Could prior endovascular interventions affect the results of lower extremity below the knee autologous vein bypasses?

BACKGROUND: Performing a non-selective primary endovascular approach involves risk of performing ineffective procedures and could compromise future treatments. The objective of this research is to determine if previous failed endovascular intervention could affect bypass results. METHODS: Retrospective cohort study including 77 below the knee (BTK) bypasses with great saphenous vein (GSV) in patients with critical limb ischemia, carried out between 2008-2018. Primary bypasses (P-BP) were compared with bypasses with history of previous failed endovascular intervention (Secondary bypasses [S-BP]). Primary outcomes included: primary, primary-assisted, and secondary patency, and major amputation-free survival (AFS). The quality of GSV used was evaluated as a potential confounding factor. RESULTS: Forty-six procedures were P-BP (59.7%) and 31 S-BP (40.3%). The mean follow-up was 35.4 (SD: 31) and 28 (DS: 30) months respectively. Univariate results showed an increased risk of loss of primary patency (HR=2.7), primary-assisted patency (HR=3.1) and secondary patency (HR=3.26) in S-BP (P<0.05). This group also presented a trend towards an increased risk of major amputation (HR=1.6; P>0.05). Suboptimal GSV was used in 29% of S-BP and 15% of P-BP. This factor was identified as confounding partially, as it decreased the influence assumed by the history of prior endovascular intervention in the analyzed variables. CONCLUSIONS: Secondary bypasses show inferior results to primary bypasses in our series. Although the cause could be a prior failed endovascular intervention, the frequent use of suboptimal GSV in this type of patients may also contribute to this effect.

Fenestrated and chimney endovascular aneurysm repair versus open surgery for complex abdominal aortic aneurysms.

BACKGROUND: Many patients with complex abdominal aortic aneurysms are unfit for open repair. New endovascular technologies and bailout techniques are being used for managing these complex anatomies. The purpose of this study is to compare the results obtained with advanced endovascular aneurysm repair (a-EVAR) techniques (fenestrated and chimney endografts) to those obtained with open repair for the treatment of complex abdominal aortic aneurysms not anatomically suitable for standard endovascular exclusion (infrarenal neck <10 mm, juxtarenal, suprarenal and Crawford's type IV thoracoabdominal aneurysms). METHODS: All patients that underwent open surgery (OS cohort; historical, January 1994-December 2015) or a-EVAR (a-EVAR cohort; prospective, January 2006-December 2015) at our institution for complex abdominal aortic aneurysms that meet the anatomical criteria described above on the preoperatory contrast-enhanced computed tomography scan were included. Vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (V-POSSUM) was employed for risk-assessment. RESULTS: A total of 108 patients were included, all of them male: 56 in the OS cohort and 52 in the a-EVAR cohort (mean age: 67.5±6.7 vs. 72.65±6.4 years, respectively; P=0.000). V-POSSUM predicted 4 deaths for the OS cohort and 3 deaths for the a-EVAR cohorts within the postoperative period and morbidity rates of 57% and a 44.4%, respectively. All-cause 30-day mortality rates were 9 patients (16%) for the OS cohort and 2 patients (3.8%) for the a-EVAR cohort (P=0.038). Thirty-day morbidity rates were 59% for the OS cohort and 44% for the a-EVAR cohort (P=0.09). Mean cost of treatment was € 15,707 per patient for the OS cohort (median: € 11,516; inter-quartilic range [IQR]: € 7901; min-max: € 5069-11,0052) and € 33,457 per patient for the a-EVAR cohort (median: € 29,663; IQR: € 5979; min-max: € 13,865-19,3536), P=0.000. CONCLUSIONS: A-EVAR is a feasible alternative to open surgery for complex abdominal aortic aneurysms at our institution, with lower 30-day mortality rates, yet increasing double the amount the total cost of the therapy.

Development of an individualized scoring system to predict mid-term survival after carotid endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) is a prophylactic surgery focused in preventing stroke in the mid-long term. The purpose of this study was to analyze mid-term mortality in patients undergoing CEA, identify predictors of 3-year mortality and design a score to estimate individual risk of mortality in this population. METHODS: A retrospective single-center study including consecutive patients undergoing CEA between 1997-2010. Demographic data and comorbidities, postoperative results and patient follow-up data were registered and evaluated. Kaplan Meier analysis was used to analyze survival. After multivariable COX regression analysis, a score based on the calculated Hazards Ratios (HR) was designed. The sum of all points performed the individual score for each patient for estimating 3-years mortality. Population was stratified into four groups according to percentiles of score obtained: Group A (-7 to 4 points), Group B (5-8 points), Group C (9-10 points), Group D (score greater than 11 points). RESULTS: A total of 453 patients with a mean follow-up of 53.4 months were included in the study. Overall 3-year survival was 88.4%. On the univariate analysis the variables associated with significant increasing in 3-year mortality were: female gender (OR 2.32), diabetes mellitus (OR 2.28), COPD (OR 2.98), ischemic heart disease (OR 2.29), critical carotid stenosis >90% (OR 2.16) and antiplatelet therapy as a protective factor (OR 0,23). Factors associated with mortality in multivariate analysis were age (HR 1.14 P=0.001), diabetes mellitus (HR 1.62, P=0.031), COPD (HR 1.88 P=0.022), ischemic heart disease (HR 1.59 P=0.05), critical stenosis >90% (HR 1.70 P=0.015) and antiplatelet therapy as a protective factor (HR 0.23 P=0.027). The scoring system includes the following items: female gender (+2 points), age (50-69 years +7 points, 70-79 years +12 points, >80 years +15 points), diabetes (+4 points), COPD (+5 points), ischemic heart disease (+4 points), carotid stenosis> 90% (+4 points). Antiplatelet (-7 points). The score range from -7 to 26 points. The 3-year mortality range was 5.6% (group A) versus 25.5% (group D). The incidence of stroke at 3-year folllow-up was not correlated with the score (99%, 100%, 97% and 94.5%, respectively groups A-D, P=0.11) CONCLUSIONS: The score developed based on the risk factors of mortality allows individualized risk prediction of 3-year mortality in patients with carotid stenosis. This represents a useful and practical tool for decision-making in the indication of the CEA, allowing surgeons to identify high-risk patients who would benefit from medical treatment due to their limited life expectancy, mainly in asymptomatic patients.