Iatrogenic acute limb ischemia with complete traumatic rupture of the popliteal artery associated with total knee arthroplasty.

Acute limb ischemia (ALI) related to total knee arthroplasty (TKA) is rare. Most occlusions are caused by thrombus formation in the popliteal artery (PA). Currently such cases are revascularized using less invasive approaches such as endovascular therapy or Fogarty thrombectomy. We report a case of ALI in a 65-year-old woman with complete rupture of the PA due to a TKA procedure. She had resting pain and motor paralysis in her right lower extremity after TKA. Contrast-enhanced computed tomography showed occlusion of the right femoropopliteal artery. Subsequently, she was referred to our hospital with a diagnosis of ALI. Initially, a less invasive revascularization procedure was unsuccessfully attempted. Therefore, we performed an emergency distal bypass and succeeded in revascularization. Intraoperative examination revealed a complete rupture of the PA. Postoperatively, the patient exhibited no signs of myonephropathic metabolic syndrome. Although there was significant motor impairment, the affected limbs were successfully salvaged. ALI with complete rupture of the PA associated with TKA has not been reported previously. In cases of iatrogenic ALI after TKA, it would be essential to consider diagnostic and revascularization methods that account for the possibility of severe injury to the PA. Learning objective: Acute limb ischemia after total knee arthroplasty is a rare and life- and limb-threatening condition. The underlying pathological mechanism is often thrombus occlusion due to mechanical stimuli of the popliteal artery (PA). There are no established treatments for this condition, and less invasive approaches such as endovascular procedures and Fogarty thrombectomy are often used. However, in cases involving severe damage to the PA, bypass surgery may be necessary, and revascularization procedures should be considered accordingly.

Influence of cardioplegic solution on incidence of acute kidney injury after coronary artery bypass surgery procedure: del Nido cardioplegia versus Histidine-Tryptophan-Ketoglutarate solution: Insight of kidney disease improving global outcomes criteria.

INTRODUCTION: We set out to investigate whether the use of Histidine-Tryptophan-Ketoglutarate (HTK) solution or del Nido cardioplegia is linked to an increased incidence of postoperative acute kidney injury (AKI) in patients undergoing coronary artery bypass surgery (CABG). METHODS: A retrospective study was carried out at our center, with a total of 478 patients included in the analysis. Among them, 268 patients were administered the del Nido solution (DN) while 210 patients received the HTK solution. The primary focus of this study was to assess the occurrence of postoperative AKI and the need for renal replacement therapy (RRT). Multivariable logistic regression was used to examine the relationship between the type of cardioplegia used and adverse kidney outcomes. Additionally, serum levels of sodium, potassium, and ionized calcium were monitored during cardiopulmonary bypass (CPB). RESULTS: The incidence of AKI was significantly higher in the HTK group compared to the DN group [(48/220 (21.81%) vs. 24/186 (12.90%), p = .049], although the rate of RRT did not show a statistically significant difference (9/48, 18.75% vs. 6/24, 25%, p = .538). Multivariate logistic regression analysis revealed that HTK was a significant risk factor for AKI. Furthermore, serum sodium and calcium levels were found to decrease following HTK cardioplegic infusion. Conclusion: Our study provides compelling evidence of the impact of cardioplegic solutions on postoperative AKI rates. It underscores the importance of optimizing cardiac arrest protocols. These findings warrant further prospective investigations into the influence of cardioplegic solutions on electrolyte imbalances and postoperative AKI rates.

Lower Extremity Bypass for Occlusive Disease: A Brief History.

OBJECTIVES: This is a narrative review that aims to highlight key advancements which led to the current state of lower extremity bypass surgery. It focuses on key contributors during the last century who have driven the standardization of surgical treatment of peripheral arterial occlusive disease. METHODS: A narrative review was conducted utilizing available resources in the scientific and historical literature to track landmark achievements in the development of modern lower extremity bypass surgery for occlusive disease, focusing primarily on the last century of advancement. RESULTS: Several critical conceptual, technological, and technical landmarks were identified as critical components of modern lower extremity bypass surgery. This includes fundamental development in the techniques of vascular anastomosis led by Carrel and others, a developing understanding of vascular occlusive disease as a localized and segmental process with broad implementation of the techniques of arteriography, and the development of safe thromboendarterectomy aided by the development and utilization of heparin for anti-coagulation. These factors led to the first femoral to popliteal artery bypass by Jean Kunlin in 1948. From here, advances in vascular prosthetic material pioneered by Voorhees and others, alternative vascular conduits, increasing acceptance of tibial revascularization, and dispelling the myth of diabetic "small vessel" disease broadened revascularization options for patients with complex patterns of occlusive disease and those who have limited conduit availability. CONCLUSIONS: Modern lower extremity bypass surgery for occlusive disease arose steadily over the course of a century driven by complex problem-solving in the pathophysiological understanding of atherosclerosis, technical developments in vascular anastomosis and arteriography, and evolution in conduit materials and pharmacologic therapy. Future advancements in bypass surgery are targeted on solving the complex problems of anastomotic intimal hyperplasia, expanding technology for alternative vascular conduits, ongoing optimization of risk factors and scrutiny of outcomes to make patient-centered, evidence-based decisions regarding revascularization strategy.

Influence of Inframalleolar Modifier P0/P1 on Wound Healing in Bypass Surgery versus Endovascular Therapy in Patients with Chronic Limb-Threatening Ischemia.

OBJECTIVE: This study aimed to compare the influence of inframalleolar (IM) P0/P1 on wound healing in bypass surgery versus endovascular therapy (EVT) in patients with chronic limb-threatening ischemia (CLTI). METHODS: We retrospectively analyzed the multicenter data of patients who underwent infra-inguinal revascularization for CLTI between 2015 and 2022. IM P represents target artery crossing into foot, with intact pedal arch (P0) and absent or severely diseased pedal arch (P1). The endpoints were wound healing, limb salvage (LS), and postoperative complications. RESULTS: We analyzed 66 and 189 propensity score-matched pairs in the IM P0 and IM P1 cohorts, respectively. In the IM P0 cohort, the 1-year wound healing rates were 94.5% and 85.7% in the bypass surgery and EVT groups, respectively (p = .092), whereas those in the IM P1 cohort were 86.2% and 66.2% in the bypass surgery and EVT groups, respectively (p < .001). In the IM P0 cohort, the 2-year LS rates were 96.7% and 94.1% in the bypass surgery and EVT groups, respectively (p = .625), and those in the IM P1 cohort were 91.8% and 81.5% in the bypass surgery and EVT groups, respectively (p = .004). No significant differences were observed between the bypass surgery and EVT in terms of postoperative complication rates in either the IM P0 or P1 cohorts. CONCLUSIONS: Bypass surgery facilitated better wound healing and LS than EVT in patients with IM P1. Conversely, no differences in wound healing or LS were observed between groups in patients with IM P0. Bypass surgery should be considered a better revascularization strategy than EVT in patients with tissue loss and IM P1 disease.

Comparison of Del Nido (a different application) and crystalloid blood cardioplegia on arrhythmia and early results.

BACKGROUND: The results of the use of del-Nido(DN) solution using a different method or crystalloid blood cardioplegia in coronary bypass patients were compared. We aimed to investigate the effects on intraoperative and postoperative arrhythmias, arrhythmia durations and early results. METHODS: The study included 175 patients using crystalloid blood cardioplegia (Group 1) and 150 patients using DN solution(Group 2). In the DN group, 75% of the calculated plegia dose was given first. the remaining part was applied by giving from grafts. Intraoperative/postoperative data were compared. RESULTS: There was no significant difference between the groups in terms of demographic characteristics. Preop troponin level was similar.(p = 0.190) However, there was a statistical difference between the postoperative 6th hour.(p = 0.001) There was no difference in troponin values at the postoperative 24th hour. (p = 0.631) Spontaneous rhythm occurred at the cardiopulmonary by pass (CPB) weaning stage in most of the patients in Group 2 (95.3%). Although the need for temporary pacing was less in Group 2, it was not significant.(p = 0.282) No patient required permanent pacing. CPB duration, cross clamp times and intraoperative glucose levels, intensive care follow-up times and hospitalization times were found to be shorter in Group 2. Although the postoperative atrial fibrillation frequency was similar (p = 0.261), the time to return to sinus was lower in Group 2.(p = 0.001). CONCLUSION: The use of DN cardioplegia solution provides significant positive contributions to avoid arrhythmias compared to crystalloid blood cardioplegia. DN solution applied with this method may contribute to reducing the anxieties associated with its use in isolated coronary artery bypass surgery.

Association of Genetic Variants with Postoperative Donor Artery Development in Moyamoya Disease: RNF213 and Other Moyamoya Angiopathy-Related Gene Analysis.

Robust postoperative bypass development is a characteristic of moyamoya disease (MMD); however, genetic factors mediating this phenomenon remain incompletely understood. Therefore, we aimed to elucidate the relationship between postoperative donor artery development and genetic variants. We retrospectively enrolled 63 patients (79 hemispheres) who underwent combined revascularization surgery. Postoperative development of the superficial temporal artery (STA), middle meningeal artery, and deep temporal artery (DTA) was assessed using the caliber-change ratio determined from magnetic resonance angiography measurements. We analyzed RNF213 and 36 other moyamoya angiopathy-related genes by whole-exome sequencing and extracted rare or damaging variants. Thirty-five participants carried RNF213 p.Arg4810Lys (all heterozygotes), whereas 5 had RNF213 rare variants (RVs). p.Arg4810Lys was significantly associated with postoperative DTA development, while age at surgery, hypertension, and hyperlipidemia were inversely associated. Multiple regression analysis revealed that age and p.Arg4810Lys held statistical significance (P = 0.044, coefficient - 0.015, 95% confidence interval (CI) - 0.029 to 0.000 and P = 0.001, coefficient 0.670, 95% CI 0.269 to 1.072, respectively). Those with RNF213 RV without p.Arg4810Lys exhibited a significant trend toward poor DTA development (P = 0.001). Hypertension demonstrated a significant positive association with STA development, which remained significant even after multiple regression analysis (P = 0.001, coefficient 0.303, 95% CI 0.123 to 0.482). Following Bonferroni correction for multiple comparisons, targeted analyses of RNF213 and 36 moyamoya angiopathy-related genes showed a significant association of only RNF213 p.Arg4810Lys with favorable DTA development (P = 0.001). A comprehensive analysis of RNF213, considering both p.Arg4810Lys and RVs, may provide a clearer prediction of postoperative DTA development.

Impact of bariatric surgery on cytochrome P 450 enzyme activity.

Bariatric surgeries are becoming more prevalent as obesity rates continue to rise. Being that it is an effective weight-loss procedure, it can induce significant anatomical, physiological, and metabolic alterations, which affect the pharmacokinetics of various medications. Cytochrome (CYP) P450 is a group of enzymes that are primarily responsible for metabolizing most medications. Bariatric surgery may affect CYP activity and consequently alter metabolism of various medications, and the resulting weight loss may influence the metabolism of various drugs. This study investigates the impact of bariatric surgery on which CYP enzymes are affected and their effects medications. Authors of this study did an extensive literature review and research in databases including PubMed and EMBASE. The evidence was gathered for medication efficacy influenced by enzyme fluctuations to advocate for further studies for patients that undergo bariatric surgery. The search was limited to English-language results and is deemed up to date as of September 2023. There are numerous studies that indicated alterations of the CYP enzyme activity, which affects the pharmacokinetics of medications used to treat acute and chronic conditions after bariatric surgery. There are various mechanisms involved in CYP enzyme activity leading to fluctuations and the clearance of medications and subsequently compromising the efficacy and safety of these agents. It is imperative to conduct more prospective randomized control studies with longer duration to guide clinicians on how to manage medications with various CYP activity for patients' post-bariatric surgery.

Pathological Findings of Donor Vessels in Bypass Surgery.

(1) Background Cerebral revascularization is necessary to treat intracranial arterial stenosis caused by moyamoya disease, atherosclerosis, or large complex aneurysms. Although various donor vascular harvesting methods have been reported safe, there are no reports on the histological evaluation of donor vessels for each disease, despite the variety of diseases wherein vascular anastomosis is required. (2) Methods Pathological findings of the superficial temporal artery (STA), radial artery (RA), occipital artery (OA), and saphenous vein (SV) harvested at the institution were analyzed. Patients classified according to aneurysm, atherosclerosis, and moyamoya disease were assessed for pathological abnormalities, medical history, age, sex, smoking, and postoperative anastomosis patency. (3) Results There were 38 cases of atherosclerosis, 15 cases of moyamoya disease, and 30 cases of aneurysm in 98 donor vessels (mean age 57.2) taken after 2006. Of the 84 STA, 11 RA, 2 OA, and 1 SV arteries that were harvested, 71.4% had atherosclerosis, 11.2% had dissection, and 10.2% had inflammation. There was no significant difference in the proportion of pathological findings according to the disease. A history of hypertension is associated with atherosclerosis in donor vessels. (4) Conclusions This is the first study to histologically evaluate the pathological findings of donor vessels according to disease. The proportion of dissection findings indicative of vascular damage due to surgical manipulation was not statistically different between the different conditions.

Spontaneous complete regression of pancreaticoduodenal artery aneurysms with celiac artery occlusion after aorto-splenic bypass without additional treatment: a case report.

BACKGROUND: Pancreaticoduodenal artery aneurysm (PDAA) is a rare, but fatal disease. However, the association between aneurysm size and the risk of rupture remains unclear. There are many options for therapeutic strategies that should be discussed well because the treatment options are often complicated and highly invasive. However, it remains unclear whether additional endovascular therapy is essential for all patients undergoing bypass surgery. Here, we present a case of triple PDAAs with celiac axis occlusion and spontaneous complete regression of inferior PDAAs (IPDAA) after aneurysmectomy of superior PDAA (SPDAA) and aorto-splenic bypass. CASE PRESENTATION: A 68-year-old woman presented with one SPDAA and two IPDAAs caused by celiac axis occlusion. Aneurysmectomy for IPDAAs was difficult because of their anatomical location and shape. Therefore, we planned a two-stage hybrid therapy. The patient underwent aorto-splenic bypass and resection of the SPDAA. Follow-up CT was performed to evaluate the IPDAAs before planned endovascular embolization. Spontaneous regression of the IPDAAs and normalized PDA arcade decreased the blood flow in the PDA arcade. The patient is doing well without graft occlusion, and the IPDAAs have completely regressed 7 years after surgery. CONCLUSION: Normalization of hyperinflow to the PDA arcade can lead to the regression of PDAA. Potentially, additional endovascular therapy may not be required in all cases when dilation of the PDA improves. However, more cases must be accumulated to establish criteria for predicting the risks of short- and long-term PDAA ruptures.

Death Anxiety in Patients with a History of Coronary Artery Bypass Graft Surgery During the COVID-19 Pandemic: The Role of Spiritual Well-Being and Coping Strategies.

Patients who have previously undergone coronary artery bypass surgery (CABG) were prone to death anxiety during the COVID-19 pandemic. It appears that spiritual well-being and appropriate coping strategies may mitigate the harmful effects of death anxiety. Therefore, this study aimed to determine the level of death anxiety in patients with CABG during the COVID-19 pandemic and investigate the relationship between spiritual well-being, coping strategies and death anxiety.This cross-sectional study was conducted on 100 patients with CABG history in Tehran from June 2021 to February 2022. The face-to-face questionnaire, containing questions on demographics, Templer's death anxiety scale, the spiritual well-being questionnaire, and the ways of coping questionnaire was administered to collect data. Statistical analysis was performed using descriptive-analytical statistics, correlation tests, and logistic regression models.Participants' mean age was 55.59 ± 12.78 years. The mean death anxiety score was 10.00 ± 2.16, with 87% of participants reporting high levels and 13% reporting low levels of death anxiety. Based on the results, there was a significant negative correlation between death anxiety and coping strategies, as well as subscales of distancing, seeking social support, accepting responsibility, and planful problem-solving. Logistic regression showed that with the increase in the score of spiritual well-being, the odds of having high levels of death anxiety decreased (p < 0.05). Furthermore, increasing the total score of coping strategies, and the score of self-controlling, seeking social support, accepting responsibility, and planful problem-solving, significantly reduced the odds of high levels of death anxiety (p < 0.05).The study showed that patients with a CABG history experienced high death anxiety during the COVID-19 pandemic. According to the findings, spiritual well-being and coping strategies, especially self-controlling, seeking social support, accepting responsibility, and planful problem-solving, may reduce the odds of severe death anxiety. These should be considered as effective targets for psychological intervention in these patients.

Duodenal-jejunal bypass improves hypothalamic oxidative stress and inflammation in diabetic rats via glucagon-like peptide 1-mediated Nrf2/HO-1 signaling.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is often accompanied by impaired glucose utilization in the brain, leading to oxidative stress, neuronal cell injury and infla-mmation. Previous studies have shown that duodenal jejunal bypass (DJB) surgery significantly improves brain glucose metabolism in T2DM rats, the role and the metabolism of DJB in improving brain oxidative stress and inflammation condition in T2DM rats remain unclear. AIM: To investigate the role and metabolism of DJB in improving hypothalamic oxidative stress and inflammation condition in T2DM rats. METHODS: A T2DM rat model was induced via a high-glucose and high-fat diet, combined with a low-dose streptozotocin injection. T2DM rats were divided into DJB operation and Sham operation groups. DJB surgical intervention was carried out on T2DM rats. The differential expression of hypothalamic proteins was analyzed using quantitative proteomics analysis. Proteins related to oxidative stress, inflammation, and neuronal injury in the hypothalamus of T2DM rats were analyzed by flow cytometry, quantitative real-time PCR, Western blotting, and immunofluorescence. RESULTS: Quantitative proteomics analysis showed significant differences in proteins related to oxidative stress, inflammation, and neuronal injury in the hypothalamus of rats with T2DM-DJB after DJB surgery, compared to the T2DM-Sham groups of rats. Oxidative stress-related proteins (glucagon-like peptide 1 receptor, Nrf2, and HO-1) were significantly increased (P < 0.05) in the hypothalamus of rats with T2DM after DJB surgery. DJB surgery significantly reduced (P < 0.05) hypothalamic inflammation in T2DM rats by inhibiting the activation of NF-κB and decreasing the expression of interleukin (IL)-1ß and IL-6. DJB surgery significantly reduced (P < 0.05) the expression of factors related to neuronal injury (glial fibrillary acidic protein and Caspase-3) in the hypothalamus of T2DM rats and upregulated (P < 0.05) the expression of neuroprotective factors (C-fos, Ki67, Bcl-2, and BDNF), thereby reducing hypothalamic injury in T2DM rats. CONCLUSION: DJB surgery improve oxidative stress and inflammation in the hypothalamus of T2DM rats and reduce neuronal cell injury by activating the glucagon-like peptide 1 receptor-mediated Nrf2/HO-1 signaling pathway.

Usefulness of combined bypass surgery for moyamoya disease in infants under 1 year of age: A technical case report.

Background: Among pediatric cases of moyamoya disease (MMD), cerebral ischemic symptoms often progress and worsen rapidly in infants under one year of age; therefore, it is important to treat them as early as possible. However, direct bypass surgery is often technically difficult for infants due to their small blood vessels. Here, we describe our technique to resolve the technical challenges encountered during superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass surgery in infants aged <1 year with MMD, focusing on specific procedures. Case Description: We performed bilateral STA-MCA and indirect bypass in a 1-year-old girl with MMD and cerebral infarction. Before treatment, a peripherally inserted central venous catheter (PICC) was placed to avoid ischemic attacks associated with crying, dehydration, and malnutrition. All examinations and procedures that would be stressful to the patient, such as blood examinations, were performed using PICC or under sedation. The STA-MCA diameters were 0.8 and 1.2 mm, respectively. After suturing the planned anastomosis with one stitch using an 11-0 monofilament nylon thread, the thread was lifted upward, and the arterial wall was incised. Anastomosis was performed using an 11-0 monofilament nylon thread with 2-4 stitches on each side. The operation was completed without patency problems. Postoperative blood flow improved, and the patient had a good treatment course. Conclusion: Direct bypass for MMD patients aged <1 year is technically challenging; however, the vessels can be connected if the procedure is carefully performed with consideration of the characteristics of the infant's vessels.

Inter-Rater Reliability for the Amputation Endpoint in the National Vascular Quality Initiative.

BACKGROUND: National quality reporting efforts after revascularization for peripheral artery disease (PAD) are ongoing. Validation of endpoints are necessary in national quality registries. OBJECTIVES: This study sought to examine the interrater reliability for the endpoint of major amputation at 1 year in the Vascular Quality Initiative (VQI) registry and the Medicare-linked Vascular Quality Initiative registry (VQI-VISION) against electronic health record (EHR) review. METHODS: Surgical or endovascular revascularization procedures between January 1, 2010, and December 31, 2017, in the VQI registry and VQI-VISION for 2 academic health systems were queried. Major amputation data were abstracted by trained data collectors for the VQI and derived from Current Procedural Terminology codes for VQI-VISION. Cases underwent protocolized adjudication for the endpoint of major amputation by EHR review. Paired tests were used to evaluate the sensitivity and specificity. Spearman's ρ and Cohen's κ were used to evaluate interrater reliability. RESULTS: Amputation endpoints for 1,936 revascularizations were examined. Compared with major amputation data in EHR review, the sensitivity for the VQI registry was 35.9% and the specificity was 99.4% (ρ = 0.53; κ = 0.48). For VQI-VISION, sensitivity was 67.7% and specificity was 98.9% (ρ = 0.75; κ = 0.74). For any amputation in VQI data, sensitivity was 35.3% and specificity was 99.3% (ρ = 0.53; κ = 0.46), and for VQI-VISION, they were 71.6% and 97.7%, respectively (ρ = 0.75; κ = 0.74). CONCLUSIONS: Almost two-thirds of the amputations in the VQI registry and one-third of amputations in VQI-VISION were missing at 1 year compared against adjudicated EHR review. In preparing for national reporting systems for major amputation tracking, data collection system reform is needed.

Choice of revascularization strategy for ischemic cardiomyopathy due to multivessel coronary disease.

OBJECTIVE: Limited comparative data guide the decision between coronary artery bypass grafting and percutaneous coronary intervention for multivessel revascularization in ischemic cardiomyopathy. The study objective was to compare the long-term outcomes of coronary artery bypass grafting and percutaneous coronary intervention for ischemic cardiomyopathy. METHODS: Clinical registries from the New Jersey Department of Health linked to administrative databases were used to compare all-cause mortality, repeat revascularization, heart failure readmissions, myocardial infarction, and stroke using Cox proportional hazards and propensity matching with competing risk analysis in 5988 patients with ejection fraction 35% or less who underwent coronary artery bypass grafting (3673, 61.3%) or percutaneous coronary intervention (2315, 38.6%) for multivessel coronary disease between 2007 and 2018. Median follow-up time was 5.2 years (range, 0-13 years); the last follow-up date was December 31, 2020. RESULTS: After controlling for completeness of revascularization, at 13 years, mortality was 57% (95% CI, 51-63) after percutaneous coronary intervention and 60% (95% CI, 53-66) after coronary artery bypass grafting (hazard ratio [HR], 1.10; 95% CI, 0.93-1.31; P = .28); risk of repeat revascularization was 18% for percutaneous coronary intervention versus 14% for coronary artery bypass grafting (HR, 1.62; 95% CI, 1.17-2.25; P = .003); risk of readmission for heart failure was 16% after percutaneous coronary intervention and coronary artery bypass grafting (HR, 1.13,95% CI, 0.84-1.51, weighted P = .10); risk of myocardial infarction was 10% versus 6%, respectively (HR, 1.91; 95% CI, 1.18-3.09; P = .007); and stroke risk was 3% versus 4%, respectively (HR, 0.79; 95% CI, 0.41-1.53; P = .52). Rate of complete revascularization was lower after percutaneous coronary intervention than after coronary artery bypass grafting and associated with higher mortality after percutaneous coronary intervention (HR, 1.35; 95% CI, 1.20-1.52; P < .001). CONCLUSIONS: Coronary bypass was associated with similar mortality, stroke, and heart failure readmissions, and reduced repeat revascularization compared with percutaneous coronary intervention in patients with ischemic cardiomyopathy if similar rates of complete revascularization were achieved. These findings support consensus recommendations for coronary artery bypass grafting and medical therapy in patients with multivessel coronary disease and left ventricular dysfunction.

Left Internal Thoracic Artery versus Saphenous Vein Grafts to Left Anterior Descending Artery after Isolated Coronary Artery Bypass Surgery.

BACKGROUND: This study compared perioperative outcomes and long-term survival of saphenous vein grafts (SVGs) versus left internal thoracic artery (LITA) to left anterior descending artery (LAD) in isolated coronary artery bypass graft surgery (CABG). METHODS: In this retrospective, single-centre study, we included patients with primary isolated CABG from January 2001 to July 2022. Baseline demographics were compared between SVG-LAD and LITA-LAD. Univariable and multivariable regressions were performed for predictors of in-hospital death. Propensity score matching was performed for LITA-LAD vs. SVG-LAD. Kaplan-Meier survival curves were generated for comparison of survival. Cox proportional hazards model was used for predictors of survival. RESULTS: A total of 8237 patients (1602 SVG-LAD/6725 LITA-LAD) were included. Median age was 67.9 years (LITA-LAD; 67.1 years vs. SVG-LAD; 71.7 years, p < 0.01). A total of 1270 pairs of SVG-LAD were propensity-matched to LITA-LAD. In matched cohorts, in-hospital mortality (0.8% vs. 1.6%, LITA-LAD and SVG-LAD respectively; p = 0.07), deep sternal wound infection, new cerebrovascular events, renal replacement therapy and hospital stay >30 days were similar. SVG-LAD did not adversely affect in-hospital mortality (OR; 2.03, CI; 0.91, 4.54, p = 0.08). Median long-term survival was similar between the groups (13.7 years vs. 13.1 years for LITA-LAD and SVG-LAD respectively, log rank p < 0.31). SVG-LAD was not a predictor of adverse long-term survival. (HR; 1.06, 95% CI; 0.92, 1.22, p < 0.40). Long-term survival was better with LITA-LAD for LVEF <30% (log rank p < 0.03). CONCLUSIONS: There was no difference in the propensity-matched cohorts for use of SVG vs. LITA to the LAD. Further contemporary long-term studies are needed for substantiation.

Infra-inguinal bypass surgery vs endovascular revascularization for chronic limb-threatening ischemia in average- and high-risk patients.

OBJECTIVE: This study aimed to evaluate treatment outcomes after bypass surgery or endovascular therapy (EVT) in average- and high-risk patients with chronic limb-threatening ischemia (CLTI). METHODS: We retrospectively analyzed multicenter data of patients who underwent infra-inguinal revascularization for CLTI between 2015 and 2022. A high-risk patient was defined as one with estimated 30-day mortality rate ≥5% or 2-year survival rate ≤50%, as determined by the Surgical Reconstruction vs Peripheral Intervention in Patients With Critical Limb Ischemia (SPINACH) calculator. The amputation-free survival (AFS), limb salvage (LS), wound healing, and 30-day mortality were compared separately for the average- and high-risk patients between the bypass and EVT with propensity score matching. RESULTS: We analyzed 239 and 31 propensity score-matched pairs in the average- and high-risk patients with CLTI. In the average-risk patients, the 2-year AFS and LS rates were 78.1% and 94.4% in the bypass group and 63.0% and 87.7% in the EVT group (P < .001 and P = .007), respectively. The 1-year wound healing rates were 88.6% in the bypass group and 76.8% in the EVT group, respectively (P < .001). The 30-day mortality was 0.8% in the bypass surgery and 0.8% in the EVT group (P = .996). In the high-risk patients, there was no differences in the AFS, LS, and wound healing between the groups (P = .591, P = .148, and P = .074). The 30-day mortality was 3.2% in the bypass group and 3.2% in the EVT group (P = .991). CONCLUSIONS: Bypass surgery is superior to EVT with respect to the AFS, LS, and wound healing in the average-risk patients. EVT is a feasible first-line treatment strategy for high-risk patients with CLTI undergoing revascularization, based on the lack of significant differences in the 2-year AFS rate, between the bypass surgery and EVT cohorts.

Fluorescein videoangiography (FL-VAG) as a predictor of cerebral bypass patency.

Background: The fluorescein videoangiography (FL-VAG) has become a valuable adjunct tool in vascular neurosurgery. This work describes using the FL-VAG during bypass surgery and proposes a classification method for evaluating surgical results. Methods: We analyzed 26 patients with 50 cerebral bypasses from September 2018 to September 2022. We used a three grades classification method based on the pass of intravenous fluorescein through the anastomosis. Grade 1 represents the synchronous and total filling of the "T" shape ("green T″) formed by the donor and recipient vessel, Grade 2, the asynchronous filling of the anastomosis (incomplete/asynchronous "green T″), and Grade 3, a non-patent anastomosis (absence of "green T″). Results: Of the 26 patients, 8 underwent one bypass, 14 underwent double bypass, 2 underwent three bypasses, and 2 underwent four bypasses in two different interventions. The type of bypass was end-to-side anastomosis in 47 (94%) cases, internal maxillary artery to middle cerebral artery bypass with a radial artery graft (IMax-MCA anastomosis) in 2 (4%), and PICA-VA transposition in one (2%). We made 24 (48%) bypasses on the right side and 26 (52%) on the left side. After the initial surgery, thirty-nine (78%) bypasses were considered as Grade 1, 5 (10%) as Grade 2, and 6 (12%) as Grade 3. After intraoperative bypass patency assessment (IBPA), 45 (90%) of the bypasses were considered Grade 1 and remained patent on CTA. Conclusions: Using FL-VAG and a three-tier classification method is a reliable tool to predict bypass patency. It is safe, low-risk, and available worldwide.

А Rare Case of an Infected, Ruptured Popliteal Artery Aneurysm Occurring Following Surgical Treatment for Panaritium.

We present a successful case of treating an infected popliteal aneurysm in a 71-year-old man who arrived at the emergency department in a septic state, reporting a three-week history of fever, lethargy, general malaise, and pain and swelling in the right popliteal fossa. Previously diagnosed with a sizable right popliteal aneurysm, the patient had undergone endovascular treatment using a Viabahn (WL Gore & Associates, Flagstaff, USA) endoprosthesis two months earlier. His fever and malaise emerged a week following minor surgery for a toe infection (panaritium) on the right foot, leading to subsequent necrotic lymphangitis on the dorsum of the same foot. A PET/CT scan strongly indicated an infection within the aneurysmal sac, while a CT angiography confirmed the integrity of the stent graft without any leaks but revealed a ruptured aneurysm. Urgent surgical intervention was necessary. An extra-anatomical autovenous bypass was conducted, followed by an aneurysm and endograft removal. Subsequently, a vacuum-assisted closure (VAC) system was employed to manage the infected wound post sac extraction. The surgical procedure went smoothly without complications, and following a course of antibiotics, the patient recovered well, eventually being discharged after 50 days.

A case of a peritoneal dialysis patient with left pleuroperitoneal communication caused by a pericardial defect after coronary artery bypass surgery.

A 74-year-old woman with reduced kidney and cardiac function and a history of coronary artery bypass surgery involving the gastroepiploic artery to the right coronary artery and posterior descending artery #4 presented with dyspnea on exertion. Shortly after the induction of peritoneal dialysis (PD), an increase in the left pleural effusion was observed, and a diagnosis of left pleuroperitoneal communication was made by puncture drainage. The pleuroperitoneal communication hole was not detected under thoracoscopic observation; however, a 10 mm-sized hole in the pericardium was found, confirming leakage of ICG-loaded peritoneal dialysate fluid (PDF). CT peritoneography using PDF mixed with iodine contrast medium revealed that the gastroepiploic artery-to-right coronary artery pathway was defective on the abdominal side. We concluded that the left pleuroperitoneal communication was caused by a two-stage fistulous pathway between the abdominal and pleural cavities through the pericardial cavity after coronary artery bypass graft surgery. Although closure of the diaphragmatic hole around the gastroepiploic artery graft should have been performed to restart PD, the patient did not wish to undergo further invasive procedures. Identification of the fistulous pathway is extremely important for prompt diagnosis and treatment of pleuroperitoneal communication.