Vein Bypass Grafts Research Articles

First Femoropopliteal Bypass for a Critical Limb Ischemia

First Femoropopliteal Bypass for a Critical Limb Ischemia

Systemic thrombolytic therapy in treatment of acute limb ischemia

Background and aim Owing to the increased risk of morbidity and mortality, the treatment of acute limb ischemia (ALI) is challenging. The authors aimed to investigate the outcomes of thrombolysis in the treatment of ALI and limb salvage. Patients and methods A retrospective observational study was conducted to revise the data of 49 patients who underwent catheter-direct thrombolysis for ALI. A total of 33 cases were at lower limb and 16 cases were at upper limb. The assessed outcomes were primary and secondary patency, survival, amputation-free survival, and conversion to surgery. Results The patients were classified according to the Rutherford classification into class I (52%), class IIa (38%), class IIb (8%), and class III (2%). The primary patency was present in 34% of the patients after the first year and 22% after the second year. On the contrary, 28% of the patients were subjected to conversion to open surgery, 8% were subjected to reintervention, and 6% were subjected to amputation within the first month. The mortality rate within 1 month was 6%. The worst primary and secondary patency rates were seen in the prosthetic grafts in addition to vein bypasses, whereas the native artery was the most successful one regarding the primary patency, secondary patency, and amputation-free survival (P<0.05 for each). Conclusion The thrombolysis of vein bypass and prosthetic grafts did not show technical success as that seen with native artery. Additional treatment at the time of thrombolysis was shown to be associated with better outcomes.

AORTOCORONARY SAPHENOUS VEIN GRAFT ANEURYSM: A SILENT COMPLICATION

AORTOCORONARY SAPHENOUS VEIN GRAFT ANEURYSM: A SILENT COMPLICATION

Comparing the Benefit of Duplex Ultrasound Surveillance Following Both Infrainguinal Bypass Surgery and Stenting for Femoro-Popliteal Disease

Duplex ultrasound surveillance (DUS) is commonly used following infrainguinal vein bypass. The role of DUS following endovascular revascularisation is as yet unclear. This study focuses on the role of DUS in a contemporary group of patients undergoing infrainguinal bypass or stent insertion. All patients undergoing either an infrainguinal vein graft bypass or stent insertion into the femoro-popliteal segment (November 2014 - January 2017) were identified. Patients were followed up for 2years. Data on entry into DUS, pre-operative characteristics, adjunctive pharmacotherapy and reintervention were collated. The primary outcomes were major lower limb amputation and mortality at 2years post revascularisation. One hundred and thirty-five patients underwent infrainguinal vein bypass and 100 patients underwent stent insertion. 107 patients in the bypass cohort and 58 patients in the stent cohort entered DUS. For the bypass cohort, entering DUS was associated with a lower mortality rate (P = .003) but was not associated with an improvement in amputation rates. The odds ratio of major amputation or mortality was greater in the no surveillance group (4.58, 95% CI: 1.855 - 11.364). In the stent cohort, DUS was not associated with a significant improvement in either major amputation or death (odds ratio 2.13 (95% CI 0.903 - 5.051; P = .081). DUS was associated with improved survival rates in patients undergoing lower limb bypass but had no benefit in those patients undergoing stent insertion. The role of DUS following stent insertion in the femoropopliteal segment needs to be better defined.

Distinct Temporal Pattern of the Prediction of Lumen Remodeling of Lower Extremity Vein Bypass Grafts by Initial Local Hemodynamics.

We predicted human lower extremity vein bypass graft remodeling by hemodynamics. Computed tomography and duplex ultrasound scans of 55 patients were performed at 1week and 1, 6, and 12months post-implantation to obtain wall shear stress (WSS) and oscillatory shear index (OSI) at 1-mm intervals via computational fluid dynamics simulations. Graft remodeling was quantified by computed tomography-measured lumen diameter changes in the early (1week-1month), intermediate (1-6months), and late (6-12months) periods. Linear mixed-effect models were constructed to examine the overall relationship between remodeling and initial hemodynamics using the average data of all cross sections within the same graft. A significant association of graft remodeling with WSS (p < 0.001) and time (p = 0.001) was found; however, the effect size decreased with time (every 2.7 dyne/cm2 increase of WSS was associated with a 0.39, 0.35, 0.002mm diameter increase in the three periods, respectively). The association of remodeling with OSI was significant only in the intermediate period (every 0.1 increase of OSI was associated with a 0.25mm lumen diameter decrease, p = 0.004). Therefore, the association of graft lumen remodeling with local hemodynamics has a distinct temporal pattern; WSS and OSI are predictive of remodeling only in certain postoperative periods.

Blood Protein Predictors of Lower Extremity Vein Bypass Graft Failure and Remodeling

Blood Protein Predictors of Lower Extremity Vein Bypass Graft Failure and Remodeling

Adiponectin Prevents Restenosis Through Inhibiting Cell Proliferation in a Rat Vein Graft Model.

ResumoFundamento:O enxerto de bypass na artéria coronária (CABG) continua a ser eficiente como tratamento para pacientes portadores de doença arterial coronariana; entretanto, o enxerto venoso tende a apresentar reestenose ou oclusão. A adiponectina (ADP) é uma proteína hormonal plasmática com a função de regular a proliferação celular.Objetivo:Foram utilizadas duas doses diferentes da proteína ADP em um modelo de enxerto venoso em ratos para estimular a alteração do enxerto venoso. O objetivo deste estudo foi investigar o efeito da ADP sobre a reestenose em enxerto venoso.Métodos:Veias jugulares autólogas foram implantadas como enxertos interposicionais de carótida pela técnica de anastomose de manga em ratos Sprague Dawley. A adiponectina (2,5 μg e 7,5 μg) foi entregue ao enxerto venoso por bypass de forma perivascular, suspensa em gel Pluronic-F127 a 30%. O grupo tratado apenas com bypass e o grupo tratado com gel veículo carregado apenas com Pluronic funcionaram como controle. Foram feitas comparações com análise de via única de variância e teste post-hoc, com p <0,05 sendo considerado significativo.Resultados:A proliferação celular (índice de PCNA) foi significativamente baixa no grupo tratado com adiponectina em comparação com o grupo de controle e o grupo tratado com o gel veículo na íntima e na adventícia dos enxertos a partir do dia 3 (p <0,01). VCAM-1 e ICAM-1 avaliados por imuno-histoquímica diminuíram significativamente em enxertos venosos tratados com adiponectina na quarta semana (p <0,01). O tratamento de enxertos venosos com gel carregado com adiponectina reduziu a espessura da íntima, da média e da adventícia, em comparação com os enxertos de controle e tratados com gel veículo no dia 28 (p <0,01).Conclusões:Este estudo oferece evidências adicionais do possível papel terapêutico da adiponectina na modulação de lesão vascular e seu reparo.

USP10 exacerbates neointima formation by stabilizing Skp2 protein in vascular smooth muscle cells

The underlying mechanism of neointima formation remains unclear. Ubiquitin-specific peptidase 10 (USP10) is a deubiquitinase that plays a major role in cancer development and progression. However, the function of USP10 in arterial restenosis is unknown. Herein, USP10 expression was detected in mouse arteries and increased after carotid ligation. The inhibition of USP10 exhibited thinner neointima in the model of mouse carotid ligation. In vitro data showed that USP10 deficiency reduced proliferation and migration of rat thoracic aorta smooth muscle cells (A7r5) and human aortic smooth muscle cells (HASMCs). Mechanically, USP10 can bind to Skp2 and stabilize its protein level by removing polyubiquitin on Skp2 in the cytoplasm. The overexpression of Skp2 abrogated cell cycle arrest induced by USP10 inhibition. Overall, the current study demonstrated that USP10 is involved in vascular remodeling by directly promoting VSMC proliferation and migration via stabilization of Skp2 protein expression.

Harvesting techniques of the saphenous vein graft for coronary artery bypass: Insights from a network meta-analysis.

The optimal harvesting technique of saphenous vein (SVG) in coronary artery bypass grafting (CABG) is still to be elucidated. The present study aimed to compare the methods of SVG harvesting technique, which were open vein harvesting (OVH), endoscopic vein harvesting (EVH), and no-touch vein harvesting (NT), using a network meta-analysis of randomized controlled trials (RCTs), and propensity-score matched (PSM) studies. MEDLINE and EMBASE were searched through April 2021 to identify RCTs and PSM studies that investigated the outcomes in patients who underwent CABG with the SVG using one of three methods; OVH, EVH, and NT. The outcomes of interest were all-cause mortality, the rates of revascularization, and graft failure. Risk ratios (RRs) were extracted for the rates of graft failure, and hazard ratios (HRs) were extracted for all-cause mortality and the rates of revascularization. Eligible seven RCT and five PSM studies were identified which enrolled a total of 8111 patients. All-cause mortality was significantly lower in patients with EVH compared with OVH (HR [95% confidence interval (CI)] =0.77 [0.65-0.92], p = .0032). The rates of revascularization were similar among the groups. The rate of graft failures was significantly lower in patients with NT compared with OVH (HR [95% CI] =0.54 [0.32-0.90], p = .019) and with EVH (HR [95% CI] =0.39 [0.17-0.86], p = .023). NT vein harvesting is favorable for graft patency, and OVH showed higher all-cause mortality than EVH. Further well-powered RCTs are needed to confirm our findings.

Blockade of Serum and Glucocorticoid Inducible Kinase-1 Can Attenuate Abdominal Aortic Aneurysm Growth

Serum and glucocorticoid inducible kinase-1 (SGK-1) is a mechanosensitive kinase implicated in vein bypass graft remodeling and atherogenesis through modulation of metalloproteinase as well as pro-inflammatory cytokine production. More specifically, our laboratory has demonstrated that SGK-1 inhibition in aortic vascular smooth muscle cells downregulated interleukin-6 production, implicating SGK-1 in signaling to accumulate macrophages that can promote degenerative aortic remodeling. It is, therefore, hypothesized that blockade of SGK-1 activity can attenuate AAA growth.

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

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

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

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

Microarray analysis of the time-dependent expression profiles of long non-coding RNAs in the progression of vein graft stenotic disease.

Long non-coding RNAs (lncRNAs) have been reported to be involved in various biological processes, including cell proliferation and apoptosis. However, the expression profiles of lncRNAs in patients with vein graft restenosis remain unknown. In the present study, the time-dependent expression profiles of genes in vein bypass grafting models were examined by microarray analysis. A total of 2,572 lncRNAs and 1,652 mRNAs were identified to be persistently significantly differentially expressed. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analysis was performed to investigate the functions of these lncRNAs. A total of 360 lncRNAs and 135 protein-coding genes were predicted to be involved in the vascular remodeling process. Co-expression network analysis revealed the association between 194 lncRNAs and seven associated protein-coding genes, including transforming growth factor-β1, Fes, Yes1 associated transcriptional regulator, sphingosine-1-phosphate receptor 1, Src, insulin receptor and melanoma cell adhesion molecule. Moreover, reverse transcription-quantitative PCR results supported those of the microarray data, and overexpression of AF062402, which regulates the transcription of Src, stimulated the proliferation of primary vascular smooth muscle cells. The findings of the present study may facilitate the development of novel therapeutic targets for vein graft restenosis and may help to improve the prognosis of patients following coronary artery bypass grafting.

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

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

An indirect comparison by Bayesian network meta-analysis of drug-coated devices versus saphenous vein graft bypass in femoropopliteal arterial occlusive disease

ObjectiveTo compare the efficacy and safety between drug-coated devices (DCDs) and bypass surgery with saphenous vein graft (BSV) in femoropopliteal arterial occlusive disease. MethodsA Bayesian network meta-analysis and indirect comparison were performed. Randomized controlled trials of BSV, bypass surgery with prosthetic graft, bare metal stents, endoluminal bypass (covered stent), percutaneous transluminal angioplasty, and DCDs treating femoropopliteal arterial occlusive disease were collected. The primary end point was target lesion revascularization/target vessel revascularization, and secondary end points were all-cause mortality, limb salvage, and early complications (PROSPERO registry number: CRD42019136530). ResultsForty-two trials and 6867 patients were included. The comparison of DCDs and BSV revealed no significant difference in the 1-year target lesion revascularization/target vessel revascularization (DCDs vs BSV: odds ratio [OR], 0.60; 95% credible interval [CrI], 0.16-2.39). Total early complications from BSV were significantly higher than those from DCDs (DCDs vs BSV: OR, 0.14; 95% CrI, 0.05-0.45), and the main complications of BSV were not death related. There was also no significant difference in systemic early complications (DCDs vs BSV: OR, 0.19; 95% CrI, 0.00-7.82) and 1-year amputation rate (DCDs vs BSV: OR, 2.81; 95% CrI, 0.16-89.53). The 30-day (DCDs vs BSV: OR, 0.38; 95% CrI, 0.00-110.46), 1-year (DCDs vs BSV: OR, 0.96; 95% CrI, 0.24-3.29), 2-year (DCDs vs BSV: OR, 1.60; 95% CrI, 0.64-4.95), and 5-year all-cause mortality rates (DCDs vs BSV: OR, 2.05; 95% CrI, 0.92-4.39) showed no significant differences between DCDs and BSV, although there was a noticeable tendency toward significant results of a higher 5-year mortality rate. ConclusionsThere is no significant difference between DCDs and BSV in short-term efficacy or short- and long-term mortality. Despite traditional BSV remaining the gold standard, DCDs provide a reasonable alternative therapy. In addition, the DCDs have a lower short-term morbidity associated with the procedure at the cost of the possible risk of higher long-term mortality. Clinical trials with more validity are required for a direct comparison between BSV and DCDs.

Long Term Outcomes of Endovascular Therapy for Failing Distal Bypass Vein Grafts

Although distal bypass using vein has been established with acceptable outcomes for chronic limb threatening ischaemia (CLTI), the major issue affecting long term outcomes is vein graft disease. This study aimed to analyse the peri-procedural results and long term outcomes of endovascular therapy (EVT) for failing vein grafts after distal bypass. A retrospective analysis of 113 failing vein grafts (94 patients, 113 limbs) after distal bypass between 2009 and 2019 at the study hospital. The mean age was 74 ± 9 years and 72% of the patients were men. Of the 113 grafts, 54 grafts (48%) were detected in asymptomatic patients, 41 grafts (36%) in patients with recurrent ulcer or gangrene, and 18 grafts (16%) in patients with rest pain. The failing grafts were treated by low pressure long inflation balloon angioplasty with a mean balloon size of 3.0 ± 0.8 mm. The mean procedural time was 60 ± 29 min and procedural success was 98% (111 grafts). During the mean follow up period of 34 months, EVT was performed a median frequency of two times (range 1–11 times). The primary and assisted primary patency of the EVT revised grafts were 41% and 80% at one year, 34% and 68% at three years, 31% and 58% at five years, respectively. Of 41 limbs with recurrent ulcer or gangrene, the wound healed in 34 limbs (85%). The complete healing rate was 71% at three months and 84% at 12 months. Eight patients required major amputation, and the freedom from major amputation rate was 96% at one year and 80% at five years. Long term outcomes including patency, wound healing rate, and amputation free survival after EVT for failing vein grafts were acceptable. EVT could be a viable alternative to surgical revascularisation in patients with a failing distal bypass graft for CLTI.

Minimally Invasive Surgical Repair of Vertebral Artery Ostium Stenosis in Patients with Ischemic Stroke: A Single-Center Case Series

Ischemic stroke is the second leading cause of death in North Macedonia. Posterior circulation disease, caused by vertebral artery (VA) ostium (VAo) stenosis, is a common cause of ischemic stroke. We established a treatment approach using surgical revascularization of posterior circulation disease. In the present observational study, we assessed the outcome after surgical revascularization of the posterior circulation ischemia caused by VAo stenosis. A retrospective analysis of 20 consecutive patients who had undergone surgery from January 2017 to December 2019. The VA was accessed through a 3-cm incision in the upper medial clavicle. The corrective procedures consisted of resection and anastomosis (15 of 20), VA to subclavian artery transposition (16 of 20), endarterectomy (10 of 20), vein graft interposition techniques (4 of 20), and vein graft bypass (1 of 20). The cohort included 9 acute cases. The mean patient age was 66.5 years (range 46-77). Of the 20 patients, 8 were women and 12 were men. Left-sided VA pathology was present in 75% of the cases. We observed rapid clinical improvement in 19 patients (95%). The total study period was 321 patient-months, with a median follow-up of 18 months (interquartile range, 5-24 months). One patient had died of an unknown cause after 12 months. During the follow-up period, 15 patients (75%) had reported permanent clinical improvement with no significant relapse of symptoms. Minimally invasive surgical revascularization of the posterior brain circulation is a clinically effective therapeutic approach to manage ischemia caused by VAo stenosis. It can be performed safely, promote long-lasting symptom relief, and prevent recurrent strokes.

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

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

Long Term Outcomes of Endovascular Therapy for Failing Distal Bypass Vein Grafts

Although distal bypass using vein has been established with acceptable outcomes for chronic limb threatening ischaemia (CLTI), the major issue affecting long term outcomes is vein graft disease. This study aimed to analyse the peri-procedural results and long term outcomes of endovascular therapy (EVT) for failing vein grafts after distal bypass. A retrospective analysis of 113 failing vein grafts (94 patients, 113 limbs) after distal bypass between 2009 and 2019at the study hospital. The mean age was 74±9 years and 72% of the patients were men. Of the 113 grafts, 54 grafts (48%) were detected in asymptomatic patients, 41 grafts (36%) in patients with recurrent ulcer or gangrene, and 18 grafts (16%) in patients with rest pain. The failing grafts were treated by low pressure long inflation balloon angioplasty with a mean balloon size of 3.0±0.8mm. The mean procedural time was 60±29min and procedural success was 98% (111 grafts). During the mean follow up period of 34 months, EVT was performed a median frequency of two times (range 1-11 times). The primary and assisted primary patency of the EVT revised grafts were 41% and 80% at one year, 34% and 68% at three years, 31% and 58% at five years, respectively. Of 41 limbs with recurrent ulcer or gangrene, the wound healed in 34 limbs (85%). The complete healing rate was 71% at three months and 84% at 12 months. Eight patients required major amputation, and the freedom from major amputation rate was 96% at one year and 80% at five years. Long term outcomes including patency, wound healing rate, and amputation free survival after EVT for failing vein grafts were acceptable. EVT could be a viable alternative to surgical revascularisation in patients with a failing distal bypass graft for CLTI.

No Difference in Mid-term and Long-Term Mortality After Vascular Paclitaxel Exposure

Concern has been raised over potential paclitaxel-related increase in mortality following treatment with drug-coated balloons. We report mid-term and long-term patient-level mortality in three trials from our institution. Patient data from the DRECOREST I and II trials, as well as the FINNPTX-trial, were included for analysis. The DRECOREST I involved patients with stenosis in a bypass vein graft, and the DRECOREST II included patients with stenosis in a dialysis fistula. The FINNPTX-trial randomized patients to either a prosthetic bypass or drug-eluting stent for long femoropopliteal lesions. Since the present retrospective study addressed mortality related to intravascular paclitaxel exposure and population data in Finland are comprehensive, we were able to include all patients exposed to paclitaxel in the three trials. Mortality data were extracted from the population registry, as well as patient records. Survival rates were analyzed for all trials pooled and separately. Late mortality was retrospectively analyzed and cross-referenced with national registry data. A total of 142 patients were included, 76 treated with paclitaxel-eluting device, and 66 without. The mean follow-up time for survivors was 3.9years. Overall all-cause mortality was 31.7% during follow-up. In the DRECOREST I-trial, 35.5% of patients died in the paclitaxel group and 37.9% in the control group (P=0.84). In the DRECOREST II, overall mortality was 55.6% in the paclitaxel group and 44.4% in the control group (P=0.51). In the FINNPTX-trial 22.2% died in the paclitaxel group and 10.5% in the control group during follow-up (P=0.30). No single cause of death was overrepresented. The most common causes of death in both groups were cardiovascular death, 59.3% in the paclitaxel group and 52.4% in the control group (P=0.733), followed by malignancy (14.8% vs. 14.3% in the groups respectively). No significant difference was seen in the overall analysis between the paclitaxel and the control group. A statistically nonsignificant elevated late mortality in the FINNPTX-trial after paclitaxel exposure was observed. However, the numbers in the individual trials are small and should be interpreted in the context of future patient-level meta-analysis.