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Background Percutaneous transluminal angioplasty and stenting in acute stroke due to severe basilar artery stenosis or basilar artery occlusion remain a matter of debate. The higher risk of stroke recurrence in patients with vertebrobasilar stenosis compared to anterior circulation atherosclerotic disease creates high expectations concerning endovascular approaches. This study aims to review our experience with percutaneous transluminal angioplasty and stenting in acute stroke caused by basilar artery steno-occlusive disease. Methods Our prospective database from June 2014 until December 2020 was screened and patients with acutely symptomatic severe (>80%) basilar artery stenosis or acute basilar artery occlusion who underwent percutaneous transluminal angioplasty and stenting were analysed. Results Twenty-five patients included: 72% men (mean age 68.6 years), all with prior modified Rankin Scale Conclusions Percutaneous transluminal angioplasty and stenting showed to be a technically feasible and reasonably safe procedure in selected patients. However, good clinical outcomes may be difficult to achieve as only 43.5% of the patients remained independent at 3 months. Randomized studies are needed to confirm the efficacy and safety outcomes of percutaneous transluminal angioplasty and stenting in acute stroke caused by basilar artery steno-occlusive disease.

To study the long-term outcomes in patients with occlusive Iliofemoral chronic venous insufficiency (CVI) of benign etiology treated by dedicated venous stents (Zilver Vena stents; Cook, Bloomington, Ind) placed at a single center.We performed retrospective analysis of prospectively collected data from 58 patients with symptomatic benign lower limb CVI during the period from January 2013 to October 2020. Patients underwent recanalization using Zilver Vena stents at Ain Shams University hospitals. We excluded patients requiring stenting after intervention for acute deep venous thrombosis, CVI due to malignancy or vascular malformations, previous ipsilateral venous interventions, or CVI due to nonobstructive pathology (reflux). Patients were clinically classified at enrollment by the clinical, etiology, anatomy, pathology class, venous disability score, and Villalta score. Primary, assisted primary, and secondary stent patency were assessed. Patients were followed clinically and by duplex, at 1, 3, 6, 12 months and annually for 5 years.There were 31 males and 27 females, with ages ranging between 25 and 60 years (mean, 43.84 years). All patients had post-thrombotic syndrome with a mean Villalta score of 16.8 (range, 10-31). Patients were treated with dedicated venous stents and had a median follow-up of 60 months. The median venous disability score was 3 at the start of the study with a significant decrease to 1 at 5-year follow-up (P .001). Twelve-month primary patency, assisted primary patency, and secondary patency were 91.4%, 96.6%, and 98.3%, respectively. At the 5-year follow-up, primary patency was 60.3%, assisted primary patency 65.5%, and secondary patency 81%. There were no instances of stent fracture, migration, or structural deformities.Treating iliofemoral venous occlusive disease with a dedicated venous stent is an excellent choice for patients with occlusive post-thrombotic syndrome. The technique has good 1-year and 5-year patency and is associated with significant clinical improvement and few complications.

The field of vascular surgery is constantly evolving and is unsurpassed in its innovation and adoption of new technologies. Endovascular therapy has fundamentally changed the treatment paradigms for aneurysm and occlusive disease. As we continue to make advances in not only endovascular therapy, but also robotic surgery, artificial intelligence, and minimally invasive surgery, it is important that the vascular community stay at the forefront. Topics include the advantages of laparoscopic and robotic surgery over open surgery for aortic procedures, robotic versus laparoscopic aortic surgery, patient candidacy for robotic-assisted aortic surgery, and how to increase training and adoption of robotic-assisted laparoscopic aortic surgery. Future growth includes the development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics in vascular surgery.

Purpose: We describe the feasibility and early results of iliac stenting using a physician-modified endograft (PMEG) to preserve a transplant renal artery in patient with iliac occlusive disease. Case Report: A 70-year-old male patient, with sub-occlusive left common iliac artery stenosis at the level of the transplanted kidney arterial anastomosis, presented with left critical limb ischemia (CLI) and pseudo-transplant renal artery stenosis (pseudo-TRAS) symptoms. He was treated with a physician-modified fenestrated covered stent introduced percutaneously via ipsilateral femoral artery after failure of simple angioplasty (percutaneous transluminal angioplasty, PTA). The modified graft was created by performing a square fenestration graftotomy on a Medtronic iliac limb stent graft (Medtronic Cardiovascular, Santa Rosa, CA, USA). The procedure was technically successful with no intraoperative complications. Procedural time was 110 minutes, including 35 minutes for device modification. On short-term follow-up, the patient had early improvement of renal function and resolution of CLI. The iliac and transplant renal artery remained patent with no sign of stent migration or kinking on 6 months surveillance computed tomography angiography and 1 year color Doppler ultrasonography. Conclusion: Use of PMEG to preserve visceral branches in occlusive iliac disease is a feasible endovascular technique with encouraging technical success and satisfying early results.

Aim: The aim of this study is to evaluate initial and short-term result of duplex guided angioplasty (DGA) for treatment of femoropopliteal arterial lesions. Methods: From October 2017 to September 2020, 50 limbs in 50 patients (30 males) underwent DGA in our institution. The study was conducted on patients suffered from chronic lower limb ischemia of grade IIb, III and IV (according to Fontaine Classifications) resulting from femoropopliteal lesions (occlusion or stenosis). Arterial access was done under duplex guidance followed by advancing a guidewire across the diseased femoropopliteal segment(s). The diseased segment(s) were then balloon-dilated. Intimal dissection or residual stenosis causing diameter reductions greater than 30% were stented with a self-expandable stent under duplex guidance. Completion duplex examinations and ankle brachial indices were obtained after the procedure. Results: The mean age of patients was 64 ±8 years. Critical ischemia was the indication in 44%, and disabling claudication was the indication in 6% of cases. Technical success was achieved in 46 cases (92%). 31 cases (62%) went through transluminal crossing of the lesions using duplex guidance alone, 11 cases (22%) went transluminally using duplex combined with contrast-free fluoroscopic assistance and 4 cases (8%) was subjected to subintimal angioplasty using combined techniques. Stenting was done in 24 cases (48%), 16 cases (32%) were having floating intimal flap; while the other 8 cases (16%) had residual stenosis > 30%. A primary patency rate of 92% was obtained by the end of the 12 months follow-up period. Conclusion: Duplex can be used as a first strategy for the treatment of femoropopliteal arterial diseases. However, the pitfalls in DGA technique make it insufficient to replace the classic fluoroscopy.

Purpose The gold standard for the treatment of complex (TASC II C and D) atherosclerotic aortoiliac lesions is still open surgical repair. Endovascular techniques have a lower mortality and morbidity rate but this comes at the cost of worse patency rates when compared with open repair. Improved short- and mid-term results have been reported using the covered endovascular reconstruction of aortic bifurcation (CERAB) technique. The aim of this study was to report our initial experience with the CERAB technique and report long-term patency rates. Materials and Methods All patients treated with the CERAB technique between 2012 and 2018 were prospectively registered in an institutional database and included in this study. Patient demographics, characteristics, symptoms, procedural, and follow-up details were collected and analyzed retrospectively. Perioperative complications and reinterventions were also identified. The Kaplan-Meier survival method was used to assess cumulative rates of patency. Results A total of 44 patients were treated with the CERAB technique and included in this study. The majority of the treated aortoiliac occlusions were classified as complex: TASC II C (n=7; 15.9%) or TASC II D (n=25; 56.8%). Primary patency rate at 60 months was 83.3%, assisted primary patency was 90.9% and secondary patency 95%. No significant differences were found in patency rates comparing noncomplex (TASC II A and B) and complex (TASC II C and D) aortoiliac lesions. Seven patients (15.9%) required at least one additional procedure to maintain either assisted primary patency or secondary patency during follow-up. The 30-day complication rate in this series was 20.5% (n=9), of which 55.6% (n=5) were minor complications. All major 30-day complications (n=4) occurred during or directly after the CERAB procedure. Thirty-day mortality was 0%. No limb occlusions occurred within 30 days of the procedure. Conclusion Good long-term patency rates can be achieved with the CERAB technique to treat aortoiliac stenosis or occlusions while maintaining advantages associated with endovascular interventions. This remains true even when a CERAB is used to treat complex aortoiliac lesions. An endo-first approach to treat complex aortoiliac lesions seems viable.

Background and aimThere is only a limited number of major publications on the outcome of interventions for isolated popliteal artery stenosis. The purpose of this study was to report our results on mid-term patency and predictors of restenosis.Patients and methodsThis single-center retrospective study included 61 symptomatic patients (males, N = 33; median age, 65.1 years [IQR, 60.7–71.9 years]; Rutherford grade 4–6, N = 14) with at least two patent crural arteries, whose atherosclerotic stenoses/occlusions were treated with percutaneous transluminal angioplasty (PTA) or stenting (using self-expanding bare-metal Astron Pulsar stents) between 2011 and 2018.ResultsTwenty-six patients had PTA, while 35 underwent stenting. The median follow-up was 29 months (IQR, 10–47 months). The primary patency rates were not significantly different (P = 0.629) between PTA and stenting groups. Restenosis developed in nine patients (34.6%) in the PTA group, and in 12 (34.3%) in the stenting group. Restenotic lesions required re-intervention in nine cases (100%) in the PTA group, and in eight (66.7%) in the stenting group. Restenosis developed significantly less frequently (P = 0.010) in patients with a popliteal/P1 stent; the primary patency rates were also significantly better (P = 0.018) in patients with a popliteal/P1 stent when compared to popliteal/P2 plus multi-segment stents. Cox regression analysis identified lesion location as a predictor of in-stent restenosis (HR, 2.5; 95% CI, 1.2–5.5; P = 0.019).ConclusionStenting was not superior when compared to PTA (if selective stenting was not considered as loss of patency). Follow-up should be more thorough in patients undergoing popliteal/P2 or multi-segment stenting.

The choice of intervention for treating suprainguinal arterial disease, open bypass vs endovascular intervention, is often tempered by patient age and comorbidities. In the present study, we compared the association of patient age with 1-year major adverse limb events (MALE)-free survival and reintervention-free survival (RFS) rates among patients undergoing intervention for suprainguinal arterial disease.The Vascular Quality Initiative datasets for bypass and peripheral endovascular intervention (PVI; aorta and iliac only) were queried from 2010 to 2017. The patients were divided into two age groups: 60 and ≥60 years at the procedure. Age-stratified propensity matching of patients in bypass and endovascular procedure groups by demographic characteristics, comorbidities, and disease severity was used to identify the analysis samples. The 1-year MALE-free survival and RFS rates were compared using the log-rank test and Kaplan-Meier plots. Proportional hazard Cox regression was used to perform propensity score-adjusted comparisons of MALE-free survival and RFS.A total of 14,301 cases from the Vascular Quality Initiative datasets were included in the present study. Propensity matching led to 3062 cases in the ≥60-year group (1021 bypass; 2041 PVI) and 2548 cases in the 60-year group (1697 bypass; 851 PVI). In the crude comparison of the matched samples, the older patients undergoing bypass had had significantly greater in-hospital (4.6% vs 0.9%; P .001) and 1-year (10.5% vs 7.5%; P = .005) mortality compared with those who had undergone endovascular intervention. The rates of MALE (7.5% vs 14.3%; P .001) and reintervention (6.7% vs 12.7%; P .001) or death were significantly higher for the younger group undergoing PVI than bypass at 1 year. However, the rates of MALE (12.9% vs 14.3%; P = .298) and reintervention (12.7% vs 12.9%; P = .881) or death for were similar both procedures for the older group. Both log-rank analyses and the adjusted propensity score analyses of MALE-free survival and RFS in the two age groups confirmed these findings. The adjusted comparison of outcomes using propensity score matching favored PVI at 1-year survival (hazard ratio, 1.4; 95% confidence interval, 1.1-1.9; P = .003) for the older group but was not different for the younger group (hazard ratio, 0.6; 95% confidence interval, 0.3-1.0; P = .054).Among the patients aged 60 years undergoing intervention for suprainguinal arterial disease, the choice of therapy should be open surgical intervention given the higher risk of reintervention and MALE with endovascular intervention. Endovascular intervention should be favored for patients aged ≥60 years because of reduced perioperative mortality.

Objective: to evaluate the cost-benefit ratio of the use of invasive intraoperative hemodynamic control of peripheral blood flow during correction of multilevel lesions in chronic arterial occlusive disease of the lower extremities.Material and methods. We compared the cost of the in-hospital period of treatment among patients of 3 comparable groups: the patients of the first group underwent interventions under angiographic control, of the second — under invasive intraoperative hemodynamic control of the state of peripheral blood flow in addition to angiography, and in the patients of the third group invasive hemodynamic control of the state of peripheral blood flow was followed by pharmacological tests.Results. The use of the given method made it possible to correct the extent of the performed procedures of revascularization and to estimate the efficiency of the phases of the operation in real time. The result of interventions in the groups with hemodynamic control was a reliable increase of the ankle-brachial index (ABI index) values (p — 00001) in shorter length of segments after revascularization (p — 0.05). At the same time, the reduced extent of the correction resulted in saving 807 BYN per case.Conclusion. The use of invasive intraoperative hemodynamic control allows of reducing the extent of the reconstruction in multisegment lesions with the achievement of satisfactory clinical outcomes with lesser economic costs.

Background Patients with diabetes mellitus (DM) have a more extensive distal arterial occlusive disease compared to non-diabetic patients. Diagnostic imaging is a necessity to identify the location and extent of the arterial occlusion in acute limb ischemia (ALI). Computed tomography angiography (CTA) is the most commonly used modality and the diagnostic performance with CTA of calf arteries may be questioned. Purpose To evaluate diagnostic performance of CTA of calf arteries in ALI and to compare patients with and without DM. Material and Methods All thrombolytic treatments performed during 2001–2018 in patients with ALI were included. Initial digital subtraction angiography (DSA) and CTA of all patients were classified according to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) below-the-knee arteries and compared to CTA. Two raters assessed the CTA images independently. Inter-rater reliability was expressed as intraclass correlation (ICC) with 95% confidence intervals (CI). Results Patients with (n = 23) and without (n = 85) DM had lower ( P = 0.006) glomerular filtration rate. ICC between CTA and DSA was 0.33 (95% CI –0.22 to 0.56) and 0.71 (95% CI 0.38–0.68) in patients with and without DM, respectively. Sensitivity with CTA for TASC D lesions in patients with and without DM was 0.14 (95% CI –0.12 to 0.40) and 0.64 (95% CI 0.48–0.80), respectively. Conclusion The sensitivity of CTA for assessment of infra-popliteal TASC D lesions in patients with ALI was not acceptable in patients with DM in contrast to those without DM. Another imaging option at present times should be considered for patients with DM.

Purpose: The performance of sirolimus-coated devices has not been studied in patients with chronic limb-threatening ischemia patients. PRESTIGE aims to investigate the 6-month efficacy and safety profile of the Selution Sustained Limus Release (SLR) sirolimus-eluting balloon for treatment of TASC II C and D tibial occlusive lesions in patients with CLTI. Materials and Methods: PRESTIGE is a pilot prospective, nonrandomized, single-arm, multi-investigator, single-center clinical study. Endpoints were adverse event-free survival at 1 month, technical success rate, primary tibial patency at 6 months, limb salvage success, target lesion revascularization (TLR), and amputation free survival (AFS). Results: A total of 25 patients were included. There were 17 (68.0%) males; mean age, 63.7±9.73 years. CLTI severity was based on the Rutherford scale (R5=25/25; 100.0%). Significant comorbidities included diabetes mellitus (n=22; 88.0%) and end-stage renal failure (n=11; 44.0%). A total of 33 atherosclerotic lesions were treated (TASC II D=15 (45.5%)). Mean lesion length treated was 191±111 mm. Technical success was 100%. Primary tibial patency at 6 months was 22/27 (81.5%) and freedom from clinically driven TLR was 25/30 (83.3%). AFS was 21/25 (84.0%; 3 deaths and 1 major lower extremity amputation). Mean Rutherford score improved from 5.00 at baseline to 1.14±2.10 (pConclusions: Selution SLR drug-eluting balloon is a safe and efficacious modality in treating complex tibial arterial occlusive lesions in what is an otherwise frail cohort of CLTI patients, with a high prevalence of diabetes and end-stage renal failure. Technical and clinical success rates are high and 6-month target lesion patency and AFS are more than satisfactory.

Background Endovascular management of isolated profunda femoris artery occlusive disease has not been well studied. Our aim is to analyze the outcomes of endovascular management of profunda artery occlusive disease. Methods This is a retrospective analysis using data from the Vascular Quality Initiative. All patients from 2013 to 2018 treated percutaneously for isolated profunda artery occlusive disease were included. Endovascular treatment included plain balloon alone, stent, stent graft, atherectomy, and drug-coated balloon without any concomitant endovascular or surgical treatment. Demographic, procedural, and follow-up data were obtained. Primary end points were primary patency, improvement of symptoms, and need for reintervention. Univariate and multivariable analysis was used to assess for significant variables. Results Of the 105,568 lower extremity endovascular interventions performed during this time period, there were 361 procedures (0.3%) performed on 341 patients for isolated profunda artery occlusive disease. The average age of these patients was 67.8 years (+/− 11.8), with 59.8% being men. The most common indication for treatment of the profunda artery was claudication (44.8%), followed by tissue loss (28.5%) and rest pain (26.0%). The most common treatment modality was plain balloon (58.5%), followed by stent (18.6%), drug-coated balloon (10.0%), atherectomy (9.4%), and stent graft (3.6%). At a mean follow-up of 13 months (+/−4.6), data were available for 238 patients (69.7%). Overall primary patency at 13 months was 92.9%. There was no significant difference in terms of patency for each treatment modality (Table I). Preoperative ambulatory status, aspirin, and statin were significantly associated with patency. At most recent follow-up, 67% of patients had improvement of their symptoms, whereas 29% were unchanged. Reintervention data were available for 247 patients, with a reintervention rate of 15.8% (n = 39) and a mean reintervention time of 226 days (+/− 173), with the majority of reinterventions (62%) occurring in the plain balloon group. Reinterventions were primarily endovascular (64%) with 9 patients (23%) undergoing surgical reintervention. Conclusions Endovascular management of profunda femoris artery occlusive disease has acceptable one-year patency rates with low reintervention rates. Endovascular treatment may be an acceptable alternative to selected patients who are high-risk for surgery.

Background There is a paucity of literature describing the recovery trajectory after surgery for upper extremity ischemia. Using Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Upper Extremity (UE), Pain Interference (PI), and Depression domains, we aimed to describe the postoperative recovery of such patients. Methods We queried our PROMIS database for patients undergoing surgery for vasospastic or occlusive disease over a 4.5-year period. Inclusion criteria were preoperative, early (average 3 weeks) and late (average 6 months) postoperative PROMIS PF and/or UE, PI, and Depression scores. The change in PROMIS scores was calculated for each time point. Changes in PROMIS scores were compared with minimal clinically important difference estimates. Results We identified 13 patients undergoing 13 surgical interventions that met inclusion criteria. More than one-half of our patients were men (n = 7 [54%]), and more than one-half of the surgeries (n = 7 [54%]) were for isolated occlusive diagnoses, with the remainder for vasospastic disease. At short-term postoperative follow-up, the change in PROMIS PF, UE, PI, and Depression scores was −6.34 (SD: 9.13), −6.81 (SD: 9.61), 3.16 (SD: 5.78), and −3.05 (SD: 8.37), respectively. At mid-term postoperative follow-up, the change in PROMIS PF, UE, PI, and Depression scores was 4.45 (SD: 10.33), 8.04 (SD: 13.84), −7.03 (SD: 7.06), and −12.27 (SD: 10.85), respectively. Conclusions Our findings suggest patients undergoing surgical treatment for upper extremity ischemia experience a worsening of functional symptoms initially, as expected, followed by notable improvement.

Bare-metal stents (BMSs) have been generally applied for the treatment of peripheral artery disease in patients with femoropopliteal disease. However, very long-term pathological findings after BMS implantation have not been elucidated to date. We experienced an autopsy case in which we performed a pathological evaluation 18 years after BMS implantation in the right superficial femoral artery. The BMS was totally occluded and filled with remarkable neointima formation. Neointima was mainly composed of a lot of rather atrophic smooth muscles and intercellular spaces containing dense collagenous fibers. Furthermore, regional fatty infiltration was also observed, but inflammatory cell infiltration, such as macrophages and lymphocytes, was not recognized obviously even around the struts. Judging from the pathological findings, the main mechanism of the very long-term in-stent restenosis in the patients with femoropopliteal disease was continuous proliferation of smooth muscle cells that led to the totally occlusive disease. This observation leads us to speculate that continuous elution of an anti-proliferating drug over a longer duration, at least beyond 1 year, would be effective to prevent chronic-phase restenosis. Further development of devices that can be used in the femoropopliteal artery is needed in light of this speculation.

Background We present early and mid-term clinical outcomes of endovascular revascularization for femoropopliteal involvement of peripheral arterial disease. Methods A total of 128 patients (113 males, 15 females; mean age: 63.4±9.9 years; range, 32 to 87 years) who underwent percutaneous transluminal angioplasty for femoropopliteal lesions between August 2016 and April 2018 were analyzed retrospectively. Treatment with Luminor® paclitaxel-coated drug-eluting balloon catheter or bailout therapy with iVolution® self-expanding nitinol stent were performed. Overall patency rates and freedom from reintervention rates were analyzed using the Kaplan-Meier analysis. The primary patency and freedom from reintervention to target lesion rates at 12 and 24 months were evaluated. Results Technical success was achieved in 133 (93%) of the interventions with a median follow-up of 11 (range, 1 to 35) months. At 12 and 24 months, the mean overall patency rates were 85.6±3.7% and 66.8±6.7%, respectively and the mean freedom from reintervention to target lesion rates were 91.6±2.9% and 78.1±6.3%, respectively. The primary patency and freedom from reintervention to target lesion rates were significantly higher in the bailout stenting group than the drug-eluting balloon group at 12 months (97.3±2.7% vs. 94.8±6.1%, respectively, p=0.025 and 97.1±2.9% vs. 84.2±5.5%, respectively, p=0.005) and at 24 months (76.9±7.9% vs. 55.8±13.4%, respectively, p=0.025 and 85.2±7.0% vs. 70.2±13.6%, respectively, p=0.005). Conclusion Endovascular procedures including drug-eluting balloon and bailout stenting seem to be effective alternative treatment modalities for treatment of infrainguinal peripheral arterial disease and can be also used in patients with long lesions and/or total occlusion of femoropopliteal arteries.

Carotid Artery Occlusive Disease or Carotid Artery Stenosis (CAS), a widely prevalent disease, involves blockage of the arterial wall through atherosclerotic plaques. Due to the high prevalence of carotid artery stenosis, innovative approaches to improve the outcome are required, particularly for more difficult and unique cases. Within this report, we present a particularly difficult case of Type III Aortic Arch – Right Internal Carotid Artery (ICA) stenosis making it a challenging case. We describe a symptomatic 87-year-old male who presented to Cardiology clinic. CT angiogram showed 70% occlusion of right internal carotid artery and patient was deemed high risk for carotid artery surgery; hence, the patient underwent internal carotid artery stenting. After the procedure, angiogram results were excellent, and the patient was transferred to CICU in stable hemodynamic condition. This case demonstrates the significance of innovative new techniques in the development of medical treatment. Keywords: Carotid Artery Stenting, Curve Sheath Technique, Type 3 Aortic Arch, Right Internal Carotid Artery Stenosis

Összefoglaló. Bevezetés: A diffúz aortobiiliacalis érszakasz occlusiv betegségének kezelésére alkalmazott aortobifemoralis bypass szerepe csökken az endovascularis műtétek térnyerése miatt. Célkitűzés: A vizsgálat célja volt a modern invazív kezelés korszakában a perioperatív és a hosszú távú eredmények elemzése aortobiiliacalis bypass után, melyek összehasonlíthatók az endovascularis megoldások eredményeivel. Módszerek: A retrospektív, egycentrumú vizsgálat során a Semmelweis Egyetem Városmajori Szív- és Érgyógyászati Klinikájának Érsebészeti és Endovaszkuláris Tanszékén 2006. 01. 01. és 2017. 12. 31. között occlusiv aortoiliacalis atherosclerosis miatt primer aortobifemoralis bypass műtéten átesett 419 beteg (átlagéletkor: 62,2 év, SD: ± 8,22; 224 férfi, 53%) adatait elemeztük. Eredmények: A posztoperatív 30 napon belüli mortalitás 5,01%, a késői mortalitás 10,98% és 29,59% volt 12, illetve 60 hónap után. A betegek 12,57%-ánál történt korai reoperáció, késői reoperáció 32 (8%) betegnél vált szükségessé. A graft elsődleges nyitva maradása 88,65% és 81,15% volt 12, illetve 60 hónap után. 21 betegnél történt amputáció (6,29%); 57,14%-ban femoralis, 35,71%-ban cruralis szinten, 7,14%-ban a boka szintje alatt. Az amputációkra 35,71%-ban a bypasst követő 30 napon belül, további 35,71%-ban 2 éven belül került sor. Az esetek 35,63%-ában lépett fel egyéb szövődmény; a leggyakoribbak: műtétet igénylő posztoperatív hernia (6,89%), cardiovascularis szövődmény (4,19%), lágyéki nyirokcsorgás vagy sebgyógyulási zavar (4,79%). Következtetés: Eredményeink alapján e betegcsoportban az aortobifemoralis bypass elfogadható, de nem jelentéktelen perioperatív halálozással és magas morbiditással jár. A graft hosszú távú nyitva maradása jó, de az újabb érműtét mind rövid, mind hosszú távon relatíve gyakori. A kevésbé invazív technikák eredményeinek összehasonlítása indokolt a hosszú szakaszú (TASC C, D) elváltozások esetén. Orv Hetil. 2021; 162(3): 99–105. Summary. Introduction: The role of aorto-bifemoral bypass in the treatment of diffuse aorto-biiliac occlusive disease decreases in the era of endovascular surgery. Objective: The aim of the study was to analyse the early and long-term postoperative results of aorto-bifemoral bypass in a recent time period. These results may be used as a baseline to compare the results of endovascular procedures. Methods: In a retrospective, single-center study, the data of 419 patients (mean age: 62.2 years, SD: ± 8.22; 224 men, 53%) who underwent primary aorto-bifemoral bypass due to occlusive aorto-iliac atherosclerosis from 01. 01. 2006 to 31. 12. 2017 at the Department of Vascular and Endovascular Surgery of Semmelweis University Heart and Vascular Center were analysed. Results: Postoperative mortality within 30 days was 5.01%, late mortality was 10.98% and 29.59% after 12 and 60 months, respectively. 12.57% of the patients needed early reoperation and late reoperation was required in 32 cases (8%). The primary graft patency was 88.65% and 81.15% after 12 and 60 months, respectively. 21 patients underwent amputation (6.29%); 57.14% at the femoral level, 35.71% at the crural level and 7.14% below the ankle level. Amputations were performed in 35.71% of the cases within 30 days after the bypass and an additional 35.71% within 2 years. Other complications occurred in 35.63% of the cases; the most common causes were postoperative hernia requiring surgery (6.89%), cardiovascular complication (4.19%) and inguinal wound healing disorders (4.79%). Conclusion: Based on our results, aorto-bifemoral bypass surgery is associated with acceptable but not insignificant perioperative mortality and high morbidity in this group of patients. The graft patency is favourable in the long term, however, additional vascular reintervention is common in short and long term as well. Short- and long-term results of percutaneous endovascular techniques in diffuse aorto-biiliac disease (TASC C and D lesions) are suggested to be compared to these recent results of open surgery. Orv Hetil. 2021; 162(3): 99–105.

Background Peripheral vascular devices (stents and balloons) coated with paclitaxel were developed to address suboptimal outcomes associated with percutaneous revascularization procedures of the femoral-popliteal arteries. In randomized controlled trials (RCT), paclitaxel-coated devices (PCD) provided increased long-term patency and a decreased need for repeat revascularization procedures compared with uncoated devices. This finding resulted in the adoption of their use for endovascular lower extremity revascularization procedures. However, in late 2018 a study-level meta-analysis showed increased all-cause mortality at 2 years or more after the procedure in patients treated with PCDs. This review examines the subsequent data evaluation following the publication of the meta-analysis. Methods We review the published responses of physicians, regulatory agencies, and patient advocates during 15-month period after the meta-analysis. We present the additional data gathered from RCTs that comprised the meta-analysis and safety outcomes from large insurance databases in both the United States and Europe. Results Immediately after the publication of the meta-analysis, concern for patient safety resulted in less PCD use, the suspension of large RCTs evaluating their use, and the publication of a letter from the U.S. Food and Drug Administration informing physicians that there was uncertainty in the benefit-risk profile of these devices for indicated patients and that the potential risk should be assessed before the use of PCDs. Review of the meta-analysis found that a mortality signal was present, but criticisms included that the evaluation was performed on study-level, not patient-level data, and the studies in the analysis were heterogenous in device type, paclitaxel doses, and patient characteristics. Further, the studies were not designed to be pooled nor were they powered for evaluating long-term safety. Clinical characteristics associated with a drug effect or causal relationship were also absent. Specifically, there was no dose response, no clustering of causes of death, and a lack of signal consistency across geographic regions. As more long-term data became available in the RCTs the strength of the mortality signal diminished and analysis of real-world use in large insurance databases, showed that there was no significant increase in all-cause mortality associated with PCD use. Conclusions The available data do not provide definitive proof for increased mortality with PCD use. A key observation is that trial design improvements will be necessary to better evaluate the risk-benefit profile of PCDs.

Aims: Diabetic patients in India present late in advanced stages of tissue loss and isolated occlusive infrapopliteal disease. We aim to determine the outcomes of angioplasty in these patients with SINBAD score >3 and infrapopliteal disease presenting with critical limb-threatening ischemia (CLTI) and tissue loss. Materials and Methods: A prospective, observational, single-center study was carried out of diabetic patients with infrapopliteal occlusive disease who underwent angioplasty for CLTI and tissue loss. Transatlantic society consensus (TASC) - classification was used for staging. Ischemia and Peripheral Artery Calcium Scoring was used to assess peripheral calcium. The patients were followed up till their ulcer healed and then every six months. Results: A total of 73 diabetic patients underwent angioplasty for CLTI. 21.8% (16/73) all-cause mortality was seen during the study. The average age was 68.9 years with 78.9% males. The average time to presentation was 55 days. 61.3% of patients had TASC C or D lesions. Technical success was achieved in 94.5% of patients. 27.4% of patients underwent angioplasty of multiple tibial vessels. The mean duration of follow-up was 2 years. 62.5% of patients had their ulcers completely heal in 6 months. Six patients went on to have major amputation. The amputation-free period was 500 days in this patient group. Ulcer healing was found to be dependent on successful revascularization. Conclusion: Mortality is seen in 1 in 10 and morbidity in 1 in 5 patients. It is difficult to accurately prognosticate healing in these patients. Successful revascularization is the only factor affecting healing in these patients.

Summary: Intravascular ultrasound (IVUS) has been used extensively in coronary applications. Its use in venous applications has increased as endovascular therapy has increasingly become the mainstay therapy for central venous diseases. IVUS has been used for both diagnostic and therapeutic purposes in managing venous stenotic disease, venous occlusive disease, and IVC filter placement and removal. IVUS has been proven to be effective in providing detailed measurement of the venous anatomy, which aid in determining the appropriate size and the approach for venous stent placement. In IVC filter placement, IVUS can provide detailed measurement and guide IVC filter placement in emergent and critical care settings. It also has certain utility in filter removal. At any rate, to date there are only a few studies examining its impact on patient outcomes. Prospective randomized controlled trials are warranted in the future.

This study compared rates of procedural success and complications between de novo cardiac resynchronization therapy (CRT) implantation versus upgrade, including characterization of technical challenges.CRT upgrade is common, but data are limited on the incidence of procedural success and complications as compared to de novo implantation.All patients who underwent a transvenous CRT procedure at a single institution between 2013 and 2018 were reviewed for procedure outcome, 90-day complications, reasons for unsuccessful left ventricular lead delivery, and the presence of venous occlusive disease (VOD) that required a modified implantation technique.Among 1,496 patients, 947 (63%) underwent de novo implantation and 549 (37%) underwent device upgrade. Patients who received a device upgrade were older (70 ± 12 years vs. 68 ± 13 years; p 0.01), with a male predominance (75% vs. 66%; p 0.01) and greater prevalence of comorbidities. There was no difference in the rate of procedural success between de novo and upgrade CRT procedures (97% vs. 96%; p = 0.28) or 90-day complications (5.1% vs. 4.6%; p = 0.70). VOD was present in 23% of patients who received a device upgrade and was more common among patients with a dual-chamber versus a single-chamber device (26% vs. 9%; p 0.001). Patients with and without VOD had a similar composite outcome of procedural failure or complication (8.0% vs. 7.8%; p = 1.0).Rates of procedural success and complications were no different between de novo CRT implantations and upgrades. VOD frequently increased procedural complexity in upgrades, but alternative management strategies resulted in similar outcomes. Routine venography before CRT upgrade may aid in procedural planning and execution of these strategies.

Peripheral artery disease (PAD) affects 3%-10% of the Western population and if remains untreated can have devastating consequences to patients and their families. This review article analyzes how healthy dietary habits can decrease PAD rates when applied in the general population. The aim is to focus on dietary, nutritional and weight management interventions in patients with established PAD. Most adults with PAD are overweight or obese, while three out of four patients are characterized by deficiencies in vitamins and minerals. Weight loss interventions when needed and specialized dietary plans should be routinely recommended in patients with PAD. Appropriate nutritional support is of paramount importance in patients with advanced stages of PAD (critical limb ischemia).

Peripheral artery disease (PAD) affects 3%-10% of the Western population and if remains untreated can have devastating consequences to patients and their families. This review article analyzes how healthy dietary habits can decrease PAD rates when applied in the general population. The aim is to focus on dietary, nutritional and weight management interventions in patients with established PAD. Most adults with PAD are overweight or obese, while three out of four patients are characterized by deficiencies in vitamins and minerals. Weight loss interventions when needed and specialized dietary plans should be routinely recommended in patients with PAD. Appropriate nutritional support is of paramount importance in patients with advanced stages of PAD (critical limb ischemia).

Background: Diabetes carries a two-fold risk of Sudden Cardiac Death (SCD). Diabetic Autonomic Neuropathy (DAN), often progressing to Cardiovascular Autonomic Neuropathy (CAN, critically low parasympathetic tone [P]), increases death 3.5-fold over 5 years, half sudden or non- renal. Oxidative stress is a major cause of DAN. Also, increased sympathetic tone (S), High Sympathovagal Balance [SB>2.5] increases SCD risk. Objective: Dysautonomic diabetic II patients were treated with the antioxidant (r) Alpha Lipoic Acid (ALA), autonomic function followed, and Sudden Death (SD) compared to untreated patients. Methods: 133 patients (mean age 66y/o) with DAN or CAN, diagnosed using the ANX 3.0 Autonomic Monitor (Physio PS, Inc., Atlanta, GA) was offered (r)-ALA: 83 agreed (Group 1), and 50 refused (Group 2). P and S were re- measured up to 3 times/yr (mean f/u 6.31 yrs); SCDs were recorded. Results: A 43% Relative Risk Reduction (RRR) in SCD occurred with (r)- ALA (25% SCD Group 1 vs. 44% SCD Group 2, p=0.0076). Initial to final patients with high SB or CAN were 21.7%-12% (p=0.010), 10.8%- 15.7% (p=0.045), Group 1 vs. 24%-22% (p=ns), 6%-12% (p=0.083), Group 2. Only Group 1 survivors increased mean resting P. The progressive increase in P’s decline, increasing CAN risk, in the other patients correlated with mortality (p

We present two preloaded techniques to facilitate gate cannulation during endovascular aortic repair. In the first case, we relined the aorta using a Gore iliac branch endoprosthesis (WL Gore and Associates, Flagstaff, Ariz) for acute occlusion. This allowed for preloading the contralateral gate, which was compressed when deployed, and subsequently dilated open over the preloaded wire to allow for cannulation. The second patient had had an infrarenal aneurysm. A Gore Excluder was partially deployed extracorporeally to preload the gate from the ipsilateral side. The "snare ride" technique was used to rapidly cannulate the gate. Preloaded wire techniques during endovascular aortic repair can facilitate rapid gate cannulation, especially in patients with challenging anatomy.