Introduction Targeted false lumen management has been described for complex presentations of aortic dissection. The “Knickerbocker” technique is often referenced and includes dilating a focal portion of an oversized endograft in the true lumen to purposefully rupture the false lumen septum, but at the expense of increased risk for visceral propagation and malperfusion. This case series describes a novel modification of the Knickerbocker technique by caging the distal end of the endograft prior to focal dilation. Methods A retrospective chart review was conducted at a tertiary academic center from 2018-2020. Patients were included if they had a history or current presentation of aortic dissection and underwent a Caged Knickerbocker (CKB) repair. Data were collected to include demographics, indications for repair, technical success, perioperative outcomes, hospital course, mortality, and further aortic interventions. Results Five patients were included in our evaluation. Four patients (80%) presented with chronic Type B aortic dissection (cTBAD) and concomitant aneurysmal degeneration of the thoracic aorta; 1 patient (20%) presented with an acute rupture secondary to cTBAD. Three patients (60%) had previous aortic repairs, 2 of which were for Type A Aortic Dissection that additionally required redo sternotomy and total arch replacement prior to CKB. CKB was technically successful in all cases with no peri-operative complications. Two (40%) patients required further aortic intervention due to aneurysmal degeneration. Conclusion Achieving complete false lumen thrombosis is a considerable challenge when managing complex aortic dissections. Our data demonstrate the technical feasibly and early successful outcomes with the CKB approach. Importantly, CKB facilitates future distal extension into the para-visceral aorta in cases of complex thoracoabdominal aortic aneurysms. Further research should focus on discerning individual patients who will benefit from targeted false lumen management and compare outcomes between different approaches.

Renal artery aneurysm (RAA) and renal arteriovenous fistula are rare vascular pathologies with reported incidences of 0.3% to 1.0% and 0.04% in the general population, respectively. We describe a 61-year-old Caucasian man who presented to the hospital with symptoms of right flank pain. Imaging demonstrated a right RAA with concurrent hilar RAA and renal arteriovenous fistula. He ultimately underwent an open right nephrectomy, ligation of the fistula, and bovine patch repair of the aortic defect.

Objective: We sought to detail the process of establishing a surgical aortic telehealth program and report the outcomes of a 5-year experience. Methods: A telehealth program was established between two regional Veterans Affairs hospitals, one of which was without a comprehensive aortic surgical program, until such a program was established at the referring institution. A retrospective review was performed of all patients who underwent aortic surgery from 2014 to 2019. The operative data, demographics, perioperative complications, and follow-up data were reviewed. Results: From 2014 to 2019, 109 patients underwent aortic surgery for occlusive and aneurysmal disease. Preoperative evaluation and postoperative follow-up were done remotely via telehealth. The median age of the patients was 68 years, 107 were men (98.2%), 28 (25.7%) underwent open aortic repair, and 81 (74.3%) underwent endovascular repair. Of the 109 patients, 101 (92.7%) had a median follow-up of 24.3 months, 5 (4.6%) were lost to follow-up or were noncompliant, 2 (1.8%) were noncompliant with their follow-up imaging studies but responded to telephone interviews, and 1 (0.9%) moved to another state. At the 30-day follow-up, eight patients (7.3%) required readmission. Four complications were managed locally, and four patients (3.6%) required transfer back to the operative hospital for additional care. Conclusions: Telehealth is a great tool to provide perioperative care and long-term follow-up for patients with aortic pathologies in remote locations. Most postoperative care and complications can be managed remotely, and patient compliance for long-term follow-up is high.

This is a retrospective cohort study evaluating the safety and effectiveness of biodegradable calcium sulfate antibiotic beads in vascular graft infections compared with standard of care. No differences in acute kidney injury or hypercalcemia were observed between the cohorts. Recurrence of infection did not occur in the 13-patient bead cohort compared with 14 patients who had recurrence in the 45-patient nonbead cohort with a number needed to treat of 4.0.

Objectives To report our experience and compare the results of percutaneous endovascular aortic aneurysm repair (PEVAR) performed under monitored anesthesia care (MAC) to PEVAR under general anesthesia (GA). Methods A retrospective review of patients who underwent non-emergency endovascular abdominal aortic aneurysm repair (EVAR) was completed. Patients were excluded if they had a complex repair, including fenestrated, branched, or parallel endografting. Demographics, operative data, 30-day mortality/morbidity and postoperative outcomes were analyzed. Results A total of 159 patients were identified with a median age of 69. 115 patients had PEVAR, 45 (39.1%) PEVAR MAC and 70 (60.9%) PEVAR GA. PEVAR MAC compared to PEVAR GA had decreased operative time (106 vs. 134 min, P < 0.001), time in the operating room (163 vs. 245 min, P = 0.016), and estimated blood loss (EBL) (115 vs. 176 mL P = 0.012). There was no statistically significant difference in the hospital length of stay (LOS) (1.9 vs. 2.7 days, P = 0.133), and post-operative complications including pulmonary (2.2 vs. 2.9%, P = 0.835). Forty-four patients had EVAR with a femoral cutdown (FC), including 14 PEVAR conversions. PEVAR conversion was associated with higher EBL (543 vs. 323 mL, P = 0.03), operative time (230 vs. 178 min, P = 0.01), and operating room time (307 vs. 275 min, P = 0.01) compared to planned EVAR with FC. Conclusions PEVAR under MAC is associated with shorter time in the operating room compared to PEVAR under GA. PEVAR under MAC does however not decrease overall morbidities, including postoperative pulmonary complications.

Acute portal vein thrombosis complicated by mesenteric ischemia requires emergent treatment to address the compromised bowel as well as the portal vein thrombus. We report a novel hybrid approach to managing this disease process. The procedure we discuss entails exploratory laparotomy and small bowel resection by the acute care emergency surgery team. Following this, the vascular surgery team performs a portal venogram through a branch mesenteric vein accessed through the laparotomy incision and then places a thrombolysis catheter. This technique and approach allows us to provide initial management efficiently and effectively under one operation.

Background Groin reconstruction with muscle flap coverage is associated with high wound complication rates. Incisional vacuum-assisted closure (iVAC) therapy may lower wound complications. We evaluated the impact of iVAC on postoperative outcomes in patients following groin reconstruction with muscle flap coverage. Methods We conducted a retrospective review of patients who underwent groin reconstruction with muscle flap coverage in 2012-2018. Patients were divided into those who received iVAC therapy and those who received standard sterile dressings (SSD). Results Of the 57 patients included, most received iVAC therapy (71%, n = 41) and the rest received SSD (28%, n = 16). The iVAC group had higher rates of diabetes, hypertension, coronary artery disease, and peripheral artery disease (p < 0.05). However, iVAC patients had comparable length of hospital stay (12 vs 8.5 days p = 0.0735), reoperations (34% vs 31%, p = 0.8415), and readmissions (32% vs 37%, p = 0.6801) with SSD patients. iVAC placement was less likely in prophylactic flaps (odds ratio 0.08, p = 0.0049). Conclusion Patients with a prophylactic flap were less likely to receive vacuum therapy, which may highlight a selection bias where surgeons pre-emptively use iVAC therapy in surgical candidates identified as high risk. The pre-emptive use of iVAC may minimize adverse postoperative outcomes in high-risk patients.

Necrotizing soft tissue infection is a rare and potentially life-threatening complication after endovascular stenting procedures. The following presents one such case of a necrotizing soft tissue infection of the femoral-popliteal artery and stent with proximal superficial femoral artery and above-knee popliteal artery by gas-producing Streptococcus anginosus. Patient information was obtained from electronic medical records at the University of Maryland Medical Center. All information was deidentified in accordance with hospital and department of vascular surgery policy and presented according to the medical education provision obtained in the surgical consent of our patients. Data and the discussion thereof are presented in compliance with the U.S. Health Insurance Portability and Accountability Act. A 77-year-old man presented to our medical center admitted from an outside medical facility with necrotizing soft tissue infection of the right groin after endovascular stent placement 9 days before admission. Stent placement was performed for the patient's complaint of claudication. On the day of admission, the patient underwent extensive débridement of skin, subcutaneous tissue, and left thigh anteromedial muscle >100 cm2 and resection of involved vascular structures, including resection of an infected femoral-popliteal artery, femoral-popliteal stent, proximal superficial femoral artery, and above-knee popliteal artery. The patient underwent subsequent return to the operating room for additional débridement on hospital days 2 and 4. On hospital day 6, he ultimately underwent a left above-knee amputation. The patient was transferred to the intensive care unit, where he received routine postoperative care including pharmacologic pressure support. Intraoperative culture specimens from his left leg were positive for S. anginosus. During his stay, he underwent an extensive infectious workup that included an echo (negative for vegetations), maxillofacial panoramic films, and computed tomography of the abdomen and pelvis that identified concern for diskitis/osteomyelitis at T11-T12. Magnetic resonance imaging confirmed concern for diskitis/osteomyelitis, resulting in a postoperative course of 6 weeks of antibiotic therapy through a right upper extremity peripherally inserted central venous catheter line. This case of necrotizing soft tissue infection represents a devastating and rare life-threatening complication of endovascular intervention in patients with significant vascular disease. Stent removal in addition to resection of grossly infected vessels and tissue and amputation represent urgent interventions that must be promptly planned and managed by skilled surgeons able to quickly identify the underlying signs and symptoms of disease.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The transcervical approach to carotid artery stenting (TCAR) has demonstrated lower periprocedural stroke risk compared to transfemoral access, particularly when using the flow reversal technique. The indications for use of the existing system limit its safe application in cases with unfavorable neck anatomy where the carotid bifurcation is less than 5 cm above the clavicle. We present our initial experience with five patients who underwent TCAR using an adjunctive prosthetic conduit technique augmented with flow reversal. The common carotid artery (CCA) was exposed and a 6-mm transcervical polytetrafluoroethylene conduit was sutured to the proximal CCA and brought out to the anterior chest wall (Figure). This created a long, sTable platform accessible to the conventional TCAR platform. The conduit also allowed for improved control and pushability in short common carotid arteries and difficult internal carotid lesions. Flow reversal was employed via access of the common femoral vein, and each patient was stented without technical complication. The conduit was suture ligated at the CCA with a small stump of prosthetic material left in place. All patients had an American Society of Anesthesiology score of 3. The indication for three of the five cases was asymptomatic restenosis following previous carotid endarterectomy with the other two cases involving symptomatic stenosis in reoperative or previously radiated necks. All procedures were performed under local with sedation with successful deployment of stents and resolution of the stenosis on completion angiogram and postoperative duplex scan. Average operative time was 2 hours and 16 minutes. All patients were discharged home with a less than 48-hour stay. Demographic, procedural, and outcomes information is presented in the Table. There were no periprocedural strokes or mortality. All patients recovered from their procedure without incident and are free from restenosis, major adverse cardiovascular events, or nerve injuries at a median of 7.6 months of follow-up (range 1.5-11.4 months). Transcervical carotid artery stenting with flow reversal via arterial conduit is a safe and feasible technique. This simple modification to existing embolic protection strategies expands the number of patients who are candidates for TCAR and presents an excellent option in patients with complex and challenging cervical and aortic arch anatomy.TableDemographic, procedural, and outcomes informationCase no.Age, yearsSexSide and stenosisOperative indicationComorbidities a and HistoryComplicating factor(s)Operative timeSurveillance, monthsComplications163FLeft80%-99%Asymptomatic RestenosisHTN, AS, obesity, Hx left CEAShort CCA, reoperative, hostile arch1' 45"11None276MLeft <70% (w/ ulcer)Symptomatic CCA ulcerHTN, AFib, Hx CABG, CVA, Hx left CEAShort CCA, hostile arch, reoperative, cardiac risk1' 46"10None386FLeft80%-89%Asymptomatic restenosisHTN, Hx PCI, Hx left CEAShort CCA, hostile arch, reoperative2' 01"5None463MRight80%-99%Symptomatic StenosisHx non-Hodgkins Lymphoma and neck radiationCCA stenosis, irradiated field, contrast allergy, tortuous CCA3' 48" (converted from initial transfemoral access)8Seroma, reoperation at 8 weeks postoperative570FLeft80%-89%Asymptomatic RestenosisHTN, Diabetes, Hx PCI, COPD, chronic kidney disease, Hx Bilateral CEAShort CCA, reoperative2' 00"1.5NoneAFib, Atrial fibrillation; AS, CABG, coronary artery bypass grafting; CCA, common carotid artery; CEA, carotid endarterectomy; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; F, female; HTN, hypertension; Hx, history; M, male; PCI, percutaneous coronary intervention. Open table in a new tab

Extracranial carotid artery aneurysms (ECAAs) have a low incidence between 0.4% and 4% of all peripheral artery aneurysms and involving 0.1-2% of all carotid artery procedures. Some form of repair is generally warranted as nonoperative management has shown mortality as high as 71%. However, to date a standard method for ECAA repair has not been suggested. Generally, open surgical repair is the preferred technique; however, it has its own limitations and risks. Recently, endovascular approach is increasingly being used not only for the elective repair of unruptured ECAA but also for the management of ruptured ECAA. Herein we present 3 cases of distal extracranial internal carotid artery aneurysms treated with placement of stent grafts.

An 84-year-old man has a history of a right hypogastric artery aneurysm that was excluded with endograft several years ago. His course was complicated by a type II endoleak with an enlarging aneurysm that required multiple attempts of coil embolization. Several years later, he presented with gross hematuria and was found to have embolization coils extruding into his bladder and an arteriovesical fistula. As seen in this case, endovascular intervention for a type II endoleak is not benign. We describe a novel complication of an arteriovesical fistula that necessitated a difficult repair and ultimate revascularization.

Background: Prolonged hemodynamic instability after carotid artery stenting (CAS) has been associated with increased incidence of stroke and other major adverse events. The objective of this study is to determine the factors associated with hypotension following CAS. In particular, this study evaluates whether involvement of the carotid bifurcation/bulb and degree of calcification can predict postoperative hypotension. Methods: A retrospective review of 90 CASs performed in 88 patients at a single tertiary center was completed. In patients with proximal internal carotid stenosis involving the carotid bifurcation, the extent of bifurcation/bulb calcification on preoperative computed tomography angiography was assessed using a scoring system. Calcium scores were assigned based on the percent of circumferential calcification of carotid bifurcation as follows: grade 1, < 10%; grade 2, 10-50%; grade 3, 50-90%; and grade 4, > 90%. Perioperative factors associated with prolonged postoperative hypotension requiring vasopressor infusion were analyzed. Results: Overall, postoperative hypotension requiring vasopressors occurred in 26 (28.9%) of CAS. There were no differences in baseline demographics, comorbidities, or CAS indication between patients who required postoperative vasopressors for hypotension and those who did not. The majority of patients (64.4%) were on 2 or more antihypertensive medications preoperatively. Stenosis involved carotid bifurcation in 64 (71.1%) cases. Of these, 27 (42.2%) were grade 1, 19 (29.7%) were grade 2, 10 (15.6%) were grade 3, and 8 (12.5%) were grade 4 based on our calcium scoring system. On risk-adjusted analysis, carotid bifurcation/bulb involvement (adjusted odds ratio [aOR] 4.5, 95% confidence interval [CI] 1.1-18.5) and preoperative regimen of 2 or more antihypertensives (aOR 4.2, 95% CI 1.1-16.0) were independent predictors of hypotension requiring vasopressors following CAS. Among patients with carotid bifurcation involvement, severity of calcium score was not a significant predictor of postoperative hypotension. Conclusions: CAS for carotid stenosis involving the carotid bifurcation/bulb is associated with a higher risk for postoperative hypotension requiring vasopressors. Patients with preoperative hypertension requiring 2 or more antihypertensive medications are also at increased risk. However, severity of carotid bifurcation calcification is not a significant predictor of need for postoperative vasopressors.

Background: This study examines the outcome of hybrid revascularization combining iliofemoral endarterectomy and iliac artery stenting using covered stents in TransAtlantic InterSociety Consensus (TASC) C and D aortoiliac occlusive disease (AIOD) involving the common femoral artery (CFA). Methods: A retrospective review was conducted in patients with TASC C and D AIOD involving the CFA and undergoing hybrid revascularization. Covered stents were used primarily. Demographics, indications for surgery, lesion classification, hospital length of stay (LOS), 30-day morbidity/mortality, hemodynamic and clinical success, and patency were assessed. Results: Thirty-six male patients (41 limbs), mean age 63.9 +/- 6 years, were identified (TASC C = 39%, D = 61%). Indications for surgery were claudication (27%), rest pain (44%), and tissue loss (29%). A simultaneous adjunctive procedure (5 infrainguinal bypass, 3 superficial femoral artery stents) was performed in 22%. Thirty-day outcomes included 1 mortality (2.7%) and 2 reoperation (5.5%), 1 for femoral artery pseudoaneurysm and 1 for bilateral groin seroma. LOS was 4 days (interquartile range 3-6). All patients with available data experienced 30-day clinical and hemodynamic success. Mean follow-up was 23 months (range 1-79 months) with a primary patency of 85.4%. Cumulative primary assisted and secondary patency was 92.6%. The femoral patch repair was the most frequent site of reintervention (3/3). Mortality was 34% during the study period, and it was significantly higher in patients with tissue loss (57.1% vs. 14.8%, P = 0.01). Conclusions: The hybrid approach has low morbidity, mortality, and fast recovery. The use of covered stents/stent grafts provides good mid-term patency. Close follow-up with noninvasive imaging is paramount to avoid repair failure, in particular at the femoral patch repair site.

Treatment of chronic peripheral ischemic wounds in patients with spinal cord injury (SCI) can be technically challenging, especially if they have significant hip contracture. This article describes the endovascular aortoiliac revascularization of a paraplegic patient with hip contracture and a hostile abdomen. It also reviews the particularity of the peripheral arterial system in SCI patients.

This study reports the outcomes of hybrid revascularization combining iliofemoral endarterectomy and iliac artery stenting using covered stents in TASC C and D aortoiliac occlusive disease involving femoral bifurcation. A retrospective review was conducted of patients with TASC C and D aortoiliac occlusive disease undergoing hybrid revascularization between December 2009 and July 2016 at a single academic center. Demographics, indications for surgery, lesion classification and location, stent location and type, length of stay (LOS), 90-day morbidity and mortality, and patency were assessed. Primary outcomes were hemodynamic success (defined as an increase in the ipsilateral ankle-brachial index [ABI] of at least 0.1), clinical success (improved symptoms of claudication, rest pain, or wound healing) at 30 days, and patency. All patients underwent a preoperative and follow-up ABI and pulse volume recording (PVR). Thirty-six male patients, mean age 63.9 ± 6.0 years, underwent revascularization of 41 limbs (TASC C: 39%; D: 61%). There were no significant differences in demographics, comorbidities, or indications between TASC C and D patients. Indications for surgery were claudication (27%), rest pain (44%), or tissue loss (29%). Mean operative time was 340 ± 100 minutes with estimated blood loss 500 mL (275-1000 mL). Seventy-seven stents were placed (66 covered, 11 bare metal). Covered stents were used primarily, and bare-metal stents were used at the iliac bifurcation to preserve internal iliac artery patency. All external iliac arteries were treated with covered stents. Simultaneous adjunctive procedures (5 infrainguinal bypasses, 3 superficial femoral artery stents) were performed in 22%. Ninety-day complications included 1 pulmonary embolus, 1 pneumonia, 4 surgical-site infections, 2 hematomas, 3 seromas, 1 stent thrombosis, 1 femoral artery pseudoaneurysm, and 1 infected covered stent. Hospital and intensive care unit LOS were 4 days (3-6 days) and 2 days (2-3 days), respectively. All patients with available data experienced 30-day clinical and hemodynamic success. Mean follow-up was 23 months (range, 1-79 months) with a primary patency of 85.4%. Cumulative primary assisted and secondary patency was 92.6%. The femoral patch repair was the most frequent site of reintervention. Mortality was 34% overall during the study period with one death at 30 days. Hybrid approach has low morbidity and mortality and fast recovery. It is a safe, effective and lasting treatment for TASC C and D aortoiliac occlusive disease involving the femoral bifurcation. The use of covered stents provides good midterm patency. Close follow-up with noninvasive imaging is paramount to avoiding repair failure by diagnosing recurrent stenosis, in particular at the femoral patch repair site.

This study determined factors associated with hypotension following carotid artery stenting (CAS). In particular, this study evaluated whether involvement of the carotid bifurcation/bulb and degree of calcification can predict postoperative hypotension. A retrospective review of 90 CAS performed in 88 patients (1 female, 87 males) at a single academic center was performed. Site of carotid stenosis was confirmed on angiography at time of CAS. In patients with proximal internal carotid stenosis involving the carotid bifurcation, extent of bifurcation/bulb calcification on preoperative computed angiogram (CTA) was assessed using a scoring system. A single operator reviewed all CTA to ensure reproducibility. Calcium scores were assigned based on percentage of circumferential calcification of carotid bifurcation as follows: grade 1, <10%; grade 2, 10% to 50%; grade 3, 50% to 90%; grade 4, >90%. Preoperative blood pressure and number of hypertensive medications were recorded. Postoperatively, systolic blood pressure was monitored by arterial line and maintained within 20% of baseline with absolute parameters between 110 and 170 mm Hg. Perioperative factors associated with postoperative hypotension requiring vasopressor were analyzed. Overall, postoperative hypotension requiring vasopressors occurred in 26 (28.9%) of CAS. Mean duration of vasopressor infusion was 21.4 hours (standard deviation, 10.9). There were no differences in baseline demographics, comorbidities, or CAS indication between patients that required postoperative vasopressors for hypotension and those that did not (Table 1). Majority of patients (64.4%) were on two or more antihypertensive medications preoperatively. Stenosis involved the carotid bifurcation in 64 (71.1%). Of these, 27 (42.2%) were grade 1, 19 (29.7%) were grade 2, 10 (15.6%) were grade 3, and 8 (12.5%) were grade 4 based on our calcium scoring system. On risk-adjusted analysis, carotid bifurcation/bulb involvement (adjusted odds ratio, 4.5; 95% confidence interval, 1.1-18.5) and preoperative regimen of 2 or more anti-hypertensives (adjusted odds ratio, 4.2; 95% confidence interval, 1.1-16.0) were independent predictors of hypotension requiring vasopressors following CAS (Table II). Among patients with carotid bifurcation involvement, severity of calcium score was not a significant predictor of postoperative hypotension. CAS for carotid stenosis involving the carotid bifurcation/bulb is associated with a higher risk for postoperative hypotension requiring vasopressors. Patients with preoperative hypertension requiring two or more antihypertensive medications are also at increased risk. However, severity of carotid bifurcation calcification is not a significant predictor of need for postoperative vasopressors.Table IBaseline characteristicsVariableaOverall (n = 88 patients, 90 CAS)No postoperative hypotension requiring vasopressors (n = 64 [71.1%])Postoperative hypotension requiring vasopressors (n = 26 [28.9%])P valueAge mean (SD), years68.0 (10.8)67.2 (12)69.9 (6.9).19Sex.19 Male87 (96.7)62 (96.9)25 (96.2) Female1 (1.1)0 (0.0)1 (3.8)Comorbidities Hypertension85 (94.4)59 (92.2)26 (100).34 Prior coronary intervention37 (41.1)26 (40.6)11 (42.3).66 Smoking history80 (88.9)58 (90.6)22 (84.6).27 Diabetes mellitus35 (39.8)25 (40.3)10 (38.5).87 COPD29 (32.2)21 (32.8)8 (30.8).64Indication for intervention Asymptomatic55 (61)39 (60.9)16 (61.5).96 Symptomatic35 (38.9)25 (39.1)10 (38.5).96Indications for CAS Previous CEA12 (13.3)10 (15.6)2 (7.7).32 Other previous neck surgery12 (13.3)9 (14.1)3 (11.5).75 Previous neck radiation16 (17.8)10 (15.6)6 (23.1).40 High anatomic lesion27 (30.0)20 (31.3)7 (26.9).69 Severe CHF26 (28.9)19 (29.7)7 (26.9).79 Severe COPD19 (21.1)14 (21.9)5 (19.2).78 Contralateral nerve injury3 (3.3)2 (3.1)1 (3.8).86Preoperative hemodynamics SBP controlled (110-170 mm Hg)84 (93.3)61 (95.3)23 (88.5).24 Antihypertensives, No..04≤132 (35.5)27 (42.2)5 (19.2)≥258 (64.4)37 (57.8)21 (80.8)Carotid stenosis involving bulb/bifurcation.07 No26 (28.9)22 (34.4)4 (15.4) Yes64 (71.1)42 (65.6)22 (34.4)Calcium score (% Row).68 1 (<10%)27 (42.2)20 (74.1)7 (25.9) 2 (10-50%)19 (29.7)11 (57.9)8 (42.1) 3 (50-90%)10 (15.6)6 (60.0)4 (40.0) 4 (>90%)8 (12.5)5 (62.5)3 (37.5)CAS, Carotid artery stenting; CEA, carotid endarterectomy; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; SBP, systolic blood pressure; SD, standard deviation.aData are shown as number (%) unless indicated otherwise. Open table in a new tab Table IIMultivariate analysis of independent predictors of hypotension following carotid artery stentingCharacteristicAdjusted OR (95% CI)P valueAge (per year)1.07 (0.99-1.2).11Comorbidities Coronary artery disease0.51 (0.2-1.7).26 Any smoking history0.32 (0.1-1.7).18 Diabetes mellitus0.83 (0.3-2.6).75Reason for carotid intervention Symptomatic ICA stenosis (vs asymptomatic)1.86 (0.1-37.0).68Preoperative hemodynamics SBP controlled (110-170 mm Hg)0.30 (0.04-2.3).25 No. of antihypertensives≥2 (vs ≤1)4.2 (1.1-16.0).035Carotid bulb/bifurcation involvement4.5 (1.1-18.5).035CI, Confidence interval; ICA, internal carotid artery; OR, odds ratio; SBP, systolic blood pressure. Open table in a new tab

Introduction: Despite a recent rise in popularity of endovascular techniques, open bypass surgery is still required for treating many lower extremity vascular lesions. Greater saphenous vein (GSV) of adequate length and caliber for successful infrainguinal lower extremity bypass is unavailable in 15% to 45% of patients. To overcome limitations imposed by absent vein due to prior use, short vessel length, or sclerotic segments, both alternate (ie, basilic and cephalic) and GSV conduits may be “spliced” together in series via venovenostomy. Although vascular surgeons typically perform a hand-sewn venovenostomy, device-based venous coupling has been performed by plastic surgeons for many years. We therefore sought to review our experience with venous coupling for segmental lower extremity bypass graft assembly. Methods: A retrospective review was performed in all patients who underwent lower extremity revascularization using autogenous vein grafts spliced together with the Synovis (Birmingham, Alabama) anastomotic coupler at a single institution over a 5-year period. Results: The anastomotic coupler device was used on 5 patients for 7 venovenostomies. The mean age of patients was 66 years, and the mean follow-up period was 751 days. Two patients were lost to follow-up, while 2 other patients died of causes unrelated to their lower extremity bypass. The average time to perform venovenostomy was 3 minutes. Three patients developed stenosis of their composite graft at a site other than the venovenostomy, who were successfully treated with either angioplasty or bypass revision. One-year primary and primary-assisted patency rates were 50% and 75%, respectively. Conclusions: Given the known benefits of the anastomotic coupling device when used for venous anastomoses in microsurgical reconstruction, transition of this device to the vascular surgery realm represents a logical progression. Although small, our series demonstrates that the anastomotic coupler can successfully be used for the formation of spliced autogenous grafts for lower extremity revascularization in the absence of adequate GSV.

BACKGROUND: The greater saphenous vein (GSV) has long been accepted as the preferred conduit for infrainguinal arterial revascularization. However, whether due to trauma, previous lower extremity revascularization or coronary artery bypass, or venous insufficiency, GSV of adequate length and caliber is unavailable in up to 15%-45% of patients.1-4 To overcome these limitations, both alternate (i.e., basilic, cephalic) and GSV conduits may be “spliced” together in series via venovenostomy. Although vascular surgeons typically perform a hand-sewn venovenostomy, device-based venous coupling has been performed by plastic surgeons for many years. Use of the anastomotic coupler to perform venovenostomy for spliced autogenous conduit assembly for lower extremity revascularization was a natural evolution of this technique. As venous coupling for segmental graft assembly has not to our knowledge been reported in the literature, we sought to review our experience with this well-studied device this novel setting. METHODS: A retrospective review was performed of all patients who underwent lower-extremity revascularization using segmental autogenous vein graft coupled with the Synovis® anastomotic coupler at a single tertiary care center. RESULTS: Six patients were included. A 3.5 or 4mm coupling device was used to fabricate saphenosaphenous (n=2), basilocephalic (n=2), basilocephalocephalic (n=1), and saphenocephalic (n=1) conduits. Assembly of each conduit required ~2-3 minutes. Follow-up ranged from 2 to 48 months, with one patient lost to follow-up. One patient suffered graft failure after 2 months due to severe pyoderma gangrenosum and significant resultant soft tissue loss. An additional patient developed an asymptomatic drop in ABI after 5 months, for which angiography demonstrated moderate stenosis at the distal graft-artery anastomosis with a widely patient venovenostomy. The remaining three patients remain asymptomatic with patent grafts by duplex surveillance. CONCLUSIONS: Given the well-known benefits of the anastomotic coupler in lower-extremity reconstruction (including shorter operative times, decreased vasospasm and thrombosis rates, and the ability to overcome moderate conduit diameter mismatch5), transition of this device to the vascular surgery realm represents the next logical progression. Although small, our series demonstrates that the coupler can successfully be used for the formation of spliced autogenous grafts for lower-extremity revascularization with patency rates that compare with standard hand-sewn autogenous conduits. Furthermore, its use requires approximately one-tenth the time of traditional venovenostomy methods.

www.PRSJournal.com 145 M oday, O cber 13 CONCLUSIONS: Distal VLN transfers have a higher early complication rate as compared to traditional fl ap procedures. Venous insufficiency is most often the cause of early complications and is related to fl ap swelling and local fl uid absorption from the lymphedematous extremity. The superfi cial venous system appears to provide improved drainage for VLN transfers as compared to the deep venous system in the distal extremity likely due to lymphedema-related compressive forces on the deep extremity compartments. Operative and non-operative strategies can be a valuable tool for fl ap salvage in these challenging scenarios.