Long-Term Results of Autologous Bifurcated Carotid Artery Reconstructions.

BACKGROUND: Carotid bifurcation revascularization using interposition grafts is rare. While internal carotid artery (ICA) revascularization is regarded as mandatory, the external carotid artery (ECA) is severed in most instances. Long-term results of an autologous bifurcated carotid artery reconstruction are discussed. METHODS: Single-center, retrospective analysis of a consecutive series of patients treated at an academic vascular surgery center. RESULTS: From December 2006 to November 2019, fifty-one patients underwent reconstruction of the carotid artery using an autologous bifurcated interposition graft (38 males, 75%; median age: 68.7 years; interquartile range [IQR]: 60.2-76.5). Thirty-eight patients were asymptomatic (74.5%). Indication for reconstruction was recurrent carotid stenosis unfavorable for endovascular treatment/redo patch plasty (n = 32, symptomatic: n = 7), carotid aneurysm (n = 11, symptomatic: n = 5), neck tumor with vascular involvement (n = 7), trauma (n = 1). Nonreversed valve depleted saphenous vein y-graft from the groin was used in 49 (94.2%) and reversed cubital vein bifurcation in 3 (5.8%) procedures. The median ICA cross-clamp time was 15 min (IQR: 13-20 min). In four procedures (7.7%), a shunt was inserted because of a significant decrease of cerebral perfusion. In one patient, additional intraoperative stent placement of a proximal common carotid artery (CCA) stenosis was performed. Six patients suffered from ischemic neurological deficits (11.5%), all but 1 recovered with no or moderate symptoms. After a median follow-up of 5.2 years (IQR: 1.1-8.7 years), 7 significant asymptomatic stenoses (13.5%) and 2 occlusions (3.8%, one symptomatic) of the ICA, two significant asymptomatic CCA stenoses (3.8%), five significant stenoses (9.6%) and 7 asymptomatic occlusions (13.5%) of the ECA were observed. This prompted 7 re-redo-interventions in 5 patients. Twenty-eight patients (54.9%) died after a median follow-up of 3.3 years (IQR: 0.5-5.6 years). Two of these patients died due to conditions related to the performed carotid artery reconstruction. CONCLUSIONS: Autologous bifurcated carotid artery interposition graft provides results comparable to other complex ICA revascularizations. Overall survival in this heterogeneous patient cohort is poor. Due to the high risk of stroke and poor long-term outcome, this procedure should be reserved for symptomatic patients with no other option for revascularization.

Preoperative anxiety as predictor of perioperative clinical events following carotid surgery: a prospective observational study.

BACKGROUND: Psychological factors like anxiety and depression are recognised to play a causal role in the development of cardiovascular disease and they may also influence outcome after vascular surgery procedures. The aim of this study was to investigate the association of anxiety and depression with postoperative outcome following elective carotid surgery. METHODS: Single centre prospective observational study of patients treated for asymptomatic carotid artery stenosis at an academic vascular surgery centre. Preoperative anxiety and depression were evaluated using self-reporting questionnaires: Spielberger State-Trait Anxiety Inventory (STAI-S/-T) and Hospital Anxiety and Depression Scale (HADS-A/-D). Postoperative morbidity and mortality were assessed with the primary composite endpoint of stroke, myocardial infarction (MI) and death. Standard reporting guidelines for carotid disease were applied. RESULTS: From June 2012 to November 2015, 393 carotid endarterectomies (CEA) were performed at our institution. Out of those, 98 asymptomatic patients were available for analysis (78% male; median age, 71.1 years). Median scores of self-reporting questionnaires did not differ from published data of the general population (STAI-T, trait component, median, 36; IQR, 31-42.75; STAI-S, state component, median, 38; IQR, 32-43; HADS-A median, 6; IQR, 3-8; HADS-D median, 4; IQR, 2-7). Cardiovascular risk factors were similar in anxious and non-anxious patients. The composite endpoint of stroke, MI and death occurred significantly more often in patients presenting with a preoperative HADS-A score higher than 6 (10.5%, 95% CI, 3-25; p =.020). CONCLUSIONS: The present study indicates that preoperative anxiety is associated with the occurrence of intra- and postoperative neurological events in patients undergoing CEA. Patients who had a preoperative HADS-A score of 6 or less had a very low probability of experiencing these complications.

Trans-Iliac Bypass Grafting for Vascular Groin Complications.

OBJECTIVES: Groin complications following vascular reconstruction, extensive trauma, or severe radiation induced scarring may complicate future revascularisation procedures of the lower limb. Although several techniques have been described, only few cases of trans-iliac bypass grafting have been published. The aim of this study was to perform a review of the literature on trans-ilac bypass grafting and add the authors' experience. METHODS: A single centre retrospective data analysis and a literature review of all trans-iliac bypass procedures was performed. Data on indication, patency, limb salvage, and survival were collected. Study endpoints were patency, limb salvage, and patient survival. RESULTS: Eight trans-iliac wing bypass grafting procedures were performed in our institution between 2003 and 2018, which represents the largest single centre series. Twenty-three procedures were reported in the literature between 1989 and 2018. Prior to the bypass procedure in the eight patients, six had local infection and two irradiation of the groin. The indication for operation was ischaemia in six cases, bleeding in one case, and infection in another case. The external iliac artery was most often used for the proximal (6 cases) and the superficial femoral artery for distal anastomosis (6 cases). Great saphenous vein was the most commonly used graft material (6 cases). The median follow up was five years with three bypass occlusions after 1, 2, and 8 months, followed by two successful thrombectomy procedures. There were no major amputations and only one death after five months, which was not procedure related. CONCLUSIONS: Trans-iliac bypass grafting is a viable alternative extra-anatomic bypass technique in patients with vascular groin complications. Patency as well as limb salvage and survival are good and may be comparable to those reported for autologous in situ repair and obturator canal bypass grafting.

Autologous Bifurcated Carotid Artery Reconstruction: Technique and 2 Year Follow Up.

OBJECTIVE/BACKGROUND: Carotid bifurcation resection with subsequent reconstruction is performed infrequently. While internal carotid artery (ICA) revascularisation is regarded as mandatory, the external carotid artery (ECA) is severed in most instances. Indications for and results of an autologous bifurcated carotid artery reconstruction are discussed. METHODS: This was a single centre retrospective analysis of a consecutive series of patients treated at an academic vascular surgery centre. RESULTS: From December 2006 to August 2015, 47 patients underwent reconstruction of the carotid artery using an autologous bifurcated interposition graft (36 men; median age 68.3 years [range 41-87 years]; 33 asymptomatic [70%]). The indication for reconstruction was recurrent carotid stenosis unfavorable for endovascular treatment/redo patch plasty (n = 29; symptomatic: n = 12), carotid aneurysm (n = 10), neck tumour with vascular involvement (n = 7), and trauma (n = 1). Groups were not different with regard to vascular risk factors. Non-reversed valve depleted saphenous/accessory saphenous vein from the groin was used in 44 (94%), and reversed valve depleted cubital vein bifurcation graft in three patients (6%). Median ICA cross clamp time was 17 min (range 8-30 min). Five patients suffered from intra-operative ischaemic neurological deficits (11%), of which all were temporary except one. One tumour patient died on post-operative day 1 due to bleeding. Median follow up was 28.3 months (range 0.1-97.4 months). Tumour erosion required graft ligation in one patient 7 months after reconstruction. Five significant stenoses of the ICA (11%), nine (19%) stenoses of the ECA, and two (4%) common carotid artery stenoses, with four (8%) re-redo interventions, were observed. Thirteen patients (28%) died after a median follow up of 6.7 months (range 1.7-56.7 months), all unrelated to the vascular procedure. CONCLUSION: Autologous bifurcated carotid artery interposition graft avoids the use of prosthetic graft material, the ECA remains patent in 80%, and it provides mid-term results comparable with other redo carotid artery procedures. Therefore, this procedure should be reserved for symptomatic patients with no other revascularisation option.

Tibiodistal vein bypass in critical limb ischemia and its role after unsuccessful tibial angioplasty.

OBJECTIVE: Technical progress in angioplasty expanded its application to very distal arterial lesions of the lower extremity. In cases of unsuccessful angioplasty tibiodistal bypass surgery may be required for limb salvage. We investigated the long-term outcome of this technique in patients with critical limb ischemia. The purpose of this study was to evaluate whether tibiodistal bypasses done after unsuccessful tibial angioplasty had inferior patency, limb salvage, or survival rates compared with primary tibiodistal bypasses. METHODS: This single-center, retrospective data analysis included all distal bypass procedures originating from a tibial artery. Primary study end points were primary patency, secondary patency, and limb salvage. Secondary end points included survival, wound healing, and systemic and local complications. Society for Vascular Surgery reporting standards were applied. RESULTS: There were 61 tibiodistal vein bypasses for critical limb ischemia performed in 23 years. Indications for tibiodistal bypass was Rutherford category 5 in 41 cases (67%) and category 6 in 20 cases (33%). Procedures were allocated to group A (primary bypass; n = 28) and group B (bypass after unsuccessful tibial angioplasty; n = 33). Primary patency was 55% versus 53% at 1 year and 47% versus 44% at 3 years (P = .58). Secondary patency was 59% versus 64% at 1 year and 52% versus 55% at 3 years (P = .36). Limb salvage was 96% versus 90% at 1 year and 91% versus 85% at 3 years (P = .44). Overall survival rates were 91% versus 97% at 1 year and 85% versus 92% at 3 years (P = .76). The median follow-up was 4.0 years in group A and 4.9 years in group B. In multivariate analyses for loss of primary patency and limb loss, no significant predictors could be identified. CONCLUSIONS: This study showed that tibiodistal vein bypass is a feasible, efficient, and safe technique in patients with critical limb ischemia. It provides acceptable primary and secondary patency rates to prevent major amputation and ensure survival. Previous unsuccessful tibial angioplasty had no significant impact on tibiodistal vein bypass outcome. This technique should be part of the armamentarium of vascular surgeons.

Successful repair of bilateral common carotid artery dissections from hanging.

The management of blunt carotid artery dissections caused by hanging remains controversial, especially with regard to diagnostic work-up and treatment options. We present 2 men, 49 and 41 years of age, who were treated for bilateral common carotid artery dissection caused by strangulation. In the first patient, additional cricotracheal separation and blunt thyroid gland trauma was observed. Bilateral saphenous vein graft interposition was accomplished in both patients. In the first patient, tracheal repair and suture of the thyroid gland completed the procedure. At 1 year of follow-up, both patients were capable of managing their lives independently. A systematic review of the literature on managing near-hanging and nonfatal strangulation victims is included in this report to allow this case series to be put into perspective.

Ultrasonic vein mapping prior to infrainguinal autogenous bypass grafting reduces postoperative infections and readmissions.

OBJECTIVE: Although duplex vein mapping (DVM) of the great saphenous vein (GSV) is common practice, there is no level I evidence for its application. Our prospective randomized trial studied the effect of preoperative DVM in infrainguinal bypass surgery. METHODS: Consecutive patients undergoing primary bypass grafting were prospectively randomized for DVM of the GSV (group A) or no DMV of the GSV (group B) before surgery. Society for Vascular Surgery reporting standards were applied. RESULTS: From December 2009 to December 2010, 103 patients were enrolled: 51 (group A) underwent DVM of the GSV, and 52 (group B) did not. Group A and group B not differ statistically in age (72.8 vs 71.1 years), sex (women, 29.4% vs 34.6%), cardiovascular risk factors, body mass index (25.9 vs 26.1 kg/m(2)), bypass anatomy, and runoff. Group A and B had equal operative time (151.4 vs 151.1 minutes), incisional length (39.4 vs 39.9 cm), and secondary bypass patency at 30 days (96.1% vs 96.2%; P = .49). Conduit issues resulted in six intraoperative changes of the operative plan in group B vs none in group A (P = .014). Median postoperative length of stay was comparable in both groups (P = .18). Surgical site infections (SSIs) were classified (in group A vs B) as minor (23.5% vs 23.1%; P = 1.0) and major (1.9% vs 21.2%; P = .004). Readmissions due to SSIs were 3.9% in group A vs 19.2% in group B (P = .028). Two patients in group B died after complications of SSIs. Multivariate analysis identified preoperative DVM as the only significant factor influencing the development of major SSI (P = .0038). CONCLUSIONS: Routine DVM should be recommended for infrainguinal bypass surgery. The study found that preoperative DVM significantly avoids unnecessary surgical exploration, development of major SSI, and reduces frequency of readmissions for SSI treatment.

Management of iatrogenic common femoral artery injuries in pediatric patients using primary vein patch angioplasty.

BACKGROUND: Invasive therapeutic and diagnostic procedures remain the most frequent causes of pediatric vascular injuries. Ideal management, especially the indication for surgical treatment, remains controversial. This study evaluates the outcome of surgical repair for iatrogenic common femoral artery (CFA) injuries in pediatric patients using primary vein patch angioplasty. METHODS: From January 1996 through February 2006, 8 patients were identified in the vascular registry of the Vienna General Hospital in Austria. A retrospective office chart review was performed on this consecutive series of patients treated for iatrogenic CFA injuries using primary vein patch angioplasty. RESULTS: The mean age was 5.8 years (range, 0.3-10.9 years). Surgical repair was performed for 5 ischemic limbs and 3 pseudoaneurysms. Urgent repair was necessary in 5 children (62.5%). After a median follow-up of 9 months (range, 1.8-77.6 months), palpable pedal pulses were present in all patients. No aneurysmatic degeneration of vein patches occurred, and no patient sustained any additional sequelae related to the arterial reconstruction. CONCLUSION: Routine use of a vein patch eases CFA repair, especially in the very young.

Redo pedal bypass surgery after pedal graft failure: gain or gadget?

Pedal bypass failure is not always associated with limb loss. Management of critical limb ischemia after failure is controversial. The aim of this study is to evaluate the results of redo bypass procedures to foot arteries in the absence of alternative tibial outflow arteries. Data of patients undergoing redo pedal bypass within a 14-year period were reviewed. The outcome after redo pedal bypass in patients whose original pedal bypass failed within 30 days versus those in patients whose original pedal bypass failed more than 30 days after the original pedal bypass were reviewed. Society for Vascular Surgery reporting standards were applied. Out of 335 pedal bypass grafts, 22 (6.6%) pedal redo bypass procedures were identified in 20 patients performed after previous pedal graft failure: 64% were male, mean age 67.7 +/- 9.5 years, diabetes 90.9%, hypertension 90.9%, coronary disease 68.2%, renal disease 18.2%. Seven patients were operated for early failure and 15 for late failure (median 193 days). The graft conduit at the first operation was ipsilateral greater saphenous vein (GSV) in 18 (81.8%), alternative vein in three (13.6%), and one expanded polytetrafluoroethylene. Redo graft conduits were as follows: ipsilateral GSV in nine (40.9%), arm vein in six (27.3%), contralateral GSV in two (9.1%), "other veins" in two (9.1%), and homologous artery in three (13.6%). The same target artery was used in 81.8%, at the initial site in 54.5% and more distally in 27.3%. Redo revascularization for early failure was successful only once. Median follow-up after late redo was 23.7 months. Seven redo grafts performed after late pedal graft failure failed after a median of 115 days. The availability of adequate autologous conduit is the limiting factor for redo procedures. Lack of alternative outflow sites adds to the difficulty of target artery dissection. Redo pedal bypass surgery after early pedal bypass failure is associated with very poor patency and limb salvage. Acceptable patency and extension of limb salvage can be achieved with redo procedures for late pedal bypass failure.

Timing of pedal bypass failure and its impact on the need for amputation.

Although the utility of dorsalis pedis (DP) bypass for limb ischemia has been well established, the fate of limbs with a failed bypass to the DP artery remains unclear. Data of all patients undergoing DP bypass grafting within a 12-year period from two university hospitals' vascular registries were retrospectively reviewed. Outcomes of early (<30 days) and delayed graft failure (>30 days) were examined. The Student's t-test and chi-squared test were used for univariate analysis; patency rates and patient survival were calculated using the Kaplan-Meier product limit method. Of 1434 DP bypass grafts, 277 (19.3%) failed grafts were identified. Sixty five (4.5%) grafts failed early (within 30 days of surgery) and 212 (14.8%) failed late at a mean time of 15.3 months (range, 1.5-105 months) after initial bypass. Of the 65 limbs with early graft failure, 28 (43.1%) proceeded directly to amputation and 20 underwent additional revascularization attempts, but limb salvage was achieved in only 7 patients; in 45 (69.2%) patients no further revascularizations were attempted. Seventy-four (34.9%) patients with late graft failure underwent redo revascularization. Thirty-nine (52.6%) had their limb saved with graft revision, but 35 patients (47.3%) ultimately lost their limb. In 138 patients with late graft failure (65.1%) no further revascularization attempts were performed. Sixty-two (44.9%) required major amputation. Overall, 49.8% of patients with failed pedal grafts ultimately suffered limb loss. Early graft failure resulted in a significantly higher rate of major amputation that did late graft failure (63.1% vs. 45.8%, respectively; p = 0.015). These results indicate that early occlusion of pedal bypass often leads to immediate major amputation and interventions to maintain graft patency in this setting are often futile. Late failure of pedal bypass is associated with a lower likelihood of amputation because of a higher rate of success of bypass revisions and a lower occurrence of critical ischemia with graft failure.

Anatomic basis of right renal vein extension for cadaveric kidney transplantation.

OBJECTIVES: The right renal vein (RRV) may be difficult to anastomose in right cadaveric kidney transplantation, especially in obese recipients in whom iliac vessels are deep. In this study, gain of length and feasibility in the presence of vascular variations obtained with three common techniques of renal vein augmentation--clamshell (CS), transverse closure of the inferior vena cava (TC), and cava conduit (CC)--were analyzed and compared to the Carrel-patch technique. METHODS: The renal vasculature and the inferior vena cava of 119 cadavers were accurately dissected and measured, and the vascular variations documented. The CS technique augmented the RRV at most by one fourth, the TC by one half the diameter of the inferior vena cava, and the CC by the length of the infrarenal inferior vena cava. An experienced transplant surgeon evaluated the situs for the feasibility of the techniques. RESULTS: The variations found were multiple veins (right, 23%; left, 6.7%), a retroaortal left vein (2.5%), a renal collar (6%); and multiple arteries (right, 20.2%; left, 19%). The RRV length varied from 21 to 71 mm, and the right renal artery (RRA) length varied between 44 and 111 mm. The RRA/RRV ratios ranged between 3.4 and 1.2. The achieved gains of length were 129% with the CS (possible in 81.5%), 190% with the TC (possible in 62.4%), and 388.4% with the CC (possible in 80.7%). CONCLUSIONS: The median RRV is one half the RRA in length so that length augmentation could be an advantage. Anatomic variations limit the choice of technique. Overall, augmentation was possible in 80%; the CS technique seldom resulted in a length equal to that of the RRA, the TC was the most susceptible to variations, and the CC always surpassed the RRA in length. Harvesting the RRV en bloc with the inferior vena cava enables the surgeon to best adapt donor vessels to the recipient's anatomy.