Left subclavian artery as an alternative site for left ventricular assist device outflow graft in challenging situations.

Left ventricular assist device (LVAD) has emerged as an effective surgical therapy for end-stage heart failure. In an attempt to reduce invasiveness and avoid difficult sternal re-entries, alternative surgical approaches have been adopted. In particular, when the thoracic aorta is severely diseased or difficult to expose, subclavian arteries could serve as site for outflow graft anastomosis. However, major concerns regarding the utilization of subclavian arteries are the small caliber of these vessels that could lead to inadequate LVAD flow, arm complications related to excessive blood flow, and possible outflow graft compression. In the present case series, we describe an innovative technique for LVAD implantation, in which the left subclavian artery was employed as an outflow graft anastomosis site, and the left ventricular apex was approached through a mini-thoracotomy. Technical issues were considered to prevent possible complications: the adequacy of left subclavian artery diameter, the banding of the artery distal to the anastomosis site to limit left arm overflow, and the outflow graft covering with a reinforced vascular graft to avoid any external compression. During follow-up, the technique reported was found to be effective in ensuring good LVAD function and flow, and no complications related to the procedure were reported.

Hybrid Approach to Popliteal Artery Aneurysm with Thromboembolic Symptoms. A Pilot Study.

BACKGROUND: The treatment of patients with thromboembolic symptoms due to a popliteal artery aneurysm (PAA) is still controversial with poor results in terms of primary patency. The aim of our pilot study was to evaluate whether improving the outflow with an endovascular pretreatment consisting in thromboaspiration and angioplasty could positively ameliorate the primary patency of the subsequent femoropopliteal (FP) bypass in symptomatic patients with at least one below the knee (BTK) patent vessel. METHODS: This is a single-center pilot case-control study that involves patients treated at the Vascular and Endovascular Surgery Unit of Udine, Italy, from January 2015 to November 2019. The inclusion criteria were the presence of thromboembolic symptoms due to PAA distal embolization, associated with the presence of a patent PAA >20 mm and a poor runoff (no more than one patent BTK artery). The case group was treated in a two-step approach: the first step consisted in thromboaspiration followed by BTK angioplasty, when appropriate, and the second one consisted in performing the surgical FP bypass. The control group moved on directly to the open surgical intervention. RESULTS: The case group was composed of 11 patients, 10 males and 1 female, with a mean age of 69.3 ± 10.8 years. The mean PAA dimension was 32.6 ± 9.9 mm. Particularly, 9 patients were operated on through the medial vascular approach and 2 through the posterior one. The grafts used were 10 polytetrafluoroethylene (PTFE) and 1 great saphenous vein (GSV) in situ. The control group was composed of 11 male patients with a mean age of 75.5 ± 8.7 years, and the mean PAA dimension was 29.8 ± 13.4 mm. All the FP bypasses were approached medially, and the materials used were 10 PTFE and 1 reversed GSV. The median follow-up was 31.5 ± 12.6 months. Primary patency in the case group was 72.7% within one year; on the contrary, it was 27.3% in the control group. The amputation rate was 0% in the case group, 27.3% in the controls. By comparing the 2 groups, we found a higher and significant risk (P = 0.0261) of early FP bypass occlusion and major limb amputation in the control group. CONCLUSIONS: This pilot study shows encouraging results; the endovascular approach is a safe and repeatable procedure which, improving the runoff in thromboembolic symptomatic PAA, seems to guarantee a better FP graft primary patency.