Infrapopliteal composite bypass with autologous vein and second generation glutaraldehyde stabilized human umbilical vein (HUV) for critical lower limb ischaemia

The IN.PACT DEEP Clinical Drug-Coated Balloon Trial: 5-Year Outcomes

OBJECTIVES

The goal of this study was to evaluate the 5-year follow-up data of the IN.PACT DEEP (Randomized IN.PACT Amphirion Drug-Coated Balloon [DCB] vs. Standard Percutaneous Transluminal Angioplasty [PTA] for the Treatment of Below-the-Knee Critical Limb Ischemia [CLI]) trial.

BACKGROUND

Initial studies from randomized controlled trials have shown comparable short-term outcomes of DCB angioplasty versus PTA in patients with CLI with infrapopliteal disease. However, the long-term safety and effectiveness of DCB angioplasty remain unknown in this patient population.

METHODS

IN.PACT DEEP was an independently adjudicated prospective, multicenter, randomized controlled trial that enrolled 358 subjects with CLI. Subjects were randomized 2:1 to DCB angioplasty or PTA. Assessments through 5 years included freedom from clinically driven target lesion revascularization, amputation, and all-cause death. Additional assessments were conducted to identify risk factors for death and major amputation, including paclitaxel dose tercile.

RESULTS

Freedom from clinically driven target lesion revascularization through 5 years was 70.9% and 76.0% (log-rank p = 0.406), and the incidence of the safety composite endpoint was 59.8% and 57.5% (log-rank p = 0.309) in the DCB angioplasty and PTA groups, respectively. The rate of major amputation was 15.4% for DCB angioplasty compared with 10.6% for PTA (log-rank p = 0.108). Given the recent concern regarding a late mortality signal in patients treated with paclitaxel-coated devices, additional analyses from this study showed no increase in all-cause mortality with DCB angioplasty (39.4%) compared with PTA (44.9%) (log-rank p = 0.727). Predictors of mortality included age, Rutherford category >4, and previous revascularization but not paclitaxel by dose tercile.

CONCLUSIONS

Tibial artery revascularization in patients with CLI using DCB angioplasty resulted in comparable long-term safety and effectiveness as PTA. Paclitaxel exposure was not related to increased risk for amputation or all-cause mortality at 5-year follow-up. (Study of IN.PACT Amphirion™ Drug Eluting Balloon vs. Standard PTA for the Treatment of Below the Knee Critical Limb Ischemia [INPACT-DEEP]; NCT00941733).

Treatment of lower limb arterial disease by Dardik graft: It takes one to know one

OBJECTIVE

To perform a comprehensive literature review on outcomes achieved with the historical Dardik graft, illustrated with a case report of a patient with 13-years primary patency and limb salvage.

METHODS

A comprehensive literature review was performed through MedLine (PubMed.gov, U.S. National Library of Medicine, National Institute of Health) from 1976 to 2018 using search terms (Umbilical Vein Graft), (Dardik graft), (Glutaraldehyde stabilized human umbilical vein [HUV]) and (HUV) to collected data on clinical use of HUV. Only papers in English and reporting adequate information about indication for surgery, short- and long-term patency and complication rate were included.

RESULTS

Data about a total of 899 patients (977 limbs) were available. Overall, 45% of patients (438 limbs) underwent HUV implantation for critical limb ischemia (rest pain or tissue loss) or for disabling claudication in 12.2% of cases (120 limbs). Others indication for surgery were acute onset limb ischemia, popliteal aneurysms or aneurysmal degeneration of a previously implanted synthetic graft. At a mean follow-up of 4.3 years (range 3-6 years), primary patency and secondary patency were 61.3% and 61%, respectively. Aneurisms formation was detected in 3% of cases (21 limbs), graft's infection in 24.4% of cases (31 limbs) and graft's thrombosis in 25.5% of cases (193 limbs).

CONCLUSION

This article provide a historical review of the use, outcomes and complications of HUV. Even though it is no longer commercially available, the knowledge of this type of substitute still remains inspirational for the development of innovative vascular conduits and fundamental for the new generations of physician both in diagnostics and in the management of complications.

Recellularization potential assessment of Wharton's Jelly-derived endothelial progenitor cells using a human fetal vascular tissue model

Mesenchymal stem cells isolated from Wharton's Jelly have demonstrated an excellent differentiation potential into the endothelial lineage. We hypothesize that endothelial progenitor cells differentiated from Wharton's Jelly-derived mesenchymal stem cells have the potential to repopulate a decellularized vascular bed employed as a biological scaffold. For this purpose, we aimed at investigating the behavior of the endothelial progenitor cells in the decellularized matrix and their potential to repopulate decellularized human vascular tissue. Our main objectives were to differentiate Wharton's Jelly-derived mesenchymal stem cells into endothelial progenitor cells and to obtain a human vascular tissue slice experimental model using the umbilical cord arteries. We employed a decellularization method using enzymatic treatment of the umbilical cord arteries and a recellularization method with the endothelial progenitor cells differentiated from Wharton's Jelly mesenchymal cells in a co-culture system, in order to investigate our hypothesis. The cellular integration within the biological scaffold was determined by using flow cytometry analysis and confirmed by visualization of histological staining as well as fluorescence microscopy. The morphological observations of the recellularized scaffolds revealed the presence of endothelial progenitor cells within the decellularized tissue slices, displaying no degradation of the scaffold's extracellular matrix. The flow cytometry analysis revealed the presence of Wharton's Jelly-derived endothelial progenitor cells population in the decellularized fetal blood vessel scaffold after recellularization. In conclusion, our results have shown that an in vitro human vascular tissue slice experimental model using decellularized human fetal arteries is able to sustain an adequate scaffold for cellular implants.

Progress in research of vascular grafts for portal vein/superior mesenteric vein reconstruction

Portal vein/superior mesenteric vein reconstruction is applied more and more broadly in abdominal surgery. This reconstructive surgery can improve radical resection rate and prolong survival in patients with abdominal carcinoma, expand the indications for liver transplantation, and increase the success rate of liver transplantation. Selection of a suitable vascular graft is key to the success of the surgery. Currently available vascular grafts include autogenous veins, ligamentum teres hepatis, artificial blood vessels, allograft veins, peritoneal patch, and pericardiac patch. This review aims to summarize recent progress in basic research, clinical application of vascular grafts for portal vein/superior mesenteric vein.

Basic data related to surgical infrainguinal revascularization procedures: a twenty year update

In 1990, Dalman and Taylor published a compilation of reported data that were identified by them as related to infrainguinal revascularization procedures in peripheral vascular surgery during the decade of the 1980s. The intervening 20 years has seen revolutionary advances in the field of peripheral vascular surgery, especially in the adoption of endovascular techniques, and an explosion of data related to emerging technologies in the field of infrainguinal revascularization. The tables in this manuscript reflect the evolution of our surgical knowledge during the turn of the 21st century. The superior patency of autologous saphenous vein in all positions is reaffirmed.