BACKGROUND:Octogenarians are regarded as one of the frailest patient groups among the chronic limb-threatening ischaemia population with high perioperative morbidity and mortality rates. As a result, alternative vein bypass surgery in the absence of sufficient great saphenous vein is often not considered as a potential treatment option. The aim of this study was to compare the results of octogenarians undergoing alternative vein bypass surgery due to chronic limb-threatening ischaemia to younger patients. METHODS:A single-centre retrospective analysis of patients undergoing bypass surgery for chronic limb-threatening ischaemia with alternative autologous vein grafts between 1997 and 2018 was performed. Patients aged over 80 years were compared with those under 80 years. Graft patency rates were assessed and a risk factor analysis for limb loss was performed. RESULTS:In total, 592 patients underwent bypass surgery during the study interval. Twenty-one per cent (n = 126) of patients were 80 years or older. At 4 years, primary, primary-assisted and secondary patency as well as limb salvage rates were not significantly different between the two groups (46% versus 50%, 60% versus 66%, 69% versus 72%, 72% versus 77%, for octogenarians versus non-octogenarians respectively). Major amputations were performed in 27 (21%) octogenarians and 91 (20%) non-octogenarians (P = 0.190). No higher 30-day and long-term mortality rates nor morbidity rates were detected in the octogenarian group with a median follow-up time of 27 (interquartile range 12-56) months. Minor amputation, the reason for alternative vein grafts, as well as the profunda femoris artery as proximal origin of the bypass were risk factors for limb loss in the postoperative course. CONCLUSION:Alternative vein bypass surgery in octogenarians with chronic limb-threatening ischaemia is safe and effective in terms of patency rates, limb salvage and survival compared with younger patients in the absence of sufficient great saphenous vein. Age alone should not be a deterrent from performing bypass surgery.

OBJECTIVE:In peripheral arterial disease, patency, limb salvage, and survival rates are mostly reported using Kaplan-Meier analyses. When comparing different revascularisation techniques, these methods have limitations in analysing complex patient flows over time. This study aimed to present, illustrate, and discuss new concepts based on multistate models of analysing outcome parameters in peripheral arterial disease. METHODS:Previously published data from a single centre, randomised controlled trial (RCT) with 218 cases that underwent either vein bypass surgery (bypass group, n = 109) or nitinol stent angioplasty (stent group, n = 109) of long femoropopliteal lesions were re-analysed using non-homogeneous Markov models. A step by step description of the concepts of states, state space, definitions, and illustration of transition probability curves as well as the benefits of multistate models is given. The RCT was registered at ISRCTN.com (ISRCTN18315574). RESULTS:Transition probability curves over time showed similar patterns in the bypass and stent groups. Significant differences in the transition probabilities were found for transitions from primary patency as well as secondary patency to end of patency. The transition probability for patients with preserved primary patency at 24 months who moved to end of patency at 48 months was 19.9% in the stent group vs. 6.4% in the bypass group (p < .001). CONCLUSION:The proposed method can answer important questions, such as: Did patients after femoropopliteal stenting with preserved primary patency at two years lose their patency more quickly within the following years compared with bypass surgery? And did stent patients after a re-intervention to maintain patency at one year lose their patency more quickly compared with bypass surgery within the following years? Completely new research questions can now be raised and answered to optimise treatment and follow up strategies; this might lead to better identification of subgroups at higher risk of clinical deterioration following revascularisation procedures.

OBJECTIVES:The aim of this study was to compare technical success, patency rates and clinical outcomes of vein bypass (VBP) with angioplasty and nitinol stents (NS) in femoropopliteal Trans-Atlantic Intersociety Consensus (TASC) II C and D lesions.SUMMARY BACKGROUND DATA:Guidelines widely recommend an endovas-cular-first strategy for long femoropopliteal lesions without sufficient data comparing it with vein bypass surgery.METHODS:A single-center prospective, randomized controlled trial (RCT) was performed, after approval of the local ethics committee, with technical success, primary and secondary patency as primary endpoints. Secondary endpoints were limb salvage, survival, complications, and clinical improvement.RESULTS:Between 2016 and 2020, 218 limbs (109 per group) in 209 patients were included. Baseline and lesion characteristics were similar in both groups with a mean lesion length of 268 mm. The indication for treatment was chronic limb threatening ischemia in 53% of limbs in both groups. Technical success was feasible in 88% in the stent group. During a 4-year follow-up, primary patency, freedom from target lesion revascularizations, limb salvage, survival and complications showed no significant differences between the groups. At 48 months secondary patency for the bypass group was 73% versus 50% in the stent group ( P = 0.021). Clinical improvement was significantly superior in the bypass group with 52% versus 19% reaching a Rutherford 0 category ( P < 0.001).CONCLUSIONS:This is the largest RCT comparing angioplasty with NS and vein bypass in femoropopliteal TASC II C and D lesions and the first to report 4-year results. The data underline the feasibility of endovascular treatment in long lesions but also emphasize the advantages of VBP.

Background: Guidelines for the treatment of long femoropopliteal lesions are not based on a high level of evidence and recent randomized controlled trials (RCTs) challenge vein bypass (VBP) as the recommended therapy. This study compared prosthetic (PTFE) bypass, VBP and angioplasty with nitinol stents in long femoropopliteal lesions. Methods: Pooled data from a RCT and a retrospective database with the same inclusion criteria were analyzed with primary and secondary patency as well as freedom from target lesion revascularization (TLR) as primary endpoints. Results: Between 2016 and 2018 a total of 172 lesions were treated in three groups (PTFE: n = 62, VBP: n = 55, stent: n = 55). Clinical and lesion characteristics were similar with mean lesion lengths between 260 and 279mm. Technical success rate in the stent group was 87%. There were no significant differences between the groups in patency rates, freedom from TLR, limb salvage and survival during 2-year follow-up. The primary patency rates for the PTFE, VBP and stent groups were 50%, 56% and 60% at 2 years. The PTFE group had significantly less complications compared to the other groups and a shorter hospital-stay compared to the VBP group. Clinical improvement was significantly better in the PTFE and VBP group compared to the stent group. Conclusions: The 2-year results indicate that the role of VBP as the recommended therapy for long femoropopliteal lesions may not be unchallenged due to the similar results in all three groups. Further RCTs are needed to determine the best revascularization modality for long femoropopliteal lesions.

Background and Objectives: The feasibility of endovascular treatment (EVT) for Trans-Atlantic Inter-Society Consensus (TASC) II C and D femoropopliteal artery lesions has been described, but no prospective study has performed a long-term follow-up. The aim of this study was to report the long-term results of nitinol stents (NS) for the treatment of long femoropopliteal lesions. Materials and Methods: A single-center prospective, randomized controlled trial (RCT) comparing EVT with NS and vein bypass surgery was previously performed. The EVT group’s follow-up was extended and separately analyzed with primary patency as the primary endpoint. The secondary endpoints were technical success, secondary patency, reinterventions, limb salvage, survival, complications, and clinical improvement. Results: Between 2016 and 2020, 109 limbs in 103 patients were included. A total of 48 TASC II C and 61 TASC II D lesions with a mean lesion length of 264 mm were reported. In 53% of limbs, the indication for treatment was chronic limb-threatening ischemia. The median follow-up was 45 months. Technical success was achieved in 88% of cases, despite 23% of the lesions being longer than 30 cm (retrograde popliteal access in 22%). At four-year follow-up, primary patency, secondary patency, and freedom from target lesion revascularizations were 35%, 48%, and 58%, respectively. Limb salvage and survival were 90% and 80% at 4 years. Clinical improvement of at least one Rutherford category at the end of follow-up was achieved in 83% of limbs. Conclusions: This study reports the longest follow-up of endovascular treatment with nitinol stents in femoropopliteal TASC II C and D lesions. The results emphasize the feasibility of an endovascular-first strategy, even in lesions beyond 30 cm in length, and clarify its acceptable long-term durability and good clinical outcomes. Large multicenter RCTs with mid- and long-term follow-up are needed to investigate the role of different endovascular techniques in long femoropopliteal lesions.

Aneurysmen der Gesichtsarterien sind selten. Sie präsentieren sich überwiegend als pulsierende Schwellung, die oft als Hämatom fehldiagnostiziert wird. Die am häufigsten betroffene Arterie ist mit etwa 85 % die A. temporalis superficialis. Retrospektiver Fallbericht von 8 posttraumatischen Gesichtsarterienaneurysmen an drei akademischen Zentren für Gefäßchirurgie aus den Jahren 2007–2020. Das mediane Alter der Gesamtkohorte liegt bei 76,7 Jahren. Die Aneurysmaursache der jungen Patienten (n = 3) mit einem medianen Alter von 29,9 Jahren war eine traumatische Fremdeinwirkung, meist infolge einer Sportausübung. Bei den älteren über 70-jährigen Patienten (n = 5) mit einem medianen Alter von 83,2 Jahren waren jedoch ausnahmslos Stürze auf spitze Gegenstände Ursache des Aneurysmas. Am häufigsten war die A. supratrochlearis (n = 4) betroffen. Eine neurologische Ursache des Traumas konnten in allen Fällen ausgeschlossen werden. Innerhalb der medianen Follow-up-Dauer von 30,6 Monaten wurde kein Rezidivaneurysma beobachtet. Dieser Fallbericht beleuchtet die Ursache und Therapie von Aneurysmen der Endäste der A. carotis externa mit einer Differenzierung in zwei Altersgruppen. Trotz des seltenen Auftretens der Gesichtsarterienaneurysmen sollten sie differenzialdiagnostisch nicht außer Betracht gelassen werden. Die Therapie der Wahl stellt die chirurgische Exzision dar.

Background: Aneurysms of the facial arteries are rare. They present mostly as a pulsatile swelling, which is often misdiagnosed as a hematoma. The most commonly affected artery, accounting for approximately 85%, is the superficial temporal artery. Material and methods: Retrospective case report of 8 posttraumatic facial artery aneurysms at 3 academic centers for vascular surgery from 2007 to 2020. Results: The median age of the total cohort was 76.7 years. The cause of aneurysms in young patients (n = 3) with a median age of 29.9 years was traumatic foreign body impact, mostly as a result of sports practice; however, in older patients over 70 years with a median age of 83.2 years (n = 5), falls on pointed objects were in all cases the cause of the aneurysm. The supratrochlear artery (n = 4) was most commonly affected. A neurological cause of trauma could be excluded in all cases. Within a median followup of 30.6 months no recurrent aneurysms were observed. Conclusions: This case report highlights the cause and treatment of aneurysms of the terminal branches of the external carotid artery with a differentiation in younger and older patients. Despite the rare occurrence of facial artery aneurysms, they should not be disregarded for differential diagnostics. Surgical excision is the treatment of choice.

INTRODUCTION: Treatment of long femoropopliteal lesions remains a challenge for vascular physicians as patients often present with multilevel complex pathologies and consequently face a high amputation risk and associated mortality. This review aimed to assess the current state of optimal revascularizations for the treatment of long femoropopliteal lesions.EVIDENCE ACQUISITION: An online literature research of medical databases for original articles and review articles on open and endovascular revascularization of femoropopliteal lesions was conducted using mesh terms.EVIDENCE SYNTHESIS: There has been an accumulation of evidence over the last years that endovascular treatment is a feasible and enduring alternative to open surgery for treatment of long femoropopliteal lesions if the lesions are restricted to the superficial femoral artery. But when disease extends to the infragenual level venous bypass remains superior with regards to long-term patency, clinical improvement and limb-salvage.CONCLUSIONS: While the role of venous bypass as a first-line treatment might be declining, especially in frail patients or claudicants, the superior clinical improvement and amputation-free survival highlighted in several trials, demonstrate the relevance of bypass surgery. More randomized clinical trials are needed to verify the non-inferiority of endovascular treatment options to open surgery, especially when arterial disease extends below the knee.

BACKGROUND:Psychological factors like anxiety and depression are recognised to play a causal role in the development of cardiovascular disease and they may also influence outcome after vascular surgery procedures. The aim of this study was to investigate the association of anxiety and depression with postoperative outcome following elective carotid surgery.METHODS:Single centre prospective observational study of patients treated for asymptomatic carotid artery stenosis at an academic vascular surgery centre. Preoperative anxiety and depression were evaluated using self-reporting questionnaires: Spielberger State-Trait Anxiety Inventory (STAI-S/-T) and Hospital Anxiety and Depression Scale (HADS-A/-D). Postoperative morbidity and mortality were assessed with the primary composite endpoint of stroke, myocardial infarction (MI) and death. Standard reporting guidelines for carotid disease were applied.RESULTS:From June 2012 to November 2015, 393 carotid endarterectomies (CEA) were performed at our institution. Out of those, 98 asymptomatic patients were available for analysis (78% male; median age, 71.1 years). Median scores of self-reporting questionnaires did not differ from published data of the general population (STAI-T, trait component, median, 36; IQR, 31-42.75; STAI-S, state component, median, 38; IQR, 32-43; HADS-A median, 6; IQR, 3-8; HADS-D median, 4; IQR, 2-7). Cardiovascular risk factors were similar in anxious and non-anxious patients. The composite endpoint of stroke, MI and death occurred significantly more often in patients presenting with a preoperative HADS-A score higher than 6 (10.5%, 95% CI, 3-25; p =.020).CONCLUSIONS:The present study indicates that preoperative anxiety is associated with the occurrence of intra- and postoperative neurological events in patients undergoing CEA. Patients who had a preoperative HADS-A score of 6 or less had a very low probability of experiencing these complications.

Introduction: Despite advances of endovascular interventions, bypass surgery remains the gold standard for treatment of long and complex arterial occlusions in the lower limb. Autologous vein is regarded superior to other options. As the graft of first choice, the great saphenous vein (GSV) is often not available due to previous bypass, stripping or poor quality. Other options like arm veins (AV) are important alternatives. As forearm portions of AVs are often unusable, a graft created from the upper arm basilic and cephalic veins provides a valuable alternative. Patients and Methods: We analyzed consecutive patients treated at an academic tertiary referral center between 01/1998 and 07/2018 using arm veins as the main peripheral bypass graft. Study endpoints were primary patency, secondary patency, limb salvage and survival. Results: In the observed time period 2702 bypass procedures were performed at our institution for below-knee arterial reconstructions. Vein grafts used included the ipsilateral GSV (iGSV; n = 1937/71.7%), contralateral GSV (cGSV; 192/7.1%), small saphenous vein (SSV; 133/4.9%), prosthetic conduits (61/2.3%) and different configurations of AV (379/14%). In the majority of patients receiving AV grafts a complete continuous cephalic or basilic vein (CAV) was used (n = 292/77%). If it was not possible to use major parts of these 2 veins, either spliced arm vein grafts (SAV) (42/11%) or an upper arm basilic-cephalic loop graft (45/12%) were used. Median follow-up was 27 (interquartile range: 8-50) months. After 3 years secondary patency (CAV: 85%; SAV: 62%; loop: 66%; p = 0.125) and limb salvage rates (CAV: 79%, SAV: 68%; loop: 79%; p = 0.346) were similar between the 3 bypass options. Conclusion: The encouraging results of alternative AV configurations highlight their value in case the basilic or cephalic veins are not useable in continuity. Especially for infragenual redo-bypass procedures, these techniques should be considered to offer patients durable revascularization options.

BACKGROUND:Bypass surgery remains the gold standard for long and complex arterial occlusions in the lower limb. The vein is regarded superior to prosthetic conduits in peripheral arterial bypass surgery. However, this option is often limited because of previous bypass, stripping, or poor quality of the ipsilateral and/or contralateral great saphenous vein (GSV). Under these circumstances, the arm vein (AV) and small saphenous vein (SSV) are the only alternative autologous vein grafts. METHODS:We analyzed all consecutive patients treated at an academic tertiary referral center between January 1998 and July 2018 using either the AV or SSV as the main peripheral bypass graft. Study end points were primary patency, secondary patency, limb salvage, and survival. RESULTS:In total, 416 bypass procedures using exclusively AV (n = 327) or SSV (n = 89) were performed. There was a predominance of male gender. The majority of risk factors were evenly distributed between groups. The mean follow-up period was 2.3 years (0.9 to 13.3 years). Five-year primary and secondary patency rates were 39% (95% CI: 31-47%) and 67% (59-75%) for AV and 53% (41-66%) and 76% (67-86%) for SSV, respectively (P = 0.2 and 0.25). The five-year limb salvage and survival rates were 71% (68-81%) and 84% (77-90%) for AV and 78% (67-88%) and 90% (82-98%) for SSV, respectively (P = 0.52 and 0.11). CONCLUSIONS:Both AV and SSV are equally effective alternatives for peripheral bypass if no GSV is available. Although there was a trend toward better results with the SSV, there was no significant difference between the 2 options.

Objective: Vein is regarded superior to artificial graft in peripheral arterial bypass surgery. However, this option is often limited owing to previous use or removal of the ipsilateral greater saphenous vein (iGSV). In this case, the contralateral great saphenous vein (cGSV), the small saphenous vein (SSV), or arm veins (AV) are possible alternatives. Experience with all three grafts for below knee vein bypass is reported. Methods: Consecutive patients treated at an academic tertiary referral centre between January 1998 and July 2018 using the cGSV, SSV, or AV as the main peripheral bypass graft were analysed. Study end points were primary patency, secondary patency, limb salvage, and survival. Results: Over the observed time period, 2642 bypass operations for treatment of peripheral artery disease with below knee target arteries were performed at the authors' institution: 1937 procedures using the iGSV; 644 bypass procedures using the cGSV (n = 186; 28.9%), SSV (n = 101; 15.7%), or AV (n = 357; 55.4%); and 61 procedures using a prosthetic graft. The median follow up period was 2.3 years (range 9 days-18.5 years). Thirty day mortality was 1.9% for the whole group and similar between the three groups. After five years, primary and secondary patency rates were comparable between the three groups. Secondary patency was 75% (95% confidence interval [CI] 66-83) in the cGSV and SSV groups, and 65% (95% CI 57-73) in the AV group (p = .47). Limb salvage and survival after five years were, respectively, 73% (95% CI 65-81) and 89% (95% CI 82-95) in the cGSV group, 79% (95% CI 69-89) and 87% (95% CI 79-95) in the SSV group, and 74% (95% CI 68-80) and 83% (77-89) in the AV group (p = .46). Conclusion: All three types of alternative autologous vein graft are equal regarding outcome parameters. Vascular surgeons should consider all autologous options if their preferred choice is not available.

We want to thank Barillà et al. for commenting on our publication and sharing their experience with a challenging vascular groin complication.1Enzmann F.K. Nierlich P. Eder S.K. Aspalter M. Dabernig W. Aschacher T. et al.Trans-iliac bypass grafting for vascular groin complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Although the primary endovascular approach in this situation was definitely effective, the use of extra-anatomic bypass techniques remains an important part of managing these complex cases. The reported subcutaneous tunnelling of the bypass graft is one of many options. Engin et al.2Engin C. Posacioglu H. Ayik F. Apaydin A.Z. Management of vascular infection in the groin.Texas Heart Inst J. 2005; 32: 529-534PubMed Google Scholar gave a good overview of some of the most practical techniques. As an alternative to the trans-iliac bypass (TIB), some of their lateral femoral bypasses were tunnelled underneath the iliopsoas fascia through the muscular lacuna.2Engin C. Posacioglu H. Ayik F. Apaydin A.Z. Management of vascular infection in the groin.Texas Heart Inst J. 2005; 32: 529-534PubMed Google Scholar We tried this approach as well but found it to be less durable and more prone to complications. Another variation was introduced by Besirli et al.3Besirli K. Cortelekoglu T. Sirin G. Tuzun H. Gurel Sayin A. An extraanatomical bypass method alternative to the obturator bypass.VASA. 2005; 34: 278-280Crossref PubMed Scopus (3) Google Scholar in creating a notch in the iliac wing for the graft. We agree with Barillà et al. that their technique is less invasive than TIB. Nevertheless, we prefer the use of autologous vein and tunnelling of the bypass through a drill hole in the iliac wing for several reasons. It enables bypassing the infected groin without having to cross the crest of the iliac wing or the inguinal ligament. In our experience, the graft is more exposed to kinking with superficial tunnelling than with TIB. Autologous vein grafts did not seem to be more likely to occlude or kink and therefore remain our primary choice, especially in patients with bacteraemia. Drill hole associated bleeding complications were neither reported in the literature nor observed in our cases. In conclusion, the evidence for extra-anatomic bypasses is scarce and the choice of technique often remains based on personal preference. We are convinced that TIB is a viable technique for vascular groin complications and should be part of the armamentarium of vascular surgeons. Re: “Trans-iliac Bypass Grafting for Vascular Groin Complications”European Journal of Vascular and Endovascular SurgeryVol. 59Issue 6PreviewWe read with much interest the article about your experience with Trans-Iliac Bypass Grafting for Vascular Groin Complications.1 Full-Text PDF Open Archive

OBJECTIVES:Groin complications following vascular reconstruction, extensive trauma, or severe radiation induced scarring may complicate future revascularisation procedures of the lower limb. Although several techniques have been described, only few cases of trans-iliac bypass grafting have been published. The aim of this study was to perform a review of the literature on trans-ilac bypass grafting and add the authors' experience.METHODS:A single centre retrospective data analysis and a literature review of all trans-iliac bypass procedures was performed. Data on indication, patency, limb salvage, and survival were collected. Study endpoints were patency, limb salvage, and patient survival.RESULTS:Eight trans-iliac wing bypass grafting procedures were performed in our institution between 2003 and 2018, which represents the largest single centre series. Twenty-three procedures were reported in the literature between 1989 and 2018. Prior to the bypass procedure in the eight patients, six had local infection and two irradiation of the groin. The indication for operation was ischaemia in six cases, bleeding in one case, and infection in another case. The external iliac artery was most often used for the proximal (6 cases) and the superficial femoral artery for distal anastomosis (6 cases). Great saphenous vein was the most commonly used graft material (6 cases). The median follow up was five years with three bypass occlusions after 1, 2, and 8 months, followed by two successful thrombectomy procedures. There were no major amputations and only one death after five months, which was not procedure related.CONCLUSIONS:Trans-iliac bypass grafting is a viable alternative extra-anatomic bypass technique in patients with vascular groin complications. Patency as well as limb salvage and survival are good and may be comparable to those reported for autologous in situ repair and obturator canal bypass grafting.

Objectives: The aim of this study was to compare technical success, patency rates and clinical outcomes of vein bypass (VBP) with angioplasty and nitinol stents (NS) in femoropopliteal Trans-Atlantic Intersociety Consensus (TASC) II C and D lesions. Summary Background Data: Guidelines widely recommend an endovas-cular-first strategy for long femoropopliteal lesions without sufficient data comparing it with vein bypass surgery. Methods: A single-center prospective, randomized controlled trial (RCT) was performed, after approval of the local ethics committee, with technical success, primary and secondary patency as primary endpoints. Secondary endpoints were limb salvage, survival, complications, and clinical improvement. Results: Between 2016 and 2020, 218 limbs (109 per group) in 209 patients were included. Baseline and lesion characteristics were similar in both groups with a mean lesion length of 268 mm. The indication for treatment was chronic limb threatening ischemia in 53% of limbs in both groups. Technical success was feasible in 88% in the stent group. During a 4-year follow-up, primary patency, freedom from target lesion revascularizations, limb salvage, survival and complications showed no significant differences between the groups. At 48 months secondary patency for the bypass group was 73% versus 50% in the stent group (P = 0.021). Clinical improvement was significantly superior in the bypass group with 52% versus 19% reaching a Rutherford 0 category (P < 0.001). Conclusions: This is the largest RCT comparing angioplasty with NS and vein bypass in femoropopliteal TASC II C and D lesions and the first to report 4-year results. The data underline the feasibility of endovascular treatment in long lesions but also emphasize the advantages of VBP.

OBJECTIVES This study sought to compare patency rates and clinical outcomes of nitinol stents and primary vein bypass in long femoropopliteal lesions. BACKGROUND An endovascular-first strategy for long femoropopliteal lesions is widely recommended without sufficient data comparing it with bypass surgery. Nitinol stents are widely used as the standard endovascular therapy. METHODS A single-center randomized controlled trial was performed with the primary endpoints of technical success, primary and secondary patency. Secondary endpoints were limb salvage, survival, complications, and clinical improvement. RESULTS A total of 110 limbs (55 per group) in 103 patients were treated. Baseline and lesion characteristics were similar, with a mean lesion length of 276 mm. Critical limb threatening ischemia was the indication for treatment in 49% of limbs in both groups. Technical success was achieved in 87% in the stent group. During a 2-year follow-up, patency rates, limb salvage, survival and complications showed no significant differences between both groups. At 24 months, primary and secondary patency rates for the stent group were 60% and 72% versus 56% and 73% in the bypass group, respectively. Clinical improvement was significantly better in the bypass group. CONCLUSIONS There were no significant differences regarding patency rates, limb salvage, survival, or complications after 2 years. Technical success and clinical improvement in the bypass group were significantly better, but the promising results of the stent group suggest that an endovascular-first strategy for femoropopliteal lesions up to 30 cm may be reasonable. Mid- as well as long-term results need to be awaited. (C) 2019 by the American College of Cardiology Foundation.

OBJECTIVES:The small saphenous vein (SSV) is a potential vein source for bypass if neither greater saphenous vein nor arm vein is available. This study reports experience using SSV as part of an all autologous vein bypass policy. METHODS:This study comprised single centre retrospective data analysis of all consecutive patients treated at an academic tertiary referral centre from January 1998 to February 2017 using the SSV as the main peripheral bypass graft. Study endpoints were primary patency, secondary patency, limb salvage, and survival. RESULTS:One hundred and twenty operations were performed in 118 patients using SSV. Indications were peripheral arterial occlusive disease (n = 91; Rutherford classification 3: n = 11; 4: n = 21; 5,6: n = 59), acute ischaemia (n = 14), popliteal artery aneurysm (n = 12), and bypass revisions (n = 3). Median follow up was 30.5 months (10 months-13.7 years). Primary patency after one, three and five years was 68% (CI: 59-77%), 58% (49-68%), and 54% (45-64%). Secondary patency was 83% (76-89%) after one year and 77% (69-85%) after three and five years. Limb salvage after one year was 88% (82-94%) and 78% (70-86%) after five years. Survival was 96% (92-99%) after one year and 91% (85-97%) at five years. Multivariable analysis identified redo surgery as an independent risk factor. Patients receiving a primary (n = 59) vs. a redo bypass (n = 61) were compared. Primary patency and secondary patency were both significantly better in the primary bypass group than in the redo group (p = .0036 and p = .0003, respectively). Limb salvage was also significantly better in primary bypass patients than in the redo group (p = .0007), whereas overall survival did not differ significantly (p = .48). CONCLUSION:The SSV is a valuable alternative vein graft in peripheral bypass surgery. It achieves excellent long-term results, particularly in patients with primary procedures but also acceptable results in patients with redo surgery.

Background: Bypass in the upper extremity is a rare procedure mainly performed for chronic ischemia, trauma, or hemodialysis access complications. Feasibility and success of use of the arm vein and small saphenous vein (SSV) for autologous vein bypass have been reported in peripheral artery bypass procedures. There are very few reports on the use of alternative veins in upper extremity bypass. We report our experience with arm vein and SSV as a graft source in upper extremity arterial disease. Methods: Retrospective analysis of a consecutively collected case series in an academic tertiary referral center from January 2010 to February 2018. Study end points were primary patency, secondary patency, limb salvage, and survival. Results: In total, 47 patients were treated with upper extremity bypass either using the SSV (n = 17) or arm veins (n = 30). Indications were either acute (n = 12) or chronic ischemia (n = 35) caused by acute (n = 8) and chronic (n = 9) trauma, sequela of iatrogenic interventions (n = 4), peripheral artery disease (n = 14), thrombangiitis obliterans (n = 3), and dialysis-access-erelated complications (n = 9). An arm vein was used in 30 and the SSV in 17 patients. Primary patency after 12 months was 87% with the SSV and 75% with an arm vein (P = 0.8) and 63% and 75% after 36 months (P = 0.9). Secondary patency were 100% with an arm vein and 100% with the SSV after 36 months (P = 0.4). One patient had to undergo major amputation and 2 minor amputations. Conclusions: Arm vein revascularization using the primarily arm vein or SSV as a bypass conduit can be performed with reasonable mortality and morbidity rates and provide good results comparable with the greater saphenous vein.

Management of recurrent thoracoabdominal aneurysmal disease of the aorta is challenging. We report three patients with previous endovascular or open aortic repair requiring redo repair by treatment by stent-graft implantation of the thoracoabdominal aorta and visceral debranching using an antegrade inflow from the ascending aorta. All three interventions were successful, with two patients alive 5 and 2 years, respectively, after this operation, while the third patient died 2 days after the procedure due to cardiac failure. No paraplegia was observed. As complications from complex open and endovascular procedures are increasing, vascular surgeons should get familiar with alternative management options.

Introduction - Vein is regarded superior to artificial graft in peripheral arterial bypass surgery. However, often this option is limited due to previous bypass, stripping, or poor quality of the ipsilateral greater saphenous vein (GSV). In this case the contralateral GSV or arm veins are preferred alternative vein grafts. The lesser saphenous vein (LSV) is a forgotten, but attractive alternative. There are only limited reports on the use of LSV as a bypass conduit available. We report our experience using LSV as part of an all autologous vein bypass policy. Methods - Retrospective analysis of a consecutive patient series treated at an academic tertiary referral center from 1/98 – 2/17. Results - 120 operations in 118 patients using LSV were performed. Indications were peripheral arterial occlusive disease (n=91; Rutherford classification 3: n=11; 4: n=21; 5,6: n=59), acute ischemia (n=14), popliteal artery aneurysm (n=12), and bypass revisions (n=3). Risk factors for vascular disease included hypertension (71%), hyperlipidemia (50%), diabetes (38%), coronary heart disease (37%), current smoking (20%). Preoperative vein mapping was performed in all patients. The vein was harvested via a dorsolateral approach with a continuous incision. In 97 patients the LSV was used as the entire conduit whereas in the remaining 23 patients it was spliced either to another vein (GSV n = 14, arm vein n =5) or prosthetic grafts (n = 4). Distal target artery was popliteal (n=49), tibial (n=36) or inframalleolar (n=35). Median Follow-up was 19.3 months (2 mos - 13,6 yrs). Patients receiving a primary bypass (n = 59) versus patients receiving redo bypass (n = 61) showed significantly better patency. Primary patency rates after 1, 3, and 5 years were 70%, 63% and 55% in the primary bypass group and respectively 50%, 41% and 31% in the redo bypass group. Secondary patency rates in the primary bypass group after 1, 3, and 5 years were 84%, 77%, and 72% respectively and 56%, 42%, and 38% in the redo group. Difference: primary patency (p = 0,026), secondary patency (p = 0,001). Limb salvage (p = 0,005) was also significantly better in primary bypass patients, whereas survival (p = 0,7) did not differ significantly. No independent risk factor could be identified for graft failure, limb salvage and survival in univariate analysis. Conclusion - The LSV is a valuable and versatile alternative vein graft in peripheral bypass surgery, especially for shorter grafts. Preoperative vein mapping is mandatory to rule out unsuitable veins before surgery and to avoid extensive dissection in the calf. The LSV vein should not be underestimated as a valuable option in bypass surgery as it has a high utilization rate, is relatively easy to harvest in regional anesthesia and achieves excellent long-term results in selected patients.