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Objective: The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR)., Methods: This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests., Results: The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively)., Conclusion: In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair., (Copyright © 2020 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

The autogenous saphenous vein is considered the best bypass graft material for arterial bypasses below the inguinal ligament. However, a synthetic graft or prosthesis is considered an acceptable alternative, especially when the distal anastomosis is situated above the knee. Some studies even suggest that patency rates for vein and synthetic grafts are comparable, whereas others indicate that a vein graft is superior to a prosthetic graft, even above the knee. To test the hypothesis that both vein grafts and synthetic prostheses are equally beneficial in the above-knee position, we performed a systematic review of available studies comparing the patency of saphenous vein and polytetrafluoroethylene (PTFE) as bypass material. English and German medical literature from 1966 to 2002 was searched using Medline, and 25 articles meeting our inclusion and exclusion criteria were selected. The patency of venous bypasses was superior to that of PTFE bypasses at all time intervals studied. After 2 years, the primary patency rate of venous bypasses was 81% as compared to 67% for PTFE bypasses, and after 5 years it was 69 and 49%, respectively. After 5 years, the secondary patency of PTFE bypasses reached 60%. When only randomized trials were considered, venous bypasses were again superior to PTFE bypasses at all intervals studied. After 2 years, the primary patency rate of venous and PTFE bypasses was 80 and 69%, respectively, and after 5 years it was 74 and 39%, respectively. Since both randomized and retrospective studies comparing venous with PTFE bypasses showed that vein grafts were 'better' than PTFE prostheses, the null hypothesis that there is no difference between the two types of graft material was rejected (p=0.008). We conclude from this systematic review that if a saphenous vein is available, a venous bypass should be chosen at all times, even if patients have an anticipated short life expectancy (<2 years). If the saphenous vein is absent or not suitable for bypass grafting, PTFE is a good alternative as bypass material.

For a femorotibial bypass graft the material of choice is autologous vein. The question remains whether prosthetic material is a reasonable alternative for limb salvage, if autologous vein is not available. From 1991 to 1998, 83 consecutive femorotibial bypass procedures were performed in 70 patients. Thin-walled, ringed 6-mm polytetrafluoroethylene (PTFE) was used, as autologous vein was not available. The indication for the femorotibial bypass was critical ischemia due to atherosclerotic occlusive disease in all cases. Three patients died in the hospital or within 30 days of the operation, resulting in a perioperative mortality rate of 3.6%. After 5 years, 33 patients had died (40%) and 3 patients were lost to follow-up (3.6%). Primary patency was 64.2% after 6 weeks and 18% +/- 5% after 5 years. Secondary patency was 74.1% after 6 weeks and 22.3% +/- 6% after 5 years. When we compared primary and secondary patency for distal anastomosis, there was no difference between the three crural arteries. The limb salvage rate was 61.9% +/- 7% after 5 years. From these results we conclude that, with a limb salvage of 61.9%, PTFE is an acceptable alternative for a femorotibial bypass graft in patients with critical ischemia, if autologous vein is not available.

The objective of this study was to describe the kinds of complications and their incidence after peripheral vascular surgery of the lower limb, coding for causes and effect on the patient. In this prospective study, a standardized complication registration system was used at the Red Cross Hospital, The Hague. All patients (n = 373) receiving an infrainguinal bypass graft during the period January 1, 1996 to December 31, 1999 were included. All postoperative complications occurring during admission were coded. In 29% of the patients 153 complications were coded. Early occlusions of the graft occurred 36 times, wound infections 21 times and postoperative hemorrhages 20 times. Postoperative retention of urine was seen most frequently of all nonspecific complications (n = 22). In 43 cases the patient needed medication or a blood transfusion for his complication. In 42 cases a re-intervention was necessary. Complications led to a prolonged stay in the hospital in 20 cases. Six patients died during admittance (mortality 1.6%). An error in surgical therapy and error in nonsurgical therapy were the cause of the complication in 108 cases (out of 153). The advantage of this complication registration is that it describes all complications, not just the specific ones. Furthermore, by categorizing all complications we force ourselves to look for errors in nonsurgical therapy and surgical technique and to describe the effect of the complication.

Objective: Controversy still exists whether polytetrafluoroethylene is equivalent to vein as bypass graft material for the above-knee femoropopliteal bypass. Therefore, a prospective randomized trial was performed to compare vein with polytetrafluoroethylene for femoropopliteal bypasses with the distal anastomosis above the knee., Methods: Between January 1993 and December 1996, 151 above-knee femoropopliteal bypasses were performed. The indications for operation were severe claudication in 120 cases, rest pain in 20 cases, and ulceration in 11 cases. After randomization, 75 reversed saphenous venous bypasses and 76 polytetrafluoroethylene bypasses were performed., Results: No perioperative mortality was seen, and 5% of the patients had minor infections of the wound, not resulting in loss of the bypass, the limb, or life. After 5 years, 38% of the patients had died and 7% were lost to follow-up. Only once was the saphenous vein necessary for coronary artery bypass grafting. Primary patency rates after 5 years were 75.6% for venous bypass grafts and 51.9% for polytetrafluoroethylene grafts (P =.035). Secondary patency rates were 79.7% for vein and 57.2% for polytetrafluoroethylene bypasses (P =.036). In the venous group, 14 bypasses failed, leading to five new bypasses. In the polytetrafluoroethylene group, 29 bypasses failed, leading to 16 reinterventions. For these 16 new bypasses, in four cases, the ipsilateral preserved saphenous vein was used. In both groups, one above-knee amputation and one below-knee amputation had to be performed., Conclusion: We conclude after 5 years of follow-up of this randomized controlled trial that a bypass with saphenous vein has better patency rates at all intervals and needs fewer reoperations. Saphenous vein should be the graft material of choice for above-knee femoropopliteal bypasses and should not be preserved for reinterventions. Polytetrafluoroethylene is an acceptable alternative if the saphenous vein is not available.