Endoluminal interventions versus surgical interventions for stenosis in vein grafts following infrainguinal bypass.

BACKGROUND: Bypass surgery using a large saphenous vein graft, or another autologous venous graft, is a well-recognised treatment option for managing peripheral arterial disease of the lower limb, including chronic limb-threatening ischaemia (CLTI) and intermittent claudication, peripheral limb aneurysms, and major limb arterial trauma. Bypass surgery has good results in terms of limb preservation rates and long-term graft patency but is limited by the possibility of vein graft failure due to stenoses of the graft. Detection of stenoses through clinical and ultrasonographic surveillance, followed by treatment, is used to avoid graft occlusion. The conventional approach to treatment of patients with graft stenosis following infrainguinal bypass consists of open surgical repair, which usually is performed under general anaesthesia. Endoluminal treatment with angioplasty is less invasive and uses local anaesthesia. Both methods aim to improve blood flow to the limb. OBJECTIVES: To assess the effectiveness of endoluminal interventions versus surgical intervention for people with vein graft stenosis following infrainguinal bypass. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov to 25 August 2020. SELECTION CRITERIA: We aimed to include all published and unpublished randomised controlled trials (RCTs) that compared endoluminal interventions versus surgical intervention for people with vein graft stenosis following infrainguinal bypass. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed all identified studies for potential inclusion in the review. We aimed to use standard methodological procedures in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. The main outcomes of interest were primary patency, primary assisted patency, and all-cause mortality. MAIN RESULTS: We identified no RCTs that met the inclusion criteria for this review. AUTHORS' CONCLUSIONS: We found no RCTs that compared endoluminal interventions versus surgical intervention for stenosis in vein grafts following infrainguinal bypass. Currently, there is no high-certainty evidence to support the use of one type of intervention over another. High-quality studies are needed to provide evidence on managing vein graft stenosis following infrainguinal bypass.

Early experience with off-the-shelf endografts using a zone 0 proximal landing site to treat the ascending aorta and arch.

OBJECTIVE: Acute type A aortic syndromes and its chronic complications are fatal diseases traditionally treated by open surgery, with high mortality rates. An endovascular approach to the ascending aorta could reduce the morbidity and mortality associated with open surgery. Our aim was to report our initial experience in treating ascending aortic pathology using commercially available descending thoracic endografts. METHODS: From 2007 to 2012, 69 patients presented to our center in Belo Horizonte, Brazil, with acute type A aortic syndrome or its chronic complications. Of the 69 patients, 8 high-risk patients had suitable anatomy, and 7 agreed to participate in the present study. RESULTS: Of the 7 patients, 4 had penetrating ulcers, 2 had acute dissections, and 1 had chronic dissection with an aneurysm. The technical success rate was 87%, with 1 intraoperative death from acute aortic valve insufficiency. The proximal landing zone was, on average, 21 mm above the aortic valve in all patients. Three patients required intraoperative cervical debranching due to a lesion in the distal third of the ascending aorta, compromising the supra-aortic branches. The distal landing zone was at zone 0 in 4 patients, zone 2 in 1 patient, and in zone 4 in 2 patients. The mean follow-up was 26.3 months. Two repeat dissections developed an average of 2 months after treatment. Both presented with acute dissection that was treated with additional open surgery and both patients survived. Thereafter, no patient had presented again with an acute aortic syndrome or other referable symptoms. CONCLUSIONS: Endovascular treatment of the ascending aorta is feasible. We had 4 good mid-term results in 7 patients who had presented with penetrating ulcers or aneurysm formation. Acute dissections seem to be more unstable, and additional research is mandatory.