), femoro-femoral bypass (12; 46,2%) and EVAR (9; 34,6%). Indications for AxFB on this group were: prosthesis thrombosis (17; 65,4%), secondary aorto-enteric fistulae (7; 26,9%) and prosthesis infection (2; 7,7%). Global primary patency of AxFB was 91,5±4,1% at 1 month, 74,8±7,6% at 1 year, and 56,1±12,8% at 5 years (Fig.1). Group survival analysis showed superior primary patency in aneurysmal disease group (p=0,063), and after urgent procedures (p=0,113). Previous vascular surgery and bypass configuration did not affect long-term primary patency. No patient with aneurysmal disease required major amputation during follow-up. In primary occlusive disease group, 83,4±5,7% patients were free-of-amputation at 1 month, 77,2±6,8% at 1 year and 5 years. Amputation rates were similar regardless previous vascular surgery status, bypass configuration and urgency character of procedure. Median time of survival was 5,1±1,1years. Patients who underwent AxFB had a survival rate of 76,8±5,6% at 1 month, 64,7±6,6% at 1 year, and 50,0±7,8% at 5 years. Survival rates were similar regardless bypass configuration and primary vascular disease. However, patients whose AxFB was a vascular reintervention or an urgent procedure had significant worse long-term survival (p=0,042 and p=0,017, respectively). Conclusion - Axillofemoral bypass, although being an increasingly uncommon procedure, still allows acceptable rates of patency and limb salvage. As patients with aortoiliac disease usually have multiple comorbidities and a short life-expectancy, axillofemoral bypass is attractive owing to its less invasive character.

Effects of patient age on patency of chronic hemodialysis vascular access

BackgroundIn this single-center, retrospective observational study, we assessed the long-term patency of vascular access (VA) after first VA placement to uncover independent risk factors associated with VA patency in Asian hemodialysis (HD) patients stratified by age. We also investigated factors associated with VA patency among older HD patients according to the type of VA in the overall study population.MethodsThe study period was from January 2011 to December 2013. A total of 651 chronic HD patients with confirmed first upper-extremity VA placement were enrolled, and their records were analyzed retrospectively. A total of 445 patients (68.4%) made up the nonelderly group (< 65 years), and 206 patients (31.6%) were in the elderly group (≥ 65 years). Study outcomes were defined as primary or secondary VA patency.ResultsAutologous arteriovenous fistula (AVF) was more common in the nonelderly group (P < 0.01). Kaplan–Meier curve survival analysis indicated that primary patency was longer in the nonelderly group (P < 0.01); secondary patency, however, was similar between groups (P = 0.37). The multivariate analysis of factors associated with primary VA patency revealed that increased age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01–1.03; P < 0.01) was associated with shorter primary patency, and AVF (HR, 0.38; 95% CI, 0.28–0.51; P < 0.01) was associated with longer primary patency. AVF (HR, 0.57; 95% CI, 0.37–0.87; P = 0.010) and diabetes mellitus (HR, 1.56; 95% CI, 1.07–2.29; P = 0.02) were independently associated with longer and shorter secondary patency periods, respectively; however, increased age was not a risk factor for decreased secondary patency.ConclusionsIncreased age was associated with shorter primary patency but not secondary patency, whereas AVF placement was associated with longer primary and secondary patency. Considering the similar rates of secondary patency between groups and the superior patency of AVF compared to arteriovenous graft, a fistula-first strategy should be applied to appropriate older patients.

LEA 19. Venous Allograft Transplantation From Living Donor as a Last Resort for Limb Salvage

The rate of endovascular procedures for limb salvage in peripheral vascular disease is increasing. Long and below-knee endovascular repairs have low patency rates. In these cases of endovascular failure, distal bypasses are performed for limb salvage. Venous bypass is preferred because of superior long-term patency. Synthetic grafts for distal bypasses have a very low patency rate and are not recommended. We present two cases in which endovascular and bypass repairs occluded and the limbs were at risk of amputation. On angiography, a distal tibial artery was demonstrated without any available autologous veins. To save the limb with long-term patency, a venous graft was required. In these cases, we performed allogeneic vein transplantation from living donor (family related or genetic matched) from femoral artery to distal tibial artery. Both the donors and recipients were screened for infectious diseases and compatibility. Patients with known malignant disease, infection, or contraindication to immunosuppression were excluded. The saphenous vein was dissected at the donor and transplanted to the recipient leg, and femorotibial bypass was performed. In both cases, an arteriovenous fistula was created between the tibial artery and the vein proximal to the bypass anastomosis. Technical success was achieved in both cases. No major complications occurred during the procedures, and at 6-month follow-up, both bypasses remained patent. The patients returned to normal daily activity after the procedure, and ischemic wounds healed. Allogeneic vein bypasses have been previously reported; however, their use is scarce. We suggest venous allograft transplantation from living donor to patients with no endovascular solutions or autologous vein for revascularization for limb salvage. It has been shown that chemical vein preparation or cryogenic vein preservation has deleterious effects and decreases graft patency rates. Immunosuppressive therapy should be administered to avoid graft rejection. We recommend complementary arteriovenous fistula to the allogeneic vein bypass for outflow augmentation. Multiorgan harvest may provide a viable opportunity for vein harvest. Allograft vein transplantation should be considered for limb salvage in such cases.

Management of intractable bladder neck strictures following radical prostatectomy using the Memokath\xae045 stent

The incidence of vesicourethral anastomotic stenosis (VUAS) post radical prostatectomy varies from 1 to 26%. Current treatment can be challenging and includes a variety of different procedures. These range from endoscopic dilations to bladder neck reconstruction to urinary diversion. We investigated a 2-stage endoscopic treatment, using the thermo-expandable Memokath®045 bladder neck stent to manage patients with VUAS post radical prostatectomy. We retrospectively reviewed 30 patients, between 2013 and 2017, who underwent a Memokath®045 stent insertion following failed primary treatment (dilation and clean intermittent catheterisation) for VUAS. The mean interval time between prostatectomy and Memokath®045 stent insertion was 13 months. The mean follow-up time was 3.6 years with all patients having a minimum of 12-month follow-up. All patients had two previous attempts at endoscopic dilatation with or without incision and a trial of clean intermittent catheterisation. During stage 1, the anastomotic stricture is dilated/incised to diameter of 30 Fr, the stricture length is measured, and a catheter is left in situ. One to 2 weeks later, post haemostasis and healing, an appropriately sized Memokath®045 stent is inserted. The stent is then removed 1-year post-op. Our series of patients had a median age of 62 (54–72). Most patients (26) had a robot-assisted radical prostatectomy (RARP) or salvage procedure. Results showed improvement in IPSS scores, IPSS quality of life scores, Qmax and PVR after the Memokath®045 stent was removed compared to pre-operation. With a minimum of 12 months post stent removal, 93% of patients were fully continent, whilst 7% of patients were socially continent. 2 (7%) patients had their stents removed and not replaced due to re-stricturing and stone formation. However, no urinary tract infections, stricture recurrence or urinary retention was observed in the rest of the cohort (93%). Overall, the Memokath®045 stent was successful in treating 93% of our patients with VUAS. Our series had minimal complications that were managed with conservative measures and in three patients’ re-operation was needed. In conclusion, the Memokath®045 stent is a minimally invasive technique with faster recovery time compared to other techniques such as bladder neck reconstruction or urinary diversion. Additionally, it provides superior patency results compared to other techniques such as bladder neck incision and injection of Mitomycin C. Therefore, this management option should be considered in the management of VUAS.

THE SKELETON IN THE CLOSET: HIGHER RATES OF GRAFT FAILURE AT 1 YEAR IN THE SKELETONIZED VERSUS PEDICLED INTERNAL MAMMARY ARTERY

Internal mammary arteries (IMA) are routinely used as conduits in CABG surgery given their superior long-term patency rates and high resistance to atherosclerosis. These conduits can be harvested pedicled, whereby the IMA is dissected along with its surrounding fascia including blood and nerve supplies (i.e. preserving the milieu of the conduit) or skeletonized, whereby the IMA is dissected from its surrounding blood supply, innervation, lymphatics, muscle and fascia (i.e. preserving the milieu of the sternum). Despite the positive effects of skeletonization on graft length and sternal wound infections, few prospective studies have examined the effect of that harvesting technique on angiographic endpoints and therefore it remains unclear whether skeletonization adversely affects the risk of graft failure. We conducted a substudy of 1,448 COMPASS trail patients randomized 4 to 14 days after CABG surgery to receive rivaroxaban, aspirin, or both and underwent a follow-up CT angiogram after 1 year. Graft failure was diagnosed by CT angiogram and included grafts with string signs in addition to complete occlusion. We present an analysis of 1,066 IMA grafts grafts examining the impact of graft harvesting technique (pedicled vs. skeletonized) on graft failure 1 year after CABG surgery. Baseline characteristics of the 3 treatment groups were similar and no differences in graft failure rates were observed between drug treatments. The rate of graft failure was 6.1% (46/752) in the pedicled IMA group versus 12.4% (39/314) in the skeletonized IMA group (odds ratio 2.18; 95% CI 1.39 to 3.41; P < 0.001). Similarly, in pedicled left-IMA (LIMA) the rate of graft failure was 5.4% compared to 9.6% in skeletonized LIMA grafts (odds ratio 1.87; 95% CI 1.11 to 3.13; P=0.02). A trend of graft failure was observed as well between pedicled (23.3%; 7/30) and skeletonized (29.5%; 13/44) in right-IMA (RIMA) grafts (odds ratio 1.38; 95% CI 0.48 to 4.00; P=0.55). The skeletonized harvesting technique is associated with a significant increase in IMA graft failure 1 year after CABG surgery compared to the pedicled technique. Further investigation of the impact of the skeletonized technique on the risk of graft failure is warranted before advocating for its widespread use.