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Jamil Y, Huttler J, Ochoa Chaar CI. Endovascular Recanalization and Stent Graft Placement for a Chronically Occluded Prosthetic Graft to Treat Critical Limb Ischemia. J Vasc Interv Radiol 2024; 35:143-145. [PMID: 37704039 DOI: 10.1016/j.jvir.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023] Open
Affiliation(s)
- Yasser Jamil
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510.
| | | | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
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2
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Meghpara MK, Tong Y, Sebastian A, Almadani M, Jacob T, Sanchez E, Pu QH, Shiferson A, Rhee RY. Effect of Direct Oral Anticoagulants versus Warfarin on Patency in High-Risk Bypass Patients. Ann Vasc Surg 2022; 88:63-69. [PMID: 35810945 DOI: 10.1016/j.avsg.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/02/2022] [Accepted: 06/06/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The use of warfarin for anticoagulation in thromboembolic disease has been the mainstay of treatment. Direct oral anticoagulants (DOACs) have demonstrated equivalent anticoagulant effects, without increased bleeding risks or need for frequent monitoring. However, the role of DOACs remains unclear in the setting of replacing warfarin for high-risk peripheral artery disease (PAD) interventions. The purpose of this study is to evaluate the efficacy of DOACs compared to warfarin during the postoperative period in patients that underwent a lower extremity high risk bypass (HRB). METHODS The study is a single institution, retrospective review of all lower extremity HRBs be-tween January 2012 and June 2021, who were previously placed on or started on anticoagulation with a DOAC or warfarin. The HRB group included all patients undergoing femoral to above or below knee bypass with an adjunct procedure, or below knee bypass with synthetic or composite vein conduit. All demographics, preoperative factors, and complications were evaluated with respect to DOAC versus warfarin. RESULTS A total of 44 patients (28 males; average age 68.8 ± 10.9) underwent a HRB during the study period. There were no significant differences in demographics and preoperative characteristics between the two groups. Among patient comorbidities, coronary artery disease was found to be significantly higher in patients on DOACs (p=0.03). The 12-month primary patency rate was 83.3% vs 57.1%, for DOAC vs warfarin respectively (p=0.03). Multivariate analyses revealed that <30-day reinterventions contribute to 12-month patency (p=0.02). CONCLUSION Patients who underwent lower extremity HRB with postoperative DOAC appeared to exhibit higher graft patency rates than those who were placed on warfarin. Due to their low incidence of undesirable side effects and the lack of frequent monitoring, DOACs could be considered a safe alternative to warfarin in the postoperative period for patients with HRB.
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Affiliation(s)
| | - Yi Tong
- Maimonides Medical Center, Brooklyn, NY
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3
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Rother U, Gruber M, Behrendt CA, Günther J, Lang W, Meyer A. Outcomes and Fate of the Distal Landing Zone Compared Between Prosthetic and Autologous Grafts After Infra-Inguinal Graft Occlusions. Front Surg 2022; 9:811126. [PMID: 35273995 PMCID: PMC8901894 DOI: 10.3389/fsurg.2022.811126] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Due to an increasing life expectancy, more and more patients experience the failure of peripheral arterial revascularization. This study aims to investigate patients treated for the failure of infra-inguinal bypass grafts, and to investigate the interaction of different bypass materials [great saphenous vein (GSV) and polytetrafluoroethylene (PTFE)] and the further outcome. Methods Retrospective single-center analysis of consecutive patients treated for acute or chronic occlusion of infra-inguinal bypasses at a university hospital was conducted. Hospitalizations from 1st January 2010 through 31st December 2019 were included. Perioperative parameters from the index operation including graft material (prosthetic vs. autologous) were assessed. After bypass occlusion, the grade of ischemia, as well as the distal landing zone of the redo bypass compared with the primary bypass was investigated. Results In this study, 158 (65% men and 35% women with a m mean age of 70.5 years) eligible patients were included (57% vein and 42% prosthetic bypass grafts). After graft occlusion, 47% of the patients presented with symptoms of acute limb-threatening ischemia, 53% with symptoms of chronic leg ischemia. The rate of acute limb-threatening ischemia was significantly higher when prosthetic graft material was used during the index operation (p =0.016). Additionally, in case of reoperation, the landing zone of the redo bypass was significantly more distally located after occlusion of prosthetic bypass graft (p = 0.014) Conclusion Occlusions of prosthetic bypass grafts were associated with significantly higher rates of acute symptoms compared with vein grafts. Additionally, a shift to a more distal landing zone was recognized after the failure of a prosthetic bypass graft during the redo bypass operation.
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Affiliation(s)
- Ulrich Rother
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
- *Correspondence: Ulrich Rother
| | - Marc Gruber
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Christian-Alexander Behrendt
- Department of Vascular Medicine, Research Group GermanVasc, University Heart and Vascular Centre UKE Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Josefine Günther
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Alexander Meyer
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
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Computational Characterization of Mechanical, Hemodynamic, and Surface Interaction Conditions: Role of Protein Adsorption on the Regenerative Response of TEVGs. Int J Mol Sci 2022; 23:ijms23031130. [PMID: 35163056 PMCID: PMC8835378 DOI: 10.3390/ijms23031130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/15/2022] [Accepted: 01/16/2022] [Indexed: 12/10/2022] Open
Abstract
Currently available small diameter vascular grafts (<6 mm) present several long-term limitations, which has prevented their full clinical implementation. Computational modeling and simulation emerge as tools to study and optimize the rational design of small diameter tissue engineered vascular grafts (TEVG). This study aims to model the correlation between mechanical-hemodynamic-biochemical variables on protein adsorption over TEVG and their regenerative potential. To understand mechanical-hemodynamic variables, two-way Fluid-Structure Interaction (FSI) computational models of novel TEVGs were developed in ANSYS Fluent 2019R3® and ANSYS Transient Structural® software. Experimental pulsatile pressure was included as an UDF into the models. TEVG mechanical properties were obtained from tensile strength tests, under the ISO7198:2016, for novel TEVGs. Subsequently, a kinetic model, linked to previously obtained velocity profiles, of the protein-surface interaction between albumin and fibrinogen, and the intima layer of the TEVGs, was implemented in COMSOL Multiphysics 5.3®. TEVG wall properties appear critical to understand flow and protein adsorption under hemodynamic stimuli. In addition, the kinetic model under flow conditions revealed that size and concentration are the main parameters to trigger protein adsorption on TEVGs. The computational models provide a robust platform to study multiparametrically the performance of TEVGs in terms of protein adsorption and their regenerative potential.
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5
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Liu S, Lin Z. Vascular Smooth Muscle Cells Mechanosensitive Regulators and Vascular Remodeling. J Vasc Res 2021; 59:90-113. [PMID: 34937033 DOI: 10.1159/000519845] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/23/2021] [Indexed: 11/19/2022] Open
Abstract
Blood vessels are subjected to mechanical loads of pressure and flow, inducing smooth muscle circumferential and endothelial shear stresses. The perception and response of vascular tissue and living cells to these stresses and the microenvironment they are exposed to are critical to their function and survival. These mechanical stimuli not only cause morphological changes in cells and vessel walls but also can interfere with biochemical homeostasis, leading to vascular remodeling and dysfunction. However, the mechanisms underlying how these stimuli affect tissue and cellular function, including mechanical stimulation-induced biochemical signaling and mechanical transduction that relies on cytoskeletal integrity, are unclear. This review focuses on signaling pathways that regulate multiple biochemical processes in vascular mesangial smooth muscle cells in response to circumferential stress and are involved in mechanosensitive regulatory molecules in response to mechanotransduction, including ion channels, membrane receptors, integrins, cytoskeletal proteins, nuclear structures, and cascades. Mechanoactivation of these signaling pathways is closely associated with vascular remodeling in physiological or pathophysiological states.
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Affiliation(s)
- Shangmin Liu
- Ji Hua Institute of Biomedical Engineering Technology, Ji Hua Laboratory, Foshan, China, .,Medical Research Center, Guangdong Academy of Medical Sciences, Guangdong General Hospital, Guangzhou, China,
| | - Zhanyi Lin
- Ji Hua Institute of Biomedical Engineering Technology, Ji Hua Laboratory, Foshan, China.,Institute of Geriatric Medicine, Guangdong Academy of Medical Sciences, Guangdong General Hospital, Guangzhou, China
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6
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Wang Y, Tao M, Wei H, Arslan Ahmad M, Ma Y, Mao X, Hao L, Ao Q. PLCL vascular external sheath carrying prednisone for improving patency rate of the vein graft. Tissue Eng Part A 2021; 28:394-404. [PMID: 34605672 DOI: 10.1089/ten.tea.2021.0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Coronary artery bypass graft surgery (CABG) is an impactful treatment for coronary heart disease. Intimal hyperplasia is the central reason for the restenosis of vein grafts after CABG. The introduction of external vascular sheaths around VGs (VGs) can effectively inhibit intimal hyperplasia and ensure the patency of VGs. In this study, the well-known biodegradable copolymer poly (ε-caprolactone-co-L, L-lactide) (PLCL) was electrospun into high porosity external sheaths. The prednisone loaded in the PLCL sheath was slowly released during the degradation process of PLCL. Under the combined effects of sheath and prednisone, intimal hyperplasia was inhibited. For the cell experiments, all sheaths show low cytotoxicity to L929 cells at different concentrations at different time intervals. The ultrasonography and histological results showed prominent dilation and intimal hyperplasia of VG without sheath after two months of surgery. But there was no dilation in PLCL and PLCLPrednisone groups. Notably, the prednisone-loaded sheath group exhibited efficacy in inhibiting intimal hyperplasia and ensured graft patency.
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Affiliation(s)
- Yang Wang
- China Medical University, 38019, School of Forensic Medicine, Shenyang, China.,China Medical University, School of Intelligent Medicine, Shenyang, China;
| | - Meihan Tao
- China Medical University, 38019, School of Intelligent Medicine, Shenyang, China;
| | - Huan Wei
- The First Affiliated Hospital of China Medical University, 159407, Shenyang, Liaoning, China;
| | | | - Yizhan Ma
- China Medical University, 38019, School of Intelligent Medicine, Shenyang, China;
| | - Xiaoyan Mao
- China Medical University, 38019, School of Intelligent Medicine, Shenyang, China;
| | - Liang Hao
- China Medical University, School of Forensic Medicine, Shenyang, China;
| | - Qiang Ao
- China Medical University, 38019, School of Intelligent Medicine, Shenyang, China.,Sichuan University, 12530, Chengdu, Sichuan, China;
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Maleckis K, Kamenskiy A, Lichter EZ, Oberley-Deegan R, Dzenis Y, MacTaggart J. Mechanically tuned vascular graft demonstrates rapid endothelialization and integration into the porcine iliac artery wall. Acta Biomater 2021; 125:126-137. [PMID: 33549808 DOI: 10.1016/j.actbio.2021.01.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 12/12/2022]
Abstract
Mechanical properties of vascular grafts likely play important roles in healing and tissue regeneration. Healthy arteries are compliant at low pressures but stiffen rapidly with increasing load, ensuring sufficient volumetric expansion without overstretching the vessel. Commercial synthetic vascular grafts are stiff and unable to expand under physiologic loads, which may result in altered hemodynamics, deleterious cellular responses, and compromised clinical performance. The goal of this study was to develop an Elastomeric Nanofibrillar Graft (ENG) with artery-tuned nonlinear compliance and compare its healing responses to conventional expanded polytetrafluoroethylene (ePTFE) grafts in a porcine iliac artery model. Human and porcine iliac arteries were mechanically characterized, and an ENG with similar properties was created by utilizing residual strains within electrospun nanofibers. The ENG was tested for implantation suitability and implanted onto n = 5 domestic swine iliac arteries, with control ePTFE grafts implanted onto the contralateral iliac arteries. After two weeks in vivo, all iliac arteries and grafts remained patent with no signs of thrombosis or dilation. The mechanically tuned ENG implants exhibited a more confluent CD31-positive cell monolayer (1.53 ± 0.73 µm2/mm vs 0.52 ± 0.55 µm2/mm, p = 0.042) on the graft lumenal surface and a higher fraction of αSMA-positive cells (16.2 ± 8.6% vs 1.4 ± 0.7%, p = 0.018) within the graft wall than the ePTFE controls. Despite heavy cellular infiltration, the ENG retained its artery-like mechanical characteristics after two weeks in vivo. These short-term results demonstrate potential advantages of mechanically tuned biomimetic vascular grafts over standard ePTFE grafts. STATEMENT OF SIGNIFICANCE: Off-the-shelf synthetic vascular grafts are often the only option available for treating advanced stages of vascular disease. Despite significant efforts devoted to improving their biochemical characteristics, synthetic peripheral arterial grafts continue to demonstrate poor clinical outcomes leading to costly reinterventions. Here, we hypothesized that a synthetic vascular graft with elastomeric mechanical properties tuned to a healthy peripheral artery promotes better healing responses than a synthetic stiff graft. To test this hypothesis, we developed an Elastomeric Nanofibrillar Graft (ENG) with artery-tuned mechanical properties and compared its performance to a commercial ePTFE graft in a preclinical porcine iliac artery model. Our results suggest that mechanically tuned ENGs can offer better healing responses, potentially leading to better clinical outcomes for peripheral arterial repairs.
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DeCarlo C, Boitano LT, Latz CA, Png CYM, Lee S, Dua A, Patel V, Schwartz SI. Patients with failed femoropopliteal covered stents are more likely to present with acute limb ischemia than those with failed femoropopliteal bare metal stents. J Vasc Surg 2021; 74:161-169.e1. [PMID: 33548436 DOI: 10.1016/j.jvs.2021.01.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/05/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Covered stents (CS) to treat superficial femoral artery (SFA) occlusive disease have become more common. However, concerns about patients presenting with acute limb ischemia (ALI) after failure due to coverage of important collaterals have been raised. Herein, we determine if CS are associated with ALI after failure. METHODS Vascular Quality Initiative peripheral vascular intervention and infrainguinal bypass datasets were queried from 2010 to 2020 for patients who underwent SFA stenting with a bare metal stent (BMS) or CS and who also had a subsequent ipsilateral SFA endovascular reintervention or bypass recorded in the Vascular Quality Initiative. The initial SFA stenting procedure will be referred to as the index procedure and the subsequent procedure will be referred to as the reintervention. Patients with aneurysmal pathology, prior infrainguinal bypass, and ALI at the index procedure were excluded. Patients with pre-index inflow/outflow procedures were not excluded. The primary outcome was ALI at reintervention. Other outcomes included higher degree of ischemia (claudication vs rest pain vs tissue loss vs ALI) and reoperative factors. Predictors of the primary outcome were determined with multivariable logistic regression. The index treatment length and pre-index ankle-brachial index were forced into the model. RESULTS There were 3721 patients: 3338 with index BMS, 383 with index CS. The mean patients age was 66.3 ± 11.0 years and 59.2% were male. Baseline covariates were similar between the groups; during the index procedure, more patients with BMS underwent plain balloon angioplasty (68.7% vs 62.1%; P = .001) and had shorter total index treatment length (median, 15.0 cm [interquartile range, 10.0-25.0 cm] vs 20.0 cm [interquartile range, 12.0-30.0 cm]; P < .001). At reintervention, ALI was the presenting symptom for 12.0% of the CS cohort vs 6.3% of the BMS cohort (P < .001). More patients with an index CS underwent major amputation at the time of reintervention (2.6% vs 1.0%; P = .006). Reinterventions for the patients with a CS more often used bypass, pharmacologic thrombolysis, and mechanical thrombolysis. CS at the index procedure was a predictor of ALI at reintervention (odds ratio, 1.87; 95% confidence interval, 1.31-2.65; P = .001) while controlling for age, time difference between procedures, body mass index, chronic obstructive pulmonary disorder, preoperative anticoagulation and antiplatelet, prior carotid intervention and major amputation, index procedure fluoroscopy time and treatment length, and pre-index ankle-brachial index. CONCLUSIONS In patients undergoing reintervention for failed SFA stents, CS are more likely to present with ALI than those with failed SFA BMS.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Chris A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - C Y Maximilian Png
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Sujin Lee
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Virendra Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian, Columbia University Irving Medical Center, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Samuel I Schwartz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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9
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Mukhamadeev IS, Oborin AA, Danilov VN, Vronskiĭ AS. [Results of loop endarterectomy and femoropopliteal bypass grafting in TASC C and D lesions]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:107-112. [PMID: 33825736 DOI: 10.33529/angio2021120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
AIM The aim of our investigation was to analyse the results of treatment of patients with atherosclerotic lesions of the femoropopliteal segment by means of femoropopliteal bypass grafting or loop endarterectomy within the framework of a single-centre retrospective study. PATIENTS AND METHODS The study included a total of 177 patients who were divided into two groups. Group One was composed of 108 patients subjected to loop endarterectomy from the arteries of the femoropopliteal segment, and Group Two comprised 69 patients who endured femoropopliteal bypass surgery using a synthetic graft. RESULTS Thoroughly analysed were the clinical, demographic, anatomical and perioperative data, as well as intra- and perioperative complications, followed by assessment of primary and secondary patency, with no statistically significant differences in these parameters revealed. Secondary patency was somewhat better in the group of loop endarterectomy. Also determined and examined were specific complications such as insufficient extraction of the plaque, perforation of the artery with the loop, thinning of the wall, detachment of the calcified plaque. This is followed by discussing variants of correction of similar events. In the group of loop endarterectomy, there were no severe complications, such as myocardial infarction, stroke, amputation in the early postoperative period. CONCLUSION Loop endarterectomy is an acceptable alternative to femoropopliteal bypass grafting with a synthetic prosthesis. Taking into account all specific complications, it is possible to achieve minimization of unsuccessful outcomes.
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Affiliation(s)
- I S Mukhamadeev
- Department of Cardiovascular Surgery, Perm Regional Clinical Hospital, Perm, Russia
| | - A A Oborin
- Chair of Cardiovascular Surgery, Perm State Medical University named after Academician E.A. Wagner under the RF Ministry of Public Health, Perm, Russia
| | - V N Danilov
- Department of Cardiovascular Surgery, Perm Regional Clinical Hospital, Perm, Russia
| | - A S Vronskiĭ
- Department of Hospital Surgery, Perm State Medical University named after Academician E.A. Wagner under the RF Ministry of Public Health, Perm, Russia
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Design and Characterization of a Fluidic Device for the Evaluation of SIS-Based Vascular Grafts. Processes (Basel) 2020. [DOI: 10.3390/pr8091198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Currently available small diameter vascular conduits present several long-term limitations, which has prevented their full clinical implementation. Commercially available vascular grafts show no regenerative capabilities and eventually require surgical replacement; therefore, it is of great interest to develop alternative regenerative vascular grafts (RVG). Decellularized Small Intestinal Submucosa (SIS) is an attractive material for RVG, however, the evaluation of the performance of these grafts is challenging due to the absence of devices that mimic the conditions found in vivo. Thereby, the objective of this study is to design, manufacture and validate in silico and in vitro, a novel fluidic system for the evaluation of human umbilical vein endothelial cells (HUVECs) proliferation on SIS-based RVG under dynamical conditions. Our perfusion and rotational fluidic system was designed in Autodesk Inventor 2018. In silico Computational Fluid Dynamics (CFD) validation of the system was carried out using Ansys Fluent software from ANSYS, Inc for dynamical conditions of a pulsatile pressure function measured experimentally over a rigid wall model. Mechanical and biological parameters such as flow regime, pressure gradient, wall shear stress (WSS), sterility and indirect cell viability (MTT assay) were also evaluated. Cell adhesion was confirmed by SEM imaging. The fluid flow regime within the system remains laminar. The system maintained sterility and showed low cytotoxicity levels. HUVECs were successfully cultured on SIS-based RVG under both perfusion and rotation conditions. In silico analysis agreed well with our experimental and theoretical results, and with recent in vitro and in vivo reports for WSS. The system presented is a tool for evaluating RVG and represents an alternative to develop new methods and protocols for a more comprehensive study of regenerative cardiovascular devices.
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Zhang Y, Fang Q, Niu K, Gan Z, Yu Q, Gu T. Time-dependently slow-released multiple-drug eluting external sheath for efficient long-term inhibition of saphenous vein graft failure. J Control Release 2019; 293:172-182. [DOI: 10.1016/j.jconrel.2018.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 11/19/2018] [Accepted: 12/01/2018] [Indexed: 12/22/2022]
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12
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Weber C, Reinhardt S, Eghbalzadeh K, Wacker M, Guschlbauer M, Maul A, Sterner-Kock A, Wahlers T, Wippermann J, Scherner M. Patency and in vivo compatibility of bacterial nanocellulose grafts as small-diameter vascular substitute. J Vasc Surg 2018; 68:177S-187S.e1. [DOI: 10.1016/j.jvs.2017.09.038] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 09/17/2017] [Indexed: 10/18/2022]
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Affiliation(s)
- Jonathan R Thompson
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Cardiovascular Center-5463, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Cardiovascular Center-5463, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA.
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Editor's Choice – A Comparison of Clinical Outcomes Between Primary Bypass and Secondary Bypass After Failed Plain Balloon Angioplasty in the Bypass versus Angioplasty for Severe Ischaemia of the Limb (BASIL) Trial. Eur J Vasc Endovasc Surg 2018; 55:666-671. [DOI: 10.1016/j.ejvs.2018.02.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/11/2018] [Indexed: 12/24/2022]
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15
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Carrabba M, Madeddu P. Current Strategies for the Manufacture of Small Size Tissue Engineering Vascular Grafts. Front Bioeng Biotechnol 2018; 6:41. [PMID: 29721495 PMCID: PMC5916236 DOI: 10.3389/fbioe.2018.00041] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/23/2018] [Indexed: 01/12/2023] Open
Abstract
Occlusive arterial disease, including coronary heart disease (CHD) and peripheral arterial disease (PAD), is the main cause of death, with an annual mortality incidence predicted to rise to 23.3 million worldwide by 2030. Current revascularization techniques consist of angioplasty, placement of a stent, or surgical bypass grafting. Autologous vessels, such as the saphenous vein and internal thoracic artery, represent the gold standard grafts for small-diameter vessels. However, they require invasive harvesting and are often unavailable. Synthetic vascular grafts represent an alternative to autologous vessels. These grafts have shown satisfactory long-term results for replacement of large- and medium-diameter arteries, such as the carotid or common femoral artery, but have poor patency rates when applied to small-diameter vessels, such as coronary arteries and arteries below the knee. Considering the limitations of current vascular bypass conduits, a tissue-engineered vascular graft (TEVG) with the ability to grow, remodel, and repair in vivo presents a potential solution for the future of vascular surgery. Here, we review the different methods that research groups have been investigating to create TEVGs in the last decades. We focus on the techniques employed in the manufacturing process of the grafts and categorize the approaches as scaffold-based (synthetic, natural, or hybrid) or self-assembled (cell-sheet, microtissue aggregation and bioprinting). Moreover, we highlight the attempts made so far to translate this new strategy from the bench to the bedside.
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Affiliation(s)
- Michele Carrabba
- School of Clinical Sciences, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Paolo Madeddu
- School of Clinical Sciences, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
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Vergnaud S, Riche VP, Tessier P, Mauduit N, Kaladji A, Gouëffic Y. Budget impact analysis of heparin-bonded polytetrafluoroethylene grafts (Propaten) against standard polytetrafluoroethylene grafts for below-the-knee bypass in patients with critical limb ischaemia in France. BMJ Open 2018; 8:e017320. [PMID: 29490953 PMCID: PMC5855478 DOI: 10.1136/bmjopen-2017-017320] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To evaluate the budget impact of progressive replacement of standard polytetrafluoroethylene (PTFE) grafts by heparin-bound PTFE (Propaten) for below-the-knee (BTK) bypass in patients with critical limb ischaemia (CLI). DESIGN From a review of the scientific literature, we calculated a theoretical BTK primary patency for Propaten grafts. Using the French hospital expenditure database (PMSI), we retrospectively estimated a rehospitalisation rate for standard PTFE grafts. From these data, a model was created to assess the budget impact of a progressive replacement from standard PTFE grafts to Propaten grafts over a 5-year horizon. We performed an univariate sensitivity analysis to assess the robustness of our results. SETTING French National Health Insurance (FNHI) perspective. PARTICIPANT Patients with CLI. MAIN OUTCOME MEASURES Budget impact analysis. RESULTS Data extraction from the PMSI revealed that 656 patients were treated with PTFE grafts in 2011 in French public hospitals for a BTK bypass. Assuming a 2-year survival rate of 76.8%, observed reinterventions rate for standard PTFE grafts at 24 months from the PMSI was 35.1%. The mean rehospitalisation cost was €10 689. The budget impact analysis based on these data found a net cumulative 5-year payer budget reduction of €112 420 in favour of Propaten, under the assumption of a 75.6% primary patency for Propaten grafts for a projected population of 3215 patients of which 801 received a Propaten graft. CONCLUSIONS Our budget impact analysis showed a positive impact on the national health insurance budget of the replacement of standard PTFE grafts by Propaten grafts for BTK bypass in patients with CLI in France. This supports the enactment of a reimbursement policy by the FNHI.
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Affiliation(s)
- Simon Vergnaud
- Innovation Cell, Partnership and Innovation Department, Directorate of Medical Affairs and Research, CHU de Nantes, Nantes, France
- Department of Medical Information, CHU de Nantes, Nantes, France
| | - Valéry-Pierre Riche
- Innovation Cell, Partnership and Innovation Department, Directorate of Medical Affairs and Research, CHU de Nantes, Nantes, France
| | - Philippe Tessier
- Innovation Cell, Partnership and Innovation Department, Directorate of Medical Affairs and Research, CHU de Nantes, Nantes, France
- SPHERE (EA4275) - Biostatistics, Clinical Research and Pharmaco-Epidemiology, Nantes University, Nantes, France
| | - Nicolas Mauduit
- Department of Medical Information, CHU de Nantes, Nantes, France
| | - Adrien Kaladji
- Service de Chirurgie Vasculaire, CHU Nantes, l'institut du Thorax, Nantes, France
| | - Yann Gouëffic
- Service de Chirurgie Vasculaire, CHU Nantes, l'institut du Thorax, Nantes, France
- Laboratoire de Physiopathologie de la Résorption Osseuse, Inserm-UN UMR-957, Nantes, France
- Faculté de médecine, Université de Nantes, Nantes, France
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Branco BC, Kougias P, Braun JD, Mills JL, Barshes NR. Distal vein patch use and limb events after infragenicular prosthetic bypasses. J Vasc Surg 2018; 68:145-152. [PMID: 29439850 DOI: 10.1016/j.jvs.2017.11.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 11/29/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE In the absence of suitable autologous vein, the use of prosthetic grafts for infragenicular bypasses in peripheral arterial disease has become standard practice. The purpose of this study was to investigate whether creating a vein patch at the distal anastomosis would further improve patency and freedom from major adverse limb events (MALEs). Furthermore, we sought to investigate whether the use of a distal vein patch (DVP) was associated with lower rates of acute limb ischemia (ALI) for those presenting with occluded prosthetic bypass graft. METHODS The cases of all patients undergoing infragenicular prosthetic bypass grafts between January 2009 and July 2016 were retrospectively reviewed. Demographics of the patients, clinical data, and outcomes (graft patency and MALEs) were collected. Patients were compared according to treatment group (DVP vs no DVP). A Cox regression analysis was used to analyze follow-up results. RESULTS During the study period, a total of 373 patients underwent infragenicular bypass at our institution; of those, 93 (24.9%) had prosthetic grafts (DVP, 39; no DVP, 54). Overall, 92 (98.9%) patients were male; the mean age was 63.3 ± 6.6 years and did not differ between the two groups. Patients undergoing prosthetic bypass with DVP were more likely to have chronic obstructive pulmonary disease (38.5% vs 14.8%; P = .009) and less likely to have chronic kidney disease (2.6% vs 20.4%; P = .011). Follow-up data were available for all patients for a median of 7.8 months (range, 1-89 months). After adjustment for differences in demographics and clinical data between the two groups, when outcomes were analyzed, MALEs were significantly lower in the DVP group (35.9% vs 57.4%; odds ratio [OR], 0.4; 95% confidence interval [CI], 0.2-0.9; P = .041). Similarly, reintervention rates were significantly lower in the DVP group (30.8% vs 50.0%; OR, 0.4; 95% CI, 0.2-0.9; P = .044). There was a trend toward higher primary patency in the DVP group (46.2% vs 35.2%; OR, 1.5; 95% CI, 0.7-3.5; P = .206) and lower rates of ALI after bypass occlusion (30.0% vs 42.9%; OR, 0.6; 95% CI, 0.2-1.8; P = .345). A Cox regression time-to-event analysis revealed late separation of freedom from MALEs for DVP relative to no DVP (log rank, P = .269). CONCLUSIONS In this evaluation of infragenicular prosthetic bypass grafts, the creation of a vein patch at the distal anastomosis was associated with lower reintervention rates and a trend toward improved primary patency and MALEs. Furthermore, for those presenting with occluded prosthetic bypass graft, the use of a DVP was associated with a trend toward lower rates of ALI.
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Affiliation(s)
- Bernardino C Branco
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Panos Kougias
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Jonathan D Braun
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Neal R Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.
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Abstract
BACKGROUND Femoro-popliteal bypass is implemented to save limbs that might otherwise require amputation, in patients with ischaemic rest pain or tissue loss; and to improve walking distance in patients with severe life-limiting claudication. Contemporary practice involves grafts using autologous vein, polytetrafluoroethylene (PTFE) or Dacron as a bypass conduit. This is the second update of a Cochrane review first published in 1999 and last updated in 2010. OBJECTIVES To assess the effects of bypass graft type in the treatment of stenosis or occlusion of the femoro-popliteal arterial segment, for above- and below-knee femoro-popliteal bypass grafts. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Vascular Specialised Register (13 March 2017) and CENTRAL (2017, Issue 2). Trial registries were also searched. SELECTION CRITERIA We included randomised trials comparing at least two different types of femoro-popliteal grafts for arterial reconstruction in patients with femoro-popliteal ischaemia. Randomised controlled trials comparing bypass grafting to angioplasty or to other interventions were not included. DATA COLLECTION AND ANALYSIS Both review authors (GKA and CPT) independently screened studies, extracted data, assessed trials for risk of bias and graded the quality of the evidence using GRADE criteria. MAIN RESULTS We included nineteen randomised controlled trials, with a total of 3123 patients (2547 above-knee, 576 below-knee bypass surgery). In total, nine graft types were compared (autologous vein, polytetrafluoroethylene (PTFE) with and without vein cuff, human umbilical vein (HUV), polyurethane (PUR), Dacron and heparin bonded Dacron (HBD); FUSION BIOLINE and Dacron with external support). Studies differed in which graft types they compared and follow-up ranged from six months to 10 years.Above-knee bypassFor above-knee bypass, there was moderate-quality evidence that autologous vein grafts improve primary patency compared to prosthetic grafts by 60 months (Peto odds ratio (OR) 0.47, 95% confidence interval (CI) 0.28 to 0.80; 3 studies, 269 limbs; P = 0.005). We found low-quality evidence to suggest that this benefit translated to improved secondary patency by 60 months (Peto OR 0.41, 95% CI 0.22 to 0.74; 2 studies, 176 limbs; P = 0.003).We found no clear difference between Dacron and PTFE graft types for primary patency by 60 months (Peto OR 1.67, 95% CI 0.96 to 2.90; 2 studies, 247 limbs; low-quality evidence). We found low-quality evidence that Dacron grafts improved secondary patency over PTFE by 24 months (Peto OR 1.54, 95% CI 1.04 to 2.28; 2 studies, 528 limbs; P = 0.03), an effect which continued to 60 months in the single trial reporting this timepoint (Peto OR 2.43, 95% CI 1.31 to 4.53; 167 limbs; P = 0.005).Externally supported prosthetic grafts had inferior primary patency at 24 months when compared to unsupported prosthetic grafts (Peto OR 2.08, 95% CI 1.29 to 3.35; 2 studies, 270 limbs; P = 0.003). Secondary patency was similarly affected in the single trial reporting this outcome (Peto OR 2.25, 95% CI 1.24 to 4.07; 236 limbs; P = 0.008). No data were available for 60 months follow-up.HUV showed benefits in primary patency over PTFE at 24 months (Peto OR 4.80, 95% CI 1.76 to 13.06; 82 limbs; P = 0.002). This benefit was still seen at 60 months (Peto OR 3.75, 95% CI 1.46 to 9.62; 69 limbs; P = 0.006), but this was only compared in one trial. Results were similar for secondary patency at 24 months (Peto OR 4.01, 95% CI 1.44 to 11.17; 93 limbs) and at 60 months (Peto OR 3.87, 95% CI 1.65 to 9.05; 93 limbs).We found HBD to be superior to PTFE for primary patency at 60 months for above-knee bypass, but these results were based on a single trial (Peto OR 0.38, 95% CI 0.20 to 0.72; 146 limbs; very low-quality evidence). There was no difference in primary patency between HBD and HUV for above-knee bypass in the one small study which reported this outcome.We found only one small trial studying PUR and it showed very poor primary and secondary patency rates which were inferior to Dacron at all time points.Below-knee bypassFor bypass below the knee, we found no graft type to be superior to any other in terms of primary patency, though one trial showed improved secondary patency of HUV over PTFE at all time points to 24 months (Peto OR 3.40, 95% CI 1.45 to 7.97; 88 limbs; P = 0.005).One study compared PTFE alone to PTFE with vein cuff; very low-quality evidence indicates no effect to either primary or secondary patency at 24 months (Peto OR 1.08, 95% CI 0.58 to 2.01; 182 limbs; 2 studies; P = 0.80 and Peto OR 1.22, 95% CI 0.67 to 2.23; 181 limbs; 2 studies; P = 0.51 respectively)Limited data were available for limb survival, and those studies reporting on this outcome showed no clear difference between graft types for this outcome. Antiplatelet and anticoagulant protocols varied extensively between trials, and in some cases within trials.The overall quality of the evidence ranged from very low to moderate. Issues which affected the quality of the evidence included differences in the design of the trials, and differences in the types of grafts they compared. These differences meant we were often only able to combine and analyse small numbers of participants and this resulted in uncertainty over the true effects of the graft type used. AUTHORS' CONCLUSIONS There was moderate-quality evidence of improved long-term (60 months) primary patency for autologous vein grafts when compared to prosthetic materials for above-knee bypasses. In the long term (two to five years) there was low-quality evidence that Dacron confers a small secondary patency benefit over PTFE for above-knee bypass. Only very low-quality data exist on below-knee bypasses, so we are uncertain which graft type is best. Further randomised data are needed to ascertain whether this information translates into an improvement in limb survival.
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Affiliation(s)
- Graeme K Ambler
- Aneurin Bevan University Health BoardSouth East Wales Vascular NetworkRoyal Gwent HospitalCardiff RoadNewportUKNP20 2UB
- Cardiff University School of MedicineDivision of Population Medicine3rd Floor Neuadd MeirionnyddHeath ParkCardiffUKCF14 4YS
| | - Christopher P Twine
- Aneurin Bevan University Health BoardSouth East Wales Vascular NetworkRoyal Gwent HospitalCardiff RoadNewportUKNP20 2UB
- Cardiff University School of MedicineDivision of Population Medicine3rd Floor Neuadd MeirionnyddHeath ParkCardiffUKCF14 4YS
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Simon-Yarza T, Bataille I, Letourneur D. Cardiovascular Bio-Engineering: Current State of the Art. J Cardiovasc Transl Res 2017; 10:180-193. [DOI: 10.1007/s12265-017-9740-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 02/24/2017] [Indexed: 12/15/2022]
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Abul-Khoudoud O, Criado FJ. An Update on Endovascular Therapy of the Lower Extremities. J Endovasc Ther 2016; 11 Suppl 2:II72-81. [PMID: 15760267 DOI: 10.1177/15266028040110s613] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Considerable advances have been made over the last decade in percutaneous technology for treatment of atherosclerotic diseases in the iliac, femoropopliteal, and distal tibioperoneal arteries. While treatment strategies are well defined in the iliofemoral segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoropopliteal and distal occlusive disease continues. The spectrum of treatment alternatives to angioplasty ranges from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and stenting. We review in this article the status of percutaneous endovascular techniques for the treatment of lower extremity vascular occlusive disease.
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Affiliation(s)
- Omran Abul-Khoudoud
- Center for Vascular Intervention and Division of Vascular Surgery, Union Memorial Hospital-MedStar Health, Baltimore, Maryland 21218, USA
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23
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A Multicenter Predictive Score for Amputation-Free Survival for Patients Operated on with an Heparin-Bonded ePTFE Graft for Critical Limb Ischemia. World J Surg 2016; 41:306-313. [DOI: 10.1007/s00268-016-3674-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Watson JDB, Houston R, Morrison JJ, Gifford SM, Rasmussen TE. A Retrospective Cohort Comparison of Expanded Polytetrafluorethylene to Autologous Vein for Vascular Reconstruction in Modern Combat Casualty Care. Ann Vasc Surg 2015; 29:822-9. [DOI: 10.1016/j.avsg.2014.12.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 12/11/2014] [Accepted: 12/29/2014] [Indexed: 11/26/2022]
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Heo SH, Park YJ, Woo SY, Kim DI, Kim YW. Comparison of long-term results of above-the-knee femoro-popliteal bypass with autogenous vein and polytetrafluoroethylene grafts. Ann Surg Treat Res 2014; 88:28-34. [PMID: 25553322 PMCID: PMC4279987 DOI: 10.4174/astr.2015.88.1.28] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 07/26/2014] [Accepted: 08/01/2014] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To analyze the long-term results of above-the-knee femoro-popliteal bypass (ATKFPB) with vein grafts compared with polytetrafluoroethylene (PTFE) grafts. METHODS A database of patients with chronic atherosclerotic occlusive disease who underwent ATKFPB was retrospectively reviewed. Characteristics of patient and arterial lesion, and follow-up results were compared between vein grafts and PTFE grafts. Graft patency was determined by periodic examinations of duplex ultrasonography or CT angiograms. Graft patency and limb salvage rates were calculated using the Kaplan-Meier method. RESULTS In total, 253 ATKFPBs (107 vein grafts; 146 PTFE grafts; critical limb ischemia, 32%) were performed on 228 patients (mean age, 68.5 years; male, 87.7%). No significant differences were observed between the two groups with respect to demographic characteristics, characteristics of arterial lesions, or distal runoff score. During the mean follow-up period of 41 months (range, 1-122 months), 14.5% patients died, and 94% of all limbs were available for follow-up. The primary patency rates were not significantly different between the two groups at 10 years after treatment (75% vs. 42%, P = 0.330). However, the primary-assisted patency rates (88% vs. 42%, P = 0.003) and secondary patency rates (91% vs. 49%, P = 0.013) were significantly higher in the vein grafts compared with the PTFE grafts. Graft occlusion developed more often in the PTFE grafts (5.6% vs. 20.5%, P = 0.001). When graft occlusion occurred, acute limb ischemia was significantly more frequent in the PTFE grafts than in the vein grafts (0% vs. 53%, P = 0.027). CONCLUSION After ATKFPB, autologous vein grafts showed significantly better long-term results compared with PTFE grafts.
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Affiliation(s)
- Seon-Hee Heo
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin-Young Woo
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Ik Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Shenouda M, Molena E, Maftei N, Ali T. Remnant Prosthetic Graft in Revision or Limb-Salvage Surgery: Routine Complete Excision? Ann Vasc Surg 2014; 28:1566.e11-5. [DOI: 10.1016/j.avsg.2013.12.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Revised: 12/22/2013] [Accepted: 12/29/2013] [Indexed: 11/15/2022]
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Friedell ML, Stark KR, Kujath SW, Carter RR. Current status of lower-extremity revascularization. Curr Probl Surg 2014; 51:254-90. [DOI: 10.1067/j.cpsurg.2014.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 02/25/2014] [Indexed: 11/22/2022]
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Soma G, Greenblatt DY, Nelson MT, Rajamanickam V, Havlena J, Fernandes-Taylor S, Greenberg CC, Kent KC. Early graft failure after infrainguinal arterial bypass. Surgery 2014; 155:300-10. [DOI: 10.1016/j.surg.2013.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/12/2013] [Indexed: 10/26/2022]
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Remote endarterectomy: an alternative to surgical bypass. Indian J Surg 2014; 75:258-61. [PMID: 24426446 DOI: 10.1007/s12262-012-0723-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 09/03/2012] [Indexed: 10/27/2022] Open
Abstract
We present our preliminary results of remote endarterectomy performed during June 2003 to June 2010. 8 cases of unilateral ileofemoral disease, 3 cases of bilateral ileofemoral disease and 4 cases of femoro-popliteal disease constituting 18 limbs were successfully operated. All patients had comorbid conditions like Diabetes mellitus, hypertension, cardiac disease and smoking. Patency at 3 months with loss of one patient for follow up was 100 %. At one year follow up, the overall success rate was 90.90 %. One patient with Iliofemoral Endarterectomy had progression of the disease and hence had to undergo Aorto-Femoral bypass. All patients who had tissue loss, showed complete recovery by 3 months and one patient was lost to follow up. A 5 year follow up had a patency rate of 74 %. Remote endarterectomy is a viable and durable alternative to standard bypass procedures. Remote endarterectomy combines the advantages of minimally invasive surgery with endovascular techniques.
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Albayrak G, Aykut K, Guzeloglu M, Gulcu A, Hazan E. Advanced treatment of acute femoropopliteal bypass graft occlusion with Fogarty catheter guidance. Vascular 2013; 22:262-6. [PMID: 23929429 DOI: 10.1177/1708538113496238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The guiding role of the Fogarty catheter was investigated among patients suffering from limb ischemia due to acute femoropopliteal bypass graft occlusion. METHODS A total of 27 patients with a history of femoropopliteal bypass operation who was admitted with acute limb ischemia were enrolled in this retrospective study. In cases in which the Fogarty catheter could not be passed through the popliteal anastomosis, the popliteal region was explored and a new bypass or patch plasty was performed for the distal anastomosis. The cases in which the blood circulation was observed in the graft, but in which the Fogarty catheter balloon was stuck in the native vessels on the proximal and distal side of the graft and the balloon could be withdrawn by deflation, were referred to conventional angiography. The stenosis observed in native vessels was managed by endovascular stent grafting and/or balloon dilatation. FINDINGS Graft patency was achieved in all patients. In 11 patients, conventional angiography was implemented following embolectomy. In these patients, all the occlusions found as significant on angiography were removed by percutaneous transluminal angioplasty. CONCLUSION Effective use of Fogarty catheter is safe in acute femoropopliteal bypass graft occlusions and in particular, in the planning of further treatment following thrombectomy.
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Affiliation(s)
- Gokhan Albayrak
- Department of Cardiovascular Surgery, Izmir University, Izmir, Turkey
| | - Koray Aykut
- Department of Cardiovascular Surgery, Izmir University, Izmir, Turkey
| | - Mehmet Guzeloglu
- Department of Cardiovascular Surgery, Izmir University, Izmir, Turkey
| | - Aytac Gulcu
- Department of Radiology, Dokuz Eylul University, Izmir, Turkey
| | - Eyup Hazan
- Department of Cardiovascular Surgery, Izmir University, Izmir, Turkey
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Knepper JP, Henke PK. Diagnosis, Prevention, and Treatment of Claudication. Surg Clin North Am 2013; 93:779-88, vii. [DOI: 10.1016/j.suc.2013.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Harskamp RE, Lopes RD, Baisden CE, de Winter RJ, Alexander JH. Saphenous vein graft failure after coronary artery bypass surgery: pathophysiology, management, and future directions. Ann Surg 2013; 257:824-33. [PMID: 23574989 DOI: 10.1097/sla.0b013e318288c38d] [Citation(s) in RCA: 237] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To review our current understanding of the epidemiology and pathogenesis of vein graft failure (VGF), give an overview of current preventive and interventional measures, and explore strategies that may improve vein graft patency. BACKGROUND VGF and progression of native coronary artery disease limit the long-term efficacy of coronary artery bypass graft surgery. METHODS We reviewed the published literature on the pathophysiology, prevention, and/or treatment of VGF by searching the MEDLINE (January 1, 1966-January 1, 2012), EMBASE (January 1, 1980-January 1, 2012), and Cochrane (January 1, 1995-January 1, 2012) databases. In addition, we reviewed references from the selected articles for studies not identified in the initial search. Basic science and clinical studies were included; non-English language publications were excluded. RESULTS Acute thrombosis, neointimal hyperplasia, and accelerated atherosclerosis are the 3 mechanisms that lead to VGF. Preventive measures include matching and quality assessment of conduit and target vessel, lipid-lowering drugs, antithrombotic therapy, and cessation of smoking. Treatment of VGF includes medical therapy, percutaneous intervention, and redo coronary artery bypass graft surgery. In patients undergoing graft intervention, the use of drug-eluting stents, antiplatelet agents, and embolic protection devices may improve clinical outcomes. CONCLUSIONS Despite advances in management, VGF remains one of the leading causes of poor in-hospital and long-term outcomes after coronary artery bypass graft surgery. New developments in VGF prevention such as gene therapy, external graft support, fully tissue-engineered grafts, hybrid grafts, and synthetic conduits are promising but unproven. Future efforts to reduce VGF require a multidisciplinary approach with a primary focus on prevention.
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Affiliation(s)
- Ralf E Harskamp
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA
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Expandable external support device to improve Saphenous Vein Graft Patency after CABG. J Cardiothorac Surg 2013; 8:122. [PMID: 23641948 PMCID: PMC3661403 DOI: 10.1186/1749-8090-8-122] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Accepted: 04/29/2013] [Indexed: 11/20/2022] Open
Abstract
Objectives Low patency rates of saphenous vein grafts remain a major predicament in surgical revascularization. We examined a novel expandable external support device designed to mitigate causative factors for early and late graft failure. Methods For this study, fourteen adult sheep underwent cardiac revascularization using two vein grafts for each; one to the LAD and the other to the obtuse marginal artery. One graft was supported with the device while the other served as a control. Target vessel was alternated between consecutive cases. The animals underwent immediate and late angiography and were then sacrificed for histopathologic evaluation. Results Of the fourteen animals studied, three died peri-operatively (unrelated to device implanted), and ten survived the follow-up period. Among surviving animals, three grafts were thrombosed and one was occluded, all in the control group (p = 0.043). Quantitative angiographic evaluation revealed no difference between groups in immediate level of graft uniformity, with a coefficient-of-variance (CV%) of 7.39 in control versus 5.07 in the supported grafts, p = 0.082. At 12 weeks, there was a significant non-uniformity in the control grafts versus the supported grafts (CV = 22.12 versus 3.01, p < 0.002). In histopathologic evaluation, mean intimal area of the supported grafts was significantly lower than in the control grafts (11.2 mm^2 versus 23.1 mm^2 p < 0.02). Conclusions The expandable SVG external support system was found to be efficacious in reducing SVG’s non-uniform dilatation and neointimal formation in an animal model early after CABG. This novel technology may have the potential to improve SVG patency rates after surgical myocardial revascularization.
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Gabrielli R, Rosati MS, Vitale S, Baciarello G, Siani A, Chiappa R, Caselli G, Irace L. Randomized controlled trial of remote endarterectomy versus endovascular intervention for TransAtlantic Inter-Society Consensus II D femoropopliteal lesions. J Vasc Surg 2012; 56:1598-605. [PMID: 23044257 DOI: 10.1016/j.jvs.2012.06.081] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 06/06/2012] [Accepted: 06/07/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study evaluated outcomes of remote endarterectomy (RE) vs endovascular (ENDO) interventions on TransAtlantic Inter-Societal Consensus (TASC)-II D femoropopliteal lesions and identified factors predictive of restenosis. METHODS From October 2004 to December 2008, 95 patients with TASC-II D lesions were randomized 1:1 to receive RE of the superficial femoral artery (SFA) with end point stenting (51 patients) or ENDO, consisting of subintimal angioplasty with stenting (44 patients). The groups were balanced for age, sex, atherosclerotic risk factors, and comorbidities. Categoric data were analyzed with χ2 tests, and time to event provided two-sided P values with a level of significance at .05 and 95% confidence intervals (CIs). Survival curves for primary patency were plotted using the Kaplan-Meier method. Univariate analysis for diabetes, hypertension, dyslipidemia, smoking, and critical ischemia was performed according to the Cox proportional hazards model. RESULTS The mean follow-up was 52.5 months (range, 35-75 months). Five RE patients and four ENDO patients were lost to follow-up (censored). Primary patency was 76.5% (39 of 51) in RE and 56.8% (25 of 44) in ENDO (hazard ratio [HR], 2.6; 95% CI, 0.99-4.2; P=.05) at 24 months and was 62.7% (32 of 46) in RE and 47.7% (21 of 40) in ENDO (HR, 1.89; 95% CI, 0.94-3.78; P=.07) at 36 months. Assisted primary patency was 70.6% (36 of 51) in RE and 52.3% (23 of 44) in ENDO (HR, 2.45; 95% CI, 1.20-5.02; P=.01). Secondary patency overlapped the primary comparison data at 12 and 24 months; at 36 months, there was a slight but significative advantage for RE (HR, 2.26; 95% CI, 1.05-4.86; P=.03). Univariate analysis demonstrated that hypercholesterolemia and critical limb ischemia (CLI) were significantly related to patency failure, whereas diabetes was significant only in ENDO. These factors (hypercholesterolemia and CLI) were independent predictors of patency on Cox multivariate analysis. CONCLUSIONS RE is a safe, effective, and durable procedure for TASC-II D lesions. Our data demonstrate a significantly higher primary, assisted primary, and secondary patency of RE vs ENDO procedures. Furthermore, overall secondary patency rates remain within the standard limits, although preoperative CLI and dyslipidemia continue to be associated with worse outcomes. Taken together, these data suggest that RE should be considered better than an endovascular procedure in SFA long-segment occlusion treatment.
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Affiliation(s)
- Roberto Gabrielli
- Department of Vascular and Endovascular Surgery, Policlinico Casilino, Rome, Italy.
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Guzeloglu M, Reel B, Atmaca S, Bagrıyanık A, Hazan E. The effects of PPARγ agonist rosiglitazone on neointimal hyperplasia in rabbit carotid anastomosis model. J Cardiothorac Surg 2012; 7:57. [PMID: 22716287 PMCID: PMC3487767 DOI: 10.1186/1749-8090-7-57] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 06/08/2012] [Indexed: 11/13/2022] Open
Abstract
Background Neointimal hyperplasia involving smooth muscle cell (SMC) proliferation, migration and extracellular matrix (ECM) degradation is an important component of atherosclerosis. It develops as a response to vascular injury after balloon angioplasty and vascular graft placement. Matrix metalloproteinases (MMPs) induce SMC proliferation, migration and contribute to intimal hyperplasia by degrading ECM. PPARγ agonists inhibit SMC proliferation, migration and lesion formation. In this study, we aimed to investigate the effects of PPARγ agonist rosiglitazone on neointimal hyperplasia and gelatinase (MMP-2 and MMP-9) expressions in rabbit carotid anastomosis model. Methods New Zealand white rabbits (n = 13, 2.7–3.2 kg) were divided into placebo and treatment groups. Right carotid artery (CA) was transected and both ends were anastomosed. Treatment group (n = 6) received rosiglitazone (3 mg/kg/day/p.o.) and placebo group (n = 7) received PBS (phosphate buffered saline, 2.5 ml/kg/day/p.o.) for 4 weeks postoperatively. After the sacrification, right and left CAs were isolated. Morphometric analyses and immunohistochemical examinations for gelatinases were performed. Results Intimal area (0.055 ± 0.005 control vs 0.291 ± 0.020 μm2 anastomosed, p < 0,05) and index (0.117 ± 0.002 control vs 0.574 ± 0.013 anastomosed, p < 0,01) significantly increased in anastomosed arteries compared to control arteries from placebo group. However, in rosiglitazone-treated group, intimal area (0.291 ± 0.020 PBS vs 0.143 ± 0.027 rosiglitazone, p < 0,05) and index (0.574 ± 0.013 PBS vs 0.263 ± 0.0078 rosiglitazone, p < 0,01) significantly decreased. Furthermore, gelatinase immunopositivity was found to have significantly increased in anastomosed arteries from placebo group and decreased with rosiglitazone treatment. Conclusions These results suggest that rosiglitazone may prevent neointimal hyperplasia, which is the most important factor involved in late graft failure, by inhibiting gelatinase enzyme expression.
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Affiliation(s)
- Mehmet Guzeloglu
- Department of Cardiovascular Surgery, Faculty of Medicine, İzmir University, Izmir, Turkey.
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Brackmann C, Dahlberg JO, Vrana NE, Lally C, Gatenholm P, Enejder A. Non-linear microscopy of smooth muscle cells in artificial extracellular matrices made of cellulose. JOURNAL OF BIOPHOTONICS 2012; 5:404-414. [PMID: 22461222 DOI: 10.1002/jbio.201100141] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Revised: 03/08/2012] [Accepted: 03/08/2012] [Indexed: 05/31/2023]
Abstract
Non-linear microscopy has been used to characterize bovine smooth muscle cells and their proliferation, migration, and differentiation in hydrogel cellulose scaffolds, toward the development of fully functional blood vessel implants. The extracellular matrix (ECM) composed of cellulose and endogenous collagen fibers was imaged using Second Harmonic Generation (SHG) microscopy and the cell morphology by Coherent Anti-Stokes Raman Scattering (CARS) microscopy. Images prove that cells adhere on the cellulose scaffold without additional surface modification and that both contractile and proliferating phenotypes are developed. This work shows that non-linear microscopy contributes with unique insights in cell interactions with (artificial) ECM components and has the potential to become an established characterization method in tissue engineering.
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Affiliation(s)
- Christian Brackmann
- Molecular Microscopy, Department of Chemical and Biological Engineering, Chalmers University of Technology, Göteborg, Sweden
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Abstract
Autologous saphenous vein is commonly used as a conduit to bypass atherosclerotic lesions in coronary and femoral arteries. Despite the wide use of arterial conduits, which are less susceptible to complications and failure, as alternative conduits, the saphenous vein will continue to be used in coronary artery bypass grafting until acceptable alternative approaches are evaluated. Hence, preservation of vein graft patency is essential for the long-term success. Gene therapy is attractive in this setting as an ex-vivo technology to genetically manipulate the conduit before grafting. The use of safe and efficient vectors for delivery is a necessity as well as a strategy to improve patency in the long term. Here, we review the current clinical practice, the pathogenesis of bypass graft failure and adenovirus-mediated gene therapy strategies designed to improve late vein graft failure by modulation of smooth muscle cells in the vein wall.
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Chander RK, Oza P, Patel M, Balar N. Recanalization of failed autogenous conduit utilizing laser revascularization. Vasc Endovascular Surg 2011; 45:636-40. [PMID: 21984029 DOI: 10.1177/1538574411414304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The traditional approach for the treatment of restenosis of autogenous vein bypass has been revision of bypass with vein patch angioplasty, interposition jump graft, or thrombectomy procedures for those patients with extensive occlusive disease and limb-threatening ischemia. Endovascular intervention traditionally involves angioplasty of the graft; however, vessels with diffuse disease or extensive longitudinal lesions are generally difficult to revascularize utilizing this technique. Surgical revision of a threatened autogenous vein graft may carry a morbidity rate as high as 13.6%. We present a series of cases in which excimer laser atherectomy (LA) was used to recanalize an occluded autogenous saphenous vein bypass. Of the occluded vein bypasses failed angioplasty and were successfully atherectomized with LA measuring lengths of 35 and 30 cm, respectively. The infrainguinal has a 6-month follow-up, while the infragencular has a follow-up of 1 year, with resolution of presenting symptoms.
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Affiliation(s)
- Rajiv K Chander
- Department of Surgery, Montefiore Medical Center—North Division, 600 East 233rd Street, Bronx, NY 10466, USA.
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Basic data related to surgical infrainguinal revascularization procedures: a twenty year update. Ann Vasc Surg 2011; 25:413-22. [PMID: 21396568 DOI: 10.1016/j.avsg.2010.10.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 10/12/2010] [Accepted: 10/17/2010] [Indexed: 11/20/2022]
Abstract
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.
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Abraham-Igwe C, Siddiqui M, Geddes L, Halls J, Irvine A, Browning N. A retrospective study examining thrombolysis for occluded femoro-popliteal grafts – Is it worthwhile? Int J Surg 2011; 9:632-5. [DOI: 10.1016/j.ijsu.2011.07.431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 07/09/2011] [Accepted: 07/26/2011] [Indexed: 11/25/2022]
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Desai M, Mirzay-Razzaz J, von Delft D, Sarkar S, Hamilton G, Seifalian AM. Inhibition of neointimal formation and hyperplasia in vein grafts by external stent/sheath. Vasc Med 2010; 15:287-97. [DOI: 10.1177/1358863x10366479] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Synthetic and to a lesser extent vein graft failure is still a major problem in the treatment of peripheral arterial disease, with neointimal hyperplasia being the main cause for graft occlusion in the medium and long term. This review aims to establish the current status of external stents or sheaths in the prevention of intimal hyperplasia in small diameter (< 6 mm) vein grafts.
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Affiliation(s)
- Mital Desai
- Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science, University College London, London, UK, Cardiovascular Haemodynamic Group, University College London, London, UK
| | - Jalaledin Mirzay-Razzaz
- Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science, University College London, London, UK, Cardiovascular Haemodynamic Group, University College London, London, UK
| | - Dirk von Delft
- Christiaan Barnard Division of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
| | - Sandip Sarkar
- Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science, University College London, London, UK
| | - George Hamilton
- Vascular Unit, Royal Free Hampstead NHS Trust Hospital, London, UK
| | - Alexander M Seifalian
- Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science, University College London, London, UK, Cardiovascular Haemodynamic Group, University College London, London, UK,
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Pektok E, Cikirikcioglu M, Tille JC, Kalangos A, Walpoth BH. Alcohol Pretreatment of Small-diameter Expanded Polytetrafluoroethylene Grafts: Quantitative Analysis of Graft Healing Characteristics in the Rat Abdominal Aorta Interposition Model. Artif Organs 2009; 33:532-7. [DOI: 10.1111/j.1525-1594.2009.00731.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The use of prosthetic grafts in complex military vascular trauma: a limb salvage strategy for patients with severely limited autologous conduit. ACTA ACUST UNITED AC 2009; 66:980-3. [PMID: 19359902 DOI: 10.1097/ta.0b013e31819c59ac] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The use of prosthetic grafts for reconstruction of military vascular trauma has been consistently discouraged. In the current conflict, however, the signature wound involves multiple extremities with significant loss of soft tissue and potential autogenous venous conduits. We reviewed the experience with the use of prosthetic grafts for the treatment of vascular injuries sustained during recent conflicts in Iraq and Afghanistan. METHODS Trauma registry records with combat-related vascular injuries repaired using prosthetic grafts were retrospectively reviewed from March 2003 to April 2006. Data collected included age, gender, mechanism of injury, vessel injured, conduit, graft patency, complications, including amputation and eventual outcome of repair. RESULTS Prosthetic grafts were placed in 14 of 95 (15%) patients undergoing extremity bypass for vascular injuries. Patients were men with an average age of 25 years (range, 19-39 years). All prosthetic grafts in this series were made of polytetrafluoroethylene. Mechanism of injury included blast (n = 6), gunshot wounds (n = 6), and blunt trauma (n = 2), resulting in prosthetic repair of injuries to the superficial femoral (n = 8), brachial (n = 3), common carotid (n = 1), subclavian (n = 1), and axillary (n = 1) arteries. Mean evacuation time from injury to stateside arrival was 7 days (range, 3-9 days). Twelve grafts were placed initially at the time of injury, and two after vein graft blow out with secondary hemorrhage. The mean follow-up period was 427 days (range, 49-1,285 days). Seventy-nine percent of prosthetic grafts stayed patent in the short term, allowing patient stabilization, transport to a stateside facility, and elective revascularization with the remaining autologous vein graft. Three prosthetic grafts were replaced urgently for thrombosis. The remaining seven grafts were replaced electively for severe stenosis (3) or exposure (4) with presumed infection. There were no prosthetic graft blow outs or deaths in this series. No patients required amputation because of prosthetic graft failure. Three (21%) patients went on to have elective lower extremity amputation, despite patent grafts for nonsalvagable limbs. CONCLUSIONS When managing patients with multiple extremity trauma and limited noninjured autogenous venous conduits, emergent use of prosthetic grafts may provide an effective limb salvage strategy. Despite being placed in multisystem trauma patients with large contaminated soft tissue wounds, emergent revascularization with polytetrafluoroethylene allowed patient stabilization, transport to a higher echelon of care, and elective revascularization with remaining limited autologous vein.
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Human P, Franz T, Scherman J, Moodley L, Zilla P. Dimensional analysis of human saphenous vein grafts: Implications for external mesh support. J Thorac Cardiovasc Surg 2009; 137:1101-8. [PMID: 19379974 DOI: 10.1016/j.jtcvs.2008.10.040] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 09/05/2008] [Accepted: 10/03/2008] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Constrictive external mesh support of vein grafts was shown to mitigate intimal hyperplasia in animal experiments. To determine the degree of constriction required for the elimination of dimensional irregularities in clinically used vein grafts, a detailed anatomic study of human saphenous veins was conducted. METHODS In 200 consecutive patients having coronary artery bypass grafting, harvested saphenous veins (length 34.4 +/- 10.8 cm) were analyzed regarding diameter irregularities, side branch distribution, and microstructure. RESULTS The mean outer diameter of surgically distended saphenous veins was 4.2 +/- 0.6 mm (men, 4.3 +/- 0.6 mm vs women, 3.9 +/- 0.5 mm; P < .0001). Although the outer diameter significantly decreased over the initial 18 cm (-7.6%; P < .0001), the overall increase between malleolus and thigh was not significant (+11.2%). Smaller-diameter veins (<3.5 mm) had more pronounced diameter fluctuations than larger veins (31.8% +/- 11.0% vs 21.2% +/- 8.8%; P < .0001), with more than 71% of all veins showing caliber changes of more than 20%. There was 1 side branch every 5.4 +/- 4.3 cm, with a significantly higher incidence between 20 and 32 cm from the malleolus (P < .0001 to distal, P < .0004 to proximal). Generally, women had more side branches than men (0.30 +/- 0.15 cm(-1) vs 0.25 +/- 0.12 cm(-1); P = .0190). Thick-walled veins (565.7 +/- 138.4 mum) had a significantly higher number of large side branches (P < .0001), and thin-walled veins (398.7 +/- 123.2 mum) had significantly more small side branches (P < .0001). Pronounced intimal thickening ("cushions") was found in 28% of vessels (119.8 +/- 28.0 mum vs 40.1 +/- 18.2 mum; P < .0001). CONCLUSION Although the preferential location of side branches may be addressed by the deliberate discarding of infragenicular vein segments, a diameter constriction of 27% on average would eliminate diameter irregularities in 98% of vein grafts.
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Affiliation(s)
- Paul Human
- Christiaan Barnard Department of Cardiothoracic Surgery, University of Cape Town, Observatory, South Africa
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De Luccia N, Brochado-Neto FC, Romiti M, Kikuchi M, Caldas dos Reis JM, Durazzo AES, Villa Albers MT. Preferential Use of Nonreversed Vein Grafts in Above-Knee Femoropopliteal Bypasses for Critical Ischemia: Midterm Outcome. Ann Vasc Surg 2008; 22:668-75. [DOI: 10.1016/j.avsg.2008.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Revised: 03/29/2008] [Accepted: 05/08/2008] [Indexed: 10/21/2022]
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Ramaiah V. Endovascular infrainguinal revascularization: technical tips for atherectomy device selection and procedural success. Semin Vasc Surg 2008; 21:41-9. [PMID: 18342735 DOI: 10.1053/j.semvascsurg.2007.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The superficial femoral artery (SFA) is the interventionalist's most frequent adversary in infrainguinal revascularization, and we have yet to conquer it. Despite having numerous devices and techniques in our arsenal, we have, in large part, been unable to devise a treatment that yields not only excellent, safe, and reproducible acute outcomes, but also consistently good results at long-term follow-up. Angioplasty and stenting of the SFA has come under severe criticism due to numerous reports of stent fractures, unacceptable restenosis rates, and lack of US Food and Drug Administration-approved specific stents in this location. An alternative to displacement techniques is now being pursued. These include debulking the atheromatous plaque. We review these techniques and also offer helpful tips to achieve maximum success in infrainguinal revascularization.
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Affiliation(s)
- Venkatesh Ramaiah
- Division of Vascular and Endovascular Surgery, Arizona Heart Hospital and Arizona Heart Institute, Phoenix, AZ 85006, USA.
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Ihnat DM, Duong ST, Taylor ZC, Leon LR, Mills JL, Goshima KR, Echeverri JA, Arslan B. Contemporary outcomes after superficial femoral artery angioplasty and stenting: The influence of TASC classification and runoff score. J Vasc Surg 2008; 47:967-74. [DOI: 10.1016/j.jvs.2007.12.050] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Revised: 12/20/2007] [Accepted: 12/21/2007] [Indexed: 11/17/2022]
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Karakayali F, Haberal N, Tufan H, Hasirci N, Basaran O, Sevmis S, Akdur A, Kiziltay A, Haberal M. Evaluation of neointimal hyperplasia on tranilast-coated synthetic vascular grafts: an experimental study. J INVEST SURG 2007; 20:167-73. [PMID: 17613691 DOI: 10.1080/08941930701365101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Tranilast is an antiallergic drug that interferes with proliferation and migration of vascular smooth muscle cell induced by platelet-derived growth factor (PDGF) and transforming growth factor-beta1 (TGF-beta1). We investigated the local effect of tranilast on neointimal hyperplasia using tranilast-coated prosthetic grafts. The inner sides of the thin-walled polytetrafluoroethylene (PTFE) grafts were coated with chitosan and tranilast containing chitosan solution. Wistar albino rats (32) were used in the study. Patches (1 x 2 mm) for vascular grafts were prepared. Three groups were tested: group 1 (n = 12; tranilast coated), group 2 (n = 10; adhesive-only film-layer-coated), and group 3 (n = 10; normal ePTFE patch grafts sutured to the carotid arteries of the rats). Recipient sites of the carotid arteries were excised 4 weeks after surgery. All sections were examined histologically for graft patency, thrombus formation, and neointimal thickness. Expression of PDGF, fibroblast growth factor, and TGF-beta1 on cross-sections of the neointima were evaluated by immunohistochemistry. No significant differences were found regarding mean neointimal thicknesses. PDGF and TGF-beta-1 expressions were significantly lower in group 1. Although a decrease in local effect of tranilast was observed for growth factor expressions at a drug concentration of 0.05 mg/cm(2), a significant reduction in neointimal hyperplasia was not achieved. The coating concentration of 0.05 mg/cm(2) may have been too low to produce an antiproliferative effect. Given our promising results, further studies are recommended and planned using different drug concentrations and time intervals.
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Affiliation(s)
- Feza Karakayali
- Department of General Surgery, Baskent University Faculty of Medicine, Ankara, Turkey
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Pedrini L. Considerations about TASC II: is it a suitable document for specialists? Eur J Vasc Endovasc Surg 2007; 34:411-4; author reply 415. [PMID: 17591449 DOI: 10.1016/j.ejvs.2007.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2007] [Accepted: 05/02/2007] [Indexed: 11/24/2022]
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Shafique S, Nachreiner RD, Murphy MP, Cikrit DF, Sawchuk AP, Dalsing MC. Recanalization of infrainguinal vessels: silverhawk, laser, and the remote superficial femoral artery endarterectomy. Semin Vasc Surg 2007; 20:29-36. [PMID: 17386361 DOI: 10.1053/j.semvascsurg.2007.02.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There are multiple endovascular options to achieve percutaneous revascularization of chronic superficial femoral artery (SFA) stenoses and occlusions. Most rely on forceful displacement of plaque via balloon angioplasty, either as a stand-alone therapy or supplemented by cold thermal injury (cryoplasty), microtome assistance (cutting balloon angioplasty), nitinol stent deployment, or expanded polytetrafluoroethylene-lined nitinol stent deployment. Excellent technical success rates are routinely described in the literature. The essential problem associated with these techniques is the predictable compromise of the initial result by neointimal hyperplasia leading to poor long-term results. An alternative to forceful displacement techniques is use of directional atherectomy or excimer laser to debulk the atheromatous lesion, with the addition of low-pressure angioplasty or stent deployment as needed. Currently, directional atherectomy is performed using the Silverhawk Plaque Excision System (FoxHollow, Redwood City, CA), while laser atherectomy is frequently performed with the CLIRpath Excimer Laser (Spectranetics Corp., Colorado Springs, CO). While both techniques can be utilized for de novo atherosclerotic lesions, even eccentric lesions or ostial lesions, proponents of these devices have also shown good short-term results in the treatment of restenoses. Remote SFA endarterectomy with the Aspire stent (Vascular Architects, San Jose, CA) is a hybrid surgical and endovascular technique that is useful for debulking plaque from the SFA with adjunctive stenting of the distal SFA. We present a review of various alternative techniques to forceful balloon dilation used in the recanalization of the SFA with potential pitfalls and complications, along with a review of literature associated with each of these techniques.
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Affiliation(s)
- Shoaib Shafique
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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