J. Nagy

Balloon Angioplasty as the Primary Treatment for Failing Infra-inguinal Vein Grafts

BACKGROUND We sought to evaluate the role of balloon angioplasty as the primary modality in the management of vein graft stenoses. METHODS Patients who underwent infrainguinal vein graft bypass from January 2002 to December 2007 were enrolled into a surveillance program. Grafts which developed critical stenoses were identified and underwent urgent angiography with a view to angioplasty of the stenotic lesion. Lesions which were deemed unsuitable for angioplasty underwent urgent surgical repair. RESULTS Four hundred and eleven grafts were followed up for a median of 19 months (range: 2-61). Ninety-six grafts (22.6%) developed critical stenosis. Twelve grafts occluded prior to repair and one was not intervened upon electively. Eight grafts underwent primary surgical repair. Seventy-six grafts underwent 99 endovascular procedures. Technical success was achieved in 60 grafts (78.9%). Of the grafts in which technical success had not been achieved, eight underwent repeat angioplasty and three were surgically repaired. Twenty-four grafts underwent repeat angioplasty for re-stenosis with a technical success rate of 71%. No difference was observed in graft patency (P=0.08) or amputation rates (P=0.32) between the grafts requiring intervention to maintain patency, and grafts which did not. Smoking [OR: 2.61 (95% CI: 1.51-4.53), (P=0.006)], diabetes [OR: 2.55 (95% CI: 1.49-4.35), (P=0.006)], renal failure [OR: 1.89 (95% CI: 1.19-3.38), (P=0.040)] and recurrent stenosis [OR: 3.22 (95% CI: 1.63-4.69), (P<0.001)] were risk factors for graft occlusion. CONCLUSIONS Balloon angioplasty of failing infrainguinal vein bypass grafts is safe and can be performed with an acceptable medium term patency rate, albeit with a significant risk of re-stenosis which can be successfully treated in most patients using repeat endovascular intervention.

Endovascular Treatment for Traumatic Popliteal Artery Pseudoaneurysms After Knee Arthroplasty

Trauma to the popliteal artery is a recognized complication of knee arthroplasty (total knee arthroplasty). It can present in a variety of ways, one of which is the development of popliteal artery pseudoaneurysm. We report the successful endovascular management of 2 patients who developed popliteal artery pseudoaneurysms following total knee arthroplasty using covered stent grafts. From presented evidence, endovascular therapy is a safe treatment modality and it appears to be a viable alternative to open surgery.

Endovascular Repair of a Ruptured Mycotic Aneurysm of the Common Iliac Artery

This report describes the case of a ruptured mycotic aneurysm of the left common iliac artery, successfully treated with endovascular stent-grafting. A 64-year-old woman underwent diagnostic coronary angiography complicated by an infected hematoma of the left groin. Seven days later, she developed methicillin-resistant Staphylococcus aureus septicemia and CT scan evidence of perivascular inflammation around the left common iliac artery. This was followed by rupture of a mycotic aneurysm of the left common iliac artery. The lesion was successfully treated with a stent-graft and prolonged antibiotic therapy, and the patient remains free of infection 10 months later. Accumulating evidence suggests that endovascular repair can be used safely for the repair of ruptured infected aneurysms.

The value of vein graft surveillance in bypasses performed with small-diameter vein grafts.

We assessed the impact of preoperative diameter of the venous conduit on reintervention rate and outcome following infrainguinal vein graft bypass. Consecutive infrainguinal vein bypasses between January 2001 and December 2006 were reviewed. All patients underwent preoperative measurement of vein graft diameter (VGD). Grafts were classified into those with VGD <3.5 mm and those with VGD > or =3.5 mm. All patients were enrolled in a duplex surveillance program. The association between VGD and reintervention rate was assessed. Graft patency and amputation rates were compared. There were 377 bypasses followed up for a median of 23 months (range 8-67). VGD was <3.5 mm in 139 grafts (36.9%) and > or =3.5 mm in 238 grafts (63.1%). A higher proportion of smaller vein grafts (32.3%) required reintervention to maintain graft patency compared with larger conduits (20.2%) (chi(2) = 7.7, p < 0.001). VGD (odds ratio [OR] = 2.87, 95% confidence interval [CI] 1.63-3.81; p < 0.001), smoking (OR = 1.83, 95% CI 1.39-3.20; p = 0.02), and type of bypass (OR = 1.86, 95% CI 1.49-2.47; p = 0.02) were variables associated with higher reintervention rate. There was no difference in graft patency (p = 0.13) or amputation rates (p = 0.35) between the two groups. Use of smaller vein grafts was associated with a higher reintervention rate. Provided that these grafts are surveyed and where necessary repaired, the use of smaller vein grafts is successful and expands the availability of autogenous conduit for infrainguinal arterial reconstruction.

Vascular access using the superficial femoral vein

Purpose The superficial femoral vein (SFV) provides an alternative autologous conduit for fistula formation in patients who might otherwise require a prosthetic graft for hemodialysis (HD) access. The purpose of this study was to assess the results of this technique. Methods Patients who underwent formation of a SFV fistula were identified from a prospectively maintained database. Casenotes were reviewed for details of the operation, complications, subsequent interventions, and to determine whether the fistula was used for vascular access. Results Fifteen patients (seven males, eight females; median age 53, range 28–72 yrs) were identified. Patients had a median of four (range 2–9) previous fistulae. In three patients, the mobilized SFV was transferred to the upper limb while 12 patients had lower limb fistulae. Twelve patients (80%) used their SFV fistula for HD. Eleven patients developed a wound complication (infection, dehiscence, hematoma or bleeding), with four patients returning to theater for formal exploration and three requiring application of a vacuum dressing. Two patients developed post-operative lower limb ischemia. Two patients died during a median follow-up time of 7 (range 1–27) months. Conclusion In selected patients who have exhausted conventional routes for vascular access the SFV fistula can be used for the maintenance of HD. There is, however, significant associated morbidity and repeated intervention is often required.

Infrainguinal aneurysms in a tertiary setting: A study of outcomes

the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: Twelve cohort studies involving 1512 patients were included. The majority of these were treated endovascularly (1168 patients).DR was associated with improved wound healing (Odds Ratio, OR 0.39, p<0.001) and limb salvage rates (OR 0.20, p<0.001) compared to IR, however this effect was lost on certain sensitivity analyses. DR had no effect on reintervention rates (OR 0.44, p1⁄40.27) or subsequent mortality (OR 0.83, p1⁄40.37). Overall study quality was low. Conclusions: DR appears superior in terms of wound healing and limb salvage. There was no evidence that the approach was less safe than IR. Vascular units performing infrapopliteal revascularisation should consider DR whenever feasible.