Search Results (64)

Chronic limb-threatening ischemia (CLTI) in patients with no conventional targets for revascularization presents a formidable challenge in limb salvage. Deep venous arterialization (DVA) is an emerging endovascular approach that redirects arterial blood flow into the venous system to perfuse the ischemic foot. Despite early promising results, appropriate wound management of the ischemic foot following a DVA procedure has been described in the literature, albeit infrequently and with limited standardization. Here, we present a case of an 85-year-old male with multiple comorbidities, including peripheral artery disease and a prior right above-knee amputation (AKA), who underwent a successful left-sided DVA following an open transmetatarsal amputation (TMA) for infection. A staged wound care approach with guillotine amputation, delayed revision and skin grafting ultimately preserved his only remaining limb and allowed for ambulation. This case underscores the potential of DVA as a limb-saving option in complex “no-option” patients when paired with multidisciplinary care and tailored wound management. Full article

Background: Multiple arterial grafting (MAG) is associated with superior long-term outcomes in coronary artery bypass grafting (CABG). The influence of prior myocardial infarction (MI) on outcomes following MAG remains uncertain. This study evaluates in-hospital outcomes and long-term survival of MAG in patients with and without previous MI. Methods: A retrospective single-center observational analysis of 2468 patients undergoing MAG was performed. Propensity score matching yielded 911 pairs based on preoperative variables. Kaplan–Meier survival analysis and Cox regression were used to assess long-term survival and predictors of mortality. Results: In the unmatched cohort, patients with prior MI had significantly higher rates of diabetes (30.6% vs. 23.9%, p < 0.001), smoking history (p < 0.001), and impaired left ventricular function (fair/poor LVEF: 32.4% vs. 11.1%, p < 0.001), along with higher logistic EuroSCORE (3.81 vs. 3.11, p < 0.001). After matching, baseline characteristics were balanced. In-hospital outcomes, including 30-day mortality (1.5% vs. 1.9%, p = 0.587), stroke, reoperation, and renal complications, were similar. Long-term survival at 10, 15, and 20 years was comparable (log-rank p = 0.814). Multivariate Cox regression identified age (HR 1.065, p < 0.001), NYHA class, diabetes (HR 0.779, p = 0.008), and off-pump CABG (HR 1.444, p < 0.001) as independent predictors of mortality. Prior MI was not associated with increased long-term mortality (HR 0.872, p = 0.105). Conclusions: Despite worse baseline risk profiles, patients with prior MI undergoing MAG had equivalent in-hospital outcomes and long-term survival. MAG remains a robust revascularization strategy irrespective of MI history, supporting its broader use in CABG. These findings should be interpreted in the context of a single-center experience from a high-volume arterial grafting program. Full article

Background/Objectives: Successful revascularization following extremity arterial injury is critical for survival and limb salvage. Graft repair is required in ~45% of patients, with the autologous vein preferred for its efficacy and safety. When unavailable, synthetic or non-autologous grafts are associated with infection, amputation, and reduced durability. Extremity arterial injury-specific cost data are lacking, with estimates extrapolated from the general trauma literature. This study characterized the costs and post-discharge healthcare resource utilization (HCRU) for U.S. adults with extremity arterial injury undergoing graft repair. Methods: Adults with extremity arterial injury undergoing graft repair (January 2018 to March 2023) were identified from the linked PINC AI Healthcare Database and Inovalon all-payer claims. Hospitalization charges, costs, and 18-month post-discharge HCRU and costs were assessed. Two-part models estimated cost drivers, adjusted for demographics, clinical characteristics, and complications. Results: Among 964 patients, grafts were autologous (74%), synthetic (14%), other (6%), or multiple (6%). Mean initial hospitalization charges and reimbursed costs were $316,600 and $75,947, respectively. Charges/costs increased with orthopedic fracture (+$639,558/+$91,462), graft infection (+$589,921/+$84,598), and amputation (+$492,986/+$116,611) (all p < 0.05). Mean post-discharge costs were $70,222 at 6 months and $93,639 at 18 months. Initial hospitalization complications predicted increased post-discharge costs: orthopedic fracture ($138,683–$145,360) and graft infection ($389,376–$422,224) (both p < 0.01). Post-discharge aneurysm, graft infection, and thrombectomy were also associated with higher costs (all p < 0.05). Post-discharge HCRU was lowest and most stable with the autologous vein. Conclusions: In-hospital and post-discharge complications are major cost drivers following arterial graft repair. Graft infection was associated with significantly increased costs across both periods, and non-autologous graft use was associated with disproportionately higher 18-month HCRU. Full article

Background and Clinical Significance: Revascularization of the circumflex territory remains technically challenging because of its anatomical position and the frequent need for distal branch grafting. Case presentation: We report the case of a 76-year-old man in whom the proximal circumflex trunk was used as the target for an in situ right internal thoracic artery routed through the transverse sinus during combined coronary and ascending aortic surgery. This approach allowed antegrade perfusion of the circumflex territory while avoiding multiple distal anastomoses. In this selected anatomical setting, the technique proved feasible and was associated with excellent intraoperative flow and 1-year radiological patency. Conclusions: Direct grafting of the circumflex trunk is not a new concept, but this case revisits it using a contemporary total arterial revascularization strategy. This approach may represent a useful adjunctive option in carefully selected patients with favorable circumflex anatomy. Full article

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are the two dominant revascularisation strategies for obstructive coronary artery disease, yet their relative roles continue to shift because they address coronary pathophysiology differently with ever-evolving techniques. PCI has advanced through iterative improvements, including balloon angioplasty, bare-metal stents, and drug-eluting stents, with contemporary outcomes increasingly driven by procedural optimisation using intracoronary imaging and physiology-guided lesion selection rather than device category alone. CABG has progressed through perioperative management, improvements in operative safety, and, critically, conduit durability. Recognition of progressive saphenous vein graft failure has underpinned a conduit-optimisation era in which the left internal mammary artery to left anterior descending artery remains the gold standard. Further, broader arterial grafting (including radial artery use, multiple arterial grafting, and selected total-arterial strategies) has been increasingly applied, albeit with deliverability and competing-risk constraints highlighted in randomised evidence. This perspective review reframes the CABG versus PCI comparison not as a binary contest, but as a context-dependent assessment in which the relative value of each strategy depends on the specific technologies, techniques, and conduits available at the time of comparison. We summarise comparative effectiveness where evidence is most consistent and where it remains sensitive to anatomy, comorbidity, and endpoint definitions. In diabetes with multivessel disease, trial data favour CABG for long-term survival and clinical outcomes despite higher stroke risk. In left main disease, outcomes depend on lesion pattern and overall complexity, with trial-era stent technology and composite endpoint definitions influencing conclusions. In ischaemic left ventricular dysfunction, a long-term survival benefit is established for CABG added to medical therapy, while multi-vessel PCI has not demonstrated comparable prognostic modification in contemporary data. We then examine hybrid coronary revascularisation as territory-specific allocation, highlighting its physiological rationale, program dependence, and limited, adequately powered randomised evidence. Finally, we outline how artificial intelligence (AI) and robotics may accelerate a precision revascularisation paradigm by standardising lesion assessment, supporting procedural planning, improving procedural reproducibility, and enabling more patient-specific selection among PCI, contemporary CABG with optimised conduits, and hybrid pathways. Full article

Ischemic cardiomyopathy is defined as coronary artery disease accompanied by left ventricular dysfunction with an ejection fraction equal to or less than 40%. The substrate of ischemic cardiomyopathy is heterogeneous, characterized by the coexistence of normal, stunned, hibernating, and scarred myocardium within the same myocardial region. Altogether, these components may represent different phases of a single pathological process. It is well-established that the assessment of isolated myocardial viability and ischemia alone has failed to reliably guide the indication for coronary artery bypass grafting (CABG). CABG in patients with low ejection fraction carries a significant risk of perioperative mortality and morbidity, largely related to the development of postcardiotomy shock. Preoperative optimization with pharmacologic or mechanical circulatory support (MCS) is often essential; the decision requires integrating multiple complex factors, including clinical presentation, response to optimization therapy, myocardial viability, the presence of hibernating or scarred myocardium, left ventricular end-systolic volume index, coronary angiography findings, hemodynamic assessment, and the Pulmonary Arterial Pressure Index score. A preoperative evaluation that incorporates anatomical, morphological, functional, and hemodynamic domains enables more precise selection and timing of MCS. Preemptive left ventricular unloading mitigates the physiological impact of cardiopulmonary bypass, preserves end-organ perfusion, and reduces the need for high-dose vasopressors. However, the risk–benefit ratio remains uncertain and may be associated with serious complications. Careful judgment regarding the indications for MCS has the potential to enhance the safety of CABG in high-risk patients, but robust, long-term, prospective studies are needed to determine its true impact on clinical outcomes. In this review, we will examine the indications and criteria for the use of MCS in patients with advanced ischemic cardiomyopathy, as well as the various devices available for preoperative or intraoperative support, including technical considerations, advantages and disadvantages, and associated complications. Full article

Vein graft disease remains a significant limitation to the long-term patency of venous conduits following coronary artery bypass grafting. Early oxidative stress, triggered by ischaemia–reperfusion injury and haemodynamic changes following the implantation of veins into the arterial circulation, disrupts endothelial integrity and initiates inflammation, apoptosis, and maladaptive remodelling. The KEAP1-NRF2 axis is a central regulator of cellular antioxidant responses; however, its role in the development of vein graft disease remains poorly defined. This narrative review aimed to summarise what is known about NRF2/KEAP1 signalling in modulating vein graft pathology. Methods: A systematic search of PubMed was conducted to identify original research studies examining the NRF2/KEAP1 pathway in human saphenous vein tissue in vivo or ex vivo. Narrative synthesis was performed due to limited evidential availability and study heterogeneity. Results: Only one study has directly evaluated NRF2 pathway activation directly in human saphenous vein tissue, and it demonstrated that Protandim (a herbal dietary supplement) treatment increased antioxidant enzyme activity and reduced oxidative stress markers, including superoxide and 4-hydroxynonenal, both known activators of MAPK-dependent smooth muscle proliferation. Adjacent studies in other cells and tissues reveal that NRF2 intersects with multiple pathways central to vein graft pathology: it suppresses NFκB-mediated inflammation, modulates eNOS-NO signalling, inhibits NADPH oxidase expression, regulates MAPK activation, and influences angiogenic responses. However, context-dependent activation of NRF2 under arterial cyclic stretch can paradoxically drive proliferation through p62-mediated KEAP1 sequestration and enhanced glutathione synthesis. Conclusions: The NRF2/KEAP1 pathway serves as a central integrator of oxidative stress responses that directly intersect with established mechanisms of intimal hyperplasia and pathological angiogenesis. Post-translational KEAP1 inhibition may offer a targeted intervention point to limit these processes. Critical gaps remain regarding our understanding of the role of NRF2 in human saphenous vein under physiological arterial conditions and sex-specific pathway regulation. Mechanistic studies in vein-specific models are essential for advancing our understanding and any potential therapeutic translation. Full article

Activation of JAK/STAT and MAPK/ERK1,2 signalling pathways has been shown to increase the production of reactive oxygen species (ROS) in multiple cell types involved in cardiovascular diseases (CVDs), including vascular smooth muscle cells (VSMCs). However, these have not yet been studied in human saphenous vein SMCs (HSVSMCs) responsible for the maladaptive remodelling leading to saphenous vein graft failure (VGF), to which patients with type 2 diabetes mellitus (T2DM) are more susceptible. Therefore, this study aimed to evaluate the contributions of the JAK/STAT and MAPK/ERK1,2 pathways towards production of mitochondrial ROS (mROS) in HSVSMCs from T2DM patients versus non-diabetic controls. HSVSMCs explanted from surplus HSV tissues from consenting patients undergoing coronary artery bypass graft surgery were stimulated in vitro with mitogenic stimuli known to be involved in neointimal hyperplasia (NIH) and VGF, which are known activators of the JAK/STAT and the MAPK/ERK1,2 signalling pathways. Flow cytometry was then used to analyse the production of mROS (superoxide) in MitoSOX-stained HSVSMCs. Additionally, we examined the effect of ruxolitinib and trametinib, selective inhibitors of JAK1/2 and MEK1/2 signalling pathways, respectively, on mROS levels in these cells. From our findings, mROS production was significantly higher in HSVSMCs from T2DM patients versus non-diabetic controls. Activation of either the JAK/STAT or MAPK/ERK1,2 signalling pathways did not significantly alter the production of mROS in HSVSMCs from both T2DM and non-diabetic patients. However, inhibition of JAK/STAT and MAPK/ERK1,2 signalling pathways with ruxolitinib and trametinib, respectively, resulted in a significant reduction in mROS in HSVSMCs from both T2DM and non-diabetic patients. Our findings demonstrate a JAK/STAT- and MAPK/ERK1,2-mediated production of mROS in HSVSMCs. Hence, they are potential targets for drug development to limit ROS production in ROS-driven proliferation and migration of HSVSMCs responsible for VGF. Full article

Background: Coronary artery bypass grafting (CABG) is a well-established revascularization strategy for patients with multivessel coronary artery disease. The effectiveness of CABG is significantly influenced by antiplatelet therapy aimed at maintaining graft patency and reducing thrombotic complications. However, substantial inter-individual variability exists in platelet function responses to standard therapies such as aspirin and clopidogrel, leading to antiplatelet resistance. This variability has been linked to increased risks of myocardial infarction, stroke, and early graft failure. Platelet function testing (PFT) offers a potential strategy to identify resistance and guide more personalized antiplatelet therapy. This study aims to evaluate the association between perioperative platelet function test results and clinical outcomes following CABG. By assessing platelet responsiveness at multiple timepoints and correlating findings with postoperative events, the study seeks to determine whether PFT can stratify risk and improve patient management. Methods: This is a prospective, single-centre, observational cohort study conducted at a tertiary NHS cardiac surgery centre. Patients having elective or urgent isolated CABG will be enrolled and undergo perioperative PFT using the TEG6s system. Clinical outcomes will be monitored for 12 months postoperatively, with primary endpoints assessing the correlation between platelet function results and major adverse cardiovascular and cerebrovascular events (MACCE). Secondary endpoints will include the prevalence of antiplatelet resistance, demographic predictors, and the feasibility of integrating PFT into clinical workflows. Results: This study will report the prevalence of aspirin and clopidogrel resistance in CABG patients based on TEG6s PFT, as well as the correlation between platelet function results and MACCE, postoperative bleeding, and the need for surgical re-exploration. Additionally, it will examine the associations between demographic and clinical factors—such as diabetes status, renal function, BMI, and surgical technique—and variability in platelet responsiveness. The feasibility of incorporating PFT into perioperative workflows will also be evaluated, assessing whether results could support personalized antiplatelet management in future clinical trials. Conclusions: Findings from this study will provide real-world evidence regarding platelet function variability in CABG patients and suggest that PFT may identify those at increased risk of thrombotic complications. This exploratory analysis supports the need for larger interventional trials aimed at optimizing individualized postoperative antiplatelet therapy to improve surgical outcomes. Full article

Background/Objectives: Arteriovenous grafts (AVGs) are critical for hemodialysis access in patients with inadequate native vasculature. The Xeltis aXess graft, a novel bioresorbable vascular access conduit, promotes endogenous tissue restoration. While early outcomes have been promising, longer-term data remain limited. This report presents the longest reported, four-year follow-up on two of the first implanted aXess devices. Case Summaries: Case 1: A 64-year-old woman underwent aXess graft placement on 10 June 2021, between the right brachial artery and vein. She experienced graft thrombosis after 12 months and 18 months, both of which were successfully resolved with thrombectomy, in one instance in combination with drug-coated balloon (DCB) angioplasty. The graft remains functional. Case 2: A 76-year-old man received an aXess graft on 11 June 2021, in the left arm. After 6 months, he underwent balloon and DCB angioplasty for graft–vein (G–V) anastomosis stenosis. After 28 months, to resolve multiple pseudoaneurysms, followed by aneurysm resection and AVG reconstruction at month 29, a tunneled catheter was placed to perform dialysis sessions in the meantime. At month 44, graft-venous (G–V) angioplasty with DCB was performed to resolve G–V and axillary vein stenoses diagnosed at month 43. The graft remains in use. Results: Both patients retained functional dialysis access after four years, despite requiring multiple interventions for thrombosis, stenosis, and pseudoaneurysms. Conclusions: These cases demonstrate that the aXess graft can maintain functionality over four years with appropriate management, although close surveillance and reinterventions may be required. Full article

Background and Objectives: In the current era of solid organ transplantation, the gap between available donors and patients on the waiting list is widening. Worldwide, surgeons are confronted with the challenge of optimizing the utilization of renal grafts, including the presence of multiple renal arteries (MRA), occurring in 20% to 30% of cases. The presence of a lower polar artery (LPA), which provides a significant vascular contribution to both the lower renal parenchyma and the upper urinary tract, constitutes an additional challenge, but its preservation is fundamental for the outcome of the kidney transplant (KT). The end-to-end (E/E) anastomosis with the recipient’s inferior epigastric artery (IEA) has been rarely reported in the literature, with variable results. The aim of this study is to report on technical aspects as well as on short- and long-term outcomes of this reconstruction in KT. Materials and Methods: A retrospective three-centre analysis was conducted on 13 KTs in which the graft’s LPA was anastomosed E/E with the recipient’s IEA. Results: Following an average follow-up period of 84 months, the patient and graft survival rate was 100%. Neither vascular nor urological complications were observed. Conclusions: In the event of KT with LPA, an E/E anastomosis with IEA performed with microsurgical technique is safe and provides excellent long-term results. Full article

A 62-year-old man presented with ST-elevation myocardial infarction and advanced tophaceous gout, despite long-term urate-lowering therapy. His history included chronic kidney disease, hypertension, heart failure, and atrial fibrillation. Examination revealed severe joint deformities with multiple tophi. Coronary angiography showed multivessel disease with critical right coronary artery stenosis, treated with primary percutaneous coronary intervention. Following a Heart Team consultation, the patient was bridged with cangrelor and underwent urgent hybrid coronary artery bypass grafting and left atrial appendage occlusion. This case highlights the systemic burden of treatment-refractory gout, with progressive cardiovascular and renal complications. Tophaceous gout represents a distinct, high-risk phenotype associated with increased mortality and reduced quality of life. Despite standard therapies, this patient experienced continued disease progression, prompting referral for advanced treatment with pegloticase and canakinumab. Multidisciplinary care and personalized strategies are essential in managing severe, refractory gout with multi-organ involvement. Full article

Background/Objectives: Heart failure (HF) with reduced ejection fraction (EF) has, in more than 50% of cases, an ischemic etiology and continues to be associated with increased mortality and morbidity despite all the progress registered in the field of medical therapy and interventional revascularization. Myocardial revascularization is extensively used in clinical practice based on the traditional concept that it can improve myocardial function and outcome in ischemic HF. This review is aimed at presenting current knowledge regarding revascularization in patients with chronic ischemic HF and reduced EF. Methods: The impact of revascularization on symptomatology, left ventricle reverse remodeling, major adverse cardiac events (MACEs), and the role of complete revascularization and of percutaneous interventional revascularization in chronic total occlusion (PCI-CTO) were analyzed. The best therapeutic strategies, revascularization and/or optimal medical therapy (OMT), are debated in different categories of patients, in order to identify who will benefit more from revascularization strategies. Results: Based on the long-term results of the STICH trial incorporated in the guidelines with a class I-b recommendation, coronary artery bypass graft (CABG) remains the main modality of revascularization for prognostic improvement in ischemic HF with multivessel disease. But real-life patients are usually old with multiple comorbidities and high surgical risk. In this category, the Heart Team opinion is required to evaluate the probability of complete revascularization and to choose between percutaneous coronary intervention (PCI) and CABG according to clinical status and coronary anatomy. Conclusions: However, until further studies are available, the results of the REVIVED-BCIS2 trial encourage OMT over PCI in patients with ischemic cardiomyopathy. The available randomized controlled trials (RCTs) showed improved angina and quality of life in PCI-CTO versus OMT, but the effect on MACEs was not demonstrated. Full article

Coronary artery bypass grafting (CABG) has evolved into a cornerstone treatment for coronary artery disease, with graft selection playing a critical role in long-term outcomes. Multiple arterial grafting (MAG) represents a significant advancement over single arterial grafting, utilizing conduits such as the internal thoracic artery and radial artery to enhance graft durability and patient survival. This review examines the outcomes, challenges, and controversies associated with MAG, highlighting its superior patency rates and reduced need for repeat revascularization procedures. While the technique provides long-term survival benefits, concerns such as the complexity of surgical techniques, increased operative time, and higher resource utilization underscore the importance of surgeon expertise and institutional infrastructure. Patient selection remains critical, as factors like age, comorbidities, and gender influence outcomes and highlight disparities in access to MAG. Emerging evidence addresses debates regarding optimal graft choice and balancing long-term benefits against short-term risks. Future directions focus on ongoing clinical trials, innovations in minimally invasive and robotic-assisted CABG, and technological advancements aimed at improving graft patency. Professional guidelines and best practices underscore the need for personalized approaches to optimize MAG’s potential. This article underscores the promise of MAG in redefining CABG care, paving the way for enhanced patient outcomes and broadened applicability. This article highlights the promise of MAG in transforming CABG care, leading to improved patient outcomes and expanded applicability. Full article

Background: Obstructive sleep apnea (OSA) is a prevalent but frequently underdiagnosed comorbidity in patients undergoing cardiac surgery, including coronary artery bypass grafting (CABG), aortic valve replacement (AVR), and mitral valve repair or replacement (MVR). This systematic review and meta-analytic synthesis investigates the relationship between OSA and postoperative morbidity and mortality, with particular attention to the predictive utility of established screening instruments. Methods: A systematic search of the PubMed database was conducted (April 2025), identifying 724 articles published in the last ten years. Seventeen primary studies met the inclusion criteria for qualitative synthesis, and four additional studies were included in the meta-analyses. Outcomes assessed included atrial fibrillation, major adverse cardiac and cerebrovascular events (MACCE), acute kidney injury (AKI), respiratory complications, pneumonia, hospital length of stay (LOS), and mortality. Risk of bias was assessed qualitatively based on study design and reporting limitations. This review was registered in the PROSPERO database under registration number CRD420251049574. Results: Meta-analyses demonstrated significantly elevated odds of atrial fibrillation (OR = 2.44, 95% CI: 1.46–4.07), major adverse cardiac and cerebrovascular events (OR = 2.06, 95% CI: 1.61–2.63), acute kidney injury (OR = 2.24, 95% CI: 1.67–3.01), and respiratory complications (OR = 1.15, 95% CI: 1.05–1.25) among patients with OSA. Additionally, OSA was associated with a significantly prolonged hospital length of stay (standardized mean difference [SMD] = 0.62, 95% CI: 0.46–0.78) and a marginal increase in pneumonia risk (OR = 1.07, 95% CI: 1.00–1.15). Evidence regarding stroke, intensive care unit (ICU) stay, and mortality was inconsistent or underpowered. Conclusions: Across core outcomes, findings were consistent across multiple studies involving a large patient population. Obstructive sleep apnea is a clinically consequential risk factor in cardiac surgery, associated with increased perioperative complications and prolonged hospitalization. These findings support the integration of routine OSA screening into preoperative risk assessment protocols. Further prospective, multicenter trials are warranted to assess the efficacy of perioperative management strategies, including continuous positive airway pressure (CPAP) therapy, in improving surgical outcomes. Full article