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Background: The availability and diversity of lower limb revascularization procedures have increased in England in the past decade. We investigated whether these developments in care have translated to improvements in patient pathways and outcomes. Methods: Individual-patient records from Hospital Episode Statistics were used to identify 103 934 patients who underwent endovascular (angioplasty) or surgical (endarterectomy, profundaplasty, or bypass) lower limb revascularization for infrainguinal peripheral artery disease in England between January 2006 and December 2015. Major lower limb amputations and deaths within 1 year after revascularization were ascertained from Hospital Episode Statistics and Office for National Statistics mortality records. Competing risks regression was used to estimate the cumulative incidence of major amputation and death, adjusted for patient age, sex, comorbidity score, indication for the intervention (intermittent claudication, severe limb ischemia without record of tissue loss, severe limb ischemia with a record of ulceration, severe limb ischemia with a record of gangrene/osteomyelitis), and comorbid diabetes mellitus. Results: The estimated 1-year risk of major amputation decreased from 5.7% (in 2006–2007) to 3.9% (in 2014–2015) following endovascular revascularization, and from 11.2% (2006–2007) to 6.6% (2014–2015) following surgical procedures. The risk of death after both types of revascularization also decreased. These trends were observed for all indication categories, with the largest reductions found in patients with severe limb ischemia with ulceration or gangrene. Overall, morbidity increased over the study period, and a larger proportion of patients was treated for the severe end of the peripheral artery disease spectrum using less invasive procedures. Conclusions: Our findings show that from 2006 to 2015, the overall survival increased and the risk of major lower limb amputation decreased following revascularization. These observations suggest that patient outcomes after lower limb revascularization have improved during a period of centralization and specialization of vascular services in the United Kingdom.

Background: Cardiovascular bypass grafting is an essential treatment for complex cases of atherosclerotic disease. Because the availability of autologous arterial and venous conduits is patient-limited, self-assembled cell-only grafts have been developed to serve as functional conduits with off-the-shelf availability. The unacceptably long production time required to generate these conduits, however, currently limits their clinical utility. Here, we introduce a novel technique to significantly accelerate the production process of self-assembled engineered vascular conduits. Methods: Human aortic smooth muscle cells and skin fibroblasts were used to construct bilevel cell sheets. Cell sheets were wrapped around a 22.5-gauge Angiocath needle to form tubular vessel constructs. A thin, flexible membrane of clinically approved biodegradable tissue glue (Dermabond Advanced) served as a temporary, external scaffold, allowing immediate perfusion and endothelialization of the vessel construct in a bioreactor. Subsequently, the matured vascular conduits were used as femoral artery interposition grafts in rats (n=20). Burst pressure, vasoreactivity, flow dynamics, perfusion, graft patency, and histological structure were assessed. Results: Compared with engineered vascular conduits formed without external stabilization, glue membrane–stabilized conduits reached maturity in the bioreactor in one-fifth the time. After only 2 weeks of perfusion, the matured conduits exhibited flow dynamics similar to that of control arteries, as well as physiological responses to vasoconstricting and vasodilating drugs. The matured conduits had burst pressures exceeding 500 mm Hg and had sufficient mechanical stability for surgical anastomoses. The patency rate of implanted conduits at 8 weeks was 100%, with flow rate and hind-limb perfusion similar to those of sham controls. Grafts explanted after 8 weeks showed a histological structure resembling that of typical arteries, including intima, media, adventitia, and internal and external elastic membrane layers. Conclusions: Our technique reduces the production time of self-assembled, cell sheet–derived engineered vascular conduits to 2 weeks, thereby permitting their use as bypass grafts within the clinical time window for elective cardiovascular surgery. Furthermore, our method uses only clinically approved materials and can be adapted to various cell sources, simplifying the path toward future clinical translation.

Background— Survivors of the Norwood procedure may experience neurodevelopmental impairment. Clinical trials to improve outcomes have focused primarily on methods of vital organ support during cardiopulmonary bypass. Methods and Results— In the Single Ventricle Reconstruction trial of the Norwood procedure with modified Blalock-Taussig shunt versus right-ventricle-to-pulmonary-artery shunt, 14-month neurodevelopmental outcome was assessed by use of the Psychomotor Development Index (PDI) and Mental Development Index (MDI) of the Bayley Scales of Infant Development-II. We used multivariable regression to identify risk factors for adverse outcome. Among 373 transplant-free survivors, 321 (86%) returned at age 14.3±1.1 (mean±SD) months. Mean PDI (74±19) and MDI (89±18) scores were lower than normative means (each P R 2 =26%) were clinical center ( P =0.003), birth weight P =0.023), longer Norwood hospitalization ( P P R 2 =34%) included center ( P P =0.04), genetic syndrome/anomalies ( P =0.04), lower maternal education ( P =0.04), longer mechanical ventilation after the Norwood procedure ( P P Conclusions— Neurodevelopmental impairment in Norwood survivors is more highly associated with innate patient factors and overall morbidity in the first year than with intraoperative management strategies. Improved outcomes are likely to require interventions that occur outside the operating room. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00115934.

Background— With recent advances in endovascular treatment, percutaneous endoluminal angioplasty has become particularly attractive for arterial lesions of Takayasu arteritis. However, data came from case reports or small series, and the long-term outcome has not been reported. The incidence of potential vascular complications after surgery or endovascular treatment is still to be determined. Methods and Results— This retrospective multicenter study analyzed the results and outcomes of 79 consecutive patients with Takayasu arteritis (median age, 39 years; interquartile range [IQR], 25–50 years; 63 women [79.7%]) who underwent 166 vascular procedures (surgery, 104 [62.7%]; endovascular repair, 62 [37.3%]) for the management of arterial complications. After a follow-up of 6.5 years (IQR, 2.2–11.5 years), 70 complications were observed, including restenosis (n=53), thrombosis (n=7), bleeding (n=6), and stroke (n=4). The overall 1-, 3-, 5-, and 10-year arterial complication–free survival rates were 78% (IQR, 69%–88%), 67% (IQR, 57%–78%), 56% (IQR, 46%–70%), and 45% (IQR, 34%–60%), respectively. Among the 104 surgical procedures, 39 (37.5%) presented a complication compared with 31 of the 62 (50%) with endovascular repair. In multivariate analysis, biological inflammation at the time of revascularization (odds ratio, 7.48; 95% confidence interval, 1.42–39.39; P =0.04) was independently associated with the occurrence of arterial complications after the vascular procedure. Patients who experienced complications had higher erythrocyte sedimentation rates ( P P P Conclusions— The overall 5-year arterial complication rate was 44%. Biological inflammation increased the likelihood of complications after revascularization in patients with Takayasu arteritis.

Background— Limited information exists on the intermediate-term graft patency and 5-year clinical outcomes of patients receiving saphenous vein grafts with multiple (m-SVG) versus single distal targets (s-SVG) during coronary artery bypass graft (CABG) surgery in the current era. Methods and Results— We studied the association of the use of m-SVG versus s-SVG conduits with 1-year SVG failure (defined as ≥75% angiographic stenosis) and 5-year clinical events (death; death or myocardial infarction [MI]; and death, MI, or revascularization) in 3014 patients undergoing their first CABG surgery enrolled in the Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV. Of 3014 patients enrolled in PREVENT IV, 1045 (34.7%) had ≥1 m-SVGs during CABG. Vein graft failure at 1-year was higher for m-SVG compared with s-SVG (adjusted odds ratio 1.24, 95% confidence interval 1.03 to 1.48). At 5 years, the adjusted composite of death, MI (including perioperative MI), or revascularization (hazard ratio 1.15, 95% confidence interval 1.00 to 1.31) and death or MI (hazard ratio 1.21, 95% confidence interval 1.03 to 1.43) were significantly higher in patients receiving m-SVGs. Conclusions— In patients undergoing first CABG surgery, the use of m-SVG was associated with a higher 1-year vein graft failure rate and trends toward worse clinical outcomes. Additional studies are needed to better understand the most appropriate conduit to improve long-term graft patency and clinical outcomes of patients undergoing CABG surgery. In the meantime, these data should encourage the use of s-SVG over m-SVG when feasible.

Describe the location and degree of the stenotic region (often focal)/length of coarctation segment.

A 51-year-old man with Marfan syndrome and multiple previous surgical interventions presented with an enlarging aortic root pseudoaneurysm. His past history was significant for type A aortic dissection at age 25 years, treated with composite root replacement with a Bjork-Shiley valved conduit. Revision of the left coronary button was performed 1 year later as a result of pseudoaneurysm formation. At age 48 years, he had documented ventricular tachycardia with an echocardiogram showing inferolateral hypokinesis. His cardiac enzymes were negative, and he received an implantable cardioverter defibrillator (ICD). Although asymptomatic, he was referred to the Marfan Clinic at our institution a few months later. Transthoracic echocardiography showed mobile density in the ascending aortic graft (Figure 1), and computed tomography (CT) angiography showed a large amount of intraluminal thrombus in the ascending aorta graft, as well as coronary button aneurysms (Figure 2). Magnetic resonance imaging of the head showed infarcts in multiple vascular distributions. The patient underwent redo aortic root replacement with a 25-mm CarboMedics composite graft that required a short segment of a saphenous vein interposition graft to the small left coronary button. A large amount of intraluminal thrombus within the ascending aorta was noted at the time of surgery (Figure 3), and histological evaluation of this thrombus revealed Ebstein-Barr virus (EBV)-associated diffuse large B-cell lymphoma (DLBCL). The neoplastic lymphocytes expressed CD20, MUM1, and BCL2 and in situ hybridization studies …

We present the case of a 39-year-old physically active male amateur hockey player with a history of preductal coarctation of the aorta repaired at the age of 10 years with an ascending-to-descending aortic conduit. He presented with neurological symptoms, which were present at rest but paradoxically resolved with physical exertion, including left upper extremity weakness, dizziness, visual changes, and facial tingling. A 2008 echocardiogram demonstrated a bicuspid aortic valve with moderate regurgitation and a mildly to moderately dilated and hypertrophied left ventricle with ejection fraction of 50%. A 2009 carotid Doppler ultrasound examination demonstrated high-velocity retrograde flow in the left vertebral artery, which reduced on exertion. Stenosis of the subclavian artery, and thus subclavian steal, which has been shown to cause neurological symptoms, was ruled out by a 2010 arteriogram.1 A recent magnetic resonance imaging (MRI) evaluation (in 2011) demonstrated worsening (moderate to severe) aortic insufficiency with a clearly visible asymmetrical diastolic flow jet (Figure 1, white arrows), mild decrease of left ventricular ejection fraction, and a patent aortic bypass conduit. Figure 1. Cardiac magnetic resonance angiography demonstrating aortic valve insufficiency and a clearly visible asymmetrical flow jet (white arrows, regions with signal void in the left ventricle). The individual images represent …

Background— We compared the outcomes in propensity score-matched high-risk patients (European System for Cardiac Operative Risk Evaluation [EuroSCORE] ≥5) undergoing off-pump coronary artery bypass graft surgery using bilateral or single skeletonized internal thoracic artery (ITA). Methods and Results— Of 794 consecutive patients undergoing isolated coronary artery bypass graft surgery (788 by the off-pump technique without emergent conversion to cardiopulmonary bypass), the 536 who had a EuroSCORE ≥5 and underwent off-pump skeletonized single (n=236) or bilateral (n=300) ITA were retrospectively analyzed after excluding the 6 who were transferred to our hospital after receiving percutaneous cardiopulmonary support, the 45 who had only 1 target in the left-side coronary area, and the 207 with EuroSCORE P =0.002) and 87.4±4.6% versus 66.1±5.7% ( P =0.001), respectively. In multivariate Cox proportional hazard models, bilateral ITA grafting was significantly associated with a lower risk of overall death (hazard ratio, 0.56; 95% CI, 0.32 to 0.87; P =0.009) and cardiac event (hazard ratio, 0.40; 95% CI, 0.24 to 0.69; P =0.001). Conclusions— In high-risk patients, off-pump skeletonized left-sided bilateral in situ ITA grafting is associated with lower risk of overall death and cardiac event than single ITA grafting without increased operative risk.

A 69-year-old man with a history of gastric ulcer and hypertension presented to the emergency department complaining of a sudden onset of epigastric pain and vomiting some coffee-ground fluid. The patient appeared to be in distress. His blood pressure was 82/64 mm Hg, and his heart rate was 79 bpm. On physical examination, his upper abdomen was tender with guarding, and we heard diffuse hypoactive bowel sounds. The chest radiograph was …