From the Veins to the Heart: A Rare Cause of Varicose Veins

The presence of pulsating varicous veins is an uncommon finding, generically attributed to right heart failure. The precise causes of this phenomenon have been poorly defined in the literature. The finding of this infrequent condition is important because it may be a sign of major diseases, often not known. Here we described a 75-year-old woman presented to the Angiology Unit for the presence of bilateral pulsatile swelling in her groin and along both lower limbs. A bedside ultrasound examination showed an arterial like pulsating flow both in the superficial and in the deep veins of the lower limbs due to a severe tricuspid regurgitation not previously known

Omniflow® II biosynthetic graft offers acceptable early and mid-term outcomes in redo surgery in patients with critical limb-threatening ischemia with no available autologous vein material

Background: In this study, the early and mid-term outcomes of Omniflow (R) II (LeMaitre Vascular, Inc., Burlington, MA, USA) biosynthetic graft in redo surgery in patients with critical limb-threatening ischemia (CLTI) with no available autologous vein material were investigated with the aim to compare the outcomes obtained in "de novo" surgery versus redo surgery. Methods: From January 2018 until December 2022, data of CLTI patients from 18 centers in Italy with no autologous vein material underwent infrainguinal bypass with Omniflow (R) II biosynthetic graft were collected. Thirty-day outcome measures including intraoperative technical success, major morbidity, mortality, and graft patency were assessed and compared. At two-year follow-up, estimated outcomes of survival, primary patency, primary assisted patency, secondary patency, freedom from reintervention, and amputation-free survival were analyzed using Kaplan-Meier curves and compared between groups using the log -rank test. Results: In the study period 119 CLTI patients had an infrainguinal bypass with Omniflow (R) II biosynthetic graft. Seventy-seven patients (64.7%) underwent bypass as "de novo" treatment (group de novo), whilst in the remaining 42 patients (35.3%) the procedure was performed as redo surgery due to occlusion and/or infection of a previous bypass graft (group redo). Two groups were homogeneous in terms of demographic, clinical, and morphological data. In group redo explantation of an infected prosthetic graft was needed in 4 cases (9.5%). Intraoperative technical success was achieved in all cases in both groups. At 30 days, the overall patency rate did not differ between the two groups (69/77, 89.6%, group de novo vs. 35/42, 83.3%, group redo; P=0.24), whilst in group redo limb loss was higher with a statistically significant different 30-day major amputation rate between the two groups (11.9% group redo vs. 1.3% group de novo; P<0.001). Overall median duration of follow-up was eight months (IQR 6-13). At two-year follow-up there were no differences between the two groups in terms of survival (67.7% group de novo vs. 55.8% group redo, P=0.53), primary patency (34.4% group de novo vs. 26.8% group redo, P=0.25), primary assisted patency (43.6% group de novo vs. 28.8% group redo, P=0.12), freedom from reintervention (64.1% group de novo vs. 68.8% group redo, P=0.98), and amputationfree survival (67.8% group de novo vs. 60% group redo, P=0.12). Secondary patency was significantly higher in group de novo (53.7% vs. 32.3%, P=0.05). During the follow-up, the overall rates of graft infection and aneurysmal degeneration were 3.4%, and 0.8%, respectively. Conclusions: Nevertheless, poorer early outcomes in terms of limb salvage, Omniflow (R) II biosynthetic graft offers acceptable ywo-year outcomes in redo surgery in CLTI patients with no available autologous vein material. Further studies with larger population sizes are needed to validate these outcomes

A multicenter comparison between autologous saphenous vein and heparin-bonded expanded polytetrafluoroethylene (ePTFE) graft in the treatment of critical limb ischemia in diabetics.

OBJECTIVES: The aim of this study was to evaluate early and follow-up results of below-knee bypasses performed using a bioactive heparin-treated expanded polytetrafluoroethylene (ePTFE) graft in diabetic patients with critical limb ischemia (CLI) in a multicenter retrospective registry involving seven Italian vascular centers and to compare them with those obtained in patients operated on with autologous saphenous vein (ASV) in the same centers in the same period of time. METHODS: Over an 8-year period, ending in 2009, a heparin-bonded prosthetic graft (Propaten Gore-Tex; W. L. Gore & Associates Inc, Flagstaff, Ariz) was implanted in 180 diabetic patients undergoing below-knee revascularization for CLI in seven Italian hospitals (group 1). In the same period in these seven centers, 133 below-knee bypasses with ipsilateral ASV in diabetics with CLI were performed (group 2). Data concerning these interventions were retrospectively collected in a multicenter registry with a dedicated database. Early (<30 days) results were analyzed in terms of graft patency, major amputation rates, and mortality. Follow-up results were analyzed in terms of primary and secondary graft patency, limb salvage, and survival. RESULTS: The interventions consisted of below-knee bypasses in 132 cases in group 1 (73%) and in 45 cases in group 2 (33%; P .9, log-rank 0.08). Primary patency rate at 48 months was significantly better in group 2 (63.5%) than in group 1 (46.3%; P = .03, log-rank 4.1). Assisted primary patency rates at 48 months were 47.3% (SE 0.05) in group 1 and 69% (SE 0.05) in group 2 (P = .01, log-rank 6.3). The rates of secondary patency at 48 months were 57.5% in group 1 and 69.6% in group 2 (P = .1, log-rank 2.3); the corresponding values in terms of limb salvage and amputation free-survival rates were 75.4% and 82.4% (P = .3, log-rank 1), and 59.9% and 64.4% (P = .3, log-rank 0.9), respectively. CONCLUSIONS: Data from this large, retrospective registry confirmed that the indexed heparin-bonded ePTFE graft provides satisfactory early and midterm results in diabetic patients undergoing surgical treatment of CLI. While autologous saphenous vein maintains its superiority in terms of primary patency, secondary patency rates are not statistically different, even in the presence of a trend for improved secondary patency with vein graft; and also limb salvage rates are comparable

A Multicenter Predictive Score for Amputation-Free Survival for Patients Operated on with an Heparin-Bonded ePTFE Graft for Critical Limb Ischemia

Aim of the study: To retrospectively create a predictive score for estimating amputation-free survival (AFS) in patients with critical limb ischemia (CLI) operated on with the use of a heparin-bonded expanded polytetrafluoroethylene (ePTFE) bypass graft (Hb-ePTFE). Methods: Over a 13-year period, ending in March 2015, a Hb-ePTFE graft was implanted in 683 patients undergoing below-knee revascularization for CLI in seven Italian vascular hospitals. Data concerning these interventions were retrospectively collected in a multicenter registry with a dedicated database. Univariate and multivariable analyses with Kaplan–Meier estimates were used to identify potential significant predictors of AFS at 5&nbsp;years, and then a predictive risk score was constructed. A qualitative assessment of the Kaplan–Meier survival estimates for each integer score was performed, and subgroups of risk were stratified on the basis of the primary end point. Results: Overall, estimated 5-year AFS rate was 48.3&nbsp;% (SE 0.024). At multivariate analysis, older age, coronary artery disease, end-stage renal disease, tissue loss and poor runoff score were predictors of AFS. The integer score ranged from 0 to 11; Kaplan–Meier analysis for AFS in each score group identified three subgroups with significant differences at 5&nbsp;years: low-risk subgroup (scores from 0 to 2, 67.7&nbsp;%), medium-risk subgroup (scores 3 and 4, 49.2&nbsp;%, p&nbsp;&lt;&nbsp;0.001 in comparison with low-risk subgroup) and high-risk subgroup (scores from 5 to 11, 25.2&nbsp;%, p&nbsp;&lt;&nbsp;0.001 in comparison with either low-risk subgroup or medium-risk subgroup). Conclusions: A category of low-risk patients with CLI treated with the indexed graft does exist, thus suggesting a primary role for Hb-ePTFE in such patients. A prospective validation of such a score is necessary

Results from a multicenter registry of heparin-bonded expanded polytetrafluoroethylene graft for above-the-knee femoropopliteal bypass

Objective: The aim of the study was to retrospectively analyze early and follow-up results of above-the-knee femoropopliteal bypasses (AKb) performed with a bioactive heparin-bonded expanded polytetrafluoroethylene (HB-ePTFE) graft in patients with peripheral arterial obstructive disease in a multicentric retrospective registry involving seven Italian vascular centers. Methods: During a 14-year period ending in March 2016, an HB-ePTFE graft was used in 1401 interventions performed for peripheral arterial obstructive disease. Comorbidities, risk factors, and follow-up outcomes were collected in a multicenter registry with a dedicated database. A post hoc analysis of the database was performed to identify 364 (25.9%) patients who underwent AKb. Early (intraoperative and &lt;30 days) results were analyzed in terms of death, thrombosis, amputations, reinterventions, and the occurrence of major local and systemic complications. Follow-up results were analyzed by life-table analysis (Kaplan-Meier test) in terms of primary and secondary graft patency, assisted primary patency, limb preservation, and amputation-free survival. The analysis of follow-up results was stopped in December 2016. Results: In 61 (16.7%) patients, AKb was performed after the failure of a previous ipsilateral revascularization. Critical limb ischemia was present in 164 (45%) cases; the remaining patients had life-limiting intermittent claudication. Perioperative mortality occurred in three (0.8%) patients: in the hospital (n = 2) due to acute myocardial infarction and after discharge (n = 1) due to fatal arrhythmia. Early thromboses occurred in six (1.6%) patients; all these patients had primary AKb for critical limb ischemia. The cumulative rate of perioperative amputations was 0.5% (2 cases), whereas the cumulative rate of early reinterventions was 3% (11 cases). Median duration of follow-up was 28 months (range, 1-168 months); the median cumulative follow-up index for survival was 0.75 (range, 0.05-1). Estimated survival at 5 years was 75.3% (standard error [SE], 0.03). Estimated 5-year primary patency was 64% (SE, 0.04); the corresponding figure in terms of assisted primary patency was 65% (SE, 0.035). Secondary patency rate at 5 years was 74.5% (SE, 0.03). The rate of limb preservation at 5 years was 95% (SE, 0.02); the corresponding figure in terms of amputation-free survival was 74% (SE, 0.04). Conclusions: In an era of endovascular enthusiasm, with conflicting results for the treatment of long or complex lesions of the superficial femoral artery, AKb with the use of HB-ePTFE graft remains an effective option, with low rate of perioperative complications and satisfactory long-term results

A Multicenter Predictive Score for Amputation-Free Survival for Patients Operated on with an Heparin-Bonded ePTFE Graft for Critical Limb Ischemia

Aim of the study: To retrospectively create a predictive score for estimating amputation-free survival (AFS) in patients with critical limb ischemia (CLI) operated on with the use of a heparin-bonded expanded polytetrafluoroethylene (ePTFE) bypass graft (Hb-ePTFE). Methods: Over a 13-year period, ending in March 2015, a Hb-ePTFE graft was implanted in 683 patients undergoing below-knee revascularization for CLI in seven Italian vascular hospitals. Data concerning these interventions were retrospectively collected in a multicenter registry with a dedicated database. Univariate and multivariable analyses with Kaplan–Meier estimates were used to identify potential significant predictors of AFS at 5&nbsp;years, and then a predictive risk score was constructed. A qualitative assessment of the Kaplan–Meier survival estimates for each integer score was performed, and subgroups of risk were stratified on the basis of the primary end point. Results: Overall, estimated 5-year AFS rate was 48.3&nbsp;% (SE 0.024). At multivariate analysis, older age, coronary artery disease, end-stage renal disease, tissue loss and poor runoff score were predictors of AFS. The integer score ranged from 0 to 11; Kaplan–Meier analysis for AFS in each score group identified three subgroups with significant differences at 5&nbsp;years: low-risk subgroup (scores from 0 to 2, 67.7&nbsp;%), medium-risk subgroup (scores 3 and 4, 49.2&nbsp;%, p&nbsp;&lt;&nbsp;0.001 in comparison with low-risk subgroup) and high-risk subgroup (scores from 5 to 11, 25.2&nbsp;%, p&nbsp;&lt;&nbsp;0.001 in comparison with either low-risk subgroup or medium-risk subgroup). Conclusions: A category of low-risk patients with CLI treated with the indexed graft does exist, thus suggesting a primary role for Hb-ePTFE in such patients. A prospective validation of such a score is necessary