Proximalization of Arterial Inflow for the Treatment of Limb Ischemia in a Transposed Femoral Arteriovenous Fistula-A Case Report.

INTRODUCTION: Femoral vein transposition is one of the final resorts for vascular access in patients with exhaustion of upper limb venous patrimony and central venous occlusive disease. Its major pitfalls include hemodialysis access-induced distal ischemia and infection. Surgical procedures may be warranted to preserve vascular access if ischemia develops. Several techniques are reported in the literature for femoral vein transposition. CASE REPORT: We expose an endoscopic femoral vein harvesting as an alternative to the single thigh incision in order to avoid its associated complications. In the setting of ischemia, proximalization of arterial inflow was used to manage femoral vein transposition associated limb ischemia. CONCLUSION: This case report aims to expose the aforementioned unreported surgical techniques for lower limb arteriovenous fistula, its advantages, and pitfalls, as well as considerations on its future use.

Navigating complexity: The Supera's triumph in femoropopliteal lesions.

INTRODUCTION: The femoropopliteal sector endovascular treatment is particularly challenging due to its high tortuosity and torsional forces. Better results are still needed to ensure the long-term patency of stenting in this area. The Supera stent appears to change this paradigm. METHODS: This single-center retrospective cohort study aims to evaluate the efficacy and safety of femoropopliteal stenting with Supera in a real-world population. Seventy-nine patients were treated between January 2015 and December 2020, and the results are reported with a median follow-up of 28 months. RESULTS: Indications for revascularization were chronic limb-threatening ischemia with tissue loss (73.6%) or ischemic rest pain (17.7%) and claudication (7.6%). Thirty-six patients (45.6%) were classified as GLASS stage III according to the Global Limb Anatomic Staging System, with 65.8% and 30.4% in grades 3 and 4 of femoropopliteal and infrapopliteal sectors, respectively. The 36-month primary, primary-assisted, and secondary patency rates were 68.6%, 72.0%, and 79.0%, respectively, with an amputation-free survival rate of 86.6%. There was no significant difference between primary patency rates in GLASS stages I-II compared with GLASS stage III (36-month primary patency rates of 72% vs 63% respectively, p = 0.342) nor in amputation-free survival (88% vs 84%, p = 0.877). After adjusting for potential confounders, only the stent conformation significantly affected the primary patency rates, with a higher hazard of reintervention for the elongated (HR = 3.179; p = 0.36; CI 1.081-9.347) and the compressed (HR = 3.014; p = 0.42; CI 1.039-8.746) forms. CONCLUSIONS: The 36-month patency of the Supera stents in our real-world cohort was similar to other reported series. The GLASS stage did not interfere with the stent patency, proving it is a good choice even in the most adverse anatomy patients. Only the non-nominal stent conformation affected the primary patency rates in our patients.

Intrastent HeROgraft deployment as a catheter-sparing procedure.

Current vascular access (VA) practice adopts arteriovenous fistulas (AVF) as first option for haemodialysis, relegating arteriovenous grafts (AVG) for patients with exhausted upper limb venous patrimony. The Hemodialysis Reliable Outflow graft (HeRO®) is a device assuring direct venous outflow to the right atrium, thus avoiding central venous obstructive disease. Its use together with early access grafts avoids the need for central venous catheters (CVC) bridging periods. We report the deployment of the HeRO device using a previous stentgraft as pathway for the placement of the outflow component, in a patient with no-option for further autogenous upper limb access. This technique spared the usual central vein's exit point for the HeRO graft and, using an early-access dialysis graft, allowed for next-day successful haemodialysis.

The Vascular Patient - Chronic Mesenteric Ischemia, AAA and Iliac Occlusion.

Peripheral arterial disease (PAD), abdominal aortic aneurysm (AAA) and chronic mesenteric ischaemia (CMI) are vascular diseases uncommonly observed in the same patient, especially when treatment is required. This case report illustrates a patient requiring mesenteric revascularization due to CMI. A long flush occlusion of the superior mesenteric artery (SMA) precluded endovascular revascularization. Therefore, we performed a retrograde bypass from the right common iliac artery (CIA) to the SMA. On the 6-month follow-up, the patient developed right limb ischemia despite the absence of intestinal angina. CT angiography revealed CIA occlusion, bypass patency through hypogastric retrograde filling and modest growth of a AAA. Due to the presence of contralateral CIA lesions and to achieve durable revascularization, we opted to perform a AAA repair with an aorto-uni-iliac endograft followed by a femorofemoral crossover bypass. This achieved AAA's repair, lower limb revascularization, and a suitable and durable inflow to the mesenteric bypass.

Asymptomatic Hypogastric Arteriovenous Fistula Detected 40 Years After Shotgun Injury.

84-year-old male, with a history of firearm incident with accidental gunshot shooting, and multiple projectile injuries, 40 years prior. No advanced medical treatment was required at the time. A CT was recently performed for unrelated reasons, and the scout view shows multiple projectiles, a total of 50, scattered in the thoracoabdominopelvic region as well as the lower limbs. CT angiography exposed CT's scout view of the multiple projectiles scattered. an arteriovenous fistula in posterior branches of the hypogastric artery with moderate dilations of the superior gluteal vein. The patient was completely asymptomatic and had no findings suggestive of AVF-related cardiac failure. Physical examination was unremarkable. Conservative treatment without further imagiological follow-up was decided, if patient continued asymptomatic.

Angiosarcoma of a Femoropopliteal Bypass Thrombosed Vein Graft.

BACKGROUND: Angiosarcoma is a rare subtype of malignant vascular tumours which has been only anecdotally described in patients submitted to lower limb revascularization. CASE PRESENTATION: This paper reports a patient previously submitted to a femoropopliteal bypass using autologous great saphenous vein (GSV). Nine years after the initial surgery, a primary angiosarcoma of the thrombosed vein graft was diagnosed, requiring en bloc surgical resection. Rampant metastatic spread was documented despite primary tumour surgical resection with a dismal outcome within months. CONCLUSIONS: Malignant transformation of autologous vein for lower limb revascularization is extremely rare and anecdotally described in the literature. It is a poorly studied complication with an aggressive behaviour. This report further reinforces the need for early recognition of this pathology.

Endovascular Treatment of Renal Artery Thrombosis in Living-Donor Kidney Transplant Recipient With Severe COVID-19 Disease.

PURPOSE: Coronavirus disease 2019 (COVID-19) patients have a higher prevalence of micro-and macrovascular thrombotic events. However, the underlying mechanism for the increased thrombotic risk is not completely understood. Solid organ transplant recipients infected with SARS-CoV-2 may have an exponential increase in thrombotic risk and the best management strategy is unknown. CASE REPORT: A female kidney transplant recipient presented with allograft's renal artery thrombosis after a recent COVID-19 infection. Due to the risk of kidney failure or exclusion, catheter directed thrombolysis was performed. Residual thrombus was excluded using an endoprosthesis with an excellent result. There were no adverse events and kidney function improved. CONCLUSION: This paper reports the endovascular treatment of renal artery thrombosis in a living-donor kidney transplant recipient with severe COVID-19 disease.

Emergency Repair of a Ruptured Para-Renal Abdominal Aortic Aneurysm in a Patient with a Functional Renal Graft: A Case Report and Review of the Literature.

INDRODUCTION: Rupture of and abdominal aortic aneurysm (AAA) in a kidney transplant patient is a rare and rarely reported event. Emergent treatment can be challenging and should achieve effective aortic repair while minimizing ischemic damage to the renal graft during aortic cross-clamping. Several renal protective measures have been proposed such as permanent or temporary shunts, renal cold perfusion and general hypothermia. CASE REPORT: We report the effective treatment of a para-renal AAA in a patient with a functional renal allograft. A temporary extra-corporeal axillofemoral shunt was constructed to maintain graft's perfusion during open surgical repair. EVAR was not an option due to a short aortic neck. The postoperative period was complicated by colon ischemia and aortic graft infection. At 3 years follow-up the patient was well and graft's function was unchanged. CONCLUSION: This case is a reminder that renal graft protection must be accounted for when AAA rupture occurs in kidney transplant patients. We reviewed the literature to find previously reported cases and how they were managed.

Iliac side branch technique for repair of bilateral iliac artery aneurysms associated with a congenital pelvic kidney.

Pelvic kidney is a congenital anomaly with few literature reports of concomitant aortoiliac aneurysmal disease. When aneurysm repair is indicated, either open or endovascular, it poses a technical challenge, since kidney preservation is paramount. This paper reports a successful endovascular repair of bilateral common iliac artery aneurysms in a patient with a right congenital pelvic kidney, using iliac side branch technique.

Laparoscopic Resection of a Splenic Artery Aneurysm with Vascular Reconstruction During Pregnancy.

Splenic artery aneurysms (SAA) are more frequent in women and have a high rupture risk during pregnancy, with catastrophic outcomes. It is advisable to treat these aneurysms in pregnant and fertile women, whatever their diameter, given their increased risk for rupture. There are several therapeutic approaches: endovascular surgery using coil embolization or stent graft coverage; laparoscopic or open surgical resection with arterial reconstruction and ligation followed by splenectomy when necessary. This paper aims to report the successful treatment of SAA in second-trimester pregnant women using a laparoscopic approach with aneurysm resection and arterial reconstruction. This is a unique report of a minimally invasive approach with arterial reconstruction in a pregnant woman, thus reducing the risk of spleen infarction and potentially avoiding splenectomy.

Emergent Endovascular Treatment in Primary Ilio-enteric Fistula.

Aortoenteric fistula (AEF) is a rare cause of gastrointestinal (GI) bleeding. If not promptly diagnosed and treated, the associated mortality is very high. The role of endovascular treatment is not yet defined. In this article, we report a clinical case of a 94-year-old male patient admitted in the emergency department with rectal bleeding. Owing to the detection of a pulsatile abdominal mass, a computed tomography angiography (CTA) scan was performed, which established the diagnosis of aorto-enteric fistula due to a left common iliac artery aneurysm (CIAA) ruptured to the sigmoid colon and also revealed an abdominal aortic aneurysm (AAA) and an internal iliac artery aneurysm (IIAA). Given the age of the patient, general condition and technical difficulty inherent to the treatment of the IIAA by conventional surgery, we chose endovascular treatment. However, we wanted to avoid contact between the endograft and the colon orifice because of the risk of infection. The patient was treated emergently with an aorto-right uni-iliac graft and a femoro-femoral bypass, IIAA embolization and 2 left iliac excluders (at the origin of the common iliac and distally in the external iliac artery). It was decided to treat colon lesion conservatively. In this case, the aorto-uni-iliac graft excluded the aortic inline flow, the distal occluder prevented retrograde flow from the external iliac, and the embolization prevented retrograde flow and treated the IIAA. This way, no arterial pressure and no prosthetic material existed inside the ruptured artery, hopefully allowing the spontaneous closing of the orifice leading the sigmoid colon to heal. The postoperative period was uneventful, and the patient was discharged at the 8th postoperative day. The patient outcome is a strong argument on the merit of the treatment strategy.

HAS-BLED Score Predicts the Risk of Major Bleeding in Chronic Anticoagulation after Lower Limb Surgical Revascularization.

BACKGROUND: Anticoagulant drugs are sometimes used after lower limb surgical bypass to improve patency. There are no bleeding risk scores validated specifically for patients with peripheral arterial disease. The HAS-BLED (hypertension, abnormal renal or liver function, stroke, history of or predisposition to bleeding, labile international normalized ratio (INR), elderly age [>65 years], and drugs or alcohol) score is a validated and frequently used tool to estimate the risk of major bleeding in patients receiving anticoagulation for atrial fibrillation. The objective of this study was to access the efficacy of the HAS-BLED score in predicting bleeding risk after lower limb bypass revascularization. METHODS: This study involved "secondary analysis of a retrospective database that includes patients with lower limb revascularization that was anticoagulated with acenocoumarol after hospital discharge." Consecutive patients treated between January 2014 and May 2016 were included. Patients previously on anticoagulants and patients on hemodialysis were excluded. RESULTS: Sixty-nine patients were included, 73.9% were males, with a mean age of 65 years. At 1-year follow-up, major bleeding occurred in 18.8% of patients. In this study, 52.1% of patients had HAS-BLED score ≥3. This subgroup had increased incidence of major bleeding: 33.3% compared to 0 risk factor (0%), 1 risk factor (0%), and 2 risk factors (4.2%) (P = 0.001). CONCLUSIONS: In this retrospective analysis, HAS-BLED score presented good association with major bleeding risk. It can be used as a tool for decision-making for the prescription of anticoagulants after lower limb revascularization. The prevalence of high scores is substantial, presuming high bleeding risk in this high-risk population.