Superficialization of dilated radial artery for vascular access: A case report.

Successful hemodialysis treatment need a well functioning vascular access (VA) allowing two cannulation sites with enough blood flow have minimum adverse events. The expectations, age of the HD population are rising as well as the lack of conventional methods due to central venous exhaustion, we have to choose some complex access, including complex or tertiary vascular access mentioned in 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) and the option to abandon the venous circuit in instead of arterial system, including arterial-arterial graft and arterial superficialization. This article report a complicated case of AVF dysfunction, central venous stenosis due to central venous catheter and aortic dissection stent as well as lower extremity arteriosclerosis occlusion, using the simple method of superficialization of enlarged radial artery to maintain hemodialysis.

Efficacy and Safety of Paclitaxel-Coated Balloon Angioplasty for Dysfunctional Arteriovenous Fistulas: A Multicenter Randomized Controlled Trial.

RATIONALE & OBJECTIVE: Previous studies have illustrated the potential superiority of drug-coated balloons (DCBs) in maintaining patency after initial angioplasty for arteriovenous fistula (AVF) dysfunction due to stenosis. Our trial evaluated the efficacy and safety of DCBs for preventing fistula restenosis in Chinese hemodialysis patients. STUDY DESIGN: Multicenter, prospective, randomized, open-label, blinded end point, controlled trial. SETTINGS & PARTICIPANTS: A total of 161 hemodialysis patients with fistula dysfunction from 10 centers in China. INTERVENTION: Participants were randomized 1:1 to treatment with initial dilation followed by DCB angioplasty or conventional high-pressure balloon (HPB) angioplasty. OUTCOMES: The primary end point was target lesion primary patency defined as the target lesion intervention-free survival in conjunction with an ultrasonography-measured peak systolic velocity ratio (PSVR) ≤2.0 at 6 months. The secondary end points included 1) device, technical, clinical, and procedural success; 2) major adverse events; 3) degree of target lesion stenosis at 6 months; and 4) clinically driven target lesion and target shunt revascularization within 12 months. RESULTS: The percentage with target lesion primary patency as defined by a PSVR ≤2.0 was higher in the DCB group than in the control group (65% vs 37%, respectively; rate difference, 28% [95% CI, 13%-43%]; P <0.001) at 6 months. The target lesion and target shunt intervention-free survival of the DCB group were not superior to those of the control group at 6 months (P = 0.3 and P = 0.2, respectively) but were superior at 12 months (target lesion intervention-free survival: 73% for DCB vs 58% for control [P = 0.04]; target shunt intervention-free survival: 73% for DCB vs 57% for control [P = 0.04]). The average degree of target lesion stenoses at 6 months was not significantly different between the 2 groups (44% ± 16% for DCB vs 49% ± 18% for control; P = 0.09). There were no significant differences in major adverse events or in device, technical, clinical, or procedural success rates between the groups. LIMITATIONS: Small sample size; short follow-up period; procedural differences between the 2 groups such as unequal inflation times and balloon lengths. CONCLUSIONS: Compared to conventional HPB angioplasty, DCB treatment achieved superior primary patency defined using PSVR measured at 6 months and superior intervention-free survival of both the target lesion and the target shunt at 12 months without evidence of greater adverse events. FUNDING: Funded by ZhuHai Cardionovum Medical Device Co., Ltd. TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT02962141.

Left innominate vein stenosis in an asymptomatic population: a retrospective analysis of 212 cases.

BACKGROUND: Although left innominate vein (LIV) stenosis has been demonstrated to be attributed to compression by adjacent anatomical structures, most of the studies are focusing on hemodialysis patients with clinical symptoms compatible with LIV stenosis. The goal of this study was to retrospectively investigate the incidence of LIV stenosis and its influencing factors in an asymptomatic, non-hemodialysis population, which has rarely been performed. METHODS: From Jan 2013 to Dec 2014, 212 consecutive cases undergoing a chest multi-detector computed tomography (MDCT) angiography were enrolled. LIV stenosis was defined as loss of the area of the LIV (that is, 1 - compression degree) >25%. Multivariate logistic regression analysis was performed to explore the independent risk factors associated with LIV stenosis. RESULTS: LIV stenosis occurred in 35.4% of cases (75/212), with the median loss of the area of the LIV of 36.2% (interquartile range 30.2-49.8%). There were significant differences in age (62.5 ± 11.7 vs. 58.6 ± 14.3 years; P = 0.041), BMI (23.9 ± 2.9 vs. 23.0 ± 3.3, P = 0.036), the frequency of crossing site of LIV over the origin of the aortic arch (54.7 vs. 24.8%, P < 0.001), and the space between aortic arch and sternum [mean ± SD, 11.6 ± 4.2 mm vs. median, 14.1 (interquartile range 11.9-16.3) mm, P < 0.001] between patients with and without LIV stenosis, but only the latter two were confirmed as independent factors by the multivariate logistic regression analysis [crossing site of LIV over the aortic arch, OR (95% CI) = 2.632 (1.401, 4.944), P = 0.003; space between the aortic arch and sternum, OR (95% CI) = 0.841 (0.770, 0.919), P < 0.001]. CONCLUSION: The patients with an older age, high BMI, LIV crossing over the origin of the aortic arch, or smaller space between aortic arch and sternum may have high risks for LIV stenosis. They should be paid more attention to exclude LIV stenosis preoperatively using MDCT angiography to prevent venous access dysfunction and symptomatic development by fistula creation when hemodialysis is required.

Altered microRNA expression in stenoses of native arteriovenous fistulas in hemodialysis patients.

OBJECTIVE: Arteriovenous fistula (AVF) disfunction is largely due to venous stenosis characterized by a marked amount of intima-media hyperplasia. However, the molecular mechanisms are currently poorly understood. MicroRNAs (miRNAs), small noncoding RNAs that are post-transcriptional regulators of gene expression, could provide insights into a mechanism for the differential expression of genes in stenotic AVFs. METHODS: A microarray study was done to detect differences in miRNA levels between stenotic AVF (n = 8) and controls (n = 4). Real-time quantitative reverse-transcription polymerase chain reaction assays with 12 stenotic AVF veins and eight control veins from predialytic patients were used for verification. Putative gene targets were retrieved from miRNA target prediction databases. Networks from the target gene set were created and examined. Western blotting and immunohistochemical staining were performed to confirm the bioinformatic findings. RESULTS: A microarray study identified 33 miRNAs with markedly different expression levels between stenotic AVFs and control veins. Among them, nine miRNAs were upregulated and 24 miRNAs were downregulated in the stenotic AVFs. Real-time reverse-transcription polymerase chain reaction confirmed statistically consistent expression of six selected miRNAs with microarray analysis. The predicted miRNA target genes differentially expressed in stenotic AVF based on databases were identified. The mitogen-activated protein kinase signaling pathway might be regulated by miRNAs according to bioinformatic analyses and further confirmed by Western blotting and immunohistochemical staining. CONCLUSIONS: Our genome-wide approach identified several differentially expressed miRNAs in stenotic AVFs. This study also suggested that the mitogen-activated protein kinase signaling pathway might play a role in the pathogenesis of stenotic AVF.

Venous stenosis in chronic dialysis patients with a well-functioning arteriovenous fistula.

PURPOSE: It is not clear whether patient who is dialyzing with a well-functioning vascular access may appear venous stenosis. The aim is to see the prevalence of central or other vein stenoses/occlusions in patients with asymptomatic, normal functioning fistulas. METHODS: A total of 54 patients met the inclusion criteria. We performed angiography examinations for these patients and reviewed venography of the superficial and deep venous systems. RESULTS: Among these patients, 21 (39%) were detected positive cases by the angiography, the remainder was negative cases. Thirteen of 54 (24%) had mild central venous stenosis (stenosis <50% diameter with or without collateral branch), 7/54 (13%) had upper arm vein system occlusion or stenosis, another one had anastomotic stenosis. There were no differences in fistula flow dynamics between those with venous abnormalities and those without such as blood flow rate, venous pressures, brachial arterial velocity, and brachial arterial flow rate. We also observed no significant differences in other variables between these two groups (including BMI, hemoglobin, albumin, gender, primary disease, URR, spKt/V P > 0.05). CONCLUSION: The frequency of venous lesion is not low in hemodialysis patients with a well-functioning AVF. To value the impact of these abnormalities on access, prognosis needs longer time follow-up.

Prevention of Neointimal Hyperplasia by Local Application of Lentiviral Vectors Encoding Pin1 shRNA in Pluronic F127.

Inhibition of intimal hyperplasia plays an important role in preventing restenosis. Previously, we reported the provocative role of Pin1 in regulating vascular smooth muscle cell (VSMC) proliferation. Here we intended to identify whether locally delivered lentivirus-mediated siPin1 via pluronic F127 (PF127) could inhibit neointimal formation and further explore the potential mechanisms thereof. In vitro studies revealed that lentivirus-mediated siPin1 dispersed in PF127 suppressed proliferation and induced senescence in VSMCs. Reduction of Pin1 expression resulted in a decrease of phospho-Akt (p-Akt) expression level in VSMCs. Reactivation of Akt phosphorylation overcame the siPin1-mediated senescence. In a rat wire injury model, periadventitial delivery of lentivirus-mediated siPin1 via PF127 produced inhibition of intimal hyperplasia 14 days after injury without evidence for toxicity. Furthermore, the reduction of intimal thickness was associated with a decreased amount of PCNA positive cells, decreased telomerase activity and shortened telomere length. Therefore, these results suggest that PF127 delivery of lentivirus-mediated siPin1 to artery may have a therapeutic potential for the treatment of restenosis.

Anatomical factors associated with left innominate vein stenosis in hemodialysis patients.

Central venous stenosis remains a challenge in hemodialysis patients. Venograms have shown that left innominate vein (LIV) stenosis often occurs in front of the trachea, where it crosses the aortic arch, suggesting that there may be an anatomical factor involved, such as iliac vein compression syndrome. The goal of this study was to determine whether LIV stenosis can be attributed to compression. From September 2008 to December 2011, 19 hemodialysis patients (ten women, nine men) with symptomatic venous hypertension of the upper-left extremity were enrolled in this study. Venography and multidetector computed tomography were used to determine the location of the venous stenosis and to assess LIV anatomy. LIV diameter and the space between the sternum and aortic arch were compared between the LIV stenosis (LIVS) group (n = 9) and the non-LIV-stenosis (NLIVS) group (n = 10). The mean age of the cohort was 63 ± 17.3 years. The mean LIV diameter was 1.69 ± 1.55 mm in the LIVS group and 8.71 ± 2.33 mm in the NLIVS group. The space between the aortic arch and sternum was smaller in the LIVS group (4.55 ± 2.67 mm) than in the NLIVS group (15.25 ± 6.12 mm, P < 0.001). A contributing factor to LIV stenosis may be due to anatomical compression of the aortic arch behind the sternum. Preoperative noncontrast computed tomography is recommended for hemodialysis patients to exclude extrinsic compression.

[Retrograde tibial approach for endovascular recanalization of popliteal and tibioperoneal artery occlusion].

OBJECTIVES: To describe a procedure of the retrograde approach for endovascular treatment of complex popliteal and/or infrapopliteal occlusions and to determine its safety and efficacy in minimizing failure rates. METHODS: Between January 2010 and March 2012, 28 patients (16 male and 12 female patients) received retrograde tibial approach after failure of antegrade intervention. There were 3 patients with severe claudication (Rutherford category 3) and 25 patients with critical limb ischemia (Rutherford category 4 to 6). From this group, two techniques were employed. Twenty-four patients were treated via a retrograde transpedal access site and 4 patients via a transcollateral loop technique. The clinical and follow-up data of these patients were analyzed retrospectively. RESULTS: The technique success rates were 92.8% (26/28). No major complications and 3 (10.7%) minor sequelaes were documented in this study. Twenty-three patients were followed up for 3 to 29 months, with a mean of (14 ± 9) months. Overall patency was 73.9% (17/23) and 47.8% (11/23) at 6 and 12 months. Overall survival and limb salvage was 95.7% (22/23), ulcer were healed in 9/10 patients. CONCLUSION: The use of retrograde tibial or pedal approach seems feasible and safety in case of failure in antegrade revascularization of popliteal and/or infrapopliteal occlusions.

Retrograde popliteal approach for challenging occlusions of the femoral-popliteal arteries.

OBJECTIVE: Antegrade ipsilateral subintimal angioplasty for recanalization of the superficial femoral arteries (SFAs) has a failure rate of 10%-20%. We report our initial experiences performing recanalization of the SFA or popliteal artery (PA) in cases of failed antegrade angioplasty using a medial infracondylar retrograde popliteal approach with the patient supine. METHODS: Between February 2010 and December 2011, 19 patients with chronic total occlusion of the SFA and/or proximal PA (mean occlusion length, 20.5 ± 5.54 cm) underwent transpopliteal procedures after failure of an antegrade procedure. Upon failure to re-enter the true lumen distal to the occlusion during initial antegrade recanalization with the patient supine, a medial retrograde popliteal access at the infracondylar plane was adopted, without turning the patient (with the leg in a 60° external rotation and the knee in a gentle flexion). Puncture of the distal PA was guided fluoroscopically and a guidewire was inserted into the true lumen, after which retrograde recanalization proceeded in accordance with standard protocol. Once the occlusion was crossed from distal to proximal, the wire was advanced through a 6F sheath in the common femoral artery. The preferred approach for angioplasty and stenting was from the femoral artery. Hemostasis at the popliteal access was achieved by combined intraluminal balloon dilatation and manual compression (3-5 minutes). The mean follow-up period was 8.6 ± 4.1 months and included measuring the ankle-brachial index and duplex ultrasound. RESULTS: Technical success (puncture of the PA and SFA recanalization) was achieved in all cases. All but one patient received stent implantation from the antegrade approach. Sheaths were used in five (26%) patients; four patients were treated with a 4F sheath and one with a 6F sheath. There was one (5.26%) major complication (a popliteal access site occlusion) and two (10.5%) minor complications (small hematomas in the popliteal region). The primary patency at 6 months was 84.2%. CONCLUSIONS: The medial infracondylar retrograde popliteal approach with the patient in the supine position can be considered safe and efficient for recanalization of the SFA or proximal PA after failure of an antegrade approach.

Features analysis of lower extremity arterial lesions in 162 diabetes patients.

Objective. This study aimed to investigate the angiographic manifestations of lower extremity atherosclerotic steno-occlusive disease in patients with diabetes. Materials and Methods. A total of 162 patients with diabetes were enrolled in this study. The angiographic findings of lower extremity arterial lesions were evaluated according to location (iliac, femoral, popliteal, and crural artery), type (stenosis or occlusion), and length (<5 cm, 5-10 cm, and >5 cm). Results. A total of 131 of 162 (80.9%) diabetics showed multiple segmental lesions, and 19.1% (31/162) presented single segmental lesions in the lower extremity artery. Crural artery was the mainly involved location (39/162, 85.8%). Among the recorded 660 lesions of 162 cases, 437 (66.2%) were occlusion lesions, while 223 (33.8%) were stenosis lesions. Of 437 occlusion lesions, 308 lesions (70.5%) were in crural artery. More than 10 cm occlusion lesion (242/392, 61.7%) was the main manifestation in crural artery, especially in anterior (92/127, 67.2%) and posterior tibial arteries (91/124, 73.4%), which was higher than that in iliac artery (8/33, 24.2%), popliteal artery (53/157, 33.8%), and femoral artery (11/78, 14.1%). Conclusion. In diabetic subjects with lower limb artery ischemia, the vascular involvement is extremely diffuse and particularly severe in crural arteries, with high prevalence of more than 10 cm occlusion lesions.

Endovascular treatment of central venous stenosis and obstruction in hemodialysis patients.

BACKGROUND: Central venous stenosis and obstruction (CVD) is a serious and prevalent challenge to both resolve the venous hypertension symptoms and maintain the pantency of the ipsilateral hemodialysis access in hemodialysis patients. This study aimed to summarize our experience of the endovascular management of the central venous stenosis or obstruction in hemodialysis patients. METHODS: Twenty-four haemodialysis cases of central vein stenosis or obstruction with ipsilateral functional vascular access in our hospital between July 2006 and February 2012 were treated by interventional therapy and the data were analyzed retrospectively. RESULTS: Eighteen males and six females with mean age of (66.4 ± 13.8) years and manifesting with arm swelling and venous hypertension were enrolled; 62.5% of them had a history of catheterization. Venography showed stenotic lesion in 10 cases including eight cases of brachiocephalic vein stenosis and two cases of subclavian vein stenosis and 14 cases of obstruction lesions including seven cases of short brachiocephalic obstruction and seven cases of long segment obstruction. Interventional therapy was performed and the technique success rate was 83.3%. Percutaneous transluminal angioplasty (PTA) was performed in nine cases and stent was performed in 11 cases firstly. The symptoms of venous hypertension were resolved after intervention in all the cases. There was no major complication and death perioperatively. During follow-up, reintervention was done, the primary patency rates were (88.9 ± 10.5)%, (64.8 ± 10.5)% and (48.6 ± 18.7)% at 3 months, 6 months and 1 year after treatment in the PTA group; (90.0 ± 9.5)% and (77.1 ± 14.4)% at 6 months and 1 year after treatment in the stent group, respectively. The secondary patency rates were (48.6 ± 18.7)% in the PTA group and (83.3 ± 15.2)% in the stent group 1 year after treatment, respectively. There was no significant difference between the two groups (primary patency, P = 0.20; secondary patency, P = 0.10). CONCLUSIONS: The endovascular intervention is a safe and effective method for CVD in short term; enhanced follow-up and repeated interventions are required to maintain patency for long term. The prevention is most important. Avoiding and minimizing the placement of the central venous catheter may be the key point for the prevention.

Retroperitoneal approach for lower extremity arteriovenous graft as long-term vascular access in a complex case.

A 76-year-old woman with stage 5 chronic kidney disease requiring hemodialysis had a long history of hypertension and diabetes. Her venous access was exhausted because of several previous access procedures including autogenous arteriovenous fistula operations and central venous catheter placements. After evaluating the function of her vessels when she was transferred to Renji hospital, we created an arteriovenous graft via a retroperitoneal approach in her right lower extremity. We inserted two grafts into her right thigh, a straight external ring and a loop graft. Twenty days after operation the patient's new access was successfully used in the treatment of hemodialysis. She has been followed up to now without occurrence of any graft-related events.

Endovascular recanalization of superior vena cava, brachiocephalic, and subclavian venous occlusions caused by nonmalignant lesions.

BACKGROUND: Endovascular recanalization (EVR) is becoming the primary therapy for patients with central venous (brachiocephalic, subclavian, and superior vena cava) occlusion (CVO) caused by benign etiology. In this study, we retrospectively analyzed our experience in using EVR to treat benign CVO in 10 patients between April 2005 and September 2010. METHODS: The mean age of the patients was 65.3 years, 2/10 cases were female, and the origin of cause of CVO in 7/10 cases was the hemodialysis access in the upper extremity. The patients were treated with primary stent placement and evaluated with immediate technical success rate and post-interventional patency rate after the procedure. RESULTS: Eight patients were treated successfully with stent placement and experienced symptomatic relief immediately. No technical complications were observed during EVR treatment. Patients were followed up by ultrasonography and venography. Median follow-up was 13 months. Three patients required secondary procedures to maintain patency. CONCLUSIONS: EVR is an effective and safe treatment in patients with benign CVO. It provides immediate symptom relief and maintains a continuous access for hemodialysis.

[Subintimal arterial flossing with antegrade-retrograde intervention technique to treat long-segment occlusion of peripheral artery].

OBJECTIVE: To discuss the technique details of subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) to improve technical success in the treatment of chronic total occlusions (CTO) diseases in lower extremity when there is failure to reenter the distal true lumen. METHODS: Between May 2009 and Aug 2010, 15 patients underwent endovascular recanalization with SAFARI technique. There were 8 male and 7 female patients with a mean age of 74.9 years. There were 3 patients with severe claudication (Rutherford category 3) and 12 patients with critical limb ischemia (Rutherford category 4 to 6). The clinical and follow-up data of these patients were analyzed retrospectively. RESULTS: Fourteen patients were treated with SAFARI technique successfully. The technique success rates were 93.3%. The mean ankle brachial index increased from 0.39 to 0.83.Symptoms were relieved in 86.6% patients, Ulcer were healed in 93.3%patients. CONCLUSIONS: SAFARI technique is a safe and effective method in treating CTO diseases, when it is failure to renter the distal true lumen with subintimal angioplasty technique.

[The efficacy analysis of endovascular intervention therapy for transatlantic inter society consensus type C and type D femoropopliteal arteriosclerosis lesion].

OBJECTIVE: To evaluate the efficacy of the endovascular intervention for transatlantic inter society consensus (TASC) type C and type D femoropopliteal artery disease. METHODS: We conducted a retrospective analysis on 95 cases (98 lower limbs) with TASC type C and type D femoropopliteal artery arteriosclerosis lesion treated by percutaneous transluminal angioplasty and/or primary stent implantation from January 2007 to April 2009. We used ankle brachial index (ABI), Fontaine stages, limb salvage percentage and primary patency to evaluate the efficacy of the endovascular intervention therapy. RESULTS: The technical success rate of the 98 limbs was 94.9%, the perioperation mortality was 4.2% and the total amputation rate was 5.1%. 81 cases (84 limbs) were followed-up for a mean time of (13 ± 7) months, whose average ABI in dorsalis pedis artery and posterior tibial artery were 0.58 ± 0.22 and 0.60 ± 0.21 and increased 0.14 ± 0.25 and 0.13 ± 0.22 respectively than the ABI before intervention therapy. The statistical analysis showed a significant difference in ABI. The limbs of critical limb ischemia (CLI) were of 16.4% in the follow-up period and of 73.5% before the intervention therapy. The statistical results showed a significant difference in the percentage of CLI. CONCLUSION: Percutaneous endovascular intervention is an effective and minimally invasive method, and has a curative clinical efficacy to treat TASC type C and type D femoropopliteal artery disease.

Inhibition of peptidyl-prolyl cis/trans isomerase Pin1 induces cell cycle arrest and apoptosis in vascular smooth muscle cells.

This study was undertaken to determine the in vitro effect of lentivirus-mediated siPin1 on cell cycle and apoptosis of vascular smooth muscle cells (VSMCs). Further we sought to provide insight into the mechanisms behind these processes. Human umbilical artery smooth muscle cells (HUASMCs) were transfected with lentiviral siPin1. Real-time RT-PCR and Western blotting were used to examine Pin1 mRNA and protein expression. MTT and [(3)H]thymidine incorporation assays were employed to observe cell proliferation status. The apoptotic rate and cell cycle were analyzed by Hoechst33258 staining and flow cytometry. Finally we measured the expression of cyclin D1, beta-catenin, CDK4, cytochrome c, procaspase-3, cleaved caspase-3, procaspase-9, cleaved caspase-9, Bcl-2, Bax, STAT3, phosphorylated STAT3 and VEGF in lentiviral siPin1 infected VSMCs. Lentivirus-mediated siPin1 effectively diminished endogenous Pin1 expression in VSMCs resulting in cell cycle arrest and enhancement of apoptosis. This was accompanied by downregulation of cyclin D1, beta-catenin, CDK4, increase of Bax/Bcl-2 ratio, release of cytochrome c, and activation of caspase-3 and -9. We concluded that this effect was mediated, at least in part, via the beta-catenin/cyclin D1/CDK4 cascade, and that the mitochondrial pathway was responsible for VSMC apoptosis in the absence of Pin1. Our observations raised the possibility that Pin1 might be a potential therapeutic target to prevent stenosis.

[The analysis of the follow-up results for the crural artery bypass].

OBJECTIVE: To review the follow-up results of the crural artery bypass. METHODS: Sixty-five limbs in 64 patients with long stenosis or occlusion in femoral artery and popliteal artery were performed 65 times femoral-crural artery bypass surgery or femoral-popliteal-crural bypass surgery during April 2001 to July 2007. The ankle-brachial index before bypass surgery was 0.35 +/- 0.20 in anterior tibial artery and 0.38 +/- 0.21 in posterior tibial artery. Critical limb ischemia was 93.8%. RESULTS: The ankle-brachial index after bypass surgery was 0.84 +/- 0.26 in anterior tibial artery and 0.83 +/- 0.22 in posterior tibial artery. The perioperative mortality rate was 1.6%, the perioperative amputation rate was 1.5%. Fifty-four patients 54 limbs were followed up. The average follow-up time was (24.1 +/- 16.6) months. The follow-up limb salvage rate was 85.2%. The follow-up mortality rate was 25.9%. Critical limb ischemia decreased as 13.0%. The follow-up ankle-brachial index was difference with before and after bypass surgery as 0.66 +/- 0.26 in anterior tibial artery and 0.64 +/- 0.25 in posterior tibial artery. It was no difference in cumulative limb salvage rate, cumulative primary and secondary patency rate by comparing autogenous vein with composite vascular as graft and comparing femoral-crural artery bypass surgery with femoral-popliteal-crural bypass surgery as surgical method. CONCLUSIONS: When the patients are failed in endovascular intervention or have long stenosis or occlusion in femoral artery and popliteal artery to face to amputation, the crural artery bypass is a feasible method. It's helpful to improve the secondary patency rate and limb salvage rate by enhancing the follow-up after operation and early intervention.

Reoperations for occluded arterial bypasses in the lower limbs.

BACKGROUND: We reviewed the outcomes of reoperations for 29 patients (30 limbs) who had undergone occluded arterial bypass in the lower limbs from May 1996 to September 2005. METHODS: The 30 lower limbs of the 29 patients with arteriosclerotic obstruction received 44 reoperations, including thrombectomy alone (group T, 27) and inflow or outflow reconstruction plus thrombectomy (group C, 17). Among the 17 operations in group C, 17.6% (3/17) were inflow reconstructions involving the axillary-femoral (1), aorta-iliac (1) and aorta-femoral (1) arteries, and 76.4% (13/17) outflow reconstructions involving the femoral-popliteal bypass-tibial (8), femoral-tibial (1), femoral-popliteal bypass-popliteal arteries below the knee (2), and the femoral-popliteal bypass-tibial-peroneal trunk (2). One patient (1 limb) underwent both inflow and outflow reconstructions with an iliac arterial stent and a graft-popliteal anastomosis patch. Polytetrafluoroethylene (PTFE) grafts were used in the inflow or outflow reconstructions above the knee. Autovenous grafts or autovenously combined PTFE grafts were used in the outflow reconstructions below the knee. RESULTS: The percentages of Fontaine stage III and IV before primary operation and reoperation were 60% (18/30) and 86.7% (26/30), respectively (P < 0.05). Four patients died of heart attack (2), stroke (1) and multiple organ failure (1) after reoperations. Among them, only 1 patient underwent occluded bypass, and others, patent bypass. Five patients after patent bypass are still alive. The accumulative patent rate was 28.6% (8/28). The average duration of patency in groups T and C was (4.16 +/- 5.68) (0.13 - 24) months and (7.14 +/- 6.37) (0.26 - 21) months, respectively (P > 0.05). Among 42 reoperations, 19 failed within 1 month in groups T (16) and C (3) (P < 0.01). Nine patients had limb amputated (10/28 limbs, 35.71%) because of graft infection (2 limbs), pseudo aneurysm at anastomosis (1 limb), and gangrene caused by failed grafts (7 limbs). The amputation was performed on 6 limbs within 1 month and on 4 limbs 1 month after reoperation (P > 0.05). The rate of limb salvage was 64.29% (18/28). CONCLUSIONS: The percentages of Fontaine stage III and IV before reoperation may be much higher than those before primary operation. Thrombectomy plus inflow/outflow reconstruction creates patency better than thrombectomy alone for re-occluded bypass.