Vascular最新文献

Objective: To report a case series of three patients with symptomatic coronary-subclavian steal syndrome (CSSS) and to review the literature on published case series.

Methods: We retrospectively reviewed three cases of CSSS patients treated with open and endovascular surgery at a single center over a period of three decades (1996-2024). A comprehensive review of case series involving more than three patients was also performed.

Results: The first patient was a 65-year-old male with a 12-year history of coronary artery bypass grafting (CABG), presenting with unstable angina. Coronary angiography revealed a patent left internal mammary artery (LIMA) graft with retrograde flow through the left subclavian artery (LSA) and occlusion at the LSA ostium. He underwent a successful carotid-subclavian bypass, which significantly improved his symptoms. He died 6 years later from heart failure. The second patient was a 73-year-old woman with a 15-year history of CABG and balloon angioplasty of the grafts. She presented with dyspnea, stable angina, and progressive functional decline. Critical stenosis in the LSA was identified, and her symptoms resolved after successful stent placement. She died 6 years later from progressive heart failure. The third patient was a 75-year-old woman with diabetes, hypertension, and heart failure, who also had a history of CABG. She presented with worsening dyspnea, orthopnea, and edema. Imaging revealed occlusion of the circumflex artery graft and severe LSA stenosis. Successful stenting of the LSA alleviated her symptoms and restored normal blood flow from the LIMA graft. She was discharged after 2 days and remains well at the six-month follow-up.

Conclusion: CSSS should be considered in the differential diagnosis of patients with a history of CABG who present with angina or heart failure. Prompt treatment can lead to significant symptom improvement.

Objectives: Basilic vein transposition (BVT) surgery is a crucial option for vascular access in hemodialysis patients when other alternatives are unavailable. One of the primary complications affecting the long-term function of arteriovenous fistulas (AVFs) is the development of pseudoaneurysms, often caused by repeated punctures at the same site. This study aims to evaluate whether increasing the length of the basilic vein available for cannulation during the second stage of BVT surgery reduces the risk of puncture-related pseudoaneurysms, thereby improving fistula longevity and functionality.

Methods: We selected 39 hemodialysis patients unsuitable for cephalic vein AVF creation or who had failed brachiocephalic fistulas. Eligibility criteria included a basilic vein diameter of more than 2.5 mm with appropriate venous anatomy confirmed via ultrasound. In the first stage of surgery, the median basilic vein was anastomosed to the superior surface of the brachial artery. One month later, once the vein had matured (diameter ≥4 mm), a second stage was performed, which involved liberating an extended segment of the basilic vein down to the forearm. The basilic vein was then anastomosed end-to-end with the median basilic vein to increase the cannulation area. Patients were followed for 1 year to evaluate outcomes.

Results and conclusions: All 39 patients successfully underwent the modified BVT technique. Over the 1-year follow-up period, none experienced significant AVF complications, particularly pseudoaneurysm formation. By increasing the usable length of the basilic vein for cannulation, multiple puncture sites were available, reducing the risk of repeated needle insertions at the same site. The modified BVT technique shows promise in reducing the risk of pseudoaneurysm formation and improving AVF patency, potentially enhancing the longevity and functionality of AVFs in hemodialysis patients. Further studies are necessary to confirm the efficacy of this technique in larger patient populations.

Background: Endovascular procedures requiring large bore access, such as Transcatheter Aortic Valve Replacement (TAVR), Thoracic Endovascular Aortic Repair (TEVAR), and Endovascular Aneurysm Repair (EVAR), have become increasingly common. Despite advancements, complications from these procedures pose clinical challenges, especially in elderly and frail patients. The clinical objective of this paper is to demonstrate the complexities and innovative management strategies for complications that arise from large bore access.

Case report: This report presents two cases illustrating percutaneous management of complications arising from large bore access during endovascular interventions. The first case involves a 74-year-old Asian female with a history of type A aortic dissection, who underwent TEVAR using a Gore TBE endograft. Post-procedure, the patient developed hemorrhagic shock due to disruption of the right external iliac artery. Interventions included upsizing the left femoral artery sheath, CODA balloon inflation in the distal aorta, and deployment of multiple VBX stents. The second case features a 24-year-old Caucasian female with a large pseudoaneurysm at the cannulation site in the aortic arch following a heart transplant. Successful TEVAR was performed to exclude the pseudoaneurysm. Closure of the right femoral artery access using 6 French ProGlide sutures was complicated, requiring balloon angioplasty to create an opening in the common femoral artery.

Conclusions: These cases highlight the challenges and innovative strategies in managing complications associated with large bore access during endovascular procedures. Insights gained from these experiences contribute to the armamentarium of interventionists, offering valuable guidance in addressing similar scenarios.

Backgrounds: Infra-inguinal bypass (IIB) surgery is a time-proven and reliable management avenue for the treatment of peripheral arterial disease (PAD). The importance of ultrasound surveillance in maintaining IIB graft patency is well-recognised, yet adherence rates are underreported. This study evaluates the impact of surveillance compliance on graft outcomes in an Australian setting.

Methods: A cross-sectional analysis of IIBs performed between 2010 and 2020 at a major vascular surgical institution in Australia was conducted retrospectively. Demographic data, peri-operative comorbidities and configuration of the bypass were captured as well as post-discharge results. Surveillance compliance was assessed based on adherence to post-operative ultrasound and clinic visits. The chief outcome measure was graft occlusion within 2 years. Secondary outcomes were major amputation, mortality and ambulatory function.

Results: Over a time period of 10 years, 239 bypasses were carried out on 207 individuals. 83% complied with surveillance protocols. Adherence rates were lower in regional patients. Non-compliance was significantly associated with vein graft occlusions (p < 0.01) but not with synthetic grafts. Regional referrals (p < 0.01), low pre-operative haemoglobin (p < 0.01), post-operative transfusion (p = 0.02) and use of prosthetic conduit (p < 0.01) were identified as significant predictors of graft thrombosis. Patients with occluded grafts were at substantially higher risk of ambulatory deterioration (2.4 fold), major limb amputation or death (8.6 fold) within 12 months. One-year survival without amputation was 88.3%.

Conclusion: Enhanced bypass graft surveillance is essential in clinical practice to minimise graft occlusion, reduction in morbidity, limb loss and death. This study reveals suboptimal compliance in Australian vascular surgical setting, particularly in regional areas, underscoring the need for improved education, resource allocation and infrastructural development.

Objectives: Endovascular therapy (EVT) for calcified nodules in patients with peripheral artery disease (PAD) remains challenging in achieving favorable outcomes. This study aims to investigate the effectiveness of orbital atherectomy (OA) for calcified nodules using an IM catheter to precisely control the device and achieve optimal engagement with the target lesion.

Methods: We performed EVT for a calcified nodule in the right common femoral artery using an OA. Due to the large vessel size, controlling the OA to effectively engage the lesion was challenging. To overcome this, we utilized an IM catheter to guide the OA toward the target lesion.

Results: The use of the IM catheter successfully directed the OA to the calcified lesion, resulting in significant lumen enlargement. The procedure was completed without any complications, and the OA achieved effective debulking of the calcified nodule.

Conclusions: The combination of OA and IM catheter facilitated effective contact with the target lesion, improving the performance of the debulking device. This approach may enhance the management of calcified lesions in large-diameter arteries during EVT, potentially leading to better clinical outcomes.

Objectives: Peripheral arterial disease (PAD) and coronary artery disease (CAD) are major contributors to global morbidity and mortality. Many PAD patients remain asymptomatic for CAD, which often leads to undetected coronary artery involvement. This hidden coronary disease poses significant risks, particularly following peripheral revascularization, as increased cardiac demand can precipitate complications.

Methods: This cross-sectional descriptive study assessed the prevalence of coronary artery stenosis in patients with Fontaine Stage IV peripheral arterial disease. Simultaneous angiography of both the coronary and lower extremity arteries was performed, and the severity of arterial stenosis was rigorously evaluated. The correlation between the extent of peripheral and coronary artery disease was analyzed.

Results: A total of 60 patients (63.3% male, 36.7% female; mean age 65.23 ± 9.86 years) were included. Comorbidities were common, with 90% having diabetes, 50% hypertension, 23.3% hyperlipidemia, and 30% smoking history. Severe peripheral artery stenosis was frequently observed, particularly in the posterior tibial artery (total occlusion in 26.6% and 20% of the right and left arteries, respectively). Significant coronary involvement was also prevalent, with 51.7% exhibiting three-vessel disease. Coronary revascularization was required in the majority of cases (CABG: 40%, PCI: 35%), with a higher proportion among women (77.2%) and men (73.7%).

Conclusion: This study highlights the necessity of comprehensive coronary evaluation in patients with advanced lower limb ischemia. A substantial proportion of these patients have silent but critical coronary disease, which, if left unaddressed, could result in serious post-revascularization complications.

Objectives: Ruptured mycotic pseudoaneurysms are rare, yet devastating complications that can prove challenging to manage. In immunocompromised populations, highly virulent organisms such as Gemella morbillorum can be especially difficult to combat. Here, we outline our approach to temporizing maneuvers in an emergent setting and definitive revascularization in a 27-year-old with a ruptured mycotic iliac artery pseudoaneurysm from necrosis of her kidney and pancreas allografts.

Methods: The initial staged repair involved covered stenting of the right iliac artery for hemorrhagic control of a ruptured pancreatic allograft arterial anastomosis, explant of ipsilaterally placed renal and pancreas allografts from the right pelvis, and iliac artery reconstruction using left femoral vein. Subsequent abscess formation leading to anastomotic blowout required repeat covered stenting followed by a femoral-femoral arterial bypass with right femoral vein.

Results: The patient was discharged home with no further vascular events and preserved lower extremity perfusion. They returned to the clinic 1 month following discharge in stable condition with no wound healing or ischemic complications.

Conclusions: The choice of femoral vein as conduit for in-line arterial repair can provide both better long-term patency and resistance to infection than prosthetic bypass material.

Background: Superior vena cava syndrome (SVCs) is a common complication in hemodialysis patients due to central vein occlusions, often caused by prior catheterizations. Management can be challenging.

Objective: To describe a successful endovascular approach to managing SVCs caused by right innominate vein (RIV) occlusion in a hemodialysis patient with a non-functional LeVeen shunt.

Method: An 80-year-old dialysis patient with upper limb edema and vascular access dysfunction was diagnosed with complete RIV occlusion around a long-standing LeVeen shunt. Recanalization was achieved via a percutaneous approach, including angioplasty and placement of a balloon-expandable covered stent, leaving the LeVeen shunt in situ to reduce risks.

Results: The procedure restored venous patency and improved vascular access functionality. Postoperative imaging confirmed excellent stent positioning and reduced venous congestion. At a 6-month follow-up, central vein patency was maintained.

Conclusion: Endovascular recanalization is a safe and effective strategy for managing SVCs, even with a retained central venous device. This approach preserved vascular access and ensured successful long-term dialysis, offering insights for treating complex venous occlusions.

Objective: To compare the efficacy of compression stockings worn for 7 days or overnight after EVRFA.

Methods: A single-centre, prospective, non-inferiority randomised controlled trial. The study included patients with clinical class C2-C4 chronic venous disease who underwent endovenous radiofrequency ablation (EVRFA) at Chulabhorn Hospital between October 2021 and October 2023. Sixty patients were assigned to wear the overnight compression group (n = 30) or for the 7-day compression group (n = 30). The primary outcome was targeted vein obliteration at 12 weeks. The secondary outcome measures were the revised Venous Clinical Severity Score (r-VCSS), Aberdeen Varicose Veins Severity Score (AVSS), pain score, complications and patient satisfaction.

Results: At 12 weeks, both groups had a 100% target vein occlusion rate. There was no statistically significant difference in the r-VCSS, AVSS, patient satisfaction score, complications or pain score at day 1, day 14 and 12-16 weeks after the procedure. Overnight compression improved r-VCSS significantly.

Conclusion: Overnight compression was non-inferior to compression for 7 days after EVRFA.

Objectives: Post-reperfusion compartment syndrome is an emergency consequence following revascularization of acute limb ischemia. Fasciotomy is the gold standard treatment for acute compartment syndrome. Some surgeons perform prophylactic fasciotomy (PF) during the same operation; however, fasciotomy may lead to wound complications and an increased length of hospital stay. This study aims to evaluate the outcomes of prophylactic fasciotomy in our hospital.

Methods: This is a retrospective observational cohort study. We reviewed the data of acute limb ischemia patients at Maharaj Nakorn Chiangmai Hospital, who were diagnosed with non-traumatic acute limb ischemia and received revascularization between January 2006 and August 2022. The primary outcomes are 30-day amputation-free survival (AFS) and overall survival (OS). Propensity score weighting with confounder adjustment was used to balance peri-operative confounders.

Results: From our data, there were 56 patients in the PF group and 301 in the non-prophylactic fasciotomy (NPF) group. The 30-day amputation rates were 12.5% and 10% in the PF and NPF groups, respectively (p-value 0.895). The 30-day AFS was similar between the PF and NPF groups, with a hazard ratio (HR) of 0.93, 95% confidence interval (CI) 0.32-2.45, and a p-value of 0.882. The 30-day OS in the PF group was statistically lower than that in the NPF group, HR 4.09, 95% CI 1.55-10.77, and a p-value of 0.004. The 1-year and 5-year AFS were not significantly different between the PF and NPF groups. However, the 1-year and 5-year OS were lower in the PF group compared to the NPF group, with HR 3.44, 95% CI 1.37-8.65, and a p-value of 0.009, and HR 3.04, 95% CI 1.24-7.45, and a p-value of 0.015, respectively. Fasciotomy wound infection rates were higher in the PF group compared to the NPF group, 5.5% versus 1.7%, respectively, p-value 0.017. Other clinical outcomes did not show significant statistical differences.

Conclusions: Prophylactic fasciotomy may not improve amputation-free survival (AFS) but increases mortality, particularly within the first 30 days, even in some high-risk patients. The use of prophylactic fasciotomy should be limited to cases where it is clearly indicated.