RESUMEN

OBJECTIVE: The use of basilic vein in iliofemoral revascularizations was previously described in the literature as an autologous option for the treatment of vascular prosthesis infection and as a primary conduit in patients at high risk of infectious surgical complications. However, the publications available include several different indications and are limited to case reports. Therefore, the aim of this study was to evaluate the outcomes of the use of arm veins as a safe and effective autologous alternative for iliofemoral reconstruction in patients with chronic limb-threatening ischemia (CLTI) and at high risk of prosthesis infection. METHODS: We performed a multicenter, retrospective cohort study with 53 consecutive iliofemoral bypasses using arm veins as an alternative conduit. The procedures were performed between November 2013 and November 2021, exclusively for patients with CLTI classified as TASC aortoiliac C or D with increased risk of postoperative surgical infection. Demographic, clinical variables, and outcomes were collected from a prospective database. Main endpoints were amputation-free survival (AFS) and major adverse cardiovascular events. Secondary endpoints included primary and secondary patencies and overall survival. Cox regression analysis was used to identify the predictors of AFS. Postoperative surgical complications and 30-day mortality were also assessed. RESULTS: The mean age was 64.2 ± 8.4 years, with a predominance of male gender. The median follow-up period was 615 days. All patients had CLTI, with a predominance of tissue loss (n = 51; 96.2%) and a median ankle-brachial index of 0.28. The basilic vein was utilized in most procedures (69.8%). Thirty-day major adverse cardiovascular events occurred in five cases (9.4%), and the 30-day mortality rate was 3.8%. The AFS, primary patency, secondary patency, and overall survival in 720 days were 71%, 72%, 89%, and 75%, respectively. Cox regression analysis revealed no association between the variables analyzed for AFS. There was no graft late infection nor pseudoaneurysmal degeneration. CONCLUSIONS: Iliofemoral bypass using arm veins as an autologous conduit proved to be an effective and safe procedure with low incidence of postoperative cardiovascular complications and high rates of AFS in patients with CLTI. Also, this suggests that arm veins can be an interesting and suitable autologous alternative conduit for iliofemoral reconstructions, especially in cases in which a prosthesis should be avoided or when it is not available.

Asunto(s)

Brazo , Isquemia Crónica que Amenaza las Extremidades , Humanos , Masculino , Persona de Mediana Edad , Anciano , Femenino , Estudios Retrospectivos , Extremidad Inferior/irrigación sanguínea , Resultado del Tratamiento , Recuperación del Miembro/métodos , Factores de Riesgo , Isquemia/diagnóstico por imagen , Isquemia/cirugía , Prótesis Vascular/efectos adversos , Complicaciones Posoperatorias/etiología , Grado de Desobstrucción Vascular

RESUMEN

OBJECTIVE: The use of basilic vein in iliofemoral revascularizations was previously described in the literature as an autologous option for the treatment of vascular prosthesis infection and as a primary conduit in patients at high risk of infectious surgical complications. However, the publications available include several different indications and are limited to case reports. Therefore, the aim of this study was to evaluate the outcomes of the use of arm veins as a safe and effective autologous alternative for iliofemoral reconstruction in patients with chronic limb-threatening ischemia (CLTI) and at high risk of prosthesis infection. METHODS: We performed a multicenter, retrospective cohort study with 53 consecutive iliofemoral bypasses using arm veins as an alternative conduit. The procedures were performed between November 2013 and November 2021, exclusively for patients with CLTI classified as TASC aortoiliac C or D with increased risk of postoperative surgical infection. Demographic, clinical variables, and outcomes were collected from a prospective database. Main endpoints were amputation-free survival (AFS) and major adverse cardiovascular events. Secondary endpoints included primary and secondary patencies and overall survival. Cox regression analysis was used to identify the predictors of AFS. Postoperative surgical complications and 30-day mortality were also assessed. RESULTS: The mean age was 64.2 ± 8.4 years, with a predominance of male gender. The median follow-up period was 615 days. All patients had CLTI, with a predominance of tissue loss (n = 51; 96.2%) and a median ankle-brachial index of 0.28. The basilic vein was utilized in most procedures (69.8%). Thirty-day major adverse cardiovascular events occurred in five cases (9.4%), and the 30-day mortality rate was 3.8%. The AFS, primary patency, secondary patency, and overall survival in 720 days were 71%, 72%, 89%, and 75%, respectively. Cox regression analysis revealed no association between the variables analyzed for AFS. There was no graft late infection nor pseudoaneurysmal degeneration. CONCLUSIONS: Iliofemoral bypass using arm veins as an autologous conduit proved to be an effective and safe procedure with low incidence of postoperative cardiovascular complications and high rates of AFS in patients with CLTI. Also, this suggests that arm veins can be an interesting and suitable autologous alternative conduit for iliofemoral reconstructions, especially in cases in which a prosthesis should be avoided or when it is not available.

RESUMEN

OBJETIVE: Great efforts have been made to determine when choosing between bypass surgery or angioplasty as first-time revascularization in chronic limb-threatening ischemia (CLTI). Endovascular therapy predominates despite limited evidence for their advantage. The purpose of this observational cohort study, was to investigate outcomes after open and endovascular infrapopliteal revascularization in extensive infrainguinal arterial disease. METHODS: The medical records of 1427 patients who underwent infrainguinal revascularization exclusively for CLTI in the period of January 2014 to February 2019 were reviewed. After detailed analysis, only infrapopliteal revascularizations classified as GLASS stage II or III were considered, resulting in 326 procedures. There were 127 patients who underwent endovascular therapy and 199 patients who underwent bypass graft surgery (BGS). The primary endpoints included amputation-free survival (AFS) and overall survival (OS). Secondary endpoints included the analyses of multiple factors related to long-term AFS. RESULTS: Regarding the primary endpoint, AFS were 75.2% and 65.2% at 1 and 3 years, respectively. Overall survival at 1 and 3 years were 91.2% and 83.1%, respectively. In the univariate analysis, the hazard of the combined endpoint of major amputation or death was higher following bypass surgery than after endovascular therapy (HR 1.80; 95% CI, 1.13-2.89; P= .013). After either revascularization method, TASCII femoropopliteal D was associated with a higher risk of amputation or death (HR 1.69; 95% CI, 1.10-2.58; P= .015). Multivariate Cox regression analysis revealed no association between the variables analysed for AFS. CONCLUSIONS: CLTI patients submitted to infrapopliteal revascularization and classified as GLASS II and III had satisfactory AFS and OS rates after indivualized team conference decision. Furthermore, the revascularization modality (endo or open) did not influence the results of AFS.

Asunto(s)

Puente de Arteria Coronaria , Procedimientos Endovasculares , Isquemia Crónica que Amenaza las Extremidades , Procedimientos Quirúrgicos Vasculares

RESUMEN

BACKGROUND: Endovascular treatment of iliofemoral occlusive disease is a challenging approach, especially for TransAtlantic Inter-Society C and D lesions. Therefore, the revascularization procedure in such situations is preferably performed by bypass graft surgery with synthetic materials. The purpose of this study is to report the feasibility and mid-term results of eversion endarterectomy of the external iliac artery (EEEIA), as an alternative autologous option. METHODS: Retrospective study with 18 EEEIA performed between September 2015 and February 2020, exclusively for chronic limb-threatening ischemia treatment in patients with increased risk of postoperative surgical infection and inadvisable for endovascular treatment. Demographic, clinical variables and outcomes were collected from a prospective database. The main end points are: amputation-free survival (AFS) and 30-day mortality. Secondary end points include: primary patency (PP), cumulative patency (CP), overall survival (OS), and postoperative surgical complication. Kaplan­Meier analysis was used to estimate cumulative time of outcomes. RESULTS: The mean age was 64.8 ± 8.3 years, with predominance of men. The median follow-up period was 1012 days, 95% confidence interval [119, 1365] days. Most had Rutherford 5 (n = 13, 72.2%) and mean ankle brachial index was 0.38 ± 0.22. The PP, CP, AFS, and OS in 730 days were 81%, 92%, 80%, and 88%, respectively. There was no 30-day mortality or postoperative surgical infection. CONCLUSIONS: Iliofemoral reconstruction through EEEIA is an effective surgical procedure with good patency rates, AFS and OS. In addition, it can be considered an useful and safe option, especially in cases in which a prosthesis should be avoided.

Asunto(s)

Arteriopatías Oclusivas , Endarterectomía , Enfermedad Arterial Periférica

RESUMEN

BACKGROUND: Endovascular treatment of iliofemoral occlusive disease is a challenging approach, especially for TransAtlantic Inter-Society C and D lesions. Therefore, the revascularization procedure in such situations is preferably performed by bypass graft surgery with synthetic materials. The purpose of this study is to report the feasibility and mid-term results of eversion endarterectomy of the external iliac artery (EEEIA), as an alternative autologous option. METHODS: Retrospective study with 18 EEEIA performed between September 2015 and February 2020, exclusively for chronic limb-threatening ischemia treatment in patients with increased risk of postoperative surgical infection and inadvisable for endovascular treatment. Demographic, clinical variables and outcomes were collected from a prospective database. The main end points are: amputation-free survival (AFS) and 30-day mortality. Secondary end points include: primary patency (PP), cumulative patency (CP), overall survival (OS), and postoperative surgical complication. Kaplan-Meier analysis was used to estimate cumulative time of outcomes. RESULTS: The mean age was 64.8 ± 8.3 years, with predominance of men. The median follow-up period was 1012 days, 95% confidence interval [119, 1365] days. Most had Rutherford 5 (n = 13, 72.2%) and mean ankle brachial index was 0.38 ± 0.22. The PP, CP, AFS, and OS in 730 days were 81%, 92%, 80%, and 88%, respectively. There was no 30-day mortality or postoperative surgical infection. CONCLUSIONS: Iliofemoral reconstruction through EEEIA is an effective surgical procedure with good patency rates, AFS and OS. In addition, it can be considered an useful and safe option, especially in cases in which a prosthesis should be avoided.

Asunto(s)

Endarterectomía , Arteria Ilíaca/cirugía , Isquemia/cirugía , Enfermedad Arterial Periférica/cirugía , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Endarterectomía/efectos adversos , Endarterectomía/mortalidad , Estudios de Factibilidad , Femenino , Humanos , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/fisiopatología , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Supervivencia sin Progresión , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Grado de Desobstrucción Vascular

RESUMEN

Acute arterial occlusion remains a major challenge for the vascular surgeon. The therapeutic approach depends mostly upon the severity of the tissue injury and the duration of symptoms. Several techniques are available in the current therapeutic arsenal, however, regardless of the technique chosen, postoperative factors frequently observed, such as poor outflow status, or even low graft flow, can contribute negatively to the outcome of revascularization. We describe a case of acute limb ischemia, in the postoperative period of a femoral-tibial bypass, which was occluded due to outflow limitation and high peripheral vascular resistance. The patient underwent a second tibial revascularization combined with construction of an arteriovenous fistula, followed by forefoot amputation and partial skin graft. An energetic approach to the at-risk limb makes it possible to reduce unfavorable outcomes, such as amputation and death, and accelerates recovery of tissues affected by acute ischemia.

RESUMEN

Resumo A oclusão arterial aguda do membro inferior continua sendo um grande desafio para o cirurgião vascular. A abordagem cirúrgica depende principalmente da gravidade da lesão tecidual e da duração dos sintomas. Diversas técnicas estão disponíveis no arsenal terapêutico atual; porém, independentemente da técnica escolhida, fatores pós-operatórios, como o escoamento arterial limitado e o baixo fluxo nos substitutos arteriais, podem contribuir negativamente no resultado da revascularização. Descrevemos um caso de oclusão arterial aguda de membro inferior, no pós-operatório de uma derivação femorotibial, que se encontrava ocluída devido a limitação de escoamento e a alta resistência vascular periférica. Foi submetido a nova revascularização femorotibial, associada à confecção de uma fístula arteriovenosa, seguido de amputação de antepé e enxerto parcial de pele. O investimento enérgico no membro em risco possibilita reduzir os desfechos desfavoráveis, como amputação e óbito, e acelera a recuperação dos tecidos acometidos pela isquemia aguda.

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Abstract Acute arterial occlusion remains a major challenge for the vascular surgeon. The therapeutic approach depends mostly upon the severity of the tissue injury and the duration of symptoms. Several techniques are available in the current therapeutic arsenal, however, regardless of the technique chosen, postoperative factors frequently observed, such as poor outflow status, or even low graft flow, can contribute negatively to the outcome of revascularization. We describe a case of acute limb ischemia, in the postoperative period of a femoral-tibial bypass, which was occluded due to outflow limitation and high peripheral vascular resistance. The patient underwent a second tibial revascularization combined with construction of an arteriovenous fistula, followed by forefoot amputation and partial skin graft. An energetic approach to the at-risk limb makes it possible to reduce unfavorable outcomes, such as amputation and death, and accelerates recovery of tissues affected by acute ischemia.

Asunto(s)

Humanos , Masculino , Persona de Mediana Edad , Derivación Arteriovenosa Quirúrgica , Fístula Arteriovenosa , Isquemia Crónica que Amenaza las Extremidades/cirugía , Resistencia Vascular , Antepié Humano/irrigación sanguínea , Trasplante de Piel , Amputación Quirúrgica

RESUMEN

ABSTRACT: In recent decades, the increasing complexity of arterial bypasses in the management of chronic limb-threatening ischemia has spurred the development of alternative techniques, such as revascularization of genicular arteries. Few publications on this technique can be found in the literature, and its use has been restricted to specialized vascular groups. This article describes the case of a patient with extensive femorotibial occlusive disease who received a collateral artery bypass, using the deep femoral artery as a donor, the cephalic vein as an alternative autogenous substitute and the descending genicular artery as a recipient. Bypass to the descending genicular artery, although underutilized, is an effective option and increases the possibility of limb salvage in the management of chronic limb-threatening ischemia.

Asunto(s)

Inhibidores de Agregación Plaquetaria/efectos adversos , Intervención Coronaria Percutánea , Toma de Decisiones Clínicas , Terapia Antiplaquetaria Doble/normas , Complicaciones Posoperatorias/inducido químicamente , Enfermedad Crónica , Duración de la Terapia , Hemorragia/inducido químicamente

RESUMEN

Over recent decades, there has been a considerable increase in use of endovascular methods to treat aortoiliac occlusive disease. It has been demonstrated that this approach offers many benefits, primarily for non-complex arterial lesions of the iliac axis, but difficulties persist with achieving adequate results over the medium and long term when treating extensive occlusive disease. Arterial bypasses to alternative vicarious arteries of the femoral-genicular complex for limb salvage are well known in the literature describing cases that are not favorable for conventional or endovascular surgery. We describe the case of a patient with extensive aortoiliac occlusive disease treated with an arterial bypass in the iliofemoral territory, using an alternative autologous substitute and the descending lateral femoral artery as recipient artery. Alternative bypasses and substitutes that are normally reserved for exceptional cases can and should be part of the vascular therapeutic arsenal and have a contribution to make in cases in which endovascular surgery does not yet enable us to achieve good results.

RESUMEN

ABSTRACT Over recent decades, there has been a considerable increase in use of endovascular methods to treat aortoiliac occlusive disease. It has been demonstrated that this approach offers many benefits, primarily for non-complex arterial lesions of the iliac axis, but difficulties persist with achieving adequate results over the medium and long term when treating extensive occlusive disease. Arterial bypasses to alternative vicarious arteries of the femoral-genicular complex for limb salvage are well known in the literature describing cases that are not favorable for conventional or endovascular surgery. We describe the case of a patient with extensive aortoiliac occlusive disease treated with an arterial bypass in the iliofemoral territory, using an alternative autologous substitute and the descending lateral femoral artery as recipient artery. Alternative bypasses and substitutes that are normally reserved for exceptional cases can and should be part of the vascular therapeutic arsenal and have a contribution to make in cases in which endovascular surgery does not yet enable us to achieve good results.

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RESUMO Nas últimas décadas, observou-se o aumento expressivo do tratamento endovascular para a doença oclusiva aortoilíaca. Muitos benefícios foram demonstrados, principalmente nas lesões arteriais não complexas do eixo ilíaco; porém, ainda existe dificuldade na obtenção de resultados adequados a médio e longo prazo quando falamos de doenças oclusivas extensas. As derivações arteriais para artérias vicariantes alternativas do complexo femoro-genicular para salvamento de membro são bem conhecidas na literatura em casos desfavoráveis para cirurgias convencionais ou endovasculares. Descrevemos o caso de um paciente portador de doença oclusiva aortoilíaca extensa tratado com derivação arterial no território ilíaco-femoral, utilizando substituto autógeno alternativo e a artéria descendente femoral lateral como artéria receptora. Derivações e substitutos alternativos, utilizados normalmente em casos de exceção, podem e devem fazer parte do arsenal terapêutico vascular, podendo contribuir nos casos em que a cirurgia endovascular ainda não nos permite alcançar bons resultados.

Asunto(s)

Trasplante Autólogo , Constricción Patológica , Aterosclerosis