Wolfgang Hitzl

Endovascular Management versus Surgery for Proximal Subclavian Artery Lesions

Current management of subclavian artery (SA) lesions is controversial. Subclavian-to-carotid artery transposition (SCT) may be challenging but exhibits unparalleled long-term results. Stent-supported percutaneous transluminal angioplasty (sPTA) is technically easier but not always feasible. Long-term results and comparisons have not been published. We compared both methods performed by vascular surgeons. Data were collected prospectively with retrospective analysis at a tertiary-care center. sPTA was performed through a retrograde transbrachial access using self-expanding nitinol stents. Open surgery was SCT only. Society for Vascular Surgery/International Society of Cardiovascular Surgery reporting standards were applied. Seventy-four patients underwent treatment from January 1995 to August 2007 (median age 62.6 years, 40 female; left-sided pathology 60 [81.1%]; risk factors: hypertension 45 [60.8%], dyslipidemia 47 [63.5%], diabetes 21 [28.4%], smoking 43 [58.1%], SA occlusion 50 [67.6%]). Forty patients (54.1%) underwent primary sPTA (62.5% occlusions) and 34 SCT (73.5% occlusions). The two groups were comparable with regard to risk factors. In 12 patients occlusions could not be recanalized (30%), and in two stents failed within 1 month (both for stenosis). All but one underwent subsequent uneventful SCT. All SCTs were successful. No risk factor could be identified for treatment failure except sPTA (p = 0.002, Fishers exact test). Median follow-up was 50.1 months with sPTA and 52.6 months with SCT. No procedure failed during follow-up in either group. sPTA can be performed successfully by surgeons. Primary sPTA failed in 48% of occlusions (30% of all sPTAs). Prediction of failure is not possible. According to our experience, we recommend primary sPTA for SA stenosis and surgery for SA occlusions.

Bioabsorbable Stent Implantation vs. Common Femoral Artery Endarterectomy: Early Results of a Randomized Trial

Purpose: To compare clinical and hemodynamic outcome in patients undergoing treatment of common femoral artery (CFA) atherosclerotic lesions by bioabsorbable stent implantation (BASI group) or by common femoral artery endarterectomy (CFE group). Methods: A randomized, controlled, single-center, open-label trial was initiated to compare outcomes of BASI or CFE in patients with chronic atherosclerotic occlusive lesions in the CFA. From May 2011 to April 2013, 116 consecutive patients were recruited; after excluding 36 patients, 80 patients (52 men; mean age 72.2±9.6 years) were enrolled 1:1 and are the subject of this intention-to-treat interim analysis (40 patients in each group). The primary endpoint was surgical site infections; secondary outcome measures were technical success, hemodynamic improvement, clinical improvement, patency, limb salvage, and survival. Results: There was no statistically significant difference between both groups regarding demographic data, cardiovascular risk factors, or CFA occlusions. The CFE patients presented with 7 surgical site infections (all minor) vs. none in the BASI group (p=0.002) and a longer mean postoperative hospital stay of 7 vs. 2 days for BASI patients (p<0.001). Technical success rates were 97.5% and 100% for the BASI and CFE groups, respectively. Postoperative ankle-brachial index means were comparable (p=0.38). The 30-day primary patency rates were 92.5% and 100% for the BASI and CFE groups, respectively (p=0.038). There were 6 reconstruction failures in CFE patients vs. none in the BASI group (p=0.02); 5 failures involved initial CFA occlusions. At 1 year, the primary and secondary patency rates were 80% vs. 100% (p=0.007) and 84% vs. 100% (p=0.01) for BASI and CFE patients, respectively. Limb salvage was equivalent, and survival rates were 88% and 90% for BASI vs. CFE patients (p=0.51) at 1 year. Conclusion: This interim analysis suggests that BASI is not an option for CFA occlusion and is only a limited option for CFA stenosis. Clinical and hemodynamic results are comparable for BASI and CFE. An increased rate of redo procedures in the BASI patients outweighs lower surgical site infection rates compared to CFE. Short-term patency rates are significantly worse in patients undergoing CFA stenting with BASI.

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

OBJECTIVEnAlthough 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.nnnMETHODSnConsecutive 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.nnnRESULTSnFrom 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).nnnCONCLUSIONSnRoutine 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.

Arm Veins versus Contralateral Greater Saphenous Veins for Lower Extremity Bypass Reconstruction: Preliminary Data of a Randomized Study

BACKGROUNDnThe aim of this randomized study was to determine whether arm vein (AV) or contralateral greater saphenous vein (CGSV) is the better alternative vein source for lower extremity bypass reconstruction.nnnMETHODSnConsecutive patients with absent ipsilateral greater saphenous vein undergoing lower extremity revascularization were allocated to group A (AV bypass) or B (CGSV bypass).nnnRESULTSnFrom 6, 2010, to 11, 2013, 64 patients (32 each group) were randomized. In all, 29 of 93 patients had to be excluded for various reasons. Median age was 76 years vs. 71 years (P = 0.01) for group A and B patients. There were no statistically significant differences regarding gender, cardiovascular risk factors, redo bypass procedures (P = 0.77), below-knee bypass procedures (P = 0.61), median bypass length (P = 0.6), and median length of incision on ipsilateral leg to perform anastomoses (P = 0.2) between group A and B patients, respectively. Incisions for vein harvest were longer in group A (P = 0.003). Overall surgical site infections (SSIs, P = 1.0) and SSI from vein harvest (P = 1.0) were equally distributed. No patient was lost to follow-up (17 vs. 18 months, P = 0.74). There was no statistically significant difference regarding primary (P = 0.77) and secondary (P = 0.25) patency rates at 1 year (group A: 52% vs. group B: 54% and group A: 72% vs. group B: 61%) and at 2 years (52% vs. 48% and 64% vs. 61%), respectively. There were 4 vs. 6 major amputations (P = 0.23) and 5 vs. 2 deaths (P = 0.1) in groups A and B during follow-up.nnnCONCLUSIONSnPreliminary results suggest that both AV and CGSV may serve as a secondary vein bypass graft equally well.

Paclitaxel-coated versus plain balloon angioplasty in the treatment of infrainguinal vein bypass stenosis

OBJECTIVEnThe aim of this study was to compare the clinical and hemodynamic outcomes of plain vs paclitaxel-coated percutaneous transluminal angioplasty (PTA) in patients with infrainguinal vein bypass stenosis.nnnMETHODSnA single-center retrospective analysis was conducted of consecutive patients treated by infrainguinal bypass PTA. Primary study end points were primary and assisted primary patency. Secondary end points were clinical and hemodynamic improvement, limb salvage, and survival. Society for Vascular Surgery reporting standards were applied.nnnRESULTSnFrom April 2008 to November 2014, 83 infrainguinal vein bypasses were treated for graft stenosis by plain (group A, n = 41) or by paclitaxel-coated PTA (group B, n = 42). The groups did not differ significantly in mean age (71.9 years for both groups; P = .99), hypertension (P = 1.0), hyperlipidemia (P = .5), diabetes (P = .6), coronary artery disease (P = 1.0), smoking (P = 1.0), preoperative ankle-brachial index (P = .08), or bypass characteristics (below-knee, P = .82). Technical success rate was 100% for both groups. Mean follow-up was 2.9 years for group A patients and 2.2 years for group B patients (P = .08). No patient was lost to follow-up. Primary patency rates were 88% vs 87% and 73% vs 75% (P = .19) and assisted primary patency rates were 88% vs 90% and 77% vs 84% (P = .76) for group A and B patients at 1 and 2 years, respectively. Repeat target lesion revascularization rates were 22% vs 14% (P = .17). At the last follow-up, there were eight vs seven bypass occlusions (P = .74) for group A and B patients, respectively. In univariate analysis, proximal in-graft stenosis (Cox F, P = .041), bypass failure <6 months after bypass surgery (Cox F, P = .013), more than one bypass stenosis per graft (Cox F, P = .047), and redo bypass procedure (Cox F, P = .0001) were significantly related to assisted primary bypass patency. Immediate hemodynamic and sustained clinical improvement rates were 88% vs 86% and 70% vs 73% for group A and B patients, respectively. There were three vs one major amputations (P = .36) and eight vs seven deaths (P = .78) in group A and B patients, respectively.nnnCONCLUSIONSnPaclitaxel-coated and plain angioplasty of significant infrainguinal vein bypass stenoses performed equally well in clinical and hemodynamic improvement and in primary and assisted primary bypass patency rates.

Patch, interposition graft or stent for treatment of restenosis after carotid endarterectomy: a retrospective study

SummaryBackgroundUncertainty surrounding the indication for treatment of post carotid-endarterectomy restenosis (pCEAR) exists. Conventional patch angioplasty (rCEA), carotid interposition graft (CIG), and stent-assisted angioplasty (CAS) have been studied; comparisons of these techniques have not been performed.MethodsA time to event analysis of consecutive patients undergoing treatment for pCEAR was performed. Primary end-point was any cerebrovascular or myocardial event or death. Long-term results were expressed in Kaplan–Meier estimates.ResultsFrom 02/1997 to 03/2013, 93 procedures for severe pCEAR were performed in 89 consecutive patients. Group 1 consisted of 37 rCEA (40u2009%), group 2 included 33 CIG (35u2009%), and group 3 contained 23 CAS (25u2009%). Median time from primary CEA was significantly longer in group 2 compared with group 3 (118 vs. 54 months; pu2009=u20090.02). Groups were comparable with regard to degree of stenosis and cardiovascular risk factors. Five patients (6u2009%) underwent initial angiography with intention of CAS, but the procedures could not be completed (insufficient access nu2009=u20093, neurological symptoms nu2009=u20092) and open surgery was performed (rCEA: nu2009=u20094; CIG: nu2009=u20091). One perioperative death related to major stroke occurred in group 3 (3.6u2009%). There were no differences in 4-year estimated survival and event-free survival, whereas patients in group 3 were more likely to undergo a tertiary intervention (13u2009% at 4 years 95u2009% CI: 11–45u2009% pu2009=u20090.014).ConclusionsAll three groups presented with similar long-term outcome with regard to the predefined endpoints. Although associated with less perioperative complications, CAS required significantly more tertiary interventions. Carotid interposition graft was not superior to redo patch plasty.

Postoperative blood pressure in patients undergoing eversion carotid endarterectomy with or without resection of the carotid sinus nerve

SummaryBackgroundThe carotid sinus nerve (CSN) is important for regulation of blood pressure (BP) and heart rate. The aim of our study was to investigate whether dissection of the carotid bifurcation during eversion carotid endarterectomy (eCEA) causes a histologically proven compromise of the CSN and how the postoperative BP was affected thereby.MethodsConsecutive patients undergoing eCEA for primary high-grade internal carotid artery (ICA) stenosis without contralateral pathology were selected for this study. In all patients, histological specimens of the periadventitial tissue within the carotid bifurcation were taken during eCEA. Nerval structures of the CSN within the carotid bifurcation were detected by immunohistochemistry. BP was continuously monitored postoperatively.ResultsFrom March 2007 to March 2008, 100 patients were selected. In 55 patients (Group A), nerval structures could be detected within specimens resected during eCEA. In 45 patients (Group B), nerval structures could not be found histologically. Both groups were equal regarding cardiovascular risk factors, degree of ICA stenosis, and indication for surgery. There was a significant difference of diastolic BP values between Group A and B 7xa0h postoperatively (pxa0=xa00.005). We observed a significant difference of mean systolic BP values between both groups 30 days after operation (pxa0=xa00.011). All other mean BP values were equal between both groups at any point of time.ConclusionsOur study showed that eCEA does not always imply a histologically proven compromise of the CSN and that BP is mainly equal in patients with and without histologically proven compromise of the CSN.

Preoperative Duplex Vein Mapping (DVM) Reduces Costs in Patients Undergoing Infrainguinal Bypass Surgery: Results of a Prospective Randomised Study

OBJECTIVESnSurgical site infections (SSIs) after bypass procedures provoke major costs. The aim of this prospective randomised trial was to assess if preoperative duplex vein mapping (DVM) reduces costs generated by SSI.nnnMATERIALS/METHODSnPatients undergoing primary infrainguinal bypass were randomised to DVM of the ipsilateral greater saphenous vein (group A) or none (group B). Costs were calculated by the hospitals accounting department.nnnRESULTSnFrom December 2009 to April 2011, 130 patients (65 each group) were enrolled. Both cohorts were equal regarding demographics, risk factors and costs for primary bypass surgery, respectively. SSIs were classified minor (A: nxa0=xa013 vs. B: nxa0=xa013, Pxa0=xa0n.s.) and major (A: nxa0=xa01 vs. B: nxa0=xa012, Pxa0=xa0.0154). Preoperative DVM was the only significant factor to prevent major SSI (Pxa0=xa0.011). Theatre costs for SSI: A: 537 € versus B 6553 € (Pxa0=xa0.16). Recovery room/intensive care unit (ICU) costs for SSI: A: 0 € versus B: 8016 € (Pxa0=xa0.22). Surgical ward costs for SSI: A: 2823 € versus B: 22xa0386 € (Pxa0=xa0.011). Costs for outpatient visits due to SSI: A: 6265 € versus B: 12xa0831 € (Pxa0=xa0.67). Total costs of patients without SSI: 8177 € versus major SSI: 10xa0963 € (Pxa0<xa0.001).nnnCONCLUSIONnDVM significantly reduces costs generated by re-admission in patients suffering from major SSI.

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

OBJECTIVE/BACKGROUNDnCarotid 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.nnnMETHODSnThis was a single centre retrospective analysis of a consecutive series of patients treated at an academic vascular surgery centre.nnnRESULTSnFrom 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 (nxa0=xa029; symptomatic: nxa0=xa012), carotid aneurysm (nxa0=xa010), neck tumour with vascular involvement (nxa0=xa07), and trauma (nxa0=xa01). 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 17xa0min (range 8-30xa0min). 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.nnnCONCLUSIONnAutologous 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.

Stent-supported percutaneous transluminal angioplasty in patients suffering from symptomatic benign or malignant central venous occlusive disease

SummaryBackgroundThe aim of this study was to investigate the outcome of patients suffering from benign or malignant superior vena cava (SVC), brachiocephalic (BCV), and subclavian (SV) vein lesions treated with nitinol stents.MethodsRetrospective analysis of consecutive patients in a university-based tertiary care center.ResultsTwenty-two patients suffering from central venous occlusive disease (CVD) (9 malignant, mean age 58 years; 13 benign, mean age 66 years) were treated 2/2003–1/2012. In total, 89u2009% of malignant central venous occlusive disease (mCVD) patients underwent successful primary stenting (one reintervention 6 months after primary stenting). Two stent occlusions (22u2009%) were seen at last follow-up. All mCVD patients died within a median follow-up of 2 months (range: 0.8–54 months). In all, 92u2009% of benign central venous occlusive disease (bCVD) patients underwent primary stenting of SV (nu2009=u20098), BCV (nu2009=u20095), and SVC (nu2009=u20091). Six repeat interventions were performed in 42u2009% of patients. There was one stent occlusion (8u2009%) at last follow-up. Of all, 69u2009% of bCVD patients died within a median follow-up of 12.7 months (range: 1.3–82 months); 22u2009% of mCVD and 8u2009% of bCVD patients underwent bypass surgery as bail out procedure due to primary (nu2009=u20092) or secondary (nu2009=u20091) endovascular failure. All CVD patients experienced immediate post-interventional relief of symptoms.ConclusionTechnical success of CVD stenting is high and leads to immediate relief of symptoms in patients with short life expectancy.