Long-Term Outcomes of a Japanese Prospective Multicenter Registry Using a Heparin-Bonded Expanded Polytetrafluoroethylene Graft for Above-the-Knee Femoropopliteal Bypasses.

BACKGROUND: Despite the widespread use of PROPATEN®, a bioactive heparin-bonded expanded polytetrafluoroethylene graft, in bypass surgery, there are only a few reports of long-term results. We evaluated the long-term results of PROPATEN®use for above-knee femoropopliteal bypass (AKFPB).Methods and Results: After PROPATEN®-based AKFPB, patients were prospectively registered at 20 Japanese institutions between July 2014 and October 2017 to evaluate long-term results. During the median follow-up of 76 months (interquartile range 36-88 months) for 120 limbs (in 113 patients; mean [±SD] age 72.7±8.1 years; 66.7% male; ankle-brachial index [ABI] 0.45±0.27; lesion length 26.2±5.7 cm; chronic limb-threatening ischemia in 45 limbs), there were 8 major amputations; however, clinical improvement was sustained (mean [±SD] ABI 0.87±0.23) and the Rutherford classification grade improved in 105 (87.5%) limbs at the latest follow-up. At 8 years, the primary patency, freedom from target-lesion revascularization, secondary patency, survival, and amputation-free survival, as estimated by the Kaplan-Meier method, were 66.3±4.8%, 71.5±4.4%, 86.5±3.4%, 53.1±5.0%, and 47.4±5.3%, respectively. CONCLUSIONS: This multicenter prospective registry-based analysis showed sustained excellent clinical improvement and secondary patency for up to 8 years following PROPATEN®-based AKFPB. PROPATEN®constitutes a durable and good revascularization option for complex superficial femoral artery lesions, especially when endovascular treatment is inappropriate or an adequate venous conduit is unavailable.

Endovascular Treatment as an Alternative to Bypass Surgery for Juxtarenal Aortic Occlusion: Results from the CHAOS (CHronic Abdominal Aortic Occlusion, ASian Multicenter) Registry.

BACKGROUND: Juxtarenal aortic occlusion (JRAO), in which the occlusion of the aorta extends to just below the renal artery, is often treated by bypass surgery because of concerns about the risk of procedural failure and fatal embolization to abdominal organs when treated with endovascular treatment (EVT). This study assessed the outcome of EVT for JRAO compared with aorto-biiliac /aorto-bifemoral (AOB) or axillo-bifemoral (AXB) bypass. METHODS: A retrospective review of an international database created by 30 centers in Asia (CHronic Abdominal Aortic Occlusion, ASian Multicenter registry) was performed for patients who underwent revascularization for chronic total occlusion of the infrarenal aorta from 2007 to 2017. Of the 436 patients, 130 with JRAO (Forty-seven AOBs, 32 AXBs, and 51 EVTs) from 25 institutions were included in this study. RESULTS: Patients were significantly older in the AXB and EVT groups and more malnourished in the EVT group than the AOB group. EVT was attempted but failed in 1 patient. Seven patients (1 [2.1%] in the AOB group, 1 [3.1%] in the AXB group, and 5 [9.8%] in the EVT group) died during hospitalization, but most of the causes in the EVT group were not related to the revascularization procedure. No visceral embolism was observed, which had been concerned, even though protection was performed only in 2 cases of the EVT group. At the latest follow-up (median duration 3.0 years), the ankle-brachial pressure index was significantly higher in the order of AOB, EVT, and AXB. At 4 years, the estimated primary and secondary patency rates of the AOB group (87.5% and 90.3%, respectively) were significantly higher than the AXB group (66.7% and 68.6%, respectively). CONCLUSIONS: AOB remains the gold standard and should be the first choice for acceptable risk patients. For frail patients, EVT is a good option and likely preferable as a first-line treatment compared to AXB.

Practicality and Hemodynamic Advantage of Microvascularly Augmented Pectoralis Major Musculocutaneous Flap: Technical Approach and Evidence Based on Indocyanine Green Angiography.

ABSTRACT: We have recently shown that including the blood flow from the lateral thoracic artery (LTA) in addition to the thoracoacromial artery in the pectoralis major muscle musculocutaneous (PMMC) flap (bipedicle PMMC flap) can increase the perfusion of the flap. We also developed the concept of the supercharged PMMC flap, in which the LTA included in the flap was once cut and anastomosed to a cervical artery under a microscope. It is an effective solution to maintain the additional blood flow from the LTA, when the length of the LTA is compromised for reconstruction. The mandibular reconstruction of an oral cancer patient was performed with a supercharged PMMC flap. Intraoperative indocyanine green angiography was performed in a single pedicle, bipedicle, and supercharged conditions, and the videos were analyzed with a quantitative assessment system of perfusion using some parameters. As a result, blood supply from the LTA was essential for flap survival in this patient, and supercharging from the cervical artery improved flap perfusion compared with the perfusion in the bipedicle condition. The supercharged PMMC flap can resolve the compromise of pedicle length and be also hemodynamically advantageous, thus making the reconstruction more reliable than the conventional technique.

Comparison of Clinical Outcomes in Patients Undergoing Common Femoral Thromboendarterectomy With or Without Patch Angioplasty.

OBJECTIVE: Surgical thromboendarterectomy (TEA) is the standard treatment for an occlusive lesion of the common femoral artery (CFA). However, there is limited knowledge on the need for patch angioplasty in CFA TEA. The objective of this study was to compare the peri-operative and two year results of CFA TEA with or without patch angioplasty. METHODS: A multicentre retrospective observational study was performed at 34 Japanese centres. Comparisons were made between patients undergoing CFA TEA with or without patch angioplasty after propensity score matching (PSM). The primary endpoints were primary patency and freedom from target lesion revascularisation (TLR) of the TEA lesion. The secondary endpoints were hospital outcomes, limb salvage, and overall survival. RESULTS: Between 2018 and 2020, 428 TEA procedures (237 with patch angioplasty and 191 with primary closure) were performed. PSM extracted 151 pairs with no significant intergroup differences in baseline characteristics. Peri-operative death and complications occurred in 0.7% vs. 1.3% (p = 1.0) and 6.0% vs. 6.6% (p = 1.0), respectively. The follow up rate was 96% over a median follow up of 14.9 months (interquartile range 8.3, 24.3). Loss of primary patency occurred in 18 patients. The two year primary patency of patch angioplasty cases was statistically significantly higher than that of primary closure cases (97.0% vs. 89.9%; p = .021). TLR was performed in 14 patients. The two year freedom from TLR in patch angioplasty cases was also statistically significantly higher than in primary closure cases (98.6% vs. 92.9%; p = .003). During follow up, seven limbs required major amputation and 40 patients died. There was no statistically significant difference in limb salvage and survival between the two groups after PSM. CONCLUSIONS: This is the first report to show that patch angioplasty may decrease re-stenosis and target lesion revascularisation of CFA TEA lesions.

Clinical significance of Bacteroides fragilis as a potential prognostic factor in colorectal cancer.

INTRODUCTION: Bacteroides fragilis (B. fragilis) is considered to act in an anti-inflammatory manner on the intestinal tract. On the contrary, enterotoxigenic B. fragilis (ETBF), a subtype of B. fragilis, produces an enterotoxin (BFT; B. fragilis toxin), leading to asymptomatic chronic infections and colonic tumor formation. However, the impact of B. fragilis and ETBF on the clinical outcome of colorectal cancer (CRC) remains unclear. We aim to assess whether their presence affects the outcome in patients with CRC after curative resection. METHODS: We obtained 197 pairs of matched formalin-fixed paraffin-embedded samples from cancerous and adjacent non-cancerous tissues of patients with pathological stage (pstage) II and III CRC after curative resection. The presence of B. fragilis and ETBF were estimated using real-time polymerase chain reaction, and recurrence-free survival (RFS) and overall survival (OS) of the patients were analyzed. RESULTS: 16S rRNA for B. fragilis and bft DNA were detected in 120 (60.9%) and 12 (6.1%) of the 197 patients, respectively. B. fragilis-positive patients had better RFS than B. fragilis-negative patients, although that was not statistically significant. In subgroup analysis, better outcomes on RFS were observed in the presence of B. fragilis in pstage II and left-sided CRC. The association of B. fragilis positivity on OS was accentuated in the depth of T4 subgroup. No significant differences were observed in RFS and OS between ETBF and non-toxigenic B. fragilis. CONCLUSIONS: Our findings suggest that the presence of B. fragilis is associated with better outcomes in patients with pstage II and III CRC after curative resection.

Midterm Results of a Japanese Prospective Multicenter Registry of Heparin-Bonded Expanded Polytetrafluoroethylene Grafts for Above-the-Knee Femoropopliteal Bypass.

BACKGROUND: This study prospectively analyzed the midterm results of above-the-knee femoropopliteal bypass (AKb) using bioactive heparin-bonded expanded polytetrafluoroethylene (HB-ePTFE) graft in patients with femoropopliteal occlusive disease.Methods and Results:This prospective, multicenter, non-randomized study reviewed limbs undergoing AKb with HB-ePTFE graft for femoropopliteal lesion in 20 Japanese institutions between July 2014 and October 2017. Primary efficacy endpoints were primary, primary assisted, and secondary graft patency. Safety endpoints included any major adverse limb event and perioperative mortality. During the study period, 120 limbs of 113 patients (mean age, 72.7 years) underwent AKb with HB-ePTFE grafts. A total of 45 patients (37.5%) had critical limb ischemia and 17 (15.0%) were on hemodialysis (HD). Median duration of follow-up was 16 months (range, 1-36 months). Estimated 1- and 2-year primary, primary assisted, and secondary graft patency rates were 89.4% and 82.7%, 89.4% and 87.2%, and 94.7% and 92.5%, respectively. On univariate analysis of 2-year primary graft patency, having 3 run-off vessels, cuffed distal anastomoses, no coronary artery disease, and no chronic kidney disease requiring HD were significantly associated with favorable patency. CONCLUSIONS: AKb using HB-ePTFE grafts achieved favorable 2-year graft patency. AKb using HB-ePTFE grafts may therefore be an acceptable, highly effective treatment option for femoropopliteal artery lesions.

De Novo Renal Artery Stenosis Developed in Initially Normal Renal Arteries during the Long-Term Follow-Up of Patients with Moyamoya Disease.

BACKGROUND: The de novo occurrence of renal artery stenosis in renal arteries that were angiographically confirmed to be normal in the past has never been reported before in patients with moyamoya disease. CASE DESCRIPTION: During the long-term follow-up of pediatric patients with moyamoya disease, we observed 3 patients who developed de novo renal artery stenosis in arteries that had been angiographically confirmed to be normal 1 year after the surgery (7 years on average, ranging from 4 to 11 years). All of these patients were neurologically stable after successful indirect bypass surgery during childhood. However, more than 10 years after the surgery (15 years on average, ranging from 14 to 23 years), they developed hypertension and were found to have de novo renal artery stenosis, which was ameliorated by endovascular angioplasty. During the follow-up after angioplasty, 1 patient experienced a recurrence of hypertension and required a second and third angioplasty for restenosis. Another patient died of intracranial hemorrhage 2 years after angioplasty. In the 2 surviving patients, gene analysis of the ring finger protein 213 (RNF213; p.R4810K) point mutation, the susceptibility gene for moyamoya disease in the Asian population, was positive for the heterozygous variant. CONCLUSIONS: De novo renal artery stenosis might develop in initially normal arteries during long-term follow-up, particularly among pediatric patients with moyamoya disease. Considering the extracranial manifestations of moyamoya disease, clinicians should keep in mind that de novo renal artery stenosis could emerge later in their life. Thus, it is crucial to continue to follow these patients for decades, even if the patients are neurologically stable after bypass surgery. Monitoring for blood pressure and the de novo occurrence of renal artery stenosis is important to prevent hypertension-related morbidity and mortality, such as intracranial hemorrhage, in this disease population.

Bilateral External Iliac Venous Aneurysms in a Long-Distance Runner.

Aneurysms of the iliac veins are very rare but are potentially fatal due to their potential to cause thromboembolic complications or even rupture. We herein report an unusual case of bilateral external iliac venous aneurysms in a 50-year-old male long-distance runner who presented with bilateral groin pain. The aneurysms were successfully treated with tangential aneurysmectomy with lateral venorrhaphy. Possible causes and management of iliac venous aneurysms are also discussed in this article.

In Patients with Severe Peripheral Arterial Disease, Revascularization-Induced Improvement in Lower Extremity Ischemia Can Be Detected by Laser Speckle Contrast Imaging of the Fluctuation in Blood Perfusion after Local Heating.

BACKGROUND: We previously reported the utility of the perfusion value (PV) fluctuation slope for detecting severe ischemia in the lower limb. Our approach was based on a thermal load test mimicking the well-known physiological reaction termed "cold-induced vasodilation," which is known to occur as a 3-phase phenomenon. The slope parameter quantifies the decrease in PVs accompanying the relative cooling (third phase) following the transient increase in blood flow (second phase) induced by the applied thermal load. This phenomenon of "relative" cold-induced vasodilation (rCIVD) can be monitored using laser speckle contrast imaging (LSCI) after applying the thermal load (LTL test). Here, we aimed to determine whether the slope parameter obtained via the LTL test also reflects the improvement in hemodynamics after revascularization. METHODS: The study enrolled 16 patients (18 limbs), who underwent revascularization for peripheral arterial disease (PAD). The measurements were performed at 2 sites in each limb (in total, 34 sites; 2 sites in one patient were excluded because of significant movement during the measurement). For each site, we recorded the slope describing the behavior of PVs (decrease or plateau) in the third phase of rCIVD, following the initial, heating-induced increase in perfusion (second phase of rCIVD). The plateau group (group P), which included patients with an abnormal rCIVD, and the decrease group (group D), which included patients with a normal rCIVD, were defined based on perfusion slope values of <0.20 and ≥ 0.20 perfusion units/min, respectively. We also quantified the transient increase in perfusion (from baseline to peak) as a descriptor of perfusion behavior during the second phase of rCIVD. RESULTS: In group P, the change in median values (25-75%) of the slope, transcutaneous oxygen tension, and ankle-brachial index (ABI) from before to after operation was (-0.02 [-0.04 to 0.02]; 4 [1-11]; and 0.08 [0-0.27]) to (0.39 [0.32-0.59]; 46 [37-54]; and 0.81 [0.72-0.90]). Conversely, in group D, the change in the median values of the slope, transcutaneous oxygen tension, and ABI between before and after operation was (0.38 [0.32-0.49]; 40.5 [35-45]; and0.58 [0.57-0.65]) to (0.44 [0.30-0.64]; 52 [43-56]; and 0.92 [0.81-0.99]). Sites exhibiting perfusion pattern of group D in the third phase of rCIVD showed no significant change in slope after revascularization (P = 0.21), whereas the slope in group P increased significantly after revascularization, becoming similar to the postoperative slopes in group D (P = 0.81). The amount of transient increase in perfusion, which quantified the behavior in the second phase of rCIVD, showed a similar behavior. Preoperatively, all patients in group P had rest pain and/or ulcer of the foot, whereas only few patients in group D had such symptoms. CONCLUSIONS: Normal rCIVD response in the LTL test indicates less-than-severe ischemia, while abnormal rCIVD response measured via the LTL test indicates severe ischemic symptoms, such as critical limb ischemia. Notably, patients with an abnormal rCIVD response can develop a normal rCIVD response following revascularization, thereby reflecting an improvement in blood flow. The LTL test assessing rCIVD response can be useful for detecting severe limb ischemia, such as critical limb ischemia (CLI), and determining the departure from severe limb ischemia by revascularization.

Open Surgical Repair for Inflammatory Abdominal Aortic and Iliac Artery Aneurysms.

BACKGROUND: This study was performed to investigate the outcomes of surgical treatment for inflammatory abdominal aortic aneurysms (IAAAs) and inflammatory iliac artery aneurysms (IIAAs). METHODS: We retrospectively reviewed the charts of patients who underwent open surgical repair (OSR) between January 2000 and June 2013. RESULTS: Nine male and 2 female patients (median age, 67 years) were treated. Five of the 11 patients who underwent OSR developed hydronephrosis, and ureteral stents were placed preoperatively. There were no intraoperative complications during OSR. After OSR, the conditions of 4 of 5 patients with preoperative hydronephrosis improved. During the follow-up period with a mean of 51 months (range, 6-120 months), 2 patients with OSR developed aneurysmal changes at the anastomosis site (84 and 21 postoperative months, respectively), and reintervention for both patients was needed. One patient died because of malignant disease at 96 months postoperatively. CONCLUSIONS: OSR can be safely performed for IAAAs and IIAAs. When an inflammatory aneurysm, especially an IIAA, is complicated by hydronephrosis, OSR might be an effective treatment procedure.

Endovascular Reintervention for Failing Infrainguinal Bypass Grafts.

OBJECTIVE: Patients with lower extremity bypass grafts that develop stenosis commonly undergo endovascular treatment (EVT) procedures. This study was performed to evaluate the outcomes of EVT procedures for infrainguinal grafts with bypass at risk (BAR). METHODS: We performed a retrospective review of 24 grafts in 22 patients from July 2010 to June 2016. The demographic information of the patients and the characteristics of lesions were examined, and the outcomes with regard to the patency and survival rates were calculated. RESULTS: Twenty-four grafts were evaluated; the initial technical success rate of EVT procedure was 91.7%. Sixteen of 24 bypass grafts (66.7%) required multiple EVT procedures due to graft restenosis. Inflow vessels from the superficial femoral artery were associated with significantly higher rates of single EVT procedures (P = 0.0206). At 2 years, the primary, assisted primary, and secondary patency rates were 30.3%, 69.5%, and 78.0%, respectively. CONCLUSIONS: The EVT procedure is one of the treatment options for the treatment of grafts with BAR and might be associated with an acceptable medium-term patency rate.

Prediction of Venous Thromboembolism after Total Knee Arthroplasty Using Dielectric Blood Coagulometry.

BACKGROUND: Venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE) frequently occurs in patients undergoing total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of dielectric blood coagulometry (DBCM) as a new technique for predicting postoperative VTE. METHODS: Thirty patients undergoing TKA were enrolled. DVT was diagnosed by ultrasonography preoperatively and on the fourth or fifth postoperative day. Enhanced computed tomography was performed to detect PE on the fourth postoperative day. The day after surgery, a blood sample was measured by DBCM. All patients received fondaparinux or low-molecular-weight heparin for postoperative thromboprophylaxis. RESULTS: Eighteen of the 30 patients had DVT postoperatively, and 10 had asymptomatic PE. Seven patients had both DVT and PE. The patterns of permittivity as a function of time and frequency from the DBCM measurement were different between patients with and without VTE. The sensitivity and specificity of the parameter constructed from a set of permittivities at the frequencies of 2.5 kHz, 1 MHz, and 10 MHz were 90% and 78%, respectively. CONCLUSIONS: DBCM was effective and efficient for predicting VTE after TKA.

The use of dielectric blood coagulometry in the evaluation of coagulability in patients with peripheral arterial disease.

BACKGROUND: Platelets and coagulation proteins contribute to the development of peripheral arterial disease, especially atherosclerotic disease. Several experimental studies have proven a significant correlation between hypercoagulability and atherosclerosis. We used dielectric blood coagulometry, which was initially designed to evaluate the coagulable status, to examine the coagulability of peripheral arterial disease patients, and investigated the factors that were significantly correlated with the results. METHODS: We performed dielectric blood coagulometry in 49 peripheral arterial disease patients. In addition, we recorded the patients' demographic information, including the presence of comorbidities, hemodynamic status, and laboratory findings. To investigate coagulability, we calculated the Tmax value, which indicates the time from recalcification to maximum normalized permittivity. RESULTS: The Tmax values of diabetes mellitus patients were significantly lower than those of non-diabetic patients (1 MHz, P = 0.010; 10 MHz, 0.011). Furthermore, the Tmax value was statistically correlated with the activated partial thromboplastin time (1 MHz, ρ = 0.286, P = 0.048; 10 MHz, ρ = 0.301, P = 0.037). CONCLUSIONS: Dielectric blood coagulometry detected the hypercoagulable status in diabetes mellitus patients, and reflected their level of coagulability, which was also evaluated by the activated partial thromboplastin time.

Novel assessment tool based on laser speckle contrast imaging to diagnose severe ischemia in the lower limb for patients with peripheral arterial disease.

OBJECTIVE: We propose a new assessment tool to diagnose severe ischemia of the lower limb in peripheral arterial disease, using laser speckle contrast imaging to evaluate heating-induced microcirculatory fluctuations in the proximal and distal sites of the dorsal foot. STUDY DESIGN: A cross-sectional study. METHODS: We recorded the slope describing the behavior of perfusion values (decrease or plateau) following the initial, heating-induced increase in perfusion in 63 feet of patients with clinical signs of peripheral arterial disease. RESULTS: The plateau and decrease groups were defined as having perfusion slopes of <0.20 and ≥0.20 PU/min, respectively. Transcutaneous oxygen tension was significantly lower (P < 0.001) in the plateau than in the decrease group (8 vs. 45 mmHg), indicating more severe ischemia. The laser speckle contrast imaging thermal load test discriminated transcutaneous oxygen tension <30 mmHg with good sensitivity (78.7%) and specificity (96.2%), and an area under the curve of 0.908. CONCLUSIONS: Both transcutaneous oxygen tension and the laser speckle contrast imaging thermal load test are useful in diagnosing severe ischemia in the foot. Lasers Surg. Med. 49:645-651, 2017. © 2017. The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Significance of the Lateral Thoracic Artery in Pectoralis Major Musculocutaneous Flap Reconstruction: Quantitative Assessment of Blood Circulation Using Indocyanine Green Angiography.

Free tissue transfer is the preferred reconstruction option in most major head and neck reconstructions. The pectoralis major muscle musculocutaneous (PMMC) flap is commonly used in salvage of necrotic free flaps and is the first choice for patients who are not candidates for free flaps. The lateral thoracic artery (LTA), which is thought to contribute to blood perfusion of the inferior and lateral mammary area, is not preserved in a conventionally harvested PMMC flap. With regard to blood supply, it has been suggested that the LTA should be preserved, in addition to the pectoral branch of the thoracoacromial artery, when a skin island is designed in the lower chest to attain a pedicle length sufficient for head and neck reconstruction. However, an effect on hemodynamic improvement using the LTA has not been shown quantitatively. In this study, we examined 8 patients with oral cancer who underwent reconstruction procedures with a bipedicle PMMC flap that included the LTA, in addition to the thoracoacromial artery. Intraoperative indocyanine green angiography was performed to examine circulation to the PMMC flap with or without LTA clamping after harvesting. After image processing, data were analyzed using a new quantitative perfusion assessment system with parameters that we recently established for assessment of peripheral arterial disease of the lower limbs. All patients had good clinical courses with whole-flap survival, no vascular insufficiency of the skin island, and no fistula formation. Intraoperative indocyanine green angiography showed an increased inflow rate into the skin island in an LTA-declamped condition in all cases, implying that the preserved LTA increased the blood supply to skin islands in the pectoralis major muscle. We conclude that preserving the LTA in a PMMC flap can increase blood perfusion and stabilize the vascularity of the flap, making the reconstruction more effective and reliable than with use of a conventionally harvested flap. Therefore, it is worthwhile to preserve the LTA as a major contributor to a lateral and distal PMMC flap.

Progression of perianeurysmal inflammation after endovascular aneurysm repair for inflammatory abdominal aortic and bilateral common iliac artery aneurysms.

The use of endovascular aneurysm repair (EVAR) to treat inflammatory abdominal aortic aneurysms (IAAAs) has been reported, and this procedure appears to be preferable to open surgical repair because of intraoperative difficulties related to inflammation. We herein report a case of IAAA and bilateral inflammatory common iliac artery aneurysms that was successfully treated with bifurcated stent grafting. The perianeurysmal inflammation worsened postoperatively, requiring the placement of a ureteric stent. EVAR is feasible in cases of inflammatory aneurysms; however, the potential for an inflammatory response should be taken into account when considering the application of EVAR in patients with IAAA.

Bilateral Axillary Artery Aneurysms Presenting as Upper Limb Ischemia.

An axillary artery aneurysm (AxAA) is a rare entity. Although some cases with AxAA are asymptomatic, complications including local pain, neurogenic symptoms, upper limb ischemia, and rupture may occur. Therefore, an early diagnosis and treatment are necessary. We herein report a case of bilateral AxAAs, in which the right AxAA showed acute upper limb ischemia and the left AxAA were asymptomatic. Both AxAAs were successfully treated by aneurysmectomy and interposition grafting. In the endovascular era, open surgical treatment for AxAAs remains a promising procedure.

Controlled antegrade and retrograde subintimal tracking technique for endovascular treatment of the superficial femoral artery with chronic total occlusion.

Although providing endovascular treatment for chronic total occlusion (CTO) in patients with peripheral arterial disease is challenging, subintimal angioplasty (SIA) has proven to be an effective procedure. However, the SIA device may not cross CTO lesions because of the inability to achieve re-entry into the distal true lumen in some cases. We herein describe 2 cases of CTO of the superficial femoral artery (SFA) segment in which we failed to cross the site of CTO using the SIA technique and therefore employed the controlled antegrade and retrograde subintimal tracking (CART) technique to successfully treat the CTO lesions of SFA. When using the CART technique, there is no need to perform extension of the region of subintimal dissection beyond the occluded lesion, which may be useful for managing CTO lesions.

Comparison between endovascular repair and open surgery for isolated iliac artery aneurysms.

PURPOSE: This study was performed to compare endovascular repair with conventional open repair of isolated iliac artery aneurysms (IAAs). METHODS: We retrospectively reviewed the charts of all patients who underwent repair of isolated IAAs between January 2008 and June 2012. Patients with infected, mycotic and ruptured iliac aneurysms and those with concurrent infrarenal abdominal aortic aneurysms greater than 30 mm in diameter were excluded from this analysis. RESULTS: A total of 32 patients were treated with isolated IAAs. There were 20 open and 12 endovascular repairs. A comparison of the length of the operation (238 ± 84 min in the open group vs 176 ± 72 min in the endovascular group, P = 0.03) and intraoperative blood loss (1,735 ± 1,177 ml in the open group vs 503 ± 711 ml in the endovascular group, P = 0.01), revealed significant differences in favor of the endovascular procedure. Postoperative complications were less common in the endovascular group, although the difference did not reach statistical significance. CONCLUSIONS: The management of isolated IAAs with both endovascular and open repair can be accomplished with very low morbidity rates. Therefore, endovascular repair can be considered an alternative treatment for isolated IAAs.