Infrapopliteal Bypass In Patients On Dialysis: Patency And Survival.

INTRODUCTION: Portugal has one of the highest prevalence of patients on a regular dialysis program. This population has a higher incidence of peripheral arterial disease with higher rates of postoperative morbidity and mortality. Our goal was to compare outcomes between dialysis and non-dialysis patients with chronic limb threatening ischemia (CLTI) submitted to infrapopliteal bypass. MATERIALS AND METHODS: A retrospective single-center study of infrapopliteal bypass for CLTI was performed between 2012 and 2019. Patients were divided in two groups based on dialysis status (group 1 incorporated patients on dialysis). Primary end point was 1-year freedom from CLTI. Secondary end points were limb-salvage, survival and primary (PP) and tertiary patency (TP) rates at 3 years of follow-up. RESULTS: A total of 352 infrapopliteal bypasses were performed in 310 patients with CLTI. Fourteen percent of the revascularizations were performed on dialysis patients (48/352). Median age was 73 years (interquartile range - IQR 15) and 74% (259/352) were male. Median follow-up was 26 months (IQR 42). Overall, 92% (325/352) had tissue loss and 44% (154/352) had some degree of infection. The majority of revascularization procedures were performed with vein grafts (61%, 214/352). The 30-day mortality was 4% (11/310), with no difference between groups (p = 0.627). Kaplan-Meier analysis showed no difference between groups regarding freedom from CLTI (76% vs. 79%; HR 0.96, CI 0.65-1.44, p=0.857), limb-salvage (70% vs. 82%; HR 1.40, CI 0.71-2.78, p=0.327) and survival (62% vs. 64%; HR 1.08, CI 0.60-1.94, p=0.799). PP rates were 39% in group 1 and 64% in group 2 (HR 1.71, CI 1.05-2.79, p=0.030). TP rates were not different between groups (57% and 78%; HR 1.79, CI 0.92-3.47, p=0.082). CONCLUSION: Infrapopliteal bypass for CLTI, on dialysis patients, resulted in lower PP rates. No differences were observed in freedom from CLTI, TP, limb salvage and survival.

Heparin-Bonded Expanded Polytetrafluoroethylene Is a Solution for Infrapopliteal Revascularization in the Absence of an Adequate Autologous Vein Graft.

BACKGROUND: To analyze the outcomes of heparin-bonded expanded polytetrafluoroethylene (HePTFE) graft as an alternative conduit in infrapopliteal revascularization of chronic limb-threatening ischemia (CLTI) in the absence of an autologous vein conduit. METHODS: A single-center retrospective analysis of patients with CLTI submitted to infrapopliteal bypasses with autologous vein graft (VEIN group) or HePTFE graft (HePTFE group) was implemented. Primary end points were freedom from CLTI at 12 months and recurrence of CLTI at 3 years. Secondary end points included freedom from major amputation, amputation-free survival (AFS), survival, and primary (PP) and secondary patency (SP) rates at 3 years of follow-up. RESULTS: A total of 348 limbs submitted to infrapopliteal bypasses, 214 with venous graft and 134 with HePTFE graft, were followed-up for a median of 25 months. Most patients of the HePTFE group were male (69%), with a median age of 76 years (interquartile range [IQR] 15). Fifty-nine percent of the limbs of the HePTFE group had Wound grade ≥2, being 46% of them infected. Eighty-eight percent were GLASS stage III. Freedom from CLTI was not significantly different between HePTFE and VEIN groups (75% vs. 84%, adjusted hazard ratio [aHR] 0.88, confidence interval [CI] 0.66-1.18, P = 0.401). Recurrence of CLTI was higher in the HePTFE group (42% vs.18% at 3 years; aHR 2.82, CI 1.59-5.00, P < 0.001). The VEIN group achieved higher rates of freedom from major amputation (87% vs.69% at 3 years; aHR 2.21, CI 1.31-3.75, P = 0.003) and AFS (59% vs. 37% at 3 years; aHR 1.39, CI 1.02-1.88, P = 0.036), but no significance in survival (aHR 1.10, CI 0.72-1.66, P = 0.667). Patency rates were inferior in the HePTFE group, with 2-year PP and SP rates of 52% vs. 74%, and 76% vs. 90%, respectively (PP: aHR 1.70, CI 1.11-2.59, P = 0.014; SP: aHR 2.51, CI 1.42-4.42, P = 0.001). CONCLUSIONS: Infrapopliteal bypass with autologous vein graft is the gold standard to treat CLTI limbs. HePTFE graft should be regarded as an alternative for complex infrapopliteal revascularization when lacking an autologous vein conduct.

Evaluation of global limb anatomic staging system for patients with chronic limb-threatening ischemia treated with autogenous bypass grafts.

OBJECTIVE: We evaluated the relationship of the global limb anatomic staging system (GLASS) stage with the clinical outcomes for patients with chronic limb-threatening ischemia (CLTI) who had undergone distal bypass with vein grafting. METHODS: We performed a single-center, retrospective analysis of patients with CLTI who had undergone distal bypass with vein grafting from January 2012 to December 2019. The primary end point was freedom from CLTI, including amputation-free survival, complete wound healing, and no ischemic rest pain. The secondary end points included a composite outcome of recurrence (patients who had achieved freedom from CLTI but had developed a new wound or ischemic rest pain), major limb amputation, amputation free-survival, overall survival, major adverse limb events, limb-based patency, and primary and secondary patency rates. RESULTS: A total of 190 patients had undergone 211 distal bypasses with a median follow-up of 30 months. Of these patients, 80% had had diabetes or end-stage renal disease requiring dialysis. Most patients (63%) had experienced major or extensive tissue loss (WIfI [wound, ischemia, foot infection] wound class ≥2), and more than one half of these had had some degree of infection of the foot. A severe anatomic pattern (GLASS stage III) was predominant, with a prevalence of 78%. No significant differences were found between GLASS stage I and II and GLASS stage III groups for all the outcomes analyzed. Approximately 80% of the 211 revascularized limbs were free of CLTI at 12 months after treatment. At 4 years of follow-up, we observed that 25% of the patients had had CLTI recurrence, 83% were free from major amputation, and 61% were free from major adverse limb events. Limb-based patency, primary patency, and secondary patency were 79%, 80%, and 93% at 1 year and 64%, 65%, and 81% at 4 years, respectively. CONCLUSIONS: The GLASS stage was not related to patency or the clinical outcomes after distal bypass with vein grafting. Distal open revascularization resulted in excellent rates of freedom from CLTI with low rates of CLTI recurrence, two key time-integrated outcomes of clinical disease severity for patients with CLTI.

Clinical outcomes of aortic arch hybrid repair in a real-world single-center experience.

OBJECTIVE: Aortic arch aneurysmal disease remains a therapeutic challenge. For patients unsuitable for standard open surgery, hybrid repair with debranching of the supra-aortic arteries followed by thoracic endovascular grafting has been shown to be an effective solution. The aim of this study was to report the clinical outcomes of a single-institution experience using hybrid aortic arch repair. METHODS: The cases of all consecutive patients submitted to hybrid aortic arch repair between January 2010 and June 2018 were prospectively collected and retrospectively analyzed. The outcomes of the study were 30-day mortality, perioperative complications, 2-year survival, endoleak, and reintervention rates. RESULTS: A total of 35 patients with a median age of 71 years (interquartile range, 62-77 years) were submitted to hybrid aortic arch repair, with a median follow-up of 26.9 months (interquartile range, 2.4-63.6 months). Ten procedures (28.6%) were performed urgently for contained rupture. The most common etiology was degenerative (n = 14 [40.0%]). The proximal landing zones according to the Ishimaru classification were zone 2 in 20 patients (57.1%), zone 1 in 12 patients (34.3%), and zone 0 in 3 patients (8.6%). Early endoleaks were observed in six patients (17.1%), equally distributed between type I and type II. Late endoleaks were identified in 4 of 24 patients (16.7%; type I, n = 2 [8.3%]; type II, n = 1 [4.2%]; and type III, n = 1 [4.2%]). Thirty-day mortality rate was 14.3% (n = 5) with an early death rate of 8.7% (2/23) in elective cases and 30.0% (3/10) in urgent cases (odds ratio [OR], 4.93; confidence interval [CI], 0.68-35.67; P = .128). Except in one patient, 30-day mortality was associated with landing zone 0 or zone 1 (26.7% vs 5.0%; OR, 6.91; CI, 0.68-69.86; P = .141). Three patients (8.6%) suffered a postoperative stroke, and no episodes of spinal cord ischemia were observed. Two-year survival rate was 67.8% (CI, 49.4%-80.8%). Survival rates were significantly lower with increasing age (hazard ratio [HR], 1.10; CI, 1.03-1.18; P = .004), urgent procedure (HR, 4.80; CI, 1.56-14.80; P = .003), zone 0 or zone 1 (HR, 6.34; CI, 1.73-23.18; P = .001), presence of arrhythmia (HR, 3.76; CI, 1.22-11.62; P = .013), and cerebrovascular disease (HR, 4.12; CI, 1.38-12.35; P = .006). A multivariate analysis identified age (HR, 1.11; P = .047) and zone 0 or zone 1 (HR, 4.93; P = .033) as the only predictors for overall mortality. CONCLUSIONS: Hybrid aortic arch repair seems to be an alternative for higher risk patients not suitable for open repair, but selection of patients is crucial and may benefit from further refinement. In this study, worse outcomes were seen in older patients and those who required more proximal landing zones.

A single-center experience in the eversion femoral endarterectomy.

OBJECTIVES: Endarterectomy is the treatment of choice for arterial occlusive disease of the femoral bifurcation. Longitudinal arteriotomy and prosthetic patch angioplasty is the standard technique but, due to the increasing concerns with prosthetic-related infections and multidrug-resistant pathogens our group adopted an alternative approach. We present our experience with eversion femoral endarterectomy. METHODS: All patients submitted to eversion femoral endarterectomy in a single institution during 2016-2019 were retrospectively analyzed. Patient demographics, surgical data, and complications were captured from medical records. RESULTS: Nineteen patients, 84.2% male and a median age of 67 years (IQR 62-78) were submitted to eversion femoral endarterectomy with a median follow-up of 180 days (IQR 71-395). Seventeen (89.4%) patients were treated for chronic limb ischemia and the other two were submitted to femoral endarterectomy during endovascular aortic aneurysm repair. Most of the patients had smoking history (84.2%), followed by hypertension (68.4%), dyslipidemia (63.2%), coronary heart disease (29.4%), and diabetes (26.3%). Only 3 patients (15.8%) were submitted exclusively to endarterectomy, 13 (68.4%) were submitted to endarterectomy as an adjuvant for peripheral endovascular treatment, 2 (10.5%) as a concomitant procedure to endovascular repair of aortic aneurysm, and 1 (5.3%) was complemented with thrombectomy of the femoro-popliteal sector. Primary patency rates were 100% and 87.5% (CI (38.7-98.1)) at 6 and 12 months, respectively. Primary-assisted and secondary patency rates were 100%. The 30-day mortality rate was 5.3% (n = 1) and complication rate 10.5% (n = 2). One patient complicated with acute renal disease related to rhabdomyolysis. Another patient developed a wound-related hematoma treated with surgical drainage, but died three days after consequent to ischemia-reperfusion injury. CONCLUSIONS: Eversion femoral endarterectomy is a safe and feasible technique, with good patency results and respecting the concept of leaving nothing behind. A careful control of the proximal and distal endpoints is essential for the success of the technique.

Hybrid Surgery in Lower Limb Revascularization: A Real-World Experience from a Single Center.

BACKGROUND: Through the association of endovascular and open procedures, hybrid surgery for lower limb revascularization allows the treatment of multilevel occlusive disease with a lower risk when compared to extensive open interventions. The aim of this study is to evaluate the immediate and midterm clinical outcomes of hybrid techniques for lower limb revascularization in a cohort of patients with multilevel arterial disease. METHODS: Data from elective procedures between 2012 and 2017 were retrospectively collected regarding hybrid lower limb revascularization procedures. The outcomes of the study were categorical clinical improvement, patency rates, major amputation rates, and mortality. RESULTS: A total of 81 patients, 89 limbs, with a median age of 69 years (interquartile range [IQR] 61-73) were submitted to hybrid lower limb revascularization, with a median follow-up of 10.7 months (IQR 2.5-25.1). Treatment indications were chronic limb-threatening ischemia in 80.9% of the cases (rest pain in 18.0% and tissue loss in 62.9%). One-year primary, primary-assisted, and secondary patency rates were 78.28% (95% confidence interval [CI] 65.20-86.92), 85.12% (95% CI 72.96-92.09), and 90.19% (95% CI 79.13-95.54), respectively. Overall categorical clinical improvement was observed in 56.2%. Major amputation and mortality rates were 14.6% and 16.0%, respectively. Multilevel Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) C or D and stage IV Leriche-Fontaine classification were strongly associated with decreased categorical clinical improvement (adjusted odds ratio [aOR] 0.08, P < 0.0001 and aOR 0.25, P = 0.013, respectively). Multilevel TASC C or D was also related to higher amputation rates, contrary to clinical presentation (adjusted hazard ratio [aHR] 11.37, P = 0.002 and aHR 4.70, P = 0.091, respectively). Primary-assisted and secondary patency rates were associated with higher categorical clinical improvement (aOR 4.30, P = 0.036 and aOR 7.36, P = 0.021, respectively) and decreased major amputation rates (aHR 0.11, P = 0.003 and aHR 0.09, P = 0.001, respectively) but were not related to multilevel TASC and Leriche-Fontaine classifications. CONCLUSIONS: The present study reports a real-world experience with a large proportion of patients with chronic limb-threatening ischemia. Hybrid interventions for lower limb revascularization revealed to be a potential approach for patients with complex arterial disease that would beneficiate from less invasive procedures.

Automatic prebent customized prosthesis for pectus excavatum minimally invasive surgery correction.

Pectus excavatum is the most common deformity of the thorax. A minimally invasive surgical correction is commonly carried out to remodel the anterior chest wall by using an intrathoracic convex prosthesis in the substernal position. The process of prosthesis modeling and bending still remains an area of improvement. The authors developed a new system, i3DExcavatum, which can automatically model and bend the bar preoperatively based on a thoracic CT scan. This article presents a comparison between automatic and manual bending. The i3DExcavatum was used to personalize prostheses for 41 patients who underwent pectus excavatum surgical correction between 2007 and 2012. Regarding the anatomical variations, the soft-tissue thicknesses external to the ribs show that both symmetric and asymmetric patients always have asymmetric variations, by comparing the patients' sides. It highlighted that the prosthesis bar should be modeled according to each patient's rib positions and dimensions. The average differences between the skin and costal line curvature lengths were 84 ± 4 mm and 96 ± 11 mm, for male and female patients, respectively. On the other hand, the i3DExcavatum ensured a smooth curvature of the surgical prosthesis and was capable of predicting and simulating a virtual shape and size of the bar for asymmetric and symmetric patients. In conclusion, the i3DExcavatum allows preoperative personalization according to the thoracic morphology of each patient. It reduces surgery time and minimizes the margin error introduced by the manually bent bar, which only uses a template that copies the chest wall curvature.

Transthoracic single port with peroral assistance: an animal experiment to assess a less invasive technique for human esophageal atresia repair.

Thoracoscopic repair of esophageal atresia has becoming the gold standard in many centers because it allows a better cosmetic result and avoids the musculoskeletal sequelae of a thoracotomy. Natural orifice translumenal endocopic surgery (NOTES) is a new surgical paradigm, and its human application has already been started in some procedures. In the present study, we explore the feasibility of performing an esophagoesophageal anastomosis using a single transthoracic single port combined with a peroral access in a rabbit model to simulate repair of esophageal atresia by hybrid NOTES in a human newborn. Adult male rabbits (Oryctolagus cuniculus, n=28) were used to perform the surgical protocol. We used a transthoracic telescope with a 3-mm working channel and a flexible endoscope with a 2.2-mm working channel by peroral access. We performed total esophagotomy with peroral scissors followed by an esophagoesophageal anastomosis achieved with a rigid transthoracic scope helped by the peroral operator. Extracorporeal transthoracic knots were performed to complete the anastomosis. The anastomoses were examined in loco and ex loco, after animal sacrifice. We successfully accomplished a complete esophageal anastomosis in all rabbits using a combination of transthoracic and peroral 3-mm instruments. This study provides important insights for a possible translation of hybrid NOTES to human newborns with esophageal atresia. Forward studies to accomplish their feasibility in human newborns will still be necessary.

CD147 immunohistochemistry discriminates between reactive mesothelial cells and malignant mesothelioma.

Malignant mesothelioma (MM) is a rare form of cancer. Its histopathological diagnosis is very difficult, as it exhibits a number of different appearances that can be misinterpreted as metastatic invasion or atypical hyperplasia. Thus, there is an urgent need to identify adequate markers to distinguish between benign and malignant cells, allowing the implementation of appropriate therapies and, possibly, specific directed therapies. MM, like other tumors, show an increase in glucose uptake, due to high rates of glycolysis, inducing an intracellular overload of acids. In this context, monocarboxylate transporters (MCTs) emerge as important players, by mediating the transmembranar co-transport of lactate with a proton, thereby, regulating pH and allowing continuous glycolysis. Importantly, proper MCT expression and activity depend on its co-expression with a chaperone, CD147, which is associated with poor prognosis in cancer. Twenty-two samples including reactive mesothelial cells, MM, and atypical mesothelial hyperplasias were evaluated for immunoexpression of MCT1, MCT4, and CD147. Expression of these proteins was compared with GLUT1 as a new promising marker for MM. Although MCT isoforms were not differentially expressed in the two types of cytological specimens, CD147, as GLUT1, was almost exclusively expressed in MM. Both MCT1 and MCT4 are not able to discriminate between mesothelial reactive cells and mesothelial malignant cells, while CD147 was able to distinguish these two proliferations. If confirmed, besides being a good marker for identification of MM, CD147 may also be a target for therapeutical strategies in this rare type of tumor.

[Quality of life evaluation of the patients and parents satisfaction after Nuss procedure in the management of Pectus Excavatum]. / Avaliação da qualidade de vida dos doentes e pais dos doentes após tratamento do pectus excavatum com a técnica de Nuss.

Pectus Excavatum is the most common congenital deformity of the chest. Although Pectus Excavatum can be associated with heart or lung problems, the main indication for surgical correction of this congenital anomaly is the body image dissatisfaction. The Nuss technique is a minimally invasive procedure that allows the placement of an intrathoracic prosthetic convex bar, previously bended, which mobilize the sternum anteriorly. The aim of this study was to evaluate the degree of satisfaction of the patients and parents after the application of the Nuss technique using the Pectus Excavatum Evaluation Questionnaire. All parameters of psychosocial character - self-image, difficulties in exposing the chest, frustration, sadness, social isolation and ridicule - found a statistically significant improvement after surgical correction of Pectus Excavatum from the perspective of patients and their parents. There was not a marked improvement and consensus regarding the overall physical performance of patients. Which is understandable, since, theoretically, the physical deformity is not responsible for significant limitations on exertion. The current surgical correction of Pectus Excavatum by the Nuss technique allows obtaining aesthetic results of the chest with the resolution of the main problems with body image. Increase awareness of health issues for psychosocial and physical factors which might be involved in this kind of deformities is important, especially when there is a satisfactory solution.