Infection of Prosthetic Patches after Femoral Endarterectomy: An Unreported Complication.

BACKGROUND: The femoral prosthetic patch is a surgical procedure frequently used to treat atherosclerotic lesions involving femoral artery bifurcation. Even though it is an easy to perform procedure, surgical management of complications, first of all graft infection, may be challenging, with a high morbidity and mortality risk for patients. We report our experience on surgical treatment of femoral patch infections. MATERIALS AND METHODS: Between April 2012 and April 2018, 26 patients (26 limbs) were referred to the emergency department at our institution for the treatment of femoral prosthetic patch infections. None of the patients had been previously treated at our institution. All patients underwent a wide debridement of the infection site. Blood flow was restored through a vein interposition graft anastomosed at least 4-5 cm from the site of infection. End points of the study were death-related events, major or minor limb loss (major loss for above or below the knee amputation and minor for foot or toe), vein interposition graft failures, recurrent graft infections, or surgical wound healing. RESULTS: A total of 26 patients (21 male and 5 female patients) underwent surgical treatment. The mean age of patients was 69 years. The majority of our patients (54%) had been previously treated with an isolated femoral artery prosthetic patch. Three (11%) patients had been treated with a bilateral prosthetic femoral patch, but only one side was infected. After debridement of the infection site, we used the great saphenous vein to revascularize the lower limb in 22 (85%) cases, whereas the cephalic vein was used in only 4 cases (15%). The 5-year survival rate was 81% (standard error [SE] = 0.12). The 5-year primary patency rate was 70% (SE = 0.14). During follow-up, 4 graft occlusions occurred, and in 2 cases, a major amputation was required. The limb salvage rate at 5 years was 81% (SE = 0.13). CONCLUSIONS: An infection can complicate the femoral prosthetic patch carrying a high rate of morbidity, mortality, and limb loss. Surgical indication for a primary procedure must be restricted to critical limb ischemia, and it must be associated to a multilevel correction of the atherosclerotic disease.

Remote iliac artery endarterectomy with selective stent use at the proximal dissection zone in TransAtlantic Inter-Society Consensus C and D lesions.

BACKGROUND: Remote iliac artery endarterectomy (RIAE) is a challenging technique in the treatment of arterial occlusive disease. The impact of proximal transection zone stenting on patency rates is still unclear. METHODS: This is a retrospective analysis of all patients who underwent RIAE in our hospital between March 2007 and October 2017. A stent was used in cases with a dissection flap or a stenosis at the proximal transection zone after RIAE. In all other cases, we did not use a stent. Study end points were patency rates, limb salvage, and survival after 5 years. RESULTS: There were 115 RIAEs performed in 108 patients. All lesions were TransAtlantic Inter-Society Consensus C (61.7%) or D (38.3%) lesions. The median follow-up time was 38.5 months (range, 0-117 months). The indications were claudication in 67.0% and critical limb ischemia in 33.0%. Group 1 (n = 56) included all patients without a stent; group 2 (n = 59) included all patients with stenting of the proximal dissection zone. Risk factors were similar between the groups. The 30-day morbidity and mortality rates between the groups were not significantly different. The primary patency rate was 81.6% (group 1, 76.2%; group 2, 87.6%; P = .286), the primary assisted patency rate was 91.9% (group 1, 94.0%; group 2, 90.0%; P = .512), and the secondary patency rate was 93.8% (group 1, 94.0%; group 2, 91.6%; P = .435) after 5 years. Limb salvage (97.2%; group 1, 100%; group 2, 94.5%; P = .084) and survival time (57.1%; group 1, 66.7%; group 2, 43.5%; P = .170) were also not significantly different between the groups. A restenosis at the transection zone occurred in 14.3% in group 1 and 1.7% in group 2 (P = .013) during follow-up. A newly formed occlusion of the hypogastric artery was seen in 5.2% of patients after RIAE. CONCLUSIONS: RIAE is a safe procedure with excellent patency rates. However, the restenosis rate is higher in cases without stenting.

[Results of hybrid loop endarterectomy from the superficial femoral artery with the MultiTASC]. / Rezul'taty gibridnoi petlevoi éndarteréktomii iz poverkhnostnoi bedrennoi arterii petlei MultiTASC.

The purpose of this study was to analyse the results of hybrid loop endarterectomy from the superficial femoral artery (SFA) in its occlusion, preformed in a total of forty-two patients. Of these, 27 patients had prior to the intervention been diagnosed with stage II B ischaemia and 15 patients had been diagnosed as having critical ischaemia. Technical success of the operation amounted to 88%, with the frequency of early thromboses equalling 2.7%. In the early postoperative period, one patient died of acute myocardial infarction. The 1-, 2- and 3-year remote cumulative primary patency rate amounted to 81, 74 and 74%, respectively. There were no amputations performed within the timeframe of the follow-up period. The technique of hybrid loop endarterectomy with the MultiTASC loop followed by stenting of the proximal portion of the popliteal artery in occlusion of the SFA and stenoses of the common femoral artery has proved to be a highly efficient intervention yielding good immediate and remote results.

Tratamiento híbrido para la revascularización de miembro inferior en paciente crítico / Hybrid treatment for leg revascularisation in a critical patient

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[Use of the "Multitask" device while performing endarterectomy from iliac arteries]. / Ispol'zovanie instrumenta «Multitasc¼ pri vypolnenii endarterektomii iz podvzdoshnykh arterii.

AIM: The study was aimed at assessing efficacy of using the "MultiTASK" device manufactured by the Le Maitre Company while performing extended endarterectomy from iliac arteries in patients presenting with multilevel atherosclerotic lesions of the arterial bed and chronic ischaemia of lower extremities. PATIENTS AND METHODS: We analysed the outcomes of surgical management of a total of 37 patients presenting with multilevel atherosclerotic lesions of the common and external iliac arteries and arteries below the inguinal ligament over the period from 2012 to 2015 at the Department of Emergency Vascular Surgery of the Scientific Research Institute of Emergency Ambulance Care named after N.V. Sklifosovsky. Twenty one (56.8%) patients presented with haemodynamically significant stenoses of the iliac artery. Eleven (29.7%) patients had occlusion of the external iliac artery and five (13.5%) patients presented with occlusion of the common iliac artery in the distal portion. In all cases there was a second block, i. e. occlusion of the superficial femoral artery. RESULTS: The primary patency rate of the external iliac artery after endarterectomy amounted to 100%. Immediate complications directly associated with endarterectomy from the external iliac artery were encountered in one (2.7%) case - during back traction of the loop there occurred perforation of the wall of the external iliac artery by a calcified plaque, thus requiring external-iliac-common-femoral prosthetic repair. Amputation was performed in two (5.4%) patients (in both cases due to thrombosis and the development of ischaemic gangrene owing to poor condition of the distal arterial bed). One (2.7%) patient died of acute myocardial infarction. CONCLUSION: Extended endarterectomy by means of the "MultiTASC" device turned out efficient, yielding good immediate outcomes in atherosclerotic lesions of femoral arteries both as an independent operation and when combined with reconstruction of arteries beneath the inguinal ligament.

Iliac Artery Stenting Combined with Open Iliofemoral Endarterectomy Facilitated by a Novel Ultrasonic Ablation Instrument for Diffuse Iliofemoral Occlusive Disease.

An 81-year-old male complained of intermittent claudication of the right leg. Computed tomography (CT) revealed a right external iliac artery (EIA) stenosis with severe calcification extending to the common femoral artery. A hybrid procedure of endarterectomy and stenting was performed. EIA endarterectomy was performed using a novel Cavitron Ultrasonic Surgical Aspirator which ablated the inside of the distal EIA without arterial injury. A stent graft was placed in the proximal EIA covering the margin of endarterectomized distal EIA. Postoperative CT showed no stenosis, and symptoms in the leg disappeared. This could be an alternative procedure for iliofemoral occlusive disease.

Tromboendarterectomía pulmonar en 106 pacientes con hipertensión pulmonar tromboembólica crónica / Pulmonary Thromboendarterectomy in 106 Patients With Chronic Thromboembolic Pulmonary Hypertension

Introducción: La tromboendarterectomía pulmonar es el tratamiento de elección en la hipertensión pulmonar tromboembólica crónica. Presentamos nuestra serie completa con esta técnica. Métodos: Desde febrero de 1996 hasta junio de 2014, hemos realizado 106 tromboendarterectomías. Analizamos las características de la población, la mortalidad y morbilidad asociadas a la técnica y los resultados a largo plazo de supervivencia, mejoría funcional y resolución de la hipertensión pulmonar. Resultados: La edad media de la población fue 53 ± 14 años. El 89% estaba en clase funcional III-IV de la OMS. La presión pulmonar media prequirúrgica fue 49 ± 13 mmHg y las resistencias vasculares pulmonares 831 ± 364 dinas.s.cm-5. La mortalidad hospitalaria fue 6,6%. La morbilidad postoperatoria más relevante fue debida al edema pulmonar por reperfusión en el 20%, que fue factor de riesgo independiente (p = 0,015) para mortalidad hospitalaria. Con una mediana de seguimiento de 31 meses (rango intercuartil 50), la supervivencia a los 3 y 5 años es 90 y 84%. Al año de seguimiento, el 91% está en clase funcional I-II de la OMS, la presión pulmonar media en 27 ± 11 mmHg y las resistencias pulmonares vasculares en 275 ± 218 dinas.s.cm-5 (significativamente menores (p < 0,05) que las basales). En 14 pacientes se diagnosticó hipertensión pulmonar persistente; aun así, su supervivencia es, a los 3 y 5 años, 91 y 73%, respectivamente. Conclusiones: La tromboendarterectomía pulmonar ofrece resultados excelentes en el tratamiento de la hipertensión pulmonar tromboembólica crónica. Proporciona una elevada supervivencia a largo plazo, mejora la capacidad funcional y resuelve la hipertensión pulmonar en la mayoría de los pacientes

Introduction: Pulmonary thromboendarterectomy is the treatment of choice in chronic thromboembolic pulmonary hypertension. We report our experience with this technique. Methods: Between February 1996 and June 2014, we performed 106 pulmonary thromboendarterectomies. Patient population, morbidity and mortality and the long-term results of this technique (survival, functional improvement and resolution of pulmonary hypertension) are described. Results: Subjects' mean age was 53 ± 14 years. A total of 89% were WHO functional class III–IV, presurgery mean pulmonary pressure was 49 ± 13 mmHg and mean pulmonary vascular resistance was 831 ± 364 dynes s cm-5. In-hospital mortality was 6.6%. The most important post-operative morbidity was reperfusion pulmonary injury, in 20% of patients; this was an independent risk factor (P = .015) for hospital mortality. With a 31-month median follow-up (interquartile range: 50), 3- and 5-year survival was 90% and 84% respectively. At 1 year, 91% were WHO functional class I–II; mean pulmonary pressure (27 ± 11 mmHg) and pulmonary vascular resistance (275 ± 218 dynes s cm-5) were significantly lower (P < .05) than before the intervention. Although residual pulmonary hypertension was detected in 14 patients, their survival at 3 and 5 years was 91% and 73%, respectively. Conclusions: Pulmonary thromboendarterectomy offers excellent results in chronic thromboembolic pulmonary hypertension. Long-term survival is good, functional capacity improves, and pulmonary hypertension is resolved in most patients

Probe endarterectomy on the beating heart for severe coronary artery disease.

Although coronary endarterectomy is a challenging procedure, its implementation might be mandatory in some cases with diffuse atherosclerotic coronary artery disease. The traditional techniques such as open, semi-closed, eversion, orificial and extraction endarterectomies have been well defined in vascular surgery, however, due to the small size of the coronary arteries, their implementation is not always possible in surgical cardiac revascularization. In this report, we describe a simple method which combines the open and closed techniques of coronary endarterectomy, in which we use the coronary probes at different sizes in order to extract and release the atheromatous plaques from coronary arteries. This technique facilitates the removal of the plaques with easy handling of the coronary probes.

Laser scoop desobliteration: a method for minimally invasive remote recanalization of chronically occluded superficial femoral arteries.

Stenosis and occlusion of the superficial femoral artery (SFA) are most common in arterial occlusive disease. There are numerous interventional, surgical, and combined approaches to reconstitute maximum blood supply to the lower limb; however, despite intense clinical research, the long-term success rates are still poor. We present the first results with a catheter prototype for laser-based minimal invasive endarterectomy, called laser scoop desobliteration (LSD). The tip of a glass fiber containing a catheter was modified with a spatula head design and connected to an ultraviolet laser. It was tested in cadavers fixed with the Thiel embalming technique preserving tissue consistency, flexibility, and plasticity. After longitudinal arteriotomy of the SFA, a circular dissection between media and adventitia was performed. Then the LSD catheter was inserted and propagated with a progress of 1 mm∕s. Afterward, the atheroma core, which showed a plain surface without substantial attaching tissue debris, was removed. Histological examination of the vessel wall showed that the dissection was performed at the media/adventitia interface. In summary, the constructed LSD catheter allowed a rapid and easy way to perform an endarterectomy, thereby offering an innovative approach in the treatment of chronic occluded SFA.

Oximetría cerebral en endarterectomía pulmonar con parada circulatoria / Cerebral oximetry in pulmonary thromboendarterectomy with circulatory arrest

La tromboendarterectomía pulmonar es un procedimiento infrecuente que precisa parada circulatoria para su realización, por lo que uno de sus principales riesgos son las lesiones neurológicas postoperatorias. La monitorización cerebral intra- y postoperatoria sería, por tanto, conveniente en estos procedimientos para detectar precozmente episodios de hipoperfusión, su intensidad, así como otros episodios postoperatorios de desaturación cerebral que puedan empeorar el pronóstico neurológico (AU)

Pulmonary thromboendarterectomy is an uncommon procedure and should be performed with circulatory arrest. One of the major concerns is the postoperative central neurological injuries. Perioperative brain oxygen monitoring is advisable in this surgical procedure for the early detection of brain hypoperfusion episodes and their intensity as well as any other postoperative episodes that can deteriorate the neurological outcome (AU)

A tissue engineered renovascular graft composed of proteins, polymers, smooth muscle and endothelial cells for renal artery stenosis.

Endarterectomy and bypass surgery to treat renal artery stenosis are increasingly shunned these days due to high risks of complications during and after the surgery. Striving to find a sound alternative solution, we pioneered the construction of a tissue engineered renovascular graft that could immediately restore the normal blood flow to kidneys and sustain renal functions without suffering restenosis after the surgery. A highly porous scaffold was first constructed by electrospinning polycaprolactone, poliglecaprone, gelatin and elastin, giving the vast majority of non-woven fibers in the scaffold a diameter below 1200 nm. To recapitulate the anatomical and functional signatures of renal arteries, a bi-layer vasculature comprising a smooth muscle layer topped by an endothelial layer was built on the scaffold. The vasculature witnessed a sustained proliferation for up to 10 days in vitro and robustly secreted prostacyclin and endothelin-1, evidencing that the vasculature was functionally comparable to native renal arteries. After 30 days as a renovascular graft in mice, the luminal diameter of the graft remained clear without a restenosis and an increased confluence of the endothelial layer was observed. The tensile test confirmed that the renovascular graft was mechanically superior to native renal arteries and retained this advantage within 30 days in vivo. Also, this renovascular graft sustained renal functions as evidenced by normal levels of serum creatinine, urine creatinine and serum urea nitrogen and the lack of edema in the kidney cortex. These results demonstrate that this renovascular graft holds a great therapeutic promise for renal artery stenosis.

Anastomoses in the common femoral artery, vascular clips or sutures? A feasibility study.

BACKGROUND: The Vessel Closure System (VCS) is commercially available since 1997. This clip system has proven to be successful for vascular anastomoses in access surgery. There is little experience with the VCS in peripheral vascular surgery. METHODS: A trial was conducted for patients with peripheral arterial disease, who required either a femoral artery endarterectomy or a peripheral bypass procedure. Patients were randomized into two groups: a VCS group, in which the proximal anastomoses were made using VCS clips; and a control group, in which both proximal and distal anastomoses were performed using Prolene sutures. Outcomes assessed were the speed of anastomosis and patency. Adverse events were monitored. RESULTS: In the VCS group, 12 patients underwent anastomoses using VCS clips. In the control group, 12 patients underwent vascular reconstruction using sutures. In the VCS group, the mean speed of anastomosis was 1.9 mm/min, whereas the mean speed in the control group was 2.5 mm/min; this was not significantly different (P = 0.096). After a follow-up of 12 months, there was no difference in patency. In the VSC group, two serious adverse events occurred, which required emergency surgery. CONCLUSION: Anastomosis in the femoral artery using VCS clips is not faster than that using running Prolene sutures, and in our small sample, two serious adverse events in the VCS group were observed. These results do not support the further use of vascular clips in peripheral vascular surgery.

Kidney transplantation in diabetic recipients with iliac atherosclerosis: arterial anastomosis with Nakayama's ring pin stapler after endarterectomy.

OBJECTIVES: To report our experience of arterial anastomosis with Nakayama's ring pin staplers (titanium staplers) after an endarterectomy in kidney transplantation of diabetic recipients with iliac atherosclerosis. METHODS: In a series of 2126 kidney transplantations carried out between January 1998 and December 2008, 62 recipients received an endarterectomy during transplantation before renal arterial anastomoses as a result of severe iliac atherosclerosis. The renal arteries were anatomosed to hypogastric arteries through titanium staplers in 32 patients (group 1), or to external/common iliac arteries with conventional suturing in 30 patients (group 2). Perioperative outcomes of the two groups have been compared. RESULTS: The mean artery anastomosis time in group 1 was considerably shorter than in the group 2 (6.4 min vs 17.3 min, P < 0.001). Group 1 showed a lower rate of delayed graft function (4.8% vs 27.5%, P = 0.004). No difference in Kaplan-Meier patient survival rate was found between group 1 and group 2 after follow up of 67 ± 28 months (P = 0.58). Graft survival rate (patient deaths included) was higher in group 1 than in group 2 (P = 0.04). CONCLUSIONS: Arterial anastomosis with a titanium stapler is more rapid than conventional suture. It can diminish the rate of delayed graft function and improve the graft survival rate in diabetic recipients with severe iliac atherosclerosis.

Endarterectomía femoral y angioplastia endovascular simultánea / Simultaneous femoral endarterectomy and endovascular angioplasty

Introducción: El tratamiento endovascular asociado a endarterectomía (EA) de la arteria femoral común (AFC) es una buena alternativa a la cirugía aortoilíaca y/o femoropoplítea. El objetivo del estudio es analizar nuestra experiencia en el tratamiento híbrido de la EA en la AFC y angioplastia endovascular simultánea. Material y métodos: Análisis retrospectivo de pacientes con enfermedad ateroesclerótica de la AFC tratados mediante EA con parche y simultáneo tratamiento endovascular ilíaco y/o femoropoplíteo entre 2004 y 2010. Resultados: Se intervinieron 50 pacientes (44 varones, 88%) con edad media de 69,4±9,41 años. Presentaban isquemia crítica 25 (50%). Se intervinieron mediante EA femoral y angioplastia ilíaca (grupo 1): 36 casos (72%) y con EA femoral y angioplastia femoropoplítea (grupo 2): 14 (28%). El éxito técnico fue del 94%. No hubo mortalidad perioperatoria. La estancia hospitalaria fue 10,7±8,28 días. El tiempo mediano de seguimiento fue: 24,18 meses (RIC: 9,6-34,4). La permeabilidad primaria a 12, 24 y 36 meses fue del 91, 83 y 74%. En esos mismos períodos temporales la primaria asistida fue del 94, 86 y 81%; el salvamento de extremidad fue del 92, 92 y 88% y la supervivencia del 92, 86 y 82%. La permeabilidad primaria fue superior en el grupo 1 (log-rank test, p=0,044). Comentarios: La EA femoral con angioplastia endovascular simultánea presenta resultados satisfactorios con escasa morbimortalidad, y es una buena alternativa a la cirugía clásica(AU)

Introduction: Endovascular treatment combined with endarterectomy (EA) of the common femoral artery (CFA) is a good alternative to aorto-iliac and/or femoropopliteal surgery. The objective of this study is to analyse our experience in the hybrid treatment of EA in the CFA and simultaneous endovascular angioplasty. Material and methods: A retrospective analysis was performed on patients with atherosclerotic disease of the CFA treated by means of EA with a patch and simultaneous endovascular iliac and/or femoropopliteal treatment between 2004 and 2010.ResultsA total of 50 patients were treated, of whom 44 (88%) were males, and with a mean age 69.4±9.41 years. Critical ischaemia was present in 25 (50%) of cases. Femoral EA and iliac angioplasty was performed in Group 1: 36 (72%) of cases, and Group 2 with femoral EA and femoropopliteal angioplasty in Group 2: 14 (28%). The technical success was 94%, with no perioperative mortality. The mean hospital stay was 10.7±8.28 days. The median follow-up time was 24.18 months (IQR 9.6-34.4). The primary patency at 12, 24 and 36 months was 91%, 83% and 74%, respectively. Within these same time periods the assisted primary patency rates were 94%, 86% and 81%; limb salvage was 92%, 92% and 88% and a survival of 92%, 86% and 82%, respectively. The primary patency was higher in Group 1 (log-rank test, P=.044). Conclusions: Femoral EA with simultaneous endovascular angioplasty shows satisfactory results with a low morbidity and mortality and is a good alternative to classic surgery(AU)

Stent-assisted remote iliac artery endarterectomy: an alternative approach to treating combined external iliac and common femoral artery disease.

OBJECTIVE: Stent-assisted remote iliac endarterectomy (SA-RIEA) is a hybrid minimally invasive technique for treating patients with combined external iliac and common femoral disease, when the only alternative would be conventional open revascularisation. DESIGN: This was a retrospective, single-centre study. MATERIALS AND METHODS: From January 2004 to April 2010, 155 SA-RIEA procedures were performed. The patients' mean age was 62 (range, 43-86) years. Indications for surgery were: severe claudication in 79 (51%), rest pain in 43 (28%) and gangrene in 33 (21%) cases. The mean length of follow-up was 21 months. RESULT: Initial technical success was achieved in 145 (93.5%) procedures. Ten patients required conversion to a conventional iliofemoral reconstructive procedure. The 1-, 3- and 5-year primary, primary-assisted and secondary patency rates were 80.2%, 74.7% and 69.3%; 84.8%, 82.4% and 78.2%; and 86.8%, 84.2% and 79.6%, respectively. Within the first 30 days, there were no early reocclusions, one (0.6%) perioperative death due to myocardial infarction, five (3.4%) minor wound complications and two (1.3%) limb losses. During follow-up, seven patients underwent open reconstruction due to symptomatic reocclusion, and four were re-operated on due to symptomatic restenosis (three percutaneous transluminal angioplasties (PTAs), one reendarterectomy). CONCLUSION: In patients with combined common femoral and external iliac disease, SA-RIEA appears to offer a safe and effective alternative to conventional open surgery.