Open surgical repair of true saccular aneurysm of dorsalis pedis artery using a reversed great saphenous vein bypass graft.

True aneurysms of the dorsalis pedis artery (DPA) are very rare phenomena with no obvious pathophysiology. Prompt diagnosis and treatment are important due to the high risk of thrombosis, distal embolization, hemorrhage, and rupture. We present a case of a true DPA saccular aneurysm in a 58-year-old man and highlight the feasibility of using a reversed great saphenous vein bypass graft in specifically treating true DPA aneurysms. Our treatment resulted in near-immediate resolution of the patient's foot pain and mass without complications and maintaining arterial patency.

Valvulotomy of the great saphenous vein in ex situ non-reversed and in situ setting: a multicenter post-market study to assess the safety and efficacy of the AndraValvulotome™".

PURPOSE: To evaluate the safety and technical success of the AndraValvulotome™ device (Andramed GmbH, Reutlingen, Germany) in patients with peripheral arterial disease (PAD) requiring bypass surgery using the great saphenous vein (GSV) as graft. METHODS: This was a multicenter, post-market observational study conducted in 2021 in 11 German centers. Safety and efficacy data were prospectively collected and analyzed. Primary endpoints were the absence of device-related serious adverse events until 30 ± 7 days follow-up, the clinical efficacy of valvulotomy, which was defined as pulsatile blood flow in the bypass and the number of insufficiently destroyed vein valves. Secondary endpoints were the number of valvulotomy passages, the primary patency rate of the venous bypass (determined by a color-duplex sonography showing a normal blood flow through the bypass and absence of stenosis or occlusion), and the primary technical success defined as the absence of product-specific (serious) adverse events and clinical efficacy. RESULTS: Fifty-nine patients were enrolled. The mean age of the patients was 71 years (46-91), and 74.6% were males. The vein material used for bypass grafting had a median length of 47.5 cm (range 20-70 cm) with a median diameter of 5.0 mm (range 3-6 mm) and 4.0 mm (range 2-6 mm) in the proximal and distal segments, respectively. The technical success rate was 96.6%. The primary patency rate was 89.9% at 30 days follow-up. The clinical efficacy was rated as very good in 81% of patients, fair in 17%, and poor in 2%. Between 1 and 5 (average 2.9) valvulotome passages were performed. One product-related serious adverse event was recorded (bypass vein dissection). CONCLUSION: The AndraValvulotome™ can be considered a safe and effective device to disrupt venous valves during in situ non-reversed bypass surgeries using GSV grafts in patients with PAD.

Bypass in situ distal / Distal bypass in situ

La revascularización distal de las extremidades inferiores siempre fue motivo de controversia en la década de losaños ochenta del siglo pasado entre los que defendían el bypass de vena safena invertida frente al bypass de venasafena in situ, aunque los resultados, como se demostró posteriormente, fueron similares. Lo importante era elmaterial sustitutivo (la vena autóloga) y la técnica de revascularización del cirujano. el bypass in situ permitía una disposición anatómica sin generar disparidad de calibres en la parte proximal y distalde las anastomosis vasculares, lo que evitaba el riesgo de torsiones. es cierto que comportaba riesgos secundarios,como la persistencia de fístulas arteriovenosas y la necesidad inherente de rasgar las válvulas venosas. Diversosartilugios y métodos se usaron a lo largo del tiempo, pero finalmente el valvulotomo de Lemaitre se estableciócomo uno de los más seguros. Los autores de este artículo describen cómo lo hacen y señalan los puntos críticospara optimizar el resultado, si bien son conscientes de que habrá variantes entre grupos quirúrgicos, pero mante-niendo la esencia del procedimiento.(AU)

Distal revascularization of the lower extremities was always a source of controversy in the 1980s among thosewho advocated reverse saphenous vein bypass versus in situ saphenous vein bypass, although the late resultsdemonstrated that both approaches were similar. the important fact was the substitute material (the autologousvein) and the revascularization technique of the vascular surgeon.the in-situ bypass allowed an anatomical position without produces caliber disparity in the proximal and distalvascular anastomoses, avoiding the risk of twisting. It is true that it carried secondary risks such as the persistenceof arteriovenous fistulas and the inherent need to tear the venous valves. Various methods were used over time,but eventually Lemaitre's valvulotome established itself as one of the safest. the authors of this article describehow they do it and point out the critical points to optimize the result, although they are aware that there will bevariations between surgical groups, but maintaining the essence of the procedure.(AU)

Outcomes following ipsilateral great saphenous vein bypass for lower extremity arterial injuries.

OBJECTIVE: Use of autologous great saphenous vein (GSV) grafts for repair of extremity arterial injuries is well established. Contralateral great saphenous vein (cGSV) is traditionally used in the setting of lower extremity vascular injury given the risk of occult ipsilateral superficial and deep venous injury. We evaluated outcomes of ipsilateral GSV (iGSV) bypass in patients with lower extremity vascular trauma. METHODS: Patient records at an ACS verified Level I urban trauma center between 2001 and 2019 were retrospectively reviewed. Patients who sustained lower extremity arterial injuries managed with autologous GSV bypass were included. Propensity-matched analysis compared the iGSV and cGSV groups. Primary graft patency was assessed via Kaplan-Meier analysis at 1-year and 3-years following the index operation. RESULTS: A total of 76 patients underwent autologous GSV bypass for lower extremity vascular injuries. 61 cases (80%) were secondary to penetrating trauma, and 15 patients (20%) underwent repair with iGSV bypass. Arteries injured in the iGSV group included popliteal (33.3%), common femoral (6.7%), superficial femoral (33.3%), and tibial (26.7%), while those in the cGSV group included common femoral (3.3%), superficial femoral (54.1%), and popliteal (42.6%). Reasons for using iGSV included trauma to the contralateral leg (26.7%), relative accessibility (33.3%), and other/unknown (40%). On unadjusted analysis, iGSV patients had a higher rate of 1-year amputation than cGSV patients (20% vs. 4.9%), but this was not statistically significant (P = 0.09). Propensity matched analysis also found no significant difference in 1-year major amputation (8.3% vs. 4.8%, P = 0.99). Regarding ambulatory status, iGSV patients had similar rates of independent ambulation (33.3% vs. 38.1%), need for assistive devices (58.3% vs. 57.1%), and use of a wheelchair (8.3% vs. 4.8%) compared cGSV patients at subsequent follow-up (P = 0.90). Kaplan-Meier analysis of bypass grafts revealed comparable primary patency rates for iGSV versus cGSV bypasses at 1-year (84% vs. 91%) and 3-years post-intervention (83% vs. 90%, P = 0.364). CONCLUSION: Ipsilateral GSV may be used as a durable conduit for bypass in cases of lower extremity arterial trauma where use of contralateral GSV is not feasible, with comparable long-term primary graft patency rates and ambulatory status.

Impact of target vessel choice on outcomes following percutaneous coronary intervention in patients with a prior coronary artery bypass graft.

OBJECTIVES: To evaluate and compare characteristics and clinical outcomes of percutaneous coronary intervention (PCI) among target vessel types in patients with a prior coronary artery bypass graft (CABG) surgery. BACKGROUND: Patients with a prior CABG often require repeat revascularization with PCI. Graft PCI has been associated with worse outcomes compared to native vessel PCI, yet the optimal PCI strategy in prior CABG patients remains unknown. METHODS: We stratified prior CABG patients who underwent PCI at a tertiary-care center between 2009 and 2017 by target vessel type: native vessel, venous graft, and arterial graft. The primary outcome of major adverse cardiac events (MACE) was a composite of all-cause death, myocardial infarction, stent thrombosis, or target vessel revascularization up to 1 year post-PCI. RESULTS: Prior CABG patients (n = 3983) represented 19.5% of all PCI interventions during the study period. PCI was most frequently performed on native vessels (n = 2928, 73.5%) followed by venous (n = 883, 22.2%) and arterial grafts (n = 172, 4.3%). Procedural success and complications were similar among the groups; however, slow- and no-reflow phenomenon was more common in venous graft PCI compared to native vessel PCI (OR 4.78; 95% CI 2.56-8.95; p < 0.001). At 1 year, there were no significant differences in MACE or in its individual components. CONCLUSIONS: Target vessel choice did not appear to affect MACE at 1 year in a large cohort of patients with prior CABG undergoing PCI. Whether PCI of surgical grafts versus native arteries truly results in similar outcomes warrants further investigation in randomized controlled trials.

Saphenous vein graft near-infrared spectroscopy imaging insights from the lipid core plaque association with clinical events near-infrared spectroscopy (ORACLE-NIRS) registry.

OBJECTIVES: We sought to examine near-infrared spectroscopy (NIRS) imaging findings of aortocoronary saphenous vein grafts (SVGs). BACKGROUND: SVGs are prone to develop atherosclerosis similar to native coronary arteries. They have received little study using NIRS. METHODS: We examined the clinical characteristics and imaging findings from 43 patients who underwent NIRS imaging of 45 SVGs at our institution between 2009 and 2016. RESULTS: The mean patient age was 67 ± 7 years and 98% were men, with high prevalence of diabetes mellitus (56%), hypertension (95%), and dyslipidemia (95%). Mean SVG age was 7 ± 7 years, mean SVG lipid core burden index (LCBI) was 53 ± 60 and mean maxLCBI4 mm was 194 ± 234. Twelve SVGs (27%) had lipid core plaques (2 yellow blocks on the block chemogram), with a higher prevalence in SVGs older than 5 years (46% vs. 5%, P = 0.002). Older SVG age was associated with higher LCBI (r = 0.480, P < 0.001) and higher maxLCBI4 mm (r = 0.567, P < 0.001). On univariate analysis, greater annual total cholesterol exposure was associated with higher SVG LCBI (r = 0.30, P = 0.042) and annual LDL-cholesterol and triglyceride exposure were associated with higher SVG maxLCBI4 mm (LDL-C: r = 0.41, P = 0.020; triglycerides: r = 0.36, P = 0.043). On multivariate analysis, the only independent predictor of SVG LCBI and maxLCBI4mm was SVG age. SVG percutaneous coronary intervention was performed in 63% of the patients. An embolic protection device was used in 96% of SVG PCIs. Periprocedural myocardial infarction occurred in one patient. CONCLUSIONS: Older SVG age and greater lipid exposure are associated with higher SVG lipid burden. © 2016 Wiley Periodicals, Inc.

Giant and complex aneurysms treatment with preservation of flow via bypass technique.

Due to their anatomical characteristics and the complexity of the procedures required to obtain their complete occlusion, the treatment of giant intracranial aneurysms is a real challenge. Direct reconstructive strategies, whether by interventional neuroradiology (coils, stents) or microsurgical (clipping) means, are not always applicable and, in patients that would not tolerate parent or collateral artery sacrifice, the adjunction of a revascularization procedure using a bypass technique might be necessary. Cerebral arterial bypasses can be classified according to their function (3 types: flow replacement, flow reversal or protective), the branching mode of the graft used (3 types: pedicled, interpositional or in situ), the sites of anastomosis (2 types: extracranial-intracranial or intracranial-intracranial) and the class of flow they are supposed to provide (3 types: low-, intermediate- or high-flow). In this article, the authors review the different aspects in the management of patients with a giant intracranial aneurysm using a bypass: preoperative work-up, types of bypass and indications, surgical techniques and results.

Long-term outcomes with first- vs. second-generation drug-eluting stents in saphenous vein graft lesions.

BACKGROUND: As compared with bare metal stents, first-generation drug-eluting stents (DES) improved post-procedural outcomes in aortocoronary saphenous vein graft (SVG) lesions, but there is limited information on outcomes after use of second-generation DES in SVGs. METHODS: We compared the outcomes of patients who received first- (n = 81) with those who received second-generation (n = 166) DES in SVG lesions at our institution between 2006 and 2013. Major adverse cardiac events (MACE) were defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization. RESULTS: Mean age was 66.0 ± 8.1 years and 97.6% of the patients were men. Mean SVG age was 11.1 ± 0.4 years. First-generation DES were sirolimus-eluting (n = 17) and paclitaxel-eluting (n = 64) stents. Second-generation DES were everolimus-eluting (n = 115) and zotarolimus-eluting (n = 51) stents. Median follow-up was 41 months. At 2-years post-procedure, patients with first- and second-generation DES had similar rates of death (20.91% vs. 20.27%, P = 0.916), target lesion revascularization (16.39% vs. 20.00%, P = 0.572), target vessel revascularization (20.97% vs. 23.16%, P = 0.747), myocardial infarction (26.15% vs. 23.00%, P = 0.644), and MACE (43.5% vs. 40.87%, P = 0.707), respectively. CONCLUSIONS: Outcomes with first- and second-generation DES in SVGs are similar. Novel stent designs are needed to further improve the clinical outcomes in this challenging patient and lesion subgroup. © 2015 Wiley Periodicals, Inc.

Bypass carótido-subclavio con vena safena como alternativa de tratamiento en la oclusión de la arteria subclavia izquierda / Carotid-subclavian bypass with saphenous vein as a choice in treating occlusion of the left subclavian artery

La oclusión de la arteria subclavia izquierda es un cuadro poco frecuente y que cursa de forma asintomática generalmente. La presencia de síntomas y posibles complicaciones indican el tratamiento quirúrgico. El bypass carótido-subclavio es la técnica quirúrgica más utilizada gracias a su baja morbilidad, mortalidad y elevados índices de permeabilidad a largo plazo. El propósito de este trabajo es presentar un procedimiento alternativo para el tratamiento quirúrgico de esta oclusión, en este caso, el bypass carótido-subclavio con injerto de vena safena interna. Se describe el caso de una paciente de 56 años, fumadora inveterada que acudió al Servicio de Cirugía Cardíaca y Vascular del Cardiocentro "Ernesto Guevara", Villa Clara en diciembre de 2014 por presentar dolor frecuente en el miembro superior izquierdo que limitaba la actividad física. Se diagnosticó oclusión de la primera porción de la arteria subclavia izquierda. Se realizó bypass carótido-subclavio con injerto de vena safena interna que solucionó su cuadro clínico. La paciente evolucionó satisfactoriamente con bypass permeable con ultrasonido y angio-tomografía computarizada a los dos años de operada. El bypass carótido-subclavio con injerto de vena safena interna representa una alternativa efectiva y segura en el tratamiento de la oclusión sintomática de la arteria subclavia izquierda(AU)

The occlusion of the left subclavian artery is an uncommon situation and mostly asymptomatic. The presence of symptoms and possible complications indicate the surgical treatment. The carotid-subclavian bypass is the classical surgical technique, due to its low morbidity and mortality rates, and long term permeability indexes. The objective of this paper was to present an alternative procedure for surgical treatment of this type of occlusion, that is, the carotid-subclavian bypass with internal saphenous vein graft. Here is a 56 year-old female , heavy smoker patient who went to the heart and vascular surgery of "Ernesto Guevara" cardiological center in Villa Clara province on December 2014. She presented with frequent pain in the left upper limb that restricted her daily physical activity; the diagnosis was occlusion of the first portion of the left subclavian artery. The patient underwent left carotid-subclavian bypass surgery using a greater saphenous vein graft that eliminated the clinical picture. The patient recovered satisfactorily with a permeable bypass and she was performed ultrasound and angiographic computer tomography after two years of operation. Carotid-subclavian bypass with greater saphenous vein graft represents an effective and safe alternative in the treatment of the symptomatic occlusion of the left subclavian artery(AU)

Anterograde flow compromise of a patent left internal mammary artery graft from a proximal subclavian artery stenosis. Myocardial ischemia not driven by the coronary-subclavian steal syndrome mechanism / Compromiso anterógrado del flujo de un puente de arteria mamaria izquierda debido a estenosis de la arteria subclavia. Isquemia miocárdica por un mecanismo distinto al síndrome de robo coronario-subclavio

A 54-year male with previous triple vessel coronary artery and aorto-bifemoral bypass graft surgeries complained of crescent angina. Stress induced myocardial ischemia on echocardiography was demonstrated. We performed direct stenting of a saphenous vein graft to the right coronary artery, via right radial approach. Subsequently stenting of a severe left subclavian artery proximal stenosis was performed via right brachial approach in order to relieve an overt myocardial ischemia in the territory supplied by a patent left internal mammary artery graft originated distally to the left subclavian stenosis. The finding of a total left axillary artery occlusion complement the pathogenesis of myocardial ischemia produced by limited anterograde flow and not driven by the common flow reversal mechanism of a typical coronary-subclavian steal syndrome.

Se trata de un paciente masculino de 54 años de edad, con antecedentes de cirugía de revasuclarización miocárdica por enfermedad coronaria trivascular, así como puentes aortobifemorales. Se presentó en nuestro centro aquejando de angina de pecho, de patrón creciente. Se demostró la existencia de isquemia miocárdica, mediante ecocardiografía con estrés farmacológico. Realizamos una angioplastia con stent a un puente de safena inversa a la coronaria derecha por vía radial derecha. Posteriormente debido a una estenosis proximal severa de la arteria subclavia izquerida, implantamos un stent mediante vía braquial derecha, con la idea de mejorar la isquemia existente en el territorio previamente revascularizado por un puente de arteria mamaria izquierda, que se originaba distalmente a la estenosis de la arteria subclavia. El hallazgo de una oclusión total crónica a nivel de la arteria axilar izquierda completó la patogénesis de la isquemia miocárdica no condicionada por robo al flujo coronario, como tradicionalmente sucede en el síndrome de robo subclavio coronario. En este caso particular, el mecanismo isquémico fue debido al compromiso anterógrado de flujo, provocado por la estenosis severa de la arteria subclavia.

The results of in situ saphenous vein bypass for infrainguinal arterial reconstruction: Comparison between two types of valvulotomes.

PURPOSE: To evaluate the authors' experiences with in situ saphenous vein bypasses that were performed using two types of valvulotomes and to respectively compare their efficacy on the basis of the operative outcomes. METHODS: Between June 1993 and December 2008, 103 constructive in situ saphenous vein bypasses were performed, of which 53 were performed between 1993 and 2000 using an Insitucat valvulotome (B Braun Melsungen AG, Germany), and 50 were performed between 2000 and 2008 using a LeMaitre valvulotome (LeMaitre Vascular Inc, USA). RESULTS: There were no statistical differences with regard to age, sex and bypass procedures between the two groups. Critical limb ischemia (P=0.021) and diabetes (P=0.005) were more frequent in the LeMaitre group than the Insitucat group. Intraoperative graft revisions (P=0.079) and graft spasms (P=0.638) were less frequent in the LeMaitre group. Graft failures in the perioperative period or within the first year were less frequent in the LeMaitre group. The five-year cumulative primary patency rates were 63.2% and 59.8% in the LeMaitre and Insitucat groups, respectively (χ(2)=0.390, not significant). The five-year cumulative secondary patency rates were 91.9% and 81.7% in the LeMaitre and Insitucat groups, respectively (χ(2)=2.690, not significant). CONCLUSIONS: The results suggested that there were no significant differences in the outcome and adverse effects between the two types of valvulotomes for in situ saphenous vein bypass.

External Carotid Artery to Middle Cerebral Artery Bypass with Saphenous Vein Graft for a Giant Internal Carotid Artery Aneurysm at the Cavernous Portion

The authors reports a case of giant carotid artery aneurysm at the cavernous portion which was treated by trapping of internal carotid artery(ICA) after external carotid artery(ECA) to middle cerebral artery(MCA) bypass by long saphenous vein graft. It was impossible to clip the aneurysm because of its position and size. The patient suffered from progressive extraocular movement disturbance and decreased visual acuity. She was intolerant to ballon occlusion test. The size of the aneurysm was 3.5x2.5x2 cm. ECA to MCA bypass was done with saphenous vein graft successfully. However, computerized tomography shows hemorrhagic infraction at left temporal lobe postoperatively. Two days later, left temporal lobectomy was done because of uncontrollable increased intracranial pressure. Internal carotid artery was trapped with proximal ligation and distal clipping at the supraclinoid segment.