Underwent Bypass Surgery Research Articles

Determining the Optimal Age for Extracranial-Intracranial Bypass Surgery: A Post Hoc Analysis of the CMOSS Randomized Trial.

Previous trials have failed to demonstrate the benefits of extracranial-intracranial (EC-IC) bypass surgery for patients with carotid or middle cerebral artery occlusion. However, little evidence has focused on the effect of age on prognosis. This study aimed to explore whether EC-IC bypass surgery can provide greater benefits than medical therapy alone in specific age groups. A post hoc analysis was performed of the CMOSS (Carotid or Middle Cerebral Artery Occlusion Surgery Study), which was a randomized, open-label, outcome assessor-blinded trial conducted at 13 centers in China between June 2013 and March 2018. A total of 324 patients with internal carotid artery or middle cerebral artery occlusion with transient ischemic attack or nondisabling ischemic stroke attributed to hemodynamic insufficiency were randomized into a surgical group (n=161) that underwent EC-IC bypass surgery with medical therapy, and a medical group (n=163) that received antiplatelet therapy and stroke risk factor control alone. The primary outcome was a composite of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days up to 2 years after randomization. Receiver operating characteristic curves were drawn to explore the optimal age boundary, and survival analyses were used to explore differences between groups. Among the 324 patients (median age, 52.7 years; 79.3% men), an age cutoff of 55.5 years predicted the primary outcome in the surgical group (area under the curve, 0.649 [95% CI, 0.530-0.769]). Patients were further divided into an older group (>55.5 years) and a younger group (≤55.5 years). Younger patients who underwent bypass surgery showed a lower risk of the primary outcome (log-rank P=0.001) than older patients. Patients who underwent EC-IC bypass surgery had a lower risk than patients with medical therapy alone in the younger group (3.2% versus 11.6%; hazard ratio, 0.255 [95% CI, 0.071-0.916]; P=0.036), but not in the older group (17.5% versus 13.3%; adjusted hazard ratio, 0.597 [95% CI, 0.225-1.580]; P=0.298). In patients aged 55.5 years or younger with symptomatic atherosclerotic occlusion of the internal carotid artery or middle cerebral artery and hemodynamic insufficiency, the addition of EC-IC bypass surgery to medical therapy significantly improved prognosis. These findings suggest that the clinical application of EC-IC bypass surgery needs more research to explore refined patient selection criteria incorporating more clinical features. URL: https://www.clinicaltrials.gov; Unique identifier: NCT01758614.

Arteriovenous access creation for hemodialysis patients with superior vena cava occlusion.

The feasibility of creating arteriovenous (AV) access in hemodialysis patients with superior vena cava occlusion (SVCO) is debated due to impaired blood return to the right atrium. However, collateral venous networks may offer an alternative solution, allowing for the creation of peripheral AV access. This study evaluates the outcomes of AV access construction in hemodialysis patients with SVCO. A retrospective review of 18 patients with SVCO and patent azygous veins was conducted between August 2021 and June 2023. These patients underwent peripheral AV access creation, including fistulas and grafts. Collected data included baseline demographics, preoperative 3D CT reconstruction of thoracic vessels, central venography, vascular access types, surgical details, postoperative complications, and the timing and methods of interventions. AV access was successfully created in all patients, including 15 AV fistulas and 3 AV grafts. The average brachial blood flow rate before cannulation was 848.67 ± 132.03 mL/min. The median follow-up period was 18.5 months (range: 10-32 months). During follow-up, six patients required interventions, such as flow reduction or percutaneous transluminal angioplasty, to optimize blood flow or resolve venous obstruction. Two cases were classified as failed access at 10 and 18 months post-creation. One patient transitioned to peritoneal dialysis due to AVG dysfunction, while the other underwent bypass surgery for chylothorax. AV access can be successfully created and maintained in patients with SVCO and a patent azygous vein. Although mild venous obstruction symptoms may develop during follow-up, timely intervention can preserve access patency. For patients with limited vascular resources and challenging catheterization, this approach represents a viable option for establishing effective access.

Complex Scalp Reconstruction in Moyamoya Disease Using Distant Flap After Free Tissue Transfer Failure.

A preferred option among many surgeons for treating large defects in the head and neck area is reconstruction using autologous tissue, particularly free tissue transfer with microvascular anastomosis. However, some defects cannot be resolved with conventional microvascular techniques or algorithmic approaches. In this case study, a 55-year-old female, who previously underwent bypass surgery for Moyamoya disease, presented with a large scalp defect following surgical necrosis. After initial coverage using a free anterolateral thigh flap, partial necrosis developed, leaving a persistent 2×4cm² defect. To resolve this, a distant thenar flap was harvested and successfully used for reconstruction. Postoperatively, the patient exhibited full recovery without complications. This case highlights the effectiveness of distant flap techniques, particularly when microvascular surgery is not feasible or has failed. The historical significance and continued applicability of distant flaps in challenging cases underscore their importance in the reconstructive armamentarium.

Long-term outcome followed for more than 5 years after revascularization surgery for the treatment of atherosclerotic steno-occlusive disease: poor outcome prediction using machine learning and analysis of the results.

Cerebral revascularization for the treatment of atherosclerotic steno-occlusive disease (ASOD) was found to have no benefit compared with medical treatment. However, there is also criticism that with sufficiently long-term follow-up, a crossover might emerge demonstrating the advantages of surgery. Therefore, we examined the long-term outcome of cerebral revascularization performed on patients with carefully selected ASOD at our center. Patients undergoing bypass surgery for non-moyamoya ischemic disease were retrospectively identified. The inclusion criteria were symptomatic ASOD with hemodynamic insufficiency, follow-up of more than 5 years, and stroke or surgical complications during follow-up. The clinical course and radiological findings were investigated. Poor outcomes were predicted using machine learning (ML) models, and Shapley additive explanation (SHAP) values and feature importance of each model were analyzed. A total of 109 patients were included from 2007 to 2018. The 30-day risk of any stroke or death was 6.4% (7/109). The risk of ipsilateral ischemic stroke during median follow-up of 116 months was 7.3% (8/109). The SHAP values showed that previously and empirically known stroke risk factors exert a relatively consistent effect on the prediction of models. The number of lesions with stenosis > 50% (odds ratio [OR] 5.77), age (OR 1.13), and coronary artery disease (OR 5.73) were consistent risk factors for poor outcome. We demonstrated an acceptable long-term outcome of cerebral revascularization surgery for patients with hemodynamically insufficient and symptomatic ASOD. Multicenter studies are encouraged to predict poor outcomes and suitable patients with large numbers of quantitative and qualitative data.

Meta-Analysis of Randomised Controlled Trials Comparing Bypass and Endovascular Revascularisation for Peripheral Artery Disease.

Peripheral artery disease affects approximately 250 million people globally. Multiple randomised controlled trials have compared bypass and endovascular interventions but the optimum revascularisation approach remains unclear. The recently published BEST-CLI and BASIL-2 trials provide current and robust data addressing this question, however their findings are not concordant. This systematic review and meta-analysis provides an overview of the worldwide randomised evidence comparing bypass surgery and endovascular revascularisation in lower limb peripheral artery disease. A comprehensive literature search of MEDLINE, Embase and CENTRAL databases was performed of all time periods up to 7 May 2023 to identify randomised controlled trials comparing bypass and endovascular revascularisation for treating lower limb peripheral artery disease. The primary outcome was major amputation. Secondary outcomes were mortality, re-intervention, 30-day adverse events and 30-day mortality. Odds ratios were calculated and pooled using the random-effects model. Risk of bias was assessed using the Cochrane risk of bias 2 tool. Fourteen cohorts were identified across thirteen studies, enrolling 3840 patients. There was no significant difference in major amputation (OR 1.12; 95% CI 0.80-1.57) or mortality (OR 0.96; 95% CI 0.79-1.17) between the bypass and endovascular groups. Bypass was associated with a significant reduction in re-intervention compared with endovascular treatment (OR 0.57, 95% CI 0.40-0.82). These findings suggest that rates of major amputation and mortality are similar following bypass and endovascular interventions. Patients who undergo bypass surgery have a significantly lower re-intervention rate post-operatively.

Effects of Left Internal Mammary Artery (LIMA) Harvesting During Coronary Artery By-Pass Grafting Surgery on Benign Breast Diseases

Introduction: Coronary artery bypass surgery of the primary conduits employed in coronary artery bypass grafting surgery (CABG) is the left internal mammary artery (LIMA), which has garnered considerable attention due to its favorable characteristics and outcomes. There are not enough studies examining the relationship between benign breast diseases (BBD) and LIMA removal. This study is one of the pioneering studies investigating the effects of LIMA removal after bypass surgery in patients with benign breast diseases. This study aims to evaluate the effect of LIMA removal on benign breast diseases in female patients undergoing bypass surgery by analyzing pre- and post-operative breast imaging. Material and Methods: A total of 47 of 452 female patients who underwent bypass surgery between February 18, 2019, and December 31, 2021, were included in the study. All patients’ LIMA were harvested and evaluated, regarding any progression of benign breast diseases. Results: There was a significant difference between the Breast Imaging Reporting and Data System (BI-RADS) classes of the patients before and after CABG (p

Anatomical Flow Diversion by Hybrid Strategy for Intractable Large Cerebral Aneurysms.

Flow diverters (FDs) provide curative endovascular treatment for wide-necked sidewall aneurysms. The efficacy of FDs for bifurcation or branching sidewall aneurysms is probably limited. We used anatomical flow diversion (AFD) for intractable large cerebral aneurysms. We report our experiences with AFD. The concept of AFD is the transformation from the bifurcation or branching sidewall type to the nonbranching sidewall type. Linearization of the parent artery by stenting, intentional branch occlusion, and aneurysmal coil embolization were performed. Furthermore, bypass surgery is performed for patients intolerant to branch occlusions. We evaluated the clinical outcomes of intractable aneurysms treated with AFD. AFD was performed in seven unruptured large aneurysms. Aneurysmal locations were the top of the basilar artery (BA), BA-superior cerebellar artery (SCA), internal carotid artery (IC)-posterior communicating artery (PcomA), and IC terminal. The mean dome diameter was 17.0 ± 4.6 mm. Six patients underwent bypass surgery. The occluded branches were the PCA + SCA, PcomA, and anterior cerebral artery (ACA) A1. An FD was used in three patients and a neck bridge stent in four patients. No intraprocedural complications occurred. Two postprocedural ischemic complications occurred in one patient. Six (86%) patients demonstrated a modified Rankin Scale (mRS) 0 at the 3-month follow-up, and one with an ischemic complication showed an mRS 5. Complete occlusion of all aneurysms was maintained with a median follow-up duration of 60 months. AFD is useful for intractable large cerebral aneurysms with high curability, although safety verification is required.

Flow capacity of a superficial temporal artery as a donor in a consecutive series of 100 patients with superficial temporal artery-middle cerebral artery bypass.

A superficial temporal artery-middle cerebral artery (STA-MCA) bypass is classically considered a low-flow bypass. It is known that the flow in the flow augmentation STA-MCA bypass is influenced by flow demand of the revascularized territory and can reach significantly higher values. The authors report their intraoperative flow measurement data in a consecutive series of 100 STA-MCA bypasses performed at their institution. Moreover, in a subanalysis, they show the postoperative bypass flow measured with quantitative MR angiography (qMRA) noninvasive optimal vessel analysis (NOVA). Between January 2013 and October 2023, 100 patients with acute, subacute, or chronic large-vessel occlusion (LVO) or moyamoya disease underwent a flow augmentation STA-MCA bypass revascularization at the authors' department with intraoperative bypass flow measurement. Patients with atherosclerotic LVO who underwent bypass surgery within a 6-week period following the onset of ischemic stroke symptoms were categorized into the acute bypass group, encompassing both acute and subacute LVO cases. Conversely, those who underwent bypass surgery > 6 weeks after the last occurrence of ischemic stroke were classified as the chronic group. Since May 2019, a consecutive subgroup of 37 patients received a postoperative (before discharge) bypass flow measurement with the qMRA-NOVA imaging tool. The mean ± SD intraoperative bypass flow in this consecutive series of 100 STA-MCA bypasses was 53.5 ± 28.8 ml/min (range 14-145 ml/min). In the subanalysis, there was no difference in the intraoperative flow capacity between the acute and chronic groups and between the moyamoya and acute groups. Patients in the moyamoya group showed a significantly higher flow rate in the STA-MCA bypass compared with the chronic group (63.0 ± 30.2 ml/min vs 48.4 ± 26.5 ml/min, p = 0.03). In a consecutive subanalysis of 37 STA-MCA bypass cases, postoperative flow measurements were also performed using qMRA-NOVA, showing a significant increase in the flow of STA-MCA bypasses after surgery compared with intraoperative flow measurements (mean intraoperative bypass flow rate vs qMRA-NOVA postoperative bypass flow rate: 73.4 ± 29.9 ml/min vs 111.3 ± 51.4 ml/min, p = 0.005). Using intraoperative and postoperative quantitative flow measurements of the STA, the data confirm that the flow in the flow augmentation STA-MCA bypass is influenced by the flow demand of the revascularized territory and can reach high values if needed. Moreover, the significant flow increase in the postoperative flow measurement using qMRA-NOVA demonstrates that the bypass can increase its flow over time.

The impact of an anomalous third segment of the vertebral artery on bypass surgery: a case report and literature review.

The horizontal part of the third segment (V3) of the vertebral artery (VA) is a critical anastomotic site for bypass procedures involving either donor or recipient vessels. It is rare for the V3 segment to deviate from its typical course of passing through the atlanto-transverse foramen. V3 anomaly encountered in occipital artery (OA)-V3 bypass surgery has not been previously reported. Here, we present a case involving a patient undergoing bypass surgery due to recurrent post-stent occlusion at the first segment (V1) of the left VA. During the operation, it was noted that the V3 horizontal segment could not be identified within the left VA groove, leading to initial suspicion of left V3 disuse atrophy attributed to prolonged chronic ischaemia. Consequently, there was a need to modify the operative method and to transition from an OA-V3 bypass to an OA-posterior inferior cerebellar artery bypass. Post-operative computed tomography angiography confirmed that indeed, the left V3 did not traverse through the transverse foramen of the atlas and instead entered the dural membrane between the first cervical vertebra (C1) and the second cervical vertebra (C2).

Quality of Life Outcomes Following Aortofemoral and Iliofemoral Bypass Surgery in Patients With Peripheral Arterial Disease: A Two-Year Follow-Up Study.

Peripheral arterial disease is a circulatory disorder characterized by reduced blood flow to the extremities, predominantly affecting the lower limbs. This study aims to evaluate the impact of aortofemoral and iliofemoral bypass surgeries on patients' quality of life two years post operation and identify predictors of quality-of-life improvements. This cross-sectional study included adult patients with aortoiliac disease who underwent bypass surgery (aortofemoral or iliofemoral) at East Jeddah General Hospital from January 2020 to December 2022. Quality of life was assessed using the Arabic version of the Short Form Health Survey 12 (SF-12) preoperatively and two years postoperatively. Data on sociodemographic factors (age, sex, education, income) and medical factors (smoking, BMI, comorbidities) were collected. Statistical analyses included descriptive statistics, t-tests, one-way ANOVA, and regression analyses using IBM SPSS version 25.0 (IBM Corp., Armonk, NY). The study included 275 patients. Significant improvements in both physical and mental SF-12 scores were observed postoperatively across all patient groups (P < 0.001). Older age, unemployment, and lower income were associated with lower SF-12 scores. Males had higher postoperative mental scores (P = 0.036). Higher BMI and smoking pack-years negatively correlated with SF-12 scores. Patients with comorbidities had significantly lower preoperative and postoperative SF-12 scores (P < 0.05)but showed significant improvements postoperatively (P < 0.001). Aortofemoral and iliofemoral bypass surgeries significantly improve the quality of life in peripheral arterial disease patients two years post operation. Key predictors of lower quality of life include older age, unemployment, lower income, high BMI, smoking, and comorbidities. Targeted interventions, such as smoking cessation programs, weight management, and comprehensive medical care, are essential for optimizing postoperative outcomes and enhancing patients' physical and mental well-being.

Therapeutic inhibition of biomechanically-activated YAP-TAZ signaling prevents vein graft atherosclerosis

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Rembrandt Institute for Cardiovascular Sciences Background Venous bypass grafts may have limited patency due to excessive intimal hyperplasia and accelerated atherosclerosis. YAP-TAZ signaling regulates cellular responses to biomechanical cues, such as disturbed flow or vessel distention as seen in vein grafts. YAP activation leads to inflammation and angiogenesis, which both contribute to vein graft atherosclerosis. Inhibition of YAP-TAZ attenuates naive atherogenesis, but its potential to inhibit intraplaque angiogenesis and reduce vein graft atherosclerosis has not been explored. Methods Saphenous vein progenitor cells (SVPs) were subjected to mechanical strain in vitro to assess YAP activation. IHC to assess YAP-expression was performed on vein grafts from pigs as well as ex vivo cultured human saphenous veins. Furthermore, YAP-IHC was performed on murine vein grafts from hypercholesterolemic ApoE3*Leiden mice harvested at early, mid- and late-stage disease timepoints to assess optimal treatment window. In a separate experiment, mice (n=11-13/group) underwent bypass surgery and were treated with the FDA-approved YAP-TAZ inhibitor Verteporfin (50 mg/kg) or vehicle 3 times/week from day 10 until sacrifice (day 28). Ultrasound was used to longitudinally quantify vascular remodeling. Vein grafts were harvested and processed for morphometric and compositional analysis. Results Mechanical strain induced activation of YAP and its downstream targets (Ctgf, Cyr61) in SVPs, which was inhibited by Verteporfin (confirmed by WB, IP and qPCR). Moreover, YAP was abundantly expressed in pig vein graft lesions, whilst Verteporfin blocked YAP expression in ex vivo cultured human saphenous veins after exposure to disturbed flow. In addition, YAP was increasingly expressed during vein graft lesion development in mice, reaching its peak around day 14, which coincides with the initiation of intraplaque angiogenesis. Furthermore, YAP was predominantly expressed in luminal and adventitial endothelial cells. Analysis of ultrasound demonstrated that Verteporfin prevented vein graft thickening in mice over time. End-point histology revealed that the intima/media ratio was significantly decreased by Verteporfin treatment (37%, p=0.001). Intraplaque angiogenesis was also reduced (34%, p=0.002), whilst neovessel maturation was improved upon verteporfin treatment. The vessel wall ACTA2 content was reduced (42%, p=0.023), whilst collagen was not altered between both groups, indicating that Verteporfin diminished the fibroproliferative response without affecting vessel wall stability. Conclusion Verteporfin inhibited YAP-TAZ activation induced by mechanical strain in vitro (SVPs) as well as ex vivo (cultured human saphenous veins). In vivo, Verteporfin treatment resulted in a significant decrease of vein graft atherosclerosis and intraplaque angiogenesis. Therefore, therapeutic targeting of YAP-TAZ using Verteporfin might be a new candidate to improve vein graft patency.

Lenti-viral overexpression of RhoGEF Trio reduces CD8 T cell extravasation into atherosclerotic vein graft lesions in mice

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Rembrandt Institute for Cardiovascular Sciences Background In advanced atherosclerotic plaques, such as vein graft lesions, neovessels grow into the hypoxic plaque. This intraplaque angiogenic neovessels lack proper endothelial cell-cell junctions and are therefore susceptible to extravasation of leukocytes, which results in inflammation and atherosclerosis. T cells are the largest leukocyte subset found in atherosclerotic plaques and are key drivers of inflammation and plaque progression. RhoGEF Trio improves endothelial barrier function by strengthening endothelial cell-cell junctions in vitro, but its effect on T cell transmigration and its therapeutic potential to impede atherogenesis remains unknown. Methods ApoE3*Leiden mice (n=10/group) underwent bypass surgery in which a donor caval vein was interpositioned into the arterial circulation at the site of the right common carotid artery. Immediately post-operatively, a pluronic gel containing either GFP-Lentivirus (LV) (control) or Trio-GFP-LV (Trio) was locally applied around the vein graft to induce local overexpression of Trio. At post-op day 28, vein grafts were harvested and processed for morphometric and compositional analysis of the atherosclerotic lesions. Additionally, CD4 and CD8 T cells were isolated from healthy human donors and used in vitro to assess the role of Trio on trans-endothelial migration over in vitro-cultured HUVECs. Results At post-op day 28, both luminal and neovessel endothelial cells were GFP positive indicating successful transfection. CD8 T cell infiltration into the atherosclerotic plaque was reduced in the Trio group (45%, p=0.0426), whilst plaque size and the number of neovessels were unaffected. Mechanistically, we observed that adherence of CD8, but not CD4 T cells to the endothelial monolayer was reduced in vitro upon transfection with Trio-LV. This resulted in a decrease in the absolute number of transmigrated CD8 T cells (56%, p=0.0197), whilst the number of transmigrated CD4 T cells was unaffected. Interestingly, CD8 T cells exhibited no difference trans-/paracellular diapedesis, whilst for CD4 T cells Trio overexpression induced transcellular, rather than paracellular, transmigration. Conclusions LV transfection of vein grafts by local application of a pluronic gel holds promise a therapeutic strategy to improve bypass surgery outcomes. LV transfection with RhoGEF Trio did reduce CD8 T cell transmigration (in vivo and in vitro), but not CD4 T cell transmigration (in vitro) into the atherosclerotic plaque, whilst plaque size was not affected. Ongoing investigations focus on the effect of Trio on micro-vascular leakage as well as infiltration of other immune cells into the plaque.

Surgical Treatment Strategies for Residual or Recurrent Intracranial Aneurysms Following Endovascular Embolization.

To explore how to effectively manage the residual or recurrent intracranial aneurysms after embolization. The authors retrospectively reviewed our experience of endovascular interventional therapy, surgical clipping, and cerebrovascular bypass surgery in the treatment of residual or recurrent aneurysms after embolization at the authors' institution from 2018 to 2022. The Glasgow Outcome Scale of 28 patients after the procedure and at discharge showed that 24 recovered well, 3 had severe disability, and 1 died. During the 24-month follow-up, 26 had a good recovery, 1 suffered from disability, and 1 died. Two cases of aneurysm recurrence were detected, and both were treated through endovascular therapy. Among them, 1 case underwent a repeat endovascular embolization, and 1 case was switched to surgical clipping. No residual aneurysms were observed in the remaining patients who underwent bypass surgery, and their bypass grafts were all patent. Based on the clinical status of patients, aneurysmal characteristics, surgical risk, and possibility of rerupture of aneurysms, an individualized strategy was proposed for residual or recurrent aneurysms after embolization. The use of endovascular interventional therapy or surgical clipping can be safely and effectively managed, and cerebrovascular bypass surgery can effectively manage complex aneurysms.

Dual Antithrombotic Therapy versus Anticoagulant Monotherapy for Major Adverse Limb Events in Patients with Concomitant Lower Extremity Arterial Disease and Atrial Fibrillation: A Propensity Score Weighted Analysis

Patients with symptomatic lower extremity arterial disease (LEAD) are recommended to receive antiplatelet therapy, while direct oral anticoagulants (DOACs) are standard for stroke prevention in patients with atrial fibrillation (AF). For patients with concomitant LEAD and AF, data comparing dual antithrombotic therapy (an antiplatelet agent used in conjunction with a DOAC) vs. DOAC monotherapy are scarce. This retrospective cohort study, based on data from the Taiwan National Health Insurance Research Database, aimed to compare the efficacy and safety of these antithrombotic strategies. Patients with AF who underwent revascularisation for LEAD between 2012 - 2020 and received any DOAC within 30 days of discharge were included. Patients were grouped by antiplatelet agent exposure into the dual antithrombotic therapy and DOAC monotherapy groups. Inverse probability of treatment weighting was used to mitigate selection bias. Major adverse limb events (MALEs), ischaemic stroke or systemic embolism, and bleeding outcomes were compared. Patients were followed until the occurrence of any study outcome, death, or up to two years. A total of 1 470 patients were identified, with 736 in the dual antithrombotic therapy group and 734 in the DOAC monotherapy group. Among them, 1 346 patients received endovascular therapy as the index revascularisation procedure and 124 underwent bypass surgery. At two years, dual antithrombotic therapy was associated with a higher risk of MALEs than DOAC monotherapy (subdistribution hazard ratio [SHR] 1.34, 95% confidence interval [CI] 1.15 - 1.56), primarily driven by increased repeat revascularisation. Dual antithrombotic therapy was also associated with a higher risk of major bleeding (SHR 1.43, 95% CI 1.05 - 1.94) and gastrointestinal bleeding (SHR 2.17, 95% CI 1.42 - 3.33) than DOAC monotherapy. In patients with concomitant LEAD and AF who underwent peripheral revascularisation, DOAC monotherapy was associated with a lower risk of MALEs and bleeding events than dual antithrombotic therapy.

What if youth is not enough? Acute coronary syndrome in young patients

Abstract Funding Acknowledgements None. Background Acute Coronary Syndromes (ACS) are the leading cause of mortality in Spain. Further research is needed in order to know risk factors and outcomes in young patients so that medicians could optimize their management and prevention. Purpose Identifying risk factors, clinical characteristics and short-term outcomes in Acute Coronary Syndrome in patients aged 40 and under. Methods A retrospective analysis of patients under 40 years of age who were admitted for ACS, out of 3,859 ACS admissions in Cardiology Intensive Care Unit (CICU) in our hospital between 2012 and 2022. Results 67 patients (1.73%) were included, most of them were males (83.6%). Baseline characteristics are summarized in Table 1. 77.6% had hypertension (HTA), 22.4% had diabetes (DM) and 34.3% had dyslipidemia (DLP). 79.1% were smokers, 9.1% had a history of alcoholism and 29.9% were cocaine users. None of them had a history of stroke, atrial fibrillation (AF). Only 3% had ischemic heart disease. 68.7% of them were ST-elevation myocardial infarction (STEMI) and inferior STEMI was the most common (38.7%). In anterior STEMI (22 patients), 15 had a severe lesion in the mid-left anterior descending artery (LAD), and 6 in the left main stem (LM). Single-vessel disease was the most common (70.8%), with 3-vessel disease in 4.6%. 75.8% received percutaneous coronary intervention (PCI), and 3% underwent bypass surgery. During admission, 10.5% progressed to Killip class III-IV. The ICU mortality was 1.5%. 9% received vasoactive drugs and 4.5% were intubated. Non-invasive ventilation was used in 3% and high-flow nasal cannula oxygen therapy in 5.3%. 3% received intra-aortic balloon pump support and 1.5% underwent dialysis or ultrafiltration. 4.5% received an implantable cardioverter-defibrillator (ICD), although none of them developed bundle branch block or atrioventricular node block, nor AF. After discharge, 11.1% had recurrent ACS, and up to 5.6% underwent PCI again, with a mortality rate of 11.8%. Conclusion Approximately 2% of ACS occur in people younger than 40 years of age. Substance abuse (smoking, cocaine and alcoholism) becomes more prevalent in this group. Prevalence of comorbidities (such as diabetes and nephropathy) are lower, making them less prone to short-term heart failure. However, they are more susceptible to recurrent ischemic events. There is a high incidence of inferior STEMI and LM-STEMI. For these reasons, medicians may need to find out a substance abuse in this group and further research into other risk factors, such as coronary disease family history.Basal characteristicsClinical evolution of patients

Alternative vein bypass in octogenarians with chronic limb-threatening ischaemia.

Octogenarians are regarded as one of the frailest patient groups among the chronic limb-threatening ischaemia population with high perioperative morbidity and mortality rates. As a result, alternative vein bypass surgery in the absence of sufficient great saphenous vein is often not considered as a potential treatment option. The aim of this study was to compare the results of octogenarians undergoing alternative vein bypass surgery due to chronic limb-threatening ischaemia to younger patients. A single-centre retrospective analysis of patients undergoing bypass surgery for chronic limb-threatening ischaemia with alternative autologous vein grafts between 1997 and 2018 was performed. Patients aged over 80 years were compared with those under 80 years. Graft patency rates were assessed and a risk factor analysis for limb loss was performed. In total, 592 patients underwent bypass surgery during the study interval. Twenty-one per cent (n = 126) of patients were 80 years or older. At 4 years, primary, primary-assisted and secondary patency as well as limb salvage rates were not significantly different between the two groups (46% versus 50%, 60% versus 66%, 69% versus 72%, 72% versus 77%, for octogenarians versus non-octogenarians respectively). Major amputations were performed in 27 (21%) octogenarians and 91 (20%) non-octogenarians (P = 0.190). No higher 30-day and long-term mortality rates nor morbidity rates were detected in the octogenarian group with a median follow-up time of 27 (interquartile range 12-56) months. Minor amputation, the reason for alternative vein grafts, as well as the profunda femoris artery as proximal origin of the bypass were risk factors for limb loss in the postoperative course. Alternative vein bypass surgery in octogenarians with chronic limb-threatening ischaemia is safe and effective in terms of patency rates, limb salvage and survival compared with younger patients in the absence of sufficient great saphenous vein. Age alone should not be a deterrent from performing bypass surgery.

Impact of diabetes on short-term outcomes in patients undergoing coronary artery bypass grafting surgery in acute coronary syndrome.

Diabetes mellitus (DM) is associated with concomitant comorbidities, such as atherosclerosis and cardiovascular disease. Coronary artery bypass grafting (CABG) surgery is the optimal therapy in diabetic patients with triple vessel disease. DM is also known to be a relevant risk factor for higher morbidity and mortality in patients who underwent elective CABG procedures. Data regarding outcomes in diabetic patients in acute coronary syndrome (ACS) is heterogeneous. This study aimed to investigate the impact of DM on short-term outcomes in patients who underwent CABG surgery in ACS. A retrospective propensity score matched (PSM) analysis of 1370 patients who underwent bypass surgery for ACS between June 2011 and October 2019 was conducted. All patients were divided into two groups: non-diabetic group (n = 905) and diabetic group (n = 465). In-hospital mortality was the primary outcome. Secondary outcomes were perioperative myocardial infarction, new onset dialysis, reopening for bleeding and duration of intensive care unit (ICU) stay. A subgroup analysis of patients with insulin-dependent and non-insulin dependent DM was also performed. After performing PSM analysis, baseline characteristics and the preoperative risk profile were comparable between both groups. The proportion of patients who underwent total arterial revascularization (p = .048) with the use of both internal thoracic arteries (p < .001) was significantly higher in the non-diabetic group. The incidence of perioperative myocardial infarction (p = .048) and new onset dialysis (p = .008) was significantly higher in the diabetic group. In-hospital mortality was statistically (p = .907) comparable between the two groups. DM was associated with a higher incidence of adverse outcomes, however with comparable in-hospital mortality in patients who underwent CABG procedure for ACS.

Metabolic Recovery with the Persistence of Proinflammatory Leucocyte Dysfunction After Bariatric Intervention for Obesity.

A suitable option for severe obesity treatment is a surgical approach. After surgery, metabolic markers and weight frequently return to adequate values; however, concerning systemic inflammatory mediators, the results are inconsistent. Furthermore, it has been suggested that leucocyte function may be affected even after weight normalization. This study aimed to determine if the surgical treatment of obesity influences the production of cytokines by LPS-stimulated as a function of leucocytes. We performed a cross-sectional study that investigated the production of cytokines in response to lipopolysaccharide (LPS) along a kinetic of simulation by leucocytes recovered from individuals with normal weight (NW, n = 8), persons living with obesity (Ob, n = 7), persons living with obesity and diabetes mellitus (Ob-DM, n = 17), and persons that used to live with obesity who underwent bypass surgery (fOb + bypass, n = 8) and recover normal weigh. IL-6 levels were significantly higher in the Ob and fOb + bypass groups than in NW (p = 0.043). IL-10 secretion without LPS was significantly higher in the NW group than in the other groups explored (p < 0.05). When exposed to LPS, the IL-10 levels increased in all groups except the NW group. As also observed for IL-18 and IL-33, the secretion curve of the fOb + bypass group was more similar to the Ob group, even when they had reached normal weight, as opposed to the NW group. Our results show that in patients with fOb + bypass, inflammatory and anti-inflammatory cytokine production dynamics remain disrupted even with improved metabolic control and normal weight recovery.

Treatment Outcomes in Octogenarians with Chronic Limb-Threatening Ischemia after Infrainguinal Bypass Surgery or Endovascular Therapy

ObjectiveThis study aimed to analyze the clinical outcomes after revascularization for CLTI in patients aged ≥80 years and <80 years. MethodsWe retrospectively analyzed multicenter data of 789 patients who underwent infrainguinal revascularization for CLTI between 2015 and 2021. The endpoints were 2-year overall survival (OS), amputation free survival (AFS), limb salvage (LS), and postoperative complications. ResultsA total of 90 patients aged ≥80 years and 200 patients aged <80 years underwent bypass surgery (BSX), and 205 patients aged ≥80 years and 294 patients aged <80 years underwent endovascular therapy (EVT). Before the propensity score matching (PSM), multivariate analyses showed that age ≥80 years, lower body mass index (BMI) and serum albumin levels, nonambulatory status, and end-stage renal disease were independent risk factors for 2-year mortality in the BSX and EVT groups. After PSM, the 2-year OS was better in the <80 years cohort than in the ≥80 years cohort in both the BSX and EVT groups (P = .018 and P = .035, respectively). There was no difference in the 2-year LS rates between the <80 years and the ≥80 years cohorts in both the BSX and EVT groups (P = .621 and P = .287, respectively). According to the number of risk factors, except for age ≥80 years, there was no difference in the 2-year AFS rates between the <80 years and ≥80 years cohorts for the BSX and EVT groups with 0–1 risk factor (P = .957 and P = .655, respectively). However, the 2-year AFS rate was poor, especially in the ≥80 years cohort in the BSX with 2–4 risk factors (P = .015). The Clavien–Dindo ≥IV complication rates tended to be higher in the ≥80 years cohort than in the <80 years cohort only in the BSX with 2–4 risk factors (P = .056). ConclusionsPatients with CLTI aged ≥80 years had poorer OS than those aged <80. However, there was no difference in LS between the ≥80 years and <80 years cohorts in both the BSX and EVT groups. Although age ≥80 years was associated with poorer OS, patients with 0–1 risk factor may benefit from revascularization, including BSX, because no difference was observed in AFS or Clavien–Dindo ≥IV complications.

Natural course of hemodynamically stable hemispheres contralateral to operated hemispheres in adult patients with ischemic moyamoya diseases

The necessity of bilateral bypass in adult moyamoya disease (MMD) remains unclear despite its recommendation for pediatric and hemorrhagic cases. We aimed to investigate the natural course of hemodynamically stable unoperated hemispheres after bypass surgery for symptomatic and hemodynamically unstable hemispheres in adult patients with ischemic MMD. Among 288 patients, the mean age at the first operation of the unstable hemispheres was 40.8 ± 12.2 years. The mean follow-up period was 62.9 ± 46.5 months. 45 patients (15.6%) experienced stroke events in the unoperated hemisphere, consisting of hemorrhagic stroke in 8 (2.8%) and ischemic stroke in 37 (12.8%), including progressive transient ischemic attack in 25 (8.7%) and infarction in 12 (4.2%). Among them, 39 patients (13.5%) underwent bypass surgery. The annual risk of total stroke is 3.0%/patient-year, with 2.5% for ischemic stroke and 0.5% for hemorrhagic stroke. The 5- and 10-year cumulative risks of ischemic stroke were 13.4% and 18.3%, respectively, and those of hemorrhagic stroke were each 3.2%. The natural course of hemodynamically stable hemispheres contralateral to the operated ones appeared fairly good. Additional bypass surgery on the unoperated hemispheres should be considered for symptomatic and hemodynamically unstable hemispheres in adult patients with ischemic MMD during the follow-up.