Venous Grafts Research Articles

Alloplastic Vascular Grafts for Venous Interposition in Pancreatic Surgery: Readily Available and Reliable.

To investigate patency and clinical outcomes of alloplastic and other venous interposition graft materials in pancreatic surgery. Vascular pancreatic surgery is increasingly performed for locally advanced pancreatic neoplasms. Different than other centers, we prefer to use alloplastic vascular graft materials for superior mesenteric vein and portal vein interposition in pancreatic surgery. Advantages are off-the-shelf availability at any customizable length, different diameters, and ring-enforcement but proposed concerns are their thrombogenicity and fatal complications. Patients who underwent elective pancreatic resections with mesoportal venous interposition grafts (ISGPS type 4) between 2003-2022 were identified from the institutional pancreatectomy registry. Alloplastic vascular grafts imply synthetic materials, either based on polytetrafluorethylene (PTFE) or polyethylene terephthalate (PET). Surgical details, clinicopathological, and follow-up data were analyzed. The patients were followed for graft patency by cross-sectional imaging. In this study, 201 patients with venous interposition grafts were included (23% simultaneous arterial resections). Total pancreatectomy (41%) and pancreatoduodenectomy (35%) were the most frequent procedures. Vascular graft materials were alloplastic in 180 patients (83% PTFE and 17% PET) with a median diameter of 10mm and a median length of 33mm (measurement by CT scan). Patency rates among all graft materials at 7-, 30-, and 90-days were 99%, 93%, and 87%. Alloplastic grafts demonstrated superior patency over other materials (hazard ratio 2.7, P=0.009), and PTFE reached a 1-year patency of 78%. The all-cause 90-day mortality rate was 10%. No graft infection occurred. Alloplastic venous vascular grafts are safe and readily available tools in pancreatic surgery, especially for long-segmental mesoportal venous reconstructions.

Impact of preoperative quantitative flow ratio on long term coronary artery bypass grafts patency

Abstract Background Preoperative fractional flow reserve (FFR) in the native coronaries is a known predictor of long-term graft patency after coronary artery bypass graft (CABG) surgery. Quantitative flow ratio (QFR) is an angiogram-based functional assessment tool of coronary stenoses. Its predictive value of graft patency is unknown. Purpose To investigate the impact of preoperative QFR value on long-term graft patency after CABG. Methods In this retrospective multicentric study we included consecutive patients treated with CABG between 2011 and 2022, with available coronary angiogram before and at any timepoint after CABG. Three-vessel QFR analysis of the preoperative angiography has been performed. Follow-up angiography was checked for graft patency. Only vessels entered the analysis for which baseline QFR was appropriate and which has been bypassed. Results 400 patients were included with mean age of 67±8 years. They received on average 2.0±0.9 bypasses. 788 coronaries and bypasses were analyzed, among the latter 455 were arterial and 333 were veins. 37% were placed on LAD, 26% on RCA and 26% on the LCx. Stenosis severity at baseline was 73±22% with a QFR value of 0.68±0.30. Follow-up angiographies were performed at 34±29 months. Overall graft patency was 83%, with higher occlusion rate for venous than arterial conduits (27% vs 9%, respectively; HR 3.9 [2.60-5.88]). Occlusion rate was lower for grafts implanted on QFR significant native vessels versus those, placed on non-significant ones (13% vs 30%, respectively; HR 2.86 [1.93-4.26]). Benefit was maintained for both, arterial (5% vs 22%, respectively; HR 5.23 [2.78-10.38]), as well as for venous conduits (24% vs 39%; HR 2.09 [1.21-3.50]). Conclusion QFR significantly predicts graft patency irrespective of whether the graft is arterial or venous. However, patency of venous grafts is poor, even if implanted on functionally significant native stenotic coronaries.Graft patency

Investigating the peri-saphenous vein graft fat attenuation index on computed tomography angiography: relationship with progression of venous coronary artery bypass graft disease and temporal trends

BackgroundTo clarify the fat attenuation index (FAI) change trend of peri-saphenous vein graft (SVG) and determine the association between FAI and graft disease progression based on CCTA images.MethodsPatients with venous coronary artery bypass grafts (CABGs) were consecutively enrolled in this retrospective study. In study 1, 72 patients who had undergone 1, 3, and 5 years of CCTA examinations without graft occlusion were recruited, and generalized estimation equation was used to analyze the peri-SVG FAI change trend over time. In study 2, 42 patients with graft disease progression and 84 patients as controls were propensity score-matched. Generalized linear mixed model and continuous net reclassification improvement (NRI) were used for assessing the associations with graft disease progression. Multivariable Cox regression analysis was used for assessing risk factors predicting cardiac events.ResultsIn study 1, both the FAI of proximal right coronary artery and SVG decreased over time. In study 2, the 1-year CTA-derived FAI of grafts and graft anastomosis were independent indicators of graft disease progression at the 3-year CCTA follow-up (graft: odds ratio [OR] = 1.106; 95% confidence interval [CI] = 1.030–1.188, P = 0.006; graft anastomosis: OR = 1.170, 95% CI = 1.091–1.254, P < 0.001). Inclusion of the graft anastomosis FAI significantly improved reclassification compared with graft FAI (continuous NRI = 0.638, 95% CI: 0.345–0.931, P < 0.001). Moreover, The graft anastomosis FAI was found to be a risk factor for cardiac events after CABG and no statistically significant difference was found in the graft FAI (graft anastomosis: HR = 1.158, 95% CI = 1.034–1.297, P = 0.011; graft: HR = 1.116, 95% CI = 0.995–1.251, P = 0.061).ConclusionsA synchronism was found in the FAI change trend between native coronary artery and venous graft, which both decreased over time. The CCTA-derived FAI of venous grafts showed the potential of demonstrating SVG disease progression and graft anastomosis served as the optimal measured location.

Comparison of autologous venous grafts and three types of extracellular matrix grafts in Peyronie's disease surgery.

Peyronie's disease (PD) is known as a wound-healing disorder for which surgery remains the gold-standard treatment, but studies comparing graft materials are limited in the literature. The aim of this study was to evaluate the mid- and long-term results of patients who underwent surgery for PD with grafting procedures performed by a single experienced surgeon according to graft materials. Patients who underwent corporoplasty between 2014 and 2020 with grafting procedures performed by a single experienced surgeon were retrospectively reviewed. A total of 115 patients were divided into 4 groups according to the grafting material used: autologous saphenous venous grafts, Group 1 (n = 36); porcine pericardial extracellular matrix grafts (EMGs; XenoGuard, MBP Medical Biomaterial Products GmbH, Neustadt-Glewe, Germany), Group 2 (n = 40); porcine intestinal submucosal EMGs (BioDesign, Cook Medical, Bloomington, IN, USA), Group 3 (n = 36); and bovine pericardial EMGs (Tutopatch, Tutogen Medical, Inc., Alachua, FL, USA), Group 4 (n = 43). The mean operation time for Group 1 was longer than that of the other groups (p < 0.001). When comparing the groups in pairs, it was observed that the duration of postoperative loss of sensation (LOS) was significantly shorter in Group 3 (12.3 ± 5.3 days) and Group 4 (15.1 ± 3.1 days) (p < 0.05). There was a statistically significant difference between Groups 1 and 4 in penile length loss when the groups were compared in pairs (p = 0.017). There was a statistically significant difference between patients with penile curvatures of 0° to 59° and patients with curvatures of ≥60° in terms of duration of postoperative LOS (14.4 ± 5 vs. 16.4 ± 5.8 days, respectively; p = 0.028) and penile length loss (2.6 ± 5 vs. 5.7 ± 6.8 mm, respectively; p = 0.002). The findings suggest that EMGs should be preferred to autologous venous grafts due to reduced postoperative erectile dysfunction, shorter operation time, and shorter recovery time for LOS.

Correlation and Agreement of Quantitative Flow Ratio With Fractional Flow Reserve in Saphenous Vein Grafts.

The applicability of quantitative flow ratio (QFR), a nonhyperemic, invasive coronary angiography-derived computation of fractional flow reserve (FFR), has not been studied in coronary artery bypass grafts. We sought to explore the correlation and diagnostic agreement between QFR and FFR in saphenous vein grafts (SVGs). A total of 129 prospectively included patients (mean age 73±8 years, 84% male) with prior coronary artery bypass grafting underwent invasive coronary angiography and pressure-derived functional assessment in 150 nonoccluded SVGs. QFR dedicated angiography images of the SVGs were acquired and used for offline QFR computation. The diagnostic performance of QFR was compared with 2-dimensional quantitative coronary angiography, using FFR as a reference. A threshold of ≤0.80 was used to define functional significance. QFR was successfully computed in 140 (93%) SVGs. We found a significant correlation between QFR and FFR (r=0.72, P<0.001). FFR indicated significant disease in 43 (31%) SVGs, whereas QFR analysis showed significant lesions in 53 (38%) bypass grafts. QFR exhibited a higher sensitivity and diagnostic accuracy compared with angiographic lesion assessment (84% versus 63%, P=0.030 and 83% versus 74%, P=0.036, respectively), whereas specificity did not differ (82% versus 79%, P=0.466). Lastly, QFR demonstrated a higher area under the receiver operating curve than quantitative coronary angiography (0.90 versus 0.82, P=0.008) for the detection of FFR-defined significant vein graft disease. This study shows the potential applicability of contemporary QFR computation in venous bypass grafts with a moderate correlation and good diagnostic accuracy compared with functional assessment using FFR.

Total Arterial Revascularisation in a Patient with Previous History of Burns

Arterial grafts have higher patency rates when compared to venous grafts. Total arterial revascularisation is commonly being done nowadays and more commonly in young patients and also in patients with poor quality veins, amputated patients, patients with DVT, post burns patients in whom veins are thrombosed and in patients with non healing ulcers and infection over the legs. A variety of configurations can be made using total arterial revascularisation, using bilateral internal mammary arteries or LIMA-RIMA-Y graft or using internal mammary arteries along with radial artery.

Outcomes of Single versus Sequential Vein Grafts in Isolated Coronary Artery Bypass Surgery: Insights from a Large Tertiary Care Center

BackgroundSaphenous venous grafts (SVG) remain the most widely used conduits in coronary artery bypass graft surgery (CABG). Data comparing outcomes of single saphenous venous grafting (SinCABG) versus sequential venous grafting (SeqCABG), however, are limited. MethodsBetween 2002 and 2012, 2,375 patients with 3-vessel coronary artery disease underwent isolated elective CABG at the Leipzig Heart Center with a left internal mammary artery graft to left anterior descending artery and ≥2 distal SVG anastomoses. Of these, 1,278 received ≥2 singular saphenous venous grafts (SinCABG) and 563 received ≥1 sequential saphenous vein grafts with >1 distal anastomoses (SeqCABG). The primary end point was long term survival. Secondary outcomes included short-term survival, early postoperative outcomes as well as early and late graft patency. ResultsAt 30-days, mortality was 1.3% following SinCABG as compared to 2.3% after SeqCABG (p=0.13). The postoperative complications rate did not differ between groups. Early postoperative coronary angiographies were performed in 127 patients (7%), while clinically indicated follow-up coronary angiographies were performed in 372 patients (20%) over a median follow up of 5 years (IQR 1.7-8.9). No differences in early or late patency rates were found between both grafting techniques (p=0.79 and p=0.39, respectively). The median duration of long-term clinical follow-up was 8.4 years (IQR 5.6-11.4). Long-term survival rates at 1, 5, 10 and 15 years in SinCABG versus SeqCABG were 95% versus 94%, 83% versus 82%, 63% versus 62%, and 47% versus 41%, respectively (p=0.22). ConclusionsShort and long-term mortality as well as early and late graft patency rates did not differ in patients undergoing SinCABG as compared to patients undergoing SeqCABG.

Role of Embolic Protection in Percutaneous Coronary Intervention without Saphenous Venous graft lesions in ST-elevation myocardial infarction - a systematic review and meta-analysis.

Embolic protection devices are catheter-based devices that can be used to capture atherosclerotic remnants released during percutaneous coronary intervention (PCI). We aim to study the efficacy and safety of EPDs in PCIs without saphenous vein grafts (SVG) in ST-elevation myocardial infarction(STEMI). 3 electronic databases of MEDLINE, Web of Science, and Embase were searched from inception to Apr 10, 2024, to identify relevant randomized controlled trials (RCTs) that compared outcomes of patients subjected to EPD during PCI with control group where EPDs were not utilized. The primary outcome was 30-day all-cause mortality. Secondary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days, post-PCI Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow attainment, ST-segment resolution at 90 minutes post-procedure and post-procedure angiographically detectable signs of distal embolization. The effect estimates of outcomes were assessed using risk ratio (RR) with a 95% confidence interval (CI). Random-effects meta-analysis was conducted using the restricted maximum likelihood method given the inter-study variance was inevitable. We included 3 RCTs enrolling 741 patients (age 61.6 ± 12.15 years, 22% females) undergoing PCI without SVG lesions. As opposed to the control group, the use of EPD did not yield a significant effect on all-cause mortality (RR, 0.76; 95% CI, 0.31-1.86; I2 = 0%), MACCE (RR, 0.66; 95% CI, 0.34-1.27; I2 = 0%), post-PCI TIMI 3 flow (RR, 1.18; 95% CI, 0.86-1.62; I2 = 77%) and ST segment resolution at 90 minutes post-procedure (RR, 1.05; 95% CI, 0.90-1.22; I2 = 0%). However, EPD significantly decreased angiographically detectable signs of distal embolization (RR, 0.60; 95% CI, 0.36 to 0.99; I2 = 0%). EPD significantly reduced angiographically detectable signs of distal embolization in PCI without SVG lesions in STEMI, though there were no clinical signs of improved flow or mortality. Further trials are necessary to thoroughly evaluate the potential benefits and requirements of EPD usage in such procedures.

Effectiveness of autologous interposition saphenous graft in the creation of proximal arteriovenous fistula: Our initial experience

Abstract: For the individuals with end-stage renal disease, maintenance hemodialysis is a common treatment. When we compare to dialysis catheters or prosthetic grafts, arteriovenous fistula (AVF) is associated with a greater maturation period but a smaller incidence of infections, central venous stenosis, hospitalizations, and mortality. Fistulas mature by a dynamic process which is known as venous arterialization, where the breakdown of elastin and release of nitric oxide promote the functional and structural remodeling of the venous wall, permitting the expansion of venous outflow. Veins made them exposed to the arterial environment at the time of venous grafts and AVFs creation. Successful adaptation of the vein to the arterial flow is the most demanding part for long-term success, identified by venous dilation followed by wall thickening. Arteriovenous fistulas (AVF) and grafts (AV graft) are the commonest form of vascular access used for maintenance of hemodialysis. In general AVF is superior than AV graft in terms of its durability, patency, complication rate and overall survival of patients. But when the calibre of the vein is not satisfactory or length is not adequate to make tension free anastomosis, interposition graft is used. Most commonly used bridging material is polytetrafluoroethylene (PTFE) polymer. In this case, we used an interposition graft of the saphenous vein for making dialysis access on a 38 year old male patient having renal insufficiency and evaluated its efficacy in maintaining flow.

802. TECHNICAL DETAILS: FREE JEJUNAL GRAFT AND REVERSE SAPHENOUS VEIN GRAFT FOR RECONSTRUCTION AFTER TOTAL PHARYNGO-LARYNGECTOMY AND PROXIMAL ESOPHAGECTOMY

Abstract Background We would like to show our tips for free jejunal graft and vascular reconstruction after pharyngo-laryngectomy and proximal esophagectomy. Methods 65 years-old man with history of hypopharynx squamous cell carcinoma cT3 cN0 cM0 who underwent radical Qt/Rt with initially complete response. After 2 years follow-up, he presented dysphagia and recurrence of squamous cell carcinoma proven by histology. Upper endoscopy shows cervical esophageal stenosis due to tumor infiltration. Rescue surgery was decided after systemic dissemination was ruled out with PET-CT. Results Pharyngo-laryngectomy, total thyroidectomy and proximal esophagectomy was performed. Free margin tumor was confirmed by frozen section. Jejunal segment with adequate vascular supply is selected, preferable with a single artery and vein. Peristaltic direction of the jejunum is marked to avoid mistakes during graft transposition. Division of mesenteric branches to prevent postoperative bleeding. Before jejunal section we recommend administration of hyoscine butilbromide 20 mg iv to avoid jejunal spams. Measuring the length graft needed before dividing the jejunum to avoid redundant or short graft is recommended. We must carefully isolate the pedicle avoiding damaging blood supply. To reduce time of ischemia, jejunal graft pedicle should not be ligated until cervical dissection is completed and we have ruled out if venous graft may be needed. After cervical artery and vein dissection, we ensure adequate blood flow and heparinize vessels before clipping. When dividing the pedicle, artery should be divided before the vein to avoid venous congestion, posteriorly we must heparinize the vessels. Povidone-iodine intraluminal washing is recommended. Jejuno-jejunal anastomosis for GI tract restoration. GI reconstruction first is recommended to avoid unnecessary traction on the vascular anastomosis. After ensuring adequate direction of the jejunal graft jejuno-esophageal anastomosis is performed with interrupted suture. Pharyngo-jejunal anastomosis is performed with barbed 3-0 running suture for anterior and posterior layer. Methylene blue test is performed for check the anastomosis. Vascular reconstruction technique depends on the vascular anatomical variations and availability. In this case, superior thyroid artery and sublingual vein were available. Saphenous vein graft might be needed, this graft must be used in reverse way to avoid the vein valves and length must be adjusted. Venous anastomosis should be performed before than arterial reconstruction after heparinize solution in both vessels to avoid thrombosis. Conclusion Free jejunal graft is a highly complex procedure that must be extremely coordinated and protocolized to avoid longer time of ischemia and risk of thrombosis that might compromise the graft viability. https://1drv.ms/v/s!AmFrct07P6MP1Fbyh_7Ce_OK5bB8?e=OMSjsK

Evaluating the Efficacy of Venous versus Arterial Grafts in CABG: A Cross-Sectional Retrospective Study

Background: Angiography of the coronary arteries is the most noninvasive advanced method of establishing graft patency post-coronary artery bypass grafting. The emergence of multi-slice computed tomography has opened a wide avenue for fast imaging around coronary angiography, with a featured scan time of 0.25 seconds, up to 32-slice detection, and multirow detector arrays, which are very important for quick evaluation. Methods and Results: This study was a retrospective cross-sectional case series that involved 56 individual patients who underwent CABG in the Erbil Cardiac Center. Clinical and radiological evaluations were carried out to evaluate arterial and venous grafts' patency, considering the sociocultural pattern of the individual, type of conduits used, and patency in relation to multiple risk factors. The patency of arterial grafts was 84.9%, while that of venous was 61.9%. Features like hypertension, diabetes mellitus, exercise, and dietary restriction were shown to have a significantly associated vessel occlusion with a P-value of less than 0.05%. Conclusion: The results of our study also confirm that arterial grafts have far better patency rates than saphenous vein grafts (SVG) in coronary artery bypass grafts. Contributory factors for graft occlusion are diabetes mellitus, hypertension, double antiplatelet therapy, and smoking habits. There is also suggestive evidence that dietary and exercise modification in the patient orientation program would improve the long-term outcome of patients after CABG.

Comparative effectiveness of antiplatelet therapies for saphenous venous graft occlusion and cardiovascular outcomes: a network meta-analysis.

The ideal antiplatelet therapy to maintain graft patency after coronary artery bypass graft surgery (CABG) remains controversial. This review of randomized controlled trials (RCTs) aims to compare aspirin monotherapy, ticagrelor monotherapy, dual antiplatelet therapy (DAPT) with aspirin and ticagrelor (Asp+Tica) or with aspirin and clopidogrel (Asp+Clopi) to evaluate differences in post-CABG saphenous vein graft (SVG) occlusion, internal mammary artery (IMA) occlusion, myocardial infarction (MI), bleeding, and all-cause mortality (ACM) rates. The literature review was conducted on several electronic databases, including Medline, Embase, and Cochrane Central, from inception to August 10, 2022. Data was extracted using a predefined proforma. A Bayesian random-effects model was used for calculating point effect estimates (odds ratio and standard deviation). Quality assessment was done using the Cochrane RoB-2 tool. Ten RCTs comprising 2139 patients taking anti-platelets post-CABG were included. For preventing SVG occlusion, Asp+Tica showed the lowest mean AR of 0.144±0.068. Asp+Tica also showed a trend toward lesser postoperative MI risk and lower ACM rates, with a mean AR of 0.040±0.053 and 0.018±0.029, respectively. For maintaining IMA graft patency, Asp+Clopi showed the lowest mean AR of 0.092±0.053. Ticagrelor had the lowest mean AR of 0.049±0.075, with Asp+Tica showing a similar mean AR of 0.049±0.045 for postoperative major bleeding risk. Our analysis demonstrates that Asp+Tica can be the ideal therapy for patients undergoing CABG using SVG as it decreases the risk of post-CABG SVG occlusion and is not associated with a significantly higher risk for major bleeding.

Evaluation of early results of diagnosis and treatment of popliteal artery injury in knee trauma at Binh Dan Hospital

Objectives:To describe the clinical and subclinical signs for early diagnosis and evaluate the short-term outcomes of surgical treatment of popliteal artery injury in knee trauma. Materials and methods: A retrospective descriptive study was conducted on 30 patients with knee trauma and popliteal artery injury who underwent surgery at Binh Dan Hospital from August 2016 to June 2021. Results: The mean age of admitted patients was 35.5±12.8 years, predominantly male (73.3%). The majority of cases were due to traffic accidents (83.4%). Peripheral pulse was absent or decreased in 76.7% of patients. Most patients (95.3%) showed loss of flow signal on ultrasound. The most common surgical intervention was venous graft repair (63.3%). After surgery, 93.3% of patients had good flow restoration. The postoperative arterial occlusion rate was 6.7%. There were two cases that required a second surgery for popliteal artery recanalisation: one case where limb salvage was achieved, and one case that resulted in amputation. Conclusion: The application of appropriate diagnostic measures, emergency management, and surgical intervention has resulted in positive treatment outcomes, helping to reduce the rate of limb amputation and other severe complications

Drug-coated balloons versus conventional percutaneous transluminal angioplasty for treatment-naïve dysfunctional arteriovenous fistulas.: A 10-year single center retrospective study.

To compare the primary patency and restenosis rates in treatment naieve dialysis arteriovenous fistulas (AVFs) after drug-coated balloons (DCB) versus plain balloon angioplasty (PTA). This retrospective study included 157 patients who underwent AVF angioplasty for treatment-native AVF stenosis between January 2012 to 2022. The fistulas were Brachiocephalic (75%), Brachiobasilic (17%), and radiocephalic (8%). The index intervention was with either DCB or percutaneous transluminal angioplasty (PTA) with subsequent follow up. Patients with central venous stenosis, thrombosed fistula, fistula stents, AV graft or surgical intervention after the index procedure were excluded. Arteriovenous fistula angioplasty was done in 28 patients using DCB and in 129 patients using PTA. A total of 108 patients presented with a single stenosis, 42 with 2 stenoses, and 7 with 3 stenoses. The location of these stenoses was in the venous outflow (57%), the juxta anastomotic segment (31%), and cephalic arch (12%). The median time to re-intervention for the PTA was 216 days compared to 304 days for the DCB (p=0.079). Primary patency at 6 months was 60.4% for PTA and 75% for DCB (p=0.141) CONCLUSION: Although DCB angioplasty of treatmentnaïve dysfunctional AVF tends to improve the time to intervention and 6-month primary patency compared to PTA, this difference did not reach statistical significance.

Staged treatment with arterial reconstruction and flap transplantation for ischemic mangled extremity: An observational study.

Patients with traumatic ischemic mangled extremities first undergo arterial reconstruction using autogenous vein grafts, followed by flap transplantation as a staged treatment for soft tissue reconstruction. This study aimed to report the outcomes of such a staged treatment. Thirteen patients underwent arterial reconstruction between February 2015 and April 2017 due to damage to the major blood vessels by the traumatic mangled extremities. Of them, 6 patients (5 males and 1 female with a mean age of 51 years, age range: 36-60 years) who underwent soft tissue reconstruction due to necrosis were retrospectively analyzed. The average Mangled Extremity Severity Score was 7.2 (range, 6-8). Injuries were found in the lower leg (4 cases), foot (1 case), and wrist and hand (1 case). Arterial reconstruction was performed using autologous venous grafts. The reconstructed arteries included the posterior tibial artery (3 cases), anterior tibial artery (1 case), dorsalis pedis artery (1 case), and radial artery (1 case). The blood circulation status of the reconstructed blood vessels was assessed using computed tomography angiography at an average of 5 weeks (range, 4-6 weeks) after arterial reconstruction. For some necrotic soft tissues, debridement and flap transplantation were performed an average of 7 weeks (range, 6-8 weeks) after arterial reconstruction. Soft tissue reconstruction was performed with an anterolateral thigh free flap in 4 cases, a local flap in 1 case, and a muscle flap in 1 case. In 5 out of 6 cases, blood circulation was maintained in the reconstructed blood vessels, resulting in the salvaging of the extremities. All the patients who underwent flap surgery survived. Notably, there were no special complications during a follow-up visit conducted at an average of 19 months post-reconstruction. To treat an ischemic mangled extremity, the limbs should first be salvaged with arterial reconstruction, followed by subsequent appropriate flap surgery when soft tissue necrosis occurs at the mangled site as a staged treatment.

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.

Management of Pediatric Lower Extremity Vascular Trauma: Adult vs Pediatric Level I Trauma Centers [RETRACTED

Pediatric lower extremity vascular injury (PLEVI) is uncommon. Though epidemiologic studies exist, the availability of granular data is sparse. Additionally, few studies compare the management between adult (ATC) and pediatric (PTC) trauma centers. The objective of this study was to analyze the surgical management of PLEVIs between a Level I ATC and a Level 1 PTCs in our metropolitan area. We performed a retrospective review of all PLEVIs (age < 18 years) managed surgically between 01/2009-12/2022. Demographics, clinical and outcome data were obtained and compared between centers. Primary outcomes included amputation and fasciotomy rates. Secondary outcomes included type of vessel repair, mortality, and intensive care unit (ICU) and hospital length of stay. Seventy-nine patients were identified, 41 at the ATC and 38 at the PTC totaling 111 vessels injured. Overall, 84.8% were male. ATC patients were older (median 16.0 vs 12.5) and almost exclusively (97.6% vs 29.0%) gunshot wounds. There was no difference in ISS. The popliteal artery was the most injured vessel, ATC (50%) and PTC (40%). Vascular surgeons managed 50% of injuries at ATC vs 60.5% of injuries at the PTC (p = 0.35). Rates of arterial or venous repair, ligation, or grafting were not significantly different. Amputations were uncommon at both centers and not significantly different. Seventeen patients (44.7%) required fasciotomies at the PTC vs 21 (51.2%) at the ATC (p = 0.56). There was no significant difference in mortality, ICU, or hospital length of stay. PLEVI have acceptable outcomes (low amputation and/or fasciotomy rates, low mortality) and are managed uniformly between ATCs and PTCs. This data adds important context to the management of PLEVI. Retrospective Chart Review, Level IV.

MITRACLIP TREATMENT FOR CARDIOGENIC SHOCK DUE TO ACUTE MITRAL REGURGITATION IN A PATIENT WITH POSTINFARCTION PAPILLARY MUSCLE RUPTURE

Abstract A 85–year–old woman presented to ED with worsening dyspnea for 24 hours; no other related symptom. Her medical history included hypertension, dyslipidemia, type 2 DM and surgical coronary revascularization 13 years before for multiple critical coronary artery disease (LIMA to LAD and sequential SVG to PDA and OM branch). The ECG promptly revealed a subacute infero–lateral STEMI. Transthoracic echocardiography (TTE) showed inferior and postero–lateral wall akinesia with severely reduced left ventricle ejection fraction (LVEF), mildly reduced right ventricle systolic function and severe mitral regurgitation (MR) due to posterior papillary muscle (PM) rupture (Fig.1). Clinical scenario was complicated by pulmonary edema and cardiogenic shock treated with diuretics and sodium nitroprusside infusion, non–invasive ventilation and IABP insertion. Urgent coronary angiography revealed a thrombotic occlusion of the venous graft for OM branch. Surgical correction was excluded due to hemodynamic instability. Graft occlusion was treated with manual thromboaspiration, balloon dilatations and abciximab infusion. After an initial stabilization, transesophageal echocardiography (TEE) was performed confirming severe MR resulting from rupture of one head of a bifid posterior PM (red arrows, Fig.1) and prolapse of the anterior leaflet combined with restrictive systolic movement of the posterior leaflet due to wall motion abnormalities. 3 days later a transcatheter mitral valve edge–to–edge repair (MTEER) was performed using a MitraClip device (1 XTR clip and 1 NTR clip, Fig.2). TEE with 3D and TrueVue vision confirmed the correct placement of clips (Fig.3), a mild–to–moderate residual MR, absence of significant transmitral gradient and a mildly reduced LVEF. No clinical events were reported during recovery; patient was discharged after 2 weeks. Conclusion MTEER is an established therapy for reducing degenerative and functional MR. Little data is available on its use in the setting of PM rupture. This rare complication of AMI carries a mortality rate of 80% during the first week without surgical correction but more than half of patients are excluded because of prohibitive operative risk. TEER may be an alternative for these patients. In this case report we described the utility of MTEER in the setting of cardiogenic shock secondary to acute ischemic MR with papillary muscle partial rupture. This procedure can be useful with acceptable safety and procedural success.

Bypass Patency and Amputation-Free Survival after Popliteal Aneurysm Exclusion Significantly Depends on Patient Age and Medical Complications: A Detailed Dual-Center Analysis of 395 Consecutive Elective and Emergency Procedures.

Background/Objectives: A popliteal artery aneurysm (PAA) is traditionally treated by an open PAA repair (OPAR) with a popliteo-popliteal venous graft interposition. Although excellent outcomes have been reported in elective cases, the results are much worse in cases of emergency presentation or with the necessity of adjunct procedures. This study aimed to identify the risk factors that might decrease amputation-free survival (efficacy endpoint) and lower graft patency (technical endpoint). Patients and Methods: A dual-center retrospective analysis was performed from 2000 to 2021 covering all consecutive PAA repairs stratified for elective vs. emergency repair, considering the patient (i.e., age and comorbidities), PAA (i.e., diameter and tibial runoff vessels), and procedural characteristics (i.e., procedure time, material, and bypass configuration). Descriptive, univariate, and multivariate statistics were used. Results: In 316 patients (69.8 ± 10.5 years), 395 PAAs (mean diameter 31.9 ± 12.9 mm) were operated, 67 as an emergency procedure (6× rupture; 93.8% severe acute limb ischemia). The majority had OPAR (366 procedures). Emergency patients had worse pre- and postoperative tibial runoff, longer procedure times, and more complex reconstructions harboring a variety of adjunct procedures as well as more medical and surgical complications (all p < 0.001). Overall, the in-hospital major amputation rate and mortality rate were 3.6% and 0.8%, respectively. The median follow-up was 49 months. Five-year primary and secondary patency rates were 80% and 94.7%. Patency for venous grafts outperformed alloplastic and composite reconstructions (p < 0.001), but prolonged the average procedure time by 51.4 (24.3-78.6) min (p < 0.001). Amputation-free survival was significantly better after elective procedures (p < 0.001), but only during the early (in-hospital) phase. An increase in patient age and any medical complications were significant negative predictors, regardless of the aneurysm size. Conclusions: A popliteo-popliteal vein interposition remains the gold standard for treatment despite a probably longer procedure time for both elective and emergency PAA repairs. To determine the most effective treatment strategies for older and probably frailer patients, factors such as the aneurysm size and the patient's overall condition should be considered.

Axillary necklace graft salvage of a locally infected Haemodialysis with Reliable Outflow (HeRO®) graft.

A 48-year-old patient presented 4 months after insertion of a right sided Haemodialysis with Reliable Outflow (HeRO®, Merit Medical) graft with a discharging abscess at the site of the brachial artery anastomosis. There was localised involvement of the arterial Gore® Acuseal inflow graft that necessitated its removal. The venous outflow component was thought salvageable as infection was well localised to the region of the antecubital fossa. Alternative access options were limited so we sought to preserve the venous outflow portion of the patient's original graft - minimising tissue damage and avoiding the need for a dialysis line. The infected arterial graft was excised, leaving behind the original SuperHero® connector and venous graft. A left sided tunnelled axillary necklace technique was utilised to restore arterial inflow. After a four-day recovery, the patient went on to successfully resume their usual haemodialysis regimen without any complications. Convalescent imaging, repeat blood cultures, and monitoring of inflammatory markers showed no signs of residual infection at 6 weeks. The originality of this case was the way in which an axillary necklace inflow graft was connected to the pre-existing venous outflow portion of the HeRO® haemodialysis graft system, allowing the excision of the infected inflow graft at the brachial anastomosis. This technique could be viewed as an effective salvage procedure as it allowed the venous outflow portion of the original graft to remain in situ, minimised tissue damage and enabled the patient to swiftly resume haemodialysis without the need for a line.