A Free-Floating Aortic Thrombus: An Uncommon Approach to Handle a Rare Clinical Entity.

BACKGROUND: Thrombotic material in the non-aneurysmatic and non-atherosclerotic aorta is a rare entity without any recommended standard treatment so far. We present a successful treatment strategy for patients who do not fit into any of the common approaches. CASE REPORT: A free-floating thrombus in the descending aorta was found as source of embolism in an 82-year-old female patient with lower limb ischemia. After initial heparinization of the patient without relevant reduction of the thrombotic mass, the thrombus was removed using an interdisciplinary approach. Under echocardiographic guidance to locate the thrombus, the AngioVac device, usually licensed to remove floating thrombi from the venous system, was used off-label to remove the thrombus by a transfemoral approach. To avoid rebuilding of a new thrombus, the attachment point with an exulcerated plaque in the descending aorta was covered by a stent graft via the same femoral access. The patient did not experience any further embolic events, and the postoperative course was uncomplicated. CONCLUSION: Patients with uncommon aortic diseases, such as the reported free-floating thrombus, should be treated by an individualized, interdisciplinary approach. Besides the recommended treatment options, there are other uncommon approaches that might offer an alternative in complex cases. CLINICAL IMPACT: Evidence is rare for the treatment of a free-floating thrombus in the descending aorta and the treatment strategy remains discussed controversially. We present a rather uncommon approach of successful off-label treatment for patients who do not fit into any of the common approaches (operative, endovascular, or conservative treatment based on patient's comorbidities). The AngioVac System has already been successfully used off-label in the arterial system but not in the above presented way of treating a free-floating thrombus in a patient with high embolization risk and treatment-limiting comorbidities.

Unintended Exchange of Target Vessels for Celiac Trunk and Superior Mesenteric Artery Branches in Complex Endovascular Aortic Repair.

PURPOSE: The treatment of thoracoabdominal aortic aneurysms (TAAAs) using branched endovascular aortic repair (BEVAR) is safe and effective. During deployment, the superior mesenteric artery (SMA) branch can unintentionally open into the celiac trunk (CT) ostium and switched catheterization of the SMA from the CT branch and the CT from the SMA branch can be used as an alternative technique in these cases. This study aimed to investigate the outcome of exchanging the intended target vessels (TVs) for the CT and SMA branches during BEVAR. MATERIALS AND METHODS: A single-center retrospective analysis of patients with TAAAs who underwent BEVAR, using off-the-shelf or custom-made devices (CMDs), with an unintended exchange of TVs for the CT and SMA branches was performed. RESULTS: Between 2014 and 2023, 397 patients were treated with BEVAR for TAAA. Eighteen (4.5%) of those patients were treated with an exchange of TVs for the CT and SMA branches. T-branch was used in 9 cases (50%) and the remaining patients were treated with CMDs. Twelve patients were treated electively, 3 were symptomatic and 3 presented with rupture. Of 36 mesenteric TVs in those 18 patients, 34 (94%) were catheterized successfully, including all 18 SMAs and 16 of the 18 CTs. No branch stenosis or occlusion of the switched mesenteric TVs was detected during follow-up. During 30-day follow-up, 3 patients died and during a median follow-up of 3 (interquartile range [IQR]: 1-15) months 3 more patients died. None of the deaths or the 2 unintended reinterventions was induced by the mesenteric TV exchange. The median hospital stay was 14 (IQR: 9-22) days with a median of 4 (IQR: 2-11) days at the intensive care unit. CONCLUSION: The exchange of the mesenteric TVs for the CT and SMA branches during BEVAR with off-the-shelf and CMD endografts is feasible with good TV patency and freedom from TV-related reinterventions. This alternative technique should be considered in selected cases when direct catheterization via the intended branch is deemed more time-consuming or not feasible. CLINICAL IMPACT: This is the first description of using an exchange of target vessels for the celiac trunk and the superior mesenteric artery branches in patients with thoracoabdominal aortic aneurysms undergoing BEVAR, using off-the-shelf or custom-made devices. The high success rate as well as the good clinical results without any branch stenosis or occlusion during follow-up highlight the feasibility of this alternative technique. It could help in challenging cases when catheterization of the intended target vessels is not possible or too time consuming, resulting in higher success rates of BEVAR and better clinical results.

Vein Bypass Versus Nitinol Stent in Long Femoropopliteal Lesions: 4-Year Results of a Randomized Controlled Trial.

OBJECTIVES: The aim of this study was to compare technical success, patency rates and clinical outcomes of vein bypass (VBP) with angioplasty and nitinol stents (NS) in femoropopliteal Trans-Atlantic Intersociety Consensus (TASC) II C and D lesions. SUMMARY BACKGROUND DATA: Guidelines widely recommend an endovas-cular-first strategy for long femoropopliteal lesions without sufficient data comparing it with vein bypass surgery. METHODS: A single-center prospective, randomized controlled trial (RCT) was performed, after approval of the local ethics committee, with technical success, primary and secondary patency as primary endpoints. Secondary endpoints were limb salvage, survival, complications, and clinical improvement. RESULTS: Between 2016 and 2020, 218 limbs (109 per group) in 209 patients were included. Baseline and lesion characteristics were similar in both groups with a mean lesion length of 268 mm. The indication for treatment was chronic limb threatening ischemia in 53% of limbs in both groups. Technical success was feasible in 88% in the stent group. During a 4-year follow-up, primary patency, freedom from target lesion revascularizations, limb salvage, survival and complications showed no significant differences between the groups. At 48 months secondary patency for the bypass group was 73% versus 50% in the stent group ( P = 0.021). Clinical improvement was significantly superior in the bypass group with 52% versus 19% reaching a Rutherford 0 category ( P < 0.001). CONCLUSIONS: This is the largest RCT comparing angioplasty with NS and vein bypass in femoropopliteal TASC II C and D lesions and the first to report 4-year results. The data underline the feasibility of endovascular treatment in long lesions but also emphasize the advantages of VBP.

Long-Term Results of Autologous Bifurcated Carotid Artery Reconstructions.

BACKGROUND: Carotid bifurcation revascularization using interposition grafts is rare. While internal carotid artery (ICA) revascularization is regarded as mandatory, the external carotid artery (ECA) is severed in most instances. Long-term results of an autologous bifurcated carotid artery reconstruction are discussed. METHODS: Single-center, retrospective analysis of a consecutive series of patients treated at an academic vascular surgery center. RESULTS: From December 2006 to November 2019, fifty-one patients underwent reconstruction of the carotid artery using an autologous bifurcated interposition graft (38 males, 75%; median age: 68.7 years; interquartile range [IQR]: 60.2-76.5). Thirty-eight patients were asymptomatic (74.5%). Indication for reconstruction was recurrent carotid stenosis unfavorable for endovascular treatment/redo patch plasty (n = 32, symptomatic: n = 7), carotid aneurysm (n = 11, symptomatic: n = 5), neck tumor with vascular involvement (n = 7), trauma (n = 1). Nonreversed valve depleted saphenous vein y-graft from the groin was used in 49 (94.2%) and reversed cubital vein bifurcation in 3 (5.8%) procedures. The median ICA cross-clamp time was 15 min (IQR: 13-20 min). In four procedures (7.7%), a shunt was inserted because of a significant decrease of cerebral perfusion. In one patient, additional intraoperative stent placement of a proximal common carotid artery (CCA) stenosis was performed. Six patients suffered from ischemic neurological deficits (11.5%), all but 1 recovered with no or moderate symptoms. After a median follow-up of 5.2 years (IQR: 1.1-8.7 years), 7 significant asymptomatic stenoses (13.5%) and 2 occlusions (3.8%, one symptomatic) of the ICA, two significant asymptomatic CCA stenoses (3.8%), five significant stenoses (9.6%) and 7 asymptomatic occlusions (13.5%) of the ECA were observed. This prompted 7 re-redo-interventions in 5 patients. Twenty-eight patients (54.9%) died after a median follow-up of 3.3 years (IQR: 0.5-5.6 years). Two of these patients died due to conditions related to the performed carotid artery reconstruction. CONCLUSIONS: Autologous bifurcated carotid artery interposition graft provides results comparable to other complex ICA revascularizations. Overall survival in this heterogeneous patient cohort is poor. Due to the high risk of stroke and poor long-term outcome, this procedure should be reserved for symptomatic patients with no other option for revascularization.

Comparison of Prosthetic and Vein Bypass with Nitinol Stents in Long Femoropopliteal Lesions.

BACKGROUND: Guidelines for the treatment of long femoropopliteal lesions are not based on a high level of evidence and recent randomized controlled trials (RCTs) challenge vein bypass (VBP) as the recommended therapy. This study compared prosthetic (PTFE) bypass, VBP and angioplasty with nitinol stents in long femoropopliteal lesions. METHODS: Pooled data from a RCT and a retrospective database with the same inclusion criteria were analyzed with primary and secondary patency as well as freedom from target lesion revascularization (TLR) as primary endpoints. RESULTS: Between 2016 and 2018 a total of 172 lesions were treated in three groups (PTFE: n = 62, VBP: n = 55, stent: n = 55). Clinical and lesion characteristics were similar with mean lesion lengths between 260 and 279mm. Technical success rate in the stent group was 87%. There were no significant differences between the groups in patency rates, freedom from TLR, limb salvage and survival during 2-year follow-up. The primary patency rates for the PTFE, VBP and stent groups were 50%, 56% and 60% at 2 years. The PTFE group had significantly less complications compared to the other groups and a shorter hospital-stay compared to the VBP group. Clinical improvement was significantly better in the PTFE and VBP group compared to the stent group. CONCLUSIONS: The 2-year results indicate that the role of VBP as the recommended therapy for long femoropopliteal lesions may not be unchallenged due to the similar results in all three groups. Further RCTs are needed to determine the best revascularization modality for long femoropopliteal lesions.

Impacts of Telomeric Length, Chronic Hypoxia, Senescence, and Senescence-Associated Secretory Phenotype on the Development of Thoracic Aortic Aneurysm.

Thoracic aortic aneurysm (TAA) is an age-related and life-threatening vascular disease. Telomere shortening is a predictor of age-related diseases, and its progression is associated with premature vascular disease. The aim of the present work was to investigate the impacts of chronic hypoxia and telomeric DNA damage on cellular homeostasis and vascular degeneration of TAA. We analyzed healthy and aortic aneurysm specimens (215 samples) for telomere length (TL), chronic DNA damage, and resulting changes in cellular homeostasis, focusing on senescence and apoptosis. Compared with healthy thoracic aorta (HTA), patients with tricuspid aortic valve (TAV) showed telomere shortening with increasing TAA size, in contrast to genetically predisposed bicuspid aortic valve (BAV). In addition, TL was associated with chronic hypoxia and telomeric DNA damage and with the induction of senescence-associated secretory phenotype (SASP). TAA-TAV specimens showed a significant difference in SASP-marker expression of IL-6, NF-κB, mTOR, and cell-cycle regulators (γH2AX, Rb, p53, p21), compared to HTA and TAA-BAV. Furthermore, we observed an increase in CD163+ macrophages and a correlation between hypoxic DNA damage and the number of aortic telocytes. We conclude that chronic hypoxia is associated with telomeric DNA damage and the induction of SASP in a diseased aortic wall, promising a new therapeutic target.

The Role of Telocytes and Telocyte-Derived Exosomes in the Development of Thoracic Aortic Aneurysm.

A hallmark of thoracic aortic aneurysms (TAA) is the degenerative remodeling of aortic wall, which leads to progressive aortic dilatation and resulting in an increased risk for aortic dissection or rupture. Telocytes (TCs), a distinct type of interstitial cells described in many tissues and organs, were recently observed in the aortic wall, and studies showed the potential regulation of smooth muscle cell (SMC) homeostasis by TC-released shed vesicles. The purpose of the present work was to study the functions of TCs in medial degeneration of TAA. During aneurysmal formation an increase of aortic TCs was identified in human surgical specimens of TAA-patients, compared to healthy thoracic aortic (HTA)-tissue. We found the presence of epithelial progenitor cells in the adventitial layer, which showed increased infiltration in TAA samples. For functional analysis, HTA- and TAA-telocytes were isolated, characterized, and compared by their protein levels, mRNA- and miRNA-expression profiles. We detected TC and TC-released exosomes near SMCs. TAA-TC-exosomes showed a significant increase of the SMC-related dedifferentiation markers KLF-4-, VEGF-A-, and PDGF-A-protein levels, as well as miRNA-expression levels of miR-146a, miR-221 and miR-222. SMCs treated with TAA-TC-exosomes developed a dedifferentiation-phenotype. In conclusion, the study shows for the first time that TCs are involved in development of TAA and could play a crucial role in SMC phenotype switching by release of extracellular vesicles.

Long-Term Results of Endovascular Treatment with Nitinol Stents for Femoropopliteal TASC II C and D Lesions.

Background and Objectives: The feasibility of endovascular treatment (EVT) for Trans-Atlantic Inter-Society Consensus (TASC) II C and D femoropopliteal artery lesions has been described, but no prospective study has performed a long-term follow-up. The aim of this study was to report the long-term results of nitinol stents (NS) for the treatment of long femoropopliteal lesions. Materials and Methods: A single-center prospective, randomized controlled trial (RCT) comparing EVT with NS and vein bypass surgery was previously performed. The EVT group's follow-up was extended and separately analyzed with primary patency as the primary endpoint. The secondary endpoints were technical success, secondary patency, reinterventions, limb salvage, survival, complications, and clinical improvement. Results: Between 2016 and 2020, 109 limbs in 103 patients were included. A total of 48 TASC II C and 61 TASC II D lesions with a mean lesion length of 264 mm were reported. In 53% of limbs, the indication for treatment was chronic limb-threatening ischemia. The median follow-up was 45 months. Technical success was achieved in 88% of cases, despite 23% of the lesions being longer than 30 cm (retrograde popliteal access in 22%). At four-year follow-up, primary patency, secondary patency, and freedom from target lesion revascularizations were 35%, 48%, and 58%, respectively. Limb salvage and survival were 90% and 80% at 4 years. Clinical improvement of at least one Rutherford category at the end of follow-up was achieved in 83% of limbs. Conclusions: This study reports the longest follow-up of endovascular treatment with nitinol stents in femoropopliteal TASC II C and D lesions. The results emphasize the feasibility of an endovascular-first strategy, even in lesions beyond 30 cm in length, and clarify its acceptable long-term durability and good clinical outcomes. Large multicenter RCTs with mid- and long-term follow-up are needed to investigate the role of different endovascular techniques in long femoropopliteal lesions.

Telocytes in the human ascending aorta: Characterization and exosome-related KLF-4/VEGF-A expression.

Telocytes (TCs), a novel interstitial cell entity promoting tissue regeneration, have been described in various tissues. Their role in inter-cellular signalling and tissue remodelling has been reported in almost all human tissues. This study hypothesizes that TC also contributes to tissue remodelling and regeneration of the human thoracic aorta (HTA). The understanding of tissue homeostasis and regenerative potential of the HTA is of high clinical interest as it plays a crucial role in pathogenesis from aortic dilatation to lethal dissection. Therefore, we obtained twenty-five aortic specimens of heart donors during transplantation. The presence of TCs was detected in different layers of aortic tissue and characterized by immunofluorescence and transmission electron microscopy. Further, we cultivated and isolated TCs in highly differentiated form identified by positive staining for CD34 and c-kit. Aortic-derived TC was characterized by the expression of PDGFR-α, PDGFR-ß, CD29/integrin ß-1 and αSMA and the stem cell markers Nanog and KLF-4. Moreover, TC exosomes were isolated and characterized for soluble angiogenic factors by Western blot. CD34+ /c-kit+ TCs shed exosomes containing the soluble factors VEGF-A, KLF-4 and PDGF-A. In summary, TC occurs in the aortic wall. Correspondingly, exosomes, derived from aortic TCs, contain vasculogenesis-relevant proteins. Understanding the regulation of TC-mediated aortic remodelling may be a crucial step towards designing strategies to promote aortic repair and prevent adverse remodelling.

Arm Vein versus Small Saphenous Vein for Lower Extremity Bypass in the Absence of Both Great Saphenous Veins.

BACKGROUND: Bypass surgery remains the gold standard for long and complex arterial occlusions in the lower limb. The vein is regarded superior to prosthetic conduits in peripheral arterial bypass surgery. However, this option is often limited because of previous bypass, stripping, or poor quality of the ipsilateral and/or contralateral great saphenous vein (GSV). Under these circumstances, the arm vein (AV) and small saphenous vein (SSV) are the only alternative autologous vein grafts. METHODS: We analyzed all consecutive patients treated at an academic tertiary referral center between January 1998 and July 2018 using either the AV or SSV as the main peripheral bypass graft. Study end points were primary patency, secondary patency, limb salvage, and survival. RESULTS: In total, 416 bypass procedures using exclusively AV (n = 327) or SSV (n = 89) were performed. There was a predominance of male gender. The majority of risk factors were evenly distributed between groups. The mean follow-up period was 2.3 years (0.9 to 13.3 years). Five-year primary and secondary patency rates were 39% (95% CI: 31-47%) and 67% (59-75%) for AV and 53% (41-66%) and 76% (67-86%) for SSV, respectively (P = 0.2 and 0.25). The five-year limb salvage and survival rates were 71% (68-81%) and 84% (77-90%) for AV and 78% (67-88%) and 90% (82-98%) for SSV, respectively (P = 0.52 and 0.11). CONCLUSIONS: Both AV and SSV are equally effective alternatives for peripheral bypass if no GSV is available. Although there was a trend toward better results with the SSV, there was no significant difference between the 2 options.

Alternative Venous Conduits for Below Knee Bypass in the Absence of Ipsilateral Great Saphenous Vein.

OBJECTIVE: Vein is regarded superior to artificial graft in peripheral arterial bypass surgery. However, this option is often limited owing to previous use or removal of the ipsilateral greater saphenous vein (iGSV). In this case, the contralateral great saphenous vein (cGSV), the small saphenous vein (SSV), or arm veins (AV) are possible alternatives. Experience with all three grafts for below knee vein bypass is reported. METHODS: Consecutive patients treated at an academic tertiary referral centre between January 1998 and July 2018 using the cGSV, SSV, or AV as the main peripheral bypass graft were analysed. Study end points were primary patency, secondary patency, limb salvage, and survival. RESULTS: Over the observed time period, 2642 bypass operations for treatment of peripheral artery disease with below knee target arteries were performed at the authors' institution: 1937 procedures using the iGSV; 644 bypass procedures using the cGSV (n = 186; 28.9%), SSV (n = 101; 15.7%), or AV (n = 357; 55.4%); and 61 procedures using a prosthetic graft. The median follow up period was 2.3 years (range 9 days-18.5 years). Thirty day mortality was 1.9% for the whole group and similar between the three groups. After five years, primary and secondary patency rates were comparable between the three groups. Secondary patency was 75% (95% confidence interval [CI] 66-83) in the cGSV and SSV groups, and 65% (95% CI 57-73) in the AV group (p = .47). Limb salvage and survival after five years were, respectively, 73% (95% CI 65-81) and 89% (95% CI 82-95) in the cGSV group, 79% (95% CI 69-89) and 87% (95% CI 79-95) in the SSV group, and 74% (95% CI 68-80) and 83% (77-89) in the AV group (p = .46). CONCLUSION: All three types of alternative autologous vein graft are equal regarding outcome parameters. Vascular surgeons should consider all autologous options if their preferred choice is not available.

Trans-Iliac Bypass Grafting for Vascular Groin Complications.

OBJECTIVES: Groin complications following vascular reconstruction, extensive trauma, or severe radiation induced scarring may complicate future revascularisation procedures of the lower limb. Although several techniques have been described, only few cases of trans-iliac bypass grafting have been published. The aim of this study was to perform a review of the literature on trans-ilac bypass grafting and add the authors' experience. METHODS: A single centre retrospective data analysis and a literature review of all trans-iliac bypass procedures was performed. Data on indication, patency, limb salvage, and survival were collected. Study endpoints were patency, limb salvage, and patient survival. RESULTS: Eight trans-iliac wing bypass grafting procedures were performed in our institution between 2003 and 2018, which represents the largest single centre series. Twenty-three procedures were reported in the literature between 1989 and 2018. Prior to the bypass procedure in the eight patients, six had local infection and two irradiation of the groin. The indication for operation was ischaemia in six cases, bleeding in one case, and infection in another case. The external iliac artery was most often used for the proximal (6 cases) and the superficial femoral artery for distal anastomosis (6 cases). Great saphenous vein was the most commonly used graft material (6 cases). The median follow up was five years with three bypass occlusions after 1, 2, and 8 months, followed by two successful thrombectomy procedures. There were no major amputations and only one death after five months, which was not procedure related. CONCLUSIONS: Trans-iliac bypass grafting is a viable alternative extra-anatomic bypass technique in patients with vascular groin complications. Patency as well as limb salvage and survival are good and may be comparable to those reported for autologous in situ repair and obturator canal bypass grafting.

The Small Saphenous Vein: An Underestimated Source for Autologous Distal Vein Bypass.

OBJECTIVES: The small saphenous vein (SSV) is a potential vein source for bypass if neither greater saphenous vein nor arm vein is available. This study reports experience using SSV as part of an all autologous vein bypass policy. METHODS: This study comprised single centre retrospective data analysis of all consecutive patients treated at an academic tertiary referral centre from January 1998 to February 2017 using the SSV as the main peripheral bypass graft. Study endpoints were primary patency, secondary patency, limb salvage, and survival. RESULTS: One hundred and twenty operations were performed in 118 patients using SSV. Indications were peripheral arterial occlusive disease (n = 91; Rutherford classification 3: n = 11; 4: n = 21; 5,6: n = 59), acute ischaemia (n = 14), popliteal artery aneurysm (n = 12), and bypass revisions (n = 3). Median follow up was 30.5 months (10 months-13.7 years). Primary patency after one, three and five years was 68% (CI: 59-77%), 58% (49-68%), and 54% (45-64%). Secondary patency was 83% (76-89%) after one year and 77% (69-85%) after three and five years. Limb salvage after one year was 88% (82-94%) and 78% (70-86%) after five years. Survival was 96% (92-99%) after one year and 91% (85-97%) at five years. Multivariable analysis identified redo surgery as an independent risk factor. Patients receiving a primary (n = 59) vs. a redo bypass (n = 61) were compared. Primary patency and secondary patency were both significantly better in the primary bypass group than in the redo group (p = .0036 and p = .0003, respectively). Limb salvage was also significantly better in primary bypass patients than in the redo group (p = .0007), whereas overall survival did not differ significantly (p = .48). CONCLUSION: The SSV is a valuable alternative vein graft in peripheral bypass surgery. It achieves excellent long-term results, particularly in patients with primary procedures but also acceptable results in patients with redo surgery.

Alternative Debranching in Patients with Thoracoabdominal Aortic Aneurysm after Open and Endovascular Aortic Aneurysm Repair.

Management of recurrent thoracoabdominal aneurysmal disease of the aorta is challenging. We report three patients with previous endovascular or open aortic repair requiring redo repair by treatment by stent-graft implantation of the thoracoabdominal aorta and visceral debranching using an antegrade inflow from the ascending aorta. All three interventions were successful, with two patients alive 5 and 2 years, respectively, after this operation, while the third patient died 2 days after the procedure due to cardiac failure. No paraplegia was observed. As complications from complex open and endovascular procedures are increasing, vascular surgeons should get familiar with alternative management options.

Small Saphenous Vein and Arm Vein as Bypass Grafts for Upper Extremity Ischemia.

BACKGROUND: Bypass in the upper extremity is a rare procedure mainly performed for chronic ischemia, trauma, or hemodialysis access complications. Feasibility and success of use of the arm vein and small saphenous vein (SSV) for autologous vein bypass have been reported in peripheral artery bypass procedures. There are very few reports on the use of alternative veins in upper extremity bypass. We report our experience with arm vein and SSV as a graft source in upper extremity arterial disease. METHODS: Retrospective analysis of a consecutively collected case series in an academic tertiary referral center from January 2010 to February 2018. Study end points were primary patency, secondary patency, limb salvage, and survival. RESULTS: In total, 47 patients were treated with upper extremity bypass either using the SSV (n = 17) or arm veins (n = 30). Indications were either acute (n = 12) or chronic ischemia (n = 35) caused by acute (n = 8) and chronic (n = 9) trauma, sequela of iatrogenic interventions (n = 4), peripheral artery disease (n = 14), thrombangiitis obliterans (n = 3), and dialysis-access-related complications (n = 9). An arm vein was used in 30 and the SSV in 17 patients. Primary patency after 12 months was 87% with the SSV and 75% with an arm vein (P = 0.8) and 63% and 75% after 36 months (P = 0.9). Secondary patency were 100% with an arm vein and 100% with the SSV after 36 months (P = 0.4). One patient had to undergo major amputation and 2 minor amputations. CONCLUSIONS: Arm vein revascularization using the primarily arm vein or SSV as a bypass conduit can be performed with reasonable mortality and morbidity rates and provide good results comparable with the greater saphenous vein.

Tibiodistal vein bypass in critical limb ischemia and its role after unsuccessful tibial angioplasty.

OBJECTIVE: Technical progress in angioplasty expanded its application to very distal arterial lesions of the lower extremity. In cases of unsuccessful angioplasty tibiodistal bypass surgery may be required for limb salvage. We investigated the long-term outcome of this technique in patients with critical limb ischemia. The purpose of this study was to evaluate whether tibiodistal bypasses done after unsuccessful tibial angioplasty had inferior patency, limb salvage, or survival rates compared with primary tibiodistal bypasses. METHODS: This single-center, retrospective data analysis included all distal bypass procedures originating from a tibial artery. Primary study end points were primary patency, secondary patency, and limb salvage. Secondary end points included survival, wound healing, and systemic and local complications. Society for Vascular Surgery reporting standards were applied. RESULTS: There were 61 tibiodistal vein bypasses for critical limb ischemia performed in 23 years. Indications for tibiodistal bypass was Rutherford category 5 in 41 cases (67%) and category 6 in 20 cases (33%). Procedures were allocated to group A (primary bypass; n = 28) and group B (bypass after unsuccessful tibial angioplasty; n = 33). Primary patency was 55% versus 53% at 1 year and 47% versus 44% at 3 years (P = .58). Secondary patency was 59% versus 64% at 1 year and 52% versus 55% at 3 years (P = .36). Limb salvage was 96% versus 90% at 1 year and 91% versus 85% at 3 years (P = .44). Overall survival rates were 91% versus 97% at 1 year and 85% versus 92% at 3 years (P = .76). The median follow-up was 4.0 years in group A and 4.9 years in group B. In multivariate analyses for loss of primary patency and limb loss, no significant predictors could be identified. CONCLUSIONS: This study showed that tibiodistal vein bypass is a feasible, efficient, and safe technique in patients with critical limb ischemia. It provides acceptable primary and secondary patency rates to prevent major amputation and ensure survival. Previous unsuccessful tibial angioplasty had no significant impact on tibiodistal vein bypass outcome. This technique should be part of the armamentarium of vascular surgeons.

Autologous Bifurcated Carotid Artery Reconstruction: Technique and 2 Year Follow Up.

OBJECTIVE/BACKGROUND: Carotid bifurcation resection with subsequent reconstruction is performed infrequently. While internal carotid artery (ICA) revascularisation is regarded as mandatory, the external carotid artery (ECA) is severed in most instances. Indications for and results of an autologous bifurcated carotid artery reconstruction are discussed. METHODS: This was a single centre retrospective analysis of a consecutive series of patients treated at an academic vascular surgery centre. RESULTS: From December 2006 to August 2015, 47 patients underwent reconstruction of the carotid artery using an autologous bifurcated interposition graft (36 men; median age 68.3 years [range 41-87 years]; 33 asymptomatic [70%]). The indication for reconstruction was recurrent carotid stenosis unfavorable for endovascular treatment/redo patch plasty (n = 29; symptomatic: n = 12), carotid aneurysm (n = 10), neck tumour with vascular involvement (n = 7), and trauma (n = 1). Groups were not different with regard to vascular risk factors. Non-reversed valve depleted saphenous/accessory saphenous vein from the groin was used in 44 (94%), and reversed valve depleted cubital vein bifurcation graft in three patients (6%). Median ICA cross clamp time was 17 min (range 8-30 min). Five patients suffered from intra-operative ischaemic neurological deficits (11%), of which all were temporary except one. One tumour patient died on post-operative day 1 due to bleeding. Median follow up was 28.3 months (range 0.1-97.4 months). Tumour erosion required graft ligation in one patient 7 months after reconstruction. Five significant stenoses of the ICA (11%), nine (19%) stenoses of the ECA, and two (4%) common carotid artery stenoses, with four (8%) re-redo interventions, were observed. Thirteen patients (28%) died after a median follow up of 6.7 months (range 1.7-56.7 months), all unrelated to the vascular procedure. CONCLUSION: Autologous bifurcated carotid artery interposition graft avoids the use of prosthetic graft material, the ECA remains patent in 80%, and it provides mid-term results comparable with other redo carotid artery procedures. Therefore, this procedure should be reserved for symptomatic patients with no other revascularisation option.

Telomere Biology and Thoracic Aortic Aneurysm.

Ascending aortic aneurysms are mostly asymptomatic and present a great risk of aortic dissection or perforation. Consequently, ascending aortic aneurysms are a source of lethality with increased age. Biological aging results in progressive attrition of telomeres, which are the repetitive DNA sequences at the end of chromosomes. These telomeres play an important role in protection of genomic DNA from end-to-end fusions. Telomere maintenance and telomere attrition-associated senescence of endothelial and smooth muscle cells have been indicated to be part of the pathogenesis of degenerative vascular diseases. This systematic review provides an overview of telomeres, telomere-associated proteins and telomerase to the formation and progression of aneurysms of the thoracic ascending aorta. A better understanding of telomere regulation in the vascular pathology might provide new therapeutic approaches. Measurements of telomere length and telomerase activity could be potential prognostic biomarkers for increased risk of death in elderly patients suffering from an aortic aneurysm.