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The left retroperitoneal approach to the aorta is a well-established technique for aortic exposure. The right retroperitoneal approach to the aorta is performed less commonly, and the outcomes remain unknown. This study aimed to evaluate the outcomes of right retroperitoneal aortic-based procedures and to determine its utility in aortic reconstruction when faced with hostile anatomy or infection in the abdomen or left flank. A retrospective query of a vascular surgery database from a tertiary referral center was performed for all retroperitoneal aortic procedures. Individual patient charts were reviewed, and data were collected. Demographics, indications, intraoperative details, and outcomes were tabulated. From 1984 through 2020, there have been 7454 open aortic procedures; 6076 were retroperitoneal-based, and 219 of which were performed from the right retroperitoneal approach (Rrp). Aneurysmal disease was the most common indication (48.9%), and graft occlusion was the most common postoperative complication (11.4%). The average aneurysm size was 5.5 cm, and the most common reconstruction was with a bifurcated graft (77.6%). Average intraoperative blood loss was 923.8 mL (range, 50-6800 mL; median, 600 mL). Perioperative complications occurred in 56 patients (25.6%) for a total of 70 complications. Perioperative mortality occurred in two patients (0.91%). The 219 patients treated with Rrp required 66 subsequent procedures in 31 patients. These included 29 extra-anatomic bypasses, 19 thrombectomies/embolectomies, 10 bypass revisions, 5 infected graft excisions, and 3 aneurysm revisions. Eight Rrp eventually underwent a left retroperitoneal approach for aortic reconstruction. Fourteen patients with a left-sided aortic procedure required a Rrp. The right retroperitoneal approach to the aorta is a useful technique in the setting of prior surgery, anatomic abnormality, or infection that complicates the use of other more frequently employed approaches. This review demonstrates comparable outcomes and the technical feasibility of this approach. The right retroperitoneal approach to aortic surgery should be considered a viable alternative to left retroperitoneal and transperitoneal access in patients with complex anatomy or prohibitive pathology for more traditional exposure. [ABSTRACT FROM AUTHOR]

Background: Optimal treatment of significant atherosclerosis of the common carotid artery (CCA) is not well-defined. The purpose of this study was to evaluate the long-term results of prosthetic subclavian to carotid bypass for occlusive disease of the CCA.Material and Methods: From January 1994 to December 2015, 45 patients, mean age 67 years, underwent an ipsilateral subclavian to carotid bypass for occlusive disease of the CCA. Thirty-eight patients (84%) presented with neurologic symptoms, including transitory ischemic attacks in 29 cases and minor strokes in 9 cases. The graft material consisted of a 7 mm polytetrafluoroethylene conduit, and the distal anastomosis was done on the carotid bulb in 21 patients, on the internal carotid artery in 19 cases, and on the distal CCA in 5 cases. Median length of follow-up was 58 months. Study endpoints were the combined postoperative stroke/mortality rate, graft infection, overall late survival, freedom from ipsilateral stroke, and graft patency.Results: Postoperative stroke/mortality rate was 2%. No graft infection was observed throughout follow-up. At 60 months, overall survival, freedom from stroke, and graft patency were 71% (standard error [SE] = 0.07), 98% (SE = 0.02), and 95.5% (SE = 0.06), respectively.Conclusions: Subclavian to carotid bypass allows very good patency rates and excellent protection from postoperative and late stroke, remaining a benchmark for any other treatment method. [ABSTRACT FROM AUTHOR]

Objective/Background The objective was to evaluate the feasibility and mid-term outcomes of endoconduits (EC) with the “pave and crack” technique during endovascular aneurysm repair (EVAR) of varying complexity. Methods This was a retrospective study. All patients undergoing EC between July 2009 and October 2015 were included. The primary endpoint was technical success of the EC defined as the ability to successfully deliver the aortic stent graft through the EC without rupture, dissection, or thrombosis of the iliac or femoral arteries, and with the absence of haemodynamically significant blood loss related to the EC. Secondary outcomes included EC patency and mortality. Results Nineteen patients underwent EVAR with EC (16 juxtarenal or thoraco-abdominal, two infrarenal and one thoracic; four were ruptured). Fourteen patients (73.7%) had TASC D lesions. In 10 cases (52.6%) adjunctive open/endovascular procedures to improve the femoral outflow were required. EC was technically successful in all cases and all EC were patent at EVAR completion. Thirty day mortality occurred in two cases (10.5%) One of these patients had been treated for rupture. One patient required two endovascular re-interventions at 1 and 5 years post-operatively to restore patency of the EC. No open re-interventions related to the EC were necessary. After a median follow-up period of 17 (interquartile range 5–37) months, the primary assisted patency of the EC was 88.9% (SE 10.5). No new onset of claudication or lower limb amputations occurred during the follow-up. Conclusion EC allows EVAR of varying complexity without the need for open surgical ilio-femoral conduits in patients with concomitant advanced iliac occlusive disease. Intra-operative haemodynamic instability was always avoided and mid-term patency was high. [ABSTRACT FROM AUTHOR]

Objective/Background Takayasu's arteritis (TA) is rare inflammatory large vessel form of vasculitis. The objective of this study was to evaluate experience in the management of TA patients and to identify the influence of inflammatory markers and clinical variables associated with disease progression, worsening ischaemic symptoms, and the need for interventions. Methods Demographics, and laboratory and clinical variables in patients that required revascularisation procedures were compared with those who had adequate symptomatic control with medical management. Categorical data were analysed with Fisher's exact test, continuous variables with two-sample t test, and a life table analysis was used to study the recurrence of symptoms in intervened patients. Results From January 1995 to May 2016, 47 patients (mean age 30 years; range 14–59 years) were managed; 44 (94%) were female. During the mean follow-up period of 120 months, 21 (45%) underwent 23 procedures (17 of these [74%] open, six [26%] endovascular). From the intervened group, eight (38%) patients presented with transient ischaemic attacks, five (24%) with renovascular hypertension, and four (19%) with upper extremity and four (19%) lower extremity claudication. Comparative analysis demonstrated that elevation of erythrocyte sedimentation rate (ESR) at the time of the diagnosis (revascularisation group: median value 28 mm/hour; medical management group: median value 15 mm/hour) was associated with progression of the disease, worsening symptoms, and subsequent need for intervention ( p = .04). Active smoking was a factor connected with the need for revascularisation ( p = .05). Immediate symptomatic improvement occurred in 19 (90%) patients that underwent surgical or endovascular revascularisation. Conclusion Patients with TA who underwent interventions had higher ESR at the time of diagnosis; this factor and active smoking were associated with progression of the disease and worsening ischaemic symptoms despite medical therapy. Revascularisation procedures are effective at relieving symptoms; lifelong surveillance is necessary. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate superficial femoral artery (SFA) occlusive disease treatment by means of covered stents. Study design: retrospective. Method: From 2000 to 2005, a Hemobahn/Viabahn® endoprosthesis was implanted in 102 limbs (95 patients; mean age: 72.1 years, 52–94) for intermittent claudication (group I, n =50 limbs), critical (group II, n =32) or acute ischemia (group III, n =20). Lesions treated were Trans-Atlantic Inter-Society Consensus (TASC) A (n =9) B (n =42), C (n =28) or D (n =23), associated with a good (2 or 3 leg arteries, n =60) or a poor (1 or 0 artery, n =42) runoff. Results: The endograft was placed successfully in all cases, but 3 early deaths (3.2%) (1 in group II and 2 in group III), and 4 acute thromboses (4%) occurred. Primary and secondary actuarial patency rates were 97±1.7%, and 99±1% at 1 month, 74±4.8% & 84±4.1% at 1 year,and 71±9.5% & 79±8.5% at 3 years, after a mean follow-up of 30.2 months (1–60). Long-term primary and secondary patencies were significantly different between TASC Cand TASC D lesions (P < .004 & .001). Conclusion: Severity of lesions, rather than preoperative symptoms or runoff, is mainly to be considered before using Hemobahn/Viabahn ® endoprosthesis in severe SFA occlusive lesions. [Copyright &y& Elsevier]

Objectives: To determine the outcome of surgical intervention in patients with HIV associated vascular disease. Design: Prospective clinical survey. Materials and methods: Routine voluntary testing for HIV/AIDS was performed in patients who presented to our unit with peripheral vascular disease. One hundred and nine patients (5.7%) were prospectively identified over a 5-year period (2001–2006). Results: 24 patients presented with aneurysmal disease whilst occlusive disease was present in 66 patients. There was not much difference between patients with aneurysmal disease and patients with occlusive disease as to age, CD4 count and other risk factors for vascular disease. The peri-operative mortality for aneurysmal disease was 10.6% versus 3.6% for occlusive disease (p =0.264). Long-term mortality was significantly worse (p =0.049) for patients with aneurysmal disease. The results of revascularization in occlusive disease were poor with a limb salvage rate of 31.6%. There was no significant difference in CD4 T-cell counts between primary amputation and revascularization groups (p =0.058). Conclusion: Patients with aneurysmal disease have a high peri-operative and long-term mortality and it appears that surgical intervention should be reserved for life-threatening aneurysms only. Patients with occlusive disease have a better survival rate but limb salvage is poor. Primary amputation may be preferable to bypass surgery in patients with critical limb ischaemia. [Copyright &y& Elsevier]

Abstract: Objective: To examine the safety and efficacy of endovascular management of isolated infrarenal aortic occlusive disease within our centre. Design and methods: Retrospective analysis of all patients who underwent endovascular treatment of occlusive disease that is confined to the infrarenal aorta between September 1993 and November 2004. Results: Primary aortic stenting was carried out in 16 women and five men using self-expanding (12 patients) and balloon expanding stents to treat both occlusions (six) and stenoses (15). Indications included intermittent claudication (13), critical limb ischaemia (six), and distal embolisation (three). Significant postoperative complications within 30 days were noted in three, including one death. Fifteen patients completed 1-year follow-up with primary patency in 14 and secondary patency in the remaining patient. Clinical improvement was documented in all patients. Conclusion: Primary stenting for occlusive disease isolated in the infrarenal aorta is relatively safe in selected patients with encouraging early follow-up results. [Copyright &y& Elsevier]

Abstract: Purpose: To assess the results of covered stents in the treatment of superficial femoral artery (SFA) occlusive disease. Method: From July 2000 till June 2003, 32 patients (34 limbs) were scheduled for procedures including Hemobahn® deployment in the SFA. Indication for treatment was claudication (group I, N=15 patients and 16 limbs, 31.2% occlusions) or critical and acute ischemia (group II, N=17 patients and 18 limbs, 61.1% occlusions). TASC D SFA lesions were excluded. No limb artery was patent pre-operatively in 19% and 89% of limbs in groups I and II, respectively (p=0.00001). Results: Outflow procedures were performed simultaneously in one limb in group I and 12 in group II (p=0.0003). The technical, hemodynamic and clinical success rates were 100, 100 and 94.1%, respectively. Mean follow-up was 18.1 months. Primary patency rates at 12 months were 81.3±10.6% in group I and 88.6±9.0% in group II (p=0.547). At 12 months, the secondary patency and limb salvage rates were, respectively, 87.5±8.9 and 100% in group I and 87.5±8.93 and 94.45±6.71% in group II. Conclusion: Treatment of SFA occlusive lesions (excluding TASC D lesions) with the Hemobahn® covered stent yielded good results for both claudicants with good outflow and patients with critical or acute ischemia with bad outflow, if concomitant outflow-improving procedures were performed. [Copyright &y& Elsevier]

Despite the continuing controversy of covered stents (CS) vs bare metal stents, the use of CS in mesenteric occlusive disease (MOD) has been recommended by expert centers. The aim of this study was to report midterm results with CS of the superior mesenteric artery. Between January 2014 and October 2019, patients with MOD with a severe atheromatous stenosis or occlusion of the superior mesenteric artery treated by mesenteric CS were included. Clinical presentation included both acute mesenteric ischemia (AMI), chronic mesenteric ischemia, and asymptomatic patients planned for major surgery. Demographics, procedure details, and follow-up data were prospectively collected and retrospectively reviewed. Study end points included primary patency, primary assisted patency, and secondary patency. During the study period, 86 patients (mean age, 70 ± 9 years; 57% males) were included. Clinical presentation was AMI (n = 42 [49%]), chronic mesenteric ischemia (n = 31 [36%]), and asymptomatic (n = 13 [15%]). The technical success rate was 97%. A total of 96 stents were implanted, including 86 proximal CS (Advanta V12, n = 73; Lifestream, n = 13). The mean length and mean diameter of the CS were 31.5 ± 6.3 mm and 6.9 ± 0.5 mm, respectively. Additional distal bare metal stents were used in 10 patients (12%) to overcome a kinking (n = 9) or a dissection (n = 1) downstream of the CS. All postoperative deaths occurred in patients with AMI (n = 11, 13%). During a median follow-up of 15.6 months (95% confidence interval [CI], 15.6 ± 3.6 months), 12 patients (14%) underwent reinterventions for either stent misplacement (n = 3), stent recoil (n = 3), stent thrombosis (n = 2), de novo stenosis at the distal edge of the CS (n = 2), or gastric ischemia (n = 1). At 1 year, overall the primary patency, primary assisted patency, and secondary patency rates were 83% (95% CI, 83% ± 9%), 99% (95% CI, 99% ± 3%), and 99% (95% CI, 99% ± 3%), respectively. At 2 years, the overall primary patency, primary assisted patency, and secondary patency rates were 76% (95% CI, 76% ± 13%), 95% (95% CI, 95% ± 8%) and 95% (95% CI, 95% ± 8%), respectively. Mesenteric CS provide very satisfactory midterm results in patients with MOD, with an excellent primary assisted patency rate at 2 years, at the price of a significant reintervention rate. [ABSTRACT FROM AUTHOR]

Severe aortoiliac occlusive disease is a relative contraindication for endovascular aneurysm repair, owing to an association with high stent graft-related complication and reintervention rates in this population. Open AAA repair requiring aortofemoral bypass (AFB), however, may represent a unique population with differing outcomes from standard open repair. We sought to compare the demographic and procedural characteristics, as well as outcomes of patients undergoing standard intra-abdominal repairs (STD) versus those requiring AFB. Using a prospectively maintained database, we retrospectively identified patients who underwent open AAA repair from 1994 to 2017. A total of 1087 consecutive cases were performed consisting of 981 STD (681 tube graft, 300 aortoiliac) and 106 AFB cases. Demographics, procedural data, postoperative complications, and long-term survival were analyzed. The AFB cohort had more women (39.0 vs 22.8%; P =.001) and higher rates of hypertension (81.1 vs 69.8%; P =.015), chronic obstructive pulmonary disease (28.3 vs 17.4%; P =.006), and smoking (50.9 vs 36%; P =.002). The AFB group had smaller mean aortic (5.22 vs 5.77 cm; P =.001) and graft (17.08 vs 18.2 mm; P =.001) diameters. Proximal clamp position and blood loss were equivalent, although total anesthesia time was longer (295 vs 234 minutes; P =.001) in the AFB cohort. Overall 30-day postoperative morbidity (38.7 vs 24.8%; P =.002) was higher in the AFB group. Specifically, postoperative renal insufficiency (8.2 vs 3.4%; P =.032), wound infection (5.7 vs 1.2%; P =.005), and hematoma/seroma (5.7 vs 1.2%; P =.003) were more likely. Hospital length of stay was longer for AFB (11.9 vs 9.9 days; P =.007). The 30-day mortality (0.9% AFB vs 1.8% STD; P =.50) and major morbidity (17 vs 11.5%; P =.10) did not differ. Reintervention rate within 30 days of the initial surgery (12.3 vs 4.6; P =.001) and overall (33 vs 18.9%; P =.001) was higher in the AFB group. Long-term survival was lower in the AFB group (5-year survival: 63.1% AFB vs 71.9% STD; hazard ratio 0.76, log-rank P =.047). Multivariate regression analysis identified age, comorbid conditions, and aneurysm characteristics—rather than repair type—as independent predictors of 30-day reintervention and mortality at 5 years. Patients requiring AFB for AAA owing to associated iliac occlusive disease have more preoperative comorbidities, postoperative complications, a longer length of stay, reintervention rates and shorter 5-year survival. Patient and aneurysm characteristics rather than surgical repair type appear to be responsible for these differences. Nevertheless, 30-day mortality and major morbidity were comparable, making AFB an attractive alternative to endovascular aneurysm repair in patients with advanced iliac occlusive disease. [ABSTRACT FROM AUTHOR]