A Retrospective Comparison Between Hybrid Treatment and Prosthetic Above-the-Knee Femoro-Popliteal Bypass in the Management of the Obstructive Disease of the Superficial Femoral Artery.

OBJECTIVE: We assessed early and late outcomes following hybrid intervention (common femoral artery endarterectomy and superficial femoral artery (SFA) stenting) versus above-the-knee (AK) femoro-popliteal bypass performed for peripheral artery occlusive disease (PAOD) in a double-center retrospective comparative cohort study. MATERIALS AND METHODS: From January 2006 to December 2017, 82 hybrid revascularizations with femoral endarterectomy and SFA stenting (HY Group) and 98 AK femoro-popliteal bypasses with femoral endarterectomy (BP Group) were performed at two academic vascular centers. The two groups were compared in terms of preoperative and intraoperative details and of perioperative (<30 days) outcomes with χ2 test. Long-term results were compared using Kaplan-Meier curves and log-rank test. RESULTS: No differences were found in demographics variables, risk factors, comorbidities and clinical presentation between the two groups. Also perioperative outcomes were similar between the two groups. Median duration of follow-up was 38 months. At five years, the estimated survival rate was 60% in HY Group and 77.5% in BP Group (p = 0.002) Five-year primary patency rates were 46% in HY Group and 64% in BP Group (p = 0.005). Overall, 13 patients in HY Group required conversion to open surgery and 6 patients in BP Group underwent below-knee (n = 4) or distal (n = 2) bypass. The 5-year rate of limb maintenance was 85% in HY Group and 94% in BP Group (p = 0.1) and was not significantly different regardless of presentation, claudication or critical limb ischemia. CONCLUSIONS: In patients with PAOD due to complex long lesions of the infrainguinal arteries, open-surgical treatment with AK bypass provided better long-term survival and patency rates compared to a hybrid approach.

Arch and access vessel complications in penetrating aortic ulcer managed with thoracic endovascular aortic repair.

BACKGROUND: To analyze our experience and to describe access and arch-related challenges when performing thoracic endovascular aortic repair (TEVAR) for penetrating aortic ulcers (PAUs). METHODS: This is a single-center, observational, cohort study. Between October 2003 and February 2019, 48 patients with PAU were identified; 37 (77.1%) treated with TEVAR were retrospectively analyzed. Primary major outcomes were early (<30 days) and late survival, freedom from aortic-related mortality (ARM), and a composite endpoint of arch/vascular access-related complications. RESULTS: On admission, 17 (45.9%) patients were symptomatic with 4 (10.8%) presenting with rupture. In-hospital mortality was 8.1% (n=3). We observed 10 (27.0%) arch/access-related complications. There were 4 (10.8%) arch issues: 2 transient ischemic attacks and 2 retrograde acute type A dissections which required emergent open conversion for definitive repair. Access issues occurred in 6 (16.2%) patients: 3 (8.1%) required common iliac artery conduit, and 1 (2.7%) patient required iliac artery angioplasty to deliver the stent-graft. In addition, 2 (5.4%) patients developed access complications which required operative repair [femoral patch angioplasty (n=2), and femoral pseudoaneurysmectomy (n=1)]. Arch/access-related mortality rate was 5.4% (n=2) and median follow-up was 24 (range, 1-156; IQR, 3-52) months. Estimated survival was 87.1% (standard error: 0.6; 95% CI: 71.2-84.9%) at 1 year, and 63.3% (SE: 0.9; 95% CI: 44.1-79%) at 4 years. Estimated freedom from reintervention was 88.9% (SE: 0.5; 95% CI: 74.8-95.6%) at 1 year, and 84.2% (SE: 0.7; 95% CI: 67.3-93.2%) at 4 years. No arch/access-related issues developed during the follow-up period. CONCLUSIONS: Our experience confirms that vascular access and aortic arch issues are still a challenging aspect of performing TEVAR for PAUs. Our cumulative 27% rate of access/arch issues is lower than previously reported due to both technological advancements and meticulous management of both access routes and arch anatomy.

Cryopreserved Human Allografts for the Reconstruction of Aortic and Peripheral Prosthetic Graft Infection.

Background: This study aimed to present cases with cryopreserved human allografts (CHAs) for vascular reconstruction in both aortic and peripheral infected prosthetic grafts. Materials and Methods: This is a single center, observational descriptive study with retrospective analysis. In all cases, the infected prosthetic graft material was completely removed. At discharge, patients were administered anticoagulants. Follow-up examinations included clinical visits, echo-color-Doppler ultrasounds, or computed tomography angiography within 30 days and at 3, 6, and 12 months after the treatment, and then twice per year. Results: We treated 21 patients (90% men, n=19) with the mean age of 71±12 years and mean interval between the initial operation and replacement with CHA of 30 months [range, 1-216; interquartile range (IQR), 2-36]. In-hospital mortality was 14% (n=3); no CHA-related complication led to death. Limb salvage was 100%. No patient was lost at the median follow-up of 14 months (range, 2-61; IQR, 6-39). No rupture, aneurysmal degeneration, or re-infection occurred. Estimated freedom from CHA-related adverse events (95% confidence interval, 43-63) was 95% at 3 years. Conclusion: In our experience, CHAs are a viable option for prosthetic graft infections and provide satisfactory clinical results and favorable stability because of a very low rate of CHA-related adverse events during follow-up.