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Aridi HD, Sansone J, Ramchandani N, Gutwein AR, Rowe VL, Zheng X, Mao J, Goodney PP, Motaganahalli RL. Long-term outcomes of great saphenous vein harvest techniques for infrainguinal arterial bypass in a Medicare-matched registry database. J Vasc Surg 2024:S0741-5214(24)01215-1. [PMID: 38912996 DOI: 10.1016/j.jvs.2024.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 06/25/2024]
Abstract
OBJECTIVE Long-term outcomes for harvesting techniques for great saphenous vein (GSV) and its impact on the outcomes of infrainguinal arterial bypass remains largely unknown. Endoscopic GSV harvesting (EVH) has emerged as a less invasive alternative to conventional open techniques. Using the Vascular Quality initiative Vascular Implant Surveillance & Interventional Outcomes Network (VQI-VISION) database, we compared the long-term outcomes of infrainguinal arterial bypass using open and endoscopic GSV harvest techniques. METHODS Patients who underwent infrainguinal GSV bypass between 2010 and 2019 were identified in the VQI-VISION Medicare linked database. Long-term outcomes of major/minor amputations, and reinterventions up to 5 years of follow-up were compared between continuous incisions, skip incision, and EVH, with continuous incisions being the reference group. Secondary outcomes included 30- and 90-day readmission, in addition to surgical site infections and patency rates at 6 months to 2 years postoperatively. Survival analysis using Kaplan-Meier curves and Cox regression hazard models were utilized to compare outcomes between groups. To adjust for multiple comparisons between the study groups, a P value of 2.5% was considered significant. RESULTS Among the 8915 patients included in the study, continuous and skip vein harvest techniques were used in 44.4% and 43.4% of cases each, whereas 12.3% underwent EVH. The utilization of EVH remained relatively stable at around 12% throughout the study period. Compared with GSV harvest using continuous incisions, EVH was associated with higher rates of reintervention at 1 year (46.5% vs 41.3%; adjusted hazard ratio [aHR], 1.22; 95% confidence interval [CI], 1.06-1.41; P = .01]. However, no significant difference was observed between EVH and continuous incisions, and between skip and continuous incisions in terms of long-term reintervention or major and minor amputations on adjusted analysis. Compared with continuous incision vein harvest, both EVH and skip incisions were associated with lower surgical site infection rates within the first 6 months post-bypass (aHR, 0.53; 95% CI, 0.35-0.82 and aHR, 0.68; 95% CI, 0.53-0.87, respectively). Loss of primary, primary-assisted, and secondary patency was higher after EVH compared with continuous incision vein harvest. Among surgeons performing EVH, comparable long-term outcomes were observed regardless of low (<4 cases/year), medium (4-7 cases/year), or high procedural volumes (>7 cases/year). CONCLUSIONS Despite higher 1-year reintervention rates, EVH for infrainguinal arterial bypass is not associated with a significant difference in long-term reintervention or amputation rates compared with other harvesting techniques. These outcomes are not influenced by procedural volumes for EVH technique.
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Affiliation(s)
- Hanaa D Aridi
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Jack Sansone
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Neal Ramchandani
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Ashley R Gutwein
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Vincent L Rowe
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Xinyan Zheng
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Jialin Mao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN.
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Khorfan R, Vely A, Batool F, Jackson MW, Hance ML, Jones DJ, Napier JA, Heidenreich MJ, Aziz A. Ten-year experience of infrainguinal bypass with endoscopic vein harvest. Vascular 2024; 32:612-618. [PMID: 36446034 DOI: 10.1177/17085381221142213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVES There is conflicting data comparing minimally invasive vein harvest (MIVH) using endoscopic technique and open vein harvest (OVH) in terms of bypass patency, wound infection incidence, and patient morbidity. Our institution has performed MIVH since 2003 for peripheral bypass procedures with a consistent team of specialized endoscopic vein harvesters. This study reviewed the major outcomes of MIVH infrainguinal bypass at our institution given a predominant cohort of critical limb ischemia. METHODS We performed a 10-year, retrospective, single-institution review from January 2005 to December 2014, identifying all patients undergoing MIVH for obstructive infrainguinal disease. Primary outcomes were primary patency, operative time, intraoperative complications, surgical site infection (SSI), and freedom from amputation. RESULTS A total of 289 patients (70% male) underwent MIVH infrainguinal bypass at an average age of 68 ± 12 years old, an obesity prevalence of 28%, and with critical limb ischemia in 81% of the patient cohort (20% rest pain, 61% tissue loss/gangrene). Ninety-four percent of patients had no intraoperative complications, 2.5% had adverse cardiac or technical complications, and 4.2% of patients required transfusion. Average operative time was 4.2 h. Femoral-popliteal TASC classification C and D constituted 80% of our patient cohort. At the last follow-up, toe pressures had increased from 30 ± 30 to 62 ± 40 mmHg (p < 0.0001). Primary bypass patency in the first 30 days was 95%. SSI incidence requiring surgical treatment was only 6%. Our median length of stay was 4.0 days, with median intravenous narcotic use of 1 day. In addition, 77% of patients returned to their baseline mobility at first follow-up (median 19 days), and 83% of patients had freedom from amputation at last follow-up (median 820 days). CONCLUSIONS In a center with experience in MIVH and a consistent group of experienced endoscopic vein harvesters, MIVH bypass has excellent patency, low surgical site infection, short length of stay, and prompt return to baseline mobility.
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Affiliation(s)
- Rhami Khorfan
- Department of Surgery, Saint Joseph Mercy Ann Arbor, Ypsilanti, MI, USA
| | - Aela Vely
- Department of Surgery, Saint Joseph Mercy Ann Arbor, Ypsilanti, MI, USA
| | - Farwa Batool
- Department of Surgery, Saint Joseph Mercy Ann Arbor, Ypsilanti, MI, USA
| | - Miles W Jackson
- Department of Surgery, Saint Joseph Mercy Ann Arbor, Ypsilanti, MI, USA
| | - M LaWaun Hance
- Section of Cardiac and Thoracic Surgery, Department of Surgery, Trinity Health Saint Joseph Mercy Ann Arbor, Ypsilanti, MI, USA
| | - Diane J Jones
- Section of Cardiac and Thoracic Surgery, Department of Surgery, Trinity Health Saint Joseph Mercy Ann Arbor, Ypsilanti, MI, USA
| | - Jarred A Napier
- Department of Surgery, Saint Joseph Mercy Ann Arbor, Ypsilanti, MI, USA
| | - Michael J Heidenreich
- Section of Vascular Surgery, Department of Surgery, Trinity Health Saint Joseph Mercy Ann Arbor, Ypsilanti, MI, USA
| | - Abdulhameed Aziz
- Section of Vascular Surgery, Department of Surgery, Trinity Health Saint Joseph Mercy Ann Arbor, Ypsilanti, MI, USA
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Cifuentes S, Sen I, Shuja F, Mendes BC, Colglazier JJ, Schaller MS, Kalra M, Morrison JJ, DeMartino RR, Rasmussen TE. Outcomes of lower extremity arterial bypass using the Human Acellular Vessel in patients with chronic limb-threatening ischemia. J Vasc Surg 2024; 79:348-357.e2. [PMID: 37890643 DOI: 10.1016/j.jvs.2023.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/13/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023]
Abstract
OBJECTIVE Patients with chronic limb-threatening ischemia (CLTI) and no great saphenous vein to use as a conduit for arterial bypass have a high risk for amputation despite advances in medical and endovascular therapies. This report presents findings from a U.S. Food and Drug Administration (FDA) supported study of the Human Acellular Vessel (HAV) (Humacyte Inc.) used as a conduit for arterial bypass in patients with CLTI and inadequate or absent autologous conduit. METHODS The HAV is a 6-mm, 40-cm vessel created from human vascular smooth muscle cells seeded onto a polyglycolic acid scaffold pulsed in a bioreactor for 8 weeks as cells proliferate and the scaffold dissolves. The resultant vessel is decellularized, creating a nonimmunogenic conduit composed of collagen, elastin, and extracellular matrix. The FDA issued an Investigational New Drug for an intermediate-sized, single-center study of the HAV under the agency's Expanded Access Program in patients with advanced CLTI and inadequate or absent autologous conduit. Technical results and clinical outcomes were analyzed and reported. RESULTS Between March 2021 and July 2023, 29 patients (20 males; mean age, 71 ± 11 years) underwent limb salvage operation using the HAV as a bypass conduit. Most patients had advanced CLTI (Rutherford class 5/6 in 72%; wound, ischemia, and foot infection stage 3/4 in 83%), and 97% had previously failed revascularization(s) of the extremity. Two HAVs were sewn together to attain the needed bypass length in 24 patients (83%). Bypasses were to tibial arteries in 23 patients (79%) and to the popliteal artery in 6 (21%). Technical success was 100%, and the 30-day mortality rate was 7% (2 patients). With 100% follow-up (median, 9.3 months), the limb salvage rate was 86% (25/29 patients). There were 16 reinterventions to restore secondary patency, of which 15 (94%) were successful. Primary and secondary patency of the HAV at 9 months were 59% and 71%, respectively. CONCLUSIONS The HAV has demonstrated short- to intermediate-term safety and efficacy as an arterial bypass conduit in a complex cohort of patients with limb-threatening ischemia and no autologous options. This experience using the FDA's Expanded Access Program provides real-world data to inform regulatory deliberations and future trials of the HAV, including the study of the vessel as a first-line bypass conduit in less severe cases of chronic limb ischemia.
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Affiliation(s)
| | - Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Melinda S Schaller
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Todd E Rasmussen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
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Miralles M, Falcón M, Requejo L, Plana E, Medina P, Sánchez-Nevárez I, Clará A. "In Vitro" Evaluation of Energy-Based Sealing of Graft Side Branches in Bypass Surgery. World J Surg 2023; 47:2888-2896. [PMID: 37432421 DOI: 10.1007/s00268-023-07107-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Our objective was to compare the in vitro efficacy of electrothermal bipolar [EB] vessel sealing and ultrasonic harmonic scalpel [HS] versus mechanical interruption, with conventional ties or surgical clips (SC), in sealing saphenous vein (SV) collaterals, during its eventual preparation for bypass surgery. METHODS Experimental in vitro study on 30 segments of SV. Each fragment included two collaterals at least 2 mm in diameter. One of them was sealed by ligation with 3/0 silk ties (control) and the other one with EB (n = 10), HS (n = 10) or medium-6 mm SC (n = 10). After incorporation in a closed circuit with pulsatile flow, the pressure was progressively increased until causing rupture. Collateral diameter, burst pressure, leak point, and histological study were recorded. RESULTS Burst pressure was higher for SC (1320.20 ± 373.847 mmHg) as compared with EB (942.2 ± 344.9 mmHg, p = 0.065), and especially with HS (637.00 ± 320.61 mmHg, p = 0.0001). No statistically significant difference between EB and HS was found, and bursting always happened at supraphysiological pressures. The leak point for HS was always detected in the sealing zone (10/10), while for EB and SC, it occurred in the sealing zone only in 6/10(60%) and 4/10(40%), respectively (p = 0.015). CONCLUSIONS Energy delivery devices showed similar efficacy and safety in sealing of SV side branches. Although bursting pressure was lower than with tie ligature or SC, non-inferiority efficacy was shown at the range of physiological pressures in both, EB and HS. Due to their speed and easy handling, they may be useful in the preparation of the venous graft during revascularization surgery. However, remaining questions about healing process, potential spread of tissue damage and sealing durability, will require further analysis.
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Affiliation(s)
- Manuel Miralles
- Department of Vascular Surgery, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Department of Surgery, Facultad de Medicina, Universidad de Valencia (UV), Valencia, Spain
- Hemostasia, Thrombosis, Arteriosclerosis and Vascular Biology, Instituto de Investigación Sanitaria IIS La Fe, Valencia, Spain
| | - Moisés Falcón
- Department of Vascular Surgery, Hospital de Manises, Valencia, Spain.
| | - Lucía Requejo
- Department of Vascular Surgery, Hospital Universitario de La Ribera, Alzira, Valencia, Spain
| | - Emma Plana
- Hemostasia, Thrombosis, Arteriosclerosis and Vascular Biology, Instituto de Investigación Sanitaria IIS La Fe, Valencia, Spain
| | - Pilar Medina
- Hemostasia, Thrombosis, Arteriosclerosis and Vascular Biology, Instituto de Investigación Sanitaria IIS La Fe, Valencia, Spain
| | | | - Albert Clará
- Department of Vascular Surgery, Hospital Universitari del Mar, Barcelona, Spain
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Akingba AG, Chow WB, Rowe VL. Lower Extremity Bypass. Surg Clin North Am 2023; 103:767-778. [PMID: 37455036 DOI: 10.1016/j.suc.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
The original description of the lower extremity bypass (LEB) provided surgeons with a reliable method of limb revascularization. The tenets of the operation have formed the foundation for the advances of surgical care. A careful evaluation of the chronic limb-threatening ischemia patient due to the numerous comorbid conditions is paramount to obtain the best possible outcomes. Use of all adjuncts including judicious target vessels control, completion imaging, and vein harvesting techniques to ensure optimal outcomes because a functioning LEB remains a key to successful limb salvage.
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Affiliation(s)
- Ajibola George Akingba
- DC VAMC, Uniformed Services University of Health Sciences, 50 Irving Street, Washington, DC 20422, USA
| | - Warren Bryan Chow
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine at UCLA, 200 Peter Morton Medical Building, Suite 526, Los Angeles, CA 90095, USA
| | - Vincent Lopez Rowe
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine at UCLA, 200 Peter Morton Medical Building, Suite 526, Los Angeles, CA 90095, USA.
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McGinigle KL, Spangler EL, Ayyash K, Arya S, Settembrini AM, Thomas MM, Dell KE, Swiderski IJ, Davies MG, Setacci C, Urman RD, Howell SJ, Garg J, Ljungvist O, de Boer HD. A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. J Vasc Surg 2023; 77:1295-1315. [PMID: 36931611 DOI: 10.1016/j.jvs.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 03/17/2023]
Abstract
The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily L Spangler
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Katie Ayyash
- Department of Perioperative Medicine (Merit), York and Scarborough Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | | | - Merin M Thomas
- Lenox Hill Hospital, Northwell Health, New Hyde Park, NY
| | | | | | - Mark G Davies
- Department of Surgery, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Sciences Center, San Antonio, TX
| | - Carlo Setacci
- Department of Surgery Surgery, University of Siena, Siena, Italy
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Joy Garg
- Department of Vascular Surgery, Kaiser Permanente San Leandro, San Leandro, CA
| | - Olle Ljungvist
- Department of Surgery, Orebro University, Orebro, Sweden
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine, and Procedure Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
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Biroš E, Staffa R, Novotný T, Krejčí M, Velecký L, Skotáková M. Long-Term Comparison of Endoscopic Versus Open Saphenous Vein Harvest for Femoral-to-Popliteal Artery Bypass. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03745-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
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Rijkenhuizen ABM, Nohl G, Jaek‐Lutz F, Sill V. Thrombosis of the median artery and its branches in a gelding: Clinical appearance, diagnosis and surgical management. EQUINE VET EDUC 2021. [DOI: 10.1111/eve.13545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - G. Nohl
- Equine Clinic Bargteheide Bargteheide Germany
| | | | - V. Sill
- Equine Clinic Bargteheide Bargteheide Germany
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Guo Q, Huang B, Zhao J. Systematic review and meta-analysis of saphenous vein harvesting and grafting for lower extremity arterial bypass. J Vasc Surg 2020; 73:1075-1086.e4. [PMID: 33091517 DOI: 10.1016/j.jvs.2020.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/10/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE In the present systematic review and meta-analysis, we compared the short- and long-term outcomes of different harvesting and grafting techniques in patients undergoing lower extremity arterial bypass. METHODS We searched multiple electronic databases (up to December 1, 2019) for comparative trials investigating different harvesting and bypass grafting techniques. RESULTS We identified a total of 37 studies for our review. Skip incision harvesting showed a similar high primary patency rate (Peto odds ratio [OR], 0.93; 95% confidence interval [CI], 0.83-1.04; P = .20) with continuous incision harvesting and comparable low wound complication rates (relative risk, 1.55; 95% CI, 0.91-2.66; P = .11) with endoscopic harvesting. In situ bypass grafting a long-term patency similar to that of reversed grafting (Peto OR, 1.01; 95% CI, 0.75-1.37; P = .93). However, for femoropopliteal bypass, the reversed bypass grafting group had significantly lower 2-year (Peto OR, 0.63; 95% CI, 0.52-0.78; P < .001) and 5-year (Peto OR, 0.70; 95% CI, 0.50-0.98; P = .04) failure rates compared with the in situ bypass grafting group. For infrapopliteal bypass, the in situ bypass grafting group had significantly lower 1-year (Peto OR, 1.54; 95% CI, 1.04-2.28; P = .03), 2-year (Peto OR, 1.52; 95% CI, 1.15-2.02; P = .003), and 3-year (Peto OR, 2.14; 95% CI, 1.13-4.05; P = .02) failure rates. CONCLUSIONS Skip incision harvesting can be considered the first-line harvesting strategy. For patients undergoing femoropopliteal bypass, reversed bypass grafting seems to result in better long-term patency. In contrast, for those undergoing infrapopliteal bypass, in situ bypass grafting resulted in superior long-term patency.
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Affiliation(s)
- Qiang Guo
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China.
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Gutowski P, Gage SM, Guziewicz M, Ilzecki M, Kazimierczak A, Kirkton RD, Niklason LE, Pilgrim A, Prichard HL, Przywara S, Samad R, Tente B, Turek J, Witkiewicz W, Zapotoczny N, Zubilewicz T, Lawson JH. Arterial reconstruction with human bioengineered acellular blood vessels in patients with peripheral arterial disease. J Vasc Surg 2020; 72:1247-1258. [DOI: 10.1016/j.jvs.2019.11.056] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/23/2019] [Indexed: 11/30/2022]
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11
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Janssen ERI, van Silfhout L. Duplex Ultrasound May Predict the Best Level of Lower Limb Amputation in Patients with Chronic Limb-Threatening Ischemia: A Retrospective Observational Cohort Study. Ann Vasc Surg 2020; 67:403-410. [PMID: 32205236 DOI: 10.1016/j.avsg.2020.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Despite improved revascularization options, many patients with chronic limb-threatening ischemia (CLI) require lower limb amputation. Duplex ultrasound (DUS) is recommended as first-choice imaging technique in CLI. However, the prognostic utility of DUS for planning lower limb amputations has never been described before. This study aims to evaluate if DUS and findings from physical examination could be used to help predict the best level of lower limb amputation in patients with CLI. METHODS A retrospective cohort of 124 patients with CLI and a lower limb amputation was analyzed. Outcome measurements were reoperation, revision, and conversion rates, which were related to findings from physical examination and DUS examinations. RESULTS Thirty-nine reoperations were performed, of which 17 stump revisions and 22 conversions were from below- to above-knee amputation. There was a discrepancy in findings of physical examination and DUS of 25% and 64% of femoral and popliteal pulsations respectively. Conversion rates increased with a more proximal occlusion on DUS. All patients with a vascular occlusion in the aortoiliac trajectory or deep femoral artery required a higher amputation level. CONCLUSIONS Physical examination seems to be unreliable, and therefore should not be used to assess the optimal level of lower extremity amputation. Performing a primary above-knee amputation in patients with vascular occlusion in the aortoiliac trajectory or deep femoral artery could significantly reduce reoperation rates.
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Affiliation(s)
- Emmy R I Janssen
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Lysanne van Silfhout
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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12
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Kronick M, Liem TK, Jung E, Abraham CZ, Moneta GL, Landry GJ. Experienced operators achieve superior patency and wound complication rates with endoscopic great saphenous vein harvest compared with open harvest in lower extremity bypasses. J Vasc Surg 2019; 70:1534-1542. [DOI: 10.1016/j.jvs.2019.02.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 02/19/2019] [Indexed: 10/26/2022]
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13
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Nikulainen V, Helmiö P, Hurme S, Hakovirta H. Vein Harvest Wound Healing after Bypass Surgery for Critical Limb Ischemia. Ann Vasc Surg 2019; 62:375-381. [PMID: 31445090 DOI: 10.1016/j.avsg.2019.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Lower-limb revascularization surgery, especially when performed using the great saphenous vein, predisposes patients to major surgical trauma on initially ischemic tissue. Vein harvest wounds (VHWs) after infrainguinal revascularization heal slowly. This study's aim was to assess the factors associated with VHW healing after infrainquinal bypass surgery for critical limb ischemia (CLI). METHODS A retrospective patient record study was conducted. All patients with CLI who underwent infrainguinal bypass surgery with autologous vein graft between January 1, 2015, and December 31, 2017, in the Turku University Hospital, were included. Follow-up data were collected until February 28, 2018. The following data was collected from the patient files; risk factors, ankle-brachial indices (ABIs), systolic toe pressures (STPs), the presence of an ischemic ulcer, VHW dehiscence, and the time when the VHW was completely healed. Procedures with outflow vessels at either popliteal or tibial artery were analyzed separately. Descriptive and univariate statistical analyses were performed. RESULTS Altogether, 195 patients were operated on for CLI, of whom 133 (68.2%) patients had ischemic ulcers. The mean follow-up time was 535.0 days (range 3.0-1143.0 days). The mean ABI improvement was 0.49 (P = 0.00), and STP improvement, 39.9 mm Hg (P = 0.00). The median time taken when VHW was healed was 48.0 days (95% confidence interval [CI], 39.4-56.6) in patients without ischemic ulcers and 82.0 days (95% CI, 59.7-104.3) in patients with ischemic ulcers, P = 0.03. VHW in patients who underwent popliteal artery bypass (62 days, 95% CI, 12.9-93.0) healed faster than VHW in those who underwent tibial artery bypass (132 days, 95% CI, 48.0-93.0), P = 0.02. Risk factors and the preoperative or postoperative ABIs or STPs had no effect on VHW healing time. CONCLUSIONS VHW healing was remarkably slower after revascularization surgery in patients with an ischemic foot ulcer than in those without ischemic ulcers.
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Affiliation(s)
- Veikko Nikulainen
- Department of Vascular Surgery, Turku University Hospital, Turku, Finland; University of Turku, Turku, Finland.
| | - Päivi Helmiö
- Department of Vascular Surgery, Turku University Hospital, Turku, Finland; University of Turku, Turku, Finland
| | | | - Harri Hakovirta
- Department of Vascular Surgery, Turku University Hospital, Turku, Finland; University of Turku, Turku, Finland
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14
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Mirza AK, Stauffer K, Fleming MD, De Martino R, Oderich G, Kalra M, Gloviczki P, Bower T. Endoscopic versus open great saphenous vein harvesting for femoral to popliteal artery bypass. J Vasc Surg 2018; 67:1199-1206. [DOI: 10.1016/j.jvs.2017.08.084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 08/25/2017] [Indexed: 10/18/2022]
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Endoscopic vein harvest does not negatively affect patency of great saphenous vein lower extremity bypass. J Vasc Surg 2016; 63:1546-54. [DOI: 10.1016/j.jvs.2016.01.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 01/08/2016] [Indexed: 11/23/2022]
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Vein harvesting technique for infrainguinal arterial bypass with great saphenous vein and its association with surgical site infection and graft patency. J Vasc Surg 2015; 61:1264-71.e2. [PMID: 25659457 DOI: 10.1016/j.jvs.2014.12.049] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/17/2014] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the association of vein harvesting technique (VHT) with surgical site infection (SSI) and graft patency after infrainguinal arterial bypass. METHODS The Vascular Quality Initiative database was used to review VHT of all patients undergoing single-segment great saphenous vein graft infrainguinal arterial bypass from 2003 to 2013. Patients were divided into three groups according to the VHT used (continuous incision, skip incision, and endoscopic). Multinomial logistic regression was performed to estimate propensity scores for each treatment group. Propensity score adjustment was included in multivariable analysis of the primary outcomes: SSI and graft primary patency. RESULTS From 2003 to 2013, 5066 patients underwent single-segment great saphenous vein graft infrainguinal bypass. The VHT was continuous incision in 48.6%, skip incision in 39.7%, and endoscopic in 12.7%. SSI rates did not differ significantly among the groups (continuous, 4.7%; skip, 4.0%; endoscopic, 3.4%; P = .278). On multivariable analysis, there was no difference in discharge primary patency between the three groups. At 1 year, primary patency rates were 69.5% for continuous, 73.0% for skip, and 58.6% for endoscopic (P < .001). After multivariable analysis, endoscopic vein harvest was independently associated with higher 1-year primary patency loss compared with both continuous (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.05-1.74; P = .020) and skip (HR, 1.53; 95% CI, 1.18-2.00; P = .002). There was no significant difference in 1-year primary patency loss between continuous and skip techniques (HR, 0.88; 95% CI, 0.73-1.05; P = .170). CONCLUSIONS No association between the choice of VHT and the development of SSI after infrainguinal arterial bypass was identified in the Vascular Quality Initiative population. Endoscopic VHT was associated with significantly reduced 1-year primary patency rate compared with both continuous and skip techniques.
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Endoscopic Vein Harvesting in Lower Extremity Arterial Bypass: A Systematic Review. Eur J Vasc Endovasc Surg 2014; 47:621-39. [DOI: 10.1016/j.ejvs.2014.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 02/11/2014] [Indexed: 11/19/2022]
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