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Background: In this study, the early and mid-term outcomes of Omniflow ® II (LeMaitre Vascular, Inc., Burlington, MA, USA) biosynthetic graft in redo surgery in patients with critical limb-threatening ischemia (CLTI) with no available autologous vein material were investigated with the aim to compare the outcomes obtained in "de novo" surgery versus redo surgery., Methods: From January 2018 until December 2022, data of CLTI patients from 18 centers in Italy with no autologous vein material underwent infrainguinal bypass with Omniflow ® II biosynthetic graft were collected. Thirty-day outcome measures including intraoperative technical success, major morbidity, mortality, and graft patency were assessed and compared. At two-year follow-up, estimated outcomes of survival, primary patency, primary assisted patency, secondary patency, freedom from reintervention, and amputation-free survival were analyzed using Kaplan-Meier curves and compared between groups using the log-rank test., Results: In the study period 119 CLTI patients had an infrainguinal bypass with Omniflow ® II biosynthetic graft. Seventy-seven patients (64.7%) underwent bypass as "de novo" treatment (group de novo), whilst in the remaining 42 patients (35.3%) the procedure was performed as redo surgery due to occlusion and/or infection of a previous bypass graft (group redo). Two groups were homogeneous in terms of demographic, clinical, and morphological data. In group redo explantation of an infected prosthetic graft was needed in 4 cases (9.5%). Intraoperative technical success was achieved in all cases in both groups. At 30 days, the overall patency rate did not differ between the two groups (69/77, 89.6%, group de novo vs. 35/42, 83.3%, group redo; P=0.24), whilst in group redo limb loss was higher with a statistically significant different 30-day major amputation rate between the two groups (11.9% group redo vs. 1.3% group de novo; P<0.001). Overall median duration of follow-up was eight months (IQR 6-13). At two-year follow-up there were no differences between the two groups in terms of survival (67.7% group de novo vs. 55.8% group redo, P=0.53), primary patency (34.4% group de novo vs. 26.8% group redo, P=0.25), primary assisted patency (43.6% group de novo vs. 28.8% group redo, P=0.12), freedom from reintervention (64.1% group de novo vs. 68.8% group redo, P=0.98), and amputation-free survival (67.8% group de novo vs. 60% group redo, P=0.12). Secondary patency was significantly higher in group de novo (53.7% vs. 32.3%, P=0.05). During the follow-up, the overall rates of graft infection and aneurysmal degeneration were 3.4%, and 0.8%, respectively., Conclusions: Nevertheless, poorer early outcomes in terms of limb salvage, Omniflow ® II biosynthetic graft offers acceptable ywo-year outcomes in redo surgery in CLTI patients with no available autologous vein material. Further studies with larger population sizes are needed to validate these outcomes.

Background: The aim of this study was to retrospectively analyze early and late outcomes of infrainguinal revascularization performed with the Omniflow-II ® (LeMaitre Vascular, Inc., Burlington, MA, USA) biosynthetic vascular graft (BVG) for complex femoro-popliteal obstructive disease., Methods: Over a 10-year period, this BVG was used in 110 patients who underwent infrainguinal femoro-popliteal or femoro-distal bypass. Early (intraoperative and <30 days) results were analyzed in terms of death, thrombosis, amputations and reinterventions. Follow-up results were analyzed in terms of primary and secondary graft patency, and amputation-free survival., Results: We performed 87 (79.1%) above-the-knee bypass, 20 (18.2%) below-the-knee bypass, and 3 (2.7%) tibial artery bypass. In-hospital mortality was not observed. Mean follow-up was 66±37 months (range, 3-150). Estimated primary patency rate at 1, 2 and 5-years of follow-up was 77%±4 (95%CI: 68-84), 73%±5 (95%CI: 63.5-83), and 59%±6 (95%CI: 47-70.5) respectively. Predictors of primary patency loss were the presence of critical limb ischemia (P=0.048; HR: 2.1; 95%CI: 1.01-4.28), and the necessity of below-the-knee bypass (P=0.012; HR: 2.4; 95%CI: 1.22-4.75). Aneurysmal degeneration of the BVG was detected in 4 (3.6%) patients, an infected BVG occurred in 3 (2.7%) patients. The amputation-free survival was 96%±2 (95%CI: 91-99), 93%±3 (95%CI: 86-96), and 76%±5 (95%CI: 66-84) at 1, 2 and 5-years respectively., Conclusions: In our experience, Omniflow-II ® is a valid first-line alternative for infrainguinal revascularization when the ipsilateral autologous saphenous vein is not available. Aneurysmal degeneration was lower than previously reported with alternative BVGs, and the incidence of BVG infection was acceptably low.

Objectives: The aim of this study was to present our experience with the management of isolated left vertebral artery during hybrid aortic arch repairs with thoracic endovascular aortic repair completion., Methods: This is a single-center, observational, cohort study. Between January 2007 and December 2018, 9 patients (4.5%) of 200 who underwent thoracic endovascular aortic repair were identified with isolated left vertebral artery. The isolated left vertebral artery was the dominant vertebral artery in 4 cases and entered the Circle of Willis to form the basilar artery in all cases. Isolated left vertebral artery transposition was performed in 2 patients during open ascending/arch repair before thoracic endovascular aortic repair completion. In 4 patients, isolated left vertebral artery transposition was performed concomitant with carotid-subclavian bypass during thoracic endovascular aortic repair completion ("zone 2" thoracic endovascular aortic repair). Primary outcomes were early (<30 days) and late survival, freedom from aortic-related mortality, and isolated left vertebral artery patency., Results: Primary technical success was achieved in all cases. Isolated left vertebral artery-related complication occurred in 1 patient (Horner syndrome). Immediate thrombosis, vagus/recurrent laryngeal nerve palsy, lymphocele, and chylothorax were never observed. Postoperative cerebrovascular accident or spinal cord injury was not observed. Median follow-up was 15 months (range, 3-72). We did not observe aortic-related mortality during the follow-up. Aortic-related intervention was never required. Both isolated left vertebral artery and carotid-subclavian bypass are still patent in all patients with no sign of anastomotic pseudoaneurysm or stenosis., Conclusions: Although isolated left vertebral artery is not a frequent occurrence, it is not so rare. It may pose additional difficulties during hybrid aortic arch surgical repairs, but isolated left vertebral artery transposition was feasible, safe, and a durable reconstruction., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to investigate the oncologic and surgical outcomes of patients treated with inferior vena cava (IVC) or iliac vein (IV) resection for retroperitoneal sarcoma (RPS). Surgery is the only curative option for patients with primary RPS. The IVC or IV can be directly invaded by RPS or can be the organ of origin of retroperitoneal leiomyosarcoma. In both cases, resection of the IVC or IV is required to achieve a complete resection., Methods: Patients who underwent IVC or IV resection for primary or recurrent RPS between 2000 and 2016 at a single referral institution were included in this retrospective study. The oncologic outcome was explored in terms of overall survival and crude cumulative incidence (CCI) of local recurrence and distant metastasis. Surgical outcomes were explored in terms of complications, renal function, lower limb edema, and vascular graft patency., Results: Sixty-seven patients were included: 24 IV resections (IV group), 39 IVC resections, and 4 IVC and IV resections (IVC group). The most frequent histologic types were leiomyosarcoma (63%) and liposarcoma (27%). Five-year overall survival, CCI of local recurrence, and CCI of distant metastasis (95% confidence interval) were 56.2% (43.6-72.4), 12.4% (5.2-29.5), and 51.5% (39.3-67.5). IVC was circumferentially resected in 38 of 43 patients; 32 were treated with graft reconstruction (22 with interposition of banked venous homograft [BVH] and 10 with polytetrafluoroethylene [PTFE] graft) and 6 with ligation only, mostly dependent on the presence of an adequate collateral vessel network. Patients with preoperative IVC obstruction treated with ligation only (n = 6) did not develop severe postoperative lower limb edema. IVC graft primary patency at 5 years was 100% in IVC PTFE grafts and 76.7% in IVC BVHs. Fifteen patients (22.4%) suffered a Clavien-Dindo grade ≥3 complication within 60 days of surgery., Conclusions: IVC or IV resection in the context of RPS surgery is of value in achieving long-term survival. A policy of vascular grafting in case of circumferential resection of a patent IVC or IV is rewarding. For IVC reconstruction, both BVHs and PTFE grafts offer good results in terms of high patency rate and low risk of infection., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Our series of secondary aorto prosthetic fistulas (PEF) to identify if and how different surgical treatment affect outcome is reviewed., Methods: Between 1982 and December 1999, in the authors department, 42 patients were investigated for a secondary PEF. Mean age was 65 years: the mean time interval since the primitive aortic procedure was 49 months. Twenty patients were treated in emergency surgery: 29 presented evidence of gastrointestinal bleeding. The preoperative work-up included esophagogastroduodenoscopy, CT scan, and aortography. The vast majority of PEF were in a duodenal location. Surgical procedure carried out was graft excision, bowel suture or bowel resection, aortic stump closure and axillofemoral (AXF) bypass (11), new in situ revascularization by synthetic prosthesis (5), simple suture (9), graft excision without revascularization (1), in situ revascularization using arterial homograft (13)., Results: The mean surgery duration was 4 hours and 53 minutes, the mean blood loss was 1845+/-1132. Two patients died shortly after proximal aortic control was obtained. Early overall mortality was 50%, the early overall bypass occlusion rate was 12.5%, the early overall amputation rate was 10%, and the early new PEF rate was 12.5%. Late overall mortality was 22.5%, the late overall bypass occlusion rate was 20%, the late overall amputation rate was 7.5%, and the late new PEF rate was 10%., Conclusions: Bleeding of the gastrointestinal tract in patients with a history of intra-abdominal reconstructive vascular surgery must raise severe suspicion as to the certainty of existence of a PEF unless the diagnostic procedure excludes this possibility. All treatment methods resulted in catastrophic failure, related to recurrent PEF or septic complication. Perhaps, in the presence of PEF extra-anatomical bypass associated with aortic ligature remains an interesting surgical solution.

The aim of the study is a retrospective review of clinical presentation and management of paraanastomotic aneurysms of the abdominal aorta (PAAA) surgically treated in our Department. From January 1984 to December 1998, 2183 aortic prosthetic grafts were implanted. During the same period, 24 patients were treated for PAAA, 19 false and five true aneurysms. Symptoms were present in 10 patients. Surgical management included tube grafting interposition (14), aortobifemoral bypass (2), graft removal with extraanatomic bypass (2) and with in situ revascularization by arterial homograft (4). Nine patients died during operation or in the early postoperative period, six died during follow-up. Mortality in symptomatic patients was 70%, while in asymptomatic group was 14% (P=0.01). Rupture of false PAAA was very frequent (47% of cases). PAAA are infrequent complications of proximal aortic graft revascularization and tend to be asymptomatic until rupture occurs. The incidence of mortality is very different in asymptomatic versus symptomatic group; rupture is particularly frequent in false PAAA, which must soon undergo surgery when diagnosed. Since PAAA may develop at any time after surgery, their incidence increase in relationship with the length of postoperative interval: therefore, all patients submitted to abdominal graft revascularization need a lifetime surveillance program.

We present two cases of partial graft removal and cryopreserved arterial homograft insertion for treatment of patent axillobifemoral (AXB) polytetrafluoroethylene (PTFE) prosthesis with infection confined only to a part of the graft. In the first patient, infection was confined to the left inguinal site; in the second, there was a cutaneous fistula in the middle prosthetic thoracic tract. Neither patient presented signs of systemic sepsis and radio immunological tests were positive only in a confined tract. After surgery, both patients showed early recovery and currently (mean follow-up 21-month) they are disease-free. Selective partial graft removal appears to give satisfactory results and may reduce the risk of complications compared with total graft removal Moreover, arterial homograft shows greater resistance to infection compared to alloplastic materials, when autologous veins are not available and/or not suitable.