Long-term results of a multicenter randomized study on direct versus crossover bypass for unilateral iliac artery occlusive disease

Long-term clinical outcomes of arterial bypass and the factors independently associated with the primary patency in patients with suprainguinal arterial occlusion

INTRODUCTION

Aortoiliac occlusive disease and iliofemoral occlusion are impact patient quality of life, cause limb loss and mortality. The aim of this study was to investigate the long-term clinical outcomes of arterial bypass, and the factors associated with the outcomes.

METHOD

This retrospective chart/image review included all types of arterial bypass procedures performed for suprainguinal arterial occlusion during January 2004 to December 2017. The primary outcome was the primary patency. The secondary outcomes were the secondary patency, amputation-free survival, overall survival and the factors associated with the outcomes.

RESULT

A total of 135 patients (107 males) were included. The median age was 65 years. The 1-year, 5-year, and 10-year primary patency rates were 74.3%, 65.7%, and 55.6%, respectively, with independent predictors of poor outcomes being underlying cerebrovascular disease (p = 0.003) and postoperative graft infection (p = 0.016). Secondary patency rates at 1-year, 5-year, and 10-year intervals were 90.1%, 87.1%, and 77.8%, respectively, with independent predictors of poor outcomes being underlying cardiovascular disease (p = 0.013) and postoperative acute kidney injury (p = 0.010). Amputation-free survival rates at 1-year, 5-year, and 10-year intervals were 77.1%, 71.6%, and 66.0%, respectively, with the independent predictor of poor outcome being preoperative foot infection (p = 0.013). Overall survival rates at 1-year, 5-year, and 10-year intervals were 84.4%, 58.6%, and 35.3%, respectively, with independent predictors of poor outcomes being chronic kidney disease (p = 0.030) and postoperative myocardial infarction (p = 0.018). However, antiplatelet therapy emerged as an independent predictor of favorable overall survival outcomes (p = 0.034).

CONCLUSION

Our results showed the primary patency rates of arterial bypass to be relatively low at our center; however, most grafts could be saved with high secondary patency. Both disease-associated factors and patient condition-associated factors were found to influence the outcomes of this fragile patient population.

[Vascularsurgical Long-term Outcome - Comparison of Orthotopic and Extraanatomic Reconstructions in Unilateral Occlusions of Iliac Artery over 10 Years]

In PAOD, several vascular regions are usually affected, the pelvic axis in 35% of cases. Interventional-radiological/endovascular or hybrid interventions have been established for recanalization, so that bypass procedures are increasingly taking a back seat, but are not losing their importance.To study unilateral iliac artery occlusions (inclusion criterion) that were repaired either by implantation of an orthotopic or extraanatomic bypass (oBP/eaBP).Over a defined period of time, the rate of open vessel, complications (frequency, type, severity) to characterize morbidity and mortality as well as the extent of clinical improvement after BP implantation were analyzed in a clinical-systematic, single-center observational study (for vascular surgical quality assurance and contribution to vascular medical-clinical health care research). The study method was not explicitly based on the STROBE criteria, but essentially corresponds to them.Over 10 years, 122 PAOD patients (50% in stage IIb-stage III and IV equally distributed; mean age: 63 [range, 44-87] years; majority ASA III) were included with the same number of reconstructions: 71 patients received an eaBP ("crossover"), 51 patients an iliacofemoral (orthotopic - oBP) bypass (neither significant difference regarding frequency nor number of risk factors per patient).The oBP is not superior to eaBP with regard to the analysis parameters of openness, complication rate and mortality. Furthermore, extraanatomic revascularization does not have to be reserved for polymorbid patients only.

Long-Term Outcomes of Anatomical and Extra-Anatomical Bypass for the Treatment of Unilateral Iliac Artery Lesions a Systematic Review Aggregated Data and Individual Participant Data Meta-Analysis

BACKGROUND

We investigated the long-term safety and efficacy of anatomical and extra-anatomical bypass for the treatment of unilateral iliac artery disease.

METHODS

A systematic search on PubMed, Scopus and Web of science for articles published by June 2023 was performed. We implemented a 2-stage individual participant data meta-analysis and pooled survival probabilities using the multivariate methodology of DerSimonian and Laird. The primary endpoint was primary patency at 5 and 10 years of follow-up.

RESULTS

Ten studies encompassing 1,907 patients were included. The 5- and 10-year pooled patency rates for anatomical bypass were 83.27% (95% confidence interval (CI): 69.99-99.07) and 77.30% (95% CI: 60.32-99.04), respectively, with a mean primary patency time representing the duration individuals remained event-free for 10.08 years (95% CI: 8.05-10.97). The 5- and 10-year pooled primary patency estimates for extra-anatomical bypass were 77.02% (95% CI: 66.79-88.80) and 68.54% (95% CI: 53.32-88.09), respectively, with a mean primary patency time of 9.25 years, (95% CI: 7.21-9.68). Upon 2-stage individual participant data meta-analysis, anatomical bypass displayed a decreased risk for loss of primary patency compared to extra-anatomical bypass, hazard ratio 0.51 (95% CI: 0.30-0.85). The 5- and 10-year secondary patency estimates for anatomical bypass were 96.83% (95% CI: 90.28-100) and 96.13% (95% CI: 88.72-100), respectively. The 5- and 10-year secondary patency estimates for extra-anatomical bypass were 91.39% (95% CI: 84.32-99.04) and 85.05% (95% CI: 74.43-97.18), respectively, with non-statistically significant difference between the 2 groups. The 5- and 10-year survival for patients undergoing anatomical bypass were 67.99% (95% CI: 53.84-85.85) and 41.09% (95% CI: 25.36-66.57), respectively. The 5- and 10-year survival for extra-anatomical bypass were 70.67% (95% CI: 56.76-87.98) and 34.85% (95% CI: 19.76-61.44), respectively. The mean survival time was 6.92 years (95% CI: 5.56-7.89) for the anatomical and 6.78 years (95% CI: 5.31-7.63) for the extra-anatomical groups. The pooled overall 30-day mortality was 2.32% (95% CI: 1.12-3.87) with metaregression analysis displaying a negative association between the year of publication and mortality (β =-0.0065, P < 0.01). Further analysis displayed a 30-day mortality of 1.29% (95% CI: 0.56-2.26) versus 4.02% (95% CI: 1.78-7.03), (P = 0.02) for studies published after and before the year 2000. Non-statistically significant differences were identified between the 2 groups concerning long-term and 30-day mortality outcomes.

CONCLUSIONS

While we have demonstrated favorable long-term primary and secondary patency outcomes for both surgical techniques, anatomical bypass exhibited a reduced risk of primary patency loss potentially reflecting its inherent capacity to circumvent the anticipated disease progression in the distal aorta and the contralateral donor artery. The reduction in perioperative mortality observed in our review, coupled with the anachronistic demographic characteristics and inclusion criteria presented in the existing literature, underscores the imperative necessity for contemporary research.

Open Surgical Therapy for Peripheral Artery Disease

PURPOSE OF REVIEW

The surgical management of symptomatic peripheral artery disease (PAD) has changed in the last few decades. Improvement in endovascular technology has resulted in more complex lesion once reserved for open surgery being addressed in an endovascular fashion. Even with these advances, there are lesions and patients that are better managed with an open surgical procedure. The aim of this review is to describe the most commonly performed open surgical procedures for PAD.

RECENT FINDINGS

The recently published Best Endovascular versus Best Surgical Therapy (BEST-CLI) trial was an international, prospective, randomized controlled trial that aimed to investigate which revascularization (endovascular vs. surgical bypass) approach was superior for limb salvage. The evidence supports an open surgical bypass as an initial approach. The advancements made in the surgical management of PAD have provided options for patients who were once deemed poor surgical candidates. The goal continues to be utilization of the best available tools to address patient disease. In this current era, it is important to be familiar with the open surgical therapies.

Extra-anatomic bypass procedures for severe aortoiliac occlusive disease-A cohort study

OBJECTIVES

Extra-anatomic bypass (ExAB) grafting has been questioned due its inferior durability compared to anatomic bypass for aortoiliac occlusive disease (AIOD). This study aims to present early and late outcomes of patients treated with ExAB as well as to evaluate potential prognostic factors.

METHODS

This is a retrospective cohort study presenting a series of patients treated with ExAB for AIOD. All patients were treated between 2005 and 2022 within the Vascular Surgery Unit of a University Surgery Clinic. Both early (30-day) and late outcomes were evaluated. Univariate and multivariate analyses were conducted for potential predictors. Kaplan-Meier curve was produced for long-term patency.

RESULTS

A total of 41 patients were treated (85.3% males; mean age: 76.3 ± 4.2 years). Indication for treatment included severe claudication or critical limb ischemia (Rutherford stages III-VI). The following procedures were recorded: Femorofemoral bypass (FFB; n = 21) and axillofemoral bypass (AxFB; n = 20). All procedures were conducted using synthetic grafts with external rings. Early outcomes included no death, no myocardial infarction, no major bleeding, no graft infection, and no major amputation. Regarding late outcomes, 14.6% patients were lost after the first month. For the rest of patients (n = 35), five-year primary patency was 88.6%, primary-assisted patency was 94.3%, and secondary patency was also 94.3%. Limb salvage was 100% within follow-up. Endarterectomy at the distal anastomosis was the only independent predictor associated with worse patency in the long-term (OR = 5.356; 95% CI (1.012-185.562); p = .041).

CONCLUSIONS

FFB and AxFB is a safe and durable strategy for treating patients with severe AIOD where no other option is feasible. Regarding predictors, only endarterectomy at the distal anastomosis site was associated with an increased risk for graft failure.

Current Status and Principles for the Treatment and Prevention of Diabetic Foot Ulcers in the Cardiovascular Patient Population: A Scientific Statement From the American Heart Association

Despite the known higher risk of cardiovascular disease in individuals with type 2 diabetes, the pathophysiology and optimal management of diabetic foot ulcers (DFUs), a leading complication associated with diabetes, is complex and continues to evolve. Complications of type 2 diabetes, such as DFUs, are a major cause of morbidity and mortality and the leading cause of major lower extremity amputation in the United States. There has recently been a strong focus on the prevention and early treatment of DFUs, leading to the development of multidisciplinary diabetic wound and amputation prevention clinics across the country. Mounting evidence has shown that, despite these efforts, amputations associated with DFUs continue to increase. Furthermore, due to increasing patient complexity of management secondary to comorbid conditions, such as cardiovascular disease, the management of peripheral artery disease associated with DFUs has become increasingly difficult, and care delivery is often episodic and fragmented. Although structured, process-specific approaches exist at individual institutions for the management of DFUs in the cardiovascular patient population, there is insufficient awareness of these principles in the general medicine communities. Furthermore, there is growing interest in better understanding the mechanistic underpinnings of DFUs to better define personalized medicine to improve outcomes. The goals of this scientific statement are to provide salient background information on the complex pathogenesis and current management of DFUs in cardiovascular patients, to guide therapeutic and preventive strategies and future research directions, and to inform public policy makers on health disparities and other barriers to improving and advancing care in this expanding patient population.

Efficacy and safety of iliofemoral bypass using arm veins as an alternative conduit for chronic limb-threatening ischemia

OBJECTIVE

The use of basilic vein in iliofemoral revascularizations was previously described in the literature as an autologous option for the treatment of vascular prosthesis infection and as a primary conduit in patients at high risk of infectious surgical complications. However, the publications available include several different indications and are limited to case reports. Therefore, the aim of this study was to evaluate the outcomes of the use of arm veins as a safe and effective autologous alternative for iliofemoral reconstruction in patients with chronic limb-threatening ischemia (CLTI) and at high risk of prosthesis infection.

METHODS

We performed a multicenter, retrospective cohort study with 53 consecutive iliofemoral bypasses using arm veins as an alternative conduit. The procedures were performed between November 2013 and November 2021, exclusively for patients with CLTI classified as TASC aortoiliac C or D with increased risk of postoperative surgical infection. Demographic, clinical variables, and outcomes were collected from a prospective database. Main endpoints were amputation-free survival (AFS) and major adverse cardiovascular events. Secondary endpoints included primary and secondary patencies and overall survival. Cox regression analysis was used to identify the predictors of AFS. Postoperative surgical complications and 30-day mortality were also assessed.

RESULTS

The mean age was 64.2 ± 8.4 years, with a predominance of male gender. The median follow-up period was 615 days. All patients had CLTI, with a predominance of tissue loss (n = 51; 96.2%) and a median ankle-brachial index of 0.28. The basilic vein was utilized in most procedures (69.8%). Thirty-day major adverse cardiovascular events occurred in five cases (9.4%), and the 30-day mortality rate was 3.8%. The AFS, primary patency, secondary patency, and overall survival in 720 days were 71%, 72%, 89%, and 75%, respectively. Cox regression analysis revealed no association between the variables analyzed for AFS. There was no graft late infection nor pseudoaneurysmal degeneration.

CONCLUSIONS

Iliofemoral bypass using arm veins as an autologous conduit proved to be an effective and safe procedure with low incidence of postoperative cardiovascular complications and high rates of AFS in patients with CLTI. Also, this suggests that arm veins can be an interesting and suitable autologous alternative conduit for iliofemoral reconstructions, especially in cases in which a prosthesis should be avoided or when it is not available.

Eversion Endarterectomy - an alternative approach to occlusive External Iliac Artery disease

OBJECTIVES

While endovascular intervention is the recommended first option for management of common iliac artery (CIA) lesions, it lacks durable patency for Trans-Atlantic Inter-Society Consensus (TASC)-II C and D lesions involving the external iliac artery (EIA). Aorto-femoral bypass is a durable option but is unsuitable in patients with significant co-morbidities. Eversion endarterectomy provides an alternative to both endovascular and extensive open aortoiliac reconstruction for occlusive EIA disease.

MATERIALS & METHODS

A single-centre, retrospective review (2000-2020) of all patients undergoing eversion endarterectomy for EIA disease was undertaken. Demographic, clinical, operative and follow-up data were recorded.

RESULTS

Fifty eversion endarterectomies were performed in 47 patients. The median age was 65.0 years (46-82) and 66.6% were male. Sixty-eight percent (n=34) were ASA grade 3. Indications for intervention were disabling claudication (44%) and critical limb ischaemia (56%). Angiography demonstrated 22 TASC C and 28 TASC D lesions. The median follow-up was 18.5 months (range 0-149 months). The technical success rate was 100% and 84% (n=42) experienced an immediate symptomatic improvement. Primary and primary-assisted patency at one, three and five years was 86%, 82% and 74%, and 100%, 96% and 92%, respectively. The five-year limb salvage rate was 96%. Eight limbs required reintervention to maintain patency, either by open (n=2), endovascular (n=3) or hybrid approach (n=3). Thirty-day mortality was 2% (n=1) with 10% (n=5) experiencing a procedure-related morbidity. All-cause mortality was 38% (n=19) during the follow-up period.

CONCLUSION

Eversion endarterectomy is a safe, effective alternative treatment for occlusive EIA disease. This study reports durable patency at five years and low perioperative morbidity and mortality.

Advances in Revascularization for Peripheral Artery Disease: Revascularization in PAD

Effective revascularization of the patient with peripheral artery disease is about more than the procedure. The approach to the patient with symptom-limiting intermittent claudication or limb-threatening ischemia begins with understanding the population at risk and variation in clinical presentation. The urgency of revascularization varies significantly by presentation; from patients with intermittent claudication who should undergo structured exercise rehabilitation before revascularization (if needed) to those with acute limb ischemia, a medical emergency, who require revascularization within hours. Recent years have seen the rapid development of new tools including wires, catheters, drug-eluting technology, specialized balloons, and biomimetic stents. Open surgical bypass remains an important option for those with advanced disease. The strategy and techniques employed vary by clinical presentation, lesion location, and lesion severity. There is limited level 1 evidence to guide practice, but factors that determine technical success and anatomic durability are largely understood and incorporated into decision-making. Following revascularization, medical therapy to reduce adverse limb outcomes and a surveillance plan should be put in place. There are many hurdles to overcome to improve the efficacy of lower extremity revascularization, such as restenosis, calcification, microvascular disease, silent embolization, and tools for perfusion assessment. This review highlights the current state of revascularization in peripheral artery disease with an eye toward technologies at the cusp, which may significantly impact current practice.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Long-Term Results of Crossover Bypass for Iliac Atherosclerotic Lesions in the Era of Endovascular Treatment: The Re-ACTION Study (Retrospective Assessment of Crossover Bypass as a Treatment for Iliac LesiONs)

Objective: The aim of this study was to elucidate the long-term results of crossover bypass (CB) for iliac atherosclerotic lesions in the era of endovascular treatment (EVT).

Methods: A retrospective multicenter cohort study was performed. CB was performed in 242 patients between 2003 and 2014 by vascular surgeons at multiple medical centers in Japan.

Results: Perioperative mortality was 1.7%. Primary patency rates were 86% at 5 years and 82% at 8 years. Univariate analysis showed that critical limb ischemia (Rutherford class 4–6), vein graft, and superficial femoral artery occlusion were significantly associated with low primary patency. In multivariate analysis, only critical limb ischemia influenced primary patency. The secondary patency rate was 87% at both 5 and 8 years. The limb salvage rate was 98% at both 5 and 8 years. The overall survival rates were 71% at 5 years and 49% at 8 years.

Conclusion: The long-term results of CB were good in our study, compared with previous reports. Our results suggest that CB remains an option for the arterial reconstruction in unilateral iliac occlusive disease after EVT failed.

[Effectiveness of biological prosthesis for femoro-femoral bypass in high risk patients]

AIM

To compare synthetic and biological prostheses for femoral bypass surgery.

MATERIAL AND METHODS

There were 40 patients with critical ischemia of lower extremities due to atherosclerotic lesion of aorto-iliac segment and severe comorbidities. They were divided into 2 groups by 20 patients. C-shaped femoro-femoral bypass with synthetic polytetrafluoroethylene and lavsan prostheses was performed in the first group and S-shaped bypass procedure with biological prosthesis from the internal thoracic arteries of the bull - in the second group.

RESULTS

Biological prosthesis is associated with reduced early postoperative morbidity by 10%, late graft thrombosis incidence by 20% and increased physical and psychological health by 7.1%.

CONCLUSION

S-shaped femoro-femoral bypass with a biological prosthesis from the internal thoracic arteries of the bull is pathogenetically substantiated and effective.

Long Term Outcomes of Femorofemoral Crossover Bypass Grafts

PURPOSE

Femorofemoral crossover bypass (FCB) is a good procedure for patients with unilateral iliac artery disease. There are many articles about the results of FCB, but most of them were limited to 5 years follow-up. The purpose of our study was to analysis the results of FCB with a 10-year follow-up period.

MATERIALS AND METHODS

Between January 1995 and December 2010, 133 patients were operated in Samsung Medical Center (median follow-up: 58.8 months). We retrospectively analysed patient characteristics, the preoperative treatment, the operative procedure, and material used.

RESULTS

The indications for FCB were claudication in 110 and critical limb ischemia in 23 patients. Three patients were died due to myocardiac infarction, intracranial hemorrhage, and acute respiratory failure within 30 days after surgery. The one-year primary and secondary patency rates were 89% and 97%, the 5-year primary and secondary patency rates were 70% and 85%, and the 10-year primary and secondary patency rates were 31% and 67%. The 5-year and 10-year limb salvage rates were 97% and 95%, respectively.

CONCLUSION

Our long term analysis suggests that FCB might be a valuable alternative treatment modality in patients with unilateral iliac artery disease.

Reparo de aneurisma de artéria ilíaca roto em criança

Relatamos o caso de uma menina de 12 anos que deu entrada na unidade de emergência com quadro de abdome agudo hemorrágico, massa abdominal pulsátil e instabilidade hemodinâmica. Confirmado o diagnóstico de aneurisma roto de artéria ilíaca direita, foi realizada correção cirúrgica de emergência por reparo aberto com reconstrução extra-anatômica, utilizando enxerto sintético de fino calibre, compatível com a anatomia. O tratamento foi bem-sucedido e a criança apresentou evolução favorável em curto prazo.

Surgical Intervention for Peripheral Arterial Disease

The prevalence of peripheral arterial disease (PAD) is increasing worldwide, with recent global estimates exceeding 200 million people. Advanced PAD leads to a decline in ambulatory function and diminished quality of life. In its most severe form, critical limb ischemia, rest pain, and tissue necrosis are associated with high rates of limb loss, morbidity, and mortality. Revascularization of the limb plays a central role in the management of symptomatic PAD. Concomitant with advances in the pathogenesis, genetics, and medical management of PAD during the last 20 years, there has been an ongoing evolution of revascularization options. The increasing application of endovascular techniques has resulted in dramatic changes in practice patterns and has refocused the question of which patients should be offered surgical revascularization. Nonetheless, surgical therapy remains a cornerstone of management for advanced PAD, providing versatile and durable solutions to challenging patterns of disease. Although there is little high-quality comparative effectiveness data to guide patient selection, existing evidence suggests that outcomes are dependent on definable patient factors such as distribution of disease, status of the limb, comorbid conditions, and conduit availability. As it stands, surgical revascularization remains the standard against which emerging percutaneous techniques are compared. This review summarizes the principles of surgical revascularization, patient selection, and expected outcomes, while highlighting areas in need of further research and technological advancement.

Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication

Peripheral arterial disease (PAD) continues to grow in global prevalence and consumes an increasing amount of resources in the United States health care system. Overall rates of intervention for PAD have been rising steadily in recent years. Changing demographics, evolution of technologies, and an expanding database of outcomes studies are primary forces influencing clinical decision making in PAD. The management of PAD is multidisciplinary, involving primary care physicians and vascular specialists with varying expertise in diagnostic and treatment modalities. PAD represents a broad spectrum of disease from asymptomatic through severe limb ischemia. The Society for Vascular Surgery Lower Extremity Practice Guidelines committee reviewed the evidence supporting clinical care in the treatment of asymptomatic PAD and intermittent claudication (IC). The committee made specific practice recommendations using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system. There are limited Level I data available for many of the critical questions in the field, demonstrating the urgent need for comparative effectiveness research in PAD. Emphasis is placed on risk factor modification, medical therapies, and broader use of exercise programs to improve cardiovascular health and functional performance. Screening for PAD appears of unproven benefit at present. Revascularization for IC is an appropriate therapy for selected patients with disabling symptoms, after a careful risk-benefit analysis. Treatment should be individualized based on comorbid conditions, degree of functional impairment, and anatomic factors. Invasive treatments for IC should provide predictable functional improvements with reasonable durability. A minimum threshold of a >50% likelihood of sustained efficacy for at least 2 years is suggested as a benchmark. Anatomic patency (freedom from restenosis) is considered a prerequisite for sustained efficacy of revascularization in IC. Endovascular approaches are favored for most candidates with aortoiliac disease and for selected patients with femoropopliteal disease in whom anatomic durability is expected to meet this minimum threshold. Conversely, caution is warranted in the use of interventions for IC in anatomic settings where durability is limited (extensive calcification, small-caliber arteries, diffuse infrainguinal disease, poor runoff). Surgical bypass may be a preferred strategy in good-risk patients with these disease patterns or in those with prior endovascular failures. Common femoral artery disease should be treated surgically, and saphenous vein is the preferred conduit for infrainguinal bypass grafting. Patients who undergo invasive treatments for IC should be monitored regularly in a surveillance program to record subjective improvements, assess risk factors, optimize compliance with cardioprotective medications, and monitor hemodynamic and patency status.

Clinical Outcomes of SMART Versus Luminexx Nitinol Stent Implantation for Aortoiliac Artery Disease: A Propensity Score-Matched Multicenter Study

BACKGROUND

Endovascular therapy for aortoiliac (AI) lesions using stents is widely accepted. However, the long-term outcome of 2 different types of nitinol stents for AI lesions is unknown. The aim of this study was to examine the long-term outcome of the SMART and Luminexx nitinol stents for the treatment of de novo AI lesions.

METHODS

This study was a multicenter retrospective analysis of a prospectively maintained database. The study enrolled consecutive patients undergoing primary stenting for de novo AI artery stenosis between January 2005 and December 2009. A total of 1503 lesions in 1229 patients treated with SMART or Luminexx primary stenting were enrolled. The primary end point was primary patency, secondary end points were the primary assisted patency, secondary patency, and major adverse limb events (MALEs), which included major amputation and major reintervention. To minimize the differences between the groups, a propensity score matching analysis was performed, and 284 lesions per group were analyzed to identify outcomes.

RESULTS

After the propensity score matching analysis, the lesion length was 60 ± 37 and 57 ± 31 mm (P = .275), and the reference vessel diameter was 8.2 ± 1.5 and 8.3 ± 1.5 mm (P = .482) in the SMART and Luminexx groups, respectively. The primary patency at 3 years was not significantly different between the groups (83.5% vs 82.2%, P = .842, respectively). The assisted primary patency and secondary patency rates were also not significantly different (91.7% vs 93.2%, P = .340, 99.2% vs 98.8%, P = .922). In addition, the MALE rate was not significantly different between the groups (98.3% vs 97.3%, P = .821).

CONCLUSION

The current data suggest that the use of nitinol stents for the AI artery provided good long-term patency and freedom from MALE for 3 years of follow-up, regardless of whether SMART or Luminexx stents were used.

[Occlusion of the aorta and iliac arteries]

Occlusion of the aorta and the iliac arteries leads to an insufficient perfusion of the legs and the genital and gluteal region. The occurring symptoms may be variable, mainly depending on the collateralization network of the internal iliac artery (IIA) circulation. Various differential diagnoses need to be excluded. Invasive therapy is almost always inevitable if an aortoiliac stenosis is established. With good patency rates and low mortality rates the indications for reconstructive procedures are liberally interpreted; therefore, invasive therapy can be performed in the early stages of claudication in certain situations. Due to lower invasiveness and therefore lower risk of complications while showing comparable long-term patency rates, endovascular treatment is the preferred first line therapy for the majority of occlusions. Because aortoiliac occlusion processes also affect patients who are actively involved in a professional career, the indications for invasive therapy can be attained even in Fontaine stage IIa.

Secondary modification into aortouniiliac configuration to salvage failed endovascular aneurysm repair is safe and effective but not associated with higher intervention rates during long-term follow-up

BACKGROUND

Reports of secondary modifications into aortouniiliac configuration to salvage-failed endovascular aneurysm repair (EVAR) are limited. We evaluated long-term results after these procedures and compared them with those after primary aortouniiliac endografting (AUE).

METHODS

A retrospective review of all EVAR performed from March 1995 until July 2011 was conducted. Patients were included when primary AUE (group I) or modification into aortouniiliac configuration (group II) was done.

RESULTS

Data analysis obtained 27 group I and 23 group II patients. Salvage of failed EVAR could be achieved in 96% of group II patients, and mortality was zero. Frequency of adverse events and amount of interventions to maintain aneurysm exclusion were not increased after secondary AUE. Kaplan-Meier estimates for long-term survival between groups were comparable (P = .36).

CONCLUSIONS

Secondary AUE allows correction of graft-related endoleaks potentially leading to late aneurysm rupture. Complications and adverse events throughout long-term follow-up were not necessarily increased when compared with primary AUE.

Neointimal hyperplasia after stent placement across size-discrepant vessels in an animal study

PURPOSE

To examine differences in neointimal hyperplasia (NIH) after placing a self-expanding (SE) stent across size-discrepant vessels.

MATERIALS AND METHODS

The subjects were 6 beagles, and the target vessels were the abdominal aorta and the external iliac artery (EIA). A nitinol SE stent was placed which was normal-sized in the aorta and oversized in the EIA. Angiography and intravascular ultrasound (IVUS) were performed immediately and after 1 and 3 months; histopathologic examinations were then performed. Furthermore, the chronic outward force (COF) on the same type of stent was investigated in vitro.

RESULTS

On IVUS, thickened intima was seen on the EIA at 1 month (5.1 ± 4.2 mm(2)) and at 3 months (7.8 ± 2.5 mm(2)). For the aorta, thickening of the intima was negligible at any time. Histopathologically, the percentage of the vessel obliterated by NIH was significantly greater on the iliac side than on the aortic side (33.2 ± 10.4 vs. 13.4 ± 4.4 %). The COF exerted when stent diameter reached that of the EIA and the aorta was 0.73 and 0.17 N/mm(2), respectively.

CONCLUSIONS

When a non-tapered stent is placed in vessels with a large discrepancy in diameter, attention must be paid to increased NIH in the oversized side.

Gender-specific risk factors for peripheral artery disease in a voluntary screening population

Background

Women have high rates of peripheral artery disease (PAD) despite fewer cardiovascular disease (CVD) risk factors, compared to men. We sought to determine the gender‐specific prevalence of low ankle brachial index (ABI) and the relationship to C‐reactive protein (CRP) levels and CVD risk factors in the Life Line Screening population.

Methods and Results

Between April 2005 and August 2011, 133 750 women and 71 996 men had ABI and CRP measured at a Life Line Screening Center. Women were slightly older than men, whereas men were more likely to be current smokers, have diabetes mellitus (DM), and coronary artery disease (CAD) (P<0.001 for each). Women were more likely to have ABI≤1.0, compared to men (26.6% versus 14.4%, respectively; P<0.001), as well as ABI≤0.9 (4.1% women versus 2.6% men; P<0.001). Women had higher median CRP levels (1.94 mg/L; interquartile range [IQR], 0.89, 4.44 mg/L), compared to men (1.35 mg/L; IQR, 0.73, 2.80 mg/L; P<0.001). Men and women shared similar risk factors for ABI≤0.9, including older age, black race, smoking, DM, hypertension, hypercholesterolemia, CAD, and elevated CRP levels. In an adjusted model, there were significant interactions between gender and age (P<0.001), CRP (P<0.001), CAD (P=0.03), and DM (P=0.06) with ABI as the outcome. The associations between age, CRP, CAD, and DM with ABI≤0.9 were stronger in men than in women.

Conclusions

Women participating in the Life Line Screening had higher CRP levels and a higher prevalence of PAD, compared to men. Neither higher CRP levels nor conventional CVD risk factors explained the excess prevalence of PAD in women.

Current state of diagnosis and management of critical limb ischemia

Critical limb ischemia represents the most severe form of peripheral arterial disease and carries with it severe morbidity and mortality risks. Because of comorbidity risks, early diagnosis and aggressive medical management make up an important part of the treatment paradigm for these individuals. However, in addition to managing these comorbid conditions, the physician caring for these individuals must be able to provide revascularization options that will improve arterial flow to the threatened extremity and assure healing of complicated wounds. Both open surgical and endovascular therapies have proven beneficial in restoring flow to severely ischemic limbs in these patients. Additionally, combinations of the above therapeutic methods have offered more available options for these patients. This article reviews care of patients with critical limb ischemia with critical assessment of options for medical and revascularization options.

Single-incision external iliac artery endarterectomy and patch angioplasty

An isolated external iliac artery chronic total occlusion is currently treated either with subintimal percutaneous transluminal angioplasty and stent or with a bypass. This article describes a new application of an old technique, endarterectomy and patch angioplasty, performed on the external iliac artery through a single flank incision. This novel approach can provide lasting patency with a low risk of complications. We present four cases and a review of the literature on the other available treatment options. This minimally invasive technique may provide a viable alternative that can be used alone or in combination with other open or endovascular techniques and can be applied in cases of groin sepsis.

Femorofemoral bypass as an alternative to a direct aortic approach in daily practice: appraisal of its current indications and midterm results

BACKGROUND

To assess our current practice concerning the indications and the immediate and midterm results of femorofemoral bypass.

METHODS

We retrospectively included all patients, from 1997 to 2008, operated on for aortoiliac occlusive disease using an extra-anatomical bypass from a donor iliac artery or a femoral artery to the contralateral femoral artery (common or profunda artery). Demographic data, initial clinical status, characteristics of the interventions, and short- and midterm results were collected. Elective surgery was distinguished from urgent surgery (critical limb ischemia, acute ischemia, vascular infection).

RESULTS

One hundred twenty-four femorofemoral bypasses were performed (103 male), mean age 68 (±12) years. Indications were critical limb ischemia (47.1%), intermittent claudication (38.8%), acute ischemia (12.1%), and vascular infections (1.7%). Perioperative outcomes were 5.6% mortality (elective surgery 0.0%, urgent surgery 9.7%, P = 0.02) and 27.4% morbidity without any secondary graft infections (elective surgery 22.5%, urgent surgery 31.9%, P = 0.17). Mean follow-up period was 3 years, and overall survival was 69.4% (elective surgery 88.7%, urgent surgery 56.7%, P = 0.08). At 3 years, primary patency was 81.8% and secondary patency was 89.3% (elective surgery 96.4%, urgent surgery 84.2%, P = 0.68). No significant risk factors for immediate and secondary thromboses were found.

CONCLUSION

In our current practice, femorofemoral bypasses are applied mainly for urgent procedures when avoiding a direct aortic approach is mandatory, with good midterm results. Although indications are limited for good-fit patients, femorofemoral bypass has confirmed safety (no perioperative deaths, no infections) and high durability (good secondary patency).

Long-term Results of Reconstructive Surgery for the Unilateral Aortoiliac Occlusive Disease and Future Risks of Contralateral Iliac Events

OBJECTIVE

Our experience with unilateral iliac reconstructive surgery was retrospectively reviewed, and the long-term patency and the morphological information was disclosed. In addition, the prognosis of contralateral iliac artery was examined, because future contralateral iliac events seem to be important for durability of unilateral iliac revascularizations.

MATERIALS AND METHODS

148 patients (mean age, 66.9 years; 88% male) who had undergone unilateral aortoiliac reconstruction without contralateral iliac lesions were evaluated. The unilateral aortoiliac reconstructive procedures included 112 (76%) aorto or iliofemoral bypasses, 27 (18%) femorofemoral bypasses, and 9 (6%) axillofemoral bypasses. The indications for arterial reconstruction were disabling claudication and limb salvage in 125 (84%) and 23 (16%) patients, respectively. Preoperative arteriograms were reviewed to determine the Inter-Society Consensus (TASC II) classification categorizing iliac artery lesions. Contralateral iliac events were defined as any arterial reconstructive procedure, intervention, amputation for progression of contralateral iliac disease, or repair of abdominal aortic aneurysm (AAA). The Kaplan-Meier survival analysis was used to predict long-term results in patients grouped based on various factors which were compared using univariate and multivariate analyses.

RESULTS

In the 148 patients, unilateral iliac reconstructive procedures were undertaken in 83 (56%) patients with TASC II type D lesions, 34 (23%) patients with TASC II type C lesions, and 31 (21%) patients with TASC II type B lesions. Overall primary and secondary patency rates were 93.8% and 96.5% at 3 years and 90.0% and 93.9% at 5 years. A multivariate analysis disclosed critical limb ischemia influencing primary patency rates, and type of aortoiliac reconstruction or gender influencing secondary patency rates. TASC II classification did not affect primary or secondary patency rates. During the follow-up period, 15 contralateral iliac events occurred, including 11 aortoiliac reconstructive or interventional procedures, 3 repairs of AAA, and one case of bilateral thigh amputation due to acute aortic occlusion. The overall probability of contralateral iliac events was 2.2% at 3 years and 5.9% at 5 years.

CONCLUSION

The long-term patency following unilateral iliac reconstructive surgery was satisfactory, and not affected by morphology of the iliac artery. Also, the future risk of contralateral iliac events appeared to be low.