Externally Supported Extra-anatomical Venous Bypass to Treat Upper Limb Ischemia with Shoulder Prosthetic Infection (original) (raw)
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Bypass for chronic ischemia of the upper extremity: Results in 20 patients
Journal of Vascular Surgery, 2007
Objective: Chronic ischemia of the upper extremity requiring surgical revascularization is an uncommon condition. We analyzed modes of presentation, methods of operative repair, and follow-up in all consecutive patients with chronic ischemia of the upper extremity requiring arterial bypass. Methods: Data prospectively entered into a vascular registry was retrospectively analyzed for all patients undergoing upper extremity arterial bypass from January 1, 1990, to June 30, 2003. Simple thromboembolectomy procedures and bypasses to an outflow target more proximal than the brachial artery were excluded. Results: We identified 20 patients. Their mean age was 57 years, and 11 (55%) were women. Eight (40%) had diabetes, and five (25%) had renal insufficiency. Indications included exercise intolerance in 11 patients (55%), tissue loss in six (30%), and rest pain in three (15%). The etiology of ischemia was atherosclerosis in seven patients (35%) and complications of iatrogenic or civilian trauma in 13 (65%). The brachial artery was used as the inflow in 13 patients (65%), the axillary in six (30%), and the ulnar in one (5%). Conduits used included the great saphenous vein in 11 patients (55%), arm vein in 7 (35%), and prosthetic in 2 (10%). Outflow targets included the brachial artery in 12 patients (55%), the radial in five (25%), and the ulnar in three (15%). There were no perioperative deaths. One graft (5%) occluded <30 days of surgery. Mean follow-up was 12 months. Mean survival after bypass was 62 months. Patency at 1 and 3 years was 85%. Two patients had associated minor amputations (a finger and a partial hand). Limb salvage rate was 100%. Conclusion: Although upper extremity ischemia is rare, results for upper extremity bypass are excellent and superior to those reported for lower extremity ischemia. These results may reflect the indications, which differ considerably from those for lower extremity bypass, with the most being performed for complications of trauma. ( J Vasc Surg 2007;46: 303-7.)
Annals of Vascular Surgery, 2013
Objectives: Patients with critical limb ischemia (CLI) have a poor life expectancy, and aggressive revascularization is accepted as a means to maintain their independence in the end stage of life. The goal of this case-control study was to evaluate the clinical outcome of distal venous arterialization and compare this with pedal bypass surgery in patients with CLI, and to identify potential risk factors that could be used to effectively identify patients at high risk of graft occlusion and amputation. Methods: A retrospective cohort of patients was treated for CLI using venous arterialization or pedal bypass between 2007 and 2012. Kaplan-Meier and Cox regression analyses were used to evaluate predictors for limb salvage and patency. Results: In 40 patients with CLI, 21 venous arterializations and 19 pedal bypasses were performed. In the venous arterialization group, early occlusion was 15%, 1-year patency was 71%, and limb salvage was 53%. In the PB group, early occlusion was 23%, one-year patency was 75% and limb salvage was 47%. The only independent risk factor for limb salvage in multivariate analysis was bypass occlusion (P < 0.001). Conclusions: Limb salvage after venous arterialization was equal to limb salvage after pedal bypass surgery in this clinical comparative study.
Alternative Conduit for Infrageniculate Bypass in Patients With Critical Limb Ischemia
Journal of Vascular Surgery, 2015
Background: Autologous great saphenous vein (GSV) has always been considered the gold standard conduit for infrainguinal revascularization. When GSV is inadequate or unavailable, alternative conduits have been used. In this study, we compared modern outcomes of different conduit types used in lower extremity bypass (LEB) for patients with critical limb ischemia (CLI). Methods: The Vascular Study Group of New England database (2003-2014) was queried for patients who underwent infrageniculate bypass originating from the femoral arteries. Conduit types were categorized as single-segment GSV, alternative autologous conduit (AAC), and nonautologous conduit (NAC). Primary outcomes were 1-year freedom from major adverse limb event (MALE), MALE-free survival, and primary graft patency. Multivariable Cox regression was used to adjust for demographics and comorbidities. Results: LEB was performed in 2148 patients, of which 1125 were to below-knee popliteal (BK-Pop) and 1023 to infrapopliteal artery (IPA) targets. The baseline characteristics differed among the conduit groups: Patients in the GSV group were younger and had fewer comorbidities than in the AAC groups. Patients undergoing BK-Pop bypass with NAC had higher rates of postoperative myocardial infarction (7.1%) and postoperative (5.8%) and 1-year death (40.8%) than in those with GSV (3.1%, 2%, and 31.7%, respectively) and AAC (0%, 0%, and 25%, respectively). In multivariable analysis, conduit type did not make a difference in 1-year MALE, MALE-free survival, or primary graft patency for BK-Pop bypasses. For IPA bypasses, NAC use was associated with higher rates of postoperative (6.4%) and in-hospital death (4.5%) compared with GSV (2.5% and 1.4%, respectively) and AAC (2.9% and 1.9%, respectively). In adjusted analysis, NAC was associated with higher risk of MALE (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.03-2.20; P [ .036) and primary patency loss (HR, 1.3; 95% CI, 0.91-1.89), and lower MALE-free survival (HR, 1.47; 95% CI, 1.03-2.09; P [ .035) compared with GSV. There was no difference between the NAC and AAC groups. Conclusions: Conduit type does not affect outcomes in BK-Pop bypass. In the absence of single-segment GSV, the use of AAC for IPA bypass does not appear to confer any additional benefit of MALE, MALE-free survival, or graft patency compared with prosthetic grafts at 1-year follow-up.
Journal of Vascular Surgery, 2012
Objective: Endoscopic vein harvest (EVH) has been demonstrated to improve early morbidity when compared with conventional open vein harvest (OVH) technique for infrainguinal bypass surgery. However, recent literature suggests conflicting results regarding mid-and long-term patency with EVH. The purpose of this study is to compare graft patency between harvest techniques specifically in patients with critical limb ischemia. Methods: This retrospective study compared two groups of patients (EVH [ 39 and OVH [ 49) undergoing lower extremity revascularization from January 2009 to December 2011. Outcome measures included patency rates, postoperative complications, and wound infection. Graft patency was assessed using Kaplan-Meier curves. Results: Both groups were matched for demographics and indications for bypass (critical limb ischemia). Median follow-up was 22 months. There was a significant reduction in the incidence of wound infection at the vein harvest site in the EVH group (OVH [ 20%; EVH [ 0%; P < .001), nevertheless, the difference was not significant when only the anastomotic sites were included (OVH [ 12.2%; EVH [ 15.4%; P [ .43). The hospital length of stay was comparable between the two groups (EVH [ 8.73 6 9.69; OVH [ 6.35 6 3.28; P [ .26) with no significant difference in the recovery time. Primary graft patency rate was 43.2% in the EVH group and 69.4% in the OVH group (P [ .007) at 3 years. The most common reason for loss of primary patency was graft occlusion (61.5%) in the OVH group and vein graft stenosis (54.5%) in the EVH group. The average number of vascular reinterventions per bypass graft was significantly lower in the OVH group compared with the EVH group (OVH [ 0.37; EVH [ 1.28; P < .001). Conclusions: Our findings demonstrate inferior primary patency when using the technique of EVH. Additionally, we identified a significantly higher rate of reintervention in the EVH cohort as well as a higher rate of vein graft body stenosis. However, EVH was associated with a decreased rate of wound complications with similar limb salvage and secondary patency rates when compared to OVH. EVH should therefore be selectively utilized in patients at high risk for wound complications.
Surgical Practice, 2014
The aim of the present study was to evaluate current results of endovascular and open-bypass treatment of critical limb ischaemia subsequent to advancement in endovascular instruments and the development of endovascular technique in the past decade. Patients and Methods: A total of 160 patients with 167 limbs treated at a single centre between 2008 and 2012 were followed up for at least 2 years and reviewed retrospectively. Patients were stratified into an endovascular group and an open-bypass group based on first intervention received. The two groups demonstrated comparable demographics, clinical profile classified by Rutherford Classifications and lesion characteristics evaluated according to TransAtlantic Intersociety Consensus staging standards. One-year primary patency, 2-year primary patency, secondary patency, overall survival rate and amputation-free-survival rate were compared between the endovascular group and open-bypass group. Results: The endovascular group showed superior results to the bypass group in terms of 1-year amputation-free-survival (endovascular: 78.2 per cent, open bypass: 61.3 per cent, P = 0.023) and 2-yearamputation-free-survival (endovascular: 73.1 per cent, open bypass: 56 per cent, P = 0.027). No significant difference was found between the two groups in 1-year primary patency (endovascular: 80.3 per cent, open bypass: 67.8 per cent, P = 0.103), 2-year primary patency (endovascular: 80.3 per cent, open bypass: 64.8 per cent, P = 0.056), 1-year secondary patency (endovascular: 77.8 per cent, open bypass: 66.7 per cent, P = 0.577) and two-year secondary patency (endovascular: 77.8 per cent, open bypass: 58.3 per cent, P = 0.350). Comparable results were noted in the 1-year survival rate (endovascular: 91 per cent, open bypass: 81.3 per cent, P = 0.082) and 2-year survival rate (endovascular: 84.6 per cent, open bypass: 72 per cent, P = 0.058). Lower median blood loss (endovascular: 15 mL, open bypass: 100 mL) and shorter mean operative time (endovascular: 27.2 min, open bypass: 143.1 min) were demonstrated in the endovascular group. Conclusion: Endovascular intervention has demonstrated superior results to bypass surgery in critical limb ischaemia in terms of 1-year and 2-year amputation-free-survival, with potential benefits of lower intraoperative blood loss and a shorter operative time. Primary patency, secondary patency and overall survival in 2 years are currently comparable between the two intervention modalities.
Upper Extremity Limb Salvage Accomplished by In Situ Vein Bypass Graft
Annals of Vascular Surgery, 1988
The need for revascularization procedures in individuals with hand ischemia is uncommon. Previous reports describe the successful utilization of reversed saphenous vein to reconstruct the distal vasculature of the arm. This case report details the use of in situ arm vein to restore perfusion to a threatened hand.
Patterns In the Management of Acute Limb Ischemia: A VESS Survey
Annals of Vascular Surgery, 2016
Objectives: Treatment strategies for acute limb ischemia (ALI) are abundant with few established guidelines. We sought to determine nationwide ALI treatment patterns in the modern era. Methods: Anonymous electronic surveys examining the management of ALI involving native vessel and bypass occlusion were sent to all members of the Vascular and Endovascular Surgery Society (VESS) (N=738). Treatment options included catheter-directed (CDL) or phrmacomechanical (PMT) thrombolysis, and open surgery (OS). CDL management strategies were evaluated for lytic and heparin dosing, fibrinogen monitoring, and treatment duration. Influence of Rutherford category (RC), time from training, practice type, hospital size, region, and protocol use was assessed. Data were analyzed by univariate contingency tables, and multinomial regression analysis. Results: 117 (response rate of 16%) surveys were completed. The most common management strategy RC 2a ischemia in all conduit occlusions was endovascular (prosthetic graft, 96 (82%) respondents; vein graft 96 (82%) respondents; native artery occlusion 79 (68%) respondents), while those with RC 3 ischemia were more commonly treated with open techniques (prosthetic graft, 96 (83%); vein graft 94 (81%); native artery occlusion 94 (80%). Of those respondents using endovascular therapy, CDL was most commonly used in RC 2a patients while PMT was most commonly used in RC 3 patients. Multivariate analysis identified prosthetic and vein graft occlusion were more likely to be treated via endovascular approach (odds ratio 2.45 and 2.78 respectively, p < .001) while those with RC 2b (odds ratio 0.19, p <.001), RC 3 (odds ratio 0.01, p<.001) or in centers without a hybrid OR (odds ratio 0.49, p = .017) were more likely to be treated by open approach. TPA dosing during CDT was usually 1 mg/hr (77%) with variable
Diabetic Foot & Ankle, 2013
Background: Patients with critical lower limb ischemia without patent pedal arteries cannot be treated by the conventional arterial reconstruction. Venous arterialization has been suggested to improve limb salvage in this subgroup of patients but has not gained wide acceptance. We report our early experience after implementing deep and superficial venous arterialization of the lower limb. Materials and methods: Ten patients with critical ischemia and without crural or pedal arteries available for conventional bypass surgery or angioplasty were treated with distal venous arterialization. Inflow was from the most distal unobstructed segment. Runoff was the dorsal pedal venous arch (n 05), the dorsal pedal venous arch and a concomitant vein of the posterior tibial artery (n 03), or the dorsal pedal venous arch and a concomitant vein of the common plantar artery (n 02) depending on the location of the ischemic lesion. Venous valves were destroyed using antegrade valvulotomes, guide wires, knob needles, or retrograde valvulotomes via an extra incision. Results: Seven of the operated limbs were amputated after 23 (1Á256) days (median [range]). The main reasons for amputation were lack of healing of either the original wound, of incisional wounds on the foot, or persisting pain at rest. In three cases, the bypass was open at the time of amputation. Two patients experienced complete wound healing after 231 and 342 days, respectively. By the end of follow-up, the last patient was ambulating with slow wound healing but without pain 309 days after surgery. Conclusion: Venous arterialization may be used as a treatment of otherwise unsalveable limbs. The success rate is, however, limited. Technical optimization of the technique is warranted.