Ten Years After Arterial Bypass Surgery for Claudication: Venous Bypass is the Primary Procedure for TASC C and D Lesions

Background: The appropriate role for surgery and endovascular therapy for severe intermittent claudication (IC) remains controversial. We present our results after infrainguinal autogenous bypass for severe IC more than 10years ago giving a reasoned argument to perform vein bypass as the primary procedure for severe IC. Methods: Our prospectively designed database includes more than 1,000 infrainguinal bypasses following an all-autogenous policy. For this review only patients operated on for severe IC at least 10years ago were included. The primary end points were survival and primary and assisted-primary patency rates. Results: From October 1988 until December 2000, 124 bypasses for IC were performed. Ninety-five patients were male and the mean age was 64.5±10.8years. Survival after 10years was 50.3% according to life table analysis. Forty bypasses were to the supragenicular artery, 62 to the infragenicular popliteal artery, and 22 to the tibial artery. Thirty-day mortality was 0.8% (1 patient). The primary patency rate after 10years was 63.5% and the assisted-primary patency rate 87.3%. Conclusion: Infrainguinal venous bypass for severe IC has excellent long-term results. Our results are strong arguments against the liberal use of stenting long lesions of the femoropopliteal artery. Venous bypass remains the primary procedure for TASC C and D lesions in claudicant

Major Vascular Resection and Prosthetic Replacement for Retroperitoneal Tumors

Introduction: Involvement of major vascular structures has been considered a limiting factor for resecting advanced tumors. The objective of this study was to evaluate the outcome after concomitant retroperitoneal tumor and vascular resection with prosthetic replacement of the aorta/vena cava. Methods: The authors reviewed a 5-year series of eight patients with a median age of 50 years (range 11-68 years) who had undergone resection of a retroperitoneal tumor and concomitant resection and replacement of the abdominal aorta, inferior vena cava, or both. The histologic diagnoses were sarcoma (five patients), teratoma (one), transitional cell carcinoma (one), and ganglioneuroma (one). The main outcome measures were early (< 30 days) and late (≥ 30 days) surgical morbidity and mortality. Secondary endpoints were vascular graft patency and tumor-free survival. Two patients underwent combined graft replacement of the aorta and vena cava. Single aortic and vena cava graft replacement were each done in three patients. Results: Two patients showed early surgical morbidity necessitating reoperation for a thrombotic graft occlusion. No patient died during the early course of the follow-up. During a median follow-up of 14 months (range 1-56 months), two patients had late surgical morbidity. The median tumor-free survival for patients with malignancy was 14 months (range 1-54 months). One patient developed locoregional tumor recurrence, and two developed distant metastases. The median survival for patients with malignancy was 14 months (range 1-60 months). Conclusions: An aggressive surgical approach for otherwise unresectable retroperitoneal tumors with vascular resection and prosthetic vascular replacement is justified in selected cases and has acceptable morbidity and mortalit

Perioperative Myocardial Injury After Non-cardiac Surgery: Incidence, Mortality, and Characterization

Perioperative myocardial injury (PMI) seems to be a contributor to mortality after noncardiac surgery. Because the vast majority of PMIs are asymptomatic, PMI usually is missed in the absence of systematic screening.; We performed a prospective diagnostic study enrolling consecutive patients undergoing noncardiac surgery who had a planned postoperative stay of ≥24 hours and were considered at increased cardiovascular risk. All patients received a systematic screening using serial measurements of high-sensitivity cardiac troponin T in clinical routine. PMI was defined as an absolute high-sensitivity cardiac troponin T increase of ≥14 ng/L from preoperative to postoperative measurements. Furthermore, mortality was compared among patients with PMI not fulfilling additional criteria (ischemic symptoms, new ECG changes, or imaging evidence of loss of viable myocardium) required for the diagnosis of spontaneous acute myocardial infarction versus those that did.; From 2014 to 2015 we included 2018 consecutive patients undergoing 2546 surgeries. Patients had a median age of 74 years and 42% were women. PMI occurred after 397 of 2546 surgeries (16%; 95% confidence interval, 14%-17%) and was accompanied by typical chest pain in 24 of 397 patients (6%) and any ischemic symptoms in 72 of 397 (18%). Crude 30-day mortality was 8.9% (95% confidence interval [CI], 5.7-12.0) in patients with PMI versus 1.5% (95% CI, 0.9-2.0) in patients without PMI (; P; &lt;0.001). Multivariable regression analysis showed an adjusted hazard ratio of 2.7 (95% CI, 1.5-4.8) for 30-day mortality. The difference was retained at 1 year with mortality rates of 22.5% (95% CI, 17.6-27.4) versus 9.3% (95% CI, 7.9-10.7). Thirty-day mortality was comparable among patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction (280/397, 71%) versus those with at least 1 additional criterion (10.4%; 95% CI, 6.7-15.7, versus 8.7%; 95% CI, 4.2-16.7;; P; =0.684).; PMI is a common complication after noncardiac surgery and, despite early detection during routine clinical screening, is associated with substantial short- and long-term mortality. Mortality seems comparable in patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction versus those patients who do.; URL: https://www.clinicaltrials.gov. Unique identifier: NCT02573532

Ten years after arterial bypass surgery for claudication : venous bypass is the primary procedure for TASC C and D lesions

The appropriate role for surgery and endovascular therapy for severe intermittent claudication (IC) remains controversial. We present our results after infrainguinal autogenous bypass for severe IC more than 10 years ago giving a reasoned argument to perform vein bypass as the primary procedure for severe IC

Surgical and antimicrobial treatment of prosthetic vascular graft infections at different surgical sites: a retrospective study of treatment outcomes.

Little is known about optimal management of prosthetic vascular graft infections, which are a rare but serious complication associated with graft implants. The goal of this study was to compare and characterize these infections with respect to the location of the graft and to identify factors associated with outcome.This was a retrospective study over more than a decade at a tertiary care university hospital that has an established multidisciplinary approach to treating graft infections. Cases of possible prosthetic vascular graft infection were identified from the hospital's infectious diseases database and evaluated against strict diagnostic criteria. Patients were divided into groups according to the locations of their grafts: thoracic-aortic, abdominal-aortic, or peripheral-arterial. Statistical analyses included evaluation of patient and infection characteristics, time to treatment failure, and factors associated specifically with cure rates in aortic graft infections. The primary endpoint was cure at one year after diagnosis of the infection.Characterization of graft infections according to the graft location did show that these infections differ in terms of their characteristics and that the prognosis for treatment seems to be influenced by the location of the infection. Cure rate and all-cause mortality at one year were 87.5% and 12.5% in 24 patients with thoracic-aortic graft infections, 37.0% and 55.6% in 27 patients with abdominal-aortic graft infections, and 70.0% and 30.0% in 10 patients with peripheral-arterial graft infections. In uni- and multivariate analysis, the type of surgical intervention used in managing infections (graft retention versus graft replacement) did not affect primary outcome, whereas a rifampicin-based antimicrobial regimen was associated with a higher cure rate.We recommend that future prospective studies differentiate prosthetic vascular graft infections according to the location of the grafts and that rifampicin-based antimicrobial regimens be evaluated in clinical trials involving vascular graft infections caused by staphylococci

FACS-purified myoblasts producing controlled VEGF levels induce safe and stable angiogenesis in chronic hind limb ischemia

We recently developed a method to control the in vivo distribution of vascular endothelial growth factor (VEGF) by high throughput Fluorescence-Activated Cell Sorting (FACS) purification of transduced progenitors such that they homogeneously express specific VEGF levels. Here we investigated the long-term safety of this method in chronic hind limb ischemia in nude rats. Primary myoblasts were transduced to co-express rat VEGF-A(164) (rVEGF) and truncated ratCD8a, the latter serving as a FACS-quantifiable surface marker. Based on the CD8 fluorescence of a reference clonal population, which expressed the desired VEGF level, cells producing similar VEGF levels were sorted from the primary population, which contained cells with very heterogeneous VEGF levels. One week after ischemia induction, 12 × 10(6) cells were implanted in the thigh muscles. Unsorted myoblasts caused angioma-like structures, whereas purified cells only induced normal capillaries that were stable after 3 months. Vessel density was doubled in engrafted areas, but only approximately 0.1% of muscle volume showed cell engraftment, explaining why no increase in total blood flow was observed. In conclusion, the use of FACS-purified myoblasts granted the cell-by-cell control of VEGF expression levels, which ensured long-term safety in a model of chronic ischemia. Based on these results, the total number of implanted cells required to achieve efficacy will need to be determined before a clinical application

Comparison of therapies for prosthetic vascular graft infections with respect to the location of the graft.^*

<p>PVGI  =  prosthetic vascular graft infection; IQR  =  interquartile range</p><p>*Percentages, IQR values, and ranges indicate relationship to the total number of patients within each respective group, not to the total number of patients included in the study.</p>†<p>A p-value ≤0.050 was considered significant.</p>‡<p>In patients with at least one surgical revision of their graft.</p>§<p>Application of negative pressure to the local wound environment using a sealed foam dressing connected to a vacuum pump.</p><p>**Adequate empirical therapy according to the susceptibility testing of the respective isolated pathogen.</p>††<p>Total duration of both empirical and pathogen-specific antimicrobial therapy.</p>‡‡<p>Percentages apply to the total number of patients who were alive at one year within each respective group.</p><p>Comparison of therapies for prosthetic vascular graft infections with respect to the location of the graft.^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0112947#nt111" target="_blank">*</a>}</p

Predictors of cure at one year in 51 patients with aortic prosthetic vascular graft infections.^*

<p>HR  =  hazard ratio; CI  =  confidence interval; PVGI  =  prosthetic vascular graft infection.</p><p>*Aortic prosthetic vascular graft infections diagnosed in 51 patients in this single-center study of PVGI over a period of almost 12 years.</p>†<p>Multivariate analysis adjusted for age of patient, location of the aortic graft, graft replacement, presence of a polymicrobial infection, and the use of rifampicin in the antibiotic regimen.</p>‡<p>A p-value ≤0.050 was considered significant.</p>§<p>Each 10-year increment of increase in age is associated with a 0.33 risk of less favorable treatment outcome.</p><p>Predictors of cure at one year in 51 patients with aortic prosthetic vascular graft infections.^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0112947#nt119" target="_blank">*</a>}</p

Comparison of primary and secondary outcomes in the treatment of prosthetic vascular graft infection.

<p>PVGI  =  prosthetic vascular graft infection. ^*p-value  = 0.006. ^†p-value  = 0.001. ^‡p-value  = 0.004. ^§p-value  = 0.012. **Removal or replacement of the infected vascular graft. ^††No surgical intervention; antimicrobial treatment only.</p