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Preece R, Mann L, Kulkarni SR, Paravastu SC. Influence of crural vessel run-off on short- and mid-term outcomes following femoro-popliteal bypass grafting. Vascular 2024; 32:626-631. [PMID: 36649215 DOI: 10.1177/17085381231153221] [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] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To determine the influence that the number of patent crural run-off vessels has on short- and mid-term outcomes following femoro-popliteal bypass. METHODS All patients undergoing index femoro-popliteal bypass grafting between 2013 and 19 at our unit were included. Preoperative imaging was used to stratify patients into cohorts with either one or ≥2 patent run-off vessels. Primary outcomes measures included bypass patency and limb salvage rates at one and 3 years post-operatively. Survival analysis was performed using Kaplan-Meier curves and Logrank test. RESULTS 147 bypasses performed on 143 patients were included. 24 patients had one-vessel run-off and 123 had ≥2 vessels patent. Patients with one-vessel run-off had a higher proportion of emergency admissions (54% vs 41%) and diabetes (42% vs 31%). 31% of patients underwent diagnostic angiogram imaging in addition to having duplex ultrasound and/or computed tomography angiography. There were no significant differences in primary, primary-assisted or secondary patency rates between the cohorts at 12 or 36 months. Limb salvage rates were significantly higher amongst those with ≥2 vessel run-off at 12 (86% vs 71%, p = 0.03) and 36 (85% vs 71%, p = 0.04) months. For those with occluded grafts, a higher proportion of patients with ≥2 vessel run-off subsequently had an attempt at redo bypass grafting. CONCLUSIONS Femoro-popliteal bypass is a reasonable treatment option for patients with one-vessel run-off. However, whilst patency rates are comparable, clinicians should be aware of the lower successful limb salvage rates for patients with one patent vessel (especially those presenting with tissue loss).
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Affiliation(s)
- Ryan Preece
- Gloucestershire and Swindon Vascular Network, Gloucester Royal Hospital, Gloucester, UK
| | - Lydia Mann
- Gloucestershire and Swindon Vascular Network, Gloucester Royal Hospital, Gloucester, UK
| | - Sachin R Kulkarni
- Gloucestershire and Swindon Vascular Network, Gloucester Royal Hospital, Gloucester, UK
| | - Sharath Cv Paravastu
- Gloucestershire and Swindon Vascular Network, Gloucester Royal Hospital, Gloucester, UK
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Lehrman B, Byerly S, Mitchell EL, Kerwin AJ, Howley IW. Trust but Verify? Utility of Intraoperative Angiography After Revascularization for Vascular Trauma. Am Surg 2024; 90:1059-1065. [PMID: 38126322 DOI: 10.1177/00031348231220593] [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] [Indexed: 12/23/2023]
Abstract
BACKGROUND Trauma surgical dogma teaches that patients should have intraoperative angiography (IA) if the surgeon cannot identify a pulse in the injured extremity following a vascular repair. This study was undertaken to assess the utility of IA in trauma patients who underwent open brachial or femoral artery revascularization. METHODS Retrospective analysis of the Prospective Observational Vascular Injury Trial (PROOVIT) database from 2013 to 2021 evaluated patients >15 years with penetrating or blunt injuries requiring operative intervention of the brachial, superficial femoral, or common femoral arteries. Prospective Observational Vascular Injury Trial data evaluated included documented pulse in the injured extremity at revascularization completion, adjunctive IA, immediate revision, and vascular reintervention during the hospitalization. RESULTS Of the 5057 patients with vascular injury, 185 patients met our inclusion criteria. The majority were male (86.5%) with a median age, injury severity score, and systolic blood pressure of 29, 12, and 117, respectively. Of the study patients, 39% underwent IA, 14% had immediate revision, and 8% required vascular reoperation during their admission. Patients who underwent IA and with no documented palpable pulse after repair were significantly more likely to require immediate revision before leaving the operating room (22% vs 9%, P = .013) and were not more likely to require reoperation, than those who did not undergo IA (7% vs 9%, P = .613). CONCLUSIONS Intraoperative angiography is a valuable tool for surgeons for vascular extremity trauma and is associated with a greater rate of immediate revision. Familiarity with angiographic technique is essential for vascular trauma and should be a focal point of training.
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Affiliation(s)
- Benjamin Lehrman
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Saskya Byerly
- Department of Surgery - Division of Trauma/Critical Care, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Erica L Mitchell
- Department of Surgery - Division of Vascular and Endovascular Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew J Kerwin
- Department of Surgery - Division of Trauma/Critical Care, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Isaac W Howley
- Department of Surgery - Division of Trauma/Critical Care, University of Tennessee Health Science Center, Memphis, TN, USA
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Silverberg D, Speter C, Bar Dayan A, Halak M. Intraoperative calf blood pressure measurements for the detection of early lower extremity ischemia following endovascular aneurysm repair. Vascular 2024; 32:267-272. [PMID: 36271683 DOI: 10.1177/17085381221135273] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND Access vessel complications during endovascular aneurysm repair (EVAR) remain a concern and has been reported to occur in 3-10% of cases. The purpose of this study is to report our experience with intraoperative, non-invasive calf blood pressure (BP) measurements and ankle brachial indexes (ABIs) before and immediately following EVAR, in evaluating the perfusion of the lower extremities and detecting early lower extremity ischemia (LEI). METHODS We performed a retrospective review of all consecutive patients who underwent EVAR at our institution between the years 2019 and 2021. All patients had blood pressure cuffs placed on their calves prior to the procedure. Calf BP measurements and ABIs were obtained prior to and immediately after the surgery. Based on the BP measurements, patients were categorized into two groups. Group 1: patients with unchanged ABIs at the end of the procedure. Group 2: patients who experienced a decrease in ABIs at the end of the procedure (no BP obtained or decrease of ABI >0.3 from preoperative measurement). Patients in group 2 underwent exploration of the access vessel. Based on these, the positive and negative predictive values of the study were calculated. RESULTS During the study period we performed 113 EVAR procedures for abdominal, thoracic, and thoracoabdominal aortic aneurysms, in which 226 femoral arteries were accessed. Mean age was 71 years and 88% were males. In 219 (97%) of the limbs, there was no change in calf BP measurements and ABIs immediately after the procedure, when compared to the preoperative measurements, and none suffered a decrease in follow up ABIs. In 7 limbs (3%), there was a decrease in the calf BP (group 2), and all underwent exploration of the femoral artery. In 5 of these, a pathology was found within the artery. The positive predictive value of the intraoperative calf BP measurement was 71%. The negative predictive value of the study was 100%. CONCLUSION Intraoperative calf BP and ABIs is a simple method to assess the lower limb perfusion and detect LEI following EVAR. The exam is particularly accurate in ruling out LEI as it has a very high negative predictive value. However, an abnormal measurement does not necessarily confirm LEI.
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Affiliation(s)
- Daniel Silverberg
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Chen Speter
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Avner Bar Dayan
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Moshe Halak
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
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Habib SG, Abdul-Malak OM, Madigan M, Salem K, Eslami MH. Trends in Utilization of Completion Imaging after Lower Extremity Bypass and Its Association with Major Adverse Limb Events and Loss of Primary Patency. Ann Vasc Surg 2023; 96:268-275. [PMID: 37178904 DOI: 10.1016/j.avsg.2023.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/15/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Failure following lower extremity bypasses (LEBs) isoften secondary to technical defects. Despite traditional teachings, routine use of completion imaging (CI) in LEB has been debated. This study assesses national trends of CI following LEBs and the association of routine CI with 1-year major adverse limb events (MALE) and 1-year loss of primary patency (LPP). METHODS The Vascular Quality Initiative (VQI) LEB dataset from 2003-2020 was queried for patients who underwent elective bypass for occlusive disease. The cohort was divided based on surgeons' CI strategy at time of LEB, categorized as routine (≥80% of cases/year), selective (<80% of cases/year), or never. The cohort was further stratified by surgeon volume category [low (<25th percentile), medium (25th-75th percentile), or high (>75th percentile)]. The primary outcomes were 1-year MALE-free survival and 1-year loss of primary patency (LPP)-free survival. Our secondary outcomes were temporal trends in CI use and temporal trends in 1-year MALE rates. Standard statistical methods were utilized. RESULTS We identified 37,919 LEBs; 7,143 in routine CI strategy cohort, 22,157 selective CI and 8,619 in never CI. Patients in the 3 cohorts had comparable baseline demographics and indications for bypass. There was a significant decrease in CI utilization from 77.2% in 2003 to 32.0% in 2020 (P < 0.001). Similar trends in CI use were observed in patients who underwent bypass to tibial outflows (86.0% in 2003 vs. 36.9% in 2020; P < 0.001). While the use of CI has decreased over time, 1-year MALE rates have increased from 44.4% in 2003 to 50.4% in 2020 (P < 0.001). On multivariate COX regression, however, no significant associations between CI use or CI strategy and risk of 1-year MALE or LPP was found. Procedures performed by high-volume surgeons carried a lower risk of 1-year MALE (HR: 0.84; 95% CI [0.75-0.95]; P = 0.006) and LPP (HR:0.83; 95% CI [0.71-0.97]; P < 0.001) compared to low-volume surgeons. Repeat adjusted analyses showed no association between CI (use or strategy) and our primary outcomes when the subgroups with tibial outflows were analyzed. Similarly, no associations were found between CI (use or strategy) and our primary outcomes when the subgroups based on surgeons' CI volume were evaluated. CONCLUSIONS The use of CI, for both proximal and distal target bypasses, has decreased over time while 1-year MALE rates have increased. Adjusted analyses indicate no association between CI use and improved MALE or LPP survival at 1 year and all CI strategies were found to have equivalent outcomes.
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Affiliation(s)
| | | | | | - Karim Salem
- Division of Vascular Surgery, UPMC, Pittsburgh, PA
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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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Zanow J, Settmacher U, Schüle S. [Intraoperative completion diagnostics in open vascular surgery]. Chirurg 2020; 91:461-465. [PMID: 32185427 DOI: 10.1007/s00104-020-01155-1] [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: 11/24/2022]
Abstract
Intraoperative imaging diagnostics during open vascular surgical procedures aim to enhance diagnostic certainty during the operation, ensure quality control documentation and reduce avoidable complications; however, the evidence for the various diagnostic imaging procedures with respect to improvement of perioperative outcome is not confirmed for carotid endarterectomy or for infrainguinal bypass surgery. Nevertheless, an intraoperative diagnostic control is principally recommended. The advantage of intraoperative imaging is confirmed and essential for the surgical reconstruction of bypass occlusions and acute thromboembolic occlusions.
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Affiliation(s)
- J Zanow
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
| | - U Settmacher
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - S Schüle
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
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Miyake K, Kikuchi S, Okuda H, Koya A, Sawa Y, Azuma N. Graft flow predictive equation in distal bypass grafting for critical limb ischemia. J Vasc Surg 2019; 70:1192-1203.e2. [DOI: 10.1016/j.jvs.2018.12.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 12/23/2018] [Indexed: 10/26/2022]
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Quality and Safety in Health Care, Part XXIII: Bypass Leg Surgery. Clin Nucl Med 2017; 42:444-445. [PMID: 28195910 DOI: 10.1097/rlu.0000000000001584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The efforts of the Vascular Quality Initiative of the Society for Vascular Surgery and its regional groups, including the Vascular Study Group of New England, have been very helpful in furthering medical knowledge in multiple areas of vascular surgery and hopefully in improving quality and safety. One of the areas focused on has been leg bypass surgery. The American College of Surgeons National Surgical Quality Improvement Program has also provided information relevant to leg bypass surgery quality improvement, but there are differences between this program and that from the Vascular Quality Initiative.
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