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Objectives To compare expanded polytetrafluoroethylene (ePTFE) prosthesis and collagen-impregnated knitted polyester (Dacron) for above-knee (AK) femoro-popliteal bypass grafts. Design A prospective multicentre randomised clinical trial. Patients and Methods Between 1992 and 1996, 228 AK femoro-popliteal bypass grafts were randomly allocated to either an ePTFE ( n =114) or a Dacron ( n =114) vascular graft (6mm in diameter). Patients were eligible for inclusion if presenting with disabling claudication, rest pain or tissue loss. Follow-up was performed and included clinical examination and duplex ultrasonography at all scheduled intervals. All patients were treated with warfarin. The main end-point of this study was primary patency of the bypass graft at 2, 5 and 10 years after implantation. Secondary end-points were mortality, primary assisted patency and secondary patency. Cumulative patency rates were calculated with life-table analysis and with log-rank test. Results After 5 years, the primary, primary assisted and secondary patency rates were 36% (confidence interval (CI): 26–46%), 46% (CI: 36–56%) and 51% (CI: 41–61%) for ePTFE and 52% (CI: 42–62%) ( p =0.04), 66% (CI: 56–76%) ( p =0.01) and 70% (CI: 60–80%) ( p =0.01) for Dacron, respectively. After ten years these rates were respectively 28% (CI:18-38%), 31% (CI:19-43%) and 35% (CI: 23-47%) for ePTFE and 28% (CI: 18-38%), 49% (CI: 37-61%) and 49% (CI: 37-61%) for Dacron. Conclusion During prolonged follow-up (10 years), Dacron femoro-popliteal bypass grafts have superior patency compared to those of ePTFE grafts. Dacron is the graft material of choice if the saphenous vein is not available.

Background Despite several modifications to the original design, patency rates of radiocephalic arteriovenous fistulas have changed little since the first report in 1966. The use of non-penetrating clips for vascular anastomosis on the outcome of such fistulas was studied. Methods Between January 2000 and August 2003, 107 primary radiocephalic fistulas were constructed in 98 patients. The vascular anastomoses were performed at random with either sutures (n = 56) or clips (n = 51). Results Although there were trends for better primary and primary assisted patency of clipped fistulas, the differences were not statistically significant. The 6-month primary patency rate was 61 per cent with sutures and 69 per cent with clips (P = 0·393). The mean(s.d.) primary patency was 315(306) and 285(285) days for clipped and sutured fistulas respectively. With regard to secondary patency, clipped fistulas were better (P = 0·009). The mean(s.d.) secondary patency was 435(376) and 344(316) days for clipped and sutured fistulas, respectively. There were no significant differences in flow characteristics, number of revisions or other morbidity. Conclusion This randomized clinical trial provided further evidence that the use of vascular clips may improve the patency rate of radiocephalic arteriovenous fistulas for haemodialysis.

Introduction: Open repair of ruptured abdominal aortic aneurysm (rAAA) still has a high mortality. Endovascular aortic repair (EVAR) may be the way to improve survival rates. However, it is not clear how many patients with rAAA will be suitable for acute EVAR. Methods: Between October 2000 and April 2002 all patients with acute symptomatic or ruptured AAA were assessed for EVAR on an intention-to-treat basis with emergency computed tomographic angiography (CTA). Patient and logistic characteristics were analysed. We used two commercially available aorto uni-iliac devices with a maximum proximal diameter of 28 and 34 mm. Results: Five out of 26 patients were excluded for CTA and EVAR because of severe and persistent hypotension (3 pts) or logistic reasons (2 pts, both eligible). Twelve patients were found not eligible for EVAR due to unsuitable infrarenal aortic neck length (3 pts), neck diameter (1 pt) or a combination of both (8 pts). The remaining six patients were treated with EVAR. After 6 months no graft failure or aneurysm related deaths were recorded in the EVAR group. Conclusion: A total of 28% of patients with symptomatic or ruptured AAA was treated with EVAR. A potential 42% of patients could have been suitable for EVAR, if the correct devices had been in stock and all patients had been properly assessed.

Introduction and Methods: The most frequent complication of polytetrafluoroethylene (PTFE) arteriovenous grafts for hemodialysis is thrombotic occlusion due to stenosis caused by intimal hyperplasia. This complication is also known for peripheral bypass grafts. Because the use of a venous cuff at the distal anastomosis improves the patency of peripheral bypass grafts, we considered that it might also improve the patency of PTFE arteriovenous grafts. Therefore, a randomized multicenter trial was carried out to study the effect of a venous cuff at the venous anastomosis of PTFE arteriovenous grafts on the development of stenoses and the patency rates. Results: Of the 120 included patients, 59 were randomized for a venous cuff. The incidence of thrombotic occlusion was lower in the cuff group (0.68 per patient-year) than in the no-cuff group (0.88 per patient-year; P =.0007). However, the primary and secondary patency rates were comparable. The cuff group tended to have fewer stenoses at the venous and arterial anastomoses when examined with duplex scan. Graft failure was higher in patients with an initial anastomosing vein diameter smaller than 4 mm (7 of 18 [39%]) than in those with a vein diameter of 4 mm or larger (16 of 88 [18%]; P =.052). Local edema, skin atrophy, and obesity yielded a higher risk on graft failure (23% vs 11%). Conclusion: A venous cuff at the venous anastomosis of PTFE arteriovenous grafts for hemodialysis reduced the incidence of thrombotic occlusions; stenosis at the venous anastomosis was reduced. However, this did not result in a better patency rate. Therefore, the venous cuff should not be used routinely. Initial vein diameter and local problems (edema, obesity, or skin atrophy) appear to be the most important risk factors for graft failure. (J Vasc Surg 2000;32:1155-63.)

Objectives: The aim of this study was to compare externally supported thin wall knitted polyester (P-EXS) and externally unsupported thin wall knitted polyester (P-non-EXS) for above-knee (AK) femoro-popliteal bypass grafting.Design: A prospective multicenter randomised clinical trial.Material and methods: Between 1999 and 2008, 265 AK femoro-popliteal bypass grafts (6 mm in diameter) were performed, including 136 P-EXS and 129 P-non-EXS. The selection of patients was based on the presence of disabling claudication or critical ischaemia. Follow-up took place at 3, 6, 12, 18, and 24 months and included clinical examination and duplex ultrasonography. The main end points of this study were primary patency rates at one and two years. Secondary end points were mortality, and primary assisted and secondary patency rates. Cumulative patency rates were calculated with life-table analysis and log-rank testing.Results: The 1-year primary, primary assisted and secondary patency rates were 65%, 70% and 84%, respectively, for P-EXS and 76% (p = 0.05), 82% (p = 0.03) and 88% (p = 0.35), respectively, for P-non-EXS. Two-year primary, primary assisted and secondary patency rates were 45%, 57% and 70%, respectively, for P-EXS and 62% (p = 0.003), 75% (p = 0.005) and 84% (p = 0.02), respectively, for P-non-EXS. The overall mortality rate after two years was 11.3%.Conclusion: In above-knee femoro-popliteal bypass grafting patency rates of externally supported knitted polyester grafts were inferior to their unsupported counterpart. ISRCTN: At the time this study started this number was not the standard. (C) 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Background The effect on outcome of the introduction of endovascular techniques for the exclusion of abdominal aortic aneurysm (AAA) is largely unknown. The aim of the study was to contrast the early and mid-term outcome after open and endovascular AAA repair. Methods Consecutive patients who underwent transfemoral endovascular aneurysm repair (EVAR; n = 93) between April 1998 and January 2003, or conventional open aneurysm repair in the time intervals before (n = 113) and after (n = 82) the introduction of EVAR were studied. All data were collected prospectively. All patients underwent elective and primary repair. Patient survival was calculated by the Kaplan–Meier method and the possible predictive value of more than 25 perioperative variables on five outcome variables (length of intensive care unit stay, morbidity, and 30-day, 6-month and overall mortality) was assessed by multivariate analysis. Results There were no differences in risk profiles between the three groups. Selection for EVAR was based on anatomical grounds only. All five outcome variables were significantly better with EVAR than either former or recent open repair. The only significant predictors of failure were advanced age and the need to perform an additional procedure for former open repair; hypertension and the preoperative use of anticoagulants for recent open repair; and renal insufficiency and pulmonary insufficiency for EVAR. Conclusion EVAR offered considerable benefits compared with conventional open repair at early and mid-term follow-up, which was not explained by selection of patients with a favourable risk profile. In the current era, in which patients are selected for open repair as a consequence of unfavourable anatomy, morbidity and mortality rates following conventional open treatment of AAA have increased at early and mid-term, but not at long-term, follow-up.

Introduction renal arteries. The proximal neck of the aneurysm was 24 mm long and 23 mm wide, without thrombus or Endoluminal repair of infrarenal aneurysms of the calcifications, and consequently fit for endovascular abdominal aorta is still controversial. Much unfixation (Fig. 2). Preoperative kidney function was certainty continues to exist about its proper application normal (urea: 5.5 mmol/l and creatinine: 91 lmol/l). and its success and reliability. The patient was operated on under epidural anWe report two cases with different types of anaesthesia. An AneuRx 26/15/165 aortoiliac stent graft eurysms of the infrarenal abdominal aorta, in which was placed transfemorally, followed by a 16/115 iliac there is, in our view, a clear preference for endoluminal contralateral leg and two iliac extensions of 15/55 right exclusion of the aneurysm. and 16/55 left (Medtronic AVE, California, U.S.A.). Occlusion time of the aorta was 5.5 minutes, fluoroscopy time was 27 min, blood loss was 200 ml, and skin-to-skin time was 105 min. The postoperative course was uneventful, except for Cases a grade I wound infection of the right groin. The abdominal aorta was not painful on palpation any A 56-year-old man presented with a 2-week history more. The patient was fully ambulatory the day after of a progressive pain in the back and abdomen. The surgery. Postoperative kidney function remained norpatient was known to have an infrarenal aneurysm of mal (urea: 6.3 mmol/l and creatinine: 128 lmol/l). CT the abdominal aorta (diameter 40 mm) and a horseshoe scan and duplex scanning of the abdomen, on diskidney. On physical examination, the aorta was paincharge (fifth postoperative day) and after 12 months, ful. Pulsations in the femoral arteries existed. The showed no evidence of endoleak and a normal (horseankle–brachial index was 1.01 at the right and 1.00 at shoe) kidney function (Fig. 1B). The aneurysm size the left side. Preoperative work-up consisted of a spiral was decreased to 43 mm. computed tomography (CT) scan and an intra-arterial An 83-year-old man, who had recovered from a abdominal angiogram and resulted in an aneurysm of pneumococcal sepsis 6 months ago, was referred to the abdominal aorta with a largest diameter of 49 mm, our hospital with an asymptomatic saccular aneurysm expanding in the common iliac arteries. There was no of the infrarenal abdominal aorta with a diameter of significant angulation of the aortic neck, or iliac ar55 mm. Preoperative work-up consisted of spiral CT teries. The inferior mesenteric artery was occluded scan and intra-arterial abdominal angiogram, which and both the internal iliac arteries were patent. Both resulted in a saccular aneurysm with a largest diameter renal arteries divide high up, next to the superior of 60 mm. On spiral CT there was no evidence of aorta mesenteric artery (Fig. 1A). There were no aberrant wall infection. The erythrocyte sedimentation rate (ESR) was 20 mm/h. Therefore, an active mycotic aneurysm was unlikely. The inferior mesenteric artery ∗ Please address all correspondence to: R. H. Geelkerken, Deas well as both the iliac arteries were patent. There partment of Vascular Surgery, Medisch Spectrum Twente, P.O. Box: 50 000, 7500 KA Enschede, The Netherlands. was no significant angulation of the aortic neck, or

An internal arteriovenous (A-V) fistula fashioned at the wrist of the nondominant arm is the ideal form of angioaccess in patients requiring maintenance haemodialysis1. However, this technique is often not feasible, since adequate superficial arm veins are absent in many patients. In these patients an internal A-V access may be created by using venous autografts, modified allografts or xenografts, or prosthetic graft materials.