Unintended Exchange of Target Vessels for Celiac Trunk and Superior Mesenteric Artery Branches in Complex Endovascular Aortic Repair.

PURPOSE: The treatment of thoracoabdominal aortic aneurysms (TAAAs) using branched endovascular aortic repair (BEVAR) is safe and effective. During deployment, the superior mesenteric artery (SMA) branch can unintentionally open into the celiac trunk (CT) ostium and switched catheterization of the SMA from the CT branch and the CT from the SMA branch can be used as an alternative technique in these cases. This study aimed to investigate the outcome of exchanging the intended target vessels (TVs) for the CT and SMA branches during BEVAR. MATERIALS AND METHODS: A single-center retrospective analysis of patients with TAAAs who underwent BEVAR, using off-the-shelf or custom-made devices (CMDs), with an unintended exchange of TVs for the CT and SMA branches was performed. RESULTS: Between 2014 and 2023, 397 patients were treated with BEVAR for TAAA. Eighteen (4.5%) of those patients were treated with an exchange of TVs for the CT and SMA branches. T-branch was used in 9 cases (50%) and the remaining patients were treated with CMDs. Twelve patients were treated electively, 3 were symptomatic and 3 presented with rupture. Of 36 mesenteric TVs in those 18 patients, 34 (94%) were catheterized successfully, including all 18 SMAs and 16 of the 18 CTs. No branch stenosis or occlusion of the switched mesenteric TVs was detected during follow-up. During 30-day follow-up, 3 patients died and during a median follow-up of 3 (interquartile range [IQR]: 1-15) months 3 more patients died. None of the deaths or the 2 unintended reinterventions was induced by the mesenteric TV exchange. The median hospital stay was 14 (IQR: 9-22) days with a median of 4 (IQR: 2-11) days at the intensive care unit. CONCLUSION: The exchange of the mesenteric TVs for the CT and SMA branches during BEVAR with off-the-shelf and CMD endografts is feasible with good TV patency and freedom from TV-related reinterventions. This alternative technique should be considered in selected cases when direct catheterization via the intended branch is deemed more time-consuming or not feasible. CLINICAL IMPACT: This is the first description of using an exchange of target vessels for the celiac trunk and the superior mesenteric artery branches in patients with thoracoabdominal aortic aneurysms undergoing BEVAR, using off-the-shelf or custom-made devices. The high success rate as well as the good clinical results without any branch stenosis or occlusion during follow-up highlight the feasibility of this alternative technique. It could help in challenging cases when catheterization of the intended target vessels is not possible or too time consuming, resulting in higher success rates of BEVAR and better clinical results.

Vein Bypass Versus Nitinol Stent in Long Femoropopliteal Lesions: 4-Year Results of a Randomized Controlled Trial.

OBJECTIVES: The aim of this study was to compare technical success, patency rates and clinical outcomes of vein bypass (VBP) with angioplasty and nitinol stents (NS) in femoropopliteal Trans-Atlantic Intersociety Consensus (TASC) II C and D lesions. SUMMARY BACKGROUND DATA: Guidelines widely recommend an endovas-cular-first strategy for long femoropopliteal lesions without sufficient data comparing it with vein bypass surgery. METHODS: A single-center prospective, randomized controlled trial (RCT) was performed, after approval of the local ethics committee, with technical success, primary and secondary patency as primary endpoints. Secondary endpoints were limb salvage, survival, complications, and clinical improvement. RESULTS: Between 2016 and 2020, 218 limbs (109 per group) in 209 patients were included. Baseline and lesion characteristics were similar in both groups with a mean lesion length of 268 mm. The indication for treatment was chronic limb threatening ischemia in 53% of limbs in both groups. Technical success was feasible in 88% in the stent group. During a 4-year follow-up, primary patency, freedom from target lesion revascularizations, limb salvage, survival and complications showed no significant differences between the groups. At 48 months secondary patency for the bypass group was 73% versus 50% in the stent group ( P = 0.021). Clinical improvement was significantly superior in the bypass group with 52% versus 19% reaching a Rutherford 0 category ( P < 0.001). CONCLUSIONS: This is the largest RCT comparing angioplasty with NS and vein bypass in femoropopliteal TASC II C and D lesions and the first to report 4-year results. The data underline the feasibility of endovascular treatment in long lesions but also emphasize the advantages of VBP.

Comparison of Prosthetic and Vein Bypass with Nitinol Stents in Long Femoropopliteal Lesions.

BACKGROUND: Guidelines for the treatment of long femoropopliteal lesions are not based on a high level of evidence and recent randomized controlled trials (RCTs) challenge vein bypass (VBP) as the recommended therapy. This study compared prosthetic (PTFE) bypass, VBP and angioplasty with nitinol stents in long femoropopliteal lesions. METHODS: Pooled data from a RCT and a retrospective database with the same inclusion criteria were analyzed with primary and secondary patency as well as freedom from target lesion revascularization (TLR) as primary endpoints. RESULTS: Between 2016 and 2018 a total of 172 lesions were treated in three groups (PTFE: n = 62, VBP: n = 55, stent: n = 55). Clinical and lesion characteristics were similar with mean lesion lengths between 260 and 279mm. Technical success rate in the stent group was 87%. There were no significant differences between the groups in patency rates, freedom from TLR, limb salvage and survival during 2-year follow-up. The primary patency rates for the PTFE, VBP and stent groups were 50%, 56% and 60% at 2 years. The PTFE group had significantly less complications compared to the other groups and a shorter hospital-stay compared to the VBP group. Clinical improvement was significantly better in the PTFE and VBP group compared to the stent group. CONCLUSIONS: The 2-year results indicate that the role of VBP as the recommended therapy for long femoropopliteal lesions may not be unchallenged due to the similar results in all three groups. Further RCTs are needed to determine the best revascularization modality for long femoropopliteal lesions.

Long-Term Results of Endovascular Treatment with Nitinol Stents for Femoropopliteal TASC II C and D Lesions.

Background and Objectives: The feasibility of endovascular treatment (EVT) for Trans-Atlantic Inter-Society Consensus (TASC) II C and D femoropopliteal artery lesions has been described, but no prospective study has performed a long-term follow-up. The aim of this study was to report the long-term results of nitinol stents (NS) for the treatment of long femoropopliteal lesions. Materials and Methods: A single-center prospective, randomized controlled trial (RCT) comparing EVT with NS and vein bypass surgery was previously performed. The EVT group's follow-up was extended and separately analyzed with primary patency as the primary endpoint. The secondary endpoints were technical success, secondary patency, reinterventions, limb salvage, survival, complications, and clinical improvement. Results: Between 2016 and 2020, 109 limbs in 103 patients were included. A total of 48 TASC II C and 61 TASC II D lesions with a mean lesion length of 264 mm were reported. In 53% of limbs, the indication for treatment was chronic limb-threatening ischemia. The median follow-up was 45 months. Technical success was achieved in 88% of cases, despite 23% of the lesions being longer than 30 cm (retrograde popliteal access in 22%). At four-year follow-up, primary patency, secondary patency, and freedom from target lesion revascularizations were 35%, 48%, and 58%, respectively. Limb salvage and survival were 90% and 80% at 4 years. Clinical improvement of at least one Rutherford category at the end of follow-up was achieved in 83% of limbs. Conclusions: This study reports the longest follow-up of endovascular treatment with nitinol stents in femoropopliteal TASC II C and D lesions. The results emphasize the feasibility of an endovascular-first strategy, even in lesions beyond 30 cm in length, and clarify its acceptable long-term durability and good clinical outcomes. Large multicenter RCTs with mid- and long-term follow-up are needed to investigate the role of different endovascular techniques in long femoropopliteal lesions.

Alternative vein bypass in octogenarians with chronic limb-threatening ischaemia.

BACKGROUND: Octogenarians are regarded as one of the frailest patient groups among the chronic limb-threatening ischaemia population with high perioperative morbidity and mortality rates. As a result, alternative vein bypass surgery in the absence of sufficient great saphenous vein is often not considered as a potential treatment option. The aim of this study was to compare the results of octogenarians undergoing alternative vein bypass surgery due to chronic limb-threatening ischaemia to younger patients. METHODS: A single-centre retrospective analysis of patients undergoing bypass surgery for chronic limb-threatening ischaemia with alternative autologous vein grafts between 1997 and 2018 was performed. Patients aged over 80 years were compared with those under 80 years. Graft patency rates were assessed and a risk factor analysis for limb loss was performed. RESULTS: In total, 592 patients underwent bypass surgery during the study interval. Twenty-one per cent (n = 126) of patients were 80 years or older. At 4 years, primary, primary-assisted and secondary patency as well as limb salvage rates were not significantly different between the two groups (46% versus 50%, 60% versus 66%, 69% versus 72%, 72% versus 77%, for octogenarians versus non-octogenarians respectively). Major amputations were performed in 27 (21%) octogenarians and 91 (20%) non-octogenarians (P = 0.190). No higher 30-day and long-term mortality rates nor morbidity rates were detected in the octogenarian group with a median follow-up time of 27 (interquartile range 12-56) months. Minor amputation, the reason for alternative vein grafts, as well as the profunda femoris artery as proximal origin of the bypass were risk factors for limb loss in the postoperative course. CONCLUSION: Alternative vein bypass surgery in octogenarians with chronic limb-threatening ischaemia is safe and effective in terms of patency rates, limb salvage and survival compared with younger patients in the absence of sufficient great saphenous vein. Age alone should not be a deterrent from performing bypass surgery.

Beyond the Slopes and Highways: Endovascular Repair of Blunt Traumatic Aortic Injuries after Skiing versus Motor Vehicle Accidents.

Background: Blunt traumatic aortic injury (BTAI) is a potentially fatal condition, typically resulting from high-velocity trauma. To date, little is known about this type of injury among skiers, who form the largest patient cohort with aortic injuries in the alpine region of Tyrol, Austria. Methods: This retrospective, single-center study at the University Hospital of Innsbruck analyzed patients who underwent endovascular treatment for blunt traumatic aortic injury from 2005 to 2023. Patient data were extracted from electronic and digitalized medical history records. Subsequent analyses compared the baseline characteristics and clinical results of the skiing accident (SA) group to the motor vehicle accident (MVA) group. Results: A total of 48 BTAI patients receiving TEVAR were included, 25 (52%) from SAs versus 23 (48%) from MVAs, who were predominantly male (92% vs. 78.3%). Despite similar preoperative risk profiles and ASA Scores (1.44 vs. 1.74) and no marked differences in BTAI injury grades or the affected aortic zones, significant disparities emerged: the SA group experienced shorter median ICU stays (3 vs. 11 days, p = 0.0007), fewer concomitant injuries (5 vs. 7, p = 0.005), and lower Injury Severity Scores (ISSs) (29 vs. 33, p = 0.003) than their MVA counterparts. The presence of rib fractures alongside other thoracic injuries, such as lung injury, pneumothorax, or hemothorax, was strongly correlated with BTAI in patients following skiing accidents (OR = 128.5). Conclusions: The injury severities and locations of BTAI in SA patients were comparable to those in MVA patients, indicating similar mechanisms of thoracic trauma. However, the SA patients experienced fewer concurrent pelvic and extremity fractures, had less post-procedural morbidity, and required shorter ICU stays. The presence of rib fractures combined with other thoracic injuries strongly suggests BTAI. These indicators should lead to prompt imaging and appropriate therapy.

Risk of Permanent Pacemaker Implantation Following Bentall Operation.

Conduction disorders following cardiac surgery are common complications with incidences of permanent pacemaker dependency up to 5%. However, data on pacemaker implantation rates in the long-term follow-up after Bentall operations are scarce. In a retrospective study, a mixed cohort of 260 patients including endocarditis and aortic dissection undergoing Bentall operation between March 1996 and December 2015 was analyzed. Median follow-up time was 60 (12-107) months. Early and late rates of permanent pacemaker implantation and associated risk factors were investigated. In the postoperative course 31 (11.9%) permanent pacemakers were implanted. The 30-day incidence of pacemaker implantations was 7.7% with operations performed after a median of 6 (3-12) days after the Bentall operation. After ten years, 21% of the Bentall patients were permanent pacemaker dependent. The risk factors for permanent pacemaker dependency included age above 75 years (16.1% vs 5.7%; P < 0.001), preoperative cardiac conduction disturbance (32.3% vs 22.7%, P = 0.018), aortic valve stenosis (38.7% vs 23.1, P = 0.008), infective endocarditis (19.4% vs 7.4%, P = 0.004), tricuspid valve reconstruction (6.5% vs 0.9%, P = 0.033), sepsis (12.9% vs 4.4%, P < 0.001) and non-cardiac reoperation (19.4% vs 8.7%, P = 0.004). Pacemaker implantation significantly increased the length of initial hospitalization (13 [8-26] days vs 8 [7-13] days; P = 0.003). In the long-term follow-up, mortality was not different between the groups. Permanent pacemaker dependency is a frequent complication in the short- and long-term follow-up after Bentall operations. Screening for cardiac conduction disturbances in the short- and long-term follow-up is recommended.

Long-Term Outcome of Bypass Surgery versus Endovascular Revascularization in Long Femoropopliteal Lesions.

Long-term follow-up data comparing surgical and endovascular revascularization of femoropopliteal lesions is rarely reported. This study presents 4-year results of revascularization for long femoropopliteal lesions (Trans-Atlantic Inter-Society Consensus Types C and D) with vein bypass (VBP), polytetrafluorethylene bypass (PTFE), and endovascular intervention with a nitinol stent (NS). Data from a randomized-controlled trial on VBP and NS was compared with a retrospective patient cohort using PTFE with the same inclusion and exclusion criteria. Primary, primary assisted, and secondary patency, as well as changes in Rutherford categories and limb salvage rates, are reported. Between 2016 and 2020, 332 femoropopliteal lesions underwent revascularization. The lesion lengths and basic patient characteristics were similar between the groups. 49% of the patients presented with chronic limb threatening ischemia at the time of revascularization. During the four-year follow-up, primary patency was comparable for all three groups. Primary assisted and secondary patency were significantly higher after VBP, while PTFE and NS had similar results. Clinical improvement was also significantly superior after VBP. After four years of follow-up, patency rates as well as the clinical outcome clearly favor VBP. If no vein is available, NS is as effective as PTFE bypass with regard to patency and clinical outcome.

The Mangled Extremity Severity Score (MESS) does not predict amputation in popliteal artery injury.

PURPOSE: Vascular injuries in lower extremity trauma, especially with involvement of the popliteal artery, are associated with considerably high rates of limb loss, especially with blunt trauma mechanisms. The aim of this study was to evaluate the risk of amputation in patients with traumatic popliteal artery lesions with special focus on the validity of the Mangled Extremity Severity Score (MESS). METHODS: In this retrospective study, all patients treated for isolated lesions of the popliteal artery following trauma between January 1990 and December 2020 at a high-volume level I trauma center were included. Primary outcome was limb salvage dependent on MESS and the influence of defined parameters on limb salvage was defined as secondary outcome. The extent of trauma was assessed by the MESS. RESULTS: A total of 50 patients (age 39.2 ± 18.6 years, 76% male) with most blunt injuries (n = 47, 94%) were included. None of the patients died within 30 days and revascularization was attempted in all patients with no primary amputation and the overall limb salvage rate was 88% (44 patients). A MESS ≥ 7 was observed in 28 patients (56%) with significantly higher rates of performed fasciotomies (92.9% vs. 59.1%; p < 0.01) in those patients. MESS did not predict delayed amputation within our patient cohort (MESS 8.4 ± 4.1 in the amputation group vs. 8.1 ± 3.8 in the limb salvage group; p = 0.765). CONCLUSION: Revascularization of limbs with isolated popliteal artery injuries should always be attempted. MESS did not predict delayed amputation in our cohort with fasciotomy being an important measure to increase limb salvage rates.

Risk factors for major amputation after arterial vascular trauma of the lower extremity.

BACKGROUND & OBJECTIVE: Arterial vascular trauma bears a great risk of poor functional outcome or limb loss. The aim of this study was to analyze amputation rates of patients after vascular trauma and to perform a predictor analysis for the risk of major amputation. METHODS: In a single-center retrospective analysis of 119 extremities treated for arterial vascular injury between 1990 and 2018 amputation rates and factors associated with limb loss were assessed. All patients were treated for traumatic vascular injuries; iatrogenic injuries were not included in the study. RESULTS: During the study period, a total of 119 legs in 118 patients were treated after arterial vascular trauma. The in-hospital major amputation rate was 16.8% and the mortality rate was 2.5%. In the predictors analysis, vascular re-operation (amputation rate 53.8% vs 12%, odds ratio = 8.56), a Rutherford category ⩾IIb (25.4% vs 4.2%, odds ratio = 6.43), work-related or traffic accidents (28.2% vs 0%, odds ratio = 4.86), concomitant soft tissue or bone injuries (26.7% vs 7.3%, odds ratio = 4.64), polytrauma (33.3% vs 12%, odds ratio = 3.68), and blunt trauma (18.9% vs 0% for penetrating trauma, odds ratio = 1.64) were found to be associated with amputation. CONCLUSIONS: Lower extremity arterial vascular trauma was associated with a significant major amputation rate. Several predictors for limb loss were identified, which could aid in identifying patients at risk and adapting their treatment.

Predictors for the need for fasciotomy after arterial vascular trauma of the lower extremity.

INTRODUCTION: Compartment syndrome of the lower extremity following arterial vascular trauma can cause irreversible damage to muscle as well as nerve tissue leading to long-term functional impairment of the extremity or worse limb loss. Prompt diagnosis and treatment of compartment syndrome is mandatory to preserve muscle tissue and prevent limb loss. The aim of the study was to analyze the fasciotomy rate of our patient cohort and to perform a predictors analysis for the need of fasciotomy. MATERIAL AND METHODS: In a retrospective study all patients treated for arterial vascular trauma since 1990 were identified. Demographics, clinical data and outcome were analysed. After separation in a fasciotomy and non-fasciotomy group, a Bayes Network was used to arrive at a predictor ranking for the need of fasciotomy via a gain ratio feature evaluation. RESULTS: In the period of 28 years, 88 (73.9%) of a total of 119 patients, predominantly male (80.7%) and aged under 40 years (37.5 ± 17.5), required fasciotomy after arterial vascular trauma. Patients of the fasciotomy group presented at higher Rutherford categories (grade III 34.1% vs. 9.7%, p = 0.005), varied in terms of the type of arterial vascular injury (dissection 25% vs. 61.3%, p <0.001, occlusion 15.9% vs. 0%, p = 0.011) and showed prolonged hospitalization (35.17 ± 29.3 vs. 21.48±25.4, p = 0.002). Ischaemia duration exceeding 2.5 h followed by the Rutherford grade IIa and greater, the site (popliteal artery segment 3), type (transection and occlusion), and mechanism of vascular trauma (work related accident over traffic and sports accidents), as well as the male gender presented as strong predictors for fasciotomy. CONCLUSIONS: Arterial vascular trauma requiring fasciotomy for compartment syndrome accounted for 73.9% of all cases. Immediate diagnosis and treatment is mandatory to prevent long-term functional impairment or limb loss. The above mentioned predictors should help identifying patients at risk for developing a compartment syndrome to provide best possible treatment.