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Objective: Different graft materials have been proposed for in situ reconstruction in the setting of vascular graft infection (VGI). We analyzed the long-term outcomes after in situ aortoiliac reconstruction with cryopreserved allografts., Methods: We performed a retrospective analysis of patients who had undergone in situ aortoiliac reconstruction with cryopreserved arterial allografts for VGI from 2000 to 2015. The end points were the perioperative and long-term mortality and graft-related complications, including stenosis, occlusion, pseudoaneurysm, and reinfection., Results: A total of 33 patients (91% male) with a median age of 67 years (range, 53-83 years) had undergone in situ aortoiliac reconstruction with cryopreserved allografts. The 30-day mortality was 6% (n = 2); both deaths were related to the allograft (one early allograft-enteric fistula and one graft rupture). Another two patients had experienced early (≤30 days) graft-related events (one allograft-enteric fistula and one graft limb occlusion), for an early graft-related complication rate of 12% (n = 4). Of the 31 discharged patients, 13 (42%) had died after a median of 47 months (range, 2-97 months). The median follow-up for the 18 remaining patients was 96 months (range, 10-146 months). The estimated survival at 1, 3, and 5 years was 88%, 81%, and 66%, respectively. Nine patients (29%) had experienced at least one of the following graft-related events during follow-up, including graft stenosis requiring intervention in five (16%), graft occlusion in four (13%), pseudoaneurysm in three (10%), and reinfection in two patients (6%). The estimated freedom from any first graft-related event at 1, 3, and 5 years was 78%, 71%, and 62%, respectively. The estimated primary patency and primary assisted patency at 1 and 3 years was 87% and 79%, and 90% and 83%, respectively., Conclusions: In situ aortoiliac reconstruction with cryopreserved allografts to treat VGI was associated with relevant perioperative graft-related complications. Although the reinfection rate was acceptable, other graft-related complications were frequent in the long term, in particular, graft occlusion and stenosis., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: In Switzerland, the outcome of vascular access creation in the 4500 current dialysis patients is unknown, mainly because there is no prospective registry for patients undergoing vascular access surgery for renal replacement therapy. The aim of the study was to assess the quality of vascular access creation and to compare it with the current literature and guidelines, in order to define strategies to improve clinical outcome., Methods: Retrospective single-centre study in a tertiary referral centre. All consecutive patients over 18 years of age undergoing primary vascular access creation between January 2013 and December 2014 were included. Follow-up data for at least 12 months were collected., Results: During the study period, 365 patients had a surgical intervention for renal replacement therapy. A primary vascular access was created in 74 patients (20%), who were further analysed in our study: 63 (85%) had an arteriovenous fistula (AVF) and 11 (15%) an arteriovenous graft (AVG). The intervention-free survival (primary patency rate) of the primary vascular access at 1 year was 46% (95% confidence interval [CI] 33-58%) for AVF and 30% (95% CI 7-58%) for AVG, with a secondary patency rate at 1 year of 75% (95% CI 63-84%) for AVF and 50% (95% CI 18-75%) for AVG. Twenty-seven patients (36%) with primary vascular access underwent central venous catheter (CVC) placement (tunnelled or non-tunnelled) before the access creation. Thirty-seven (50%) patients had their first dialysis through a CVC. Thirty-one patients (42%) never received a CVC., Conclusions: The primary patency of vascular access was unexpectedly low, and the number of CVC requests unexpectedly high. In light of this, we consider it essential that centres creating vascular access should register their activities and compare their outcomes with current guidelines to check and improve clinical management. To facilitate this, there is an initiative starting in 2018 encouraging all Swiss vascular surgeons to provide data on vascular access interventions, including 1-year follow-up, in the national online registry "SwissVasc 2.0".

Background: The aim of this study was to evaluate a new surgical concept for the treatment of graft infections after operation or endovascular treatment of thoracic, thoracoabdominal, and abdominal aortic diseases., Methods: Between 2004 and 2011, 15 patients (mean age 72 ± 10 years, 87% men) with prosthetic graft or endovascular graft infection were treated with complete removal of the infected prosthetic material, extensive debridement of the surrounding tissues, and orthotopic vascular reconstruction with self-made xenopericardial tube grafts constructed from a patch. Perioperative and long-term outcomes were evaluated., Results: Perioperative mortality was 27% (n = 4). All deaths were due to multiorgan failure resulting from uncontrolled septicemia from the local infectious process. Mean observational follow-up was 24 months (5 to 83 months). Control computed tomographic scans showed normal findings at the operative site in all patients. Antibiotic treatment was continued for a mean of 6 months. Freedom from reinfection was 100%. Freedom from reoperation was also 100%., Conclusions: Treatment of graft infections after operation or endovascular treatment of thoracic, thoracoabdominal, and abdominal aortic diseases by complete removal of the infected prosthetic material and extensive debridement as well as orthotopic vascular reconstruction using self-made xenopericardial tube grafts as neoaortic segments provides excellent results with regard to durability and freedom from reinfection and reoperation. This new concept is an additional alternative to cryopreserved homografts that extends the armamentarium for treating patients with these highly complex conditions., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether advanced age was independently associated with prohibitive surgical risks or impaired long-term prognosis after ruptured aortic aneurysm repair., Design: Post-hoc analysis of prospective cohort., Materials: Consecutive patients undergoing ruptured aneurysm repair between January 2001 and December 2010 at a tertiary referral centre., Methods: Surgical mortality (i.e., <30 days) was compared between octogenarians and younger patients using logistic regression modelling to adjust for suspected confounders and to identify prognostic factors. Long-term survival was compared with matched national populations., Results: Sixty of 248 involved patients were octogenarians (24%) and almost all were offered open repair (n = 237). Surgical mortality of octogenarians was 26.7% (adjusted odds ratio (OR) 2.1; 95% confidence interval (CI), 0.9-5.2) and confounded by cardiac disease. Hypovolaemic shock predicted perioperative death of octogenarians best (OR 5.1; 95%CI, 1.1-23.4; P = 0.037). After successful repair, annual mortality of octogenarians averaged 13.7% vs. 5.2% for younger patients. At 2 years, octogenarian survival was at 94% of the expected 'normal' survival in the general population (vs. 96% for younger patients)., Conclusions: Surgical mortality of ruptured aneurysm repair was not independently related to advanced age but mainly driven by cardiac disease and manifest hypovolaemic shock. An almost normal long-term prognosis of aged patients after successful repair justifies even attempts of open repair, particularly in carefully selected patients., (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Treatment of dialysis access-related hand ischaemia with preservation of the access remains an issue. We report the case of a patient presenting critical hand ischaemia 2 years after proximalisation of a distal radio-cephalic fistula with preservation of the original access. After valvulotomy, the distal cephalic vein was used as in situ bypass and directly anastomosed to the distal brachial artery, providing a direct flow to the hand. This procedure relieved the hand ischaemia without sacrificing the functioning fistula. Six months later, the fistula and bypass were still patent, showing that flow reversal of a previous fistula can be an efficient strategy to correct dialysis access-related hand ischaemia in selected cases., (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Low cardiac output impairs the hepatic arterial buffer response (HABR). Whether this is due to low abdominal blood flow per se is not known. Dobutamine is commonly used to increase cardiac output, and it may further modify hepatosplanchnic and renal vasoregulation. We assessed the effects of isolated abdominal aortic blood flow changes and dobutamine on hepatosplanchnic and renal blood flow. Twenty-five anesthetized pigs with an abdominal aorto-aortic shunt were randomized to 2 control groups [zero (n = 6) and minimal (n = 6) shunt flow], and 2 groups with 50% reduction of abdominal blood flow and either subsequent increased abdominal blood flow by shunt reduction (n = 6) or dobutamine infusion at 5 and 10 microg kg(-1) min(-1) with constant shunt flow (n = 7). Regional (ultrasound) and local (laser Doppler) intra-abdominal blood flows were measured. The HABR was assessed during acute portal vein occlusion. Sustained low abdominal blood flow, by means of shunt activation, decreased liver, gut, and kidney blood flow similarly and reduced local microcirculatory blood flow in the jejunum. Shunt flow reduction partially restored regional blood flows but not jejunal microcirculatory blood flow. Low-but not high-dose dobutamine increased gut and celiac trunk flow whereas hepatic artery and renal blood flows remained unchanged. Neither intervention altered local blood flows. The HABR was not abolished during sustained low abdominal blood flow despite substantially reduced hepatic arterial blood flow and was not modified by dobutamine. Low-but not high-dose dobutamine redistributes blood flow toward the gut and celiac trunk. The jejunal microcirculatory flow, once impaired, is difficult to restore.

Objectives: This observational study was set up to prospectively follow all bovine heterograft (ProCol) fistulas implanted for hemodialysis access between 1998 and 2002., Methods: ProCol was implanted if autogenous vein was not available or if patients presented with a history of failed, infected or otherwise complicated ePTFE grafts and/or on immunosuppressive therapy. Fistula patency was the primary outcome; secondary outcomes were clinical events and the rate of access revisions., Results: Sixty-two ProCol grafts were implanted in 56 patients. The mean primary (PP) and secondary patency (SP) was 334 (SEM 57) and 528 (SEM 59) days, respectively. Coronary heart disease was associated with a significantly better SP (OR 0.2, 95% CI 0.1-0.9) whilst diabetes mellitus was associated with a significantly worse SP (OR 0.2, 95% CI 0.1-0.9). Reinterventions were performed at a mean rate of 1.23 (SEM 0.17) per fistula. The relative risk of access revision was significantly higher in patients with diabetes mellitus (OR 9.2, 95% CI 2.3-37.2)., Conclusions: ProCol grafts, used for AV-fistulas, demonstrate acceptable patency rates in high-risk haemodialysis patients. Diabetes mellitus jeopardizes the patency of these fistulas and is associated with a high revision rate.

Objectives: Poor results have been reported following infrainguinal reconstructions using heterogenous grafts. The objective of this study was to assess the use of bovine mesenteric vein (ProCol) graft in patients with critical limb ischaemia (CLI), tissue loss/infection and no autologous vein available for reconstruction., Methods: Prospective analysis of 32 patients with CLI and tissue loss/infection, in whom reconstruction with ProCol was undertaken between October 1999 and May 2002., Results: The primary patency rate was 16% at 1 month. After thrombectomy, the secondary patency rate was 50% at 1 month and 26% at 14 months. No graft infections were seen. Aneurysmal dilatation of the graft occurred in 2 (6%). Limb salvage at 14 months was 47%., Conclusion: In patients with critical limb ischaemia, tissue loss/infection and no available vein, the ProCol graft may be an alternative. However, primary patency is a problem. In situations without tissue loss/infection, where the risk of graft infection is less, prosthetic material may be a better alternative.

Background: Comparison of intrathoracic latissimus dorsi (LD) versus serratus anterior (SA) muscle transposition for treatment of infected spaces, broncho-pleural fistulae, and for prophylactic reinforcement of the mediastinum after extended resections following induction therapy., Patients and Methods: Twenty LD and 17 SA transfers were performed for prophylactic reinforcement (11 LD; nine SA), and treatment of infections (nine LD; eight SA) from 1995 to 1998., Results: The 30-day mortality was 0% following prophylactic reinforcement and 29% following treatment of infections (three LD; two SA). Prophylactic mediastinal reinforcement was successful in 11 of 11 patients with LD and nine of nine with SA transpositions, and treatment of infected spaces in eight of nine patients with LD and two of three with SA transfers. Morbidity requiring re-intervention consisted of flap necrosis (one LD), bleeding (one SA), and skin necrosis over a winged scapula (one SA). Subcutaneous seromas and chest wall complaints were more frequent following LD (45 and 36%, respectively) compared with SA transfers (29 and 27%, respectively), whereas impaired shoulder girdle function was more frequent after SA than after LD transfer (27 vs. 21%)., Conclusion: Intrathoracic LD and SA muscle transpositions are both efficient for the prevention or control of infections following complex thoracic surgery, and are both associated with similar and acceptable morbidity and long-term sequelae.

Objectives: in a retrospective study, attempts have been made to identify individual organ-dysfunction risk profiles influencing the outcome after surgery for ruptured abdominal aortic aneurysms., Methods: out of 235 patients undergoing graft replacement for abdominal aortic aneurysms, 57 (53 men, four women, mean age 72 years [s.d. 8.8]) were treated for ruptured aneurysms in a 3-year period. Forty-eight preoperative, 13 intraoperative and 34 postoperative variables were evaluated statistically. A simple multi-organ dysfunction (MOD) score was adopted., Results: the perioperative mortality was 32%. Three patients died intraoperatively, four within 48 h and 11 died later. A significant influence for pre-existing risk factors was identified only for cardiovascular diseases. Multiple linear-regression analysis indicated that a haemoglobin <90 g/l, systolic blood pressure <80 mmHg and ECG signs of ischaemia at admission were highly significant risk factors. The cause of death for patients, who died more than 48 h postoperatively, was mainly MOD. All patients with a MOD score >/=4 died (n=7). These patients required 27% of the intensive-care unit (ICU) days of all patients and 72% of the ICU days of the non-survivors., Conclusion: patients with ruptured aortic aneurysms from treatment should not be excluded. However, a physiological scoring system after 48 h appears justifiable in order to decide on the appropriateness of continual ICU support., (Copyright 2000 Harcourt Publishers Ltd.)