In Situ Vein Bypass Is Superior to Endovascular Treatment of Femoropopliteal Lesions in Chronic Limb-Threatening Ischemia.

BACKGROUND: The objective of the study was to compare bypass surgery and endovascular revascularization of the femoropopliteal segment in patients with peripheral arterial disease and critical limb-threatening ischemia (CLTI). METHODS: This is a single-center study including patients undergoing first-time lower extremity intervention with peripheral bypass surgery or percutaneous transluminal angioplasty with or without stenting (PTA/S) of the femoropopliteal segment because of CLTI from 2011 to 2015. Based on prospective entered data from the Danish Vascular Registry, the primary end points were amputation-free survival, overall mortality, and reinterventions. RESULTS: A total of 679 patients with CLTI were included of which 35% (n = 239) were treated with PTA/S, 54% (n = 363) with vein bypass, and 11% (n = 77) with synthetic bypass. After 3 years, amputation-free survival was significantly better with a vein bypass (41.8% [95% CI: 35-48.4]) than both PTA/S (29.7% (95% CI: 22.7-37)) and synthetic bypass (31.7% [95% CI: 19-45.1]). Overall, the endovascular-treated patients faced more than 50% increased risk of major amputation or death than that of a vein bypass, after adjusting for comorbidity and Trans-Atlantic Inter-Society Consensus (TASC) classification (HR: 1.56 [95% CI: 1.21-2.05]). As expected, postoperative complications, length of hospital stay, and reinterventions were more frequent in the bypass groups. CONCLUSIONS: In this nonrandomized study, autologous vein bypass was superior to both PTA/S and synthetic bypass in regard to amputation-free survival and overall mortality. Despite the increased frequency of surgical complications, a vein bypass appears justified in both shorter (TASC B-C) and longer (TASC D) femoropopliteal lesions.

The Role of Routine Ultrasound Surveillance after In Situ Infrainguinal Peripheral Vein Bypass for Critical Limb-Threatening Ischemia.

BACKGROUND: To evaluate systematic duplex ultrasound (DUS) surveillance of patients treated with in situ great saphenous vein bypass (ISSVB) due to critical limb-threatening ischemia (CLTI) we performed a retrospective analysis of prospectively entered registry data. METHODS: Single-center study including consecutive patients undergoing elective ISSVB surgery due to CLTI between 2011 and 2015. Postoperative graft surveillance program included clinical examination, ankle-brachial indices (ABIs), and DUS at 6 weeks and 3 and 12 months. All DUS scans were performed by trained nurse sonographers. Patient data were extracted from the Danish Vascular Registry, electronic medical records and Picture Archiving and Communication System (PACS). Primary outcomes were reintervention rate, patency, and survival. RESULTS: In total, 363 consecutive and treatment-naive CLTI patients were revascularized with ISSVB and included in the study. Of those, 310 patients had minimum one follow-up visit and in total 1,199 DUS examinations. During the study period, 84 (23%) patients received 125 graft preserving reinterventions of which 20 were indicated solely on routine DUS without concurrent ischemic symptoms and/or significant (>15%) decrease in ABI. Hence, to find one asymptomatic graft stenosis requiring reintervention, we needed to scan 60 patients. After 1, 2, and 3 years, assisted primary patency was (Kaplan-Meier estimate) 79.4% (95% CI: 74.4, 83.5), 76.3% (95% CI: 70.7, 81.0), and 73.6% (95% CI: 66.9, 79.2), respectively. Survival rates were 82.6% (95% CI: 78.1, 86.3), 64.2% (95% CI: 57.8, 69.9) and 47.7% (95% CI: 40.6, 54.4) at 1, 2, and 3 years, respectively. CONCLUSIONS: In this study, one in four patients received a graft preserving intervention, but very few were driven by routine DUS and most graft lesions were detected on clinical findings. These findings suggest that development of a more individualized surveillance program differentiating between high- and low-risk infrainguinal bypass patients may increase cost-effectiveness.

[The relation between depression and inflammation].

Accumulating evidence suggests, that inflammatory processes contribute to the pathophysiology of major depressive disorder. Subgroups of patients have elevated plasma levels of pro-inflammatory cytokines, which seem to normalise in response to conventional antidepressive treatment. In this review of the current studies on the relation between depression and inflammation we discuss possible future directions for individualised treatment of major depressive disorder.