Chronic mesenteric ischemia, renovascular hypertension and critical limb threatening ischemia treated with thoraco-visceral and lower extremity bypass: Major open surgical techniques will remain essential.

A 68-year-old female with extensive medical and surgical history, including open and endovascular procedures, presented with chronic limb-threatening ischemia, hypertension, and chronic mesenteric ischemia. A computed tomographic angiogram showed significant paravisceral aortic atherosclerosis involving the celiac, superior mesenteric, and renal arteries. She underwent an open descending aorta to superior mesenteric artery, left renal artery, and left common femoral artery bypass with a "trifurcated" ringed polytetrafluoroethylene graft. Nine months after surgery, she was progressing with significant improvement of her symptoms. Open surgical approaches in aortoiliac disease are reserved for patients with unfavorable anatomy or previous failed endovascular attempts. Detailed preoperative planning and careful patient selection are imperative for optimal outcomes.

A Decade of Progress: Assessing Three Revascularization Strategies for Iliac Occlusive Disease Through a 580-Case, 10-Year-Experience Literature Comparison.

INTRODUCTION:  Peripheral arterial disease (PAD) is a critical concern, particularly in the context of an aging population and escalating risk factors such as diabetes, hypertension, and smoking. PAD leads to significant morbidity and disability, imposing considerable healthcare and economic burdens. A detailed understanding of the functional outcomes of revascularization is essential as it influences the choice of therapeutic strategies. This is crucial for the patient-doctor dialogue, enabling informed decisions based on the benefits, risks, and costs associated with each option. This study specifically examines the effectiveness of various revascularization methods for iliac occlusive disease by analyzing factors such as procedural success rates, complication frequencies, long-term patency, and patient quality of life. By evaluating these characteristics, the study aims to guide surgeons in selecting the most appropriate treatment approach in modern vascular surgery. METHODS: A 10-year single-center retrospective analysis was conducted, examining 521 patients (580 interventions) from January 2009 to December 2018. Treatments included endovascular recanalization and stenting (endovascular treatment, EVT) (31.4%), hybrid surgical treatment (HST) (31.6%), and open surgical treatment (OST) (37.07%). The examined characteristics were primary patency, primary assisted patency, secondary patency, complications, and the degree of limb salvage. RESULTS: The study assessed variables such as age, gender, diabetes, hypertension, dyslipidemia, smoking status, chronic kidney disease, and anesthesiological risk (American Society of Anesthesiologists (ASA) grade). Patency rates across the three methods were 92.4%, with thrombosis observed in 7.6% of cases. Assisted primary reconstructions, identified in the analysis, were few in number. Across the three revascularization strategies, a total of 41 interventions were undertaken to preserve the patency of the index reconstruction. In cases of chronic limb-threatening ischemia (CLTI), the probability of losing patency is higher and occurs earlier. OST showed the longest patency duration (471.7±71.5 days), and EVT demonstrated consistent primary patency. Complications were the highest in OST, including five perioperative mortalities. Survival analysis revealed significant differences in patency between treatment methods, with EVT and HST showing better outcomes compared to OST, particularly in patients with CLTI. CONCLUSION: By far, this is one of the largest studies done comparing all three revascularization strategies. Endovascular, surgical, and hybrid interventions should be considered complementary elements in the vascular surgeon's toolkit. However, in the presented study, endovascular and hybrid treatment appeared to produce better outcomes compared to open surgical treatment, especially in patients with CLTI. Keeping this in mind the surgeon should be able to provide a more optimal and personalized treatment for patients with chronic lower limb ischemia.

An Unusual Case of CD5-Positive Extranodal Marginal Zone Lymphoma of the Mucosa-Associated Lymphoid Tissue (MALT) Involving the Appendix.

Non-Hodgkin lymphoma (NHL) includes a diverse group of hematological malignancies. The common site for extranodal involvement of NHL is the gastrointestinal tract (GIT), with the stomach being the most prevalent site. The appendix is a very unusual site of involvement in NHL. This case report describes an uncommon instance of an appendicular mass in an elderly female who complained of vomiting for two weeks, as well as abdominal pain, and was radiologically suspected to have appendicular malignancy. A right hemicolectomy was done, and she was diagnosed with extranodal mucosa-associated lymphoid tissue (MALT) lymphoma involving the appendix. Postoperatively, she also developed thrombo-occlusive disease in her right lower limb, with right foot dry gangrene, for which thromboembolectomy was done. Later, a below-knee amputation was carried out. Lymphoma associated with thrombophilia is a rare presentation and not many cases have been reported in the literature. We present this case here on account of the rarity of lymphoma involving the appendix with associated thrombophilia.

Spliced-vein Conduit Offers Better Patency and Limb Salvage Than Prosthetic Graft for Femoral-Tibial Bypasses in Critical Limb Threatening Ischemia.

BACKGROUND: Single-segment great saphenous vein (ssGSV) is the gold standard conduit for femoral-tibial bypasses in patients with critical limb-threatening ischemia (CLTI). In the absence of a good single-segment saphenous vein, alternative options are prosthetic grafts or spliced-vein conduits. Although spliced-vein conduits may provide better long-term patency/limb salvage, prosthetic grafts are more often the chosen conduit due to shorter operative and presumably better immediate postoperative outcomes; nevertheless, there is little data supporting this practice. In this study, we compared 30-day outcomes between spliced-vein and prosthetic conduits in CLTI bypass using a national registry. METHODS: CLTI patients who underwent lower extremity bypass using spliced vein (SpV) or prosthetic conduits only were selected from National Surgical Quality Improvement Program (NSQIP) targeted database. A 1:5 propensity-score matching was conducted between SpV and prosthetic groups to address preoperative differences. Thirty-day outcomes, including primary patency, reintervention, major amputation, mortality, major morbidity, transfusion, and wound complications, were compared between the two groups. RESULTS: There were 886 patients who underwent femoral-tibial bypass without ssGSV (104 SpV and 782 prosthetic grafts). All SpV patients were propensity-score matched to 445 prosthetic patients. SpV exhibited significantly better 30-day primary patency than prosthetic (87.5% vs 74.38%, P = 0.004). SpV was associated with significantly longer operative time (346 min vs 222 min, P < .001) and higher transfusion (43.3% vs 27.87%, P =0.003), but those did not translate into higher 30-day mortality or major systemic complications. There was no difference in wound complications or 30-day limb loss. CONCLUSION: Spliced-vein conduit affords significantly better 30-day primary patency than prosthetic grafts without increased mortality and morbidities. Therefore, despite greater procedural complexity and longer operative time, spliced-vein conduit should be considered when available. Future prospective studies are needed to investigate the long-term outcomes of these two conduits.

Inotuzumab ozogamicin in adult acute lymphoblastic leukemia: Development, current status, and future directions.

Inotuzumab ozogamicin (InO) is an antibody-drug conjugate approved for the treatment of relapsed/refractory B-cell acute lymphoblastic leukemia (ALL). Several clinical trials are investigating InO in combination with low-intensity chemotherapy or other anti-ALL-targeted therapies in the salvage and frontline settings, notably in older adults who often cannot tolerate intensive chemotherapy and tend to have higher-risk disease. InO is also increasingly used to bridge patients to hematopoietic stem cell transplantation (HSCT), in sequence with chimeric antigen receptor T-cell therapy, to eliminate measurable residual disease and to prevent post-HSCT relapse. Veno-occlusive disease/sinusoidal obstruction syndrome is a potential complication of InO treatment, particularly when followed by HSCT. Herein, the authors review the historical development and current status of InO, strategies for mitigating the risk of InO-related veno-occlusive disease/sinusoidal obstruction syndrome, and future directions for InO research and clinical use.

Intravascular Lithotripsy and Aortic Bare-Metal Stenting: A Low-Profile Solution for the Treatment of Heavily Calcified Aorto-Iliac Disease.

PURPOSE: To present a novel technique for the treatment of heavily calcified aorto-iliac disease using intravascular lithotripsy (IVL) and self-expanding bare-metal stents (BMS). TECHNIQUE: We present our experience with 4 cases of calcified aorto-iliac disease that were treated with IVL as vessel preparation followed by BMS deployment. Intravascular lithotripsy was performed using a 7-mm or 8-mm Shockwave catheter from 1 access and a non-compliant balloon introduced from the second access in a "hugging-balloon" configuration. Afterward, a self-expandable BMS is deployed in the infrarenal aorta and additional bare-metal balloon-mounted stents are deployed in the iliac arteries as needed. This technique provides a low-profile solution with only 6- and 7-French introducers, preservation of the collateral circulation while also preserving the option for an up-and-over approach in the future. Technical success was achieved in all cases and no periprocedural complications were observed. CONCLUSION: Intravascular lithotripsy in combination with BMS for the infrarenal aorta and the aortic bifurcation seems to be a safe and effective low-profile treatment option for heavily calcified lesions. Large-scale studies with long-term follow-up are needed to validate our positive early results. CLINICAL IMPACT: Endovascular treatment of heavily calcified aortoiliac disease poses significant challenges, including the risk of rupture and dissection. The proposed technique uses intravascular lithotripsy and bare-metal stenting of the aortic bifurcation and represents a low-profile solution that preserves collaterals and potentially reduces the risk of dissection with IVL vessel preparation.

Popliteal Access for Iliofemoral Occlusive Disease in the Office-Based Catheter Laboratory.

OBJECTIVE: Popliteal access (PA) as an alternative to conventional femoral access has not been reported in the office-based catheter laboratory setting (OBL) and may be perceived to have higher risks. The purpose of this study is to evaluate the safety and efficacy of popliteal access for endovascular treatment of iliofemoral arterial occlusive disease in an OBL setting. METHODS: From 10/2018 - 10/2023 a total of 1,408 PAD interventions were performed in our OBL. A cohort of 27 popliteal access consecutive procedures for femoral and iliac artery occlusions were studied. All interventions were done using a micro-puncture needle under ultrasound guidance. All patients were discharged 1 hour after completion of the procedure. Indications for popliteal access were presence of aortoiliac stent/grafts, aorto-bifemoral or aortoiliac bypasses, difficult contralateral or antegrade femoral access, and flush superficial femoral artery (SFA) occlusions. Procedures were determined to be successful upon complete resolution of the target lesions and safety was measured peri-operatively and at 90-days. Patency was determined clinically, by arterial duplex, and by need for reintervention up to 2 years. RESULTS: 27 popliteal access procedures were performed in 25 patients (21 complete femoral artery occlusions, 6 severe stenosis). Iliac disease was present in 9. Indications for PA were existing aortoiliac stent graft 11, aorto-bifem-iliac bypass 4, non-crossable iliac occlusions 3, failed antegrade femoral access 4, flush SFA occlusion 3, and bilateral common femoral artery disease precluding access 2. TASC pre-op was B: 4, C: 4, D:19. Treatments included atherectomy/balloon angioplasty (BA) and stent 12, BA and stenting 4, atherectomy/BA 5, BA alone 6. Successful opening of occlusions occurred in 25/27 (92.5%). No complications or major adverse cardiac events (MACE) occurred except 1 asymptomatic small popliteal AV fistula. Of the 25 successful procedures duplex patency at 3, 6 & 12 months was 19/20 (95%), 11/15 (69.3%) & 11/13 (61%). Rutherford Classification improved from pre-op > 4 in 24/27 (89%) to post-op < 2 at 1 month in 23/23 (100%), 3 months in 19/20 (95%), 6 months in 11/15 (69.3%), 12 months in 11/13 (61%). Freedom from re-intervention at 3 months in 19/20 (95%), 6 months in 13/15 (86%), and 12 months in 12/13 (79%). CONCLUSIONS: Popliteal artery access for complex iliofemoral disease is safe and effective and should be considered as a valid alternative option in the OBL setting.

Newly Designed, Self-Expanding Large-Bore Nitinol Stents for Symptomatic Central Venous Stenosis: Technical and Long-Term Clinical Outcome.

PURPOSE: To retrospectively analyze the technical and long-term clinical outcome of angioplasty and stenting using the Venovo™ venous stent for the treatment of malignant and benign superior vena cava (SVC) occlusive disease. MATERIALS AND METHODS: Consecutive patients treated with the Venovo™ venous stent for SVC occlusive disease were included. SVC obstruction symptoms were classified according to the Kishi score. The Wilcoxon signed-rank test was used for testing significance of changes. Technical success, defined as correct placement of the stent, completely covering and re-expanding the obstruction, between groups was tested using the Fisher exact test. Overall survival was calculated using the Kaplan-Meier method. RESULTS: Fifty-five patients underwent stent insertion for symptomatic benign (n = 13; 24%) or malignant (n = 42; 76%) SVC occlusive disease. A significant drop in Kishi score, mean 3.91 before versus mean 1.02 after the procedure (P < 0.0001), was observed. In one patient (1.8%), an additional balloon-expandable stent was needed to manage incomplete expansion of the nitinol stent. In one patient, a procedure-related lung embolic complication was noted. Early thrombotic occlusion of the stent occurred in one patient. Late symptomatic restenosis occurred in 3 patients. Overall primary stent patency and primary-assisted stent patency were 86% (95% CI 66-95) and 97% (95% CI 83-100) at 1-year follow-up and 98% (95% CI 87-100), 98% (87-100) at 2-year follow-up, respectively. CONCLUSION: In this retrospective analysis, angioplasty and stent placement using the Venovo™ venous stent is safe and clinically effective for the treatment of both benign and malignant SVC occlusive disease. Reintervention for symptomatic restenosis is rare.