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.

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 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.

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.

Preoperative anxiety as predictor of perioperative clinical events following carotid surgery: a prospective observational study.

BACKGROUND: Psychological factors like anxiety and depression are recognised to play a causal role in the development of cardiovascular disease and they may also influence outcome after vascular surgery procedures. The aim of this study was to investigate the association of anxiety and depression with postoperative outcome following elective carotid surgery. METHODS: Single centre prospective observational study of patients treated for asymptomatic carotid artery stenosis at an academic vascular surgery centre. Preoperative anxiety and depression were evaluated using self-reporting questionnaires: Spielberger State-Trait Anxiety Inventory (STAI-S/-T) and Hospital Anxiety and Depression Scale (HADS-A/-D). Postoperative morbidity and mortality were assessed with the primary composite endpoint of stroke, myocardial infarction (MI) and death. Standard reporting guidelines for carotid disease were applied. RESULTS: From June 2012 to November 2015, 393 carotid endarterectomies (CEA) were performed at our institution. Out of those, 98 asymptomatic patients were available for analysis (78% male; median age, 71.1 years). Median scores of self-reporting questionnaires did not differ from published data of the general population (STAI-T, trait component, median, 36; IQR, 31-42.75; STAI-S, state component, median, 38; IQR, 32-43; HADS-A median, 6; IQR, 3-8; HADS-D median, 4; IQR, 2-7). Cardiovascular risk factors were similar in anxious and non-anxious patients. The composite endpoint of stroke, MI and death occurred significantly more often in patients presenting with a preoperative HADS-A score higher than 6 (10.5%, 95% CI, 3-25; p =.020). CONCLUSIONS: The present study indicates that preoperative anxiety is associated with the occurrence of intra- and postoperative neurological events in patients undergoing CEA. Patients who had a preoperative HADS-A score of 6 or less had a very low probability of experiencing these complications.

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.

Nitinol Stent Versus Bypass in Long Femoropopliteal Lesions: 2-Year Results of a Randomized Controlled Trial.

OBJECTIVES: This study sought to compare patency rates and clinical outcomes of nitinol stents and primary vein bypass in long femoropopliteal lesions. BACKGROUND: An endovascular-first strategy for long femoropopliteal lesions is widely recommended without sufficient data comparing it with bypass surgery. Nitinol stents are widely used as the standard endovascular therapy. METHODS: A single-center randomized controlled trial was performed with the primary endpoints of technical success, primary and secondary patency. Secondary endpoints were limb salvage, survival, complications, and clinical improvement. RESULTS: A total of 110 limbs (55 per group) in 103 patients were treated. Baseline and lesion characteristics were similar, with a mean lesion length of 276 mm. Critical limb threatening ischemia was the indication for treatment in 49% of limbs in both groups. Technical success was achieved in 87% in the stent group. During a 2-year follow-up, patency rates, limb salvage, survival and complications showed no significant differences between both groups. At 24 months, primary and secondary patency rates for the stent group were 60% and 72% versus 56% and 73% in the bypass group, respectively. Clinical improvement was significantly better in the bypass group. CONCLUSIONS: There were no significant differences regarding patency rates, limb salvage, survival, or complications after 2 years. Technical success and clinical improvement in the bypass group were significantly better, but the promising results of the stent group suggest that an endovascular-first strategy for femoropopliteal lesions up to 30 cm may be reasonable. Mid- as well as long-term results need to be awaited.

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.

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.

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.

Paclitaxel-coated versus plain balloon angioplasty in the treatment of infrainguinal vein bypass stenosis.

OBJECTIVE: The aim of this study was to compare the clinical and hemodynamic outcomes of plain vs paclitaxel-coated percutaneous transluminal angioplasty (PTA) in patients with infrainguinal vein bypass stenosis. METHODS: A single-center retrospective analysis was conducted of consecutive patients treated by infrainguinal bypass PTA. Primary study end points were primary and assisted primary patency. Secondary end points were clinical and hemodynamic improvement, limb salvage, and survival. Society for Vascular Surgery reporting standards were applied. RESULTS: From April 2008 to November 2014, 83 infrainguinal vein bypasses were treated for graft stenosis by plain (group A, n = 41) or by paclitaxel-coated PTA (group B, n = 42). The groups did not differ significantly in mean age (71.9 years for both groups; P = .99), hypertension (P = 1.0), hyperlipidemia (P = .5), diabetes (P = .6), coronary artery disease (P = 1.0), smoking (P = 1.0), preoperative ankle-brachial index (P = .08), or bypass characteristics (below-knee, P = .82). Technical success rate was 100% for both groups. Mean follow-up was 2.9 years for group A patients and 2.2 years for group B patients (P = .08). No patient was lost to follow-up. Primary patency rates were 88% vs 87% and 73% vs 75% (P = .19) and assisted primary patency rates were 88% vs 90% and 77% vs 84% (P = .76) for group A and B patients at 1 and 2 years, respectively. Repeat target lesion revascularization rates were 22% vs 14% (P = .17). At the last follow-up, there were eight vs seven bypass occlusions (P = .74) for group A and B patients, respectively. In univariate analysis, proximal in-graft stenosis (Cox F, P = .041), bypass failure <6 months after bypass surgery (Cox F, P = .013), more than one bypass stenosis per graft (Cox F, P = .047), and redo bypass procedure (Cox F, P = .0001) were significantly related to assisted primary bypass patency. Immediate hemodynamic and sustained clinical improvement rates were 88% vs 86% and 70% vs 73% for group A and B patients, respectively. There were three vs one major amputations (P = .36) and eight vs seven deaths (P = .78) in group A and B patients, respectively. CONCLUSIONS: Paclitaxel-coated and plain angioplasty of significant infrainguinal vein bypass stenoses performed equally well in clinical and hemodynamic improvement and in primary and assisted primary bypass patency rates.

First Episode of Spontaneous Pneumothorax: CT-based Scoring to Select Patients for Early Surgery.

BACKGROUND: Although recurrence of primary spontaneous pneumothorax (PSP) is frequent, guidelines do not routinely recommend surgery after first presentation. A CT-based lung dystrophy severity score (DSS) has recently been proposed to predict recurrence following conservative therapy. This study compares the DSS in surgically and conservatively treated patients. METHODS: This is a retrospective analysis of first episode PSP patients, comparing video-assisted thoracic surgery (VATS; group A) to conservative treatment with or without chest drainage (group B). CT scans were reviewed for blebs or bullae, and patients were assigned DSS values and stratified into risk groups (low and high-grade). Primary end point was ipsilateral or contralateral recurrence. RESULTS: Fifty-six patients were included, 33 received VATS and 23 conservative treatment. In total, 37.5 % experienced recurrence, with a 5-year estimated recurrence rate of 40.7 % (group A: 13.3 %; group B: 73.9 %; p < 0.001). In group B, detection of any dystrophic lesions resulted in significantly higher 5-year recurrence rates (86.7 vs. 50.0 %; p = 0.03), there was no significant difference in group A (17.7 vs. 7.7 %; p = 0.50). Greater DSS values correlated with higher 5-year recurrence rates in group B (p = 0.02), but not in group A (p = 0.90). Comparing low- and high-grade patients in group B resulted in a significant 5-year recurrence rate of 53.8 versus 100 % (p = 0.023). CONCLUSIONS: The DSS is useful to indicate VATS after the first episode. For routine application, assigning patients to low- and high-grade groups seems most practical. We recommend CT-evaluation for every PSP patient and early surgery for those with lesions exceeding one bleb. After VATS, the preoperative DSS is not beneficial in predicting recurrence.

Arm veins versus contralateral greater saphenous veins for lower extremity bypass reconstruction: preliminary data of a randomized study.

BACKGROUND: The aim of this randomized study was to determine whether arm vein (AV) or contralateral greater saphenous vein (CGSV) is the better alternative vein source for lower extremity bypass reconstruction. METHODS: Consecutive patients with absent ipsilateral greater saphenous vein undergoing lower extremity revascularization were allocated to group A (AV bypass) or B (CGSV bypass). RESULTS: From 6, 2010, to 11, 2013, 64 patients (32 each group) were randomized. In all, 29 of 93 patients had to be excluded for various reasons. Median age was 76 years vs. 71 years (P = 0.01) for group A and B patients. There were no statistically significant differences regarding gender, cardiovascular risk factors, redo bypass procedures (P = 0.77), below-knee bypass procedures (P = 0.61), median bypass length (P = 0.6), and median length of incision on ipsilateral leg to perform anastomoses (P = 0.2) between group A and B patients, respectively. Incisions for vein harvest were longer in group A (P = 0.003). Overall surgical site infections (SSIs, P = 1.0) and SSI from vein harvest (P = 1.0) were equally distributed. No patient was lost to follow-up (17 vs. 18 months, P = 0.74). There was no statistically significant difference regarding primary (P = 0.77) and secondary (P = 0.25) patency rates at 1 year (group A: 52% vs. group B: 54% and group A: 72% vs. group B: 61%) and at 2 years (52% vs. 48% and 64% vs. 61%), respectively. There were 4 vs. 6 major amputations (P = 0.23) and 5 vs. 2 deaths (P = 0.1) in groups A and B during follow-up. CONCLUSIONS: Preliminary results suggest that both AV and CGSV may serve as a secondary vein bypass graft equally well.

Bioabsorbable stent implantation vs. common femoral artery endarterectomy: early results of a randomized trial.

PURPOSE: To compare clinical and hemodynamic outcome in patients undergoing treatment of common femoral artery (CFA) atherosclerotic lesions by bioabsorbable stent implantation (BASI group) or by common femoral artery endarterectomy (CFE group). METHODS: A randomized, controlled, single-center, open-label trial was initiated to compare outcomes of BASI or CFE in patients with chronic atherosclerotic occlusive lesions in the CFA. From May 2011 to April 2013, 116 consecutive patients were recruited; after excluding 36 patients, 80 patients (52 men; mean age 72.2±9.6 years) were enrolled 1:1 and are the subject of this intention-to-treat interim analysis (40 patients in each group). The primary endpoint was surgical site infections; secondary outcome measures were technical success, hemodynamic improvement, clinical improvement, patency, limb salvage, and survival. RESULTS: There was no statistically significant difference between both groups regarding demographic data, cardiovascular risk factors, or CFA occlusions. The CFE patients presented with 7 surgical site infections (all minor) vs. none in the BASI group (p=0.002) and a longer mean postoperative hospital stay of 7 vs. 2 days for BASI patients (p<0.001). Technical success rates were 97.5% and 100% for the BASI and CFE groups, respectively. Postoperative ankle-brachial index means were comparable (p=0.38). The 30-day primary patency rates were 92.5% and 100% for the BASI and CFE groups, respectively (p=0.038). There were 6 reconstruction failures in CFE patients vs. none in the BASI group (p=0.02); 5 failures involved initial CFA occlusions. At 1 year, the primary and secondary patency rates were 80% vs. 100% (p=0.007) and 84% vs. 100% (p=0.01) for BASI and CFE patients, respectively. Limb salvage was equivalent, and survival rates were 88% and 90% for BASI vs. CFE patients (p=0.51) at 1 year. CONCLUSION: This interim analysis suggests that BASI is not an option for CFA occlusion and is only a limited option for CFA stenosis. Clinical and hemodynamic results are comparable for BASI and CFE. An increased rate of redo procedures in the BASI patients outweighs lower surgical site infection rates compared to CFE. Short-term patency rates are significantly worse in patients undergoing CFA stenting with BASI.

Successful repair of bilateral common carotid artery dissections from hanging.

The management of blunt carotid artery dissections caused by hanging remains controversial, especially with regard to diagnostic work-up and treatment options. We present 2 men, 49 and 41 years of age, who were treated for bilateral common carotid artery dissection caused by strangulation. In the first patient, additional cricotracheal separation and blunt thyroid gland trauma was observed. Bilateral saphenous vein graft interposition was accomplished in both patients. In the first patient, tracheal repair and suture of the thyroid gland completed the procedure. At 1 year of follow-up, both patients were capable of managing their lives independently. A systematic review of the literature on managing near-hanging and nonfatal strangulation victims is included in this report to allow this case series to be put into perspective.

Ultrasonic vein mapping prior to infrainguinal autogenous bypass grafting reduces postoperative infections and readmissions.

OBJECTIVE: Although duplex vein mapping (DVM) of the great saphenous vein (GSV) is common practice, there is no level I evidence for its application. Our prospective randomized trial studied the effect of preoperative DVM in infrainguinal bypass surgery. METHODS: Consecutive patients undergoing primary bypass grafting were prospectively randomized for DVM of the GSV (group A) or no DMV of the GSV (group B) before surgery. Society for Vascular Surgery reporting standards were applied. RESULTS: From December 2009 to December 2010, 103 patients were enrolled: 51 (group A) underwent DVM of the GSV, and 52 (group B) did not. Group A and group B not differ statistically in age (72.8 vs 71.1 years), sex (women, 29.4% vs 34.6%), cardiovascular risk factors, body mass index (25.9 vs 26.1 kg/m(2)), bypass anatomy, and runoff. Group A and B had equal operative time (151.4 vs 151.1 minutes), incisional length (39.4 vs 39.9 cm), and secondary bypass patency at 30 days (96.1% vs 96.2%; P = .49). Conduit issues resulted in six intraoperative changes of the operative plan in group B vs none in group A (P = .014). Median postoperative length of stay was comparable in both groups (P = .18). Surgical site infections (SSIs) were classified (in group A vs B) as minor (23.5% vs 23.1%; P = 1.0) and major (1.9% vs 21.2%; P = .004). Readmissions due to SSIs were 3.9% in group A vs 19.2% in group B (P = .028). Two patients in group B died after complications of SSIs. Multivariate analysis identified preoperative DVM as the only significant factor influencing the development of major SSI (P = .0038). CONCLUSIONS: Routine DVM should be recommended for infrainguinal bypass surgery. The study found that preoperative DVM significantly avoids unnecessary surgical exploration, development of major SSI, and reduces frequency of readmissions for SSI treatment.

An in vitro model of adult mammalian nerve repair.

The role of pathway-derived growth factors in the support of peripheral axon regeneration remains elusive. Few appropriate knock-out mice are available, and gene silencing techniques are rarely 100% effective. To overcome these difficulties, we have developed an in vitro organotypic co-culture system that accurately models peripheral nerve repair in the adult mammal. Spinal cord sections from P4 mice that express YFP in their neurons are used to innervate segments of P4 peripheral nerve. This reconstructed ventral root is then transected and joined to a nerve graft. Growth of axons across the nerve repair and into the graft can be imaged repeatedly with fluorescence microscopy to define regeneration speed, and parent neurons can be labeled in retrograde fashion to identify contributing neurons. Nerve graft harvested from adult mice remains viable in culture by both morphologic and functional criteria. Motoneurons are supported with GDNF for the first week in culture, after which they survive axotomy, and are thus functionally adult. This platform can be modified by using motoneurons from any genetically modified mouse that can be bred to express XFP, by harvesting nerve graft from any source, or by treating the culture systemically with antibodies, growth factors, or pathway inhibitors. The regeneration environment is controlled to a degree not possible in vivo, and the use of experimental animals is reduced substantially. The flexibility and control offered by this technique should thus make it a useful tool for the study of regeneration biology.