RESUMO
OBJECTIVES: To evaluate the long-term angiographic patency of saphenous vein grafts (SVG) harvested using the no-touch technique compared to the conventional technique. METHODS: This was a single-center, retrospective, cohort study. The inclusion criteria were individuals who underwent a CABG (coronary artery bypass grafting) between January 1995 and July 2020, and who successively needed a clinically-driven angiography. The primary endpoint was long-term patency. The secondary endpoints were differences in patency based on sub-group analysis (single vs. sequential graft, divided by target vessel). RESULTS: The study included 1520 individuals (618 no-touch, 825 conventional and 77 arterial grafts). The mean clinical follow-up time was 8.4 years ± 5.5 years. The patency per patient was 70.7% in the no-touch grafts vs. 46.7% in the conventional grafts (p < 0.001, OR = 2.8). The graft patency was 75.9% in the no-touch grafts vs. 62.8% in the conventional grafts (p < 0.001, OR = 1.8). CONCLUSIONS: The no-touch vein grafts were associated with statistically significantly higher patency at long-term compared to the conventional grafts. CLINICAL TRIAL REGISTRATION: NCT04656366, 7 December 2020.
Assuntos
Ponte de Artéria Coronária , Veia Safena , Grau de Desobstrução Vascular , Humanos , Feminino , Veia Safena/transplante , Masculino , Estudos Retrospectivos , Ponte de Artéria Coronária/métodos , Idoso , Pessoa de Meia-Idade , Oclusão de Enxerto Vascular , Angiografia Coronária/métodos , Fatores de Tempo , Coleta de Tecidos e Órgãos/métodos , SeguimentosRESUMO
Background and Objectives: The saphenous vein graft (SVG) remains the most frequently used conduit worldwide, despite its common disadvantage of early graft failure. To solve the problem and reduce the SVG damage, Souza implemented a new technique where a vein is harvested with surrounding fascia and fat tissue (the so-called no-touch technique). Materials and Methods. A prospective study conducted from February 2019 to June 2024 included 23 patients who underwent myocardial revascularization using a no-touch vein, with follow-up control examinations using computed tomographic angiography to detect graft stenosis or occlusion. Results. Of the entire patient group, 17 (73.9%) were male, with a mean age of 67.39 ± 7.71 years. The mean follow-up period was 25 months. There were no major adverse cardiovascular or cerebrovascular events (MACCEs) during hospitalization, although one patient died in the hospital. Another patient died due to malignancy, but no MACCEs occurred during the follow-up period. According to multi-slice CT coronary angiography, the results were impeccable, with an astonishing 100% patency observed in all 20 IMA grafts and 58 no-touch SVGs examined. Conclusions. The excellent patency rate during the early follow-up period confirmed that the no-touch technique is a good option for surgical revascularization.
Assuntos
Angiografia por Tomografia Computadorizada , Ponte de Artéria Coronária , Veia Safena , Humanos , Masculino , Feminino , Idoso , Estudos Prospectivos , Seguimentos , Veia Safena/transplante , Veia Safena/diagnóstico por imagem , Pessoa de Meia-Idade , Ponte de Artéria Coronária/métodos , Angiografia por Tomografia Computadorizada/métodos , Sérvia , Grau de Desobstrução VascularAssuntos
Fenômeno de não Refluxo , Intervenção Coronária Percutânea , Veia Safena , Humanos , Veia Safena/transplante , Veia Safena/diagnóstico por imagem , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Fenômeno de não Refluxo/etiologia , Fenômeno de não Refluxo/diagnóstico por imagem , Masculino , Ponte de Artéria Coronária/efeitos adversos , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/diagnóstico por imagem , Angiografia Coronária , Resultado do TratamentoRESUMO
OBJECTIVE: Reversed great saphenous vein (GSV) graft is widely used for revascularization in limb-sparing surgery for sarcoma invading great vessels. However, a mismatch in caliber between the reverse graft and cut end of the artery can threaten graft patency. Recently, we introduced the use of a venous valvulotome to allow nonreversed GSV graft. The purpose of this study was to evaluate the safety and versatility of this technique. DESIGN: We retrospectively compared long-term patency and limb salvage rates between nonreversed GSV and reversed GSV in patients undergoing limb-sparing surgery for sarcoma. METHODS: Thirty-seven patients were included, with 21 in the nonreversed GSV group and 16 in the reversed GSV group. Patient characteristics, surgical details, and complications were reviewed from the hospital records. The patency of the reconstructed vessels was assessed using contrast-enhanced CT or MRI. Statistical analyses, including Kaplan-Meier survival analysis, were employed for comparisons. RESULTS: The median follow-up was 38 months. Overall graft patency was 90.4% (19 of 21 patients) in the nonreversed GSV group and 81.2% (13 of 16) in the reverse GSV (RGSV) group. In the nonreversed GSV group, there was 1 case of graft occlusion each in the acute and chronic phases, but limb circulation remained intact and all limbs were spared. CONCLUSION: Nonreversed GSV grafting with valvulotome offers a safe and versatile alternative to reversed GSV grafts in limb-sparing sarcoma surgery. It eliminates the need for vein reversal and minimizes diameter mismatch, potentially expanding the indication for autologous revascularization to previously ineligible cases.
Assuntos
Salvamento de Membro , Extremidade Inferior , Veia Safena , Sarcoma , Grau de Desobstrução Vascular , Humanos , Veia Safena/transplante , Masculino , Feminino , Estudos Retrospectivos , Sarcoma/cirurgia , Pessoa de Meia-Idade , Adulto , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/cirurgia , Idoso , Salvamento de Membro/métodos , Procedimentos de Cirurgia Plástica/métodos , Adolescente , Adulto Jovem , Resultado do Tratamento , Neoplasias de Tecidos Moles/cirurgiaRESUMO
This study aimed to examine the influence of diabetes on the left internal mammary artery (LIMA) and saphenous vein (SV) graft failure for 5-year follow-up. We enrolled 202 patients who underwent isolated off-pump coronary artery bypass grafting (CABG) surgery in 2014, angiographic follow-up occurred at 5 years after surgery. Angiographic outcomes in patients with or without diabetes were analyzed. Multivariate logistic regression analysis was used to identify independent predictors of graft dysfunction. A total of 66 (32.7%) patients had diabetes. Five-year rates of LIMA and SV graft failure were similar in patients with and without diabetes. In addition, in diabetics, the proportion of complete graft failure was significantly lower in the LIMA grafts (12/66, 18.2%) than in the SV grafts (57/133, 42.9%) (Pâ =â .001). In nondiabetic, the proportion of complete graft failure was also significantly lower in the LIMA grafts (28/136, 20.6%) than in the SV grafts (105/275, 38.2%) (Pâ <â .001). Multivariate logistic regression analysis showed that mean graft flow (MGF) was an independent predictor factor for LIMA (odds ratio = 1.186, 95% CI = 1.114-1.263, Pâ <â .001) and SV (odds ratio = 1.056, 95% CI = 1.035-1.077, Pâ <â .001) graft failure. Diabetes did not influence the patency of LIMA or SV grafts over a 5-year follow-up. LIMA grafts should be maximized in patients undergoing off-pump CABG surgery. Diabetes does not affect the patency of grafts CABG. Using angiography, our study proved that diabetes does not affect the patency of grafted vessels after CABG for 5 years.
Assuntos
Angiografia Coronária , Ponte de Artéria Coronária sem Circulação Extracorpórea , Artéria Torácica Interna , Grau de Desobstrução Vascular , Humanos , Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Masculino , Feminino , Angiografia Coronária/métodos , Pessoa de Meia-Idade , Idoso , Artéria Torácica Interna/transplante , Artéria Torácica Interna/diagnóstico por imagem , Veia Safena/transplante , Veia Safena/diagnóstico por imagem , Diabetes Mellitus/epidemiologia , Oclusão de Enxerto Vascular/epidemiologia , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Estudos Retrospectivos , Doença da Artéria Coronariana/cirurgia , Doença da Artéria Coronariana/diagnóstico por imagem , SeguimentosRESUMO
INTRODUCTION: Controversy surrounds the long-term clinical benefit of coronary artery bypass grafting (CABG) using dual arterial grafts (DAGs) compared to single arterial grafts (SAGs). We investigated outcomes of DAG, using single internal thoracic artery and radial artery (DAG-RA) or bilateral internal thoracic artery grafts (DAG-BITA), compared to SAG, using the left internal thoracic artery and saphenous vein grafts, in the U.S. Veterans Health Administration (VA). METHODS: We conducted a cross-sectional study of U.S. Veterans undergoing isolated on-pump CABG between 2005 and 2015 at 44 VA medical centers. The primary composite outcome was first occurrence of a major adverse cardiac and cerebrovascular event (MACCE), comprised of death from any cause, myocardial infarction, stroke, or repeat revascularization. RESULTS: Among 25,969 Veterans undergoing isolated CABG, 1261 (4.9%) underwent DAG (66.8% DAG-RA and 33.2% DAG-BITA). Over a 5-y follow-up, DAG was associated with lower rates of all-cause death (adjusted hazard ratio [AHR] 0.70, 95% confidence interval [CI] 0.58-0.85), MACCE (AHR 0.80, 95% CI 0.71-0.91), and stroke (AHR 0.74, 95% CI 0.57-0.96) versus SAG. DAG-BITA was associated with lower rates of all-cause death (AHR 0.52, 95% CI 0.35-0.77) and MACCE (AHR 0.66, 95% CI 0.51-0.84) than SAG, while DAG-RA was associated with lower rates of all-cause death (AHR 0.79, 95% CI 0.64-0.99). CONCLUSIONS: In the VA, DAG was associated with improved long-term MACCE outcomes compared to SAG. These results suggest that the practice of DAG in the VA benefits Veterans and should be promoted further.
Assuntos
Ponte de Artéria Coronária , United States Department of Veterans Affairs , Humanos , Masculino , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária/estatística & dados numéricos , Feminino , Pessoa de Meia-Idade , Idoso , Estudos Transversais , Estados Unidos/epidemiologia , United States Department of Veterans Affairs/estatística & dados numéricos , Resultado do Tratamento , Doença da Artéria Coronariana/cirurgia , Doença da Artéria Coronariana/mortalidade , Veia Safena/transplante , Artéria Radial/transplante , Artéria Torácica Interna/transplante , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos RetrospectivosRESUMO
The saphenous vein graft (SVG) remains the most used conduit as a second graft in Coronary Artery Bypass Grafting (CABG).1 Traditionally, surgeons harvest SVG with an open approach, making a long incision along the medial part of the leg or thigh. This procedure can potentially result in important complications, such as delayed wound healing, postoperative pain and infection.2 Thus, less invasive techniques for vessel harvesting have grown in popularity. Endoscopic vein harvesting (EVH) is a minimally invasive harvesting procedure, which only requires a short incision, leading to less wound complications and a faster return to normal daily activities. This article intends to describe how we do EVH technique in our centre, from the preparation of the patient to the postoperative period and share some tips and tricks from our experience.
Assuntos
Ponte de Artéria Coronária , Endoscopia , Veia Safena , Coleta de Tecidos e Órgãos , Humanos , Coleta de Tecidos e Órgãos/métodos , Veia Safena/transplante , Ponte de Artéria Coronária/métodos , Endoscopia/métodosRESUMO
OBJECTIVE: Long-term outcomes for harvesting techniques for great saphenous vein (GSV) and its impact on the outcomes of infrainguinal arterial bypass remains largely unknown. Endoscopic GSV harvesting (EVH) has emerged as a less invasive alternative to conventional open techniques. Using the Vascular Quality initiative Vascular Implant Surveillance & Interventional Outcomes Network (VQI-VISION) database, we compared the long-term outcomes of infrainguinal arterial bypass using open and endoscopic GSV harvest techniques. METHODS: Patients who underwent infrainguinal GSV bypass between 2010 and 2019 were identified in the VQI-VISION Medicare linked database. Long-term outcomes of major/minor amputations, and reinterventions up to 5 years of follow-up were compared between continuous incisions, skip incision, and EVH, with continuous incisions being the reference group. Secondary outcomes included 30- and 90-day readmission, in addition to surgical site infections and patency rates at 6 months to 2 years postoperatively. Survival analysis using Kaplan-Meier curves and Cox regression hazard models were utilized to compare outcomes between groups. To adjust for multiple comparisons between the study groups, a P value of 2.5% was considered significant. RESULTS: Among the 8915 patients included in the study, continuous and skip vein harvest techniques were used in 44.4% and 43.4% of cases each, whereas 12.3% underwent EVH. The utilization of EVH remained relatively stable at around 12% throughout the study period. Compared with GSV harvest using continuous incisions, EVH was associated with higher rates of reintervention at 1 year (46.5% vs 41.3%; adjusted hazard ratio [aHR], 1.22; 95% confidence interval [CI], 1.06-1.41; P = .01]. However, no significant difference was observed between EVH and continuous incisions, and between skip and continuous incisions in terms of long-term reintervention or major and minor amputations on adjusted analysis. Compared with continuous incision vein harvest, both EVH and skip incisions were associated with lower surgical site infection rates within the first 6 months post-bypass (aHR, 0.53; 95% CI, 0.35-0.82 and aHR, 0.68; 95% CI, 0.53-0.87, respectively). Loss of primary, primary-assisted, and secondary patency was higher after EVH compared with continuous incision vein harvest. Among surgeons performing EVH, comparable long-term outcomes were observed regardless of low (<4 cases/year), medium (4-7 cases/year), or high procedural volumes (>7 cases/year). CONCLUSIONS: Despite higher 1-year reintervention rates, EVH for infrainguinal arterial bypass is not associated with a significant difference in long-term reintervention or amputation rates compared with other harvesting techniques. These outcomes are not influenced by procedural volumes for EVH technique.
Assuntos
Bases de Dados Factuais , Medicare , Doença Arterial Periférica , Sistema de Registros , Veia Safena , Coleta de Tecidos e Órgãos , Enxerto Vascular , Grau de Desobstrução Vascular , Humanos , Veia Safena/transplante , Veia Safena/cirurgia , Masculino , Idoso , Feminino , Estados Unidos , Doença Arterial Periférica/cirurgia , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/mortalidade , Fatores de Tempo , Coleta de Tecidos e Órgãos/efeitos adversos , Coleta de Tecidos e Órgãos/métodos , Resultado do Tratamento , Estudos Retrospectivos , Idoso de 80 Anos ou mais , Enxerto Vascular/efeitos adversos , Enxerto Vascular/métodos , Enxerto Vascular/mortalidade , Fatores de Risco , Amputação Cirúrgica , Salvamento de Membro , Medição de Risco , Reoperação/estatística & dados numéricos , Endoscopia/efeitos adversosRESUMO
OBJECTIVE: The Human Acellular Vessel (HAV) is a novel, off-the-shelf biologic conduit being evaluated for arterial reconstructions. Regulatory studies in peripheral arterial disease (PAD) to date have consisted of single-arm cohorts with no comparator groups to contrast performance against established standards. This study aimed to compare outcomes of the HAV with autologous great saphenous vein (GSV) in patients with advanced PAD undergoing infrageniculate bypass. METHODS: Patients with advanced PAD and no autologous conduit who underwent bypass with the 6-mm diameter HAV (Group 1; n = 34) (March 2021-February 2024) were compared with a multicenter historical cohort who had bypass with single-segment GSV (group 2; n = 88) (January 2017-December 2022). The HAV was used under an Investigational New Drug protocol issued by the Food and Drug Administration (FDA) under the agency's Expanded Access Program. RESULTS: Demographics were comparable between groups (mean age 69 ± 10 years; 71% male). Group 1 had higher rates of tobacco use (37 pack-years vs 28 pack-years; P = .059), coronary artery disease (71% vs 43%; P = .007), and prior coronary artery bypass grafting (38% vs 14%; P = .003). Group 1 had more patients classified as wound, ischemia, and foot infection clinical stage 4 (56% vs 33%; P = .018) and with previous index leg revascularizations (97% vs 53%; P < .001). Both groups had a similar number of patients with chronic limb-threatening ischemia (Rutherford class 4-6) (88% vs 86%; P = .693) and Global Anatomic Staging System stage III (91% vs 96%; P = .346). Group 1 required a composite conduit (two HAV sewn together) in 85% of bypasses. The tibial vessels were the target in 79% of group 1 and 100% of group 2 (P < .001). Group 1 had a lower mean operative time (364 minutes vs 464 minutes; P < .001). At a median of 12 months, major amputation-free survival (73% vs 81%; P = .55) and overall survival (84% vs 88%; P = .20) were comparable. Group 1 had lower rates of primary patency (36% vs 50%; P = .044), primary-assisted patency (45% vs 72%; P = .002), and secondary patency (64% vs 72%; P = .003) compared with group 2. CONCLUSIONS: Implanted under Food and Drug Administration Expanded Access provisions, the HAV was more likely to be used in redo operations and cases with more advanced limb ischemia than GSV. Despite modest primary patency, the HAV demonstrated resilience in a complex cohort with no autologous conduit options, achieving good secondary patency and providing major amputation-free survival comparable with GSV at 12 months.
Assuntos
Amputação Cirúrgica , Isquemia Crônica Crítica de Membro , Doença Arterial Periférica , Veia Safena , Grau de Desobstrução Vascular , Humanos , Veia Safena/transplante , Feminino , Masculino , Idoso , Pessoa de Meia-Idade , Doença Arterial Periférica/cirurgia , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/mortalidade , Fatores de Tempo , Estudos Retrospectivos , Resultado do Tratamento , Isquemia Crônica Crítica de Membro/cirurgia , Salvamento de Membro , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Implante de Prótese Vascular/instrumentação , Fatores de Risco , Complicações Pós-Operatórias/etiologiaRESUMO
INTRODUCTION: Surgical site infection after saphenous vein harvest is common, with reported leg wound infection rates ranging from 2 to 24%. There have been few investigations into sex-related differences in complication rates. Moreover, varied effects of smoking have been reported. The aim of this study was to investigate risk factors such as gender and smoking, associated with surgical site infection after vein graft harvesting in coronary artery bypass grafting surgery. METHODS: We included 2,188 consecutive patients who underwent coronary artery bypass grafting surgery with at least one vein graft at our centre from 2009 to 2018. All patients were followed up postoperatively. Risk factors for leg wound infection requiring antibiotic treatment and surgical revision were analysed using logistic regression analysis. RESULTS: In total, 374 patients (17.1%) received antibiotic treatment and 154 (7.0%) underwent surgical revision for leg wound infection at the harvest site. Female sex, high body mass index, diabetes mellitus, longer operation time, peripheral vascular disease and direct oral anticoagulants were independently associated with any leg wound infection at the harvest site. Among surgically revised patients, female sex and insulin or oral treatment for diabetes mellitus as well as longer operation time were independent risk factors. Smoking was not associated with leg wound infection. CONCLUSION: Female sex is associated with increased risk of leg wound infection. The underlying mechanism is unknown. In the current population, previous or current smoking was not associated with an increased risk of leg wound infection.
Assuntos
Ponte de Artéria Coronária , Veia Safena , Infecção da Ferida Cirúrgica , Coleta de Tecidos e Órgãos , Humanos , Ponte de Artéria Coronária/efeitos adversos , Feminino , Masculino , Veia Safena/transplante , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Estudos Retrospectivos , Fatores de Risco , Idoso , Pessoa de Meia-Idade , Coleta de Tecidos e Órgãos/efeitos adversos , Coleta de Tecidos e Órgãos/métodos , Fatores SexuaisRESUMO
OBJECTIVES: Endoscopic vein harvesting (EVH) is an alternative technique to obtain the saphenous vein for coronary artery bypass grafting (CABG) surgery. We aimed to evaluate the early and mid-term outcomes of patients with EVH in CABG. METHODS: This cohort study included consecutive isolated CABG patients in Nanjing First Hospital from July 2020 to December 2022 using propensity score matching methods. Patients were classified to EVH group and open vein harvesting (OVH) group according to the vein harvesting methods. The primary outcome was the all-cause death, and the secondary outcomes were major adverse cardiovascular events (MACEs) including cardiovascular death, heart failure, myocardial infarction and revascularization and asymptomatic survival in the follow-up. RESULTS: Totally 1247 patients were included in the study with 849 in OVH group and 398 in EVH group. Patients with EVH were more female, diabetes, higher body mass index, more multi-vessel and left main diseases. 308 pairs were formed after the matching. There was no significant difference in the rates of in-hospital death (EVH vs. OVH, 2.3% vs. 1.3%, P = 0.543). During the 3 years follow-up, EVH grafts were considered not inferior to OVH grafts, no differences were found in all-cause death [8.5% vs. 5.0%, hazard ratio (HR) 1.565, 95% confidence interval (CI): 0.77-3.17, P = 0.21], MACEs (8.1% vs. 7.1%, HR 1.165, 95CI: 0.51-2.69, P = 0.71) and asymptomatic survival (66.7% vs. 72.5%, HR 1.117, 95%CI: 0.65-1.92, P = 0.68). CONCLUSIONS: EVH grafts were considered comparable to OVH grafts in patients following CABG in the 3 years follow-up.
Assuntos
Ponte de Artéria Coronária , Endoscopia , Veia Safena , Coleta de Tecidos e Órgãos , Humanos , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Veia Safena/transplante , Endoscopia/métodos , Coleta de Tecidos e Órgãos/métodos , Idoso , Doença da Artéria Coronariana/cirurgia , Resultado do Tratamento , Pontuação de PropensãoAssuntos
Aneurisma Coronário , Embolização Terapêutica , Humanos , Resultado do Tratamento , Aneurisma Coronário/diagnóstico por imagem , Aneurisma Coronário/cirurgia , Aneurisma Coronário/etiologia , Aneurisma Coronário/terapia , Masculino , Embolização Terapêutica/instrumentação , Ponte de Artéria Coronária/efeitos adversos , Angiografia Coronária , Idoso , Veia Safena/transplante , Veia Safena/diagnóstico por imagemRESUMO
BACKGROUND: The descending genicular artery (DGA) and medial thigh region have been underused as donor sites for perforator flaps. This study evaluated the anatomical relationship between the perforators of the DGA and the saphenous vein (SV) to review the clinical applications of the free descending genicular artery perforator (DGAP) flap for locoregional reconstruction. METHODS: Fifteen cadavers were arterially perfused with red latex and dissected. Thirty-one patients with extremity tissue defects were treated with a free DGAP flap, including six patients who received a chimeric flap. The minimum distance between the DGAP and the SV was measured during surgery. RESULTS: In all patients, the skin branch of the descending genicular artery was found in the medial femoral condyle plane in front of the SV. The average distance between the descending genicular artery perforator and the SV was 3.71 ± 0.38 cm (range: 2.9-4.3 cm). Thirty flaps survived completely, and one flap developed partial necrosis; however, this flap healed two weeks after skin grafting. The average follow-up time was 11.23 months. CONCLUSIONS: We conclude that the SV can be preserved when harvesting the descending genicular artery perforator flap, causing less damage to the donor site and having no effect on flap survival. The free descending genicular artery perforator flap without the SV is a better therapy for complicated tissue defects.
Assuntos
Cadáver , Retalho Perfurante , Procedimentos de Cirurgia Plástica , Veia Safena , Humanos , Retalho Perfurante/irrigação sanguínea , Masculino , Feminino , Veia Safena/transplante , Pessoa de Meia-Idade , Idoso , Adulto , Procedimentos de Cirurgia Plástica/métodosRESUMO
OBJECTIVE: The recent Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) study showed that bypass was superior to endovascular therapy (ET) in patients with chronic limb-threatening ischemia (CLTI) deemed suitable for either approach who had an available single-segment great saphenous vein (GSV). However, the superiority of bypass among those lacking GSV was not established. We aimed to examine comparative treatment outcomes from a real-world CLTI population using the Vascular Quality Initiative-Medicare-linked database. METHODS: We queried the Vascular Quality Initiative-Medicare-linked database for patients with CLTI who underwent first-time lower extremity revascularization (2010-2019). We performed two one-to-one propensity score matchings (PSMs): ET vs bypass with GSV (BWGSV) and ET vs bypass with a prosthetic graft (BWPG). The primary outcome was amputation-free survival. Secondary outcomes were freedom from amputation and overall survival (OS). RESULTS: Three cohorts were queried: BWGSV (N = 5279, 14.7%), BWPG (N = 2778, 7.7%), and ET (N = 27,977, 77.6%). PSM produced two sets of well-matched cohorts: 4705 pairs of ET vs BWGSV and 2583 pairs of ET vs BWPG. In the matched cohorts of ET vs BWGSV, ET was associated with greater hazards of death (hazard ratio [HR] = 1.34, 95% confidence interval [CI], 1.25-1.43; P < .001), amputation (HR = 1.30, 95% CI, 1.17-1.44; P < .001), and amputation/death (HR = 1.32, 95% CI, 1.24-1.40; P < .001) up to 4 years. In the matched cohorts of ET vs BWPG, ET was associated with greater hazards of death up to 2 years (HR = 1.11, 95% CI, 1.00-1.22; P = .042) but not amputation or amputation/death. CONCLUSIONS: In this real-world multi-institutional Medicare-linked PSM analysis, we found that BWGSV is superior to ET in terms of OS, freedom from amputation, and amputation-free survival up to 4 years. Moreover, BWPG was superior to ET in terms of OS up to 2 years. Our study confirms the superiority of BWGSV to ET as observed in the BEST-CLI trial.
Assuntos
Amputação Cirúrgica , Isquemia Crônica Crítica de Membro , Bases de Dados Factuais , Procedimentos Endovasculares , Salvamento de Membro , Doença Arterial Periférica , Humanos , Masculino , Feminino , Idoso , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Idoso de 80 Anos ou mais , Estados Unidos , Doença Arterial Periférica/cirurgia , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Estudos Retrospectivos , Isquemia Crônica Crítica de Membro/cirurgia , Isquemia Crônica Crítica de Membro/mortalidade , Fatores de Tempo , Fatores de Risco , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Medição de Risco , Veia Safena/transplante , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade , Medicare , Resultado do Tratamento , Isquemia/cirurgia , Isquemia/mortalidade , Isquemia/fisiopatologia , Isquemia/terapiaRESUMO
OBJECTIVE: Saphenous vein graft disease (SVGD) remains a challenging issue for patients with coronary artery bypass grafting (CABG). It is associated with poor outcomes and atherosclerosis is the major cause of SVGD. Uric acid to albumin ratio (UAR) is a new marker which associated with cardiovascular mortality. We aim to evaluate the relationship between the SVGD and UAR. METHODS: We retrospectively enrolled 237 patients who underwent elective coronary angiography (CAG) for stable angina or positive stress test results >1â year after CABG. The patients were divided into two groups; SVGD (+) patients and SVGD (-) patients. The SVGD was defined as presence of at least 50% stenosis in at least 1 SVG. RESULTS: UAR were significantly higher in the SVGD (+) group ( P â <â 0.001). Similarly, Hs-CRP, white blood cell count, and neutrophil count were significantly higher in SVGD (+) group ( P â =â 0.03, P â =â 0.027 P â =â 0.01, respectively). In multivariate logistic regression analysis, time interval after CABG [ORâ =â 1.161, 95% confidence interval (CI) 1.078-1.250; P â <â 0.001] and UAR (ORâ =â 2.691, 95% CI 1.121-6.459; P â <â 0.001) were found to be independent predictors of SVGD. CONCLUSION: Our results suggested that UAR could be a simple and available marker to predict SVGD in patients with CABG who underwent elective percutaneous coronary intervention.
Assuntos
Biomarcadores , Angiografia Coronária , Ponte de Artéria Coronária , Oclusão de Enxerto Vascular , Veia Safena , Albumina Sérica Humana , Ácido Úrico , Humanos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Masculino , Feminino , Veia Safena/transplante , Veia Safena/diagnóstico por imagem , Ácido Úrico/sangue , Estudos Retrospectivos , Pessoa de Meia-Idade , Biomarcadores/sangue , Idoso , Angiografia Coronária/métodos , Albumina Sérica Humana/análise , Oclusão de Enxerto Vascular/sangue , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/diagnóstico , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/epidemiologia , Fatores de Risco , Doença da Artéria Coronariana/cirurgia , Doença da Artéria Coronariana/sangue , Valor Preditivo dos Testes , Modelos Logísticos , Resultado do Tratamento , Análise Multivariada , Razão de Chances , Fatores de Tempo , Distribuição de Qui-Quadrado , Albumina Sérica/metabolismo , Albumina Sérica/análiseRESUMO
OBJECTIVE: The aim of this study was to evaluate the outcomes of cold stored saphenous vein allografts (CSVAs) for haemodialysis vascular access. METHODS: A retrospective, two centre study was conducted between January 2016 and December 2020 of all patients who had CSVA placement for haemodialysis vascular access. Primary, primary assisted, and secondary patency were analysed, as well as procedural complications and re-interventions. RESULTS: One hundred and nine patients (n = 55 women) with a mean age of 67.2 ± 13.6 years, with no options for creating an autogenous arteriovenous fistula, were included in the study. At one year, primary, primary assisted, and secondary patency were 37.6%, 59.0%, and 73.3%, respectively; and at two years 19.9%, 42.5%, and 54.9%, respectively. During a mean follow up period of 26 ± 18 months, five patients (4.6%) had an access infection, with no related death. During the follow up period, 32 patients (29.4%) died and 13 patients (11.9%) underwent a kidney transplant. None of these patients showed immunoconversion before transplantation. The cumulative incidence of adverse events by the Fine-Gray method was calculated. Considering competing risks (death and renal transplantation), 9.2% of patients lost their vascular access at one year and 18% at two years. Moreover, 57.8% patients had stenosis, mainly on the outflow (45.9%), and 49.5% had thrombosis. CONCLUSION: With a comparable patency rate associated with a low infection rate, CSVA offers a potential alternative to expanded polytetrafluoroethylene grafts. This creates haemodialysis vascular access when the venous capital is exhausted in patients with reported risk factors for vascular access infection, i.e., insertion in the thigh, advanced age, diabetes mellitus, immunocompromised state, obesity, or revision of an infected prosthetic graft.
Assuntos
Derivação Arteriovenosa Cirúrgica , Diálise Renal , Veia Safena , Grau de Desobstrução Vascular , Humanos , Feminino , Masculino , Estudos Retrospectivos , Idoso , Veia Safena/transplante , Pessoa de Meia-Idade , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/métodos , Resultado do Tratamento , Aloenxertos , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/epidemiologia , Oclusão de Enxerto Vascular/fisiopatologia , Idoso de 80 Anos ou mais , Fatores de Risco , Fatores de Tempo , Criopreservação , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentaçãoRESUMO
Deep venous arterialization (DVA) is a final option for limb salvage in patients with end stage arterial anatomy. We report a 66-year-old dialysis dependent male with forefoot gangrene, Rutherford class 6 chronic limb ischemia, who required a redo endovascular DVA. On initial presentation an angiogram was demonstrated a desert foot with absent tibial runoff to his bilateral lower extremities. After discussion, patient elected to trial DVA in hope of avoiding a major amputation. A hybrid DVA was performed using a Pioneer Plus and .018â³ Viabahn stents from the peroneal artery into the peroneal venous system; following this, the peroneal vein was anastomosed to the lesser saphenous vein via an open posterior approach at the ankle. 3 months later, a second DVA was performed by exposing the above knee popliteal artery and vein and creating an end-to-side anastomosis. Of note, the great saphenous vein was less than 2 mm in diameter and no arm vein was available due to history of prior fistulas in bilateral arms. Via the popliteal vein, the posterior tibial vein was selected and additional .018â³ Viabahn stents were deployed from the malleolus to the P2 segment of the popliteal vein. Three months after the second hybrid DVA, the patient's forefoot had healed after split thickness skin grafting. Continued patency is noted of the re-do hybrid DVA with minimal calf edema. Newer creative strategies are required for "No Option Chronic Limb Ischemia" which is becoming more relevant in diabetic and dialysis dependent patients. This case illustrates the potential to convert a deep venous arterialization to a superficial venous arterialization for improved venous outflow and wound healing.
Assuntos
Procedimentos Endovasculares , Isquemia , Salvamento de Membro , Veia Poplítea , Veia Safena , Stents , Grau de Desobstrução Vascular , Humanos , Masculino , Idoso , Resultado do Tratamento , Isquemia/fisiopatologia , Isquemia/diagnóstico por imagem , Isquemia/cirurgia , Isquemia/etiologia , Procedimentos Endovasculares/instrumentação , Veia Poplítea/fisiopatologia , Veia Poplítea/diagnóstico por imagem , Veia Poplítea/cirurgia , Veia Safena/transplante , Veia Safena/diagnóstico por imagem , Veia Safena/fisiopatologia , Diálise Renal , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/terapia , Doença Arterial Periférica/cirurgia , Reoperação , Doença Crônica , GangrenaRESUMO
BACKGROUND: This study investigated the impact of complete revascularization (CR) and incomplete revascularization (IR) on long-term survival in patients undergoing isolated coronary artery bypass grafting (CABG) using multiple arterial graft (MAGs) or a single artery with saphenous vein grafts (SAGs). METHODS: Between January 2006 and December 2020, 12,625 patients underwent CABG and were divided into 4 groups: MAG CR (n = 1066), MAG IR (n = 286), SAG CR (n = 8360), and SAG IR (n = 2913). Inverse probability of treatment weighting based on the generalized propensity score was used to minimize imbalance between the groups. RESULTS: In the weighted cohort, median follow-up time was 8.35 years (interquartile range, 5.01-11.6 years). MAG CR was associated with similar long-term survival compared with MAG IR (hazard ratio [HR], 0.79; 95% CI, 0.60-1.03; P = .084). SAG CR was associated with improved long-term survival compared with SAG IR (HR, 0.67; 95% CI, 0.52-0.84; P = .01). MAG CR was associated with better long-term survival compared with SAG CR (HR, 0.45; 95% CI, 0.35-0.57; P < .001). Moreover, MAG IR was protective compared with SAG IR (HR, 0.62; 95% CI, 0.45-0.85; P = .033). Additional analysis was performed comparing perfect CR vs imperfect CR vs IR in MAG and SAG patients, separately. In the weighted sample of MAG, there were no differences in the long-term survival between perfect CR, imperfect CR, and IR. However, in the weighted sample of the SAG cohort, SAG perfect CR was associated with improved survival compared with SAG imperfect CR (HR, 0.81; 95% CI, 0.0.72-0.92; P = .001). Whereas, SAG perfect and imperfect CR were both associated with improved survival compared with SAG IR (HR, 0.51; 95% CI, 0.0.35-0.87; P = .006 and HR, 0.72; 95% CI, 0.64-0.82; P < .001), respectively. CONCLUSIONS: MAG CR is associated with better survival compared with SAG CR. If IR is inevitable, patients with MAG IR had better long-term survival compared with patients receiving SAG IR. Moreover, similar long-term survival is observed whether perfect CR, imperfect CR, or IR is achieved in the MAG population but not in SAG patients.