Terms Of Patency Research Articles

Comparative study between brachiocephalic fistula and proximal radiocephalic fistula for hemodialysis in patients with end-stage renal disease

Objectives To evaluate the proximal radiocephalic arteriovenous fistula (AVF) versus brachiocephalic fistula for hemodialysis in terms of patency and complications. Background The distal radiocephalic fistula at wrist is the gold standard AVF for hemodialysis as it reduces the incidence of steal syndrome but with high failure rate. If distal vessels are not suitable or exhausted, elbow fistula is a good vascular access but with increased incidence of steal syndrome, so doing proximal radiocephalic AVF is a good alternative option. Patients and methods A prospective randomized study including 60 patients in need for hemodialysis access was done between January 2016 and January 2017 and was followed up to July 2017 at Menoufia University Hospital. The patients were randomly categorized into two groups including 30 patients in each group. Primary success rate, primary patency, secondary patency rates, and complications of each group were collected and analyzed. Results In the proximal radiocephalic group, primary fistula failure was 0%, while six (20%) fistulas failed later, four of them due to thrombosis, one due to anastomotic aneurysm and the other due to severe venous hypertension. No patients developed steal syndrome, whereas in the brachiocephalic group, primary fistula failure was also 0% and six (20%) fistulas failed later on, three of them due to thrombosis, one due to anastomotic aneurysm, one due to venous hypertension, and the last one due to steal syndrome. Primary patency rates for both proximal radiocephalic and brachiocephalic groups at 6 months were 63.3 and 65.1%, respectively, whereas the secondary patency rates at 6 months were 73.3 and 75.4%, respectively. Conclusion For patients with exhausted or unsuitable wrist vessels, we believe that a proximal radiocephalic, should precede creation of brachiocephalic fistula as it had nearly the same patency and complications rates but it avoided the risk of dialysis associated steal syndrome.

Various surgical techniques for the repair of injured vas deferens in rat experiments

The aim of this study was to evaluate whether the different vasovasostomy techniques can be performed using only the operating loupe in a rat model. The secondary aims were to evaluate the patency rate and inflammation of the vas deferens (VD) after contusion and the different vasovasostomy repair techniques. A total of 40 male rats were divided into 4 groups based on the type of surgery: 1. contusion of the VD; 2. cutting of the VD and vasovasostomy with absorbable sutures; 3. cutting and joining of the VD using absorbable sutures with an intraluminally situated lead fibre; and 4. cutting and joining of the VD using non-absorbable sutures with an intraluminally situated lead fibre. Ninety days after the surgery the VD was resected, patency and histopathological signs of inflammation in the VD were evaluated. All vasovasostomy techniques were successfully performed in all animals using only the operating loupe. The patency rate was 100% in the subgroup with contusion. Differences in the patency rates were found among the subgroups with vasovasostomy (P=0.007). The patency rate was higher in the subgroup that underwent group 3. Compared with vasovasostomies, contusion was associated with lower rates of inflammation (P=0.02) and severe inflammation (P=0.003). No differences were found among the subgroups of vasovasostomy techniques. Contusion of the VD was not related to impairment in terms of patency. Vasovasostomy with an intraluminally situated lead fibre resulted in the highest patency rate among the standard vasovasostomy techniques.

Assessing changes in tissue oxygenation by near-infrared spectroscopy following brachial plexus block for arteriovenous fistula surgery: A prospective observational pilot study.

Near-infrared spectroscopy (NIRS) can be used to measure tissue oxygen saturation (StO2) in different sites and in a wide range of clinical scenarios. Peripheral regional anaesthesia induces vascular changes causing increased arterial blood flow and venodilatation, but its effect on StO2 is still under debate. This is especially so for patients undergoing arteriovenous fistula surgery, wherein latest data suggest an improved outcome under brachial plexus block (BPB) compared with local anaesthesia, but no data are available. The aim of this study was to investigate changes in StO2 following BPB prior to arteriovenous fistula surgery using NIRS. A prospective observational study. A secondary teaching hospital from August 2016 to March 2017. Fifteen patients undergoing arteriovenous fistula surgery. Ultrasound-guided BPB in 15 patients undergoing arteriovenous fistula surgery. StO2 at baseline and compared with baseline and the contralateral arm following BPB measured using NIRS of the thenar eminence (NIRSth). Baseline values of StO2 assessed by NIRSth were 42.6 ± 7.7% in the arteriovenous fistula arm and 42.7 ± 9.7% in the contralateral arm. There was no significant difference between the two. Five minutes after BPB, there was a significant increase in StO2 of the blocked arm, compared with the control arm expressed as difference of absolute values (7.1 ± 9.7%). At 60 min, an absolute difference of 21.0 ± 13.5% was reached. The absolute increase in StO2 of the blocked arm compared with baseline reached significance after 5 min (8.8 ± 4.6%) and increased up to 23.2 ± 8.2% after 60 min. NIRSth indicates that BPB significantly increases StO2 of the arteriovenous fistula arm in patients undergoing haemodialysis. Clinicaltrials.gov: NCT03044496.

Treating benign ureteroenteric strictures: 27-year experience comparing endourological techniques with open surgical approach

PurposeTo compare open surgical anastomotic revision with endourological techniques for the treatment of ureteroenteric strictures in patients with urinary diversions.MethodsAll records of patients treated for ureteroenteric strictures in our clinic between 1989 and 2016 were retrospectively reviewed. In 76 patients, 161 completed procedures were analyzed: 26 open revisions vs. 135 endourological treatments, including balloon dilation, Wallstent and/or laser vaporization.ResultsMedian follow-up was 34 months. At 60 months, patency rates were 69% (95% CI 52–92%) after open vs. 27% (95% CI 19–39%) after endo-treatment (p = 0.003); median patency duration was 15.5 vs. 5 months, respectively (p = 0.014). Eventually, 15% of patients required open surgery after primary endo-treatment and 21% received endoscopic re-treatment after primary open surgery. Cox regression analysis revealed no confounding factors among the risk factors added to the model. Complication rates were higher after open surgery (27% Clavien 2, 12% Clavien 3–4 vs. 5% Clavien 1–2, 3% Clavien 3, p = 0.528). Median postoperative hospital stay was 14 days (open) vs. 2 days (endo), p < 0.001. Mean estimated glomerular filtration rate improved with + 17 (open) vs. + 8.1 (endo), p = 0.024. Renal function was compromised in 8% of patients in the open surgery group vs. 6% in the endo-treatment group.ConclusionsIn these patients, in terms of patency and patency duration, open surgery was superior to endourology. Nevertheless, endourological treatments offer a safe and less-invasive alternative to delay or avoid open surgery, especially in patients who are unfit for open surgery.

Manejo de 3 endoprótesis aórticas infectadas y revisión de la literatura

The endograft infection is a rare clinical entity that usually has insidious symptoms. However, its clinical consequences are devastating for the patient, with high morbidity and mortality in the published literature. Therefore, early diagnosis and establishment of antibiotic treatment, as well as surgical management, are essential to improve the results. There are several therapeutic options, ranging from conservative management in patients with prohibitive surgical risk, to percutaneous drainage, in situ reconstruction using antibiotic or silver coated prosthetic grafts, or even uncoated prosthetic material and extra-anatomic reconstruction, leaving an aortic stump. However, in recent years, complete removal of the device and aortic in situ reconstruction has gained popularity due to its good results in terms of patency and resistance to infection. Based on our clinical experience, due to its durability and high resistance to reinfections, it is recommended to use superficial femoral veins as autologous material and the bovine pericardium patch as a xenograft, and even a combination of both materials, if a longer graft is needed.

Transposed Brachial-Basilic Arteriovenous Fistula for Vascular Access in Japan.

As more than 320,000 patients are currently receiving hemodialysis treatment in Japan, the creation and maintenance of hemodialysis access is a major concern. The national guidelines recommend autogenous arteriovenous hemodialysis, and the brachial–basilic arteriovenous fistula has been the focus of attention, because the need for secondary, tertiary, or even more vascular access is growing. Although favorable results have been reported in terms of patency and access-related complication, this fistula involves various unsolved or controversial issues, with limitations including complex procedures, which might contribute to the lower prevalence at this point in Japan. This review addresses those issues and discusses the role of fistula in Japan.

Abstract No. 597 Successful use of drug-eluting balloons for the management of a recalcitrant hepatic vein stenosis following extended right hepatectomy in a child with hepatoblastoma

Angioplasty with drug-eluting balloons is a treatment option in peripheral arterial occlusive disease and coronary artery stenosis. It has shown benefits in terms of patency, re-stenosis and distal flow of the treated vessel. It also shows promising results in the treatment of dysfunctional AV fistulas. Mechanical and biological response due to local injury during angioplasty leads to restenosis. The antineoplastic drug delivered in the vessel wall inhibits the cell proliferation improving the long-term results. We present a case in which drug-eluting balloons were used to treat a recalcitrant hepatic vein stenosis following venous surgical reconstruction after hepatoblastoma resection. 3-year, 6-month-old boy, history of hepatoblastoma at 15 months. Treated with chemotherapy + right hepatectomy + hepatic vein/inferior vena cava reconstruction. Presented with acute stenosis due to thrombosis. Treated 5 times with conventional angioplasty with recurrence of the stenosis. Stent appeared not an optimal option. It was decided to use a Paclitaxel coated balloon to alleviate symptoms and provide a long-term therapeutic alternative. Informed consent was obtained. A 6mm-4cm Paclitaxel drug coated balloon was utilized. Control venography was performed at 8 and 24 weeks after the initial intervention. Treatment was repeated at controls. Results were compared to standard angioplasty done before. The patient showed a significant clinical improvement, without any signs or symptoms of hepatic vein hypertension. The 8 and 24 weeks follow-up venography showed superior patency of the hepatic vein and post-surgical area in comparison with the previous standard angioplasty procedures. No complications were observed. 32 weeks clinical follow-up is satisfactory. No new interventions are planned. In the case presented, drug-eluting balloons showed superior 8 and 24 weeks patency and clinical outcome in a child with post-surgical hepatic vein stenosis in comparison to conventional balloons. Its use in similar cases of hepatic vein stenosis due to other etiologies may be considered in the future.

Which Offers the Best? Stent Graft or Bare Metal Stent for Endovascular Treatment of Aortoiliac Disease

Background: In the present study, it was aimed to compare the stent grafts and bare-metal stents in terms of post-procedural patency, clinical recovery and complications in the subjects with symptomatic aorto-iliac arterial disease. Methods: A total of 79 subjects with symptomatic aorto-iliac arterial disease treated with endovascular methods were included in the present study. Forty three subjects received self-expendable bare metal stent (ev3 Protege stent system, Endovascular Inc., Plymouth, Minnesota, USA) and 36 subjects received PTFE-covered stent graft (Fluency Plus Stent Graft, Bard Peripheral Vascular, Tempe, Arizona). The subjects were compared after and at Months 1, 6, and 12 following the procedure in terms of Rutherford’s classification, ankle-arm index (AAI), patency rates, and complications. Results: The subjects receiving bare metal stent and stent graft for aorto-iliac arterial disease were followed for averagely 15 months. For the subjects receiving bare metal stent, primary patency rates at months 1, 6, and 12 were 98%, 81%, and 70%, respectively, while secondary patency rate at month 12 was found to be 84%. For the group of stent graft, primary patency rates were found as 97%, 97%, and 92%, respectively and secondary patency rate at month 12 was found to be 94%. Stent grafts were applied at the same time in 2 patients who had metal bare metal because the rupture occurred during the procedure. In the comparison between two groups, the group of stent graft was found to be statistically superior to the other in terms of patency, clinical and post-procedural complications. Conclusion: In conclusion, it was found that the stent grafts were superior to the bare metal stents in terms of patency and complication rates in the subjects with symptomatic aortoiliac disease.

Forearm versus upper arm grafts for vascular access.

Forearm and upper arm arteriovenous grafts perform similarly in terms of patency and complications. Primary patency at 1 year for forearm arteriovenous grafts versus upper arm grafts ranges from 22%-50% versus 22%-42%, and secondary patency at 1 year ranges from 78%-89% versus 52%-67%), respectively. Secondary patency at 2 years, ranges from 30%-64% versus 35%-60% for forearm and upper arteriovenous graft, respectively. Ample pre-operative planning is essential to improved clinical success and the decision to place a graft at one location versus the other should be based solely on previous access history, physical exam, appropriate venous imaging, and other factors that make up the clinical picture. Operative implant strategies and risk of complications are very similar between the two configurations. Postoperative ischemia due to steal syndrome is a potential complication that requires immediate attention. Utilization of the proximal radial or ulnar artery for inflow for the graft can minimize risk of clinically relevant steal syndrome.

Bilateral internal thoracic artery graft configuration and coronary artery bypass grafting conduits.

Bilateral internal thoracic arteries (BITAs) have demonstrated their superiority over all other types of graft in terms of patency and survival benefit. BITA implementation requires the surgeon's evaluation of the patient's coronary anatomy and demographics. There is no single ideal approach to BITA utilization, but instead a variety of configurations that can be implemented based on the patient characteristics. This article details the advantages and disadvantages of several BITA configurations in the setting of left-sided myocardial revascularization and right-sided myocardial revascularization. Different BITA configurations will be described and will ultimately serve as a guide to avoiding technical difficulties and helping surgeons construct decision-making trees to direct the implementation of BITA grafts. BITA grafting provides long-term clinical benefit over conventional grafting. Efforts should be directed toward a more efficient use of internal thoracic arteries, reducing the need for a third complementary graft, and toward identification of the best alternative to the saphenous vein graft as the third graft material for complete revascularization. Surgeons should ask their cardiologists to be as accurate as possible regarding the severity of the coronary lesion. If the severity of the lesion is not obvious upon an informal qualitative assessment, a functional flow reserve of the lesion should be performed, in order to identify the optimal graft.

Outcomes of the Endovascular Treatment of Stenotic Lesions versus Chronic Total Occlusions in the Iliac Sector

This study compares outcomes of the endovascular treatment (EVT) of iliac artery occlusive disease according to whether the treated lesion is a stenosis or a chronic total occlusion (CTO). Patients undergoing EVT from 2003 to 2013 for iliac artery occlusive disease were identified and the lesions treated stratified into stenotic (Group 1, n=375) or CTO (Group 2, n=87). Patients were followed clinically and hemodynamically (thigh-brachial index, TBI). Comorbidities, procedural factors, and outcomes were compared between the 2 groups using Kaplan-Meier, Breslow, and Cox models. Four hundred sixty-two iliac endovascular procedures in 378 patients were included in a retrospective study. The 2 groups only differed in preprocedural TBI [0.77 (Group 1) vs. 0.67 (Group 2), P<0.001], lesion length [39.7 mm (Group 1) vs. 49.9mm (Group 2), P<0.001], and the use of a covered stent [11.6% (Group 1) vs. 46.2% (Group 2), P<0.001]. The technical success rate was higher in Group 1 (99.2% vs. 89.7%, P<0.001). Five early occlusions were recorded in Group 1 and 3 in Group 2 (1.3% vs. 3.8%, P = 0.146). Median follow-up was 34months (1-113). At 12 and 36months, stenotic lesions showed better primary (P1) and secondary (P2) patency rates [P1 93.0% and 85.8% vs. 83.1% and 74.7%, hazard ratio (HR) 1.90 (1.15-3.14), P = 0.018; P2 97.8% and 96.8% vs. 93.0% and 87.4%, HR 2.86 (1.39-5.90), P = 0.007] and freedom from reintervention (FFR) rates [91.6% and 83.5% vs. 84.1% and 78.9%, HR 1.51 (0.90-2.53), P = 0.132]. In a multivariate analysis, CTO showed a worse P2 than stenotic lesions [HR 2.81 (1.17-6.76), P = 0.021], yet no differences emerged in P1 [HR 1.41 (0.76-2.63), P = 0.277] or FFR [HR 1.43 (0.79-2.57), P = 0.237]. A lower preprocedural TBI was correlated with a greater risk of EVT failure in terms of patency and FFR (P<0.05). The use of a stent shorter than 40mm emerged as a protective factor with an HR for P1 of 3.68 (1.53-8.87) (P = 0.004). EVT for iliac artery disease offers good outcomes in terms of long-term patency, although improved results were observed here for the treatment of stenotic lesions over CTO. Procedures performed in patients with a lower TBI and the use of a stent >40mm were related to a worse stent patency.

A two-year experience with a rapid access, self-sealing, polycarbonate urethane nanofiber vascular access graft for hemodialysis.

Evaluating the safety and efficacy of the AVflo™ graft in terms of patency and complications (early and late) over 2 years. Twelve end-stage renal disease (ESRD) patients (age: mean 68.5 ± 10 years) were followed up for a mean period of 946 ± 570 days after receiving an implantation of the graft for HD. The grafts were implanted at the lower arm (loop configuration), upper arm (straight configuration) and the thigh (loop configuration). First dialysis was performed at day 7 (3-21) following implantation. After a mean follow up of 24 months, the primary patency was 56% and the secondary patency was 82%. In this group, AVflo™ shows similar if not superior efficacy and safety to that of available grafts in terms of safety, complications, and long-term patency.

Cirurgia aberta e endovascular no tratamento de aneurisma de artéria poplítea: experiência de cinco anos do HCRP-FMRP-USP

Resumo Contexto Aneurismas de artéria poplítea (AAPs) correspondem a 70,00% dos aneurismas periféricos. A indicação cirúrgica é para aneurismas com diâmetros maiores que 2,0 cm ou sintomáticos. O tratamento é feito por técnicas cirúrgicas convencionais ou endovasculares. Esta última tem ganho muitos adeptos, mas ainda não há consenso estabelecido sobre sua indicação. Objetivo Apresentar a experiência da Divisão de Cirurgia Vascular e Endovascular do Hospital das Clínicas de Ribeirão Preto da Universidade de São Paulo no tratamento dos AAPs. Método Foram revisados casos de reparo convencional e endovascular de AAPs tratados nos últimos cinco anos, avaliando dados demográficos, comorbidades, indicação cirúrgica, complicações pré e pós-operatórias precoces e tardias, tempo de internação e de perviedade em até um ano. Resultados Foram realizadas no período dez cirurgias endovasculares (CE) e 21 cirurgias abertas (CA). O grupo CE teve maior frequência de comorbidades. Houve maior frequência de pacientes sintomáticos no grupo CA (85,00%) do que no grupo CE (40,00%). O Grupo CE apresentou menor número de complicações clínicas e cirúrgicas. A idade entre os grupos e o tempo de internação de cada grupo não apresentaram diferença estatística. A perviedade primária em um ano no Grupo CE foi de 80,00%, enquanto no Grupo CA foi de 75,00%. Conclusão O tratamento endovascular para AAPs apresenta bons resultados, em termos de perviedade com taxas de complicações aceitáveis, em pacientes com risco cirúrgico elevado e anatomia favorável, justificando, assim, a necessidade de mais estudos controlados para modificar a posição da técnica endovascular como uma terapia alternativa para casos selecionados.

Role of Hybrid Procedures in the Treatment of Iliac Femoral Occlusive Disease

Introduction: At aorta-iliac district for occlusive disease the first choice have became endovascular procedures because offer excellent results in terms of patency, low mortality and morbidity rates. Stenosis/occlusion to the femoral artery may reduce the patency and the technical success rate of the endovascular procedures. In these cases a hybrid approach with femoral endarterectomy and iliac stenting may be considered. We evaluated the results in patients treated by hybrid and traditional surgery in order to establish if these procedures could be considered as the first choice. Methods: We performed a retrospective study analyzing a frame time of 13 years in order to identify patients with iliac femoral atheromatous disease (TASC II C/D). Primary end points have been considered the primary patency rate, limb savage and survival rate. Secondary end points such as secondary assisted patency, re-interventions and complications rate. Results: We identified 178 limbs in 168 patients (100 vs. 78 limbs treated respectively with Open and Hybrid approach). In the Hybrid group 86% of the patients were classified as ASA III/IV vs. 31% in Open group. Median age was 68 vs. 75 respectively per open and hybrid group. Indication for hybrid procedures was given in 93 limbs but after an accurate pre-operative study with Angio-CT scan we excluded 15 limbs due heavy calcification in 13 patients classified as ASA III/IV that underwent to extra-anatomic repair. The technical success was 91.7% vs.100% (Open versus Hybrid). Primary patency in Open vs. Hybrid group at 1, 5 years was respectively 98%,99% vs. 7.5%,96.1%, assisted patency at 1, 5 years 99%, 98% vs. 98.7%, 97.5%, limb salvage at 1, 5 years 99%,98% vs. 96%,93.5%. 30 days mortality and at 1, 5 years were 5.6% e 28.4% vs. 1.2% e 25.6% Open vs. Hybrid group. Similar post-operative complications rate (6%) were observed in both groups, but 8.1% of open group needed admission intensive unit care. Conclusion: Hybrid procedures offered good results in terms of patency and limb salvage rate and with a low 30 mortality in patients classified at high risk for surgery. Similar survival rates between the 2 groups despite the high co-morbidities and older age that characterized the Hybrid group. Considering the good results the hybrid procedures could be considered as the first choice, but in some patients the anatomic arterial features remain the main limitation that still need traditional repair.

Comparison between Aorto-bifemoral Bypass and Aorto-iliac Kissing Stent in Patients with Complex Aorto-iliac Obstructive Disease

s 401 evaluated the results in patients treated by hybrid and traditional surgery in order to establish if these procedures could be considered as the first choice. Methods: We performed a retrospective study analyzing a frame time of 13 years in order to identify patients with iliac femoral atheromatous disease (TASC II C/D). Primary end points have been considered the primary patency rate, limb savage and survival rate. Secondary end points such as secondary assisted patency, re-interventions and complications rate. Results: We identified 178 limbs in 168 patients (100 vs. 78 limbs treated respectively with Open and Hybrid approach). In the Hybrid group 86% of the patients were classified as ASA III/IV vs. 31% in Open group. Median age was 68 vs. 75 respectively per open and hybrid group. Indication for hybrid procedures was given in 93 limbs but after an accurate pre-operative study with Angio-CT scan we excluded 15 limbs due heavy calcification in 13 patients classified as ASA III/IV that underwent to extraanatomic repair. The technical success was 91.7% vs.100% (Open versus Hybrid). Primary patency in Open vs. Hybrid group at 1, 5 years was respectively 98%,99% vs. 7.5%,96.1%, assisted patency at 1, 5 years 99%, 98% vs. 98.7%, 97.5%, limb salvage at 1, 5 years 99%,98% vs. 96%,93.5%. 30 days mortality and at 1, 5 years were 5.6% e 28.4% vs. 1.2% e 25.6% Open vs. Hybrid group. Similar post-operative complications rate (6%) were observed in both groups, but 8.1% of open group needed admission intensive unit care. Conclusion: Hybrid procedures offered good results in terms of patency and limb salvage rate and with a low 30 mortality in patients classified at high risk for surgery. Similar survival rates between the 2 groups despite the high co-morbidities and older age that characterized the Hybrid group. Considering the good results the hybrid procedures could be considered as the first choice, but in some patients the anatomic arterial features remain the main limitation that still need traditional repair. Comparison between Aorto-bifemoral Bypass and Aorto-iliac Kissing Stent in Patients with Complex Aorto-iliac Obstructive Disease W. Dorigo , G. Piffaretti , F. Benedetto , R. Pulli , P. Castelli , F. Spinelli , C. Pratesi 1 1 Dept. of Vascular Surgery, University of Florence, Italy 2 Dept. of Vascular Surgery, University of Varese, Italy 3 Dept. of Vascular Surgery, University of Messina, Italy Introduction: To retrospectively compare early and late results of aortobifemoral bypass and endovascular recanalization with the kissing stent technique in the management of TASC II C and D lesions in the aorto-iliac district in a multicentre study. Methods: From January 2006 to December 2013, 293 open and endovascular interventions for TASC-II class C and D aorto-iliac obstructive lesions were performed at three Italian teaching hospitals. In 210 patients the intervention was performed for aortic and bilateral iliac involvement: an aorto-bifemoral bypass was performed in 82 patients (Group 1) while in the remaining 128 an endovascular recanalization with the kissing stent technique (Group 2). Early results in the two groups were compared with c test. Follow up results were analyzed with Kaplan-Meyer curves and compared with log rank test. Results: There were no differences between the two groups in terms of demographic data, comorbidities, or risk factors for atherosclerosis, except for a higher percentage of females and of diabetic patients in group 2. Critical limb ischemia was present in 29 patients in group 1 (35.5%) and in 31 patients in group 2 (24%, p 1⁄4 0.07). Technical success in group 2 was 98.5%; two patients required immediate conversion to open surgery for iliac rupture. There was one peri-operative death in group 1 (mortality rate 1.2%, p 1⁄4 0.2 in comparison with group 2). Four peri-operative thromboses occurred; two in group 1 and two in group 2 (in one case requiring conversion to open surgical intervention) and no amputations at 30 days were recorded. Post-operative local and systemic complications occurred in 20 patients in group 1 (24%) and in 13 patients in group 2 (10% p 1⁄4 0.006). Mean duration of follow up was 39 months (range 1 e108 months). Survival rates at 6 years were 65% (SE 0.07) in group 1 and 82% (SE 0.05) in group 2 (p1⁄4 0.07). At the same time interval, primary, assisted primary and secondary patency rates were similar; re-intervention rates were 6% in group 1 (SE 0.05) and 11% in group 2 (SE 0.04; p 1⁄4 0.2). Conclusion: Endovascular repair of complex aorto-iliac lesions with the kissing stent technique, in the multicentre experience, provided similar satisfactory early and late results to those obtained with open surgery, however with a lower rate of peri-operative complications and a trend towards better long-term survival. Long Term Outcomes of Common Femoral Artery Endovascular Repair A. Kaladji, P.-A. Vent, P. Chaillou, A. Costargent, T. Quillard, Y. Goueffic

A 12-Year Experience With Chimney and Periscope Grafts for Treatment of Type I Endoleaks

Purpose: To evaluate the midterm outcomes of chimney and/or periscope grafts (CPGs) in patients presenting type I endoleak after a previous endovascular aneurysm repair (EVAR). Methods: Between June 2002 and April 2014, 24 consecutive patients (mean age 73.9±9.2 years; 23 men) presenting a type I endoleak were addressed with CPGs to extend the proximal and/or distal landing zone and to maintain side branch perfusion. Indication for treatment was a type Ia endoleak in 23 (96%) patients and a type Ib endoleak in one. Median interval from the previous EVAR to endoleak treatment with CPGs was 52.2±48.9 months (range 0.2–179). All patients had proximal/distal landing zones precluding any standard endovascular reintervention. Measured outcomes included technical success and perioperative mortality and morbidity. Technical success was defined as a procedure completed as intended, with no secondary procedures within 30 days. Midterm outcomes included survival, CPG patency, endoleaks, and freedom from reintervention. Results: Technical success was 96%; a single patient required an additional procedure to seal a recurrent type Ia endoleak. Intraoperative revascularization of all 55 target vessels (2.3/patient) with CPGs was successful. One (4%) patient died within 30 days. Estimated survival at 12, 24, and 36 months was 83%; estimated CPG patency at the same intervals was 94%. Over a mean follow-up of 23.4±29 months, 6 (25%) reinterventions were performed; of these, 4 were secondary to type I endoleak. Aneurysm diameters reduced from 88.3±26 to 85.5±33 mm (p=0.49) over the mean follow-up. Conclusion: The CPG technique is a safe and effective tool for treatment of type I endoleak after previous EVAR. The CPG technique is feasible even in nonelective patients, with excellent outcomes in terms of patency. Close imaging follow-up is warranted to rule out recurrent or de novo endoleaks.

Alternative Venous Outflow by Brachial to Jugular Vein Vascular Access for Hemodialysis in the Exhausted Upper Extremities

A shunt is usually created from the distal arm (wrist) to the proximal arm (axillary loop) as long as no central stenosis has occurred. Creating vascular access in a patient with central vein stenosis could induce venous hypertension in the upper extremities. In such patients, an ipsilateral internal jugular vein (IJV) as an arteriovenous (AV) outflow vein should be the last option for using a particular arm. Thirty-two patients who had AV hemodialysis access via a jugular vein were analyzed retrospectively from 2001 to 2011. All patients had an ipsilateral subclavian or axillary vein stenosis. The preserved IJV and innominate veins were preoperatively confirmed with Doppler echocardiography and contrast venography. Mean age of the patients was 57.6 ± 12.3 years, and the mean follow-up period was 43.5 ± 27.4 months. Primary patency was 74%, 54%, 32%, 15% and 5% at 6 months, 1, 2, 3 and 4 years, respectively. Secondary patency was 97%, 93%, 93%, 89%, 79% and 72% at 6 months, 1, 2, 3, 4, and 5 years, respectively. One case of steal syndrome, 2 of seroma, 1 hematoma, 3 swollen arm, 2 infections, 1 pseudoaneurysm, 1 bleeding from puncture site, 8 stenoses and 13 thrombosis cases were noted. A brachial-jugular AV graft showed satisfactory results in terms of patency and complication rate. The IJV could be a good outflow vein for an AV fistula if the IJV is preserved in patients with chronic renal failure who have subclavian or axillary vein stenosis or occlusion.

Current status of endoscopic biliary drainage for unresectable malignant hilar biliary strictures.

The management of jaundice and cholangitis is important for improving the prognosis and quality of life of patients with unresectable malignant hilar biliary strictures (UMHBS). In addition, effective chemotherapy, such as a combination of gemcitabine and cisplatin, requires the successful control of jaundice and cholangitis. However, endoscopic drainage for UMHBS is technical demanding, and continuing controversies exist in the selection of the most appropriate devices and techniques for stent deployment. Although metallic stents (MS) are superior to the usual plastic stents in terms of patency, an extensive comparison between MS and "inside stents", which are deployed above the sphincter of Oddi, is necessary. Which techniques are preferred remains as yet unresolved: for instance, whether to use a unilateral or bilateral drainage, or a stent-in-stent or side-by-side method for the deployment of bilateral MS, although a new cell design and thin delivery system for MS allowed us to accomplish successful deployments of bilateral MS. The development of techniques and devices for re-intervention after stent occlusion is also imperative. Further critical investigations of more effective devices and techniques, and increased randomized controlled trials are warranted to resolve these important issues.

Abstract 15504: A New Coronary Anastomotic Connector in a Preclinical Safety Study

Introduction: A facilitated construction of a distal coronary anastomosis is the key towards less invasive coronary bypass surgery, ideally in an endoscopic hybrid approach. This study evaluates a new laser-assisted, zero ischemia coronary anastomotic connector in comparison to the hand-sutured anastomotic technique, in a long-term follow-up porcine off-pump bypass model. The initial results of this preclinical comparative safety study are presented. Hypothesis: We assessed the hypothesis that the coronary connector is not inferior to the hand-sutured technique, in terms of patency, healing, and hemodynamic function. Methods: In 22 pigs (3 months follow-up, n=10; 6 months follow-up, n=12), the so-called Trinity Clip connector facilitated a LITA-to-LAD anastomosis, and in 14 pigs (3 months follow-up, n=6; 6 months follow-up, n=8) the anastomosis was hand-sutured. All anastomoses (n=36) were evaluated intraoperatively by means of graft flow measurements and at follow-up by angiography and histology. Results: After construction, complete hemostasis was obtained in 95% (21/22) of the connector facilitated anastomoses and in 86% (12/14) of the hand-sutured. Both groups had a mean coronary outer diameter of 1.8 ± 0.1 mm. The mean peak hyperemic flow response (peak [following 30-second graft occlusion]/base flow) was 4.1 ± 1.0 in the connector group versus 4.2 ± 1.1 in the hand-sutured group. The patency in both groups was 100% (connector group: at 6 months [n=3/3] and 3 months [n=5/5]; hand-sutured group: at 6 months [n=1/1] and 3 months [n=4/4]). Conclusions: The initial data of this preclinical study demonstrates similar anastomosis success rate in both groups. The connector is easy-to-use and seems to be safe and reliable in the long-term porcine off-pump bypass model. Complete data on the long-term will be expected soon and the resulting histological and angiographic data will further elucidate the future relevance of this new coronary anastomotic device. In conclusion, albeit the preliminary study status, the connector has potential to facilitate minimally invasive or endoscopic CABG.

Resultados del bypass infrainguinal protésico en isquemia crítica: factores asociados a permeabilidad y salvamento de la extremidad

ObjectivesTo assess the outcomes of prosthetic bypass grafts in critical limb ischemia, as well as to determine the predictors of patency and limb salvage. Materials and methodsRetrospective cohort study of patients with critical limb ischemia undergoing a prosthetic infrainguinal bypass graft between 1997 and 2013 in a single centre. The pre- and post-operative data were collected, and the cohort was divided into 3 groups according to the location of the distal anastomosis: Above-knee popliteal artery (POP1), below-knee popliteal artery (POP3), or femorodistal. An assessment was made of the primary patency, assisted primary patency, secondary patency, limb salvage, and survival. Stratified statistical analysis using the Kaplan-Meier for patency, limb salvage and survival. Univariate and multivariate analysis of risk factors associated with the results using Cox regression. ResultsA total of 154 prosthetic graft bypass, divided into POP1 36.4% (n=56), POP3 50% (n=77), and femorodistal 13.6% (n=21). Differences were found in mean age (POP1 68.9 years, POP3 77.2 years, femorodistal 76.8 years; P<.001). Median follow-up was 11 months. The best outcomes were found in POP1, and the worse in femorodistal in terms of patency and limb salvage (Log Rank P1 0.004, P1A 0.001, P2 0.001 and SE 0.025), with no differences in survival time (Log Rank 0.068). Coronary artery disease and femorodistal bypass were independent risk factors in patency and limb salvage. Older patients and those with chronic renal failure had higher mortality rates. ConclusionsProsthetic infrainguinal bypass graft has fairly good outcomes in critical limb ischemia. The worst outcomes may be expected in patients with coronary artery disease and femorodistal bypass.