Novel prefabricated bovine pericardial grafts as alternate conduit for septic aortoiliac reconstruction.

OBJECTIVE: Infection of prosthetic aortic grafts represents a serious complication with high morbidity and mortality. Replacement with autologous material is recommended; however, in its absence, biological material should be favored. In the present retrospective cohort study, we evaluated the short- and midterm results with the use of commercially available prefabricated bovine pericardium grafts (BPGs) used for the management of aortic graft infection or aortic reconstructive surgery in the presence of systemic infection. METHODS: We performed a retrospective analysis of patients in whom BPGs had been used for aortic reconstruction at two vascular centers. Prefabricated vascular pericardium grafts were preferred over other biological reconstruction techniques for selected cases. Comorbidities, procedure-related details, perioperative morbidity, clinical outcomes, and mortality were analyzed. RESULTS: From 2014 to 2019, 21 patients had received BPGs at two Austrian vascular centers. Their median age was 63 years (interquartile range [IQR], 55-71 years), the patients were predominantly male (76%), and the median body mass index was 25.3 kg/m2 (IQR, 21.7-27.3 kg/m2). The major comorbidities included arterial hypertension, peripheral artery disease, smoking, and chronic pulmonary disease. The indications for surgery were vascular graft or endograft infection in 62% and aortic reconstruction in the presence of systemic infection in 38%. Three patients (14%) had aortoenteric fistulas. Surgery was technically successful in all cases. The median follow-up was 21.6 months (IQR, 6.0-34.6 months). The 30-day mortality was 9.5%. The 1- and 2-year overall survival was 84% and 75%, respectively. Of the 21 patients, 89% had remained free of recurrent infection. One of the two reinfections had resolved after treatment of the underlying focus. At 2 years, the primary and assisted primary patency rates were 86% and 94%, respectively. No limbs were lost during follow-up. CONCLUSIONS: Prefabricated BPGs represent a promising alternative for the management of aortic graft infections and aortoiliac reconstruction in the presence of systemic infection.

External beam radiation for prevention of intimal hyperplasia in peripheral arterial bypasses.

PURPOSE: Neointimal hyperplasia is one of the limiting factors in infrainguinal prosthetic vascular grafting. We conducted a pilot study to assess the possible role of radiotherapy for the prevention of this proliferating cellular process. METHODS AND MATERIALS: Ten patients (7 men, 3 women; median age: 73 years) suffering from critical leg ischemia were treated by infrainguinal revascularization using 6-mm polytetrafluoroethylene. Postoperative radiation therapy of the anastomotic sites started within 24 h. A dose of 20.4 Gy was delivered in 12 fractions in 2.5 weeks by external beam radiation with electrons. The target volume was defined as the clip-marked anastomotic region plus a 1.5-cm safety margin in each direction. RESULTS: Radiation therapy was technically feasible in all cases without radiation-related side effects. In one patient, radiotherapy had to be terminated prematurely, because of a hematoma at the distal anastomotic site with consequent skin necrosis. One patient developed an occlusion of a suprainguinal graft without anastomotic stenosis after 9 months; 2 other grafts occluded at 12-month intervals. At a median follow-up of 16 months, the remaining 6 patients had no signs of restenosis. CONCLUSIONS: The restenosis rate of peripheral vascular grafts after external beam radiation was lower than expected without additional treatment. The value of this approach will now be determined in a randomized prospective trial.

False aneurysm after balloon dilation of a calcified innominate artery stenosis.

PURPOSE: To describe the occurrence of a false aneurysm after percutaneous transluminal angioplasty of a severely calcified, high-grade stenosis of the brachiocephalic trunk. CASE REPORT: A 68-year-old patient was admitted with cerebrovascular insufficiency, right upper extremity ischemia, and recurrent amaurosis fugax. Magnetic resonance arteriography (MRA) and duplex ultrasound revealed a severely calcified, high-grade stenosis of the innominate artery. Balloon dilation of this lesion was performed with minimal morphological success. After dilation, the patient suffered a reversible ischemic neurological deficit, from which he recovered completely. The patient's symptoms improved, but after 3 weeks he was re-admitted with palsy of the recurrent laryngeal nerve. An MRA showed a false aneurysm at the dilation site. Open surgery was performed, and the patient received a bifurcated aorto-subclavian-carotid bypass graft. He was discharged free of his preoperative symptoms. CONCLUSIONS: This case illustrates the potential hazards of angioplasty of severely calcified stenoses of the supra-aortic vessels.

Preliminary observations on the need for control angiography after peripheral endovascular brachytherapy using a centering balloon.

PURPOSE: To examine the need for completion angiography after endovascular femoropopliteal brachytherapy using a centering catheter. METHODS: Nine consecutive patients (7 men; mean age 68 years, range 53-79) were enrolled in a double-blinded multicenter randomized trial of endovascular brachytherapy after femoropopliteal balloon angioplasty. All patients underwent postdilation angiography, after which the centering catheter was placed in the dilated segment. The patients were randomized and transferred to the radiotherapy unit; the centering catheter was inflated only in patients randomized to receive brachytherapy (18 Gy of gamma radiation delivered to the target site 2 mm from an iridium-192 source axis). Because the local ethics committee required angiography after any interventional procedure (not stipulated in the study protocol), our patients were taken back to the angiosuite for angiography. RESULTS: There were no complications of angioplasty or centering catheter introduction. In the 5 patients randomized to brachytherapy, the median inflation time of the centering catheter was 12.1 minutes (range 9.1-13.3). The completion angiogram following brachytherapy showed peripheral embolization in 2 patients and lesion recoil that required redilation in another; all the complications were confined to the treatment group. CONCLUSIONS: Three of 5 patients who received brachytherapy via a centering catheter demonstrated sequelae on postradiation angiography. Therefore, as in any other peripheral vascular intervention, completion angiography after brachytherapy seems to be essential in preventing delayed diagnosis of procedural complications.