Long-term clinical outcomes of arterial bypass, and the factors independently associated with the primary patency of arterial bypass 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.

Navigating Challenges in the Endovascular Treatment of Asymptomatic Aortoiliac Aneurysms: A 10-Year Comparative Analysis.

BACKGROUND: Treating an abdominal aortoiliac aneurysm (AAIA) with endovascular methods can be challenging when the internal iliac artery (IIA) is involved. Embolizing the IIA and extending the limb to the external iliac artery (IIAE + EE) to prevent a type 2 endoleak may lead to pelvic ischemic complications. To avoid these complications, strategies that preserve the IIA, such as the bell-bottom technique (BBT) and the iliac branch device (IBD), have been proposed. This study aims to compare the outcomes of these three endovascular approaches for AAIA. METHODS: Between January 2010 and December 2019, 174 patients with asymptomatic AAIA were enrolled in this retrospective analysis. They were divided into two groups: 81 patients underwent non-IIAE procedures, and 93 patients underwent IIAE procedures. The iliac limb study group consisted of 106 limbs treated with the BBT, 113 limbs treated with the IIAE + EE, and 32 limbs treated with the IBD. The primary outcomes included the 30-day mortality rate and intraoperative limb complications. The secondary outcomes included postoperative pelvic ischemia, freedom from reintervention, and the overall 10-year survival rate. RESULTS: There was no significant difference in the perioperative mortality rate between the non-IIAE group (0%) and the IIAE group (2.1%), p = 0.500. The intraoperative limb complications did not differ significantly between the BBT limbs (7.5%), the IIAE + EE limbs (3.5%), and the IBD limbs (3.1%) groups, p = 0.349. The incidence of buttock claudication was significantly greater in the bilateral IIAE + EE group compared to the unilateral IIAE + EE and non-IIAE groups (25%, 11%, and 2.5%, p-value < 0.004), and was similar to the incidence of buttock rest pain with skin necrosis (15%, 0%, and 0%, p < 0.001). During the 10-year follow-up, the BBT limbs group had a significantly lower rate of iliac limb reintervention free time than the IIAE + EE limbs and the IBD limbs groups (88.7%, 98.2%, and 93.8%, p = 0.016). There was no significant difference in the overall 10-year survival rate between the non-IIAE and IIAE groups (51.4% vs. 55.9%, p = 0.703). CONCLUSIONS: The early and late mortality rates were similar between the non-IIAE and IIAE groups. Preserving the IIA is recommended to avoid pelvic ischemic complications. Considering the higher rate of reintervention in the BBT group, the IBD strategy may be preferred for AAIA.

Prevalence and predictors of combined >50% iliocaval venous obstruction and superficial venous reflux in chronic venous insufficiency patients with healed or active venous leg ulcer.

OBJECTIVE: The aim of the present study was to investigate the prevalence and predictors of combined >50% iliocaval venous obstruction (ICVO) and superficial venous reflux (SVR) in patients with chronic venous insufficiency (CVI) with a healed (C5) or an active (C6) venous leg ulcer (VLU). METHODS: We conducted a retrospective review of prospectively collected data from patients with CVI with CEAP (Clinical, Etiology, Anatomy, Pathophysiology) class C5 (healed ulcer) or C6 (active ulcer) with SVR who had been treated at our institution from February 2017 to January 2018. The demographic, clinical, and surgical data and duplex ultrasound and computed tomography venography findings were collected. We used OsiriX MD, version 2.9, software (Pixmeo SARL, Bernex, Switzerland) to measure the vein diameter via multiplanar reconstruction. The prevalence of combined >50% ICVO and SVR was evaluated, and univariate and multivariate analyses were performed to identify the independent predictors of >50% ICVO in patients with CVI and SVR. RESULTS: A total of 79 limbs from 67 patients were enrolled. The mean age was 59.82 ± 12.86 years, the mean body mass index was 28.68 ± 6.41 kg/m2, and 41.8% were men. The prevalence of >50% ICVO in the patients with SVR was 31.6%. Univariate analysis showed a history of deep vein thrombosis (DVT) in the affected leg (P = .001), a VLU in the left leg (P = .033), a history of a recurrent VLU (P = .038), and reversed flow in the superficial epigastric vein (P = .004) were significantly associated with >50% ICVO in patients with CVI and SVR. Multivariate analysis revealed a history of DVT in the affected leg (adjusted odds ratio [aOR], 8.31; 95% confidence interval [CI], 2.29-30.19; P = .001), a VLU in the left leg (aOR, 3.95; 95% CI, 1.18-13.19; P = .026), and a history of a recurrent VLU (aOR, 3.08; 95% CI, 1.02-9.32; P = .047) to be independently associated with combined >50% ICVO and SVR in patients with CVI. CONCLUSIONS: The prevalence of combined >50% ICVO and SVR in patients with CVI and CEAP C5 or C6 was 31.6%. The independent predictors of combined >50% ICVO and SVR in those with CVI were a history of DVT in the affected leg, a VLU in the left leg, and recurrent VLUs.

The Geriatric Nutritional Risk Index predicts amputation after infrapopliteal angioplasty in critical limb ischemia patients.

OBJECTIVE: To validate the Critical Limb Ischemia Frailty Index (CLIFI), and to identify independent predictors of 2-year amputation-free survival after infrapopliteal endovascular treatment for chronic limb-threatening ischemia (CLTI) in Thai patients. METHODS: This retrospective study was conducted during the June 2014 to February 2017 study period. CLTI patients treated with infrapopliteal angioplasty were enrolled and analyzed. A patient was defined as CLIFI positive if two or more of the following criteria were present: Geriatric Nutritional Risk Index (GNRI) < 89.8, low skeletal muscle mass index (<6.87 kg/m2 in males, and <5.46 kg/m2 in females), and/or non-ambulatory status. Kaplan-Meier survival analysis was used to assess 2-year amputation-free survival (AFS), and comparisons were performed using log-rank test. Univariate and multivariate Cox proportional hazards models were used to analyze for significant and independent association, respectively, between preoperative characteristics and AFS. RESULTS: A total of 266 patients and 286 limbs were included. Forty (15.0%) patients were CLIFI positive, and 226 (85.0%) patients were CLIFI negative. The 2-year amputation-free survival rate was 90.3% in the CLIFI positive group, and 86.6% in the CLIFI negative group (p = 0.59). Multivariate analysis revealed the GNRI to be an independent risk factor for amputation within two years after infrapopliteal revascularization (adjusted hazard ratio: 4.87, 95% confidence interval: 1.20-19.70; p = 0.02). CONCLUSIONS: The GNRI was found to independently predict 2-year amputation after infrapopliteal angioplasty in Thai CLTI patients; however, the CLIFI was not found to significantly predict 2-year amputation in this patient population.

Early and Late Outcomes of Endovascular Aneurysm Repair for Infected Abdominal Aortic and/or Iliac Aneurysms.

BACKGROUND: Infected abdominal aortic and/or iliac aneurysm (AAIA) is a rare condition with a high mortality rate when treated with open surgery. In the past decade, the condition has increasingly been treated with endovascular aneurysm repair (EVAR). However, early and late outcomes, including the continued need for antibiotic treatments and predictors of persistent infection, are poorly understood. METHODS: We evaluated the outcomes of patients who underwent EVAR for infected AAIA from January 2010 to October 2017. We collected data including patient age, gender, clinical presentation, aneurysm location, culture results, intraoperative details, postoperative complications, 30-day mortality, in-hospital mortality, persistent infection, reintervention, and survival. RESULTS: Among 792 patients diagnosed with AAIA, 64 were diagnosed with primary infected aneurysm, underwent EVAR, and were included in this study (81.3% male; median age, 72 years; range, 18-94 years). The most commonly isolated organisms were Salmonella species (34%), followed by Streptococcus (21%), and Staphylococcus species (21%). Aneurysms were intact in 48 patients (75%) and were ruptured in 16 (25%). The perioperative mortality was 4.7% (3 patients) of whom one was diagnosed with ruptured infected AAIA. Six (9.4%) patients died during hospitalization, 5 of severe sepsis with multiorgan failure and one of myocardial infarction. Among the 58 surviving patients, 34 (58.6%) had persistent infection, of whom 13 (22.4%) required early and late reintervention, including 2 with endograft infection, 8 with primary and secondary aortoenteric fistula, 2 with recurrent new aortic infection, and one with graft limb occlusion. The remaining 24 patients were able to discontinue antibiotics and had no recurrence or need for reintervention. Overall survival rates at 1, 3, and 5 years in the antibiotic-discontinuation group were 91.7%, 87.5%, and 68.0%, respectively, and 82.4%, 52.6%, and 32.9%, respectively, in the persistent-infection group (P = 0.009). In multivariable analysis, primary aortoenteric fistula (Adjusted OR [aOR], 20.469; 95% confidence interval (CI), 1.265-331.320; P = 0.034) and preoperative serum albumin level <3 g/dL (aOR, 7.399; 95% CI, 1.176-46.558; P = 0.033) were preoperative parameter that predicted persistent infection. A C-reactive protein level more than 5 mg/L (aOR, 34.378; 95% CI, 4.888-241.788; P < 0.001) was observed in patients with persistent infection. CONCLUSIONS: EVAR is a feasible treatment with acceptable perioperative mortality for infected AAIA. Patients able to discontinue antibiotics have better survival and lower reintervention rates than those with persistent infection. A preoperative albumin level below 3 g/dL and primary aortoenteric fistula predicted persistent infection in this population.

Thrombus extension after cyanoacrylate closure of incompetent saphenous veins.

BACKGROUND: Cyanoacrylate closure (CAC) is a minimally invasive surgery to treat incompetent saphenous veins. This study aimed to investigate the incidence, the risk factors for, and the management of thrombus extension after cyanoacrylate closure (TEACAC) of incompetent saphenous veins in patients with chronic venous disease. METHODS: This retrospective study included patients aged >18 years who were diagnosed with chronic venous disease with superficial venous reflux in the great saphenous vein, anterior accessory saphenous vein, or small saphenous vein, and who were treated with CAC at Siriraj Hospital (Bangkok, Thailand) during January 2017 to December 2018. RESULTS: A total of 126 saphenous veins of 101 patients were included. TEACAC occurred in 5 of 101 (4.9%) patients, and in 5 of 126 (3.9%) treated saphenous veins. The mean follow-up time was 285±12 days. Based on Kabnick classification of endovenous heat-induced thrombosis (EHIT), the following TEACAC grades were observed: grade I (N.=2), grade II (N.=1), grade III (N.=2), and grade IV (N.=0). No patient or procedural predictive factors for TEACAC were identified. In patients with TEACAC-1 or TEACAC-2, the thrombus spontaneously disappeared by the 2-week follow-up. Patients with TEACAC-3 received therapeutic rivaroxaban or dabigatran, which resolved the thrombus within 2-4 weeks. No deep vein thrombosis or symptomatic pulmonary embolism was found. CONCLUSIONS: TEACAC was found not to be a rare complication after CAC. All patients should be informed of the risk of TEACAC prior to treatment. Treatment of TEACAC class 1-3 following EHIT guideline seems to be both safe and effective.

Novel culture media enhances mononuclear cells from patients with chronic limb-threatening ischemia to increase vasculogenesis and anti-inflammatory effect.

BACKGROUND: Quality and Quantity culture media (QQ culture media) was reported to enhance vasculogenesis and angiogenesis function of mononuclear cells (MNCs) from healthy volunteers. In this study, MNCs from chronic limb-threatening ischemia (CLTI) patients were cultured in QQ culture media, and then investigated for angiogenesis-related phenotype and function. METHODS: Patients aged ≥ 18 years with CLTI caused by atherosclerosis of the lower extremities were prospectively recruited at Siriraj Hospital (Bangkok, Thailand) during July 2017-December 2018. Peripheral blood mononuclear cells (PBMNCs) were isolated from peripheral blood. PBMNCs were cultured in either QQ culture media or standard culture media. The number of CD34+CD133+ cells, CD206+ cells, CD4+CD25+CD127+ cells, colony formation assay, and human umbilical vein endothelial cell (HUVEC) tube formation assay in MNCs were compared between those cultured in QQ culture media and those cultured in standard culture media. RESULTS: Thirty-nine patients were included with a mean age of 69 ± 11 years. Diabetes mellitus was found in 25 (64%) patients. The percentage of CD34+CD133+ progenitor cells in MNCs cultured in QQ culture media and in MNCs cultured in standard culture media was 4.91 ± 5.30% and 0.40 ± 0.46%, respectively (p < 0.0001). The percentage of CD206+ cells in MNCs cultured in QQ culture media and in MNCs cultured in standard culture media was 19.31 ± 11.42% and 4.40 ± 2.54%, respectively (p < 0.0001). The percentage of inactive population of T regulatory cells (CD4+CD25+CD127+ cells) in MNCs cultured in standard culture media and in MNCs cultured in QQ culture media was 14.5 ± 10.68% and 1.84 ± 1.37%, respectively (p < 0.0001). The total number of colony-forming units from MNCs cultured in QQ culture media and in MNCs cultured in standard culture media was 8.86 ± 8.35 of 2 × 105 cells/dish, and 0.58 ± 1.05 of 2 × 105 cells/dish, respectively (p < 0.0001). The mean intensity of Dil-Ac-LDL uptake that incorporated into the HUVEC forming tube was 1.37 ± 0.88 in MNCs cultured in QQ culture media, and 0.78 ± 0.41 in MNCs cultured in standard culture media. (p < 0.0003). CONCLUSIONS: MNCs from CLTI patients that were cultured in QQ culture media had a significantly higher number of CD34+CD133+ cells and anti-inflammatory cells, and higher angiogenesis-related function compared to MNCs cultured in standard culture media.

Hypersensitivity reaction after cyanoacrylate closure of incompetent saphenous veins in patients with chronic venous disease: A retrospective study.

PURPOSE: The objective of this study was to evaluate the incidence of, the risk factors for, the nature of the disease, and the management of hypersensitivity reaction (HSR) after cyanoacrylate closure (CAC) of incompetent saphenous veins in patients with chronic venous disease. METHODS: Data consisting of all incompetent saphenous veins, including great saphenous veins, anterior accessory saphenous veins, and small saphenous veins, treated with CAC at Siriraj Hospital (Bangkok, Thailand) from January 2017 to December 2018 were retrospectively evaluated. RESULTS: A total of 126 saphenous veins, including 106 great saphenous veins (84.1%), 7 anterior accessory saphenous veins (5.6%), and 13 small saphenous veins (10.3%) of 126 limbs from 101 patients were included. A HSR occurred in 16 of 101 patients (15.8%), in 19 of 126 limbs (15.0%), and in 19 of 126 treated saphenous veins (15.0%). HSR-related erythema, itching, swelling, and pain occurred in 100.0%, 95.0%, 68.4%, and 52.6%, of HSR patients, respectively. HSR occurred 1 week after CAC. All HSR symptoms were mild, could be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and antihistamine, and were resolved within 1 week. The risk factors for HSR were suprafascial saphenous vein with a depth <1 cm from the skin, and saphenous vein diameter of ≥8 mm. CONCLUSIONS: A HSR occurred in 15.8% of patients and in 15.0% of limbs after CAC. Risk factors for HSR were a suprafascial saphenous vein located close to the skin and a large saphenous vein. All HSR symptoms were mild in severity, occurred at 1 week after CAC, and were resolved within 1 week after treatment with nonsteroidal anti-inflammatory drugs and antihistamines. To prevent HSR, CAC should be avoided in suprafascial saphenous veins that are located close to the skin, and CAC in saphenous veins with a size of ≥8 mm should be performed with caution.

Early and late outcomes of endovascular aneurysm repair to treat abdominal aortic aneurysm compared between severe and non-severe infrarenal neck angulation.

BACKGROUND: Abdominal aortic aneurysm with severe infrarenal neck angle (>60°) has long been thought to be an obstacle to endovascular aneurysm repair. However, some previous studies reported endovascular aneurysm repair to be safe and efficacious for treating abdominal aortic aneurysm in patients with severe neck angulation. The aim of this study was to investigate the early and late outcomes of endovascular aneurysm repair to treat abdominal aortic aneurysm compared between patients with severe and non-severe infrarenal neck angulation. METHODS: Fifty-four severe and 144 non-severe neck angulation patients who were treated at Siriraj Hospital (Bangkok, Thailand) during January 2010-October 2013 were recruited. The primary endpoints were intraoperative neck complications (e.g., type 1A endoleak or proximal graft migration) and immediate adjunct aortic neck procedures. The secondary endpoints included perioperative mortality, overall survival, and the proportion of patients that were reintervention-free at five years compared between the severe and non-severe groups. RESULTS: Severe angulation patients were significantly older than non-severe angulation patients (77 ± 6.3 vs. 74 ± 7.9 years; p = 0.021). The median proximal angle was significantly greater in the severe group (82° vs. 13.5°; p < 0.001). Intraoperative proximal neck complications developed in 29.6% of patients in the severe angulation group compared with 9.0% in the non-severe group (p < 0.001). Significantly more patients in the severe group required intraoperative adjunct procedures (29.6% vs. 7.6%; p < 0.001). There was no significant difference in perioperative mortality between groups. At the five-year follow-up, there was no significant difference between groups for overall survival or the proportion of patients that remained reintervention-free. CONCLUSIONS: Endovascular aneurysm repair to treat abdominal aortic aneurysm in patients with severe proximal neck angulation is technically feasible and safe Although the severe angulation group had a higher rate of intraoperative neck complications and immediate adjunct neck procedures than the non-severe group, there was no significant difference between groups for 30-day mortality, overall survival or the proportion of patients who remained reintervention-free at five years.

CTA Assessment of Midterm Morphological Changes to Chimney Grafts Used in the Treatment of Juxtarenal Aortic Aneurysms.

Purpose: To evaluate chimney stent-graft position and morphological changes of the aneurysm sac as visualized by postoperative computed tomography angiography (CTA) over a minimum 24-month follow-up period. Materials and Methods: Twenty-one patients (mean age 75.7±8.6 years; 20 men) with juxtarenal aortic aneurysms who underwent successful chimney endovascular aneurysm repair (ch-EVAR) with the Endurant stent-graft and had 2 postoperative CTAs separated by at least 24 months were included in the study. CTA-based measurements of aortic stent-graft migration, target vessel angle, and chimney angle were compared between the serial scans. Results: During a mean follow-up of 34.9 months (range 24-69.2), the mean migration of the aortic stent-grafts was under 5 mm (2.76±2.4 mm). The average migration distance per year was 1.15 mm. The aneurysm diameter reduced a mean 3.25 mm (p=0.048). The right renal artery angle moved significantly upward 6.72° (p=0.025), while the right renal chimney stent-graft moved significantly downward 7.83° (p=0.042). The left renal artery angle also moved upward 1.87° (p=0.388) and the corresponding chimney moved downward 5.68° (p=0.133). During the study period, no type I/III endoleak or chimney occlusion was observed. Conclusion: Midterm morphometric assessment of ch-EVAR using CTA showed significant aneurysm sac shrinkage and a stable 3-year position of the abdominal devices, with the mean downward migration of the aortic stent-graft being <5 mm in the majority of cases. The chimney grafts seem to be prone to take an oblique rather than parallel configuration during follow-up. However, there was no relevant clinical consequence related to this phenomenon.

Outcomes of Open Repair, Fenestrated Stent Grafting, and Chimney Grafting in Juxtarenal Abdominal Aortic Aneurysm: Is It Time for a Randomized Trial?

BACKGROUND: The well-established, gold standard treatment for juxtarenal abdominal aortic aneurysms (JAAAs) is open repair (OR). However, endovascular treatment with fenestrated or chimney grafts has been increasingly performed in the past decade. This study compared the outcomes of OR with 2 endovascular methods in JAAA. METHODS: We retrospectively reviewed consecutive patients with JAAA who underwent OR (n = 32), repair with fenestrated stent grafts (fenestrated endovascular aortic aneurysm repair [FEVAR], n = 20), or chimney grafts (Ch-EVAR, n = 23) during the period from January 2011 to December 2016 at a single center. Our primary end point was perioperative mortality. Secondary end points included renal function impairment, new-onset dialysis, procedural details, and postoperative complications. Kaplan-Meier analysis was used to estimate freedom from late reintervention, primary patency of target vessel stent grafts, and overall survival. RESULTS: There were no significant differences between groups in baseline characteristics. Perioperative mortality was similar in all the 3 groups (3.1% (1/32) in the OR group, 0% in the FEVAR group, and 4.3% (1/23) in the Ch-EVAR group. Mean follow-up duration was 36.7 months (range 1-75 months). There were no significant differences between groups regarding any of the secondary end points, except for blood loss (which was significantly greatest in the OR group), and there was no significant difference in overall survival. Estimated target vessel stent patency at 1 and 4 years was 93.8% and 93.8% in the FEVAR group, and 89.5% and 89.5% in the Ch-EVAR group. There was no significant difference between groups in estimated freedom from late reintervention (96.4% in the OR group, 77.2% in the FEVAR group, and 82.3% in the Ch-EVAR group). CONCLUSIONS: Open surgery is an acceptable and effective treatment for JAAA. However, FEVAR and Ch-EVAR also showed high technical success rates and low perioperative mortality, with acceptable reintervention rates during follow-up.

Conical neck is strongly associated with proximal failure in standard endovascular aneurysm repair.

OBJECTIVE: Hostile proximal aortic neck (HN) challenges the suitability for standard endovascular aneurysm repair (EVAR) of patients at high risk for "open" repair. However, there has been little if any focus placed on the individual role of the "nonlength" HN features in EVAR outcomes. The aim of this study was to evaluate their individual and potentially predictive role in outcomes of EVAR under HN conditions. METHODS: Data of 156 consecutive EVAR patients with short (<15 mm) HN, treated with the Endurant device (Medtronic Cardiovascular, Santa Rosa, Calif) at three European academic vascular centers between 2007 and 2015, were collected and retrospectively analyzed. All patients had at least one of the four well-known nonlength HN criteria (width >32 mm or bulge, angulation >60 degrees, reverse taper anatomy, and circumferential thrombus or calcification >50%) and underwent standard EVAR without additional techniques, such as use of chimney grafts or endoanchors. Primary end points were absence of type IA endoleak at 1 month and midterm follow-up and aneurysm sac stabilization or shrinkage. Secondary end points were 30-day mortality, overall survival, and secondary interventions related to EVAR. The study cohort was classified in two subgroups related to neck length (length <10 mm and length between 10 and 14 mm) as well as in two subgroups according to on-label or off-label stent graft use. RESULTS: Mean clinical and radiologic follow-up was 41.1 ± 24.7 and 31.7 ± 19.0 months, respectively. Overall EVAR-related mortality was 1.9% (n = 3). The total type IA endoleak rate was 5.8% (n = 9). In four patients, the type IA endoleak was detected intraoperatively and solved by endovascular means. A type IA endoleak was detected in three patients at 1 month and in two patients at 2-year follow-up. During follow-up, five patients showed an increase of aneurysm diameter due to type II endoleak and were treated by secondary endovascular reinterventions. The total number of all EVAR-related secondary procedures in the midterm was 12 (7.7%). Univariate analysis showed that the center of treatment and the clinical or anatomic features were not associated with adverse outcomes. Multiple regression and Cox regression analysis of HN features revealed that reverse taper anatomy (conical neck) was the single and significantly associated predictor of proximal EVAR failure (P < .012). Width >32 mm, angulation >60 degrees, and calcification or thrombus were not associated with adverse outcomes. Analysis between HN length cohorts and between on-label and off-label subgroups revealed no difference in outcomes. CONCLUSIONS: A conical neck in hostile anatomies represents the single strongest factor associated with proximal failure of standard EVAR. This finding should be considered and highlighted apart from the length of the infrarenal neck to prevent midterm failure of standard EVAR.

Importance of Early Aortic Surveillance after Endovascular Treatment of Type B Aortic Dissection with Malperfusion Syndrome.

BACKGROUND: The aim of the study was to assess the incidence and timing of adverse events and complications occurring after endovascular treatment of type B aortic dissection (TBAD) complicated with malperfusion syndrome (MPS). METHODS: Twenty-eight patients with TBAD and MPS treated endovascularly at our center from January 2006 to January 2015 were evaluated through a retrospective scrutiny of the medical records. The primary end point of the study was aorta-related reintervention. The secondary end point was all-cause mortality. RESULTS: The MPS included the mesenteric and renal arteries in 14 (50%) and 21 (75%) patients, respectively, the lower extremities in 14 (50%) patients and the spinal cord in 3 (10.7%). The 1-year and 5-year freedom of reintervention rate were 86.2% and 74.7%, respectively. The median time to reintervention was 4.5 months. The main reason for reintervention was type I proximal endoleak which was treated by proximal endograft extensions and appropriate arch-branch management. The perioperative mortality was 14.3% (4 of 28). The mean follow-up was 61.7 months (range, 2-96 months). The short-term and long-term survivals were 82.1% at 1 and 5 years, respectively. CONCLUSIONS: The results suggest that closer follow-up and imaging surveillance of the aorta are warranted after thoracic endovascular aortic repair treatment of TBAD and MPS. And especially so during the first 6 months to enable timely detection and correction of potential complications.

Outcomes and factors influencing prognosis in patients with vascular pythiosis.

OBJECTIVE: Vascular pythiosis, caused by Pythium insidiosum, is associated with a high mortality rate. We reviewed the outcomes and established the factors predicting prognosis of patients treated in our institution with surgery, antifungal therapy, or immunotherapy. METHODS: We undertook a retrospective record review of patients with vascular pythiosis treated in Siriraj Hospital, Bangkok, Thailand, between January 2005 and January 2015. Patient characteristics, type of surgery, adjunctive antifungal treatment, adjunctive immunotherapy, and disease status of surgical arterial and surrounding soft tissue margins were recorded. We calculated the mortality rate and established factors predicting prognosis. RESULTS: The records of 11 patients were reviewed. All patients had thalassemia. Nine patients (81.8%) had a history of contact with contaminated water. The clinical presentations were chronic ulcers (45.5%), toe gangrene (27.3%), pulsatile mass (27.3%), and acute limb ischemia (27.3%). Above-knee amputation was required in 10 patients (90.9%). The mortality rate was 36.4%. Independent variables between survivors and nonsurvivors were lack of an arterial disease-free surgical margin (P = .003), lack of a surrounding soft tissue disease-free surgical margin (P < .05), a suprainguinal lesion (P < .05) and duration of symptoms (P < .05). Adjuvant itraconazole, terbinafine, and Pythium vaccine have a role to play in patients with a disease-free arterial surgical margin but in whom infected surrounding soft tissue could not be completely excised. CONCLUSIONS: Achieving adequate disease-free surgical margins-especially the arterial margin-at amputation or débridement is the most important prognostic factor in patients with vascular pythiosis. Early detection combined with a multidisciplinary approach to treatment, including surgery, antifungal agents, and immunotherapy, allows the best possible outcome to be obtained.

Carotid Endarterectomy in Symptomatic Extracranial Internal Carotid Artery Stenosis: A Result of the First 100 Consecutive Cases in a University Hospital.

Background: Extracranial carotid artery stenosis has been recognized in 9.2% of ischemic stroke patients by duplex ultrasonography in Thailand. The treatment program of this disease has not been established countrywide. Objective: Carotid endarterectomy in our institute was firstly evaluated for safety and long-term efficiency in order to assess the possibility of expanding this treatment throughout the country. Material and Method: An observational study with long-term follow-up was carried out in 100 consecutive symptomatic patients with severe stenosis (70-99% diameter stenosis) of extracranial internal carotid artery that underwent carotid endarterectomies. All carotid endarterectomies were performed under general anesthesia, with routine use of intravascular shunts during carotid cross clamps and saphenous vein patches for arteriotomy closures. Perioperative mortality and morbidity were evaluated for the safety of this procedure. The long-term stroke-free survival was assessed to announce the efficiency of this treatment. Results: One hundred consecutive patients (68% male and 32%female) with the mean age of 69.9 years were included in the present study. Mean duration of neurological symptoms prior to surgery was 2.5 months. Hemiplegia (64%) was the most common symptom leading to surgery. Hypertension (87%) was the most common comorbidity in the present series. Mean duration of surgical procedure was 210 minutes. Mean durations of total carotid shunting and carotid cross clamp during shunt removal were 75 minutes and 4.5 minutes respectively. Mean length of ICU stay was 1.4 days. The perioperative mortality rate was 1%. The perioperative major stroke rate was also 1%. Ten-year follow-up of the patients revealed no death related to neurovascular event and no evidence of recurrent ipsilateral stroke in the present series. The cumulative 5- and 10-year stroke-free survivals were 86.1% and 73.7% respectively. Duplex ultrasonography in all survivors demonstrated no recurrent stenosis in the affected carotid artery. Conclusion: Carotid endarterectomy with a consistent technique in the present series had a comparable outcome of safety and long-term efficiency with the standard surgical practice. The information may initiate the treatment guideline for the patient with extracranial carotid artery stenosis in Thailand.

Outcomes of abdominal aortic aneurysm with aortic neck thrombus after endovascular abdominal aortic aneurysm repair.

BACKGROUND: Endovascular abdominal aortic aneurysm repair (EVAR) has increasingly been performed for the last two decades. One of the anatomical exclusion criterion of EVAR is the presence of thrombus within the infrarenal neck of an aneurysm. OBJECTIVE: To investigate the influence of proximal aortic neck thrombus morphology on clinical outcomes after EVAR. MATERIAL AND METHOD: The subjects were retrospectively recruited from all the patients whom undergone EVAR in our institution between January 2010 and December 2012. The patients with apparent thrombus of more than 40% at proximal aortic neck were included Primary endpoints consisted of technical success and perioperative mortality. Secondary endpoints included adjuvant procedures at neck, procedural details, perioperative adverse events, ICU, and hospital stay. The late outcomes of stent grafts related complications were the presence of endoleak, aneurysm expansion, stent graft migration, stent graft thrombosis, AAA rupture, secondary intervention rate, and conversion to open repair RESULTS: Twenty-one out of 145 patients having thrombus of more than 40% of circumferential aortic neck underwent EVAR. The mean follow-up was 15.4 months (range, 2-36 months). There was 100% technical success with no perioperative death. Adjuvant of aortic neck procedure was required in three patients. One patient developed graft limb occlusion. In addition, one patient developed renal infarction requiring long-term hemodialysis and two patients presented with blue toe syndrome and trash feet. During late follow-up, three, five, and two patients had a type II endoleak at one, six, and 12 months, respectively without AAA sac expansion. There was no stent graft migration, stent graft thrombosis, or ruptured AAA. Three patients expired during the late follow-up. In addition, there was neither conversion to opened repair nor secondary intervention. CONCLUSION: The presence of aortic neck thrombus may not be a contraindication for EVAR in selected patients. However, it seems to negatively influence the outcomes in the aspect of renal and peripheral embolization, which could be prevented during EVAR procedure. There was no adverse graft-related complication, secondary intervention, or aneurysm-related mortality during mid-term follow-up period.

Suprainguinal vascular pythiosis: effective long-term outcome of aggressive surgical eradication.

Vascular pythiosis, a vascular infectious disease in hemoglobinopathy patients, caused by Pythium insidiosum, has an endemic area in tropical and subtropical countries. According to literature review, suprainguinal vascular pythiosis leads to 100% of mortality. The authors report a 35-year-old thalassemic patient who presented with a right inflammatory pulsatile groin mass and right limb ischemia. The computerized tomography angiography indicated a false aneurysm at the right external iliac artery and thrombosed entire right leg arteries. The management comprised antifungal agent, immunotherapy, and surgical removal of all infected arteries (high up to the right common iliac artery and above-knee amputation). The patient was found in a good condition at 36 months after the follow-up period.

Catheter-directed thrombolysis for acute limb ischemia caused by native artery occlusion: an experience of a university hospital.

OBJECTIVE: To evaluate the efficiency and complications of catheter-directed thrombolysis (CDT) of acute limb ischemia (ALI) resulting from thromboembolic occlusion. MATERIAL AND METHOD: A retrospective study of CDT was carried out in patients with acute thromboembolic arterial occlusion and marginally threatened ischemia of the extremities between February 2006 and December 2011. After the tip of the angiographic catheter was placed within the blood clot, recombinant tissue plasminogen activator (rt-PA) was used for thrombolysis. The CDT procedure included an initial bolus injection of high dose rt-PA (5-15 mg) followed by a tapering of infusion rate (1-2 mg/hour) through the catheter Primary outcome was 1-year amputation free survival rate and mortality rate. Secondary outcome included technical and clinical success rates, time to lysis, and complication rate. The complete reestablishment of the occluded arteries without major amputation and death was considered successful treatment. RESULTS: Thirty-seven patients (30 males and 7 females) with the mean age of 55.6 years (range, 27-86 years) were enrolled in the present study. The number of acute arterial occlusion was 23 (62.2%) of acute arterial embolism and 14 (37.8%) of acute arterial thrombosis. Embolism involved two aortic bifurcations, two iliac arteries, five femoral arteries, 13 popliteal arteries, and one both popliteal arteries. The sites of thrombosis were one of aorto-iliac segment, three of iliac artery, five of femoral artery, three of popliteal artery, one of bilateral popliteal, and one of tibio-peroneal artery. The mean duration of completed infusions was 21.29 hours (range, 2-58 hours). Successful adjunctive percutaneous intervention or arterial bypass was performed in seven patients (18.9%) whose stenotic lesions were disclosed following CDT The 30-day perioperative mortality and 30-day amputation-free survival rates of the patients treated by CDT were 10.8% (4 of 37 patients) and 86.5% (32 of 37 patients) respectively. Both 6-month and 1-year amputation free survival rate were 78.4% (29/37). Technical success rate was 75.7% (28/37) whereas clinical success was 86.5% (32/37). Technical success rate was 80.0% (28/35) if ischemic symptom onset was no longer than six weeks. The 30-day major complications included two patients (5.4%) requiring more than four units of blood transfusion for access site hematoma, two (5.4%) large fatal intracerebral hemorrhages, one (2.7%) small intracerebral hemorrhage, one (2.7%) acute embolic stroke, and one (2.7%) death of multiple organ failure following conversion to surgical revascularization. Minor complications were distal thromboembolization in one patient (2.7%), small hematoma in seven patients (18.9%), and pseudoaneurysm in one patient (2.7%). CONCLUSION: CDT is an effective armamentarium to salvage the ischemic limb resulting from acute embolism and acute thrombosis of native artery. However bleeding complication is a major problem of this treatment. Although CDT is usually applied for ALI patients with ischemic symptom onset less than 14 days, it also provides technical success for those with the symptom onset between the second and the sixth weeks.

Transfemoral temporary aortic balloon occlusion assisting open repair for ruptured abdominal aortic aneurysms.

UNLABELLED: The mortality rate of ruptured abdominal aortic aneurysm (rAAA) is still high despite an advance in surgical technology and critical care. The authors report three patients who had successful open repairs of rAAA assisted by transfemoral temporary aortic balloon occlusion. Before the operation, these patients had severe abdominal pain with hypotension. An aortic balloon occlusion catheter was introduced into the abdominal aorta under fluoroscopy at pararenal level, which was accessed from the right common femoral artery under local anesthesia. After balloon inflation, a rapid increase in arterial blood pressure was found and general anesthetic induction was started. Finally, open repair of rAAA was successfully carried out with rapid proximal neck control by aortic balloon palpation. All the patients made an uneventful recovery during the postoperative period and were discharged on day 16, day 8, and day 17 respectively. CONCLUSION: Transfemoral temporary aortic balloon occlusion is an effective strategy in rapid proximal aortic control before a conventional open repair of rAAA. It provides immediate hemostasis resulting in stabilized blood pressure before and during anesthetic induction, and facilitated aortic neck identification.

Successful outcome of obturator bypass surgery in infected femoral pseudoaneurysm: three cases report and literature review.

The authors report a successful management of obturator bypass surgery in three patients with infected femoral pseudoaneurysm. This bypass reconstruction is an uncommon operation due to the difficult surgical technique and infrequent indications. In the present report, the authors reviewed the literature published between 1988 and 2008 consisting of 78 cases with the claim of obturator bypass surgery for this condition. It is important to note that this type of extra-anatomical bypass together with debridement and excision of infected femoral pseudoaneurysm might be another option to decrease the risk of vascular conduit infection and increase successful limb salvageability.