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Journal of Vascular Surgery Jun 2024Major adverse limb event-free survival (MALE-FS) differed significantly by initial revascularization approach in the BEST-CLI randomized trial. The BEST-CLI trial...
OBJECTIVE
Major adverse limb event-free survival (MALE-FS) differed significantly by initial revascularization approach in the BEST-CLI randomized trial. The BEST-CLI trial represented a highly selected subgroup of patients seen in clinical practice; thus, we examined the endpoint of MALE-FS in an all-comers tertiary care practice setting.
METHODS
This is a single-center retrospective study of consecutive, unique patients who underwent technically successful infrainguinal revascularization for chronic limb-threatening ischemia (2011-2021). MALE was major amputation (transtibial or above) or major reintervention (new bypass, open bypass revision, thrombectomy, or thrombolysis).
RESULTS
Among 469 subjects, the mean age was 70 years, and 34% were female. Characteristics included diabetes (68%), end-stage renal disease (ESRD) (16%), Wound, Ischemia, and foot Infection (WIfI) stage 4 (44%), Global Limb Anatomic Staging System (GLASS) stage 3 (62%), and high pedal artery calcium score (pMAC) (22%). Index revascularization was autogenous vein bypass (AVB) (30%), non-autogenous bypass (NAB) (13%), or endovascular (ENDO) (57%). The composite endpoint of MALE or death occurred in 237 patients (51%) at a median time of 189 days from index revascularization. In an adjusted Cox model, factors independently associated with MALE or death included younger age, ESRD, WIfI stage 4, higher GLASS stage, and moderate-severe pMAC, whereas AVB was associated with improved MALE-FS. Freedom from MALE-FS, MALE, and major amputation at 30 days were 90%, 92%, and 95%; and at 1 year were 63%, 70%, and 83%, respectively. MALE occurred in 144 patients (31%) and was associated with ESRD, WIfI stage, GLASS stage, pMAC score, and index revascularization approach. AVB had superior durability, with adjusted 2-year freedom from MALE of 72%, compared with 66% for ENDO and 51% for NAB. Within the AVB group, spliced vein conduit had higher MALE compared with single-segment vein (hazard ratio, 1.8; 95% confidence interval, 0.9-3.7; P = .008 after inverse propensity weighting), but there was no statistically significant difference in major amputation. Of the 144 patients with any MALE, the first MALE was major reintervention in 47% and major amputation in 53%. Major amputation as first MALE was associated with non-AVB index approach. Indications for major reintervention were symptomatic stenosis/occlusion (54%), lack of clinical improvement (28%), asymptomatic graft stenosis (16%), and iatrogenic events (3%). Conversion to bypass occurred after 6% of ENDO cases, two-thirds of which involved distal bypass targets at the ankle or foot.
CONCLUSIONS
In this consecutive, all-comers cohort, disease complexity was associated with procedural selection and MALE-FS. AVB independently provided the greatest MALE-FS and freedom from MALE and major amputation. Compared with the BEST-CLI randomized trial, MALE after ENDO in this series was more frequently major amputation, with relatively few conversions to open bypass.
Topics: Humans; Male; Female; Retrospective Studies; Aged; Limb Salvage; Amputation, Surgical; Risk Factors; Time Factors; Peripheral Arterial Disease; Middle Aged; Risk Assessment; Chronic Limb-Threatening Ischemia; Progression-Free Survival; Aged, 80 and over; Endovascular Procedures; Treatment Outcome
PubMed: 38401777
DOI: 10.1016/j.jvs.2024.02.022 -
European Journal of Cardio-thoracic... Mar 2024Our aim was to report an anatomic model of an autologous flap based on the internal thoracic blood supply: the pedicled thoraco-chondro-costal flap; and establish the...
OBJECTIVES
Our aim was to report an anatomic model of an autologous flap based on the internal thoracic blood supply: the pedicled thoraco-chondro-costal flap; and establish the feasibility of various types of extended tracheal replacement with this novel flap, according to a newly proposed topographic classification.
METHODS
In a cadaveric model, a cervicotomy combined with median sternotomy was performed. The incision was extended laterally to expose the chest wall. The internal thoracic pedicle was freed from its origin down to the upper limit of the delineated flap to be elevated. The perichondria and adjacent periostea were incised longitudinally to remove cartilages and adjacent rib segments, preserving perichondria and periostea. A full-thickness quadrangular chest wall flap pedicled on internal thoracic vessels was then elevated and shaped into a neo conduit to replace the trachea with the pleura as an inner lining.
RESULTS
Various types of extended non-circumferential and full-circumferential tracheal replacements were achieved with this composite flap. No anastomosis tension was noticed despite the absence of release manoeuvres.
CONCLUSIONS
This model could represent a suitable autologous tracheal substitute, which is long, longitudinally flexible and eventually transversely rigid. No microsurgical vascular anastomoses are required. The technique is reproducible. The perichondria and periostea would regenerate vascularized neo-cartilaginous rings, potentially decreasing the need for long-term stenting. The inner pleural lining could potentially transform into ciliated epithelium as shown in previous preclinical studies.
Topics: Humans; Plastic Surgery Procedures; Trachea; Stents; Ribs; Cadaver
PubMed: 38400739
DOI: 10.1093/ejcts/ezae063 -
Annals of Vascular Surgery Jun 2024Transcarotid artery revascularization (TCAR) is a hybrid technique with excellent initial outcomes. The technical success and safety of TCAR is heavily dependent on an...
BACKGROUND
Transcarotid artery revascularization (TCAR) is a hybrid technique with excellent initial outcomes. The technical success and safety of TCAR is heavily dependent on an anatomically suitable common carotid artery (CCA). Many patients do not meet anatomic criteria and therefore are not eligible for this therapy. We sought to extend the eligibility of TCAR to patients with unfavorable CCA anatomy via the adoption of a prosthetic arterial conduit.
METHODS
A single-center retrospective study of patients with critical carotid artery stenosis who underwent TCAR via a prosthetic conduit between June 2019 and October 2021 was performed. All patients in the study were considered high-risk for carotid endarterectomy based on anatomic features, such as restenosis post-carotid endarterectomy and neck radiation. Unfavorable CCA anatomy was defined as a clavicle to carotid bifurcation distance <5 cm, a CCA diameter <6 mm, and/or significant atherosclerotic disease at the intended arterial access site. The primary outcome of interest was technical success. Secondary outcomes included perioperative complications, intermediate and long-term patency, intermediate and long-term stroke and/or mortality and in-hospital length of stay. Follow-up ranged from 1 to 29 months.
RESULTS
Eight patients underwent 10 TCAR procedures via a prosthetic conduit. A total of 2 procedures (20%) were performed on female patients and 8 procedures (75%) were performed on male patients. The mean age was 65 years old (standard deviation 11 years). Technical success was 100%. The 30-day ipsilateral stroke rate was 0%. The 30-day patency was 90%. There was no re-exploration for hemorrhage and 30 day mortality was 0%.
CONCLUSIONS
TCAR is an excellent option for carotid artery revascularization. Unfavorable CCA anatomy has limited its applicability. TCAR via a prosthetic conduit has the potential to expand eligibility for this promising therapy.
Topics: Humans; Male; Female; Retrospective Studies; Aged; Treatment Outcome; Feasibility Studies; Blood Vessel Prosthesis; Carotid Stenosis; Time Factors; Vascular Patency; Blood Vessel Prosthesis Implantation; Middle Aged; Carotid Artery, Common; Risk Factors; Prosthesis Design; Aged, 80 and over; Endovascular Procedures; Risk Assessment
PubMed: 38395342
DOI: 10.1016/j.avsg.2023.12.075 -
JTCVS Techniques Feb 2024The configuration of the gastric conduit after esophagectomy can lead to chronic gastrointestinal and respiratory issues. Surgical revision of the gastric conduit has...
INTRODUCTION
The configuration of the gastric conduit after esophagectomy can lead to chronic gastrointestinal and respiratory issues. Surgical revision of the gastric conduit has been described in small series but appears to be infrequently used. We investigated outcomes of revising dilated or redundant conduit in patients with severe quality-of-life issues.
METHODS
We identified all patients from 2016 to 2022 at our institution who underwent gastric conduit revision after previous esophagectomy either at our or another institution. Chart review was performed to assess prerevision course and perioperative outcomes. Pre- and postrevision imaging was compared for all patients to assess the impact of surgery on anatomic configuration. Patient-reported gastrointestinal and respiratory issues before and after surgery were examined.
RESULTS
The use of right thoracotomy combined with laparotomy to reduce redundancy and improve gastric emptying was performed in 8 patients. The symptoms necessitating reoperation included intolerance to oral intake and poor gastric emptying associated with both acute and chronic aspiration episodes. The median length of stay was 8 [4, 25] days, and there were no perioperative mortalities. Seven (87.5%) patients were tolerating oral intake at discharge. All patients had improvement in their prerevision symptoms on follow-up.
CONCLUSIONS
Gastric conduit revision can improve severe postesophagectomy gastrointestinal and respiratory symptoms in patients with dilated/redundant conduits with limited perioperative morbidity.
PubMed: 38351992
DOI: 10.1016/j.xjtc.2023.11.006 -
Surgical Case Reports Feb 2024In patients with retrosternal neo-esophageal conduit after right thoracotomy, the approach to cardiac surgery could be challenging. Particularly, in patients with...
BACKGROUND
In patients with retrosternal neo-esophageal conduit after right thoracotomy, the approach to cardiac surgery could be challenging. Particularly, in patients with infective endocarditis, there is a risk of injury to the conduit through standard median sternotomy. Moreover, right lung adhesions could be predicted. Herein, we present a case of successful mitral valve repair in a patient with infective endocarditis through a redo right thoracotomy after esophageal reconstruction.
CASE PRESENTATION
A 66-year-old male patient was diagnosed with infective endocarditis and a large anterior mitral leaflet vegetation after a previous esophageal reconstruction via right thoracotomy for esophageal cancer. Due to the retrosternal esophageal reconstruction, we performed a mitral valve repair through a redo right thoracotomy. After resecting the vegetation, the defect was closed with a fresh autologous pericardial patch. Mitral valve annuloplasty was performed. Postoperatively, antibiotics controlled the infection. The patient was discharged on postoperative day 30.
CONCLUSIONS
Successful mitral valve repair was performed for infective endocarditis through a redo right thoracotomy after esophageal reconstruction.
PubMed: 38332244
DOI: 10.1186/s40792-024-01836-7 -
Proceedings of the National Academy of... Feb 2024Tree mortality due to global change-including range expansion of invasive pests and pathogens-is a paramount threat to forest ecosystems. Oak forests are among the most...
Tree mortality due to global change-including range expansion of invasive pests and pathogens-is a paramount threat to forest ecosystems. Oak forests are among the most prevalent and valuable ecosystems both ecologically and economically in the United States. There is increasing interest in monitoring oak decline and death due to both drought and the oak wilt pathogen (). We combined anatomical and ecophysiological measurements with spectroscopy at leaf, canopy, and airborne levels to enable differentiation of oak wilt and drought, and detection prior to visible symptom appearance. We performed an outdoor potted experiment with saplings subjected to drought stress and/or artificially inoculated with the pathogen. Models developed from spectral reflectance accurately predicted ecophysiological indicators of oak wilt and drought decline in both potted and field experiments with naturally grown saplings. Both oak wilt and drought resulted in blocked water transport through xylem conduits. However, oak wilt impaired conduits in localized regions of the xylem due to formation of tyloses instead of emboli. The localized tylose formation resulted in more variable canopy photosynthesis and water content in diseased trees than drought-stressed ones. Reflectance signatures of plant photosynthesis, water content, and cellular damage detected oak wilt and drought 12 d before visual symptoms appeared. Our results show that leaf spectral reflectance models predict ecophysiological processes relevant to detection and differentiation of disease and drought. Coupling spectral models that detect physiological change with spatial information enhances capacity to differentiate plant stress types such as oak wilt and drought.
Topics: Ecosystem; Quercus; Droughts; Forests; Trees; Water
PubMed: 38315867
DOI: 10.1073/pnas.2316164121 -
Journal of Vascular Surgery Jun 2024Cryopreserved (CP) products are utilized during challenging cases when autogenous or prosthetic conduit use is not feasible. Despite decades of experience with cadaveric...
OBJECTIVE
Cryopreserved (CP) products are utilized during challenging cases when autogenous or prosthetic conduit use is not feasible. Despite decades of experience with cadaveric greater saphenous vein (GSV), there is limited available data regarding the outcomes and patency of other CP products, specifically arterial and deep venous grafts. This study was designed to evaluate outcomes of non-GSV CP conduits in patients undergoing urgent, emergent, and elective arterial reconstruction at our institution. We hypothesized that non-GSV CP allografts have adequate patency and outcomes and are therefore a feasible alternative to GSV in settings where autologous graft is unavailable or prosthetic grafts are contraindicated.
METHODS
This study was approved by the Institutional Review Board at our institution. We retrospectively reviewed charts of patients undergoing arterial reconstructions using CP conduits from 2010 to 2022. Data collected included demographics, comorbidities, smoking status, indications for surgery, indication for CP conduit use, anatomic reconstruction, urgency of procedure, and blood loss. Time-to-event outcomes included primary and secondary graft patency rates, follow-up amputations, and mortality; other complications included follow-up infection/reinfection and 30-day complications, including return to the operating room and perioperative mortality. Time-to-event analyses were evaluated using product-limit survival estimates.
RESULTS
Of 96 identified patients receiving CP conduits, 56 patients received non-GSV conduits for 66 arterial reconstructions. The most common type of non-GSV CP product used was femoral artery (31 patients), followed by aorto-iliac artery (22 patients), and femoral vein (19 patients), with some patients receiving more than one reconstruction or CP product. Patients were mostly male (75%), with a mean age of 63.1 years and a mean body mass index of 26.7 kg/m. Indications for CP conduit use included infection in 53 patients, hostile environment in 36 patients, contaminated field in 30 patients, tissue coverage concerns in 30 patients, inadequate conduit in nine patients, and patient preference in one patient. Notably, multiple patients had more than one indication. Most surgeries (95%) were performed in urgent or emergent settings. Supra-inguinal reconstructions were most common (53%), followed by extra-anatomic bypasses (47%). Thirty-day mortality occurred in 10 patients (19%). Fifteen patients (27%) required return to the operating room for indications related to the vascular reconstructions, with 10 (18%) cases being unplanned and five (9%) cases planned/staged. Overall survival at 6, 12, and 24 months was 80%, 68%, and 59%, respectively. Primary patency at 6, 12, and 24 months was 86%, 70%, and 62%, respectively. Amputation freedom at 6 months, 12 months, and 24 months was 98%, 95%, and 86%, respectively for non-traumatic indications.
CONCLUSIONS
Non-GSV CP products may be used in complex arterial reconstructions when autogenous or prosthetic options are not feasible or available.
Topics: Humans; Retrospective Studies; Male; Female; Aged; Vascular Patency; Middle Aged; Cryopreservation; Time Factors; Treatment Outcome; Risk Factors; Blood Vessel Prosthesis Implantation; Arteries; Amputation, Surgical; Peripheral Arterial Disease; Limb Salvage; Plastic Surgery Procedures; Aged, 80 and over; Blood Vessel Prosthesis; Postoperative Complications
PubMed: 38286153
DOI: 10.1016/j.jvs.2024.01.201 -
Archives of Medical Sciences.... 2023Choosing appropriate bypass conduits is important in the consideration of long-term outcomes after surgical revascularization. When deciding on a grafting strategy,...
Choosing appropriate bypass conduits is important in the consideration of long-term outcomes after surgical revascularization. When deciding on a grafting strategy, attention should be given to technical, anatomic, and angiographic determinants of conduit properties, as well as the clinical characteristics of the patient. The aim of the study was to present a current review of available choices of conduits in coronary artery bypass surgery. To date, only 4 conduits have proven to be effective: the saphenous vein (SVG), the internal mammary arteries (IMAs), the radial artery (RA), and the right gastroepiploic artery (RGEA). The IMA has unique biological properties that confer protection to intimal growth and atherosclerotic plaque formation, making it the conduit of choice for coronary artery bypass grafting. SVG exhibits a lower patency rate than those of IMAs. The RGEA allows revascularization of the inferior wall but is less commonly used, given that it is more prone to spasms.
PubMed: 38089163
DOI: 10.5114/amsad/170215 -
The Journal of Surgical Research Mar 2024Study aims were to evaluate the elastic properties of vascular substitutes frequently used for pulmonary artery (PA) replacement, and then to compare their compliance... (Review)
Review
INTRODUCTION
Study aims were to evaluate the elastic properties of vascular substitutes frequently used for pulmonary artery (PA) replacement, and then to compare their compliance and stiffness indexes to those of human PA.
METHODS
A bench-test pulsatile flow experiment was developed to perfuse human cadaveric vascular substitutes (PA, thoracic aorta, human pericardial conduit), bovine pericardial conduit, and prosthetic vascular substitutes (polytetrafluorethylene and Dacron grafts) at a flow and low pulsed pressure mimicking pulmonary circulation. Intraluminal pressure was measured. An ultrasound system with an echo-tracking function was used to monitor vessel wall movements. The diameter, compliance, and stiffness index were calculated for each vascular substitute and compared to the human PA at mean pressures ranging from 10 to 50 mmHg.
RESULTS
The compliance of the PA and the thoracic aorta were similar at mean physiological pressures of 10 mmHg and 20 mmHg. The PA was significantly less compliant than the aorta at mean pressures above 30 mmHg (P = 0.017). However, there was no difference in stiffness index between the two substitutes over the entire pressure range. Compared to the PA, human pericardial conduit was less compliant at 10 mmHg (P = 0.033) and stiffer at 10 mmHg (P = 0.00038) and 20 mmHg (P = 0.026). Bovine pericardial conduit and synthetic prostheses were significantly less compliant and stiffer than the PA for mean pressures of 10, 20, and 30 mmHg. There were no differences at 40 and 50 mmHg.
CONCLUSIONS
Allogenic arterial grafts appear to be the most suitable vascular substitutes in terms of compliance and stiffness for PA replacement.
Topics: Humans; Animals; Cattle; Pulmonary Artery; Ultrasonography; Pulsatile Flow
PubMed: 38039727
DOI: 10.1016/j.jss.2023.10.022 -
Plant Methods Nov 2023The evolution of plants to efficiently transport water and assimilates over long distances is a major evolutionary success that facilitated their growth and colonization... (Review)
Review
The evolution of plants to efficiently transport water and assimilates over long distances is a major evolutionary success that facilitated their growth and colonization of land. Vascular tissues, namely xylem and phloem, are characterized by high specialization, cell heterogeneity, and diverse cell components. During differentiation and maturation, these tissues undergo an irreversible sequence of events, leading to complete protoplast degradation in xylem or partial degradation in phloem, enabling their undisturbed conductive function. Due to the unique nature of vascular tissue, and the poorly understood processes involved in xylem and phloem development, studying the molecular basis of tissue differentiation is challenging. In this review, we focus on methods crucial for gene expression research in conductive tissues, emphasizing the importance of initial anatomical analysis and appropriate material selection. We trace the expansion of molecular techniques in vascular gene expression studies and discuss the application of single-cell RNA sequencing, a high-throughput technique that has revolutionized transcriptomic analysis. We explore how single-cell RNA sequencing will enhance our knowledge of gene expression in conductive tissues.
PubMed: 37981669
DOI: 10.1186/s13007-023-01109-8